Carcinoma of the head of the pancreas

BACKGROUND/AIMS: Extended radical surgery might provide a survival advantage for patients with carcinoma of the head of the pancreas. METHODOLOGY: Between January 1980 and December 1999, 144 patients with carcinoma of the head of the pancreas were treated in a community hospital setting, of whom 69 patients who underwent radical surgery were retrospectively reviewed. Surgical procedures included standard pancreaticoduodenectomy (27 patients), pylorus-preserving pancreaticoduodenectomy (27 patients), and total pancreatectomy (15 patients). Portal vein resection was performed for 15 patients. Retroperitoneal lymphadenectomy was performed for 35 patients. No patients received adjuvant chemotherapy or radiotherapy. RESULTS: The surgical resection rate was 47.9% with a surgical mortality rate of 4.3% during this period. The overall 5-year survival rate after radical surgery was 16.1% with a median survival of 12 months. Seven patients survived five years, making 16.3% of the patients available for a more than 5-year follow-up. Long-term survivors had less than two positive lymph nodes in the posterior pancreatic head. Fourteen of 15 patients undergoing portal vein resection died within 21 months. One patient having no portal vein invasion microscopically survived 27 months without recurrence. CONCLUSIONS: Extended radical surgery did not prolong survival for patients with carcinoma of the head of the pancreas.     

Pancreatic dissection in the procedure of pancreaticoduodenectomy (with videos)

The procedure of pancreaticoduodenectomy consists of three parts: resection, lymph node dissection, and reconstruction. A transection of the pancreas is commonly performed after a maneuver of the pancreatic head, exposing of the portal vein or lymph node dissection, and it should be confirmed as a safe method for pancreatic transection for decreasing the incidence of pancreatic fistula. However, there are only a few clinical trials with high levels of evidence for pancreatic surgery. In this report, we discuss the following issues: dissection of peripancreatic tissue, exposing the portal vein, pancreatic transection, dissection of the right hemicircle of the peri-superior mesenteric artery including plexus and lymph nodes, and dissection of the pancreatic parenchyma.     

Neuroendocrine carcinoma of the stomach with peripancreatic lymph node metastases successfully treated with pancreaticoduodenectomy

Neuroendocrine carcinoma of the stomach is an uncommon tumor, usually associated with highly malignant biological behavior and extremely poor prognosis. In this report, we described a case of advanced neuroendocrine carcinoma of the stomach with the peripancreatic lymph node metastases which was treated with pancreaticoduodenectomy with extended lymphadenectomy. The patient was admitted to our hospital for anemia. An upper gastrointestinal endoscopy revealed a 4x4-cm fungating tumor with its fundus locating mainly in the duodenal bulbus and extending to the gastric antrum, and tumor biopsy revealed the histological findings of adenocarcinoma. Computed tomography (CT) showed a large mass in the duodenal bulbus with regional lymph node metastases. The patient's disease was diagnosed as primary duodenal cancer with regional lymph node metastases preoperatively. During the operation, an obviously swollen lymph node on the anterior surface of the head of the pancreas 4.0 x 3.5 cm in size was found growing into the parenchyma of the pancreas head and could not be separated from the pancreas, and the swollen lymph node along the superior mesenteric vein was also hard and suspected to be a metastatic node. A pancreaticoduodenectomy with extended lymphadenectomy was performed to achieve a radical resection. Histopathologically, the origin of the primary tumor was considered as a gastric origin, and the tumor was composed of diffused small cells with a moderate mitotic index and occasional rosette formation. Immunohistochemical investigations of the neoplastic cells confirmed the tumor to be neuroendocrine carcinoma. The obvious swollen lymph node on the anterior surface of the head of the pancreas and the swollen lymph node along the superior mesenteric vein were also identified as metastatic lymph nodes. Adjuvant chemotherapy with TS-1 was administered on an out-patient basis 6 weeks after the operation. The patient is well and has now been free of symptoms of recurrence and metastasis for 8 months.     

