Radical Pancreatoduodenectomy Research Articles

Treatment of Ampullary Adenocarcinoma

The ampulla of Vater is a small projection formed by the confluence of the main pancreatic duct and common bile duct in the second part of the duodenum. Primary ampullary adenocarcinoma is a rare malignancy, accounting for only 0.2% of gastrointestinal cancers and approximately 7% of all periampullary cancers. Jaundice from a biliary obstruction is the most common symptom of ampullary adenocarcinoma. In the early stages, radical pancreatoduodenectomy is the standard surgical approach. On the other hand, no randomized controlled trial has provided evidence to guide physicians on the choice of adjuvant/palliative chemotherapy because of the rarity of the disease and the paucity of related research. This paper reports the biology, histology, current therapeutic strategies, and potential future therapies of ampullary adenocarcinoma.

Gastroblastoma without GLI1 and EWSR1 gene breaks

ObjectiveTo report a rare gastroblastoma; discuss its clinical features, histopathological morphology, diagnosis, differential diagnosis, treatment, and prognosis; and so as to improve the understanding on this disease and provide reference for its diagnosis, treatment, and prognosis.MethodsThe diagnosis and treatment, imaging examination, pathological, and genetic data of a 19-year-old young female patient with gastroblastoma were analyzed retrospectively, and the relevant literature was reviewed and summarized.ResultsThe patient was found to have a “gastrointestinal stromal tumor” for 3 days by physical examination in another hospital. Abdominal CT and MRI considered “solid pseudopapilloma of pancreas” and clinically planned to perform “radical pancreatoduodenectomy.” During the operation, the tumor was observed to bulge from the posterior wall of the gastric antrum, and the root was located in the gastric antrum, so it was changed to “partial gastrectomy + Ronx-y gastrojejunal anastomosis.” The postoperative pathology showed that the tumor was bi-differentiated between gastric epithelium and mesenchymal. Combined with the results of IHC and the opinions of several consultation units, the diagnosis of gastric blastoma (low-grade malignancy) was supported. However, the fracture rearrangement of GLI1 and EWSR1 genes was not detected by FISH. After 19 months of follow-up, no signs of tumor recurrence and metastasis were found.ConclusionCombined with existing literature reports, gastroblastoma occurs in young people, equally in men and women, and tends to occur in the gastric antrum. The biological behavior of the tumor tends to be inert, and the prognosis of most cases is good. Postoperative pathology and IHC are reliable methods for the diagnosis of gastric blastoma, and surgical resection of the lesion is the preferred treatment.

Development and validation of a nomogram for predicting survival in patients with pancreatic ductal adenocarcinoma after radical pancreatoduodenectomy

Abstract Objectives Hypercoagulation and malnutrition are the characteristic pathophysiological changes associated with pancreatic ductal adenocarcinoma (PDAC), which are intimately related to cancer progression and prognosis. We aimed to integrate related indicators to build a nomogram model to predict the overall survival (OS) of PDAC patients underwent radical pancreatoduodenectomy (PD). Methods Clinicopathological and survival data of 138 patients were retrospectively analyzed according to inclusion and exclusion criteria. A nomogram was built based on the multivariate Cox regression analysis. The receiver operating characteristic curve (ROC) and calibration curves were performed based on the bootstrap method to evaluate the predictive performance of the nomogram. Decision curve analysis (DCA) was performed to assess the clinical usefulness of the nomogram. Results High-grade tumor (Hazard ratio [HR]: 3.70; 95% confidence interval [CI]: 1.51–3.82; p<0.001), vessel carcinoma embolus (HR: 2.69; 95% CI: 1.30–5.31, p=0.007), N2 (HR: 2.90; 95% CI: 1.47–7.37; p=0.004), anemia (HR: 1.98; 95% CI: 1.01–2.70; p=0.047), PLR>244.8 (HR: 2.13; 95% CI: 1.05–3.45; p=0.033), FBG>3.50 g/L (HR: 2.10; 95% CI: 1.04–3.09, p=0.008), and DRR>1.1 (HR: 2.69; 95% CI: 1.56–4.27; p<0.001) served as independent risk factors for poor OS of patients with PDAC underwent radical PD and were implemented to construct a nomogram. The area under curve (AUCs) for the first, second, and third years were 0.713, 0.777, and 0.845, respectively. Besides, calibration curves fitted well to the ideal line. DCA shows that the nomogram has greater net benefit than the existing TNM staging system, suggesting that this model is a more practical clinical tool for predicting the prognosis of PDAC patients. Conclusions The nomogram we established based on the characteristic pathophysiological alterations of PDAC for predicting OS in patients who underwent radical pancreatoduodenectomy presented considerable predictive power. It may facilitate prognostic risk stratification and optimize therapeutic decision-making.

