New insights in surgical pancreatology

Abstract

This review focuses on surgical pancreatology and major issues discussed at the IHPBA Meeting 2006 in Edinburgh. The main topics and new studies regarding surgical pancreatology presented at the meeting were probiotics in acute pancreatitis (AP), delayed gastric emptying, technical feasibility studies, spleen-preserving distal pancreatectomy, distal pancreatectomy, endoscopic sphincterotomy (ES) prior to pancreatoduodenectomy (PD), survival in pancreatic cancer, vessel invasion and vascular resection, advanced tumours, pancreatic resection for metastatic adenocarcinoma and hepatic resection in pancreatic cancer. Lutgendorff and colleagues described how infection of pancreatic necrosis is caused by small bowel bacterial overgrowth and increased intestinal permeability. In an experimental rat model used by van Minnen and co-workers, prophylactic probiotics reduced bacterial translocation and late mortality. Therefore probiotics might be a potential new therapeutic approach to limit disease progression in patients with infected pancreatic necrosis. This is certainly a new approach deserving more attention. Delayed gastric emptying was significantly reduced by antecolic versus retrocolic reconstructions of duodenojejunostomy in pylorus-preserving pancreatoduodenectomy (PPPD). Yamaue and colleagues also described a reduction of postoperative morbidity, length of presence of a nasogastric tube and a lower hospital duration time. In technical feasibility studies, modified pancreaticogastrostomy in PPPD with an isoperistaltic gastric tube was created along the greater curvature of the stomach. No leakage of pancreatic secretions was detected in this trial by Costa and Lucas. Nakao proposed a function-preserving pancreatic head resection with a segmental duodenectomy (PHRSD) with no observation of operative mortality in 40 patients who have undergone this procedure so far. Spleen-preserving distal pancreatectomy versus distal pancreatectomy with splenectomy in benign or low grade malignant disease (n=74) showed a higher effectiveness (95%) of the spleen-preserving method. A higher complication rate as regards abdominal infection (34% versus 18%) was found in the splenectomy group. Carrere and Pradere did not examine any significant differences in operation time, mortality or length of hospital stay. A meta-analysis of distal pancreatectomy with stapler closure by Diener did not reveal a significant difference as regards the incidence of pancreatic fistula in comparison to hand-sutured closure. However, no randomized clinical trials exist and therefore more studies urgently need to be performed. A prospective multicentre study (DISPACT-TRIAL) is planned to compare stapler closure with hand-sewn closure with the endpoints of pancreatic fistula and death. Endoscopic sphincterotomy (ES) prior to pancreatoduodenectomy in ampullary cancer was analysed in a retrospective trial (n=124) by Saxena and colleagues. The tumour recurrence rate in the ES group after 24 months was 93% in comparison with 50% in the controls that did not undergo ES prior to surgery. Interestingly, the liver was the only site of recurrence in the ES group. A survival advantage of 11 months for the non-ES group was determined, so that ES obviously predisposes to dissemination into the portal circulation and development of liver metastasis. Due to a disproportionate rate of interventions, survival in pancreatic cancer correlates with higher socioeconomic status. Brown proposed that future studies need to be performed to determine whether this actually represents inequality in access to medical services. Depth of portal vein invasion is a prognostic factor for survival of pancreatic cancer. Primary unresectable pancreatic cancer can be down-staged, i.e. regression of vessel invasion, by systemic chemotherapy to be eligible for surgery. This leads to a prolonged mean survival and is therefore an option for patients with local unresectable status. In advanced tumours, extended pancreatic resection with vascular resection and reconstruction was not associated with higher mortality and morbidity as found by Schmidt and co-workers. A new approach in a pilot study of 10 patients with intratumoral injection of the immunocytokine MALP-2 (macrophage activation lipopeptide-2) in unresectable tumours led to an improved survival, making this injection an interesting and innovative approach to treatment of pancreatic cancer in addition to surgery. Shrikhande pointed out that randomized clinical trials are needed to determine the indications for palliative Whipple resection, including resection of liver and peritoneal metastases. Major pancreatic surgery with extended resection in metastatic disease could be performed safely in highly selected patients with advanced pancreatic cancer. Interaortocaval lymph node dissection might be an option for metastatic but locally resectable pancreatic cancer. Hepatic resection in pancreatic cancer was analysed in a retrospective multicentre experience (n=40) by Adam and colleagues. Curative hepatic resection was associated with long-term survival, especially in cases with improved disease-free intervals. The median survival was 19 months and in complete resection (R0) 31 months. Adjuvant therapy might further increase survival time in patients with liver metastasis.