Extended lymphadenectomy in cephalic pancreatoduodenectomy. Personal observations

BACKGROUND/AIMS: Long-term survival in patients with cancer of the pancreatic head is disappointing. Surgery is the only curative therapy. Unfortunately the prognosis of resected patients (10-15%) is extremely poor due to loco-regional cancer recurrence (50%). Lymphatic and perineural invasion may account for local recurrence. Japanese studies have reported the importance of an extended lymphadenectomy during the classic Whipple exeresis (40% of patients present lymph node metastases). METHODOLOGY: At the General Surgical Clinic of Pavia University 20 patients (14 men, 6 women, mean age 62.4 yr) with pancreatic head cancer (17 adenocarcinoma, 1 lymphoma, 2 carcinoma) underwent Whipple's exeresis with a regional (peripancreatic or R1) and juxta-regional (para-aortic or R2) lymphadenectomy according to the Ishikawa technique, between 1996-2000. R1 nodes consisted of lymph nodes at the pylorus, superior pancreatic head, common bile duct, anterior pancreaticoduodenal region, inferior pancreatic head and superior mesenteric vessels. R2 nodes consisted of lymph nodes at the superior and inferior pancreatic body, mid colic region, common hepatic duct, celiac axis and para-aortic region. RESULTS: The wide dissection was quite easy in patients with a serious cholestatic disease. Intraoperative mortality was 0%. Operative mortality was 5%. Postoperative complications (20%) consisted of 1 sepsis, 1 hepato-renal syndrome with hepatic coma, 1 intestinal obstruction by adhesive bands, and 1 wound infection. Eight patients (40%) died during a mean follow-up period of 6 months (neoplastic recurrence 50%). Notwithstanding the advanced disease (stage III 50%; N1+ 50%), 12 patients (60%) had a median postoperative survival rate of 18.4 months (range 1-48 months) without neoplastic recurrence. Tumor diameter was less than 4cm in 83.3% of cases. CONCLUSIONS: An earlier diagnosis (with tumor diameter <4 cm) can improve pancreatic head cancer prognosis. A wide surgical exeresis with R2 lymph nodes clearance together with surrounding connective and nervous tissue can remove micrometastases and better control local recurrence.     

Arterial and vena caval resections combined with pancreaticoduodenectomy in highly selected patients with periampullary malignancies

BACKGROUND/AIMS: To obtain a margin-negative resection and increase the indication for resection of periampullary malignancies, pancreaticoduodenectomy with a SM-PVR (superior mesenterico-portal vein resection) has been performed. However, an arterial resection, other vascular resections except SM-PVR (e.g., an inferior vena caval resection), or a metastatic tumor resection combined with pancreaticoduodenectomy has yet to be fully elucidated because of the high risk of postoperative complications and extremely poor long-term survival in patients undergoing these exceptional procedures. The present report focused on highly selected patients undergoing an arterial resection or a vena caval resection associated with pancreaticoduodenectomy. METHODOLOGY: Besides 31 patients with periampullary tumors undergoing pancreaticoduodenectomy associated with SM-PVR in our department, a group of 4 patients underwent arterial resections and another patient underwent pancreaticoduodenectomy combined with a resection of liver metastasis together with an inferior vena caval resection. These five patients were reported in the present study. RESULTS: A 27 year-old-woman presented pancreatic ductal adenocarcinoma of the pancreatic head and a liver metastasis in which involvements of the superior mesenterico-portal vein and the inferior vena cava were shown. Pancreaticoduodenectomy was performed with SM-PVR associated with a left hemihepatectomy combined with a segment 1 resection and an inferior vena caval resection. The patient did not present severe postoperative complications and experienced a good quality of life during 16 months after surgery. Four other patients underwent arterial resections. These arterial resections were performed only when a margin-negative resection was feasible. The superior mesenteric artery was resected and reconstructed with a Goretex graft in one patient. The right hepatic artery was resected and reconstructed with a saphenous graft in two patients. The other patient underwent a resection of the common hepatic artery and reconstruction was performed with the splenic artery. Three of the four patients presented postoperative complications but were conservatively treated. Two patients are still alive 25 months and 8 months after surgery. One patient died of sepsis 5 months after surgery, and the other died of cancer progression 19 months after surgery. CONCLUSIONS: The indication for retropancreatic arterial resection associated with pancreaticoduodenectomy should be carefully evaluated only when a margin-negative resection can be achieved. An appropriate bypass method of arterial reconstruction should be selected because a direct end-to-end anastomosis is not always feasible. Hepatectomy for metastases of pancreatic ductal carcinoma should be also regarded as an exceptional procedure.     

