Analysis of Long-term Survivors after Pancreatoduodenectomy in the Patients with Pancreatic Cancer

PURPOSE: Pancreatic ductal adenocarcinoma is known to be very dismal. Although some publications reported marked improved survival data after surgical resection recently, many clinicians have pessimistic views on the treatment of pancreatic cancer. So we set the objectives of this study to evaluate the clinical results of pancreatoduodenectomy in pancreatic cancer and investigate what constitutes long term survival after pancreatoduodenectomy for pancreatic cancer. METHODS: We analyzed 286 patients with pancreatic head ductal adenocarcinoma hospitalized in Seoul National University Hospital between 1985 and 1995, retrospectively. We excluded the patients with cystic pancreatic tumor and solid pseudo-papillary tumor in this study. Of them, 67 patients received pancreatoduodenectomy. We re-reviewed the histologic specimens of resected cases and tried to find clinico- pathological features in long-term survivors after pancreatoduodenectomy. RESULTS: Median survival of total patients with pancreatic head cancer was 8 months. Significant survival difference could be found between resected cases (15 months) and non-resected cases (6 months) (p<0.001). Of the patients who underwent pancreatoduodenectomy, there were nine patients who survived more than three years. In the patients who underwent pancreatoduodenectomy, depth of invasion, lymph node metastasis, UICC stage, CEA level, adjuvant chemotherapy were the prognostic factors. After histologic re-review in the long-term survivors, there were only 4 typical ductal adenocarcinoma, and 2 cases of variant ductal adenocarcinoma (mucinous noncystic adenocarcinoma, undifferentiated adenocarcinoma), the others were re-diagnosed with bile duct cancer, papillary mucinous carcinoma, and pancreatoblastoma. When we excluded the patients with non ductal adenocarcinoma according to the pathologic review, the median survival of the patients with pancreatoduodenectomy (n=64) decreased (14 months). CONCLUSION: Only the 2% of all the pancreatic cancer and 11% of the resected cases could be considered as 'cure'. In the long-term survivors, there were various types of pathology associated with good prognosis, so typical ductal adenocarcinoma of pancreas would have poorer prognosis than expected. Careful pathologic review must be preceded in the analyzing the survival data.

Comparison of Pancreatic Function after Pylorus Preserving Pancreatoduodenectomy according to the Pancreatoenterostomy

BACKGROUND: Since the introduction of the Whipple procedure, it has been the standard treatment method for periampullary carcinomas. However, since the pancreatoduodenectomy has high operative morbidity and mortality, numerous modifications of the pancreatoduodenectomy have been developed to reduce the operative risk. Among the modifications of the pancreatoduodenectomy, the pancreatogastros tomy was developed to reduce pancreatic leakage, which is the most serious complication after a pancreatoduodenectomy. Many favorable data about the pancreatogastrostomy have been published recently. However, some surgeons are reluctant to do a pancreatogastrostomy for fear of early remnant pancreatic insufficiency due to reflux of gastric juice. For that reason, we compare the functional aspects of a pancreatoduodenectomy between a pancreatojejunostomy (P-J) and a pancreatogastrostomy (P-G). METHODS: We studied 35 patients who underwent a pylorus-preserving pancreatoduodenectomy (PPPD) with a diagnosis of a periampullary carcinoma (n=34) or pancreatitis (n=1) at Seoul National University Hospital between 1994 and 1997 and who lived without recurrence for over 1 year. The mean age was 57 year, and the sex ratio was 20:15. Among them, 20 patients received a pancreatojejunostomy; the others received a pancreatogastrostomy. To compare the two groups, we analyzed (1) general nutritional status, (2) gastrointestinal (GI) symptoms and pancreatic exocrine function by measuring fecal elastase, and (3) pancreatic endocrine function by using the oral glucose tolerance test (GTT). RESULTS: After a PPPD, the body weight was decreased in both groups compared to that of the preoperative healthy state, but there was no difference between two groups. Also, no statistical difference could be found in triceps skin-fold thickness and serum protein and albumin and postoperative gastrointestinal symptoms except steatorrhea. There were 4 mild and 15 severe pancreatic exocrine insufficiencies in P-J patients, but all P-G patients showed severe pancreatic insufficiency on the stool elastase test. Excluding preoperative diabetes patients, 44% (7/16) of the P-J patients had an abnormal GTT after the operation, but 75% (9/12) of the P-G patients had an abnormal GTT (p=0.114). CONCLUSION: Exocrine and endocrine pancreatic insufficiencies developed after a PPPD, but did not induce the general malnutrition. A P-G had more deterioration of the pancreatic function than a P-J did. Thus, we must consider the general nutritional status, as well as the risk of pancreatic leakage, in the determination of pancreatoenteric anastomosis.

Pancreatic Head Resection with Segmental Duodenectomy

PURPOSE: Duodenum-preserving resection of the head of the pancreas (DPRHP) requires meticulous dissection to preserve vascular circulation to the parapapillary area and has high risks for ischemia of these organs and associated complications. Pancreatic head resection with a segmental duodenectomy (PHRSD) is introduced to overcome technical difficulty and high risk. METHODS: A PHRSD was performed in 4 patients, one each with duodenal mucosa cancer, intraductal an papillary mucinous neoplasm of the pancreas, a villotubular adenoma of the papilla, and a serous cystadenoma of the pancreas. A bilateral subcostal incision was used for the laparotomy. By using Kocher's maneuver and dividing the adjacent ligament, we achieved full mobilization of the duodenum with the pancreas head, and confirmed a pathologic lesion. The superior pancreatiocoduodenal arteries were ligated and divided at the root with preservation of the gastroduodenal and the right gastroepiploic arteries. The anterior inferior pancreaticoduodenal artery was also preserved. The pancreatic head was resected using a 3- to 5-cm segmental duodenectomy at level 6 cm below the pyloric ring. After resection, reconstruction was performed using a pancreaticogastrostomy, duodenoduodenostomy, choledochoduodenostomy. RESULTS: No transfusions were required, and the mean operation time was 357 minutes. After this operation, no serious complications were developed. Minor pancreatic leakage developed in one case and was easily cured by conservative management. All patients were followed up without any clinical problems till now. CONCLUSION: A PHRSD can be recommended for the management of benign or low-grade malignant lesions of the pancreatic head and can also be used for the treatment of early cancer or polypoid lesions, which cannot be removed by using endoscopy, located in the duodenal second portion or the papilla.