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

Central vascular ligation and mesentery based abdominal surgery

In the nineteenth century the idea of a correct surgical approach in oncologic surgery moved towards a good lymphadenectomy. In colon cancer the segment is removed with adjacent mesentery, in gastric cancer or pancreatic cancer a good oncologic resection is obtained with adequate lymphadenectomy. Many guidelines propose a minimal lymph node count that the surgeon must obtain. Therefore, it is essential to understand the adequate extent of lymphadenectomy to be performed in cancer surgery. In this review of the current literature, the focus is on "central vascular ligation", understood as radical lymphadenectomy in upper and lower gastrointestinal cancer, the evolution of this approach during the years and the improvement of laparoscopic techniques. For what concerns laparoscopic surgery, the main goal is to minimize post-operative trauma introducing the "less is more" concept whilst preserving attention for oncological outcomes. This review will demonstrate the importance of a scientifically based standardization of oncologic gastrointestinal surgery, especially in relation to the expansion of minimally invasive surgery and underlines the importance to further investigate through new randomized trials the role of extended lymphadenectomy in the new era of a multimodal approach, and most importantly, an era where minimally invasive techniques and the idea of "less is more" are becoming the standard thought for the surgical approach.

Reconsideration of the Appropriate Dissection Range Based on Japanese Anatomical Classification for Resectable Pancreatic Head Cancer in the Era of Multimodal Treatment

Patients with resectable pancreatic cancer are considered to already have micro-distant metastasis, because most of the recurrence patterns postoperatively are distant metastases. Multimodal treatment dramatically improves prognosis; thus, micro-distant metastasis is considered to be controlled by chemotherapy. The survival benefit of "regional lymph node dissection" for pancreatic head cancer remains unclear. We reviewed the literature that could be helpful in determining the appropriate resection range. Regional lymph nodes with no suspected metastases on preoperative imaging may become areas treated with preoperative and postoperative adjuvant chemotherapy. Many studies have reported that the R0 resection rate is associated with prognosis. Thus, "dissection to achieve R0 resection" is required. The recent development of high-quality computed tomography has made it possible to evaluate the extent of cancer infiltration. Therefore, it is possible to simulate the dissection range to achieve R0 resection preoperatively. However, it is often difficult to distinguish between areas of inflammatory changes and cancer infiltration during resection. Even if the "dissection to achieve R0 resection" range is simulated based on the computed tomography evaluation, it is difficult to identify the range intraoperatively. It is necessary to be aware of anatomical landmarks to determine the appropriate dissection range during surgery.

The Current Treatment Paradigm for Pancreatic Ductal Adenocarcinoma and Barriers to Therapeutic Efficacy

Pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis, with a median survival time of 10-12 months. Clinically, these poor outcomes are attributed to several factors, including late stage at the time of diagnosis impeding resectability, as well as multi-drug resistance. Despite the high prevalence of drug-resistant phenotypes, nearly all patients are offered chemotherapy leading to modest improvements in postoperative survival. However, chemotherapy is all too often associated with toxicity, and many patients elect for palliative care. In cases of inoperable disease, cytotoxic therapies are less efficacious but still carry the same risk of serious adverse effects, and clinical outcomes remain particularly poor. Here we discuss the current state of pancreatic cancer therapy, both surgical and medical, and emerging factors limiting the efficacy of both. Combined, this review highlights an unmet clinical need to improve our understanding of the mechanisms underlying the poor therapeutic responses seen in patients with PDAC, in hopes of increasing drug efficacy, extending patient survival, and improving quality of life.

Differences in the clinicopathological features of pancreatic head carcinoma in dorsal and ventral pancreas: A single institution retrospective review

ABSTRACT

The embryonic development of the pancreas originates from dorsal and ventral anlagen, and the pancreatic cancer arising from dorsal or ventral pancreas may have different clinical pathology features. This study aims to explore whether there are differences in clinicopathological features and prognosis of pancreatic head carcinoma arising from dorsal or ventral pancreas.Between January 2014 and February 2018, 101 patients with resectable pancreatic head cancer who underwent pancreaticoduodenectomy in our institution were retrospectively reviewed. The patients were assigned into 2 groups according to tumor location on preoperative imaging materials (computed tomography/magnetic resonance imaging [CT/MRI]), and the clinicopathological features and prognosis were retrospectively analyzed in view of the embryonic development of the pancreas.Among these patients with pancreatic head cancer, 42 patients had tumors arising from dorsal pancreas (D group) and 59 patients had tumors arising from ventral pancreas (V group). The frequency of lymph node (LN) metastasis around the common hepatic artery (CHA) and hepatoduodenal ligament lymph nodes in the D group was higher than that in the V group (45.2% vs 10.2%, P = .001). And the rate of LN metastasis in the superior mesenteric artery (SMA) region in the V group is higher than that in the D group (32.2% vs 4.8%, P = .002). The D group was more likely to invade the common bile duct (78.6% vs 59.3%, P = .042) and duodenum (71.4% vs 44.1%, P = .006) than the V group. In addition, the survival outcome of V group was better than D group (median overall survival [OS], 15.37 months vs 10.53 months, P = .048, median DFS 9.73 months vs 5.93 months, P = .046).The clinicopathological features of pancreatic head carcinoma arising from dorsal or ventral pancreas are different, and the pancreatic head carcinoma arising from ventral pancreas has a better survival outcome.

Optimal Lymphadenectomy of the Mesopancreas Based on Fluorescence Imaging During Pancreaticoduodenectomy

BACKGROUND

Excision of the mesopancreas with lymphadenectomy is an important component of pancreatoduodenectomy. However, the optimal extent of lymphadenectomy remains unclear. Furthermore, accurate description of the mesopancreatic lymphatic pathways is difficult, probably because of the complex anatomy. Intestinal derotation simplifies the anatomy and facilitates both examination of lymphatic flow and the surgical procedure. The aim of this study was to evaluate lymphatic flow in the mesopancreas using indocyanine green fluorescence imaging with an intestinal derotation technique, and to clarify the optimal extent of mesopancreas excision and lymphadenectomy in pancreatoduodenectomy.

METHODS

Indocyanine green solution (2.5 × 10^-3 mg) was injected into the pancreatic head parenchyma. After intestinal derotation, the spread of indocyanine green was observed using near-infrared imaging.

RESULTS

Participants comprised 10 patients who underwent pancreatoduodenectomy for periampullary neoplasms. With indocyanine green fluorescence imaging, 9 of the 10 patients showed lymphatic flow from the pancreatic head to the superior mesenteric artery via the inferior pancreaticoduodenal artery and first jejunal artery (but not via the second and more distant arteries), with eventual drainage into the paraaortic region.

CONCLUSIONS

Lymphatic pathways from the pancreatic head were connected to the superior mesenteric artery via the inferior pancreaticoduodenal artery and first jejunal artery. Excision of the mesopancreas with the inferior pancreaticoduodenal artery and first jejunal artery while preserving the second or more distant arteries appears optimal in pancreatoduodenectomy for periampullary malignancies.

Practical significance of pancreatectomy with lymphadenectomy around the superior mesenteric artery for pancreatic cancer: comparison of prognosis after adjusting for major prognostic factors

INTRODUCTION

Although pancreatectomy with lymph node (LN) and nerve plexus dissection has usually been performed for pancreatic cancer, recent randomized controlled trials have questioned its survival benefits. However, superior mesenteric artery (SMA) LN dissection has still been included in standard treatment guidelines.

METHODS

A total of 94 patients who underwent pancreaticoduodenectomy for resectable pancreatic cancer without LN enlargement around the SMA on imaging were identified between 2008 and 2017. Disease-free survival (DFS), overall survival (OS), and complications were compared between those with LN and hemicircumferential nerve plexus dissection around the SMA (SMA ly+) and those without thorough LN and nerve plexus dissection around the SMA (SMA ly-) after adjusting for major prognostic factors.

RESULTS

A total of 78 and 16 patients with SMA ly+ and SMA ly- were identified, respectively. Our data demonstrated no difference in DFS and OS rates between both groups (P = 0.18 and 0.83, respectively). Patients with SMA ly+ had significantly more complications, particularly severe diarrhea, compared to those with SMA ly- (P = 0.001).

