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Turner KM, Wilson GC, Patel SH, Ahmad SA. ASO Practice Guidelines Series: Management of Resectable, Borderline Resectable, and Locally Advanced Pancreas Cancer. Ann Surg Oncol 2024; 31:1884-1897. [PMID: 37980709 DOI: 10.1245/s10434-023-14585-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/29/2023] [Indexed: 11/21/2023]
Abstract
Pancreatic adenocarcinoma is an aggressive disease marked by high rates of both local and distant failure. In the minority of patients with potentially resectable disease, multimodal treatment paradigms have allowed for prolonged survival in an increasingly larger pool of well-selected patients. Therefore, it is critical for surgical oncologists to be abreast of current guideline recommendations for both surgical management and multimodal therapy for pancreas cancer. We discuss these guidelines, as well as the underlying data supporting these positions, to offer surgical oncologists a framework for managing patients with pancreatic adenocarcinoma.
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Affiliation(s)
- Kevin M Turner
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gregory C Wilson
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sameer H Patel
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Syed A Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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Mizumoto T, Takahara T, Nishimura A, Mii S, Uchida Y, Iwama H, Kojima M, Kato Y, Uyama I, Suda K. Challenge in optimizing robotic pancreaticoduodenectomy including nerve plexus hanging maneuver: a Japanese single center experience of 76 cases. Surg Endosc 2024; 38:1077-1087. [PMID: 38168732 DOI: 10.1007/s00464-023-10653-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 12/17/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Robotic pancreaticoduodenectomy (RPD) is technically demanding, and 20-50 cases are required to surpass the learning curve. This study aimed to show our experience of 76 cases from the introduction of RPD and report the changes in surgical results owing to the accumulation of cases and optimization of surgical techniques. METHODS A total of 76 patients who underwent RPD between November 2009 and May 2023 at the Fujita Health University Hospital were divided into three groups: competency (n = 23, Nov 2009-Mar 2020), proficiency (n = 31, Apr 2020-Jun 2022), and mastery (n = 22, Jul 2022-May 2023) phases. In the mastery phase, for the education of new surgeons and maintenance of surgical quality, optimization of the procedure, including hanging maneuver with or without stapling transection of the retropancreatic tissue was implemented. The surgical outcomes were compared between the groups. RESULTS The mean operation time decreased over time despite of the participation of newly started operators in mastery phase [competency: 921.5 min (IQR 775-996 min) vs. proficiency: 802.8 min (IQR 715-887 min) vs. mastery: 609.2 min (IQR 514-699 min), p < 0.001]. Additionally, Clavien-Dindo ≥ grade IIIa complications decreased from 52.2% in competency phase to 35.5% and 9.1% in proficiency and mastery phases, respectively (p = 0.005). CONCLUSION Operation time and major complications decreased along the learning curve from the introduction of RPD. In addition, optimization of the procedure, including hanging maneuver of the retropancreatic tissue seemed to be effective in reducing operation time and educating new RPD surgeons.
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Affiliation(s)
- Takuya Mizumoto
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, Japan
| | - Takeshi Takahara
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan.
| | - Akihiro Nishimura
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Satoshi Mii
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Yuichiro Uchida
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Hideaki Iwama
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Masayuki Kojima
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Yutaro Kato
- Department of Advanced Robotic and Endoscopic Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Ichiro Uyama
- Department of Advanced Robotic and Endoscopic Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
| | - Koichi Suda
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan
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Abstract
The distinct biology of pancreatic cancer with aggressive and early invasive tumor cells, a tumor promoting microenvironment, late diagnosis, and high therapy resistance poses major challenges on clinicians, researchers, and patients. In current clinical practice, a curative approach for pancreatic cancer can only be offered to a minority of patients and even for those patients, the long-term outcome is grim. This bitter combination will eventually let pancreatic cancer rise to the second leading cause of cancer-related mortalities. With surgery being the only curative option, complete tumor resection still remains the center of pancreatic cancer treatment. In recent years, new developments in neoadjuvant and adjuvant treatment have emerged. Together with improved perioperative care including complication management, an increasing number of patients have become eligible for tumor resection. Basic research aims to further increase these numbers by new methods of early detection, better tumor modelling and personalized treatment options. This review aims to summarize the current knowledge on clinical and biologic features, surgical and non-surgical treatment options, and the improved collaboration of clinicians and basic researchers in pancreatic cancer that will hopefully result in more successful ways of curing pancreatic cancer.
