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ORIGINAL ARTICLE
Year : 2023 | Volume
: 22
| Issue : 4 | Page : 537-543
Pancreatic Resection for Pancreatic Tumors our Experience at Suburban Hospital
Prabhat B Nichkaode, Bijay Sharma, Sreemanth Reddy, Ram Teja Inturi
Department of Surgery, D.Y. Patil Medical College and Research Centre, Affiliated to D.Y. Patil Vidyapeeth, Pune, Maharashtra, India
Correspondence Address:
Prabhat B Nichkaode
Department of Surgery, D.Y. Patil Medical College and Research Centre, Affiliated to D.Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_165_22
Abstract
Introduction: Resection of pancreatic tissue is necessary for many pancreatic diseases. The most common form of cancer, pancreatic duct adenocarcinoma, manifests with early metastases and is thought to be resistant to other currently known treatment regimens. Such tumors present a complex and difficult management and handling challenge for a surgeon. Surgical resection affords a better prognosis with a median survival of 14–20 months following resection and up to 25% 5-year survival rates. In this study, data from 75 pancreatic resections for diverse malignant pancreatic lesions will be presented. Methods: At a teaching institute in Central India, this ongoing longitudinal study began in 2009 and was carried on till 2018. Only 75 of the 122 patients who underwent pancreatic resection were deemed appropriate for the current study. All patients were thoroughly examined after being admitted before being given the option of surgery. There were 22 female patients and 53 male patients. The age range for the group was 34–67 years. Results from a range of different malignancies and various pancreatic resection procedures are presented in this study. Results: One of the most aggressive cancers, pancreatic adenocarcinoma, responds to surgical treatment better than other alternative techniques. Out of 75 patients in our series, 32 had pancreatic head cancer, 28 had periampullary cancer, 2 had duodenal cancer, 8 had distal cholangiocarcinoma, and 1 had mucin-producing cystadenocarcinoma. Four patients had pancreatic cancer in both the body and tail. Fifty-three men and 22 women, ages 34–67 years, Whipple's operation and distal pancreatectomy were the most frequent procedures. In our series, survival ranged from 18 to 24 months, and the 5-year survival rate was 12%, which is primarily seen with periampullary carcinoma. Conclusion: The sole option for long-term survival or a cure for pancreatic cancer is surgery. Chemoradiation is ineffective as a first line of treatment. However, some reports contend that palliative chemotherapy actually improves the quality of life. The biology of the illness rules and determines the result; the kind of surgery performed had no bearing on survival, morbidity, or fatality. Context: The above study was taken up in the context of – pancreatic tumors and pathological types, how imaging helps in deciding the plan of surgical management without biopsy. Outcomes of pancreatic resections for pancreatic cancer. Settings and Design: In a suburban hospital which is a tertiary care center, this longitudinal prospective study was conducted from 2009 to 2018.