CONCLUSION

LN and nerve plexus dissection around the SMA did not prolong survival and significantly increased the frequency of severe diarrhea, suggesting that performing in all cases carries less practical significance.

Current Status and Future Perspectives of Perioperative Therapy for Resectable Biliary Tract Cancer: A Multidisciplinary Review

Simple Summary

For decades, there has been no globally accepted neoadjuvant or adjuvant therapy in resectable biliary tract cancer. Based on the results of the BILCAP trial, adjuvant capecitabine has been widely regarded as standard adjuvant therapy. Focusing on the management of resectable biliary tract cancer, this article reviews each therapeutic strategy including surgery, chemotherapy and radiotherapy, and summarises published and ongoing clinical trials of neoadjuvant and adjuvant therapy.

Abstract

Biliary tract cancers (BTCs) are a group of aggressive malignancies that arise from the bile duct and gallbladder. BTCs include intrahepatic cholangiocarcinoma (IH-CCA), extrahepatic cholangiocarcinoma (EH-CCA), and gallbladder cancer (GBCA). BTCs are highly heterogeneous cancers in terms of anatomical, clinical, and pathological characteristics. Until recently, the treatment of resectable BTC, including surgery, adjuvant chemotherapy, and radiation therapy, has largely been based on institutional practice guidelines and evidence from small retrospective studies. Recently, several large randomized prospective trials have been published, and there are ongoing randomized trials for resectable BTC. In this article, we review prior and recently updated evidence regarding surgery, adjuvant and neoadjuvant chemotherapy, and adjuvant radiation therapy for patients with resectable BTC.

Insulinbedarf und Glukosehomöostase bei Menschen nach partieller und totaler Pankreatektomie im Vergleich zu Menschen mit anderen Diabetesformen

Einleitung Pankreasresektionen werden bei schwerwiegenden Pankreaserkrankungen durchgeführt. Bei Komplikationen einer chronischen Pankreatitis, teilweise jedoch auch bei Raumforderungen, kann eine Pankreasteilresektion sinnvoll sein. Eine totale Pankreatektomie führt zum absoluten Insulinmangel und der Notwendigkeit einer Insulintherapie. Bei Teilresektionen (partielle Pankreatektomie) werden weniger gravierende Konsequenzen für den Glukosemetabolismus erwartet. Es ist das Ziel der vorliegenden Arbeit, die Insulinregime nach Pankreatektomie mit denen anderer Diabetesformen zu vergleichen.

Material und Methodik Es wurden Patientencharakteristika und Details der postoperativen Insulintherapie von pankreasoperierten Patienten einer spezialisierten Universitätsklinik für Viszeralchirurgie ausgewertet. Diese Daten wurden mit Kohorten nicht operierter Patienten mit Typ-1-Diabetes (T1DM; absoluter Insulinmangel) bzw. Typ-2-Diabetes (T2DM; Insulinresistenz und relativer Insulinmangel), jeweils unter Insulintherapie, verglichen. Ergänzt wurde diese Datenanalyse durch eine Literaturrecherche zu den Stichworten „pancreatogenic diabetes“, „type 3c diabetes“ und „pancreatectomy diabetes“.

Ergebnisse Daten von 32 (68,8 % Frauenanteil) bzw. 41 (43,9 % Frauenanteil) Patienten nach totaler bzw. partieller Pankreatektomie wurden analysiert. Vor der totalen Pankreatektomie hatten 56,3 % der Patienten einen Diabetes mellitus, postoperativ bestand bei allen Patienten eine Insulinpflichtigkeit. Dabei waren die Insulindosierungen im Vergleich mit Patienten mit T1DM (unter intensivierter Insulintherapie) signifikant niedriger (p < 0,0001). Die Dosierungen von Basal- (48,6 % weniger) und Mahlzeiteninsulin (38,1 % weniger) waren gleichermaßen betroffen. Eine partielle Pankreatektomie führte deutlich seltener zu einem Diabetes mellitus, und eine Insulintherapie war nur bei 26,8 % der Patienten erforderlich.

Diskussion Der basale und prandiale Insulinbedarf nach Pankreatektomie ist niedriger als bei einem T1DM und einem T2DM. Dies sollte bei der Blutzuckereinstellung nach Pankreatektomie berücksichtigt werden.

Extended lymph node resection versus standard resection for pancreatic and periampullary adenocarcinoma

BACKGROUND

Pancreatic and periampullary adenocarcinomas account for some of the most aggressive malignancies, and the leading causes of cancer-related mortalities. Partial pancreaticoduodenectomy (PD) with negative resection margins is the only potentially curative therapy. The high prevalence of lymph node metastases has led to the hypothesis that wider excision with the removal of more lymphatic tissue could result in an improvement of survival, and higher rates of negative resection margins.

OBJECTIVES

To compare overall survival following standard (SLA) versus extended lymph lymphadenectomy (ELA) for pancreatic head and periampullary adenocarcinoma. We also compared secondary outcomes, such as morbidity, mortality, and tumour involvement of the resection margins between the two procedures.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PubMed, and Embase from 1973 to September 2020; we applied no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCT) comparing PD with SLA versus PD with ELA, including participants with pancreatic head and periampullary adenocarcinoma.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened references and extracted data from study reports. We calculated pooled risk ratios (RR) for most binary outcomes except for postoperative mortality, for which we estimated a Peto odds ratio (Peto OR), and mean differences (MD) for continuous outcomes. We used a fixed-effect model in the absence of substantial heterogeneity (I² < 25%), and a random-effects model in cases of substantial heterogeneity (I² > 25%). Two review authors independently assessed risk of bias, and we used GRADE to assess the quality of the evidence for important outcomes.

MAIN RESULTS

We included seven studies with 843 participants (421 ELA and 422 SLA). All seven studies included Kaplan-Meier curves for overall survival. There was little or no difference in survival between groups (log hazard ratio (log HR) 0.12, 95% confidence interval (CI) -3.06 to 3.31; P = 0.94; seven studies, 843 participants; very low-quality evidence). There was little or no difference in postoperative mortality between the groups (Peto odds ratio (OR) 1.20, 95% CI 0.51 to 2.80; seven studies, 843 participants; low-quality evidence). Operating time was probably longer for ELA (mean difference (MD) 50.13 minutes, 95% CI 19.19 to 81.06 minutes; five studies, 670 participants; moderate-quality evidence). There was substantial heterogeneity between the studies (I² = 88%; P < 0.00001). There may have been more blood loss during ELA (MD 137.43 mL, 95% CI 11.55 to 263.30 mL; two studies, 463 participants; very low-quality evidence). There was substantial heterogeneity between the studies (I² = 81%, P = 0.02). There may have been more lymph nodes retrieved during ELA (MD 11.09 nodes, 95% CI 7.16 to 15.02; five studies, 670 participants; moderate-quality evidence). There was substantial heterogeneity between the studies (I² = 81%, P < 0.00001). There was little or no difference in the incidence of positive resection margins between groups (RR 0.81, 95% CI 0.58 to 1.13; six studies, 783 participants; very low-quality evidence).

AUTHORS' CONCLUSIONS

There is no evidence of an impact on survival with extended versus standard lymph node resection. However, the operating time may have been longer and blood loss greater in the extended resection group. In conclusion, current evidence neither supports nor refutes the effect of extended lymph lymphadenectomy in people with adenocarcinoma of the head of the pancreas.

Clinical Implication of Node-negative Resectable Pancreatic Cancer

BACKGROUND

Lymph node metastasis is one of the strongest prognostic factors of pancreatic cancer. However, the clinical implication of pathologically node-negative pancreatic cancer (pN0-PC) has not been fully investigated.

METHODS

Patients who underwent surgical resection for radiologically resectable pancreatic cancer between 2002 and 2018 were included in this study. A clinicopathological examination focusing on pN0-PC was performed.

