Clinical efficacy of radical resection of pancreatic cancer after neoadjuvant conversion therapy / 中华消化外科杂志

Objective:To investigate the clinical efficacy of radical resection of pancreatic cancer after neoadjuvant conversion therapy.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 23 patients who underwent radical resection of pancreatic cancer after neoadjuvant conversion therapy in Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School from January 2019 to May 2022 were collected. There were 17 males and 6 females, aged 58(range, 33-73)years. After neoadjuvant conversion therapy, the three-dimensional (3D) visualization was used to evaluate and classify tumor vascular invasion, and surgical plan was planned and implemented. Observation indicators: (1) situations of neoadjuvant conversion therapy; (2) surgical situations; (3) postoperative histopathological examination; (4) postoperative recovery; (5) follow-up. Measurement data with normal distribution were represen-ted as Mean± SD, and measurement data with skewed distribution were represented as M(range) or M( Q1, Q3). Count data were described as absolute numbers. Results:(1) Situations of neoadjuvant conversion therapy. All 23 patients received the AG combination chemotherapy (albumin-paclitaxel+gemcitabine), including 14 patients combined with stereotactic body radiation therapy. Of the 23 patients, 22 cases achieved partial response, and 1 case showed stable disease. The CA19-9 of the 23 patients was 85.06(29.74,634.5)U/mL and 13.96(9.74,25.02)U/mL before and after neoadjuvant conversion therapy, respectively. (2) Surgical situations. According to the results of preoperative 3D visualization of tumor vascular invasion, 7 of the 23 patients were evaluated as arterial invasion, 8 cases were evaluated as venous invasion, 5 cases were evaluated as arterial and venous invasion, and there were 3 cases showing negative of vascular invasion. Of the 23 patients, 12 cases underwent pancreaticoduodenectomy, 4 cases underwent radical antegrade modular pancreatosplenectomy, 7 cases underwent total pancreaticoduodenectomy. For vascular reconstruction, there were 10 patients without vascular reconstruction, and there were 13 patients undergoing artificial vascular vein reconstruction. The operation time and volume of intraoperative blood loss of the 23 patients was (524±171)minutes and 1 000(400,1 600)mL, respectively. (3) Postoperative histopathological exami-nation. Results of postoperative histopathological examination in 23 patients showed that there were 2 cases with moderate-well differentiated tumor, 10 cases with moderate differentiated tumor, 7 cases with moderate-poorly differentiated tumor, 2 cases with poorly differentiated tumor, and 2 cases negative of tumor. The number of lymph node dissected in 23 patients was 16±7. There were 5 cases with lymph node metastasis and 18 cases without lymph node metastasis. There were 17 cases with nerve invasion and 6 cases without nerve invasion. All 23 patients were negative of vascular invasion. Of the 23 patients, there were 21 cases with R 0 resection and 2 cases with R 1 resection. For pathological TNM staging, there were 2 cases with 0 stage, 13 cases with Ⅰ stage, 7 cases with Ⅱ stage, and 1 case with Ⅳ stage. For postoperative pathological scoring, there were 2 cases achieved 0 point (complete pathological remission), 16 cases achieved 2 points (partial remission), and 5 cases achieved 3 points (no significant effect). (4) Postoperative recovery. The postoperative duration of hospital stay of 23 patients was 19(14,31)days. There were 17 of 23 patients underwent postoperative complications, including 11 cases with Clavien-Dindo Ⅱ stage complications, 3 cases with Clavien-Dindo Ⅲa stage complications, 1 case with Clavien-Dindo Ⅲb stage complication, 1 case with Clavien-Dindo Ⅳ stage complication, and 1 case with Clavien-Dindo Ⅴ stage complica-tion. (5) Follow-up. There were 22 patients underwent follow-up, with follow-up time as 12(9,23)months. There were 9 patients underwent postoperative recurrence and metastasis, with recurrence and metastasis time as 7.8(range, 6.0-12.0)months. During the follow-up, 15 of the 22 patients survived. Conclusion:Radical resection of pancreatic cancer after neoadjuvant conversion therapy is feasible.

Technical points of combined vascular rsection and reconstruction in radical hilar cholangiocarcinoma / 中华肝胆外科杂志

Hilar cholangiocarcinoma (HCCA) is a highly malignant tumor adjacent to liver tissue and the anatomical site of the hepatic portal, which easily invades the hepatic arteries and portal veins. Consequently, vascular resection and reconstruction are significant for the surgical treatment of HCCA, which are the key to improving the R 0 resection rate and long-term efficacy. The resection and reconstruction of hepatic hilar vessels, especially the hepatic arteries, have always been a challenge for surgeons. The purpose of this article is to discuss the surgical points of HCCA radical treatment combined with resection and reconstruction of portal vein and hepatic artery to help clinicians improve the R 0 resection rate of HCCA, thus improving the outcomes and prognosis of patients.

Clinical application of combined hepatic artery resection and reconstruction in surgical treatment for hilar cholangiocarcinoma / 中华外科杂志

