Download PDF
Zentralbl Chir 2003; 128(5): 390-395
DOI: 10.1055/s-2003-40033
Originalarbeiten und Übersichten

© Georg Thieme Verlag Stuttgart · New York

Operatives Management bei der Therapie des Pankreaskarzinoms

Operative management in the treatment of pancreatic cancerL. Fischer*1 , H. Friess1 , K. Z'graggen1 , W. Uhl1 , M. W. Büchler1
  • 1Chirurgische Universitätsklinik Heidelberg
Further Information

Publication History

Publication Date:
18 June 2003 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Das Pankreaskarzinom ist eine der 10 häufigsten Todesursachen bei Krebsleiden in der westlichen Welt. Aufgrund seiner geringen Ansprechrate bei Bestrahlung und/oder Chemotherapie ist die radikale Operation die einzige kurative Therapieoption. Jedoch weisen ca. 80 % der Patienten bereits bei Diagnosestellung aufgrund lokaler Tumorinfiltration oder Fernmetastasen ein nicht mehr kurativ resezierbares Tumorstadium auf. Dies ist eine der Ursachen für die schlechte 5-Jahres-Überlebensrate von 3-24 % bei Pankreaskarzinompatienten. Bei gegebener Resektabilität gilt der klassische Whipple bei Pankreaskopftumoren immer noch als die Operationsmethode der Wahl. Studien zeigen jedoch zunehmend die Bedeutung der Pylorus-erhaltenden Whipple Operation, so dass diese OP-Methode bereits als gleichwertiges Standardverfahren angesehen werden kann. Die vor allem von japanischen Chirurgen propagierten erweiterten- bzw. regionalen Pankreasresektionen scheinen vom Konzept her in eine zukunftweisende Richtung zu deuten, allerdings konnte im Vergleich zum klassischen- oder Pylorus-erhaltenden Whipple bisher kein Vorteil im Hinblick auf das Langzeitüberleben bewiesen werden. Die europäische Multizenterstudie ESPAC-1 zeigt erstmalig in einem prospektiven, kontrollierten und randomisierten Studienansatz mit ausreichender Patientenzahl, dass Patienten nach einer Pankreaskarzinomresektion von einer adjuvanten Chemotherapie (5-FU und Folsäure), jedoch nicht von einer Radiochemotherapie (40 Gy und 5-FU) im Hinblick auf eine Verlängerung des medianen Überlebens (19,7 Monate vs. 14,0 Monate) profitieren.

Abstract

The carcinoma of the pancreas is one of the 10 leading causes of death in the Western countries. Because of the resistance of pancreatic cancer against radiation and/or chemotherapy surgery is still the only possibility for cure. However, about 80 % of patients with the diagnosis of pancreatic cancer are no more suitable for curative resection at the time of diagnosis because of local tumor infiltration or the presence of distant metastases. This is one reason for the unsatisfactory situation in terms of 5-year-survival rate of 3 to 24 %. In resectable tumors of the pancreas head the standard Whipple dominates still as the surgical method of choice. However, the pylorus preserving Whipple has been established as a surgical alternative to the classical Whipple. Other surgical procedures like extended or regional pancreatic resections, predominantly done by Japanese surgeons seem to fit the concept of radical resection. But compared to the classical Whipple or the pylorus preserving Whipple resection there is still no clear advantage in terms of long term survival. The prospective European multicenter study ESPAC-1 firstly demonstrated a survival advantage for adjuvant chemotherapy (5-FU and folic acid) but no gain for radiochemotherapy in the treatment of patients with R0 or R1 resected pancreatic cancer in terms of prolongation of mean survival (19.7 months vs. 14.0 months).

Schlüsselwörter

Pankreaskarzinom - chirurgische Therapie - Operationsverfahren - Morbidität - Mortalität