RESULTS

Of all 533 patients, 155 (29.1%) were diagnosed with pN0-PC and 378 (70.9%) were diagnosed with node-positive pancreatic cancer (pN1/2-PC). The 5-year survival rates of patients with pN0-PC and pN1/2-PC were 57.1% and 25.0%, respectively (p < 0.001). A multivariate analysis revealed six prognostic factors in pN0-PC: age ≥ 70 years, nonadministration of adjuvant chemotherapy, anterior serosal invasion, nerve plexus invasion, and microscopic lymphatic and venous invasions. The 5-year survival rates of patients who had pN0-PC with 0-1 risk factor, with 2-3 risk factors, and with 4-6 risk factors were 87.6%, 47.9%, and 16.4%, respectively. Survival of patients who had pN0-PC with 4-6 risk factors was comparable to that of pN1/2 patients. The diagnostic capability of metastasis-negative lymph node was unsatisfactory, with a predictive value of < 43%.

CONCLUSIONS

Although the prognosis of patients with pN0-PC was better than that of patients with pN1/2-PC, it is not satisfactory. Survival of patients who had pN0-PC with 0-1 risk factors was extremely favorable; however, survival of patients who had pN0-PC with 4-6 risk factors was similar to those with pN1/2-PC.

[Stereotactic body radiotherapy for locally advanced pancreatic cancer: A systemic review]

Stereotactic body radiation therapy (SBRT) for locally advanced pancreatic cancer (LAPC) is an emerging treatment option. Most studies showed local control of approximately 75% with no evidence of improved overall survival. Gastrointestinal toxicities could be significant, ranging up to 22% for acute toxicities≥grade 3+ and 44% for late toxicities≥grade 3+. Currently, no standardized guidelines for treatment and management scheme. We conducted a systemic review of published prospective and retrospective trials to evaluate the efficacy, safety, technical data, and discuss future directions.

Role of Node Dissection in Pancreatic Tumor Resection

BACKGROUND

Pancreatic cancer is a lethal disease, and, even with modern therapies, the mortality has not decreased significantly in decades. The prognostic importance of lymph node status is well defined; however, the role of extended lymphadenectomy to improve local recurrence and overall survival remains debated. Six randomized controlled trials have evaluated the extent of lymph node dissection in pancreaticoduodenectomy for pancreatic cancer.

OBJECTIVE

We sought to review the current literature to evaluate the role of lymphadenectomy in pancreatic cancer. The impact of each trial and its contribution to the literature is discussed.

CONCLUSIONS

Multiple randomized trials have failed to note an improvement in overall survival with extended lymphadenectomy for pancreatic cancer. Rather, extended lymphadenectomy was associated with increased morbidity, operating room time, and length of stay.

Essential updates 2018/2019: Current topics in the surgical treatment of pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is highly malignant. While cancers in other organs have shown clear improvements in 5-year survival, the 5-year survival rate of pancreatic cancer is approximately 10%. Early relapse and metastasis are not uncommon, making it difficult to achieve an acceptable prognosis even after complete surgical resection of the pancreas. Studies have been performed on various treatments to improve the prognosis of PDAC, and multidisciplinary approaches including non-surgical treatments have led to gradual improvement. In the present literature review, we have described the significance of anatomical and biological resectability criteria, the concept of R0 resection in surgical treatment, the feasibility of minimally invasive surgery, the remarkable development of perioperative chemotherapy, the effectiveness of conversion surgery for unresectable PDAC, and ongoing challenges in PDAC treatment. We also provide an essential update on these subjects by focusing on recent trends and topics.

En bloc proximal peri-mesenteric clearance for pancreatic head cancer surgery

The superior mesenteric artery (SMA) first approach and meso-pancreas excision (MPE) during pancreatoduodenectomy (PD) for pancreatic head cancer have been suggested for complete local tumor control, less operative blood loss, and early determination of resectability. However, SMA-first approach is merely a mode of approach and the concept of MPE has been challenged due to its anatomical obscurity. Dissection around proximal mesenteric vessels, superior mesenteric vein and SMA, is a critical procedure point for local tumor control as tumor infiltration is frequently observed both at the time of initial diagnosis and recurrence. The meso-pancreas, which encompasses the soft tissue between the uncinated process and SMA, does not include all the aforementioned points of proximal mesenteric areas. Therefore, the authors propose a new terminology named, “en bloc proximal peri-mesenteric clearance (PPMC)”, to describe the removal of all the lymph nodes including soft tissue around proximal mesenteric vessels, especially the SMA, to ensure complete local tumor control of pancreatic head cancer. The SMA-first approach applied either by the mesenteric approach or supra-colic approach can make this procedure more feasible. The extent of the circumferential dissection of the peri-SMA nerve plexus can be adjusted according to the primary disease. PPMC including the removal of all lymph nodes around the proximal SMA may be considered as a standard extent of PD for pancreatic head cancer.

Pattern of local recurrence after curative resection in pancreatic ductal adenocarcinoma according to the initial location of the tumor

BACKGROUND/PURPOSE

The aim of the present study was to identify the types of recurrence in pancreatic ductal adenocarcinoma (PDAC) and discover the frequent location of the local recurrence.

METHODS

This study included 361 patients with PDAC who underwent curative-intent surgery between 2007-2014.

RESULTS

Among 361 patients, 75.1% (n = 271) developed recurrence during the follow-up period. The 5-year overall survival rate of recurred patients was 8.3%. The patterns of recurrence were classified as local (17.7%), systemic (62.0%), and loco-systemic (20.3%). According to the preoperative tumor locations, patients with uncinate and head cancer showed higher rates of local recurrence than those with body and tail cancer (47.8% vs 17.2%, P < .001). When comparing uncinate and head cancer only, patients with uncinate cancer had much more frequent local recurrence around the superior mesenteric artery/vein (M zone) than around the hepatoduodenal ligament/common hepatic artery (H zone). Patients with head cancer had a higher rate of local recurrence in the H zone (H zone vs M zone; 53.5% vs 81.4% in uncinate cancer, P = .001; 66.7% vs 44.4% in head cancer, P = .056).

CONCLUSION

Discovering the patterns of recurrence and frequent locations of recurrence may assist in local control as well as in the development of a customized individual approach for each patient.

Predictors of early recurrence following a curative resection in patients with a carcinoma of the ampulla of Vater

PURPOSE

Ampulla of Vater (AoV) carcinoma has a relatively good prognosis. The 5-year recurrence rate for AoV is still around 40%-50% however, and most recurrences occur in the early period. The aim of this study was to identify predictors of an early recurrence in AoV patients following a curative resection.

METHODS

The clinicopathological data for 501 consecutive patients that underwent a resection for AoV in our institute between January 2000 and December 2015 were retrospectively reviewed. The characteristics of any recurrences and early recurrence patients were analyzed accordingly. Early recurrence was defined as occurring within one year of resection.

RESULTS

There were 170 diagnosed recurrences in our study population, 57.1% of whom were men, with a mean age of 60.1 years (range, 30-94 years). Almost all of the study patients underwent a pancreaticoduodenectomy, and 9% underwent minimally invasive surgery. Of the 170 recurrent cases, 107 were diagnosed with an early recurrence and had 1-, 3-, and 5-year overall survival rates of 77.7%, 18.4%, 10.5%, respectively. The factors that significantly influenced early recurrences, determined by multivariate analysis, lymphovascular invasion (LVI), lymph node ratio (LNR), and poor differentiation were found to be independent determinants of a recurrence within 1 year.

CONCLUSION

An early recurrence in AoV patients is ultimately lethal even though this cancer has a good prognosis. LVI, LNR, and poor differentiation are powerful predictors of an early recurrence in AoV. Hence, intensive surveillance and new therapeutic strategies should be considered for AoV patients with these predictors following a curative resection.

Risk Stratification for the Intensive Care Unit Following Pancreaticoduodenectomy

INTRODUCTION

In view of the limited capacities in intensive care units and the increasing economic burden, identification of risk factors could allow better and more efficient planning. Therefore, the aim of this study was to assess independent risk factors for the duration of intensive care unit stay after pancreatoduodenectomy (PD).

