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Chaudhari VA, Kunte AR, Chopde AN, Ostwal V, Ramaswamy A, Engineer R, Bhargava P, Bal M, Shetty N, Kulkarni S, Patkar S, Bhandare MS, Shrikhande SV. Evolution and improved outcomes in the era of multimodality treatment for extended pancreatectomy. BJS Open 2024; 8:zrae065. [PMID: 39088732 PMCID: PMC11293468 DOI: 10.1093/bjsopen/zrae065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 04/07/2024] [Accepted: 05/02/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND The evolution and outcomes of extended pancreatectomies at a single institute over 15 years are presented in this study. METHODS A retrospective analysis of the institutional database was performed from 2015 to 2022 (period B). Patients undergoing extended pancreatic resections, as defined by the International Study Group for Pancreatic Surgery, were included. Perioperative and survival outcomes were compared with data from 2007-2015 (period A). Regression analyses were used to identify factors affecting postoperative and long-term survival outcomes. RESULTS A total of 197 (16.1%) patients underwent an extended resection in period B compared to 63 (9.2%) in period A. Higher proportions of borderline resectable (5 (18.5%) versus 51 (47.7%), P = 0.011) and locally advanced tumours (1 (3.7%) versus 24 (22.4%), P < 0.001) were resected in period B with more frequent use of neoadjuvant therapy (6 (22.2%) versus 79 (73.8%), P < 0.001). Perioperative mortality (4 (6.0%) versus 12 (6.1%), P = 0.81) and morbidity (23 (36.5%) versus 83 (42.1%), P = 0.57) rates were comparable. The overall survival for patients with pancreatic adenocarcinoma was similar in both periods (17.5 (95% c.i. 6.77 to 28.22) versus 18.3 (95% c.i. 7.91 to 28.68) months, P = 0.958). Resectable, node-positive tumours had a longer disease-free survival (DFS) in period B (5.81 (95% c.i. 1.73 to 9.89) versus 14.03 (95% c.i. 5.7 to 22.35) months, P = 0.018). CONCLUSION Increasingly complex pancreatic resections were performed with consistent perioperative outcomes and improved DFS compared to the earlier period. A graduated approach to escalating surgical complexity, multimodality treatment, and judicious patient selection enables the resection of advanced pancreatic tumours.
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Affiliation(s)
- Vikram A Chaudhari
- GI & HPB Surgical Services, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Aditya R Kunte
- GI & HPB Surgical Services, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Amit N Chopde
- GI & HPB Surgical Services, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Vikas Ostwal
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Reena Engineer
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Prabhat Bhargava
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Munita Bal
- Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Nitin Shetty
- Department of Interventional Radiology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Suyash Kulkarni
- Department of Interventional Radiology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Shraddha Patkar
- GI & HPB Surgical Services, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Manish S Bhandare
- GI & HPB Surgical Services, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Shailesh V Shrikhande
- GI & HPB Surgical Services, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
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Kaya K, Mungan U. Multiple vascular reconstructions during pancreatectomy: Surgical techniques and strategies. Vascular 2023; 31:861-867. [PMID: 35477336 DOI: 10.1177/17085381221091053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Pancreatic body and tail tumors account for one-third of all pancreatic tumors and can be diagnosed later than pancreatic head tumors because they present symptoms much later. When analyzed, most of them are generally unresectable because they are invaded into adjacent organs and vascular structures. We aimed to present our cases of vascular resection and anastomosis, where isolated tumor resection cannot be performed due to invasion of adjacent vascular structures. METHODS Between January 2019 and January 2021, the files of eight patients who had one or more vascular invasions due to the pancreatic body and tail tumor and therefore underwent vascular resection in addition to pancreatectomy were accessed. RESULTS Portal vein and hepatic artery repair were performed in all eight patients. Superior mesenteric artery anastomosis was performed in four patients, inferior vena cava repair was performed in two patients, and renal vein anastomosis was performed in two patients. Primary end-to-end repair, Dacron graft, ring-enforced polytetrafluoroethylene graft, and saphenous vein graft techniques were used during vascular interventions. CONCLUSIONS We wanted to share our experience with the resection of vascular structures and anastomosis techniques. We believe that the indications of tumor surgery can be improved and redesigned by performing more routinely vascular resections and reconstructions in the future.
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Affiliation(s)
- Kaan Kaya
- Department of Cardiovascular Surgery, Lokman Hekim Akay Hospital, Ankara, Turkey
| | - Ufuk Mungan
- Department of Cardiovascular Surgery, Lokman Hekim Akay Hospital, Ankara, Turkey
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Brasoveanu V, Barbu I, Ichim F, Balescu I, Bacalbasa N. Distal Pancreatectomy En Bloc With Splenectomy, Celiac Axis and Portal Vein Resection Followed by Arterial Reconstruction Using a Cadaveric Graft - A Case Report and Literature Review. In Vivo 2021; 34:1521-1525. [PMID: 32354957 DOI: 10.21873/invivo.11940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND/AIM Locally advanced pancreatic body tumors invading the celiac axis and the portal vein have been considered since long as unresectable lesions; however, due to improvement of surgical techniques, in certain cases surgery with curative intent might be taken in consideration. CASE REPORT We present the case of a 48-year-old female investigated for epigastric pain that was diagnosed with a locally invasive pancreatic body tumor. The patient was submitted to computed tomography which revealed the presence of a locally advanced pancreatic tumor with no demarcation line with the celiac axis and the portal vein. The endoscopic ultrasound raised the suspicion of malignancy and retrieved a biopsy which demonstrated the presence of a pancreatic adenocarcinoma. The patient was submitted to surgery, distal pancreatectomy en bloc with splenectomy, celiac axis and portal vein resection was performed; the hepatic artery was reconstructed by placing a cadaveric graft while the portal vein was sutured per primam by an end to end anastomosis. The postoperative outcome was favorable, and the patient was discharged in the 10th postoperative day. CONCLUSION Multiple vascular resections followed by reconstructions might be needed in order to achieve resection with negative margins in patients with pancreatic body tumors.
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Affiliation(s)
- Vladislav Brasoveanu
- "Dan Setlacec" Center of Gastrointestinal Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania.,"Titu Maiorescu" University of Medicine and Pharmacy, Bucharest, Romania
| | - Ion Barbu
- "Dan Setlacec" Center of Gastrointestinal Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Florin Ichim
- "Dan Setlacec" Center of Gastrointestinal Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | | | - Nicolae Bacalbasa
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Center of Excellence in Translational Medicine, Fundeni Clinical Institute, Bucharest, Romania.,"I. Cantacuzino" Clinical Hospital, Bucharest, Romania
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Truty MJ, Colglazier JJ, Mendes BC, Nagorney DM, Bower TC, Smoot RL, DeMartino RR, Cleary SP, Oderich GS, Kendrick ML. En Bloc Celiac Axis Resection for Pancreatic Cancer: Classification of Anatomical Variants Based on Tumor Extent. J Am Coll Surg 2020; 231:8-29. [DOI: 10.1016/j.jamcollsurg.2020.05.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/04/2020] [Accepted: 05/04/2020] [Indexed: 12/20/2022]
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Lan J, Chen Y, Wang S, Zhou Y. Distal pancreatectomy with en bloc celiac axis resection for pancreatic cancer: a pooled analysis of 109 cases. Updates Surg 2020; 72:709-715. [PMID: 32495281 DOI: 10.1007/s13304-020-00826-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/29/2020] [Indexed: 12/19/2022]
Abstract
The aim of this study was to define the clinical outcome and prognostic determinants of distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for pancreatic body/tail cancer. A pooled data analysis was performed on individual data for patients who underwent DP-CAR for pancreatic body/tail cancer as identified by systematic literature search. A total of 32 articles involving 109 patients were eligible for inclusion. Postoperative morbidity and mortality were 53% and 4%, respectively. Preoperative abdominal and/or back pain was completely relieved immediately after surgery in 98% of patients. The 1, 3 and 5 years overall survival (OS) rates were 59%, 21% and 10%, and the median OS was 14 months. Patients who received neoadjuvant treatment had a median OS of 23 months. In conclusion, DP-CAR for locally advanced pancreatic body/tail cancer can be performed safely with low mortality and provides survival benefit when combined with neoadjuvant treatment.
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Affiliation(s)
- Jianfa Lan
- Department of Hepatobiliary and Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Yufeng Chen
- Department of General Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Shijie Wang
- Department of Hepatobiliary and Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Yanming Zhou
- Department of Hepatobiliary and Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Xiamen, China.
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Pancreatoduodenectomy With Arterial Resection for Locally Advanced Pancreatic Cancer of the Head: A Systematic Review. Pancreas 2020; 49:621-628. [PMID: 32433398 DOI: 10.1097/mpa.0000000000001551] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The development of increasingly effective chemotherapy regimens and increasing tumor necrosis is allowing radical pancreatectomy to be re-evaluated. This systematic review examines the outcome of patients with locally advanced cancer of the pancreatic head after pancreatectomy with arterial resection. Electronic searches were performed on PubMed and Medline databases between January 2000 and December 2018. The end points were to determine the safety and overall survival after arterial resection in pancreatectomy. Thirteen studies with 467 patients were included. Celiac, hepatic, mesenteric, and splenic arteries were resected across all studies. The median overall morbidity was 52% (range, 37%-100%) and with major complications occurring in a median of 25% (range, 12%-54%) of patients. The median 90-day mortality was 5% (range, 0%-17%). R0 was achieved in 66% (range, 43%-100%) and R1 in 31% (range, 0%-74%). The median survival was 17 (range, 7-29) months with a 1- and 3-year survival of 59% (range, 16%-92%) and 17% (range, 0%-13%), respectively. Pancreatectomy with arterial resection may be safely performed in high-volume centers with acceptable survival results in highly selected patients. Pooling of data through a multi-institutional registry will allow a more accurate assessment of the safety and efficacy of this treatment strategy.
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Sonohara F, Yamada S, Takami H, Hayashi M, Kanda M, Tanaka C, Kobayashi D, Nakayama G, Koike M, Fujiwara M, Fujii T, Kodera Y. Novel implications of combined arterial resection for locally advanced pancreatic cancer in the era of newer chemo-regimens. Eur J Surg Oncol 2019; 45:1895-1900. [PMID: 31147087 DOI: 10.1016/j.ejso.2019.05.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/08/2019] [Accepted: 05/17/2019] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION In this study, we assessed the prognostic efficacy and feasibility of combined arterial resection (AR) for locally advanced pancreatic cancer (LAPC), and aimed to identify significant prognostic factors for patients who underwent combined AR. METHODS Between 1981 and 2018, 733 consecutive patients who underwent pancreatic surgery for PC were identified. The 730 cases with detailed information were enrolled in the analysis. RESULTS Among 730 resected PC patients, 44 (6%) underwent AR including 21 hepatic (48%), 12 celiac (27%), five splenic (12%), four superior mesenteric (9%), and two other arteries (4%). The combined AR surgery showed significantly longer operative time (median, 608 vs 451 min, P < 0.0001), and the incidence of intraoperative blood transfusion was significantly higher in AR than surgery without AR (P = 0.0002), whereas there was no significant difference in the intraoperative blood loss (970 vs 1200 mL, P = 0.2) and occurrence of major complications (P = 0.5). In prognostic analysis of AR cases, multivariate Cox proportional hazard models revealed preoperative and postoperative therapy were the independent factors for both recurrence-free survival (RFS) and overall survival (OS) (preoperative therapy: RFS, HR = 0.21, P = 0.007; OS, HR = 0.18, P = 0.01; postoperative therapy: RFS, HR = 0.31, P = 0.003; OS, HR = 0.19, P = 0.002). CONCLUSION This study showed the feasibility of combined AR for LAPC and robust association of pre- and postoperative therapy and survival after AR surgery. Preoperative therapy following combined AR surgery is potentially powerful strategy for LAPC.
