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DOI: 10.1055/a-1682-7456
Operationsindikationen bei Tumoren der Bauchspeicheldrüse
Indications for the surgical management of pancreatic neoplasms![](https://www.thieme-connect.de/media/zfg/202210/lookinside/thumbnails/zfg-0076_10-1055-a-1682-7456-1.jpg)
Zusammenfassung
Aufgrund einer steigenden Inzidenz nehmen Pankreasneoplasien, welche hauptsächlich Adenokarzinome, neuroendokrine und zystische Neoplasien umfassen, im klinischen Alltag eine zunehmende Relevanz ein.
Auf Grundlage einer systematischen Literaturrecherche wurden von Pankreasexperten im Auftrag der DGAV zur Verbesserung der Indikationsqualität evidenzbasierte Empfehlungen zur Indikationsstellung bei Pankreasneoplasien erarbeitet.
Eine eindeutige Operationsindikation besteht bei primär oder sekundär resektablen Pankreaskarzinomen ohne Metastasierung, bei funktionell aktiven sowie über 2 cm großen funktionell inaktiven neuroendokrinen Neoplasien und bei symptomatischen oder malignitätsverdächtigen zystischen Pankreasneoplasien einschließlich intraduktaler papillär-muzinöser Neoplasien (IPMN) vom Hauptgang und vom Mischtyp, muzinös-zystischer Neoplasien (MCN) > 4 cm und solid pseudopapillärer Neoplasien (SPN). Eine Operation kann bei Pankreaskarzinomen mit isolierter arterieller Gefäßinfiltration oder über längere Zeit stabiler Oligometastasierung im Rahmen von neuroendokrinen Neoplasien zur Metastasen- oder Debulkingchirurgie sowie bei Seitengang-IPMN mit Risikokriterien und MCN < 4 cm indiziert sein. Keine primäre Operationsindikation ergibt sich bei lokal fortgeschrittenen und metastasierten Pankreaskarzinomen oder serös-zystischen Neoplasien (SCN).
Insgesamt sollte die Operationsindikationsstellung individualisiert unter Berücksichtigung von Alter, Komorbiditäten und Patientenwunsch erfolgen.
Summary
Due to its rising incidence, pancreatic neoplasia, which mainly include adenocarcinomas, neuroendocrine and cystic neoplasia of the pancreas, is becoming increasingly relevant in everyday clinical practice.
Based on a systematic literature search, a working group of pancreatic experts developed evidence-based recommendations for surgical indications in pancreatic neoplasia to improve the quality.
There is a clear surgical indication for primary or secondary resectable pancreatic carcinomas without metastasis, for functionally active, symptomatic and functionally inactive neuroendocrine neoplasia of more than 2 cm in size and for cystic neoplasm with symptoms or signs of malignancy including all intraductal papillary-mucinous neoplasia (IPMN) of the main duct and mixed type, all mucinous-cystic neoplasia (MCN) > 4 cm and all solid pseudopapillary neoplasia (SPN). Surgery can be indicated for pancreatic carcinomas with isolated arterial vascular infiltration or for long periods of stable oligometastasis, regarding neuroendocrine neoplasias for metastasis or debulking surgery as well as for branch-duct IPMN with risk criteria and MCN <4 cm. There is no primary indication for surgery in locally advanced and metastatic pancreatic cancer or asymptomatic serous-cystic neoplasia (SCN).
The indication for surgery should always be individualized taking into account age, comorbidities and patient wishes.
Schlüsselwörter
Pankreasneoplasien - Pankreaskarzinom - Neuroendokrine Neoplsie des Pankreas - Zystische Pankreasneoplasie - Operationsindikation - PankreaschirurgieKeywords
Pancreatic neoplasia - pancreatic cancer - neuroendocrine pancreatic neoplasia - cystic pancreatic neoplasia - indication for surgery - pancreatic surgery* geteilte Erstautorenschaft
** geteilte Letztautorenschaft
Publikationsverlauf
Eingereicht: 02. Mai 2021
Angenommen nach Revision: 24. Oktober 2021
Artikel online veröffentlicht:
24. November 2021
© 2021. Thieme. All rights reserved.
