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Surgical Treatment of Pancreatic Cancer


performed before laparotomy as it is an accurate method of excluding cancer spread to the peritoneum, regional lymph glands and extrapancreatic tissue.27


show extrapancreatic disease, one may proceed to laparotomy.


The first phase of the operation includes a thorough inspection of the peritoneal surfaces and dissection of the hepatoduodenal ligament, duodenum, pancreatic head and superior mesenteric vessels, with the dual aim of excluding extrapancreatic spread and preparing for resection. In the second phase, the antrum, the bile duct and the first part of the jejunum are transected. The pancreatic neck is transected over the portal vein and after ligation of multiple vessels between the pancreatic head and mesenteric vessels, the specimen can be removed. The posterior (retroperitoneal) dissection plane is of utmost importance, and the dissection should also proceed very close to the superior mesenteric vessels to remove all perivascular nervous and lymphatic tissue.25


Whipple’s operation has become a highly standardised procedure. The technical details are well described by Warshaw28 et al.25


In the third and final


phase, gastrointestinal continuity is restored by creating three anastomoses: pancreaticojejunostomy (PJ), hepaticojejunostomy and gastrojejunostomy. Leakage in the PJ, which occurs in 2–30% of patients, is a serious problem after PD as it is a major cause of post-operative morbidity and mortality.18,22,29–37


anastomotic techniques have been described, including the new ‘binding anastomosis ad modum Peng’.38,39


Stenting the anastomosis


with a plastic tube represents another approach to reducing leakage; currently, there are two randomised studies suggesting a positive effect of this technique.40,41


Table 2: Selected Reports of Long-term Outcome with Pancreaticoduodenectomy for Pancreatic Cancer


Furthermore, several technical


modifications of the Whipple procedure have been designed to reduce this risk (see below).


When a post-operative pancreatojejunal leakage occurs, percutaneous drainage rather than re-operation is the initially preferred method today.29,42


sepsis or uncontrolled bleeding.43


Rarely, the pancreatic remnant must be removed due to Improved management of leakage


and other complications, which afflict 20–40% of patients, has drastically improved the post-operative mortality rate in the last few decades. In surgical series from more recent years, the reported post-operative mortality rates usually amount to a few per cent only (see Table 1).13–24


There are no randomised controlled studies of pancreatic resection versus no resection looking at the efficacy of the operation. However, there is a randomised Japanese study comparing surgery and chemoradiotherapy for resectable pancreatic cancer, which showed a better survival rate after surgical resection.44


Recent surgical series


usually report a median survival of 12–24 months and a corresponding five-year survival rate of 10–20% (see Table 2).13,20,21,23,24,45–49 wide range of outcomes can be noted among different series.


However, a


Several studies have performed analyses of factors that may influence the long-term outcome, usually employing multivariance statistics (see Table 3).21,23,24,45,48,50–54


One of the most important factors for


achieving a ‘good’ result with surgery is patient selection.50,51 Important patient-related factors are age and intercurrent disease.23,24 Among tumour-specific factors, tumour grade and size have been found to be significant, as has the presence of regional lymph gland metastases (the ‘N factor’).21,23,24,45,48,52–54


While patient-related and tumour-specific factors should influence the pre- and peri-operative EUROPEAN ONCOLOGY & HAEMATOLOGY


Institution, Year, Reference


MSKCC, 199345


Mayo clinic, 199513 Mannheim, 200320 Bern, 200421


Birmingham, 200423 Amsterdam, 199546 Amsterdam, 200447 Johns Hopkins, 200624 Indianapolis, 200648 MDACC, 200749


Period


Patients MST (n)


1983–1990 146 1981–1991 186


17.5


1972–1998 (R0) 122 24 1993–2001 (R0) 160 24.2 (R1/2) 51 11.5 13.4 18 17 18 –


1987–2002 251 1983–1992 176 1992–2002 160 1970–2006 1,423 1990–2002 226


1990–2004 (R0) 300 27.8 (R1) 60


21.5 Five-year


(months) Survival (%) 18


24 6.8


25.4 20.1 4.3 –


15 8


18


(actual) 4 30 17


MDACC = MD Anderson Cancer Center; MSKCC = Memorial Sloan-Kettering Cancer Center; MST = median survival time.


assessment, the execution of surgery may have a more direct influence on short- and long-term outcome. As would be expected, a completed R0 resection has repeatedly been found to improve the post-operative prognosis.21,52,53


The presence of post-operative


complications such as bile leak and peri-operative blood transfusion has a negative effect on long-term survival, although the causal relationship is not clear.24,48,52


In the last few decades, data have also


accumulated that convincingly show an association between the result of surgery and the case load on the surgeon/team as well as the size of the cancer hospital. Several studies indicate that larger hospitals achieve better results after pancreatic resection, in both the long and short term.17,51,55–58


and Pedrazzoli


Table 1: Selected Reports of Short-term Outcome with Pancreaticoduodenectomy for Pancreatic Cancer


If the pre-operative investigation does not


Institution, Year, Period Reference


Mayo clinic,


199513 Harvard, 199514


Kansas City, 199615


MSKCC, 199616 Amsterdam, 200017


Harvard, 200118 Johns Hopkins, 200219


Mannheim, 200320


Bern, 200421 Indianapolis, 200422


Birmingham, 200423


Consequently, several


Johns Hopkins, 200624


Patients Post-operative Post-operative (n)


1981–1991 186 1991–1994 142 1970–1995 100


1983–1989 118 1992–1999 300


1990–2000 489 1996–2001 146 148


1972–1998 194


1993–2001 160 1980–2002 516


1987–2002 251 1970–2006 1,423 MSKCC = Memorial Sloan-Kettering Cancer Center.


Morbidity (%) Mortality (%) 33


3 43 22 – 48 –


29 43 30


(44) 43


30 38 0.4 3


3 1


1 4 2


3.1


2.5 3.9


4.8 2


The case load on the individual surgeon


seems important, but there may also be other potential but poorly defined factors due to differences in patient selection, referral patterns, waiting lists and so on.57


In the last decade, these data have led to a plea for centralisation of pancreatic surgery in the developed 37


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