Bypass Surgery Versus Palliative Pancreaticoduodenectomy in Patients with Advanced Ductal Adenocarcinoma of the Pancreatic Head, with an Emphasis on Quality of Life Analyses

Surgical and survival outcomes after robotic and open pancreaticoduodenectomy with positive margins

BACKGROUND

Though nowadays a palliative pancreaticoduodenectomy (PD) can be performed safely with relatively low mortality and acceptable morbidity rates in experienced centers, there have been no studies on the routine use of a palliative PD or on the advantages of performing surgical resection as a debulking procedure. Furthermore, the impact of resection margins on survival outcomes has been a matter of controversy. Therefore, this study aimed to clarify the role of robotic PD (RPD) in pancreatic and periampullary adenocarcinomas with positive resection margins.

METHODS

Patients undergoing RPDs and open PDs (OPDs) were included in this study. Based on the resection margins, the patients were divided into the R0, R1, and R2 PD groups. Surgical risks and survival outcomes were analyzed.

RESULTS

There were 348 PDs, including 29 (8.3%) palliative and 319 (91.7%) curative. Primary tumor origin, tumor sizes, perineural invasions, and abnormal serum carcinoembryonic antigen (CEA) levels were factors leading to palliative resection. The multivariate analysis showed that only pancreatic head adenocarcinomas and abnormal serum CEA levels (>5 ng/mL) were independent predictors. The surgical risks between curative and palliative PD were similar. There were no significant differences in the surgical risks and other surgical parameters between palliative RPDs and OPDs. For curative resection, RPDs resulted in less blood loss, greater harvested lymph nodes yield, less postoperative complications, less delayed gastric emptying, and shorter hospital stays than OPDs. The survival outcome was significantly better following R0 resection in overall periampullary adenocarcinomas, whereas a significant survival difference was shown only between the R0 and R2 resections for pancreatic head adenocarcinomas.

CONCLUSION

Compared with R0 PDs, palliative R1 PDs could benefit patients with pancreatic head adenocarcinomas when considering survival outcomes without increasing surgical risks. RPD can be considered for curative purposes and as an alternative for palliative management.

A systematic review into patient reported outcomes following pancreaticoduodenectomy for malignancy

BACKGROUND

Pancreaticoduodenectomy is associated with high rates of morbidity. This combined with the psychological burden of cancer, may impact on a patient's quality of life (QoL), which can be measured by using patient-reported outcomes (PRO).

OBJECTIVE

To perform a systematic review to evaluate the measurement of PRO after pancreaticoduodenectomy for cancer.

METHODS

7 different databases were searched using 2 groups of search terms, one relating to pancreaticoduodenectomy, and one to PRO. Three authors screened the search results independently in a systematic manner based on predefined inclusion and exclusion criteria.

RESULTS

27 studies, with 2173 eligible patients were included in the final analysis. Most of the included studies used validated instruments. The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire was most popular and used in 12 studies. The methodology of all included studies was also scrutinised. 12 studies were deemed to have high quality methodology according to pre-defined criteria.

CONCLUSION

The instruments and methods used to measure PRO are variable. The quality of PRO within the available literature has improved over time, as has the number of studies measuring PRO. PRO should be measured with uniformity in future trials so that patients can be provided with more comprehensive information regarding post-operative recovery and QoL during the shared decision-making process preoperatively.

[Palliative therapy concepts for pancreatic carcinoma]

The majority of patients with ductal pancreatic adenocarcinoma are already in a locally advanced or metastatic stage at the time of diagnosis and require palliative therapy. Interventional and operative measures are available for the restoration of biliary outflow in bile duct obstruction and the continuity of the upper intestinal lumen in duodenal or gastric outlet obstruction. In the presence of tumor-related pain, pain therapy according to the World Health Organization (WHO) scheme or a truncus coeliacus blockade, in cachexia a nutritional therapy and in thromboembolic events an anticoagulant therapy are used. An individualized palliative chemotherapy regimen should be selected for each patient, taking into account the patient's general condition and the side effects profile of the chemotherapeutic agents. Radiochemotherapy and local ablative therapies should currently only be used within the framework of studies. A palliative resection is not recommended according to current knowledge.

Systematic review on the impact of pancreatoduodenectomy on quality of life in patients with pancreatic cancer

BACKGROUND

Patients undergoing pancreatoduodenectomy for pancreatic cancer have a high risk of major postoperative complications and a low survival rate. Insight in the impact of pancreatoduodenectomy on quality of life (QoL) is therefore of great importance. The aim of this systematic review was to assess QoL after pancreatoduodenectomy for pancreatic cancer.

