Avram M. Cooperman

Surgical Experience with Pancreatic and Periampullary Cancer

Between 1940 and 1978, 179 patients underwent pancreatic resection (64 total, 102 Whipple, 13 distal) at the Presbyterian Hospital, predominantly for carcinoma of the pancreas and periampullary area. With respect to operative morbidity and mortality and survival, these patients have been compared with 141 patients subjected to pancreatic biopsy only, and with 172 by-passed for palliation. Likewise, total pancreatectomy has been compared to pancreaticoduodenectomy (Whipple) in terms of safety and efficacy. The overall major postoperative complication rate for pancreatic resection was 36%, in contrast with 13.5% for biopsy only and 16.8% for by-pass. Of the resected cases with major complications postoperatively, roughly half died, a mortality of 17.9%. Patients who underwent Whipple resections fared significantly better than did those having total pancreatectomies; the postoperative mortality following 102 Whipples was 14.7%, as compared with 23.4% for total pancreatectomies. Intra-abdominal sepsis accounted for most of the postoperative deaths; nine pancreatic and four biliary leaks or fistulae followed Whipple resections. The later complications were of interest; 18 patients undergoing biliary-en-teric by-pass procedures later developed gastroduodenal obstruction, 15 of whom required reoperation, and in 18 survivors of pancreatic resection, upper gastrointestinal hemorrhage (mostly from marginal ulcers) developed, necessitating surgery in seven. Brittle diabetes was a problem in nine patients following pancreatectomy. Survival rates were discouraging in all categories. For ductal carcinoma of the pancreas, median survival for biopsy only was two months, for by-pass six months, for total pancreatectomy nine months, and for Whipple resection 14 months. There were three five-year survivors following resection, a rate of 4.5%. Five-year survival rates following resection for ampullary, common duct, duodenal, and islet cell cancer were 27.8, 33.3, 27.3, and 37.5%, respectively. It is concluded that survival after resection for ductal pancreatic cancer is so rare as to be considered more a biologic aberration than a result of radical surgery. Despite theoretical advantages of total pancreatectomy over Whipple resections, our experience would suggest that the latter can be carried out with lower morbidity and mortality, and with equal chance for cure. Resection for pancreatic cancer should not be abandoned, but rather undertaken with greater selectivity. Operative morbidity and mortality can probably be improved additionally by preoperative transhepatic biliary decompression, and later complications reduced by including vagotomy with gastric resection at the time of pancreatectomy and by performing prophylactic gastroenterostomies in conjunction with by-pass procedures.

Endoscopic ultrasonographic criteria of vascular invasion by potentially resectable pancreatic tumors

Endoscopic ultrasonography was used to examine 38 patients with a pancreatic neoplasm (mean size, 2.8 cm; range, 1 to 5 cm). Three EUS signs appear to be reliable criteria for the identification of tumor invasion of major veins forming the portal confluence: (1) peri-pancreatic venous collaterals in the area of a mass that obliterates the normal anatomic location of a major portal confluence vessel; (2) tumor within the vessel lumen; and (3) abnormal vessel contour with loss of the vessel-parenchymal sonographic interface. At least one of these signs was present in each of the 21 patients with vascular invasion; none of them was present in the 17 patients without vascular invasion. Findings were confirmed by laparotomy plus biopsy (33 patients), autopsy (1 patient), or angiography plus biopsy (4 patients). Arterial involvement was identified by alteration of vessel course and caliber. All 7 patients with arterial involvement also had venous involvement. These signs provide reliable criteria for endoscopic ultrasonographic definition of unresectable tumors in patients with a pancreatic neoplasm that appears to be resectable on standard radiologic tests.

Combined modality therapy for stage II and stage III pancreatic carcinoma.

PURPOSE To study the outcome achieved with three-drug chemotherapy and split-course external-beam radiotherapy as a treatment for unresectable stage II and III pancreatic carcinoma. PATIENTS AND METHODS Radiotherapy was given in three cycles of 2 Gy/d on days 1 to 5 and 8 to 12 (total dose, 54 Gy) concurrently with fluorouracil (FU) 1,000 mg/m2/d by continuous infusion for 4.5 days, streptozocin (STZ) 300 mg/m2 on days 1, 2, and 3 and cisplatin (P) 100 mg/m2 on day 3 of each every-28-day cycle. Subsequent treatment consisted of leucovorin (LV) 200 mg/m2 and FU 600 to 1,000 mg/m2 every 14 days. RESULTS The median survival time for the 35 patients was 15 months and 26% of patients were alive at 24 months. Fifteen patients (42.8%) had objective responses to therapy. Six (17%) had a complete response (CR). Three of nine patients with partial responses (PRs) achieved a radiographic CR within the next 3 months. Nine patients underwent attempts at surgical resection: five were resected (median survival time, 31 months; range, 12.8 to 44.7+), two had no residual disease found at complete resection, and three others also had a complete resection. Of four others who could not be resected, three underwent intraoperative radiotherapy and one had occult metastatic disease. Of primary tumors, 91% did not produce either back pain or local gastrointestinal complications for 2 years. The rates of severe side effects were stomatitis 15%, anemia 14%, granulocytopenia 6%, and thrombocytopenia 6%. CONCLUSION Palliation and survival compare favorably with other series, including many surgical series. The response findings encourage studies of both unresectable and (as neoadjuvant therapy) resectable tumors.