Superior mesenteric artery‑first approach for resectable pancreatic head cancer

Superior mesenteric artery‑first approach has been proposed for the surgical treatment of pancreatic head cancer. However, little is known about its effects on resectable pancreatic head cancer. In the present study, data from patients with resectable pancreatic head cancer, who underwent radical pancreatoduodenectomy with or without the superior mesenteric artery‑first approach at from January, 2014 to December, 2019, were retrospectively collected and analyzed. A total of 204 patients were included in the study. The blood loss and blood transfusion of the arterial approach group (n=94) were less than those of the conventional approach group (n=110). Diarrhea occurred in 31 cases (15.2%) of the arterial approach group and in 18 cases (8.8%) of the conventional approach group (P<0.05). A higher rate of R0 resection and a higher number of lymph nodes harvested were achieved in the arterial approach group (P<0.05). The 1‑, 2‑ and 3‑year tumor‑free survival rates of the patients in the arterial approach group were 60.9, 43.2 and 37.9%, respectively, and those of the patients in the conventional approach group were 64.2, 24.9 and 15.6%, respectively (P<0.05). Moreover, the 1‑, 2‑, and 3‑year overall survival rates of the patients in the arterial approach group were 79.5, 49.7 and 36.7%, and those of the patients in the conventional approach group were and 75.9, 38.6 and 18.7%, respectively (P<0.05). On the whole, the present study demonstrates that the superior mesenteric artery‑first approach can reduce intraoperative blood loss and consequent blood transfusion, facilitate the achievement of an R0 resection, and thus prolong the survival of patients, despite resulting in a higher rate of diarrhea.

Standard Pancreatoduodenectomy Versus Radical Pancreatoduodenectomy With Retroperitoneal Nerve Resection in Patients With Pancreatic Head Cancer (RAPNER): A Multicentre Randomized Controlled Trial

