Octreotide and postoperative pancreatic fistula after pancreaticoduodenectomy: What we know so far? A narrative review

Postoperative pancreatic fistula (POPF) is the most feared complication following pancreatic resection. Octreotide, a synthetic somatostatin analog, has been widely used by pancreatic surgeons worldwide after pancreatic resections, often as per surgeon抯 discretion, to prevent POPF especially in cases at high risk of developing POPF. We herein analyze the data available till date of the subject. A PubMed search with keywords 搒omatostatin OR octreotide OR somatostatin analogues AND postoperative pancreatic fistula� was made. Further filters were applied in the search 揅linical Trial, Meta?Analysis, Randomized Controlled Trial, Systematic Review, from 1990 � 2021,� and the 68 results thus obtained were analyzed and included in this narrative review. There is considerable heterogeneity among the studies assessing the role of octreotide in the prevention of POPF making data comparison difficult, and hence results remain inconclusive. Most of the earlier studies used different definitions of POPF and other complications; included patients with varied pancreatic pathologies such as cancer, chronic pancreatitis, and benign lesions; surgical techniques such as pancreaticoduodenectomy, distal pancreatectomy, and other procedures; use of somatostatin and its analogs such as octreotide, lanreotide, pasireotide, and vapreotide; varied surgeon and institutional volume; and so on. Besides, pancreatic surgery is per se a complex surgical procedure and has its own inherent biases related to patient and the pancreas itself affecting the overall outcome. Data indicate favorable role of newer somatostatin analogs, and further studies are urgently needed. The question about the efficacy of prophylactic octreotide to reduce POPF after pancreaticoduodenectomy remains open to debate

One hundred sixty pancreaticoduodenectomies for periampullary cancers in a growing-volume setting: a single-institution and a single-surgeon's experience

PURPOSE: Many studies have concluded that cancer patients may have better outcomes when their surgery is performed in high-volume centers, especially when the procedure is pancreaticoduodenectomy (PD). However, some studies concluded that experienced surgeons or incorporation of expertise from high-volume centers may achieve satisfactory outcomes after PD in low-volume centers. METHODS: I retrospectively collected and analyzed the outcomes of PD for periampullary cancers treated with curative intent in my center. RESULTS: From August 2, 2005 to December 10, 2018, 160 pancreatic resections were done with curative intent in my center. The number of operations per year was 1 in 2005 and gradually increased to 21 in 2018. Thirty-day mortality was 0, and 90-day mortality was 1 (0.6%). Morbidity was found in 65 cases (40.6%). The median follow-up period was 23.2 months and 5-year survival rates were 28.5% for pancreas head cancer, 48.2% for distal CBD cancer, and 72.6% for AOV cancer. I divided patients into 2 groups by the number of annual operations, which is more than 21 per 2 years. The 2 groups showed no differences in terms of morbidity and mortality. CONCLUSION: A well-trained low-volume surgeon may perform PD safely at a well-equipped low-volume center.

Clinical outcomes of biliary and duodenal self-expandable metal stent placements for palliative treatment in patients with periampullary cancer

BACKGROUND: Endoscopic self-expandable metal stent (SEMS) insertions for palliation of malignant biliary and duodenal obstructions have been revealed to be an effective treatment. We present our clinical experience with the use of SEMS for malignant biliary and duodenal obstructions caused by periampullary cancer. METHODS: We performed a retrospective review of all patients who underwent endoscopic biliary and duodenal SEMS insertion for palliation of malignant biliary and duodenal obstruction caused by periampullary cancer between July 2007 and October 2016. The patients received simultaneous or sequential endoscopic biliary stenting and duodenal stenting with COMVITM stents (partially covered; Taewoong, Seoul, Korea). RESULTS: The final diagnoses of our enrolled patients were 15 pancreas head cancer, and 3 distal common bile duct (CBD) cancer. The main stricture site in the duodenum was bulb (n = 4, 22.2%), 2nd portion (n = 9, 50.0%), and 3rd portion (n = 5, 27.8%). The technical success rates of CBD and duodenal stenting were 100% (18/18), and 100% (18/18), respectively. The clinical success rates of CBD and duodenal stenting were 100% (18/18), and 88.9% (16/18), respectively. Median actuarial stent patency for biliary and duodenal SEMS were 6.5 months (range, 1-2 months) and 4.5 months (range, 1-14 months), respectively. Three patients (16.7%) had recurrent biliary obstruction and all of them underwent percutaneous trans-hepatic biliary drainage (PTBD) with biliary SEMS reinsertion. Three other patients (16.7%, totally different from patients with CBD restenosis) had recurrent duodenal obstruction and all of them underwent upper gastrointestinal endoscopy with duodenal SEMS reinsertion. CONCLUSION: Endoscopic SEMS insertions for simultaneous palliation of malignant biliary and duodenal obstruction in patients with periampullary cancer may provide a safe, and less invasive alternative to surgical palliation with a successful clinical outcome.

