Reoperative pancreaticoduodenectomy for periampullary carcinoma

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Reoperative Pancreaticoduodenectomy Periampullary Carcinoma

for

Emily K. Robinson, MD, Jeffrey E. Lee, MD, Andrew M. Lowy, MD, Claudia J. Fenoglio, Peter W.T. Pisters, MD, Douglas B. Evans, MD, Houston, Texas

BACKGROUND: We have noted a continued increase in the number of patients referred to our institution for presumed or biopsy-proven periampullary carcinoma following an “exploratory” laparotomy during which tumor resection was not performed. Although previous work has demonstrated the safety of reoperative pancreaticoduodenectomy (PD), the need to avoid nontherapeutic laparotomy in these patients is obvious. In the current study, we sought to determine why PD was not performed at the initial operation. METHODS: Using the prospective pancreatic cancer database, we identified all patients who underwent reoperative PD at our institution between June 1990 and October 1995. Radiologic imaging prior to reoperation was standardized and based on thin-section, contrast-enhanced computed tomography (CT); helical CT was used in more recent cases. Pathologic data were obtained, and initial outside operative reports were reviewed to determine why a PD was not performed at the initial procedure. RESULTS: Twenty-nine patients underwent reoperative PD. Resection was not performed at the initial laparotomy because of the surgeon’s assessment of local unresectability (17 patients), lack of a tissue diagnosis of malignancy (9), misdiagnoses (2), and error in intraoperative management (1). In the 17 patients deemed to have unresectable disease, successful reoperative PD required vascular resection in 10. All 10 of these patients had resection with negative microscopic margins of excision. Of the 9 patients who did not have resection owing to diagnostic uncertainty, all 9 had undergone multiple intraoperative biopsies interpreted as negative for malignancy; 6 of 9 had carcinoma confirmed on permanent-section analysis of the biopsy specimens. Four patients suffered major complications from intraoperative large-needle biopsy.

From the Department of Surgical Oncology, the University of Texas M. D. Anderson Cancer Center, Houston, Texas. Requests for reprints should be addressed to Douglas B. Evans, MD, Section of Endocrine Tumor Surgery, Department of Surgical Oncology, Box 106, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030. Presented at the 48th Annual Meeting of the Southwestern Surgical Congress, Scottsdale, Arizona, April 28-May 1, 1996.

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0 1996 by Excerpta All rights reserved.

Medica,

Inc.

RN,

CONCLUSIONS: Detailed preoperative imaging and a clearly defined operative plan would have allowed successful resection at the initial operation in 27 of 29 patients who underwent reoperative PD. Avoidable patient morbidity and the cost of unnecessary surgery argue strongly against “exploratory” surgery in patients with presumed periampullary neoplasms. 0 7996 by Excerpta Medica, Inc. Am J Surg. 1996;172:462-436.

A

dvances in diagnostic imaging, surgical technique, and interventional endoscopy have significantly changed the diagnostic and treatment algorithms for patients with malignant obstruction of the extrahepatic bile duct secondary to exocrine pancreatic cancer. Laparotomy is no longer necessary for diagnosis or palliative biliary decompression in the majority of patients. Local tumor resectability can be accurately predicted based on highquality computed tomography (CT) images,’ and in patients with unresectable disease, the cytologic diagnosis can be obtained with CT-guided fine-needle aspiration (FNA).’ Biliary decompression, if necessary, can be achieved with endoscopic3 or laparoscopic techniques.4 Laparotomy can thereby be reserved for carefully selected patients with localized disease amenable to pancreaticoduodenectomy as part of a multimodality treatment program that includes systemic chemotherapy and extemalbeam radiation therapya Despite these technological advances, pancreatic adenocarcinoma remains the fifth leading cause of adult cancer mortality in this country.6 Surgical resection remains the only hope for long-term survival. The lack of effective systemic therapy results in the short survival of patients with unresectable, metastatic, or recurrent disease. This has resulted in the liberal use of “exploratory” laparotomy in all patients with apparently localized disease in the hopes that the tumor will be found to be completely resectable. However, the majority of patients are found at s,urgery to have locally advanced or metastatic disease, and the laparotomy results in a perioperative morbidity of 20% to 30%, a mean hospital stay of 14 to 20 days, a recovery period lasting an additional 15 to 20 days, and a median survival of only 6 months.7s Such an indiscriminate application of surgery to patients with advanced disease ignores such iissues as quality of life, cost, and the timely use of phase I and phase II investigational treatment programs. We have noted a continued increase in the number of patients referred to our institution for presumed or biopsyproven periampullary carcinoma following an initial laparotomy during which a tumor resection was not performed. Although our previous work has demonstrated the safety of 00’02-961 O/96/$1 PII SOOO2-9610(96)00218-8

