Reoperative pancreaticoduodenectomy

Is Pancreaticoduodenectomy Feasible for Recurrent Remnant Bile Duct Cancer Following Bile Duct Segmental Resection?

BACKGROUND

When bile duct cancer recurs after surgery, treatment options are limited. This study examines the usefulness of reoperative pancreaticoduodenectomy for recurrent cancer after initial segmental bile duct resection.

METHODS

Six patients (5 males, 1 females; median age 65 years) who underwent pancreaticoduodenectomy for recurrent remnant bile duct cancer following segmental bile duct resection were included: 4 underwent surgery at Severance Hospital and 2 at Gangnam Severance Hospital from January 2000 to December 2013. Medical records data were retrospectively reviewed, including demographics, type of first and second surgery, radicality of resection, TNM stage, adjuvant treatments, complications, and survival. Kaplan-Meier curves were used to analyze survival.

RESULTS

The median interval between operations was 57 (range 7-95) months. Median operation time was 6.9 (range 5.2-12.8) h, blood loss was 400 (range 50-1170) mL, intensive care unit stay was 1 (range 1-2) day, and postoperative hospital stay was 33 (range 15-55) days. No patient died. Four had severe complications. The median survival after pancreaticoduodenectomy was 16 (range 5-89) months. Four patients had recurrence. T stage, N stage, and resection radicality influenced survival.

CONCLUSION

Pancreaticoduodenectomy is reasonable for recurrent remnant bile duct cancer following segmental bile duct resection, particularly for patients with no distant metastasis, locally confined recurrence, and good general condition.

Multimodality therapy offers a chance for cure in patients with pancreatic adenocarcinoma deemed unresectable at first operative exploration

BACKGROUND

Patients identified at surgical exploration with unresectable pancreatic ductal adenocarcinoma receive palliative, noncurative therapy. We hypothesized that accurate radiographic restaging, multimodality treatment, and advanced surgical technique can offer patients deemed unresectable at previous exploration the possibility for curative salvage pancreatectomy.

STUDY DESIGN

Review of a prospectively maintained pancreatic ductal adenocarcinoma database identified all patients (1990 to 2010) evaluated after being deemed unresectable at first exploration elsewhere. Referring hospitals were categorized per National Cancer Data Base criteria as academic, community, or international. Patients were restaged using objective imaging (CT) criteria and classified based on anatomic resectability. Clinicopathologic factors and cancer-related outcomes were assessed.

RESULTS

We evaluated 88 patients who underwent previously unsuccessful resection attempts at academic (n = 50), community (n = 25), and international (n = 13) centers. Radiographic restaging confirmed that 7 (8%) patient tumors were locally advanced and unresectable, but 81 (92%) were resectable (n = 61) or borderline resectable (n = 20). Using a surgery first (9%) or preoperative chemoradiation (91%) approach, successful reoperative pancreatectomy was performed in 66 (81%) patients, with 94% receiving R0 resections. Vascular resection/reconstruction was required in 30 (46%) patients and 50 (76%) required complex revision of previously created biliary/gastrointestinal bypass. The major complication rate was 20% and 3 (4.5%) patients died perioperatively. Median overall survival was 29.6 months for successfully resected patients vs 10.6 and 5.1 months (p < 0.0001) for those patients with locally advanced unresectable disease at initial referral or in whom metastatic disease developed before resection, respectively.

CONCLUSIONS

In this very selected cohort of high-risk patients, the majority had anatomically resectable tumors on restaging. Accurate radiographic restaging, a multimodality treatment strategy, and advanced surgical techniques can provide an opportunity for cure in a substantial proportion of select patients who were deemed unresectable at exploration.

Multimodality therapy offers a chance for cure in patients with pancreatic adenocarcinoma deemed unresectable at first operative exploration

BACKGROUND

Patients identified at surgical exploration with unresectable pancreatic ductal adenocarcinoma receive palliative, noncurative therapy. We hypothesized that accurate radiographic restaging, multimodality treatment, and advanced surgical technique can offer patients deemed unresectable at previous exploration the possibility for curative salvage pancreatectomy.

STUDY DESIGN

Review of a prospectively maintained pancreatic ductal adenocarcinoma database identified all patients (1990 to 2010) evaluated after being deemed unresectable at first exploration elsewhere. Referring hospitals were categorized per National Cancer Data Base criteria as academic, community, or international. Patients were restaged using objective imaging (CT) criteria and classified based on anatomic resectability. Clinicopathologic factors and cancer-related outcomes were assessed.

RESULTS

We evaluated 88 patients who underwent previously unsuccessful resection attempts at academic (n = 50), community (n = 25), and international (n = 13) centers. Radiographic restaging confirmed that 7 (8%) patient tumors were locally advanced and unresectable, but 81 (92%) were resectable (n = 61) or borderline resectable (n = 20). Using a surgery first (9%) or preoperative chemoradiation (91%) approach, successful reoperative pancreatectomy was performed in 66 (81%) patients, with 94% receiving R0 resections. Vascular resection/reconstruction was required in 30 (46%) patients and 50 (76%) required complex revision of previously created biliary/gastrointestinal bypass. The major complication rate was 20% and 3 (4.5%) patients died perioperatively. Median overall survival was 29.6 months for successfully resected patients vs 10.6 and 5.1 months (p < 0.0001) for those patients with locally advanced unresectable disease at initial referral or in whom metastatic disease developed before resection, respectively.

CONCLUSIONS

In this very selected cohort of high-risk patients, the majority had anatomically resectable tumors on restaging. Accurate radiographic restaging, a multimodality treatment strategy, and advanced surgical techniques can provide an opportunity for cure in a substantial proportion of select patients who were deemed unresectable at exploration.

Contemporary single-center surgical experiences in redo procedures of the pancreas: improved outcome and reduction of operative risk

INTRODUCTION

Redo procedures of the pancreas are complex operations associated with significant morbidity and mortality rates. The operative risk may be minimised when indications for redo procedure are well reflected and operation is performed by an experienced surgeon. The aim of this study was to confirm this hypothesis evaluating our experiences with redo procedures.

