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

Postoperative pancreatic fistula: an international study group (ISGPF) definition

BACKGROUND

Postoperative pancreatic fistula (POPF) is still regarded as a major complication. The incidence of POPF varies greatly in different reports, depending on the definition applied at each surgical center. Our aim was to agree upon an objective and internationally accepted definition to allow comparison of different surgical experiences.

METHODS

An international panel of pancreatic surgeons, working in well-known, high-volume centers, reviewed the literature on the topic and worked together to develop a simple, objective, reliable, and easy-to-apply definition of POPF, graded primarily on clinical impact.

RESULTS

A POPF represents a failure of healing/sealing of a pancreatic-enteric anastomosis or a parenchymal leak not directly related to an anastomosis. An all-inclusive definition is a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase content greater than 3 times the serum amylase activity. Three different grades of POPF (grades A, B, C) are defined according to the clinical impact on the patient's hospital course.

CONCLUSIONS

The present definition and clinical grading of POPF should allow realistic comparisons of surgical experiences in the future when new techniques, new operations, or new pharmacologic agents that may impact surgical treatment of pancreatic disorders are addressed.

Current management of locally advanced pancreatic cancer

Almost 30% of patients with pancreatic cancer present with large, locally advanced tumors in the absence of distant metastases. Because surgical resection is frequently contraindicated by vascular invasion, locally advanced pancreatic cancer has a dismal prognosis with a 6-10-month median survival. Recent advances in the multimodality treatment of other gastrointestinal malignancies have not altered the management of patients with locally advanced pancreatic cancer, a clinical dilemma reflected by the number of nonrandomized trials and anecdotal reports addressing this difficult disease. Our review summarizes the current status of aggressive surgical resection and neoadjuvant chemoradiation for locally advanced pancreatic cancer and suggests a treatment algorithm for patients with this disease based upon published clinical evidence.

Peripyloric lymph node metastasis is a rare condition in carcinoma of the pancreatic head

OBJECTIVES

Pylorus preserving pancreatoduodenectomy (PPPD) was introduced to achieve a better functional result compared with the conventional Kausch-Whipple procedure (PD). In PPPD, peripyloric and perigastric lymphatic tissue is not removed compared with PD. The aim of this prospective study was to identify the frequency of peripyloric and perigastric lymph node metastases in ductal adenocarcinoma of the pancreatic head (PC).

METHODS

Fifty specimens following Kausch-Whipple procedure including partial gastric resection for PC were analyzed for peripyloric and perigastric lymph node metastases by a standardized clearing technique. All lymph nodes of the specimens were counted, discriminating between those not removed ("group A") and those removed ("group B") in pylorus preserving resection of the pancreatic head. Additionally, the duodenal wall and paraduodenal tissue at a potential duodenal resection margin 2 cm distal of the pylorus were investigated histologically.

RESULTS

Three of the 50 specimens (6%) carried peripyloric lymph node metastases, whereas 32 of the 50 specimens (64%) contained lymph node metastases in total. Four of 362 group A and 90 of 748 group B lymph nodes showed metastatic spread of the carcinoma. The 4 lymph node metastases in group A could be identified exclusively in 88 peripyloric lymph nodes but in none of the 274 perigastric lymph nodes at the lesser or greater curvature. In 2 of the 3 patients with peripyloric lymph node metastases, these lymph nodes were the only lymph nodes with metastatic involvement in the entire specimen. In 1 specimen, a small tumor nest of less than 2 mm in diameter was detected at a distance of less than 1 mm to the pylorus, although pyloric involvement was not suspected intraoperatively. The potential PPPD resection margin of the duodenal wall was not infiltrated by intramural tumor spread in any specimen.

CONCLUSION

In a minority of 6%, PC metastasizes in peripyloric lymph nodes. Lymph nodes of the lesser and greater curvature of the stomach are not involved in patients with PC. Thus, we conclude by the data of this prospective study that the limited benefits of the extended lymph node dissection in a conventional Kausch-Whipple resection are far outweighed by the disadvantages construed by this procedure.

Intraoperative radiotherapy for patients with carcinoma of the pancreas

BACKGROUND/AIMS

Local recurrence is one of the most common sites of failure after resection of exocrine pancreatic adenocarcinoma. Intraoperative radiotherapy (IORT) involves delivery of high doses of irradiation to the pancreas in patients with locally advanced disease, and to the surgical bed following pancreatic resection while uninvolved and dose-limiting tissues are displaced. Here we report our current experience with IORT in patients with pancreatic cancer.

METHODS

IORT was given as adjuvant treatment in 18 and palliatively in 37 patients. External beam radiotherapy (EBRT) was in addition delivered to 10 patients in the resection group and 29 in the palliation group. The cancer diagnosis was verified histologically and/or cytologically in all patients.

RESULTS

There was no hospital mortality. Among the resected patients the postoperative complication rate was 44% (8/18). The corresponding figure after palliative operation was 14% (5/37). None of the postoperative complications were regarded as a consequence of IORT. Symptoms and complaints were observed after EBRT in 70 and 90%, respectively, in the two groups. However, no symptom was serious in nature. After resection the median survival time was 9 months (range 3-58) and local recurrence was diagnosed in 33% (6/18). In the palliatively treated patients the median survival was 7 months (range 2-30) and pain requiring opioids was present in 89% (24/27) of the patients within 6 months.

CONCLUSION

In this nonrandomized study no apparent beneficial effects were seen after IORT in patients with pancreatic cancer, neither adjuvantly nor palliatively. However, radiotherapy did not lead to any major complications.

Trp53R172H and KrasG12D cooperate to promote chromosomal instability and widely metastatic pancreatic ductal adenocarcinoma in mice

To define the genetic requirements for pancreatic ductal adenocarcinoma (PDA), we have targeted concomitant endogenous expression of Trp53(R172H) and Kras(G12D) to the mouse pancreas, revealing the cooperative development of invasive and widely metastatic carcinoma that recapitulates the human disease. The primary carcinomas and metastases demonstrate a high degree of genomic instability manifested by nonreciprocal translocations without obvious telomere erosion-hallmarks of human carcinomas not typically observed in mice. No mutations were discovered in other cardinal tumor suppressor gene pathways, which, together with previous results, suggests that there are distinct genetic pathways to PDA with different biological behaviors. These findings have clear implications for understanding mechanisms of disease pathogenesis, and for the development of detection and targeted treatment strategies.

Surgery for pancreatic cancer: recent controversies and current practice

Pancreatic duct carcinoma remains a common disease with a poor prognosis. More than 30,000 Americans will die of the disease in 2004, making it the fourth leading cause of cancer death. Despite significant advances in the treatment of many other human tumors, the 5-year survival rate for persons diagnosed with pancreatic cancer has not changed in decades and remains <5%. This is due both to the inherently aggressive biology of the disease and to its late diagnosis in most cases. Surgical resection of localized disease remains the only hope for cure of pancreatic cancer. Over the past 2 decades, significant advances in diagnostic imaging, staging, surgical technique, and perioperative care have led to marked improvement in the surgical management of pancreatic cancer patients. Operative mortality rates for pancreaticoduodenectomy are now <5% at major centers, and the average length of hospital stay has been reduced to <2 weeks. Improvements in patient outcome after pancreatic cancer surgery have made possible, for the first time, the design and conduct of large adjuvant therapy studies in pancreatic cancer. Such clinical trials are critical for improving outcomes for pancreatic cancer patients.