Background: Pancreatic cancer is a highly fatal disease and is becoming an increasingly common cause of cancer mortality. The extent of pancreatoduodenectomy for pancreatic head cancer is still controversial, and more high-level clinical evidence is needed. We compared the outcomes of standard pancreatoduodenectomy (SPD) with those of radical pancreatoduodenectomy (RPD) with retroperitoneal nerve resection in pancreatic head cancer patients in this multicentre randomized controlled trial. Methods: RAPNER was open-label, multicentre randomised trial, patients aged 18–80 years with stage I or II pancreatic head cancer undergoing curative resection were enrolled at 6 centres from China. Patients were allocated (1:1) by use of a computer-based randomisation service to assigned to receive standard pancreatoduodenectomy (PD) or radical PD, with the latter followed by the combined dissection of additional lymph nodes (LNs), nerves and soft tissues 270° on the right side surrounding the superior mesenteric artery and celiac axis. This trial is registered with Chinese Clinical Trial Registry (http://www.chictr.org.cn), ChiCTR-TRC-12002548. Findings: Between October 3, 2012, and February 15, 2017, 468 patients were enrolled; of these, 400 were randomly assigned to the RPD group (n=201) or the SPD group (n=199). The operation time was longer with RPD than with SPD, but the R1 resection rate was slightly higher in the SPD group (12·56%) than in the RPD group (8·46%). Both the total number of retrieved LNs and number of positive LNs were significantly higher in the RPD group (20 (7-63) and 1 (0-29)) than in the SPD group (15 (7-63) and 1 (0-11)). Both the morbidity and inpatient mortality rates were comparable between the two groups. The median overall survival (OS) of the RPD and SPD groups were 23·0 months and 20·2 months (p=0·100), and the disease-free survival (DFS) were 15·6 months and 13·5 months (p=0·060). In the subgroup with a preoperative CA19-9 level less than 200 U/ml, the median OS in the RPD group was 30·8 months, which was significantly longer than that in the SPD group (20·9 months; p=0·009), and the median DFS was significantly longer in the RPD group than in the SPD group (22·3 months vs. 15·0 months, p=0·002). Furthermore, clinical benefit could be found in the RPD group in the subgroup of well & moderate histological differentiation, preoperative CEA level less than 5·00 ng/ml, R0 resection and postoperative adjuvant chemotherapy based on DFS analysis. A multivariate Cox proportional hazards model showed that initial CA19-9≥200 U/ml, N1 stage and poor differentiation suggested poor OS. Radical resection achieved equivalent prognosis regardless of perineural invasion except for aortic nerve plexus invasion. The RPD group exhibited significantly lower locoregional and mesenteric LN recurrence rates but a higher peritoneal seeding frequency. The RPD group also exhibited significantly less back pain intensity 6 months after surgery than the SPD group. Interpretation: This study suggests that in pancreatic head cancer patients, RPD with retroperitoneal nerve resection does not provide a significant survival benefit compared with SPD. RPD can be performed safely, and be considered a treatment option with improving prognosis for patients with a low chance of systemic metastasis in pancreatic head cancer. Trial Registration: ChiCTR-TRC-12002548. Funding Statement: Sun Yat-sen University Clinical Research 5010 Program (Grant No. 2012007), China; National Natural Science Foundation of China (Grant No. 81871945). Declaration of Interests: We declare no competing interests. Ethics Approval Statement: This study was approved and overseen by the clinical ethics committee of each participating hospital.

Mesopancreatic excision for pancreatic ductal adenocarcinoma improves local disease control and survival

BackgroundSurvival in ductal adenocarcinoma of the pancreatic head (hPDAC) is poor. After implementation of the circumferential resection margin (CRM) into standard histopathological evaluation, the margin negative resection rate has drastically dropped. However, the impact of surgical radicality on survival and the influence of malignant infiltration of the mesopancreatic fat remains unclear. At our institution, a standardized dissection of the mesopancreatic lamina and peri-pancreatic vessels are obligatory components of radical pancreatoduodenectomy. The aim of our study was to histopathologically analyze mesopancreatic tumor infiltration and the influence of CRM-evaluated resection margin on relapse-free and overall survival. MethodClinicopathological and survival parameters of 264 consecutive patients who underwent surgery for hPDAC were evaluated. ResultsThe rate of R0 resection R0(CRM-) was 48.5%, after the implementation of CRM. Mesopancreatic fat infiltration was evident in 78.4% of all consecutively treated patients. Patients with mesopancreatic fat infiltration were prone to lymphatic metastases (N1 and N2) and had a higher rate of positive resection margin (R1/R0(CRM+)). In multivariate analysis, only R0 resection was shown to be an independent prognostic parameter. Local recurrence was diagnosed in only 21.1% and was significantly lower in patients with R0(CRM-) resected hPDACs (10.9%, p < 0.001). ConclusionMesopancreatic excision is justified, since mesopancreatic fat invasion was evident in the majority of our patients. It is associated with a significantly improved local tumor control as well as longer relapse-free and overall survival.

Changes in preoperative and postoperative lipoprotein-associated phospholipase A2 activity in patients with malignant obstructive jaundice.

