Surgery for Carcinoma of the Pancreas in Japan

Abstract

Pancreatic cancer surgery was first performed in Japan in the 1940s, although it was not until the 1970s that pancreatic resectional surgery became widely available. In the late 1970s, influenced by the application of regional pancreatectomy by Fortner and colleagues, several institutions in Japan introduced radical pancreatic cancer surgery. Aggressive strategies in pancreatic cancer surgery were approved in Japan in the 1980s. Japanese surgeons introduced additional modifications to pancreatic cancer surgery, including radical pancreatoduodenectomy with extended lymph node and connective tissue dissection and portal vein resection. However, it became clear that such extended operations impair the quality of life of the patient, even though the resectability of cancer increased to up to about 50%. Improvements to radical pancreatoduodenectomy were therefore introduced. Pylorus-preserving pancreatoduodenectomy with extended lymphadenectomy, connective tissue dissection, and portal vein resection is a Japanese modification to radical pancreatectomy that improves the quality of life of the patient and does not reduce the survival rate. Another modification applicable to low-grade malignancies is organ-preserving pancreatectomy, such as duodenum-preserving total pancreatic head resection, ventral pancreatectomy, and medial or segmental pancreatectomy. Although aggressive Japanese surgical strategies have provided important data, most studies have been retrospective. In the near future, Japanese surgeons will need to reevaluate their strategies in term of the importance of extended lymphadenectomy with connective tissue dissection and its influence on long-term survival of patients. Such reevaluation will require randomized controlled trials performed according to a detailed and strict protocol.

International Consensus Guidelines for Management of Intraductal Papillary Mucinous Neoplasms and Mucinous Cystic Neoplasms of the Pancreas

“…However, limited pancreatectomy has its problems, including technical diffi culty (mostly related to a complicated surgical anatomy), a higher incidence of postoperative complications including pancreatic fi stulae, and the risk of recurrence from potentially residual neoplasm. For pancreatic head lesions, duodenum-preserving pancreas head resection [60][61][62] , pancreatic head resection with second portion duodenectomy [63] , ventral pancreatectomy [64] , resection of uncinate process [65] , and ductal branch-oriented minimal pancreatectomy [66] have been proposed, for pancreatic body diseases, a dorsal pancreatectomy [67] and middle segmentectomy [68,69] , and for pancreatic tail neoplasms, spleenpreserving distal pancreatectomy [52][53][54] . Branch duct IPMNs with possible in-situ carcinoma and MCNs can be candidates for limited pancreatectomy as far as negative ductal margins can be obtained and safe pancreatectomy can be performed but no good follow-up data on recurrence are available.…”

Multicenter randomized phase II trial of prophylactic right‐half dissection of superior mesenteric artery nerve plexus in pancreatoduodenectomy for pancreatic head cancer

“…[3][4][5][6] Among some extended surgery techniques for PDAC, right-half dissection of the superior mesenteric artery (SMA) nerve plexus has been considered a standard technique of pancreatoduodenectomy in Japan. 7,8 Although this concept was initiated to accomplish R0 resection and totally extirpate the tissue that had the potential for nerve plexus invasion, subsequent refractory diarrhea is a major concern. This refractory diarrhea often decreases the relative dose intensity of adjuvant chemotherapy, which has been demonstrated to be a significant prognostic factor in PDAC.…”

Current understanding of precursors to pancreatic cancer

“…Two hundred thirty thousand patients with pancreatic cancer are registered world‐wide every year, and 98% of them die of their disease . The history of pancreatic oncological surgeons may be characterized as the struggle against this devastating disease . Recrcporandomized controlled trials have shown that extended radical resection, including paraaortic lymph adenectomy, does not improve the survival of the patients, but that their quality of life deteriorates as compared with conventional resection ,.…”

“…1 The history of pancreatic oncological surgeons may be characterized as the struggle against this devastating disease. 2 Recent randomized controlled trials have shown that extended radical resection, including paraaortic lymph adenectomy, does not improve the survival of the patients, but that their quality of life deteriorates as compared with conventional resection. 3,4 Irradiation, chemotherapy, immunotherapy, and other therapies in combination with, or without, surgery have been employed to treat patients with pancreatic cancer.…”