Outcome of microscopically nonradical, subtotal pancreaticoduodenectomy (Whipple's resection) for treatment of pancreatic head tumors

Abstract

From 1983 to 1992 a total of 240 patients with a pancreatic head tumor underwent laparotomy to assess the resectability of the tumor. In 44 patients the tumor was not resected because of distant metastases (n = 20) or major vascular involvement or local tumor infiltration (n = 24) not detected during the preoperative workup. A palliative biliary and gastric bypass was performed in these patients. All other patients underwent a subtotal (Whipple's resection, n = 164) or total (n = 32) pancreaticoduo-denectomy. However, in 56 cases after Whipple's resection, microscopic examination of the specimen showed tumor invasion in the dissection margins. For this reason, these resections were considered palliative. We compared hospital mortality, morbidity, and long-term survival of patients who had undergone a biliary and gastric bypass for a locally advanced tumor (group A, n = 24) with a matched group of patients who had undergone a macroscopically radical Whipple's resection that on microscopic examination proved to be nonradical (group B, n = 36). Both groups were comparable with regard to age (mean 61 years in both groups), duration of symptoms (8 weeks in group A and 10 weeks in group B), and tumor size (mean 4.25 cm in group A and 4.30 cm in group B). Median postoperative hospital stay was 18 days in group A and 25 days in group B. Postoperative complications (intraabdominal abscess, gastrointestinal hemorrhage, anastomotic leakage, delayed gastric emptying) occurred in 33% of patients in group A and in 44% of patients in group B. Hospital mortality was 0% and 3% in group A and group B, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Are There Indications for Palliative Resection in Pancreatic Cancer?

“…In two recent studies, one from The Johns Hopkins Hospital, Baltimore (USA) and the other from our institution (Academic Medical Center, Amsterdam, The Netherlands), surgical bypass and palliative resection were compared [16,17]. Both studies are retrospective and therefore suffer from methodologic flaws.…”

“…This is another important factor that could influence survival. From these two studies it was concluded that the perioperative morbidity and mortality after palliative resection were acceptable, and therefore a more aggressive approach should be offered to patients with pancreatic cancer [16,17].…”

Complications of Pancreatic Cancer Resection

“…Abscesses may contribute to septicaemia, which is found in 1–4% of patients [39, 44]. Abscesses commonly arise from anastomotic leak at the pancreatoduodenostomy, the hepaticojejunostomy, the duodenojejunostomy, the gastrojejunostomy or the jejunojejunostomy and often herald as right subhepatic or left subdiaphragmatic collections [51, 52].…”

“…The relatively high incidence of post-operative complications refers to the complexity of surgery with multiple anastomoses of different types and the rather poor nutritional status and high background co-morbidity of the patient group [10, 32, 39, 41, 42]. Medical complications evoked as a consequence of surgery include cardiac problems (angina, infarction and arrhythmias), cardiovascular accidents (strokes), cardiorespiratory distress, renal dysfunction, pneumonia, thrombosis, pulmonary embolism, psychological disturbances and hepatic and metabolic dysfunction.…”

“…High through-put centres have convincingly reported low operative mortalities [10, 14, 15, 17, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36](table 1). The incidence of post-operative complications, however, still remains high with overall complication rates of up to 60% [10, 15, 17, 32, 36, 37, 38, 39, 40, 41](table 2). …”