The posterior approach in pancreaticoduodenectomy: preliminary results

BACKGROUND/AIMS: We present our technical version of pancreaticoduodenectomy by posterior approach that enables a complete dissection of the right side of the mesenteric superior artery and of the portal vein, as well as a complete excision of the retroportal pancreatic process (or lamina), and report the preliminary outcomes of the first 10 selected patients. METHODOLOGY: Between 1 December 2005 and 1 March 2006 10 patients (7 males and 3 females) with a mean age of 60.6 years (range 45-81 years) were operated on using this technique. The patients were diagnosed with carcinoma of the pancreatic head (8 cases), ampullary carcinoma (1 case), and carcinoma of the distal part of the common bile duct (1 case). Invasion of the portal vein occurred in 2 of the 8 cases of carcinoma of the pancreatic head. RESULTS: No significant intraoperative incident was recorded. The mean operative time was 225 minutes (ranging between 180 and 240 minutes) and the mean blood loss was 372,25cc (range 150-800cc). Two cases of carcinoma of the pancreatic head that had a segmental resection of the portal vein needed vascular reconstruction which was performed by Goretex graft interpositing. The pylorus-preserving procedure was used in 2 cases (ampullary carcinoma, and carcinoma of the distal part of the common bile duct, respectively). Postoperative complications consisted of intraabdominal hemorrhage from an arterial source of the pancreatic capsule (on the day of the operation necessitating reoperation for hemostasis) in one case, and pancreatic fistula (that required conservative treatment) in another case. No postoperative diarrhea, delayed gastric emptying episodes or postoperative deaths were recorded. There were no postoperative deaths. The mean length of hospitalization was 12.2 days (range 10-24 days). CONCLUSIONS: The posterior approach in pancreaticoduodenectomy offers an early selection of patients during the operation (in terms of resectability). As compared to the standard procedure, it enables an adequate lymphadenectomy that can be safely performed (by early dissection and isolation of the superior mesenteric artery), and avoids possible intraoperative accidents secondary to anatomical arterial abnormalities. This approach is particularly recommended in cases with portal vein invasion because it allows a "no-touch" resection.     

Extended lymphadenectomy in hilar cholangiocarcinoma: What it will bring?

Lymph node dissection is always a hot issue in radical resection of hilar cholangiocarcinoma(HCCA). There are still controversies regarding whether some lymph nodes should be dissected, of which the para-aortic lymph nodes are the most controversial. This review synthesized findings in the literature using the Pub Med database of articles in the English language published between 1990 and 2019 on the effectiveness of extended lymphadenectomy including paraaortic lymph nodes dissection in radical resection of HCCA. Hepatobiliary surgeons have basically achieved a consensus that enough lymph nodes should be obtained to accurately stage HCCA. Only a very small number of studies have focused on the effectiveness of extended lymphadenectomy including para-aortic nodes dissection on HCCA. They reported that extended lymphadenectomy can bring some survival benefits for patients with potential para-aortic lymph node metastasis and more lymph nodes can be obtained to make the patient's tumor staging more accurate without increasing the related complications. Extended lymphadenectomy should not be adopted for HCCA patients with intraoperatively confirmed distant lymph node metastases. For these patients,radical resection combined with postoperative adjuvant chemotherapy seems to be a better choice. A prospective, multicenter, randomized, controlled clinical study of regional lymphotomy and extended lymphadenectomy in HCCA should be conducted to guide clinical practice. A standardized extended lymphadenectomy may help to more accurately stage HCCA. Future studies are required to further assess whether extended lymphadenectomy can improve long-term survival in negative celiac, superior mesenteric, and para-aortic lymph node diseases.     

