Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality

Adjuvant therapy for pancreatic cancer

Ductal adenocarcinoma of the pancreas is one of the leading causes of cancer death in the UK, Europe and US, with incidence closely paralleling mortality. Until recently, enthusiasm for treating these patients was limited for a number of reasons: the majority of patients undergoing surgery would relapse early, adjuvant treatment was of unproven value and systemic therapy in advanced disease had only a small chance of a short-term benefit. More recently, however, it has become recognised that specialist surgery can improve results and there is evidence that adjuvant chemotherapy has a significant advantage in terms of 5-year survival. In particular adjuvant systemic 5-fluorouracil with folinic acid can result in 5-year survival of < or = 29% (compared with 11% for controls) and adjuvant gemcitabine can improve disease-free survival to 13.4 months from a median of 6.9 months in controls, but not overall survival. In contrast the role of adjuvant chemoradiation in addition to chemotherapy remains unproven and the survival results appear to be inferior to systemic chemotherapy alone. New agents, such as capecitabine and erlotinib, are emerging with some activity in this dismal disease signalling hope for the future.

Pancreatojejunal leakage after pancreas head resection: anatomic and surgeon-related factors

Leakage of pancreatojejunostomies after pancreatic resections remains a challenge even at high volume centers. We here utilized a simple pancreas anatomy classification to study the effect of pancreatic anatomy on the development of pancreatic fistula after pancreas resection and pancreatojejunostomies. Also, the effect of surgical experience on the development of pancreatic fistulas was studied. Three hundred ninety-one patients undergoing pancreatic resections and reconstruction with a pancreatojejunostomy were studied. Closed suction drain was placed behind the anastomosis, and drainage fluid was collected postoperatively. A twofold increase over the serum amylase level was considered a fistula and was classified as described by the International Study Group on Pancreatic Fistula Definition. In 67 patients, the structural quality of the pancreatic parenchyma and the diameter of the pancreatic duct were classified as being <2 mm (2 points), between 2 and 5 mm (1 point), or >5 mm (0 points). The pancreatic parenchyma was assessed as being soft (2 points), intermediate (1 point), or hard (0 points). Pancreatic leakage as a function of surgeons' experience was also studied. Leakage was found in 25.1%, 8.9% being of type A, 10.2% being of type B, and 5.9% of type C. Pancreatic fistulas were only observed in patients with a score of 2 points or more. Age over 70 years, operations >6 h, and extended lymphadenectomy or surgeons experience were not associated with a higher leakage rate. In this study, leakage after pancreatojejunostomy was only associated with pancreatic anatomy, classified with a simple score. That score might improve comparability of studies on pancreatic leakage. Furthermore, drainage of pancreatic anastomosis might safely be omitted in patients with a low risk score for leakage.

Surgical techniques for resectable pancreatic cancer

Pancreatic cancer is a highly aggressive cancer with a rising incidence in most European countries. Due to both the aggressive biology of the disease and the late diagnosis in many cases, pancreatic duct carcinoma is still a disease with a poor prognosis. Today, surgical resection of localized tumor remains the only potentially curative option available for these patients. Advances in surgical techniques and perioperative care has improved significantly in the last 20 years, causing an extension of indications for surgical intervention. However, despite new diagnostic techniques, the surgical exploration still plays the key role for the finally assessment of resectability. For evaluation of local resectability, laparoscopy alone cannot generally be recommended today and explorative laparotomy is required. Contraindications for pancreatic resection are liver metastasis, peritoneal metastasis, and tumor infiltration of visceral arteries. The surgical management of pancreatic cancer consists of two phases: first, assessment of tumor resectability and second, if resectability is given, the pancreaticoduodenectomy with consecutive reconstruction. Standard surgical strategies are the classic pancreaticoduodenectomy including a distal gastrectomy and the pylorus-preserving pancreaticoduodenectomy (PPPD) preserving antral and pyloric function, respectively. Both surgical procedures are equally effective for the treatment of pancreatic carcinoma. Delicate lymphadenectomy during pancreaticoduodenectomy is important for radical oncological enforcement. An extended lymphadenectomy showed no benefit in several trials. Despite the encouraging advances in surgical treatment, actuarial 5-year survival rates after pancreatic resection are only at about 20%.

Pancreatic anastomotic leakage after pancreaticoduodenectomy in 1,507 patients: a report from the Pancreatic Anastomotic Leak Study Group

Several definitions for pancreatic leakage after pancreaticodoudenectomy exist, and the reported range of 2-50% underscores this variation. The goal was to determine if drain data alone was predictive of a leak and validate International Study Group on Pancreatic Fistula (ISGPF) leak criteria. Participating surgeons entered de-identified data into a web-based database designed to collect Whipple-related data. Definitions used were the ISGPF definition, > or = 3 days, amylase 3x normal; and Sarr's definition, > or = 5 days, amylase 5x normal, > 30 ml. We compared how well these two definitions were at detecting a leak and its complications. There were 1,507 cases submitted from 16 international institutions. A pancreaticoduodenectomy (PPPD) was performed in 76.2%. Drain placement occurred in 98.0%. Using the ISGPF definition, the pancreatic leak rate was 26.7 and 14.3% with the Sarr definition. There were more grades A and B leaks detected by the ISGPF definition. Both determined grade C leaks equally. Both definitions correlated with an increased length of stay (LOS), need for percutaneous drains, reoperation, and delayed gastric emptying (DGE). Neither was associated with an increased risk of intensive care unit (ICU) stay or 30-day mortality. The ISGPF was able to capture more patients with clinically relevant leaks than Sarr's criteria; however, the ability to detect a leak by drain data alone is imperfect.

Prognostic significance of pathologic nodal status in patients with resected pancreatic cancer

BACKGROUND

The purpose of this study was to evaluate the significance of pathologic nodal assessment and extent of nodal metastases on patient outcome in patients with pancreatic adenocarcinoma.

MATERIALS AND METHODS

A prospectively maintained pancreatic cancer database was reviewed, and 696 consecutive patients were identified who underwent resection for pancreatic adenocarcinoma between 1995 and 2005. Overall survival was compared to lymph node (LN) status, absolute number of pathologically assessed LN, and LN ratio expressed as the number of positive LN to the total LN assessed.

RESULTS

Of the 696 patients, 598 (86%) had pancreaticoduodenectomy (PD), and 96 (14%) had distal pancreatectomy (DP). For all patients, median follow-up was 13 months (range, 0-122 months), and estimated 5-year survival was 16%. A total of 243 (35%) patients were LN-negative (N0) and had a median survival of 27 months. When assessed as a continuous variable, the number of pathologically assessed LN did not correlate with survival for N0 patients undergoing either PD or DP. The median survival for the 453 patients with node-positive (N1) disease was 16 months. When analyzed as a continuous variable, the absolute number of positive LNs was a significant predictor of survival for N1 patients with a linear relationship up to eight positive LNs. LN ratio, as a continuous variable, also predicted survival with a linear relationship up to a ratio of 0.35. A ratio of 0.18 was associated with a 19-month median survival and served as the best cutoff, p < 0.01.