METHODS

147 patients who underwent pancreatoduodenectomy in the time period from 2013 to 2015 were identified from a prospective database and a retrospective analysis was performed. The primary endpoint was length of time spent in the ICU. A retrograde analysis was performed using univariate and multivariate regression analysis. All pre-, intra- and postoperative parameters were considered in the analysis.

RESULTS

The median time spent in the intensive care unit (ICU) is one day. The univariate analysis demonstrated increased pack years, cerebrovascular events, anticoagulation, elevated creatinine and CA 19-9 as preoperative risk factors. In multivariate analysis, antihypertensive medication (AHT; OR 2.46; 95% CI 1.57 - 3.87; p = 0.05), operation time (OR 1.01; 95% CI 1.00 - 1.01; p = 0.03), extended LAD (OR 5.46; 95% CI 2.77 - 10.75; p = 0.01) and severe PPH (OR 4.01; 95% CI 2.07 - 7.76; p = 0.04) are significant risk factors for longer ICU stay.

DISCUSSION

Patients with cardiovascular risk factors and elevated preoperative creatinine level are at greater risk for a prolonged ICU stay. Risk and benefit of an extended LAD should be weighed during the operation. Median duration on ICU/IMC after PD is one day or less for patients without risk factors. Whether routine monitoring in the ICU/IMC after PD is necessary must be clarified in further studies.

Pancreatic body and tail cancer and favorable metastatic lymph node behavior on the left edge of the aorta

BACKGROUND

Lymph node (LN) metastasis in pancreatic body-tail cancer is a poor prognostic factor and the optimal LN dissection area for distal pancreatectomy (DP) remains unclear. Lymphatic flow from the tumors is thought to depend on the tumor sites. We examined LN metastasis frequency based on tumor site and recurrent patterns post-DP.

METHODS

With a retrospective, single institutional study, we examined 100 patients who underwent DP as an upfront surgery for pancreatic cancer over 17 years. Tumor sites were classified as tumor confined to pancreatic body (and neck) (Pb(n)); and pancreatic tail (Pt). We compared metastatic LN and recurrence patterns based on tumor site. The median overall survival (OS) and disease-free survival (DFS) were analyzed.

RESULTS

LN metastasis occurred in 59/100 (59.0%), with 23 and 25 tumors located in the Pb(n), and Pt, respectively. Those with the tumor in Pt had metastases to #10, #11d/p, and #18 LN mainly. However, the patients with the Pb(n) tumor had metastases to #8a/p, #11p, and #14p/d LN. There was no metastasis to #10 and #11d LN. The OS and DFS were 34 and 15 months, respectively. No significant difference was found in the OS, DFS, and recurrence patterns based on tumor sites.

CONCLUSION

Differences in metastatic LN sites were observed in pancreatic body-tail cancer when tumors were confined to the left or right of the left aortic edge. Although it is necessary to validate this finding with a large-scale study, organ-preserving DP might be a treatment option for selected patients depending on the tumor sites.

Critical evaluation of quality of hepatopancreatic surgery in a medium-volume center in Finland using the Accordion Severity Grading System and the Postoperative Morbidity Index

Background

Hepatopancreatobiliary surgery is prone to complications. Methods are needed to monitor surgical outcomes and enable comparison between institutions.

Methods

Complications were collected prospectively and reviewed using the modified Accordion Severity Grading System (MASGS) and the Postoperative Morbidity Index (PMI).

Results

This study included 527 consecutive patients receiving either pancreatic or liver resection in 2000-2017 in Central Finland Central Hospital. The PMI was 0.177 for all patients, and 0.192, 0.094, 0.285, and 0.129 for patients receiving major pancreatic (n=218), minor pancreatic (n=93), major liver (n=73), and minor liver (n=143) resection, respectively. The rates of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomies (n=200) were 6.5% for grade B and 5.5% for grade C; rates for biliary leak were 1.0% (grade A), 2.5% (grade B), and 0.5% (grade C). Similarly, the rates for delayed gastric emptying (DGE) were 2.8% (grade A), 15.6% (grade B), and 3.7% (grade C). Postoperative hepatic dysfunction occurred in 2.3%, major surgical site bleeding in 2.3%, and biloma in 7.9% of patients after liver resection. Ninety-day mortality rates were 3.7% and 1.1% in major and minor pancreatic resections, and 8.2% and 0.7% in major and minor liver resections. Major complications occurred in 13.3% and 3.3% in pancreatic, and 19.2% and 6.3% in liver resections, respectively.

Conclusions

Major pancreatic and hepatic surgery are associated with significant morbidity and burden in our center, comparable with previous population-based studies. PMI is an informative way to monitor surgical outcomes and enable comparison between institutions.

Impact of examined lymph node count on prognosis in patients with lymph node-negative pancreatic body/tail ductal adenocarcinoma

Background

Because the overall prognosis remains dismal for patients with resected pancreatic cancer (PC), we aimed to explore the prognostic impact of examined lymph node (ELN) count on lymph node (LN)-negative pancreatic body/tail ductal adenocarcinoma.

Methods

Patients' data were extracted from the Surveillance, Epidemiology, and End Results (SEER) database (National Cancer Institute, USA) to investigate the relationship between ELN count and survival outcomes of LN-negative pancreatic body/tail ductal adenocarcinoma.

Results

A total of 700 patients were included, and the median number of ELNs was 11. The respective 1-, 3-, 5-year overall survival (OS) rates were 75.3%, 37.7%, 30.3%, and the 1-, 3-, 5-year cancer-specific survival (CSS) were 78.3%, 41.7%, 34.5%. The X-tile analysis showed that 14 was the most optimal cutoff for both OS and CSS. Kaplan-Meier survival analysis indicated that patients with ELNs >14 had better OS and CSS than ELNs ≤14. Multivariate Cox analysis showed ELNs ≤14 was an independent risk factor for both OS [hazard ratio (HR), 1.357; 95% confidence interval (CI), 1.080-1.704; P=0.009] and CSS (HR, 1.394; 95% CI, 1.092-1.778; P=0.008).

Conclusions

ELN count is associated with the survival rate in patients with LN-negative pancreatic body/tail ductal adenocarcinoma. Accurate nodal staging for these patients requires more than 14 ELNs.

Role of lymphadenectomy in resectable pancreatic cancer

BACKGROUND

Pancreatic cancer (PC) remains one of the most devastating malignant diseases, predicted to become the second leading cause of cancer-related death by 2030. Despite advances in surgical techniques and in systemic therapy, the 5-year relative survival remains a grim 9% for all stages combined. The extent of lymphadenectomy has been discussed intensively for decades, given that even in early stages of PC, lymph node (LN) metastasis can be detected in approximately 80%.

PURPOSE

The primary objective of this review was to provide an overview of the current literature evaluating the role of lymphadenectomy in resected PC. For this, we evaluated randomized controlled studies (RCTs) assessing the impact of extent of lymphadenectomy on OS and studies evaluating the prognostic impact of anatomical site of LN metastasis and the impact of the number of resected LNs on OS.

CONCLUSIONS

Lymphadenectomy plays an essential part in the multimodal treatment algorithm of PC and is an additional therapeutic tool to increase the chance for surgical radicality and to ensure correct staging for optimal oncological therapy. Based on the literature from the last decades, standard lymphadenectomy with resection of at least ≥ 15 LNs is associated with an acceptable postoperative complication risk and should be recommended to obtain local radicality and accurate staging of the disease. Although radical surgery including appropriate lymphadenectomy of regional LNs remains the only chance for long-term tumor control, future studies specifically assessing the impact of neoadjuvant therapy on extraregional LNs are warranted.

Mesopancreas level 3 dissection in robotic pancreaticoduodenectomy

BACKGROUND

There are no reports of performing mesopancreas dissections in robotic pancreaticoduodenectomy. This study evaluated the feasibility and justification for mesopancreas level 3 dissection in robotic pancreaticoduodenectomy.

METHODS

Surgical outcomes after robotic pancreaticoduodenectomy and open pancreaticoduodenectomy were evaluated and compared.

