Chinese expert consensus on minimally invasive radical surgery for pancreatic ductal adenocarcinoma (version 2022) / 中华外科杂志

Although there are still controversies over the efficiency and safety of minimally invasive radical surgery for pancreatic ductal adenocarcinoma (PDAC), most available studies have suggested a promising application of minimally invasive radical surgery. This consensus, referring to Chinese expert opinions and worldwide researches, aimed to discuss the related issues on minimally invasive radical surgery for PDAC to ensure the perioperative and oncological outcomes. Quality of evidence and strength of recommendations were evaluated based on the GRADE approach. The 15 recommendations covered 5 topics: oncological outcomes and patient safety of laparoscopic and robotic pancreatoduodenectomy, left-side pancreatectomy for PDAC, learning curve, safety of neoadjuvant therapy, and vascular resection in minimally invasive radical surgery for PDAC. This consensus gives reference and guidance to surgeons on the use of minimally invasive radical surgery for PDAC. Although this consensus is not sufficient to answer all the questions about minimally invasive radical surgery for PDAC, it represents the current consensus on the application of the techniques in the treatment of PDAC on the Chinese mainland.

Supervivencia a largo plazo luego de pancreatectomía por cáncer de páncreas / Long-term survival after pancreatic cancer surgery

Resumen El adenocarcinoma ductal de páncreas es una enfermedad agresiva asociada con pobres resultados de supervivencia a largo plazo. La resección quirúrgica y los nuevos tratamientos oncológicos pe rioperatorios han logrado mejorar la supervivencia de estos pacientes en la experiencia internacional. En este estudio retrospectivo se analiza la supervivencia global y la libre de enfermedad de todos los pacientes operados por cáncer de páncreas en el Hospital Italiano de Buenos Aires de enero 2010 a enero 2020. Se identificaron 242 pacientes con resecciones pancreáticas por adenocarcinoma de páncreas o carcinoma indiferenciado. La supervivencia global mediana fue de 22.8 meses (IC 95%: 19.5-29) y la tasa de supervivencia global a 1, 3 y 5 años fue de 72%, 32.5% y 20.8% respectivamente. La supervivencia libre de enfermedad mediana fue de 13.8 meses (IC 95%: 12-17.6) y la tasa de supervivencia libre de enfermedad a 1, 3 y 5 años fueron de 56.1%, 21.8% y 19.4% respectivamente. El grupo de pacientes que logró completar el tratamiento adyuvante mostró una mayor supervivencia global (p<0.0001).

Abstract Pancreatic cancer is an aggressive disease associated with poor results regarding long term survival. Surgical treatment along with new onco logic treatments have improved the survival of these patients in international experience reports. The aim of this study was to describe overall survival and disease-free survival after pancreatectomy for pancreatic ductal adenocarcinoma. A retrospective study of consecutive patients undergoing pancreatic resection due to PDAC or undifferentiated carcinoma from January 2010 to January 2020 in a single tertiary center was performed. Overall, 242 patients underwent complete pancreatic resections for pancreatic ductal adenocarcinoma or undifferentiated carcinoma. Median overall survival was 22.8 months (95% CI: 19.5-29) and survival at 1, 3 and 5 years were 72%, 32.5% and 20.8% respectively. The median disease-free survival was 13.8 months (95% CI: 12-17.6) and 1, 3- and 5-years disease-free survival were 56.1%, 21.8% and 19.4% respectively. The groups of patients that completed adjuvant treatment showed a better overall survival (p < 0.0001).

Whether early stage pancreatic ductal adenocarcinoma patients could benefit from the post-operation chemotherapy regimens: a SEER-based propensity score matching study / 浙江大学学报·医学版

