Pancreatoduodenectomy using a no-touch isolation technique
Department of Surgery, Kumamoto Regional Medical Center, 5-16-10 Honjo, Kumamoto City, Kumamoto 860-0811, Japan. American journal of surgery
(Impact Factor: 2.29).
01/2009; 199(5):e65-8. DOI: 10.1016/j.amjsurg.2008.06.035
Pancreatoduodenectomy is the only effective treatment for cancers of the periampullary region. Because surgeons usually grasp tumors during pancreatoduodenectomy, this procedure may increase the risk of squeezing and shedding the cancer cells into the portal vein, retroperitoneum, and/or peritoneal cavity. In an effort to overcome these problems, we have developed a surgical technique for no-touch pancreatoduodenectomy.
From March 2005 through May 2008, 42 patients have been operated on following this technique. Resected margins were microscopically analyzed.
We describe a technique for pancreatoduodenectomy using a no-touch isolation technique. We resect cancers with wrapping them within Gerota's fascia and transect the retroperitoneal margin along the right surface of the superior mesenteric artery and abdominal aorta without grasping tumors.
No-touch pancreatoduodenectomy has many potential advantages that merit further investigation in future randomized controlled trials.
Available from: PubMed Central
- "Arterial congestion of the pancreas head occurs and the pancreas head is the source of bleeding. To prevent this bleeding, the head of the pancreas should be clamped with an aortic clamp . Another way to prevent bleeding is early devascularization of the arterial inflow to the pancreas head. "
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ABSTRACT: Pylorus-preserving pancreatoduodenectomy has become a standard operation for distal and middle bile duct cancers. Bile duct cancer typically extends longitudinally and invades vertically. It frequently metastasizes to the lymph nodes and infiltrates the perineural spaces. The presence of residual cancer in the bile duct stump and lymph node metastases are significant prognostic factors. Negative surgical margins and D2 lymph node dissection are necessary for curative resection. The clinical course after portal vein resection for bile duct cancer with portal vein invasion is better than that of non-resectable bile duct cancer. Portal vein resection can therefore be useful. The efficacy of prophylactic portal vein resection is unclear. We describe here our methods for performing pylorus-preserving pancreatoduodenectomy for bile duct cancer.
Electronic supplementary material
The online version of this article (doi:10.1007/s00534-011-0480-8) contains supplementary material, which is available to authorized users.
Available from: Masahiko Hirota
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ABSTRACT: In pancreatic cancer, even for patients who have undergone curative resection (R0), survival analysis has revealed a poor survival rate due to cancer recurrence. Because the operation itself might have caused the dissemination of these cancer cells, the no-touch isolation technique and extensive intraoperative peritoneal lavage may be a potential operative procedure for improving the outcome.
Eight patients treated by the no-touch isolation technique were compared with 10 patients treated using conventional techniques.
Cancer cell detection rates in the portal venous blood, frequency of recurrence, and survival rate. We also analyzed the lymphatic fluid squeezed from the resected cancerous pancreatic tissue.
In 5 out of 10 cases (50%) in the conventional procedure group, CEA mRNA was identified in the portal blood after tumor manipulation, while only 1 out of 8 cases (13%) in the no-touch isolation technique group was positive for portal CEA mRNA. All lymphatic fluid samples squeezed from the resected cancerous pancreatic tissue were positive (8/8) for CEA mRNA. The recurrence rate was 90% (9/10) in the conventional procedure group, and 38% (3/8) in the no-touch isolation technique group (P=0.043). In the conventional procedure group, hepatic metastasis, local recurrence, peritoneal dissemination, and extraabdominal recurrence were identified in 6 (60%), 4 (40%), 4 (40%), and 2 patients (20%), respectively. On the other hand, among the no-touch isolation technique group, recurrence was identified in 1 (13%), 1 (13%), 0 (0%), and 1 patient (13%), respectively. There was no peritoneal dissemination along with the decreased hepatic recurrence rate. Mean (+/-SEM) survival time was 21.2+/-5.8 months for the conventional procedure group and 41.5+/-5.6 months for the no-touch isolation technique group (P=0.018). The 3-year survival rate was 12.5+/-11.5% for the conventional procedure group and 75.0+/-21.7% for the no-touch isolation technique group.
This study presented the potential of cancer dissemination during the intraoperative manipulation of tumors and its contribution to cancer recurrence, as well as the significance of the no-touch isolation technique and extensive intraoperative peritoneal lavage for pancreatic cancer surgery.
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