Malignant obstructive jaundice (MOJ) leads to hyperbilirubinemia and systemic pathophysiological changes. The main clinical treatments for MOJ include radical pancreatoduodenectomy, palliative surgical treatment, and minimally invasive treatment, which can relieve biliary obstruction, drain bile, reduce jaundice, and improve liver function. In rat models, hepatic exposure to endotoxin resulted in rapid increases in biliary and plasma lipoprotein-associated phospholipase A2 (Lp-PLA2) levels, and our previous study revealed that Lp-PLA2 activity was strongly associated with liver damage. The present study aimed to clarify the serum Lp-PLA2 activity changes and evaluate the associations between Lp-PLA2 activity and laboratory parameters in MOJ patients preoperatively and postoperatively. Twenty-one patients with MOJ were enrolled in this prospective study. Lp-PLA2 activity and other laboratory parameters were analyzed using a Hitachi 7600 automatic biochemical analyzer. Spearman correlation coefficients, percent differences, and dynamic difference plots were used to evaluate the changes in preoperative and postoperative Lp-PLA2 activity and the associations of Lp-PLA2 activity with other laboratory parameters. The postoperative Lp-PLA2 activity at 1 day [646 (range, 175-1,025) U/L], 1 week [419 (range, 144-949) U/L], and day of hospital discharge [347 (range, 165-698) U/L] differed significantly from the preoperative baseline activity (636 (range, 172-1,664) U/L; P<0.05 for all). Lp-PLA2 activity was correlated with total bilirubin (TB) at specific time points (P<0.05 for all). The percent differences and dynamic difference graphs revealed that Lp-PLA2 activity, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and TB gradually decreased after biliary obstruction was relieved by surgical treatment. Lp-PLA2 activity in MOJ patients was associated with biliary obstruction and liver damage. Serum Lp-PLA2 can be used as a novel indicator for biliary obstruction severity and treatment monitoring.

FRII-08 DR. ALEXANDER BRUNSCHWIG (1901-1969) - A FOUNDER OF THE TOTAL PELVIC EXENTERATION AND OTHER RADICAL SURGICAL ADVANCES OF THE 20TH CENTURY.

You have accessJournal of UrologyHistory of Urology II (Moderated Poster)1 Apr 2014FRII-08 DR. ALEXANDER BRUNSCHWIG (1901-1969) - A FOUNDER OF THE TOTAL PELVIC EXENTERATION AND OTHER RADICAL SURGICAL ADVANCES OF THE 20TH CENTURY. Ariel Schulman, James Kashanian, Ervin Teper, and Ciril Godec Ariel SchulmanAriel Schulman More articles by this author , James KashanianJames Kashanian More articles by this author , Ervin TeperErvin Teper More articles by this author , and Ciril GodecCiril Godec More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1746AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Introduction and Objectives The total pelvic exenteration is the most invasive procedure in the repository of the pelvic surgeon. Though morbid, it provides functional improvement, palliation and in some cases enduring cure in the setting of invasive disease. The basic principles remain from the procedures developed in the 1940’s. We describe the contributions of Dr. Alexander Brunschwig who was among the first to perform this “brutal and cruel,” yet effective procedure. Methods Medical journals and news publications were reviewed regarding the work of Dr. Brunschwig. Results Alexander Brunschwig was born in El Paso, Texas on Sept. 11th, 1901. He attended Rush Medical School followed by training at Boston City Hospital, the University of Chicago and the University of Strasbourg, France. He was on staff at the University of Chicago from 1931 to 1947 when he performed the first one-stage radical pancreatoduodenectomy in 1937 which disproved the prevailing thought that an intact pancreas was required. He subsequently published “The Surgery of Pancreatic Tumors” in 1942, a milestone work in the developing field of hepatobiliary surgery. In 1947, Brunschwig became Chief of Gynecology at Memorial Hospital for Cancer in New York where he remained for the duration of his career. While Bricker performed the first pelvic exenteration in 1940 for rectal cancer, Brunschwig was operating largely on advanced gynecologic cancers and published the first case series of 22 patients in 1948 in the first volume of the journal ‘Cancer.’ Brunschwig’s initial cases had ‘wet colostomies’ with implantation of the ureters into segments of colon. His work was the subject of criticism from some contemporaries who considered him a “butcher,” but largely favorable recognition culminating with the publication of ‘L’Exenteration pelvienne’ in 1964 that reported 5 year survival in 116 of 562 patients. Dr. Brunschwig’s commitment to surgical therapy is exemplified in his aggressive approach, while his feelings about alternatives are reflected by his belief that “more people make a living giving chemotherapy than are cured by it.” Conclusions On August 7th, 1969, Dr. Brunschwig collapsed in the operating room during his final surgical procedure. He died the same night at the age of 67 due to a cardiac event. His early contributions to the surgical management of advanced pelvic malignancy, and multitude of other fields, deserve a place in the History of Urology. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e629-e630 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Ariel Schulman More articles by this author James Kashanian More articles by this author Ervin Teper More articles by this author Ciril Godec More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Decoy receptor 3 (DcR3) overexpression predicts the prognosis and pN2 in pancreatic head carcinoma

