Radical Resection in Patients with Pancreatic Head Carcinomas. A Retrospective Survival Analysis in a Group of 307 Subjects


Authors: M. Ryska ;  R. Strnad ;  F. Bělina ;  M. Zavoral 1;  C. Šálek 1;  P. Hrabal 2;  I. Buřič 3;  E. Lásziková 4;  H. Kvičerová ;  B. Jurenka 4;  I. Holcátová 5
Authors‘ workplace: Chirurgická klinika 2. LF UK a ÚVN Praha, přednosta: prof. MUDr. M. Ryska, CSc. ;  I. interní klinika 1. LF UK a ÚVN Praha, přednosta: doc. MUDr. M. Zavoral, Ph. D. 1;  Oddělení patologie ÚVN Praha, primář: MUDr. P. Hrabal, CSc. 2;  Rentgenologické oddělení ÚVN Praha, primář: MUDr. F. Charvát, CSc. 3;  Oddělení anesteziologie a resuscitace ÚVN Praha, primář: MUDr. B. Jurenka 4;  Ústav hygieny a epidemiologie 1. LF UK a VFN, přednosta: prof. MUDr. V. Bencko, DrSc. 5
Published in: Rozhl. Chir., 2007, roč. 86, č. 8, s. 432-439.
Category: Monothematic special - Original

Overview

Introduction:
The Czech Republic has the world’s highest rates of pancreatic carcinomas. The pancreatic carcinoma is the fourth commonest cause of deaths due to malignancies, in our republic. Resection procedure is currently the only current treatment method, which has a curative potential and significantly prolongs a patient’s life.

Aim:
To assess morbidity, mortality and survival of patients following radical and paliative procedures in the pancreatic head carcinoma patients.

Methods and Patient Group:
Only patients, who, based on the preoperative staging, were expected to require the following procedures, were indicated for surgery: 1 – radical resection, i.e. stage I, II patients, 2 – palliative resection – i.e. stage III or IV patients, where no angioinvasion was detected preoperatively. Patients with peroperative detection of angioinvasion into the portomesenteric venous drainage area who required partial vein resection , were also included in the above subgroup. 3 – palliative bypass, where longer survival was expected.

Radical resection included proximal pancreatoduodenectomy (PDE) with preservation of the pylorus according to Traverso-Longmire, with N1-2 lymphadenectomy and with reconstruction to an excluded jejunal loop. The same procedure was followed in cases of palliative resections. The collected data were statistically assessed using the Logrank test.

From 05/1998 to 12/2006, a total of 307 patients with carcinomas of the pancreas and the Vater papila were treated. In 242 patients, the carcinoma was located within the pancreatic head, in 65 subjects, the pancreatic body and cauda were affected. Resection for the pancreatic head carcinoma was performed in 78 patients: 46 males, 32 females, the mean age was 63.5 y.o.a, with the median of 64 years. Bypass procedures were performed in 109 subjects and explorations in 55 subjects.

Results:
Surgical procedures, with exception of 55 subjects who underwent exploration only, were performed in 187 subjects. Out of the total 78 PDEs, resections in stage I and II were performed in 22 subjects, in stage III in 41 subjects. In the group of 63 radical resection subjects, 2 subjects exited: the first one due to multiorgan failure, the second one for necrotizing postoperative pancreatitis. In the group of 15 palliative resections, 3 subjects exited. 10 patients died during the early postoperative period after palliative bypass procedures. A total of 15 subjects, i.e. 8%, exited during the early postoperative period. 5 subjects exited after resection procedures, i.e. 6.4%, 3% after radical resections. 3 subjects exited after palliative resections. Early complications were recorded in 44 subjects: pancreato-jejuno anastomosis insufficiency in 6 patients, insufficiency of hepaticojejunoanastomosis in 5 subjects, postoperative pancreatitis in 5 subjects, intraabdominal absces in 10 subjects, wounds infections with secondary healing in 19 subjects and cardiopulmonary complications in 33 subjects. In 19 subjects (43 % of all complications), surgical revision was performed.

