Radical surgery for cancer of the pancreas

Kothaj P
Bratisl Lek Listy 2002; 103 (11): 400402
Department oI Surgery, F.D. Roosevelt`s Hospital, Banska Bystrica,
Slovakia
Address for correspondence: P. Kothaj, MD, Dept oI Surgery, F.D.
Roosevelt`s Hospital, 974 01 Banska Bystrica, Slovakia.
Phone: Fax:
The paper was presented at the 55th Kostlivy Surgical Day December 7,
2001, in Bratislava, Slovakia.
Department of Surgerv, F.D. Roosevelts Hospital, Banska Bvstrica, Slovakia.bllfmed.uniba.sk
Abstract
The basic principles of oncological radicality in surgery are: a) the surgeon have to perform always an
R0 resection and he have to use perioperative investigation of resection margin, b) lymphadenectomy
must be rational meaning that it is enough to perform regional lymphadenectomy (radical lymphadenec-
tomy is not necessary), c) if portal vein resection enables increased curability of resection, then it is
valuable to resect part of this vessel and to perform end-to-end venous anastomosis. 4AB #
400
From the time oI the Iirst operations on the pancreas in 1898
by William Halsted at John Hopkins Hospital in Baltimore, Ior
along time the only operations on the pancreas were ampulecto-
mies. Later, when Allan Whipple on May 6, 1940 in Presbyteri-
an Hospital in New York perIormed the cephalic pancre-
atoduodenectomy, operations were limited to the removal oI the
tumour without knowledge oI the resection margin and without
lymphadenectomy. Since that time the approach to radical sur-
gery oI the pancreas has changed considerably.
Today oncological radicality in the surgery oI the pancreas
means:
a) radical surgery directly on the pancreas and surrounding
peripancreatic tissue R0 resection (curative resection with mi-
croscopicly negative resection margins),
b) radical lymphadenectomy (to perIorm regional or radical
lymphadenectomy),
c) importance oI vessel resection (resection oI the large ves-
sels in cases where it is possible).
Even beIore the operation, the surgeon must know the tvpe
and stage oI the tumor because his chances Ior success are only
in the case oI well or moderately diIIerentiated carcinomas.
Stages III and IV as well as poorly diIIerentiated carcinoma
with quick lymphogenic and haematogenic progression have
such a bad prognosis that the surgeon cannot have an inIluence
(in these cases is surgery always only palliative). TNM classi-
Iication gives the stages: 1st stage T1 or T2, N0, M0. 2nd
stage T3, N0, M0. 3rd stage T13, N1, M0. 4th stage any
T and N, M1. Patients with positive lymphatic nodes (N1) have
a Iour-times worse prognosis than patients with negative lymph
nodes (N0).
The tvpe of the tumour (tvping) can be determinated preoper-
ativly by the Iine-needle aspiration cytology (FNAC) guided by
CT or USG control. The accuracy oI this procedure is 8590 ;
Ialse positive results are only 5 ; Ialse negative results are about
20 . This procedure has a low rate oI complications. In com-
paring, FNAC is not accepted by all surgeons as the routine meth-
od. It is important to do FNAC especially in cases where there is
a bigger risk oI perioperative mortality and morbidity and where
the decision to submit the high risk patient to a diIIicult resec-
tion is not so easy. In the case oI a clinical suspicion to carcino-
ma, the operation indicated is also the negative result oI FNAC.
At our Department oI Surgery we have perIormed the FNAC in
cooperation with the Department oI Pathology since 1985 and
its accuracy in our group oI patients is now 92 .
The stage of the tumour (staging) can be Iind preoperatively
by spiral CT with contrast medium. This procedure can show
tumors as small as 1 cm in diameter (T), the presence oI the
lymph nodes as small as 5 mm in diameter (N) and the presence
oI liver methastases (M). To evaluate the resectability oI the tu-
mor correctly (it is limited by the inIiltration oI the tumor to the
vessels), this procedure has eIIicacy oI 90 which is almost as
good as angiography. At present, coeliacography or mesenteri-
Kothaj P. Radical surgery Ior cancer oI the pancreas 401
cography is indicated only in cases when CT cannot exclude in-
Iiltration to the vessels. It is important that the resectability oI
the tumor is evaluated together by the radiologist and the operat-
ing surgeon because this can Iocus an the places where surgeon
can have problems and it also provides postoperative Ieed-back
Ior the radiologist. At our Department oI Surgery aIter such a
common evaluation oI CT scans the eIectivity oI resectabilty in-
creased up to 95 . The next possibility oI preoperative staging
is laparoscopic staging which can reveal nonsuspected metastas-
es in up to 30 oI cases.