Pancreatic carcinoma: reappraisal of surgical experiences in one Japanese university hospital

BACKGROUND/AIMS: Even with the recent advances of diagnostic and therapeutic modalities, the clinical course of patients with pancreatic cancer remains dismal. Five-year survivors are rare, cure is exceptional, and the operative mortality rate is significant. In this study, univariate and multivariate retrospective analyses were performed with regard to the prognostic parameters to clarify the problems in order to improve survival rates after surgical resection. METHODOLOGY: Clinical courses of 60 Japanese patients with pancreatic cancer who underwent surgical resection in one Japanese University Hospital were reviewed to scrutinize the influence of 22 prognostic (9 host-side, 5 operative and 8 tumor-side) factors. A special reference was made on intra-operative radiation therapy, portal vein resection, lymph node dissection around the aorta, and conventional pancreatoduodenectomy versus pylorus-preserving pancreatoduodenectomy in pancreatic head cancer. RESULTS: Univariate analysis showed that operation time, comprehensive stage, comprehensive curability, histopathologic grade of differentiation and histopathologic venous invasion were statistically significant factors. Multivariate Cox regression analysis regarding the 5 profound factors showed that histopathologic grade of differentiation and histopathologic venous invasion were independently significant factors. The 1- and 3-year survival rates of 18 patients with intra-operative radiation therapy were 56% and 39%, while those of 36 patients without intra-operative radiation therapy were 54% and 18%. The 1- and 3-year survival rates of 43 patients with PV0,1 were 58% and 28%, while those of 17 with PV2,3 were 50% and 10%. Three patients with PV2 in 1 and PV3 in 2 underwent a portal vein resection. Two of the 3 patients were dead from liver metastasis 3 and 5 months after a surgical resection of liver metastasis. The 1- and 3-year survival rates of 17 with radical lymph node dissection including the para-aortic area were 61% and 26%, while those of 27 without para-aortic lymph node dissection were 66% and 25%. Of the 17 patients, the para-aortic lymph node was metastasized in 1 patient. The 1- and 3-year survival rates of 31 with pancreatoduodenectomy were 53% and 18%, while the 1- and 3-year survival rates with pylorus preserving pancreatoduodenectomy were 68% and 28%, respectively. CONCLUSIONS: These findings suggest that the clinical outcome after surgical resection of pancreatic carcinoma depends on tumor-side factors not operative parameters or host-side parameters. The clinical course seems to rely upon the nature of pancreatic cancer not upon the operative procedure.     

Significance of para-aortic lymph node dissection in advanced gastric cancer.

BACKGROUND/AIMS: Since surgical results in advanced gastric cancer remain poor and para-aortic lymph node dissection may contribute to survival, it is useful to determine the significance of para-aortic lymph node dissection. METHODOLOGY: Para-aortic lymph node dissection was provisionally indicated for patients with invasion depth deeper than the subserosal layer. Clinicopathologic variables were retrospectively analyzed using univariate analysis and multivariate analysis to predict para-aortic lymph node metastasis. Similarly, they were analyzed using univariate analysis and the Cox's proportional hazards regression model to estimate the prognostic factor in 120 patients who underwent para-aortic lymph node dissection. Surgical results and post-operative complications were compared between para-aortic lymph node dissection and D2 dissection. RESULTS: Univariate analysis revealed that the mean diameter, the degree of lymph node metastasis, and the invasion depth were significant predictors of para-aortic lymph node metastasis. Multivariate analysis showed that n2 was the only independent predictive factor as to para-aortic lymph node metastasis. Univariate analysis revealed tumor site, tumor diameter, lymph node metastasis, number of positive lymph nodes, INF, and stage were significantly associated with 5-year survival. The Cox's proportional hazards regression model showed that the number of positive lymph nodes and the number of positive para-aortic lymph nodes were independent prognostic factors. Patients with < or = 10 positive lymph nodes in any stage or < or = 3 positive para-aortic lymph nodes in stage IVb had significantly better surgical results. Surgical results for patients who underwent para-aortic lymph node dissection with n2 or invasion depth deeper than the exposed serosa were significantly higher than those in D2. As to post-operative complications, pancreatic fistula and respiratory complications were significantly frequent after para-aortic lymph node dissection. CONCLUSIONS: n2 is helpful in predicting para-aortic lymph node metastasis. Whereas, post-operative morbidity such as pancreatic fistula and respiratory complications after para-aortic lymph node dissection were significantly higher, they were controllable. Para-aortic lymph node dissection should be indicated in advanced gastric cancer patients in which lymph node metastasis is over n2 or invasion depth is deeper than the exposed serosa. But the number of positive para-aortic lymph nodes must be less than three.     

