|
1
|
Seufferlein T, Mayerle J, Boeck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie Exokrines Pankreaskarzinom – Version 3.1. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1724-1785. [PMID: 39389105 DOI: 10.1055/a-2338-3716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Affiliation(s)
| | | | | | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Gastroenterologie und Endokrinologie Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik und Poliklinik für Allgemein-, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Medizinische Klinik und Poliklinik II Onkologie und Hämatologie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
| |
Collapse
|
|
2
|
Seufferlein T, Mayerle J, Boeck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie Exokrines Pankreaskarzinom – Version 3.1. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:874-995. [PMID: 39389103 DOI: 10.1055/a-2338-3533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Affiliation(s)
| | | | | | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Gastroenterologie und Endokrinologie Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik und Poliklinik für Allgemein-, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Medizinische Klinik und Poliklinik II Onkologie und Hämatologie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
| |
Collapse
|
|
3
|
Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
| |
Collapse
|
|
4
|
Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Kurzversion 2.0 – Dezember 2021, AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:991-1037. [PMID: 35671996 DOI: 10.1055/a-1771-6811] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
| |
Collapse
|
|
5
|
Brunner M, Krautz C, Weber GF, Grützmann R. [Better Therapy for Pancreatic Cancer through More Radical Surgery?]. Zentralbl Chir 2022; 147:173-187. [PMID: 35378558 DOI: 10.1055/a-1766-7643] [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: 02/07/2023]
Abstract
Despite advances in the treatment of pancreatic cancer, the survival of affected patients remains limited. A more radical surgical therapy could help to improve the prognosis, in particular by reducing the local recurrence rate, which is around 45% in patients with resected pancreatic cancer. In addition, patients with oligometastatic pancreatic cancer could also benefit from a more radical indication for surgery.Based on an analysis of the literature, important principles of pancreatic cancer surgery were examined.Even if even more radical surgical approaches such as an "extended" lymphadenectomy or a standard complete pancreatectomy do not bring any survival advantage, complete resection of the tumour (R0), a thorough locoregional lymphadenectomy and an adequate radical dissection in the area of the peripancreatic vessels including periarterial nerve plexuses should be the standard of pancreatic carcinoma resections. Whenever necessary to achieve an R0 resection, resections of the pancreas have to be extended, as well as additional venous vascular resections and multivisceral resections had to be performed. Simultaneous arterial vascular resections as part of pancreatic resections as well as surgical resections in oligometastatic patients should, however, be reserved for selected patients. These aspects of the surgical technique in pancreatic carcinoma mentioned above must not be neglected from the point of view of an "existing limited prognosis". On the contrary, they form the absolutely necessary basis in order to achieve good survival results in combination with system therapy. However, it may always be necessary to adapt these standards according to the age, comorbidities and wishes of the patient.
Collapse
Affiliation(s)
- Maximilian Brunner
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - Christian Krautz
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - Georg F Weber
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Erlangen, Deutschland
| | - Robert Grützmann
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Erlangen, Erlangen, Deutschland
| |
Collapse
|
|
6
|
Habib JR, Kinny-Köster B, van Oosten F, Javed AA, Cameron JL, Lafaro KJ, Burkhart RA, Burns WR, He J, Thompson ED, Fishman EK, Wolfgang CL. Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: Surgical planning with the "halo sign" and "string sign". Surgery 2020; 169:1026-1031. [PMID: 33036782 DOI: 10.1016/j.surg.2020.08.031] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/11/2020] [Indexed: 12/23/2022]
Abstract
Most patients diagnosed with pancreatic cancer are classified as nonoperative candidates based on the contemporary guidelines of resectability. The advent of more potent control of systemic disease using neoadjuvant chemotherapy has enabled more aggressive operative interventions. In our multidisciplinary practice, patients with Stage III, locally advanced pancreatic cancer and superior mesenteric artery (SMA) encasement are now carefully triaged with high quality, preoperative imaging to determine if they can be considered candidates for operative resection with periadventitial dissection of the SMA. Patients displaying a "halo sign," where the encased SMA remains fully patent and free from arterial invasion, are now candidates for SMA periadventitial dissection. This procedure involves the surgical stripping of the infiltrated neurolymphatic tissue off the SMA leaving behind a bare "skeletonized artery." Alternatively, the "string sign" involving the SMA confers a more likely case of arterial invasion, where a complete oncologic resection cannot be achieved successfully. This method of patient selection in case of SMA involvement abandons the traditional metrics of circumferential degrees of the arterial encasement to guide surgical decisions. Our institutional approach has allowed us to meaningfully expand our operative methods of resection with the potential for improved longitudinal outcomes to pancreatic cancer patients who were deprived historically from the more effective and possibly curative treatment.
Collapse
Affiliation(s)
- Joseph R Habib
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Floortje van Oosten
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ammar A Javed
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John L Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kelly J Lafaro
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Richard A Burkhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William R Burns
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elizabeth D Thompson
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elliot K Fishman
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | | |
Collapse
|
|
7
|
R0 Versus R1 Resection Matters after Pancreaticoduodenectomy, and Less after Distal or Total Pancreatectomy for Pancreatic Cancer. Ann Surg 2019; 268:1058-1068. [PMID: 28692477 DOI: 10.1097/sla.0000000000002345] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to decipher the true importance of R0 versus R1 resection for survival in pancreatic ductal adenocarcinoma (PDAC). SUMMARY OF BACKGROUND DATA PDAC is characterized by poor survival, even after curative resection. In many studies, R0 versus R1 does not result in different prognosis and does not affect the postoperative management. METHODS Pubmed, Embase, and Cochrane databases were screened for prognostic studies on the association between resection status and survival. Hazard ratios (HRs) were pooled in a meta-analysis. Furthermore, our prospective database was retrospectively screened for curative PDAC resections according to inclusion criteria (n = 254 patients) between July 2007 and October 2014. RESULTS In the meta-analysis, R1 was associated with a decreased overall survival [HR 1.45 (95% confidence interval, 95% CI 1.37-1.52)] and disease-free survival [HR 1.44 (1.30-1.59)] in PDAC when compared with R0. Importantly, this effect held true only for pancreatic head resection both in the meta-analysis [R0 ≥0 mm: HR 1.21 (1.05-1.39) vs R0 ≥1 mm: HR 1.66 (1.46-1.89)] and in our cohort (R0 ≥0 mm: 31.8 vs 14.5 months, P < 0.001; R0 ≥1 mm, 41.2 vs 16.8 months; P < 0.001). Moreover, R1 resections were associated with advanced tumor disease, that is, larger tumor size, lymph node metastases, and extended resections. Multivariable Cox proportional hazard model suggested G3, pN1, tumor size, and R1 (0 mm/1 mm) as independent predictors of overall survival. CONCLUSION Resection margin is not a valid prognostic marker in publications before 2010 due to heterogeneity of cohorts and lack of standardized histopathological examination. Within standardized pathology protocols, R-status' prognostic validity may be primarily confined to pancreatic head cancers.