Gastric carcinoma. A ten-year review.

Data on 164 patients treated at the Cleveland Clinic with gastric adenocarcinoma during the ten year period 1970 to 1980 was analyzed. Fiberoptic esophagogastroduodenoscopy was introduced as a routine diagnostic modality during this time and yielded a positive tissue diagnosis in 86% of patients in this series. Laparotomy was performed on 150 patients; 49 patients (30%) were biopsied only, 19 (12%) were bypassed for palliation, and 82 (58%) underwent gastrectomy. Of the latter group, only 45 patients (27%) were resected for cure. The overall operative mortality rate was 6%. All patients were staged according to the International TNM classification (stage I—10%, II—24%, III—12%, and IV—53%). Survival at 5 years was influenced by tumor location and extent of gastric resection but was most significantly related to stage of disease at operation (stage I—65%, II—22%, III—5%, and IV—0%; p < 0.0001) and to the status of regional nodes (positive—17%, negative—56%; p < 0.005). Despite the routine use of fiberoptic endoscopy, the majority of gastric cancers were advanced at diagnosis and their prognosis remains discouraging. Improvement of results will require a more aggressive approach to the endoscopic investigation of upper gastrointestinal symptoms and earlier surgical intervention.

Current concepts in cancer: cancer of the pancreas.

THE incidence of cancer of the pancreas has steadily increased during the past 20 years; this disease now accounts for 3 per cent of all cancers and 5 per cent of all cancer deaths in the United St...

Carcinoma of the ampulla of Vater: Review of 38 cases with emphasis on treatment and prognostic factors.

Thirty-eight cases of carcinoma of the ampulla of Vater are presented. The diagnosis has been confirmed at laparotomy in all patients. Three operations were done, a pancreaticoduodenal resection in 23 patients, a biliary-enteric bypass in 7 patients and a biliary-enteric bypass plus excision of tumor in 8 patients. The operative mortality was 8% following resection, 14% following bypass plus excision of the ampulla and 13% following biliary-enteric bypass. Five patients survived 5 or more years. The longest survivors have followed pancreaticoduodenal resections (131 and 216 months). The level of bilirubin or presence of pain did not correlate with prognosis. Prognosis was better in the absence of nodal metastases, and in the presence of papillary tumors

Surgery and Chronic Pancreatitis

It is hoped that, in this millennium, chronic pancreatitis will be diagnosed earlier in the course of the disease process. Improved axial imaging of the pancreatic duct and pancreatic parenchyma will diminish the need for other invasive tests. Surgical procedures are directed at pancreatic duct decompression or resection of the pancreas (head, body or tail) or, infrequently, total pancreatectomy. Pain relief in 75% to 90% is the general rule, with diabetes developing subsequently in as many as 33% of patients. Surgery for chronic pancreatitis is effective in correcting sequelae of pancreatic fibrosis. Endoscopic stenting of the pancreatic and bile duct is used more frequently today. Until their place is ascertained, careful performance of surgery will continue to be a mainstay of treatment.

Changes in the pathogenesis and detection of intrahepatic abscess.

A comparison of two distinct 11 year time periods at our institution demonstrated a change not only in the cause of intrahepatic abscess but also in the procedures used to diagnose this condition. Significant improvement in the methods of detection of intrahepatic abscess permits earlier diagnosis and therapy and thus a significantly improved prognosis.

Congenital duodenal diaphragms in adults: a delayed cause of intestinal obstruction.

Congenital duodenal diaphragms in the adult are uncommon, unsuspected lesions that infrequently cause intestinal obstruction. The diaphragms may be single or multiple and are usually located near the ampulla of Vater. Three cases are summarized and the recent literature reviewed. At least 35 cases have been reported. Treatment most often consisted of duodenotomy, excision of the web and duodenal closure.

Cancer of the Pancreas

THE incidence of cancer of the pancreas has steadily increased during the past 20 years; this disease now accounts for 3 per cent of all cancers and 5 per cent of all cancer deaths in the United St...