Prognosis and surgical treatment of gastric cancer invading the pancreas

The short- and long-term effect of laparoscopic total gastrectomy in D2 radical treatment combined with spleno-pancreatectomy under membrane anatomy

OBJECTIVE

To explore the short- and long-term effect of laparoscopic total gastrectomy in D2 radical treatment combined with spleno-pancreatectomy under membrane anatomy.

METHODS

From June 2013 to June 2018, 70 patients with gastric cancer underwent total gastrectomy combined with spleno-pancreatectomy involving 37 cases in laparoscopy group and 33 cases in laparotomy group. The intraoperative and postoperative conditions of patients in the two groups were compared and analyzed.

RESULTS

In the laparoscopy group, the operation time and the number of positive lymph node dissection was similar to the laparotomy group. Statistical difference was found in intraoperative bleeding [(79.19 ± 39.63)ml vs (214.39 ± 152.47)m1], the number of lymph node dissection [(47.27 ± 13.94) vs (35.45 ± 9.81)], the first time of aerofluxus [(2.92 ± 0.76)d vs (3.76 ± 1.09)d], the first fluid intake time [(7.49 ± 0.96)d vs (8.27 ± 1.91)d] and the postoperative hospital stay [(11.95 ± 1.90)d vs (15.39 ± 4.07)d] (P < 0.05), So the laparoscopy group was significantly superior to the laparotomy group. The incidences of postoperative complications in laparoscopy group and the laparotomy group were 35.13% and 27.27%, and the difference was not statistically significant. (P > 0.05). No stark difference in postoperative complications of Clavien-Dindo Classification (P > 0.05). The K-M survival curve showed no significant difference in 3-year overall survival (OS) and 3-year disease-free survival (DFS) between the two groups (P > 0.05).

CONCLUSION

The laparoscopic total gastrectomy in D2 radical treatment combined with spleno-pancreatectomy under membrane anatomy is feasible and safe, which can remove more perigastric lymph nodes. With advantages of less intraoperative blood loss and fast postoperative recovery, it cannot increase postoperative complications and long-term survival are comparable to open surgery.

Laparoscopic Whipple's Operation for Locally Advanced Gastric Cancer Invading the Pancreas and Duodenum: a Case Report

Few surgeons have adopted pancreaticoduodenectomy (PD) for the treatment of advanced gastric cancer (AGC) invading the pancreas or duodenum because it remains controversial whether its prognostic benefits outweigh the high morbidity rates in such advanced cases. However, recent technical advances have revived diverse surgical procedures in minimally invasive approaches. Inspired by this trend, laparoscopic PD procedures have been performed for AGC in our institute since 2014. We recently performed a laparoscopic Whipple's operation in a case of cT4b gastric cancer with invasion of the pancreatic head and duodenum.

[Synopsis on clinical practice guideline of gastric cancer in Korea: an evidence-based approach]

Although, gastric cancer is quite common in Korea, the treatment outcome is relatively favorable compared to that of Western countries. However, there is no Korean multidisciplinary guideline for gastric cancer and thus, a guideline adequate for domestic circumstances is required. Experts from related societies developed 22 recommendation statements for the diagnosis (n=9) and treatment (n=13) based on relevant key questions. Evidence levels based on systematic review of literatures were classified as five levels from A to E, and recommendation grades were classified as either strong or weak. The topics of this guideline cover diagnostic modalities (endoscopy, endoscopic ultrasound, radiologic diagnosis), treatment modalities (surgery, therapeutic endoscopy, chemotherapy, radiotherapy) and pathologic evaluation. External review of the guideline was conducted at the finalization phase.

Clinical practice guidelines for gastric cancer in Korea: an evidence-based approach

Although gastric cancer is quite common in Korea, the treatment outcome is relatively favorable compared to those in western countries. However, there are currently no Korean multidisciplinary guidelines for gastric cancer. Experts from related societies developed guidelines de novo to meet Korean circumstances and requirements, including 23 recommendation statements for diagnosis (n=9) and treatment (n=14) based on relevant key questions. The quality of the evidence was rated according to the GRADE evidence evaluation framework: the evidence levels were based on a systematic review of the literature, and the recommendation grades were classified as either strong or weak. The applicability of the guidelines was considered to meet patients' view and preferences in the context of Korea. The topics of the guidelines cover diagnostic modalities (endoscopy, endoscopic ultrasound, and radiologic diagnosis), treatment modalities (surgery, therapeutic endoscopy, chemotherapy, and radiotherapy), and pathologic evaluation. An external review of the guidelines was conducted during the finalization phase.