METHODS

A systematic review of the literature was performed according to the PRISMA guidelines. A systematic search of all the English literature available in PubMed and Medline was performed. All studies assessing QoL with validated questionnaires in pancreatic cancer patients undergoing pancreatoduodenectomy were included.

RESULTS

After screening a total of 788 articles, the full texts of 36 articles were assessed, and 17 articles were included. QoL of physical and social functioning domains decreased in the first 3 months after surgery. Recovery of physical and social functioning towards baseline values took place after 3-6 months. Pain, fatigue and diarrhoea scores deteriorated postoperatively, but eventually resolved after 3-6 months.

CONCLUSION

Pancreatoduodenectomy for malignant disease negatively influences QoL in the physical and social domains at short term. It will eventually recover to baseline values after 3-6 months. This information is valuable for counselling and expectation management of patients undergoing pancreatoduodenectomy.

Anxiety, depression and quality of life in people with pancreatic cancer and their carers

BACKGROUND

People with pancreatic cancer have high levels of anxiety and depression and reduced quality of life (QoL), but few studies have assessed these outcomes for patient-carer dyads. We therefore investigated these issues in an Australian population-based study.

METHODS

Patients with pancreatic cancer (n = 136) and many of their carers (n = 84) completed the Hospital Anxiety and Depression Scale (HADS) and Functional Assessment of Cancer Therapy QoL questionnaire at a median of three months after diagnosis. Overall QoL and well-being subscales (physical, social, emotional, functional) were compared with general population norms. Intraclass correlation coefficients were used to compare anxiety, depression and QoL scores of patients and their respective carers.

RESULTS

Fifteen percent of patients and 39% of carers had HADS scores indicative of anxiety and 15% of patients and 14% of carers of depression, respectively. Overall, 70% of patients and 58% of carers had QoL scores below the Queensland population average. Patients' anxiety, depression, overall QoL, social, emotional and functional wellbeing scores were significantly related to those scores in their carers. Among patients and carers, accessing psychological help was associated with elevated anxiety. Not receiving chemotherapy was associated with elevated depression among patients and younger age was associated with poorer outcomes in carers.

CONCLUSIONS

More carers had symptoms of anxiety than patients with pancreatic cancer, but symptoms of depression were similarly common in patients and carers. Further research is needed to assess whether interventions to reduce patients' distress could also improve QoL among carers, or whether carer-focussed interventions are required.

Improved survival after palliative resection of unsuspected stage IV pancreatic ductal adenocarcinoma

BACKGROUND

Palliative resection of stage IV pancreatic ductal adenocarcinoma (PDAC) has not shown its benefit until now. In our retrospective review, we compared the results of palliative resection to non-resection.

METHODS

Between 2000 and 2009, metastasis of PDAC was confirmed in the operating room in 150 patients. 35 underwent palliative resection (resection group; R) and 115 did bypass or biopsy. 35 patients (biopsy or bypass group: NR) in the 115 patients were matched with the patients undergoing resection for tumor size and the metastasis of peritoneal seeding. Demographic, clinical, operative data and survival were analyzed.

RESULTS

There was no significant difference of major complication (Clavien-Dindo classification 3-5) between two groups. There was no 30-day mortality in either group. More patients in R received postoperative chemotherapy (82.9% vs. 57.1%; P = 0.019). Multivariate analysis showed resection and postoperative chemotherapy as independent factor related to survival (hazard ratio, 0.44; 95% CI, 0.25-0.76; P = 0.003). Patients in R showed better survival rates compared to those in NR (P < 0.001).

CONCLUSION

Our study suggests resection for stage IV PDAC can be associated with increased survival. In patients of stage IV PDAC, palliative resection with chemotherapy could have some benefit in selected patients.

Does neoadjuvant treatment before oncologic esophagectomy affect the postoperative quality of life? A prospective, longitudinal outcome study

To evaluate the cancer patients' quality of life (QoL) following esophagectomy the focus was placed on the impact of neoadjuvant treatment before surgery. For patients undergoing oncologic surgery, the QoL is generally accepted as an important outcome parameter in addition to clinical parameters. This prospective nonrandomized study evaluated QoL in patients treated by preoperative chemo(radio)therapy followed by either surgery or surgery alone with special focus on the postoperative course. QoL was assessed in 131 consecutive patients who underwent surgery for esophageal cancer. The EORTC-QLQ-C30 and a tumor-specific module were administered before surgery, at discharge, 3, 6, 12, and 24 months after surgery. Clinical data were collected prospectively and a follow up was performed every 6 months. The histological type of cancer was squamous cell carcinoma in 49.6% and adenocarcinoma in 50.4%. There was no significant difference between patients that were treated neoadjuvantly and those that were first operated on with regard to morbidity, mortality, and survival rates (5-year survival rate of 34%). Most QoL scores dropped significantly below the baseline in the early postoperative period and recovered slowly during the follow-up period to almost preoperative levels in many scores. There was no statistically significant difference in any of the QoL scales between neoadjuvantly treated or primary operated patients. Esophageal resections are associated with significant deterioration of QoL, which slowly recovers during the follow-up period to an almost preoperative level. Neoadjuvant treatment seems to not further negatively affect the QoL deterioration.