Key words

Pancreatic cancer - surgical therapy - operation methods - morbidity - mortality

Literatur

  • 1 Allema J H, Reinders M E, Vangulik T M. et al . Prognostic factors for survival after pancreatoduodenectomy for patients with carcinoma of the pancreas head region.  Cancer. 1995;  75 2069-2076
    PubMedSearch in Google Scholar
  • 2 Allison D C, Piantadosi S, Hruban R H. et al . DANN content and other factors associated with ten years survival after resection of pancreatic carcinoma.  J Surg Oncol. 1998;  67 151-159
    PubMedSearch in Google Scholar
  • 3 Andrén-Sandberg A, Ihse I. Factors influencing survival after total pancreatectomy in patients with pancreatic cancer.  Ann Surg. 1983;  198 605-610
    PubMedSearch in Google Scholar
  • 4 Andrén-Sandberg A, Lindberg C G, Lundstedt C, Ihse I. Computed tomography and laparoscopy in the assessment of the patient with pancreatic cancer.  J Am Coll Surg. 1998;  186 35-40
    CrossrefPubMedSearch in Google Scholar
  • 5 Baumel H, Huguer M, Manderscheid J C. et al . Results of resection for cancer of the exocrine pancreas: a study from the French Association of Surgery.  Br J Surg. 1994;  81 102-107
    PubMedSearch in Google Scholar
  • 6 Beger H G, Büchler M W, Friess H. Chirurgische Ergebnisse und Indikationen zu adjuvanten Maßnahmen beim Pankreaskarzinom.  Chirurg. 1994;  65 246-252
    PubMedSearch in Google Scholar
  • 7 Begg C B, Cramer L D, Hoskins W J. et al . Impact of hospital volume on operative mortality for major cancer surgery.  JAMA. 1998;  280 1747-1751
    CrossrefPubMedSearch in Google Scholar
  • 8 Birkmeyer J D, Warshaw A L, Finlayson S TG. et al . Relationship between hospital volume and late survival after pancreatoduodenectomy.  Surgery. 1999;  126 178-183
    CrossrefPubMedSearch in Google Scholar
  • 9 Büchler M W, Ebert M, Beger H G. et al . Grenzen chirurgischen Handelns beim Pankreaskarzinom.  Langenbecks Arch Suppl. 1993;  75 460-464 (Kongressber.)
    PubMedSearch in Google Scholar
  • 10 Büchler M W, Friess H, Wagner M, Kulli C, Wagener V, Z'graggen K. Pancreatic fistula after pancreatic head resection.  Br J Surg. 2000;  87 883-889
    CrossrefPubMedSearch in Google Scholar
  • 11 Cameron J L, Crist D W, Sitzmann J V. et al . The united states experience with surgery for pancreatic cancer.  Int J Pancreatol. 1991;  9 153-156
    PubMedSearch in Google Scholar
  • 12 Cameron J l, Crist D W, Sitzmann J V. et al . Factors influencing survival after pancreaticoduodenectomy for pancreatic cancer.  Am J Surg. 1991;  161 120-124
    CrossrefPubMedSearch in Google Scholar
  • 13 Cangemi V, Volpino P, Mingazzini P. et al . Role of surgery in ductal carcinoma of the pancreas.  Int Surg. 1992;  77 158-163
    PubMedSearch in Google Scholar
  • 14 Ceccherelli A. La chirurgie du pancréas.  XIIIme Congrès International de Médecine, Paris. 1990;  10 159-163
    PubMedSearch in Google Scholar
  • 15 Connolly M M, Dawson P J, Michelassi F. et al . Survival in 1001 patients with carcinoma of the pancreas.  Ann Surg. 1987;  206 366-373
    PubMedSearch in Google Scholar
  • 16 Cooperman A M, Kini S, Snady H. et al . Current surgical therapy for carcinoma of the pancreas.  J Clin Gastroenterol. 2000;  31 107-113
    CrossrefPubMedSearch in Google Scholar
  • 17 Dalton R R, Sarr M G, van Heerden J A. et al . Carcinoma of the body and tail of the pancreas: is curative resections justified?.  Surgery. 1992;  111 489-494
    PubMedSearch in Google Scholar
  • 18 Diederichs C G, Staib L, Vogel J. et al . Values and limitations of 18F- fluorodeoxyglucose-positron-emission tomography with preoperative evaluation of patients with pancreatic masses.  Pancreas. 2000;  20 109-116
    PubMedSearch in Google Scholar
  • 19 Edis A J, Kierman P D, Taylor W F. et al . Attempted curativ resection of ductal carcinoma of the pancreas.  Mayo Clin Proc. 1980;  55 531-536
    PubMedSearch in Google Scholar