Systematic review of pancreaticoduodenectomy for locally advanced gastric cancer

BACKGROUND

The purpose of this study was to identify and synthesize findings from all articles on surgical and long-term outcomes in patients with gastric cancer undergoing gastrectomy combined with pancreaticoduodenectomy (PD).

METHODS

Electronic literature searches were conducted using Medline, EMBASE, and Cochrane databases from January 1, 1985, to December 31, 2009.

RESULTS

Eight retrospective case series were included, with 132 patients having PD combined with gastrectomy. PD was combined with total gastrectomy in 27 patients, and subtotal gastrectomy in 81 patients; 24 patients had undocumented gastric resection type. Clinical stage was available for 92 patients (4 stage I, 7 stage II, 26 stage III, and 55 stage IV). Five studies (98 patients having PD combined with gastrectomy) compared PD and gastrectomy to gastrectomy alone. In the four studies reporting morbidity, PD had a higher morbidity. The pooled pancreatic anastomotic leak rate was 24.5% for the seven studies in which complications were reported; however, there were no peri-operative deaths. Long-term survival (37.3% at 5 years) in gastric cancer patients with PD combined with gastrectomy was described; however, survival was poor in the setting of incurable factors. Due to heterogeneity of patients and staging techniques in the case series no recommendations can be made on the appropriate selection criteria for patients undergoing PD and gastrectomy.

CONCLUSION

PD for gastric cancer invading the pancreas is associated with a higher morbidity; given the heterogeneous data, defining exact selection criteria is difficult.

A systematic review of spleen and pancreas preservation in extended lymphadenectomy for gastric cancer

BACKGROUND

The overall prognosis and survival of patients with advanced gastric cancer are generally poor. Extended lymphadenectomy is recommended for patients with advanced gastric cancer; however, splenectomy and distal pancreatectomy performed with an extended lymph node dissection may be associated with increased morbidity and mortality.

METHOD

Electronic literature searches were conducted using Medline, Embase, and the Cochrane Central Register of Controlled Trials from 1 January 1998 to 31 December 2009. Studies on gastric carcinoma investigating extended lymphadenectomy with splenectomy and/or pancreaticosplenectomy that reported data on surgical outcomes or survival were selected.

RESULTS

Forty studies were included in this review. Decreased complication rates were demonstrated with spleen preservation in two prospective studies and three retrospective studies, and with pancreas preservation in five retrospective studies. No randomized controlled trial showed survival benefit or detriment for preservation of spleen or pancreas in extended lymphadenectomy. Improved survival was demonstrated with spleen preservation in two prospective and eight retrospective studies, and with pancreas preservation in one prospective and four retrospective studies.

CONCLUSIONS

Preservation of the spleen and pancreas during extended lymphadenectomy for gastric cancer decreases complications with no clear evidence of improvement or detriment to overall survival.

Significance of palliative gastrectomy for late-stage gastric cancer patients

PURPOSE

To investigate the significance of palliative gastrectomy for different types of metastatic gastric cancer patients displaying peritoneal dissemination, hepatic metastasis, distant lymph node metastasis occurring locally during late-stage disease, and multi-organ metastases.

METHODS

We performed a retrospective study of 862 patients who were histologically diagnosed as late-stage gastric cancer who could not undergo radical surgery at the Sun Yat-sen University Cancer Center between January 1993 and December 2008. The follow-up lasted until December 2010. Chi-square tests and Kaplan-Meier methods were employed to compare the adverse events and prognoses.

RESULTS

In the peritoneal dissemination and multi-organ metastases groups, palliative gastrectomy has no survival benefit (P = 0.705, 0.331, respectively). In the patients with distant lymph-node metastases, liver metastasis and locally late-stage gastric cancer patients, palliative gastrectomy was a prognostic factor (P < 0.001, P < 0.001, P = 0.010, respectively). Multivariable analysis demonstrated that palliative gastrectomy was an independent prognostic factor for distant lymph-node metastases, liver metastasis, and local late-stage gastric cancer patients. Palliative gastrectomy combined with hepatectomy proved to be an independent prognostic factor to improve the overall survival of patients with liver metastases who underwent palliative gastrectomy (P = 0.008).

CONCLUSION

For late-stage gastric cancer patients, palliative gastrectomy should be considered for locally late-stage, distant lymph node metastasis, and resectable liver metastasis patients. Especially among patients with liver metastasis, transfer medicine is essential for potentially curable patients to obtain access to radical surgery to improve the prognosis.