CONCLUSIONS

The absolute number of positive LNs and LN ratio are strong predictors of survival for patients with node-positive pancreatic adenocarcinoma. Inadequate surgical lymphadenectomy or pathologic LN assessment understages node-negative patients.

Variations in Surgical Treatment and Outcomes of Patients With Pancreatic Cancer: A Population-Based Study

BACKGROUND

There is ongoing debate on how variations in surgical technique affect outcomes in pancreatic cancer. This population-based study examines current surgical practice and outcomes for cancer of the pancreatic head.

METHODS

All patients 18 to 85 years old diagnosed with nonmetastatic adenocarcinoma of the pancreatic head from 1998 through 2003 were identified from the Surveillance, Epidemiology and End Results (SEER) Program registry. Multivariable regression was used to elucidate factors associated with the type of pancreaticoduodenectomy performed, extent of lymph node (LN) assessment, early mortality, and late survival.

RESULTS

Overall, 2111 patients were included in the study, with 83.7% treated with a standard Whipple pancreaticoduodenectomy (PD). However, there was marked regional variation in the use of pylorus-preserving pancreaticoduodenectomy (PPPD; range, .03%-32.0%; P < .0001) and total pancreatectomy (TP; range, .04%-19.5%; P < .0001). TP was associated with significantly higher early mortality (odds ratio, 2.6; 95% confidence interval, 1.6 to 4.1; P < .0001), but late survival did not differ significantly between TP, PPPD, and PD (P = .69). Significant variation was also seen in the number of LN assessed (range across SEER regions, 7.3-13.5; P < .0001). Decreased LN assessment reduced the odds of diagnosing a patient as node positive and was associated with worse late survival.

CONCLUSIONS

In this population-based study, we found marked clinically important variability in the surgical treatment of adenocarcinoma of the pancreatic head, with respect to the use of TP, PPPD, or PD, and the extent of LN assessment. Further research is warranted to elucidate the underlying reasons, and to clarify the role of adequate lymphadenectomy.

Treatment guidelines for branch duct type intraductal papillary mucinous neoplasms of the pancreas: when can we operate or observe?

BACKGROUND

The objectives of this study were to investigate the clinicopathological features of branch intraductal papillary mucinous neoplasm (IPMN) and to determine safe criteria for its observation. Most clinicians agree that surgical resection is required to treat main duct-type IPMN because of its high malignancy rate. However, no definite treatment guideline (with respect to surgery or observation) has been issued on the management of branch duct type IPMN.

METHODS

We retrospectively reviewed the clinicopathological data of 138 patients who underwent operations for IPMN between 1993 and 2006 at five institutes in Korea.

RESULTS

Of 138 patients (mean age, 60.6 years; 87 men, 51 women), 76 underwent pancreatoduodenectomy, 39 distal pancreatectomy, 4 total pancreatectomy, and 20 limited pancreatic resection. There were 112 benign cases: 47 adenoma, 63 borderline cases, and 26 malignant cases, with 9 of these being noninvasive and 17 invasive. By univariate analysis, tumor size and the presence of a mural nodule were identified as meaningful predictors of malignancy. By receiver operating characteristic curve analysis, a tumor size of >2 cm was found to be the most valuable predictor of malignancy. When cases were classified according to tumor size and the presence of a mural nodule, the malignancy rate for a tumor </=2 cm without a mural nodule was 9.2%, for a tumor of </=2 cm plus a mural nodule was 25%, and for other conditions such as tumor >2 cm, >25%.

CONCLUSIONS

Many branch duct IPMNs are malignant. Surgical treatment is recommended, except in cases that are strongly suspected to be benign or cases that present a high operative risk. Observation is only recommended in patients with a tumor size of </=2 cm without a mural nodule.

Presidential address: adjusting the art and the science of surgery

Why are there so many opinions for surgical treatments? Why do surgeons not agree on the same definitions? To adjust the art and science of surgery, we should understand the reason behind this Tower of Babel and ourselves by grasping the three biological lessons of history. These lessons are instincts of man--our instincts have not changed for as long as there has been recorded history. The lessons were elucidated by Will and Ariel Durant and these are competition, selection, and reproduction. How might they be applied to improving our surgical science? First, competition has always forced individuals or small groups to strengthen themselves with cooperation. Cooperate or not survive. Cooperation increases with social development and technology. Next, we must realize that nature relishes diversity. We are all born unequal and diverse. The second biological lesson is selection; which individual among a diverse group of individuals will succeed (by improving)? Therefore, by nature, man's instincts provide diverse opinions and bias. This creates a myopic view when surgeons try to discern the truth. The results are the trendy bandwagons that divert us, like tonsillectomy. Too much diversity is bad, and a balance is required. Man's third lesson of history is reproduction. Better stated is that nature loves quantity. We naturally give priority to quantity over quality. To obtain quality rather than just quantity, we need the antidotes for competition and diversity--that would be cooperation using the Deming guidelines of leadership, profound knowledge, and technology. One example of this urge for quantity and diversity is our lack of standardized definitions. These three biological lessons can be summarized by viewing competition as an impediment for quality improvement in the complex challenges of modern healthcare. Cooperation (trust) is the antidote to the bandwagon effect of unproven treatments. Cooperation and technology can be joined to establish a successful team using the global technology of the internet ("Club Web"). To improve, we must measure real cases in a registry and generate a standard set of definitions and benchmarks. A focus group that trusts each other through the common interest of a disease or organ could succeed. Only then does comparison (and improvement) become possible.

Surgical management of early-stage pancreatic cancer

BACKGROUND

Pancreatic cancer remains a difficult disease to treat. Diagnosis at an early stage may allow curative treatment with resection. In the past, the mortality associated with surgical treatment of pancreatic carcinoma was prohibitive but mortality associated with resection is now commensurate with all other major oncologic resections. Thus, the focus of surgical management has shifted to address several issues: the diagnosis and evaluation of patients with suspected pancreatic cancer, the role of preoperative endobiliary stenting, the role of laparoscopy, the extent of resection, the role of adjuvant and neoadjuvant treatment, and the role of specialized centers in treating the disease.

METHODS

The current literature is reviewed to address these issues and help guide physicians who first encounter patients with suspected pancreatic cancer as well as surgeons who ultimately resect them. Practical evidence-based information to guide the decision-making process is provided.

RESULTS

Surgical morbidity and mortality have achieved parity with other types of major oncologic resection, and a distinct survival advantage is possible when such therapy is applied early in the disease stage. Issues regarding the use of stents, extent of resection, and pre- vs post-operative chemoradiation therapy are becoming clearer as our collective experience broadens.

CONCLUSIONS

Surgical treatment of pancreatic cancer should be aggressively pursued given the clearly established survival advantage and relief of symptoms achieved when it is applied appropriately.

Technical limitations of lymph node mapping in pancreatic cancer

AIM

The high incidence of lymphatic and peri-neural invasion in pancreatic cancer results in poor loco-regional control. Radical pancreatico-duodenectomy may achieve better loco-regional control, but is accompanied by increasing morbidity. Our hypothesis was that if intra-operative mapping of pathological lymph nodes (LN) is technically feasible in pancreatic cancer, it would allow for selective radical resection.

