Pankreaskarzinom

Das Pankreaskarzinom stellt Chirurgen vor große Herausforderungen. Neue Therapiekonzepte und fortschrittliche Operationstechniken eröffnen jedoch Möglichkeiten für Patienten mit fortgeschrittenen und initial inoperablen Tumoren. Multiviszerale Resektionen und arterio-venöse Gefäßrekonstruktionen in spezialisierten Zentren können im Vergleich zur Palliation die Überlebenschancen deutlich verbessern. Der Artikel beleuchtet aktuelle Kriterien der Resektabilität, die Bedeutung des „Mesopankreas“, die arterio-venösen Rekonstruktionsmöglichkeiten und die Indikationen für komplexe chirurgische Eingriffe.

Kernaussagen

• Bei Borderline-resektablen oder lokal fortgeschrittenen Pankreaskarzinomen mit Infiltration von Nachbarorganen und von arteriovenösen Strukturen besteht nach erfolgter neoadjuvanter Chemotherapie die Indikation zur En-bloc-Resektion, sofern dadurch eine R0-Resektion erzielt werden kann.

• Mehrere Resektions- und Rekonstruktionsverfahren stehen abhängig von der Tumorlokalisation und -infiltration zur Verfügung.

• Arteriovenöse Resektionen und/oder Multiviszeralresektion erlauben eine Verbesserung der Überlebensrate im Vergleich zur alleinigen palliativen Systemtherapie, ohne dabei die postoperative Letalität im Vergleich zu konventionellen Pankreasresektionen relevant zu erhöhen, wenngleich die Morbidität und der Klinikaufenthalt mit steigendem Resektionsausmaß zunehmen.

• Arteriovenöse Resektionen und/oder Multiviszeralresektionen beim Pankreaskarzinom sollten daher für gut selektionierte Patienten angeboten werden.

• Weitere prospektiv randomisierte Daten sind jedoch für eine bessere Auswahl der Patienten und Indikationsstellung nötig.

Schlüsselwörter

Pankreaskarzinom - Rekonstruktionsverfahren - multiviszerale Resektion - arterielle Resektion - venöse Resektion