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Literatur
- 1 Kromrey ML, Bülow R, Hübner J. et al. Prospective study on the incidence, prevalence and 5-year pancreatic-related mortality of pancreatic cysts in a population-based study. Gut 2018; 67 (01) 138-145 DOI: 10.1136/gutjnl-2016-313127. (PMID: 28877981)
- 2 de Jong K, Nio CY, Hermans JJ. et al. High prevalence of pancreatic cysts detected by screening magnetic resonance imaging examinations. Clin Gastroenterol Hepatol 2010; 8 (09) 806-811 DOI: 10.1016/j.cgh.2010.05.017. (PMID: 20621679)
- 3 Crippa S, Partelli S, Zamboni G. et al. Incidental diagnosis as prognostic factor in different tumor stages of nonfunctioning pancreatic endocrine tumors. Surgery 2014; 155 (01) 145-153 DOI: 10.1016/j.surg.2013.08.002. (PMID: 24646958)
- 4 Robert Koch-Institut. Zentrum für Krebsregisterdaten G. Krebs in Deutschland für 2013/2014. 11. Ausgabe 2017.
- 5 Grützmann R, Post S, Saeger HD. et al. Intraductal papillary mucinous neoplasia (IPMN) of the pancreas: its diagnosis, treatment, and prognosis. Dtsch Arztebl Int 2011; 108 (46) 788-794 DOI: 10.3238/arztebl.2011.0788. (PMID: 22163260)
- 6 Distler M, Welsch T, Aust D. et al. Intraductal papillary mucinous neoplasm of the pancreas (IPMN)--standards and new aspects. Zentralbl Chir 2014; 139 (03) 308-317 DOI: 10.1055/s-0033-1350892. (PMID: 24241954)
- 7 Belyaev O, Uhl W. Pankreaskarzinom – Chirurgie im Wandel der multimodalen Therapiemöglichkeiten. Allgemein- und Viszeralchirurgie up2date 2019; 13 (06) 511-530
- 8 Falconi M, Eriksson B, Kaltsas G. et al. Enets consensus guidelines update for the management of patients with functional pancreatic neuroendocrine tumors and non-functional pancreatic neuroendocrine tumors. Neuroendocrinology 2016; 103 (02) 153-171 DOI: 10.1159/000443171. (PMID: 26742109)
- 9 Mansky T, Nimptsch U, Grützmann R, Lorenz D. Zentrenbildung in der Pankreas- und Ösophaguschirurgie. In: Klauber J, Geraedts M, Friedrich J, Wasem J. Krankenhaus-Report 2017. Stuttgart: Schattauer; 2017: 95-106
- 10 Nimptsch U, Krautz C, Weber GF. et al. Nationwide In-hospital Mortality Following Pancreatic Surgery in Germany is Higher than Anticipated. Ann Surg 2016; 264 (06) 1082-1090 DOI: 10.1097/SLA.0000000000001693. (PMID: 26978570)
- 11 Belyaev O, Bösch F, Brunner M. et al. Von der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV)-konsentierte Operationsindikationen beim duktalen Pankreasadenokarzinom. Zentralbl Chir 2020; 145 (04) 354-364 DOI: 10.1055/a-1161-9501. (PMID: 32615624)
- 12 Bösch F, Belyaev O, Brunner M. et al. Operationsindikationen bei neuroendokrinen Neoplasien des Pankreas. Zentralbl Chir 2020; 145 (04) 365-373 DOI: 10.1055/a-1168-7103. (PMID: 32599635)
- 13 Brunner M, Belyaev O, Bösch F. et al. Operationsindikationen bei zystischen Tumoren des Pankreas. Zentralbl Chir 2020; 145 (04) 344-353 DOI: 10.1055/a-1158-9536. (PMID: 32498095)
- 14 Radulova-Mauersberger O, Belyaev O, Bösch F. et al. Indikationen zur chirurgischen und interventionellen Behandlung der akuten Pankreatitis. Zentralbl Chir 2020; 145 (04) 374-382 DOI: 10.1055/a-1164-7099. (PMID: 32557429)