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Affiliation(s)
- Benno Traub
- Clinic for General and Visceral Surgery, University of Ulm, Albert-Einstein Allee 23, Ulm, Germany.
| | - Karl-Heinz Link
- Clinic for General and Visceral Surgery, University of Ulm, Ulm, Germany; Surgical and Asklepios Tumor Center (ATC), Asklepios Paulinen Klinik Wiesbaden, Richard Strauss-Str. 4, Wiesbaden, Germany.
| | - Marko Kornmann
- Clinic for General and Visceral Surgery, University of Ulm, Albert-Einstein Allee 23, Ulm, Germany.
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Liu C, Tian X, Xie X, Gao H, Zhuang Y, Yang Y. Comparison of Uncinate Process Cancer and Non-Uncinate Process Pancreatic Head Cancer. J Cancer 2016; 7:1242-9. [PMID: 27390599 PMCID: PMC4934032 DOI: 10.7150/jca.15062] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 05/01/2016] [Indexed: 12/20/2022] Open
Abstract
The special anatomical position accounts for unusual clinicopathological features of uncinate process cancer. This study aimed to compare clinicopathological features of patients with uncinate process cancer to patients with non-uncinate process pancreatic head cancer. Total 160 patients with pancreatic head cancer were enrolled and classified into two groups: uncinate process cancer and non-uncinate process pancreatic head cancer. We found that the ratio of vascular invasion was significantly higher in patients with uncinate process cancer than in patients with non-uncinate process pancreatic head cancer. In addition, the rate of R1 resection was significantly higher in patients with uncinate process cancer. Furthermore, the median disease-free survival (11 months vs. 15 months, p=0.043) and overall survival (15 months vs. 19 months, p=0.036) after R0 resection were lower for uncinate process cancer. Locoregional recurrence was more frequent (p=0.017) and earlier (12 months vs. 36 months; p=0.002) in patients with uncinate process cancer than in patients with non-uncinate process pancreatic head cancer. In conclusion, uncinate process cancer is more likely to invade blood vessel and has worse prognosis due to the earlier and more frequent locoregional recurrence.
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Affiliation(s)
- Chang Liu
- Department of General Surgery, Peking University First hospital, 8th Xishiku Street, Beijing 100034, People's Republic of China
| | - Xiaodong Tian
- Department of General Surgery, Peking University First hospital, 8th Xishiku Street, Beijing 100034, People's Republic of China
| | - Xuehai Xie
- Department of General Surgery, Peking University First hospital, 8th Xishiku Street, Beijing 100034, People's Republic of China
| | - Hongqiao Gao
- Department of General Surgery, Peking University First hospital, 8th Xishiku Street, Beijing 100034, People's Republic of China
| | - Yan Zhuang
- Department of General Surgery, Peking University First hospital, 8th Xishiku Street, Beijing 100034, People's Republic of China
| | - Yinmo Yang
- Department of General Surgery, Peking University First hospital, 8th Xishiku Street, Beijing 100034, People's Republic of China
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Rebibo L, Peltier J, Gerin O, Michel D, Robert B, Regimbeau JM. Unusual course of the aberrant right hepatic artery running through the pancreatic parenchyma during modified Frey's procedure. Morphologie 2014; 98:182-186. [PMID: 25260643 DOI: 10.1016/j.morpho.2014.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 07/05/2014] [Accepted: 07/16/2014] [Indexed: 06/03/2023]
Abstract
We report a variation of an aberrant right hepatic artery arising from the superior mesenteric artery and crossing into pancreatic head without other hepatic artery substitution. The variant was discovered during radiological examinations in a patient with symptomatic chronic pancreatitis requiring Frey's procedure with reinsertion of the common bile duct into the pancreatic head. An aberrant right hepatic artery arising from the superior mesenteric artery is present in 10 to 20% of case and its course is usually retro-pancreatic. The course of this artery into the pancreatic head is uncommon and can be present up to 10% in case of ARHA. Knowledge of an aberrant right hepatic artery crossing into the pancreatic head is important before pancreatic surgery in order to avoid surgical complications, especially for liver necrosis.