RESULTS

There were 289 robotic pancreaticoduodenectomy and 162 open pancreaticoduodenectomy patients included in the study. Postoperative diarrhea occurred in 34.5% of mesopancreas level 3 dissection cases and was higher than in levels 2 and 1 dissection cases, P < .001. Blood loss in the robotic pancreaticoduodenectomy group was higher for mesopancreas level 3 dissection, with a median loss of 263 mL (P = .015). The rate of R0 resection with margin >1 mm was higher for mesopancreas level 3 dissection (93.8%) than for level 2 dissection (72.2%) (P < .001). The lymph node yield was higher for mesopancreas level 3 dissection in robotic pancreaticoduodenectomy; the median lymph node yield was 21 for level 3, 18 for level 2, and 14 for level 1 (P < .001). Compared with mesopancreas levels 1 and 2 dissections in the robotic pancreaticoduodenectomy groups, level 3 dissection did not show increased surgical mortality or postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, postpancreatectomy hemorrhage, chyle leakage, bile leakage, or wound infection. Compared with open pancreaticoduodenectomy, mesopancreas level 3 dissection in robotic pancreaticoduodenectomy had less blood loss, no delayed gastric emptying, and lower chyle leakage.

CONCLUSION

Mesopancreas level 3 dissection in robotic pancreaticoduodenectomy is feasible without compromising surgical safety. Therefore, robotic pancreaticoduodenectomy can be recommended as a safe alternative to open pancreaticoduodenectomy for mesopancreas level 3 dissection.

Reconsidering the Optimal Regional Lymph Node Station According to Tumor Location for Pancreatic Cancer

BACKGROUND

A consensus regarding the optimal extent of lymph node dissection for pancreatic cancer has not yet been achieved. The purpose of this study was to evaluate the efficacy of lymph node dissection according to the location for pancreatic cancer.

METHODS

A total of 495 patients diagnosed with invasive ductal carcinoma of the pancreas who had undergone a pancreatectomy between October 2002 and December 2015 were analyzed. The efficacy index (EI) was calculated for each lymph node station via multiplication of the frequency of metastasis to the station and the 5-year survival rate of the patients with metastasis to that station.

RESULTS

For pancreatic head (Ph) tumors, mesocolon lymph nodes had a high EI, although not regional. For pancreatic body (Pb) tumors, peri-Ph lymph nodes had a high EI, although not regional. For pancreatic tail (Pt) tumors, lymph nodes along the celiac axis and common hepatic artery had a zero EI, although regional. When the Ph was segmented into the pancreatic neck (Ph-neck), uncinate process (Ph-up), and periampullary regions, hepatoduodenal ligament lymph nodes had a zero EI for Ph-up, although regional; the mesojejunum lymph node also had a zero EI, even for Ph-up, regardless of a high incidence of metastasis. Regarding lymph node recurrence after surgery, recurrence was most frequently found at the peri-Ph lymph node (12%) in patients with Pb tumors who had undergone a distal pancreatectomy.

CONCLUSIONS

The optimal extent of lymph node dissection should be estimated in regard to the tumor location.

The Necessity of Dissection of No. 14 Lymph Nodes to Patients With Pancreatic Ductal Adenocarcinoma Based on the Embryonic Development of the Head of the Pancreas

Objectives: Pancreaticoduodenectomy (PD) followed by lymphadenectomy is performed for patients with pancreatic ductal adenocarcinoma (PDAC) located in the head of the pancreas. Because the head of the pancreas could be divided into dorsal or ventral primordium in relation to embryonic development, the metastasis of lymph node (LN) may differ. In this retrospective study, we evaluated the impact of extended or standard LN dissection for PDAC located in ventral or dorsal primordia of the pancreatic head.

Methods: From February 2016 to November 2018, 178 patients who underwent PD for PDAC were enrolled at the Pancreatic Disease Center, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University. According to the tumor location and the range of LN dissection, all patients were divided into three groups: ventral primordium with extended lymphadenectomy (VE group), ventral primordium with standard lymphadenectomy (VS group), and dorsal primordium with extended lymphadenectomy (DE group). Clinical and pathological features were retrospectively analyzed as were the long-term survival outcomes.

Results: More patients in the VE group were detected with metastasis in the lymph nodes around the superior mesenteric artery (LN14) than those in the DE group (LN along the right side of the superior mesenteric artery, LN14ab): 22.9 vs. 5.9%, p = 0.005; (LN along the left side of the superior mesenteric artery, LN14cd): 10.0 vs. 0.0%, p = 0.022. LN14 was involved in more patients in the VE group than in the VS group (22.9 vs. 5.0%, p = 0.015). For IIb-stage patients in the VE group, the overall survival time (18.3 vs. 9.3 months, p < 0.001) and disease-free survival time (12.2 vs. 5.1 months, p = 0.045) were longer in those with LN14cd (–) than those with LN14cd (+).

Conclusion: This study suggested that patients with PDAC located in the ventral head of the pancreas had higher risk of LN14 involvement compared with those at dorsal. Thus, a thorough dissection of LN14 in PDAC located in the ventral head of the pancreas is recommended to optimize the regional extended lymphadenectomy.

Effect of bile duct clamping versus no clamping on surgical site infections in patients undergoing pancreaticoduodenectomy: a randomized controlled study

BACKGROUND

Infectious complications cause significant morbidity after pancreatoduodenectomy (PD). The impact of uncontrolled spillage of bile during PD has not been systematically studied.

METHODS

Patients undergoing PD for malignant lesions between March 2017 and May 2019 were considered for inclusion. All patients underwent standard pre-operative preparation and antibiotic prophylaxis. After confirmation of resectability, the patients were randomized into one of the two groups: common hepatic duct clamping using atraumatic bulldog clamp after biliary division (Group I) or no clamping (Group II). Post-operative outcomes including surgical site infection (SSI) were compared.

RESULTS

Fifty-two patients were assessed for eligibility and eventually 40 were randomized (median age: 53.5 years, 28 (70%) males). Twenty patients were randomized into each group and 14 in each group had undergone pre-operative biliary drainage. Incidence of co-morbidities, operative time and blood loss were comparable between the two groups. SSI was significantly lower in Group I (4 (20%) versus 11 (55%), P = 0.02). Number needed to treat to prevent one SSI was 3. Incidence of intra-abdominal collections was higher in Group II, though, not statistically significant (2 (10%) versus 6 (30%), P = 0.23). The duration of post-operative antibiotics was significantly higher in Group II (7 IQR 4 versus 11 IQR 7 days, P = 0.04). Among the risk factor evaluated in the entire population, higher incidence of SSI was seen in patients with positive bile culture (13 (65%) versus 2 (10%), P = 0.04).

CONCLUSION

Bile duct clamping during PD reduces risk of superficial SSI.

Pancreatoduodenectomy With Arterial Resection for Locally Advanced Pancreatic Cancer of the Head: A Systematic Review

The development of increasingly effective chemotherapy regimens and increasing tumor necrosis is allowing radical pancreatectomy to be re-evaluated. This systematic review examines the outcome of patients with locally advanced cancer of the pancreatic head after pancreatectomy with arterial resection. Electronic searches were performed on PubMed and Medline databases between January 2000 and December 2018. The end points were to determine the safety and overall survival after arterial resection in pancreatectomy. Thirteen studies with 467 patients were included. Celiac, hepatic, mesenteric, and splenic arteries were resected across all studies. The median overall morbidity was 52% (range, 37%-100%) and with major complications occurring in a median of 25% (range, 12%-54%) of patients. The median 90-day mortality was 5% (range, 0%-17%). R0 was achieved in 66% (range, 43%-100%) and R1 in 31% (range, 0%-74%). The median survival was 17 (range, 7-29) months with a 1- and 3-year survival of 59% (range, 16%-92%) and 17% (range, 0%-13%), respectively. Pancreatectomy with arterial resection may be safely performed in high-volume centers with acceptable survival results in highly selected patients. Pooling of data through a multi-institutional registry will allow a more accurate assessment of the safety and efficacy of this treatment strategy.

Total mesopancreas excision for periampullary malignancy: a single-center propensity score-matched comparison of long-term outcomes

PURPOSE

Few comparative studies are available on the long-term prognostic role of mesopancreas (MP) excision after pancreaticoduodenectomy (PD). We compared the long-term outcomes of patients undergoing standard PD (sPD) and PD with MP excision (PD-MPe).