Early retropancreatic dissection during pancreaticoduodenectomy

BACKGROUND

During pancreaticoduodenectomy, early neck division may be inadequate, particularly in cases of replaced or accessory right hepatic artery (RHA) or diffuse intraductal papillary and mucinous neoplasm (IPMN) or when invasion of superior mesenteric artery is suspected.

METHODS

Modification of the technique of pancreaticoduodenectomy with dissection of the superior mesenteric vessels performed from behind the head of the pancreas before any pancreatic or digestive transection. The pancreas is divided later, after adequate mobilization of the specimen from the vessels, on either the neck or the body, according to underlying disease.

RESULTS

We used this technique successfully in 20 patients with a replaced or accessory RHA, which was successfully preserved in 19; one patient had inadvertent division of a 2-mm diameter accessory RHA that was ligated with no postoperative complications. Additionally, we used this technique in 18 patients with IPMN-14 pancreaticoduodenectomies extended to the body and 4 total pancreatectomies-and in 3 patients with adenocarcinoma involving the porto-mesenteric confluence and needing en-bloc vascular resection.

CONCLUSIONS

Early division of retroperitoneal margin is a useful technical variant of pancreaticoduodenectomy, which can be recommended in selective indications to improve safety and radicality of the procedure.

Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical Whipple resection—long term results

Background

It is not known whether pylorus-preserving duodenopancreatectomy is as effective as the classical Whipple procedure in the resection of pancreatic and periampullary tumours. A prospective randomized trial was undertaken to compare the results of the two procedures.

Methods

Clinical data, histological findings, short-term results, survival and quality of life of all patients having surgery for suspected pancreatic or periampullary cancer between June 1996 and September 2001 were analysed.

Results

Two hundred and fourteen patients were randomized to undergo either a standard or a pylorus-preserving Whipple resection. After exclusion of 84 patients on the basis of intraoperative findings, 130 patients (66 standard Whipple operation and 64 pylorus-preserving resection) were entered into the trial. Of these, 110 patients with proven adenocarcinoma (57 standard Whipple and 53 pylorus-preserving resection) were analysed for long-term survival and quality of life. There was no difference in perioperative morbidity. Long-term survival, quality of life and weight gain were identical after a median follow-up of 63·1 (range 4–93) months. At 6 months, capacity to work was better after the pylorus-preserving procedure (77 versus 56 per cent; P = 0·019).

Conclusion

Both procedures were equally effective for the treatment of pancreatic and periampullary cancer. Pylorus-preserving Whipple resection offers some minor advantages in the early postoperative period, but not in the long term.

The role of splenomesenteric vein anastomosis after division of the splenic vein in pancreatoduodenectomy

Division of the splenic vein was performed in 29 patients who underwent pancreatoduodenectomy to achieve lymph node dissection and neural resection around the superior mesenteric artery. The basic protocol for the splenic vein reconstruction to reduce congestion of the spleen and stomach is as follows. When the inferior mesenteric vein (IMV) drained into the splenic vein, the confluence was preserved without reconstruction of the splenic vein. When the IMV drained into the superior mesenteric vein (SMV) or the splenomesenteric angle, the division of the IMV and spleno-IMV anastomosis were performed. In postoperative venography, nine patients showed downward flow (from the splenic vein to the IMV) and three patients showed upward flow (from the IMV to the splenic vein). Postoperative computed tomography scans showed venous dilatation and splenomegaly in the upward flow group; there were no patients in the downward flow group. In selected patients, splenic vein reconstruction is necessary to reduce congestion of the spleen and stomach. When the flow is downward, spleno-IMV flow should be preserved. When the flow is upward, spleno-SMV anastomosis is necessary instead of spleno-IMV anastomosis.

[Pancreaticoduodenectomy in the era of evidence based medicine]

The aim of this comprehensive literature review was to analyse evidence based data in the field of pancreaticoduodenectomy. Pylorus preserving does reduce mortality or morbidity of the standard procedure and could increase the risk of delayed gastric emptying. Pancreaticogastrostomy does not decrease the rate of postoperative pancreatic fistula and is not superior to the pancreaticojejunal anastomosis which is more physiological. No other procedure (chemical occlusion, octreotide, stenting) has been demonstrated to prevent pancreatic fistula. Octreotide injection could be advocated in centres where there is a high rate of pancreatic fistula, when pancreatic parenchyma is soft and the main pancreatic duct thin. Intra-abdominal drainage is not beneficial and could be associated with some morbidity. Its use needs to be further evaluated. When a resection is done for pancreatic cancer, less than 5% of patients are a live five years after surgery with postoperative mortality rate of 5% in expert centres and a high morbidity rate (25-50%). Extended lymphadenectomy does not increase survival. The first trials showed that adjuvant therapies could be beneficial for pancreatic cancers, but further trials did not confirm these findings. Adjuvant therapy is not validated for pancreatic cancers and needs to be considered only in the settings of clinical trials.

Value of regional lymphadenectomy in pancreatic cancer

Radical surgical resection and adjuvant chemotherapy are the goal standard to attempt significant long term survival in patients suffering from ductal pancreatic cancer. The role of extended lymph-node dissection is still a debated issue. In this paper a deep review of the experiences reported in the literature is carried out. Several studies are limited, not randomized and retrospective: generally speaking they seem to suggest a positive role in node dissection. Unfortunately, this trend is not confirmed in the only two trials conducted in a prospective and randomized setting. Moreover the results of these studies are also difficult to compare. At the moment we can say that extended lymphadenectomy does not play a determinant role for long term survival but a positive trend has been shown for node positive patients.

Survival of patients with periampullary carcinoma is predicted by lymph node 8a but not by lymph node 16b1 status

BACKGROUND

The aim of this study was to assess the impact of metastatic disease in lymph nodes 8a and 16b1 (as defined by the Japanese Pancreas Society) on survival in patients with periampullary malignancy.

METHODS

Patients undergoing resection for primary pancreatic ductal adenocarcinoma or intrapancreatic bile duct adenocarcinoma were identified from a prospective database (September 1997-May 2003).

RESULTS

Thirteen of 54 and ten of 44 evaluable patients had metastatic involvement of lymph nodes 8a and 16b1 respectively. Metastatic involvement of lymph node 8a was associated with a significantly shorter median survival (197 versus 470 days; P = 0.003) but metastatic involvement of lymph node 16b1 did not affect survival (457 versus 503 days; P = 0.185). Multivariate analysis showed lymph node 8a status to be the strongest predictor of outcome (P = 0.006). Median survival of those with metastatic lymph node 8a was not significantly different from that of 81 patients with overt metastatic periampullary cancer at the time of diagnosis (98 days; P = 0.072)

CONCLUSION

Lymph node 8a was an independent prognostic factor in patients with periampullary malignancy, but lymph node 16b1 was not. Survival in those with metastatic lymph node 8a was not significantly different from that in patients with metastatic disease at presentation. Preoperative determination of lymph node 8a status may have important implications in selecting patients for treatment.