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reoperative pancreaticoduodenectomy,’ the need to avoid nontherapeutic laparotomy in these patients is obvious. In the current study we sought to determine why pancreaticoduodenectomy was not performed at the initial operation.

PATIENTS

AND METHODS

Data on 29 patients who underwent reoperative pancreaticoduodenectomy between June I990 and October 1995 for biopsy-proven, or suspected carcinoma of the pancreatic head or periampullary region were retrieved from the prospective pancreatic surgery database. All patients had undergone abdominal laparotomy for planned pancreaticoduodenectomy prior to referral to our institution. We excluded patients who had undergone recent abdominal or biliary surgery for reasons other than resection of a periampullary or pancreatic head tumor and patients who had undergone minilaparotomy for biopsy alone. Also excluded were patients who underwent reoperative pancreaticoduodenectomy for recurrent neoplasms (carcinomas of duodenum or colon, soft tissue sarcoma) involving the duodenum and pancreas. To determine why the tumor was not resected during the first laparotomy prior to referral to our institution, the previous medical record and surgical operative note were retrospectively reviewed for all patients. In many cases, there was direct communication with the referring surgeon. Pretreatment evaluation at our institution included physical examination, chest radiography, and contrast-enhanced CT. Computed tomography was performed at 1.5~ or 3-mm section thickness and 5-mm scan interval at the time of intravenous contrast enhancement.’ Staging laparoscopy was not performed in these patients because recent laparotomy had demonstrated no evidence of extrapancreatic disease. Visceral angiography was performed in all patients who had undergone a biliary bypass involving the common bile duct to define hepatic arterial anatomy with special reference to the presence of a replaced right hepatic artery. Patients were required to fulfill strict CT criteria for resectability, which were ( 1) the absence of extrapancreatic disease, (2) no evidence of tumor encasement of the superior mesenteric artery (SMA) or celiac axis as defined by the presence of a normal fat plane between the tumor and these arterial structures, and (3) a patent superior mesenteric-portal venous (SMPV) confluence.’ Focal involvement of the SMPV did not preclude tumor resection and was treated with segmental venous resection.5 Sixteen patients were enrolled in our studies of preoperative chemoradiation, which involved the use of extemalbeam radiation therapy of 50.4 Gy or 30.0 Gy and concomitant protracted-infusion 5-fluorouracil (5FU) 300 mg/m* per day.” Patients who received preoperative chemoradiation underwent restaging with chest radiography and abdominal CT prior to reoperation. All surgical resections were performed using a standardized technique as previously described.” Electron-beam intraoperative radiation therapy (10 to 15 Gy) was delivered to the bed of the resected pancreas in a dedicated surgical suite, obviating patient relocation.‘* A standardized pathologic evaluation of the pancreaticoduodenectomy specimen was performed as recently desctibed.i3 Tumor size was determined following surgical resection by measuring the greatest transverse diameter of the tumor. In patients who THE

AMERICAN

PANCREATlCODUODENECTOMY/ROUINSON

ET AL

received preoperative chemoradiation, this was often difficult as gross tumor could not be demarcated from uninvolved pancreatic parenchyma in some patients. The retroperitoneal margin was defined as the soft tissue margin directly adjacent to the proximal 3 to 4 cm of the SMA. This margin was evaluated by microscopic examination of a Z- to 3-mm full-face (en-face) section of the margin taken jointly by the surgeon and pathologist.‘,i3 The day of surgery was counted as day 1 in determining hospital stay. Perioperative (in hospital or within 30 days of surgery) deaths and complications resulting in reoperation, the need for percutaneous drainage of intra-abdominal fluid collections, transfer to the intensive care unit, or delay in discharge (defined as a hospital stay of more than 21 days) were recorded. Following the completion of all treatment, patients were evaluated by physical examination, chest radiography, and CT every 3 to 4 months. Local tumor recurrence was defined as the development of a new low-density lesion in the region of the pancreatic bed on CT. Regional recurrence (peritoneal carcinomatosis) was defined as the development of new ascites or radiographic evidence of multifocal soft tissue nodules on abdominal CT. Distant recurrence was defined as the development of a new low-density lesion in the liver on CT or the presence of new lesions in the lung on standard chest radiography.