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Affiliation(s)
- L Rebibo
- Department of Digestive Surgery, Amiens North Hospital, Jules-Verne University of Picardie, place Victor Pauchet, 80054 Amiens, France
| | - J Peltier
- Laboratory of anatomy and organogenesis, Jules-Verne University of Picardie, 3 rue des Louvels, 80054 Amiens, France
| | - O Gerin
- Department of Digestive Surgery, Amiens North Hospital, Jules-Verne University of Picardie, place Victor Pauchet, 80054 Amiens, France
| | - D Michel
- Departments of radiology, Amiens university medical center and the Jules-Verne university of Picardie, 80054 Amiens, France
| | - B Robert
- Departments of radiology, Amiens university medical center and the Jules-Verne university of Picardie, 80054 Amiens, France
| | - J-M Regimbeau
- Department of Digestive Surgery, Amiens North Hospital, Jules-Verne University of Picardie, place Victor Pauchet, 80054 Amiens, France.
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Abstract
Traditionally, pancreatic ductal adenocarcinoma with regional vascular involvement was thought to represent unresectable disease and was associated with disease progression and death within 1 year of diagnosis. Recent evidence demonstrates that pancreaticoduodenectomy with vascular resection and reconstruction can be safely performed in select patients with 5-year survival rates as high as 20%. In order to safely treat and to optimize survival in these complex patients, it is essential to accurately identify vascular involvement preoperatively, to utilize a multidisciplinary treatment approach, and to emphasize meticulous surgical technique with awareness of the critical margins of resection.
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Affiliation(s)
- Joe Spencer Liles
- Department of Surgical Oncology, Division of Surgery, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6000, Houston, TX 77030, USA
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Gundara JS, Wang F, Alvarado-Bachmann R, Williams N, Choi J, Gananadha S, Gill AJ, Hugh TJ, Samra JS. The clinical impact of early complete pancreatic head devascularisation during pancreatoduodenectomy. Am J Surg 2013; 206:518-25. [PMID: 23809671 DOI: 10.1016/j.amjsurg.2013.01.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 12/22/2012] [Accepted: 01/23/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Early inferior pancreaticoduodenal artery (IPDA) ligation reduces intraoperative blood loss during pancreatoduodenectomy, but the impact on oncologic and long-term outcomes remains unknown. The aim of this study was to review the impact of complete pancreatic head devascularization during pancreatoduodenectomy on blood loss, transfusion rates, and clinicopathologic outcomes. METHODS Clinicopathologic and outcome data were retrieved from a prospective database for all pancreatoduodenectomies performed from April 2004 to November 2010 and compared between early (IPDA+; n = 62) and late (IPDA-; n = 65) IPDA ligation groups. RESULTS Early IPDA ligation was associated with reduced blood loss (394 ± 21 vs 679 ± 24 ml, P < .001) and perioperative transfusion (P = .031). A trend toward improved R0 resection was seen in patients with pancreatic adenocarcinoma (IPDA+ vs IPDA-, 100% vs 82%; P = .059), but this did not translate to improved 2-year (IPDA+ vs IPDA-, 76% vs 65%; P = .426) or overall (P = .82) survival. CONCLUSIONS Early IPDA ligation reduces blood loss and transfusion requirements. Despite overall survival being unchanged, a trend toward improved R0 resection is encouraging and justifies further studies to ascertain the true oncologic significance of this technique.
