An evaluation of extended pancreatectomy with resecting pylorus alone for advanced adenocarcinoma of the pancreas

Abstract

In resecting pancreatic cancer, the 5-year survival rate was improved from 11 to 29% in stage III and from 0 to 3% in stage IV, by extending the range of lymphatic and connective tissue clearance (D2α). Longterm survivors were obtained from the patients in the t2-subgroup regardless of the nodal involvement, however there was no 5-year survivor who had received D2α in the t3-subgroup. Liver perfusion chemotherapy via both portal vein and hepatic artery (2-channel treatment) significantly decreased the incidence of liver metastasis, resulting in a 25% 5-year survival rate for the t3-subgroup patients. Micrometastasis was examined in the peripyloric lymph node and surrounding connective tissues by histologic, cytologic and genetic (k-ras point mutation by MASA method) examinations. As a result, microinvasion was positive in two out of 15 patients by histologic examination alone, and in other three cases by cytologic or genetic examination. In order to eradicate the possible cancer cells around the pylorus and improve the patient's QOL, we performed pylorus resecting PD (PrPD) which preserved nearly entire stomach. In comparison with conventional PD, PrPD showed a smaller loss of body weight and earlier recovery. This result seemed to be supported by our isotopic analysis where the PrPD showed a longer gastric emptying speed than conventional PD. From these results, it is concluded that we need some adjuvant therapies, like 2-channel treatment, in addition to an extended pancreatectomy if we intend to resect advanced pancreatic cancer (t3). Likewise, the PrPD would be helpful in improving the patient's QOL after pancreatoduodenectomy without escalating the chance of local recurrence.