METHODS

Sixty sPDs were compared to 60 matched PD-MPe patients for intraoperative and postoperative data, histopathological findings, and long-term outcomes.

RESULTS

R0 rate was similar in the two groups (p = 0.17). However, PD-MPe related to a lower rate of MP resection margin positivity (16.7% vs 5%; p = 0.04) and to a higher harvested lymph nodes number (19.8 ± 7.6 vs 10.1 ± 5.1; p < 0.0001). Local tumor recurrence was more frequent in the sPD cohort (55.5% vs 26.8% in the PD-MPe group; p = 0.002), with a consequent worse disease-free survival (DFS) (14.8% vs 22.3%; p = 0.04). An inferior 5-year overall survival (OS) was noted in case of MP margin positivity compared with MP margin negativity (0% vs 29%; p < 0.0001). MP positivity resulted as an independent prognostic factor for both a worse OS and DFS at the multivariate analysis.

CONCLUSION

PD-MPe offers clinical advantages in terms of MP resection margin status, local recurrence, long-term mortality, and DFS. The lower MP positivity rate, achieved with PD-MPe, leads to better outcomes both in terms of OS and DFS.

Comparative Effectiveness of Pylorus-Preserving Versus Standard Pancreaticoduodenectomy in Clinical Practice

OBJECTIVES

We compared risk-adjusted short- and long-term outcomes between standard pancreaticoduodenectomy (SPD) and a pylorus-preserving pancreaticoduodenectomy (PPPD).

METHODS

The National Cancer Database was queried for the years 2004 to 2014 to identify patients with adenocarcinoma of the pancreatic head undergoing SPD and PPD. Margin status, lymph node yield, length of stay (LOS), 30- and 90-day mortality, and overall survival were compared.

RESULTS

A total of 11,172 patients were identified, of whom 9332 (83.5%) underwent SPD and 1840 (16.5%) PPPD. There was no difference in patient age, sex, stage, tumor grade, radiation treatment, and chemotherapy treatment between the 2 groups. Total number of regional lymph nodes was examined, and surgical margin status and overall survival were also comparable. However, patients undergoing PPPD had a shorter LOS (11.3 vs 12.3 days, P < 0.001), lower 30-day mortality (2.5% vs 3.7%, P = 0.02), and 90-day mortality (5.5% vs 6.9%, P = 0.03). On multivariate analyses, patients undergoing SPD were at higher risk for 30-day mortality compared with PPPD (odds ratio, 1.51; 95% confidence interval, 1.07-2.13).

CONCLUSIONS

Standard pancreaticoduodenectomy and PPPD are oncologically equivalent, yet PPPD is associated with a reduction in postoperative mortality and shorter LOS.

Regional pancreatoduodenectomy versus standard pancreatoduodenectomy with portal vein resection for pancreatic ductal adenocarcinoma with portal vein invasion

Background

Pancreatoduodenectomy (PD) with portal vein resection (PVR) is a standard operation for pancreatic ductal adenocarcinoma (PDAC) with portal vein (PV) invasion, but positive margin rates remain high. It was hypothesized that regional pancreatoduodenectomy (RPD), in which soft tissue around the PV is resected en bloc, could enhance oncological clearance and survival.

Methods

This retrospective study included consecutive patients who underwent PD with PVR between January 2005 and December 2016 in a single high‐volume centre. In standard PD (SPD) with PVR, the PV was skeletonized and the surrounding soft tissue dissected. In RPD, the retropancreatic segment of the PV was resected en bloc with its surrounding soft tissue. The extent of lymphadenectomy was similar between the procedures.

Results

A total of 268 patients were included (177 SPD, 91 RPD). Tumours were more often resectable in patients undergoing SPD (60·5 per cent versus 38 per cent in those having RPD; P = 0·014), and consequently they received neoadjuvant therapy less often (7·9 versus 25 per cent respectively; P < 0·001). R0 resection was achieved in 73 patients (80 per cent) in the RPD group, compared with 117 (66·1 per cent) of those in the SPD group (P = 0·016), although perioperative outcomes were comparable between the groups. Median recurrence‐free (RFS) and overall (OS) survival were 17 and 32 months respectively in patients who had RPD, compared with 11 and 21 months in those who had SPD (RFS: P = 0·003; OS: P = 0·004).

Conclusion

RPD is as safe and feasible as SPD, and may increase the survival of patients with PDAC with PV invasion.

Role of lymphadenectomy, adjuvant chemotherapy, and treatment at high-volume centers in patients with resected pancreatic cancer-a distinct view on lymph node yield

PURPOSE

While the importance of lymphadenectomy is well-established for patients with resectable pancreatic cancer, its direct impact on survival in relation to other predictive factors is still ill-defined.

METHODS

The National Cancer Data Base 2006-2015 was queried for patients with resected pancreatic adenocarcinoma (stage IA-IIB). Patients were dichotomized into the following two groups, those with 1-14 resected lymph nodes and those with ≥ 15. Optimal number of resected lymph nodes and the effect of lymphadenectomy on survival were assessed using various statistical modeling techniques. Mediation analysis was performed to differentiate the direct and indirect effect of lymph node resection on survival.

RESULTS

A total of 21,912 patients were included; median age was 66 years (IQR 59-73), 48.9% were female. Median number of resected lymph nodes was 15 (IQR 10-22), 10,163 (46.4%) had 1-14 and 11,749 (53.6%) had ≥ 15 lymph nodes retrieved. Lymph node positivity increased by 4.1% per lymph node up to eight examined lymph nodes, and by 0.6% per lymph node above eight. Five-year overall survival was 17.9%. Overall survival was better in the ≥ 15 lymph node group (adjusted HR 0.91, CI 0.88-0.95, p < 0.001). On a continuous scale, survival improved with increasing LNs collected. Patients who underwent adjuvant chemotherapy and were treated at high-volume centers had improved overall survival compared with their counterparts (adjusted HR 0.59, CI 0.57-0.62, p < 0.001; adjusted HR 0.86, CI 0.83-0.89, p < 0.001, respectively). Mediation analysis revealed that lymphadenectomy had only 18% direct effect on improved overall survival, while 82% of its effect were mediated by other factors like treatment at high-volume hospitals and adjuvant chemotherapy.

DISCUSSION

While higher number of resected lymph nodes increases lymph node positivity and is associated with better overall survival, most of the observed survival benefit is mediated by chemotherapy and treatment at high-volume centers.

Local radicality and survival outcome of pancreatic cancer surgery

Pancreatic cancer remains a therapeutic challenge. Surgical resection in combination with systemic chemotherapy is the only option promising long-term survival and potential cure. However, only about 20% of patients are diagnosed with tumors that are still in a resectable stage. Even after potentially curative resection and modern regimens for adjuvant chemotherapy, the majority of patients develop local and systemic recurrence resulting in median overall survival times of 28-54 months. The predominance of systemic recurrence and its impact on survival may lead to the assumption that surgical radicality and local control play only minor roles in the treatment of pancreatic cancer. This review provides an overview of the recent literature on surgical radicality and survival outcome in pancreatic cancer. The current evidence on the extent of lymphadenectomy, the prognostic impact of the extent of lymph node involvement, and the impact of the resection margin status on postresection survival are reviewed. Data from recent studies performed in the context of modern surgery and adjuvant therapy provide good evidence of a considerable impact of local radicality on survival after pancreatic cancer surgery. Surgical techniques that have been developed to refine oncological resections and to increase local control as well as resectability are highlighted. These techniques include artery-first approaches, level-3 dissection with removal of the periarterial nerve plexus, the triangle operation, and extended resections. Local radicality and quality of surgical resection remain among the most important parameters that determine the chances for survival in patients with non-metastatic pancreatic cancer.

Comparison of Perioperative Outcomes Between Laparoscopic and Open Approach for Pancreatoduodenectomy: The PADULAP Randomized Controlled Trial

OBJECTIVE

To compare perioperative outcomes of pancreatoduodenectomy (PD) performed through the laparoscopic route or by open surgery.

