MANAGEMENT OF ADVANCED PANCREATIC CANCER

N.J. LYGIDAKIS

Hospital Henry Dupont; Athens, GREECE

Pancreatic cancer is a disease full of conflicts, dilemmas and controversies with a poor prognosis. 90% of patients die within 1 year after the diagnosis, and only 5 – 25% of patients are eligible for resection. The severe outcome is attributed to the late stage at time of diagnosis (90% present at stage III at the time of diagnosis). Other reasons include the increased potential of the pancreatic malignancies for neuro- and vaso-invasion, the high incidence of early lymph node involvement and the increased incidence of regional vascular involvement.

The exceptional aggressiveness of Pancreatic Cancer remains largely unexplained. Mutations in K-ras, INK4A/ARF, TP53 & DPC4/SMAD4 have been implicated.

Despite refinement of surgical techniques & acquired experience although mortality and morbidity became acceptable [early (operative) mortality is <5%], overall long term survival & disease free survival remains unchanged for the last 30 years. We investigate whether it is possible to further improve these results by a more extended resection through extended lymphadenectomy, perineural resection and in case f vascular involvement, a vascular resection.

1. Perineural resection: In patients of pancreatic carcinoma, the incidence of neural invasion is 45-100%. The neural plexi involved may be extrapancreatic or intrapancreatic. The extrapancreatic neural plexus consists of the (according to the Japanese Pancreatic Society) the Celiac plexus, the Superior mesenteric plexus, the splenic plexus, the common hepatic plexus and the plexus in the hepatoduodenal ligament. The Superior Mesenteric plexus consists of two main parts; part one extending from right coeliac ganglion to upper medial margin of uncinate process and part two, the Plexus capitalis extending from the Superior mesenteric artery to medial margin of uncinate process . The 2nd part of nerve plexus is the most frequent site of invasion in pancreatic head carcinoma. The procedure for a perineural resection starts with the standard Whipple’s procedure, during which perineural excision around the Superior mesenteric artery is started on the right side, and a frozen biopsy is taken. If frozen section on right side is negative, no further resection is done. If biopsy on right side is positive, perineural resection performed on right side. Then, biopsies are taken on the left side. If biopies are positive on left, the a complete bilateral clearance of perineural tissue of SMA & vein is performed.

2. Extended lymphadenectomy: Incidence of Lymphogenic invasion in Pancreatic carcinoma is 33%. Lymphatic flow in viscinity of SMA passes outside of Neural plexus (ie. both have separate paths) (Nagakawa et al). The extended Lymph Node Stations of Pancreas include: the Hepatic artery up to and including celiac axis, the between the origin of SMA and jejunal branches, the aorto-caval nodes. These have to be cleared in extended resection to achieve R0 survival advantage.

3.Vascular Resection: Incase of vascular involvement, a vascular resection must be performed. However, a vascular resection in pancreatic carcinoma is to be performed only if we can obtain a R0 resection.

Conclusions: Radical resection remains the corner stone of treatment for Pancreatic Cancer. Our standard approach consists of extended surgery to achieve radical resection, which, while being equally safe and easy, carries the advantage of longer survival. Extended surgery is defined as the multi-targeted attack against the peri-neural spread, the lymphatic spread and the vascular involvement. Thus, after an extended radical lymphadenectomy and regional vascular resection in cases of vascular involvement, our standard approach has broadened with the addition of peri-neural excision of the nervous plexuses around the Superior Mesenteric Vessels. Presented data confirm the value of perivascular and perineural resection of Superior Mesenteric Vessels, and following our policy, we achieve a more radical resection, that corresponds directly with prolongation of Disease Free Survival and Overall Survival.

ENDOVASCULAR OCCLUSSION OF THE FULS POSTTRAUMATIC ANEURYSM OF THE HEPATIC ARTERY LEFT BRANCH COMPLICATED BY A RUPTURE IN THE BILIARY TRACT

A.G. MAGOMEDOV, A.S. SKOROVAROV, A.A. AGOMEDOV

Daghestan State Medical Academy and the Center for cardiology and cardiovascular surgery of the Republic Daghestan, Makhachkala, RUSSIA

30 years old patient was taken to our hospital with complaints of pain in the right upper quadrant, fatigue, nausea, vomiting and black stools. Due to the increasing pattern of gastrointestinal bleeding (source of bleeding could not be determined by fibroesophagogastroduodenoscopy) the patient was operated. Intraoperatively, after gastroduodenotomy, found a large quantity of blood clots in the duodenum and the fresh blood leaking from a large duodenal papilla. After cholecystectomy and choledochotomy a large quantity of blood clots in the common bile duct and gallbladder was found. Common bile duct flushed, there is no ongoing bleeding. Operation is complete by drainage of the choledoch according to Керу.. (посмотри как правильно пишется) On the third day after the operation, bleeding resumed on drainage of the biliary tract. In this connection is made transfemoral aortography. In the liver, was found a cavity of 3-5 cm, rapidly filling by the contrast agent from the left branch of the hepatic artery. Occlusion of the artery produced by two embolic mass "Emboks" 1000 microns. In order to achieve complete occlusion of the artery additionally installed spiral GIANTURCO 3x4 mm. By the end of transcatheter intervention bleeding from bile duct drainage has ceased. Discharged from the hospital in satisfactory condition at 3 days postoperatively.

Date: 2014-12-28; view: 880