Long-term survival of resected advanced gastric cancer with hepatic and pancreatic invasion

A 64-year-old man was transferred to our division with a suspicion of gastric cancer. Computed tomography showed widespread irregular thickening of the stomach walls close to the liver and pancreas. Gastrointestinal fiberscopy showed a type 5 tumor in the upper to lower stomach, histologically diagnosed as tubular adenocarcinoma. Gastric cancer with hepatic and pancreatic invasion was diagnosed. Distant metastasis was not proven and complete resection was planned. At laparotomy, the tumor showed general expanding growth and invasion through the lateral segment of the liver and pancreas. Total gastrectomy and combined resection of the distal pancreas, spleen and left segment of the liver were performed. Hepatic and pancreatic invasion and lymph node metastasis were microscopically proven. Pancreatic fistula occurred postoperatively. On postoperative days 40, he was discharged. He received two cycles of adjuvant tegafur/gimeracil/oteracil chemotherapy. He has had no sign of recurrence for 7 years and 8 months.

Imaging features of hematogenous metastases to the pancreas: pictorial essay

This pictorial essay illustrates the imaging appearances of a wide variety of metastases to the pancreas as seen on computed tomography (CT), magnetic resonance imaging and positron emission tomography/CT. Key clinical and radiologic features (lesion distribution, non-contrast imaging appearance, enhancement pattern and pattern of spread) that may aid differentiation of primary from solitary secondary pancreatic malignancies are discussed.

Prognosis and surgical treatment of gastric cancer invading adjacent organs

BACKGROUND

The prognostic factors and surgical management of gastric cancer invading adjacent organs remains controversial. The aim was to provide valuable prognostic and surgical information on patients with gastric cancer invading adjacent organs.

METHODS

The retrospectively study included 367 patients who underwent gastric resection for gastric cancer invading adjacent organs. Clinicopathologic variables were evaluated as predictors of long-term survival by univariate and multivariate analyses. Multivariate analysis was performed using Cox's proportional hazards model.

RESULTS

The five-year survival rate was 10.1%, and median survival period was 14 months. The five-year survival rate was influenced by histologic type, lymph node metastasis, liver metastasis, peritoneal dissemination, extent of lymph node dissection and curability of operation. Of these, independent prognostic factors were lymph node metastasis (N2, N3 versus N0, N1, relative risk 2.028, P < 0.001), liver metastasis (present versus absent, relative risk 1.582, P= 0.023) and curative resection (no versus yes, relative risk 1.719, P < 0.001). A significant survival benefit for curative resection was observed with a five-year survival rate of 21.5% compared with non-curatively resected cases (5.1%).

CONCLUSIONS

In patients with gastric cancer invading adjacent organs, three independent prognostic factors were lymph node metastasis, liver metastasis, and curative resection. For patients with gastric cancer invading adjacent organs, we recommend performing combined organ resection in patients with locally advanced gastric carcinoma regardless of curability.

Pancreaticoduodenectomy for locally advanced stomach cancer: preliminary results

BACKGROUND

Pancreaticoduodenectomy (PD) for locally advanced stomach cancer involving duodenum or/and pancreatic head was controversial and rarely carried out. It was mainly reported from the Japanese institutions.

METHODS

A review of prospective database from January 2003 to December 2006 of patients who had locally advanced stomach cancer involving duodenum or/and head of pancreas that precluded curative subtotal gastrectomy who underwent diagnostic laparoscopy or exploratory laparotomy to exclude peritoneal metastatic disease. Patients were advised to undergo neoadjuvant chemotherapy before PD.

RESULTS

Seven patients underwent PD during the above-mentioned period. Only four patients had neoadjuvant chemotherapy before PD. The median operative time was 8 h (range 6-9 h). Five patients had combined tranverse colectomy done. There was no 30-day operative mortality or re-operation. Three patients developed controlled pancreatic leaks and fistulas that were successfully treated with conservative measures. The length of hospital stay was 10-53 days (median 15 days). Median survival was 13 months and 2-year survival rate was 60%. Patients who received neoadjuvant chemotherapy seemed to have better survival rate (P = 0.039).

CONCLUSION

Our initial experience has shown that with careful and stringent patients selection, PD for locally advanced stomach cancer can be carried out with acceptable morbidity and mortality. Early results for patients who received neoadjuvant chemotherapy showed trend towards prolonged survival. However, longer follow up and further patient recruitment are needed to confirm our initial optimistic findings.

Survival benefits of pancreatoduodenectomy for gastric cancer: relationship to the number of lymph node metastases

BACKGROUND AND AIMS

Pancreatoduodenectomy (PD) for advanced gastric cancer is rarely performed because of the high frequency of associated morbidity and mortality. The aim of this study was to determine the limited indication of PD for advanced gastric cancer.

