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DIAGNOSIS AND SURGICAL TREATMENT OF BILIOPANCREATODUODENAL CANCER
Vi Maljartchouk*, Ae Klimov**, Va Ivanov*, Naresh Row***
*Professor; **Ass. Professor; ***Postgraduate, Department of Surgery, Russian People’s Friendship University, Moscow.
INTRODUCTION
Pancreatic cancer is diagnosed in 6%, cancer of Vater’s papilla in 1.6%, cancer of distal part of common bile duct in 2.8% of all cases of malignant tumours. Low respectability in cases of biliopancreatoduodenal cancer, which does not exceed 27%, is explained by difficulties in diagnosis of early stages. High mortality after pancreatoduodenal resection, up to 40%, frequency of specific postoperative complications, attaining 60%, and low five year survivability in cases of pancreatic head cancer, up to 8%, with mean life up to 18-21 months became the reason to start this work.
MATERIAL AND METHODS
The work is based on the analysis of results of diagnosis and treatment of 272 patients with biliopancreatoduodenal cancer, operated on at the period from 1986 to 1999. There were 157 females and 115 males with a mean age of 65 years. Obstructive jaundice was observed in 247 (91%) patients. The same results were obtained in other researches.
In case of pancreatic head cancer in 80% of patients the IIIrd and the IVth stages of disease were diagnosed. In case of Vater’s papilla cancer the IIIrd B stage was the most frequent, up to 40%. In case of cancer of distal part of the common bile duct the IIIrd A and the IVth stages were usually diagnosed.
DIAGNOSIS
At present, the main methods of diagnosis of oncological diseases, of biliopancreatoduodenal region are : ultrasound tomography, computed tomography, radiocontrast methods - percutaneous - transhepatic cholangiography and retrograde cholangiopancreatography.
Ultrasound Diagnosis. Ultrasound tomography was performed in 99.6% of patients. Due to methods of visualisation of distal part of the common bile duct and the major papilla, worked out in our clinic, the informativity of the examination has increased considerably. In case of pancreatic head cancer (Fig. 1) the informativity of the examination raised from 72.7% to 95.2%. In case of major papilla cancer (Fig. 2) - from 73.3% to 97.9% and in case of the cancer of distal part of the common bile duct (Fig. 3) - from 74.1% to 97.3%.
Fig : 1 Fig 2 Fig 3
This technique has permitted not only to reveal exact localisation of the process, but also to determine the signs of local and general dissemination : lesions of liver, and lymphatic nodes, dissemination of tumour in to blood vessels and neighbouring organs.
of patients, the greatest informativity of duodenoscopy was obtained in cases of major papilla cancer (Fig. 4) and made up 70.2%. Such low informativity is explained by frequent inverted development of the tumour into the common bile or pancreatic ducts. This type of Vater’s papilla tumour development was diagnosed in 35.4% of patients.
Radiocontrast Methods. Retrograde cholangiography and percutaneous-transhepatic cholangiography (Fig. 5). The highest accuracy, 89.6% was achieved by ERCP, in the pancreatic head cancer cases. Percutaneous - transhepatic cholangiography was accurate in 87.1% of cases of major papilla cancer.
Fig 4 Fig 5
Based on these results, an algorithm of diagnosis of biliopancreatoduodenal cancer was worked out in the clinic. The key place in the diagnosis is taken by US tomography. Applying this algorithm, accurate localisation and dissemination of tumour was determined in 97% of cases.
Preoperative Preparation
The aim of preoperative preparation was to decompress the biliary tract. Drainage of bile ducts was carried out in 46 patients. Percutaneous transhepatic cholangiostomy was performed in 26 (56.5%) patients, cholecystostomy in 15 (32.6%) patients, nasobiliary drainage in 5 (10.9%) patients. In a group of patients, operated without preoperative decompression of the biliary tract, mortality rate was 24.6%, after palliative surgery and 12.9% after radical surgery. In case of preoperative biliary decompression, mortality rate was 15.8% after palliative operations and 7.1% after radical surgery. Thus, preoperative decompression of the biliary tract allows to reduce considerable post operative mortality caused by hepato renal insufficiency.
carried out in 203 patients. The aim of palliative surgery was to restore food passage through the intestine. The method depends on the condition of the biliary tract - functional or blocked gall bladder, changes in the wall of the gall bladder, stomach stagnation, duodenal stasis, patient’s status, allow or restrict to carry out complicated surgery, complications after invasive methods of examination.