Migration of a Biliary Self-Expanding Metal Stent into the Stomach after Stent Placement in a Patient with Periampullary Cancer / 대한소화기내시경학회지

Migration of a biliary self-expanding metallic stent (SEMS) may occur proximally or distally after placing a stent for the palliative treatment of patients with unresectable periampullary malignancy. However, migration of a biliary SEMS into the stomach has not yet reported in the English medical literature. Herein we report on a case of periampullary cancer for which a stent that was placed to treat this malady migrated into the stomach. A biliary SEMS had been placed in the distal common bile duct in an 82-year-old woman who was diagnosed with periampullary cancer. The abdominal CT and esophagogastroduodenoscopic findings disclosed that the biliary SEMS had migrated into the stomach and there was marked luminal narrowing of the second portion of the duodenum due to the enlarged periampullary tumor. The migrated stent was easily removed by using a polypectomy snare. We presume that the distally migrated SEMS might have moved into the stomach against the normal direction of peristaltic movement instead of migrating to the intestine because of the duodenal obstruction caused by the growing mass.

Role of Palliative Gastrojejunostomy for Unresectable Periampullary Carcinoma

PURPOSE: Most patients diagnosed with a periampullary carcinoma are defined as having an unresectable tumor. Therefore, the appropriate relief of the main symptoms such as obstructive jaundice, duodenal obstruction, and pain is of utmost importance to these patients. In these patients, a biliary bypass can improve the quality of life. However, there is some controversy regarding the efficacy of gastrojejunostomy for preventing a duodenal obstruction. This study, evaluated the effect of a palliative gastrojejunostomy and the quality of life in patients with an unresectable periampullary carcinoma. METHODS: Between January 2000 and December 2003, among a total of 46 patients with an unresectable periampullary carcinoma, 24 patients underwent a palliative gastrojejunostomy (Group I) and 22 patients underwent non surgical management (Group II). In these two groups the frequency of nausea and vomiting, serum protein and albumin levels, oral intake, and other metrics were carefully monitored. RESULTS: Of the 46 patients, there were no significant differences in terms of age, gender, TNM stage, and preoperative symptoms. The incidence of nausea and vomiting preoperatively were similar in both groups (43.8% and 40.5%, respectively, P=0.126). However, there were statistically significant differences at the three months after surgery (36.6%, 54.5%, P=0.033). The preoperative protein and albumin were similar in both groups (6.6 g/dl, 6.4 g/dl). On the other hand, protein and albumin levels 3 months after surgery were significantly different (5.9 g/dl, 5.2 g/dl, P=0.010). CONCLUSION: These results suggest a palliative gastrojejunostomy in patients with an unresectable periampullary cancer can reduce the symptoms related to a duodenal obstruction and might contribute to maintaining the patients' quality of life secondary to possible oral intake for a longer period postoperatively.