Endoscopic and operative palliation strategies for pancreatic ductal adenocarcinoma

Malignant biliary obstruction, duodenal, and gastric outlet obstruction, and tumor-related pain are the complications of unresectable pancreatic adenocarcinoma that most frequently require palliative intervention. Surgery involving biliary bypass with or without gastrojejunostomy was once the mainstay of treatment in these patients. However, advances in non-operative techniques-most notably the widespread availability of endoscopic biliary and duodenal stents-have shifted the paradigm of treatment away from traditional surgical management. Questions regarding the efficacy and durability of endoscopic stents for biliary and gastric outlet obstruction are reviewed and demonstrate high rates of therapeutic success, low rates of morbidity, and decreased cost. Surgery remains an effective treatment modality, and still produces the most durable relief in appropriately selected patients.

Non-radical resection versus bypass procedure for pancreatic cancer - a consecutive series and systematic review

BACKGROUND

Most survival studies comparing non-radical resections to bypass surgery in patients with pancreatic cancer often do not differentiate between an R1 and R2 resection. The aim of this study was to evaluate whether non-radical R1 and R2 resections have better postoperative outcomes and survival compared to a palliative bypass.

METHODS

A single center cohort study was performed analyzing mortality, morbidity and 1-year survival after R1 (tumor cells within 1 mm from the circumferential margin), R2 and bypass surgery in patients with pancreatic cancer. For the systematic review, studies were identified comparing R1 or R2 resections with bypass, in patients with pancreatic cancer. Postoperative outcomes were compared including the cohort study.

RESULTS

The cohort study (n=405) showed higher morbidity rates after R1 (n=191) and R2 (n=11) resections compared to bypass (52% and 73% vs. 34%, p < 0.01). In-hospital mortality did not differ (overall 1.7%). 1-year survival rates were 71%, 46% and 32% after R1, R2 resection and bypass (p=0.6 between R2 and bypass). The systematic review identified 8 studies, after including the cohort study 1535 patients were analyzed. Increased morbidity after R1-R2 resection (48%) compared to bypass (30-34%) was found. Median survival was 14-18 months after R1 resection vs. 9-13 months after bypass and 8.5-11.5 months after R2 resection vs. 7.5-10.7 months after bypass.

CONCLUSION

An R2 resection should be avoided in patients with pancreatic cancer due to its poor prognosis. Survival benefit after an R1 resection, as compared to bypass surgery, justifies a resection despite the increased morbidity rate.

Portal vein resection in borderline resectable pancreatic cancer: a United Kingdom multicenter study

BACKGROUND

Until recently, in the United Kingdom, borderline resectable pancreatic cancer with invasion into the portomesenteric veins often resulted in surgical bypass because of the presumed high risk for complications and the uncertainty of a survival benefit associated with a vascular resection. Portomesenteric vein resection has therefore remained controversial. We present the second largest published cohort of patients undergoing portal vein resection for borderline resectable (T3) adenocarcinoma of the head of the pancreas.

STUDY DESIGN

This is a UK multicenter retrospective cohort study comparing pancreaticoduodenectomy with vein resection (PDVR), standard pancreaticoduodenectomy (PD), and surgical bypass (SB). Nine high-volume UK centers contributed. All consecutive patients with T3 (stage IIA to III) adenocarcinoma of the head of the pancreas undergoing surgery between December 1998 and June 2011 were included. The primary outcomes measures are overall survival and in-hospital mortality. Secondary outcomes measure is operative morbidity.

RESULTS

One thousand five hundred and eighty-eight patients underwent surgery for borderline resectable pancreatic cancer; 840 PD, 230 PDVR, and 518 SB. Of 230 PDVR patients, 129 had primary closure (56%), 65 had end to end anastomosis (28%), and 36 had interposition grafts (16%). Both resection groups had greater complication rates than the bypass group, but with no difference between PD and PDVR. In-hospital mortality was similar across all 3 surgical groups. Median survival was 18 months for PD, 18.2 months for PDVR, and 8 months for SB (p = 0.0001).

CONCLUSIONS

This study, the second largest to date on borderline resectable pancreatic cancer, demonstrates no significant difference in perioperative mortality in the 3 groups and a similar overall survival between PD and PDVR; significantly better compared with SB.