Pancreaticoduodenectomy with vascular resection: margin status and survival duration

Major vascular resection performed at the time of pancreaticoduodenectomy (PD) for adenocarcinoma remains controversial. We analyzed all patients who underwent vascular resection (VR) at the time of PD for any histology at a single institution between 1990 and 2002. Preoperative imaging criteria for PD included the absence of tumor extension to the celiac axis or superior mesenteric artery (SMA). Tangential or segmental resection of the superior mesenteric or portal veins was performed when the tumor could not be separated from the vein. As a separate analysis, all patients who underwent PD with VR for pancreatic adenocarcinoma were compared to all patients who underwent standard PD for pancreatic adenocarcinoma. A total of 141 patients underwent VR with PD. Superior mesenteric-portal vein resections included tangential resection with vein patch (n=36), segmental resection with primary anastomosis (n=35), and segmental resection with autologous interposition graft (n=55). Hepatic arterial resections were performed in 10 patients, and resections of the anterior surface of the inferior vena cava were performed in 5 patients. PD was performed for pancreatic adenocarcinoma in 291 patients; standard PD was performed in 181 and VR in 110. Median survival was 23.4 months in the group that required VR and 26.5 months in the group that underwent standard PD (P=0.177). A Cox proportional hazards model was constructed to analyze the effects of potential prognostic factors (VR, tumor size, T stage, N status, margin status) on survival. The need for VR had no impact on survival duration. In conclusion, properly selected patients with adenocarcinoma of the pancreatic head who require VR have a median survival of approximately 2 years, which does not differ from those who undergo standard PD and is superior to historical patients believed to have locally advanced disease treated nonoperatively.

Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula

A significant fraction of patients undergoing pancreaticoduodenectomy develop a postoperative pancreaticocutaneous fistula. To identify risk factors for this complication and to delineate its impact on patient outcomes, we conducted a retrospective review of 1891 patients undergoing pancreaticoduodenectomy between 1981 and 2002. Overall, 216 patients (11.4%) developed a postoperative pancreaticocutaneous fistula. In univariate analysis, gender, coronary disease, diabetes mellitus, operative times, blood loss, radical lymphadenectomy, gland texture, and specimen pathology correlated with fistula rates. In a multivariate model, however, only gland texture and coronary disease were statistically predictive. A soft gland was associated with a 22.6% fistula rate, a 20.4-fold increase in fistula risk over those patients with a medium or firm gland (95% confidence interval, 4.7-90.9). No patient with a firm gland developed a fistula. Although 30-day postoperative mortality was not different between those patients with and those without fistula (1.4% versus 1.5%), the mean length of stay was longer (26.0 days versus 13.2 days) and the rates of certain complications were increased in those patients with fistula. In this single-institution experience, pancreaticocutaneous fistula was most strongly predicted by pancreatic texture. Choice of anastomotic technique did not correlate with fistula rates. Pancreaticocutaneous fistula increases postoperative length of stay and morbidity but was not directly associated with increased postoperative mortality.

Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors

OBJECTIVE

A prospective randomized multicenter study was performed to assess whether the results of pylorus-preserving pancreaticoduodenectomy (PPPD) equal those of the standard Whipple (SW) operation, especially with respect to duration of surgery, blood loss, hospital stay, delayed gastric emptying (DGE), and survival.

SUMMARY BACKGROUND DATA

PPPD has been associated with a higher incidence of delayed gastric emptying, resulting in a prolonged period of postoperative nasogastric suctioning. Another criticism of the pylorus-preserving pancreaticoduodenectomy for patients with a malignancy is the radicalness of the resection. On the other hand, PPPD might be associated with a shorter operation time and less blood loss.

METHODS

A prospective randomized multicenter study was performed in a nonselected series of 170 consecutive patients. All patients with suspicion of pancreatic or periampullary tumor were included and randomized for a SW or a PPPD resection. Data concerning patients' demographics, intraoperative and histologic findings, as well as postoperative mortality, morbidity, and follow-up up to 115 months after discharge, were analyzed.

RESULTS

There were no significant differences noted in age, sex distribution, tumor localization, and staging. There were no differences in median blood loss and duration of operation between the 2 techniques. DGE was observed equally in the 2 groups. There was only a marginal difference in postoperative weight loss in favor of the standard Whipple procedure. Overall operative mortality was 5.3%. Tumor positive resection margins were found for 12 patients of the SW group and 19 patients of the PPPD group (P < 0.23). Long-term follow-up showed no significant statistical differences in survival between the 2 groups (P < 0.90).

CONCLUSIONS

The SW and PPPD operations were associated with comparable operation time, blood loss, hospital stay, mortality, morbidity, and incidence of DGE. The overall long-term and disease-free survival was comparable in both groups. Both surgical procedures are equally effective for the treatment of pancreatic and periampullary carcinoma.

The role of extended resection in pancreatic adenocarcinoma: is there good evidence-based justification?

Thus far, there are no studies concerning the radicality of pancreaticoduodenectomy which, in well-performed, randomized-controlled trials employing high standards of evidence-based medicine, show a benefit over extended lymphadenectomy. The results of the only two prospective randomized studies are not comparable and both are underpowered (level of evidence Ib). Therefore, it is still unclear whether extended lymphadenectomy for pancreatic carcinoma improves outcome. Only one study suggests a positive tendency toward increased survival rates in node-positive patients. Extended approaches including additional venous resection can be performed without a rise in the morbidity and mortality rates of patients with pancreatic carcinoma. In the future appropriately powered randomized trials of standard vs. extended resections may show the benefit of extended surgical resections. In addition, well powered trials of postoperative adjuvant therapies or preoperative neoadjuvant strategies together with surgical resections may identify more effective combinations showing a survival benefit in patients with pancreatic carcinoma.

Recurrent disease after microscopically radical (R0) resection of periampullary adenocarcinoma in patients without adjuvant therapy

The survival rate after microscopically radical resection of pancreatic duct adenocarcinoma is still poor. Patients with ampulla of Vater and distal common bile duct adenocarcinoma indicate a much more favorable prognosis. Controversy exists as to whether adjuvant therapy could improve the outcome in these patients after resection. The aim of the present study was to analyze the pattern of recurrence in patients with periampullary adenocarcinoma after pancreatoduodenectomy. Between January 1992 and December 2002, all patients with an R0 resection were identified and used for this analysis. A total of 190 patients underwent a microscopically radical resection and received no adjuvant therapy. Of those, 72 patients were diagnosed with pancreatic duct adenocarcinoma, 86 patients were diagnosed with ampulla of Vater adenocarcinoma, and 31 patients were diagnosed with distal common bile duct adenocarcinoma. Recurrent disease was indicated in 81% of the patients with pancreatic duct adenocarcinoma, 50% of the patients with ampulla of Vater adenocarcinoma, and in 74% of the patients with bile duct adenocarcinoma. Multivariate analysis revealed that lymph node metastases were prognostic for recurrent disease in patients with pancreatic duct adenocarcinoma (P = 0.038). The depth of invasion (T4, P < 0.032) and lymph node metastases (P < 0.001) were prognostic in patients with ampulla of Vater adenocarcinoma. Poor tumor differentiation (P < 0.001) was prognostic in patients with distal bile duct adenocarcinoma. Selected patients with periampullary malignancies exhibited a high recurrence rate and should be encouraged to enroll in clinical trials for adjuvant treatment including local therapy (radiotherapy) according to the identified prognostic factors.

Current standards of surgery for pancreatic cancer

Background

Pancreatic cancer carries a dismal prognosis but there has been a vast increase in evidence on its management in the past decade.

Methods

An electronic and manual search was performed for articles on the surgical treatment of pancreatic cancer published in the past 10 years.