Collapse
|
|
8
|
Miyasaka Y, Ohtsuka T, Velasquez VV, Mori Y, Nakata K, Nakamura M. Surgical management of the cases with both biliary and duodenal obstruction. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2018. [DOI: 10.18528/gii80015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Yoshihiro Miyasaka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takao Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Vittoria Vanessa Velasquez
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhisa Mori
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| |
Collapse
|
|
9
|
Mullan D, Uberoi R. The obstructed afferent loop: Percutaneous options. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii160019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Damian Mullan
- Department of Interventional Radiology, The Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Raman Uberoi
- Department of Interventional Radiology, Oxford University Hospitals NHS Trust, Oxford, UK
| |
Collapse
|
|
10
|
Elberm H, Ravikumar R, Sabin C, Abu Hilal M, Al-Hilli A, Aroori S, Bond-Smith G, Bramhall S, Coldham C, Hammond J, Hutchins R, Imber C, Preziosi G, Saleh A, Silva M, Simpson J, Spoletini G, Stell D, Terrace J, White S, Wigmore S, Fusai G. Outcome after pancreaticoduodenectomy for T3 adenocarcinoma: A multivariable analysis from the UK Vascular Resection for Pancreatic Cancer Study Group. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2015; 41:1500-1507. [PMID: 26346183 DOI: 10.1016/j.ejso.2015.08.158] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 07/30/2015] [Accepted: 08/04/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Most resectable pancreatic cancers are classified as T3, including those involving the porto-mesenteric vein. Survival and perioperative morbidity for venous resection have been found to be comparable to standard resection. We investigate factors associated with short and long term outcomes in pancreaticoduodenectomy with (PDVR) and without (PD) venous resection exclusively for T3 adenocarcinoma of the head of the pancreas. METHODS This is a UK multicenter retrospective cohort study assessing outcomes in patients undergoing PD and PDVR. All consecutive patients with T3 only adenocarcinoma of the head of the pancreas undergoing surgery between December 1998 and June 2011 were included. Multivariable logistic and proportional hazards regression analyses were performed to determine the association between the surgical groups and in-hospital mortality (IHM) and overall survival (OS). RESULTS 1070 patients were included of whom 840 (78.5%) had PD and 230 (21.5%) had PDVR. Factors independently associated with IHM were a high creatinine (aHR 1.14, p = 0.02), post-operative bleeding (aHR 2.86, p = 0.04) and a re-laparotomy (aHR 8.42, p = 0.0001). For OS, multivariable analyses identified R1 resection margin status (aHR 1.22, p = 0.01), N1 nodal status (aHR 1.92, p = 0.0001), perineural invasion (aHR 1.37, p = 0.002), tumour size >20mm (aHR 0.63, p = 0.0001) and a relaparotomy (aHR 1.84, p = 0.0001) to be independently associated with overall mortality. CONCLUSION This study on T3 adenocarcinoma of the head of the pancreas suggests that IHM is strongly associated with perioperative complications whilst OS is affected by histological parameters. Detailed pre-operative disease evaluation and advances in oncological treatment have the potential to improve OS.
Collapse
Affiliation(s)
- H Elberm
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, UK.
| | - R Ravikumar
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - C Sabin
- Research Department of Infection and Population Health, UCL, Royal Free Campus, UK
| | - M Abu Hilal
- Department of HPB Surgery, Southampton General Hospital, Southampton, UK
| | - A Al-Hilli
- Department of HPB Surgery, Southampton General Hospital, Southampton, UK
| | - S Aroori
- Department of HPB Surgery, Plymouth Hospitals, Plymouth, UK
| | - G Bond-Smith
- Department of HPB Surgery, Royal London Hospital, London, UK
| | - S Bramhall
- Liver Unit, University Hospital Birmingham, Birmingham, UK
| | - C Coldham
- Liver Unit, University Hospital Birmingham, Birmingham, UK
| | - J Hammond
- Department of HPB, Nottingham University Hospitals, UK
| | - R Hutchins
- Department of HPB Surgery, Royal London Hospital, London, UK
| | - C Imber
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - G Preziosi
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - A Saleh
- Department of HPB and Transplantation, Freeman Hospital, Newcastle, UK
| | - M Silva
- Department of HPB Surgery, Churchill Hospital, Oxford, UK
| | - J Simpson
- Department of HPB, Nottingham University Hospitals, UK
| | - G Spoletini
- Department of HPB Surgery, Churchill Hospital, Oxford, UK
| | - D Stell
- Department of HPB Surgery, Plymouth Hospitals, Plymouth, UK
| | - J Terrace
- Department of HPB and Liver Transplant Surgery, Royal Infirmary of Edinburgh, UK
| | - S White
- Department of HPB and Transplantation, Freeman Hospital, Newcastle, UK
| | - S Wigmore
- Department of HPB and Liver Transplant Surgery, Royal Infirmary of Edinburgh, UK
| | - G Fusai
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, UK
| |
Collapse
|
|
11
|
Pandanaboyana S, Bell R, Windsor J. Artery first approach to pancreatoduodenectomy: current status. ANZ J Surg 2015; 86:127-32. [PMID: 26246127 DOI: 10.1111/ans.13249] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The need for an early determination of resectability and before an irreversible step is taken during pancreatoduodenectomy promoted the development of an 'artery first approach' (AFA). The aim of this study was to review the current evidence related to this approach, with particular reference to margins and survival. METHODS An electronic search was performed in MEDLINE, EMBASE and PubMed databases from 1960 to 2015 using both subject headings (MeSH) and truncated word searches to identify all published related articles to this topic. RESULTS Six different AFAs have been published. Four studies evaluated the impact of AFA on perioperative outcomes and survival. Three studies showed no difference in the perioperative outcomes, margin status, lymph node yield and survival while one study showed improved margin status and survival comparing AFA with standard resection. CONCLUSION The current evidence regarding the benefits of AFA in relation to decreasing margin positivity or increasing survival is sparse. Further larger studies and randomized controlled trails are needed to ascertain the benefits of AFA.
