Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis

OBJECTIVE: To review the current status of pancreatoduodenectomy for pancreatic cancer and chronic pancreatitis using evidence-based methodology. SUMMARY BACKGROUND DATA: Despite improved results of pancreatoduodenectomy over the recent years, the reputation of the Whipple procedure and its main modifications has remained poor. In addition, the current status of newer modifications of standard pancreatoduodenectomy is still under debate. METHODS: Medline search and manual cross-referencing were performed to identify all relevant articles for classification and analysis according to their quality of evidence. The search was limited to articles published between 1990 and 2001. RESULTS: The mortality rate of pancreatoduodenectomy has declined to less than 5% for chronic pancreatitis and 3% to 8% for pancreatic cancer. In contrast, overall morbidity rates remain high, ranging between 20% and 70%. Delayed gastric emptying represents almost half of all complications. The overall 5-year survival rate for patients with pancreatic cancer remains poor, ranging between 5% and 15%, with a median survival of 13 to 17 months. Mortality and morbidity are not related to the type of pancreatoduodenectomy; however, patients with pancreatic cancer tend to be at increased risk for complications. Extended lymph node dissection and portal vein resection can be performed with similar mortality and morbidity rates as standard procedures, but without apparent survival benefits in the long term. Major relief of pain is achieved in 70% to 100% of patients with chronic pancreatitis. CONCLUSIONS: Pancreatoduodenectomy and its main modifications are safe and effective treatment modalities, especially in experienced centers with a high patient volume. For chronic pancreatitis, surgical resection provides major relief of pain and thus increased quality of life. Overall survival for patients with pancreatic cancer is determined predominantly by the pathology within the resected specimen.     

Intraoperative Transfusion: Is It a Real Prognostic Factor of Periampullary Cancer Following Pancreatoduodenectomy?

The purpose of this study was to clarify the prognostic significance of transfusion following pancreatoduodenectomy for periampullary cancers. We analyzed 357 periampullary cancers from 1985 to 1997 (ampullary cancer 130 cases, distal bile duct cancer 141 cases, pancreatic head cancer 86 cases). A total of 215 (60%) of the 357 patients have received intraoperative transfusion. The 5-year survival rate of 130 ampullary cancer patients was 59%; altogether, 76 patients (58%) underwent intraoperative transfusion. The 5-year survival rate of patients without intraoperative transfusion was 79%, whereas that of patients with a transfusion was 47% (p = 0.029). Following multivariate analysis, intraoperative transfusion was found to be an independent poor prognostic factor for those with ampullary cancer (relative risk 2.174). Among those with common bile duct cancer, the overall 5-year survival rate was 33%, and the 5-year survival rates for patients with (n = 87) or without (n = 54) transfusion were 25% and 38%, respectively, which did not reach statistical significance (p = 0.0717). For those with pancreatic head cancer, the overall 5-year survival rate was 16%, and there was no survival difference between transfused (n = 52) and untransfused (n = 34) patients. In the present study the reason was not clear, although intraoperative transfusion was an independent significant prognostic factor for ampullary cancer. Careful dissection to minimize intraoperative bleeding is mandatory during pancreatoduodenectomy for ampullary cancer.     

胰头部肿块型慢性胰腺炎诊断与治疗

胰头部肿块型慢性胰腺炎从临床表现上很难与胰头癌相鉴别,目前已将发生于胰头部的肿块型慢性胰腺炎视为胰腺癌发生的癌前病变。影像学检查在肿块型慢性胰腺炎诊断中起着重要作用,对于手术指征的掌握、胰头部肿块的可切除性、手术方式的选择以及手术困难程度的估计很有帮助。胰头部肿块型慢性胰腺炎的手术方式是直接针对胰头的,不同的手术方法包括胰十二指肠切除术（保留或不保留幽门的Whipple手术）和胰头部分切除加胰管引流术（Frey 手术,Beger 手术）。胰头肿块型慢性胰腺炎一旦诊断明确即应积极手术治疗,手术方式尽可能采用胰十二指肠切除术,因为它不仅切除了胰头部肿块、解除了胆道和胰管及十二指肠的梗阻,而且也去除了胰头癌的潜在病因;如胰头肿块巨大,行胰十二指肠切除有极大风险,可考虑行保留十二指肠的胰头切除术。     

