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

Surgical implication of micrometastasis for pancreatic cancer

OBJECTIVES

The clinical significance of micrometastasis to regional lymph nodes for pancreas cancer is controversial in patients who underwent curative resection.

METHODS

Nine of 42 patients who underwent macroscopically curative resection of pancreatic head cancer were found to have pN(-) by routine examination. Complete serial section examination of the resected specimens was done to detect micrometastasis in these 9 patients.

RESULTS

A total of 16,505 sections were examined by immunohistochemistry or hematoxylin and eosin staining. Micrometastases were identified in 7 (78%) of 9 patients and 17 (3.6%) of 474 lymph nodes. All micrometastases were found in the pancreas head area. However, the frequency of micrometastases around the superior mesenteric artery was 44%. There were no micrometastases to the para-aortic nodes. There was a tendency that the patients with micrometastases showed better survival than those with overt nodal involvement (P = 0.053). Micrometastasis did not provide the poor prognostic factor in patients who underwent optimal regional lymphadenectomy.

CONCLUSIONS

Even in overtly pN(-) pancreatic cancer, micrometastases occur high frequently (78%) and widely, including the nodes around the superior mesenteric artery. These results provide important pathological information when we consider the preoperative, perioperative, and postoperative strategies, even when patients seem to have no nodal involvement by preoperative examinations.

Dasatinib inhibits the development of metastases in a mouse model of pancreatic ductal adenocarcinoma

BACKGROUND & AIMS

Pancreatic ductal adenocarcinoma (PDAC) is a highly invasive and metastatic disease for which conventional treatments are of limited efficacy. A number of agents in development are potential anti-invasive and antimetastatic agents, including the Src kinase inhibitor dasatinib. The aim of this study was to assess the importance of Src in human PDAC and to use a genetically engineered mouse model of PDAC to determine the effects of dasatinib on PDAC progression.

METHODS

Src expression and activity was measured by immunohistochemistry in 114 human PDACs. Targeting expression of Trp53(R172H) and Kras(G12D) to the mouse pancreas results in the formation of invasive and metastatic PDAC. These mice were treated with dasatinib, and disease progression monitored. Cell lines were derived from mouse PDACs, and in vitro effects of dasatinib assessed.

RESULTS

Src expression and activity were up-regulated in human PDAC and this correlated with reduced survival. Dasatinib inhibited the migration and invasion of PDAC cell lines, although no effects on proliferation were seen at concentrations that inhibited Src kinase activity. In addition, dasatinib significantly inhibited the development of metastases in Pdx1-Cre, Z/EGFP, LSL-Kras(G12D/+), LSL-Trp53(R172H/+) mice. However, there was no survival advantage in the dasatinib-treated animals owing to continued growth of the primary tumor.

CONCLUSIONS

This study confirms the importance of Src in human PDAC and shows the usefulness of a genetically engineered mouse model of PDAC for assessing the activity of potential antimetastatic agents and suggests that dasatinib should be evaluated further as monotherapy after resection of localized invasive PDAC.

Quality improvement for pancreatic cancer care: is regionalization a feasible and effective mechanism?

Variability exists in the quality of pancreatic cancer care provided in the United States. High-volume centers have been shown to have improved outcomes for pancreatectomy. Regionalization of pancreatic cancer care to high-volume centers has the potential to improve care and outcomes. Practical limitations such as overloading currently available high-volume centers, extending patient travel times, sharing patients within a multipayer health system, and incorporating patient preferences must be addressed for regionalization to become a reality. The benefits and limitations of regionalization of pancreatic cancer care are discussed in this review. To improve the overall quality of pancreatic cancer care at all hospitals in the United States, a combination of referral of patients with pancreatic cancer to high- and moderate-volume hospitals in conjunction with specific quality-improvement efforts at those institutions is proposed.

Update on adjuvant trials for pancreatic cancer

Adjuvant therapy for pancreatic cancer remains a controversial topic, with a paucity of randomized controlled trials in this area and various limitations in the trials that have been conducted to date, leaving many questions as to a true "standard of care" for patients with resectable or potentially resectable disease. Several large and well-conducted phase 3 trials have reported results recently and have helped to solidify the role of chemotherapy, with either 5-fluorouracil or gemcitabine, as an effective intervention in the adjuvant setting. The role of radiotherapy remains unclear, but it does seem to be feasible and safe, and there are trials in development that may shed more light on this question. Many small trials have pointed to the potential utility of neoadjuvant strategies in selecting the patients who are most likely to benefit from surgery and in improving outcomes by providing systemic therapy early on. Larger trials are ongoing in hopes that they will give more definitive answers as to when this strategy should be used. It is hoped that trials using novel agents, either alone or in combination with more traditional therapies, will better define the best strategy for improving outcomes in patients with resectable disease.

Portal vein resection

The American Hepato-Pancreatico-Biliary Association and Society of Surgical Oncology published a consensus statement in 2009 on the subject of vein resection and reconstruction during pancreaticoduodenectomy (PD), and concluded that PD with vein resection and reconstruction is a viable option for treatment of some pancreatic adenocarcinomas. This article describes the current approaches and recent advances in the management, staging, and surgical techniques regarding portal vein resection. With proper patient selection, a detailed understanding of the anatomy of the root of mesentery, and adequate surgeon experience, vascular resection and reconstruction can be performed safely and does not impact survival duration. Isolated venous involvement is not a contraindication to PD when performed by experienced surgeons at high-volume centers as part of a multidisciplinary and multimodal approach to localized pancreatic cancer.

Neoadjuvant therapy for pancreatic cancer: a current review

The optimal therapy for pancreatic cancer continues to evolve. Neoadjuvant chemoradiation is a key component of current treatment regimens, and evaluation of previous treatment options will help guide future trials. Here the authors present a review of the current literature with discussion of future directions.

Extended pancreatic resections and lymphadenectomy: An appraisal of the current evidence

Surgery remains the mainstay of treatment for pancreatic ductal adenocarcinoma and complete removal of the cancer confers a definite survival advantage, especially in early disease. However, the majority of patients do not present with early disease, thus precluding the chance of a cure by standard pancreatoduodenectomy (PD), distal pancreatectomy or total pancreatectomy. For this reason, pancreatic surgeons have attempted to push the limits of resection over the last three decades. The aim of these resections has been to determine whether obtaining a complete resection by extending the limits of conventional resection in patients with advanced disease will yield the results seen with PD alone in early disease. This article revisits the data from such studies in an attempt to determine if the available literature supports the performance of extended resections for pancreatic cancer in terms of improvement of survival.

Does the mechanism of lymph node invasion affect survival in patients with pancreatic ductal adenocarcinoma?

BACKGROUND

Lymph node metastases are prognostically significant in pancreatic ductal adenocarcinoma. Little is known about the significance of direct lymph node invasion.

AIM

The aim of this study is to find out whether direct lymph node invasion has the same prognostic significance as regional nodal metastases.