Abstract in French Résumé
Introduction: La résection du tissu pancréatique est nécessaire pour de nombreuses maladies pancréatiques. La forme de cancer la plus courante, l'adénocarcinome du canal pancréatique, se manifeste par des métastases précoces et on pense qu'elle est résistante aux autres schémas thérapeutiques actuellement connus. De telles tumeurs présentent un défi de gestion et de manipulation complexe et difficile pour un chirurgien. La résection chirurgicale offre un meilleur pronostic avec une survie médiane de 14 à 20 mois après la résection et jusqu'à 25 % de taux de survie à 5 ans. Dans cette étude, les données de 75 résections pancréatiques pour diverses lésions pancréatiques malignes seront présentées. Méthodes: Dans un institut d'enseignement du centre de l'Inde, cette étude longitudinale en cours a débuté en 2009 et s'est poursuivie jusqu'en 2018. Seuls 75 des 122 patients ayant subi une résection pancréatique ont été jugés appropriés pour l'étude actuelle. Tous les patients ont été soigneusement examinés après leur admission avant de pouvoir subir une intervention chirurgicale. Il y avait 22 patients de sexe féminin et 53 patients de sexe masculin. La tranche d'âge du groupe était de 34 à 67 ans. Les résultats d'une gamme de différentes tumeurs malignes et de diverses procédures de résection pancréatique sont présentés dans cette étude. Résultats: L'un des cancers les plus agressifs, l'adénocarcinome du pancréas, répond mieux au traitement chirurgical que les autres techniques alternatives. Sur les 75 patients de notre série, 32 avaient un cancer de la tête du pancréas, 28 un cancer périampullaire, un cancer duodénal, 8 un cholangiocarcinome distal et 1 un cystadénocarcinome producteur de mucine. Quatre patients présentaient un cancer du pancréas au niveau du corps et de la queue. Cinquante-trois hommes et 22 femmes, âgés de 34 à 67 ans, l'opération de Whipple et la pancréatectomie distale étaient les procédures les plus fréquentes. Dans notre série, la survie variait de 18 à 24 mois et le taux de survie à 5 ans était de 12 %, ce qui est principalement observé dans le carcinome périampullaire. Conclusion: La seule option pour survivre à long terme ou guérir le cancer du pancréas est la chirurgie. La chimioradiothérapie est inefficace en première intention. Cependant, certains rapports affirment que la chimiothérapie palliative améliore réellement la qualité de vie. La biologie de la maladie gouverne et détermine le résultat ; le type d'intervention chirurgicale pratiquée n'avait aucune incidence sur la survie, la morbidité ou le décès. Contexte: L'étude ci-dessus a été reprise dans le contexte des tumeurs pancréatiques et des types pathologiques, comment l'imagerie aide à décider du plan de prise en charge chirurgicale sans biopsie. Résultats des résections pancréatiques pour le cancer du pancréas. Paramètres et conception: Dans un hôpital de banlieue qui est un centre de soins tertiaires, cette étude prospective longitudinale a été menée de 2009 à 2018.
Mots-clés: Complications, résections pancréatiques, résultats
Keywords: Complications, pancreatic resections, results
Introduction 
The presence of malignant and benign pancreatic illnesses determines how much pancreatic tissue needs to be removed. Examples of head resections include the common pancreaticoduodenectomy and other less invasive procedures such as central pancreatectomy and distal pancreatic resection. Pancreatic ductal carcinoma, the most common type of pancreatic cancer, presents with early metastases and it responds poorly to most treatment options. For the operating surgeon or his team, treating such cancer is a challenging and demanding task.[1],[2],[3] The prognosis is markedly improved with surgical excision after a median survival period of 14–20 months and an 8% 5-year survival rate.[4],[5] Patients in the surgical group fared quite well when surgical resection was compared to radiochemotherapy for resectable pancreatic cancer, with a median survival of 17 months versus 11 months in the chemoradiation group.[6],[7] Few studies suggest that the use of gemcitabine as first-line chemotherapy, in particular, is predominantly responsible for quality-of-life improvements.[8] For the head of pancreas cancer, duodenal cancer, distal cholangiocarcinoma (DCC), and periampullary cancer, the standard surgical approach is Whipple's or its pylorus-preserving variation. A distal pancreatectomy is required when the pancreatic body and tail are affected by tumors. Numerous studies have shown that adjuvant chemotherapy can help prolong overall life, even though neoadjuvant chemotherapy is still in its infancy.[9] To present data from 75 individuals who underwent various pancreatic resections for pancreatic cancer in light of this, was the aim of our study.