BackgroundThis study was carried out to examine decoy receptor 3 (DcR3) expression and investigate its clinical and prognostic significance in patients with pancreatic head carcinoma.MethodsTissue samples were obtained from 50 patients with pancreatic head carcinoma. DcR3 protein expression in tissues and sera was assessed by immunohistochemistry and ELISA. Correlations between DcR3 and clinicopathologic features and prognoses were analyzed statistically.ResultsSerum DcR3 levels were significantly elevated in patients with pancreatic head carcinoma compared with patients with cystadenoma and healthy individuals (P < 0.01 and P < 0.01, respectively). DcR3 overexpression correlated with lymph node metastases and TNM stages (P < 0.05 and P < 0.05, respectively). Median overall survival for the high DcR3 group was 16.3 months, compared to 21.6 months for the low DcR3 group (P < 0.05). In the low DcR3 group, no significant difference was found in the overall survival between patients who underwent standard pancreatoduodenectomy (SPD) and those who had radical pancreatoduodenectomy (RPD) (P > 0.05). In the high DcR3 group, the median overall survival rates were 16.8 months in the RPD group and 13.5 months in the SPD group (P < 0.05).ConclusionsWe found that DcR3 was overexpressed in pancreatic head carcinoma. The patients with high DcR3 levels had higher pN2 stages than those with low DcR3 levels. Detecting serum DcR3 level preoperatively might be an additional approach for evaluating pN2 stage and guiding the range of lymphadenectomy.

Pancreatoduodenectomy for melanoma with metastasis to the common bile duct

Melanoma with metastasis to the common bile duct is relatively rare. This report presents the case of a 56-year-old Japanese male that showed an abnormal laboratory profile 18 months after resection of a skin melanoma occurring on the left fifth finger. The cytology of bile obtained by endoscopic retrograde cholangiopancreatography yielded a diagnosis of melanoma with metastasis to the common bile duct. Surgery revealed melanoma within the distal common bile duct. There were no other secondary metastases in the abdomen and a radical pancreatoduodenectomy was performed. The patient survived for 13 months without any signs of recurrence and died of progressive systemic metastatic melanoma 34 months after surgery. Therefore, radical surgical resection appears to be effective for the prolongation of survival in cases of melanoma with metastasis to the common bile duct.

Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas

The value of pancreatoduodenectomy (PD) with extended lymphadenectomy for pancreatic cancer has been evaluated by many retrospective studies and 3 randomized controlled trials (RCT). However, the protocols used and the results found in the 3 RCTs were diverse. Therefore, a multicenter RCT was proposed in 1998 to evaluate the primary end point of long-term survival and the secondary end points of morbidity, mortality and quality of life of patients undergoing standard versus extended lymphadenectomy in radical PD for pancreatic cancer. From March 2000 to May 2003, 112 patients with potentially curable pancreatic head cancer were enrolled and intraoperatively randomized to a standard or extended lymphadenectomy group. No resected patients received any adjuvant treatments. A hundred and one eligible patients were analyzed. Demographic and histopathological characteristics of the two groups were similar. The mean operating time, intraoperative blood loss and number of retrieved lymph nodes were greater in the extended group, but the other operative results were comparable. Although this multicenter RCT was conducted in a strict setting, extended lymphadenectomy in radical PD did not benefit long-term survival in patients with resectable pancreatic head cancer and led to levels of morbidity, mortality and quality of life comparable to those found after standard lymphadenectomy.