Extent of the resection on the pancreas
The Iirst condition Ior curative resection is the correct deci-
sion oI kind oI resection to perIorm. The tumors oI the pancreat-
ic head and ampulomas require cephalic partial duodenopancre-
atectomy Whipple operation (about 70 oI operations Ior pan-
creatic carcinoma). Tumors oI the pancreatic head spreading to
the pancreatic body or diIIuse pancreatic carcinoma (impossible
to perIorm saIe pancreatic anastomosis) require total duodeno-
pancreatectomy. Tumors oI the pancreatic tail require distal pan-
createctomy. Tumors oI the pancreatic body and tail require sub-
total distal pancreatectomy Child 95 resection. The ques-
tion is whether to use the pylorus-preserving duodenopancreate-
ctomy in cases oI carcinoma. The recent opinion is that this pro-
cedure can be used in carcinomas only iI they are ampulomas or
the tumours oI pancreatic head (processus uncinatus tumors) Iar
enough Irom the pylorus.
It is necessary to be sure with the microscopic oI the nega-
tivity oI resection margin by using perioperative biopsv of re-
section margin not only in the line oI pancreatic resection but
also in retropancreatic tissue. On the pancreas, which is oIten
Iibrotic, it is diIIicult macroscopicly to evaluate how Iar the mi-
croscopic changes are spread. In our group oI patients, when we
compared curative resections in patients with and without perio-
perative investigation oI resection margin, we Iound out that iI
the resection margin was not evaluated during operation, only
60 oI resections were curative.
Extent of lymphadenectomy
The reasons Ior lymphadenectomy are clear and today it is
known that it is necessary to also remove the regional lymphatic
drainage. The reasons Ior lymphadenectomy are as Iollows:
A) almost 50 lymph nodes which appear macroscopicly nega-
tive are microscopicly positive. B) iI microscopicly positive
lymphonodes are not removed, the probability oI 3-year survival
drops Irom 30 to 3 . Experience Iorm big medical centers
like Memorial Sloan-Kettering Cancer Center in New York and
Mayo Clinic in Rochester say that beIore the era oI lymphadenec-
tomy no patients survived 5 years and aIter its introduction the
5-year survival is almost 25 (Kothaj, 1996).
Today the question is not whether to do a lymphadenectomy,
but the question is whether to do only regional lymphadenecto-
my (right Irom superior mesenteric artery) or to do a radical lym-
phadenectomy proposed by Japanese surgeons (also leIt Irom
superior mesenteric artery including sceletisation oI coeliac trunc
and mesenteric vessels). Radical lymphadenectomy was proposed
by Ishikawa in 1988. This radical lymphadenectomy extends the
time oI operation (up to 10 hours) and has a higher postopera-
tive morbidity (diarrhea, risk oI Iatal erosion oI the vessels in
case oI leakage oI the pancreatic anastomosis) but increased sur-
vival oI patients: 1-year survival Irom 39 to 56 , 3-year Irom
13 to 38 and 5-year Irom 9 to 28 (Ishikawa, 1988).
The only valid prospective randomised trial comparing re-
gional and radical lymphadenectomy in the literature is the trial
oI Henne-Bruns published in the World Journal oI Surgery in
May 2000 (Henne-Bruns, 2000) which showed that radical lym-
phadenectomy did not have a signiIicantly better results and that
regional lvmphadenectomv is suIIicient Ior the curative resec-
tion oI pancreatic carcinoma. This means removal oI the praepan-
creatic and retropancreatic lymph nodes along with the common
hepatic artery andcoeliac trunc aand the paraaortal lymph nodes
distally up to the origin oI inIerior mesenteric artery. Every lym-
phadenectomy is valuable only under three conditions: the tu-
mor is in stage I or II, there is no portal vein invasion and an R0
resection can be done.