METHODS

Retrospective review of patients resected between 1/1/1993 and 7/31/2008. "Direct" was defined as tumor extension into adjacent nodes, and "regional" was defined as metastases to peripancreatic nodes.

RESULTS

Overall, 517 patients underwent pancreatic resection for adenocarcinoma, of whom 89 had one positive node (direct 26, regional 63), and 79 had two positive nodes (direct 6, regional 68, both 5). Overall, survival of node-negative patients was improved compared to patients with positive nodes (N0 30.8 months vs. N1 16.4 months; p < 0.001). There was no survival difference for patients with direct vs. regional lymph node invasion (p = 0.67). Patients with one positive node had a better overall survival compared to patients with >/=2 positive nodes (22.3 and 15 months, respectively; p < 0.001). The lymph node ratio (+LN/total LN) was prognostically significant after Cox regression (p < 0.001).

CONCLUSIONS

Isolated direct invasion occurs in 20% of patients with one to two positive nodes. Node involvement by metastasis or by direct invasion are equally significant predictors of reduced survival. Both the number of positive nodes and the lymph node ratio are significant prognostic factors.

[Tumors of the upper gastro-intestinal tract]

The appropriate extent of lymph node dissection in tumors of the upper gastro-intestinal tract continues to be debated. The basic tenet of surgical oncology that cancerous lymph nodes are indicators not governors of survival is under question and derives from the different theories of metastasis. Is the metastatic flow linear (indicators) or does it occur in parallel to tumorigenesis (governor)? If the latter theory is true there would be only a limited indication for lymphadenectomy (LA).Extended LA leads to an ameliorated staging of the N category. Following LA locoregional tumor control is significantly improved for esophageal and gastric cancer. In case of gastric cancer it is evident that there is a group of patients in which extended LA lead to improved long-term survival. This gain in prognosis affects patients in which lymph node metastasis is not or only slightly advanced. In locally advanced tumors there is no prognostic benefit. Patients who might benefit from the extended procedure cannot be assessed during preoperative staging. Therefore, the indications for the procedure should be liberally carried out by experienced hands and in experienced centers. According to randomized studies there is no indication for extended radical LA in pancreatic cancer.

Robot-assisted laparoscopic pancreatic surgery: single-surgeon experience

BACKGROUND

Use of robotic surgery has gained increasing acceptance over the last few years. There are few reports, however, on advanced pancreatic robotic surgery. In fact, the indication for robotic surgery in pancreatic disease has been controversial. This paper retrospectively reviews one surgeon's experience with robotic surgery to treat pancreatic disease, and analyzes its indications and outcomes, as well as the controversy that exists.

METHODS

A retrospective review of the charts of all patients who underwent robotic surgery for pancreatic disease by a single surgeon at two different institutions was carried out.

RESULTS

From October 2000 to January 2009, 134 patients underwent robotic-assisted surgery for different pancreatic pathologies. All procedures were performed using the da Vinci robotic system. Of the 134 patients, 83 were female. The average age of all patients was 57 years (range 24-86 years). Mean operating room (OR) time was 331 min (75-660 min). There were 14 conversions to open surgery. Mean length of stay was 9.3 days (3-85 days). Length of stay for patients with no complications was 7.9 days (3-15 days). The postoperative morbidity rate was 26% and the mortality rate was 2.23% (three patients). Among the procedures performed were 60 pancreaticoduodenectomies, 23 spleen-preserving distal pancreatectomies, 23 splenopancreatectomies, 3 middle pancreatectomies, 1 total pancreatectomy, and 3 enucleations. Another 21 patients underwent different surgical procedures for treatment of acute and chronic pancreatitis. Two cases of pancreaticoduodenectomy were performed in outside institutions and are not included in this series.

CONCLUSIONS

This is the largest series of robotic pancreatic surgery presented to date. Robotic surgery enables difficult technical maneuvers to be performed that facilitate the success of pancreatic minimally invasive surgery. The results in this series demonstrate that it is feasible and safe. Complication and mortality rates are comparable to those of open surgery but with the advantages of minimally invasive surgery.

Outcomes of adjuvant chemoradiation after pancreaticoduodenectomy with mesenterico-portal vein resection for adenocarcinoma of the pancreas

PURPOSE

Surgery followed by chemotherapy and radiation (CRT) offers patients with pancreatic adenocarcinoma a chance for extended survival. In some patients, however, resection is difficult because of vascular involvement by the carcinoma, necessitating resection and grafting of the mesenterico-portal vessels. The purpose of this study was to compare outcomes between pancreaticoduodenectomy (PD) with and without mesenterico-portal vein resection (VR) in patients receiving adjuvant CRT for pancreatic adenocarcinoma.

METHODS AND MATERIALS

Between 1993 and 2005, 160 patients underwent PD with 5-FU-based adjuvant CRT followed by maintenance chemotherapy at the Johns Hopkins Hospital; 20 (12.5%) of the 160 underwent VR. Clinical outcomes, including median survival, overall survival, and complication rates were assessed for both groups.

RESULTS

Patients who underwent VR had significantly longer operative times (p = 0.009), greater intraoperative blood loss (p = 0.01), and longer postoperative lengths of stay (p = 0.03). However, postoperative morbidity, median survival, and overall survival rates were similar between the two groups. Most patients (70%) from both groups were able to complete CRT, and a subgroup analysis demonstrated no appreciable differences in terms of complications. None of the VR patients who received adjuvant CRT developed veno-oclusive disease or graft failure/leakage.

CONCLUSION

In a cohort of patients treated with adjuvant 5-FU-based CRT at the Johns Hopkins Hospital, having a VR at the time of PD resulted in similar complication rates and survival. These data support the feasibility and safety of adjuvant CRT in patients undergoing VR at the time of PD.

Extrapancreatic neural plexus invasion by pancreatic carcinoma: characteristics on magnetic resonance imaging

BACKGROUND

Our objective is to study the characteristics of extrapancreatic neural plexus invasion by pancreatic carcinoma on MR imaging.

METHODS

20 patients with both pancreatic carcinoma and extrapancreatic neural plexus invasion confirmed by pathology were recruited in this study. MR imaging was performed within 1 month before surgery. On MR images, signal intensity at the site of potential extrapancreatic neural plexus invasion, lymph nodes and tumor size were noted. The relationship of extrapancreatic neural plexus invasion to these findings was analyzed.

RESULTS

Signs of extrapancreatic neural plexus invasion were depicted on MR imaging in 80% of patients, which included streaky and strand-like signal intensity structure in fat tissue in 50% of patients and irregular masses adjacent to tumor in 30%. Signal intensity at invasion site was similar to that of pancreatic carcinoma. The frequencies of patients with vascular invasion and with lymph nodes larger than 5 mm were, respectively, 50% and 55%. Tumor diameter was 24 +/- 7 mm on MR imaging. Extrapancreatic neural plexus invasion was correlated with vascular invasion (r = 0.58, P < 0.005), slightly related with lymphadenopathy (r = 0.35, 0.1 > P > 0.05), but not related with tumor size.