Collapse
Affiliation(s)
- Sanjay Pandanaboyana
- HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Richard Bell
- Department of Hepatobiliary and Pancreatic Surgery, St James Hospital, Leeds, UK
| | - John Windsor
- HBP/Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
|
12
|
Habermehl D, Brecht IC, Bergmann F, Rieken S, Werner J, Büchler MW, Springfeld C, Jäger D, Debus J, Combs SE. Adjuvant radiotherapy and chemoradiation with gemcitabine after R1 resection in patients with pancreatic adenocarcinoma. World J Surg Oncol 2015; 13:149. [PMID: 25889749 PMCID: PMC4404664 DOI: 10.1186/s12957-015-0560-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 03/23/2015] [Indexed: 02/07/2023] Open
Abstract
Background The purpose of the study was to evaluate the effect of radiation therapy and chemoradiation with gemcitabine (GEM) after R1 resection in patients with pancreatic adenocarcinoma (PAC). Methods We performed a retrospective analysis of 25 patients who were treated with postoperative radiotherapy (RT) or chemoradiation (CRT) after surgery with microscopically positive resection margins for primary pancreatic cancer (PAC). Median age was 60 years (range 34 to 74 years), and there were 17 male and 8 female patients. Fractionated RT was applied with a median dose of 49.6 Gy (range 36 to 54 Gy). Eight patients received additional intraoperative radiotherapy (IORT) with a median dose of 12 Gy. Results Median overall survival (mOS) of all treated patients was 22 months (95% confidence interval (CI) 7.9 to 36.1 months) after date of resection and 21.1 months (95% CI 7.6 to 34.6 months) after start of (C)RT. Median progression-free survival (mPFS) was 13.0 months (95% CI 0.93 to 25 months). Grading (G2 vs. G3, P = 0.005) and gender (female vs. male, P = 0.01) were significantly correlated with OS. There was a significant difference in mPFS between male and female patients (P = 0.008). A total of 11 from 25 patients experienced local tumour progression, and 19 patients were diagnosed with either locoregional or distant failure. Conclusions We demonstrated that GEM-based CRT can be applied in analogy to neoadjuvant protocols in the adjuvant setting for PAC patients at high risk for disease recurrence after incomplete resection. Patients undergoing additive CRT have a rather good OS and PFS compared to historical control patient groups.
Collapse
Affiliation(s)
- Daniel Habermehl
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Ingo C Brecht
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Frank Bergmann
- Institute of Pathology, University of Heidelberg, Im Neuenheimer Feld 220/221, 69120, Heidelberg, Germany.
| | - Stefan Rieken
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Jens Werner
- Department of Visceral Surgery, Klinikum der Universität München (LMU), Marchioninistraße 15, 81377, Munich, Germany.
| | - Markus W Büchler
- Department of Visceral Surgery, University Hospital of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
| | - Christoph Springfeld
- National Center for Tumor Diseases, Medical Oncology, University Hospital Heidelberg, University of Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany.
| | - Dirk Jäger
- National Center for Tumor Diseases, Medical Oncology, University Hospital Heidelberg, University of Heidelberg, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany.
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital of Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675, Munich, Germany.
| |
Collapse
|
|
13
|
Tol J, Busch O, van Gulik T, Gouma D. Pancreatic Cancer: The Role of Bypass Procedures. PANCREATIC CANCER, CYSTIC NEOPLASMS AND ENDOCRINE TUMORS 2015:83-93. [DOI: 10.1002/9781118307816.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
|
|
14
|
Tol JAMG, Eshuis WJ, Besselink MGH, van Gulik TM, Busch ORC, Gouma DJ. Non-radical resection versus bypass procedure for pancreatic cancer - a consecutive series and systematic review. Eur J Surg Oncol 2014; 41:220-7. [PMID: 25511567 DOI: 10.1016/j.ejso.2014.11.041] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 11/06/2014] [Accepted: 11/16/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Most survival studies comparing non-radical resections to bypass surgery in patients with pancreatic cancer often do not differentiate between an R1 and R2 resection. The aim of this study was to evaluate whether non-radical R1 and R2 resections have better postoperative outcomes and survival compared to a palliative bypass. METHODS A single center cohort study was performed analyzing mortality, morbidity and 1-year survival after R1 (tumor cells within 1 mm from the circumferential margin), R2 and bypass surgery in patients with pancreatic cancer. For the systematic review, studies were identified comparing R1 or R2 resections with bypass, in patients with pancreatic cancer. Postoperative outcomes were compared including the cohort study. RESULTS The cohort study (n=405) showed higher morbidity rates after R1 (n=191) and R2 (n=11) resections compared to bypass (52% and 73% vs. 34%, p < 0.01). In-hospital mortality did not differ (overall 1.7%). 1-year survival rates were 71%, 46% and 32% after R1, R2 resection and bypass (p=0.6 between R2 and bypass). The systematic review identified 8 studies, after including the cohort study 1535 patients were analyzed. Increased morbidity after R1-R2 resection (48%) compared to bypass (30-34%) was found. Median survival was 14-18 months after R1 resection vs. 9-13 months after bypass and 8.5-11.5 months after R2 resection vs. 7.5-10.7 months after bypass. CONCLUSION An R2 resection should be avoided in patients with pancreatic cancer due to its poor prognosis. Survival benefit after an R1 resection, as compared to bypass surgery, justifies a resection despite the increased morbidity rate.