RESULTS Twenty-nine patients underwent successful reoperative pancreaticoduodenectomy. Twenty-five patients had been referred after uneventful recovery from their initial laparotomy. Four patients had been referred as direct hospital transfers because of acute complications following an unsuccessful attempt at pancreaticoduodenectomy. Two of these 4 patients had near complete gastric outlet obstruction due to large retrogastric fluid collections. Following percutaneous drainage, these proved to be pancreatic fistulas secondary to presumed transection of the pancreatic duct at the time of intraoperative core-needle biopsy of the pancreas. An additional patient had a large pancreatic phlegmon also secondary to intraoperative biopsy. A fourth patient was transferred with a large subhepatic bile collection and an intra-abdominal hematoma. The bile collection was drained percutaneously, and the hematoma resolved without interventional treatment. All 4 patients improved with medical management and intravenous hyperalimentation. Three of these 4 patients received 5-FU--based chemoradiation prior to reoperative pancreaticoduodenectomy. Tumors were not resected at the initial laparotomy owing to the surgeon’s intraoperative assessment of local tumor unresectability in 17 of the 29 patients (Table I). In these I7 patients’ operative reports, local unresectability was defined as tumor involvement of the superior mesenteric vein (SMV) or portal vein (6 patients), SMA (4), or hepatic artery (l), or as tumor extension into the root of the mesentery and transverse mesocolon ( 1); unresectability was not defined in 5 patients’ operative reports. In 9 of the 29 patients, the surgeon’s decision not to proceed with pancreaticoduodenectomy was due to the inability to obtain a cytologic or histologic diagnosis of malignancy despite multiple attempts at needle biopsy with frozen-section pathologic evaluation. Tumors were not resected in 2 patients JOURNAL

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1996

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TABLE I Reasons

ET AL 1 TABLE Survival

for not Performing Pancreaticoduodenectomy during the initial Laparotomy Number of Patients

Surgeon’s intraoperative assessment of unresectability Lack of a tissue diagnosis of malignancy Error in diagnosis Error in intraoperative management * 10/l 7 required

vascular

and Pattern of First Tumor with Adenocarcinoma

in Patients No. Patients

No evidence of disease Recurrent disease* Local-regional recurrence+ Distant recurrence* Median survival (months) Median follow-up (months)

17’ 9 2 1

resection.

11 11 6 6 19 13

* Dead of disease, 7; alive with disease, 4. + One patient had simultaneous local-regiona/ t 66 had recurrence in the liver.

and

distant

(liver) recurrence.

cholangiogram consistent with a malignant-appearing obstruction of the intrapancreatic portion of the common bile duct. On permanent-section histologic evaluation, no evidence of carcinoma could be found. Three (14%) of 22 patients with adenocarcinoma of the pancreas were found to have a microscopically positive retroperitoneal margin; no patient had a grossly positive margin of resection. All other margins (pancreatic and biliary) were histologically negative on pathologic evaluation. Of the 17 patients believed to have unresectable disease at their initial laparotomy, 10 required resection of an adjacent vascular structure at the time of reoperative pancreaticoduodenectomy. None of these 10 patients were found to have a positive retroperitoneal margin of excision. In 7 patients, the SMPV confluence was resected and repaired with either a primary anastomosis (3) or an autologous internal jugular vein interposition gral’t (4). A short segment of hepatic artery at the origin of the ;gastroduodenal artery was resected in 1 patient and repaired with a primary anastomosis. A replaced right hepatic artery was resected in 1 patient and repaired with a reversed saphenous vein interposition graft. Lastly, 1 patient required resection of the anterior wall of the inferior vena cava., and this was repaired with a patch using two segments of saphenous vein sewn together. Vascular resection was required in 4 of the remaining 12 patients. Patterns of tumor recurrence and survival. in the 22 patients with adenocarcinoma of the pancreas
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