CONCLUSION

MR imaging is useful to depict extrapancreatic neural plexus invasion by pancreatic carcinoma.

Management of pancreatic cancer: Current status and future directions

Despite advances in surgery and adjuvant therapy pancreatic ductal adenocarcinoma has a dismal prognosis. Surgical resection with negative margins remains the mainstay of treatment, and results can be improved with neoadjuvant therapy when the lesion is of borderline resectability. Extended lymphadenectomy has no role in improving survival, but may worsen quality of life. Venous resection can be performed if it helps to achieve an R0 resection, but arterial resection is not justified. A host of newer agents, both cytotoxic and targeted, are being evaluated. The article summarizes the critical issues and looks ahead to the future.

Should all distal pancreatectomies be performed laparoscopically?

Despite the relatively slow start of laparoscopic pancreatectomy relative to other laparoscopic resections, an increasing number of these procedures are being performed around the world. Operations that were once considered impossible to perform laparoscopically, such as pancreaticoduodenectomy and central pancreatectomy are gaining momentum. Technology continues to improve, as does surgical experience and prowess. There are both enough experience and data (though retrospective) to confirm that LDP with or without spleen preservation appears to be a safe treatment for benign or noninvasive lesions of the pancreas. Based on the fact that LDP can be performed with similar or shorter operative times, blood loss, complication rates, and length of hospital stay than ODP, it can be recommended as the treatment of choice for benign and noninvasive lesions in experienced hands when clinically indicated. It is very difficult to make clear recommendations with regard to laparoscopic resection of malignant pancreatic tumors due to the lack of conclusive data. As long as margins are negative and lymph node clearance is within accepted standards, LDP appears to have no untoward oncologic effects on outcome. Certainly more data, preferably in the manner of a randomized clinical trial, are needed before additional recommendations can be made. Potential benefits of laparoscopic resection for cancer include the ability to inspect the abdomen and abort the procedure with minimal damage if occult metastases are identified. This does not delay the onset of palliative chemotherapy, which would be the primary treatment in that circumstance. In fact, there is evidence to suggest that there is a greater likelihood of receiving systemic therapy if a laparotomy is avoided in patients who have radiologically occult metastases. Patients may also undergo palliative laparoscopic gastric and biliary bypass if indicated. Faster wound healing may also translate into a shorter waiting time before initiating adjuvant chemotherapy and/or radiation therapy. If the patient develops a wound infection, the infection should be more readily manageable with smaller incisions. Although not proven clinically relevant in humans, the reduction in perioperative stress associated with laparoscopic resection may translate to a cancer benefit for some patients. One report compared markers of systemic inflammatory response in 15 subjects undergoing left pancreatectomy. Eight had hand-access laparoscopic procedures and the rest had standard open surgery. The subjects in the laparoscopic group had statistically lower C-reactive protein levels than the open group on postoperative days one (5.5 mg/dL versus 9.7 mg/dL, P = .006) and three (8.5 mg/dL versus 17.7 mg/dL, P = .003), suggesting that the laparoscopic approach to left pancreatectomy is associated with less inflammation. While this report is underpowered, it supports the notion that MIS cancer surgery may induce less of a systemic insult to the body than standard open cancer surgery. More work in this area is necessary before any firm conclusions can be drawn. An important issue to consider is that of training surgeons to perform these complex procedures laparoscopically. Not all pancreatectomies are amenable to the laparoscopic approach, even in the most skilled hands. As such, only a percentage of cases will be performed this way and expectations to educate surgeons adequately to perform advanced laparoscopic procedures can be unrealistic, resulting in more "on-the-job" training. Another aspect that draws some controversy is that of the totally laparoscopic procedure versus the hand-access approach. No laparoscopic instrument provides the tactile feedback possible to obtain with the hand. The HALS approach allows for this, and the opportunity to control bleeding during the procedure. HALS also provides a way to improve confidence during the learning-curve phase of these operations. Finally, it is important to remember that if the procedure is failing to progress laparoscopically, or if cancer surgery principles are likely to be violated, the surgeon (and the patient) must be willing to abort the laparoscopic approach and complete the operation using standard open technique. During the next few years we can expect to see more robust outcome data with laparoscopic pancreatectomy. The expectation is that more data will come to light demonstrating benefits of laparoscopic pancreatic resection as compared with open technique for selected patients. Several groups are considering randomized trials to look at these endpoints. Although more retrospective and prospectively maintained data will certainly be presented, it is less likely that randomized data specifically examining the question oflaparoscopic versus open pancreatectomy for cancer will mature, due to some of the limitations discussed above. Additional areas of discovery are in staple line reinforcement for left pancreatectomy and suturing technology for pancreatico-intestinal anastomosis. Robotic surgery may have a role in pancreatic surgery. Improving optics and visualization with flexible endoscopes with provide novel surgical views potentially improving the safety of laparoscopy. Another area in laparoscopic surgery that is gaining momentum is that of Natural Orifice Transluminal Endoscopic Surgery (NOTES). NOTES represents the "holy grail" of incisionless surgery. Can we enucleate a small tumor off the pancreatic body by passing an endoscope through the gastric (or colonic) wall, and bring the specimen out via the mouth or anus? Can we use this approach for formal left pancreatectomies? Pioneers have already developed a porcine model of left pancreatectomy. This technology must clear several hurdles before it is cancer ready; however, technology is moving at a rapid pace.

Synergistic action of Smad4 and Pten in suppressing pancreatic ductal adenocarcinoma formation in mice

Mutations of SMAD4/DPC4 are found in about 60% of human invasive pancreatic ductal adenocarcinomas (PDACs); yet, the manner in which SMAD4 deficiency enhances tumorigenesis remains elusive. Using a Cre-LoxP approach, we generated a mutant mouse carrying a targeted deletion of Smad4 in the pancreas. We showed that the absence of Smad4 alone did not trigger pancreas tumor formation; however, it increased the expression of an inactivated form of Pten, suggesting a role of Pten in preventing Smad4-/- cells from undergoing malignancy. To investigate this, we disrupted both Pten and Smad4. We showed that Pten deficiency initiated widespread premalignant lesions, and a low tumor incidence that was significantly accelerated by Smad4-deficiency. The absence of Smad4 in a Pten-mutant background enhanced cell proliferation and triggered transdifferentiation from acinar, centroacinar and islet cells, accompanied by activation of Notch1 signaling. We showed that all tumors developed in the Smad4/Pten-mutant pancreas exhibited high levels of pAKT and mTOR, and that about 50 and 83% of human pancreatic cancers examined showed increased pAKT and pmTOR, respectively. Besides the similarity in gene expression, the pAKT and/or pmTOR-positive human PDACs and mouse pancreatic tumors also shared some histopathological similarities. These observations indicate that Smad4/Pten-mutant mice mimic the tumor progression of human pancreatic cancers that are driven by activation of the AKT-mTOR pathway, and uncovered a synergistic action of Smad4 and Pten in repressing pancreatic tumorigenesis.