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Affiliation(s)
- J S Gundara
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, University of Sydney, St Leonards, Australia
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Tempero MA, Arnoletti JP, Behrman SW, Ben-Josef E, Benson AB, Casper ES, Cohen SJ, Czito B, Ellenhorn JDI, Hawkins WG, Herman J, Hoffman JP, Ko A, Komanduri S, Koong A, Ma WW, Malafa MP, Merchant NB, Mulvihill SJ, Muscarella P, Nakakura EK, Obando J, Pitman MB, Sasson AR, Tally A, Thayer SP, Whiting S, Wolff RA, Wolpin BM, Freedman-Cass DA, Shead DA. Pancreatic Adenocarcinoma, version 2.2012: featured updates to the NCCN Guidelines. J Natl Compr Canc Netw 2012; 32:e80-4. [PMID: 22679115 DOI: 10.1200/jco.2013.48.7546] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Pancreatic Adenocarcinoma discuss the workup and management of tumors of the exocrine pancreas. These NCCN Guidelines Insights provide a summary and explanation of major changes to the 2012 NCCN Guidelines for Pancreatic Adenocarcinoma. The panel made 3 significant updates to the guidelines: 1) more detail was added regarding multiphase CT techniques for diagnosis and staging of pancreatic cancer, and pancreas protocol MRI was added as an emerging alternative to CT; 2) the use of a fluoropyrimidine plus oxaliplatin (e.g., 5-FU/leucovorin/oxaliplatin or capecitabine/oxaliplatin) was added as an acceptable chemotherapy combination for patients with advanced or metastatic disease and good performance status as a category 2B recommendation; and 3) the panel developed new recommendations concerning surgical technique and pathologic analysis and reporting.
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Tempero MA, Arnoletti JP, Behrman SW, Ben-Josef E, Benson AB, Casper ES, Cohen SJ, Czito B, Ellenhorn JDI, Hawkins WG, Herman J, Hoffman JP, Ko A, Komanduri S, Koong A, Ma WW, Malafa MP, Merchant NB, Mulvihill SJ, Muscarella P, Nakakura EK, Obando J, Pitman MB, Sasson AR, Tally A, Thayer SP, Whiting S, Wolff RA, Wolpin BM, Freedman-Cass DA, Shead DA. Pancreatic Adenocarcinoma, version 2.2012: featured updates to the NCCN Guidelines. J Natl Compr Canc Netw 2012; 10:703-13. [PMID: 22679115 DOI: 10.6004/jnccn.2012.0073] [Citation(s) in RCA: 203] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Pancreatic Adenocarcinoma discuss the workup and management of tumors of the exocrine pancreas. These NCCN Guidelines Insights provide a summary and explanation of major changes to the 2012 NCCN Guidelines for Pancreatic Adenocarcinoma. The panel made 3 significant updates to the guidelines: 1) more detail was added regarding multiphase CT techniques for diagnosis and staging of pancreatic cancer, and pancreas protocol MRI was added as an emerging alternative to CT; 2) the use of a fluoropyrimidine plus oxaliplatin (e.g., 5-FU/leucovorin/oxaliplatin or capecitabine/oxaliplatin) was added as an acceptable chemotherapy combination for patients with advanced or metastatic disease and good performance status as a category 2B recommendation; and 3) the panel developed new recommendations concerning surgical technique and pathologic analysis and reporting.
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Katz MHG, Wang H, Balachandran A, Bhosale P, Crane CH, Wang X, Pisters PWT, Lee JE, Vauthey JN, Abdalla EK, Wolff R, Abbruzzese J, Varadhachary G, Chopin-Laly X, Charnsangavej C, Fleming JB. Effect of neoadjuvant chemoradiation and surgical technique on recurrence of localized pancreatic cancer. J Gastrointest Surg 2012; 16:68-78; discussion 78-9. [PMID: 22065318 DOI: 10.1007/s11605-011-1748-7] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2011] [Accepted: 10/13/2011] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine the influence of neoadjuvant chemoradiation and standardized dissection of the superior mesenteric artery upon the oncologic outcome of patients with localized pancreatic adenocarcinoma. METHODS One hundred ninety-four patients with pancreatic adenocarcinoma who underwent pancreaticoduodenectomy between 2004 and 2008 were evaluated. The retroperitoneal dissection was performed directly along the superior mesenteric artery in all cases. A standard histopathologic protocol that measured the "superior mesenteric artery (SMA) margin distance" between cancer cells and the superior mesenteric artery was employed. RESULTS Seventy-six percent of patients received neoadjuvant chemoradiation. The SMA margin was positive in 4% of patients but an additional 22% of patients with a negative margin had a SMA margin distance of ≤1 mm. Preoperative CT images overestimated the SMA margin distance in 73% of cases. Patients who received chemoradiation had longer SMA margin distances than those who did not. Patients who received chemoradiation and had a SMA margin of >1 mm had the lowest recurrence rates. Administration of neoadjuvant chemoradiation and lower estimated blood loss were independently associated with longer progression-free survival on multivariate analysis. CONCLUSIONS Preoperative chemoradiation and meticulous dissection of the superior mesenteric artery maximize the distance between cancer cells and the SMA margin and may influence locoregional control.
