Comparison of proton beam radiotherapy and hyper-fractionated accelerated chemoradiotherapy for locally advanced pancreatic cancer.

OBJECTIVES: We compared the clinical outcomes of proton beam radiotherapy (PBRT) and those of conventional chemoradiotherapy via hyper-fractionated acceleration radiotherapy (HART) after induction chemotherapy in patients with locally advanced pancreatic cancer (LAPC). METHODS: Twenty-five consecutive patients with LAPC received induction chemotherapy comprising gemcitabine and S-1 before radiotherapy. Of these, 15 and 10 were enrolled in the HART and PBRT groups, respectively. RESULTS: Moderate hematological toxicities were observed only in the HART group, whereas two patients in the PBRT group developed duodenal ulcers. All patients underwent scheduled radiotherapy, with overall disease control rates of 93% and 80% in the HART and PBRT groups, respectively. Local progression was observed in 60% and 40% of patients in the HART and PBRT groups, respectively. However, there was no statistical significance between the two groups regarding the median time to progression (15.4 months in both) and the median overall survival (23.4 v.s. 22.3 months). CONCLUSIONS: PBRT was feasible and tolerable, and scheduled protocols could be completed with careful attention to gastrointestinal ulcers. Despite the lower incidence of local recurrence, PBRT did not yield obvious progression control and survival benefits relative to conventional chemoradiotherapy.

Pancreaticogastrostomy after Pancreaticoduodenectomy Using Twin Square Wrapping with Duct-to-Mucosa Anastomosis.

BACKGROUND/PURPOSE: This study aimed to evaluate the feasibility and safety of a novel pancreaticogastrostomy technique for diminishing pancreatic fistulas after pancreaticoduodenectomy using gastric wrapping of the pancreatic stump with a twin square-shaped horizontal mattress and a suture fixing the main pancreatic duct to the gastric mucosa anastomosis [twin square wrapping (TSW) method]. METHODS: Fifty-three patients undergoing pancreaticogastrostomy after pancreaticoduodenectomy were included in the study and chronologically divided into a conventional group (n = 32) and a TSW group (n = 21). The perioperative factors and the postoperative outcomes were retrospectively analyzed. RESULTS: The operating time for the pancreatic anastomosis, the total operating time, and the blood loss volume in the TSW group were lower than in the conventional group, but without a statistically significant difference. The TSW group had a significantly lower postoperative white blood cell count and C-reactive protein level, with a reduced intra-abdominal fluid accumulation as assessed by computed tomography on postoperative day 7, had a lower incidence of postoperative complications and pancreatic fistulas, and achieved a shorter duration of drain placement and shorter postoperative hospital stays as compared to the conventional group. CONCLUSIONS: The TSW technique should be considered for reducing pancreatic fistulas by diminishing the postoperative inflammatory response and improving patient outcomes without increasing the operating time.

Subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) prevents postoperative delayed gastric emptying.

BACKGROUND AND OBJECTIVES: Delayed gastric emptying (DGE) is one of main complications after pylorus-preserving pancreaticoduodenectomy (PPPD) with regional lymph node dissection (RLND). The aim of this study was to retrospectively investigate whether subtotal stomach-preserving PD (SSPPD) decreased incidence of DGE. METHODS: This study included 112 consecutive patients underwent PPPD (n = 48) or SSPPD (n = 64) with/without RLND. DGE was classified into three categories (grades A, B, and C) according to the guideline proposed by the International Study Group of Pancreatic Surgery. RESULTS: The incidence of DGE grade B/C in SSPPD with RLND (13.0%) was lower compared with that (34.8%) in PPPD with RLND (P = 0.0326). Consequently, the mean length of postoperative hospital stay of SSPPD with RLND group was significantly shorter than that of PPPD with RLND (P = 0.0476). CONCLUSIONS: SSPPD could be substituted for PPPD due to decreased postoperative DGE when RLND is involved. A randomized control trial of SSPPD versus PPPD should be considered.

[Chemoradiotherapy for locally recurrence after primary resection of biliary-pancreatic cancer].

Chemoradiotherapy for the unresectable pancreatic cancer and biliary cancer has been used for improving survival. In this study, we examined its safety and efficacy in cases with the local recurrence of pancreatic or biliary cancer after primary resection. Seven consecutive patients with recurrence of carcinoma of pancreas (n=3) and biliary system (n =4) were treated chemoradiotherapy. Local recurrence occurred around the portal vein in 6 patients and remnant pancreas in one patient respectively. Disease free survival after primary surgery was 22 months (range: 5-84). All patients received 50 Gy of conformal three-dimensional radiotherapy with concurrent 5-FU, Gemcitabine or S-1. Grade 3 of anorexia and elevation of transaminase level occurred in one patient respectively. Local tumor response was observed in two patients of pancreatic and biliary cancer respectively. Median survival calculated from the start of the chemoradiotherapy was 14.5 months (range: 6.4-23.9) in pancreatic cancer and 13.5 months (range: 10.8-19.8)in biliary cancer. Our data suggest that chemoradiotherapy is feasible and effective treatment option in patients who present local recurrence after primary surgery in pancreatic or biliary cancer.

Clinical impact of intraoperative navigation using a Doppler ultrasonographic guided vessel tracking technique for pancreaticoduodenectomy.

During pancreaticoduodenectomy (PD), early ligation of critical vessels such as the inferior pancreaticoduodenal artery (IPDA) has been reported to reduce blood loss. Color Doppler flow imaging has become the useful diagnostic methods for the delineation of the anatomy. In this study, we assessed the utility of the intraoperative Doppler ultrasonography (Dop-US) guided vessel detection and tracking technique (Dop-Navi) for identifying critical arteries in order to reduce operative bleeding. Ninety patients who received PD for periampullary or pancreatic disease were enrolled. After 14 patients were excluded because of combined resection of portal vein or other organs, the remaining were assigned to 1 of 2 groups: patients for whom Dop-Navi was used (n = 37) and those for whom Dop-Navi was not used (n = 39; controls). We compared the ability of Dop-Navi to identify critical vessels to that of preoperative multi-detector computed tomography (MD-CT), using MD-CT data, as well as compared the perioperative status and postoperative outcome between the 2 patient groups. Intraoperative Dop-US was significantly superior to MD-CT in terms of identifying number of vessels and the ability to discriminate the IPDA from the superior mesenteric artery (SMA) based on blood flow velocity. The Dop-Navi patients had shorter operation times (531 min versus 577 min; no significance) and smaller bleeding volumes (1120 mL versus 1590 mL; P < 0.01) than the control patients without increasing postoperative complications. Intraoperative Dop-Navi method allows surgeons to clearly identify the IPDA during PD and to avoid injuries to major arteries.

Pancreaticogastrostomy: a pancreas-transfixing method with duct-to-mucosa anastomosis (with video).

Pancreatic fistula still remains a persistent problem after pancreaticoduodenectomy. We have devised a pancreas-transfixing suture method of pancreaticogastrostomy with duct-to-mucosa anastomosis. This technique is simple and reduces the risk of pancreatic leakage by decreasing the risk of suture injury of the pancreas and by embedding the transected stump into the wall of the stomach. This novel technique of pancreaticogastrostomy is an effective reconstructive procedure following pancreaticoduodenectomy, especially for patients with a soft and fragile pancreas.