Current status and future direction of pancreatic surgery
- VernacularTitle:Нойр булчирхайн мэс заслын өнөөгийн байдал болон ирээдүйн чиг хандлага
- Author:
Hiroki Yamaue
- Publication Type:journal article
- From:Innovation
2014;8(4):106-107
- CountryMongolia
- Language:Mongolian
-
Abstract:
Background: The survival of the patients with pancreatic cancer has been
still dismal despite of the development of surgical techniques. To improve the
survival after pancreatic surgery, postoperative adjuvant therapy is reported to
be an independent prognostic factor and surgery without morbidity is strongly
required. I introduce our experiences of a RCT regarding reduction of pancreatic
fistula using isolated Roux-en-Y method (Tani et al. Br J Surg 2014), and review
the surgical technique for reduction of pancreatic fistula. What regimen should
be selected for postoperative pancreatic cancer patients? In this lecture, results
of JASPAC-01 will be presented for superiority of S-1 comparing gemcitabine.
Moreover, the treatment strategy for borderline resectable pancreatic cancer will
be stressed in this lecture.
1. Reduction of pancreatic fistula after whipple operation
We conducted the randomized clinical trial compared the incidence of pancreatic
fistula between the isolated Roux-en-Y (IsoRY) and conventional reconstruction
(CR) methods. The primary endpoint was the incidence of pancreatic fistula.
Pancreatic fistula occurred in 26 patients (34 %) in the CR group and 25 (33
per cent) in the IsoRY group (P =0.909). The number of patients with a clinically
relevant pancreatic fistula (grade B or C) was similar in the two groups and
mortality (none in either group). This study showed that IsoRY reconstruction
does not reduce the incidence of pancreatic fistula compared with CR.
2. Postoperative adjuvant therapy
Global golden standard of chemotherapy for pancreatic cancer has been
gemcitabine since the report by Barris 1997 (J Clin Oncol), and clinical trials
of several combinations with gemcitabine have been attempted for elongation
of the survival. Anticancer drugs and molecular targeting agents including
bevacizumab have been tried, however any drug has no advantage, comparing
gemcitabine alone. However, nab-paclitaxel has been a first drug to possess
the benefit of combination with gemcitabine, and also FOLFIRINOX clearly
shows the superiority effect compared to gemcitabine. How’s the situation for
adjuvant setting? Japanese trial, JASPAC-01 has shown a superior effect of S-1 to
gemcitabine. In japan, S-1 is a standard drug for adjuvant use after surgery.
3. Treatment strategy for borderline resectable (BR) pancreatic cancer
The definition of BR cancer has been proposed by NCCn-guideline, and briefly
it should be the cancer with difficulty of R0 with pancreatic surgery. Therefore,
some additional strategy is strongly needed. In this lecture, neoadjuvant
chemotherapy (NAC) and chemoradiotherapy (NACRT) will be discussed.
Moreover, who should undergo distal pancreatectomy with en-bloc celiac
axis resection (DP-CAR). The indications for DP-CAR in pancreatic carcinoma
remain controversial. Fifty-two consecutive patients with pancreatic cancer who
underwent distal pancreatectomy, including 36 standard distal pancreatectomies
(standard DP) and 16 DP-CAR were reviewed retrospectively. After DP-CAR, the
estimated overall survival rate in patients who were pathologically negative for
portal venous and artery invasion was greater than that of the other patients.
The estimated overall 1- and 2-year survival rates after standard DP / DP-CAR
were 81/81% and 52/53%, and the median survival times were 32/25 months,
respectively, with no significant differences noted between the groups. DP-CAR
was a feasible and safe procedure, similar to standard DP. DP-CAR should be
reserved for patients without tumor infiltrating both the portal venous and arterial
systems.
Conclusion: According to the results of RCTs, the surgical technique should be
improved to get zero morbidity and mortality, and allow the patients to be given
a suitable postoperative adjuvant therapy. The treatment strategy for patients with
borderline resectable pancreatic cancer has been still controversial, and further
studies and discussion will be needed to confirm the appropriate treatment.
