S3-Guideline “Exocrine Pancreatic Carcinoma” 20071 ... - DGVS

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462 Leitlinie postoperative complications. Therefore, the comparison of published data is difficult. A new classification of pancreatic fistulas was developed at a consensus conference in 2005 [167]. This is an attempt to make an internationally accepted and comparable definition of fistulas in future publication possible. Therefore, a general recommendation on the perioperative application of somatostatin cannot be given. Objectives for intraoperative resection margins Recommendation There are no definite data on necessary safety margins when resecting pancreatic carcinoma. Macroscopically assessed resection margins for curative resection (R0) can be deduced from practical experience. They should be as follows: E in pancreas tissue: 10 mm, E for bile ducts: 10 mm, E at the stomach/pylorus: 10 mm. For anatomic reasons, no objectives can be given for R 0 resections in the area of the retroperitoneum. Recommendation grade: D, evidence level 5, consensus Intraoperative sonography of the liver Recommendation An intraoperative sonography is not necessary if the preoperative abdominal CT is inconspicuous. Recommendation grade: B, evidence level 3, consensus If the results of abdominal sonography or CT are not clear, a clarification should be attempted prior to surgery. In unclear cases an intraoperative sonography can lead to further clarification. Recommendation grade: D, evidence level 3, consensus Comments The quality of the new generation of multi-detector-CT is so high that if metastases were not detected using preoperative CT diagnostics, an intraoperative sonography would give no further information. Therefore, if a preoperative CT is inconspicuous, an intraoperative sonography is not necessary [168]. If the preoperative clarification of changes in the liver is still unclear, an intraoperative sonography may be useful to assess the operability of pancreatic tumors. If the resectability of the pancreatic tumor was assessed laparoscopically, an intraoperative sonography can replace the palpation and add to the mere inspection of the liver surface [169]. Intraoperative peritoneal lavage/cytology Recommendation Intraoperative peritoneal lavages have no therapeutic consequences. Therefore, there is no indication for a peritoneal lavage with cytology. Recommendation grade: B, evidence level 3, strong consensus Comments Most patients have a relapse after curative resection of pancreatic carcinoma. It is speculated that this is due to micrometastases in the peritoneum which are not detectable at the time of surgery [170]. Even though peritoneal micrometastases could be detected in peritoneal lavages, a prognostic relevance of positive cytologic results was not found. Therefore, micrometastases are not an exclusion criterion for radical resection, and a peritoneal lavage is not necessary [171, 172]. Adler G et al. S3-Guideline “Exocrine Pancreatic… Z Gastroenterol 2008; 46: 449–482 Extent of resection/surgical technique/preferred anastomosis technique Recommendation The aim of pancreatic surgery is an R0 resection independently of the location of the tumor. Pancreas head carcinoma Recommendation The resection of the pancreas head tumors usually includes the partial duodenopancreatectomy with or without pylorus preservation. In rare cases a total pancreatectomy may be necessary if the carcinoma has spread. If neighboring organs and other structures are infiltrated, the resection should be extended. Recommendation grade: A, evidence level 1c, consensus Classic Whipple versus pp-Whipple Recommendation Both procedures (pylorus preserving [pp] versus stomach resecting partial duodenopancreatectomy [classic]) are comparable with respect to postoperative complications and oncologic long-term results (1a). Recommendation grade: A, evidence level 1a, consensus Comment A meta-analysis of the literature on pylorus preserving and classic duodenopancreatectomy demonstrated no relevant differences between both procedures with respect to patient mortality, morbidity, and survival. However, the studies that were analyzed were very heterogeneous [173]. Carcinoma of the pancreatic tail Recommendation The surgical procedure for pancreas tail carcinomas is left-sided pancreatic resection. The abovementioned criteria on the surgical expansion apply [174 –176]. Recommendation grade: A, evidence level 3, consensus Pancreatic body cancer Recommendation In general a subtotal left-sided pancreatic resection or if necessary a total duodenopancreatectomy is indispensable for pancreas body cancer [174–176]. Recommendation grade: B, evidence level 3, consensus Tumor adherence to surrounding organs Recommendation An R0 resection can be performed even if the neighboring organs are infiltrated (extrahepatic local manifestations). The goal of every resection must be an R0 resection [148–152]. Recommendation grade: C, evidence level 3, consensus Radical extension of lymphadenectomy Recommendation So far, a benefit of extended lymph node resections was not observed. Recommendation grade: B, evidence level 2b, consensus Comments A standardized lymphadenectomy during pancreas head cancer surgery according to Whipple should be performed as follows: complete and circular dissection of the lymph nodes of the hepatoduodenal ligament as well as around the common hepatic Downloaded by: Thieme Verlagsgruppe. Copyrighted material.