METHODS

In an ethically approved and statistically powered feasibility study of 72 (stopped after 20% enrollment) patients with suspected pancreatic cancer undergoing resection, we injected methylene blue dye peri- and intra-tumorally and studied its progress to identify putative 'sentinel lymph node(s)'. The Kausch-Whipple procedure (or total pancreatectomy, if required) was carried out in addition to radical LN dissection, which was evaluated histopathologically according to the Japanese criteria.

RESULTS

Over 18 months, 14/16 patients prospectively recruited underwent lymph node mapping and a mean of 20 (range 11-37) LNs per patient were harvested. Methylene blue dye injection identified blue LN(s) in 4/14 patients, none of which were positive for malignant deposits, whilst 10/14 patients had LN metastases. The commonest stations for LN metastasis were 17A or B (9/10), 8A (2/10) and 6 (3/10). The median survival for the 13 patients with cancer was 22.3 months (IQR: 10.4-30 months).

CONCLUSION

Sentinel lymph node mapping is not technically feasible in pancreatic cancer.

Surgery insight: surgical management of pancreatic cancer

Pancreatic ductal adenocarcinoma is a common malignancy of the gastrointestinal tract. The number of new cases diagnosed and the number of deaths each year are almost identical, demonstrating the particularly dismal prognosis for patients affected by this disease. Despite recent advances in the field of medical and radiation oncology, and the introduction of neoadjuvant and adjuvant regimens, surgery remains the single most important modality for the treatment of pancreatic ductal adenocarcinoma. Surgery for pancreatic cancer is widely viewed as a complex procedure associated with considerable perioperative morbidity and mortality. Many aspects of surgery for pancreatic cancer, such as the extent of resection, the value of vascular resection, the use of laparoscopy, and the importance of treatment at high-volume centers, are currently under debate. This Review describes the current status of surgical treatment for pancreatic ductal adenocarcinoma, and highlights the new developments in this field.

New advances in pancreatic surgery

PURPOSE OF REVIEW

New understanding of the dynamic of acute pancreatitis, the clinical impact of local pathology in chronic pancreatitis and cystic neoplastic lesions bearing high potential for malignant transformation has changed the management of pancreatic diseases.

RECENT FINDINGS

In acute pancreatitis, risk factors independently determining outcome in severe acute pancreatitis are early and persistent multiorgan failure, infected necrosis and extended sterile necrosis. The management of severe acute pancreatitis is based on early intensive-care treatment and late surgical debridement. In chronic pancreatitis, recent data from randomized controlled clinical trials have demonstrated duodenum-preserving pancreatic head resection with an inflammatory mass of the head as superior to pylorus-preserving Whipple resection. Cystic neoplasms are local lesions of the pancreas with high malignant potential. Local organ-preserving resection techniques have been applied with low morbidity and mortality, replacing a Whipple-type resection. Resection of pancreatic cancer is ineffective to cure patients. After an R0-resection, a significant survival benefit has been achieved when adjuvant chemotherapy has additionally been applied.

SUMMARY

New knowledge about the nature of inflammatory diseases, cystic neoplastic lesions and malignant pancreatic tumours has changed the indication for surgical treatment and the application of organ-preserving surgical techniques.

Vascular resection and reconstruction for pancreatic malignancy: a single center survival study

INTRODUCTION

Pancreatic cancer is one of the leading causes of cancer-related death in the USA. Recently, several centers have introduced portal and superior mesenteric vein resection and reconstruction during extended pancreatectomy, rendering the previously inoperable cases resectable.

AIM

The aim of this study is to confirm whether patients with locally advanced pancreatic cancer and mesenteric vascular invasion can be cured with extended pancreatectomy with vascular reconstruction (VR) and to compare their survival to patients treated with pancreatectomy without VR and those treated without resection (palliation).

METHODS

Survival of 22 patients who underwent pancreatectomy with VR was compared with two control groups: 54 patients who underwent pancreatectomy without the need for VR and 28 patients whose pre-operative imaging suggested resectability but whose laparotomy indicated inoperability.

RESULTS

A slight survival benefit was noted in patients who did not require VR (33.5%) compared to those who did require VR [20%, p = 0.18], although not reaching statistical significance. Despite a low 15% three-year survival in patients treated palliatively, this was not statistically different compared to survival after resection with VR (P = 0.23). The presence of nodal metastasis was associated with worse survival (p = 0.006), and the use of adjuvant therapy was associated with better survival (p = 0.001).

CONCLUSION

Pancreatic cancers that require VR to completely resect the tumor have a similar survival to those not requiring VR. Long-term survival was achievable in approximately 1 out 5 patients requiring VR, although we were not able to demonstrate statistically improved survival compared to palliative care.

Factors influencing perioperative blood transfusions in patients with gastrointestinal cancer

BACKGROUND

Patients undergoing major cancer resections often receive blood transfusions (TFs). Preoperative erythropoietin (EPO) offers the rationale to reduce TFs and related morbidity.

METHODS

Perioperative TF information was collected prospectively in a single surgeon practice over 5 years.

RESULTS

Three hundred forty-four patients underwent a major procedure, including pancreatic (n = 130, 38%), hepatobiliary (n = 87, 25%), gastroesophageal (n = 69, 20%), and other operations (n = 58, 17%). Median estimated blood loss (EBL) was 375 mL. PRBC TFs were given in 83 cases (24%), at a median of 2 units [1-16]. TF frequency and EBL did not differ between diagnoses. Multivariate TF associations existed for Hgb (P < 0.0001, OR 0.335), EBL (P < 0.0001, OR 1.007), serum Cl (P = 0.004, OR 1.25), serum Na (P = 0.02, OR 0.810), and age (P = 0.04, OR 1.033). TFs (versus no TFs) were linked to major complications (43 versus 20%, P = 0.0002), mortality (12% versus 3%, P = 0.001), and increased LOS (9 versus 7 days, P < 0.0001). A potential benefit for preoperative EPO to avoid TFs could be derived for only 31 patients (9%).

CONCLUSIONS

In this low TF rate of 24% for major visceral resections, few preoperative parameters are able to identify subgroups at risk for TFs aside from blood counts. Our data would not support generalized preoperative EPO administration.