Expression of Hedgehog Proteins in Periampullary Cancer / 대한소화기학회지

BACKGROUND/AIMS: Hedgehog protein is an essential molecule for gastrointestinal tract development, and disruption of hedgehog signaling pathway is linked to some gastrointestinal tumorigenesis. Here, we performed hedgehog immunostaining in periampullary cancer to evaluate the differences according to the location type of cancer and the differentiation of adenocarcinoma. METHODS: We retrieved surgical specimens from 43 periampullary cancer patients (15 ampulla of Vater cancer, 12 distal common bile duct cancer, 13 pancreatic head cancer, and 3 combined ampulla of Vater/bile duct cancer). Immunohistochemical stain was performed in both normal and cancerous tissue portions of each case using Sonic hedgehog (H-160) rabbit polyclonal antibody. Immunohistochemical stain results were grouped into three groups according to the percentage of positive cytoplasmic stain in tumor volume (unstained: 50%). RESULTS: All of the normal tissue revealed negative immunohistochemical stain while cancerous tissue revealed positivity in 95.3% (41/43 cases). Strongly stained cases were more frequently seen in ampulla of Vater cancers (13/15) and in combined ampulla of Vater/bile duct cancers (3/3) than in distal common bile duct cancers (4/12) and in pancreatic head cancers (3/13) (p=0.002). In addition, strongly stained cases were more frequently seen in well-differentiated adenocarcinoma than the others (p<0.001). CONCLUSIONS: Most of the periampullary cancers show hedgehog protein expression. In addition, hedgehog protein immunostainings shows stronger expression in ampulla of Vater cancers and in well-differentiated adenocarcinoma.

Cyclooxygenase-2 Expression in Periampullary Cancer

PURPOSE: Cyclooxygenase-2 (COX-2) expression is up-regulated in several types of human cancers and it has been suggested that COX-2 is closely inked to carcinogenesis. The objectives of this study were to investigate COX-2 expression in periampullary cancer and to evaluate the association of the clinicopathological factors with its expression. METHODS: Thirty specimens which were resected from patients with periampullary cancers (13 pancreatic adenocarcinomas, 8 common bile duct cancers, 9 ampulla of vater cancers) were investigated by immunohistochemical staining using Anti COX-2 monoclonal Ab. The 30 specimens were divided into stain-positive and stain-negative groups. The correlation between COX-2 expression and the various clinicopathological factors including the tumor size, nodal metastasis, differentiation, perineural and vascular invasion, were studied. RESULTS: COX-2 was expressed in 69% of pancreatic adenocarcinomas, 100% of common bile duct cancers and 78% of ampulla of vater cancers. However there was no significant correlation between COX-2 expression and the clinicopathological factors. CONCLUSION: COX-2 is highly expressed in periampullary cancer. Even though there was no correlation with the clinicopathological factors, the utility of the COX-2 inhibitors in preventing or treating periampullary cancer remains undetermined but warronts further investigation.

Preoperative Biliary Drainage for Periampullary Cancer: A comparison between endoscopic drainage and percutaneous transhepatic drainage

PURPOSE: A preoperative biliary drainage procedure (endoscopic nasogastric biliary drainage, ENBD; endoscopic retrograde biliary drainage, ERBD; or percutaneous transhepatic biliary drainage, PTBD) is infrequently performed in periampullary cancer patients with obstructive jaundice. Among these different biliary drainage procedures, a safer and more informative procedure should be performed in the indicated cases. However, no comparative study has been done between the two biliary drainage methods (endoscopic vs. percutaneous). The aim of this study is to compare the clinical outcome of these two biliary drainage methods in periampullary cancer and to suggest guidelines for selecting the appropriate preoperative biliary drainage procedure. METHODS: Between January 1996 and June 2002, 25 patients underwent pancreaticoduodenectomy (Whipples' operation or pylorus preserving pancreaticoduodenectomy) after ENBD/ERBD (Group A) due to periampullary cancer. Twenty- five patients who ubderwent PTBD preoperatively were matched with Group A, according to age group, sex, diagnosis, and type of operation during the same period (Group B). RESULTS: There were no differences in operative time, intraoperative/postoperative transfusion, total/postoperative length of hospital stay, incidence of postoperative complication, TNM staging, or perineural/endovascular/endolymphatic invasion. However, the thickness of CBD wall (Group A: Group B=1.78+/-0.55 mm : 1.14+/-0.37 mm, P Group B, P<0.001) were significantly different between the two groups. CONCLUSION: Although a significant difference of clinical outcome between the two preoperative biliary drainage methods could not be identified in this study, the inflammation of operative field resulting from ENBD/ERBD is expected to cause surgical difficulties and ultimately affect postoperative complications.