To investigate whether chemotherapy could prolong the postoperative survival time in patients with early stages pancreatic ductal adenocarcinoma (PDAC). A total of 5280 stage ⅠA -ⅡB PDAC patients diagnosed from 2010 to 2015 were selected from surveillance，epidemiology，and end results (SEER) database. Propensity score matching (PSM) analysis was adopted to reduce the baseline differences between the groups. Univariate survival analysis was conducted with the Kaplan-Meier method. Multivariate survival analysis was performed with the Cox proportional hazards model. Univariate and multivariate survival analyses showed that age, differentiation, stage, chemotherapy were independent risk factors for the survival of PDAC patients. After PSM, it is found that adjuvant chemotherapy could prolong the median overall survival time (mOS) for stage ⅠB, ⅡA and ⅡB patients. However, for stage ⅠA patients, there were no significant differences in 3-year survival rate and mOS between patients with chemotherapy (=283) and without chemotherapy (=229) (57.4% vs 55.6%, vs all >0.05). Further analyses show that among 101 patients with well differentiated PDAC and 294 patients with moderately differentiated PDAC, there were no significant differences in survival rate and mOS between patients with and without chemotherapy (all >0.05). Among 117 patients with low-differentiated + undifferentiated PDAC, 3-year survival rate and mOS in patients with chemotherapy were significantly better than those without chemotherapy (48.5% vs 34.1%, vs all <0.05). Chemotherapy regimen used currently is not beneficial for patients with moderately and well differentiated stage ⅠA PDAC, but it is an independent prognostic factor for low-differentiated + undifferentiated PDAC patients.

Pancreatectomía corpo-caudal con resección en bloque de tronco celíaco: reporte de 2 casos / Corporal caudal pancreatectomy with celiac trunk block resection: report of 2 cases

INTRODUCCIÓN: El adenocarcinoma de cuerpo y cola de páncreas corresponde a cerca de un tercio del total de cánceres pancreáticos. Evoluciona en forma silenciosa hasta alcanzar estadios avanzados, llegando a comprometer muchas veces grandes vasos como tronco celíaco y sus ramas, y la arteria mesentérica superior. La resolución quirúrgica parece ser la única alternativa en estos casos. OBJETIVO: Presentar dos casos de adenocarcinoma de cuerpo y cola de páncreas tratados en nuestro hospital con pancreatectomía corpo-caudal y resección en bloque de tronco celíaco (procedimiento de Appleby modificado). DISCUSIÓN: Este procedimiento ha demostrado aumentar la sobrevida de estos pacientes, además de generar un alivio inmediato y duradero del dolor. Sin embargo, corresponde a una intervención con una alta morbilidad, siendo la fístula pancreática y la gastropatía isquémica las complicaciones más frecuentes. La evaluación del flujo de los vasos colaterales es un paso crítico para evitar las complicaciones isquémicas. CONCLUSIONES: La pancreatectomía corpo-caudal con resección en bloque de tronco celíaco, es una alternativa factible en adenocarcinoma de cuerpo y cola de páncreas localmente avanzado. Su indicación debe ser cuidadosa debido a que corresponde a un procedimiento con alta morbilidad.

INTRODUCTION: Adenocarcinoma of the body and tail of the pancreas corresponds to about one third of all pancreatic cancers. It evolves silently to reach advanced stages, often involving large vessels such as the celiac trunk and its branches, and the superior mesenteric artery. Surgical resolution seems to be the only alternative in these cases. AIM: To present two cases of adenocarcinoma of the body and tail of the pancreas treated in our hospital with distal pancreatectomy and celiac trunk en block resection (modified Appleby procedure). DISCUSSION: This procedure has been shown to increase the survival of these patients, in addition to generating immediate and lasting pain relief. However, it corresponds to an intervention with a high morbidity, being the pancreatic fistula and the ischemic gastropathy the most frequent complications. The evaluation of the flow of the collateral vessels is a critical step to avoid ischemic complications. CONCLUSIONS: Distal pancreatectomy with en bloc resection of the celiac trunk is a feasible alternative in locally advanced adenocarcinoma of the body and tail of the pancreas. Its indication must be careful since is a procedure with high morbidity.