Feasibility and reliability of pancreatic cancer staging using fiberoptic confocal fluorescence microscopy in rats

BACKGROUND & AIMS

Surgical management of pancreatic cancer depends on tumor resectability and staging. This study evaluated a new in vivo technique, fiberoptic confocal fluorescence microscopy (FCFM), for detection and staging of pancreatic tumors in rats.

METHODS

FCFM was used with a protease-activated fluorescent marker (ProSense; VisEn Medical Inc, Woburn, MA) for in vivo imaging of solid organs (1.8-microm resolution) in a rat model of pancreatic ductal adenocarcinoma. A preliminary study described the FCFM rendering of normal and pathologic tissues. Subsequently, 2 double-blind studies compared FCFM to standard histology in (1) detection of tumors in rat models of cancer and controls and (2) detection of nodal involvement (splenic, celiac, mesenteric, and colic) 4, 5, and 6 weeks after tumor induction vs controls.

RESULTS

Tumor cells displayed a fluorescent ductal pattern compared with non-fluorescent normal pancreas or normal follicular pattern of lymph nodes (LNs). FCFM detected all the pancreatic tumors (1.7-mm mean diameter) and identified 23 LNs that contained metastases of 99 LNs examined. Standard histologic analyses resulted in 1 false-negative result in tumor detection and 2 false negatives in LN detection, whereas FCFM produced no false-negative results. Additional serial sectioning confirmed all tumors and 16 metastatic LNs; FCFM had a negative predictive value of 100% and a positive predictive value of 69.6%.

CONCLUSIONS

Real-time "virtual biopsy" using FCFM detects tumors and LN metastases with 100% sensitivity and 92.2% specificity in rats, making it a reliable technique for detection and staging of pancreatic cancer.

Pancreatectomy for pancreatic cancer with reference to combined resection of the vessels, twenty nine year experience by a single surgeon

Between 1978 and 2007 one hundred and seven patients consecutively underwent resection for primary pancreatic adenocarcinoma. There were 28 pN0 patients, 41 pN1 and 37 pN2 or more (one unknown). Combined resection of the portal vein was performed in 62 out of 107 patients (58%). The hepatic artery in 10 patients, superior mesenteric artery in 8 patients and celiac trunk in 7 patients were also resected additionally to the portal vein. The 5-year survival rate and 10-year survival rate of all 107 cases were 12.1% and 2.8% respectively. The 5-year survival rate of the pN0 group was 37%, significantly better than the 14% 5-year survival rate in the pN1 group (p=0.043). Of 69 patients with pN0 or pN1, 38 patients underwent combined resection of the portal vein. There was not significant difference between the 24% 5-year survival rate in the group without the portal vein resection and the 19% 5-year survival rate in the group with portal vein resection. The 20% 5-year survival rate of the portal vein only group and the 5-year survival rate of both the portal vein and hepatic artery group were the same. The groups of the further resection of the superior mesenteric artery and of the celiac trunk showed no long-term survival. It is concluded that aggressive combined resection of the portal vein or additional resection of the hepatic artery be feasible for a survival benefit in pN0 and pN1 diseases.

Pancreatic cancer: incidence, treatment and survival trends--1175 cases in Calvados (France) from 1978 to 2002

AIM

To assess the trends in incidence, therapeutic modalities and survival of pancreatic cancer between 1978 and 2002 in a well-defined population, as recorded in the Calvados digestive cancer registry database.

PATIENTS AND METHODS

All patients living in Calvados with a diagnosis of pancreatic cancer were registered. Clinical data and treatment modalities were prospectively recorded. This 25-year database was divided into five 5-year periods. Data were compared using log-rank tests and the Cox model.

RESULTS

A total of 1175 cases of pancreatic cancer (617 men, 558 women) were registered. Its incidence increased with an average annual coefficient of +2.8% in men and +5.1% in women. Therapeutic modalities changed over the five time periods: surgical resection increased from 6.8 to 13.4% (median survival 15 months) while radiation therapy and/or chemotherapy also increased from 5.5 to 13.2%. Palliative surgery decreased from 54.6 to 32.0% and favored interventional endoscopic techniques. Postoperative mortality decreased significantly. Survival increased significantly over the five time periods, although the median survival time remained stable (4 months).

CONCLUSION

From 1978 to 2002, pancreatic cancer incidence increased in Calvados (France). Therapeutic modalities changed, with endoscopic treatments preferred over palliative surgery. The improvement in survival could be explained by the decrease in postoperative mortality.

A reduction in delayed gastric emptying by classic pancreaticoduodenectomy with an antecolic gastrojejunal anastomosis and a retrogastric omental patch

BACKGROUND

Delayed gastric emptying (DGE) continues to be a major cause of morbidity following pancreaticoduodenectomy (PD). A change in the method of reconstruction following PD was instituted in an attempt to reduce the incidence DGE.

METHODS

Patients undergoing PD from January 2002 to December 2008 were reviewed and outcomes determined. Pylorus-preserving pancreaticoduodenectomy (PPPD) with a retrocolic duodenojejunal anastomosis (n = 79) or a classic PD with a retrocolic gastrojejunostomy (n = 36) was performed prior to January 2008. Thereafter, a classic PD with an antecolic gastrojejunal anastomosis and placement of a retrogastric vascular omental patch was undertaken (n = 36).

RESULTS

A statistically significant decrease in DGE was noted in the antecolic group compared to the entire retrocolic group (14% vs 40%; p = 0.004) and compared to patients treated by classic PD with a retrocolic anastomosis alone (14% vs 39%; p = 0.016). On multivariate analysis, the only modifiable factor associated with reduced DGE was the antecolic technique with an omental patch, odds ratio (OR) 0.3 (confidence interval (CI) 0.1-0.8) p = 0.022. Male gender was associated with an increased risk of DGE with OR 2.3 (CI 1.1-4.8) p = 0.026.

CONCLUSION

A classic PD combined with an antecolic anastomosis and retrogastric vascular omental patch results in a significant reduction in DGE.

Consensus on the treatment of pancreatic cancer in Spain

Pancreatic cancer (PC) represents one of the greatest oncological challenges of our century, due to its high mortality and incidence. A group of Spanish experts in PC treatment reviewed data available on different therapeutic combinations and established consensus on what would be the best strategy in PC management, depending on the stage of the disease. Surgery with complete resection may produce 5-year survival rates of 18-24%, but definitive control is still precarious. In the absence of consensus, the best evidence suggests that adjuvant chemotherapy with gemcitabine for 6 months using the CONKO-001 regime is the treatment of choice after resection of PC for patients with acceptable functional status. This group recommends chemoradiotherapy (CT-RT) in patients with factors for poor loco-regional prognosis. However, chemotherapy is an option for the treatment of locally advanced PC in patients with good general status and in the absence of metastatic disease the recommended treatment is CT-RT followed by gemcitabine-based chemotherapy. A period of chemotherapy followed by consolidation CT-RT may be appropriate, as it allows selection of patients with locally advanced disease who may benefit most from combined treatment. Erlotinib combined with gemcitabine shows significant survival improvement in PC and must be considered an option in the first-line treatment of advanced and metastatic PC. The gemcitabine-erlotinib combination is proposed as the standard treatment for metastatic PC in patients with PS=/>2. In patients with PS<2, gemcitabine-erlotinib is recommended as the first-line treatment option, supported by a maximum degree of evidence, without ruling out other options, such as gemcitabine-oxaliplatin, gemcitabine-capecitabine or gemcitabine alone.