METHODS

We reviewed 28 patients (mean age of 54 years; range 11-75 years) undergoing a redo procedure of the pancreas from January 2004 to June 2008 at our hospital. The term redo procedure was defined as a pancreatic reoperation that was carried out after preceding pancreatic surgery. Relaparotomies following acute complications after pancreatic surgery were not taken into consideration.

RESULTS

The following parameters were evaluated: median operative time 332 min (range 160-730 min), median intraoperative blood loss 625 ml (range 300-2,800 ml), median postoperative stay on Intensive Care Unit 20 h (range 0-112 h), median postoperative hospital stay 15 days (range 7-98), morbidity (14%), and mortality (3.6%).

CONCLUSIONS

Redo procedures of the pancreas can be performed with low complication rates. In order to achieve a satisfactory outcome, the indication of redo procedures has to be well reflected, and operation may be performed by specialised and experienced surgeons.

PET and PET/CT for pancreatic malignancies

FDG PET imaging is useful for preoperative diagnosis of pancreatic carcinoma in patients with suspected pancreatic cancer in whom CT fails to identify a discrete tumor mass or in whom FNAs are nondiagnostic. FDG PET imaging is useful for M staging and restaging by detecting CT occult metastatic disease, allowing noncurative resection to be avoided in this group of patients. FDG PET can differentiate post-therapy changes from recurrence and holds promise for monitoring neoadjuvant chemoradiation therapy. The technique is less useful in periampullary carcinoma and marginally helpful in staging except for M staging. As with other malignancies, FDG PET is complementary to morphologic imaging with CT, therefore, integrated PET/CT imaging provides optimal images for interpretation and thus more optimal patient care.

PET and PET/CT for Pancreatic Malignancies

FDG PET imaging is useful for preoperative diagnosis of pancreatic carcinoma in patients with suspected pancreatic cancer in whom CT fails to identify a discrete tumor mass or in whom FNAs are nondiagnostic. FDG PET imaging is useful for M staging and restaging by detecting CT occult metastatic disease, allowing noncurative resection to be avoided in this group of patients. FDG PET can differentiate post-therapy changes from recurrence and holds promise for monitoring neoadjuvant chemoradiation therapy. The technique is less useful in periampullary carcinoma and marginally helpful in staging except for M staging. As with other malignancies, FDG PET is complementary to morphologic imaging with CT, therefore, integrated PET/CT imaging provides optimal images for interpretation and thus more optimal patient care.

Second-look operation for unresectable pancreatic ductal adenocarcinoma at a high-volume center

Background

The value of re-exploration for pancreatic ductal adenocarcinoma after the initial diagnosis of unresectability is unclear.

Methods

In this study, we analyzed 33 patients who were re-explored after an initial diagnosis of unresectability.

Results

At the time of reoperation, a resectable tumor was found in 18 patients: therefore, 15 pancreaticoduodenectomies, two total pancreatectomies and one left resection were performed with three vascular resections. Morbidity and mortality rates for the cohort were 6/33 and 1/33, without significant differences between resectable and nonresectable patients. Length of stay, duration of operation, and blood loss were significantly increased in the resection group. Kaplan–Meier survival analysis demonstrated increased median survival for resected patients (1078 days after the initial operation versus 547 days in the group of unresectable patients; p = 0.018). Analysis of the reasons against initial resection showed that, if the patients had been sent to a tertiary referral center for pancreatic surgery, a different decision in favor of resection would probably have been made in 14 out of 33 patients. A review of 10 published reports on reoperation for pancreatic cancer revealed results comparable to our study in terms of low morbidity and mortality as well as a survival benefit.

Conclusions

Reoperation for pancreatic ductal adenocarcinoma that is initially deemed unresectable can be safely performed in a selected group of patients by experienced surgeons, supporting the concept of patient centralization in pancreatic surgery. Resection at the second operation may confer a survival benefit even when the initial findings preclude a potentially curative approach.

Pancreatic redo procedures: to do or not to do -- this is the question

BACKGROUND

Pancreatic redo procedures belong to the most difficult abdominal operations because of altered anatomy, significant adhesions, and the potential of recurrent disease. We report on our experience with 15 redo procedures among a series of 350 consecutive pancreatic operations.

PATIENT AND METHODS

From January 1, 2004 to May 31, 2006 a total of 350 patients underwent pancreatic surgery in our department. There were 15 patients identified who had pancreatic redo surgery for benign (14) or malignant (1) disease. Perioperative parameters and outcome of 15 patients undergoing redo surgery after pancreatic resections were evaluated.

RESULTS

Operative procedures included revision and redo of the pancreaticojejunostomy after resection of the pancreatic margin (6), completion pancreatectomy (3), conversion from duodenum-preserving pancreatic head resection to pylorus-preserving pancreaticoduodenectomy (3), classic pancreaticoduodenectomy after nonresective pancreatic surgery (1), redo of left-sided pancreatectomy (1), and classic pancreaticoduodenectomy after left-sided pancreatectomy (1). Histology revealed chronic pancreatitis in 14 and a mucinous adenocarcinoma of the pancreas in 1 patient. Median operative time was 335 min (235-615 min) and median intraoperative blood loss was 600 ml (300-2,800 ml). Median postoperative ICU stay was 20 h (4-113 h) and median postoperative hospital stay was 15 days (7-30 days). There was no perioperative mortality and morbidity was 33%.

CONCLUSION

Pancreatic redo surgery can be performed with low morbidity and mortality. Redo surgery has a defined spectrum of indications, but to achieve good results surgery may be performed at high-volume centers.

Reoperative Surgery for Chronic Pancreatitis: Is It Safe?

INTRODUCTION

Eleven percent to fifty-six percent of patients do not achieve adequate pain relief with initial operative treatment for chronic pancreatitis, and reoperations for recurrent or persistent pain are common. This study evaluates the influence of prior pancreatic procedures on operative morbidity for chronic pancreatitis.