Results

Six major areas of advancement were identified. Groups at high risk of developing pancreatic cancer, notably those with chronic pancreatitis and hereditary pancreatitis, have been defined, raising the need for secondary screening. Methods of staging pancreatic cancer for resection have greatly improved but accuracy is still only 85–90 per cent. Pylorus-preserving partial pancreatoduodenectomy without extended lymphadenectomy is the simplest procedure; it does not compromise long-term survival. Adjuvant chemotherapy significantly improves long-term survival. Patients who are free from major co-morbidity have better palliation by surgery (with a double bypass) than by endoscopy. High-volume centres improve the results of surgery for all outcome measures including long-term survival.

Conclusion

The surgical management of pancreatic cancer has undergone a significant change in the past decade. It has moved away from no active treatment. The standard of care can now be defined as potentially curative resection in a specialist centre followed by adjuvant systemic chemotherapy.

Management of bleeding and leakage after pancreatic surgery

Pancreatic surgery has advanced considerably during the past decades. Recent studies report reduced morbidity rates and virtually no mortality after resection. However, postoperative complications are still a formidable menace. In this chapter we discuss the management of postoperative bleeding and leakages which are considered the most feared complications, and discuss the advent of minimal invasive methods for management of these complications. Patients who develop postoperative bleeding almost always present with septic complications and a sentinel bleed before onset of bleeding. These patients should undergo early diagnostic angiography followed by embolisation. If this does control the bleeding an emergency laparotomy should be performed as last resort. Patients who develop pancreatic leakage are generally managed conservatively by means of percutaneous drainage. Aggressive surgery should be performed at the first sign of severe sepsis. The condition of the pancreatic remant found during reoperation dictates the type of surgical intervention best performed.

Adjuvant therapy following resection for pancreatic adenocarcinoma

Pancreatic adenocarcinoma remains a lethal disease. Approximately 10% to 15% of patients who are able to undergo resection will be alive at 5 years, but most of those will have late recurrence and ultimately die of the disease. Multiple adjuvant treatments have been tested, including extended operations, chemotherapy, radiation therapy, and immunotherapy--the vast majority with minimal, if any, effect. There is a small suggested benefit from adjuvant chemotherapy but little other cause for optimism. At the current time, given the relative failure of standard adjuvant approaches, it is reasonable to suggest that all patients should have tissue harvested for molecular markers and enter into investigative regimens.

Outcome of paraaortic node-positive pancreatic head and bile duct adenocarcinoma

BACKGROUND

This retrospective study aimed to identify the clinicopathologic features and surgical results of paraaortic node-positive periampullary adenocarcinoma.

METHODS

Between 1995 and 1999, 101 patients underwent pancreatectomy with regional and paraaortic lymphadenectomy. Fifteen (15%) patients had histologically proven paraaortic lymph node disease.

RESULTS

The 15 patients included 9 (26%) of 34 patients with pancreatic head carcinoma and 6 (17%) of 36 patients with bile duct adenocarcinoma. All 15 patients had locally advanced tumor invading adjacent structures. The 1-, 2-, and 3-year survival rates were 33%, 27%, and 0%, with median survival of 12 months (range 3 to 33). In patients with pancreatic head carcinoma or bile duct adenocarcinoma, survival curve for those without paraaortic lymph node metastasis was significantly better than that for those with involved paraaortic lymph nodes (P = 0.0033 or P = 0.0149).

CONCLUSIONS

When the paraaortic lymph nodes obtained from sampling biopsy are histologically positive, radical pancreatectomy with extended lymphatic and soft tissue clearance should be abandoned owing to poor outcome.

Intraductal papillary mucinous neoplasms of the pancreas: an updated experience

OBJECTIVE

To update the authors' experience with intraductal papillary mucinous neoplasms (IPMNs) of the pancreas.

BACKGROUND DATA

IPMNs are intraductal mucin-producing cystic neoplasms of the pancreas with clear malignant potential. Since the authors' 2001 report, the number of IPMNs resected at our institution has more than doubled, providing an opportunity to define the clinical features of this distinct neoplasm.

METHODS

All patients undergoing pancreatic resection for an IPMN at the Johns Hopkins Hospital between January 1987 and March 2003 were evaluated. Noninvasive IPMNs were classified as "adenoma," "borderline," or "carcinoma-in situ" (CIS) depending on the degree of dysplasia within the specimen. Invasive cancers were classified as tubular, colloid, mixed, or anaplastic types. Pathology was retrospectively reviewed to identify main-duct or branch-duct origin of the tumors. Long-term overall survival for patients having IPMNs with invasive cancer was compared with those patients having IPMNs without an invasive component.

RESULTS

Between January 1987 and March 2003, inclusive, 136 pancreatic resections were performed for patients with IPMNs, with 78 resections performed since January 2001. The mean age of the patients was 66.8 +/- 1.1 years, with 57% being male and 89% white. Pancreaticoduodenectomy was performed in 71% of patients, total pancreatectomy in 15%, distal pancreatectomy in 12%, and central pancreatic resection in 2%. IPMNs without evidence of invasive cancer were identified in 62% (n = 84) of patients (17% adenoma, 28% borderline, or 55% CIS). The remaining 38% (n = 52) of patients had IPMNs with associated invasive cancer (60% tubular, 27% colloid, 7% mixed, and 6% anaplastic). The mean age of patients with IPMN adenoma was 63.2 years, 66.7 years for those with borderline/CIS IPMNs, and 68.1 years for those with invasive cancer (P = 0.08, adenomas vs. invasive cancer). In those patients with invasive cancers, 15% had invasive cancer at the final surgical margin, 23% had IPMN without invasive cancer at the margin, and 54% had lymph node metastases. Residual IPMN was identified at the neck or uncinate margin in 24% of patients with noninvasive IPMNs. The overall 5-year survival for patients having IPMNs without invasive cancer was 77% (several deaths secondary to metachronous invasive cancer), compared with 43% in those patients with an invasive component (P < 0.0001). There were no differences in survival when comparing adenomas, borderline neoplasms, and CIS. Similarly, there were no statistically significant differences in survival when comparing branch-duct, main-duct, and combined variants; however, the branch-duct variants were more often noninvasive. For those patients with invasive IPMNs, 2-year survival was 40% when margins were positive for invasive cancer or for IPMN without invasive cancer, and 60% when margins were tumor-free (P = 0.15). Those patients with colloid carcinomas (n = 14) had improved survival compared with those with tubular carcinomas (n = 31), with 5-year survival rates of 83% and 24%, respectively. IPMN recurrences and deaths from cancer occurred in patients with both invasive and noninvasive IPMNs at initial resection.

CONCLUSIONS

IPMNs continue to be recognized with increasing frequency. Five-year survival for those patients following resection of IPMNs with invasive cancer (43%) is improved compared with those patients with resected pancreatic ductal adenocarcinoma in the absence of IPMN (averages 15%-25%). Survival following resection of IPMNs without invasive cancer (regardless of degree of dyplasia) is good, but recurrent disease in the residual pancreas suggests that long-term surveillance is critical. Based on the age at resection data, there appears to be a 5-year lag time from IPMN adenoma (63.2 years) to invasive cancer (68.1 years).

Main-duct intraductal papillary mucinous neoplasms of the pancreas: clinical predictors of malignancy and long-term survival following resection

OBJECTIVE

To describe clinical characteristics and outcomes of a large cohort of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas affecting the main pancreatic duct.