Long mesentericoportal vein resection and end-to-end anastomosis without graft in pancreaticoduodenectomy

INTRODUCTION

The feasibility and safety of pancreaticoduodenectomy (PD) combined with long segmental mesentericoportal vein (MPV; >5 cm) resection and end-to-end anastomosis without graft has rarely been demonstrated.

MATERIALS AND METHODS

Eight patients with pancreatic head adenocarcinoma underwent PD combined with long MPV resection between August 2006 and May 2008 in Peking University School of Oncology.

RESULTS

By liver mobilization and Cattell-Braasch maneuver, direct and tension-free end-to-end anastomosis was easily performed even when the resected segment of the MPV was longer than 5 cm. All the eight patients experienced uneventful recovery without severe complications.

CONCLUSIONS

PD with long MPV resection and direct end-to-end anastomoses is safe and effective.

Prognostic implications of tumor invasion or adhesion to peripancreatic vessels in resected pancreatic cancer

BACKGROUND

The purpose of this study was to evaluate the operative risk and the prognostic implications of pancreatectomy plus resection and reconstruction of peripancreatic vessels (PPV) in patients with pancreatic adenocarcinoma.

METHODS

One hundred ten patients who underwent pancreatectomy with PPV resection and reconstruction (Study Group; SG) were retrospectively compared with 62 patients without distant metastasis who were palliated, (Control Group 1; CG-1), as well as 197 patients who underwent "conventional"pancreatectomy (Control Group 2; CG-2).

RESULTS

Postoperative morbidity and mortality were similar in SG (33% and 3%), in CG-1 (26% and 3%), and in CG-2 (40% and 6%) patients. Median survival time (MST) of SG patients (15 months) was longer than that of CG-1 patients (6 months; P < .0001) and similar to that of CG-2 patients (18 months). Patients undergoing isolated venous resection (n = 84) had the best outcome (MST: 15 months) ( P < .0001 vs CG-1 patients), while patients undergoing resection of multiple PPV (n = 14) had the worst outcome (MST: 8 months). PPV infiltration, histologically proven in 64 patients (65%), was associated with decreased MST only if the tunica intima was infiltrated (26%) (11 months; P < .001). Multivariate analysis showed that no adjuvant therapy, intimal invasion, and poorly differentiated histology were associated with a higher hazard of death by 2.2, 2.2, and 2.5-fold, respectively.

CONCLUSION

In properly selected patients, pancreatectomy plus resection and reconstruction of PPV was performed as safely as palliation or "conventional" pancreatectomy and was associated with better survival when compared to palliation.

Current state of adjuvant therapy in resected pancreatic adenocarcinoma

Pancreatic carcinoma cannot generally be cured by surgery alone. This review summarizes the development of adjuvant therapy over the past two decades. Four randomized controlled trials compare long-term survival of different treatments. The small GITSG-study supports combined chemoradiation, but the EORTC-study found no significant effect. A Norwegian study of adjuvant chemotherapy found an increased median survival, but no effect beyond two years. The large ESPAC-1 study shows a benefit for 5-FU based chemotherapy, while chemoradiation had a negative effect. Thus, evidence favours adjuvant therapy, but 5-FU may not be the ultimate drug. Support for gemcitabine is given by preliminary data from a German randomized trial, and further American and European studies are upcoming. However, postoperative therapy is problematic, as 20-30% of resected patients never undergo treatment because of slow recovery or other reasons. Preoperative therapy has some theoretical advantages, and moreover, patients with rapidly progressive disease may be spared surgery. Randomized controlled trials are lacking, but published results compare well with postoperative, adjuvant therapy. The value of locally targeted therapy is difficult to assess. Reasonable results have been obtained with regional chemotherapy, whereas intraoperative radiotherapy does not seem to increase survival despite reducing reducing local recurrences.

The lymph node ratio is the strongest prognostic factor after resection of pancreatic cancer

INTRODUCTION

Survival after surgery of pancreatic cancer is still poor, even after curative resection. Some prognostic factors like the status of the resection margin, lymph node (LN) status, or tumor grading have been identified. However, only few data have been published regarding the prognostic influence of the LN ratio (number of LN involved to number of examined LN). We, therefore, evaluated potential prognostic factors in 182 patients after resection of pancreatic cancer including assessment of LN ratio.

METHODS

Since 1994, 204 patients underwent pancreatic resection for ductal pancreatic adenocarcinoma. Survival was evaluated in 182 patients with complete follow-up evaluations. Of those 182 patients, 88% had cancer of the pancreatic head, 5% of the body, and 7% of the pancreatic tail. Patients underwent pancreatoduodenectomy (85%), distal resection (12%), or total pancreatectomy (3%). Survival was analyzed by the Kaplan-Meier and Cox methods.

RESULTS

In all 204 resected patients, operative mortality was 3.9% (n = 8). In the 182 patients with follow-up, 70% had free resection margins, 62% had G1- or G2-classified tumors, and 70% positive LN. Median tumor size was 30 (7-80) mm. The median number of examined LN was 16 and median number of involved LN 1 (range 0-22). Median LN ratio was 0.1 (0-0.79). Cumulative 5-year survival (5-year SV) in all patients was 15%. In univariate analysis, a LN ratio > or = 0.2 (5-year SV 6% vs. 19% with LN ratio < 0.2; p = 0.003), LN ratio > or = 0.3 (5-year SV 0% vs. 18% with LN ratio < 0.3; p < 0.001), a positive resection margin (p < 0.01) and poor differentiation (G3/G4; p < 0.03) were associated with poorer survival. In multivariate analysis, a LN ratio > or = 0.2 (p < 0.02; relative risk RR 1.6), LN ratio > or = 0.3 (p < 0.001; RR 2.2), positive margins (p < 0.02; RR 1.7), and poor differentiation (p < 0.03; RR 1.5) were independent factors predicting a poorer outcome. The conventional nodal status or the number of examined nodes (in all patients and in the subgroups of node positive or negative patients) had no significant influence on survival. Patients with one metastatic LN had the same outcome as patients with negative nodes, but prognosis decreased significantly in patients with two or more LN involved.

CONCLUSIONS

Not the lymph node involvement per se but especially the LN ratio is an independent prognostic factor after resection of pancreatic cancers. In our series, the LN ratio was even the strongest predictor of survival. The routine estimation of the LN ratio may be helpful not only for the individual prediction of prognosis but also for the indication of adjuvant therapy and herein related outcome and therapy studies.