Inclusion criteria
All operable masses on imaging in the pancreas or in the distal common bile duct (CBD)All locally operable tumors of pancreas and distal CBDPatients with no metastasis in the liverPatients with good nutritional status and who are fully fit for supra-major surgery.Exclusion criteria
Patients with peritoneal and liver metastasisPatients with ascitesPatients who are immunocompromisedPatients who do not want to enroll in the studyBorderline resectable disease was not included. Methods In 2009, a teaching facility in Central India began this ongoing longitudinal study. Of the 122 pancreatic cancer patients, only 75 were deemed qualified for the study. One patient was also initially diagnosed as pancreatic tail adenocarcinoma, but after the tumor was excised, it was discovered to be a neuroendocrine tumor (glucagonoma), hence the was excluded from the study. The 46 patients who were still alive, all had locally advanced or metastatic pancreatic cancer, which was identified through imaging studies. There were 22 women and 53 men among the patients. The range of ages was 34–67 years. Every patient provided a thorough medical history, and all required examinations were performed, with an emphasis on liver and renal function, coagulation profile, CA 19–9, ultrasonography (USG) abdomen, upper gastrointestinal (GI) endoscopy, and biopsy when indicated. To evaluate the severity of the sickness and the involvement of the circulatory systems surrounding the pancreas, an abdominal computed tomography (CT) scan is performed [Figure 1]. Participants in the study were not included if they had ascites, peritoneal metastases, or liver metastases. When bilirubin levels were above 22 mg%, magnetic resonance cholangiopancreatography (MRCP)/endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting was performed before considering surgery. Due to a paucity of endoscopic USG technology, all patients underwent laparoscopies to determine their operability before surgery. As with any major surgery, all patients who were to receive pancreatic resection underwent preoperative planning, and they were intensively monitored in the surgical intensive care unit for 48–72 h. On days 3, 5, and 10 following surgery, drain amylase was performed to check for any pancreatic leak. The study compares standard Whipple's method to pylorus-preserving pancreaticoduodenectomy and provides pertinent changes in survival between the two approaches as well as morbidity and mortality of the surgery pylorus-preserving pancreaticoduodenectomy (PPPD) [Figure 2]. Any drain output that was evident after postoperative day 3 (POD 3) and had an amylase concentration that was more than three times higher than the serum amylase activity was referred to as a postoperative pancreatic fistula (POPF). The study was conducted in accordance with these definitions. Postoperative mortality was defined as passing away within 30 days of surgery or before being discharged from the hospital. After 7 days following surgery, the requirement for nasogastric decompression or the inability to swallow food or liquids is considered sign of delayed gastric emptying. The issues listed below were identified and categorized as problems: Contaminated internally (fluid requiring drainage), wound infection, and bleeding following surgery (requiring transfusion, endoscopic, or operative intervention), barrier leak (bilious drainage from intraoperatively placed drains or bile collection requiring drainage), cardiac (myocardial infarction or an emerging arrhythmia that needs to be treated) (myocardial infarction or new onset of arrhythmia requiring intervention) pneumonia, an effusion that needs to be drained, or reintubation. Within 30 days following the original treatment, sepsis (fever, leukocytosis, or bacteremia) must be surgically treated once more before the patient is planned for discharge.
Figure 2: Showing specimen of pylorus preserving pancreatico dudodenectomy with peri ampullary growthTechnicalities of the surgery
Allan Whipple did 1st successful surgery of pancreatic head cancer in 1912 as pancreatic duodenectomy with continuity of enterobiliary, pancreaticoenteric, and gastroenteric anastomosis. He noticed considerable morbidity and death in his series. Exploration, resection, and restoration of the GI continuity are the three fundamental processes in a pancreaticoduodenectomy. The procedure morbidity has currently decreased significantly as a result of technological changes. The traditional Whipple procedure entails the removal of the pancreatic head together with the duodenum, pylorus, and first few cm of the jejunum. Today, we have a wide variety of alterations, such as expanded lymphadenectomy, multivisceral surgeries, and large vascular resections. However, pancreaticoduodenectomy is still regarded as the gold standard of care for pancreatic cancer. This procedure carries a lot of complications, including chest issues, stomach dumping, POPF, and hemorrhage. In the current study, 32 patients with carcinoma head of pancreas, 28 with carcinoma periampullary region, 8 with carcinoma terminal part of bile duct, and 2 with adenocarcinoma 2nd part of duodenum underwent Whipple's procedure or its modification, PPPD distal pancreatectomy with or without splenectomy, were performed on five individuals with body and tail tumors. R-0 resection was performed on each of the 70 patients who underwent pancreaticoduodenectomy, in which pancreatic neck was transected 1 cm left to the portal vein. The distance between each anastomosis was roughly 10 cm from each anastomosis. The standard anastomosis at 10-cm pancreaticojejunostomy duct to mucosa, followed by at 20-cm hepaticojejunostomy by Blumgart's technique and then at 30-cm gastrojejunal anastomosis hand-sewn two-layered technique.