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Affiliation(s)
- Fuminori Sonohara
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Suguru Yamada
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Hideki Takami
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masamichi Hayashi
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mitsuro Kanda
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Chie Tanaka
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daisuke Kobayashi
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Goro Nakayama
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiko Koike
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Michitaka Fujiwara
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Yoshitomi H, Sakai N, Kagawa S, Takano S, Ueda A, Kato A, Furukawa K, Takayashiki T, Kuboki S, Miyzaki M, Ohtsuka M. Feasibility and safety of distal pancreatectomy with en bloc celiac axis resection (DP-CAR) combined with neoadjuvant therapy for borderline resectable and unresectable pancreatic body/tail cancer. Langenbecks Arch Surg 2019; 404:451-458. [DOI: 10.1007/s00423-019-01775-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 03/01/2019] [Indexed: 01/04/2023]
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Özsoy M, Şahin E, Yavuz M, Özsoy Z, Okur N, Şahin S, Yılmaz S, Arıkan Y. Alternative hepatic arterial reconstruction technique in a case of total pancreaticoduodenectomy after celiac artery resection in pancreas cancer: Iliac-hepatic bypass. Turk J Surg 2018; 35:146-150. [PMID: 32550321 DOI: 10.5578/turkjsurg.3983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 06/05/2017] [Indexed: 01/28/2023]
Abstract
Surgery is the only treatment method in pancreatic cancer. Unfortunately, metastatic diseases or invasion of the main vascular structures are observed in a majority of cases at the time of diagnosis; these structures originate from the body, neck, and tail of the pancreas and are considered inoperable. The first celiac artery resection for the treatment of cancer was described by Appleby in 1953. Here, we describe our hepatic artery reconstruction technique in a case with pancreatic body cancer. A 37-year-old male patient was admitted to our emergency department due to syncope. The patient was diagnosed with acute renal failure secondary to fluid loss. Thereafter, his general condition was stable and laboratory results improved. Abdominal computed tomography was performed. Pancreatic cancer originating from the pancreatic body was detected. A pancreatic biopsy was performed and neoadjuvant gemcitabine and paclitaxel chemoradiotherapy were initiated. Surgical treatment was recommended for the identification of regression after neoadjuvant chemoradiotherapy. Following intraoperative Doppler ultrasonography, en bloc distal pancreatectomy and splenectomy involving the celiac artery trunk and total gastrectomy were performed. However, surgical margin reliability in frozen section revealed that the tumor was still present. Therefore, the surgical procedure was replaced with total pancreaticoduodenectomy. Hepatic artery reconstruction was performed from the left main iliac artery using a 4-mm ringed GORE-TEX® graft. The iliac-hepatic bypass for hepatic artery reconstruction in pancreatic cancer could be an alternative surgical technique.
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Affiliation(s)
- Mustafa Özsoy
- Department of General Surgery, Parkhayat Hospital, Afyon, Turkey
| | - Enes Şahin
- Department of General Surgery, Selçuk University School of Medicine, Konya, Turkey
| | - Mustafa Yavuz
- Department of General Surgery, Afyon State Hospital, Afyon, Turkey
| | - Zehra Özsoy
- Department of Internal Medicine, Afyon State Hospital, Afyon, Turkey
| | - Nazan Okur
- Department of Radiology, Süleyman Demirel University School of Medicine, Isparta, Turkey
| | - Süleyman Şahin
- Department of General Surgery, Parkhayat Hospital, Afyon, Turkey
| | - Sezgin Yılmaz
- Department of General Surgery, Afyon Kocatepe University School of Medicine, Afyon, Turkey
| | - Yüksel Arıkan
- Department of General Surgery, Afyon Kocatepe University School of Medicine, Afyon, Turkey
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Tee MC, Krajewski AC, Groeschl RT, Farnell MB, Nagorney DM, Kendrick ML, Cleary SP, Smoot RL, Croome KP, Truty MJ. Indications and Perioperative Outcomes for Pancreatectomy with Arterial Resection. J Am Coll Surg 2018; 227:255-269. [PMID: 29752997 DOI: 10.1016/j.jamcollsurg.2018.05.001] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/04/2018] [Accepted: 05/03/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pancreatectomy with arterial resection (AR) is performed infrequently. As indications evolve, we evaluated indications, outcomes, and predictors of mortality, morbidity, and survival after AR. STUDY DESIGN We performed a single-institution review of elective pancreatectomies with AR (from July1990 to July 2017). Univariate and multivariate analyses were performed for predictors of outcomes and survival. RESULTS A total of 111 patients underwent pancreatectomy with AR including any hepatic (54%), any celiac (44%), any superior mesenteric (14%), or multiple ARs (14%), with revascularization in 55%. The majority of cases were planned (77%) and performed post-2010 (78%). Overall 90-day major morbidity (≥grade III) and mortality were 54% and 13%, respectively, due to post-pancreatectomy hemorrhage (PPH), postoperative pancreatic fistula (POPF), or ischemia in the majority of cases. There was a significant decrease in mortality post-2010 (9% vs 29%, p = 0.02), and this was protective on multivariate analysis (odds ratio [OR] 0.1, p = 0.004); PPH increased mortality (OR 6.1, p < 0.001). Post-pancreatectomy hemorrhage was associated with major morbidity (OR 5.1, p = 0.005), reoperation (OR = 23.0, p = 0.004), ICU (OR 5.5, p < 0.001), and readmission (OR 2.6, p = 0.004). Other morbidity predictors were AR with graft (OR 4.0, p = 0.031) and POPF (OR 3.1, p = 0.003). Median survival was 28.5 months and improved for ductal adenocarcinoma after neoadjuvant chemotherapy (p = 0.038). There were no differences in survival based on AR type. CONCLUSIONS Regardless of indication or type, pancreatectomy with AR is associated with risks greater than standard resections. Mortality has decreased in the modern era; however, morbidity remains high from hemorrhagic, fistula, or ischemia-related complications. Mitigation measures are needed if advanced resections are considered with increasing frequency given the potential oncologic benefit of AR in selected cases after modern chemotherapy.
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Affiliation(s)
- May C Tee
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | - Rory L Smoot
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - Mark J Truty
- Department of Surgery, Mayo Clinic, Rochester, MN.
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How to treat borderline resectable pancreatic cancer: current challenges and future directions. Jpn J Clin Oncol 2018; 48:205-213. [DOI: 10.1093/jjco/hyx191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 12/18/2017] [Indexed: 01/08/2023] Open
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Sato T, Saiura A, Inoue Y, Takahashi Y, Arita J, Takemura N. Distal Pancreatectomy with En Bloc Resection of the Celiac Axis with Preservation or Reconstruction of the Left Gastric Artery in Patients with Pancreatic Body Cancer. World J Surg 2017; 40:2245-53. [PMID: 27198999 DOI: 10.1007/s00268-016-3550-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND A distal pancreatectomy with en bloc celiac axis resection (DP-CAR) is indicated for left-sided locally advanced pancreatic ductal adenocarcinoma. However, ischemic complication resulting from the sacrifice of the common hepatic artery and left gastric artery (LGA) remain problematic. The aim of this study was to analyze the feasibility of DP-CAR with preservation or reconstruction of the left gastric artery. METHOD Between April 2011 and December 2014, we treated 17 cases using DP-CAR with preservation or reconstruction of the LGA. If the tumor had involved the LGA, the LGA was dissected and reconstructed using the middle colic artery. We retrospectively analyzed the feasibility of this procedure. RESULTS Among 17 consecutive patients who underwent DP-CAR, the LGA was preserved in 13 patients and reconstructed in four patients. Major postoperative complications were observed in seven cases (41 %). A pancreatic fistula (grade B/C) or delayed gastric emptying (grade B/C) occurred in 7 (41 %) and 2 (12 %) cases, respectively. The overall R0 resection rate was 94 % (16/17). Eleven cases developed recurrences (liver, n = 4; lymph nodes, n = 2; peritoneal dissemination, n = 2; lung, n = 2; local recurrence, n = 1). The overall 1- and 3-year postoperative survival rates were 74 and 45 %, respectively. CONCLUSIONS Our preliminary data showed that DP-CAR with preservation or reconstruction of the LGA is a safe and feasible approach, and that this procedure may reduce the risk of ischemic complications.
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Affiliation(s)
- Takafumi Sato
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Akio Saiura
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan.
| | - Yosuke Inoue
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Yu Takahashi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Junichi Arita
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Nobuyuki Takemura
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
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13
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Klompmaker S, de Rooij T, Korteweg JJ, van Dieren S, van Lienden KP, van Gulik TM, Busch OR, Besselink MG. Systematic review of outcomes after distal pancreatectomy with coeliac axis resection for locally advanced pancreatic cancer. Br J Surg 2017; 103:941-9. [PMID: 27304847 DOI: 10.1002/bjs.10148] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/07/2016] [Accepted: 02/08/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pancreatic cancer involving the coeliac axis is considered unresectable by most guidelines, with a median survival of 6-11 months. A subgroup of these patients can undergo distal pancreatectomy with coeliac axis resection, but consensus on the value of this procedure is lacking. The evidence for this procedure, including the impact of preoperative hepatic artery embolization and (neo)adjuvant therapy, was evaluated. METHODS A systematic review was performed according to the PRISMA guidelines until 27 May 2015. The primary endpoint was overall survival; secondary endpoints included morbidity and radical resection rates. RESULTS A total of 19 retrospective studies, involving 240 patients, were included. The methodological quality of the studies ranged from poor to moderate. A radical resection was reported in 74·5 per cent (152 of 204), major morbidity in 27 per cent (26 of 96), ischaemic morbidity in 9·0 per cent (21 of 223) and 90-day mortality in 3·5 per cent (4 of 113). Overall, 35·5 per cent of patients (55 of 155) underwent preoperative hepatic artery embolization without an apparent beneficial impact on ischaemic morbidity. Overall, 15·7 per cent (29 of 185) had neoadjuvant and 51·0 per cent (75 of 147) had adjuvant therapy. There was a difference in survival between patient series where less than half of patients had (neo)adjuvant chemotherapy and series where more than half were receiving this treatment: case-weighted median overall survival was 16 (range 9-48) versus 18 (10-26) months respectively (P = 0·002). Overall median survival for the whole study population was 14·4 (range 9-48) months. CONCLUSION Distal pancreatectomy with coeliac axis resection seems a valuable option for selected patients with pancreatic cancer involving the coeliac axis with acceptable morbidity and mortality, and a median survival of 18 months when combined with (neo)adjuvant therapy.