METHODS

The records of 336 consecutive patients who underwent pancreaticoduodenectomy (PD, n=78), lateral pancreaticojejunostomy (LPJ, n=152), distal pancreatectomy (DP, n=83), transduodenal sphincteroplasty (SP, n=20), and total pancreatectomy (TP, n=3) for chronic pancreatitis were retrospectively reviewed and analyzed.

RESULTS

Seventy-four patients underwent reoperation after failed prior pancreatic surgery. Patients with de novo pancreatic operations had a similar complication rate as those with reoperation (PD: 48% versus 65%, P>0.05; LPJ: 23% versus 23%, P>0.05; DP: 26% versus 28%, P>0.05; SP: 21% versus 100%, P>0.05). Major complications such as pancreatic leak or abdominal abscess were similar in the two groups. Minor complications such as delayed gastric emptying or wound infections were more common in the reoperation group. There was no difference in postoperative hospital length of stay.

CONCLUSIONS

Patients who undergo reoperative surgery for chronic pancreatitis have an increased risk for minor perioperative complications. The overall complication rate and the incidence of major complications are similar compared to de novo procedure. Reoperative surgery therefore appears feasible and safe in experienced hands.

Reoperative pancreaticoduodenectomy for periampullary carcinoma

BACKGROUND

Potentially resectable periampullary tumours may not be treated appropriately due to lack of local expertise in both assessment of resectability and resection in referring centres. Tata Memorial Hospital is a major referral centre for oncology and these patients are finally referred to this institution. In carefully selected patients, resection can be accomplished. The purpose of the present paper was to determine the perioperative morbidity and mortality for patients undergoing reoperative pancreaticoduodenectomy at a major comprehensive cancer centre.

METHODS

Between January 1991 and December 2001 15 patients, who had undergone previous non-resectional surgery for operable periampullary carcinoma, underwent re-exploration. The perioperative morbidity and mortality were analysed and compared with that of the group of patients undergoing primary pancreaticoduodenectomy (143 patients) in the same period.

RESULTS

All the 15 patients undergoing re-exploration had a successful resection by pancreaticoduodenectomy. In the reoperative group eight patients (53%) underwent classic pancreaticoduodenectomy and seven patients (46%) had a pylorus-preserving pancreaticoduodenectomy, as compared to 102 (71%) and 41 (29%) patients in the primary surgery group, respectively. Although the mean operative time and the estimated blood loss were higher in the reoperative group, the morbidity and mortality rates were similar in the two groups. The overall 30-day mortality rate was 6.6% and 6.9% in the reoperative and the primary surgery group, respectively. Major morbidity occurred in two of the 15 patients (13.3%), and one patient (6.6%) died following surgery in the reoperative group.

CONCLUSION

Reoperative pancreaticoduodenectomy can be performed safely in carefully selected patients with resectable, localized periampullary tumours with similar morbidity and mortality to patients undergoing primary surgery.

Surgery for pancreatic cancer: recent controversies and current practice

Pancreatic duct carcinoma remains a common disease with a poor prognosis. More than 30,000 Americans will die of the disease in 2004, making it the fourth leading cause of cancer death. Despite significant advances in the treatment of many other human tumors, the 5-year survival rate for persons diagnosed with pancreatic cancer has not changed in decades and remains <5%. This is due both to the inherently aggressive biology of the disease and to its late diagnosis in most cases. Surgical resection of localized disease remains the only hope for cure of pancreatic cancer. Over the past 2 decades, significant advances in diagnostic imaging, staging, surgical technique, and perioperative care have led to marked improvement in the surgical management of pancreatic cancer patients. Operative mortality rates for pancreaticoduodenectomy are now <5% at major centers, and the average length of hospital stay has been reduced to <2 weeks. Improvements in patient outcome after pancreatic cancer surgery have made possible, for the first time, the design and conduct of large adjuvant therapy studies in pancreatic cancer. Such clinical trials are critical for improving outcomes for pancreatic cancer patients.

Surgical treatment of non-functioning pancreatic islet cell tumors

Pancreatic endocrine tumors (PETs) are rare neoplasms originating from the amine precursor uptake and decarboxylation (APUD) stem cells. Although the majority of PETs are sporadic, they frequently occur in familial syndromes. PETs may cause a variety of functional syndromes or symptoms of local progression if they are non-functional. General neuroendocrine tumor markers are highly sensitive in the diagnostic assessment of a PET. Imaging studies for tumor localization and staging include computer tomography (CT) scan, magnetic resonance imaging (MRI), In(111)-octreotide scan, MIBG, and endoscopic ultrasonography (EUS). Treatment of PETs often requires a multi-modality approach; however, surgical resection remains the only curative therapy for localized (non-metastatic) disease. Treatment of metastatic disease includes biologic agents, cytotoxic chemotherapy, and liver-directed therapies.

Evidence that wild-type p53 in neuroblastoma cells is in a conformation refractory to integration into the transcriptional complex

Neuroblastoma (NB) cells reportedly accumulate wild-type p53 exclusively in the cytoplasm. However, immunofluorescence assays with five different antibodies showed that p53 accumulates in the nucleus of up to 10% of NB cells. PAb1801 detected cytoplasmic 'punctate structures' which were also found in p53-null cells, rendering this antibody unsuitable for p53 detection. A comparison of DO-1 and PAb1801 staining in NB tissue sections confirmed the results obtained with NB cells. Nuclear accumulation of p53 was induced in NB cells using substances which disturb p53's tertiary structure at its zinc finger motif, or by treatment with mitomycin C. Constitutive nuclear accumulation was observed in an SK-N-SH variant, AW-1, which has a point mutation in p53 at Cys176>Ser, disturbing the same motif. Even though p53 showed DNA-binding capability after mitomycin C treatment of NB cells, the target gene products MDM2 and p21(WAF1,CIP1,SDI1) were not synthesized and no p53 transactivating activity measured in a reporter gene assay. Therefore we suggest that p53 in NB cells might be predominantly in a conformation refractory to integration into the transcriptional complex, resulting in at least partial transcriptional inactivity, hyperactive nuclear export and resistance to degradation by exogenously expressed MDM2.

