Surgical management of carcinoma of the pancreas and periampullary region

Surgical Management of Carcinoma of the Pancreas and Periampullary Region GEORGE L. JORDAN, JR., M.D., Houston,

From tbe Cora and Webb Mading Department of Surgery, Baylor University College of Medicine, and tbe Jefferson Davis, Metbodist, St. Luke’s Episcopal, and Veterans Administration Hospitals, Houston, Texas.

ADICAL resections of Iesions invoIving the head of the pancreas and periampuhary region have been accomplished with increasing frequency since the first successfu1 operation was reported by Whipple in 1933 [I]. Genera1 agreement stiII does not exist, however, concerning the exact indications for this operation or the technic which should be empIoyed. Furthermore, the reported experience has Ied some to f)eIieve that the operation is usefu1 in certain peripancreatic lesions, particuIarIy carcinoma of the amp&a of Vater, whiIe of littIe vaIue in lesions arising in the pancreas. To obtain additiona1 information concerning the utilization of this operation, the treatment of sixty-four patients with lesions arising in the pancreas, ampulla of Vater, duodenum or common biIe duct has been reviewed.

R

MATERIALS AND METHODS This study incIudes sixty-four consecutive pancreatoduodena1 resections for carcinoma of the pancreas and periampuIIary region performed by the senior and resident surgica1 staffs of BayIor University College of Medicine during the period January I, 1946, through February 28, 1963. Only one of these operations was performed prior to January 1949. Thirtysix patients were treated for carcinoma of the head of the pancreas, nineteen patients for carcinoma of the amp&a of Vater, five for carcinoma of the duodenum and four for carcinoma of the common biIe duct. The age range was thirty-three to seventy-four years, a11 but one patient being more than forty years of age. Fifty-eight patients were maIe and six were femaIe. 1313

Texas

AI1 the patients but one were jaundiced at the time of operation, and expIoration was performed with a preoperative diagnosis of extrahepatic obstructive jaundice. At Iaparotomy, a thorough assessment of the abdomina1 cavity was accompIished to obtain evidence of distant metastasis. No radica1 resections were performed when metastases to the Iiver, peritoneum or other organs could be demonstrated. Penetration through the serosa or the presence of metastatic deposits in Iymph nodes which would be removed in a bIock dissection, however, were not considered contraindications to remova1. Resection incIuded the dista1 portion of the stomach, entire duodenum and first portion of the jejunum with a segment of the extrapancreatic portion of the common bile duct. The gaIIbIadder was removed in some but not al1 patients. The extent of pancreatic resection varied depending upon the Iocation of the lesion. The minima1 amount of pancreatic tissue removed incIuded the head, neck and uncinate process, while the maximal resection of pancreatic tissue was 80 per cent of the gIand, excising al1 but a portion of the tai1. A variety of reconstructive technics was used, but in the majority, an end to end pancreatojejunostomy, an end to side choledochojejunostomy and an end to side gastrojeiunostomy were empIoyed. (Fig. I.) RESULTS Postoperative Complications and Mortality. Thirty-five patients had uneventful postoperative courses, while thirty-five complications occurred in the other twenty-nine patients. The majority of the serious complications were directIy reIated to the operative procedure and incIuded IistuIa formation as we11 as hemorrhage. (TabIe I.) TweIve of the fourteen fistuIas were pancreatic in origin. The onIy biIiary American

Journal

of Surgery,

Volume

107, February

1964

Jordan TABLE POSTOPERATIVE

I COMPLICATIONS

-

Complication

I\Tumber ‘er cent

FistuIa. Pancreatic. Biliary........................ Gastric . . w ound InfectIon.. Intra-abdominal hemorrhage. Intra-abdomina1 abscess. Gastrointestinal hemorrhage.. Rena1 failure. IntestinaI infarction.. Aspiration pneumonia. Coronary 0ccIusion..

22

‘4 12

‘9 2

I I

2

5

8

5

8

4 2

6

2 I

3 2

I

2

I

2

3

TABLE CAUSE

OF

DEATH

IN

II FOURTEEN

PATIENTS

Complication FIG. I. The usua1 method of reconstruction creatoduodena1 resection.