Guidelines for the Surgical Management of Pancreatic Adenocarcinoma

Pancreaticoduodenectomy remains the most formidable operative procedure for the surgical treatment of gastrointestinal malignancy. Improved outcomes after the Whipple procedure have been attributed to better preoperative patient selection, advances in three-dimensional radiographic imaging, and regionalization of referrals to high-volume, tertiary care centers. Despite these advances, morbidity and mortality after pancreaticoduodenectomy are not insignificant and the overall prognosis following resection for adenocarcinoma of the pancreas remains poor. Improvements in endoscopic decompression of malignant biliary obstruction have decreased the need for palliative bypass operations and have focused current surgical issues on ways to improve clinical outcomes following potentially curative resections. Controversies such as whether or not to perform extended lymph node dissections, and standard versus pylorus-preserving resections have been addressed by randomized, prospective clinical trials. Major venous resections secondary to local tumor extension are now performed without an increase in morbidity or mortality and with survival rates comparable to standard resections. This has led to even more aggressive resections following neoadjuvant therapy for lesions previously considered unresectable and now perhaps better categorized as borderline resectable. The impact of surgical specialization and regionalization of referrals to tertiary care centers is evident in markedly improved perioperative mortality rates. This article will attempt to describe current guidelines for the preoperative, intraoperative, and postoperative management of patients with localized pancreatic adenocarcinoma.

Distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic body cancer: long-term results

OBJECTIVE

To analyze the long-term results of distal pancreatectomy with en bloc celiac axis resection (DP-CAR), a newly designed extended surgical procedure for locally advanced cancer of the pancreatic body.

SUMMARY BACKGROUND DATA

Pancreatic body cancer often involves the common hepatic artery and/or the celiac axis and is regarded as an unresectable disease. We previously reported the feasibility and safety of DP-CAR in 10 patients and 3 preliminary cases; however, the long-term results are unknown.

METHODS

Between May 1998 and September 2005, 23 patients underwent DP-CAR. No reconstruction of the arterial system was required because of early development of the collateral arterial pathways via the pancreatoduodenal arcades from the superior mesenteric artery. We routinely used preoperative coil embolization of the common hepatic artery to enlarge the collateral pathways.

RESULTS

The postoperative mortality rate was 0%, despite a high morbidity rate (48%). The chief postoperative complications were pancreatic fistula and ischemic gastropathy. Contrary to expectations, postoperative diarrhea was mild. Preoperative intractable abdominal and/or back pain in 10 patients was completely alleviated immediately after surgery. The surgical margins were histologically negative in 21 patients (91%). The estimated overall 1- and 5-year survival rates were 71% and 42%, respectively, and the median survival was 21.0 months. The sites of recurrence were the liver in 6 patients and local recurrence in 2.

CONCLUSIONS

DP-CAR offers a high R0 resectability rate and may potentially achieve complete local control in selected patients. The persisting early hepatic recurrence may indicate DP-CAR for the treatment of less advanced disease.

Pancreatic resection in Veterans Affairs and selected university medical centers: results of the patient safety in surgery study

BACKGROUND

Pancreatectomy is a high-risk, technically demanding operation associated with substantial perioperative morbidity and mortality. This study aims to describe the 30-day morbidity and mortality for pancreatectomy and to compare outcomes between private-sector and Veterans Affairs hospitals using multiinstitutional data.

STUDY DESIGN

This is a retrospective review of patients who underwent pancreatic resection for neoplasia at private-sector (PS) and Veterans Affairs (VA) hospitals participating in the National Surgical Quality Improvement Program Patient Safety in Surgery Study in fiscal years 2002 to 2004. The variables reviewed were demographics, preoperative medical conditions, intraoperative variables, and outcomes. Using logistic regression to control for differences in patient comorbidities, 30-day mortality and morbidity rates between PS and VA hospitals were compared.

RESULTS

A total of 1,069 patients underwent pancreatectomy for neoplasia at 97 participating hospitals. Six hundred ninety-two patients were treated at PS hospitals and 377 at VA hospitals. The average number of patients treated at each hospital was 11.0, with a range of 1 to 83 during the 3-year study period. There were 842 patients who underwent pancreaticoduodenectomy (CPT 4815x) and 227 who underwent distal/subtotal pancreatectomy (CPT 4814x). Significant differences were observed between PS patients and VA patients with regard to comorbidities and patient demographics. The 30-day unadjusted morbidity rate was 33.8% overall, 42.2% at VA hospitals versus 29.1% at PS hospitals (p < 0.0001). Unadjusted and adjusted odds ratio (OR) for postoperative morbidity comparing VA with PS hospitals was 1.781 (95% CI, 1.369-2.318) and 1.581 (95% CI, 1.064-2.307). The 30-day unadjusted operative mortality rate was 3.8% overall, 6.4% at VA hospitals and 2.5% at PS hospitals (p = 0.0015). Unadjusted and adjusted OR for postoperative mortality was 2.909 (95% CI, 1.525-5.549) and 2.533 (95% CI, 1.020-6.290), respectively. Similar outcomes were observed when looking at pancreaticoduodenectomy (CPT 4815x) when analyzed independent of other types of pancreatic resections.

CONCLUSION

Pancreatectomies are high-risk operations with substantial perioperative morbidity and mortality. Risk-adjusted outcomes for patients treated at PS hospitals were found to be superior to those for patients treated at VA hospitals in the study.

Pancreaticoduodenectomy of pancreatic ductal adenocarcinoma in the elderly

PURPOSE

Pancreatic ductal adenocarcinoma has the highest incidence between the ages of 60 and 70 years. As the elderly population has been increasing in the last several decades, the proportion of patients older than 70 years of age with resectable pancreatic cancer is expected to increase in our society. This retrospective observation was performed to evaluate surgical value of pancreaticoduodenectomy for the elderly patients with pancreatic ductal adenocarcinoma.

MATERIALS AND METHODS

From January 1990 to June 2005, among the patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma, the elder patients older than 70 years of age were retrospectively reviewed. Perioperative surgical outcomes, including general clinicopathologic features, morbidity, mortality, and survival outcomes, were investigated based on available medical records.

RESULTS

Seventy-seven patients underwent pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma. Among them, 11 patients (14.3%) were 70 years older. More frequent incidences of morbidity (8 out of 11 vs. 25 out of 65, p=0.049), especially delayed gastric emptying (3 out of 8 vs. 3 out of 66, p=0.035), were observed and overall length of hospital stay was also longer in the elderly (49.2 +/- 13.9 days vs. 36.1 +/- 13.2, p=0.012). However, no significant differences in mortality rate and survival outcomes were noted when comparing with those of the younger patients (p > 0.05).

CONCLUSION

We agree with the opinion that age factor can not be absolute contraindication for pancreaticoduodenectomy, however, appropriate preoperative evaluations, proper patient selection considering life expectancy, advanced surgical techniques and detailed perioperative management are mandatory to guarantee the safety of pancreaticoduodenectomy performed in the elderly with pancreatic ductal adenocarcinoma.