Collapse
Affiliation(s)
- J A M G Tol
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
| | - W J Eshuis
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - M G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - T M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - O R C Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - D J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
|
15
|
Gall TM, Thompson Z, Dinneen EP, Sodergren M, Pai M, Frampton AE, Jiao LR. Surgical techniques for improving outcomes in pancreatic ductal adenocarcinoma. Expert Rev Gastroenterol Hepatol 2014; 8:241-6. [PMID: 24491183 DOI: 10.1586/17474124.2014.881251] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Pancreatic ductal adenocarcinoma is a devastating disease with extremely poor survival despite patients undergoing potentially curative resections and improvements in chemotherapeutic agents. Surgery for operable cancer in the head of the pancreas typically involves an open pancreaticoduodenectomy with a post-operative median survival of 21 months. Newer surgical techniques, however, aim to improve patient outcomes in terms of both their hospital experience and better oncological results. This article focuses on the evidence to date for some of these surgical techniques including laparoscopic and robotic surgery, the no-touch technique, venous and arterial resection, intra-operative radiofrequency ablation and intra-operative irreversible electroporation. With the increased use of these techniques we hope to see better quality of life and survival for these patients.
Collapse
Affiliation(s)
- Tamara Mh Gall
- Department of Surgery and Cancer, HPB Surgical Unit, Imperial College, Hammersmith Hospital campus, Du Cane Road, London, W12 0HS, UK
| | | | | | | | | | | | | |
Collapse
|
|
16
|
Glazer ES, Hornbrook MC, Krouse RS. A meta-analysis of randomized trials: immediate stent placement vs. surgical bypass in the palliative management of malignant biliary obstruction. J Pain Symptom Manage 2014; 47:307-14. [PMID: 23830531 PMCID: PMC4111934 DOI: 10.1016/j.jpainsymman.2013.03.013] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 03/27/2013] [Accepted: 03/29/2013] [Indexed: 12/27/2022]
Abstract
CONTEXT Many patients with unresectable pancreatic and peripancreatic cancer require treatment for malignant biliary obstruction. OBJECTIVES To conduct a meta-analysis of the English language literature (1985-2011) comparing immediate biliary stent placement and immediate surgical biliary bypass in patients with unresectable pancreatic and peripancreatic cancer and analyze associated hospital utilization patterns. METHODS After identifying five randomized controlled trials comparing immediate biliary stent placement and immediate surgical biliary bypass, we performed a meta-analysis for dichotomous outcomes, using a random effects model. We compared resource utilization in terms of the number of hospital days before death by reviewing high-quality literature. RESULTS Three hundred seventy-nine patients were identified. We found no statistically significant differences in success rates between the two treatments (risk ratio [RR] 0.99; 95% CI 0.93-1.05; P = 0.67). Major complications and mortality were not significantly higher after surgical bypass (RR 1.54; 95% CI 0.87-2.71; P = 0.14). Recurrent biliary obstruction was significantly less frequent after surgical bypass than after stent placement (RR 0.14; 95% CI 0.03-0.63; P < 0.01). Despite similar overall survival rates, longer survival was associated with more hospital days before death in stent patients than in surgical patients. CONCLUSION Nearly all patients with unresectable pancreatic cancer benefit from some procedure to manage biliary obstruction. Patients with low surgical risk benefit more from surgery because the risk of recurrence and subsequent hospital utilization are lower than after stent placement.
Collapse
Affiliation(s)
- Evan S Glazer
- Department of Surgery, College of Medicine, The University of Arizona, Tucson, Arizona, USA
| | - Mark C Hornbrook
- The Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Robert S Krouse
- Department of Surgery, College of Medicine, The University of Arizona, Tucson, Arizona, USA; Cancer Center, The University of Arizona, Tucson, Arizona, USA; Surgical Care Line, Southern Arizona Veterans Affairs Health Care System, Tucson, Arizona, USA.
| |
Collapse
|
|
17
|
Ravikumar R, Sabin C, Abu Hilal M, Bramhall S, White S, Wigmore S, Imber CJ, Fusai G. Portal vein resection in borderline resectable pancreatic cancer: a United Kingdom multicenter study. J Am Coll Surg 2013; 218:401-11. [PMID: 24484730 DOI: 10.1016/j.jamcollsurg.2013.11.017] [Citation(s) in RCA: 155] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 11/05/2013] [Accepted: 11/06/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Until recently, in the United Kingdom, borderline resectable pancreatic cancer with invasion into the portomesenteric veins often resulted in surgical bypass because of the presumed high risk for complications and the uncertainty of a survival benefit associated with a vascular resection. Portomesenteric vein resection has therefore remained controversial. We present the second largest published cohort of patients undergoing portal vein resection for borderline resectable (T3) adenocarcinoma of the head of the pancreas. STUDY DESIGN This is a UK multicenter retrospective cohort study comparing pancreaticoduodenectomy with vein resection (PDVR), standard pancreaticoduodenectomy (PD), and surgical bypass (SB). Nine high-volume UK centers contributed. All consecutive patients with T3 (stage IIA to III) adenocarcinoma of the head of the pancreas undergoing surgery between December 1998 and June 2011 were included. The primary outcomes measures are overall survival and in-hospital mortality. Secondary outcomes measure is operative morbidity. RESULTS One thousand five hundred and eighty-eight patients underwent surgery for borderline resectable pancreatic cancer; 840 PD, 230 PDVR, and 518 SB. Of 230 PDVR patients, 129 had primary closure (56%), 65 had end to end anastomosis (28%), and 36 had interposition grafts (16%). Both resection groups had greater complication rates than the bypass group, but with no difference between PD and PDVR. In-hospital mortality was similar across all 3 surgical groups. Median survival was 18 months for PD, 18.2 months for PDVR, and 8 months for SB (p = 0.0001). CONCLUSIONS This study, the second largest to date on borderline resectable pancreatic cancer, demonstrates no significant difference in perioperative mortality in the 3 groups and a similar overall survival between PD and PDVR; significantly better compared with SB.