Conformational phenotype of p53 is linked to nuclear translocation

P53 is inactivated in tumors by mechanisms other than mutations in the p53 gene itself. To gain insight into the mechanisms by which this inactivation occurs, we chemically mutagenized A1-5 cells expressing high levels of temperature sensitive p53val135 (tsp53) and selected for clones that were capable of growth at the permissive temperature for p53 activation. We expanded 22 clones (ALTR cells for A1-5 Low Temperature Resistant) that could grow at the permissive temperature. Most exhibited cytoplasmic sequestration as the mechanism by which p53 was inactivated. We show here that this cytoplasmically sequestered tsp53 protein is maintained in a mutant conformation. Only in clones with nuclear localized p53 is it also expressed in the wild-type conformation suggesting that subcellular localization of tsp53 is important in determining the conformation of the protein. Consistent with this, we show that the changes in conformation of p53 in A1-5 and SK-N-SH cells induced by ionizing radiation also correlate with nuclear translocation of p53. We suggest that nuclear translocation of p53 can result in a change in the conformation from mutant to wild-type but that these may be two separable events. Oncogene (2000) 19, 4042 - 4049.

18Fluorodeoxyglucose-positron emission tomography in the management of patients with suspected pancreatic cancer

OBJECTIVE

To assess the accuracy and clinical impact of 18fluorodeoxyglucose-positron emission tomography (18FDG-PET) on the management of patients with suspected primary or recurrent pancreatic adenocarcinoma, and to assess the utility of 18FDG-PET in grading tumor response to neoadjuvant chemoradiation.

SUMMARY BACKGROUND DATA

The diagnosis, staging, and treatment of pancreatic cancer remain difficult. Small primary tumors and hepatic metastases are often not well visualized by computed tomographic scanning (CT), resulting in a high incidence of nontherapeutic celiotomy and the frequent need for "blind resection." In addition, the distinction between local recurrence and nonspecific postoperative changes after resection can be difficult to ascertain on standard anatomic imaging. 18FDG-PET is a new imaging technique that takes advantage of increased glucose metabolism by tumor cells and may improve the diagnostic accuracy of preoperative studies for pancreatic adenocarcinoma.

METHODS

Eighty-one 18FDG-PET scans were obtained in 70 patients undergoing evaluation for suspected primary or recurrent pancreatic adenocarcinoma. Of this group, 65 underwent evaluation for suspected primary pancreatic cancer. Nine patients underwent 18FDG-PET imaging before and after neoadjuvant chemoradiation, and in eight patients 18FDG-PET scans were performed for possible recurrent adenocarcinoma after resection. The 18FDG-PET images were analyzed visually and semiquantitatively using the standard uptake ratio (SUR). The sensitivity and specificity of 18FDG-PET and CT were determined for evaluation of the preoperative diagnosis of primary pancreatic carcinoma, and the impact of 18FDG-PET on patient management was retrospectively assessed.

RESULTS

Among the 65 patients evaluated for primary tumor, 52 had proven pancreatic adenocarcinoma and 13 had benign lesions. 18FDG-PET had a higher sensitivity and specificity than CT in correctly diagnosing pancreatic carcinoma (92% and 85% vs. 65% and 62%). Eighteen patients (28%) had indeterminate or unrecognized pancreatic masses on CT clarified with 18FDG-PET. Seven patients (11%) had indeterminate or unrecognized metastatic disease clarified with 18FDG-PET. Overall, 18FDG-PET suggested potential alterations in clinical management in 28/65 patients (43%) with suspected primary pancreatic adenocarcinoma. Of the nine patients undergoing 18FDG-PET imaging before and after neoadjuvant chemoradiation, four had evidence of tumor regression by PET, three showed stable disease, and two showed tumor progression. CT was unable to detect any response to neoadjuvant therapy in this group. Eight patients had 18FDG-PET scans to evaluate suspected recurrent disease after resection. Four were noted to have new regions of 18FDG-uptake in the resection bed; four had evidence of new hepatic metastases. All proved to have metastatic pancreatic adenocarcinoma.

CONCLUSIONS

These data confirm that 18FDG-PET is useful in the evaluation of patients with suspected primary or recurrent pancreatic carcinoma. 18FDG-PET is more sensitive and specific than CT in the detection of small primary tumors and in the clarification of hepatic and distant metastases. 18FDG-PET was also of benefit in assessing response to neoadjuvant chemoradiation. Although 18FDG-PET cannot replace CT in defining local tumor resectability, the application of 18FDG-PET in addition to CT may alter clinical management in a significant fraction of patients with suspected pancreatic cancer.

Reexploration for periampullary carcinoma: resectability, perioperative results, pathology, and long-term outcome

OBJECTIVE

This single-institution experience retrospectively reviews the outcomes of patients undergoing reexploration for periampullary carcinoma at a high-volume center.

SUMMARY BACKGROUND DATA

Many patients are referred to tertiary centers with periampullary carcinoma after their tumors were deemed unresectable at previous laparotomy. In carefully selected patients, tumor resection is often possible; however, the perioperative results and long-term outcome have not been well defined.

METHODS

From November 1991 through December 1997, 78 patients who underwent previous exploratory laparotomy and/or palliative surgery for suspected periampullary carcinoma underwent reexploration. The operative outcome, resectability rate, pathology, and long-term survival rate were compared with 690 concurrent patients who had not undergone previous exploratory surgery.