  • 20 Fabre J M, Houry S, Manderscheid J C. et al . Surgery for left-sided pancreatic cancer.  Br J Surg. 1996;  83 1065-1070
    PubMedSearch in Google Scholar
  • 21 Farnell M B, Nagorney D M, Sarr M G. The Mayo clinic approach to the surgical treatment of adenocarcinoma of the pancreas.  Surg Clin North Am. 2001;  81 611-623
    CrossrefPubMedSearch in Google Scholar
  • 22 Forsmark C E, Albert C A, Lambiase L. et al . Diagnostic tests for pancreatic cancer.  Gastointest Endosc. 1993;  9 A314-A318
    PubMedSearch in Google Scholar
  • 23 Fortner J G. Regional resection of cancer of the pancreas: a new surgical approach.  Surgery. 1973;  73 307-320
    PubMedSearch in Google Scholar
  • 24 Friess H, Kleeff J, Silva J C. et al . The role of diagnostic laparoscopy in pancreatic and periampullary malignancies.  J Am Coll Surg. 1998;  186 575-582
    PubMedSearch in Google Scholar
  • 25 Gall F P, Hermanek P, Gebhardt C. et al . Erweiterte Resektion der Pankreas- und periampullären Karzinome. Regionale, totale und partielle Duodenopankreatektomie.  Leber Magen Darm. 1981;  11 179-184
    PubMedSearch in Google Scholar
  • 26 Grace P A, Pitt H A, Longmire W P. Pancreatoduodenectomy with pylorus preservation for adenocarcinoma of the head of the pancreas.  Br J Surg. 1986;  73 647-650
    PubMedSearch in Google Scholar
  • 27 Grace P E, Pitt A, Longmire W P. Pylorus Preserving pancreatoduodenectomy: an overview.  Br J Surg. 1990;  77 968-974
    PubMedSearch in Google Scholar
  • 28 Grahm A L, Andrén-Sandberg A. Prospective evaluation of pain in exocrine pancreatic cancer.  Digestion. 1997;  58 542-549
    CrossrefPubMedSearch in Google Scholar
  • 29 Guo X, Friess H, Graber H U. et al . KAI 1 expression is up-regulated in early pancreatic cancer and decreased in the presence of metasasis.  Cancer Res. 1996;  56 4876-4880
    PubMedSearch in Google Scholar
  • 30 Halsted W S. Contributions to the surgery of the bile passage, especially the common bile duct.  Boston Med Surg J. 1899;  141 645-661
    PubMedSearch in Google Scholar
  • 31 Henne-Bruns D, Vogel I, Luttges J. et al . Ductal adenocarcinoma of the pancreas head: Survival after regional versus extended lymphadenectomy.  Hepatogastroenterology. 1998;  45 855-866
    PubMedSearch in Google Scholar
  • 32 Hennig R, Tempia-Caliera A A, Hartel M, Friess H. Staging laparoscopy and its indications in pancreatic patients.  Dig Surg. 2002;  19 484-488
    CrossrefPubMedSearch in Google Scholar
  • 33 Herter F P, Cooperman A M, Ahlborn N, Antinori C. Surgical experience with pancreatic and periampullary cancer.  Ann Surg. 1982;  195 274-281
    PubMedSearch in Google Scholar
  • 34 Holzman M D, Reintgen K L, Tyler D S. et al . The role of laparoscopy in the management of suspected pancreatic and periampullary malignancies.  J Gastrointest Surg. 1997;  1 236-244
    PubMedSearch in Google Scholar
  • 35 Hruban R H, Canto M I, Yeo C J. et al . Prevention of pancreatic cancer and strategies for management of familiar pancreatic cancer.  Dig Dis. 2001;  19 76-84
    PubMedSearch in Google Scholar
  • 36 Hunt D R, McLean R. Pylorus preserving pancreatectomy: functional results.  Br J Surg. 1989;  76 173-176
    PubMedSearch in Google Scholar
  • 37 Ihse I, Andrén-Sandberg A, Permerth J. et al .Early results of subtotal pancreatectomy for cancer: an interim report. In: Beger HG, Büchler MW, Malfertheiner P (eds). Standards in pancreatic surgery. Berlin, Heidelberg, Springer Verlag 1993; 641 - 645
  • 38 Ishikawa O. Surgical technique, curability and postoperative quality of life in an extended pancreatectomy for adenocarcinoma of the pancreas.  Hepatogastrenterology. 1996;  43 320-325
    PubMedSearch in Google Scholar
  • 39 Kausch W. Das Carcinom der Papilla duodeni und seine radikale Entfernung.  Beitr Klin Chir. 1912;  78 439-452
    PubMedSearch in Google Scholar