Three-year survival rates were recorded in 60, resp. 29.5 and 39.5 % of the patients in stage I, resp. II and III, while they were recorded in 15.6.% of the stage IVa subjects and only in 10.5% of the stage IVb subjects. There is a significant difference between survival rates of the stage I, II and III patients, compared to the stage IV patients (p < 0.005). There is no significant difference in the over- 3- years survival rates between the patients undergoing radical or palliative resections, however, the radical resection patients have significantly higher survival rates 3 months to 2 years postoperatively (p < 0.05).The radical resection subjects have significantly higher survival rates during the first 36 postoperative months, compared to the palliative resection and BDA subjects (p < 0.05). Comparison of survival rates in patients with radical or palliative resections is affected by a small number of the palliative resection subjects (n = 15), where no differences in survival rates were detected from the end of 9th postoperative month to the end of 3rd postoperative year. There is a significant difference in the survival rates between the resection and exploration subjects (p < 0.05). The survival rates differences between the subjects with palliative resections and BDAs cannot be evaluated in our study, due to nonhomogenity of the subjects.

Conclusion:
Radical PDEs for the pancreatic head carcinoma results in significantly longer survival of the subjects, compared to palliative bypasses. Stage I, II or III patients survive significantly longer, compared to those operated in stage IV.

Key words:
pancreatic carcinoma – radical resection – palliative treatment – complications – survival


Sources

1. ÚZIS ČR 2006

2. Beger, H. G., Rau, B., Gansauge, F., et al. Treatment of pancreatic cancer: challenge of the facts. World J. Surg., 2003, 27: 1075–1084.

3. Balaš, V., Pešková, M., Šváb, J. Naše zkušenosti s radikálním léčením nemocných rakovinou slinivky břišní a papily Vaterské. Rozhl. Chir., 57, 1978: 710–715.

4. Leffler, J., Polouček, P., Krejčí, T. Karcinom hlavy pankreatu a periampulární karcinomy. Výsledky resekční léčby za 10 let. Rozhl. Chir., 2005, 84: 610–616.

5. Ryska, M., Bělina, F., Strnad, R. Chirurgická terapie. In: Zavoral, M., et al.: Karcinom pankreatu. Galén, 2005: 167–219.

6. Ryska, M., Bělina, F., Strnad, R., et al. Resekční výkon – metoda volby terapie karcinomu pankreatu. Bull HPB, 12, 2004: 90–92.

7. Meyenfeldt, M. F. Nutritional support during treatment of biliopancreatic malignancy. Ann. Oncol., 10, 1999, Suppl. 4: S273–S277.

8. Allema, J. H., Reinders, M. E., van Gulik, T. M., et al. Prognostic factors for survival after pancreaticoduodenectomy for patients with carcinoma of the pancreatic head region. Cancer, 75, 1995: 2069–2076.

9. Lillemoe, K. D., Cameron, J. L., Kaufman, H. S., et al. Chemical splanchnicectomy in patients with unresectable pancreatic cancer: a prospective randomized trial. Ann. Surg., 217, 1993: 447–457.

10. Bluemke, D. A., Cameron, J. L., Hruban, R. H., et al. Potentially resectable pancreatic adenocarcinoma: spiral CT assessment with surgical and pathological correlation. Radiology, 1995, 197: 381–385.

11. Traverso, L. W., Longmire, P. Preservation of the pylorus in pancreaticoduodenectomy. SGO 146, 1978: 959–962.

12. Gouma, D. J., Nieveen van Dijkum, E. J. M. The standard work-up and surgical treatment of pancreatic head tumours. Eur. J. Surg. Oncol., 25, 1999: 113–123.

13. Bonnet, F., Marret, E. Influence of anasthetic and analgesic techniques on outcome after surgery. BJA, 2004, 95: 52–58.

14. Büchler, M. W., Friess, H., Klempa, I., et al. Role of octreotide in the prevention of postoperative complications following pancreatic resection. Am. J. Surg., 163, 1992: 125–130.

15. Watanapa, P., Williamson, R. C. N. Surgical palliation for pancreatic cancer: developments dutiny the past two decades. BJS, 1992, 79: 8–20.

16. Beger, H., Büchler, M. W., Malfrtheiter, P. Standards in pancreatic surgery. Berlin, Springer Verlag, 1993: 614–630.

17. Friess, H., Kleeff, J., Kulli, C., et al. The impact of different types of surgery in pancreatic cancer. Eur. J. Surg. Oncol., 25, 1999: 124–131.

18. Pitt, H. A. Pancreatic cancer: evaluation, management from a surgical perspective. Postgr Course AASGE, Chicago, 2000.

19. Arcidiacono, P. G., Carrara, S. EUS: impact in diagnosis, staging and management of pancreatic tumors. An overview. JOP, 2004, 5: 247–252.

20. Ruf, J., Hänninen, E. L., Böhmig, M., et al. Impact of FDG-PET/MRI image vision on the detection of pancreatic cancor. Pancreatology, 2006, 6: 512–519.

