Total pancreatectomy for ductal adenocarcinoma of the pancreas with special reference to resection of the portal vein and multicentric cancer

Abstract

Between March 1, 1968 and March 1, 1986, 323 patients underwent surgery for cancer of the pancreas or the periampullary region. Extirpative procedures were performed in 91 patients, of whom 51 had ductal carcinoma of the pancreas. Forty-seven patients had total pancreatectomy, 9 associated with resection of the portal vein and 1 with total gastrectomy. Operative mortality was 15% but fell to zero for the 19 total pancreatectomies performed after 1981. With the introduction of total pancreatectomy, the resectability rate increased from 15% to 32%. Overall mean survival was 14.4 months. Actuarial survival was 42.4% at 1 year, 25.6% at 2 years, 11.9% at 3 years, and 8% at 5 years. Six patients are alive 7, 11, 14, 30, 30, and 73 months, respectively, after operation. Survival was calculated according to the classifications of Hermreck, Tryka and Brooks, and the TNM system. Ductal carcinoma was multifocal in 32% of patients, and 25% had epithelial dysplasia of the pancreatic duct. When portal vein resection was necessary, mean survival was 6.1 months, compared with 18.25 months when it was not performed. We conclude that total pancreatectomy has increased our resectability rate, mainly in patients with tumor spread beyond the usual margins of division for Whipple's procedure. However, the procedure does not appear worthwhile when portal vein resection is necessary or when multicentric cancer or neoplastic emboli are observed in the operative specimen.

Incidence of Synchronous and Metachronous Pancreatic Carcinoma in 168 Patients with Branch Duct Intraductal Papillary Mucinous Neoplasm

“…A considerably high incidence of multicentric PanIN lesions in the pancreas has been documented in a series of total pancreatectomies of patients with PC [25]. Furthermore, multifocal carcinomas of the pancreas were found at an incidence of 32% in 47 patients with PC.…”

Total Pancreatectomy and Subtotal Duodenopancreatectomy for the Management of Carcinoma of the Head of the Pancreas: An Institutional Experience and Evolving Trends

“…One of the major controversies regarding radical resection is the role of total pancreatectomy for ductal adenocarcinomas. As the results of Whipple procedures were disappointing, some surgeons converted to total pan createctomy [3][4][5], When the study commenced in 1973, we advocated total pancreatectomy as the treatment of choice for cancer of the pancreas. This seemed justified because of the pos sible spread to the left of the mesenteric vessels by cancer situated in the head of the pancreas; the procedure achieved a wider lymphadenectomy as well as ensuring removal of multicentric malignant foci.…”

“…The major criti cisms leveled against total pancreatectomy have been the high postoperative morbidity and mortality rates ob served in most series. Thus in 1986, we reviewed the results of 47 consecutive total pancreatectomies for carci noma of the head of the pancreas, of which 9 were associ ated with portal vein resection [4], The resectability rates increased from 15 to 32%, because patients with tumour spread beyond the usual margin of division for the Whip ple procedure were being excluded. However, we found this extended procedure to be of no benefit when portal vein resection was necessary or when multicentric cancer or neoplastic emboli were present in the operative speci men.…”

General Aspects of Surgical Treatment of Pancreatic Cancer

“…In recent years, however, at least 841 patients who underwent portal vein resection have been reported (table 1), without a significant increase in morbidity and mortality rate in most of the reports. In Western reports [32, 33, 34, 35, 36, 37, 38, 39, 40]portal vein resection was performed almost only when pancreatic cancer was in such an advanced stage that nonresectional procedures were no longer an option and venous resection was the only way to complete the procedure without macroscopically residual tumor. A more aggressive approach was adopted by some Western authors [28, 30, 41]and by Japanese surgeons [42, 43, 44, 45, 46, 47, 48, 49, 50, 51]: in every case of suspected mesenterico/portal vein invasion, in an attempt to improve lymphatic and soft tissue clearance, en bloc resection of the pancreas and of the vein was performed.…”