- 15 Müller-Debus C, Wellner U, Belyaev O. et al. Operationsindikation bei der chronischen Pankreatitis. Zentralbl Chir 2020; 145 (04) 383-389 DOI: 10.1055/a-1168-7314. (PMID: 32726816)
- 16 Wittel UA, Lubgan D, Ghadimi M. et al. Consensus on determining the resectability of locally progressed pancreatic ductal adenocarcinoma – results of the Conko-007 multicenter trial. BMC Cancer 2019; 19 (01) 979 DOI: 10.1186/s12885-019-6148-5. (PMID: 31640628)
- 17 Isaji S, Mizuno S, Windsor JA. et al. International consensus on definition and criteria of borderline resectable pancreatic ductal adenocarcinoma. Pancreatology 2017; 18: 2-11 DOI: 10.1016/j.pan.2017.11.011. (PMID: 29191513)
- 18 Takaori K, Bassi C, Biankin A. et al. International Association of Pancreatology (IAP)/European Pancreatic Club (EPC) consensus review of guidelines for the treatment of pancreatic cancer. Pancreatology 2016; 16: 14-27 DOI: 10.1016/j.pan.2015.10.013. (PMID: 26699808)
- 19 Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF): S3-Leitlinie Exokrines Pankreaskarzinom, Langversion 1.0, 2013, AWMF Registernummer: 032–010OL. http://leitlinienprogramm-onkologie.de/Leitlinien.7.0.html.
- 20 Tempero MA. et al. National Comprehensive Cancer Network (NCCN) Guidelines. Pancreatic Adenocarcinoma, Version 1.2019 – November 8th, 2018.
- 21 National Institute for Health and Care Excellence. Pancreatic cancer in adults: diagnosis and management. NICE Guideline NG 85, February 2018.
- 22 Barenboim A, Lahat G, Geva R. et al. Neoadjuvant FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer: An intention to treat analysis. Eur J Surg Oncol 2018; 44: 1619-1623 DOI: 10.1016/j.ejso.2018.07.057. (PMID: 30146251)
- 23 Sohal DPS, Kennedy EB, Khorana A. et al. Metastatic pancreatic cancer: ASCO clinical practice guideline update. J Clin Oncol 2018; 36 (24) 2545-2556 DOI: 10.1200/JCO.2018.78.9636. (PMID: 29791286)
- 24 Tachezy M, Gebauer F. et al. Synchronous resections of hepatic oligometastatic pancreatic cancer: disputing a principle in a time of safe operations in a retrospective multicenter analysis. Surgery 2016; 160: 136-144
- 25 Hackert T, Niesen W. et al. Radical surtgery of oligometastatic pancreatic cancer. Eur J urg Oncol 2017; 43: 358-363
- 26 Bosch F, Hofmann K, Coenen M. et al. Surgical treatment of pnet – experience of a "high-volume" center. Surg Oncol 2018; 27 (03) 409-414 DOI: 10.1016/j.suronc.2018.05.027. (PMID: 30217295)
- 27 Rindi G, Falconi M, Klersy C. et al. Tnm staging of neoplasms of the endocrine pancreas: Results from a large international cohort study. J Natl Cancer Inst 2012; 104 (10) 764-777 DOI: 10.1093/jnci/djs208. (PMID: 22525418)
- 28 Ehehalt F, Franke E, Pilarsky C. et al. Molecular pathogenesis of pancreatic neuroendocrine tumors. Cancers (Basel) 2010; 2 (04) 1901-1910 DOI: 10.3390/cancers2041901. (PMID: 24281208)
- 29 Ehehalt F, Saeger HD, Schmidt CM. et al. Neuroendocrine tumors of the pancreas. Oncologist 2009; 14 (05) 456-467 DOI: 10.1634/theoncologist.2008-0259. (PMID: 19411317)
- 30 Mintziras I, Keck T, Werner J. et al. StuDoQ|Pancreas study group of the German Society for General and Visceral Surgery (DGAV). Implementation of Current ENETS Guidelines for Surgery of Small (≤2 cm) Pancreatic Neuroendocrine Neoplasms in the German Surgical Community: An Analysis of the Prospective DGAV StuDoQ|Pancreas Registry. World J Surg 2019; 43 (01) 175-182 DOI: 10.1007/s00268-018-4751-2. (PMID: 30097704)