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Affiliation(s)
- S Klompmaker
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - T de Rooij
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - J J Korteweg
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - S van Dieren
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - K P van Lienden
- Departments of Interventional Radiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - T M van Gulik
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - O R Busch
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - M G Besselink
- Departments of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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Miyazaki M, Yoshitomi H, Takano S, Shimizu H, Kato A, Yoshidome H, Furukawa K, Takayashiki T, Kuboki S, Suzuki D, Sakai N, Ohtuka M. Combined hepatic arterial resection in pancreatic resections for locally advanced pancreatic cancer. Langenbecks Arch Surg 2017; 402:447-456. [PMID: 28361216 DOI: 10.1007/s00423-017-1578-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 03/21/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Arterial involvement in advanced pancreatic cancer generally defines local unresectability. This study was aimed to evaluate the clinical outcomes of combined common hepatic arterial resection with pancreaticoduodenectomy or total pancreatectomy in patients with locally advanced pancreatic cancer involving the hepatic artery. METHODS Of 348 patients with pancreatic head cancers who underwent surgical resection between June 1999 and September 2015, 21 underwent combined common hepatic arterial resection with pancreaticoduodenectomy (17) or total pancreatectomy (4). Preoperative common hepatic arterial embolization was performed in 12 patients. Preoperative CT findings of hepatic arterial involvement, postoperative complications, survival rates, and prognostic factors for survival were analyzed. Twenty-one unresectable patients with locally advanced pancreatic cancer who underwent laparotomy in this study period were selected as the control group. RESULTS Rates of pathological arterial invasion were significantly higher in patients with level III (>1800) CT findings (90%,9/10) than in patients with levels I and II (<1800) (27%, 3/11) (p < 0.01). No surgical deaths occurred. Survival after surgical resection in all 21 patients was 47.6%, 6.6%, and 6.6% at 1, 3, and 5 years, and median survival was 11 months. The preoperative serum CA19-9 level was a significant prognostic factor for overall survival, median survivals were 21.5 and 8.3 months in the low CA19-9 and high CA19-9 groups, respectively. No significant difference in survival between the high-CA19-9 group and the unresectable group was found. CONCLUSIONS Combined common hepatic arterial resection in pancreaticoduodenectomy or total pancreatectomy might be feasible with an acceptable rate of surgical complications, and may have a beneficial effect on the prognosis only in patients with low preoperative serum CA19-9 levels.
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Affiliation(s)
- Masaru Miyazaki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan.
| | - Hideyuki Yoshitomi
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Shigetsugu Takano
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Hiroaki Shimizu
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Atsushi Kato
- International University of Health & Welfare Mita Hospital, Tokyo, Japan
| | - Hiroyuki Yoshidome
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Katunori Furukawa
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Tsukasa Takayashiki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Satoshi Kuboki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Daisuke Suzuki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Nozomu Sakai
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Masayuki Ohtuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
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15
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Peters NA, Javed AA, Cameron JL, Makary MA, Hirose K, Pawlik TM, He J, Wolfgang CL, Weiss MJ. Modified Appleby Procedure for Pancreatic Adenocarcinoma: Does Improved Neoadjuvant Therapy Warrant Such an Aggressive Approach? Ann Surg Oncol 2016; 23:3757-3764. [PMID: 27328946 DOI: 10.1245/s10434-016-5303-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND With improved neoadjuvant regimens, more aggressive surgical resections may be warranted for patients with locally advanced pancreatic cancer (LAPC) with focal encasement of the celiac axis (CA) and proximal common hepatic artery (HA). We sought to investigate the clinicopathological features and outcomes of the modified Appleby procedure (DP-CAR) in light of improved neoadjuvant therapies. METHODS A prospectively maintained database of all pancreatectomies performed at Johns Hopkins Hospital, Baltimore, MD, USA, was reviewed to identify all patients who underwent DP-CAR for pancreatic ductal adenocarcinoma (PDAC) between 2004 and 2016. A 3:1 match for patients undergoing distal pancreatectomy (DP) versus DP-CAR was performed on the basis of their clinicopathological features. RESULTS Seventeen patients who underwent DP-CAR were matched to 51 patients who underwent DP for resection of PDAC. Prior to DP-CAR, 15 (88.2 %) patients received neoadjuvant therapy, and the most frequently used regimen was FOLFIRINOX (80.0 %). DP-CAR was associated with longer operative time (404 vs. 309 min; p = 0.003) and elevated postoperative liver transaminases compared with DP. No difference was observed in estimated blood loss and length of hospitalization. R0 resection was achieved in 82.4 % of DP-CAR patients versus 92.2 % of DP patients (p = 0.355). No difference was observed in postoperative outcomes, including overall complications, pancreatic fistula, readmission, and mortality. Median survival for DP-CAR was 20 versus 19 months in the DP group (p = 0.757). CONCLUSION In light of improved neoadjuvant therapeutic regimens, the modified Appleby procedure is a feasible and safe treatment option for patients with LAPC involving the CA, with morbidity and mortality similar to patients undergoing classic DP.
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Affiliation(s)
- Niek A Peters
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA.,University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ammar A Javed
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - John L Cameron
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Martin A Makary
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Kenzo Hirose
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Timothy M Pawlik
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jin He
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | | | - Matthew J Weiss
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA.
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16
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Latona JA, Lamb KM, Pucci MJ, Maley WR, Yeo CJ. Modified Appleby Procedure with Arterial Reconstruction for Locally Advanced Pancreatic Adenocarcinoma: A Literature Review and Report of Three Unusual Cases. J Gastrointest Surg 2016; 20:300-6. [PMID: 26525205 DOI: 10.1007/s11605-015-3001-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 10/08/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreatic body and tail ductal adenocarcinomas are often diagnosed with local vascular invasion of the celiac axis (CA) and its various branches. With such involvement, these tumors have traditionally been considered unresectable. The modified Appleby procedure allows for margin negative resection of some such locally advanced tumors. This procedure involves distal pancreatectomy with en bloc splenectomy and CA resection and relies on the presence of collateral arterial circulation via an intact pancreaticoduodenal arcade and the gastroduodenal artery to maintain prograde hepatic arterial perfusion. When the resultant collateral circulation is inadequate to provide sufficient hepatic and gastric arterial inflow, arterial reconstruction (AR) is necessary to "supercharge" the inflow. Herein, we review all reported cases of AR with modified Appleby procedures that we have identified in the literature, and we report our experience of three recent cases with arterial reconstruction including two cases with arterial bypasses not requiring interposition grafting. METHODS Perioperative and oncologic outcomes from our Institutional Review Board-approved database of pancreatic resections at the Thomas Jefferson University were reviewed. Additionally, PubMed search for cases of distal or total pancreatectomy with celiac axis resection and concurrent AR was performed. RESULTS From the literature, 12 reports involving 28 patients were identified of distal and total pancreatectomy with AR after CA resection. The most common AR in the literature, performed in 12 patients, was a bypass from the aorta to the common hepatic artery (CHA) using a variety of interposition conduits. In our institutional experience, patient #1 had a primary side-to-end aorto-CHA bypass, patient #2 had a primary end-to-end bypass of the transected distal CHA to the left gastric artery in the setting a replaced left hepatic artery, and patient #3 required an aortic to proper hepatic artery bypass with saphenous vein graft and portal venous reconstruction. All patients recovered from their operations without ischemic complications, and they are currently 16, 15, and 13 months post-op, respectively. CONCLUSIONS The criteria for resectability in patients with locally advanced pancreatic body and tail neoplasms are expanding due to increasing experience with AR in the setting of the modified Appleby procedure. When performing AR, primary arterial re-anastomosis may be considered preferable to interposition grafting as it decreases the potential for the infectious and thrombotic complications associated with conduits and it reduces the number of vascular anastomoses from two to one. Consideration must also be given to normal variant anatomy of the hepatic circulation during operative planning as the origin of the left gastric artery is resected with the CA. The modified Appleby procedure with AR, when used in appropriately selected patients, offers the potential for safe, margin negative resection of locally advanced pancreatic body and tail tumors.
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Affiliation(s)
- Jessica A Latona
- The Jefferson Pancreas, Biliary and Related Cancer Center, Department of Surgery, Thomas Jefferson University, 1015 Walnut Street, 620 Curtis Building, Philadelphia, PA, 19107, USA
| | - Kathleen M Lamb
- The Jefferson Pancreas, Biliary and Related Cancer Center, Department of Surgery, Thomas Jefferson University, 1015 Walnut Street, 620 Curtis Building, Philadelphia, PA, 19107, USA
| | - Michael J Pucci
- The Jefferson Pancreas, Biliary and Related Cancer Center, Department of Surgery, Thomas Jefferson University, 1015 Walnut Street, 620 Curtis Building, Philadelphia, PA, 19107, USA
| | - Warren R Maley
- The Jefferson Pancreas, Biliary and Related Cancer Center, Department of Surgery, Thomas Jefferson University, 1015 Walnut Street, 620 Curtis Building, Philadelphia, PA, 19107, USA
| | - Charles J Yeo
- The Jefferson Pancreas, Biliary and Related Cancer Center, Department of Surgery, Thomas Jefferson University, 1015 Walnut Street, 620 Curtis Building, Philadelphia, PA, 19107, USA.
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Egorov VI, Petrov RV, Starostina NS, Zhurina YA, Grigorievsky MV. [Results of the modified Appleby procedure]. Khirurgiia (Mosk) 2016:9-17. [PMID: 27070870 DOI: 10.17116/hirurgia201639-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
AIM To evaluate safety and efficacy of distal pancreatectomy with en bloc celiac artery resection (DP-CAR) for pancreatic malignancy. MATERIAL AND METHODS Medical reports of 17 patients who underwent DP-CAR procedure (15 of them with pancreatic malignancy) were retrospectively analyzed. Also we studied 27 publications describing more than 2 cases of DP-CAR. RESULTS R0- and R1-resection was performed in 14 (82%) and 3 (18%) patients respectively. Postoperative complications ware observed in 11 (65%) cases. Nine of them were successfully treated. Full pain control was achieved in all patients. There were no any ischemic complications. 16 patients received chemotherapy. 2 (11%) patients died in early postoperative period due to aortic dissection in 10 days and fungal sepsis in 44 days after surgery. Median survival was 20 months. Literature review included 27 articles describing 311 operations. Herewith postoperative complications developed in 43% of cases and 90-day postoperative mortality was 4%. Median survival ranged from 9.3 to 26 months. CONCLUSION DP-CAR is effective and safe procedure in certain patients with locally advanced pancreatic cancer.