Nimotuzumab y gemcitabina en el tratamiento del cáncer de páncreas y metástasis esplénica / Nimotuzumabe e gencitabina no tratamento do câncer de pâncreas e metástases esplênicas / Nimotuzumab and gemcitabine in the treatment of pancreatic cancer and splenic metastases

Se presentó un paciente masculino de 69 años con una colestasis extrahepática, pérdida de peso, astenia y anorexia, antecedentes de pancreatitis crónica, diabetes mellitus e hipertensión arterial, el cual fue diagnosticado con adenocarcinoma de páncreas con metástasis esplénica. Se le realizó colecistoyeyunostomía con yeyunoyeyunostomía por ser irresecable el tumor. Fue incluido en el ensayo clínico IIC RDEC166 y tratado con nimotuzumab y gemcitabina. En los estudios evolutivos no se apreciaron las imágenes metastásicas que se observaron antes del tratamiento lo que presupone la utilidad de estos fármacos para el control de éstas. No se encontraron referentes sobre el tema en la literatura nacional e internacional consultadas(AU)

A 69-year-old male patient presented with extrahepatic cholestasis, weight loss, asthenia and anorexia, a history of chronic pancreatitis, diabetes mellitus and arterial hypertension, who was diagnosed with adenocarcinoma of the pancreas with splenic metastases. A cholecystojejunostomy was performed with jejunum jejunostomy because the tumor was unresectable. It was included in the IIC RDEC166 clinical trial and treated with nimotuzumab and gemcitabine. In the evolutionary studies the metastatic images that were observed before the treatment were not appreciated, which presupposes the usefulness of these drugs for their control. No references on the subject were found in the national and international literature consulted(AU)

Paciente do sexo masculino, 69 anos, apresentou colestase extrahepática, perda de peso, astenia e anorexia, história de pancreatite crônica, diabetes mellitus e hipertensão arterial, diagnosticada com adenocarcinoma do pâncreas com metástases esplênicas. Uma colecistojejunostomia foi realizada com jejuno jejunostomia porque o tumor era irressecável. Foi incluído no ensaio clínico IIC RD-EC166 e tratado com nimotuzumab e gencitabina. Nos estudos evolutivos, as imagens metastáticas observadas antes do tratamento não foram apreciadas, o que pressupõe a utilidade desses medicamentos para seu controle. Não foram encontradas referências sobre o assunto na literatura nacional e internacional consultada(AU)

Manejo quirúrgico simultáneo de una paciente con cáncer de páncreas distal, tumores del estroma gastrointestinal (GIST) gástricos y hemangioma hepático / Simultaneous surgical management of a patient with distal pancreatic cancer, gastric gastrointestinal tumors (GIST) and hepatic hemangioma

Introduction: The occurrence of gastric Gastrointestinal Stromal Tumors (GIST) associated to pancreatic adenocarcinoma has been reported in 0.2 percent pancreatic cancers. There are no published reports on distal pancreatic adenocarcinoma associated to gastric antral GIST and the surgical management of this clinical condition. Case report: Herein, we discuss a 75 years-old female patient who was admitted to our institution with upper digestive hemorrhage. The endoscopy showed large, superficial erosions over the cardia and on the posterior wall of the antrum a rounded sub-mucosal non-eroded lesion suspected of gastric GIST. An abdominal computed tomography scan found a hepatic hemangioma on the left hepatic lobe. In the pancreatic distal body and tail a solid exophytic lesion was identified. In the gastric antrum a rounded submucosal tumor in close contact with the pancreatic lesion was found. The patient was subjected to distal pancreatectomy, splenectomy, and distal gastrectomy. The biopsy identified a well-differentiated ductal adenocarcinoma localized in the pancreatic tail and the proximal part of the body, resected with negative margins. The gastric tumor was positive for CD117, CD34, and DOG-1; it had a positive Ki67 in less than 2 percent, and 2 or less mitoses per 50 high-power fields. Conclusion. This uncommon case illustrates the occurrence of synchronous tumors of different cellular origins incidentally diagnosed and their simultaneous surgical treatment. The individual incidence of these tumors is low and if associated they probably will continue to be found incidentally.

