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Gastrointestinal Cancer


Table 3: Independent Factors Related to Prognosis in Pancreatic Cancer Surgery in Multivariate Analysis


Author, Year, Reference


Geer, 199345 Sohn, 200052 Neoptolemos,


2001 (ESPAC-1)53 Wagner, 200421 Jarufe, 200423 Winter, 200624


Howard, 200648


Butturini, 200854 (meta-analysis)


Tumour-specific Factors


Tumour grade, size <2.5cm, N0 Tumour grade, size <3cm, N0


Tumour grade, size, N0 –


Tumour grade, N0 Tumour grade, size <3cm, N0 Tumour grade, size <3cm


Tumour grade, size <3cm


ESPAC-1 = European Study Group for Pancreatic Cancer 1.


world, although Dutch data indicate that the change may take time.58 However, it is important that, when discussing the organisation of healthcare and technological progress, we keep the surgeon’s and surgery’s roles in perspective. This was eloquently stated by Dr Blake Cady in 1997: “In the field of surgical oncology, tumor biology is king, patient selection is queen, and technical manoeuvres are the prince and princess who try, but usually fail, to usurp the throne”.59


Modifications of Pancreaticoduodenectomy Several modifications of Whipple’s operation have been described. Pylorus-preserving PD (PPPD) was introduced in 1978 as a more ‘physiological’ procedure.60


Preservation of the hormonal secretion


and sphincter function of the antrum–pylorus complex was supposed to give benefits in terms of nutrition and gastrointestinal function. In the last decade, PPPD has been compared with classic PD in several randomised studies and meta-analyses, and the two procedures have been found to be equal in terms of biliary leakage, post-operative bleeding, wound infection and pulmonary complications, as well as the rate of re-operations and mortality.61–72


An early observation was that


PPPD seemed to cause an increased rate of delayed gastric emptying, but this was not verified in the randomised studies (it may have been related to a too early evaluation during the learning curve). Also, regarding post-operative quality of life and long-term outcome, no significant differences have been found. In summary, PPPD and classic PD seem to be equally safe and efficient, but it has been suggested that PPPD should be used carefully in cases of tumours close to the proximal duodenum.73


Pancreaticogastrostomy (PG) was tailored as a safer mode of reconstruction. A further suggested benefit is the possibility of inspecting and cannulating the pancreatogastric anastomosis by a simple gastroscopy. To date, there have been four randomised controlled trials comparing PG with pancreaticojejunal anastomosis.74–77 Three of the studies did not reveal significant differences between the two methods, while the fourth randomised controlled trial showed that post-operative abscesses and pancreatic fistulae were less common after PG.76


A meta-analysis from 200678 suggested that PG was the safer


mode of pancreatic reconstruction, but was based mainly on observational studies together with only one of the randomised controlled trials.74


38 Another meta-analysis found PG to be superior or


Procedure-related Factors


– R0, blood loss R0 R0 Bile leak Complication – equal to PJ, but signs of bias were also revealed.79 Currently, there


is insufficient evidence to favour PG over pancreatojejunostomy, or vice versa.


Ligation or occlusion of the pancreatic duct represent further attempts to reduce pancreatojejunal leakage, but generally these attempts have not been successful. In three randomised controlled trials, duct occlusion did not decrease post-operative complications, but resulted in an increased risk of diabetes.80–82


Adminstration of somatostatin or its analogues aims to reduce the secretion of pancreatic juice and, thereby, the rate or consequences of pancreaticojejunal leakage. Despite a large number of randomised controlled trials and meta-analyses, clear-cut evidence for the use of somatostatin (or its analogues) has not been established.83–100


Specifically,


a recent meta-analysis was unable to show a significant reduction of pancreas-specific complications.100


Although it has been suggested that


the drugs may be of use in cases of ‘fragile pancreas’ or other technical problems, sufficient data to support this assumption are lacking. Currently, there is not enough evidence for the routine use of somatostatin (or its analogues) in pancreatic resection, even though many surgeons use it when the pancreatic remnant is soft or has a small duct.


Other Pancreatic Resections


Left-sided resection is indicated for malignancies in the pancreatic body and tail.25


Involvement of the splenic vein or artery does not constitute a contraindication, as long as a radical excision is possible. When compared stage to stage, long-term survival seems to be similar to that of pancreatic head cancer.106,107


There are several case series describing short- and long-term outcome, but no randomised controlled trials.101–106 Pancreatic fistulae occur at a rate at least similar to that of Whipple’s procedure, although the consequences may be less grave. Left-sided pancreatic cancers are less often resectable than right-sided cancers, as they are notoriously symptom-free until they are in an advanced stage.4


Thus, although it is an option for


a subset of patients only, resection of left-sided pancreatic cancer represents an effective treatment in selected cases.


Total pancreatectomy is an option for diffuse neoplastic disease (such as intraductal papillary mucinous neoplasms), and is also rarely used for cancers growing diffusely or multifocally in the pancreatic body. The long-term nutritional and metabolic sequelae (especially brittle diabetes) of this operation make it a less attractive alternative if a lesser resection is possible.108


Extended Procedures


Extensive lymphadenectomy did not increase post-operative morbidity or mortality, but failed to increase long-term survival.19,109–113


the data are not consistent.19,111–113


There seems to be a higher rate of late sequelae, but Also, a meta-analysis of 16


comparative studies failed to show a significant benefit of the extended procedure.114


To conclude, extensive lymphadenectomy does not increase post-operative morbidity or mortality, but does not improve long-term survival either. However, if better adjuvant treatment becomes available, this conclusion may have to be re-evaluated.


EUROPEAN ONCOLOGY & HAEMATOLOGY


The poor long-term prognosis after PD, as well as the high rate of lymph node metastases (40–60%) in many series, is the rationale for attempts of more extensive lymph node dissection. Early uncontrolled series were published from Japan, and later three randomised controlled trials compared extensive lymphadenectomy with the standard operation.19,109–113


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