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Current state of surgical management of pancreatic cancer.

Hackert T, Büchler MW, Werner J - Cancers (Basel) (2011)

Bottom Line: Pancreatic surgery is a technically challenging procedure and has significantly changed during the past decades with regard to technical aspects as well as perioperative care.Furthermore, there is growing evidence that also more extended resections including multivisceral approaches, vessel reconstructions or surgery for tumor recurrence can be carried out safely with favorable outcomes.The impact of adjuvant treatment, especially chemotherapy, has increased dramatically within recent years, leading to significantly improved postoperative survival, making pancreatic cancer therapy an interdisciplinary approach to achieve best results.

View Article: PubMed Central - PubMed

Affiliation: Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany. thilo_hackert@med.uni-heidelberg.de.

ABSTRACT
Pancreatic cancer is still associated with a poor prognosis and remains-as the fourth leading cause of cancer related mortality-a therapeutic challenge. Overall long-term survival is about 1-5%, and in only 10-20% of pancreatic cancer patients is potentially curative surgery possible, increasing five-year survival rates to approximately 20-25%. Pancreatic surgery is a technically challenging procedure and has significantly changed during the past decades with regard to technical aspects as well as perioperative care. Standardized resections can be carried out with low morbidity and mortality below 5% in high volume institutions. Furthermore, there is growing evidence that also more extended resections including multivisceral approaches, vessel reconstructions or surgery for tumor recurrence can be carried out safely with favorable outcomes. The impact of adjuvant treatment, especially chemotherapy, has increased dramatically within recent years, leading to significantly improved postoperative survival, making pancreatic cancer therapy an interdisciplinary approach to achieve best results.

No MeSH data available.


Related in: MedlinePlus

Pylorus-preserving (left) and classical (right) pancreatico-duodenectomy. End-to-side pancreatico-jejunostomy (1), end-to-side hepato-jejunostomy (2) and end-to-side duodeno- or gastro-jejunostomy (3), respectively.
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f1-cancers-03-01253: Pylorus-preserving (left) and classical (right) pancreatico-duodenectomy. End-to-side pancreatico-jejunostomy (1), end-to-side hepato-jejunostomy (2) and end-to-side duodeno- or gastro-jejunostomy (3), respectively.

Mentions: Partial pancreatico-duodenectomy with resection of the distal stomach (Whipple resection) is the historical standard procedure for tumors of the pancreatic head. During the last two decades, preservation of the pylorus has been widely accepted, as proven to be equally effective compared to the classical pancreatico-duodenectomy with regard to tumor recurrence and long-term survival [11], Figure 1. A recent meta-analysis has confirmed these findings and, furthermore, has shown that preservation of the pylorus shortens operation time and reduces blood loss [12], Table 1. Therefore, the classical Whipple procedure should only be performed in situations where tumor spread towards the stomach cannot be ruled out, lymph node metastases are suspected in this area or distal stomach perfusion is critical, e.g., due to dissection of venous vessels. A crucial step during reconstruction after partial pancreatico-duodenectomy is the creation of the pancreatic anastomosis. A large number of variations including pancreatico-gastrostomy and pancreatico-jejunostomy with or without internal stent placement have been introduced and are currently used worldwide. The most important aspect of this anastomosis is technical standardization to achieve low fistula rates and avoid further consequent complications. The consensus paper of the International Study Group Pancreatic Fistula in 2005 [13] has defined postoperative fistula as drainage fluid on or after day 3 postoperatively with an amylase content of at least three-times that of serum amylase activity. The additional clinical grading of A-C reflects the severity and potential danger for the patient and makes study results on various anastomosis techniques comparable in a standardized way [14,15]. Surgical techniques with low fistula rates such as the binding anastomosis [16] or the duct-to-mucosa suture with internal stenting [17] have been reported and are currently used. Regardless which kind of anastomosis is performed, insufficiency rates of less than 3.5% should be achieved [18]. Bile-duct reconstruction should be standardized as well to avoid insufficiency and postoperative bile collection. Leakages of the hepatico-jejunostomy occur less frequent than pancreatic fistulas, but can also cause severe and long-lasting complications. The end-to side duodeno-jejunostomy or gastro-jejunostomy completes the reconstruction. Several studies and a current metaanalysis have shown that antecolic reconstruction should be preferred to avoid delayed gastric emptying [19,20]. This observation can be explained by the interposition of omental tissue and the transverse colon between the pancreatic anastomosis and the stomach which protects the anastomosis from any inflammatory or chemical irritation by the pancreatic anastomosis which may cause gastric dysfunction and emptying delay.