All anastomoses were performed by a surgeon who at least held the rank of Associate Professor and had experience doing these anastomoses. Anastomosis was performed in two layers using 4–0 PDS sutures. Texture of pancreas whether hard or soft determines the technique of anastomosis. The pancreas dunk-in approach was used while it was soft (having good exocrine function), or else it was duct to mucosa anastomosis.
Results Of the 75 patients, 53 (70.7%) were men and 22 (29.33%) were women. The age range was 34–67 years. In our 75-patient study group, 32 (42.66%) had pancreatic head cancer, 28 (37.33%) had periampullary cancer, 2 (2.66%) had duodenal cancer, 8 (10.66%) had distal cholangiocarcinoma, and 1 (1.33%) had mucinous cystadenocarcinoma including the body and tail. Four individuals (5.33%) had pancreatic cancer in both the body and the tail [Table 1]. Sixty-seven patients (89.33%) presented with jaundice. About 2.66% of the patients had symptoms of gastric outlet blockage. The diagnosis of duodenal cancer was confirmed by upper GI endoscopy and histology. Five patients (6.66%) with body and tail pancreatic cancer presented with abdominal pain with a tumor and nebulous abdominal symptoms. In carefully chosen individuals, an initial USG is followed by a CT scan to complete the diagnosis, along with an ERCP or MRCP. Due to financial limitations, we were unable to do a guided biopsy and endoscopic ultrasound, and we did not employ magnetic resonance imaging to map the lymph nodes in our investigation. The primary goal of a CT scan was to evaluate the severity of illness surrounding significant vascular structures [Figure 3]. In our series, we were against large vascular resections. Out of 75 patients, Whipple's pancreaticoduodenectomy was performed on 70 (93.33%). Of the 70 patients, 37 (52.85%) underwent a PPPD operation and 33 (47.14%) had a traditional Whipple's procedure. Due to the tumor's near closeness to the splenic hilum, four patients received splenectomy and five patients (6.66%) underwent distal pancreatectomy. Whipples' average operating time ranged from 180 to 270 min, while the distal pancreatectomy procedure took 180–220 min. One hundred and fifty ml of blood on average were lost. No patient had an intraoperative blood transfusion exceeding 200 ml. The histological diagnosis for all patients was adenocarcinoma; one patient had mucinous cystadenocarcinoma. As the patient had diabetes, a distal pancreatectomy with splenectomy was performed after fine-needle aspiration cytology under CT guidance revealed an adenocarcinoma in the patient's pancreatic tail tumor. Unexpectedly, the patient developed hypoglycemia and developed a necrolytic rash on both their upper and lower limbs. This validated the glucagonoma diagnosis, which was further confirmed by histopathology and immunohistochemistry. The patient was, therefore, excluded from the current series.