Efficacy of simplified binding pancreaticojejunostomy

Objective To investigate the methods and techniques of simplified binding pancreaticojejunostomy for patients with periampullary malignant tumor after radical pancreatoduodenectomy (RPD). Methods From March 2005 to May 2010, 323 patients with periampullary malignant tumor received RPD at the Tongji Hospital of Huazhong University of Science and Technology, and their clinical data were retrospectively analyzed.Simplified binding pancreaticojejunostomy was applied after RPD: the distal end of pancreas was freed for 3-4 cm;a No. 6 or No. 8 silicone urinary catheter was inserted into the pancreatic duct for 4-5 cm, and the remaining urinary catheter (6-8 cm) out of the pancreatic duct was sutured to the pancreatic stump with absorbable sutures.The cutting end of the jejunum (2-3 cm) was everted, and the everted mucosa of the jejunum ( 1 cm) was injured by electrocautery, then the everted jejunum was reverted to its normal position. The cutting end of the mesentery of jejunum and its opposite side, as well as the mid-point of these two parts were sutured symmetrically with the lower and upper edges of the pancreas, and with the capsule of pancreas between them. The everted jejunum was wrapped over the pancreatic stump and sutured it to the pancreas for fixation. The cutting end of the jejunum was bound to the pancreatic stump with 1-0 absorbable suture after confirming the jejunum was completely invaginated into the pancreas. The alimentary tract was reconstructed by using Child's method. Results Simplified binding pancreaticojejunostomy was successfully completed in all patients, Pancreatic fistula was detected in one patient who was complicated with anastomotic bleeding on the third day after secondary laparotomy. The patient was discharged with catheter and spontaneously recovered one month later. Pancreatic fistula was also detected in two patients with distal bile duct carcinoma and two patients with carcinoma in the uncinate process of pancreas at postoperative day 3, 6, 8 and 11, and they were cured by expectant treatment. The incidence of pancreatic fistula was 1.5% (5/323). Conclusion Simplified binding pancreaticojejunostomy is simple, safe and feasible, and it can significantly reduce the incidence of pancreatic fistula. Key words: Periampullary malignant neoplasms; Pancreaticoduodenectomy; Binding pancreaticojejunostomy, simplified

Clinical significance of nerve, lymph node and soft tissue dissection in retroperitoneum in radical resection of ductal adenocarcinoma in pancreatic head

To investigate the clinical significance of radical pancreatoduodenectomy plus retroperitoneal nerve, lymph node and soft tissue dissection in carcinoma of pancreatic head. Forty-six patients with carcinoma of pancreatic head were treated at our hospital from 1995 to 2005. They were divided into two groups: radical pancreatoduodenectomy plus retroperitoneal nerve, lymph node and soft tissue dissection (Group A, n = 25) and routine Whipple's operation (Group B, n = 21). Two groups had no significant difference in age, gender and pre-operative risk factors. And the peri-operative conditions, pathological data and survival rates were compared and analyzed. There was no difference in tumor size, intra-operative findings, post-operative complications and length of hospitalization. But the number and positive rate of resected lymph node in Group A were significantly higher than those in Group B (P < 0.05). The survival rates of 1, 3-year in Group A were 80% and 52.9% respectively. And they were higher than those in Group B (P < 0.05). There was significant difference in the survival rates between patients with nerve infiltration and those without in Group A (P < 0.05). The radical pancreatoduodenectomy plus retroperitoneal nerve, lymph node and soft tissue dissection can effectively remove the lymph node and nerve tissues with tumor infiltration and reduce the local recurrent rate so as to improve the long-term survival rate.