Introducción: La ocurrencia simultánea de tumores del estroma gastrointestinal (GIST) del estómago con cáncer de páncreas, ha sido reportada en 0,2 por ciento. No existen reportes publicados sobre cáncer de páncreas distal asociado a GIST gástrico y el manejo de esta situación clínica. Caso clínico: Paciente de 75 años de edad, hospitalizada en nuestra institución por hemorragia digestiva alta. La endoscopía mostró erosiones superficiales sobre el cardias y en la pared posterior del antro una lesión submucosa redondeada no-ulcerada, sospechosa de un GIST. La tomografía abdominal demostró un hemangioma hepático en el lóbulo izquierdo, en la cola del páncreas se identificó una lesión sólida y en el antro gástrico se encontró un tumor redondeado en contacto con la lesión pancreática pero sin relación íntima con la misma. La paciente fue sometida a pancreatectomía distal, esplenectomía, gastrectomía distal y resección del hemangioma. La biopsia identificó en la cola y cuerpo distal del páncreas un adenocarcinoma ductal bien diferenciado con márgenes negativos. El GIST gástrico fue positivo para CD117, CD34 y DOG-1, el Ki67 fue positivo en menos de 2 por ciento y se identificaron 2 o menos mitosis por 50 campos de aumento mayor. Conclusión: Este caso ilustra la ocurrencia sincrónica de tres tumores de estirpes celulares diferentes diagnosticados incidentalmente y su tratamiento quirúrgico simultáneo. La incidencia individual de estos tumores en estas localizaciones es baja y su diagnóstico, seguramente, seguirá siendo incidental.

Neoplasias mucinosas papilares intraductales de páncreas en el Hospital Nacional Guillermo Almenara Irigoyen, Lima, Perú / Intraductal papillary mucinous neoplasms of the pancreas in Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru

Objetivo: Analizar en forma retrospectiva las características clínicas, radiológicas e histopatológicas, así como los resultados quirúrgicos de los pacientes con diagnóstico de neoplasia mucinosa papilar intraductal de páncreas (NMPI). Materiales y métodos: Usando la base de datos del servicio de Cirugía de Páncreas, Bazo y retroperitoneo del Hospital Nacional Guillermo Almenara Irigoyen (HNGAI) se identificaron a los pacientes con diagnóstico de NMPI sometidos a resección pancreática desde enero del 2006 a setiembre del 2013. Resultados: Se identificaron 11 pacientes (9 mujeres, 2 varones) con una edad promedio de 67,36 años. 2 casos fueron tipo conducto principal, 3 tipo rama y 6 tipo mixta. Todos los pacientes fueron sintomáticos, siendo el dolor el síntoma más frecuente, 27% presentaron pancreatitis. Para el diagnóstico 100% contaron con tomografía, 90% con resonancia magnética. En 10 pacientes se realizó una duodenopancreatectomía y en uno una pancreatectomía distal. Dos pacientes tuvieron fístula pancreática tipo C. Se reoperaron dos pacientes y hubo un fallecido. En 5 pacientes se observó displasia de bajo grado, en 2 displasia de moderado grado, en 1 displasia de alto grado y en 3 carcinoma invasor. Conclusiones: Esta patología está presente en nuestro medio, siendo más frecuente en mujeres. Las NMPI de tipo mixta son las de mayor frecuencia. La fístula pancreática es la complicación de mayor incidencia y la mortalidad es baja. El potencial de malignidad encontrado fue alto.

Objective: To analyze retrospectively the clinical, radiologic and pathologic features as well as the surgical results of the patients with diagnosis of intraductal papillary mucinous neoplasms of the pancreas (IPMN). Materials and methods: Patients with diagnosis of IPMN who underwent pancreatectomy were identified from January 2006 to September 2013, using the prospective data base of the Pancreas, Spleen and retroperitoneum HNGAI service. Results: A total of 11 patients were found (9 females and 2 males). The mean age was 67.36 years. 2 were main duct type IPMN, 3 branch type and 6 mixed type. All patients had symptoms. The pain was the most frequent symptom, 27% had pancreatitis. For the diagnosis 100% had CT scan, 90% MRI. 10 patients underwent pancreaticoduodenectomy and 1 distal pancreatectomy. 2 patients had type C pancreatic fistula. 2 patients underwent reoperation and 1 died. 5 patients had low grade dysplasia, 2 moderate dysplasia, 1 high grade dysplasia and 3 invasive carcinoma. Conclusions: This entity is present in our country being more common in women. The mixed type IPMN is the most frequent type. Complication with the highest incidence is the pancreatic fistula and the mortality rate is low. The IPMN´s malignancy potential founded was high.