Collapse
Affiliation(s)
- Reena Ravikumar
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, UK.
| | - Caroline Sabin
- Research Department of Infection and Population Health, UCL, Royal Free Campus, UK
| | - Mohammad Abu Hilal
- Department of HPB Surgery, Southampton General Hospital, Southampton, UK
| | - Simon Bramhall
- Liver Unit, University Hospital Birmingham, Birmingham, UK
| | - Steven White
- Department of HPB and Transplantation, Freeman Hospital, Newcastle, UK
| | - Stephen Wigmore
- Department of HPB and Liver Transplant Surgery, Royal Infirmary of Edinburgh, UK
| | - Charles J Imber
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - Giuseppe Fusai
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | | |
Collapse
|
|
18
|
John BJ, Naik P, Ironside A, Davidson BR, Fusai G, Gillmore R, Watkins J, Rahman SH. Redefining the R1 resection for pancreatic ductal adenocarcinoma: tumour lymph nodal burden and lymph node ratio are the only prognostic factors associated with survival. HPB (Oxford) 2013; 15:674-80. [PMID: 23458477 PMCID: PMC3948534 DOI: 10.1111/hpb.12019] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Accepted: 09/26/2012] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The presence of positive nodal disease (LND) and the number of lymph nodes involved (LNB) are known to be significant prognostic markers for resected adenocarcinoma of the pancreas. In addition, the ratio of the number of involved nodes to the number of nodes resected known as the lymph node ratio (LNR) is emerging as an important prognostic marker. The role of the resection margin (RM) as presently defined (R1 ≤ 1 mm) is unclear as results differ based on the dataset. The aim of this study was to assess the impact of nodal disease and a redefined RM on outcome. MATERIAL AND METHODS Retrospective analysis of pancreatic head resections for adenocarcinomas from 2003-2009. The RM was re-analysed based on tumour clearance and categorized into: histopathological evidence of a tumour; ≤ 0.5 mm, ≤ 1 mm, ≤ 1.5 mm, or ≤ 2.0 mm of the actual surgical resection margin. The impact of histopathological variables on cancer-specific survival (CSS) and disease-free survival (DFS) was analysed. RESULTS LND, LNB and LNR were independent prognostic markers for CSS (P = 0.048, 0.003, 0.016) but, did not influence DFS. A LNR < 0.143 was associated with a higher CSS [38.16 ± 4.69 versus 20.59 ± 2.20 months, P = 0.0042, hazard ratio (HR) 3.74 (95% confidence interval (CI) 1.52-9.23)]. An R1 RM was not associated with CSS or DFS on multivariate analysis, irrespective of the distance. LNB and LNR maintained independent significance irrespective of the size of the RM. CONCLUSION LNB and LNR are the only prognostic factors for CSS in patients with pancreatic head adenocarcinoma, but do not predict recurrence. Microscopic RMs does not seem to influence the outcome even when redefined. Further prospective studies are indicated to substantiate these findings.
Collapse
Affiliation(s)
- Biku J John
- Centre for HPB Surgery and Liver Transplantation, The Royal Free London NHS Foundation TrustLondon, UK
| | - Prashant Naik
- Centre for HPB Surgery and Liver Transplantation, The Royal Free London NHS Foundation TrustLondon, UK
| | | | - Brian R Davidson
- Centre for HPB Surgery and Liver Transplantation, The Royal Free London NHS Foundation TrustLondon, UK
| | - Guiseppe Fusai
- Centre for HPB Surgery and Liver Transplantation, The Royal Free London NHS Foundation TrustLondon, UK
| | | | | | - Sakhawat H Rahman
- Centre for HPB Surgery and Liver Transplantation, The Royal Free London NHS Foundation TrustLondon, UK,Correspondence Sakhawat H. Rahman, Consultant Pancreatic and Minimally Invasive Surgery, Royal Free Hospital, Pond Street, London, NW3 2QG, UK. Tel: +44 2077940500. Fax: +44 2078302688. E-mail:
| |
Collapse
|
|
19
|
Pancreatic ductal adenocarcinoma: is there a survival difference for R1 resections versus locally advanced unresectable tumors? What is a "true" R0 resection? Ann Surg 2013; 257:731-6. [PMID: 22968073 DOI: 10.1097/sla.0b013e318263da2f] [Citation(s) in RCA: 305] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Patients who undergo an R0 resection of their pancreatic ductal adenocarcinoma (PDAC) have an improved survival compared with patients who undergo an R1 resection. It is unclear whether an R1 resection confers a survival benefit over locally advanced (LA) unresectable tumors. Our aim was to compare the survival of patients undergoing an R1 resection with those having LA tumors and to explore the prognostic significance of a 1-mm surgical margin. METHODS Clinicopathologic data from a pancreatic cancer database between January 1993 and July 2008 were reviewed. Locally advanced tumors had no evidence of metastatic disease at exploration. RESULTS A total of 1705 patients were evaluated for PDAC in the Department of Surgery. Of the 1084 (64%) patients who were surgically explored, 530 (49%) were considered unresectable (286 locally unresectable, 244 with distant metastasis). One hundred fifty-seven (28%) of the resected PDACs had an R1 resection. Patients undergoing an R1 resection had a slightly longer survival compared with those who had locally advanced unresectable cancers (14 vs 11 months; P < 0.001). Patients with R0 resections had a favorable survival compared with those with R1 resections (23 vs 14 months; P < 0.001), but survival after resections with 1-mm margin or less (R0-close) were similar to R1 resections: both groups had a significantly shorter median survival than patients with a margin of greater than 1 mm (R0-wide) (16 vs 14 vs 35 months, respectively; P < 0.001). CONCLUSIONS Patients undergoing an R1 resection still have an improved survival compared with patients with locally advanced unresectable pancreatic adenocarcinoma. R0 resections have an improved survival compared with R1 resections, but this survival benefit is lost when the tumor is within 1 mm of the resection margin.
Collapse
|
|
20
|
Ravikumar R, Holroyd D, Fusai G. Is there a role for arterial reconstruction in surgery for pancreatic cancer? World J Gastrointest Surg 2013; 5:27-29. [PMID: 23556057 PMCID: PMC3615300 DOI: 10.4240/wjgs.v5.i3.27] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 01/24/2013] [Indexed: 02/06/2023] Open
Abstract
Surgery remains the only potentially curative treatment for patients with pancreatic cancer. Locally advanced pancreatic cancer with vascular involvement remains a surgical challenge because high perioperative risk and the uncertainty of a survival benefit. Whilst portal vein resection has started to gather momentum because the perioperative morbidity and long term survival is comparable to standard pancreatectomy, there isn’t yet a consensus on arterial resections. There have been various reports and case series of arterial resections in pancreatic cancer, with mixed survival results. Mollberg et al have appraised the heterogeneous published literature available on arterial resection in pancreatic cancer in an attempt to compare this to standard pancreatectomy. In this article, we discuss the results of this systematic review and meta-analysis, and the limitations associated with analysing results from heterogenous data. We have outlined the important features in surgery for pancreatic cancer and specifically to arterial resections, and compared arterial resections to the published literature on venous resections.
