Pancreaticoduodenectomy for borderline resectable pancreatic head cancer with a modified artery-first approach technique

BACKGROUND： The treatment of borderline resectable pancreatic head cancer（BRPHC） is still controversial and challenging. The artery-first approaches are described to be the important options for the early determination. Whether these approaches can achieve an increase R0 rate, better bleeding control and increasing long-term survival for BRPHC are still controversial. We compared a previously reported technique, a modified artery-first approach（MAFA）, with conventional techniques for the surgical treatment of BRPHC.METHODS： A total of 117 patients with BRPHC undergone pancreaticoduodenectomy（PD） from January 2013 to June 2015 were included. They were divided into an MAFA group（n=78） and a conventional-technique group（n=39）. Background characteristics, operative data and complications were compared between the two groups.RESULTS： Mean operation time was significantly shorter in the MAFA group than that in the conventional-technique group（313 vs 384 min; P=0.014）; mean volume of intraoperative blood loss was significantly lower in the MAFA group than that in the conventional-technique group（534 vs 756 m L; P=0.043）; and mean rate of venous resection was significantly higher in the conventional-technique group than that in the MAFA group（61.5% vs 35.9%; P=0.014）. Pathologic data, early mortality and morbidity were not different significantly between the two groups.CONCLUSIONS： MAFA is safe, simple, less time-consuming, less intraoperative blood loss and less venous resection, and therefore, may become a standard surgical approach to PD for BRPHC with the superior mesenteric vein-portal vein involvement but without superior mesenteric artery invasion.

Pancreatic head cancer: Open or minimally invasive pancreaticoduodenectomy?

Pancreatic head cancer still represents an insurmountable barrier for patients and pancreatic surgeons.Pancreaticoduodenectomy(PD)continues to be the operative standard of care and potentially curative procedure for pancreatic head cancer.Despite the rapid development of minimally invasive techniques,whether the efficacy of minimally invasive pancreaticoduodenectomy(MIPD)is noninferior or superior to open pancreaticoduodenectomy(OPD)remains unclear.In this review,we summarized the history of OPD and MIPD and the latest staging and classification information for pancreatic head cancer as well as the proposed recommendations for MIPD indications for patients with pancreatic head cancer.By reviewing the MIPD-vs.OPD-related literature,we found that MIPD shows noninferiority or superiority to OPD in terms of safety,feasibility,enhanced recovery after surgery(ERAS)and several short-term and long-term outcomes.In addition,we analyzed and summarized the different MIPD outcomes in the USA,Europe and China.Certain debates over MIPD have continued,however,selection bias,the large number of low-volume centers,the steep MIPD learning curve,high conversion rate and administration of neoadjuvant therapy may limit the application of MIPD for pancreatic head cancer.

Laparoscopy and laparoscopic ultrasonography in judging the resectability of pancreatic head cancer

OBJECTIVE: To explore the clinical value of laparoscopy and laparoscopic ultrasonography (LUS) in judging the resectability of pancreatic head cancer. METHODS: LUS was employed as a prospective diagnosis of tumor staging before exploratory laparotomy in 22 patients diagnosed with pancreatic head cancer to identify whether the liver and peritoneum had small metastases or local invasion to the portal vein, superior mesenteric vessel, aorta, inferior vena cava. RESULTS: In the 22 patients receiving laparoscopy and LUS, we found peritoneal or surface liver metastases (3 patients), hepatic parenchyma metastases (1), and pancreatitis proved by biopsy under ultrasound guidance (1). Laparotomy was avoided in these 5 patients. Of the remaining 17 patients, 8 patients, including 2 patients with portal vein emboli due to tumor metastases had hypertrophic lymph nodes or tumor invasion of local vessels in the peritoneal cavity, retroperitoneum, and omentum and the other 9 patients had resectable tumors shown by LUS. The 17 patients were subjected to exploratory laparotomy, and pancreaticoduodenectomy was successful in 8 patients. CONCLUSIONS: Laparoscopy and LUS can be used to precisely estimate the possibility of resection of pancreatic head cancer, and prevent unnecessary exploratory laparotomy and its complications. It can be used as a routine examination before exploratory laparotomy.

