Pancreatic Cancer Surgery at Ist Surgical Clinic of the Olomouc Faculty Hospital (FN Olomouc)

Česká verzia

Authors: M. Loveček; Č. Neoral; Dušan Klos ; P. Skalický ; J. Kysučan; R. Vrba; B. Melichar ¹; H. Švébišová ¹; Tozzi Di Angelo I. ²; M. Kliment ³; R. Havlík
Authors place of work: I. chirurgická klinika LF UP a FN Olomouc, přednosta: doc. MUDr. Č. Neoral, CSc. ; Onkologická klinika FN Olomouc ¹; II. interní klinika FN Olomouc ²; Centrum péče o zažívací trakt, Vítkovická nemocnice a. s., Ostrava-Vítkovice ³
Published in the journal: Rozhl. Chir., 2010, roč. 89, č. 12, s. 731-739.
Category: Monothematic special - Original

Summary

Introduction:
Surgical treatment plays a key role in the efforts to improve prognosis of patients with pancreatic cancer. The pancreatic cancer incidence rates are on increase and so does the number of patients undergoing potentially curative resection procedures. However, despite all diagnostic advancements and treatments adjusted to specific patientęs needs, the outcomes are not satisfactory enough. The aim of the surgical procedure is to radically remove the tumor, including the regional lymph nodes, to promote early and uncomplicated healing and to facilitate early initiation of oncological treatment.

Aim:
The aim of the study was to assess current potential of diagnostic and surgical treatment in pancreatic cancer when all currently available diagnostic methods are emloyed and to present the university clinic’s outcomes.

Methods and Patient group:
From 2006 to IX 2010, a total of 177 pancreatic resections and 123 right-sided pancreatoduodenectomies for malignant disorders were performed at the authors’ clinic. 76 pancreatoduodenectomies were performed for ductal carcinoma of the pancreatic head. The study group included 51 males and 25 females, the mean age of 62.9 years. Based on the TNM classification (UICC), 11% of the subjects presented with stage I, 78% with stage II and 3% with stage III diseases. The procedures radicality was the following: R0 in 59 subjects, R1 in 5 subjects while in 12 subjects, the radicality was undetected by the authors. Histopatological grading in this patient group was as follows: G1 in 20%, G2 in 34% and G3 in 46% of the subjects. Perineural invasion, invasion into lymphatic vessels or other vessels was not detected in 21 subjects (27.6%). The authors assessed complication rates based on the DeOliveira classification and survival rates in individual disease stages.

Outcomes:
Complications occurred in 44.7% of the operated subjects. Serious complications requiring reintervention were reported in 13 subjects (17.1%), including reinterventions in general anesthesia in 10 subjects (13.1%). Two patients died: a 79-year old female died from multiorgan failure as a result of aspiration, and a 76-year old male died from multiorgan failure following completion of pancreatectomy due to pancreaticojejunal anastomosis insufficiency. The thirty- and sixty-day mortality rate was 2.6%, however, it was null over the past three years. The mean survival time was 17.1 months, with the median of 13.5 months. The patient group’s overall 3-, 6-, 9-, 12, 15- and 18- month survival following radical resections was 95.6%, 90.3%, 76.3%, 62.7%, 52.3% and 45%, respectively. 82%, 52%, 35% and 35% of the operated stage I patients survived 1, 2, 3 and 4 years, respectively. The mean hospitalization duration was 16.8 days (10–45).

Conclusion:
Although the procedures are extremely demanding, especially in the reconstruction phase, the outcomes have improved significantly due to ongoing experience, improvements in the surgical technique and in the complex postoperative care. At specialized clinics, the mortality rate has dropped below 5%, the morbidity rate below 40% and the postoperative dehiscence rates below 10%. During the past three years, the authors’ clinic has reached null 30- and 60-day mortality rate following the pancreatic head resections, the complication rate following pancreaticoduodenal anastomosis is slightly above 5% (6.5%) and the morbidity rate is slightly above 40% (44.7%). The authors consider the procedure safe at their clinic and all indicated patients are expected to benefit from it.

Key words:
pancreatic cancer – radical resection – complications – survival

Zdroje

1. Zavoral, M., Ryska, M.: Karcinom slinivky břišní. Projekt IGA MZ, 8027-3 [online]. Dostupný na http://www.genomac.cz/cz/karcinom-slinivky-brisni.php

2. ÚZIS 2007, www.uzis.cz

3. Kollárová, H., Janoutová, G., Foretová, L., et al. Epidemiologie karcinomu pankreatu. Epidemiol. Mikrobiol. Imunol., 2007; 56, 38–43.

4. Kysučan, J., Loveček, M., Klos, D., et al. Přínos PET/CT v předoperačním stagingu karcinomu pankreatu. Rozhl. Chir., 2010, roč. 89, č. 7, 433–440.

5. Kalser, M. H., Barkin, J., MacIntyre, J. M. Pancreatic cancer. Assessment of prognosis by clinical presentation. Cancer, 1985; 56, 397.