Collapse
|
|
21
|
Nordby T, Ikdahl T, Bowitz Lothe IM, Fagerland MW, Heiberg T, Hauge T, Labori KJ, Buanes T. Improved survival and quality of life in patients undergoing R1 pancreatic resection compared to patients with locally advanced unresectable pancreatic adenocarcinoma. Pancreatology 2013; 13:180-185. [PMID: 23561977 DOI: 10.1016/j.pan.2013.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 12/21/2012] [Accepted: 01/16/2013] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To prospectively record the clinical consequences of R1 resection of pancreatic adenocarcinoma compared to patients with locally advanced tumours not undergoing surgery. BACKGROUND Surgery is the only potentially curative treatment of pancreatic cancer, and postoperative safety is increasing. The rate of R1 resections might also increase unintentionally as surgical procedures with curative goal become more comprehensive, and the clinical outcome requires further prospective evaluation. MATERIAL AND METHODS Prospective observational cohort study from October 2008 to December 2010. Outcome after R1 resection (group 1, surgery, n = 32) and conservative palliative chemoradiation/endoscopy (group 2, no surgery, n = 56) is compared with survival and longitudinal patient-reported quality of life (QoL) as endpoints. QoL was assessed by the Edmonton Symptom Assessment System (ESAS). RESULTS Demographic characteristics and tumour diameters were similar in both groups: 38.0 (31.3, 49.8) mm in group 1 versus 44.0 (39.6, 49.1) mm in group 2 (p = 0.18). Perioperative morbidity was 25% with no mortality. Disease-specific survival was 18.0 (14.5, 23.8) months in group 1 versus 8.1 (4.8, 10.1) months in group 2 (p < 0.0001). Overall survival was 11 (7.8, 14.4) months. Reduction in fatigue was significantly improved in the surgery group 6, 12, and 19 weeks after baseline, whereas reduction in global health was significantly better in group 2. CONCLUSION Radical removal (R0 resection) is the primary aim of surgery, but also R1 resection seems to improve survival and QoL, compared to outcome in patients with locally advanced tumours not undergoing surgery.
Collapse
Affiliation(s)
- Tom Nordby
- Department of Cancer, Surgery, and Transplantation, Oslo University Hospital, and Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | | | | | | | | | | | | | | |
Collapse
|
|
22
|
Wellner UF, Makowiec F, Bausch D, Höppner J, Sick O, Hopt UT, Keck T. Locally advanced pancreatic head cancer: margin-positive resection or bypass? ISRN SURGERY 2012; 2012:513241. [PMID: 22779001 PMCID: PMC3385665 DOI: 10.5402/2012/513241] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Accepted: 04/29/2012] [Indexed: 06/01/2023]
Abstract
Pancreatic cancer is a highly aggressive disease with poor survival. The only effective therapy offering long-term survival is complete surgical resection. In the setting of nonmetastatic disease, locally advanced tumors constitute a technical challenge to the surgeon and may result in margin-positive resection margins. Few studies have evaluated the implications of the latter in depth. The aim of this study was to compare the margin-positive situation to palliative bypass procedures and margin-negative resections in terms of perioperative and long-term outcome. By retrospective analysis of prospectively maintained data from 360 patients operated for pancreatic cancer at our institution, we provide evidence that margin-positive resection still yields a significant survival benefit over palliative bypass procedures. At the same time, perioperative severe morbidity and mortality are not significantly increased. Our observations suggest that pancreatic cancer should be resected whenever technically feasible, including, cases of locally advanced disease.
Collapse
Affiliation(s)
- Ulrich Friedrich Wellner
- Department of General and Visceral Surgery, University of Freiburg, Hugstetter Street 55, 79106 Freiburg, Germany
| | - Frank Makowiec
- Department of General and Visceral Surgery, University of Freiburg, Hugstetter Street 55, 79106 Freiburg, Germany
| | - Dirk Bausch
- Department of General and Visceral Surgery, University of Freiburg, Hugstetter Street 55, 79106 Freiburg, Germany
| | - Jens Höppner
- Department of General and Visceral Surgery, University of Freiburg, Hugstetter Street 55, 79106 Freiburg, Germany
| | - Olivia Sick
- Department of General and Visceral Surgery, University of Freiburg, Hugstetter Street 55, 79106 Freiburg, Germany
| | - Ulrich Theodor Hopt
- Department of General and Visceral Surgery, University of Freiburg, Hugstetter Street 55, 79106 Freiburg, Germany
| | - Tobias Keck
- Department of General and Visceral Surgery, University of Freiburg, Hugstetter Street 55, 79106 Freiburg, Germany
| |
Collapse
|
|
23
|
Verbeke CS, Gladhaug IP. Resection margin involvement and tumour origin in pancreatic head cancer. Br J Surg 2012; 99:1036-49. [PMID: 22517199 DOI: 10.1002/bjs.8734] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2012] [Indexed: 12/26/2022]
Abstract
BACKGROUND Assessment of the origin of adenocarcinoma in pancreatoduodenectomy specimens (pancreatic, ampullary or biliary) and resection margin status is not performed in a consistent manner in different centres. The aim of this review was to identify the impact of such variations on patient outcome. METHODS A systematic literature search for articles on pancreatic, ampullary, distal bile duct and periampullary cancer was performed, with special attention to data on resection margin status, pathological examination and outcome. RESULTS The frequent reclassification of tumour origin following slide review, and the wide variation in published incidence of pancreatic (33-89 per cent), ampullary (5-42 per cent) and distal bile duct (5-38 per cent) cancers indicate that the histopathological distinction between the three cancer groups is less accurate than generally believed. Recent studies have shown that the wide range of rates of microscopic margin involvement (R1) in pancreatoduodenectomy specimens (18-85, 0-27 and 0-72 per cent respectively for pancreatic, ampullary and distal bile duct cancers) is mainly caused by differences in pathological assessment rather than surgical practice and patient selection. As a consequence of the existing inconsistency in reporting of these data items, the clinical significance of microscopic margin involvement in each of the three cancer groups remains unclear. CONCLUSION Inaccurate and inconsistent distinction between pancreatic, ampullary and distal bile duct cancer, combined with inaccuracies in resection margin assessment, results in obfuscation of key clinicopathological data. Specimen dissection technique plays a key role in the quality of the assessment of both tumour origin and margin status. Unless the pathological examination is meticulous and standardized, comparison of results between centres and observations in multicentre trials will remain of limited value.