Outcome 1 year after digestive surgery in malnourished, elderly patients, with an emphasis on quality of life analysis

BACKGROUND

Quality of life data after digestive surgery in malnourished, elderly patients are rarely reported. What can we expect as 1-year outcomes in these high-risk patients after digestive surgery?

METHODS

We conducted a prospective observational study in a digestive surgery department in a tertiary, nonacademic hospital in Mulhouse, France. Malnourished, older patients (according to the Nutritional Risk Index) undergoing digestive surgery between November 2007 and December 2008 were included and followed up for 1 year. Quality of life was measured by the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire at the end of the study period.

RESULTS

We included 37 patients with a median age of 76 (range 66-86) years in our study. The mean global health status and quality of life score in 17 of 24 living patients 1 year after surgery was 68.6 (standard deviation [SD] 12.4), and no difference with the score of a reference population 70.8 (SD 22.1) was observed (p = 0.68). In-hospital mortality was 11% and morbidity was 70%.

CONCLUSION

The present study suggests that despite high postoperative mortality and morbidity, an acceptable quality of life can be achieved in malnourished, elderly survivors of digestive surgery.

Advanced-stage pancreatic cancer: therapy options

Pancreatic ductal adenocarcinoma is one of the most aggressive cancers, and surgical resection is a requirement for a potential cure. However, the majority of patients are diagnosed with advanced-stage disease, either metastatic (50%) or locally advanced cancer (30%). Although palliative chemotherapy is the standard of care for patients with metastatic disease, management of locally advanced adenocarcinoma is controversial. Several treatment options, including extended surgical resections, neoadjuvant therapy with subsequent resections, as well as palliative radiotherapy and/or chemotherapy, should be considered. However, there is little evidence available to support treatment options for locally advanced disease. As valid predictive biomarkers for stratification of therapy are not available today, future trials need to define the role of the different treatment options. This Review summarizes the current evidence and discusses available treatment options for both locally advanced and metastatic pancreatic adenocarcinoma.

Pancreatic ductal adenocarcinoma: is there a survival difference for R1 resections versus locally advanced unresectable tumors? What is a "true" R0 resection?

OBJECTIVE

Patients who undergo an R0 resection of their pancreatic ductal adenocarcinoma (PDAC) have an improved survival compared with patients who undergo an R1 resection. It is unclear whether an R1 resection confers a survival benefit over locally advanced (LA) unresectable tumors. Our aim was to compare the survival of patients undergoing an R1 resection with those having LA tumors and to explore the prognostic significance of a 1-mm surgical margin.

METHODS

Clinicopathologic data from a pancreatic cancer database between January 1993 and July 2008 were reviewed. Locally advanced tumors had no evidence of metastatic disease at exploration.

RESULTS

A total of 1705 patients were evaluated for PDAC in the Department of Surgery. Of the 1084 (64%) patients who were surgically explored, 530 (49%) were considered unresectable (286 locally unresectable, 244 with distant metastasis). One hundred fifty-seven (28%) of the resected PDACs had an R1 resection. Patients undergoing an R1 resection had a slightly longer survival compared with those who had locally advanced unresectable cancers (14 vs 11 months; P < 0.001). Patients with R0 resections had a favorable survival compared with those with R1 resections (23 vs 14 months; P < 0.001), but survival after resections with 1-mm margin or less (R0-close) were similar to R1 resections: both groups had a significantly shorter median survival than patients with a margin of greater than 1 mm (R0-wide) (16 vs 14 vs 35 months, respectively; P < 0.001).

CONCLUSIONS

Patients undergoing an R1 resection still have an improved survival compared with patients with locally advanced unresectable pancreatic adenocarcinoma. R0 resections have an improved survival compared with R1 resections, but this survival benefit is lost when the tumor is within 1 mm of the resection margin.

Improved survival and quality of life in patients undergoing R1 pancreatic resection compared to patients with locally advanced unresectable pancreatic adenocarcinoma

OBJECTIVE

To prospectively record the clinical consequences of R1 resection of pancreatic adenocarcinoma compared to patients with locally advanced tumours not undergoing surgery.

BACKGROUND

Surgery is the only potentially curative treatment of pancreatic cancer, and postoperative safety is increasing. The rate of R1 resections might also increase unintentionally as surgical procedures with curative goal become more comprehensive, and the clinical outcome requires further prospective evaluation.

MATERIAL AND METHODS

Prospective observational cohort study from October 2008 to December 2010. Outcome after R1 resection (group 1, surgery, n = 32) and conservative palliative chemoradiation/endoscopy (group 2, no surgery, n = 56) is compared with survival and longitudinal patient-reported quality of life (QoL) as endpoints. QoL was assessed by the Edmonton Symptom Assessment System (ESAS).