SUMMARY BACKGROUND DATA

IPMNs are being diagnosed with increasing frequency. Preoperative determination of malignancy remains problematic, and reported results of long-term survival following resection are conflicting.

METHODS

The combined databases from the Massachusetts General Hospital and the Pancreatic Unit of the University of Verona were analyzed. To avoid confusing overlap with mucinous cystic neoplasms, only patients with tumors of the main pancreatic duct (with or without side branch involvement) were included. A total of 140 tumors consecutively resected between 1990 and 2002 were classified as either benign (adenoma and borderline tumors) or malignant (carcinoma in situ or invasive cancer) to compare their characteristics and survival.

RESULTS

Men and women were equally affected (mean age 65 years). Seven patients (12%) had adenomas, 40 (28%) borderline tumors, 25 (18%) carcinoma in situ, and 58 (42%) invasive carcinoma. The median age of patients with benign IPMN was 6.4 years younger than those with malignant tumors (P = 0.04). The principal symptoms were abdominal pain (65%), weight loss (44%), acute pancreatitis (23%), jaundice (17%), and onset or worsening of diabetes (12%); 27% of patients were asymptomatic. Jaundice and diabetes were significantly associated with malignant tumors. Five- and 10-year cancer-specific survival for patients with noninvasive tumors was 100%, and comparable survival of the 58 patients with invasive carcinoma was 60% and 50%.

CONCLUSIONS

Cancer is found in 60% of patients with main-duct IPMNs. Patients with malignant tumors are 6 years older than their benign counterparts and have a higher likelihood of presenting with jaundice or new onset diabetes. No patients with benign tumors or carcinoma in situ died of their disease following resection, and those with invasive cancer had a markedly better survival (60% at 5 years) than pancreatic ductal adenocarcinoma. These findings support both the concept of progression of benign IPMNs to invasive cancer and an aggressive policy of resection at diagnosis.

Survival after surgical management of pancreatic adenocarcinoma: does curative and radical surgery truly exist?

Surgery for pancreatic cancer offers a low success rate but it provides the only likelihood of cure. Modern series show that, in experienced hands, the standard Whipple procedure is associated with a 5-year survival of 10%-20%, with a perioperative mortality rate of less than 5%. Most patients, however, will develop recurrent disease within 2 years after curative treatment. This occurs, usually, either at the site of resection or in the liver. This suggests the presence of micrometastases at the time of operation. Negative lymph nodes are the strongest predictor for long-term survival. Other predictors for a favourable outcome are tumour size, radical surgery and a histopathologically well-differentiated tumour. Adjuvant therapy has, so far, shown only modest results, with 5FU chemotherapy, to date, the only proven agent able to increase survival. Nowadays, the choice of therapy should be based on histopathological assessment of the tumour. Knowledge of the molecular basis of pancreatic cancer has led to various discoveries concerning its character and type. Well-known examples of genetic mutations in adenocarcinoma of the pancreas are k-ras, p53, p16, DPC4. Use of molecular diagnostics and markers in the assessment of tumour biology may, in future, reveal important subtypes of this type of tumour and may possibly predict the response to adjuvant therapy. Defining the subtypes of pancreatic cancer will, hopefully, lead to target-specific, less toxic and finally more effective therapies. Long-term survival is observed in only a very small group of patients, contradicting the published actuarial survival rates of 10%-45%. Assessment of clinical benefit from surgery and adjuvant therapy should, therefore, not only be based on actuarial survival but also on progression-free survival, actual survival, median survival and quality of life (QOL) indicators. Survival in surgical series is usually calculated by actuarial methods. If there is no information on the total number of patients and the number of actual survivors, and no clear definition of the subset of patients, actuarial survival curves can prove to be misleading. Proper assessment of QOL after surgery and adjuvant therapy is of the utmost importance, as improvements in survival rates have, so far, proved to be disappointing.

Prognostic factors in resected pancreatic adenocarcinoma: analysis of actual 5-year survivors

BACKGROUND

Pancreatic cancer is a rapidly fatal disease with very few 5-year survivors even after aggressive surgical treatment. Our objective was to determine the actual 5-year survival rate of patients with pancreatic adenocarcinoma who underwent a resection with curative intent in 5 teaching hospitals within the University of Toronto system. We then sought to determine clinical and histopathologic features of 5-year survivors to determine factors associated with a favorable prognosis.

STUDY DESIGN

A retrospective chart review was performed using surgeon and hospital databases to identify patients who had a surgical resection for pancreatic adenocarcinoma between January 1, 1988, and December 31, 1996.

RESULTS

One hundred twenty-three patients who had a resection and a pathologic diagnosis of pancreatic adenocarcinoma with complete followup were identified from seven surgical practices. Mean survival (+/- standard error) in this series was 31.7 +/- 3.5 months (median 13.6 months). There were 18 5-year survivors (14.6%), including 5 patients (4.1%) who survived longer than 10 years. The survivors included 13 patients who had undergone a Whipple resection, 4 who had undergone a distal pancreatectomy, and 1 who had undergone a total pancreatectomy. Tumor size, lack of jaundice at presentation, negative nodal disease, low tumor grade, and a low tumor stage were all significant predictors of survival in univariate analysis (all p < 0.05). Only tumor stage (hazard ratio [95% confidence interval]: stage IIA 1.5 [0.8 to 2.8], stage IIB 2.6 [1.4 to 4.7], stage III 1.8 [0.8 to 4.3]) and tumor grade (hazard ratio [95% confidence interval]: moderately differentiated 1.6 [0.9 to 2.9], and poorly differentiated 3.1 [1.6 to 6.2]) were independently associated with survival differences in a multivariate Cox proportional hazards model.

CONCLUSIONS

We conclude that longterm survival from pancreatic adenocarcinoma is possible if the disease is identified in its early stages. These and other similar data should provide further stimulus for the development and evaluation of novel screening strategies to improve early detection of this disease.

Extended radical resection versus standard resection for pancreatic cancer: the rationale for extended radical resection

OBJECTIVES

This clinical study was carried out to clarify the indications for extended radical resection for pancreatic carcinoma.

METHODS

From July 1981 to September 2003, 250 of 391 (63.9%) patients with pancreatic carcinoma underwent tumor resection in our department. Portal vein resection was performed in 171 of these 250 (68.4%) resected cases. The postoperative survival rate was studied using the operative and histologic findings.

RESULTS

Most of the patients who survived for 2 or 3 years were in the carcinoma-free surgical margins group.

CONCLUSION

The most important indication for an extended radical resection combined with portal vein resection for pancreatic cancer is the ability to obtain surgical cancer-free margins. There is no indication for an extended resection in patients in whom the surgical margins will become cancer positive if such an operation is employed.

Phase I study of stereotactic radiosurgery in patients with locally advanced pancreatic cancer

PURPOSE

To determine the feasibility and toxicity of delivering stereotactic radiosurgery to patients with locally advanced pancreatic cancer.

METHODS AND MATERIALS

Patients with Eastern Cooperative Oncology Group performance status < or=2 and locally advanced pancreatic cancer were enrolled on this Phase I dose escalation study. Patients received a single fraction of radiosurgery consisting of either 15 Gy, 20 Gy, or 25 Gy to the primary tumor. Acute gastrointestinal toxicity was scored according to the Radiation Therapy Oncology Group criteria. Response to treatment was determined by serial high-resolution computed tomography scanning.