Table 1 shows that in 66.4% of cases cholecysto-enteral anastomosis was performed as palliative surgery, in order to eliminate obstructive jaundice.
Table 1 :
Palliative surgeriesName No. of cases
Cholecysto-gastrostomy 101 (49.7%) Cholecysto-enterostomy 34 (16.7%) Hepatico-enterostomy 43 (21.2%) Choledocho-duodenostomy 20 (9.8%) Gastro-enterostomy 3 (1.5%) Hepato-enterostomy 1 (0.5%) Cholecystostomy 1 (0.5%) Total 203 (100%) Complications after palliative operations 31 (15.3%) patients. Fifty seven patients died after surgery, (mortality rate 28.1%). The cause in 33 patients was increasing hepato renal insufficiency. Specific complications associated with surgical technique related to incompetence of biliodigestive anastomsis, developed in five cases and caused mortality in four cases (16.7%).
Radical Surgeries : The main radical operation in the case of biliopancreatoduodenal cancer, in the opinion of majority surgeons is pancreatoduodenal resection or Whipple’s operation. This operation was carried out in 59 patients : 16 (27.1%) cases of pancreatic head cancer, 32 (54.3%) cases of major cancer and 11 (18.7%) cases of cancer of the distal part of CBD.
In 1986, an original schema of reconstructive step of pancreaticoduodenal resection, was developed in our department (Fig. 6).
Fig 6
One of the main features is including pancreas in digestion. The operation is performed using precision technique in formation of pancreatico-and hepato-enteroanastomosis. Illaxon is used as suture material (absorbable). Pancreaticoenteral anastomosis was performed in two variants : in the first variant, pancreaticoenteral anastomosis was formed on drainage exposed outside. In the second variant, the pancreatic duct was separated by means of additional resection and anastomosed with the intestine, radial arrangement of sutures of anastomosis provides stretching of the ducts, opening while tieing up sutures.
Restoration of bile is released by formation of precision hepaticoenteral anastomosis. Gastroenteral anastomosis is formed on a separate loop of intestine, formation of anastomosis on different loops allows to avoid development of jejuno-biliary and jejuno-pancreatic refluxes. That decreases the risk of dehiscence of anastomosis in the nearest postoperative period and the risk of cholangitis and pancreatitis in the long term post operative period. Fifty seven operations were carried out by this method. Pancreaticoenteral anastomosis was formed on drainage in 43 cases and without drainage of pancreatic duct in other 23 cases. Total post operative mortality rate was 12 (21.1%).
Specific complications developed in seven cases and caused lethal outcome in six cases. The most frequent of mortality was pancreonecrosis (six cases). Dehiscence of pancreatico enteral anastomosis developed in two cases, dehiscence of hepatico- and pancreatico - enteral anastomosis in one case.
The complications depend on the method of the treatment of the pancreatic remnant. In cases of formation of pancreatico enteral anastomosis on drainage, the frequency of post operative complication was lower, (5.8% and 2.9%) than in cases of formation of pancreatico enteral anastomosis without drainage (12.9% and 12.9%). Pancreatic necrosis caused death in the first group, in one case. There were no lethal outcome due to dehiscence of pancreatoenteral anastomosis in this group.
Long Term Results
From those 200 patients who discharged from the hospital after surgery long term results were examined in 78 cases.
In case of Vater’s papilla cancer five year survival rate was 75% with mean life up to 48 months, in case cancer of distal part of common bile duct five year survival rate was 33% with mean life up to 46 months. In cases of pancreatic head cancer, only 33% of patients lived to two years of with mean life 18.3 months.
CONCLUSIONS
1.The key place for the diagnosis is taken by US tomography in combination with radiocontrast examination.
2.The compression of biliary tract should be included in preoperative preparation.
3.Original technique with separate passage of bile, pancreatic secretion and food is the rational method in the construction.
4.In case of pancreatic head cancer, independently of the stage of disease either palliative or radical surgeries, do not considerably influence the mean life.
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