- 31 Mintziras I, Keck T, Werner J. et al. StuDoQ|Pancreas Study Group of the German Society for General, Visceral Surgery (DGAV). Indications for resection and perioperative outcomes of surgery for pancreatic neuroendocrine neoplasms in Germany: an analysis of the prospective DGAV StuDoQ|Pancreas registry. Surg Today 2019; 49 (12) 1013-1021 DOI: 10.1007/s00595-019-01838-1. (PMID: 31240463)
- 32 Kuo EJ, Salem RR. Population-level analysis of pancreatic neuroendocrine tumors 2 cm or less in size. Ann Surg Oncol 2013; 20 (09) 2815-2821 DOI: 10.1245/s10434-013-3005-7. (PMID: 23771245)
- 33 Hashim YM, Trinkaus KM, Linehan DC. et al. Regional lymphadenectomy is indicated in the surgical treatment of pancreatic neuroendocrine tumors (pnets). Ann Surg 2014; 259 (02) 197-203 DOI: 10.1097/SLA.0000000000000348. (PMID: 24253141)
- 34 Reid MD, Balci S, Saka B, Adsay NV. Neuroendocrine tumors of the pancreas: Current concepts and controversies. Endocr Pathol 2014; 25 (01) 65-79 DOI: 10.1007/s12022-013-9295-2. (PMID: 24430597)
- 35 Shah MH, Goldner WS, Halfdanarson TR. et al. Nccn guidelines insights: Neuroendocrine and adrenal tumors, version 2.2018. J Natl Compr Canc Netw 2018; 16 (06) 693-702 DOI: 10.6004/jnccn.2018.0056. (PMID: 29891520)
- 36 Oberg K. Management of functional neuroendocrine tumors of the pancreas. Gland Surg 2018; 7 (01) 20-27 DOI: 10.21037/gs.2017.10.08. (PMID: 29629316)
- 37 Mehrabi A, Fischer L, Hafezi M. et al. A systematic review of localization, surgical treatment options, and outcome of insulinoma. Pancreas 2014; 43 (05) 675-686 DOI: 10.1097/MPA.0000000000000110. (PMID: 24921202)
- 38 Bartsch DK, Albers M, Knoop R. et al. Enucleation and limited pancreatic resection provide long-term cure for insulinoma in multiple endocrine neoplasia type 1. Neuroendocrinology 2013; 98 (04) 290-298 DOI: 10.1159/000357779. (PMID: 24356648)
- 39 Norton JA, Foster DS, Blumgart LH. et al. Incidence and prognosis of primary gastrinomas in the hepatobiliary tract. JAMA Surg 2018; 153 (03) e175083 DOI: 10.1001/jamasurg.2017.5083. (PMID: 29365025)
- 40 Norton JA, Foster DS, Ito T. et al. Gastrinomas: Medical or surgical treatment. Endocrinol Metab Clin North Am 2018; 47 (03) 577-601 DOI: 10.1016/j.ecl.2018.04.009. (PMID: 30098717)
- 41 Ito T, Igarashi H, Jensen RT. Zollinger-ellison syndrome: Recent advances and controversies. Curr Opin Gastroenterol 2013; 29 (06) 650-661 DOI: 10.1097/MOG.0b013e328365efb1. (PMID: 24100728)
- 42 Lopez CL, Falconi M, Waldmann J. et al. Partial pancreaticoduodenectomy can provide cure for duodenal gastrinoma associated with multiple endocrine neoplasia type 1. Ann Surg 2013; 257 (02) 308-314 DOI: 10.1097/SLA.0b013e3182536339. (PMID: 22580937)
- 43 Hruban RH, Kloeppel G, Bofetta P. et al. Tumours of the pancreas. In: Bosman FT, Carneiro F, Hruban RH. WHO classification of tumours of the digestive system. 4. Aufl. Lyon: International Agency for Research on Cancer; 2010: 280-330
