When Allen Whipple published his landmark report describing the surgical removal of the head of the pancreas for cancer in 1935, hospital mortality rates were in the 45% range. Mortality rates have improved significantly since that time. In an outcome analysis based on nearly 50,000 pancreatectomies that were performed between 1996 and 2004, Turaga et al reported a national morbidity rate of 35% with a national mortality rate was 9% and an average length of stay of 15 days. In addition, Birkmeyer et al showed that larger hospital size improves mortality, with adjusted mortality rates for pancreatic resections decreased if surgery was done at a high volume center.
At present, surgical resection is the only potential curative treatment. Although the operation for head of pancreas cancer (the Whipple procedure) has been historically associated with a high mortality rate, this rate has declined to less than 4% in the last few years. One important reason for this decline is due to the experience provided by a limited number of surgeons who perform the Whipple procedure regularly in high-volume institutions.
Despite the progress in the operative treatment of pancreatic cancer, the optimal surgical approach aimed at improving outcomes remains controversial for a number of reasons. First, it is unknown whether more extensive surgery will improve outcomes. Proponents of more extensive resection, such as total pancreatectomy, with or without extensive en bloc regional lymph node dissection, argue that the more extensive operation allows removal of multifocal disease as well as potentially involved peripancreatic nodes. Another potential advantage of total pancreatectomy is the elimination of the need for a pancreaticojejunal anastomosis, which removes the risk of pancreatic anastomotic leak and therefore would improve perioperative mortality and morbidity; yet, a clear disadvantage of total pancreatectomy is the iatrogenic induction of diabetes, which could be brittle. Paradoxically, in a study to support the use of total pancreatectomy in selected patients to yield a tumor-free margin in which conventional partial pancreatic resection could not, long-term outcomes were not necessarily worse following total pancreatectomy as compared to partial pancreatectomy. Overall, population-based studies examining large numbers of patients and randomized controlled trials have failed to demonstrate improved survival with total pancreatectomy or extended lymphadenectomy.
A second major controversy involves the definition, management, and outcomes of patients with pancreatic cancer who have limited vascular involvement (borderline resectable pancreatic cancer). A systematic review of single center reports concluded that portal vein or superior mesenteric vein resection combined with pancreatectomy is a safe and feasible procedure that expands the pool of patients who can undergo curative resection, therefore providing important survival benefits to patients. In contrast, an American College of Surgeons National Surgical Quality Improvement Project database study suggested a higher rate of postoperative morbidity (39.9% versus 33.3%) and mortality (5.7% versus 2.9%) in patients undergoing the Whipple procedure with vascular resection compared to those without vascular resection. The inclusion of patients treated at institutions with different levels of expertise as well as the unplanned nature of some of the vascular resections may have contributed to the higher mortality and morbidity rates noted in that study.
A third area of controversy is the modification of the conventional Whipple procedure with the so-called “mini” Whipple procedure, where the entire stomach and pylorus are preserved (pylorus-preserving pancreaticoduodenectomy) or the stomach with part of the abdomen is preserved (subtotal stomach-preserving pancreaticoduodenectomy). These modifications aim to decrease the incidence of delayed gastric emptying, dumping, marginal ulcerations, and bile reflux gastritis. To date, an association of improved morbidity with the stomach-preserving operations has been elusive. In experienced hands, excellent results can be achieved by either the conventional Whipple or the mini Whipple approach.
With the advent of new technology, more specifically, robotic techniques, the optimal surgical approach to pancreatic cancer has evolved in yet another direction, with proponents of the minimally invasive approach citing early recovery with comparable perioperative mortality and morbidity. However, robot-assisted pancreaticoduodenectomy is a technically complex procedure that is plagued by long operative times, a steep learning curve, and substantial allocation of resources.
In summary, although the best surgical approach for patients with pancreatic cancer remains controversial, our clinical pathway at Moffitt Cancer Center for these patients follows the NCCN goal of margin negative (R0) pancreatic resection, which includes vascular resection and reconstruction for those cancers with limited vascular involvement.
About the Doctors
Dr. Mokenge P. Malafa obtained his B.S. from the University of Wisconsin Greenbay and his M.D. from the University of Wisconsin School Of Medicine in Madison. His internship and surgery residency was conducted at the Medical College of Ohio. He completed his fellowship and a postdoctoral research fellowship in the Molecular Oncology Program at the City of Hope National Medical Center. He held academic appointments in the Department of Surgery at the Southern Illinois School of Medicine where he served as Vice Chair of Research. He joined the H. Lee Moffitt Cancer Center & Research Institute faculty in 2002 as an Associate Member, and in 2003 was appointed Chief of the Gastrointestinal Tumor Program Division where he has served for the last ten years, currently as a Senior Member/Professor. Dr. Malafa has demonstrated the pre clinical potential of specific vitamin E compounds in the prevention and therapy of breast, melanoma, and colorectal cancers.
Dr. Pamela J. Hodul earned her B.S. from the University of Michigan where she graduated with a degree in Neuropsychology with High Distinction. She earned her M.D. degree, graduating Magna Cum Laude, from Loyola University Chicago, IL. Stritch School of Medicine, Maywood, IL and was inducted into the honor society of AOA. She completed her surgical oncology fellowship at Moffitt Cancer Center, where she has served as an Assistant Member/Assistant Professor since 2006 with an active clinical and research focus in the areas of neuroendocrine tumors, GISTs, and pancreatic cancer.
Both Drs. Malafa and Hodul are accepting new patient referrals at Moffitt which can be scheduled through the New Patient Appointment Center.
Adapted from Florida MD, September 2013