Diagnositic and Prognoistic values of serum CEA and CA19-9 levels in Periampullary Cancer / 한국간담췌외과학회지

PURPOSE: The value of carcinoembryonic antigen(CEA) and carbohydrate antigen 19-9(CA19-9) in periampullary cancers have not been clearly established. Diagnostic and prognostic values of these two markers in resectable periampullary cancer were clarified in this study. METHODS: Preoperative serum levels of CEA and CA19-9, and clinicopathologic features were reviewed in 151 surgical patients with periampullary cancer who were admitted in department of General Surgery of Seoul National University Hospital from Feb. 1996 to Dec. 2000. Postoperative serum levels of these tumor markers were also reviewed. For comparison with benign disease, preoperative serum levels of these tumor markers in GB stone patients were reviewed. After resection, serial tumor markers had been followed up. Disease recurrence was confirmed by imaging study. RESULTS: The CA19-9 concentration was above the cut-off limit (37U/ml) in 60.8% and the CEA concentration was above the cut-off limit(5ng/ml) in 10.5% of the periampullary cancer. Preoperative serum CEA and CA19-9 did not demonstrate the TMN stage, pathologic differentiation and the tumor size. The difference between the survival curves of the preoperative serum CA19-9 level (cut-off 100U/ml) was highly significant (p<0.05) in ampullary cancer. After curative resection, the serum CEA and CA19-9 level were decreased below cut-off level (5ng/mg in CEA, 37U/ml in CA19-9) in 55.6% and 71.2% of total periampullary cancer patients respectively. The mean survival period of the group with normalized CA19-9 level after surgery was significantly longer than that of the group with persistent elevated serum CA19-9 level (52.18 vs 21month, p<0.005) in ampullary cancer. The recurrent sensitivities of the CA19-9 were 57%, 50%, 67% in ampullary cancer cancer, distal CBD cancer, pancreatic head cancer respectively. CONCLUSION: Serial check of serum levels of the CA19-9, CEA is useful in diagnosis and recurrence detection in periampullary cancer.

Gastrojejunostomy with Duodenal Partition for Unresectable Periampullary Cancer

PURPOSE: The most appropriate palliative treatment to relieve symptoms caused by extrahepatic biliary obstruction appears to be a surgically constructed double bypass. However, gastrojenunostomy may be a disease rather than an operation because the ingested food would take the duodenal route and reenter the stomach through the gastrojejunostomy. Therefore, there has been a renewed interest in the role of the duodenal partition for preventing this circulus vomitig. METHODS: A total of 97 patients were treated with palliative loop gastrojejunostomy due to unresectable periampullary cancer at Kangbuk Samsung Hospital between March 1998 and December 2000. Of the 56 patients of this group who underwent prophylactic gastrojejunostomy, 25 patients had both gastojejunostomy and duodenal partition (Group I) and 31 gastrojejunostomy alone (Group II). RESULTS: The postoperative in-hospital mortality rate was 0 percent and the morbidity rate was 5.4 percent. However, the morbidity rate associated with duodenal partition was 0 percent. Circulus vomiting was absent in patients who had a duodenal partition, although statistical analysis did not show this to be significant. The reason for the statistical insignificance of the result may be the relatively small sample size. CONCLUSION: Due to the ease and safety of the technique, the duodenal partition added to the loop gastrojejunostomy decreased circulus vomiting without prolonging the operative time or increasing the compication rates. This finding suggests that the duodenal partition should be liberally applied in prophylactic gastric bypass procedures.

The Prognostic Significance of Transfusion in Periampullary Cancer Following Pancreatoduodenectomy

PURPOSE: There are several reports that intraoperative transfusion may be a prognostic factor in periampullary cancer, but it is not conclusive. The purpose of this study is to clarify the prognostic significance of a transfusion following a pancreatoduodenectomy for periampullary cancers. METHODS: We analyzed 357 periampullary cancers from 1985 to 1997 (ampullary cancer: 130 cases; distal bile duct cancer: 141 cases; and pancreatic head cancer: 86 cases). Analytic variables for possible prognostic factors were various clinicopathologic factors combined with the presence of the perioperative transfusion. RESULTS: Of the overall 357 patients, 215 (60%) have received an intraoperative transfusion. The 5-year survival rate of the 130 ampullary cancer patients was 59%, and 76 cases (58%) underwent an intra operative 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, an intraoperative transfusion was an independent prognostic factor in ampullary cancer (relative risk: 2.174). In common bile duct cancer, the overall 5-year survival rate was 33%, and the 5-year survival rates of patients with (N=87) or without (N=54) a transfusion were 25% and 38% respectively, which showed a marginal statistical significance (p=0.0717). In 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. CONCLUSION: In the present study, intraoperative transfusion was an independent significant prognostic factor in ampullary cancer. Careful dissection to minimize intraoperative bleeding is mandatory in pancreatoduodenectomy for ampullary cancer.