  • 40 Kleeff J, Ishiwata T, Friess H. et al . The helix-loop-helix protein Id2 is overexpressed in human pancreatic cancer.  Cancer Res. 1998;  58 3769-3772
    PubMedSearch in Google Scholar
  • 41 Klinkenbijl J HG, van der Schellung G P, Hop W CJ. et al . The advantages of pylorus-preserving pancreaticoduodenectomy in malignant disease of the pancreas and the periampullary region.  Ann Surg. 1992;  216 142-145
    CrossrefPubMedSearch in Google Scholar
  • 42 Kozuschek W, Reith H B, Haarmann W. The role of pylorus-preserving duodenopancreatic head resection. In: Beger HG, Büchler MW, Malfertheimer P (eds). Standards in pancreatic surgery. Berlin, Heidelberg, Springer Verlag 1993; 414 - 417
  • 43 Livingston E H, Welton M L, Reber H A. et al . Surgical treatment of pancreatic cancer: the United States experience.  Int J Pancreatol. 1991;  9 153-157
    PubMedSearch in Google Scholar
  • 44 Matsuno S, Sato T. Surgical treatment for carcinoma of the pancreas. Experience in 272 patients.  Am J Surg. 1986;  152 499-504
    PubMedSearch in Google Scholar
  • 45 Mayo W J. The surgery of the pancreas.  Ann Surg. 1913;  63 145-150
    PubMedSearch in Google Scholar
  • 46 Mosca F, Giulianotti P C, Balestracci T. et al . Preservation of the pylorus in duodenencephalopancreatectomy in pancreatic and periampullary carcinoma.  Chir Ital. 1994;  46 59-67
    PubMedSearch in Google Scholar
  • 47 Mosca F, Giulianotti P C, Balesstracci. et al . Long-term survival in pancreatic cancer: pylorus-preserving vs. Whipple pancreatoduodenectomy.  Surgery. 1997;  122 553-566
    CrossrefPubMedSearch in Google Scholar
  • 48 Mukaiya M, Hirata K, Satoh T. et al . Lack of survival benefit of extended lymph node dissection for ductal adenocarninoma of the head of the pancreas: retrospective multi-instutional analysis in Japan.  World J Surg. 1998;  22 248-252
    PubMedSearch in Google Scholar
  • 49 Nagakawa T, Kobayashi H, Ueno K. et al . The pattern of lymph node involvement in carcinoma of the head of the pancreas. A histologic study of the surgical findins in patients undergoing extensive nodal dissection.  Int J Pancreatol. 1993;  13 15-22
    PubMedSearch in Google Scholar
  • 50 Neoptolemos J P, Dunn J A, Stocken D D, Almond J, Link K, Beger H, Bassi C, Falconi M, Pederzoli P, Dervenis C, Fernandez-Cruz L, Lacaine F, Pap A, Spooner D, Kerr D J, Friess H, Büchler M W, for the members of the European Study Group for Pancreatic Cancer ( ESPAC). ESPAC-1: a European randomised controlled study of adjuvant chemoradiation and chemotherapy in resectable pancreatic cancer.  Lancet. 2001;  358 1576-1585
    CrossrefPubMedSearch in Google Scholar
  • 51 Neoptolemus J P, Stocken D D, Dunn J A. et al . Influence of resection margins on survival for patients with pancreatic cancer treated by adjuvant chemoradiation and/or chemotherapy in the ESPAC-1 randomized controlled trial.  Ann Surg. 2001;  234 758-768
    PubMedSearch in Google Scholar
  • 52 Nordback I H, Hruban R H, Boitnott J K. et al . Carcinoma of the body and tail of the pancreas.  Am J Surg. 1992;  164 26-31
    PubMedSearch in Google Scholar
  • 53 Parkin D M, Muir C S, Whelan S L. et al .Cancer incidence in 5 continents. Volume VI Lyon: International Agency for Research on Cancer (IARC Scientific Publication No. 120) Oxford University Press 1992
  • 54 Pedrazzoli S, DiCarlo V, Dionigi R. et al . Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy group.  Ann Surg. 1998;  228 508-517
    Search in Google Scholar
  • 55 Pisters P W, Lee J E, Vauthey J N. et al . Laparoscopy in the staging of pancreatic cancer.  Br J Surg. 2001;  88 325-337
    CrossrefPubMedSearch in Google Scholar
  • 56 Pitt H A, Nordback I H. Resection of the distal pancreas. In: Howard J, Idezuki Y, Ihse I, Prinz R (eds). Surgical diseases of the pancreas (ed 3). Baltimore, Williams & Wilkins 1998; 579 - 585
  • 57 Poston G J, Gillespie J, Guillou P J. Biology of pancreatic cancer.  Gut. 1991;  32 800-812