Extended Resection for Pancreatic Adenocarcinoma

Adenocarcinoma of the pancreas presents a number of therapeutic challenges. Given the poor long-term outcomes after pancreaticoduodenectomy (PD), many surgeons have sought to improve survival via a radical or "extended" pancreatectomy which may include (a) total pancreatectomy (TP), (b) extended lymph node dissection (ELND), and (c) portal/mesenteric vascular resections. These themes of "extended" resection are addressed in this review. TP should not be performed for most cases of adenocarcinoma of the pancreatic head because of the nominal incidence of lymph node involvement along the body and tail of the pancreas, the scarcity of multicentric disease, and the better management of pancreatic leaks after PD. Most studies show no difference in long-term survival and demonstrate greater postoperative morbidity after TP than after PD. Performing ELND in addition to PD is not worthwhile because most studies do not demonstrate any long-term benefits from ELND and the circumferential dissection around the mesenteric vessels required to harvest distant lymph nodes increases postoperative morbidity. Major arterial resection increases postoperative morbidity after PD and worsens long-term survival as the need for arterial resection to achieve negative resection margins indicates more aggressive disease. In contrast, portal and/or mesenteric venous resection does not increase the morbidity after PD or impact long-term survival as venous resection is often performed because of tumor location and not extent of disease. The disappointing experience with extended resections underscores the need for better adjuvant systemic strategies and the interdisciplinary care of patients with pancreatic adenocarcinoma.

Multimodality therapy for pancreatic cancer

Neoadjuvant chemoradiotherapy can be administered safely to patients with pancreatic cancer. Complete pathologic responses are rare, however, and the benefits of this approach compared with standard adjuvant therapy are uncertain. The only way to evaluate the efficacy of neoadjuvant chemoradiotherapy is a prospective trial involving a uniform patient population comparing the results of neoadjuvant and adjuvant therapy and a cohort receiving surgery alone. Such a study can be designed in an ethically sound manner but requires the collaboration of numerous institutions and careful coordination to achieve statistically conclusive results. The future of pancreatic cancer research rests on the availability and rapid transfer of new therapies from the laboratory to clinical research.

Current understanding of precursors to pancreatic cancer

Precursors to pancreatic cancer have been investigated for a century. Previous studies have revealed three distinct precursors, i.e. mucinous cystic neoplasm (MCN), intraductal papillary mucinous neoplasm (IPMN), and pancreatic intraepithelial neoplasia (PanIN), harboring identical or similar genetic alterations as does invasive pancreatic carcinoma. The current understanding of precursors to pancreatic cancer can be illustrated by progressive pathways from noninvasive MCN, IPMN, and PanIN toward invasive carcinoma. MCNs consist of ovarian-type stroma and epithelial lining with varying grades of atypia, and are occasionally associated with invasive adenocarcinoma. The epithelium of noninvasive IPMNs shows a variety of different directions of differentiation, including gastric, intestinal, pancreatobiliary (PB), and oncocytic types. IPMNs can also harbor varying grades of architectural and cytologic atypia. IPMNs confined to branch ducts are mostly the gastric type, and IPMNs involving the main ducts are often intestinal type, while PB and oncocytic types are rare. Small (<1 cm) IPMNs of the gastric type are not always morphologically distinguishable from low-grade PanINs. Mucin expression profiles suggest intestinal-type IPMNs progress to mucinous noncystic (colloid) carcinoma, while PB-type IPMNs progress toward ductal adenocarcinoma. It is a well-described paradigm that PanIN lesions progress toward ductal adenocarcinoma through step-wise genetic alterations. The activation of Hedgehog and Notch signaling pathways in PanIN lesions as well as in pancreatic adenocarcinoma suggest that developmental pathways may be disregulated during carcinogenesis of the pancreas. Further study is needed to elucidate the pathways from precursors toward invasive carcinoma of the pancreas.

Adenocarcinoma of the ampulla of Vater: T-stage, chromosome 17p allelic loss, and extended pancreaticoduodenectomy are relevant prognostic factors

OBJECTIVE

To evaluate the prognostic significance of different clinico-pathological and molecular factors, and to compare survival after standard and extended pancreaticoduodenectomy (PD) in ampulla of Vater adenocarcinoma (AVAC). There are discordant data on factors affecting prognosis, and hence therapeutic choices, in AVAC.

PATIENTS AND METHODS

Clinical-pathological factors were evaluated in 59 patients, subjected to PD for AVAC; in 42 subjects information on chromosome 17p and 18q allelic losses (LOH) and microsatellite instability (MSI) was also available. The association between survival and type of PD was investigated in the 25 patients operated between 1990 and 2001 (16 standard and nine extended).

RESULTS

The overall 5- and 10-year tumor-related survival rates were 46% and 33%, respectively. Sixteen patients had T-stages 1-2, 14 T-stage 3, and 29 T-stage 4 cancers. Chromosome 17p and 18q LOH were detected in 23 (55%) and 15 cases (36%), respectively, and in 12 cases (29%) coexisted. Five cases were MSI-positive (12%). At univariate analysis, poor survival was associated with cancer ulceration (P = 0.051), poor differentiation (P = 0.008), T-stage 4 (P < 0.001), nodal metastases (P = 0.004), chromosome 17p (P < 0.001) and 18q LOH (P = 0.002), and absence of MSI (P = 0.009). At multivariate analysis, only T-stage (P = 0.002) and 17p LOH (P = 0.001) were independent predictors of survival. All patients with MSI-positive cancers were long-survivors (>12 yrs), whereas only 30% of MSI-negative cancer patients survived at 5 years. Extended pancreaticoduodenectomy was associated with a 3-year disease-related survival higher than standard resection (83% vs 31%; P = 0.018).

CONCLUSION

MSI and chromosome 17p status allow to better define prognosis within ampullary cancers at the same stage. Surgery alone resulted curative in MSI-positive cancer patients, whereas it was inadequate in patients showing allelic losses, who might benefit from adjuvant therapy. In this observational study, extended PD was associated with increased survival compared to standard procedures.

Adjuvant Therapy of Pancreatic Cancer

Of the 33,370 patients diagnosed with pancreatic carcinoma in the United States this year, approximately 20% will present with resectable disease. At present, surgery offers the only means of cure. Radiation therapy and chemotherapy approaches have been used to enhance local and systemic control and survival. Phase III trials evaluating these modalities have led to conflicting results, leading to controversy in the use and selection of therapy. Phase II studies are now being conducted to evaluate target agent therapy with chemoradiation.

Hepaticojejunostomy--analysis of risk factors for postoperative bile leaks and surgical complications

Anastomoses between the jejunum and the bile duct are an important component of many surgical procedures; however, risk factors for clinically relevant bile leaks have not yet been adequately defined. The objective of this study was to describe the incidence of bile leaks after hepaticojejunostomy and to define predictive factors associated with this risk and with surgical morbidity. Between October 2001 and April 2004, hepaticojejunostomies were performed in 519 patients in a standardized way. Patient- and treatment-related data were documented prospectively. A bile leak was defined as bilirubin concentration in the drains exceeding serum bilirubin with a consecutive change of clinical management or occurrence of a bilioma necessitating drainage. Surgical morbidity occurred in 15% of patients, the incidence of a bile leak was 5.6%. Multivariate analysis confirmed preoperative radiochemotherapy, preoperative low cholinesterase levels, biliary complications after liver transplantation necessitating a hepaticojejunostomy, and simultaneous liver resection as risk factors for bile leakages, whereas biliary complications after liver transplantation necessitating hepaticojejunostomy, simultaneous liver resection, and diabetes mellitus were significantly associated with postoperative surgical morbidity. Our results demonstrate that hepaticojejunostomy is a safe procedure if performed in a standardized fashion. The above found factors may help to better predict the risk for complications after hepaticojejunostomy.