Pancreatic excisions for chronic pancreatitis and cancer: their rationale for "factual" surgery. Evidence-based medicine

Despite significant improvement in the results of pancreatoduodenecomy over recent years, the Whipple procedure and its main modifications still has a poor reputation. Based on the principles of evidence-based medicine, we reviewed the current status of pancreatoduodenectomy for pancreatic cancer and chronic pancreatitis. Mortality of pancreatoduodenectomy has declined to less than 5% for chronic pancreatitis and to 3-5% for pancreatic cancer. In contrast, overall morbidity remains high, ranging from 20% to 70%. Delayed gastric emptying accounts for almost 50% of all complications. Major relief of pain is achieved in 70% to 100% of patients with chronic pancreatitis. Overall 5-year survival for patients with pancreatic cancer remains poor, ranging from 5% to 15%, with a median survival of 13 to 17 months. Mortality ad morbidity are not related to the type of pancreatoduodenectomy, however patients with pancreatic cancer tend to have a higher risk for complications. Extended lymph node dissection and portal vein resection can be performed with similar mortality and morbidity compared with standard procedures, however without any survival benefit in the long-term course.     

The impact of pylorus-preserving pancreatoduodenectomy on surgical treatment for cancer of the pancreatic head

Pylorus-preserving pancreatoduodenectomy (PPPD) was reintroduced in 1978. This pylorus-preserving modification was designed to minimize complications related to gastric resection, such as early satiety, marginal ulceration, and bile reflux gastritis, as well as diarrhea and dumping. Since 1978, PPPD has been performed preferentially for benign and malignant diseases of the periampullary region and pancreatic head. Some groups have argued against PPPD for cancer of the pancreatic head, because the pylorus-preserving procedure is likely to compromise the field of resection and does not allow lymph node dissection of the peripyloric and perigastric groups. However, comparative survival rates after PPPD have been the same as, or better than, those with classic pancreatoduodenectomy, showing the rationale for PPPD as a radical resection procedure for cancer of the pancreatic head. PPPD can be performed with low mortality. Delayed gastric emptying, which is the most common complication in the immediate postoperative period after PPPD, is always transient. Many investigators have shown that body weight and the majority of nutritional parameters are better than after PD. PPPD does not appear to cause any negative outcomes. We conclude that PPPD is the surgical procedure of choice for cancer of the head of the pancreas. Received: April 13, 2001 / Accepted: June 6, 2001     

慢性胰腺炎伴胰管结石的诊断与外科治疗

目的：探讨慢性胰腺炎伴胰管结石的诊断特点与手术方法的选择。方法：回顾分析外科治疗的慢性胰腺炎伴胰管结石的16例临床资料。结果：16例中常见的临床症状是腹痛(占100％)、食欲不振及恶心呕吐(占62．5％)、脂肪泻(占12．5％)、消瘦(占18．8％)及腹部肿块(占6．3％)。胰管扩张及胰腺结石的B超诊断率分别为81．3％及75．0％；胰管结石的腹部平片诊断率为81．3％；胰管结石的CT和MRI诊断率均为61．5％，包括胰头部局限性肿大为23．1％和胆总管扩张15．4％。手术方式包括胰管切开减压胰管空肠内引流术10例(Partington手术9例及Puestow手术1例)，胰十二指肠切除术3例(Child方法)，胰体尾部切除术3例(联合胆总管切开、T管引流术2例)。结论：严格选择适应证和合理的手术方式，对改善慢性胰腺炎伴胰管结石患者的生活质量和控制疾病发展具有重要作用。     