Prevention and cure of the complications after radical pancreatoduodenectomy

To investigate the causes and the measures of prevention and cure of the dangerous complications (bleeding, pancreatic fistula, biliary fistula and death) after radical pancreatoduodenectomy (RPD) for periampullary malignant tumor. The rate and management of dangerous complications of 156 cases with RPD which were continuous performed by Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology between January 2006 and June 2008 were analyzed retrospectively, including 97 males and 59 females with 37 - 79 years old, the mean age was 56.9 years old. Among the 156 cases with RPD, four patients had massive hemorrhage of gastrointestinal tract due to stress ulcer, two patients had bleeding in the pancreas-intestinal anastomosis after the operation, the rate of postoperative bleeding was 3.9% (6/156). One patient with massive hemorrhage of gastrointestinal tract due to stress ulcer had severe pulmonary infection and ARDS, and died of respiratory failure finally (the overall mortality rate was 0.7%) after ICU for two months. One patients with bleeding in the pancreas-intestinal anastomosis had pancreatic fistula (the rate of pancreatic fistula was 0.7%) 3 days after the second laparotomy to open the jejunum of the pancreas-intestinal anastomosis and make a transfixion of the bleeding points in the stump. Another patient who had the tumor located in the inferior segment of the bile common duct had biliary fistula 11 days after the operation (the rate of biliary fistula was 0.7%). Two patients with fistula had good recovery by expectant treatment of ultrasound-guided puncture and drainage. Prompt and effective treatment of the complications of bleeding, pancreatic fistula, biliary fistula could maximally decrease the perioperative death rate.

Radical pancreatoduodenectomy combined with retroperitoneal nerve, lymph, and soft-tissue dissection in pancreatic head cancer

Recent studies have revealed that the reason for the low surgical resection rate of pancreatic carcinoma partly lies in its biological behavior, which is characterized by neural infiltration. This study aimed to investigate the clinical significance of radical pancreatoduodenectomy combined with retroperitoneal nerve, lymph, and soft-tissue dissection for carcinoma of the pancreatic head. Forty-six patients with pancreatic head cancer were treated in our hospital from 1995 to 2005. The patients were divided into two groups: radical pancreatoduodenectomy combined with retroperitoneal nerve, lymph and soft-tissue dissection (group A, n = 25) and routine Whipple's operation (group B, n = 21). There were no significant differences between the two groups in relation to age, gender and preoperative risk factors, and perioperative conditions, pathological data and survival rates were studied. There were no significant differences in tumor size, surgical procedure time, postoperative complications, and time of hospitalization. However, the number and positive rate of resected lymph nodes in group A were significantly higher than those in group B (P < 0.05). The 1- and 3-year survival rate in group A were 80% and 53%, respectively, which was higher than those in group B (P < 0.05). There were significant differences in the survival rates between patients with and without nerve infiltration in group A (P < 0.05). Radical pancreatoduodenectomy combined with retroperitoneal nerve, lymph and soft-tissue dissection, can effectively remove the lymph and nerve tissues that were infiltrated by tumor. Meanwhile, this method can reduce the local recurrence rate so as to improve the long-term survival of patients.

Carcinoma of the pancreatic head – Improvement of long-term Results of an oncologic center

Standard pancreatoduodenectomy (PD) for the treatment of resectable tumors of the periampullary region or the pancreatic head involves a radical pancreatoduodenectomy with an extensive gastric resection. The modified Whipple operation aims to preserve the stomach, pylorus and proximal duodenum so as to decrease postgastrectomy complications and improve the patient's quality of life. However, there were still many postoperative complications after pylorus-preserving pancreatoduodenectomy (PPD).

MODIFIED EXTENDED PANCREATODUODENECTOMY: EN BLOC RESECTION OF THE PERIPANCREATIC RETROPERITONEAL TISSUE AND THE HEAD OF PANCREAS

Malignant periampullary tumours often invade into retroperitoneal peripancreatic tissues and a positive resection margin following pancreatoduodenectomy is associated with a poor survival. For complete extirpation of the tumour, en bloc resection of the pancreatic head with all retroperitoneal peripancreatic tissue is essential to achieve negative resection margin. A modified radical pancreatoduodenectomy technique that aims to resect all peripancreatic retroperitoneal tissue en bloc with the head of the pancreas is described. We have used this new technique in the last 30 consecutive cases of pancreatoduodenectomy with excellent results as presented in this paper. This technique allows complete en bloc resection of retroperitoneal peripancreatic tissues while preserving normal functional tissue. This technique's advantage is that the resection can be carried out without breaching the retroperitoneal tumour extension plane, thereby minimizing tumour cell spillage.