Treatment strategy for pancreatic head cancer with celiac axis stenosis in pancreaticoduodenectomy:A case report and review of literature

BACKGROUND During pancreaticoduodenectomy in patients with celiac axis(CA)stenosis due to compression by the median arcuate ligament(MAL),the MAL has to be divided to maintain hepatic blood flow in many cases.However,MAL division often fails,and success can only be determined intraoperatively.To overcome this problem,we performed endovascular CA stenting preoperatively,and thereafter safely performed pancreaticoduodenectomy.We present this case as a new preoperative treatment strategy that was successful.CASE SUMMARY A 77-year-old man with a diagnosis of pancreatic head cancer presented to our department for surgery.Preoperative assessment revealed CA stenosis caused by MAL.We performed endovascular stenting in the CA preoperatively because we knew that going into the operation without a strategy could lead to ischemic complications.Double-antiplatelet therapy(DAPT)–which is needed when a stent is inserted–was then administered in parallel with neoadjuvant chemotherapy(NAC).This allowed us to administer DAPT for a sufficient period before the main pancreaticoduodenectomy procedure while obtaining therapeutic effects from NAC.Subtotal stomach-preserving pancreaticoduodenectomy was thenperformed.The operation did not require any unusual techniques and was performed safely.Postoperatively,the patient progressed well,without any ischemic complications.Histopathologically,curative resection was confirmed,and the patient had no recurrence or complications due to ischemia up to six months postoperatively.CONCLUSION Preoperative endovascular stenting,with NAC and DAPT,is effective and safe prior to pancreaticoduodenectomy in potentially resectable pancreatic cancer.

Extended radical operation of pancreatic head cancer: Appraisal of its clinical significance

AIM: To evaluate the significance of extended radical operation and its indications.METHODS: Between January 1995 and December 1998, 56inpatients with pancreatic head cancer received operation.Among them 35 patients (group 1) experienced the Whipple operation, and 21 patients (group 2) received the extended radical operation. The 1-, 2-, 3-year cumulative survival rates were used to evaluate the efficacy of the two operative procedures. Clinical stage (CS) was assessed retrospectively with the help of CT. The indications for extended radical operation were discussed.RESULTS: There was no difference in hospital mortality and morbidity rates. Whereas the 1-, 2-, 3-year cumulative survival rates were 84.8%, 62.8%, 39.9% in the extended radical operation group, and were 70.8%, 47.6%, 17.2%in the Whipple operation group, there was a significant difference between the two groups (P＜0.001, P＜0.001,P＜0.001, respectively). Most of the deaths within 3 years after operation were due to recurrence in the two groups.However, the 1-, 2-, 3-year cumulative rates of death due to local recurrence were decreased from 37.4% in patients that received the Whipple procedure to 23.8% in those who received by extended radical operation. Patients who survived for more than 3 years were only noted in those with CS1 in the Whipple procedure group and were founded in cases with CS1, CS2 and part of CS3 in the extended radical operation group.CONCLUSION: The extended radical operation appears to benefit patients with pancreatic head carcinoma which was indicated in CS1, CS2 and part of CS3 without severe invasion.

The optional extent of lymph node dissection for pancreatic head cancer

Objective The extent of lymph node dissection for pancreatic head cancer(PHC)is uncertain and controversial;therefore,this study evaluated whether PHC patients can benefit from different extents of lymph node dissection.Methods A total of 106 PHC patients underwent standard regional lymphadenectomy(SRLN;n=56,52.8%)and extended regional lymphadenectomy(ERLN;n=50,47.2%)between September 2015 and September 2019.None of the study participants had distant metastases.The median survival time and complications were compared between the two groups.Results The median survival time in the SRLN and ERLN groups was 27.01 months and 21.17 months,respectively(P=0.30).The postoperative major morbidity and mortality rates were 37.50%and 1.79%in the SRLN group,and 46.00%and 2.00%in the ERLN group,respectively.Moreover,the tumor differentiation,tumor diameter,lymph node involvement,perineural invasion,vascular invasion,and margin status all correlated with survival(P<0.05).Conclusion For PHC patients,ERLN cannot provide a significant survival benefit over SRLN.Moreover,ERLN increased morbidity and mortality,although without statistical significance.This indicates that ERLN should not be considered in PHC patients.