RESULTS

Fifty-two of the 78 patients (67%) undergoing reexploration underwent successful resection by pancreaticoduodenectomy; the remaining 26 patients (34%) were deemed to have unresectable disease. Compared with the 690 patients who had not undergone recent related surgery, the patients in the reoperative group were similar with respect to gender, race, and resectability rate but were significantly younger. The distribution of periampullary cancers by site in the reoperative group undergoing pancreaticoduodenectomy (n = 52) was 60%, 19%, 15%, and 6% for pancreatic, ampullary, distal bile duct, and duodenal tumors, respectively. These figures were similar to the 65%, 14%, 16% and 5% for resectable periampullary cancers found in the primary surgery group (n = 460). Intraoperative blood loss and transfusion requirements did not differ between the two groups. However, the mean operative time was 7.4 hours in the reoperative group, significantly longer than in the control group. On pathologic examination, reoperative patients had smaller tumors, and the percentage of patients with positive lymph nodes in the resection specimen was significantly less. The incidence of positive margins was similar between the two groups. Postoperative lengths of stay, complication rates, and perioperative mortality rates were not higher in reoperative patients. The long-term survival rate was similar between the two resected groups, with a median survival of 24 months in the reoperative group and 20 months in those without previous exploration.

CONCLUSIONS

These data demonstrate that patients undergoing reoperation for periampullary carcinoma have similar resectability, perioperative morbidity and mortality, and long-term survival rates as patients undergoing initial exploration. The results suggest that selected patients considered to have unresectable disease at previous surgery should undergo restaging and reexploration at specialized high-volume centers.

Venting intraluminal drains in pancreaticoduodenectomy

The utility of placing biliary, pancreatic, or enteric "venting"tubes (externally draining devices traversing the bowel or bile duct that have their distal tip located intraluminally near the biliary or pancreatic anastomosis) when performing a pancreaticoduodenectomy has received little attention to date. We hypothesize that these venting tubes do not decrease the morbidity or mortality associated with pancreaticoduodenectomy and may actually be a source of additional morbidity. To characterize our use of and the effect of these drains, we retrospectively analyzed 136 pancreaticoduodenectomies (127 partial, 9 total) performed over a 24-month period. Venting drain use, drain type and size, drain location, duration of intubation, hospital course, and postoperative complications were noted. Venting tubes were used in 80 patients (59%). The use of these drains had no significant relationship to postoperative length of stay, the development of major complications, overall morbidity, or mortality (P>0.05). Such drains also did not significantly shorten the length of hospital stay (P>0.05) or improve outcome when available to augment local control following luminal leak (n = 6) or regional abscess (n = 7). These drains were removed at a median interval of 29 days postoperatively (range 6 to 77 days). Seven patients had complications that were directly related to the venting drain; four of these patients had a documented intra-abdominal luminal leak from the site of drain removal, whereas the other three were hospitalized for presumed leakage secondary to immediate, severe abdominal pain following removal of the drain. These seven patients were elderly (mean age 70 years) and often harbored pancreatic ductal carcinoma (n = 6). Intraluminal drains afford no distinct advantage in terms of shortening the postoperative length of stay, decreasing operative morbidity and mortality, or improving local control with regional sepsis in pancreaticoduodenectomies. Furthermore, they may add an additional source of morbidity and we no longer employ them routinely.

Prospective, randomized trial of octreotide to prevent pancreatic fistula after pancreaticoduodenectomy for malignant disease

OBJECTIVE

This study was conducted to determine whether the perioperative administration of octreotide decreases the incidence of pancreatic anastomotic leak after pancreaticoduodenectomy for malignancy.

SUMMARY BACKGROUND DATA

Three multicenter, prospective, randomized trials concluded that patients who receive octreotide during and after pancreatic resection have a reduction in the total number of complications or a decreased incidence of pancreatic fistula. However, in the subset of patients who underwent pancreaticoduodenectomy for malignancy, either no analysis was performed or no benefit from octreotide could be demonstrated.

METHODS

A single-institution, prospective, randomized trial was conducted between June 1991 and December 1995 involving 120 patients who were randomized to receive octreotide (150 microg subcutaneously every 8 hours through postoperative day 5) or no further treatment after pancreaticoduodenectomy for malignancy. The surgical technique was standardized, and the pancreaticojejunal anastomosis was created using the duct-to-mucosa or invagination technique.

RESULTS

The two patient groups were similar with respect to patient demographics, treatment variables, and histologic diagnoses. The rate of clinically significant pancreatic leak was 12% in the octreotide group and 6% in the control group (p = 0.23). Perioperative morbidity was 30% and 25%, respectively. Patients who underwent reoperative pancreaticoduodenectomy had an increased incidence of pancreatic anastomotic leak, whereas those who received preoperative chemoradiation had a decreased incidence of pancreatic anastomotic leak.

CONCLUSIONS

The routine use of octreotide after pancreaticoduodenectomy for malignancy cannot be recommended.

Reoperative pancreaticoduodenectomy for periampullary carcinoma

BACKGROUND

We have noted a continued increase in the number of patients referred to our institution for presumed or biopsy-proven periampullary carcinoma following an "exploratory" laparotomy during which tumor resection was not performed. Although previous work has demonstrated the safety of reoperative pancreaticoduodenectomy (PD), the need to avoid nontherapeutic laparotomy in these patients is obvious. In the current study, we sought to determine why PD was not performed at the initial operation.

METHODS

Using the prospective pancreatic cancer database, we identified all patients who underwent reoperative PD at our institution between June 1990 and October 1995. Radiologic imaging prior to reoperation was standardized and based on thin-section, contrast-enhanced computed tomography (CT); helical CT was used in more recent cases. Pathologic data were obtained, and initial outside operative reports were reviewed to determine why a PD was not performed at the initial procedure.

RESULTS

Twenty-nine patients underwent reoperative PD. Resection was not performed at the initial laparotomy because of the surgeon's assessment of local unresectability (17 patients), lack of a tissue diagnosis of malignancy (9), misdiagnoses (2), and error in intraoperative management (1). In the 17 patients deemed to have unresectable disease, successful reoperative PD required vascular resection in 10. All 10 of these patients had resection with negative microscopic margins of excision. Of the 9 patients who did not have resection owing to diagnostic uncertainty, all 9 had undergone multiple intraoperative biopsies interpreted as negative for malignancy; 6 of 9 had carcinoma confirmed on permanent-section analysis of the biopsy specimens. Four patients suffered major complications from intraoperative large-needle biopsy.