Importance of vascular resection
Although vascular invasion can be evaluated even preopera-
tively Irom the CT and AG, the most precise evaluation oI vas-
cular invasion is via intraportal endovascular ultrasonography
(IPEUS) which was introduced into practice in 1990 by Japa-
nese surgeons Nakao and Kaneko. This procedure involves the
introdution the catheter via the superior mesenteric vein into the
portal vein and allows the surgeon to evaluate vascular invasion.
The accuracy oI this procedure to reveal vascular invasion (later
histologically proved) is 95 (Kaneko, 1993). The importance
oI this method is that it can Iind macroscopicaly undetectable
vascular invasion and enables the surgeon to resect the vessel
(usually portal vein) and perIorm curative resection.
Although vascular resection is commonly considered as a
last resort and the chances Ior long-term survival in such pa-
tients are minimal, the paper published in current American Jour-
nal oI Surgery (Bachelier, 2001) shows that pancreatic surgeons
still perIorm vascular resection. (portal and superior mesenteric
vein). Nakao in Nagoya 78 (104 patients 1995), Ogata Irom
Tokyo 55 (107 patients 1997), Ishikawa Irom Osaka 70
(35 patients 1999), Trede Irom Manheim 11 (60 patients
1997) and Fortner Irom New York 17 (58 patients 1996).
Mortality in these patients is comparable with the mortality oI
patients without vascular resection. While Japanese surgeons per-
Iorm resection oI the portal vein or the superior mesenteric vein to
increase local eIIect oI the operation and expect longer survival
and delay oI local recurrency, American and European surgeons
perIorm portal vein resection en bloc with the tumor as a 'no touch
technique and expect later incidence oI liver metastasis. This me-
tastasis usually occurr aIter manipulation oI the tumor aspreading
tumor cells to the portal vein even preoperatively.
Bratisl Lek Listy 2002; 103 (11): 400402 402
Our experience
At the Department oI Surgery in Roosevelt Hospital in Ban-
ska Bystrica Irom 19912000 we perIormed 81 pancreatic re-
sections Ior pancreatic tumor. From these patients 19 had benign
tumor (tumor mass in chronic pancreatitis) and 62 patients had
histologically proved carcinoma. From these resections, 49 were
Whipple operations, 11 total duodenopancreatectomies, 7 sub-
total distal pancreatectomies (Child) and 14 distal pancreatecto-
mies. Overall mortality in this group was 4.5 (4 patients). We
perIormed regional lymphadenectomy (not radical). Comparing
the two groups oI patients with and without lymphadenectomy
there was statistically signiIicant diIIerence in survival in Iavour
oI the group with lymphadenectomy (p0.05) but with compara-
ble mortality and morbidity. The survival oI patients aIter oper-
ations Ior pancreatic head carcinoma was: 1-year 65 , 2-year
47 , 5-year 18 and the average survival was 18 months
which is comparable with published results. SigniIicantly better
survival aIter radical resection compares to the palliative opera-
tions in stage Iand II; but in stage III this diIIerence was not
signiIicant.
References
1. Bachelier T, Nakano H et al. Is pancreaticoduodenectomy with
mesenericoportal venous resection saIe and worthwhile? Amer J Surg
2001; 182 (2): 120129.
2. Henne-Bruns D, Vogel I, Lttges 1, Klpel G, Krener B. Surgery
Ior ductal adenocarcinoma oI the pancreatic head: staging, complicati-
ons and survival aIter regional versus extended lymphadenectomy. Wold
J Surg 2000; 24 (5): 595602.
3. Ishikawa O et al. Practical useIulness oI lymphatic and connective
tissue clearence Ior the carcinoma oI the pancreatic head. Ann Surg
1988; 208 (2): 215220.
4. Kaneko T, Nakao A, Inoue S et al. Intraportal endovascular ultraso-
nography as anew diagnostic procedure in pancreatic cancer. Hepato-
Gastroenterology 1995; 42 (5): 711716.
5. Kothaj P. Chirurgicka liecba rakoviny pankreasu (Surgical treatment
oI pancreatic carcinoma). Banska Bystrica, Own edition 1996, 152 p.
Received August 20, 2002.
Accepted September 16, 2002.