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??Diagnosis and treatment of chronic pancreatitis with mass in the head of the pancreas ZHANG Zhong-tao, YIN Jie.Department of General Surgery, Beijing Friendship Hospital Affiliated to Capital University of Medical Sciences, Beijing 100050, China Corresponding author: ZHANG Zhong-tao, E-mail: zhangzht@medmail. com.cn Abstract Chronic pancreatitis (CP) with mass and pancreatic cancer are difficult to identify from the Clinical performance. At present, we have the CP with mass as a precancerous lesion of pancreatic cancer. Imaging methods in the diagnosis of the CP with mass plays an important role, which is very helpful for the Indications for surgery of the hands, of resectable pancreatic head tumor, and surgical options, as well as estimates of the difficulty of the surgery. Surgical strategy in CP with mass has been directed at the pancreatic head with a variety of tactics including pancreatoduodenectomy(Whipple procedure with or without pylorus preservation) and partial resection of the pancreatic duct drainage(Frey operation, Beger operation ). Once the diagnosis of the CP with mass should be clear that the surgical treatment, pancreatoduodenectomy is preformed in the treatment of CP with mass, not only resection of the pancreatic head mass, the lifting of the bile duct and pancreatic duct and obstruction of the duodenum, but also in addition to the potential causes of pancreatic cancer. Pancreatoduodenectomy is great risk When the great mass of pancreatic head, but the partial head resection can be accomplished with relative safety.     

Indications and outcomes of surgical management of chronic pancreatitis: literature review

Surgical management of chronic pancreatitis remains a challenge for surgeons. Last decades, the improvement of knowledge regarding to pathophysiology of chronic pancreatitis, improved results of major pancreatic resections, and new diagnostic techniques in clinical practice resulted in significant changes in the surgical approach of this condition. Intractable pain, suspicion of malignancy, and involvement of adjacent organs are the main indications for surgery, while the improvement of patient's quality of life is the main purpose of surgical treatment. The surgical approach to chronic pancreatitis should be individualized based on pancreatic anatomy, pain characteristics, exocrine and endocrine function, and medical co-morbidity. The surgical treatment approach usually involves pancreatic duct drainage procedures and resectional procedures including longitudinal pancreatojejunostomy, pancreatoduodenectomy, pylorus-preserving pancreatoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum-preserving pancreatic head resection (Beger's procedure), and local resection of the pancreatic head with longitudinal pancreatojejunostomy (Frey's procedure). Recently, non-pancreatic and endoscopic management of pain have also been described (splancnicectomy). Surgical procedures provide long-term pain relief, improve the patients? quality of life with preservation of endocrine and exocrine pancreatic function, and are associated with low mortality and morbidity rates. However, new studies are needed to determine which procedure is safe and effective for the surgical management of patients with chronic pancreatitis.     

Pylorus preserving pancreatoduodenectomy: an overview

Pylorus preserving pancreatoduodenectomy (PPPD) was reintroduced 12 years ago. Since that time, over 400 patients have undergone PPPD with approximately 41 per cent having chronic pancreatitis and 54 per cent having pancreatic and other periampullary malignancies. Reported 5-year survivals in this latter group have been comparable to those achieved by the classic Whipple procedure. The postoperative mortality rate in 339 reported patients has been 3.8 per cent. Postoperative morbidity, including delayed gastric emptying, has been similar to that of the classic Whipple operation. However, PPPD has been associated with fewer late problems with dumping, diarrhoea, delayed gastric emptying (8.6 per cent), and marginal ulceration (3.6 per cent). Moreover, most patients undergoing PPPD have been able to return to their preoperative and preillness weight. The additional advantage of decreased operative time makes PPPD an attractive alternative to the classic pancreatoduodenectomy.     