Long Percutaneous Stent Insertion in Pancreatic Duct and Monitoring of Pancreaticojejunostomy Site Leakage in Periampullary Cancer Patients

BACKGROUND: Periampullary cancer is a relatively common malignancy, and its incidence is increasing. A pancreaticoduodenectomy is the procedure of choice in patients with periampullary cancer. However, leakage of the pancreaticojejunal anastomosis has been a major complication after a pancreaticoduodenectomy, with a frequently reported incidence of 5 percent to 25 percent. The ideal management of the pancreatic stump has not yet been determined. Thus we tried to find a safe and effective pancreatic stump management technique and to monitor the security of the pancreatic stump anastomosis by using the body fluid amylase level. PATIENTS AND METHODS: Forty six (46) consecutive patients who had undergone a pancreaticoduodenectomy, between January 1990 and January 1998, were evaluated retrospectively. Before June 1997, we did 36 pancreaticojejunostomies without long stent insertion into the pancreatic duct (group 2). After that, we did 10 P-Jstomies with long stent insertion (group 1). A long silicone stent was used for intubation of the anastomosis. Also the amount of pancreatic juice drainage from the long pancreatic duct tube was checked daily. We placed two Penrose drains and one Jackson-Pratt drain near the anastomosis. Patients were monitored for clinical evidence of a pancreatic fistula by evaluation of the amylase concentration in serum and the peritoneal drainage at postoperative day 7. The normal range of body fluid amylase was defined to be within five times of the normal serum amylase level. Cholangiography, which was obtained through a T-tube or a percutaneous transhepatic catheter, was performed on postoperative day 7 and was used to assess to leakage from or the obstruction at any of the three reconstructive anastomoses. RESULTS: In group 1, there was no leakage from the P-Jstomy site. The daily mean pancreatic juice amount and body fluid amylase level were 76.6 ml/day (range, 0.4-137.4 ml/day) and 147.4 U/L (range,44-323 U/L). In group 2, there were 4 cases of leakage at the P-Jstomy site (11.1%). CONCLUSION: An external long pancreatic duct stent insertion is an effective and safe method for management of a pancreatic remnant. We could check the amount of the daily pancreatic juice precisely. Effective decompression of the P-Jstomy was achieved by long stent insertion. We could monitor the security of the pancreatic stump anastomosis by the body fluid amylase level. We suggest that our method, which monitors the body fluid amylase level, is effective in early detection and treatment of P-Jstomy site leakage. The effort to find the best method for management of the pancreatic remnant should be continued.

Changes of Serum CEA and CA19-9 Levels According to the Serum Bilirubin Level in Periampullary Cancer Patients Whipple or pylorus preserving pancreatoduodenectomy versus a biliary bypass or a biliary drainage procedure