Invasive intraductal papillary-mucinous neoplasm of the pancreas: comparison with pancreatic ductal adenocarcinoma

BACKGROUND AND OBJECTIVES

The aim of this study was to clarify the clinicopathological differences between patients with invasive intraductal papillary-mucinous neoplasm (IPMN) of the pancreas and pancreatic ductal adenocarcinoma.

METHODS

The medical records of 16 patients with invasive IPMN and 106 patients with pancreatic ductal adenocarcinoma, who underwent surgical resection, were retrospectively reviewed, and the clinicopathological factors and survival were compared between the two groups.

RESULTS

The presence of retroperitoneal tissue invasion, portal or splenic vein invasion, nodal involvement, and positive surgical margins were significantly lower in patients with invasive IPMN than in those with ductal adenocarcinoma (P < 0.05). The actuarial 5-year overall survival rates in patients with invasive IPMN and ductal carcinoma were 40% and 18%, respectively (P = 0.008). However, the actuarial 5-year survival rate of patients with invasive IPMN was only 27% for UICC stage II disease, although this was significantly higher than that of patients with UICC stage II ductal adenocarcinoma (P = 0.049).

CONCLUSIONS

Invasive IPMN has a favorable prognosis compared with pancreatic ductal adenocarcinoma that is likely due to the less aggressive nature of the disease. However, the prognosis for cases of advanced invasive IPMN is not always favorable despite complete tumor resection.

Redefining resection margin status in pancreatic cancer

Curative resection is crucial to survival in pancreatic cancer; however, despite optimization and standardization of surgical procedures, this is not always achieved. This review highlights that the rates of microscopic margin involvement (R1) vary markedly between studies and, although resection margin status is believed to be a key prognostic factor, the rates of margin involvement and local tumour recurrence or overall survival of pancreatic cancer patients are often incongruent. Recent studies indicate that the discrepancy between margin status and clinical outcome is caused by frequent underreporting of microscopic margin involvement. Lack of standardization of pathological examination, confusing nomenclature and controversy regarding the definition of microscopic margin involvement have resulted in the wide variation of reported R1 rates that precludes meaningful comparison of data and clinicopathological correlation.

Advances in the treatment of pancreatic cancer: limitations of surgery and evaluation of new therapeutic strategies

Pancreatic ductal carcinoma is one of the most dismal malignancies of the gastrointestinal system. Even after curative resection, the actual 5-year survival is only 10%-20%. Of all the treatments used against pancreatic cancer, surgery is still the only one that can achieve complete cure. Pancreatic cancer spreads easily to the adjacent tissues and distant metastasis is common. Typically, this cancer invades the retropancreatic neural tissue, duodenum, portal vein (PV), and superior mesenteric vein (SMV), or regional lymph nodes. For this reason, aggressive surgery that removes the cancerous lesion completely is recommended. Several retrospective and prospective studies have been conducted to validate the usefulness of aggressive surgery for pancreatic cancer in the past few decades. Surprisingly, the survival benefits of aggressive surgery have been denied by most randomized controlled trials (RCTs). This implies that surgery alone is not enough. Thus, adjuvant therapy, such as radiotherapy and chemotherapy, has been given in combination with surgery to improve survival. Although the benefits of radiotherapy alone are limited, the results of chemotherapy are promising. Other newly evolving molecular targeting drugs may also improve the treatment outcomes of pancreatic cancer.

Enteral nutrition and biliopancreatic diversion effectively minimize impacts of gastroparesis after pancreaticoduodenectomy

BACKGROUND

Since gastroparesis is unavoidable in a certain proportion of patients after pancreaticoduodenectomy, measures to avoid its occurrence or at least minimize its impact are needed. A prospective randomized trial was performed to test the effectiveness of biliopancreatic diversion with modified Roux-en-Y gastrojejunostomy reconstruction and of enteral feeding to minimize impacts of gastroparesis after pancreaticoduodenectomy.

METHODS

In total, 247 patients with periampullary tumors were randomized at the time of pancreaticoduodenectomy to have either (1) modified Roux-en-Y gastrojejunostomy reconstruction (by creating a side-to-side jejunojejunostomy between afferent and efferent loop and closing the afferent loop with a TA-30-3.5 stapler) and insertion of a jejunostomy feeding tube (modified group) or (2) conventional gastric bypass (control group). Outcomes including complications, duration of nasogastric tube placement, and length of hospital stay were followed prospectively.

RESULTS

Gastroparesis occurred in 20 patients (16.3%) in the modified group and 27 patients in the control group (21.7%, P = 0.27). However, the International Study Group of Pancreatic Surgery grades of gastroparesis were significantly lower in the modified group (10A, 5B, 5C) than in the control group (4A, 5B, 18C, P = 0.01).

CONCLUSIONS

Modified procedure does not reduce the risk of gastroparesis but appears to reduce the severity when it occurs.

Does lymph node ratio impact survival in resected periampullary malignancies?

BACKGROUND

Lymph node ratio (LNR) has been associated with long-term survival in patients with pancreatic adenocarcinoma; however, this has not been demonstrated in other periampullary malignancies. The purpose of this study was to determine if LNR is associated with survival in other periampullary malignancies.

METHODS

A retrospective review of a prospective database of 522 pancreaticoduodenectomies (PDs) performed between 1988 and 2007 was undertaken. Clinicopathologic data were collected, and LNR was calculated. Patients with positive lymph node (LN) status were placed into the following groups: (1) LNR = 0; (2) LNR < or =0.2; (3) LNR < or =0.4; and (4) LNR >0.4.

RESULTS

Of the 364 malignancies identified, there were 219 (60%) pancreatic adenocarcinomas, 36 (10%) duodenal adenocarcinomas, 75 (21%) ampullary adenocarcinomas, and 35 (10%) cholangiocarcinomas. Positive LN status affected patient survival in all malignancies studied. Increasing LNR is associated with decreased survival in PA (P = .03) and AA (P = .04).

CONCLUSIONS

Positive LN status in all patients with periampullary malignancies is associated with worse survival rates than in those with no evidence of disease. LNR is inversely associated with survival rates in pancreatic and ampullary adenocarcinoma patients.

Surgery for recurrence of periampullary malignancies

AIM

Few studies have addressed the surgical treatment of recurrent disease after pancreatic resection. The aim of this study was to evaluate the indications, the short- and long-term outcome, and the prognostic factors impacting survival in patients undergoing a re-laparotomy for recurrence of periampullary malignancies.

METHODS

Between 1990 and 2007, 16 re-laparotomies were performed in 15 patients (one patient had a second re-laparotomy) with a median age of 61 years (range 31-84). Patients were identified from a prospective database and records were reviewed retrospectively.