    PubMedSearch in Google Scholar
  • 58 Rode J. The pathology of pancreatic cancer.  Bailliere's Clin Gastroenterol. 1990;  4 793-813
    PubMedSearch in Google Scholar
  • 59 Roder J D, Stein H J, Hüttl W. et al . Pylorus-preserving versus standard pancreaticoduodenectomy: an analysis of 110 pancreatic and periampullary carcinomas.  Br J Surg. 1992;  79 152-155
    PubMedSearch in Google Scholar
  • 60 Ross D E. Carcinoma of the pancreas: a plea for total pancreatectomy.  Am J Surg. 1954;  87 20-33
    PubMedSearch in Google Scholar
  • 61 Sanberg A A, Wagner M, Tihany T. et al . Technical Aspects of left sided pancreatic resection for cancer.  Digestive Surgery. 1999;  16 305-312
    CrossrefPubMedSearch in Google Scholar
  • 62 Seiler C, Wagner M, Schaller C. et al . Pylorus-erhaltender oder klassischer Whipple bei Tumoren - erste klinische Resultate einer prospektiv ransomisierten Studie.  Swiss Surg. 2000;  6 275-282
    PubMedSearch in Google Scholar
  • 63 Singh S M, Longmire W P, Reber H A. et al . Surgical palliation for pancreatic cancer: The UCLA experience.  Ann Surg. 1990;  212 132-139
    CrossrefPubMedSearch in Google Scholar
  • 64 Sperti C, Pasquali C, Piccoli A. et al . Survival after resection for ductal adenocarcinoma of the pancreas.  Br J Surg. 1996;  83 625-631
    PubMedSearch in Google Scholar
  • 65 Traverso L W, Longmire W P. Preservation of the pylorus in pancreatoduodenectomy.  Surg Gynecol Obstet. 1978;  146 959-962
    PubMedSearch in Google Scholar
  • 66 Trede M, Schwall G, Seager H D. Survival after pancreatoduodenectomy: 118 consecutive resections without an operative mortality.  Ann Surg. 1990;  211 447-458
    PubMedSearch in Google Scholar
  • 67 Trede M. Left hemipancreatectomy. In: Trede M, Carter DC (eds). Surgery of the pancreas. Edinburgh, Churchill Livingstone 1993; 477 - 480
  • 68 Tsao J I, Rossi R L, Lowell J A. Pylorus-preserving pancreatoduodenectomy.  Arch Surg. 1994;  129 405-412
    PubMedSearch in Google Scholar
  • 69 van Berge M I, van Gulik T M, DeWit L T. et al . Delayed gastric emptying after standard pancreaticoduodenectomy versus pylorus-preserving pancreaticoduodenectomy: an analysis of 200 consecutive patients.  J Am Coll Surg. 1997;  185 373-379
    CrossrefPubMedSearch in Google Scholar
  • 70 van Heerden J A. Pancreatic resection for carcinoma of the pancreas: Whipple versus total pancreatectomy - an institutional perspective.  World J Surg. 1984;  8 880-888
    CrossrefPubMedSearch in Google Scholar
  • 71 Wagner M, Friess H, Büchler M W. Conservative versus radical resection of the pancreas. In: Neoptolemos JP, Lemoine NR (eds). Pancreatic cancer - molecular and clinical advances. 1996; 248 - 254
  • 72 Wagner M, Kulli C, Friess H. et al . Chirurgie des Pankreaskarzinoms.  Swiss Surg. 2000;  6 264-270
    PubMedSearch in Google Scholar
  • 73 Watson K. Carcinoma of the ampulla of Vater. Successful radical resection.  Br J Surgery. 1944;  20 368-477
    PubMedSearch in Google Scholar
  • 74 Whipple A O, Parsons J W, Mullins C R. et al . Treatment of carcinoma of the ampulla of Vater.  Ann Surg. 1935;  102 763-769
    CrossrefPubMedSearch in Google Scholar
  • 75 Yeo C J, Abrams R A, Grochow L B. et al . Pancreaticoduodenectomy for pancreatic adenocarcinoma: postoperativ adjuvant chemoradiation improves survival. A prospective, single-institution experience.  Ann Surg. 1997;  225 621-633
    CrossrefPubMedSearch in Google Scholar
  • 76 Yeo C J, Cameron J L, Sohn T a. et al . Six hundred fifty consecutive pancreaticoduodenectomies in the 1990 s. Pathology, complications, and outcome.  Ann Surg. 1997;  226 248-257
    CrossrefPubMedSearch in Google Scholar

PD Dr. med. H. Friess

Abteilung für Allgemein-, Viszeral- und Unfallchirurgie der Universität Heidelberg

INF 110, Chirurgische Klinik

69120 Heidelberg

Phone: 0 62 21/56 69 00

Fax: 0 62 21/56 69 03

Email: Helmut_Friess@med.uni-heidelberg.de