BACKGROUND: Periampullary cancer is a relatively common malignancy, and its incidence is increasing. Prognosis in these patients depends upon resection of the tumor because surgery is the only effective treatment for irradicating the disease. There has, therefore, been a renewed interest in the role of serological markers early diagnostic tools for periampullary cancer. The potential role of serological markers is not limited only to early detection, but may also be of assistance in the difficult clinical dilemma of differentiating periampullary cancer from other diseases. Furthermore, serological markers of periampullary cancer might be used in follow-up patients after treatment, particularly after surgical resection, in order to select those with minimal disease likely to respond better to adjuvant treatment and/or radiotherapy. METHODS: From March 1989 to May 1997, 54 patients were admitted to Sanggye Paik Hospital, InJe University, and had pathologically confirmed periampullary cancer. Of those, 28 patients underwent a biliary bypass or a drainage procedure [Group I], and the others received resection procedures (Whipple's operation or pylorus-preserving pancreatoduodenectomy)[Group II]. Preoperative and postoperative serum levels of bilirubin, carcinoembryonic antigen (CEA), and carbohydrate antigen 19-9(CA19-9) were measured in all patients. We evaluated the relation of the postoperative increase or decrease in those tumor markers to survival, and we discuss the usefulness of those markers as prognostic indicators in periampullary cancer. In this study, we focused on the changes in the CEA and the CA19-9 levels as function of the serum bilirubin concentration change. RESULTS: The bilirubin, CEA, and CA19-9 concentrations decreased significantly in Groups I and II after operation. The correlation between the decreases of the bilirubin and the CEA levels was statistically significant, but that between the bilirubin and CA19-9 had no statistical significance, in spite of the fact that the preoperative and the postoperative tumor marker concentrations had changed markedly. The reason for the statistical insignificance of the CA19-9 result may be the its relatively small sample size and the wide standard variation. The overall median and mean survival time of Group I were 4 months and 11 months, respectively, and those of Group II were 17 months and 21 months. CONCLUSION: We found that the serum the CEA and the CA19-9 levels could be used as a useful prognostic indicator change according to the serum bilirubin concentration even after a biliary drainage procedure and a biliary bypass. We conclude that various biliary bypass and drainage procedures can be effective treatments in periampullary cancer. However, because it is thought that many tumor markers are greatly affected by hyperbilirubinemia, liver dysfunction or cholestasis, further studies of the exact mechanism for the decrease or the increase in the tumor marker level as a function of the serum bilirubin concentration are mandatory. Precise information obtained by using multivariate analysis of large samples is essential for more accurate evaluation.

Clinical Significance of Serum CEA, CA19-9, and CA125 Level Changes in Periampullary Cancer

Numerous tumor markers have been investigated and have been in clinical use for the management of cancer patients. Among them, carcimoembryonic antigen(CEA), CA19-9, and CA125 are the most commonly used tumor markers in periampullary cancer. We carried out this study to estimate the usefulness of these three tumor markers in the management of periampullary cancer. The serum levels of CEA, CA19-9, and CA125 were measured in 55 patients between Jan. 1990 and Feb. 1997. We also valuated the changes in the levels of these three tumor markers after surgery. The serum level of CEA was elevated in 30 patients(60%) preoperatively. The serum level of CA19-9 was elevated in 38 patients(83%), and the serum CA125 level was elevated in 13 patients(59%) preoperatively. The CA19-9 levels decreased in 20(95%) of 21 patients who had received a tumor resection, while only one of those patients had an elevated level of serum CA19-9 postoperatively. Similarly, the CEA levels decreased in 23(88%) of 26 patients who had received a tumor resection. The mean level of CA19-9 has higher in advanced stages than in early stages, but this difference was not statistically significant. In conclusion, there was no single reliable tumor marker in periampullary cancer. However, CA19-9 was the most sensitive tumor marker among the three.