CONCLUSIONS

Detailed preoperative imaging and a clearly defined operative plan would have allowed successful resection at the initial operation in 27 of 29 patients who underwent reoperative PD. Avoidable patient morbidity and the cost of unnecessary surgery argue strongly against "exploratory" surgery in patients with presumed periampullary neoplasms.

Regional chemotherapy for inoperable pancreatic carcinoma

BACKGROUND

Survival for adenocarcinoma of the pancreatic remains unchanged over the last two decades. The majority of patients (85%) are diagnosed with an inoperable tumor. Patterns of failure reveal that pancreatic cancer involves three compartments: the pancreatic bed and regional lymph nodes, the liver and the peritoneal surfaces. Twelve patients with advanced, unresectable pancreatic cancer, Stage II/III, were treated with regional intra-arterial chemotherapy and extracorporeal hemofiltration directed towards the pancreatic tumor-bearing area and the liver.

METHODS

Five patients had an arterial catheter/port system placed within the celiac axis; the rest had an angiographically placed arterial catheter. All patients had a 16 Fr PFM filtration catheter inserted in the vena cava positioning the tip at the level of the diaphragm and then connected to a hemofiltration unit. Mitomycin C was infused over 25 minutes followed by 5-FU over 10 minutes. The hemofiltration was begun before the drug infusion and continued for 70 minutes. The twelve patients underwent 33 cycles of regional chemotherapy plus hemofiltration.

RESULTS

Five patients had a partial response (45.5%), five had stable disease (45.5%), and one had progression (9%). Four patients were re-explored with one patient undergoing a curative resection. The average survival for patients with unresectable pancreatic adenocarcinoma is 13 months. Tumor implantation and progression on the peritoneal surfaces remains the major site of treatment failure.

CONCLUSIONS

Regional chemotherapy plus hemofiltration with MMC and 5-FU appears to improve the response of Stage II/III inoperable pancreatic cancer and can convert some patients to resectability without significant complications and with no mortality.

Pancreatic carcinoma in perspective. A continuing challenge

There are approximately 27,000 new cases of carcinoma of the pancreas each year and most afflicted patients will die of the disease. Although smoking is a common denominator, chronic pancreatitis is considered an important precursor lesion in a smaller number of cancers. Pancreatic cancer is primarily a disease of the pancreatic ducts. The molecular events are under intense study, but c-K-ras mutation is involved in approximately 80% of the cases and p53 to a slightly lesser degree (60-80%). Early manifestations are usually occult, but jaundice is a common manifestation in patients with cancers of the pancreatic head. Thin-slice computed tomography, portography, and endoscopic retrograde cholangiopancreatography are currently the most sensitive detection techniques. The developing use of endoscopic ultrasound and laparoscopy appear to enhance detection and are under evaluation. In many patients with advanced disease, endoscopic bypass may eliminate the need for unnecessary surgery, although gastrointestinal bypass is still required in some patients (10-15%). Curative resection is possible in selected patients (perhaps 10-15%), with expectation of extended survival ranging from 6->20% in some series. The survival differences may be related to stage, patient selection, and the expertise of the operative team. Preoperative chemotherapy/radiation is under study and may improve outcome. Clinical trial participation is essential for improvement in treatment outcomes.

Molecular diagnosis of exocrine pancreatic cancer using a percutaneous technique

BACKGROUND

The K-ras oncogene is activated by point mutations at codon 12 in most patients with exocrine pancreatic cancer. Mutant-enriched polymerase chain reaction (PCR) amplification can enhance the detection of mutated K-ras. This technique was applied to patients undergoing percutaneous fine-needle aspiration (FNA) biopsy of suspect pancreatic lesions.

METHODS

Twenty-five patients underwent percutaneous FNA of the pancreas for cytologic and molecular analysis. After preparing cytologic smears, the 22-gauge needle and syringe used for FNA were rinsed in RPMI-1640. The specimen was centrifuged, and DNA was extracted from the supernatant and subjected to mutant-enriched PCR using appropriate mismatched primers that introduce a BstNI restriction endonuclease clevage site at codon 12 of wild-type, but not mutant, K-ras. After digestion with BstNI, the DNA was reamplified. To increase assay sensitivity, the final five PCR cycles were completed incorporating 5 microCi of (alpha-32P)dCTP. The DNA was then redigested and subjected to gel electrophoresis and autoradiography.

RESULTS

The median amount of DNA retrieved per specimen was 3.33 micrograms. Mutant K-ras was detected as a band of 143 bps; residual wild-type DNA was seen as a 114-bp fragment. Twenty-one of 25 specimens demonstrated mutated K-ras DNA. Two patients with nondiagnostic cytology results had mutated K-ras DNA; adenocarcinoma of pancreatic origin was confirmed in both cases after pancreatectomy.

CONCLUSION

The molecular diagnosis of pancreatic cancer through identifications of mutations in K-ras can be readily performed on specimens obtained by percutaneous FNA. As aggressive multimodality management of this disease becomes more common, pretreatment analysis of molecular determinants may have greater clinical significance.

The use of spiral computed tomography in the evaluation of vessel encasement for pancreatic cancer

CONCLUSIONS

Spiral CT allows for a noninvasive evaluation of the mesenteric arterial and venous vessels. This test can be performed quicker, with less expense, and with a reduced radiation and contrast load than angiography. Comparison studies of angiography and spiral CT are needed in patients with pancreatic cancer to determine the best method of evaluating possible vessel involvement.

BACKGROUND

Preoperative imaging of patients with pancreatic cancer is crucial in determining resectability and planning management. Computed tomography (CT) remains the diagnostic procedure of choice for the evaluation of the primary tumor and angiography is the gold standard to evaluate vessel encasement. This case evaluates the usefulness of spiral computed tomography in determining vessel encasement.

METHODS

A 53-yr-old female presented with vague abdominal complaints and evaluation revealed a mass in the pancreas. CT suggested portal vein involvement and collateralization was noted in the upper abdomen. Spiral CT revealed normal arterial anatomy and near complete obstruction of the portal vein at the superior mesenteric vein (SMV) splenic vein (SV) confluence.