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Affiliation(s)
- Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 444, Houston, TX 77030, USA.
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Katz MHG, Merchant NB, Brower S, Branda M, Posner MC, William Traverso L, Abrams RA, Picozzi VJ, Pisters PWT. Standardization of surgical and pathologic variables is needed in multicenter trials of adjuvant therapy for pancreatic cancer: results from the ACOSOG Z5031 trial. Ann Surg Oncol 2011; 18:337-44. [PMID: 20811779 PMCID: PMC3922125 DOI: 10.1245/s10434-010-1282-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND Standardization of surgical and pathologic techniques is crucial to the interpretation of studies evaluating adjuvant therapies for pancreatic cancer (PC). METHODS To assess the degree to which treatment administered prior to enrollment of patients in trials of adjuvant therapy is quality controlled, the operative and pathology reports of patients in American College of Surgeons Oncology Group (ACOSOG) Z5031-a national trial of chemoradiation following pancreaticoduodenectomy (PD)-were rigorously evaluated. We analyzed variables with the potential to influence staging or outcome. RESULTS 80 patients reported to have undergone R0 (75%) or R1 (25%) pylorus-preserving (38%) or standard (62%) PD were evaluated. A search for metastases was documented in 96% of cases. The proximity of the tumor to the superior mesenteric vein was reported in 69%; vein resection was required in 9% and lateral venorrhaphy in 14%. The method of dissection along the superior mesenteric artery (SMA) was described in 68%, being ultrasonic dissection (17%), stapler (24%), and clamp and cut (59%). SMA skeletonization was described in 25%, and absence of disease following resection was documented in 24%. The surgeon reported marking the critical SMA margin in 25%; inking was documented in 65% of cases and evaluation of the SMA margin was reported in 47%. A range of 1-49 lymph nodes was evaluated. Only 34% of pathology reports met College of American Pathologists criteria. CONCLUSIONS Trials of adjuvant therapy following PD suffer from a lack of standardization and quality control prior to patient enrollment. These data suggest areas for improvement in the design of multidisciplinary treatment protocols.
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Affiliation(s)
- Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Moszkowicz D, Peschaud F, El Hajjam M, Saiag P, Nordlinger B. Preservation of an intra-pancreatic hepatic artery during duodenopancreatectomy for melanoma metastasis. Surg Radiol Anat. 2011;33:547-550. [PMID: 21221968 DOI: 10.1007/s00276-010-0770-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Accepted: 12/23/2010] [Indexed: 02/06/2023]
Abstract
We describe the case of a hepatic artery originating from a hepato-mesenteric trunk and traveling through the head of the pancreas, found preoperatively in a 44-year-old woman presenting two metachrone intra-pancreatic metastasis of a skin melanoma. Few cases with this anatomic variation have been found in the published literature consulted and this is the first case of duodenopancreatectomy for melanoma metastasis associated with this anatomic variant. In this patient, multidetector CT image with angiography and 3-D reconstruction demonstrated that the common hepatic artery arose from the superior mesenteric artery without any other arterial supply to the liver. Pancreatoduodenectomy with arterial conservation and without reconstruction was performed. Routine preoperative computerized tomographic angiography helps to recognize the hepatic vascular anatomy and thereby prepares the surgeon to better deal with at risk vascular variants intraoperatively. During pancreatic resection, every attempt should be made to preserve the variant hepatic vessels, particularly if they irrigate the entire liver. Increased alertness of the vascular anatomy would decrease the probability of intraoperative vascular injury and consequent postoperative complications such as biliary necrosis, biliary anastomotic leaks or hemorrhage.
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