- 44 European Study Group on Cystic Tumours of the Pancreas. European evidence-based guidelines on pancreatic cystic neoplasms. Gut 2018; 67 (05) 789-804
- 45 Cizginer S, Turner BG, Bilge AR. et al. Cyst fluid carcinoembryonic antigen is an accurate diagnostic marker of pancreatic mucinous cysts. Pancreas 2011; 40 (07) 1024-1028 DOI: 10.1097/MPA.0b013e31821bd62f. (PMID: 21775920)
- 46 Gaddam S, Ge PS, Keach JW. et al. Suboptimal accuracy of carcinoembryonic antigen in differentiation of mucinous and nonmucinous pancreatic cysts: results of a large multicenter study. Gastrointest Endosc 2015; 82 (06) 1060-1069 DOI: 10.1016/j.gie.2015.04.040. (PMID: 26077458)
- 47 Tanaka M, Fernández-Del Castillo C, Kamisawa T. et al. Revisions of international consensus Fukuoka guidelines for the management of IPMN of the pancreas. Pancreatology 2017; 17 (05) 738-753 DOI: 10.1016/j.pan.2017.07.007. (PMID: 28735806)
- 48 Vege SS, Ziring B, Jain R. et al. Clinical Guidelines Committee; American Gastroenterology Association. American gastroenterological association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology 2015; 148 (04) 819-822 DOI: 10.1002/14651858.MR000040.pub3. (PMID: 33289919)
- 49 Seo N, Byun JH, Kim JH. et al. Validation of the 2012 International Consensus Guidelines Using Computed Tomography and Magnetic Resonance Imaging: Branch Duct and Main Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas. Ann Surg 2016; 263 (03) 557-564 DOI: 10.1097/SLA.0000000000001217. (PMID: 25822687)
- 50 Hackert T, Fritz S, Klauss M. et al. Main-duct Intraductal Papillary Mucinous Neoplasm: High Cancer Risk in Duct Diameter of 5 to 9 mm. Ann Surg 2015; 262 (05) 875-880 DOI: 10.1097/SLA.0000000000001462. (PMID: 26583679)
- 51 Abdeljawad K, Vemulapalli KC, Schmidt CM. et al. Prevalence of malignancy in patients with pure main duct intraductal papillary mucinous neoplasms. Gastrointest Endosc 2014; 79 (04) 623-629 DOI: 10.1016/j.gie.2013.08.024. (PMID: 24094923)
- 52 Tanaka M, Fernández-del Castillo C, Adsay V. et al. International Association of Pancreatology. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas. Pancreatology 2012; 12 (03) 183-197 DOI: 10.1097/SLA.0000000000001173. (PMID: 25775066)
- 53 Matos JM, Grützmann R, Agaram NP. et al. Solid pseudopapillary neoplasms of the pancreas: a multi-institutional study of 21 patients. J Surg Res 2009; 157 (01) e137-e142 DOI: 10.1016/j.jss.2009.03.091. (PMID: 19818965)
- 54 Liu M, Liu J, Hu Q. et al. Management of solid pseudopapillary neoplasms of pancreas: A single center experience of 243 consecutive patients. Pancreatology 2019; 19 (05) 681-685 DOI: 10.1016/j.pan.2019.07.001. (PMID: 31281058)
- 55 Crippa S, Capurso G, Cammà C. et al. Risk of pancreatic malignancy and mortality in branch-duct IPMNs undergoing surveillance: A systematic review and meta-analysis. Dig Liver Dis 2016; 48 (05) 473-479 DOI: 10.1016/j.dld.2016.02.003. (PMID: 26965783)
- 56 Del Chiaro M, Ateeb Z, Hansson MR. et al. Survival Analysis and Risk for Progression of Intraductal Papillary Mucinous Neoplasia of the Pancreas (IPMN) Under Surveillance: A Single-Institution Experience. Ann Surg Oncol 2017; 24 (04) 1120-1126 DOI: 10.1245/s10434-016-5661-x. (PMID: 27822633)
