Current opinion on lymphadenectomy in pancreatic cancer surgery

BACKGROUND:Adenocarcinoma of the pancreas exhibits aggressive behavior in growth,inducing an extremely poor prognosis with an overall median 5-year survival rate of only 1%-4%.Curative resection is the only potential therapeutic opportunity. DATA SOURCES:A PubMed search of relevant articles published up to 2009 was performed to identify information about the value of lymphadenectomy and its extent in curative resection of pancreatic adenocarcinoma. RESULTS:Despite recent advances in chemotherapy,radio-therapy or even immunotherapy,surgery still remains the major factor that affects the outcome.The initial promising performance in Japan gave conflicting results in Western countries for the extended and more radical pancreatectomy; it has failed to prove beneficial.Four prospective,randomized trials on extended versus standard lymphadenectomy during pancreatic cancer surgery have shown no improvement in long-term survival by the extended resection.The exact lymph node status,including malignant spread and the total number retrieved as well as the lymph node ratio,is the most important prognostic factor.Positive lymph nodes after pancreatectomy are present in 70%.Paraaortic lymph node spread indicates poor prognosis. CONCLUSIONS:Undoubtedly,a standard lymphadenectomy including>15 lymph nodes must be no longer preferred in patients with the usual head location.The extended lymphadenectomy does not have any place,unless in randomized trials.In cases with body or tail location,the radical antegrade modular pancreatosplenectomy gives promising results.Nevertheless,accurate localization and detailed examination of the resected specimen are required for better staging.

Efficacy and safety of laparoscopic radical resection following neoadjuvant therapy for pancreatic ductal adenocarcinoma:A retrospective study

BACKGROUND Multiple studies have demonstrated that neoadjuvant chemotherapy(NACT) can prolong the overall survival of pancreatic ductal adenocarcinoma(PDAC) patients. However, most studies have focused on open surgery following NACT.AIM To investigate the efficacy and safety of laparoscopic radical resection following NACT for PDAC.METHODS We retrospectively analyzed the clinical data of 15 patients with pathologically confirmed PDAC who received NACT followed by laparoscopic radical surgery in our hospital from December 2019 to April 2022. All patients underwent abdominal contrast-enhanced computed tomography(CT) and positron emission tomography-CT before surgery to accurately assess tumor stage and exclude distant metastasis.RESULTS All 15 patients with pancreatic cancer were successfully converted to surgical resection after NACT, including 8 patients with pancreatic head cancer and 7 patients with pancreatic body and tail cancer. Among them, 13 patients received the nab-paclitaxel plus gemcitabine regimen(gemcitabine 1000 mg/m^(2) plus nabpaclitaxel 125 mg/m^(2) on days 1, 8, and 15 every 4 wk) and 2 patients received the modified FOLFIRINOX regimen(intravenous oxaliplatin 68 mg/m^(2), irinotecan 135 mg/m^(2), and leucovorin 400 mg/m^(2) on day 1 and fluorouracil 400 mg/m^(2) on day 1, followed by 46-h continuous infusion of fluorouracil 2400 mg/m^(2)). After each treatment cycle, abdominal CT, tumor markers, and circulating tumor cell counts were reviewed to evaluate the treatment efficacy. All 15 patients achieved partial remission. The surgical procedures included laparoscopic pancreaticoduodenectomy(LPD, n = 8) and laparoscopic radical antegrade modular pancreatosplenectomy(L-RAMPS, n = 7). None of them were converted to a laparotomy. One patient with pancreatic head carcinoma was found to have portal vein involvement during the operation, and LPD combined with vascular resection and reconstruction was performed. The amount of blood loss and operation times of L-RAMPS vs LPD were 435.71 ± 32.37 m L vs 343.75 ± 145.01 m L and 272.52 ± 49.14 min vs 444.38 ± 68.63 min, respectively. The number of dissected lymph nodes was 16.87 ± 4.10, and 3 patients had positive lymph nodes. One patient developed grade B postoperative pancreatic fistula(POPF) after LRAMPS, and one patient experienced jaundice after LPD. None of the patients died after surgery. As of April 2022, progressive disease was noted in 4 patients, 2 patients had liver metastasis, and one had both liver metastasis and lymph node metastasis and died during the follow-up period.CONCLUSION Laparoscopic radical resection of PDAC after NACT is safe and effective if it is performed by a surgeon with rich experience in LPD and in a large center of pancreatic surgery.