Head dorsal pancreatectomy: An alternative to the pancreaticoduodenectomy for not enucleable benign or low-grade malignant lesions

BackgroundHead dorsal pancreatectomy (HDP) is a segmental pancreatic resection, conservative variant of total dorsal pancreatectomy, applied to preserve the functional pancreatic parenchyma as an alternative to pancreaticoduodenectomy in not enucleable benign or low-grade malignant lesions. The absences of biliary and gastrointestinal resection/reconstruction are the other advantages of the technique.MethodsWe reported a case of HDP performed in a female 39-year-old patient for a neuroendocrine tumour of the dorsal portion of the pancreatic head.ResultsThe superior mesenteric vein was dissected from the pancreatic neck. The pancreas was transected at the left margin of the superior mesenteric vein. After identification and mobilisation of gastroduodenal artery and the anterior superior pancreatico-duodenal artery, the head dorsal segment was dissected stepwise from the duodenal wall toward the common bile duct plane; the dissection of the pancreatic parenchyma was completed along the anterior surface of the common bile duct. An end-to-side duct-to-mucosa pancreaticojejunostomy was performed. The main pancreatic duct in the ventral segment on the dissection parenchymal surface was ligated. With the inclusion of this case, there are a total of 3 cases involving resection of the dorsal portion of the pancreatic head reported in the literature.ConclusionHDP seems to be technically feasible and safe for not enucleable benign or low-grade malignant neoplasms involving the dorsal pancreatic head. However, due to the singularity of the indications and the few cases reported in the literature, further studies are needed to validate the technique.     

Clinical and paraclinical identification by various imaging technics of congenital anomalies of the inferior vena cava (apropos of 4 cases)

Four cases of anomalies of the inferior vena cava (IVC) were studied by two noninvasive imaging techniques: real-time ultrasonography and computed tomography. These techniques were used alone in 1 case of left IVC to determine the diagnosis. The other 3 cases were studied initially by phlebography: left IVC with iliac phlebitis; double IVC, also with iliac phlebitis, and a special case in which it was not clear whether the diagnosis was agenesis of the IVC or postnatal caval thrombosis. The two patients with recent iliac vein thrombosis were treated by heparin, but the other two received no particular therapy. Concerning these 4 cases, the authors speak of the known complexity of embryogenesis of the IVC which accounts for the great diversity in its anomalies. Left and double IVC are among the most frequent anomalies along with periaortic venous rings and the ureter behind the IVC. These anomalies are most often asymptomatic, but an understanding of them is essential for correct interpretation of the results of different imaging techniques and for effective performance of surgical and medical acts concerning the IVC directly or indirectly. For diagnosis of IVC anomalies, iliac venacavography, when not performed initially, can in certain cases be replaced by routine noninvasive imaging techniques, to which may now be added magnetic resonance imaging.     

Surgery for carcinoma of the pancreas in Japan. Past, present, and future aspects

Pancreatic cancer surgery was first performed in Japan in the 1940s, although it was not until the 1970s that pancreatic resectional surgery became widely available. In the late 1970s, influenced by the application of regional pancreatectomy by Fortner and colleagues, several institutions in Japan introduced radical pancreatic cancer surgery. Aggressive strategies in pancreatic cancer surgery were approved in Japan in the 1980s. Japanese surgeons introduced additional modifications to pancreatic cancer surgery, including radical pancreatoduodenectomy with extended lymph node and connective tissue dissection and portal vein resection. However, it became clear that such extended operations impair the quality of life of the patient, even though the resectability of cancer increased to up to about 50%. Improvements to radical pancreatoduodenectomy were therefore introduced. Pylorus-preserving pancreatoduodenectomy with extended lymphadenectomy, connective tissue dissection, and portal vein resection is a Japanese modification to radical pancreatectomy that improves the quality of life of the patient and does not reduce the survival rate. Another modification applicable to low-grade malignancies is organ-preserving pancreatectomy, such as duodenum-preserving total pancreatic head resection, ventral pancreatectomy, and medial or segmental pancreatectomy. Although aggressive Japanese surgical strategies have provided important data, most studies have been retrospective. In the near future, Japanese surgeons will need to reevaluate their strategies in term of the importance of extended lymphadenectomy with connective tissue dissection and its influence on long-term survival of patients. Such reevaluation will require randomized controlled trials performed according to a detailed and strict protocol.     

