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 beenstill dismal despite of the development of surgical techniques. To improve thesurvival after pancreatic surgery, postoperative adjuvant therapy is reported tobe an independent prognostic factor and surgery without morbidity is stronglyrequired. I introduce our experiences of a RCT regarding reduction of pancreaticfistula using isolated Roux-en-Y method (Tani et al. Br J Surg 2014), and reviewthe surgical technique for reduction of pancreatic fistula. What regimen shouldbe selected for postoperative pancreatic cancer patients? In this lecture, resultsof JASPAC-01 will be presented for superiority of S-1 comparing gemcitabine.Moreover, the treatment strategy for borderline resectable pancreatic cancer willbe stressed in this lecture.1. Reduction of pancreatic fistula after whipple operationWe conducted the randomized clinical trial compared the incidence of pancreaticfistula 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 (33per cent) in the IsoRY group (P =0.909). The number of patients with a clinicallyrelevant pancreatic fistula (grade B or C) was similar in the two groups andmortality (none in either group). This study showed that IsoRY reconstructiondoes not reduce the incidence of pancreatic fistula compared with CR.2. Postoperative adjuvant therapyGlobal golden standard of chemotherapy for pancreatic cancer has beengemcitabine since the report by Barris 1997 (J Clin Oncol), and clinical trialsof several combinations with gemcitabine have been attempted for elongationof the survival. Anticancer drugs and molecular targeting agents includingbevacizumab have been tried, however any drug has no advantage, comparinggemcitabine alone. However, nab-paclitaxel has been a first drug to possessthe benefit of combination with gemcitabine, and also FOLFIRINOX clearlyshows the superiority effect compared to gemcitabine. How’s the situation foradjuvant setting? Japanese trial, JASPAC-01 has shown a superior effect of S-1 togemcitabine. In japan, S-1 is a standard drug for adjuvant use after surgery.3. Treatment strategy for borderline resectable (BR) pancreatic cancerThe definition of BR cancer has been proposed by NCCn-guideline, and brieflyit should be the cancer with difficulty of R0 with pancreatic surgery. Therefore,some additional strategy is strongly needed. In this lecture, neoadjuvantchemotherapy (NAC) and chemoradiotherapy (NACRT) will be discussed.Moreover, who should undergo distal pancreatectomy with en-bloc celiacaxis resection (DP-CAR). The indications for DP-CAR in pancreatic carcinomaremain controversial. Fifty-two consecutive patients with pancreatic cancer whounderwent distal pancreatectomy, including 36 standard distal pancreatectomies(standard DP) and 16 DP-CAR were reviewed retrospectively. After DP-CAR, theestimated overall survival rate in patients who were pathologically negative forportal 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-CARwere 81/81% and 52/53%, and the median survival times were 32/25 months,respectively, with no significant differences noted between the groups. DP-CARwas a feasible and safe procedure, similar to standard DP. DP-CAR should bereserved for patients without tumor infiltrating both the portal venous and arterialsystems.Conclusion: According to the results of RCTs, the surgical technique should beimproved to get zero morbidity and mortality, and allow the patients to be givena suitable postoperative adjuvant therapy. The treatment strategy for patients withborderline resectable pancreatic cancer has been still controversial, and furtherstudies and discussion will be needed to confirm the appropriate treatment.