RESULTS

Demographic characteristics and tumour diameters were similar in both groups: 38.0 (31.3, 49.8) mm in group 1 versus 44.0 (39.6, 49.1) mm in group 2 (p = 0.18). Perioperative morbidity was 25% with no mortality. Disease-specific survival was 18.0 (14.5, 23.8) months in group 1 versus 8.1 (4.8, 10.1) months in group 2 (p < 0.0001). Overall survival was 11 (7.8, 14.4) months. Reduction in fatigue was significantly improved in the surgery group 6, 12, and 19 weeks after baseline, whereas reduction in global health was significantly better in group 2.

CONCLUSION

Radical removal (R0 resection) is the primary aim of surgery, but also R1 resection seems to improve survival and QoL, compared to outcome in patients with locally advanced tumours not undergoing surgery.

Palliative pancreaticoduodenectomy in pancreatic and periampullary adenocarcinomas

OBJECTIVE

The objective of the study was to clarify the role of a palliative pancreaticoduodenectomy in both pancreatic and periampullary adenocarcinomas.

METHODS

Survival outcomes were compared between resections and bypass operations, and between curative (R0) and palliative resections, with a microscopically (R1) and a grossly (R2) positive resection margin.

RESULTS

There were 595 surgical patients, including 207 undergoing bypass operations and 388 undergoing pancreaticoduodenectomies, with 47.4% curative resections (R0) and 17.8% palliative resections (R1 + R2). The overall positive margin rate after a pancreaticoduodenectomy was 27.3% (R1 = 8.0%, R2 = 19.3%). For periampullary adenocarcinomas, there was a significant survival difference between the R0, palliative, and no resection groups. However, there was no significant survival difference between the R0 and palliative resection for pancreatic head adenocarcinoma. Note that the survival outcome after either a curative or a palliative pancreaticoduodenectomy was still better than the survival outcome of a bypass operation.

CONCLUSIONS

There was a survival benefit after a pancreaticoduodenectomy regardless of the resection margin or primary origin of the periampullary adenocarcinoma, as compared with a bypass operation. The resection margin after a pancreaticoduodenectomy did not play a role in the survival outcome in pancreatic head adenocarcinoma. Therefore, we recommend that pancreaticoduodenectomies should be attempted whenever possible.

Symptomatic change and gastrointestinal quality of life after pancreatectomy

BACKGROUND

Pancreatectomy affects gastrointestinal (GI) symptoms. Our purpose was to assess the quality of life of pancreatectomy patients in relation to GI function.

METHODS

Pancreatectomy patients were asked qualitative, open-ended questions about symptoms. They also completed the Gastrointestinal Symptom Rating Scale (GSRS) for reflux syndrome, acute pain syndrome, indigestion syndrome, diarrhoea syndrome and constipation syndrome.

RESULTS

A total of 52 patients participated. Of these, 69% reported an improvement and 31% reported no change in preoperative symptoms. No patients reported a worsening of symptoms. Half (50%) of the patients experienced new, different symptoms. Median GSRS scores were 0 for reflux syndrome [interquartile range (IQR): 0-1.0], 0 for acute pain syndrome (IQR: 0-1.0), 2.0 for indigestion syndrome (IQR: 1.0-4.0), 2.0 for diarrhoea syndrome (IQR: 0.5-4.5), and 0 for constipation syndrome (IQR: 0-1.0). Whipple operation patients scored higher on the reflux syndrome (0.5 vs. 0; P= 0.08) and indigestion syndrome (3.5 vs. 1.5; P= 0.06) domains. A total of 68% of Whipple operation patients experienced new symptoms, compared with 32% of patients who had undergone other types of pancreatectomy (P= 0.002). Scores of patients who had undergone surgery <2 years and >2 years earlier, respectively, did not differ.

CONCLUSIONS

Patients who underwent pancreatectomy frequently experienced an improvement in preoperative symptoms, but also experienced new postoperative symptoms. This was more common after Whipple operations. However, these symptoms were relatively mild in severity. These mild symptoms seem to persist over time.

Management of pancreatic cancer: current status and future directions

Pancreatic ductal adenocarcinoma has a dismal prognosis, despite advances in surgery, and adjuvant therapy. Surgical resection with negative margins remains the mainstay of treatment, and results can be improved with neoadjuvant therapy when the lesion is of borderline respectability. 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.

Pancreatoduodenectomy for ductal adenocarcinoma in the very elderly; is it safe and justified?

BACKGROUND

The outcomes of complex major surgery in the elderly are being scrutinized because of the demands on surgical services by an aging population and the concern whether such endeavors are justified. Pancreatoduodenectomy (PD) for pancreatic adenocarcinoma presents special challenges because of the high morbidity of the procedure, dismal prognosis of the disease, and the increasing incidence of pancreatic cancer with age.

