Chirurgie des Pankreaskarzinoms

Zusammenfassung

Das duktale Pankreasadenokarzinom ist aktuell das vierthäufigste zu Tode führende Krebsleiden mit einer Überlebensrate von weniger als 5 %, wenn alle Stadien einbezogen werden. Andere maligne Pankreastumore haben eine deutlich bessere Prognose. Selbst nach vollständiger Resektion und adjuvanter Chemotherapie beträgt die 5-Jahres-Überlebensrate nur 20 – 25%. Gründe dafür sind neben einer hohen Chemotherapieresistenz und einer frühen lympho- und hämatogenen Metastasierung auch häufig eine Tumorausdehnung über die medialen und dorsalen Resektionsgrenzen hinaus. Bei standardisierter, pathologischer Untersuchung können noch in ca. 75 % Krebszellen an den Resektionsrändern nachgewiesen werden, was Zeugnis des aggressiven und infiltrierenden Tumorwachstums ist und wahrscheinlich die hohe Lokalrezidivrate erklärt. Die Standardoperationen zur kurativen Tumorresektion sind die pyloruserhaltende Pankreatikoduodenektomie (PPPD) sowie die Pankreaslinksresektion mit Splenektomie bei Pankreasschwanztumoren. In High-volume-Zentren konnte bei einer Steigerung der Resektionsrate die Mortalität unter 3 % reduziert und das Langzeitüberleben nach Resektion verbessert werden. Bei den chirurgischen Komplikationen spielt die Pankreasfistel mit einer Prävalenz von bis zu 10 % eine entscheidende Rolle. Die Technik der Pankreasanastomose sowie der Verschluss des Pankreasschwanzes stellen daher die größten chirurgischen Herausforderungen dar. Im Hinblick auf die hohe Rezidivrate des Pankreaskarzinoms wurden die erweiterten Operationsverfahren in zahlreichen Studien untersucht. Während eine Infiltration der Pfortader keine Kontraindikation zur kurativen Resektion mit Gefäßrekonstruktion darstellt und in vergleichbaren Überlebensdaten resultiert, erscheint eine radikale, erweiterte Lymphadenektomie aufgrund der Datenlage nicht sinnvoll. In ausgewählten Einzelfällen können Patienten aber von einer neoadjuvanten Radiochemotherapie zum Downstaging eines irresektablen Tumors und anschließender Resektion, einer Metastasenresektion oder der Resektion eines Lokalrezidivs profitieren. Die R0-Resektion und tumorfreie Lymphknoten (N0-Stadium) sind die beiden Faktoren, die die beste Prognose für Patienten mit Pankreaskarzinom in Aussicht stellen und dann ein medianes Überleben von 2 Jahren mit guter Lebensqualität bieten können. Die Pankreaschirurgie orientiert sich zunehmend an evidenzbasierten Daten aufgrund randomisiert kontrollierter Studien. Um in Zukunft eine weitere und dringend notwendige Verbesserung der Behandlungsergebnisse zu erreichen, sollten wenn möglich alle geeigneten Patienten für den Einschluss in aktuelle klinische Studien zur neoadjuvanten, operativen oder adjuvanten Therapie berücksichtig werden.

Abstract

Ductal pancreatic carcinomas are currently the fourth most common fatal cancer disease with a survival rate of less than 5 % when all stages are considered. Other malignant pancreatic tumours have markedly better prognoses. Even after complete resection and adjuvant chemotherapy, the 5-year survival rate amounts to merely 20 – 25%. Besides a high resistance to chemotherapy and early lympho- and haematogenic metastases, the reason for this is often tumour extension beyond the medial and dorsal resection margins. In standardised pathological examinations cancer cells can be detected in the resection margins in about 75 % of the cases, which reflect the aggressive and infiltrative tumour growth and probably explains the high rate of local recurrence. Standard operations for curative tumour resection are the pylorus-preserving pancreatoduodenectomy (PPPD) and the left pancreatic resection with splenectomy in cases of pancreas tail tumours. In high-volume centres the mortality can be reduced to under 3 % and the long-term survival improved with an increase of the resection rate. Considering surgical complications, pancreatic fistulas with a prevalence of up to 10 % play a decisive role. The technique of the pancreatic anastomosis as well as closure of the pancreatic tail thus represents major surgical challenges. In view of the high recurrence rate of pancreatic carcinomas, extended surgical procedures have been examined in numerous studies. Although infiltration of the portal vein is not a contraindication for curative resection with vascular reconstruction which gives comparable survival rates, a radical, extended lymphadenectomy does not seem reasonable on the basis the available data. In selected, individual cases, patients may benefit from neoadjuvant radiochemotherapy to down-stage an unresectable tumour with subsequent tumour resection, a metastasis resection, or a resection of a local recurrence. An R0 resection and tumour-free lymph nodes (N0 stage) are the two factors that can provide the best prognosis for the patient with a median survival of 2 years and a good quality of life. Pancreas surgery is being increasingly oriented to the evidence-based data from randomised, controlled studies. In order to achieve a further and urgently needed improvement in treatment results, one should consider, if possible, all suitable patients for enrolment in current clinical studies on neoadjuvant, surgical, or adjuvant therapy.

Schlüsselwörter

Gastro-entero-pankreatische Tumoren - Chirurgie - Pankreaskarzinom - High-volume-Zentren

Key words

gastro-entero-pancreatic tumours - surgery - pancreatic cancer - high-volume centres

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