artery and the portal vein and the cranial part of the superior mesenteric artery. Furthermore, lymph nodes at the right side of the celiac trunk and the lymph nodes at the right hemicircumference of the superior mesenteric artery stem should be dissected. The term “radical extension of lymphadenectomy” includes different degrees of dissection. The number of removed lymph nodes and the additional time needed for an extended lymphadenectomy differ significantly between the 4 randomized studies on this topic [177–179]. Consistently all 4 studies from Europe, Japan, and the USA showed no additional benefit with respect to long-term survival after extended radical dissection of the lymph nodes compared to standard dissection (definition see above). Thus, so far no benefit was shown for the extended resection. Operative strategy for IPMT/cystic pancreatic tumors Recommendation All potentially malignant tumor entities of the pancreas are primarily resected with the same goal and to the same extent as the ductal pancreatic carcinoma. Recommendation grade: B, evidence level 3, consensus Comments Cystic pancreatic tumors have a wide spectrum of histologic characteristics including inflammatory (pseudocysts) and benign (serous) cysts as well as cysts of unknown or malignant origin (IPMT, mucinous) [180]. A definite differentiation between benign and malignant is not possible with modern CT or MRT examinations. Endosonographic and cytologic differentiation of cystic contents are not as good as differentiation using CEA values of cystic contents and, thus, not definite [181, 182]. If the operative risk is justifiable, resection is recommended, because it is not possible to differentiate benign and malignant cystic lesions preoperatively [183–185]. However, for high risk patients and patients with small serous tumors without symptoms a resection can be sustained. In this case, a close monitoring of the pancreas is useful [184]. A limited resection (segmental resection, enucleation) for serous cystic adenoma and the early stages of IPMT of the collateral duct are sufficient [180, 185]. All potentially malignant tumor entities should primarily be operated with the same goal and to the same extent of resection as the ductual pancreatic carcinoma, because the prognosis of advanced IPMT and mucinous cystic adenocarcinoma is identical to ductual adenocarcinoma. Therapeutic procedures for distant metastases Recommendation Resection of distant metastases of ductal pancreatic cancer (organ metastases, peritoneal carcinosis, lymph node metastases that are defined as distant metastases) does not improve the prognosis and, thus, should usually be avoided. Recommendation grade: A, evidence level 3, consensus Resection of intraoperatively detectable distant metastases Recommendation Even if the tumor is resectable, a resection should not be done if distant metastases are only detectable intraoperatively. Recommendation grade: B, evidence level 3, consensus Leitlinie 463 Comments In high volume centers, the morbidity of pancreatic surgery is markedly reduced and the mortality is under 5%. If metastases have been detected and the complication rate is acceptable, pancreas resection can lead to excellent pain control. In several publications it was already considered to be an alternative to palliative double bypass surgery. However, despite the progress in adjuvant therapy, so far no survival advantage has been shown for resection of metastatic pancreatic cancer [186–188]. Laparoscopic surgical techniques Recommendation Pancreatic cancer is an indication for laparoscopic tumor staging. However, laparoscopic surgery of pancreatic carcinoma is currently not recommended. Recommendation grade: B, evidence level 3, strong consensus Comments In about 20% of the cases a curative resection is not possible despite standardized preoperative staging of pancreatic cancer using modern imaging techniques. This is due to local tumor spreading or peritoneal carcinosis or liver metastasis that is only detectable intraoperatively [189]. In this case patients can benefit from diagnostic laparoscopy, as a minimal invasive technique. It can complete the staging (see also Topic 2) [189, 190]. A diagnostic laparoscopy is especially useful for the staging of cancer in the pancreatic body and tail, because of the late development of symptoms compared to pancreatic head carcinomas. In contrast, laparoscopically performed oncologic pancreatic resections, although possible, are experimental [191]. Intraoperative frozen section examination Recommendation Pancreas and if applicable bile duct resection margins should be tested by frozen section analysis independently of frozen section testing for the diagnosis of distant metastases [192]. In addition, putative liver metastases and possibly peritoneal carcinosis should be assessed. Lymph nodes and the retroperitoneal margin do not have to be evaluated. Recommendation grade: A, evidence level 1c, consensus Intraoperative needle or incision biopsies of the primary pancreatic tumor should not be done to clarify its dignity. Recommendation grade: B, evidence level 4, consensus Histologic evaluation of resected tumors Recommendation Criteria for the R0 resection are tumor-free margins at the hepatic duct, the pancreas resection area, as well as the circumferential inclusive retroperitoneal margin. An additional prerequisite is that no distant metastases (organs, peritoneum, lymph nodes) remain [193, 194]. Recommendation grade: B, evidence level 2, consensus The specimen should be prepared using ink to mark the retroperitoneal margin [193, 194]. Recommendation grade: B, evidence level 2b, consensus Necessary information from the pathologist: a) pT-classification Recommendation grade: B, evidence level 3, strong consensus b) pN-classification Recommendation grade: B, evidence level 3, strong consensus Adler G et al. S3-Guideline “Exocrine Pancreatic… Z Gastroenterol 2008; 46: 449–482 Downloaded by: Thieme Verlagsgruppe. Copyrighted material.
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