Surgical treatment of pancreatic head cancer: concept revolutions and arguments

As we have a deeper and more thorough understanding of the biological behavior of pancreatic head cancer, surgical treatment concepts of this lethal disease are changing all the time. Meanwhile, numerous arguments emerge. Thus, we will probe into the focuses and arguments in the surgical treatment of pancreatic head cancer in this article, including the scope of lymphadenectomy, total mesopancreas excision（TMp E）, vascular resection, minimally invasive pancreaticoduodenectomy（PD）, palliative resection, surgery for recurrent disease and surgery for primary pancreatic cancer and liver metastasis.

Standard pancreatoduodenectomy versus extended pancreatoduodenectomy with modified retroperitoneal nerve resection in patients with pancreatic head cancer:a multicenter randomized controlled trial

Background:The extent of pancreatoduodenectomy for pancreatic head cancer remains controversial,and more high-level clinical evidence is needed.This study aimed to evaluate the outcome of extended pancreatoduodenectomy(EPD)with retroperitoneal nerve resection in pancreatic head cancer.Methods:This multicenter randomized trial was performed at 6 Chinese highvolume hospitals that enrolled patients between October 3,2012,and September 21,2017.Four hundred patients with stage I or II pancreatic head cancer and without specific pancreatic cancer treatments(preoperative chemotherapy or chemoradiation)within three months were randomly assigned to undergo standard pancreatoduodenectomy(SPD)or EPD,with the latter followed by dissection of additional lymph nodes(LNs),nerves and soft tissues 270◦on the right side surrounding the superior mesenteric artery and celiac axis.The primary endpoint was overall survival(OS)by intention-to-treat(ITT).The secondary endpoints were disease-free survival(DFS),mortality,morbidity,and postoperative pain intensity.Results:TheR1 ratewas slightly lower with EPD(8.46%)thanwith SPD(12.56%).The morbidity and mortality rates were similar between the two groups.The median OS was similar in the EPD and SPD groups by ITT in the whole study cohort(23.0 vs.20.2 months,P=0.100),while the median DFS was superior in the EPD group(16.1 vs.13.2 months,P=0.031).Patients with preoperative CA19–9<200.0 U/mL had significantly improved OS and DFS with EPD(EPD vs.SPD,30.8 vs.20.9 months,P=0.009;23.4 vs.13.5 months,P<0.001).The EPD group exhibited significantly lower locoregional(16.48%vs.35.20%,P<0.001)andmesenteric LNrecurrence rates(3.98%vs.10.06%,P=0.022).The EPD group exhibited less back pain 6 months postoperation than the SPD group.Conclusions:EPD for pancreatic head cancer did not significantly improve OS,but patients with EPD treatment had significantly improved DFS.In the subgroup analysis,improvements in bothOS and DFS in the EPD armwere observed in patients with preoperative CA19–9<200.0 U/mL.EPD could be used as an effective surgical procedure for patients with pancreatic head cancer,especially those with preoperative CA19–9<200.0 U/mL.