影响胰头、壶腹部癌患者胰十二指肠切除术后生存的因素

目的分析影响胰头癌、壶腹部癌行胰十二指肠切除术的患者生存期的因素。方法收集1990年1月至2005年6月因胰头癌、壶腹部癌行胰十二指肠切除术的95例患者,有完整随访资料的68例纳入分析。观察的影响因素包括性别,年龄,术前黄疸、GPT、贫血,临床分期,原发肿瘤大小,淋巴结转移,住院期间输血量。Kaplan-Meier法计算累计生存率,单因素分析采用Logrank法,多因素分析采用COX回归模型。结果胰头癌1年、2年、3年生存率分别为37%,12%,12%;壶腹部癌1年、2年、3年生存率分别为60%,38%,31%。单因素分析提示,胰头癌患者的临床分期、肿瘤大小、淋巴结转移及输血量与预后有关(P<0.05);壶腹部癌患者的各观察指标与预后的关系无统计学意义。多因素分析提示输血是胰头癌的独立预后因素;壶腹部癌患者无明确的影响预后的独立因素。结论输血是影响胰头癌预后的独立因素,加强围手术期处理有助改善胰头癌患者的预后。     

胰腺腺泡细胞癌10例临床分析

目的 探讨胰腺腺泡细胞癌的组织学特点、生物学特征、治疗方法及预后.方法 回顾性分析1999至2008年间收治的10例胰腺腺泡细胞癌患者的临床特点、影像学改变、病理学特征、治疗经过及随访资料.结果 10例胰腺腺泡细胞癌患者中男9例,女1例,平均年龄(62±8)岁.CT检查示肿瘤位于胰腺钩突部1例,胰头7例,胰体尾2例;肿瘤大小平均为4.5 cm ×4.7 cm;7例胆总管和肝内胆管明显扩张、胰管扩张;2例侵犯肠系膜上静脉.行胰头十二指肠切除术8例,其中3例合并扩大淋巴结清扫术,2例合并门静脉切除置换;2例行胰体尾+脾切除.病理检查示瘤体平均4.0 cm×3.3cm×3.4 cm;镜下见5例胰头肿瘤侵犯十二指肠,2例侵犯肠系膜上静脉;7例肿瘤侵犯神经;6例淋巴结转移.随访9例,1例失访.术后存活3～51个月,平均存活18个月,均死于肿瘤复发和转移.结论 胰腺腺泡细胞癌是胰腺一个独立的高度恶性的类型,对放化疗可能都不敏感,其生物学特征有待进一步研究.     

Incidental detection of inferior vena caval dissection by intraoperative high frequency vascular duplex ultrasonography

Inferior vena caval (IVC) dissection has been rarely reported. This could be due to less susceptibility of the venous structure to dissect or under recognition of this entity. We first report a case of IVC dissection detected by high frequency surface ultrasonography following tumor thrombectomy of adrenal cortical carcinoma. This report described the value of intraoperative surface echocardiography and reviewed previous literatures with regard to IVC dissection.     

Mesopancreas:A boundless structure,namely the rationale for dissection of the paraaortic area in pancreaticoduodenectomy for pancreatic head carcinoma

This review highlights the rationale for dissection of the 16a2 and 16b1 paraaortic area during pancreaticoduodenectomy(PD)for carcinoma of the head of the pancreas.Recent advances in surgical anatomy of the mesopancreas indicate that the retropancreatic area is not a single entity with well defined boundaries but an anatomical site of embryological fusion of peritoneal layers,and that continuity exists between the neuro lymphovascular adipose tissues of the retropancreaticand paraaortic areas.Recent advances in surgical pathology and oncology indicate that,in pancreatic head carcinoma,the mesopancreatic resection margin is the primary site for R1 resection,and that epithelialmesenchymal transition-related processes involved in tumor progression may impact on the prevalence of R1 resection or local recurrence rates after R0 surgery.These concepts imply that mesopancreas resection during PD for pancreatic head carcinoma should be extended to the paraaortic area in order to maximize retropancreatic clearance and minimize the likelihood of an R1 resection or the persistence of residual tumor cells after R0 resection.In PD for pancreatic head carcinoma,the rationale for dissection of the paraaortic area is to control the spread of the tumor cells along the mesopancreatic resection margin,rather than to control or stage the nodal spread.Although mesopancreatic resection cannot be considered"complete"or"en bloc",it should be"extended as far as possible"or be"maximal",including dissection of16a2 and 16b1 paraaortic areas.     