Collapse
Affiliation(s)
- C S Verbeke
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institute, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | | |
Collapse
|
|
24
|
Abstract
BACKGROUND There is an assumption that multivisceral resections (MVRs) in patients with a pancreatic malignancy are associated with higher morbidity. The oncologic benefit, however, remains controversial. METHODS The aim was to identify risk factors for complications in cases of MVR in patients with pancreatic cancer. Of 1099 patients who underwent major pancreatic resection at our institution between January 1992 and October 2008, a total of 55 were treated with an MVR involving resection of one or more additional organs. This group was compared with 154 patients who had palliative bypass surgery and 303 patients who underwent standard pancreatic head resection. RESULTS Multivisceral resection patients had an overall higher incidence of major surgical complications (p < 0.001). In-hospital mortality was comparable in all groups. Median survival after MVR was inferior to that after standard resection but was significantly better than that after palliative bypass. Univariate logistic regression analysis identified concomitant colon, kidney, and liver resections and any intraoperative transfusion as predictors of complications; in the multivariate analysis, only kidney resections and any intraoperative transfusion were confirmed predictors. In contrast, T status, kidney resection, resection of four or more organs, any postoperative transfusion, and intensive care unit stay of >2 days were identified as predictors of survival in the univariate Cox regression analysis; in the multivariate analysis, only the T status was confirmed. Median survival after MVR was 16 months, after palliative bypass 6 months, and after standard resection 18 months (p < 0.001). CONCLUSIONS Multivisceral resections are technically feasible procedures with increased survival when compared to palliative bypass procedures. The incidence of postoperative complications was increased with kidney resection and when intraoperative transfusion was required.
Collapse
|
|
25
|
Torre ML, Nigri G, Ferrari L, Cosenza G, Ravaioli M, Ramacciato G. Hospital Volume, Margin Status, and Long-Term Survival after Pancreaticoduodenectomy for Pancreatic Adenocarcinoma. Am Surg 2012. [DOI: 10.1177/000313481207800243] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
An association between hospital surgical volume and short- and long-term outcomes after pancreatic surgery has been demonstrated. Identification of specific factors contributing to this relationship is difficult. In this study, the authors evaluated if margin status can be identified as a measure of surgical quality, affecting overall survival, as a function of hospital pancreaticoduodenectomy volume. A systematic review of the literature was performed. Two models for analysis were created, dividing the 18 studies identified into quartiles and two quantiles based on the average annual hospital pancreatectomy volume. Regression modeling and analysis of variance were used to find an association between hospital volume, margin status, and survival. Increasing hospital volume was associated with a significantly increased negative margin status rate: 55 per cent for low-volume, 72 per cent for medium-volume, 74.3 per cent for high-volume, and 75.7 per cent for very high-volume centers ( P = 0.008). The negative margin status rates were 64 per cent and 75.1 per cent for volume centers with less and more than 12 pancreaticoduodenectomies/year, respectively ( P = 0.04). Low-volume centers negatively affected both margin positive resection and 5-year survival rates, compared with high-volume centers. Margin status rate after pancreaticoduodenectomy could, therefore, be considered a measure of quality for selection of hospitals dedicated to pancreatic surgery.
Collapse
Affiliation(s)
- Marco La Torre
- Department of Hepato-Biliary and Pancreatic Surgery, Sant'Andrea Hospital, Faculty of Medicine and Psychology University of Rome “La Sapienza”, Rome, Italy
| | - Giuseppe Nigri
- Department of Hepato-Biliary and Pancreatic Surgery, Sant'Andrea Hospital, Faculty of Medicine and Psychology University of Rome “La Sapienza”, Rome, Italy
| | - Linda Ferrari
- Department of Hepato-Biliary and Pancreatic Surgery, Sant'Andrea Hospital, Faculty of Medicine and Psychology University of Rome “La Sapienza”, Rome, Italy
| | - Giulia Cosenza
- Department of Hepato-Biliary and Pancreatic Surgery, Sant'Andrea Hospital, Faculty of Medicine and Psychology University of Rome “La Sapienza”, Rome, Italy
| | - Matteo Ravaioli
- Department of Hepato-Biliary and Pancreatic Surgery, Sant'Andrea Hospital, Faculty of Medicine and Psychology University of Rome “La Sapienza”, Rome, Italy
| | - Giovanni Ramacciato
- Department of Hepato-Biliary and Pancreatic Surgery, Sant'Andrea Hospital, Faculty of Medicine and Psychology University of Rome “La Sapienza”, Rome, Italy
| |
Collapse
|
|
26
|
Walter J, Nier A, Rose T, Egberts J, Schafmayer C, Kuechler T, Broering D, Schniewind B. Palliative partial pancreaticoduodenectomy impairs quality of life compared to bypass surgery in patients with advanced adenocarcinoma of the pancreatic head. Eur J Surg Oncol 2011; 37:798-804. [PMID: 21767928 DOI: 10.1016/j.ejso.2011.06.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 06/24/2011] [Accepted: 06/28/2011] [Indexed: 11/12/2022] Open
|
|
27
|
Turrini O, Wiebke EA, Delpero JR, Viret F, Lillemoe KD, Schmidt CM. Preservation of replaced or accessory right hepatic artery during pancreaticoduodenectomy for adenocarcinoma: impact on margin status and survival. J Gastrointest Surg 2010; 14:1813-9. [PMID: 20697832 DOI: 10.1007/s11605-010-1272-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2010] [Accepted: 06/15/2010] [Indexed: 01/31/2023]
Abstract
AIM The aim of the study was to determine the impact of replaced or accessory right hepatic artery (RARHA) during pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA). METHODS Four hundred seventy-one consecutive patients underwent PD for PA at the two institutions; 47 patients (10%) had RARHA: 16 patients (neoRARHA group) received neoadjuvant chemoradiation, and 31 patients did not receive preoperative treatment (RARHA group). Thirty-one matched patients without RARHA comprised our control group. RESULTS RARHA was preserved in 44 patients; three patients with involved RARHA had reconstruction (n = 2) or ligation (n = 1). Patients with R1 resection (n = 8) had tumor size ≥3 cm. Patients in the neoRARHA group had identical positive margin rate when compared with patients in RARHA group (p = 0.6). No difference was noted in median or 3-year overall survival times between RARHA group and control group. Two patients in RARHA group with involved RARHA died of disease progression after 6 and 12 months of follow-up. One patient in neoRARHA group with involved RARHA was still alive without recurrence after 28 months' follow-up. CONCLUSIONS Pathologic findings did not show increased positive margins despite preservation of RARHA. In contrast, patients with frank RARHA involvement seemed to have poor survival. Thus, patients with suspicion of involved RARHA should be considered for neoadjuvant chemoradiation.