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Affiliation(s)
- V I Egorov
- City Clinical Hospital #5, Moscow Department of Health
| | - R V Petrov
- City Clinical Hospital #5, Moscow Department of Health
| | | | - Yu A Zhurina
- City Clinical Hospital #5, Moscow Department of Health
| | - M V Grigorievsky
- A.I. Evdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of the Russian Federation, Moscow
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18
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Abstract
BACKGROUND Vascular resection interventions and the associated necessity of a reconstruction for maintenance particularly of hepatic and small intestinal perfusion are important aspects especially for the surgical treatment of pancreatic cancer. An R0 resection is the only curative treatment option for patients with pancreatic cancer. Venous or arterial vascular infiltration by the tumor and the associated resection and reconstruction for complete tumor removal and establishment of a sufficient perfusion of the dependent organs represents one of the greatest challenges in pancreatic surgery. In addition the oncological significance with respect to arterial vascular resections is controversial. OBJECTIVE In this review article the indications and technical aspects of vascular resection and reconstruction in the therapy of pancreatic cancer are presented and discussed based on the current literature. MATERIAL AND METHODS A systematic search of Medline, Embase and the Cochrane Library was carried out to identify studies reporting the results of venous or arterial vascular resection techniques, postoperative morbidity, mortality and patient survival after surgery for pancreatic cancer. Results Pancreatic cancer with vascular infiltration should not principally be seen as non-resectable but must always be checked for the possibility of a curative resection. A decisive factor is the differentiation between venous and arterial vascular involvement. Various safe technical options are available for venous vascular resection, depending on the extent of tumor infiltration. Arterial vascular resections are associated with an increased morbidity and mortality. In selected patients a complete tumor resection and prolonged survival can be achieved by arterial vascular resection.
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19
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Glebova NO, Hicks CW, Tosoian JJ, Piazza KM, Abularrage CJ, Schulick RD, Wolfgang CL, Black JH. Outcomes of arterial resection during pancreatectomy for tumor. J Vasc Surg 2015; 63:722-9.e1. [PMID: 26610641 DOI: 10.1016/j.jvs.2015.09.042] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Accepted: 09/17/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Arterial resection (AR) during pancreatic tumor resection is controversial. We examined the safety and efficacy of AR during pancreatectomy. METHODS We used a prospective institutional database that includes 6522 patients who underwent pancreatectomy from 1970 to 2014; 35 had AR. We performed a 2:1 propensity match for patients without and with AR on the basis of preoperative patient and tumor variables. We then compared operative and postoperative outcomes between matched groups. RESULTS AR included 18 hepatic, 8 celiac, 3 splenic, 3 middle colic, 2 superior mesenteric, and 1 left renal artery. There were 20 primary, 4 vein, and 2 graft reconstructions; 11 were emergent and 24 elective. Before matching, patients with AR were younger (58 ± 2 vs 63 ± 0.2 years old; P = .05), more likely to be of black race (26% vs 9%; P = .003), to have received preoperative chemotherapy (17% vs 2%; P < .001), have a later stage and larger tumor (4 ± 0.8 vs 3 ± 0.04 cm; P = .05), more resections that included removal of all macroscopic disease, but microscopic residual tumor remained (31% vs 14%; P = .02), greater blood loss (1285 ± 276 vs 822 ± 16 mL; P = .02), and more frequent cardiac complications (11% vs 4%; P = .03) compared with patients without AR. After propensity matching, baseline patient characteristics were similar between groups. For perioperative outcomes, the groups did not differ in surgical time, blood loss, length of stay, or complications including anastomotic leaks, bleeding, cardiac, infectious complications, or liver infarct or failure (all; P = not significant). Patency was 97% at a mean follow-up of 510 ± 184 days with 1 hepatic artery AR thrombosis. Long-term outcomes were significantly different: patients with AR had a lower rate of local tumor recurrence (20% vs 47%; P = .007) but also lower 1-year (50% vs 87%; P = .002) and median survival (22 ± 18 vs 49 ± 7 months; P = .002). CONCLUSIONS AR during pancreatectomy is safe and not associated with increased complications. Although it significantly reduces the risk of local tumor recurrence, AR is associated with worse survival compared with patients who do not undergo AR.
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Affiliation(s)
- Natalia O Glebova
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Colorado Denver, Aurora, Colo; Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Jeffrey J Tosoian
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, Md
| | - Kristen M Piazza
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Richard D Schulick
- Division of GI, Tumor, and Endocrine Surgery, Department of Surgery, University of Colorado Denver, Aurora, Colo
| | - Christopher L Wolfgang
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md.
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20
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Preoperative Diagnostic Angiogram and Endovascular Aortic Stent Placement for Appleby Resection Candidates: A Novel Surgical Technique in the Management of Locally Advanced Pancreatic Cancer. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2015; 2015:523273. [PMID: 26491217 PMCID: PMC4600866 DOI: 10.1155/2015/523273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 08/01/2015] [Accepted: 08/26/2015] [Indexed: 11/18/2022]
Abstract
Background. Pancreatic adenocarcinoma of the body and tail usually presents late and is typically unresectable. The modified Appleby procedure allows resection of pancreatic body carcinoma with celiac axis (CA) invasion. Given that the feasibility of this technique is based on the presence of collateral circulation, it is crucial to confirm the presence of an anatomical and functional collateral system. Methods. We here describe a novel technique used in two patients who were candidates for Appleby resection. We present their clinical scenario, imaging, operative findings, and postoperative course. Results. Both patients had a preoperative angiogram for assessment of anatomical circulation and placement of an endovascular stent to cover the CA. We hypothesize that this new technique allows enhancement of collateral circulation and helps minimize intraoperative blood loss when transecting the CA at its takeoff. Moreover, extra length on the CA margin may be gained, as the artery can be transected at its origin without the need for vascular clamp placement. Conclusion. We propose this novel technique in the preoperative management of patients who are undergoing a modified Appleby procedure. While further experience with this technique is required, we believe that it confers significant advantages to the current standard of care.
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21
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Ham H, Kim SG, Kwon HJ, Ha H, Choi YY. Distal pancreatectomy with celiac axis resection for pancreatic body and tail cancer invading celiac axis. Ann Surg Treat Res 2015; 89:167-75. [PMID: 26446424 PMCID: PMC4595816 DOI: 10.4174/astr.2015.89.4.167] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 07/03/2015] [Accepted: 07/17/2015] [Indexed: 12/19/2022] Open
Abstract
Purpose Pancreatic body/tail cancer often involves the celiac axis (CA) and it is regarded as an unresectable disease. To treat the disease, we employed distal pancreatectomy with en bloc celiac axis resection (DP-CAR) and reviewed our experiences. Methods We performed DP-CAR for seven patients with pancreatic body/tail cancer involving the CA. The indications of DP-CAR initially included tumors with definite invasion of CA and were later expanded to include borderline resectable disease. To determine the efficacy of DP-CAR, the clinico-pathological data of patients who underwent DP-CAR were compared to both distal pancreatectomy (DP) group and no resection (NR) group. Results The R0 resection rate was 71.4% and was not statistically different compared to DP group. The operative time (P = 0.018) and length of hospital stay (P = 0.022) were significantly longer in DP-CAR group but no significant difference was found in incidence of the postoperative pancreatic fistula compared to DP group. In DP-CAR group, focal hepatic infarction and transient hepatopathy occurred in 1 patient and 3 patients, respectively. No mortality occurred in DP-CAR group. The median survival time (MST) was not statistically different compared to DP group. However, the MST of DP-CAR group was significantly longer than that of NR group (P < 0.001). Conclusion In our experience, DP-CAR was safe and offered high R0 resection rate for patients with pancreatic body/tail cancer with involvement of CA. The effect on survival of DP-CAR is comparable to DP and better than that of NR. However, the benefits need to be verified by further studies in the future.
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Affiliation(s)
- Hyemin Ham
- Departmet of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sang Geol Kim
- Department of Surgery, Kyungpook National University Medical Center, Daegu, Korea
| | - Hyung Jun Kwon
- Department of Surgery, Kyungpook National University Medical Center, Daegu, Korea
| | - Heontak Ha
- Department of Surgery, Kyungpook National University Medical Center, Daegu, Korea
| | - Young Yeon Choi
- Departmet of Surgery, Kyungpook National University School of Medicine, Daegu, Korea
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22
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Early vein reconstruction and right-to-left dissection for left-sided pancreatic tumors with portal vein occlusion. J Gastrointest Surg 2014; 18:2034-7. [PMID: 25091848 DOI: 10.1007/s11605-014-2616-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 07/22/2014] [Indexed: 01/31/2023]
Abstract
Large left-sided pancreatic tumors are frequently associated with portal vein (PV) and/or superior mesenteric vein (SMV) occlusion. Traditionally, vein reconstruction is deferred until after removal of the tumor. However, division of venous collaterals, as is done in a typical left-to-right fashion, leads to progressive portal hypertension and increased risk of variceal hemorrhage during the dissection. Conversely, early PV/SMV resection and reconstruction restores mesenteric-portal flow and decompresses varices, thereby enabling a safer and easier right-to-left pancreatic resection. This "How I Do It" report describes the technique and advantages of a "reconstruction-first" approach for large left-sided pancreatic tumors with venous involvement and left-sided portal hypertension.
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23
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Vicente E, Quijano Y, Ielpo B, Duran H, Diaz E, Fabra I, Oliva C, Olivares S, Caruso R, Ferri V, Ceron R, Moreno A. Is arterial infiltration still a criterion for unresectability in pancreatic adenocarcinoma? Cir Esp 2014; 92:305-15. [PMID: 24636076 DOI: 10.1016/j.ciresp.2013.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 11/04/2013] [Indexed: 12/20/2022]
Abstract
As surgical resection remains the only hope for cure in pancreatic cancer (PC), more aggressive surgical approaches have been advocated to increase resection rates. Venous resection demonstrated to be a feasible technique in experienced centers, increasing survival. In contrast, arterial resection is still an issue of debate, continuing to be considered a general contraindication to resection. In the last years there have been significant advances in surgical techniques and postoperative management which have dramatically reduced mortality and morbidity of major pancreatic resections. Furthermore, advances in multimodal neo-adjuvant and adjuvant treatments, as well as the better understanding of tumor biology and new diagnostic options have increased overall survival. In this article we highlight some of the important points that a modern pancreatic surgeon should take into account in the management of PC with arterial involvement in light of the recent advances.