6. Khorana, A. A., Fine, R. L. Pancreatic cancer and tromboembolic disease. Lancet Oncol., 2004; 5: 655.

7. Chari, S. T., Leibson, C. L., Rabe, K. G., et al. Probability of pancreatic cancer following diabetes: a population-based study. Gastroenterology, 2005; 129: 504.

8. Kliment, M., Urban, O., Cegan, M., et al. Endoscopic ultrasound-guided fine needle aspiration of pancreatic masses: the utility and impact on management of patiens. Scand. J. Gastroenterol., 2010 Jul 14 [Epub ahead of print].

9. Horton, K. M., Fishman, E. K. Multidetector row CT with dual-phase CT angiography in the preoperative evaluation of pancreatic cancer. Crit. Rev. Comput. Tomogr., 2002; 43: 323.

10. DeWitt, J., Deveraux, B., Chriswell, M., et al. Comparison of endoscopic ultrasonography and multidetector computed tomography for detecting and staging pancreatic cancer. Ann. Intern. Med., 2004; 141: 753.

11. Okamoto, K., Koyama, I., Miyazawa, M., et al. Preoperative 18[F]-fluorodeoxyglucose positron emission tomography/computed tomography predicts early recurrence after pancreatic cancer resection. Int. J. Oncol., 2010 Sep 23. [Epub ahead of print].

12. Zavoral, M. Karcinom pankreatu. Praha, Galén, 2005.

13. Gürlich, R., Oliverius, M., Lipár, K., et al. Výsledky jednoročního přežití u nemocných po resekci hlavy slinivky břišní s resekcí žil portomezenterické oblasti (PMO). Rozhl. Chir., 2009, roč. 88, č. 8, s. 417–421.

14. Fernandes del Castillo, C., Tanabe, K. K., Howell, D. A. Clinical manifestations, diagnosis and surgical staging of exocrine pancreatic cancer. UpToDate v. 18.1, January 2010.

15. DeOliveira, M. L., Winter, J. M., Schafer, M., et al. Assessment of complications after pancreatic Surgery. A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Annals of Surgery, 2006; 6: 931–939.

16. Michalski, Ch. W., Weitz, J., Buchler, M. W. Surgery insight: surgical management of pancreatic cancer. Natural clinical practice oncology, 2007; 9: 526–535.

17. Bassi, C., Dervenis, C., Butturini, G., et al. Postoperative pancreatic fistula: an international study group (ISGPF). Surgery, 2005; 138: 8–13.

18. Fernandes-del Castillo, C., Jimenez, R. E., Steer, M. L. Surgery in treatment of exocrine pancreatic cancer and prognosis. Up To Date v. 18.2. 2010, May.

19. Smeenk, H. G., Erdmann, J., van Dekken, H., et al. Long-term survival after radical resection for pancreatic head and ampullary cancer: a potential role for the EGF-R. Dig. Surg., 2007; 24: 38–45.

20. Sommerville, C. A., Limongelli, P., Pai, M., et al. Survival analysis after pancreatic resection for ampullary and pancreatic head carcinoma: an analysis of clinicopathological factors. J. Surg. Oncol., 2009; 100: 651–656.

21. Ouaissi, M., Hubert, C., Verhelst, R., et al. Vascular reconstruction during pancreatoduodenectomy for ductal adenocarcinoma of the pancreas improves resectability but does not achieve cure. World J. Surg., 2010; Jul 7. Epub ahead of print.

22. Hatzaras, I., George, N., Muscarella, P., et al. Predictors of survival in periampullary cancers following pancreaticoduodenectomy. Ann. Surg. Oncol., 2010; 17: 991–997.

23. Ryska, M., Strnad, R., Bělina, F., et al. Radikální resekce u nemocných s karcinomem hlavy pankreatu. Retrospektivní analýza přežívání u souboru 307 nemocných. Rozhl. Chir., 2007; 89, 432–439.

24. Friess, H., Uhl, W., Silva, J. C., et al. Preoperative laparoscopy: do we need it in patients with pancreatic malignancies? Am. J. Surg., 1998; 175: 172–178.

25. Gooszen, H. Carcinoma of the head of the pancreas: indication for emergency Surgery. Ned. Tijdschr. Geneeskd., 2010; 154: A2148.

26. Morganti, A. G., Massaccesi, M., LaTorre, G., et al. A Systematic Review of Resectability and Survival After Concurrent Chemoradiation in Primarily Unresectable Pancreatic Cancer. Ann. Surg. Oncol., 2010; 17: 194–205.

27. Al-Haddad, M., Eloubeidi, M. A. Interventional EUS for the diagnosis and treatment of locally advanced pancreatic cancer. JOP, 2010; 11: 1–7.

28. Gress, F. G., Howell, D. A., Travis, A. C., et al. The role of endoscopic ultrasound in the staging of pancreatic adenocarcinoma. Up to date vision 18. 1, January 2010.