RCAS1在胰腺癌诊断中的作用

目的 评价SiSo细胞表达的受体结合癌抗原(RCAS1)在胰腺癌诊断中的作用.方法 应用酶联免疫吸附分析法检测46例胰腺癌患者、18例慢性胰腺炎患者和20名健康人血清中RCAS1、CA19-9和CA242的含量.用ROC曲线法对检测结果进行分析.应用免疫组织化学染色法对32例胰腺癌、10例慢性胰腺炎以及6例正常胰腺组织切片进行染色,观察RCAS1在胰腺癌和正常胰腺组织中的表达情况.同时对结果进行统计学分析.结果 3种肿瘤标志物的水在胰腺癌组均高于慢性胰腺炎组和正常对照组,且差异均有统计学意义(P＜0.01).运用ROC曲线法对3种肿瘤标志物的检测结果进行处理.RCAS1、CA19-9和CA242的曲线下面积分别为0.826、0.804和0.737.分层分析表明,RCAS1和CA19-9在有梗阻性黄疸组高于无梗阻性黄疸组(P＜0.01),CA19-9在手术无法切除组高于手术可切除组(P＜0.01).胰腺癌组织中RCAS1表达的阳性率为87.5%,慢性胰腺炎组织为40.0%,两组差异有统计学意义(P＜0.05).结论 RCAS1在胰腺癌组织中高表达,作为血清肿瘤标志物对胰腺癌的综合诊断能力优于CA19-9和CA242,若同时联合检测CA19-9,则对提高胰腺癌早期诊断和术前可切除性评估准确率有一定的临床价值.     

胰头肿块型胰腺炎的诊断与治疗

胰头肿块型慢性胰腺炎从临床表现上很难与胰头癌相鉴别,影像学检查在肿块型慢性胰腺炎诊断中起重要作用,对于手术指征的掌握、胰头部肿块的可切除性、手术方式的选择以及手术困难程度的估计很有帮助.目前已将发生于胰头的肿块型慢性胰腺炎视为胰腺癌发生的癌前病变.胰头肿块型慢性胰腺炎的手术方式是直接针对胰头的,不同的手术方法包括:胰十二指肠切除术(保留或不保留幽门)和胰头部分切除(Beger手术)加胰管引流术(Frey手术).胰头肿块型慢性胰腺炎一旦诊断明确即应积极手术治疗,手术方式尽可能采用胰十二指肠切除术,因为它不仅切除了胰头肿块、解除了胆道和胰管及十二指肠的梗阻,而且也去除了胰头癌的潜在病因;若胰头肿块巨大胰十二指肠切除有极大风险,可考虑保留十二指肠的胰头切除术.     

The anatomy of the parapancreaticoduodenal vessels and the introduction of a new pylorus-preserving pancreatoduodenectomy with increased vessel preservation

Classical pancreaticoduodenectomy for malignant tumors of the pancreatoduodenal region or chronic pancreatitis has recently been discussed in terms of the quality of life, associated with long-term postoperative morbidity. Pylorus-preserving pancreatoduodenectomy (PPPD) for the patient with chronic pancreatitis was first reported by Traverso and Longmire. Since that time, PPPD has become an accepted surgical procedure that is being increasingly indicated for certain malignancies. Herein, we report a PPPD that also preserves the parapancreatoduodenal vessels. The reasons why PPPD with the preservation of these vessels is significant are related to the length of the preserved duodenum and the reactions of gastrointestinal hormones. However, it may appear that this new PPPD poses a little greater risk of cancer recurrence, since the surgery is less radical than the usual PD. If the indications listed below are strictly observed, this operation should enable. The indications are: (1) chronic pancreatitis with tumor formation in the pancreatic head, (2) ampullary carcinoma, (3) inferion biliary duct carcinoma, (4) early duodenal carcinoma (all without pancreatic invasion), and (5) certain benign cystic tumors. Whether this operation should also be recommended for patients with small carcinomas or islet cell tumors arising in the head of the pancreas is now being investigated.     

New techniques in the management of pancreatic pseudocysts

The results of an analysis on the mortality-morbidity data of 1698 operations performed for the treatment of chronic pancreatitis and/or its complications at the First Department of Surgery of Semmelweis University Medical School between 1975 and 1995 are presented herein. Special attention was focused on the effectiveness of such recently introduced techniques as posterior cystogastrostomy, cysto-Wirsungo gastrostomy, modified pylorus-preserving pancreatoduodenectomy, and blunt transparenchymal cystoduodenostomy. The posterior cystogastrostomy is technically easier to perform than the traditional Juras operation, as only the posterior ventricular wall needs to be cut open, and it can be combined with decompression-type operations. On the other hand, the cysto-Wirsungo gastrostomy achieves a long-lasting effect, and the cyst drainage in this operation ensures decompression. Moreover, if this operation is performed at an early stage, the progression of chronic pancreatitis is slowed down. The modified pylorus-preserving pancreatoduodenectomy eliminates the disadvantages of the Whipple operation and is a commonly performed operation for chronic pancreatitis localized within the head of the pancreas. However, since the introduction of the blunt transparenchymal cystoduodenostomy, the number of pancreatoduodenectomies has been reduced by 60%. This is an effective method with long-lasting results for the treatment of smaller cysts localized deeply in the head of the pancreas. The findings of this study strongly suggest that that these procedures give significantly better results for certain pathological conditions such as pancreatic pesudocysts than traditional methods.     