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Affiliation(s)
- Emilio Vicente
- Hospital Universitario Madrid Sanchinarro, Centro Integral Oncológico Clara Campal, Facultad de Medicina, Universidad CEU San Pablo, Madrid, España.
| | - Yolanda Quijano
- Hospital Universitario Madrid Sanchinarro, Centro Integral Oncológico Clara Campal, Facultad de Medicina, Universidad CEU San Pablo, Madrid, España
| | - Benedetto Ielpo
- Hospital Universitario Madrid Sanchinarro, Centro Integral Oncológico Clara Campal, Facultad de Medicina, Universidad CEU San Pablo, Madrid, España
| | - Hipolito Duran
- Hospital Universitario Madrid Sanchinarro, Centro Integral Oncológico Clara Campal, Facultad de Medicina, Universidad CEU San Pablo, Madrid, España
| | - Eduardo Diaz
- Hospital Universitario Madrid Sanchinarro, Centro Integral Oncológico Clara Campal, Facultad de Medicina, Universidad CEU San Pablo, Madrid, España
| | - Isabel Fabra
- Hospital Universitario Madrid Sanchinarro, Centro Integral Oncológico Clara Campal, Facultad de Medicina, Universidad CEU San Pablo, Madrid, España
| | - Catalina Oliva
- Hospital Universitario Madrid Sanchinarro, Centro Integral Oncológico Clara Campal, Facultad de Medicina, Universidad CEU San Pablo, Madrid, España
| | - Sergio Olivares
- Hospital Universitario Madrid Sanchinarro, Centro Integral Oncológico Clara Campal, Facultad de Medicina, Universidad CEU San Pablo, Madrid, España
| | - Riccardo Caruso
- Hospital Universitario Madrid Sanchinarro, Centro Integral Oncológico Clara Campal, Facultad de Medicina, Universidad CEU San Pablo, Madrid, España
| | - Valentina Ferri
- Hospital Universitario Madrid Sanchinarro, Centro Integral Oncológico Clara Campal, Facultad de Medicina, Universidad CEU San Pablo, Madrid, España
| | - Ricardo Ceron
- Hospital Universitario Madrid Sanchinarro, Centro Integral Oncológico Clara Campal, Facultad de Medicina, Universidad CEU San Pablo, Madrid, España
| | - Almudena Moreno
- Hospital Universitario Madrid Sanchinarro, Centro Integral Oncológico Clara Campal, Facultad de Medicina, Universidad CEU San Pablo, Madrid, España
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24
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Zhou YM, Zhang XF, Li XD, Liu XB, Wu LP, Li B. Distal pancreatectomy with en bloc celiac axis resection for pancreatic body-tail cancer: Is it justified? Med Sci Monit 2014; 20:1-5. [PMID: 24382572 PMCID: PMC3890411 DOI: 10.12659/msm.889847] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The aim of this study was to evaluate the safety and efficacy of distal pancreatectomy with en bloc celiac axis resection (DP-CAR) for pancreatic body-tail cancer. MATERIAL AND METHODS The medical records of 12 patients who underwent DP-CAR for pancreatic body-tail cancer were retrospectively studied, together with a literature review of studies including at least 3 cases of DP-CAR. RESULTS There were no deaths among our 12 cases. Postoperative morbidity developed in 9 cases and was successfully managed by non-surgical treatment. No patients developed ischemic complications. Median overall survival was 10 months. A total of 19 studies involving 203 patients who underwent DP-CAR were included in the literature review. The overall morbidity and mortality rates were 50.2% and 3.0%, respectively. The overall median survival after surgery ranged from 9.3 to 26 months. CONCLUSIONS DP-CAR is a safe and effective treatment for patients with locally advanced pancreatic body-tail cancer.
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Affiliation(s)
- Yan-Ming Zhou
- Department of Hepatobiliary and Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Oncologic Center of Xiamen, Xiamen, China (mainland)
| | - Xiao-Feng Zhang
- Department IV of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Shanghai, China (mainland)
| | - Xiu-Dong Li
- Department of Hepatobiliary and Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Oncologic Center of Xiamen, Xiamen, China (mainland)
| | - Xiao-Bin Liu
- Department of Hepatobiliary and Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Oncologic Center of Xiamen, Xiamen, China (mainland)
| | - Lu-Peng Wu
- Department of Hepatobiliary and Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Oncologic Center of Xiamen, Xiamen, China (mainland)
| | - Bin Li
- Department of Hepatobiliary and Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Oncologic Center of Xiamen, Xiamen, China (mainland)
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25
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En masse resection of pancreas, spleen, celiac axis, stomach, kidney, adrenal, and colon for invasive pancreatic corpus and tail tumor. Case Rep Surg 2013; 2013:376035. [PMID: 24159408 PMCID: PMC3789274 DOI: 10.1155/2013/376035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 07/22/2013] [Indexed: 11/17/2022] Open
Abstract
Providing a more comfortable life and a longer survival for pancreatic corpus/tail tumors without metastasis depends on the complete resection. Recently, distal pancreatectomy with celiac axis resection was reported as a feasible and favorable method in selected pancreatic corpus/tail tumors which had invaded the celiac axis. Additional organ resections to the celiac axis were rarely required, and when necessary it was included only a single extra organ resection such as adrenal or intestine. Here, we described a distal pancreatic tumor invading most of the neighboring organs-stomach, celiac axis, left renal vein, left adrenal gland, and splenic flexure were treated by en bloc resection of all these organs. The patient was a 60-year-old man without any severe medical comorbidities. Postoperative course of the patient was uneventful, and he was discharged on postoperative day eight without any complication. Histopathology and stage of the tumor were adenocarcinoma and T4 N1 M0, respectively. Preoperative back pain of the patient was completely relieved in the postoperative period. As a result, celiac axis resection for pancreatic cancer is an extensive surgery, and a combined en masse resection of the invaded neighboring organs is a more extensive surgery than the celiac axis resection alone. This more extensive surgery is safe and feasible for selected patients with pancreatic cancer.
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Flores García JÁ, Galeano Díaz F, Botello Martínez F, Gallarín Salamanca IM, Blanco Fernández G. [Non-functioning primary neuroendocrine tumor of the liver with extension to the celiac trunk]. Cir Esp 2013; 93:415-7. [PMID: 24050830 DOI: 10.1016/j.ciresp.2013.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 06/17/2013] [Indexed: 10/26/2022]
Affiliation(s)
- José Ángel Flores García
- Servicio de Cirugía Hepatobiliopancreática y Trasplante, Hospital Infanta Cristina, Badajoz, España.
| | - Francisco Galeano Díaz
- Servicio de Cirugía Hepatobiliopancreática y Trasplante, Hospital Infanta Cristina, Badajoz, España
| | | | | | - Gerardo Blanco Fernández
- Servicio de Cirugía Hepatobiliopancreática y Trasplante, Hospital Infanta Cristina, Badajoz, España
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27
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Wolfgang CL, Herman JM, Laheru DA, Klein AP, Erdek MA, Fishman EK, Hruban RH. Recent progress in pancreatic cancer. CA Cancer J Clin 2013; 63:318-48. [PMID: 23856911 PMCID: PMC3769458 DOI: 10.3322/caac.21190] [Citation(s) in RCA: 668] [Impact Index Per Article: 55.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 03/22/2013] [Accepted: 03/22/2013] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is currently one of the deadliest of the solid malignancies. However, surgery to resect neoplasms of the pancreas is safer and less invasive than ever, novel drug combinations have been shown to improve survival, advances in radiation therapy have resulted in less toxicity, and enormous strides have been made in the understanding of the fundamental genetics of pancreatic cancer. These advances provide hope but they also increase the complexity of caring for patients. It is clear that multidisciplinary care that provides comprehensive and coordinated evaluation and treatment is the most effective way to manage patients with pancreatic cancer.
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Affiliation(s)
- Christopher L. Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
| | - Joseph M. Herman
- Department of Radiation Oncology & Molecular Radiation Sciences, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
| | - Daniel A. Laheru
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
| | - Alison P. Klein
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
- Department of Epidemiology, the Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Michael A. Erdek
- Department of Anesthesiology and Critical Care Medicine, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
| | - Elliot K. Fishman
- Department of Radiology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
| | - Ralph H. Hruban
- Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine
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28
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Left-sided pancreatic cancer: distal pancreatectomy and its variants: radical antegrade modular pancreatosplenectomy and distal pancreatectomy with celiac axis resection. Cancer J 2013. [PMID: 23187843 DOI: 10.1097/ppo.0b013e31827596c5] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Adenocarcinoma of the body and tail of the pancreas is an aggressive malignancy, and classically there have been few survivors after surgery. Radical antegrade modular pancreatosplenectomy and distal pancreatectomy with celiac axis resection are new procedures for these tumors. Radical antegrade modular pancreatosplenectomy is designed to establish an operation with oncologic rationales both for the dissection planes used to achieve negative margins and the extent of node dissection. The extent of lymph node dissection is based on the descriptions of N1 lymph node drainage, and dissection planes are based on fascial planes of the retroperitoneum. Radical antegrade modular pancreatosplenectomy is modular, adjusting the posterior plane of dissection based on the position of the tumor on preoperative computed tomograms. It is also performed right to left to increase visibility and control blood supply early. Radical antegrade modular pancreatosplenectomy is not an extended pancreatectomy but brings the rationales of the modern Whipple procedure to left-sided tumors. In long-term results from our center in 47 patients, there was a high negative tangential margin rate of 89% and an actuarial overall 5-year survival rate of 35.5%. The actual 5-year survival in 23 patients was 30.4%. Distal pancreatectomy with celiac axis resection is a procedure for cancers that have involved the celiac axis. It is based on the fact that resection of the celiac axis may be performed without devascularizing the liver, which then receives its blood supply by the pancreaticoduodenal arcade. It is an extended pancreatectomy. Mature long term results are just becoming available. Results with distal pancreatectomy with celiac axis resection are mixed with some series reporting few or no long-term survivors, whereas others report long-term survival at approximately 20%.
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29
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Schoellhammer HF, Goldner BS, Kim J, Singh G. Beyond the whipple operation: radical resections for cancers of the head of the pancreas. Indian J Surg Oncol 2013; 6:41-6. [PMID: 25937763 DOI: 10.1007/s13193-013-0258-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 07/02/2013] [Indexed: 12/11/2022] Open
Abstract
Pancreatic adenocarcinoma is the most common pancreatic malignancy, and it occurs most commonly in the pancreatic head. It has a relatively low incidence; however it is a deadly disease and is the fourth most common cause of cancer deaths for males and females in the United States. Surgical resection in the form of pancreaticoduodenectomy is the mainstay of treatment and can lead to improved overall survival as well as the possibility of a cure, although only 10 % of patients are resectable at presentation. In an attempt to improve outcomes and survival, surgeons over the decades have employed various aggressive resectional strategies to combat this disease. In this paper we review the development of pancreaticoduodenectomy and touch on the role played by the American surgeon Allan Whipple in this development. We review modern data regarding radical pancreaticoduodenectomy and extended lymphadenectomy for pancreatic head cancers, as well as data and controversies regarding arterial and venous resection performed during the course of pancreaticoduodenectomy. The role of extended and vascular resections in the treatment of pancreatic neuroendocrine tumors in contrast to adenocarcinomas is also examined. We summarize the current state of data regarding radical pancreaticoduodenectomy and discuss pushing the boundaries of surgical resection to help improve outcomes for select groups of patients.