Pancreatic head tumors with portal vein involvement: an alternative surgical approach.

BACKGROUND/AIMS: One of the determining factors for the unresectability of pancreatic head tumors is the involvement of the portal venous system. Recent reports show that the resection of tumors with portal vein involvement has similar results to lesions with same stage without portal vein invasion. The aim of this study is to present a technique that allows the resection of portal vein segments without the use of grafts and with a shorter period of intraoperative venous occlusion. METHODOLOGY: Fifteen patients with pancreatic head tumors and portal vein involvement were submitted to pancreaticoduodenectomy according to this technique. The main feature of the technique is starting the pancreatic dissection at the posterior aspect of the head of the pancreas. The superior mesenteric artery is completely dissected from the pancreatic tissues leaving the section of the pancreas and the resection of the portal vein to the last step. RESULTS: Portal vein flow occlusion did not exceed 10 minutes. There were no major postoperative complications or mortality. CONCLUSIONS: This maneuver allows an easier resection of the mobilized portal vein with a shorter period of venous clamping and reconstruction without the need of venous graft.     

Right pneumonectomy for T4 non-small cell lung cancer invading intrapericardial pulmonary vein in a patient with a right aortic arch

A 59 year-old man with a right-sided aortic arch who had a T4 right lung cancer invading the proximal superior pulmonary vein underwent an intrapericardial-pneumonectomy with partial left atrium resection and a radical lymphadenectomy. The presence of a right-sided aortic arch required particular attention during dissection of the lymph nodes. This is the first case of a right-pneumonectomy for T4-lung cancer in a patient with a right-sided aortic arch.     

Diagnosis and surgical treatment of pancreatic cancer

Despite sustained efforts, intensive research has not been proven successful to reveal risk factors, which relevantly influence early diagnostics or effective treatment of pancreatic carcinoma. Principally, it must be noted, that currently no ideal tumor marker exists for the (early) detection of pancreatic carcinoma. The most important imaging modalities are high-resolution computed tomography, abdominal ultrasound, and endosonography. Surgical procedures in therapy have become more and more standardised and lead to a decrease in morbidity and mortality on the one hand and to an increase in resectability on the other hand. Pylorus-preserving partial pancreaticoduodenectomy is the treatment of choice for a tumor of the pancreatic head, whereas resection of the left pancreas (including splenectomy) is the standard therapy for carcinomas of the pancreatic tail. In all cases, a local systematic lymphadenectomy is mandatory; hence the prognostic gain of an extended lymphadenectomy remains indeterminate. An infiltration of mesenteric and portal veins does not prevent respectability, as long as by venous resection an R0 status can be achieved. However arterial involvement in general excludes resection. Patients with marginally resectable or locally non-resectable tumors should be recruited into neoadjuvant radiochemotherapy trials since one third of these patients could be considered for potentially curative resection. However the majority of pancreatic cancer patients show locally unresectable or metastasized disease and therefore palliative treatment concepts are needed. Both, endoscopic or percutaneous stenting procedures and operative bypass surgery, are safe and reach high success rates.     

Pancreatic endocrine carcinoma presenting with gastric varices derived by left-sided portal hypertension: a case report

We herein report a 71-year-old man with pancreatic carcinoma presenting as gastric varices caused by an obstruction of the splenic vein compressed by the tumor, which also invaded the spleen, stomach, transverse colon, left kidney, and left adrenal gland. A complete resection of distal pancreatomy and lymph node dissection with splenenctomy, left adrenalectomy, left nephrectomy, and partial resection of transverse colon and stomach were performed. After the resection, the gastric varices completely disappeared without any interventional therapy. The gastric varices observed in this case were considered to be derived from left-sided portal hypertension secondary to splenic vein occlusion, which is an uncommon complication mostly associated with pancreatitis and pancreatic carcinoma. Now that 17 months have passed after his operation, the patient is alive and in satisfactory condition without any signs of recurrence.