Table 1: Pancreatic cancer location, patient count, operations performed, and 5-year survivalThe Kaplan–Meier method was used to quantify morbidity, hospital mortality, and estimate survival, with the date of operation serving as the starting point and death as the endpoint. Six (8.57%) of the patients in our series experienced pancreatic leaks in Whipples. There was hospital mortality in all six individuals. All pancreatic leaks were identified by the presence of significant levels of amylase in drain fluid between the 3rd and 7th PODs, wound discharge, and subsequent wound dehiscence. Day 4 through day 6 saw the demonstration of a pancreatic leak. Bile leak from a hepaticojejunostomy was present in one patient (1.75%), and treatment was cautious and ended after 2 weeks. Following up on every last patient, it was discovered that head cancer patients had an average survival time of 16–20 months. No patients lived for 5 years, although we did see a 3-year survival rate in about 5% of the patient group with head cancer. No cholangiocarcinoma patient ever lived longer than 12–16 months. In contrast, periampullary malignancies had a survival time of 24–40 months. In this cohort, four patients (14.28%) had a 5-year survival rate following surgery. After 5 years, patients who underwent distal pancreatic resection for mucinous cystadenocarcinoma in the body and tail of the pancreas are still alive [Figure 4]. In our series, the average survival time for pancreatic body and tail adenocarcinomas was 12–18 months. After 18 months, no patients were still alive. Within 18 months, two duodenal cancer patients also passed away.
Discussion Since the time of Kausch and Whipple, different pancreatic and peripancreatic cancers have been treated by pancreatic resections. One of the most frequent pathologies is discovered to be pancreatic ductal adenocarcinoma, which is followed by ampullary or periampullary cancer. Distal cholangiocarcinoma requires Whipple's technique, and distal pancreatectomy is used to treat malignancies of the body and tail [Figure 5].[1],[2],[3] With a median life expectancy of 14–20 months and 5-year survival rates of <7% to 10%, surgical excision gives a dramatically improved prognosis.[1],[4],[5] In such a complicated circumstance, [Table 1], the current scenario is a challenging proposition because the results of various alternative therapies are unacceptably poor in terms of survival and quality of life.[6],[7],[8] According to several recent findings, using gemcitabine as a first line of therapy improves survival.[9] Males make up the majority of the pancreatic cancer patients in our dataset, with 53 (70.7%) men and 22 (29.33%) women among the 75 total patients. Thirty-two patients (42.66%) had carcinoma head of pancreas, 28 patients (37.33%) had carcinoma periampullary region, 2 had adenocarcinoma 2nd part of duodenum, 8 had carcinoma terminal part of bile duct, 1 had body-and-tail mucinous cystadenocarcinoma, and 4 had body-and-tail pancreatic cancer. The average age was between 46 and 56, with a range of 34–67. According to published research, the incidence of pancreatic head cancer ranges from 0.3 to 13.7/100000.[9] With an estimated frequency of 2.9 incidences per million people and accounting for roughly 0.2% of GI tract carcinomas, duodenal cancer is a very uncommon neoplasm. It makes up about 6% of periampullary malignancies. According to the published series, standard whipples surgery (SWS) 50% done for duodenal adenocarcinoma had overall 5-year survival rates that varied greatly but were often reported to be >50% in cases of curative resection.[10],[11] DCC The average age of the 56 DCCs in the study was 65 + 15 years. The median disease-free survival was 14.6 months, and recurrence occurred in 35 patients (67%) primarily in the liver (37%). The overall survival rate was 36.9 months on average.[12],[13][Table 2] and [Table 3] Seventy (75.333%) of the 75 patients in our study group received Whipple's pancreaticoduodenectomy. Of the 70 patients, 37 (52.85%) underwent a PPPD operation and 33 (47.14%) had a traditional Whipple's procedure. Due to the tumor proximity to the splenic hilum, four patients underwent splenectomy and five patients (6.66%) underwent distal pancreatectomy. A 2014 Cochrane Review looked at six randomized controlled trials (RCTs) that involved 465 patients with pancreatic or periampullary cancer and compared traditional Whipple pancreaticoduodenectomy with PPPD.[16] Between the two surgeries, the authors were unable to identify any meaningful differences in mortality, morbidity, or survival. With 512 participants across 8 RCTs, this review was updated in 2016. Even though some perioperative outcome markers significantly favored PPPD, the investigators did not find any indication of any differences in mortality, morbidity, or survival between the two surgeries that were important.[17] The most common reason for deadly complications following a Whipple's operation is POPF [Table 4].
