Extended Resection for Pancreatic Adenocarcinoma

Abstract

LEARNING OBJECTIVESAfter completing this course, the reader will be able to:1. Discuss the evidence in favor of and against the role of surgical resection in the management of pancreatic adenocarcinoma.2. Explain how the components of an extended pancreatectomy, including total pancreatectomy, extended lymph node dissection, and major intestinal arterial resection, do not improve survival above what is provided after pancreaticoduodenectomy and are associated with substantial morbidity.3. Discuss how portal/mesenteric vein resection to achieve negative resection margins does not add to the morbidity of pancreaticoduodenectomy, does not worsen survival after resection, and is most often performed because of tumor location.Access and take the CME test online and receive 1 AMA PRA Category 1 Credit ™ at CME.TheOncologist.com CME CME ABSTRACTAdenocarcinoma of the pancreas presents a number of therapeutic challenges. Given the poor long-term outcomes after pancreaticoduodenectomy (PD), many surgeons have sought to improve survival via a radical or "extended" pancreatectomy which may include (a) total pancreatectomy (TP), (b) extended lymph node dissection (ELND), and (c) portal/mesenteric vascular resections. These themes of "extended" resection are addressed in this review. TP should not be performed for most cases of adenocarcinoma of the pancreatic head because of the nominal incidence of lymph node involvement along the body and tail of the pancreas, the scarcity of multicentric disease, and the better management of pancreatic leaks after PD. Most studies show no difference in long-term survival and demonstrate greater postoperative morbidity after TP than after PD. Performing ELND in addition to PD is not worthwhile because most studies do not demonstrate any long-term benefits from ELND and the circumferential dissection around the mesenteric vessels required to harvest distant lymph nodes increases postoperative morbidity. Major arterial resection increases postoperative morbidity after PD and worsens long-term survival as the need for arterial resection to achieve negative resection margins indicates more aggressive disease. In contrast, portal and/or mesenteric venous resection does not increase the morbidity after PD or impact long-term survival as venous resection is often performed because of tumor location and not extent of disease. The disappointing experience with extended resections underscores the need for better adjuvant systemic strategies and the interdisciplinary care of patients with pancreatic adenocarcinoma.

PADULAP study: To compare postoperative and pathologic results between open and laparoscopic approach for pancreaticoduodenectomy

“…La DPC es la técnica quirúrgica de elección para el tratamiento radical de las neoplasias ubicadas en el duodeno, región periampular, confluente bilio-pancreático y cabeza del páncreas (1)(2)(3). Aunque su indicación por lo general es en patología maligna, también puede ser el tratamiento de elección para algunas enfermedades benignas como la pancreatitis crónica, la distrofia quística de la pared duodenal, etc.…”

“…La tasa de fístula pancreática clínicamente relevante varía de un 10-30% de los casos según las series (9-11), si bien la tasa global puede ser de hasta un 50% de los casos (8,11). La tasa de complicaciones globales se cifra en un considerable 36 -50 % (2,7,8,12,13). Mientras que la mortalidad postoperatoria en centros de referencia varía entre un 1-8% (7-13), en hospitales comarcales no universitarios puede llegar a superar el 15 % (14).…”

Perioperative treatment options in resectable pancreatic cancer - how to improve long-term survival

“…To this end, more radical or "extended" surgical techniques have been established in the last decades, whereat "extended" in this context means a more aggressive marginal clearance [26][27][28] . This may include total duodenopancreatectomy, resection of the portal-mesenterical axis, and extended lymph node dissection.…”

Extended pancreatectomy for pancreatic cancers

“…Also, most studies reveal no survival benefi t and increased morbidity and mortality with total pancreatectomy over pancreaticoduodenectomy and distal pancreatectomy [11,12]. However, in rare situations including a soft pancreas with risk of a leak from pancreatoenterostomy, or if positive margins on sequential frozen sections are obtained while resection is carried out into the pancreatic tail, or if there are papillomatous changes or dysplasia throughout the pancreatic duct, or if a family history of multicentric disease exists total pancreatectomy should be considered [13].…”

“…Studies have demonstrated that segmental venous resection and subsequent reconstruction is the ideal means of managing tumours adherent to the SMV and PV, and can achieve survival equivalent to any margin-negative pancreaticoduodenectomy [17]. It is worth noting that the effi cacy of arterial resection is much lesser than venous resection, and histologically confi rmed tumour infi ltration into the vascular tunica media is associated with no signifi cant benefi t in long-term survival [13,14].…”