RESULTS

Operative findings confirmed the involvement of the portal vein at the confluence of the SMV and SV. Pancreatico-duodenectomy with portal vein resection and primary anastomosis was performed. The patient's postoperative course was uneventful and she was discharged home on the 13th postoperative day.

Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group

OBJECTIVE

Tumor invasion of the superior mesenteric-portal vein (SMPV) confluence is often considered a contraindication to pancreaticoduodenectomy for patients with malignant tumors of the pancreas or periampullary region. The authors sought to determine whether pancreaticoduodenectomy with en bloc resection of the SMPV confluence could be safely performed and whether tumors involving the SMPV confluence were associated with pathologic parameters suggesting poor prognosis.

SUMMARY BACKGROUND DATA

Several centers have reported high rates of retroperitoneal margin positivity after pancreaticoduodenectomy for tumors of the pancreatic head and periampullary region. Positive-margin or incomplete resection is associated with early tumor recurrence and no survival benefit compared with palliative therapy. Tumor adherence to the lateral of posterior wall of the SMPV confluence often represents the only barrier to complete tumor resection at the time of pancreaticoduodenectomy.

METHODS

Data on all patients undergoing pancreaticoduodenectomy for adenocarcinoma of the pancreas or periampullary region over a 3.5-year period were entered prospectively in a pancreatic tumor database. To be considered for surgery, patients were required to fulfill the following computed tomography criteria for resectability: 1) the absence of extrapancreatic disease, 2) no tumor encasement of the superior mesenteric artery or celiac axis, and 3) a patent SMPV confluence. Tumor adherence to the superior mesenteric vein or SMPV confluence was assessed intraoperatively, and en bloc venous resection was performed when necessary to achieve complete tumor extirpation. Data on operative characteristics, morbidity, mortality, tumor size, nodal metastases, margin positivity, perineural invasion, and tumor DNA content were compared for patients who did and did not receive venous resection.

RESULTS

Fifty-nine patients underwent pancreaticoduodenectomy, 36 without venous resection and 23 with en bloc resection of the SMPV confluence. No differences in median hospital stay, morbidity, mortality, tumor size, margin positivity, nodal positivity, or tumor DNA content were observed between groups.

CONCLUSIONS

When necessary, segmental resection of the SMPV confluence may be performed safely during pancreaticoduodenectomy for periampullary malignant tumors. Tumors invading the SMPV confluence are not associated with histologic parameters suggesting a poor prognosis. Our data suggest that venous involvement is a function of tumor location rather than an indicator of aggressive tumor biology.

Preoperative chemoradiation, pancreaticoduodenectomy, and intraoperative radiation therapy for adenocarcinoma of the pancreatic head

BACKGROUND

Local recurrence in the bed of the resected pancreas is the most common site of tumor recurrence following a standard pancreaticoduodenectomy (PD) for adenocarcinoma of the pancreatic head. In an attempt to improve local and regional disease control and thereby enhance the quality and length of survival in patients undergoing potentially curative PD, we have used a protocol of preoperative multimodality therapy.

PATIENTS AND METHODS

All patients were treated with external-beam radiation (30.0 or 50.4 Gy) and concomitant 5-fluorouracil (300 mg/m2 per day) prior to PD. Electron-beam intraoperative radiation therapy was given to the bed of the resected pancreas before reconstruction. Patients were assessed for recurrence by physical examination, chest roentgenography, and computed tomography scan performed at 3-month intervals following treatment.

RESULTS

Thirty-nine patients completed all therapy; 1 perioperative death occurred. Thirty-eight tumor recurrences have been documented in 29 patients at a median of 11 months from the date of diagnosis; 23 patients died of disease. The liver was the most frequent site of recurrence, and liver metastases were a component of treatment failure in 53% of patients. Isolated local or peritoneal recurrences were documented in only 4 patients (11%). The only significant clinical or pathologic variable predictive of local-regional recurrence was a previous laparotomy and intraoperative biopsy. The median survival of all 39 patients was 19 months, and the 4-year actuarial survival rate was 19%.

CONCLUSIONS

Preoperative chemoradiation, PD, and electron-beam intraoperative radiation therapy for adenocarcinoma of the pancreatic head have resulted in improved local-regional tumor control, with distant metastatic disease becoming the predominant site of tumor recurrence. Future treatment strategies should incorporate effective multimodality therapy for local-regional disease as demonstrated in this study. Major improvements in overall survival will likely await the development of systemic or regional therapy for liver metastases.

Radical reoperation for advanced pancreatic carcinoma

The indications and outcomes of aggressive reoperation in patients referred to the National Cancer Institute (NCI) for protocol therapy of locally advanced pancreatic carcinoma were investigated. Twenty-nine patients referred to the NCI after exploration and determination of unresectability elsewhere were considered to have localized disease after a metastatic work-up. These patients were then entered onto NCI adjuvant therapy protocols and taken to exploratory laparotomy. Intraoperatively, patients underwent complete resection if possible; otherwise varying palliative surgical procedures were performed. Of the 29 patients, 16 underwent complete resection of their disease, and 13 were unresectable. Two patients suffered postoperative mortality. Disease-specific survival of the resected patients was significantly better than that of the unresectable patients (P < 0.01). The two long-term survivors (53 and > 109 months) underwent definitive surgery after a palliative procedure elsewhere. Complete resection of pancreatic carcinoma contributes to increased survival. The intraoperative definition of unresectability in pancreatic cancer varies with the degree of pancreatitis present, the surgical expertise of the surgeon, and the available ancillary services. Given the extremely grave prognosis of patients with unresectable pancreatic carcinoma, locally unresectable patients without peritoneal seeding of distant metastases at exploration should be considered for referral for protocol therapy to centers where expertise in radical surgery for pancreatic cancer exists.

Preoperative chemoradiation for adenocarcinoma of the pancreas: excessive toxicity of prophylactic hepatic irradiation

PURPOSE

In an effort to reduce relapse in the liver and improve survival in patients with potentially resectable adenocarcinoma of the pancreatic head, we combined whole-liver irradiation with our standard preoperative chemoradiation regimen.