METHODS

All patients who underwent PD for pancreatic adenocarcinoma from 1981 to 2007 were analyzed for perioperative outcomes, tumor-related parameters, use of adjuvant therapy, and long-term survival. Specifically those aged ≥80 years were compared with a control group aged ≤80 years. Continuous variables are displayed as median and interquartile range (IQR); log-rank test and Cox's proportional hazards were used to determine survival and effect of age as an independent marker against other covariates.

RESULTS

Fifty-three patients aged ≥80 years underwent PD. Twenty-six (51%) developed complications, including delayed gastric emptying (nine, 17%), pancreatic leak (six, 11%), and postoperative bleeding (five, 9%). There was one in-hospital death (2%). The hospital stay was 13.5 days (IQR 9-19). Forty-one (79%) patients were discharged home; of the 11 (21%) patients who went to an outside health care facility (pancreatic leak/drains and feeding issues--five, delayed gastric emptying/nutritional--four, no home support--one), one died in a nursing home at 5 months while the other ten patients returned to their previous abode (median 4 weeks). The median disease-free and overall survivals were 11.8 (IQR 7.8-18.4) and 13.5 months (IQR 12-21.3). Compared to the non-octogenarians (n = 567), the older population had more poor risk patients with respect to ASA status (P < 0.0004), stayed longer as in-patients (P < 0.04), were more likely to develop complications (P < 0.001), and were less likely to receive adjuvant therapy (P < 0.0001). There was no difference in long-term disease-free or overall survival (log-rank P < 0.30 and P < 0.14), and age did not appear to be an independent marker of prognosis when analyzed (Cox's proportional hazards P < 0.26; chi-square, 1.25).

CONCLUSIONS

In experienced institutions, PD for ductal adenocarcinoma is a viable option in the ambulatory octogenarian population who are deemed operative candidates for a PD. The trade off is a greater complication rate and the prospect of discharge (one in five) to a chronic care facility. The majority, however, can be discharged home with a reasonable functional status, and those discharged to temporary health care rehabilitation facilities are likely to make a recovery over a few weeks.

Functional changes after pancreatoduodenectomy: diagnosis and treatment

Relatively little is known about the gastrointestinal function after recovery of a pancreatoduodenectomy. This review focuses on the functional changes of the stomach, duodenum and pancreas that occur after pancreatoduodenectomy. Although the mortality in relation to pancreatoduodenectomy has decreased over the years, it remains associated with considerable morbidity, which occurs in 40-60% of patients. Physical complaints early after the operation are often caused by motility disorders, in particular delayed gastric emptying, which occurs in up to 40% of patients. During longer follow-up of these patients the occurrence of endocrine and exocrine pancreatic insufficiency becomes more predominant. Diabetes mellitus develops in 20-50% of patients after a pancreatic resection (pancreatogenic diabetes). The main presenting symptoms of exocrine insufficiency are weight loss and steatorrhea. Its presence is suspected on clinical ground and can be supported by fecal elastase-1 measurement. Exocrine insufficiency can be compensated with oral enteric-coated enzyme supplements. The quality of life issue will be addressed as an important outcome measurement after pancreaticoduodenectomy. Furthermore, the functional changes after pancreatoduodenectomy are described in detail with suggestions for diagnosis and treatment.

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.

Margin positive pancreaticoduodenectomy is superior to palliative bypass in locally advanced pancreatic ductal adenocarcinoma

BACKGROUND

Pancreatic ductal adenocarcinoma is an aggressive disease. Surgical resection with negative margins (R0) offers the only opportunity for cure. Patients who have advanced disease that limits the chance for R0 surgical resection may undergo margin positive (MP) pancreaticoduodenectomy (PD), palliative surgical bypass (PB), celiac plexus neurolysis alone (PX), or neoadjuvant chemoradiation therapy in anticipation of future resection.

OBJECTIVE

The aim of this study was to determine if there is a difference in the perioperative outcomes and survival patterns between patients who undergo MP PD and those who undergo PB for locally advanced disease in the treatment of pancreatic ductal adenocarcinoma.

METHODS

We reviewed our pancreatic surgery database (January 2005-December 2007) to identify all patients who underwent exploration with curative intent of pancreatic ductal adenocarcinoma of the head/neck/uncinate process of the pancreas. Four groups of patients were identified, R0 PD, MP PD, PB, and PX.

