Extended lymphadenectomy in cephalic pancreatoduodenectomy. Personal observations
Meriggi, F.; Gramigna, P.; Forni, E.
Hepato-Gastroenterology 54(74): 549-555
2007
ISSN/ISBN: 0172-6390 PMID: 17523320 Document Number: 607584
Background/Aims: Long-term survival in patients with cancer of the pancreatic head is disappointing. Surgery is the only curative therapy. Unfortunately the prognosis of resected patients (10-15%) is extremely poor due to loco-regional cancer recurrence (50%). Lymphatic and perineural invasion may account for local recurrence. Japanese studies have reported the importance of an extended lymphadenectomy during the classic Whipple exeresis (40% of patients present lymph node metastases).Methodology: At the General Surgical Clinic of Pavia University 20 patients (14 men, 6 women, mean age 62.4 yr) with pancreatic head cancer (17 adenocarcinoma, 1 lymphoma, 2 carcinoma) underwent Whipple's exeresis with a regional (peripancreatic or R-1) and juxta-regional (para-aortic or R-2) lymphadenectomy according to the Ishikawa technique, between 1996-2000. R-1 nodes consisted of lymph nodes at the pylorus, superior pancreatic head, common bile duct, anterior pancreaticoduodenal region, inferior pancreatic head and superior mesenteric vessels. R-2 nodes consisted of lymph nodes at the superior and inferior pancreatic body, mid colic region, common hepatic duct, celiac axis and para-aortic region.Results: The wide dissection was quite easy in patients with a serious cholestatic disease. Intraoperative mortality was 0%. Operative mortality was 5%. Postoperative complications (20%) consisted of 1 sepsis, 1 hepato-renal syndrome with hepatic coma, 1 intestinal obstruction by adhesive bands, and I wound infection.Eight patients (40%) died during a mean follow-up period of 6 months (neoplastic recurrence 50%). Notwithstanding the advanced disease (stage III 50%; N-1+ 50%, 12 patients (60%) had a median postoperative survival rate of 18.4 months (range 1-48 months) without neoplastic recurrence. Tumor diameter was less than 4cm in 83.3% of cases.Conclusions: An earlier diagnosis (with tumor diameter <4cm) can improve pancreatic head cancer prognosis. A wide surgical exeresis with R-2 lymph nodes clearance together with surrounding connective and nervous tissue can remove micrometastases and better control local recurrence.