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Affiliation(s)
- Hans F Schoellhammer
- Division of Surgical Oncology, Department of Surgery, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA 91010 USA
| | - Bryan S Goldner
- Division of Surgical Oncology, Department of Surgery, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA 91010 USA
| | - Joseph Kim
- Division of Surgical Oncology, Department of Surgery, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA 91010 USA
| | - Gagandeep Singh
- Division of Surgical Oncology, Department of Surgery, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA 91010 USA
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30
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Wolfgang CL, Herman JM, Laheru DA, Klein AP, Erdek MA, Fishman EK, Hruban RH. Recent progress in pancreatic cancer. CA Cancer J Clin 2013. [PMID: 23856911 DOI: 10.1002/caac.21190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Pancreatic cancer is currently one of the deadliest of the solid malignancies. However, surgery to resect neoplasms of the pancreas is safer and less invasive than ever, novel drug combinations have been shown to improve survival, advances in radiation therapy have resulted in less toxicity, and enormous strides have been made in the understanding of the fundamental genetics of pancreatic cancer. These advances provide hope but they also increase the complexity of caring for patients. It is clear that multidisciplinary care that provides comprehensive and coordinated evaluation and treatment is the most effective way to manage patients with pancreatic cancer.
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Affiliation(s)
- Christopher L Wolfgang
- Associate Professor, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Associate Professor, Department of Oncology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD; Associate Professor, Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD
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31
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Egorov VI, Petrov RV, Solodinina EN, Karmazanovsky GG, Starostina NS, Kuruschkina NA. Computed tomography-based diagnostics might be insufficient in the determination of pancreatic cancer unresectability. World J Gastrointest Surg 2013; 5:83-96. [PMID: 23717744 PMCID: PMC3664295 DOI: 10.4240/wjgs.v5.i4.83] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 12/15/2012] [Accepted: 03/01/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To inquire into a question of an overestimation of arterial involvement in patients with pancreatic cancer (PC).
METHODS: Radiology data were compared with the findings from 51 standard, 58 extended and 17 total pancreaticoduodenectomies; 9 distal resections with celiac artery (CA) excision; and 28 palliations for PC. The survival of 11 patients with controversial computed tomography (CT) and endoscopic ultrasound data with regard to arterial invasion, after R0/R1 procedures (false-positive CT results, Group A), was compared to survival after eight R2 resections (false-negative CT results, Group B) and after 12 bypass procedures for locally advanced cancer (true-positive CT results, Group C).
RESULTS: In all of the cases in group A, operative exploration revealed no arterial invasion, which was predicted by CT. The one-year survival in Group A was 88.9%, and the two-year survival was 26.7%, with a median follow-up of 22 mo. One-year survival was not attained in groups B and C, with a significant difference in survival (Pa-b = 0.0029, Pb-c = 0.003).
CONCLUSION: Arterial encasement on CT does not necessarily indicate arterial invasion. Whenever PC is considered unresectable, endoUS should be used. In patients with controversial CT an EUS data for peripancreatic arteries involvement radical resection might be possible, providing survival benefits as compared to R2- resections or palliative surgery.
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32
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Müller SA, Tarantino I, Martin DJ, Schmied BM. Pancreatic surgery: beyond the traditional limits. Recent Results Cancer Res 2013; 196:53-64. [PMID: 23129366 DOI: 10.1007/978-3-642-31629-6_4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Pancreatic cancer is one of the five leading causes of cancer death for both males and females in the western world. More than 85 % pancreatic tumors are of ductal origin but the incidence of cystic tumors such as intrapapillary mucinous tumors (IPMN) or mucinous cystic tumors (MCN) and other rare tumors is rising. Complete surgical resection of the tumor is the mainstay of any curative therapeutic approach, however, up to 40 % of patients with potentially resectable pancreatic cancer are not offered surgery. This is despite 5-year survival rates of up to 40 % or even higher in selected patients depending on tumor stage and histology. Standard procedures for pancreatic tumors include the Kausch-Whipple- or pylorus-preserving Whipple procedure, and the left lateral pancreatic resection (often with splenectomy), and usually include regional lymphadenectomy. More radical or extended pancreatic operations are becoming increasingly utilised however and we examine the data available for their role. These operations include major venous and arterial resection, multivisceral resections and surgery for metastatic disease, or palliative pancreatic resection. Portal vein resection for local infiltration with or without replacement graft is now well established and does not deleteriously affect perioperative morbidity or mortality. Arterial resection, however, though often technically feasible, has questionable oncologic impact, is not without risk and is usually reserved for isolated cases. The value of extended lymphadenectomy is frequently debated; the recent level I evidence demonstrates no advantage. Multivisceral resections, i.e. tumors, often in the tail of the pancreas, with invasion of the colon or stomach or other surrounding tissues, while associated with an increased morbidity and a longer hospital stay, do however show comparable mortality-and survival rates to those without such infiltration and therefore should be performed if technically feasible. Routine resection for metastatic disease however does not seem to show any advantage over palliative treatment but may be an option in selected patients with easily removable metastases. In conclusion pancreatic surgery beyond the traditional limits is established in tumors infiltration the venous system and may be a considered approach in selected patients with locally infiltrating pancreatic cancer or metastasis.
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Affiliation(s)
- Sascha A Müller
- Department of Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
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33
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Egorov VI, Petrov RV, Lozhkin MV, Maynovskaya OA, Starostina NS, Chernaya NR, Filippova EM. Liver blood supply after a modified Appleby procedure in classical and aberrant arterial anatomy. World J Gastrointest Surg 2013; 5:51-61. [PMID: 23556062 PMCID: PMC3615305 DOI: 10.4240/wjgs.v5.i3.51] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 11/02/2012] [Accepted: 12/20/2012] [Indexed: 02/06/2023] Open
Abstract
Reported here are two cases of a modified Appleby operation for borderline resectable ductal adenocarcinoma of the pancreatic body, in one of which a R0 distal resection was attended to by excision, not only of the celiac axis, but also of the common and left hepatic arteries in the presence of arterial anatomic variation Michels, type VIIIb. The possibility and avenues of the maintenance of the blood supply to the left hepatic lobe after surgical aggression of this kind are demonstrated employing computed tomography (CT) and 3-D CT angiography. Furthermore, both cases highlight all important worrisome aspects of pancreatic cancer resectability prediction.
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Affiliation(s)
- Vyacheslav I Egorov
- Vyacheslav I Egorov, Ostroumov 14 City Hospital, Department of Surgical Oncology, Sechenov First State Medical University, 117997 Moscow, Russia
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34
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Mossdorf A, Ulmer T, Kalverkamp S, Neumann U, Heidenhain C. Transposition of the hepatic artery as a salvage procedure for an aortic pseudoaneurysm after liver transplantation. Liver Transpl 2013; 19:105-7. [PMID: 23152169 DOI: 10.1002/lt.23568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 10/13/2012] [Indexed: 01/12/2023]
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35
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Tanaka E, Hirano S, Tsuchikawa T, Kato K, Matsumoto J, Shichinohe T. Important technical remarks on distal pancreatectomy with en-bloc celiac axis resection for locally advanced pancreatic body cancer (with video). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2012; 19:141-7. [PMID: 22076669 DOI: 10.1007/s00534-011-0473-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND We have already reported the feasibility, safety, and excellent long-term results of distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) for locally advanced pancreatic body cancer. An international standard for the surgical technique of DP-CAR has yet to be established. METHODS DP-CAR was carefully performed in 42 patients in Hokkaido University Hospital from 1998 to July 2007. Arterial blood flow alteration and collateral flow development toward the liver and stomach was obtained following preoperative routine transcatheter arterial embolization of the common hepatic artery. The right-sided approach to the superior mesenteric artery and celiac artery, and the preservation of the inferior pancreatoduodenal artery during the dissection of the plexus around the pancreatic head, are the key techniques in DP-CAR. RESULTS The operative morbidity and mortality were 43 and 4.8%, respectively. R0 resection could be done in 39 (93%) patients. Median operation time and intraoperative blood loss were 478 min and 1030 ml, respectively. Ischemic gastropathy was complicated in 5 (12%) patients, but liver abscess was found in only one patient and no liver failure was encountered. CONCLUSIONS We emphasize again the feasibility and safety of DP-CAR; it should be a treatment of choice for locally advanced pancreatic body cancer.
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Affiliation(s)
- Eiichi Tanaka
- Division of Cancer Diagnostics and Therapeutics, Hokkaido University Graduate School of Medicine, Sapporo, 060-8638, Japan.
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36
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Baumgartner JM, Krasinskas A, Daouadi M, Zureikat A, Marsh W, Lee K, Bartlett D, Moser AJ, Zeh HJ. Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic adenocarcinoma following neoadjuvant therapy. J Gastrointest Surg 2012; 16:1152-9. [PMID: 22399269 DOI: 10.1007/s11605-012-1839-0] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 02/02/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Celiac trunk encasement by adenocarcinoma of the pancreatic body is generally regarded as a contraindication for surgical resection. Recent studies have suggested that a subset of stage III patients will succumb to their disease in the absence of distant metastases. We hypothesized that patients with stage III tumors invading the celiac trunk, who are free of distant disease following neoadjuvant therapy, may derive prolonged survival benefit from aggressive surgical resection. METHODS We performed a retrospective review of distal pancreatectomies with en bloc celiac axis resection for pancreatic adenocarcinoma. RESULTS Eleven patients underwent a distal pancreatectomy with en bloc celiac axis resection after completing neoadjuvant chemoradiation therapy. Median operative time was 8 h, 14 min, and median estimated blood loss was 700 ml. Median length of stay was 9 days. Five patients (45%) had postoperative complications; three were Clavien grade I. Four patients (35%) had pancreatic leaks; two were ISGPF grade B, and two were grade A. There were two 90-day perioperative deaths. Ten patients had R0 resections (91%). After a median follow-up of 41 weeks, six patients recurred. Four of the five patients with SMAD4 loss recurred, and two of the five patients with intact SMAD4 recurred. Median disease-free and overall survival were 21 weeks and 26 months, respectively. CONCLUSIONS Resection of pancreatic body adenocarcinoma with celiac axis resection is technically feasible with acceptable perioperative morbidity and mortality.