RESULTS

Fifteen patients were treated at 3 dose levels (3 patients received 15 Gy, 5 patients received 20 Gy, and 7 patients received 25 Gy). At these doses, no Grade 3 or higher acute gastrointestinal toxicity was observed. This trial was stopped before any dose-limiting toxicity was reached, because the clinical objective of local control was achieved in all 6 evaluable patients treated at 25 Gy.

CONCLUSIONS

It is feasible to deliver stereotactic radiosurgery to patients with locally advanced pancreatic cancer. The recommended dose to achieve local control without significant acute gastrointestinal toxicity is 25 Gy.

Survival efficacy of adjuvant cytosine-analogue CS-682 in a fluorescent orthotopic model of human pancreatic cancer

Adjuvant treatment with the cytosine analogue 1-(2-C-cyano-2-deoxy-beta-D-arabino-pentofuranosyl)-N(4)-palmitoylcytosine (CS-682) results in a highly significant increase in survival in the aggressive orthotopic MIA-PaCa-2 human pancreatic cancer mouse model. Seven days after implantation, mice were randomized into eight groups, depending on whether they were to be treated by tumor resection, 5 weeks of CS-682 chemotherapy at 40-60 mg/kg once daily, or both. Throughout the course of treatment, noninvasive optical whole-body imaging based on brilliant red fluorescent protein expression of the tumor permitted visualization and quantification of primary, metastatic, and recurrent disease. Total tumor burden negatively correlated with survival. Untreated mice died of disseminated disease with a median survival of 26 days. Surgical resection alone conferred a small but significant survival advantage (median survival, 28 days, P = 0.03). Primary CS-682 treatment at all doses also significantly prolonged survival compared with untreated animals (P < 0.05) and was more effective than surgery alone at doses of 50 and 60 mg/kg (median survival, 34 days, P = 0.045, and 38.5 days, P = 0.03, respectively). Maximal survival (median, 48 days, with 30% of animals surviving longer than 60 days) was achieved by adjuvant CS-682 (50 mg/kg), given after surgical resection of the primary pancreatic tumor (P = 0.004 compared with surgery alone). The results demonstrate that adjuvant oral administration of CS-682 for pancreatic cancer is highly effective with acceptable toxicity, suggesting its potential for cure of this disease in appropriate combinations.

How can clinicians measure safety and quality in acute care?

The demand for high quality care is increasing and warranted. Evidence suggests that the quality of care in hospitals can be improved. The greatest opportunity to improve outcomes for patients over the next quarter century will probably come not from discovering new treatments but from learning how to deliver existing effective therapies. To improve, caregivers need to know what to do, how they are doing, and be able to improve the processes of care. The ability to monitor performance, though challenging in healthcare, is essential to improving quality of care. We present a practical method to assess and learn from routine practice. Methods to evaluate performance from industrial engineering can be broadly applied to efforts to improve the quality of healthcare. One method that may help to provide caregivers frequent feedback is time series data--ie, results are graphically correlated with time. Broad use of these tools might lead to the necessary improvements in quality of care.

Surgical treatment of pancreatic adenocarcinoma; actual survival and prognostic factors in 343 patients

Survival data of patients with pancreatic carcinoma are often overestimated because of incomplete follow-up. Therefore, the aim of this study was to approach complete follow-up and to analyse survival and prognostic factors of patients who underwent surgical treatment for pancreatic adenocarcinoma. Between 1992 and 2002, 343 patients underwent surgical treatment for pancreatic adenocarcinoma. One hundred and sixty patients underwent a resection with a curative intention and 183 patients underwent bypass surgery for palliation. Follow-up was complete for 93% of patients. Median survival after resection and bypass was 17.0 and 7.5 months, and 5-year survival was 8% and 0, respectively. In multivariate analysis, tumour-positive lymph nodes, non-radical surgery, poor tumour differentiation, and tumour size were independent prognostic factors for survival after resection. For patients treated with bypass surgery, metastatic disease and tumour size independently predicted survival. In conclusion, actual survival of patients with pancreatic adenocarcinoma is disappointing compared with the actuarial survival rates reported in the literature. The independent prognostic factors for survival of patients who underwent surgical treatment for pancreatic adenocarcinoma are tumour-related.

Risk factors for complications after pancreatic head resection

BACKGROUND

Postoperative morbidity is high after pancreatic head resections. Data about risk factors are controversial. The aim of this study was to evaluate risk factors for complications after pancreatic head resection and to assess whether the complication rate changed during the study period.

METHODS

Data of 301 patients undergoing pancreatic head resection were recorded prospectively. Risk factors were assessed by multivariate analysis. The first and second part of the study period were compared.

RESULTS

Mortality was 3%. Overall and surgery-related complications occurred in 42% and 28%, respectively. Independent risk factors for postoperative morbidity were impaired renal function (odds ratio [OR] 2.7), absence of preoperative biliary drainage (OR 1.9), and resection of other organs (OR 3.2). Complication rate, duration of surgery, amount of blood transfused, and length of hospital stay decreased during the study period.

CONCLUSIONS

Increasing hospital experience decreased complication rates. Patients with risk factors should be considered for transferal to specialized centers.

The challenge of pancreatic cancer

Adenocarcinoma of the pancreas is the fourth leading cause of cancer death in men and women in the United States. It affects nearly as many people each year as does the human immunodeficiency virus and has a much worse outcome. This article reviews the progress in treatment of this disease since 1975, outlines the current clinical and research challenges in the field, and suggests a plan of action to address these challenges. The world literature in the field since 1975 was reviewed, and the pancreatic cancer Progress Report Group of the National Cancer Institute (NCI) is reviewed and presented. Some progress has been made in understanding and treating pancreatic cancer since 1975. Much remains to be done. The lack of progress in the field can largely be attributed to the lack of importance and subsequent lack of research dollars attributed to it by the NCI. The NCI is addressing this issue by proposing to fund Specialized programs of research excellence grants in pancreatic cancer. In addition, other mechanisms exist within the NCI to allow for additional funding of pancreatic cancer. Using the tremendous progress made in the field of human immunodeficiency virus research as an example, it is hoped that similar improvements can be made in the field of pancreatic cancer if substantial and sustained efforts are made.

Preoperative staging and evaluation of resectability in pancreatic ductal adenocarcinoma

BACKGROUND

Cancer of the pancreas is a common disease, but the large majority of patients have tumours that are irresectable at the time of diagnosis. Moreover, patients whose tumours are clearly beyond surgical cure are best treated non-operatively, if possible, by relief of biliary obstruction and percutaneous biopsy to confirm the diagnosis and then consideration of oncological treatment, notably chemotherapy. These facts underline the importance of a standard protocol for the preoperative determination of operability (is it worth operating?) and resectability (is there a chance that the tumour can be removed?). Recent years have seen the advent of many new techniques, both radiological and endoscopic, for the diagnosis and staging of pancreatic cancer. It would be impracticable in time and cost to submit every patient to every test. This review will evaluate the available techniques and offer a possible algorithm for use in routine clinical practice.