Resultados actuales de la pancreatoduodenectomía para el tratamiento de los tumores periampulares y análisis de factores pronósticos de sobrevida / Results of pancreaticoduodenectomy in the treatment of periampullary tumors

Background: The diagnosis and treatment of periampullary tumors represents a challenge for current medicine. Aim: To review the results of pancreaticoduodenectomy (PDD) in the treatment of periampullary tumors and to identify risk factors that impact the long-term survival. Patients and Methods: We performed a retrospective study of patients who underwent a PDD for periampullary tumors between 1993 and 2009. We reviewed perioperative results and long term survival. We performed a multivariate analysis for long-term survival. Results: A PDD was performed in 181 patients aged 58 ± 12 years (98 females). Piloric preservation was done in 53 percent and a pancreatogastric anastomosis was used in 94 percent of cases. Morbidity was 62 percent and postoperative mortality was 5.5 percent. Pancreatic cancer was the most frequent pathological finding in 41 percent, followed by ampullary cancer in 28 percent and distal bile duct cancer in 16 percent. Median survival was 17 months, with a five years survival of 24 percent. Survival for ampullary tumors was 28 months with a five years survival of 32 percent. The median and five years survival were 14 months and 16 percent for bile duct cancer and 11 months and 14 percent for pancreatic cancer. Multivariate analysis identified tumor type (pancreas /bile duct) and lymph node dissemination as independent predictors of mortality. Conclusions: One quarter of patients experienced long term survival. Mortality predictors were tumor type and lymph node dissemination.

Neoplasia mucinosa intraductal del páncreas: [revisión] / Intraductal papillary mucinous neoplasm of the pancreas: [review]

Intraductal papillary mucinous neoplasm of the pancreas is characterized by a dilatation of the main pancreatic duct and/or secondary ducts, mucin production and the absence of ovarian ¡ike struma. The symptoms are non-specific and often the diagnosis is incidental. The treatment of choice is surgery, since these tumors may become malignant. The prognosis depends on the type of lesion, whether the excision is complete and lymph node involvement. The aim of this review is to analyze the clinical, diganostic, therapeutic and pathological characteristics of this disease.

Prótesis metálicas autoexpandibles en el manejo poliativo de la ictericia obstructiva maligna: experiencia local / Self-expandable metallic stents in the management of poliativo malignant obstructive jaundice: local experience

La ictericia obstructiva es una manifestación frecuente de las neoplasias que afectan la vía biliar. La obstrucción maligna del tracto biliar puede ser causada por Carcinoma ampular, Carcinoma Pancreático, Carcinoma del ducto biliar y Enfermedad metastásica. Estos tumores suelen tener mal pronóstico, de forma que una minoría son resecables en el momento del diagnóstico (10-20 por ciento) y, de ellos sólo una escasa proporción tienen expectativas de curación. Desde su primera descripción en el año 1979 las endoprótesis biliares se han tornado en un importante componente del manejo multimodal de este complejo problema clínico. Las prótesis biliares endoscópicas proveen pilación efectiva en estos pacientes, aliviando la ictericia y mejorando el estado nutricional y calidad de vida durante el tiempo restante de vida del paciente. Las prótesis metálicas autoexpandibles ofrecen un diámetro mayor que las plásticas y se asocian a una tasa de oclusión mas baja, eliminando la necesidad de recambio. En este trabajo presentamos nuestra experiencia en el tratamiento paliativo definitivo de la ictericia obstructiva maligna. Desde el 20-10-2000 hasta mayo del 2003, hemos colocado un total de 22 prótesis metálicas autoexpandibles en vía biliar. Un caso correspondió a una estenosis "benigna" del ducto hepático común que complicó una Cirugía de vesícula biliar. Los restantes 21 casos correspondieron a estenosis malignas siendo discriminadas de la siguiente manera: 12 casos de Tumores de cabeza de páncreas, 6 tumores del ducto biliar, 2 tumores de papila duodenal y un caso de infiltración de la pared coledociana por tumor de Vesicula biliar. El rango de edad de estos pacientes osciló entre 49 y 94 años con una edad promedio de 66 años. La sobrevida de estos pacientes ha oscilado entre 5 dìas y 2 años. No se presentaron complicaciones en el momento de la colocación de la prótesis. De los Tumores del ducto biliar, dos estaban localizados en la bifurcación.