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Affiliation(s)
- Joel M Baumgartner
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, Pittsburgh, PA 15232, USA
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37
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Takahashi Y, Kaneoka Y, Maeda A, Isogai M. Distal pancreatectomy with celiac axis resection for carcinoma of the body and tail of the pancreas. World J Surg 2012; 35:2535-42. [PMID: 21901326 DOI: 10.1007/s00268-011-1245-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND We retrospectively investigated our experiences with distal pancreatectomy with celiac axis resection (DP-CAR) for locally advanced pancreatic cancer and compared the operative outcome and long-term survival between DP-CAR and standard distal pancreatectomy (DP). Although several authors reported that DP-CAR increases resectability rates, the long-term results of this operation are not clear, and there are few reports presenting a comparison of the short- and long-term results between DP-CAR and DP. METHODS From 1993 to 2010, 43 patients with invasive ductal carcinoma of the body or tail of the pancreas underwent a macroscopically curative resection (R0/1). Sixteen patients underwent DP-CAR and 27 patients underwent DP. No DP-CAR patients underwent any preoperative coil embolization of the common hepatic artery (CHA) to stimulate the development of collateral pathways from the superior mesenteric artery. The perioperative and histopathologic parameters and survival data were analyzed to compare the two operations. RESULTS There was no difference in mean operative time, mean blood loss, postoperative mortality, and morbidity between DP-CAR and DP. The rates of morbidity and in-hospital mortality of DP-CAR were 56 and 6%, respectively. In DP-CAR, 15 patients did not require reconstruction of the hepatic artery and no hepatic infarctions were clinically encountered after surgery. The estimated overall 1- and 3-year survival rates in patients who underwent DP-CAR were 42.6 and 25.6%, respectively, and their survival time was significantly less than that of patients who underwent DP (median survival time: 9.7 vs. 30.9 months, P = 0.033). The R1 resection rates of these groups were 44% in DP-CAR and 22% in DP, respectively. CONCLUSION DP-CAR is a safe and rational procedure for locally advanced pancreatic cancer without preoperative embolization of the CHA. Although the short-term results were equivalent to that for DP, DP-CAR did not improve the long-term survival because of the high rate of R1 resection at present.
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Affiliation(s)
- Yu Takahashi
- Department of Surgery, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, 503-8502, Japan
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38
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Zakharova OP, Karmazanovsky GG, Egorov VI. Pancreatic adenocarcinoma: Outstanding problems. World J Gastrointest Surg 2012; 4:104-13. [PMID: 22655124 PMCID: PMC3364335 DOI: 10.4240/wjgs.v4.i5.104] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 05/10/2012] [Accepted: 05/18/2012] [Indexed: 02/06/2023] Open
Abstract
Pancreatic adenocarcinoma remains the fourth leading cause of cancer-related death and is one of the most aggressive malignant tumors with an overall 5-year survival rate of less than 4%. Surgical resection remains the only potentially curative treatment but is only possible for 15%-20% of patients with pancreatic adenocarcinoma. About 40% of patients have locally advanced nonresectable disease. In the past, determination of pancreatic cancer resectability was made at surgical exploration. The development of modern imaging techniques has allowed preoperative staging of patients. Institutions disagree about the criteria used to classify patients. Vascular invasion in pancreatic cancers plays a very important role in determining treatment and prognosis. There is no evidence-based consensus on the optimal preoperative imaging assessment of patients with suspected pancreatic cancer and a unified definition of borderline resectable pancreatic cancer is also lacking. Thus, there is much room for improvement in all aspects of treatment for pancreatic cancer. Multi-detector computed tomography has been widely accepted as the imaging technique of choice for diagnosing and staging pancreatic cancer. With improved surgical techniques and advanced perioperative management, vascular resection and reconstruction are performed more frequently; patients thought once to be unresectable are undergoing radical surgery. However, when attempting heroic surgery, a realistic approach concerning the patient’s age and health status, probability of recovery after surgery, perioperative morbidity and mortality and life quality after tumor resection is necessary.
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Affiliation(s)
- Olga P Zakharova
- Olga P Zakharova, Grigory G Karmazanovsky, Department of Radiology, Vishnevsky Institute of Surgery, 117997 Moscow, Russia
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39
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Takasaka I, Kawai N, Sato M, Tanihata H, Sonomura T, Minamiguchi H, Nakai M, Ikoma A, Nakata K, Sanda H. Preoperative microcoil embolization of the common hepatic artery for pancreatic body cancer. World J Gastroenterol 2012; 18:1940-5. [PMID: 22563175 PMCID: PMC3337570 DOI: 10.3748/wjg.v18.i16.1940] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 12/20/2011] [Accepted: 03/10/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate safety and feasibility of microcoil embolization of the common hepatic artery under proper or distal balloon inflation in preoperative preparation for en bloc celiac axis resection for pancreatic body cancer.
METHODS: Fifteen patients (11 males, 4 females; median age, 67 years) with pancreatic body cancer involving the nerve plexus surrounding the celiac artery underwent microcoil embolization. To alter the total hepatic blood flow from superior mesenteric artery (SMA), microcoil embolization of the common hepatic artery (CHA) was conducted in 2 cases under balloon inflation at the proximal end of the CHA and in 13 cases under distal microballoon inflation at the distal end of the CHA.
RESULTS: Of the first two cases of microcoil embolization with proximal balloon inflation, the first was successful, but there was microcoil migration to the proper hepatic artery in the second. The migrated microcoil was withdrawn to the CHA by an inflated microballoon catheter. Microcoil embolization was successful in the other 13 cases with distal microballoon inflation, with no microcoil migration. Compact microcoil embolization under distal microballoon inflation created sufficient resistance against the vascular wall to prevent migration. Distal balloon inflation achieved the requisite 1 cm patency at the CHA end for vascular clamping. All patients underwent en bloc celiac axis resection without arterial reconstruction or liver ischemia.
CONCLUSION: To impede microcoil migration to the proper hepatic artery during CHA microcoil embolization, distal microballoon inflation is preferable to proximal balloon inflation.
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40
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Alizai PH, Mahnken AH, Klink CD, Neumann UP, Junge K. Extended distal pancreatectomy with en bloc resection of the celiac axis for locally advanced pancreatic cancer: a case report and review of the literature. Case Rep Med 2012; 2012:543167. [PMID: 22567019 PMCID: PMC3332186 DOI: 10.1155/2012/543167] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 01/23/2012] [Accepted: 01/24/2012] [Indexed: 01/12/2023] Open
Abstract
Due to a lack of early symptoms, pancreatic cancers of the body and tail are discovered mostly at advanced stages. These locally advanced cancers often involve the celiac axis or the common hepatic artery and are therefore declared unresectable. The extended distal pancreatectomy with en bloc resection of the celiac artery may offer a chance of complete resection. We present the case of a 48-year-old female with pancreatic body cancer invading the celiac axis. The patient underwent laparoscopy to exclude hepatic and peritoneal metastasis. Subsequently, a selective embolization of the common hepatic artery was performed to enlarge arterial flow to the hepatobiliary system and the stomach via the pancreatoduodenal arcades from the superior mesenteric artery. Fifteen days after embolization, the extended distal pancreatectomy with splenectomy and en bloc resection of the celiac axis was carried out. The postoperative course was uneventful, and complete tumor resection was achieved. This case report and a review of the literature show the feasibility and safety of the extended distal pancreatectomy with en bloc resection of the celiac axis. A preoperative embolization of the celiac axis may avoid ischemia-related complications of the stomach or the liver.
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Affiliation(s)
- Patrick H. Alizai
- Department of General, Visceral and Transplantat Surgery, University Hospital of the RWTH Aachen, Pauwelsstr 30, 52074 Aachen, Germany
| | - Andreas H. Mahnken
- Department of Diagnostic and Interventional Radiology, University Hospital of the RWTH Aachen, Pauwelsstr 30, 52074 Aachen, Germany
| | - Christian D. Klink
- Department of General, Visceral and Transplantat Surgery, University Hospital of the RWTH Aachen, Pauwelsstr 30, 52074 Aachen, Germany
| | - Ulf P. Neumann
- Department of General, Visceral and Transplantat Surgery, University Hospital of the RWTH Aachen, Pauwelsstr 30, 52074 Aachen, Germany
| | - Karsten Junge
- Department of General, Visceral and Transplantat Surgery, University Hospital of the RWTH Aachen, Pauwelsstr 30, 52074 Aachen, Germany
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Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis. Ann Surg 2012; 254:882-93. [PMID: 22064622 DOI: 10.1097/sla.0b013e31823ac299] [Citation(s) in RCA: 328] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The majority of pancreatic cancers are diagnosed at an advanced stage. As surgical resection remains the only hope for cure, more aggressive surgical approaches have been advocated to increase resection rates. Institutions have begun to release data on their experience with pancreatectomy and simultaneous arterial resection (AR), which has traditionally been considered a general contraindication to resection. The aim of the present meta-analysis was to evaluate the perioperative and long-term outcomes of patients with AR during pancreatectomy for pancreatic cancer. METHODS The Medline, Embase, and Cochrane Library and J-East databases were systematically searched to identify studies reporting outcome of patients who underwent pancreatectomy with AR for pancreatic cancer. Studies that reported perioperative and/or long-term results after pancreatectomy with AR were eligible for inclusion. Meta-analyses included comparative studies providing data on patients with and without AR and were performed using a random effects model. RESULTS The literature search identified 26 studies including 366 and 2243 patients who underwent pancreatectomy with and without AR. All studies were retrospective cohort studies and the methodological quality was moderate to low. Meta-analyses revealed AR to be associated with a significantly increased risk for perioperative mortality [Odds ratio (OR) = 5.04; 95% confidence interval (CI), 2.69-9.45; P < 0.0001; I² = 24%], poor survival at 1 year (OR = 0.49; 95% CI, 0.31-0.78; P = 0.002; I² = 35%) and 3 years (OR = 0.39; 95% CI, 0.17-0.86; P = 0.02; I² = 49%) compared with patients without AR. The increased perioperative mortality (OR = 8.87; 95% CI, 3.40-23.13; P < 0.0001; I² = 5%) and lower survival rate at 1 year (OR = 0.50; 95% CI, 0.31-0.82; P = 0.006; I² = 40%) was confirmed in the comparison to patients undergoing venous resection. Despite substantial perioperative mortality, pancreatectomy with AR was associated with more favorable survival compared with patients who did not undergo resection for locally advanced disease. CONCLUSIONS AR in patients undergoing pancreatectomy for pancreatic cancer is associated with a poor short and long-term outcome. Pancreatectomy with AR may, however, be justified in highly selected patients owing to the potential survival benefit compared with patients without resection. These patients should be treated within the bounds of clinical trials to assess outcomes after AR in the era of modern pancreatic surgery and multimodal therapy.