Table 2: Pancreatic cancer patient's survival information after pancreatic resection
Table 3: Surgical procedure, operating time, average blood loss, hospital stay in days
Figure 5: Whipples procedure:divided neck of pancreas for peri ampullary cancer
Table 4: Mortality and morbidity after pancreatic resections for pancreatic cancerPancreaticoenterostomy still lacks a well-approved procedure, particularly in individuals with soft pancreas. The modified Blumgarts approach is risk-free, easy to use, and enhances postoperative results.[17] In our series, operational times in Whipples typically varied from 180 to 270 min. With a median blood loss of 570 ml (range: 50–850 ml), the median SWS lasted 265 min (range: 203–475). The distal pancreatectomy took 180–220 min to complete. The typical blood loss ranges from 150 to 200 ml. After SWS, patients' hospital stays ranged from 17.5 to 19.7 days on average, with around 27 of them being released within 12 days. A 2013 study reveals a hospital stay of 19.7 + 7.7 days. Delay in discharge is related to postoperative complications, which occurred in 62.5% (95/152) of cases and was the cause of mortality in 5.29% (5/152). A few factors that are linked to problems include age, body mass index, surgical method, blood transfusion, and hydration input.[19],[20] The patients who had PPPD underwent surgery for an average of 232 (165–270) min, with an average blood loss of 100–1300 cc. Pancreatic leak (5.5%) and delayed gastric emptying were seen more commonly with PPPD 6/14 (P = 0.05). With regard to survival and the 5-year survival rate, there is no discernible difference between the SWS and PPPD. According to recent estimates, the average patient's survival was 16 months, and their 5-year survival rate was 9.4%. The prognosis was impacted by blood loss during the procedure.[14],[15],[21],[22] All patients had the adenocarcinoma histological diagnosis; one patient had mucinous cystic adenocarcinoma. Billroth conducted the first distal pancreatectomy in 1884; it makes up about 25% of all pancreatic resections nowadays. Although the occurrence of the pancreatic leak is a prevalent source of morbidity, distal pancreatic resections can be accomplished with a low mortality rate. The technique used to close the pancreatic stump may affect postoperative morbidity.[18]
In contrast to real advice, the technical variations in the management of the resection and reconstructive components of surgery depend on the surgeon's preference. Surgery for pancreatic excision carries some risk of morbidity and mortality. Currently, it appears that pancreatic resection is the best treatment choice for pancreatic cancer in terms of quality of life and survival. However, it is necessary to analyze all of these surgical resections and innovative therapy methods in controlled clinical trials using the best statistical analyses. Borderline resectable tumors were not included in our study. Hence, no patients with neoadjuvant chemotherapy and radiotherapy were included. No patients with stage 3 and stage 4 were included. All these patients were decided on CT scan with pancreatic protocol who had no vascular involvement. Only stage 1 and stage 2 patients were included in the study.
Conclusion In contrast to real advice, the technical variations in the management of the resection and reconstructive components of surgery depend on the surgeon's preference. Surgery for pancreatic excision carries some risk of morbidity and mortality. Currently, it appears that pancreatic resection is the best treatment choice for pancreatic cancer in terms of quality of life and survival. However, it is necessary to analyse all of these surgical resections and innovative therapy methods in controlled clinical trials using the best statistical analyses. Borderline resectable tumours were not included in our study. So no patients with neo adjuvant chemotherapy and radiotherapy were included. No patients with stage 3 and stage 4 were included. All these patients were decided on CT scan with pancreatic protocol who had no vascular involvement. Only stage 1 and stage 2 patients were included in the study.
Financial support and sponsorship
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Conflicts of interest
There are no conflicts of interest.
References 
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