联合血管切除重建治疗胰头肿块型慢性胰腺炎

目的 探讨联合血管切除重建的胰头十二指肠切除术治疗胰头肿块型慢性胰腺炎的必要性和合理性.方法 回顾性分析我科自2000年1月～2006年3月收治胰头肿块患者13例,其中男10例,女3例,年龄37～71岁,平均51岁,行联合门静脉、肠系膜上静脉切除重建的胰头十二指肠切除术.结果 13例患者均经病理证实为慢性胰腺炎,术后无死亡病例,发生胃排空障碍1例,经保守治疗治愈;胰瘘1例,经引流、给予生长抑素等保守治疗治愈.随访19～86个月,13例患者疼痛症状均消失,至今未复发,黄疸均消退无复发.结论 对于胰头慢性炎症组织粘连周围血管,术中难以分离的病例,联合血管切除重建增加了切除率,手术安全,可大大提高患者的生活质量,且避免了遗漏炎症组织内癌灶而失去了治愈的机会.     

The surgical treatment of pancreatic carcinoma

This is a report on 501 pancreatic and periampullary cancers treated at the Mannheim Surgical Clinic during the past 11 years. Modern diagnostic measures (computerized axial tomography, endoscopic retrograde cholangiopancreatography, and angiography), while failing to detect the early operable tumors, have contributed to a rise in the rate of resectability of cancers of the pancreatic head (from 5% to 21%). Tactical problems of surgical treatment include the extent of resection required (total or partial), the rationale of preliminary biliary decompression, the symptomatic but unidentified mass in the head of the pancreas, and concomitant celiac artery stenosis. In 118 duodenopancreatectomies performed for cancer and 81 performed for severe and complicated chronic pancreatitis, the operative and hospital mortality rate was 2.5%. Of the 28 patients whose pancreatic resections for cancer occurred more than 5 years ago, 10 reached the 5-year survival limit.     

Early carcinoma in the periampullary region: Report of two cases

Two cases of early carcinoma in the periampullary region detected microscopically are reported. In Case 1, the carcinoma was found in part of an adenomatous polyp resected transduodenally. In Case 2, carcinoma was located within 1 cm from the main pancreatic duct hidden in the surrounding inflammatory tissue of the pancreatic head excised by radical pancreatoduodenectomy. Case 1 survived more than 3 years after the operation and Case 2 more than 5 years without any evidence of recurrence. The practical significance of such early carcinoma is discussed.     

Pyloric preservation with the Whipple procedure

The pylorus-preserving pancreatoduodenectomy simplifies resection, allows a satisfactory postoperative weight gain, prevents postgastrectomy symptoms, is followed by a low rate of jejunal ulceration, and can be performed with an extremely low postoperative mortality rate, providing that the pancreatic and biliary anastomoses are constructed so that no leakage occurs. Preliminary data indicate a satisfactory survival rate when this procedure is used for periampullary cancer, and reasonable relief of pain is achieved when the procedure is used in chronic pancreatitis.     

Operation nach Kausch-Whipple

The Kausch-Whipple operation is the standard procedure for resection of pancreatic head cancer, distal bile duct cancer, and periampullary cancers. It is also used for some cases of chronic pancreatitis. Traditionally, this operation is associated with high perioperative morbidity and mortality. The aim of our study was to present our current technique for Kausch-Whipple pancreaticoduodenectomy and to demonstrate that acceptable perioperative and long-term outcomes can be achieved by a standardised technique in a high-volume centre.     