Current state of surgical management of pancreatic cancer.

Hackert T, Büchler MW, Werner J - Cancers (Basel) (2011)

Pylorus-preserving (left) and classical (right) pancreatico-duodenectomy. End-to-side pancreatico-jejunostomy (1), end-to-side hepato-jejunostomy (2) and end-to-side duodeno- or gastro-jejunostomy (3), respectively.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3756412&req=5

f1-cancers-03-01253: Pylorus-preserving (left) and classical (right) pancreatico-duodenectomy. End-to-side pancreatico-jejunostomy (1), end-to-side hepato-jejunostomy (2) and end-to-side duodeno- or gastro-jejunostomy (3), respectively.
Mentions: Partial pancreatico-duodenectomy with resection of the distal stomach (Whipple resection) is the historical standard procedure for tumors of the pancreatic head. During the last two decades, preservation of the pylorus has been widely accepted, as proven to be equally effective compared to the classical pancreatico-duodenectomy with regard to tumor recurrence and long-term survival [11], Figure 1. A recent meta-analysis has confirmed these findings and, furthermore, has shown that preservation of the pylorus shortens operation time and reduces blood loss [12], Table 1. Therefore, the classical Whipple procedure should only be performed in situations where tumor spread towards the stomach cannot be ruled out, lymph node metastases are suspected in this area or distal stomach perfusion is critical, e.g., due to dissection of venous vessels. A crucial step during reconstruction after partial pancreatico-duodenectomy is the creation of the pancreatic anastomosis. A large number of variations including pancreatico-gastrostomy and pancreatico-jejunostomy with or without internal stent placement have been introduced and are currently used worldwide. The most important aspect of this anastomosis is technical standardization to achieve low fistula rates and avoid further consequent complications. The consensus paper of the International Study Group Pancreatic Fistula in 2005 [13] has defined postoperative fistula as drainage fluid on or after day 3 postoperatively with an amylase content of at least three-times that of serum amylase activity. The additional clinical grading of A-C reflects the severity and potential danger for the patient and makes study results on various anastomosis techniques comparable in a standardized way [14,15]. Surgical techniques with low fistula rates such as the binding anastomosis [16] or the duct-to-mucosa suture with internal stenting [17] have been reported and are currently used. Regardless which kind of anastomosis is performed, insufficiency rates of less than 3.5% should be achieved [18]. Bile-duct reconstruction should be standardized as well to avoid insufficiency and postoperative bile collection. Leakages of the hepatico-jejunostomy occur less frequent than pancreatic fistulas, but can also cause severe and long-lasting complications. The end-to side duodeno-jejunostomy or gastro-jejunostomy completes the reconstruction. Several studies and a current metaanalysis have shown that antecolic reconstruction should be preferred to avoid delayed gastric emptying [19,20]. This observation can be explained by the interposition of omental tissue and the transverse colon between the pancreatic anastomosis and the stomach which protects the anastomosis from any inflammatory or chemical irritation by the pancreatic anastomosis which may cause gastric dysfunction and emptying delay.

Bottom Line: Pancreatic surgery is a technically challenging procedure and has significantly changed during the past decades with regard to technical aspects as well as perioperative care.Furthermore, there is growing evidence that also more extended resections including multivisceral approaches, vessel reconstructions or surgery for tumor recurrence can be carried out safely with favorable outcomes.The impact of adjuvant treatment, especially chemotherapy, has increased dramatically within recent years, leading to significantly improved postoperative survival, making pancreatic cancer therapy an interdisciplinary approach to achieve best results.

View Article: PubMed Central - PubMed

Affiliation: Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany. thilo_hackert@med.uni-heidelberg.de.

ABSTRACT
Pancreatic cancer is still associated with a poor prognosis and remains-as the fourth leading cause of cancer related mortality-a therapeutic challenge. Overall long-term survival is about 1-5%, and in only 10-20% of pancreatic cancer patients is potentially curative surgery possible, increasing five-year survival rates to approximately 20-25%. Pancreatic surgery is a technically challenging procedure and has significantly changed during the past decades with regard to technical aspects as well as perioperative care. Standardized resections can be carried out with low morbidity and mortality below 5% in high volume institutions. Furthermore, there is growing evidence that also more extended resections including multivisceral approaches, vessel reconstructions or surgery for tumor recurrence can be carried out safely with favorable outcomes. The impact of adjuvant treatment, especially chemotherapy, has increased dramatically within recent years, leading to significantly improved postoperative survival, making pancreatic cancer therapy an interdisciplinary approach to achieve best results.

No MeSH data available.


Related in: MedlinePlus