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Abstract
OBJECTIVES Limited involvement of the major peripancreatic vessels is no longer considered a contraindication for resection in cases of locally advanced pancreatic cancer. Extended open pancreatectomies associated with vascular resection are performed in experienced centers with mortality and morbidity rates comparable to standard pancreatic resection. We evaluate the safety, feasibility, and outcomes of robotic extended pancreatectomy with vascular resection. METHODS We reviewed data of 5 patients with a median age of 60 years (range, 52-74 years) who underwent robotic surgery for pancreatic tumors with vascular involvement between May 2007 and March 2010 at our institution. The types of resection included 2 left-sided splenopancreatectomy with celiac axis resection, 1 left-sided splenopancreatectomy with portal vein resection, and 2 pancreaticoduodenectomy with portal vein resection. RESULTS No conversions occurred. The overall mean operating time was 392 ± 66 minutes (range, 310-460 min). The overall mean blood loss was 200 ± 61 mL (range, 150-300 mL) with no transfusions. No mortalities occurred. At a median follow-up of 6 months (range, 3-20 months), 4 patients were alive and disease free. CONCLUSIONS This early series by a single surgeon supports the feasibility and safety of robotic pancreatectomy with vascular resection for selected patients with locally advanced pancreatic tumor.
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Baiocchi G, Portolani N, Gheza F, Giulini SM. Collagen-based biological glue after Appleby operation for advanced gastric cancer. World J Gastroenterol 2011; 17:4044-7. [PMID: 22046095 PMCID: PMC3199565 DOI: 10.3748/wjg.v17.i35.4044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Revised: 02/10/2011] [Accepted: 02/17/2011] [Indexed: 02/06/2023] Open
Abstract
Pancreatic fistula is a common complication of distal pancreatectomy; although various surgical procedures have been proposed, no clear advantage is evident for a single technique. We herein report the case of a 38-year-old patient affected by an advanced gastric carcinoma infiltrating the pancreas body, with extensive nodal metastases involving the celiac trunk, who underwent total gastrectomy with lymphadenectomy, distal pancreatectomy and resection en bloc of the celiac trunk (Appleby operation). At the end of the demolitive phase, the pancreatic stump and the aorta at the level of the celiac ligature were covered with a layer of Tachosil®, a horse collagen sponge made with human coagulation factors (fibrinogen and thrombin). Presenting this case, we wish to highlight the possible sealing effect of this product and hypothesize a role in preventing pancreatic fistula and postoperative lymphorrhagia from extensive nodal dissection.
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Bachellier P, Rosso E, Lucescu I, Oussoultzoglou E, Tracey J, Pessaux P, Ferreira N, Jaeck D. Is the need for an arterial resection a contraindication to pancreatic resection for locally advanced pancreatic adenocarcinoma? A case-matched controlled study. J Surg Oncol 2011; 103:75-84. [PMID: 21105000 DOI: 10.1002/jso.21769] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Arterial resection (AR) has traditionally been considered as a contraindication to pancreatic resection for locally advanced pancreatic adenocarcinoma. The objective was to evaluate if pancreatic resection with AR was worthwhile. METHODS Between January 1990 and December 2008 the records of 26 consecutive patients who underwent a curative-intent pancreatic resection for adenocarcinoma of the pancreas with AR (AR+ group) were matched 1:1 to those of the whole series of pancreatic resection performed in our institution. The final study population (n = 52) included two groups of patients: the study group AR+ = 26 and the control group AR- = 26. RESULTS The 1- and 3-year survival rates were similar in the two groups (65.9% and 22.1%, median 17 months for the group AR + , versus 50.0% and 17.6%, median 12 months, for the group AR-; P = 0.581). The multivariate analysis showed that: arterial wall invasion at the site of AR, the total number of resected lymph nodes of ≤15, and perineural invasion were independent prognostic factors for survival. CONCLUSION Pancreatic resections with AR for adenocarcinoma allowed to obtain a 3-survival rate similar to that of a matched group of patients not requiring AR.
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Affiliation(s)
- Philippe Bachellier
- Centre de Chirurgie Viscérale et de Transplantation, Hôpitaux Universitaires de Strasbourg, CHU Hautepierre, Strasbourg Cedex, France.
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Distal pancreatectomy with en bloc resection of the celiac trunk for extended pancreatic tumor disease: an interdisciplinary approach. Cardiovasc Intervent Radiol 2010; 34:1058-64. [PMID: 20936285 DOI: 10.1007/s00270-010-9997-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Accepted: 09/09/2010] [Indexed: 01/11/2023]
Abstract
PURPOSE Infiltration of the celiac trunk by adenocarcinoma of the pancreatic body has been considered a contraindication for surgical treatment, thus resulting in a very poor prognosis. The concept of distal pancreatectomy with resection of the celiac trunk offers a curative treatment option but implies the risk of relevant hepatic or gastric ischemia. We describe initial experiences in a small series of patients with left celiacopancreatectomy with or without angiographic preconditioning of arterial blood flow to the stomach and the liver. MATERIALS AND METHODS Between January 2007 and October 2009, six patients underwent simultaneous resection of the celiac trunk for adenocarcinoma of the pancreatic body involving the celiac axis. In four of these cases, angiographic occlusion of the celiac trunk before surgery was performed to enhance collateral flow from the gastroduodenal artery. Radiologic and surgical procedures, findings, and outcome were analyzed retrospectively. RESULTS Complete tumor removal (R0) succeeded in two patients, whereas four patients underwent R1-tumor resection. After surgery, one of the two patients without angiographic preparation experienced an ischemic stomach perforation 1 week after surgery. The other patient died from severe bleeding from an ischemic gastric ulcer. Of the four patients with celiac trunk embolization, none presented ischemic complications after surgery. Mean survival was 371 days. CONCLUSION In this small series, ischemic complications after celiacopancreatectomy occurred only in those patients who did not receive preoperative celiac trunk embolization.
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Distal pancreatectomy with en bloc celiac axis resection after neoadjuvant therapy for locally advanced pancreatic adenocarcinoma. Pancreas 2010; 39:1111-3. [PMID: 20861699 DOI: 10.1097/mpa.0b013e3181df2754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Sperti C, Berselli M, Pedrazzoli S. Distal pancreatectomy for body-tail pancreatic cancer: is there a role for celiac axis resection? Pancreatology 2010; 10:491-8. [PMID: 20720451 DOI: 10.1159/000276984] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Accepted: 01/06/2010] [Indexed: 02/05/2023]
Abstract
BACKGROUND/AIMS Body-tail pancreatic cancer is an aggressive disease with a low resectability rate and a poor prognosis. Celiac axis invasion usually contraindicates resection. The aim of this study was to analyze the feasibility of distal pancreatectomy (DP) with celiac axis resection (DP-CAR) for locally advanced body-tail pancreatic cancer. METHODS All DPs performed between January 1989 and December 2007 were considered. DP and DP-CAR were reviewed for pre-, intra- and postoperative data. An extensive, detailed literature review on DP and DP-CAR was also performed. RESULTS DP was performed in 49 of our patients, and 745 cases were retrieved from the literature. The overall morbidity and mortality rates were 32.0 and 3.0%, respectively. We performed DP-CAR in 5 patients with no mortality but 80% morbidity. A further 90 patients were retrieved from the literature. Arterial reconstruction was needed in 1/5 of our patients and in 13/90 of patients in the literature. Collaterals from superior mesenteric artery maintained adequate hepatic artery blood flow in the remaining 81 patients. The overall morbidity and mortality rates were 40.6 and 2.1%, respectively. The median survival ranged between 4.5 and 25 months after DP and was 13 months after DP-CAR. CONCLUSIONS DP-CAR improves resectability without increasing the mortality rate. The complication rate after DP-CAR was higher than after DP, but still within the range of extended DP. DP-CAR should be considered for the inclusion among the 'extended' procedures for the treatment of body-tail pancreatic cancers invading the celiac axis. and IAP.
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Affiliation(s)
- Cosimo Sperti
- IV Surgical Clinic, Department of Medical and Surgical Sciences, University of Padua, Padua, Italy
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48
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Andreou A, Glanemann M, Guckelberger O, Denecke T, Grieser C, Podrabsky P, Neuhaus P. [Distal pancreatectomy with splenectomy and en bloc resection of the celiac trunk for locally advanced cancer of the pancreatic body with infiltration of the celiac trunk]. ACTA ACUST UNITED AC 2010; 105:227-31. [PMID: 20455038 DOI: 10.1007/s00063-010-1031-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Locally advanced cancer of the body of the pancreas with infiltration of the celiac trunk and its branches is often considered an unresectable disease. Distal pancreatectomy with resection of the celiac trunk was described as a new concept for the curative treatment of these tumors. CASE REPORT The case of a 61-year-old female patient is reported, who underwent distal pancreatectomy with splenectomy and resection of the celiac trunk for locally advanced cancer of the pancreatic body with infiltration of the celiac trunk. The celiac trunk was embolized preoperatively in order to assure arterial perfusion of the liver. CONCLUSION Distal pancreatectomy with en bloc resection of the celiac trunk offers a high resectability rate and thus a curative option for locally advanced cancer of the pancreatic body with vascular invasion. The optimization of patient selection and the development of effective adjuvant chemotherapy could significantly improve the survival of patients subjected to this operation.
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Affiliation(s)
- Andreas Andreou
- Klinik für Allgemein-, Visceral- und Transplantationschirurgie, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany.
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Barreto SG, Shukla PJ, Shrikhande SV. Tumors of the Pancreatic Body and Tail. World J Oncol 2010; 1:52-65. [PMID: 29147182 PMCID: PMC5649906 DOI: 10.4021/wjon2010.04.200w] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2010] [Indexed: 12/11/2022] Open
Abstract
Tumors of the pancreatic body and tail are uncommon. They have a propensity to present late and often attain a large size with local invasion before they produce any clinical symptoms. The current review aims at comprehensively analysing these tumors with respect to their pathology, presentation, the investigation of these tumors, and finally the latest trends in their surgical and medical management.
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Affiliation(s)
- Savio George Barreto
- Department of General and Digestive Surgery, Flinders Medical Centre, Adelaide - South Australia
| | - Parul J Shukla
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shailesh V Shrikhande
- Department of Gastrointestinal Surgical Oncology, Tata Memorial Hospital, Mumbai, India
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50
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Shrikhande SV, Barreto SG. Extended pancreatic resections and lymphadenectomy: An appraisal of the current evidence. World J Gastrointest Surg 2010; 2:39-46. [PMID: 21160848 PMCID: PMC2999214 DOI: 10.4240/wjgs.v2.i2.39] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 12/11/2009] [Accepted: 12/18/2009] [Indexed: 02/06/2023] Open
Abstract
Surgery remains the mainstay of treatment for pancreatic ductal adenocarcinoma and complete removal of the cancer confers a definite survival advantage, especially in early disease. However, the majority of patients do not present with early disease, thus precluding the chance of a cure by standard pancreatoduodenectomy (PD), distal pancreatectomy or total pancreatectomy. For this reason, pancreatic surgeons have attempted to push the limits of resection over the last three decades. The aim of these resections has been to determine whether obtaining a complete resection by extending the limits of conventional resection in patients with advanced disease will yield the results seen with PD alone in early disease. This article revisits the data from such studies in an attempt to determine if the available literature supports the performance of extended resections for pancreatic cancer in terms of improvement of survival.
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Affiliation(s)
- Shailesh V Shrikhande
- Shailesh V Shrikhande, Department of Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Mumbai 400 012, India
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