RESULTS

Seven re-laparotomies were performed for a surgical emergency and nine patients had a re-laparotomy for recurrence found at imaging studies. Perioperative mortality was observed in three patients presenting with surgical emergency and a poor performance status (Eastern Cooporative Oncology Group score >or=3). Perioperative morbidity was 40%. Median survival after the first re-laparotomy for the 15 patients was 7.4 months, and was not different for patients presenting a surgical emergency versus no emergency. Patients with peritoneal carcinomatosis had a median survival of 1.4 month. In a univariate analysis of survival, a performance status of ECOG score >or=2 and a pre-operative hemoglobin level <12 g/dl were predictors of poor survival.

CONCLUSION

In selected patients, a re-laparotomy for recurrence of periampullary malignancies is feasible. Peritoneal recurrence was not a good indication for surgery. The predictors of poor survival after the re-laparotomy were a poor performance status and a low preoperative hemoglobin level.

Does lymph node ratio impact survival in resected periampullary malignancies?

BACKGROUND

Lymph node ratio (LNR) has been associated with long-term survival in patients with pancreatic adenocarcinoma; however, this has not been demonstrated in other periampullary malignancies. The purpose of this study was to determine if LNR is associated with survival in other periampullary malignancies.

METHODS

A retrospective review of a prospective database of 522 pancreaticoduodenectomies (PDs) performed between 1988 and 2007 was undertaken. Clinicopathologic data were collected, and LNR was calculated. Patients with positive lymph node (LN) status were placed into the following groups: (1) LNR = 0; (2) LNR < or =0.2; (3) LNR < or =0.4; and (4) LNR >0.4.

RESULTS

Of the 364 malignancies identified, there were 219 (60%) pancreatic adenocarcinomas, 36 (10%) duodenal adenocarcinomas, 75 (21%) ampullary adenocarcinomas, and 35 (10%) cholangiocarcinomas. Positive LN status affected patient survival in all malignancies studied. Increasing LNR is associated with decreased survival in PA (P = .03) and AA (P = .04).

CONCLUSIONS

Positive LN status in all patients with periampullary malignancies is associated with worse survival rates than in those with no evidence of disease. LNR is inversely associated with survival rates in pancreatic and ampullary adenocarcinoma patients.

Vascular resection in pancreatic cancer surgery: survival determinants

INTRODUCTION

Pancreaticoduodenectomy (PD) is the standard operation for cancer of the pancreatic head. To achieve complete tumor resection and, thus, improve long-term survival, venous resection of the portal or superior mesenteric vein with reconstruction has become routine for advanced pancreatic adenocarcinoma (PDAC). However, its clinical benefit still remains controversial. The aim of this study was to investigate morbidity, mortality, and survival of patients with advanced PDAC following PD with venous resection and to identify significant survival determinants.

MATERIAL AND METHODS

From October 2001 to December 2007, 488 patients with PDAC of the pancreatic head underwent PD at our department. Venous resection was performed in 110 patients (22.5%). Clinical data, surgical techniques, perioperative parameters, and histopathologic data were analyzed on a prospective database.

RESULTS

Major venous reconstruction was accomplished through primary lateral venorrhaphy in 18 patients (16.3%), polytetrafluoroethylene grafting (n = 14, 12.7%), primary end-to-end anastomosis (n = 72, 65.5%), an autologous saphenous venous graft patch (n = 4, 4.6%) or a Goretex(R) patch (n = 2, 2.3%). In 78.1% histopathologic examination revealed cancer invasion of the vein, whereas the remainder had peritumoral inflammation extending to the vessel wall. Perioperative morbidity rate was 41.8%; and the mortality rate 3.6%. The 1-, 2-, and 3-year survival rates were 55.2%, 23.1%, and 14.4%, respectively. Operating time (>420 min) and advanced age (>70 years) were the only prognostic variables, which significantly diminished survival on multivariate analysis.

CONCLUSION

Resection of the superior mesenteric or portal vein to achieve macroscopic tumor clearance can be performed safely with acceptable operative morbidity and mortality. However, improved local clearance in these patients cannot achieve a favorable long-term survival for all patients because distant metastases or local recurrence is frequent.

Does portal-superior mesenteric vein invasion still indicate irresectability for pancreatic carcinoma?

BACKGROUND

Pancreatic carcinoma frequently infiltrates the portal vein or the superior mesenteric vein; pancreatectomy combined with portal vein/superior mesenteric vein resection represents a potentially curative treatment in these cases but is still a controversial procedure.

METHODS

After performing a computerized Medline search, 12 series published during the last 8 years were selected, enrolling 399 patients who underwent pancreatectomy combined with portal vein/superior mesenteric vein resection for pancreatic carcinoma. Data were examined for information about indications, operation, adjuvant therapies, histopathology of resected specimens, perioperative results, and survival. Also, previous literature regarding the issue was extensively reviewed.

RESULTS

Operative mortality and postoperative complication rates ranged from 0 to 7.7% and 16.7% to 54%, respectively. Median survival varied from 13 to 22 months; 5-year survival rate ranged from 9% to 18%.

CONCLUSIONS

The current literature suggests that portal vein/superior mesenteric vein resection combined with pancreatectomy is a safe and feasible procedure that increases the number of patients who undergo curative resection and, therefore, provides important survival benefits to selected groups of patients. This procedure should always be considered in case of suspected tumor infiltration of portal/superior mesenteric vein to achieve clear resection margins, in the absence of other contraindications for resection.

The pathology and genetics of metastatic pancreatic cancer

CONTEXT

Metastatic disease is the most critical determinant of resectability of pancreatic cancer and accounts for the poor outcome of patients with this disease. Thus, a better understanding of metastatic pancreatic cancer will afford new opportunities for therapeutic intervention.

OBJECTIVE

To summarize and discuss the current understanding of the clinical and molecular features of metastatic pancreatic cancer.

DATA SOURCES

Published literature on advanced stage pancreatic cancer, pancreatic cancer metastasis, and autopsy findings in patients with pancreatic cancer.

CONCLUSIONS

In the clinical setting, it can be difficult to distinguish a metastatic pancreatic carcinoma from primary neoplasms in the liver, lung, or ovary. However, immunolabeling for DPC4 protein as part of a diagnostic panel is useful for making this distinction. Emerging data from a variety of investigators now indicate that overexpression of EphA2, loss of DPC4 and MKK4, and aberrant activation of the Hedgehog signaling pathway are associated with metastatic propensity of pancreatic cancers, providing novel therapeutic targets for the most lethal stage of this disease.

Preoperative serum CA19-9 and dissected peripancreatic tissue margin as determiners of long-term survival in pancreatic cancer

BACKGROUND

Pancreatic cancer, a particularly deadly form of malignancy, has increased in the last decade worldwide. The purpose of this study is to identify markers for determining and identifying possible long-term survivors in cases of advanced pancreatic cancer.

PATIENTS AND METHODS

117 patients with pancreatic ductal carcinoma, including 89 with invasive tubular adenocarcinoma of the pancreas, Japan Pancreas Society (JPS) stage III-IVb patients, who underwent tumor resection between 1986 and 2006.