Prognostic relevance of lymph node ratio following pancreaticoduodenectomy for pancreatic cancer

BACKGROUND

The presence or absence of lymph node metastases is known to be an important prognostic factor for patients with pancreatic cancer. Few studies have investigated the ratio of the number of lymph nodes harboring metastatic cancer to the total number of lymph nodes examined (lymph node ratio [LNR]) with regard to outcome after pancreaticoduodenectomy for ductal cancer of the pancreas.

METHODS

Between 1995 and 2005, a total of 905 patients underwent pancreaticoduodenectomy for pancreatic adenocarcinoma. Demographics, operative data, number of lymph nodes evaluated, number of lymph nodes with metastatic carcinoma, LNR, pathologic margin status, and long-term survival were analyzed.

RESULTS

There were 187 (20.7%) of the 905 patients who had negative peripancreatic lymph nodes (N0), whereas 718 (79.3%) of the 905 patients had lymph node metastases (N1). The median number of lymph nodes evaluated in the N0 group was 15 versus 18 in the N1 group (P = .12). At median follow-up of 24 months, the median survival for all patients was 17.4 months, and the 5-year actuarial survival rate was 16.1%. Patients with lymph node metastases had a shorter median overall survival (16.5 months) compared with patients with negative lymph nodes (25.3 months; P = .001). Compared with the total number of lymph nodes examined or total number of lymph node metastases, LNR was the most compelling predictor of survival. As the LNR increased, median overall survival decreased (LNR = 0, 25.3 months; LNR > 0 to 0.2, 21.7 months; LNR > 0.2 to 0.4, 15.3 months; LNR > 0.4, 12.2 months; P = .001). After adjusting for other factors associated with survival, LNR remained an independent predictor of overall survival (P < .001).

CONCLUSIONS

After pancreaticoduodenectomy for adenocarcinoma of the pancreas, LNR was one of the most powerful predictors of survival. LNR should be considered when stratifying patients in future clinical trials.

Treatment options for hepatobiliary and pancreatic cancer

Hepatobiliary and pancreatic cancers account for 4% of all cancers in the United States. Traditionally, these cancers have had a high mortality rate and have been poorly responsive to therapy. Because of a growing number of treatment options, patients are now living longer. For hepatocellular carcinoma, a broad number of treatment options are available, including surgery, ablation, embolization, systemic therapy, and liver transplantation. Treatment options for cholangiocarcinoma include surgery, systemic therapy, and liver transplantation. For pancreatic cancer, surgery, radiation, and systemic therapy all have potential roles. This review provides an updated summary of diagnosis and assessment together with treatment options for this group of cancers.

Pancreaticoduodenectomy with extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma

Surgical resection provides the only chance for long-term survival for patients diagnosed with pancreatic and other associated periampullary adenocarcinomas. In the past, it had been suggested that the performance of an extended lymphadenectomy in association with a pancreaticoduodenal resection might have improved long-term survival for some patients. In response, six prospective trials have been performed and reported addressing this issue. These studies, including a large randomized trial of 280 patients from Johns Hopkins University, indicate that there is no demonstrable survival benefit to extended lymphadenectomy for periampullary cancer.

Resection of the mesopancreas (RMP): a new surgical classification of a known anatomical space

Background

Prognosis after surgical therapy for pancreatic cancer is poor and has been attributed to early lymph node involvement as well as to a strong tendency of cancer cells to infiltrate into the retropancreatic tissue and to spread along the peripancreatic neural plexuses. The objective of our study was to classify the anatomical-surgical layer of the mesopancreas and to describe the surgical principles relevant for resection of the mesopancreas (RMP). Immunohistochemical investigation of the mesopancreatic-perineural lymphogenic structures was carried out with the purpose of identifying possible routes of metastatic spread.

Methods

Resection of the mesopancreas (RMP) was performed in fresh corpses. Pancreas and mesopancreas were separated from each other and the mesopancreas was immunohistochemically investigated.

Results

The mesopancreas strains itself dorsally of the mesenteric vessels as a whitish-firm, fatty tissue-like layer. Macroscopically, in the dissected en-bloc specimens of pancreas and mesopancreas nerve plexuses were found running from the dorsal site of the pancreatic head to the mesopancreas to establish a perineural plane. Immunohistochemical examinations revealed the lymphatic vessels localized in direct vicinity of the neuronal plexuses between pancreas and mesopancreas.

Conclusion

The mesopancreas as a perineural lymphatic layer located dorsally to the pancreas and reaching beyond the mesenteric vessels has not been classified in the anatomical or surgical literature before. The aim to ensure the greatest possible distance from the retropancreatic lymphatic tissue which drains the carcinomatous focus can be achieved in patients with pancreatic cancer only by complete resection of the mesopancreas (RMP).

Systematic review and meta-analysis of standard and extended lymphadenectomy in pancreaticoduodenectomy for pancreatic cancer

BACKGROUND

Although some retrospective studies of extended radical lymphadenectomy for pancreatic cancer have suggested a survival advantage, this is controversial.

METHODS

A literature search identified randomized controlled trials comparing extended with standard lymphadenectomy in pancreatic cancer surgery. Overall survival was analysed using hazard ratios and standard errors. Pooled estimates of overall treatment effects were calculated using a random effects model (odds ratio and 95 per cent confidence interval).

RESULTS

Of four randomized trials identified for systematic review, three were included in a meta-analysis of survival. The log hazard ratios (standard errors) for survival for the three trials were 0.36 (0.22), - 0.15 (0.17) and - 0.21 (0.15); the weighted mean log hazard ratio for survival overall was 0.93 (95 per cent confidence interval 0.77 to 1.13), revealing no significant differences between the standard and extended procedure (P = 0.480). Morbidity and mortality rates were also comparable, with a trend towards higher rates of delayed gastric emptying for extended lymphadenectomy. The number of resected lymph nodes was significantly higher in the extended lymphadenectomy groups (P < 0.001).

CONCLUSION

The extended procedure does not benefit overall survival, and there may even be a trend towards increased morbidity. Therefore extended lymphadenectomy should be performed only within adequately powered controlled trials, if at all.

Tumour characteristics predictive of survival following resection for ductal adenocarcinoma of the head of pancreas

AIMS

We have maintained a highly conservative policy in selecting patients with carcinoma of the head of pancreas for resection. This has been based on tumour size, evidence of lymph node involvement or local invasion outside of the gland at laparotomy, laparoscopy or CT imaging. This study investigated our survival rates following pancreatic resection and examined clinicopathological predictors of survival.

METHODS

Sixty-two consecutive patients undergoing pancreatic resections for malignancy were identified from 1999 onwards. Thirty-three underwent resection for pancreatic ductal adenocarcinoma and were included in our analysis, the remainder included resections for ampullary adenocarcinoma (n=20) or other malignancies (n=9). Patient, tumour and operative characteristics were analysed to assess predictors of survival following resection (Kaplan-Meier survival curves).