MATERIALS AND METHODS

From January 1984 and December 2005 patient's charts were reviewed and outcomes after PD for gastric cancer were compared between two subgroups; those with a 'high' number (7<or= group) of lymph node metastases and those with 'low' numbers (6>or= group).

RESULTS

PD was intraoperatively selected because of direct tumor invasion into the pancreas (52.2% of the 7<or= group vs 12.5% of the 6>or= group) or pancreatic lymph node infiltration (47.8% of the 7<or= group vs 87.5% of the 6>or= group; P = 0.058). The postoperative histological analysis showed 22 cases from 23 (95.7%) in 7<or= group with T3 or T4 tumor, compared with only 4 cases (50%) in 6>or= group (P = 0.014). The 5-year survival rates were significantly better in the 6>or= group compared with the 7<or= group (P = 0.014).

CONCLUSIONS

The indication for PD in advanced gastric cancer should consider the degree of extensive lymph node metastases and incurable factors.

Results of combined gastrectomy and pancreatic resection in patients with advanced primary gastric carcinoma

BACKGROUND/AIMS

Although the incidence of primary gastric carcinoma is decreasing, the majority of patients in Western countries are still diagnosed with advanced tumor stages. In many cases surgical therapy can be performed only by multivisceral resections including the pancreas.

METHODS

Between April 1986 and April 1997, thirty-three patients with primary gastric carcinoma underwent gastric resection and segmental/total pancreatectomy at our institution (21 males, 12 females; median age 57 years). The operative and pathologic findings and clinical course in these patients were analyzed retrospectively.

RESULTS

In all patients total gastrectomy with D2 lymphadenectomy was performed. In 26 patients (79%) the pancreatic tail was also resected. Other resections included the pancreatic head in 5 patients (15%) and the whole pancreas in 2 cases (6%). Radical (R0) resections were possible in 73% of all cases (n = 24). 22 patients (67%) had stage-IV disease due to liver/peritoneal metastases (n = 11) or to extensive lymph node metastases (N3, n = 11). Histology showed a predominance of the diffuse type according to Laurén (n = 16, 49%). Intraoperatively suspected tumor infiltration of the pancreas was confirmed by histology only in 39% (n = 13) of the examined resection specimens. Postoperative morbidity was 36% (n = 12) and mortality was 9% (n = 3). Five patients developed pancreatitis or peripancreatic abscess, 2 with a lethal outcome. Overall the median survival was 13 months. Following R0 resection median survival was 17 months. If the pancreas was microscopically not infiltrated, median survival was 23 months.

CONCLUSION

Pancreatic invasion in patients with gastric carcinoma is often associated with positive lymph nodes and liver metastases or peritoneal carcinomatosis. Intraoperatively, true pancreas invasion is difficult to differentiate from inflammatory reactions. Postoperative morbidity and mortality are increased by pancreatic resection, mainly due to pancreatitis or peripancreatic abscess. Curative (R0) resection improves prognosis and even long-term survival can be achieved in selected individual cases. Palliative resections can be performed for local complications like bleeding or obstruction refractory to other therapies.

Pancreatic Resection for Locally Advanced Primary and Metastatic Nonpancreatic Neoplasms

We conducted a retrospective review of our single-institution experience with pancreas resection for locally advanced primary malignancy or metastases from other organs. From January 1989 through April 2001 35 patients underwent pancreatic resection for locally advanced primary (17) and recurrent nonpancreatic (18) tumors. Patient records were examined for recurrence and survival. Seventeen patients with locally advanced primary tumors presented with pancreatic extension either into the head/body (six) or tail (11). Pancreatic resections were completed as en bloc procedures with the primary disease of stomach (five), colon (four), sarcoma (five), adrenal gland (one), or spleen (one). Procedures performed included pancreaticoduodenectomy for proximal lesions and distal pancreatectomy for disease limited to the pancreatic tail. Median overall survival was 56 months. Fourteen of 17 patients remain alive: three with disease and 11 without evidence of recurrence. Eighteen patients presented with recurrent tumor from a previously resected right upper quadrant tumor (nine) or metastases from an intra-abdominal source (nine). The primary source was colon (eight), biliary (three), sarcoma (three), melanoma (two), ovary (one), and unknown primary (one). Patients underwent pancreaticoduodenectomy, distal pancreatectomy, or resection of residual pancreas. Overall median survival was 46 months. In this group of 18 patients there was no increased survival in those patients with a time to recurrence from their primary tumor resection greater than 2 years. We conclude that pancreatic resection for locally advanced nonpancreatic or recurrent intra-abdominal malignancies is possible in properly selected patients. The ability to obtain disease-free margins through en bloc resection is a key component of therapy.