- 57 Brunner M, Weber GF, Kersting S. et al. Branch duct intraductal papillary mucinous neoplasm – contra resection. Chirurg 2017; 88 (11) 918-926 DOI: 10.1007/s00104-017-0495-z. (PMID: 28871376)
- 58 Malleo G, Marchegiani G, Borin A. et al. Observational study of the incidence of pancreatic and extrapancreatic malignancies during surveillance of patients with branch-duct intraductal papillary mucinous neoplasm. Ann Surg 2015; 261 (05) 984-990 DOI: 10.1097/SLA.0000000000000884. (PMID: 25493361)
- 59 Lévy P, Jouannaud V, O'Toole D. et al. Natural history of intraductal papillary mucinous tumors of the pancreas: actuarial risk of malignancy. Clin Gastroenterol Hepatol 2006; 4 (04) 460-468 DOI: 10.1016/j.cgh.2006.01.018. (PMID: 16616351)
- 60 Tanno S, Nakano Y, Nishikawa T. et al. Natural history of branch duct intraductal papillary-mucinous neoplasms of the pancreas without mural nodules: long-term follow-up results. Gut 2008; 57 (03) 339-343 DOI: 10.1136/gut.2007.129684. (PMID: 17660227)
- 61 Uehara H, Nakaizumi A, Ishikawa O. et al. Development of ductal carcinoma of the pancreas during follow-up of branch duct intraductal papillary mucinous neoplasm of the pancreas. Gut 2008; 57 (11) 1561-1565 DOI: 10.1136/gut.2007.145631. (PMID: 18477671)
- 62 Distler M, Kersting S, Niedergethmann M. et al. Pathohistological subtype predicts survival in patients with intraductal papillary mucinous neoplasm (IPMN) of the pancreas. Ann Surg 2013; 258 (02) 324-330 DOI: 10.1097/SLA.0b013e318287ab73. (PMID: 23532107)
- 63 Grützmann R, Niedergethmann M, Pilarsky C. et al. Intraductal papillary mucinous tumors of the pancreas: biology, diagnosis, and treatment. Oncologist 2010; 15 (12) 1294-1309 DOI: 10.1634/theoncologist.2010-0151. (PMID: 21147870)
- 64 Niedergethmann M, Grützmann R, Hildenbrand R. et al. Outcome of invasive and noninvasive intraductal papillary-mucinous neoplasms of the pancreas (IPMN): a 10-year experience. World J Surg 2008; 32 (10) 2253-2260 DOI: 10.1007/s00268-008-9692-8. (PMID: 18668283)
- 65 Wellner UF, Grützmann R, Keck T. et al. Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie e. V., Qualitätskommission. [Quality indicators for pancreatic surgery: Scientific derivation and clinical relevance]. Chirurg 2018; 89 (01) 32-39 DOI: 10.1007/s00104-017-0564-3. (PMID: 29197019)
- 66 Krautz C, Nimptsch U, Weber GF. et al. Effect of Hospital Volume on In-hospital Morbidity and Mortality Following Pancreatic Surgery in Germany. Ann Surg 2018; 267 (03) 411-417 DOI: 10.1097/SLA.0000000000002248. (PMID: 28379871)
- 67 Weber GF, Schmid A, Uder M, Grützmann R. Management of Complications of Pancreatic Anastomoses. Zentralbl Chir 2018; 143 (03) 259-269 DOI: 10.1055/s-0043-119896. (PMID: 29126330)
- 68 Keane MG, Shamali A, Nilsson LN. et al. Risk of malignancy in resected pancreatic mucinous cystic neoplasms. Br J Surg 2018; 105 (04) 439-446 DOI: 10.1002/bjs.10787. (PMID: 29488646)
- 69 Postlewait LM, Ethun CG, McInnis MR. et al. Association of Preoperative Risk Factors with Malignancy in Pancreatic Mucinous Cystic Neoplasms: A Multicenter Study. JAMA Surg 2017; 152 (01) 19-25 DOI: 10.1001/jamasurg.2016.3598. (PMID: 27760255)