Collapse
Affiliation(s)
- Olivıer Turrini
- Department of Surgery, Institut Paoli Calmettes, Marseille, France
| | | | | | | | | | | |
Collapse
|
|
28
|
Laasch HU. Obstructive jaundice after bilioenteric anastomosis: transhepatic and direct percutaneous enteral stent insertion for afferent loop occlusion. Gut Liver 2010; 4 Suppl 1:S89-95. [PMID: 21103301 DOI: 10.5009/gnl.2010.4.s1.s89] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Recurrent tumour after radical pancreaticoduodenectomy may cause obstruction of the small bowel loop draining the liver. Roux-loop obstruction presents a particular therapeutic challenge, since the postsurgical anatomy usually prevents endoscopic access. Careful multidisciplinary discussion and multimodality preprocedure imaging are essential to accurately demonstrate the cause and anatomical location of the obstruction. Transhepatic or direct percutaneous stent placement should be possible in most cases, thereby avoiding long-term external biliary drainage. Gastropexy T-fasteners will secure the percutaneous access and reduce the risk of bile leakage. The static bile is invariably contaminated by gut bacteria, and systemic sepsis is to be expected. Enteral stents are preferable to biliary stents, and compound covered stents in a sandwich construction are likely to give the best long-term results. Transhepatic and direct percutaneous enteral stent insertion after jejunopexy is illustrated and the literature reviewed.
Collapse
Affiliation(s)
- Hans-Ulrich Laasch
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| |
Collapse
|
|
29
|
Liszka Ł, Pająk J, Zielińska-Pająk E, Gołka D, Mrowiec S, Lampe P. Different approaches to assessment of lymph nodes and surgical margin status in patients with ductal adenocarcinoma of the pancreas treated with pancreaticoduodenectomy. Pathology 2010; 42:138-46. [DOI: 10.3109/00313020903494060] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|
|
30
|
Lavu H, Mascaro AA, Grenda DR, Sauter PK, Leiby BE, Croker SP, Witkiewicz A, Berger AC, Rosato EL, Kennedy EP, Yeo CJ. Margin positive pancreaticoduodenectomy is superior to palliative bypass in locally advanced pancreatic ductal adenocarcinoma. J Gastrointest Surg 2009; 13:1937-46; discussion 1946-7. [PMID: 19760308 DOI: 10.1007/s11605-009-1000-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2009] [Accepted: 08/14/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma is an aggressive disease. Surgical resection with negative margins (R0) offers the only opportunity for cure. Patients who have advanced disease that limits the chance for R0 surgical resection may undergo margin positive (MP) pancreaticoduodenectomy (PD), palliative surgical bypass (PB), celiac plexus neurolysis alone (PX), or neoadjuvant chemoradiation therapy in anticipation of future resection. OBJECTIVE The aim of this study was to determine if there is a difference in the perioperative outcomes and survival patterns between patients who undergo MP PD and those who undergo PB for locally advanced disease in the treatment of pancreatic ductal adenocarcinoma. METHODS We reviewed our pancreatic surgery database (January 2005-December 2007) to identify all patients who underwent exploration with curative intent of pancreatic ductal adenocarcinoma of the head/neck/uncinate process of the pancreas. Four groups of patients were identified, R0 PD, MP PD, PB, and PX. RESULTS We identified 126 patients who underwent PD, PB, or PX. Fifty-six patients underwent R0 PD, 37 patients underwent MP PD, 24 patients underwent a PB procedure, and nine patients underwent PX. In the PB group, 58% underwent gastrojejunostomy (GJ) plus hepaticojejunostomy (HJ), 38% underwent GJ alone, and 4% underwent HJ alone. Of these PB patients, 25% had locally advanced disease and 75% had metastatic disease. All nine patients in the PX group had metastatic disease. The mean age, gender distribution, and preoperative comorbidities were similar between the groups. For the MP PD group, the distribution of positive margins on permanent section was 57% retroperitoneal soft tissue, 19% with more than one positive margin, 11% pancreatic neck, and 8% bile duct. The perioperative complication rates for the respective groups were R0 36%, MP 49%, PB 33%, and PX 22%. The 30-day perioperative mortality rate for the entire cohort was 2%, with all three of these deaths being in the R0 group. The median follow-up for the entire cohort was 14.4 months. Median survival for the respective groups was R0 27.2 months, MP 15.6 months, PB 6.5 months, and PX 5.4 months. CONCLUSIONS Margin positive pancreaticoduodenectomy in highly selected patients can be performed safely, with low perioperative morbidity and mortality. Further investigation to determine the role of adjuvant treatment and longer-term follow-up are required to assess the durability of survival outcomes for patients undergoing MP PD resection.
Collapse
Affiliation(s)
- Harish Lavu
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
31
|
Abstract
In patients affected by periampullary tumors, surgical resection represents the only treatment with curative intent. Preoperative evaluation of vascular involvement is necessary to avoid surgical treatments unable of curative intent resection. The aim of our update article is to assess the performance of multidetector computed tomography (MDCT), endoscopic ultrasonography (EUS), and color Doppler ultrasonography (CDU) in the evaluation of vascular involvement of major peripancreatic vessels, in periampullary tumors, analyzing the current and past literature.
Collapse
|