RESULTS

Univariate prognostic analyses of the 5-year disease-specific survival (DSS) revealed that JPS stage (P < 0.0001), preoperative serum carbohydrate antigen 19-9 (CA19-9) level (preCA19-9; P < 0.0001), dissected peripancreatic tissue margin (DPM; P < 0.0001), residual tumor (R factor; P = 0.0007), lymph node metastasis density over 10% (ND10; P = 0.006), volume of the stromal connective tissue (stroma factor; P = 0.008), growth pattern (P = 0.01), and histology (P = 0.03) were all significantly associated with poor outcome in advanced pancreatic cancer. Multivariate logistic analysis confirmed that preCA19-9 [P = 0.0006, relative risk (RR) = 2.16] and DPM (P = 0.04, RR = 1.62) were prognostic factors that remained, independent of JPS stage (P = 0.001). The higher preCA19-9 was, the worse the prognosis was. Astonishingly, among JPS stage III cases, 76.9% of the patients with preCA19-9 below 37 U/ml survived more than 5 years. This, combined with an analysis of DPM, allowed us to identify those with the potentiality for long-term survival.

CONCLUSION

Our results reveal for the first time that it is possible with JPS stage III-IVb invasive tubular adenocarcinomas of the pancreas to differentiate prognostic groups and potential survival rates, like with other cancers.

Portal or superior mesenteric vein resection for pancreatic head adenocarcinoma: prognostic value of the length of venous resection

BACKGROUND

We investigated retrospectively the operative outcomes of portal vein resection (PVR) for portal vein (PV) and/or superior mesenteric vein (SMV) involvement and clarified the validity of PVR.

METHODS

Between 1993 and 2006, 84 patients with invasive pancreatic head adenocarcinoma were resected by pancreatoduodenectomy with macroscopically curative resection. Forty-two patients underwent PVR by means of segmental resection with end-to-end anastomosis in 27 patients and autologous vein graft using an external iliac vein in 15 patients because of macroscopic venous involvement. Venous involvement was classified macroscopically as unilateral involvement (< or =180 degrees ; n = 27) or circumferential involvement (n = 15) and as short (the length of PVR < 3 cm; n = 15) or long (> or =3 cm; n = 27). Histopathologic parameters and survival were analyzed to confirm prognostic factors.

RESULTS

Morbidity and mortality were not different based on PVR status. Median and 5-year survivals were 26 months and 32%, respectively, when there was no PVR (n = 42) and 12 months and 17% when there was PVR (n = 42); these values of median and 5-year survivals differed (P < .04 each) between the groups without and with PVR. Limiting the analysis to R0 (histologically curative) resections, median and 5-year survivals were 26 months and 34% when there was no PVR (n = 39) and 20 months and 23% when there was PVR (n = 32); these survivals were not significantly different between groups. In patients with PVR, there were no statistical differences in survival between those resected with or without a venous allograft and those with unilateral or circumferential involvement; however, short PVR showed better 5-year survival than long PVR (39% vs 4%; P = .017) despite similar positive rates of histologic venous invasion.

CONCLUSION

PVR has comparable survival compared with no PVR only in patients undergoing an R0 resection. The short PV/SMV invasion that requires PVR <3 cm in length can result in respectable survival rates.

Extended pancreatoduonectomy

Pancreatoduodenectomy remains a conventional procedure for pancreatic head cancer, however, it has been associated with high incidence of recurrence and low survival rate due to the specific characteristics of biological behavior of pancreatic head cancer, leading to the introduction of extended pancreatoduodenectomy with an attempt to improve the curative resection rate. With the latest literature review, this article presents the evidence for extended pancreatoduodenectomy from a pathological and anatomical point of view, and also described the standardized procedures, indications, and risk of extended pancreaticoduodenectomy for lymphadenectomy, neural clearance and combined vascular resection. Extended pancreatoduodenectomy for pancreatic head cancer significantly improves resection rate but doesn't increase surgical risk.

An exploration of the extended lymph node dissection and skeletonization of the vasculature for pancreatic adenocarcinoma

About 50%-90% of patients with pancreas carcinoma are found to have metastatic tumors when diagnosis is confirmed. The metastasis routes include via circulation system, lymph-node, and invasion to solar nerve plexus which usually occurs in 70% of patients. Pancreatoduodenectomy (PD) is the routine operation performed for pancreas carcinoma. There is also operation plan suggesting the resection of the nerve plexus and soft tissue distributing along the artery vessels, and the nerve fiber bat around the pancreas. This operation is also named as skeletonization of the vasculature. There have been different point-views from different surgery groups, on whether the extended lymphadenectomy (ELND) can extend the survival length and improve life quality of patients or not. However, ELND is considered to be possible to prolong the survival time for the patients with positive nodal metastasis.

Pancreaticojejunostomy of duct to mucosa anastomosis can be performed more safely without than with a stenting tube

BACKGROUND

The aim of this study was to evaluate the safety of performing a pancreaticojejunostomy with a duct-to-mucosa anastomosis without a stenting tube.

METHODS

One hundred twenty-one patients with pancreaticojejunostomy, classified into 2 groups of those with duct-to-mucosa anastomoses with stenting tubes (group A; n = 49) and without stenting tubes (group B; n = 72), were investigated. Outcomes, including complications and survival rates, are reported.

RESULTS

In group A, morbidity was 32.7%, 6.7% had pancreatic fistulas, 14.3% had delayed gastric emptying, 6.1% had remnant pancreatitis, 2% had intra-abdominal abscesses, 2% had intra-abdominal bleeding, and mortality was 2%. In group B, morbidity (15.3%) and delayed gastric emptying (2.8%) showed significant differences from group A. Other results were nonsignificant. In the normal soft pancreas, pancreatic fistulas in group B (3.3%) were less frequent than in group A (12.5%).

CONCLUSION

Pancreaticojejunostomy of a duct-to-mucosa anastomosis could be performed more safely without than with a stenting tube to obtain a definitive anastomosis and transection of the pancreas.

Laparoscopic pancreatic resection for cancer

Laparoscopic (lap) organ resection is now commonly performed for the management of solid tumors of the kidney, colon, adrenal glands and prostate. Surgeons have been slower to adopt minimally invasive approaches to the pancreas owing to operative complexity and complication potential. The majority of existing reports concerning lap pancreatectomy are single-center studies that describe experience with fewer than 20 cases. Only recently have larger experiences surfaced demonstrating the safety and efficacy of lap tumor enucleation and lap left pancreatectomy. As neoplastic disease is the most common indication for pancreatic resection, understanding the effects of the lap approach to pancreatectomy on cancer outcome is crucial. In addition to concerns of port-site tumor recurrence and tumor dissemination due to lap manipulation in the setting of pneumoperitoneum, adequacy of resection as defined by margin status and nodal assessment must be considered. This review covers the development and current state-of-the-art of lap pancreatic surgery for cancer. Existing data are reviewed for both open and lap pancreatic resections, with particular attention to pancreatic ductal adenocarcinoma. Projections of future advances in the field of lap pancreatic surgery are provided.