Publication History

Article published online:
05 September 2024

• Literatur

• 1 Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten e. V. (DGVS). S3-Leitlinie Exokrines Pankreaskarzinom. Version 3.0. 2024 Accessed July 18, 2024 at: https://register.awmf.org/de/leitlinien/detail/032-010OL
• 2 Garnier J, Robin F, Ewald J. et al. Pancreatectomy with Vascular Resection After Neoadjuvant FOLFIRINOX: Who Survives More Than a Year After Surgery?. Ann Surg Oncol 2021; 28: 4625-4634
• 3 Mollberg N, Rahbari NN, Koch M. et al. Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis. Ann Surg 2011; 254: 882-893
• 4 Loos M, Kester T, Klaiber U. et al. Arterial Resection in Pancreatic Cancer Surgery: Effective After a Learning Curve. Ann Surg 2022; 275: 759-768
• 5 Gong H, Ma R, Gong J. et al. Distal Pancreatectomy With En Bloc Celiac Axis Resection for Locally Advanced Pancreatic Cancer: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2016; 95: e3061
• 6 Loos M, Khajeh E, Mehrabi A. et al. Distal Pancreatectomy With En Bloc Celiac Axis Resection (DP-CAR) for Locally Advanced Pancreatic Cancer: A Safe and Effective Procedure. Ann Surg 2023; 278: e1210-e1215
• 7 Wiltberger G, den Dulk M, Bednarsch J. et al. Perioperative and long-term outcome of en-bloc arterial resection in pancreatic surgery. HPB (Oxford) 2022; 24: 1119-1128
• 8 Zhang Q, Wu J, Tian Y. et al. Arterial resection and reconstruction in pancreatectomy: surgical technique and outcomes. BMC Surg 2019; 19: 141
• 9 Salehi O, Vega EA, Kutlu OC. et al. Combining Appleby with RAMPS - Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Celiac Trunk Resection. J Gastrointest Surg 2020; 24: 2700-2701
• 10 Latona JA, Lamb KM, Pucci MJ. et al. Modified Appleby Procedure with Arterial Reconstruction for Locally Advanced Pancreatic Adenocarcinoma: A Literature Review and Report of Three Unusual Cases. J Gastrointest Surg 2016; 20: 300-306
• 11 Miao Y, Cai B, Lu Z. Technical options in surgery for artery-involving pancreatic cancer: Invasion depth matters. Surg Open Sci 2023; 12: 55-61
• 12 Diener MK, Mihaljevic AL, Strobel O. et al. Periarterial divestment in pancreatic cancer surgery. Surgery 2021; 169: 1019-1025
• 13 Schneider M, Hackert T, Strobel O. et al. Technical advances in surgery for pancreatic cancer. Br J Surg 2021; 108: 777-785
• 14 Kleive D, Vetrhus M, Silva MA, Bratlie SO, Søreide K. Pancreatoduodenectomy with Portal Vein Resection. In: Søreide K, Stättner S. Textbook of Pancreatic Cancer. Cham: Springer; 2021.
• 15 Oba A, Kato T, Inoue Y. et al. Extent of venous resection during pancreatectomy-finding the balance of technical possibility and feasibility. J Gastrointest Oncol 2021; 12: 2495-2502
• 16 Wang X, Demir IE, Schorn S. et al. Venous resection during pancreatectomy for pancreatic cancer: a systematic review. Transl Gastroenterol Hepatol 2019; 4: 46
• 17 Oehme F, Distler M, Müssle B. et al. Results of portosystemic shunts during extended pancreatic resections. Langenbecks Arch Surg 2019; 404: 959-966
• 18 Bhayani NH, Enomoto LM, James BC. et al. Multivisceral and extended resections during pancreatoduodenectomy increase morbidity and mortality. Surgery 2014; 155: 567-574
• 19 Giuliani T, Di Gioia A, Andrianello S. et al. Pancreatoduodenectomy associated with colonic resections: indications, pitfalls, and outcomes. Updates Surg 2021; 73: 379-390
• 20 Panzeri F, Marchegiani G, Malleo G. et al. Distal pancreatectomy associated with multivisceral resection: results from a single centre experience. Langenbecks Arch Surg 2017; 402: 457-464
• 21 Malinka T, Klein F, Andreou A. et al. Distal Pancreatectomy Combined with Multivisceral Resection Is Associated with Postoperative Complication Rates and Survival Comparable to Those After Standard Procedures. J Gastrointest Surg 2018; 22: 1549-1556
• 22 Ramia JM, Del Río-Martín JV, Blanco-Fernández G. et al. Distal pancreatectomy with multivisceral resection: A retrospective multicenter study – Case series. Int J Surg 2020; 82: 123-129
• 23 Ferrari C, Leon P, Falconi M. et al. Multivisceral resection for left-sided pancreatic ductal adenocarcinoma: a multicenter retrospective analysis from European countries. Langenbecks Arch Surg 2023; 408: 386
• 24 Zhou Q, Fengwei-GaoGong J. et al. Assessement of postoperative long-term survival quality and complications associated with radical antegrade modular pancreatosplenectomy and distal pancreatectomy: a meta-analysis and systematic review. BMC Surg 2019; 19: 12
• 25 Huo Z, Zhai S, Wang Y. et al. Comparison of Radical Antegrade Modular Pancreatosplenectomy with Standard Retrograde Pancreatosplenectomy for Left-Sided Pancreatic Cancer: A Meta-Analysis and Experience of a Single Center. Med Sci Monit 2019; 25: 4590-4601
• 26 Kim HS, Hong TH, You YK. et al. Radical antegrade modular pancreatosplenectomy (RAMPS) versus conventional distal pancreatectomy for left-sided pancreatic cancer: findings of a multicenter, retrospective, propensity score matching study. Surg Today 2021; 51: 1775-1786
• 27 Hackert T, Sachsenmaier M, Hinz U. et al. Locally Advanced Pancreatic Cancer: Neoadjuvant Therapy With Folfirinox Results in Resectability in 60% of the Patients. Ann Surg 2016; 264: 457-463