DISCUSSION

In deciding whether to operate with a view to resecting a pancreatic cancer, the surgeon must take into account factors related to the patient, the tumour and the institution and team entrusted with the patient's care. Patient-related factors include age, general health, pain and the presence or absence of malnutrition and an acute phase inflammatory response. Tumour-related factors include tumour size and evidence of spread, whether to adjacent organs (notably major blood vessels) or further afield. Hospital-related factors chiefly concern the volume of pancreatic cancer treated and thus the experience of the whole team. Determination of resectability is heavily dependent upon detailed imaging. Nowadays conventional ultrasonography can be supplemented by endoscopic, laparoscopic and intra-operative techniques. Computed tomography (CT) remains the single most useful staging modality, but MRI continues to improve. PET scanning may demonstrate unsuspected metastases and likewise laparoscopy. Diagnostic cholangiography can be performed more easily by MR techniques than by endoscopy, but ERCP is still valuable for preoperative biliary decompression in appropriate patients. The role of angiography has declined. Percutaneous biopsy and peritoneal cytology are not usually required in patients with an apparently resectable tumour. The prognostic value of tumour marker levels and bone marrow biopsy is yet to be established. Preoperative chemotherapy or chemoradiation may have a role in down-staging an irresectable tumour sufficiently to render it resectable. Selective use of diagnostic laparoscopy staging is potentially helpful in determination of resectability. Laparotomy remains the definitive method for determining the resectability of pancreatic cancer, with or without portal vein resection, and should be undertaken in suitable patients without clear-cut evidence of irresectability.

Preinvasive and invasive ductal pancreatic cancer and its early detection in the mouse

To evaluate the role of oncogenic RAS mutations in pancreatic tumorigenesis, we directed endogenous expression of KRAS(G12D) to progenitor cells of the mouse pancreas. We find that physiological levels of Kras(G12D) induce ductal lesions that recapitulate the full spectrum of human pancreatic intraepithelial neoplasias (PanINs), putative precursors to invasive pancreatic cancer. The PanINs are highly proliferative, show evidence of histological progression, and activate signaling pathways normally quiescent in ductal epithelium, suggesting potential therapeutic and chemopreventive targets for the cognate human condition. At low frequency, these lesions also progress spontaneously to invasive and metastatic adenocarcinomas, establishing PanINs as definitive precursors to the invasive disease. Finally, mice with PanINs have an identifiable serum proteomic signature, suggesting a means of detecting the preinvasive state in patients.

Treatment of pancreatic cancer: challenge of the facts

Adenocarcinoma of the pancreas is associated with the worst survival of any form of gastrointestinal malignancy. In spite of the progress in surgical treatment, resulting in increasing resection rates and a decrease in treatment-related morbidity and mortality, the true figures of cure are even today below 3%. The dissemination of pancreatic cancer behind the local tissue compartments restricts the short-term (< 3 years) and long-term outcome for patients who have undergone resection. By histological evaluation, less than 15% of the patients undergoing R(0) resection have a pN(0) status, more than 60% suffer from lymph angiosis carcinomatosa, and more than 50% suffer extrapancreatic nerve plexus infiltration. Hematoxylin and eosin-negative lymph nodes were found to be cancer positive when reverse transcriptase polymerase chain reaction (RT- PCR) or immunostaining was applied to the HE-negative lymph nodes. Cancer of the uncinate process has a very poor prognosis because there are no early symptoms; vessel wall involvement occurs early and frequently; a high association of liver metastasis exists as well. Surgery offers a low success rate, but it provides the only chance of cure. Ductal pancreatic cancer is diagnosed in more than 95% of the cases in an advanced stage; potentially curative resection can be performed only in about 10%-15% of these patients. Major contributions of surgery to improved treatment results are the reduction of surgical morbidity--e.g., early postoperative local and systemic complications--and a decrease of hospital mortality below 3%-5%. In most recently published prospective trials, R(0) resection has been reported to result in an increase in short-term survival beyond that recorded for patients with residual tumor. However, R(0) resection fails to improve long-term survival. In many published R(0) series, standard tissue resection of pancreatic head cancer with the Kausch-Whipple procedure failed to include remote cancer cell-positive tissues in the operative specimen; e.g., N(2)-lymph nodes, nerve plexus, and perivascular extrapancreatic and retropancreatic tissues were not excised. Cancer recurrence after so-called R(0) resection with curative intent is frequently the consequence of cancer left behind. Thus, long-term survival (> 5 years) is observed in a very small group of patients, contradicting the published 5-year actuarial survival rates of 20%-45% for resected patients. The assessment of clinical benefit from surgical or medical cancer treatment should therefore be based on several end points, not only on actuarial survival. Publication of actuarial survival figures must include the number of observed (actual) survivals, the definition of the subset of patients followed after resection, and the total number of patients in the study group; anything less is misleading. In reporting pancreatic cancer treatment trial results after oncological resections, more convincing primary end points to evaluate treatment efficacy are median survival (in months), actual survival at 1-5 years, and progression-free survival (in months). In series with multimodality treatment, clinical benefit response as well as quality of life measurements using the EORTC Quality of Life index C30 (QLQ-C30) are of importance in evaluating survival data. Adjuvant treatment improves survival after oncological resection; however, the short-term and long-term benefit after adjuvant chemotherapy in R(0) as well as in R(1)-(2) resected patients has not yet been underscored by data from controlled clinical trials. The survival benefit (median survival time) of adjuvant chemotherapy or radiochemotherapy has been demonstrated to be 6-10 months. Therefore, after oncological resection of pancreatic cancer each patient should be offered adjuvant treatment. A neoadjuvant treatment protocol for pancreatic cancer, however, has not been established.

Survival benefits of portal vein resection for pancreatic cancer

BACKGROUND

The efficacy of portal vein resection for pancreatic cancer is controversial.

METHODS

Eighty-one consecutive patients with pancreatic cancer undergoing surgical resection were retrospectively analyzed. The clinicopathological findings and relationship between portal vein resection and survival were investigated.

RESULTS

Thirty-three patients with pancreatic cancer underwent pancreatic resection with portal vein resection. Histological examination revealed that 17 patients had definite invasion to the portal vein (group 1) and 16 patients had no invasion (group 2). Forty-eight patients with pancreatic cancer underwent pancreatic resection without portal vein resection (group 3). There were no significant differences in survival rates (P = 0.437) between patients with portal vein resection and patients without portal vein resection. However, patients in group 1 had a significantly (P = 0.021) worse prognosis as compared with those in group 2. Despite aggressive surgical resection, the surgical margin was positive in 35% of patients in group 1 as compared with 13% of patients in group 2 and 21% of patients in group 3.

CONCLUSIONS

Patients undergoing portal vein resection for pancreatic cancer had a prognosis similar to patients without portal vein resection. Negative microscopic invasion to the portal vein was significantly associated with improved survival.

An evidence-based approach to the surgical management of resectable pancreatic adenocarcinoma

BACKGROUND

Randomized prospective trials have addressed various treatment approaches to pancreatic adenocarcinoma in order to improve on the dismal prognosis associated with this disease. We conducted a comprehensive review of prospective randomized clinical trials and summarized the contemporary treatment of resectable pancreatic carcinoma.

STUDY DESIGN

A literature search strategy identified prospective randomized clinical trials for pancreatic carcinoma using standard medical subject heading terms. The articles were critically reviewed and ranked according to a standardized three-tiered system (Ia, Ib, Ic) by a panel of experts.