Evaluation of positron emission tomography with 2-[18F]fluoro-2-deoxy-D-glucose for the differentiation of chronic pancreatitis and pancreatic cancer

BACKGROUND: The clinical presentation of patients with pancreatic cancer may resemble the clinical picture of chronic pancreatitis. A definitive preoperative diagnosis is not always obtained in patients with a history of chronic pancreatitis despite the use of modern imaging techniques. Operative strategy therefore remains unclear before operation in these patients. METHODS: Positron emission tomography (PET) with 2-[18F]fluoro-2-deoxy-D-glucose (FDG) was introduced recently into clinical oncology because of its ability to demonstrate metabolic changes associated with various disease processes. The impact of FDG-PET on the differentiation of chronic pancreatitis and pancreatic cancer was investigated. FDG-PET was performed in 48 patients with chronic pancreatitis (n = 12), acute pancreatitis (n = 3) and pancreatic cancer (n = 27), and in controls (n = 6). Histological examination was undertaken in all cases except controls. The FDG-PET results were obtained without knowledge of results of other imaging procedures. The results were then compared with those of computed tomography, ultrasonography, endoscopic retrograde cholangiopancreaticography, operative findings and histology. PET images were analysed semiquantitatively by calculating a standard uptake value (SUV) 90-120 min after application of the tracer. RESULTS: Cut-off values were validated as follows: SUV greater than 4.0 for pancreatic cancer, SUV of 3.0-4.0 for chronic pancreatitis, and SUV of less than 3.0 for controls. Sensitivity and specificity of PET imaging were 0.96 and 1.0 for pancreatic cancer, and 1.0 and 0.97 for chronic pancreatitis. In five cases only FDG-PET led to the correct preoperative diagnosis. CONCLUSION: The results give further evidence that FDG-PET is an important non-invasive method for the differentiation of chronic pancreatitis and pancreatic cancer. Delayed image acquisition in the glycolysis plateau phase permits improved diagnostic performance. This imaging technique is extremely helpful before operation in patients with an otherwise unclear pancreatic mass, despite its costs.     

Pancreatoduodenectomy with preservation of the pylorus and gastroduodenal artery.

OBJECTIVE: The authors evaluated the rationale for and feasibility of gastroduodenal artery preservation in pylorus-preserving pancreatoduodenectomy (PPPD) for periampullary cancer in which the pancreatic remnant maintains a normal function and morphologic characteristics. SUMMARY BACKGROUND DATA: Pylorus-preserving pancreatoduodenectomy has become one of the standard treatments used for benign and malignant diseases of the pancreatoduodenal region, surpassing ordinary pancreatoduodenectomy in terms of technical ease, mortality rate, and postoperative nutrition. Pylorus-preserving pancreatoduodenectomy is usually associated with gastroduodenal artery division, which presents potential risks of insufficient duodenal vascularity and lethal postoperative bleeding from the gastroduodenal artery stump. The latter complication particularly occurs after resection of bile duct or ampullary cancer in a patient whose pancreas remains functionally and morphologically normal to have much more pancreatic secretion than the fibrotic pancreas seen in pancreatic cancer. According to the authors data on the volume of secretion from the residual pancreas via a stent tube after pancreatoduodenectomy, the sclerotic pancreas, as seen in cancer of the pancreatic head, secrets only 20 to 50 mL/day, whereas the secretion from the soft pancreas, as seen in bile duct cancer, amounts to 300 to 600 mL/day, even during the period of nothing by mouth. METHODS: Retrospectively, we made a histopathologic study of eight specimens of distal bile duct and ampullary cancer resected by pancreatoduodenectomy or PPPD with gastroduodenal artery division. Prospectively, we performed gastroduodenal artery- preserving PPPD for 10 patients with distal bile duct, ampullary, and islet cell cancers. RESULTS: The histopathologic study revealed no invasion or metastasis around the gastroduodenal artery. Clinical application of gastroduodenal artery-preserving PPPD showed no technical difficulty, and neither severe complications nor recurrence around the gastroduodenal artery were observed for up to 22 months after surgery. CONCLUSIONS: Gastroduodenal artery- preserving PPPD might be recommended as a safe procedure for patients who have a functionally and morphologically normal pancreas.