Objective@#To clarify whether the surgical treatment for hilar cholangiocarcinoma combined with artery reconstruction is optimistic to the patients with hilar cholangiocarcinoma with hepatic artery invasion.@*Methods@#There were 384 patients who received treatment in the First Affiliated Hospital to Army Medical University from January 2008 to January 2016 analyzed retrospectively. There were 27 patients underwent palliative operation, 245 patients underwent radical operation, radical resection account for 63.8%. Patients were divided into four groups according to different operation method: routine radical resection group(n=174), portal vein reconstruction group (n=47), hepatic artery reconstruction group (n=24), palliative group(n=27). General information of patients who underwent radical operation treatment was analyzed by chi-square test and analysis of variance. The period of operation time, blood loss, the length of hospital stay and hospitalization expenses of the radical operation patients were analyzed by one-way ANOVA. Comparison among groups was analyzed by LSD-t test.@*Results@#The follow-up ended up in June first, 2016. Each of patients followed for 6 to 60 months, the median follow-up period was 24 months. 1-, 3-, and 5-year survival rates were 81.3%, 44.9% and 13.5% of routine radical operation group, and were 83.0%, 44.7% and 15.1% of portal vein reconstruction group, and were 70.8%, 27.7% and 6.9% of hepatic artery reconstruction group, respectively. And 1-, 3-, and 5-year survival rates of hepatic artery reconstruction group was lower than routine radical group and portal vein reconstruction group significantly (P<0.05). However, the rate of postoperative complications of the hepatic artery reconstruction group and the routine radical operation group and the portal vein reconstruction group were 62.5%(15/24), 55.3%(96/174) and 51.5%(24/47), respectively. There was no significant difference among them (P>0.05). The data shows that the ratio of lymphatic metastasis in hepatic artery reconstruction group (70.8%) is much higher than them in routine radical operation group (20.1%) and portal vein reconstruction group (19.1%) significantly (P<0.05). The presented data also indicate that hepatic artery resection prolongs survival time comparing with patients undergoing palliative therapy for hilar cholangiocarcinoma. Cox regression analysis indicate that hepatic artery resection and reconstruction is a protective factor compare with palliative therapy (RR=0.38, 95%CI: 0.22-0.67). The significant reason for shorter survival time is a positive correlation between hepatic artery invasion and lymph node metastasis.@*Conclusion@#Hepatic artery resection and reconstruction has beneficial impact on oncologic long-term outcome in patients with advanced stage hilar cholangiocarcinoma.

Clinical significance of combined vascular resection and reconstruction in pancreaticoduodenectomy for pancreatic cancer / 中华消化外科杂志

Objective To investigate the significance of combined vascular resection and reconstruction in surgery for pancreatic cancer.Methods The clinical data of 231 patients with pancreatic canccr who received pancreaticoduodenectomy at the Southwest Hospital from January 2006 to December 2011 were retrospectively analyzed.All the patients were divided into the combined vascular resection and reconstruction group (97patients) and non-vascular resection and reconstruction group (134 patients).Effects of operation,results of pathological examination,prognosis and lymph node metastasis on the prognosis of the patients in the 2 groups were compared.Two independent samples t test was used to analyze the measurement data,and the count data were analyzed using the chi-square test.The survival curve was drawn by the Kaplan-Meier method,and the survival was analyzed using the Log-rank test.Results The operation time and intraoperative volume of blood loss were (554 ± 136)minutes and (1110 ± 939)rnl in the combined vascular resection and reconstruction group,and (445 ±106)minutes and (623 ±349)ml in the non-vascular resection and reconstruction group,with significant difference between the 2 groups (t =6.552,4.873,P ＜ 0.05).The mortality,morbidity and positive rate of lymph node metastasis of were 8.2％ (8/97),20.6％ (20/97) and 32.0％ (31/97) in the combined vascular resection and reconstruction group and 3.0％ (4/134),8.2％ (11 / 134) and 16.4％ (22/134) in the non-vascular resection and reconstruction group.There was no significant difference in the mortality between the 2 groups (x2=3.164,P ＞ 0.05),while significant differences in the morbidity and positive rate of lymph node metastasis were detected between the 2 groups (x2 =7.458,7.687,P ＜ 0.05).A total of 223 patients were followed up till September 2012,53 patients were with lymph node metastasis,and their median survival time was 8.4 months (range,6.9-10.0 months) ; 170 patients were with negative lymph node metastasis,and their median survival time was 18.6 months (range,15.8-21.5 months),which was significantly longer than that of patients with positive lymph node metastasis (x2=17.045,P ＜ 0.05).Of the 53 patients with lymph node metastasis,31 were in the combined vascular resection and reconstruction group,and their median survival time was 8.5 months (range,6.3-10.7 months) ; 22 were in the non-vascular resection and reconstruction group,and their median survival time was 8.3 months (range,6.1-10.5 months),with no significant difference between the 2 groups (x2 =0.022,P ＞ 0.05).Of the 178 patients with negative lymph node metastasis,64 were in the combined vascular resection and reconstruction group,and their median survival time was 13.2 months (range,9.2-17.1 months) ; 106 were in the non-vascular resection and reconstruction group,and their median survival time was 21.7 months (range,18.1-25.3 months),with significant difference between the 2 groups (x2 =11.908,P ＜ 0.05).Conclusions Although pancreaticoduodenectomy combined with vascular resection and reconstruction increases the incidence of postoperative complications,it could achieve the complete removal of tumors without significantly increasing the mortality rate.For patients with lymph node metastasis,pancreaticoduodenectomy combined with vascular resection and reconstruction has no influence on the postoperative survival time,while it might have influence on the patients without lymph node metastasis.

Radical resection of pancreatic cancer combined with vascular resection and reconstruction / 中华消化外科杂志

Most of the pancreatic cancer was diagnosed at advanced stages and the resection rate was only 10％-20％.Vascular invasion was a common event in the pathogenesis of pancreatic cancer.However,in the traditional view,vascular invasion is a contraindication of pancreatic resection.With the development of surgical techniques and perioperative management,radical resection of pancreatic cancer with vascular resection and reconstruction was performed in some large centers.Preliminary results suggested that this procedure could increase the resection rate and 5-year survival to 26％-46％ and 20％ respectively,without increasing morbidity and mortality.Radical resection of pancreatic cancer with vascular resection and reconstruction was a safe and effective method for the surgical treatment of advanced pancreatic cancer,which should be performed by experienced pancreatic surgeons.