SUMMARY BACKGROUND DATA

Laparoscopic PD is being progressively performed in selected patients.

METHODS

An open-label single-center RCT was conducted between February 2013 and September 2017. The primary endpoint was the length of hospital stay (LOS). Secondary endpoints were operative time, transfusion requirements, specific pancreatic complications (pancreatic or biliary fistula, pancreatic hemorrhage, and delayed gastric emptying), Clavien-Dindo grade ≥ 3 complications, comprehensive complication index (CCI) score, poor quality outcome (PQO), and the quality of pathologic resection. Analyses were performed on an intention to treat basis.

RESULTS

Of 86 patients assessed for PD, 66 were randomized (34 laparoscopic approach, 32 open surgery). Conversion to an open procedure was needed in 8 (23.5%) patients. Laparoscopic versus open PD was associated with a significantly shorter LOS (median 13.5 vs. 17 d; P = 0.024) and longer median operative time (486 vs. 365 min; P = 0.0001). The laparoscopic approach was associated with significantly better outcomes regarding Clavien-Dindo grade ≥ 3 complications (5 vs. 11 patients; P = 0.04), CCI score (20.6 vs. 29.6; P = 0.038), and PQO (10 vs. 14 patients; P = 0.041). No significant differences in transfusion requirements, pancreas-specific complications, the number of lymph nodes retrieved, and resection margins between the two approaches were found.

CONCLUSIONS

Laparoscopic PD versus open surgery is associated with a shorter LOS and a more favorable postoperative course while maintaining oncological standards of a curative-intent surgical resection.

TRIAL REGISTRY

ISRCTN93168938.

The efficacy of polyglycolic acid felt reinforcement in preventing postoperative pancreatic fistula after pancreaticojejunostomy in patients with main pancreatic duct less than 3 mm in diameter and soft pancreas undergoing pancreatoduodenectomy (PLANET-PJ trial): study protocol for a multicentre randomized phase III trial in Japan and Korea

BACKGROUND

Partial pancreatoduodenectomy is performed for malignant and benign diseases of the pancreatic head region. The procedure is considered highly difficult and highly invasive. Postoperative pancreatic fistula (POPF) is an important complication because of several consequent complications, including intraabdominal haemorrhage, often increasing hospital stays and surgical mortality. Although many kinds of pancreaticojejunostomy aimed at reducing POPF have been examined to date, the technique has not yet been standardized. We devised a new method using double-coated polyglycolic acid felt after pancreaticojejunostomy. The aim of the PLANET-PJ trial is to evaluate the superiority of polyglycolic acid felt reinforcement in preventing POPF after pancreaticojejunostomy in patients undergoing partial pancreatoduodenectomy to previous anastomosis methods.

METHODS

Patients diagnosed with pancreatic or periampullary lesions in whom it is judged that the main pancreatic duct diameter was 3 mm or less on the left side of the portal vein without pancreatic parenchymal atrophy due to obstructive pancreatitis are considered eligible for inclusion. This study is designed as a multicentre randomized phase III trial in Japan and the Republic of Korea. Eligible patients will be centrally randomized to either group A (polyglycolic acid felt reinforcement) or group B (control). In total, 514 patients will be randomized in 31 high-volume centres in Japan and Republic of Korea. The primary endpoint is the incidence of POPF (International Study Group of Pancreatic Surgery grade B/C).

DISCUSSION

The PLANET-PJ trial evaluates the efficacy of a new method using double-coated polyglycolic acid felt reinforcement for preventing POPF after pancreaticojejunostomy. This new method may reduce POPF.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03331718 . University Hospital Medical Information Network Clinical Trials Registry, UMIN000029647. Registered on 30 November 2017. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000033874.

Detection of visually occult metastatic lymph nodes using molecularly targeted fluorescent imaging during surgical resection of pancreatic cancer

BACKGROUND

Although most patients with PDAC experience distant failure after resection, a significant portion still present with local recurrence. Intraoperative fluorescent imaging can potentially facilitate the visualization of involved peritumoral LNs and guide the locoregional extent of nodal dissection. Here, the efficacy of targeted intraoperative fluorescent imaging was examined in the detection of metastatic lymph nodes (LNs) during resection of pancreatic ductal adenocarcinoma (PDAC).

METHODS

A dose-escalation prospective study was performed to assess feasibility of tumor detection within peripancreatic LNs using cetuximab-IRDye800 in PDAC patients. Fluorescent imaging of dissected LNs was analyzed ex vivo macroscopically and microscopically and fluorescence was correlated with histopathology.

RESULTS

A total of 144 LNs (72 in the low-dose and 72 in the high-dose cohort) were evaluated. Detection of metastatic LNs by fluorescence was better in the low-dose (50 mg) cohort, where sensitivity and specificity was 100% and 78% macroscopically, and 91% and 66% microscopically. More importantly, this method was able to detect occult foci of tumor (measuring < 5 mm) with a sensitivity of 88% (15/17 LNs).

CONCLUSION

This study provides proof of concept that intraoperative fluorescent imaging with cetuximab-IRDye800 can facilitate the detection of peripancreatic lymph nodes often containing subclinical foci of disease.

Frequency of Appropriate Use of Pancreatic Enzyme Replacement Therapy and Symptomatic Response in Pancreatic Cancer Patients

OBJECTIVES

Pancreatic cancer (PC) and its treatments can result in pancreatic exocrine insufficiency that requires pancreatic enzyme replacement therapy (PERT). Appropriate PERT usage is during meals and snacks. The aim was to determine the frequency of appropriate use of PERT and its impact on symptom alleviation in PC through a patient-reported outcomes online platform.

METHODS

Users in the Pancreatic Cancer Action Network's Patient Registry were prompted to answer a standalone questionnaire about their experience with PERT.

RESULTS

Two hundred sixty-two users completed the PERT questionnaire (January 2016-January 2018). Patients who reported taking PERT with meals had higher alleviation of symptoms compared with those taking PERT prior to or after meals. Specifically, "feeling of indigestion," "light-colored or orange stools," and "visible food particles in stool" were significantly decreased. Patients taking PERT with meals reported weight gain and less weight loss.

CONCLUSIONS

Of the 89% of PC patients prescribed PERT, 65% were prescribed PERT appropriately with all meals and snacks. Overall compliance with PERT administration guidelines was low (50% [105/208]). Improvement in symptoms significantly correlated with appropriate use of PERT. Increase in PC patient and provider education about appropriate PERT usage and administration is warranted.

Risk factors for post-pancreaticoduodenectomy delayed gastric emptying in the absence of pancreatic fistula or intra-abdominal infection

BACKGROUND AND OBJECTIVES

Delayed gastric emptying (DGE) occurs commonly following pancreaticoduodenectomy (PD), but the rate of DGE in the absence of other intra-abdominal complications is poorly understood. The objectives of this study were to define the incidence of DGE and identify risk factors for DGE in patients without pancreatic fistula or other intra-abdominal infections.

METHODS

Retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program pancreatectomy variables to identify patients with DGE following PD without evidence of fistula or intra-abdominal infection. Multivariable models were developed to assess preoperative, intraoperative, and technical factors associated with DGE.

RESULTS

The rate of DGE was 11.7% in 10502 cases without pancreatic fistula or intra-abdominal infection. Patients were more likely to develop DGE if age ≥75 (odds ratio [OR], 1.22; P = 0.003), male (OR, 1.29; P < 0.001), underwent pylorus-sparing PD (OR, 1.27; P = 0.004), or had a prolonged operative time (OR, 1.38 if greater than seven vs less than 5 hours; P = 0.005). Factors not associated with DGE included BMI, pathologic indication, and surgical approach.

CONCLUSION

The incidence of DGE after PD is notable even in patients without other abdominal complications. Identification of patients at increased risk for DGE may aid patient counseling as well as decisions regarding surgical technique, enteral feeding access, and enhanced-recovery pathways.

Management of pancreatic head adenocarcinoma: From where to where?