RESULTS

Surgical studies have demonstrated that morbidity and mortality are similar for pylorus-preserving and classic pancreaticoduodenectomy. Extended retroperitoneal lymphadenectomy can be performed with similar mortality but increased morbidity compared with standard pancreaticoduodenectomy but does not prolong survival. Pancreaticogastrostomy and pancreaticojejunostomy appear to be comparable techniques for pancreatic duct reconstruction. Pancreatic-enteric anastomosis is associated with lower rates of pancreatic fistula and endocrine insufficiency than duct occlusion without anastomosis. Intraperitoneal drainage after pancreatic resection is unwarranted and may contribute to intraabdominal complications. Routine use of prophylactic octreotide does not lower the rate of pancreatic fistula; it should be considered for reoperative pancreatic resection or for a soft gland. Early trials found that adjuvant chemoradiation therapy prolongs survival. But in more recent studies chemoradiation after resection has failed to show a survival advantage over surgery alone.

CONCLUSIONS

Surgical resection remains the only potentially curative therapy for adenocarcinoma of the pancreas. There is no clear indication as to a single preferable resection approach.

Pancreaticoduodenectomy: role of interventional radiologists in managing patients and complications

Although the mortality rate after pancreaticoduodenectomy has decreased, the morbidity rate remains high. Major morbidity is often managed with the aid of interventional radiologists. The objective of this study was to evaluate the cooperative roles of interventional radiologists and pancreatic surgeons in complex pancreatic surgery, specifically pancreaticoduodenectomy. Our pancreaticoduodenectomy database was reviewed for all patients undergoing pancreaticoduodenectomy between January 1, 1995 and December 31, 2000. The interventional radiologic procedures for each patient were evaluated. A total of 1061 patients underwent pancreaticoduodenectomy. The overall mortality and morbidity rates were 2.3% and 35%, respectively. Five hundred ninety patients (56%) had no interventional radiologic procedures, whereas 471 patients (44%) had interventional radiologic procedures. Of those, 342 (32%) had preoperative biliary drainage (PBD) and 129 (12%) required postoperative interventional radiologic procedures. Percutaneous aspiration/catheter drainage was required in 84 patients for intra-abdominal abscess, biloma, or lymphocele, with 24 requiring two or more abscess drains. Thirty-nine patients underwent postoperative PBD for bile leaks due to anastomotic disruption, undrained biliary segments, or T-tube/bile stent dislodgment. Eighteen patients had hemobilia/gastrointestinal bleeding treated by angiography with embolization. The reoperation rate for the entire cohort of 1061 patients was 4.1% (n = 43). Nineteen of the 129 patients (15%) requiring postoperative radiologic intervention required reoperation. Although 4 of 18 patients who required embolization for bleeding subsequently required surgical intervention for the same reason, only 4 of 84 patients undergoing abscess drainage later required operation for anastomotic disruption or unsuccessful percutaneous drainage. As would be expected, the patients who required postoperative radiologic intervention (n = 129) had a higher incidence of postoperative complications including pancreatic fistula (20% vs. 6%, P < 0.01), bile leakage (22% vs. 1%, P < 0.01), and wound infection (16% vs. 8%, P < 0.01). With the complications in these 129 patients, the postoperative mortality rate was only 6.2% compared to 1.7% in patients who did not require radiologic intervention (n = 932, P < 0.01). The median postoperative length of stay was 15 days in those patients requiring postoperative radiologic intervention, 10 days in those not requiring intervention (P < 0.01; postoperative interventional radiology vs. no postoperative interventional radiology), and 29.5 days for patients needing reoperation. Interventional radiologists play a critical role in the management of some patients undergoing pancreaticoduodenectomy. Although complications such as anastomotic leaks, abscess formation, and bleeding can result in increased mortality and a longer hospital stay, the skills of the interventional radiology team provide expert management of some life-threatening complications, thus avoiding reoperation, speeding recovery times, and minimizing morbidity.

Standard vs. radical pancreaticoduodenectomy for periampullary adenocarcinoma: a prospective, randomized trial evaluating quality of life in pancreaticoduodenectomy survivors

This study was designed to assess the health-related quality of life (QOL) of patients who had been randomly assigned to either standard or radical pancreaticoduodenectomy for periampullary adenocarcinoma. Pancreaticoduodenectomy has been performed in increasing numbers for periampullary adenocarcinoma. The appropriate extent of resection (standard vs. radical [extended]) remains controversial, particularly as concerns survival benefit. Past reports comparing standard vs. radical resection have suggested that the more extensive resection is attended by negative functional outcomes (diarrhea and weight loss) and poorer QOL, diminishing the impact of any possible survival advantage of the radical resection. A prospective, randomized single-institution trial comparing standard pancreaticoduodenectomy (pylorus preservation preferred) to radical pancreaticoduodenectomy (including distal gastrectomy and retroperitoneal lymphadenectomy) evaluated 299 patients with periampullary adenocarcinoma between April 1996 and June 2001. A standard Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep) QOL survey designed for hepatobiliary cancer was sent to 150 of these patients surviving pancreaticoduodenectomy. QOL and functional status were assessed via a series of subscale scores for physical, social, emotional, and functional well-being. A total of 105 QOL surveys (70%) were returned and analyzed, with 55 of the patients having been randomized to the standard group and 50 to the radical group. The patients were evaluated at a mean of 2.2 years after pancreaticoduodenectomy. The two groups were statistically similar with regard to multiple parameters including age at operation (64.6 years), race, intraoperative blood transfusions, pathologic diagnosis and staging, and perioperative complications. The radical group had a significantly higher percentage of men (66% vs. 44%; P = 0.02), a longer operative time (369 minutes vs. 327 minutes; P < 0.001), and a longer postoperative length of hospital stay (13.6 days vs. 10.1 days; P < 0.01). The FACT-Hep total QOL scores were similar between the standard and radical groups: 143.5 vs. 147.3, respectively. Additionally, the individual FACT-G subscale scores evaluating physical (22.1 vs. 23.3), social (24.5 vs. 24.4), emotional (19.2 vs. 19.6), and functional well-being (20.6 vs. 22.4) were comparable between the standard and radical groups. Subgroup analyses based on pathologic diagnosis (pancreatic, ampullary, distal bile duct, etc.) failed to reveal any differences in QOL assessment between the standard and radical pancreaticoduodenectomy groups. Finally, QOL measures were similar when comparing time since operation (<2 years' follow-up vs. >2 years' follow-up) and age (< or =65 years vs. >65 years). This is the largest report comparing QOL assessment in survivors of pancreaticoduodenectomy randomized between standard and radical resection. These data demonstrate no differences in long-term QOL between standard and radical resection. These results imply that no negative long-term QOL measures are associated with radical pancreaticoduodenectomy (as performed in this study) for periampullary adenocarcinoma.

Gastrointestinal problems in diabetes

Gastrointestinal symptoms are often encountered in patients with diabetes mellitus. Symptoms may arise in any region of the alimentary tract; common symptoms are heartburn, nausea, vomiting, diarrhea, constipation, fecal incontinence, and abdominal pain. This article reviews practical approaches to the identification of the pathophysiologic mechanisms involved in diabetic enteropathies and their complications and briefly outlines strategies to treat these symptoms. Particular emphasis is placed on applied physiologic tests and the choice of pharmacotherapy (e.g., cisapride, erythromycin, or octeotide). The current role of pancreatic transplantations also is briefly reviewed.