Impact of resection margins on long-term survival after pancreaticoduodenectomy for pancreatic head carcinoma

BACKGROUND The impact of resection margin status on long-term survival after pancreaticoduodenectomy(PD) for patients with pancreatic head carcinoma remains controversial and depends on the method used in the histopathological study of the resected specimens. This study aimed to examine the impact of resection margin status on the long-term overall survival of patients with pancreatic head carcinoma after PD using the tumor node metastasis standard.METHODS Consecutive patients with pancreatic head carcinoma who underwent PD at the Chinese People's Liberation Army General Hospital between May 2010 and May 2016 were included. The impact of resection margin status on long-term survival was retrospectively analyzed.RESULTS Among the 124 patients, R0 resection was achieved in 85 patients(68.5%), R1 resection in 38 patients(30.7%) and R2 resection in 1 patient(0.8%). The 1-and 3-year overall survival(OS) rates were significantly higher for the patients who underwent R0 resection than the rates for those who underwent R1 resection(1-year OS rates: 69.4% vs 53.0%;3-year OS rates: 26.9% vs 11.7%). Multivariate analysis showed that resection margin status and venous invasion were significant risk factors for OS.CONCLUSION Resection margin was an independent risk factor for OS for patients with pancreatic head carcinoma after PD. R0 resection was associated with significantly better OS after surgery.

Treatment of Candida albicans liver abscess complicated with COVID-19 after liver metastasis ablation:A case report

BACKGROUND Liver interventional surgery is a relatively safe and minimally invasive surgery.However,for patients who have undergone Whipple surgery,the probability of developing a liver abscess after liver interventional surgery is very high.Fungal liver abscess has a high mortality rate,especially when complicated with malignant tumors,diabetes,coronavirus disease 2019(COVID-19)and other complications.Fungal liver abscess is rare,and there are no guidelines or expert consensus on the course of antifungal therapy.CASE SUMMARY A 54-year-old woman with pancreatic head cancer received albumin-bound paclitaxel in combination with gemcitabine chemotherapy after laparoscopic pancreaticoduodenectomy.Liver metastasis was found 1 mo after completion of 8 cycles of chemotherapy,followed by ablation of the liver metastasis.After half a month of liver metastasis ablation,the patient experienced fever after chemotherapy and was diagnosed with liver abscess complicated with COVID-19 by contrast-enhanced abdominal computed tomography and real-time polymerase chain reaction detection.The results of pus culture showed Candida albicans,which was sensitive to fluconazole.The patient underwent percutaneous catheter drainage,antifungal therapy with fluconazole,and antiviral therapy with azvudine.During antifungal therapy,the patient showed a significant increase in liver enzyme levels and was discharged after liver protection therapy.Oral fluconazole was continued for 1 wk outside the hospital,and fluconazole was used for a total of 5 wk.The patient recovered well and received 4 cycles of fluorouracil,leucovorin,oxaliplatin,and irinotecan after 2 mo of antifungal therapy.CONCLUSION Effective treatment of Candida albicans liver abscess requires early detection,percutaneous catheter drainage,and 5 wk of antifungal therapy.Meanwhile,complications such as COVID-19 should be actively managed and nutritional support should be provided.

The "meso" of the rectum and the "meso" of the pancreas: similar terms but distinct concepts in surgical oncology

A correspondence between the ＂meso＂ of the rectum and of the pancreas has recently been reported. Here we highlight the differences between mesorectum and mesopancreas. Based on anatomical findings from a series of 89 consecutive pancreaticoduodenectomies and 71 consecutive total mesorectal excisions, we observed that in contrast to the mesorectum, the mesopancreas did not have well-defined anatomic boundaries and was continuous and connected through its components with the para-aortic area. In rectal cancer,tumor deposits and nodal involvement could be confined to the mesorectum（i.e., within the mesorectal fascia）, whereas in pancreatic carcinoma, tumor deposits and nodal metastases occurred in the boundless mesopancreatic area. Total mesorectal excision was made en bloc with the rectum by dissecting along the mesorectal fascia; this was not the case for mesopancreatic excision since anatomical demarcation of the mesopancreas did not exist. Moreover, the growth pattern of pancreatic cancer showed greater dispersion, which was more prominent at the invasive front of the tumor and could potentially affect the status of the resection margin. These findings indicate that the mesorectum and mesopancreas are completely distinct from the pathological, surgical, and oncological standpoints.