RESULTS

Median survival following resection for ductal pancreatic adenocarcinoma was 54 months (ampullary adenocarcinomas achieved a median survival of 62 months) and thirty-day mortality was 2.7% (n=1). Survival was not associated with any demographic or intraoperative factors, such as blood loss, operative duration or anaesthetic technique. Survival curves were significantly worse when perineural or vascular invasion was evident histologically (p=0.023 and 0.0023 respectively). Patients with positive lymph nodes had a significantly shorter survival (p=0.0030) especially when lymph node status was expressed as a percentage of total lymph node yield. If more than 20% of retrieved lymph nodes were positive for tumour, this was a clear predictor of survival (p<0.0001). A positive resection margin was also associated with shortened survival (p=0.0291).

CONCLUSION

Despite the advances made in the management of pancreatic cancer, tumour biology still dictates long-term survival. A highly selective surgical approach to the management of these patients results in good long-term survival.

Feasibility of en-bloc wedge resection of the pancreas and/or the duodenum as an alternative to pancreatoduodenectomy for advanced gallbladder cancer

Pancreatoduodenectomy has been described as a possible treatment for gallbladder cancer that presents with evidence of direct invasion to the pancreas and/or the duodenum. This procedure does, however, carry a significantly higher morbidity and mortality if performed with a hepatectomy. An alternative procedure, therefore, of wedge resection of the invaded organ(s) was investigated in this study. On recognition of infiltration of the tumor into the pancreas and/or the duodenum, an en-bloc wedge resection of the organ(s) combined with the original tumor was the intended procedure. However, a pancreatoduodenectomy was performed if the tumor was not resectable by an attempted wedge resection. Operative and long-term outcomes were compared between patients who underwent wedge resection (n = 9) and pancreatoduodenectomy (n = 8). One patient in each group was incorrectly diagnosed preoperatively as having cancer invasion, as opposed to inflammatory changes, as recognized by subsequent histology. All tumors were excised with tumor-free pancreatic and duodenal margins. Postoperative complications occurred in one patient with wedge resection and four with pancreatoduodenectomy. One in-hospital death occurred in each group; one patient died with wedge resection of sepsis and one patient with pancreatoduodenectomy died of a pancreatic leak. No local recurrence occurred in either group. There was no difference in cumulative survival rates between the groups. Wedge resection was considered to be a feasible surgical procedure, in terms of morbidity, respectability, and long-term outcome.

Current surgical treatment for bile duct cancer

Since extrahepatic bile duct cancer is difficult to diagnose and to cure, a safe and radical surgical strategy is needed. In this review, the modes of infiltration and spread of extrahepatic bile duct cancer and surgical strategy are discussed. Extended hemihepatectomy, with or without pancreatoduodenectomy (PD), plus extrahepatic bile duct resection and regional lymphadenectomy has recently been recognized as the standard curative treatment for hilar bile duct cancer. On the other hand, PD is the choice of treatment for middle and distal bile duct cancer. Major hepatectomy concomitant with PD (hepatopancreatoduodenectomy) has been applied to selected patients with widespread tumors. Preoperative biliary drainage (BD) followed by portal vein embolization (PVE) enables major hepatectomy in patients with hilar bile duct cancer without mortality. BD should be performed considering the surgical procedure, especially, in patients with separated intrahepatic bile ducts caused by hilar bile duct cancer. Right or left trisectoriectomy are indicated according to the tumor spread and biliary anatomy. As a result, extended radical resection offers a chance for cure of hilar bile duct cancer with improved resectability, curability, and a 5-year survival rate of 40%. A 5-year survival rate has ranged from 24% to 39% after PD for middle and distal bile duct cancer.

Impact of lymph node involvement on long-term survival after R0 pancreaticoduodenectomy for ductal adenocarcinoma of the pancreas

Pancreaticoduodenectomy remains the only potentially curative treatment for adenocarcinoma of the pancreas. The aim of this study was to analyze prognostic factors impacting survival after R0 pancreaticoduodenectomy for adenocarcinoma in the head of the pancreas. Between 1995 and 2002, a potentially curative (R0) pancreaticoduodenectomy with pancreatogastrostomy for ductal adenocarcinoma in the head of the pancreas was performed in 81 patients (42 women and 39 men) with a mean age of 64 years (range 35-84). Patients were identified from a prospective database and records were reviewed retrospectively. Postoperative mortality was 1%, and 40% of patients had complications. Median survival was 18 months, and the 5-year survival was 24%. Fifteen patients were alive at 5 years. Factors associated with poor survival in multivariate analysis were (1) two or more positive lymph nodes, (2) tumor diameter greater than 30 mm, and (3) age greater than 70 years. In patients with no or with one positive lymph node, the 5-year survival was 44%. On the other hand, in patients with two or more positive lymph nodes, both the 3- and 5-year survival was 5%. The main risk factor associated with poor survival after an R0 pancreaticoduodenectomy for adenocarcinoma in the head of pancreas was lymph node status: The presence of two or more positive lymph nodes was associated with decreased survival.

Clinical impact of multidetector row computed tomography on patients with pancreatic cancer

OBJECTIVES

This study was designed to compare multidetector row computed tomography (MDCT) and CT-assisted hepatic arteriography (CTHA)/CT during arterial portography (CTAP)/angiography/contrast-enhanced CT (CECT) findings prospectively for accuracy in the detection of liver metastasis and vascular involvement of the tumor.

METHODS

The study included 43 patients with pancreatic cancer who were evaluated from September 2002 to December 2003. These patients underwent preoperative evaluation by angiography/CTHA/CTAP/CECT (7-mm thickness) and by MDCT (1.25-mm thickness).

RESULTS

The sensitivity, specificity, positive predictive value, and negative predictive value of liver metastasis diagnosis were all superior using MDCT relative to CTHA/CTAP. The diagnostic accuracy of liver metastasis for patients with tumors less than 10 mm in diameter was particularly superior with MDCT relative to CTHA/CTAP. The surgical and pathological findings of vascular involvement were more accurately diagnosed by MDCT than by CTHA/CTAP/angiography/CECT. Although MDCT findings were generally similar to surgical findings of vascular involvement, MDCT overestimated the incidence of pathological vascular involvement.

CONCLUSIONS

Multidetector row CT imaging can potentially offer more accurate staging of pancreatic cancer and may be useful to surgeons both in preoperative planning and for intraoperative guidance.