• 28 Al-Saeedi M, Sauer HB, Ramouz A. et al. Celiac Axis Stenosis is an Underestimated Risk Factor for Increased Morbidity After Pancreatoduodenectomy. Ann Surg 2023; 277: e885-e892
• 29 Hempel S, Oehme F, Tahirukaj E. et al. More is More? Total Pancreatectomy for Periampullary Cancer as an Alternative in Patients with High-Risk Pancreatic Anastomosis: A Propensity Score-Matched Analysis. Ann Surg Oncol 2021; 28: 8309-8317
• 30 Hartwig W, Hackert T, Hinz U. et al. Multivisceral resection for pancreatic malignancies: risk-analysis and long-term outcome. Ann Surg 2009; 250: 81-87
• 31 Schünke M, Schulte E, Schumacher U. Prometheus LernAtlas – Innere Organe. 6. vollständig überarbeitete und erweiterte Auflage Stuttgart: Thieme; 2022
• 32 Nöldge G, Weber MA, Ritzel R. et al. Invasive Diagnostik bei Insulinomen des Pankreas. Radiologe 2009; 49: 224-232
• 33 Litkevych S, Wellner UF, Keck T. Relevante Gefäßanatomie für die minimalinvasive Pankreaschirurgie. Allgemein- und Viszeralchirurgie up2date 2022; 16: 537-565
• 34 Bartsch F, Heinrich S, Roth W. et al. Lymphadenektomie in der onkologischen Viszeralchirurgie – Teil 1. Chirurg 2019; 90: 423-438
• 35 Izbicki J, Perez D. Expertise Allgemein- und Viszeralchirurgie Pankreas. Stuttgart: Thieme; 2018.
• 36 Nagakawa Y, Yi SQ, Takishita C. et al. Precise anatomical resection based on structures of nerve and fibrous tissue around the superior mesenteric artery for mesopancreas dissection in pancreaticoduodenectomy for pancreatic cancer. J Hepatobiliary Pancreat Sci 2020; 27: 342-351
• 37 Vawter K, Kuhn S, Pitt H. et al. Complications and failure-to-rescue after pancreatectomy and hospital participation in the targeted American College of Surgeons National Surgical Quality Improvement Program registry. Surgery 2023; 174: 1235-1240
• 38 Gleeson E, Pitt H, Mackay T. et al. Global Audits on Pancreatic Surgery Group (GAPASURG). Failure to Rescue After Pancreatoduodenectomy: A Transatlantic Analysis. Ann Surg 2021; 274: 459-466
• 39 Krautz C, Nimptsch U, Weber GF. et al. Effect of Hospital Volume on In-hospital Morbidity and Mortality Following Pancreatic Surgery in Germany. Ann Surg 2018; 267: 411-417
• 40 Smits F, Henry A, Besselink M. et al. Algorithm-based care versus usual care for the early recognition and management of complications after pancreatic resection in the Netherlands: an open-label, nationwide, stepped-wedge cluster-randomised trial. Lancet 2022; 399: 1867-1875
• 41 Belyaev O, Uhl W. Pankreaskarzinom – Chirurgie im Wandel der multimodalen Therapiemöglichkeiten. Allgemein- und Viszeralchirurgie up2date 2019; 13: 511-530
• 42 Bachellier P, Addeo P, Faitot F. et al. Pancreatectomy With Arterial Resection for Pancreatic Adenocarcinoma: How Can It Be Done Safely and With Which Outcomes? A Single Institution’s Experience With 118 Patients. Ann Surg 2020; 271: 932-940
• 43 Perinel J, Nappo G, El Bechwaty M. et al. Locally advanced pancreatic duct adenocarcinoma: pancreatectomy with planned arterial resection based on axial arterial encasement. Langenbecks Arch Surg 2016; 401: 1131-1142
• 44 Cannella R, Borhani A, Zureikat A. et al. Appleby Procedure (Distal Pancreatectomy With Celiac Artery Resection) for Locally Advanced Pancreatic Carcinoma: Indications, Outcomes, and Imaging. AJR Am J Roentgenol 2019; 213: 35-44
• 45 Egorov V, Kim P, Kharazov A. et al. Hemodynamic, Surgical and Oncological Outcomes of 40 Distal Pancreatectomies with Celiac and Left Gastric Arteries Resection (DP CAR) without Arterial Reconstructions and Preoperative Embolization. Cancers (Basel) 2022; 14: 1254
• 46 Ueda A, Sakai N, Yoshitomi H. et al. Is hepatic artery coil embolization useful in distal pancreatectomy with en bloc celiac axis resection for locally advanced pancreatic cancer?. World J Surg Oncol 2019; 17: 124
• 47 Thomaschewski M, Zimmermann M, Honselmann K. et al. Robotisch assistierte Resektion eines zentralen neoadjuvant behandelten Pankreaskarzinoms mit En-bloc-Resektion des Truncus coeliacus (modifizierte Appleby-Operation). Zentralbl Chir 2021; 146: 552-559
• 48 Ocuin L, Miller-Ocuin J, Novak S. et al. Robotic and open distal pancreatectomy with celiac axis resection for locally advanced pancreatic body tumors: a single institutional assessment of perioperative outcomes and survival. HPB (Oxford) 2016; 18: 835-842
• 49 Klompmaker S, van Hilst J, Gerritsen S. et al. Outcomes After Distal Pancreatectomy with Celiac Axis Resection for Pancreatic Cancer: A Pan-European Retrospective Cohort Study. Ann Surg Oncol 2018; 25: 1440-1447
• 50 Aumüller G, Aust G, Conrad A, Engele J, Kirsch J, Maio G, Mayerhofer A, Mense S, Reißig D, Salvetter J, Schmidt W, Schmitz F, Schulte E, Spanel-Borowski K, Wennemuth G, Wolff W, Wurzinger LJ, Zilch H-G. Duale Reihe Anatomie. 4. aktualisierte Auflage Stuttgart: Thieme; 2017.
• 51 Xu YC, Yang F, Fu DL. Clinical significance of variant hepatic artery in pancreatic resection: A comprehensive review. World J Gastroenterol 2022; 28: 2057-2075
• 52 Kimura Y, Imamura M, Kuroda Y. et al. Clinical usefulness of saphenous vein graft in major arterial reconstruction during extended pancreatectomy. Langenbecks Arch Surg 2020; 405: 1051-1059
• 53 Brunner M, Maak M, Grützmann R. Chirurgische Anatomie. In: Grützmann R. Referenz Allgemein- und Viszeralchirurgie – Pankreas. Stuttgart: Thieme; 2021.