21. Callery, M. P., Strasberg, S. M., Doherty, G. M., et al. Staging laparoscopy with laparoscopic ultrasonography: optimizing resectability in hepatobiliary and pancreatic malignancy. J. Am. Coll. Surg., 185, 1997: 33–39.

22. Dooley, W. C., Cameron, J. L., Pitt, H. A., et al. Is preoperative angiography useful in patients with periampullary tumors ? Ann. Surg., 211, 1990: 649–655.

23. Parsons, L. Jr., Palmer, Ch. How accurate is fine-needle biopsy in malignant neoplasia of the pancreas? Arch. Surg., 1989, 124: 681–683.

24. Pedrazzoli, S., Pasquali, C., Sperte, C. General aspects of surgical treatment of pancreatic cancer. Dig. Surg., 1999, 16: 265–275.

25. Pedrazzoli, S., Pasquali, C., Sperti, C. Definition in pancreatic cancer surgery – Castelfranco consensus meeting. In: Dervenis, C. G., Bassi, C.: Pancreatic tumors. Thieme, 2000: 138–146.

26. Jones, L., Russell, Ch., Mosca, F., et al. Standard Kausch-Whipple pancreatoduodenectomy. Dig. Surg., 16, 1999: 297–304.

27. Patel, A. G., Toyama, M. K., Kusske, A. M., et al. Pylorus - preserving Whipple resection for pancreatic cancer. Is it better? Arch. Surg., 130, 1995: 838–843.

28. Whipple, A. O., Parsons, W. B., Mullins, C. R. Treatment of cancer of the ampulla of Vater. Ann. Surg., 102, 1935: 763–779.

29. Ihse, I., Andrén-Sandberg, A. Surgical treatment: total pancreatectomy. In: Beger, H., Warshaw, A. L., Büchler, M. W., et al. Pancreas. Blackwell Science, London, 1998: 1047–1054.

30. Sasson, A. R., Hoffman, J. P., Ross, E. A., et al. En block resection for locally advanced cancer of the pancreas: is it worthwhile? J. Gastrointest. Surg., 2002, 6: 147–158.

31. Pedrazzolli, P., DiCarlo, V., Dionigi, R., et al. Standard vs extended lymphadenectomy associated with PDE in the surgical treatment od adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy study group. Ann. Surg., 1998, 228: 508–517.

32. Yeo, C. J., Cameron, J. L., Lilemoe, K. D., et al. PDE with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized control trial evaluating survival, morbidity, and mortality. Ann. Surg., 2002, 236: 355–368.

33. van Wagensveld, B. A., Coene, P. P. L. O., van Gulik, T. M., et al. Outcome of paliative biliary and Bystric vypase surgery for pancreatic in 126 patients. BJS, 1997, 84: 1402–1406.

34. van Berge Henegouwen, M. I., DeWitt, L. T., van Gulik, T. M., et al. Incidence, risk factors and treatment of pancreatic leakage after pancreatoduodenectomy: drainage versus resection of the pancreatic remnant. J. Am. Coll. Surg., 185, 1997: 18–24.

35. van Berge Henegouwen, M. I., Gouma, D. J., Obertop, H. Postoperative complications after surgery for pancreatic cancer. In: Dervenis, C. G., Bassi, C.: Pancreatic tumors. Tyjeme, 2000: 216–225.

36. Petr, W. T., Pistes, M. D., Wayne, A., et al. Effect of praeoperative biliary decompression on pancreaticoduodenectomy – associated morbidity in 300 consecutive patients. Ann. Surg., 234, 2001: 47–55.

37. Neoptolemos, J. P., Dunn, J. A., Stocken, D. D., et al. Adjutant chemoradiotherapy and chemotherapy in resectable pancreatic cancer: a randomised controlled trial. The Lancet, 2001, 358: 1576–1585.

38. Alexakis, N., Halloran, C., Raraty, M., et al. Current standards of surgery for pancreatic cancer. BJS, 2004, 91: 1410–1427.

39. Bang, S., Jeon, T. J., Kim, M. H., et al. Phase II study of Cisplatin combined with weekly Gemcitabine in the treatment of patiens with metastatic pancreatic carcinoma. Pancreatology, 2006, 6: 635–641.

40. Nisanevic, V., Felsenstein, I., Almogy, G., et al. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology 2005, 103: 25–32.

Labels
Surgery Orthopaedics Trauma surgery
Login
Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account