RESULTS

We identified 126 patients who underwent PD, PB, or PX. Fifty-six patients underwent R0 PD, 37 patients underwent MP PD, 24 patients underwent a PB procedure, and nine patients underwent PX. In the PB group, 58% underwent gastrojejunostomy (GJ) plus hepaticojejunostomy (HJ), 38% underwent GJ alone, and 4% underwent HJ alone. Of these PB patients, 25% had locally advanced disease and 75% had metastatic disease. All nine patients in the PX group had metastatic disease. The mean age, gender distribution, and preoperative comorbidities were similar between the groups. For the MP PD group, the distribution of positive margins on permanent section was 57% retroperitoneal soft tissue, 19% with more than one positive margin, 11% pancreatic neck, and 8% bile duct. The perioperative complication rates for the respective groups were R0 36%, MP 49%, PB 33%, and PX 22%. The 30-day perioperative mortality rate for the entire cohort was 2%, with all three of these deaths being in the R0 group. The median follow-up for the entire cohort was 14.4 months. Median survival for the respective groups was R0 27.2 months, MP 15.6 months, PB 6.5 months, and PX 5.4 months.

CONCLUSIONS

Margin positive pancreaticoduodenectomy in highly selected patients can be performed safely, with low perioperative morbidity and mortality. Further investigation to determine the role of adjuvant treatment and longer-term follow-up are required to assess the durability of survival outcomes for patients undergoing MP PD resection.

Diagnostic ascertainment of suspicious pancreatic mass: a threshold analysis

BACKGROUND & AIMS

It is frequently difficult to differentiate between a benign and malignant pancreatic mass. The aim of this study was to assess the parameters that affect the decision to perform surgery on a suspicious pancreatic head lesion.

METHODS

A cost-benefit analysis, using decision tree and threshold analysis, accumulates costs and quality-adjusted life years in patients undergoing pancreaticoduodenectomy or expectant management. The threshold value is defined as the diagnostic probability for pancreatic cancer when the cost-benefit relationships of pancreaticoduodenectomy or expectant management are equal.

RESULTS

For a localized pancreatic head lesion, the threshold probability of cancer is 43%. Any higher probability of pancreatic cancer makes pancreaticoduodenectomy the preferred treatment option. Within a range of $20,000 to $80,000 spent on surgery, the threshold in favor of Whipple procedure remains relatively low at 40% to 65%. A reduced quality of life after surgery weighs against surgery and raises its threshold. Varying quality of life between 100% and 80% changes the threshold between 31% and 67%. The threshold also is increased in younger patients because of the potentially more dire consequences of unnecessary surgery in instances of long life expectancy.

CONCLUSIONS

Even if diagnostic certainty cannot be achieved, it frequently is beneficial to perform surgery despite the risk of subjecting the occasional patient with benign pancreatic head lesion to an unnecessary pancreaticoduodenectomy.

Outcome of R1 resection in patients undergoing pancreatico-duodenectomy for pancreatic cancer

BACKGROUND

Pancreatico-duodenectomy (PD) is the only potentially curative treatment for pancreatic cancer, but most surgeons are reluctant to perform a palliative resection. The aim was to define the outcome for microscopically incomplete PD (R1).

METHODS

Ninety-nine consecutive patients underwent laparotomy to perform PD. Sixty-seven patients were resected and 32 underwent palliative bypass (PSB) because of locally advanced disease.

RESULTS

Of the 67 PD, 27 were classified as R0 and 40 as R1. Median survival for R0, R1 and PSB were 24, 18 and 9 months, respectively. Survival in the PSB group was 34% at 1 year and 0% at 2 years. 1-, 2- and 5-year survival in the R0 and R1 groups was 79% and 70%, 48.3% and 39.1%, 21.5% and 9.9%, respectively. Compared to PSB, both other groups were less likely to die over follow-up (p=0.002). Survival was not significantly different between the R0 and R1 groups (p=0.21). Perioperative morbidity and mortality were similar in the PD and PSB groups (29.9% and 3.0% vs 31.3 and 3.1%, respectively, p=1.00).

CONCLUSIONS

Better survival in the resection group and similar perioperative risk would support the decision to perform PD even when there is the possibility of incomplete microscopic clearance.

Pancreaticoduodenectomy in a Latin American country: the transition to a high-volume center

OBJECTIVE

To analyze data in a single institution series of pancreaticoduodenectomies (PD) performed in a 7-year period after the transition to a high-volume center for pancreatic surgery.

BACKGROUND

PD has developed dramatically in the last century. Mortality is minimal yet complications are still frequent (around 40%). There are very few reports of PD in Latin America.

METHODS

Data on all PDs performed by a single surgeon from March 2000 to July 2006 in our institution were collected prospectively.