Pancreatic head adenocarcinoma (PHAC) is one of the most aggressive malignancies, and it has low long-term survival rates. Surgery is the only option for long-term survival. The difficulties associated with PHAC include higher frequencies of regional or distant lymph node metastases and vascular involvement, and positive resection margins in pancreatic and retroperitoneal tissues. Radical resections increase margin negativity and life expectancy; however, the extend of the surgery applied is controversial. Thus, western and eastern centers may use different approaches. Multiorgan, peripancreatic nerve plexus, and vascular resections have been discussed in relation to radical surgery for pancreatic cancer as have the roles of neoadjuvant and adjuvant therapy regimens. Determining the appropriate limits for surgery, standardizing definitions and surgical techniques according to guidelines, and centralizing pancreatic surgery within high-volume institutions to reduce mortality and morbidity rates are among the most important issues to consider. In this review, we evaluate the basic concepts underlying and the roles of radical surgery for PHAC, and lymphadenectomy, nerve plexus, retroperitoneal tissue, vascular, and multivisceral resections, total pancreatectomy, and liver metastases are discussed.

Pancreatic cancer surgical management

Pancreatic ductal adenocarcinoma (PDAC) remains a dismal prognosis and surgery is the only chance for cure. However, only few of the patients have localized tumor eligible for curative complete resection. Preoperative management and well-staging of the disease are the cornerstone for appropriate surgery and major issues to define the best therapeutic strategy. This review focuses on the surgical and optimal perioperative management of PDAC and summarizes updates data on the subject.

Prognostic Value of Metastatic Lymph Node Ratio in Pancreatic Cancer

Lymph node involvement in pancreatic adenocancer is one of the strongest predictors of prognosis. However, the extent of lymph node dissection is still a matter of debate and number of dissected nodes varies widely among patients. In order to homogenize this diverse group of patients and more accurately predict their prognosis, we aimed to analyze the effect of metastatic lymph node ratio as an independent prognostic factor. We retrospectively analyzed medical recordings of 326 patients with pancreatic cancer who were treated in a tertiary medical oncology center over a 10-year period. Both in univariate and multivariate analyses, metastatic lymph node ratio proved to be a strong predictor of prognosis which was unaffected from heterogeneity of our patient population and can be used to facilitate predict prognosis of patients who underwent lymph node dissection to various extents and with future studies it can emerge as a successful tool for creating prognostic subgroups of the disease.

The Surgical Choice of Incidental Periampullary Carcinoma Management in Emergency Laparotomy

Background

Laparotomy patients are occasionally diagnosed as having incidental periampullary cancers, making emergency pancreaticoduodenectomy (PD) inevitable. In this situation is difficult to decide whether to perform an emergency PD or a two-stage PD.

Material/Methods

A total of 27 patients who underwent emergency abdominal laparotomy were diagnosed with periampullary or pancreatic cancer during the operation without enough preoperative preparation. Ten patients underwent emergency one-stage PD and 17 patients underwent two-stage PD. Data of 137 patients with elective PD were selected as the control group. The preoperative, operative, and postoperative parameters, including hospital stay, medical cost, blood loss, and postoperative complications between elective PD and emergency PD (one-stage and two-stage) and between one-stage PD and two-stage PD were analyzed by chi-square test, Fisher test, or t test.

Results

Patients undergoing emergency two-stage PD had less blood loss (P=0.014), while patients with one-stage PD had shorter hospital stay (P=0.004), shorter operation time (P=0.047), and lower treatment costs (P=0.003). Additionally, the complications rates between one-stage and two-stage PD had no significant difference (P=0.365). Elective PD was the optimal method due to shorter hospital stay (P<0.001), less hemorrhage (P<0.001), shorter operative time (P<0.001), and lower cost (P<0.001) compared with emergency PD.

Conclusions

Based on our experience, one-stage PD had advantages of shorter hospital stay, shorter operation time, and lower treatment costs, while two-stage PD had less blood loss. The emergency two-stage PD may be more suitable for patients with unstable vital signs if emergency PD is inevitable in an emergency laparotomy.

A Predictive Risk Scoring System for Clinically Relevant Pancreatic Fistula After Pancreaticoduodenectomy

Background

Postoperative pancreatic fistula remains a challenge after pancreaticoduodenectomy (PD). This study aimed to establish a scoring system to predict clinically relevant postoperative pancreatic fistula (CR-POPF) after PD.

Material/Methods

The clinical records of 361 consecutive patients who underwent PD between 2009 and 2017 were reviewed retrospectively. Patients were divided into a study group (225 patients) and a validation group (136 patients). CR-POPF was defined and classified based on the 2016 ISGPS definition and classification system. Univariate and multivariate logistic regression analyses were performed and we thus developed a scoring system based on the regression coefficient of the multivariate logistic regression model. The predictive value was determined using the receiver operating characteristic (ROC) curve.

Results

A predictive scoring system with a maximum of 6 points for CR-POPF was established using the following 4 factors: 1 point for soft pancreatic texture (OR 2.09, 95%CI 1.10–3.98, P=0.025), 1.5 points for main pancreatic duct diameter ≤2.5 mm (OR 2.72, 95%CI 1.23–5.99, P=0.013), 0.5 points for extended lymphadenectomy (OR 1.57, 95%CI 1.13–2.18, P=0.007), 0.5 points for a 25–30 g/L postoperative day 1 serum albumin (OR 1.43, 95%CI 1.02–2.00, P=0.037), and 3 points for postoperative day 1 serum albumin ≤25 g/L (OR 5.12, 95%CI 1.82–14.41, P=0.002). The ROC curve showed that this scoring system was highly predictive for CR-POPF in the validation group (AUC=0.806, 95%CI: 0.735–0.878).

Conclusions

This 6-point risk scoring system will be useful for perioperative risk management of CR-POPF.

Clinical Management: Resectable Disease

Despite the identification of more active systemic therapy combinations for pancreatic cancer, cures remain elusive and feasible only in patients with localized, operable disease. When examining outcome data from phase III adjuvant trials conducted during the past decade, the survival for patients with localized disease has improved, likely owing to a combination of factors including more active adjuvant therapy and improved surgical and perioperative care. Perhaps the greatest recent change in the care of patients with localized pancreatic cancer has been the extension of surgery to tumors previously thought to be inoperable because of involvement of major blood vessels. These so-called "borderline resectable pancreatic cancers" have now been objectively defined, and their management is being studied in randomized trials. This has been made feasible by the availability of more active systemic therapy combinations that are increasingly being used in the neoadjuvant setting. Given the increasing activity of systemic regimens, the challenges in delivering such therapy in the postoperative setting, and the numerous novel agents in late stages of clinical development, it is reasonable to hypothesize that the neoadjuvant setting may eventually become the standard of care for patients with resectable disease.

Internal biliary drainage for isolated posterior segmental biliary obstruction: a case report

Background

Biliary system anatomical abnormalities can be preoperatively detected on magnetic resonance imaging; therefore, some presume that the number of bile duct injuries should decline. However, once a bile duct injury occurs, repair may be difficult. There are various ways to repair bile duct injuries, but successful repair may be exceptionally difficult.

Case presentation

A 72-year-old Japanese man underwent a pancreaticoduodenectomy due to a diagnosis of middle bile duct cancer. We had a complication of an isolated posterior segmental biliary obstruction when pancreaticoduodenectomy was performed. We conducted a drip infusion cholecystocholangiography-computed tomography test to determine the positional relationship between his bile duct and elevated jejunum. To secure the bile duct we punctured the bile duct under computed tomography guidance, and the hepaticojejunal anastomosis site was visualized by inserting an endoscope. We vibrated the bile duct wall by inserting a guide wire through a puncture needle and verified the vibrations with the endoscope. We observed a partially compressed elevated jejunal wall upon guide wire insertion; therefore, we could verify a puncture needle penetration into the elevated jejunum by endoscope on insertion. We also successfully inserted an 8.5-Fr pigtail catheter into the elevated jejunum. We removed all drains after percutaneously inserting an uncovered metallic stent. Our patient’s subsequent clinical course was unremarkable. He visits our institution as an out-patient and has had no stent occlusion even after 6 months.

Conclusions

When repairing bile duct injuries, it is important to accurately determine the positional relationships between the injured bile duct and the surrounding organs.