Surgical treatment of pancreatic cancer: the role of adjuvant and multimodal therapies

Surgical treatment in specialized referral centers has improved the prognosis of resectable pancreatic cancer considerably despite the generally aggressive behavior of this malignancy. At the same time, adjuvant therapy for pancreatic cancer has been shown to be effective in providing a survival benefit. However, some controversy remains over whether to use chemotherapy alone or combined chemoradiation. Few prospective randomized controlled clinical trials (RCTs) on the use of adjuvant chemotherapy and chemoradiation have demonstrated a distinct survival advantage of systemic chemotherapy (5-FU/FA or gemcitabine) following surgical resection. The most notable published trial is the European Study Group for Pancreatic Cancer (ESPAC)-1 trial. In addition, there are several retrospective analyses and two randomized studies on adjuvant radiation and chemoradiation. Some of these suggested increased survival rates using chemoradiation, which was subsequently widely introduced in clinical routine, especially in the United States. RCTs and a recent meta-analysis of these RCTs confirm, however, the superiority of chemotherapy over chemoradiation, except for a subgroup of patients with positive resection margins. Thus, curative surgery followed by adjuvant systemic chemotherapy should be the standard treatment for patients with resectable, locally confined pancreatic cancer. Further RCTs may clarify potential benefits of chemoradiation in the adjuvant treatment setting. Moreover, the best chemotherapy, or a combination thereof, remains to be determined in large-scale randomized trials.

Carcinoma of the ampulla of Vater: factors influencing long-term survival of 127 patients with resection

INTRODUCTION

The prognosis for patients with carcinoma of the ampulla of Vater is improved relative to other periampullary neoplasms. Identification of independent prognostic factors in ampullary carcinomas has been limited by the small number of tumors resected. The aim of the present study was to determine the clinicopathologic factors that influence long-term survival in patients with resected ampullary carcinoma.

METHODS

Clinicopathologic data were retrospectively reviewed for patients with ampullary carcinomas radically resected between March 1987 and September 2002. The correlation between clinicopathologic variables and survival of patients after resection was examined by the Kaplan-Meier method, the log-rank test, and Cox proportional hazards regression. Ampullary carcinomas were radically resected in 127 patients either by pancreaticoduodenectomy (n = 124) or local resection (n = 3).

RESULTS

Hospital mortality was 9.7%. The overall actuarial survival rates (including hospital deaths) at 1, 3, 5, and 10 years were 76.2%, 46.8%, 43.3%, and 35.7%, respectively. Factors that significantly influenced survival were lymph node status (P < 0.001), depth of tumor infiltration (P = 0.029), and TNM stage (P < 0.001) on univariate analysis. On multivariate analysis, both depth of infiltration and lymph node status were the independent determinants of survival after resection (P = 0.003, P = 0.005, respectively).

CONCLUSIONS

Carcinoma of the ampulla of Vater has a higher resectability rate and a much better survival rate than pancreatic cancer. Pancreaticoduodenectomy is the treatment of choice for this tumor. Long-term survival was independently influenced by the depth of tumor infiltration and lymph node metastasis.

A systematic review and meta-analysis of pylorus-preserving versus classical pancreaticoduodenectomy for surgical treatment of periampullary and pancreatic carcinoma

OBJECTIVE

Comparison of effectiveness between the pylorus-preserving pancreaticoduodenectomy ("pylorus-preserving Whipple" [PPW]) and the classic Whipple (CW) procedure.

METHODS

A systematic literature search (Medline, Embase, Cochrane Library, Biosis, Science Citation Index, Ovid Journals) was performed to identify all eligible articles. Randomized controlled trials (RCTs) comparing PPW versus CW for periampullary and pancreatic carcinoma were eligible for inclusion. The methodologic quality of included studies was evaluated independently by 2 authors. Quantitative data on perioperative parameters (blood loss, transfusion, operation time, and length of hospital stay), mortality, morbidity, and survival were extracted from included studies for meta-analysis. Pooled estimates of overall treatment effect were calculated using a random effects model.

RESULTS

In total, 1235 abstracts were retrieved and checked for eligibility and 6 RCTs finally included. The critical appraisal revealed vast heterogeneity with respect to methodologic quality and outcome parameters. The comparison of overall in-hospital mortality (odds ratio, 0.49; 95% CI, 0.17 to 1.40; P = 0.18), morbidity (odds ratio 0.89; 95% CI, 0.48 to 1.62; P = 0.69), and survival (hazard ratio, 0.74; 95% CI, 0.52 to 1.07; P = 0.11) showed no significant difference. However, operating time (weighted mean difference, -68.26 minutes; 95% CI, -105.70 to -30.83; P = 0.0004), and intraoperative blood loss (weighted mean difference, -766 mL; 95% CI, -965.26 to -566.74; P = 0.00001) were significantly reduced in the PPW group.

CONCLUSION

Hence, in the absence of relevant differences in mortality, morbidity, and survival, the PPW seems to be as effective as the CW. Given obvious clinical and methodological interstudy heterogeneity, efforts should be intensified in the future to perform high quality RCTs of complex surgical interventions on the basis of well defined outcome parameters.

Lymph node dissection impact on staging and survival of extrahepatic cholangiocarcinomas, based on U.S. population data

Cholangiocarcinomas (CC) frequently demonstrate lymphatic spread. We investigated lymph node (LN) counts after resection of extrahepatic CC and survival based on the SEER 1973-2004 database. Out of 20,068 CC patients, 1,518 individuals were selected based on M0 stage and at least one LN examined. Primary cancer sites included gallbladder (29%), extrahepatic bile ducts (26%), and intrapancreatic/ampullary bile ducts (45%); 42% of patients were LN-positive. The median number of LNs examined was four (range 1-39). Median survival was 37 months for LN-negative and 16 months for LN-positive cancers. Multivariate prognostic variables were the number of positive LNs, primary site, age (all at p < 0.0001), gender (p = 0.002), size (p = 0.005), T category (p = 0.009), and total LN count (or number of negative LNs obtained, p = 0.01). The impact of total LN counts was seen in LN-negative (median survival, 1 vs 10 or more LNs examined: 27 vs 51 months, p = 0.002) and LN-positive disease (10 vs 22 months, p < 0.0001). Survival prediction of extrahepatic CCs is strongly influenced by total LN counts and numbers of negative LNs obtained. Although the resulting incremental benefit is small, dissection and examination of 10 or more LNs should be considered for curative intent resections.

Prognostic implication of para-aortic lymph node metastasis in resectable pancreatic cancer

BACKGROUND

The survival curve of patients who undergo surgical resection of pancreatic cancer displays a steep decline within 1 year and a relatively slow decline thereafter. The patients with a short survival time may have identifiable clinicopathologic factors that lead to rapid relapse.

STUDY DESIGN

We analyzed clinicopathologic factors in 133 patients who underwent margin-negative pancreatoduodenectomy with extended radical lymphadenectomy for invasive ductal carcinoma of the pancreas to detect factors that could be responsible for the short survival.

RESULTS

Tumor size, invasion of the anterior pancreatic capsule, retroperitoneal invasion, portal venous invasion, major arterial invasion, and metastasis to the para-aortic lymph nodes were variables associated with survival time in univariate analysis. Metastasis to the para-aortic lymph nodes was the single independent factor with a significant association with mortality in multivariate analysis. Some 84% of the patients who had positive para-aortic lymph nodes died within 1 year, versus 46% of the patients with negative nodes.

CONCLUSIONS

Although tumors that involve the para-aortic lymph nodes may technically be resectable, the expected postoperative survival time for most patients is less than 1 year. If para-aortic nodal metastasis is detected, alternative treatment strategies should be considered.