THE MAYO CLINIC APPROACH TO THE SURGICAL TREATMENT OF ADENOCARCINOMA OF THE PANCREAS

Ductal carcinoma of the pancreas remains a challenging problem for gastrointestinal surgeons. Significant progress has been made in diagnosis, preoperative staging, and safety of surgery; however, long-term survival after resection is unusual, and cure is rare. That said, the authors maintain their aggressive posture regarding this disease, recognizing that resection offers the only potential for cure. The authors' approach such patients in the most efficient and least invasive manner possible, relying primarily on triple phase helical abdominal CT for clinical diagnosis and staging, reserving ERCP and EUS for diagnostic dilemmas. In fit candidates with potentially resectable lesions, the authors eschew pre- or intraoperative biopsy, angiography, or endoscopic stenting and use preliminary limited staging laparoscopy selectively. Surgical palliation is chosen for fit patients who, at exploration for potentially curative resection, are found to have occult distant metastases or locally unresectable disease. Radical pancreatoduodenectomy can be performed with a mortality rate of 3% or less, and although morbidity remains significant, most can be managed with conservative measures. Quality of life after pancreatoduodenectomy is good and, if not, is generally a manifestation of recurrence rather than physiologic alterations inherent to the procedure. Adjuvant chemoradiation is standard therapy after resection, recommended for those with locally unresectable disease but used selectively for those with distant metastasis. Survival after potentially curative resection has remained disappointing. Whether extended lymphadenectomy or neoadjuvant chemoradiation improves survival has not been determined. Clearly, methods for earlier diagnosis of pancreatic cancer and more effective adjuvant therapies are sorely needed.

A CLINICAL STUDY OF ADVANCED PRIMARY DUODENAL CARCINOMA

Primary duodenal cancer is a rare disease that accounts for 0.8-2% of all gastrointestinal malignancies. Surgical resection is only the curative treatment, but optimal treatment opinion has not been established. We have experienced seven patients with primary advanced duodenal carcinoma so far, and successfully performed radical pancreatoduodenectomy for them. All tumors were at the second portion of the duodenum, and large over 50mm in maximum diameter. Tumors were resected safely in all patients, no local recurrences occurred after the operation. Pancreas invasion was seen in six patients, and lymph node metastasis was detected in three patients, however, the 5-year survival rate (66.7%) was excellent compared to prognoses of other periampullary tumors. Consequently, we should make an attempt to perform surgical treatment for primary duodenal cancer, if pancreas invasion or lymph node metastasis is suspected in preoperative examination.

Pancreatoblastoma in children. Case report and review of the literature.

Pancreatolblastomas are rare embryonal malignancies in childhood. We report a 3-year-old girl with a tumor of the head of pancreas. Staging by bone scintigraphy and CT scans of abdomen and chest did not show evidence of metastatic disease. Tumor markers showed elevated levels of alpha-1 fetoprotein (64 ng/ml; normal 0-10 ng/ml) and lactate dehydrogenase (423 U/l; normal range below 300 U/l). The tumor was macroscopically completely removed by local resection. Postoperative tumor grading was pT1, NO, MO. The child recovered very soon after surgery without severe complications. Tumor markers dropped to normal values, indicating complete remission (follow-up time 12 months). According to the biological growth characteristics of pancreatoblastomas and to the literature, localized and non-metastatic tumors should be completely resected without radical pancreatoduodenectomy and without adjuvant chemotherapy. This is the most conservative therapy with a good prognosis. However, metastatic disease, primarily inoperable conditions or local relapses are indications for chemotherapy combined with radiotherapy and followed by resection of the tumor. At present, the prognosis of such cases is rather poor.