Deaths

after panFistuIa................................. Pancreatic. BiIiary............................... Gastric............................... Intra-abdominal hemorrhage.. Intra-abdomina1 hemorrhage and pancreatic fistuIa................................ GastrointestinaI hemorrhage and pancreatic fistula................................ Intestinal infarction from injury of the superior mesenteric artery. Rena1 faiIure.. Rena1 faiIure and aspiration pneumonia. C oronary occlusron.

fistuIa occurred from the Iigated end of the common biIe duct when the gaIIbIadder was used for the biliary anastomosis. This technic has not been used during the past ten years and no biliary fistuIas have occurred from choIedochojejuna1 anastomoses. Intra-abdominal hemorrhage occurred from the porta vein or its branches and from erosion into the hepatic artery, particuIarIy at the site of Iigature of the gastroduodena1 artery. EIeven of fourteen postoperative deaths were directIy attributabIe to intra-abdomina1 compIications. (TabIe II.) FistuIa formation was associated with the greatest number of deaths, but the development of severe intra-abdomina1 hemorrhage carried a worse prognosis, as 80 per cent of patients with this compIication died. The highest operative mortaIity occurred in patients treated for cancer of the common biIe duct, whiIe the Iowest occurred in patients treated for Iesions arising in the ampuIIa of Vater. The over-a11 mortaIity was 22 per cent. (TabIe III.) CompIete foIIow-up data were Late Results. obtained for a11 patients. An evaIuation of the Iong-term resuIts discIosed that fifty-one patients were operated upon three or more years prior to the time of this study. TweIve (23 per cent) of these Iived three or more years after

3

I

I I

operation. Nine patients died in the immediate postoperative period; thus, the three year surviva1 rate among forty-two patients who underwent a successfu1 operation was 29 per cent. OnIy one of three patients treated for cancer of the common biIe duct more than three years ago survived operation. This patient Iived more than five years postoperativeIy. With this exception, the highest three year surviva1 rate occurred in patients treated for Iesions of the ampuIIa of Vater, as 40 per cent of those surviving operation Iived three or more years. (Table IV.) Thirty-eight patients underwent operation prior to June 1958 and were studied for determination of the five year surviva1 rate. Six (I 6 per cent) survived five years or Ionger, representing 3’4

Carcinoma

of Pancreas

and

Periampullary

Region TABLE III

per cent of the thirty who survived the operative procedure. One of these patients died five and a half years postoperatively lvithout chnical evidence of recurrent carcinoma, although microscopic evidence of malignancy was found in retroperitonea1 Iymph nodes at necropsy. The remaining five are still ahve for periods ranging from six to tweIve years. None of the surviving patients has evidence of recurrent carcinoma. (TabIe v.) Some patients who survived more than three years but less than five years deserve specific comment. One patient with carcinoma of the pancreas died four and a haIf years after pancreatoduodenectomy from postoperative complications after surgery for a herniated nucleus puIposus. This patient’s death was in no way related to the carcinoma, and he undoubtedly would have survived five years if another disease had not developed. A second patient who had carcinoma of the ampuha of Vater died Iifty-one months postoperatively. The cause of death was gastrointestina1 hemorrhage, presumably from marginal uIcer. There was no clinical evidence of carcinoma at the time of death. Two patients died of recurrent carcinoma more than four but Iess than five years postoperatively. Two patients, one treated for carcinoma of the ampuha of Vater and one treated for islet cell carcinoma of the pancreas, are alive more than three but Iess than five Thus, in June 1963, years postoperativeIy. twelve of the sixty-four patients were alive, five having lived more than five years, two alive more than three years and five alive less than two years. Several interesting probIems arose in the Iate management of five of the six five-year survivors. Jaundice developed in two patients in the late postoperative period because of stricture of the choledochojejunostomy. In both instances, the patients were re-expIored, repair was successfully accomplished and both of these patients survived Ionger than five years. AIthough cholecystitis is listed as a complication Iikeiy to develop when the gaIlbladder is not removed, this problem has developed in only one of the patients in this series. Seven years postoperatively acute choIecystitis deveIoped in a male patient, and ChoIecystectomy was successfully performed. This patient had earlier had n stricture of the common biIe duct and is still alive tweIve years after pancreatoduodenectomg for cancer of the ampuha of Vater, 20

Number of

Site of Lesion

! I

Deaths

I

~ Cases Number I Pancreas. Ampukr of Vater Duodenum Bileducts..

Percent

. ..’

Total

TABLE THREE

YEAR

SURVII'AL

IV

RATES OF

ACCORDIN<;

Number Surviving Operation

Site of Lesion

TO

LOCATION

LESIOY

Three I.c;rr Survivals _~~~ Per cent

Pancreas. AmpuIla of Vater Duodenum. Bile ducts.

22 13

j

4

I

TABLE FIVE

YEAR

SURVIVAL

Site of Lesion

Pancreas. AmpulIa of Vater Duodenum. Bile ducts. Totai.

.

I

i

12

i

29

v

RATES OF

I8 40 25 100

I

I

42

Total..