METHODS AND MATERIALS

Eleven patients with biopsy-proven, potentially resectable adenocarcinoma of the pancreatic head were treated with 50.4 Gy of external beam irradiation to the pancreas (1.8 Gy/day, 5 days/week) and concurrent continuous infusion 5-fluorouracil (300 mg/m2 per day). The liver was treated with 23.4 Gy on Days 8 through 21 (13 fractions; 1.8 Gy/fraction). Patients, who upon restaging with radiography and computed tomography were considered to have resectable tumors, were subsequently taken to surgery. If, at surgery, tumors were resectable, pancreaticoduodenectomy was performed, and 10 Gy of intraoperative electron-beam radiation therapy was delivered to the bed of the resected pancreas.

RESULTS

All 11 patients completed chemoradiation. Two treatment-related deaths occurred following chemoradiation, prompting premature termination of the study. Of seven patients taken to surgery, four underwent resection. Seven patients have died of disease, five with liver metastases.

CONCLUSIONS

Prophylactic hepatic chemoradiation, as given in this study, was associated with two treatment-related deaths and a higher than expected incidence of subsequent liver metastases. Our data do not support the use of this treatment program in patients with adenocarcinoma of the pancreas.

Significance of peritoneal cytology in patients with potentially resectable adenocarcinoma of the pancreatic head

BACKGROUND

Recurrence in the peritoneum occurs in up to 50% of patients after a potentially curative pancreaticoduodenectomy. Previous authors have implicated preoperative fine-needle aspiration (FNA) as a cause of intraperitoneal tumor dissemination, although prior studies of peritoneal cytology findings have largely involved patients with locally advanced disease.

METHODS

A consecutive series of patients referred to our institution between 1991 and 1993 with suspected or biopsy-proven adenocarcinoma of the pancreatic head was studied prospectively. All patients fulfilled criteria for resectability as assessed by computed tomography: no metastatic disease, no encasement of the superior mesenteric or hepatic arteries, and a patent superior mesenteric-portal venous confluence. Peritoneal washings were obtained at the time of staging laparoscopy and/or at subsequent laparotomy. Data regarding peritoneal cytology results, previous FNA, preoperative chemoradiation, eventual resection, pattern of disease recurrence, and survival were collected.

RESULTS

A total of 80 peritoneal washings from 60 consecutive patients were prospectively examined. Forty-nine (82%) of 60 patients underwent FNA before peritoneal washings were obtained. A total of four patients (7%) had positive peritoneal cytology findings: three (6%) of 49 who underwent prior FNA and one (9%) of 11 with no prior FNA. Similarly, no differences in eventual peritoneal failure or short-term survival were observed for patients who underwent prior FNA compared with patients who did not. All four patients with positive peritoneal cytology findings had metastatic disease (liver, three; peritoneum, one) at a median of 4.8 months after diagnosis; three of the four died of disease at a median of 8 months.

CONCLUSIONS

Positive peritoneal cytology findings are rare in patients with radiologically resectable adenocarcinoma of the pancreas. When found, positive peritoneal washings are an indicator of advanced disease characterized by unresectability, early metastasis, and short survival. Computed tomographic-guided FNA does not appear to increase the risk for positive peritoneal washings and represents a valid approach to the pretreatment diagnosis of patients with suspected pancreatic malignancy.

Pancreaticoduodenectomy for suspected but unproven malignancy

BACKGROUND

Pancreaticoduodenectomy is an accepted surgical option for certain benign conditions and biopsy proven cancer. Whether this procedure should be performed when malignancy of the pancreas and periampullary region is suspected but not confirmed represents a fairly common intraoperative dilemma.

PATIENTS AND METHODS

Sixty-seven patients who had undergone pancreaticoduodenectomy during a 15-year period were evaluated retrospectively.

RESULTS

The indications for resection were symptomatic benign conditions (n = 10, 15%), proven pancreatic or periampullary cancer (n = 37, 55%), and suspected but unproven malignancy (n = 20, 30%). The patients with suspected malignancy ranged in age from 27 to 73 years. Common findings in this group were abdominal pain (75%), jaundice (70%), weight loss (65%), and alcohol use (45%). There were 14 pancreatic and 6 ampullary masses. Biopsies obtained preoperatively (n = 15) and intraoperatively (n = 11) were nonconfirmatory. Postoperatively 9 patients (45%) were found to have tumors, including 6 pancreatic adenocarcinoma, 2 duodenal adenocarcinoma, and 1 islet cell tumor. Six of the 8 adenocarcinomas (75%) were stage I. Seven patients were alive 11 to 108 months later. The most common benign diagnosis was pancreatitis. There were 8 complications and 1 death.

CONCLUSIONS

Pancreaticoduodenectomy performed based on suspicion alone frequently reveals malignancy. Immediate and long-term outcomes are acceptable. These findings justify a continued aggressive approach to suspected pancreatic and periampullary malignancy.

Managing unsuspected tumor invasion of the superior mesenteric-portal venous confluence during pancreaticoduodenectomy

Most surgeons believe that tumor invasion of the superior mesenteric-portal venous (SMPV) confluence is a contraindication to pancreaticoduodenectomy for adenocarcinoma of the pancreas or periampullary region. Traditional techniques for performing pancreaticoduodenectomy have emphasized the importance of establishing a tumor-free plane between the SMPV confluence and the neck of the pancreas. However, this maneuver does not reveal tumor invasion of the lateral wall of the superior mesenteric vein (SMV) until after gastric and pancreatic transection--a point at which the surgeon has committed to resection. This unexpected but not uncommon finding likely contributes to the high incidence of margin-positive resections and subsequent local tumor recurrence. We describe our technique for segmental resection of the SMPV confluence at the time of pancreaticoduodenectomy. Routine ligation of the splenic vein and primary anastomosis of the SMV and portal vein have been abandoned in favor of an interposition graft using internal jugular vein.