RESULTS

During the study's time frame 122 PDs were performed; 84% were classical resections. Mean age was 57.9 years. Of the patients, 51% were female. Intraoperative mean values included blood loss 881 ml, operative time 5 h and 35 min, and vein resection in 14 cases. Both ampullary and pancreatic cancer accounted for 34% of cases (42 patients each), 5.7% were distal bile duct and 4% duodenal carcinomas. Benign pathology included chronic pancreatitis, neuroendocrine tumors, cystic lesions, and other miscellaneous tumors. Overall operative mortality was 6.5% in the 7-year period, 2.2% in the later 5 years. There was a total of 75 consecutive PDs without mortality. Of the patients, 41.8% had one or more complications. Mean survival for pancreatic cancer was 22.6 months and ampullary adenocarcinoma was 31.4 months.

CONCLUSION

To our knowledge, this is the largest single surgeon series of PD performed in Latin America. It emphasizes the importance of experience and expertise at high-volume centers in developing countries.

Surgical palliation of advanced pancreatic cancer

In about 80% of patients with pancreatic cancer surgical resection is not feasible at the time of diagnosis. Therefore, palliative treatment plays a key role in the treatment of pancreatic cancer. The defined goals of palliative treatment are: reduction of symptoms, reduction of in-hospital stays, and an adequate control of pain. In patients with nonresectable pancreatic carcinoma the leading goal of palliative strategies should be the control of biliary and duodenal obstructions such as jaundice-associated pruritus or sustained nausea and vomiting due to gastric outlet obstruction. Although the role of endoscopy for palliation has been increasing, operative palliation is still indicated in selected cases. Obstructive jaundice is found in approximately 70% of patients suffering from carcinoma of the pancreatic head at diagnosis and has to be eliminated to avoid progressive liver dysfunction and liver failure. In up to 50% of patients with pancreatic cancer, clinical symptoms such as nausea and vomiting occur. For the treatment of malignant biliary obstructions in patients with pancreatic carcinoma, endoscopic biliary drainage is the option of first choice. In case of persistent stent-problems such as occlusion or recurrent cholangitis, a hepaticojejunostomy should be considered. The role of a prophylactic gastroenterostomy is still under discussion. In patients with combined biliary and gastric obstruction a combined bypass should be performed to avoid a second operation. The significance of laparoscopic biliary bypass is not yet clear. A surgical, minimally invasive approach for treating bile duct obstruction is not the standard nowadays. The role of surgical pain relief is mostly negligible today. Computed tomography (CT)- or EUS-guided celiac plexus neurolysis has replaced surgical intervention today. The significance of palliative resections is currently a controversial topic. However, beyond controlled randomized studies, a palliative pancreaticoduodenectomy in patients with advanced pancreatic carcinoma cannot be recommended at this time.

Impact of the site of anastomosis after oncologic esophagectomy on quality of life--a prospective, longitudinal outcome study

BACKGROUND

For patients undergoing oncologic surgery, the quality of life (QoL) is generally accepted as an important outcome parameter in addition to long-term survival, mortality, and complication rates. Our study focused on outcome in terms of QoL in patients with esophageal cancer, comparing the sites of anastomosis (cervical versus thoracic anastomosis).

METHODS

In a prospective longitudinal single-center study from 1998 to 2005, 105 patients underwent surgery for esophageal cancer. To assess QoL the EORTC-QLQ-C-30 and a tumor-specific module were administered before surgery, at discharge, and three, six, 12, and 24 months after surgery. Clinical data were collected prospectively and follow-up was performed every six months.

RESULTS

The histological type was squamous cell carcinoma in 51.4% of the cases, adenocarcinoma in 41.9%, and some other type in 6.7%. There was no significant difference between cervical and thoracic anastomosis with regard to morbidity, mortality, and survival rates (30% five-year survival rate), whereas tumor stage was a significant (p < 0.001) prognostic factor. Most QoL scores dropped significantly below baseline in the early postoperative period. Even though they recovered slowly during the follow-up period, they never reached preoperative levels again. There was no statistically significant difference in any of the QoL scales between patients with a cervical or a thoracic anastomosis.

CONCLUSIONS

Esophageal resections are associated with significant deterioration of QoL, which persists during the follow-up period. The surgical technique and position of the esophagogastrostomy did not affect QoL deterioration.

Surgery insight: surgical management of pancreatic cancer

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

The role of protein kinases in pancreatic carcinogenesis

BACKGROUND

Pancreatic cancer is a devastating disease with a very poor prognosis.

METHODS

Protein kinases are aberrantly expressed in pancreatic ductal adenocarcinoma as analyzed by microarray-based expression analysis and have an impact for pancreatic cancer. Many regulatory proteins have an impact on cancer progression similar to the kinases. The list contains several regulators of kinases derived from the cell cycle control or the mitogen-activated protein (MAP)-kinase pathway.

CONCLUSION

Both signalling pathways are essential for tumor progression and pancreatic ductal adenocarcinoma (PDAC) malignancy.