( ii

ACCORDING

TO

LO<.9TIO.N

LESION

Number Surviving Operation

Five Year Survivals

I6 II 2 I

3o

ten years after revision of the ChoIedochojejunostomy and five years after cholecystectomy. Another problem of interest has been the deveIopment of a second primary malignancy. Two patients who survived five years have had this problem. A second primary malignancy 3’5

Jordan deveIoped in the ascending colon near the hepatic ffexure in one patient fifteen months after a Whipple resection. The colonic Iesion was aIso successfuIIy resected and this patient is now aIive six and three-quarter years after a WhippIe procedure for carcinoma of the pancreas and five and a half years after resection of a carcinoma of the colon, without evidence of recurrence of either Iesion. The second patient underwent resection of the carcinoma of the duodenum and seven years postoperativeIy a second primary carcinoma deveIoped aIso in the ascending coIon near the hepatic ffexure. Right coIectomy was successfuIIy performed in June 1963. A fifth patient treated for carcinoma of the ampuIIa of Vater had a singIe metastatic implant in an abdominal wound which was successfuIIy removed one year postoperatively. This patient is aIive six years after a WhippIe resection and five years after excision of the metastatic Iesion.

Iarge vesseIs shouId be separated from the area of pancreatic, choIedocha1 and gastric anastomoses. This is readiIy accompIished by using the entire omentum to form a serosal Iayer between the anastomoses and major vesseIs. If fistula or abscess formation occurs, the IikeIihood of erosion into a vesse1 and resuIting exsanguinating hemorrhage is reduced. MortaIity foIIowing operation by the senior surgica1 staff has decreased significantIy in recent years, forty-three consecutive resections have been performed by members of the senior staff during the past ten years with a mortaIity of 12 per cent. Rare instances of Iong-term survival of Iesions in this area treated by Iesser procedures have been recorded; however, there is no question that the best resuIts are obtained with this operation, as over 100 patients surviving for five years or more have been recorded in the Iiterature. CarefuI foIIow-up study of a11 patients is mandatory if optima1 Iong-term surviva1 is to be achieved. Patients with findings suggesting recurrent carcinoma should be re-expIored, for four of our six five-year survivors wouId have died of benign disease or a second resectabIe malignancy if this policy had not been foIIowed.

COMMENTS

The mortality in this series is simiIar to that reported from many other cIinics. This rate is aIso similar to that after paIIiative procedures for relief of obstructive jaundice [2]. The postoperative mortaIity can be reduced, however, by carefu1 attention to technica detai1. CompIete prevention of pancreatic f%tuIa is apparentIy not possibIe with current technics of anastomosis; however, the incidence of this compIication wil1 be reduced to a minimum by an accurate two Iayer anastomosis. CarefuI drainage is important for even though a fistuIa occurs, it can be successfuIIy treated if generaIized peritonea1 contamination or abscess formation is avoided. This is we11 iIIustrated by our experience with the treatment of pancreatic fistuIas resuIting from traumatic wounds. None of twenty-three such patients died [?I. Thus, if a we11 established drainage tract exists before Ieakage occurs and if pancreatic juice has free egress to the exterior, death shouId rarely occur from this complication. A second technica point of some importance is carefu1 contro1 of hemorrhage at a11 times. ParticuIar attention shouId be paid to ligation of major branches of the hepatic artery. At present, I suture the stump of the gastroduodena artery with pIastic arteria1 suture rather than appIy a Iigature. A suture gives more secure contro1 and the plastic materiaIs are Iess Iikely to give rise to compIications if fistuIa formation or infection occurs. Furthermore, the

SUMMARY

Sixty-four consecutive patients were treated for malignancy of the pancreas and periampulIary region with pancreatoduodenectomy, with an operative mortaIity of 22 per cent. CarefuI attention to technica detai1 and famiIiarity with the operative procedure can resuIt in a lowered mortaIity as attested by an operative mortaIity of 12 per cent in patients operated upon by the senior staff in the past ten years. The three year surviva1 rate among forty-two patients who underwent a successfu1 operation was 29 per cent and the five year surviva1 rate among thirty patients was 20 per cent. Pancreatoduodena1 resection is the best treatment currentIy avaiIabIe for cancer of the pancreas and periampuIIary region. REFERENCES

PARSONS, W. B. and MULLINS, C. R. Treatment of carcinoma of the ampulla of Vater. Am. Surgeon, 102: 763, 1935. 2. HOWELL. J. F., BURRUS. G. R. and JORDAN, G. L., JR. S&gicaI. management of pancreatic injuries. J. Trauma, I: 32, 1961. 3. HOWARD, J. M. and JORDAN, G. L., JR. SurgicaI Diseases of the Pancreas. PhiIadelphia, x960. J. B. Lippincott & Co. I. WHIPPLE, A. O.,

316