Volume 65 - 2002 - Fasc.3 - Symposium
Radical resection for pancreatic cancer
Ductal adenocarcinoma of the pancreas is still characterized by (1) poor prognosis after surgery and (2) extreme difficulty in early diagnosis, and we need a breakthrough. For the first problem, we have performed a wide range of lymphatic and connective tissue clearance (extended pancreatectomy) which has succeeded in improving the 5-year survival rate from 8% to 24% via decreasing the incidence of locoregional recurrence. When liver perfusion chemotherapy via the hepatic artery and the portal vein was added to the patients who had received extended pancreatect-omy, the 5-year survival rate was further elevated to 40% via decreas- ing the incidence of hepatic metastasis. We conclude that pancre- atic cancer should be treated by the better-balanced treatments between locoregional control and prevention of hepatic metastasis. For the second problem, we have more actively collected pancre- atic juice to perform cytodiagnosis even though no obvious tumor was delineated by the conventional imaging diagnoses. When can- cer cells were detected in the pancreatic juice, our method of intra- operative cytology was very useful in precisely locating the occult lesion indicating an appropriate range of pancreatectomy. The resected pancreas was proven to have included borderline malig- nancy and in situ or minimally-invasive carcinoma by the post- operative histology, and disease-free 5-year survival rate was 100%. In the future, we need to detect patients with a high risk of pancreatic cancer and develop a less-painful method to collect the pancreatic juice. (Acta gastroenterol. belg., 2002, 65, 166-170).
Gastric cancer : the french survey
Presentation of a multicentric retrospective french study con- cerning 4 655 cases of gastric cancer operated between 1980 and 1996. The mean age was 67,4 years old with a male predominance of 63,1%. Pains was the predominant presenting symptom (60%) followed by alteration of the general condition (44%) and aneamia (20%). 35,5% of tumors were of distal, 18,8% of middle and 18,6% of proximal localisation. As regard cancer stages, 40% were of stage I,-II and 60% of stages III,-IV. Subtotal gastrectomy was realised in 44%, total radical gastrectomy in 42,1% and other sur- gical procedures in 14% of cases (proximal gastric resection or atypical resection).D1 lymphadenectomy was associated in 58,4% and D2 in 41,6%. Morbidity was of 23% and mortality of 11,9% which passed from 19% during the first (1980,-85) to 8% in the last interval of time (1990,-96). The 5 years survival was 41% in case of gastric resection. In univariate analysis the 5 years relative survival was better in female patients (44% at 5 years), in patients younger than 50 years old (46%), when pain was the only clinical symptom (52,7%), in middle and distal third localisation (47%), in case of subtotal distal resection (47%) and in less advanced stages (79% at 5 years for stage I cancer). In multivariate analysis the 5 years survival was essentially correlated to the stage of the tumor and no real prognosis improvement was shown during the period of the study. (Acta gastroenterol. belg., 2002, 65, 161-165).
Palliative treatment in “peri"-pancreatic carcinoma: stenting or surgical therapy ?
Mostly, patients with peri-pancreatic cancer (including pan- creatic, ampullary and distal bile duct tumors) are diagnosed in a stage in which curative resection is not possible. The median sur- vival rate of patients with non resectable peri-pancreatic cancer varies between 6 and 12 months. During this period palliative treatment is necessary, which should focus on major symptoms as obstructive jaundice, duodenal obstruction and pain. Controversy exists about how to provide optimal palliative treatment.
Both surgical and non surgical palliative procedures relief obstructive jaundice. From early retrospective and prospective randomized studies it is known that in the early phase after treat- ment, more complications are found after surgical palliation, whereas in the late phase more complications are seen after endo- scopic palliation. Because more recent studies clearly showed improved results after surgical palliation, current recommenda- tions probably should be that patients with a suspected poor short- term survival (< 6 months) should be offered non surgical pallia- tive therapy and those with a longer life expectancy may best be treated with bypass surgery.
Unfortunately, valid criteria for estimating the remaining sur- vival time are not available, except for the presence of metastases. The use of a prognostic score chart might assist in estimating the prognosis. Literature does not give sufficient information to make a well deliberated (evidence based) selection between the different types of surgical bypasses, but a choledochojejunostomy is gene- rally preferred.
After stenting, a correlation is found between survival and the development of duodenal obstruction, and between 9% and 21% of the patients who underwent a surgical biliary bypass without a prophylactic gastric bypass, will develop gastric outlet obstruc- tion. Therefore, in patients with a relatively good prognosis it is recommended to perform routinely a double - biliary and gastric - bypass.
Pain is a frequent symptom and is related with poor survival. Pain management aside from pain medication can be performed by means of a celiac plexus blockade or a thorascopic splanch- nicectomy, and also radiotherapy seems to have a positive result on pain. (Acta gastroenterol. belg., 2002, 65, 171-175).