Clinical analysis of periampullary cancer / 한국간담췌외과학회지

BACKGROUND: Periampullary cancer is referred to malignant tumor that occurs in pancreatic head, distal common bile duct, ampulla of Vater and duodenum according to anatomical position and poor prognosio he clinical symptoms, diagnosis and treatments are identical to positional characteristics. Since 1935, after Whipple originally described the removal of periampullary tumors, both the surgical method and the outcome associated with it have changed extensively. The mortality and morbidity rates associated with the procedure as performed today have decreased. (Objective) The authors evaluated the incidence, resectability and the clinical outcome of periampullary cancer. PATIENTS AND METHODS: We performed the clinical analysis retrospectively on 124 cases of periampullary cancer in the Department of Surgery and Internal medicine, School of Medicine, Wonkwang University from Oct. 1986 to July 1996. RESULTS: There were 77 men and 47 women and the male to female ratio was 1.64:1. The prevalent ages were in the 7th decade (44.4%), and 8th decade (27.4%). Fifty-four pancreatic head carcinomas(43.4%), 40 distal common bile duct carcinomas(32.3%), 28 Ampulla of Vater carcinomas( 22.6%), and 2 carcinomas of the periampullary duodenum(1.6%) were found. The major clinical symptoms and signs were abdominal pain (71%), jaundice (60.5%), and weight loss(33.1%). Resectability of pancreatic head cancer, distal common bile duct cancer, and ampulla of Vater cancer were 44.4%, 72.5%, and 85.7%, respectively. The mean resectability rate was 63.7%. The resection was performed in 60 cases ; Pylorus-preserving pancreaticoduodenectomy (29 cases), Whipple's operation (28 cases), total pancreatectomy (3 cases). The palliative procedure was performed in 14 cases ; gastrojejunostomy (6 cases), choledochotomy with T-tube drainage (5 cases), explolaparotomy with biopsy (4 cases). Postoperative mortality in resection surgery was 8.3%. Postoperative complication in resection surgery was 36.7%. The major causes of postoperative complications were wound complication( 16.7%) and respiratory complication(5.0%). The 1- year and 3-year survival rates after the resection were 47.1% and 22.0%, but those of nonresection group were 15.4% and 0%. The survival rate of resection group was significantly better than that of nonresection group (p<0.05). In the nonresection group, the 1-year survival rate in conservative treatment group including interventional procedure was 8.7% and 0% in palliative surgery group. Survival of nonoperable group was significantly better than that of palliative surgery group (p<0.05). According to anatomical tumor site, the 1-year and 3-year survival rates of pancreatic head cancer were 23.1%, 11.8%, and those of distal common bile duct cancer were 34.2%, 6.5%, and Ampulla of vater cancer 63.0%, 27.0%, respectively. SUMMARY: The pancreas head is the most common site of periampullary cancer. Survival of resection group and conservative treatment group is better than that of nonresection group and palliative surgery group, respectively.

Perimpullary Carcinoma: A Study on Prognostic Factors Influencing long Term Survival After Pancreaticoduodenectomy

From November 1987 to December 1995, 76 patients with periampullary cancer underwent resectional surgery in the department of surgery, Kosin medical college. The object of this study was to assess the prognostic factors of the periampullary cancer after pancreaticoduodenectomy. The postoperative mortality rate was 11.8%. Significant morbidity occurred in 39.5% of the patients, early reoperation was required in 9.2% of these patients, and the mean hospital stay was 21.7 days. Univariate analysis on all patients revealed that the survival rate was significantly related to the size of the tumor (> or =3.0 cm 13%, 50 20.5%, 0.05). These results indicated that patients with a tumor size lesser than 3cm, without lymph node involvement, and under the age of 50 had a long term survival rate.

Surgical treatment of periampullary cancer: Review of 766 surgical experiences of 8 hospitals

The incidence of periampullary cancer has been steadily rising in Korea. In the present study, we have reviewed 766 cases of surgically treated periampullary cancers, including 122 cases of our own, which were published in the Korean literature from 1984 to 1992. The 6th decade was the most prevalent age group, occupying 38% of the patients. The ratio of male of female was 1.7 to 1. Approximately 60% of lesion located at the head of the pancreas. Computed tomography which had 85% sensitivity was the most commonly employed modality for a diagnosis. The diagnostic sensitivity of percutaneous transhepatic cholangiography was 72%, of endoscopic retrograde cholangiopancreatography was 71%, and of ultrasonography was 54% in order of frequency. Tumor markers such as CA-19, CEA, and CA-125 were also studied in pancreatic cancer. The combinations of these markers recorded a higher positivity than using solely. The resection rate for lesions at the head of the pancreas was 21%, and that of distal common bile duct, ampulla of vater, and duodenum were 37%, 85%, and 50%, respectively. The morbidity and mortality rates after pancreatoduodenectomy were 44% and 12%, respectively. TNM staging revealed 66% of patients were in stage III, 26% in stage I, and 8% in stage II. The actual 5-year survival rates for cancer of the head of the pancreas was 11%, and that of duodenal cancer, distal choledochal cancer, and ampullary cancer were 21%, 18%, and 15%, respectively. In nonresected group, none survived over 18 months after treatment. Relatively high portion of lymph node metastatic patients may explain the poor survival observed in our series.