Surgical Extent and Types in Pancreatic Cancer Song Cheol Kim, M.D. Department of Surgery, Ulsan University College of Medicine & Asan Medical Center, Seoul, Korea Pancreatic cancer continues to pose a major problematic concerns of all forms of gastrointestinal malignancy because of its worst survival. Although the progressions were made in surgical treatment in terms of increasing resection rate and decreasing treatment related morbidity and mortality, the true survival rate remains below 3% today. Surgical options for surgrcal extent and types in pancreas cancer are based on its unique anatomy and physiology, catastrophic tumor biology, experience of surgeon, and status of patients or pancreas. Four main options exist for surgical extent and types in pancreas cancer. They include standard Whipple pancreaticoduodenectomy (PD), pylorus preserving PD, distal pancreatectomy (left side pancreatectomy), and total pancreatectomy. Portal vein involvement with tumor is regarded as a anatomical extension of disease, and en bloc resection of portal vein with tumor is recommended if it is feasible technically, which is shown up in 2002 AJCC tumor staging for pancreas cancer. Comparing the survival times after standard and extended resection of pancreas head cancer no significant survival benefits demonstrated from the retro and prospective reports. PPPD may be superior to standard PD in respect to outcomes of nutrition and quality of life without any deleterious effect of long term survival or recurrence. Conclusively, in the future, multicenter prospective randomized trail should be carried out to clarify the effect of various options and to improve the survival times on th basis of standardization of surgical technique and evidence based data. (Korean J HBP Surg 2004;8:133-139) Key Words: Carcinoma, Pancreatic Ductal Pancreatectomy Pancreaticoduodenectomy :,,
Head Neck Body Tail Distal pancreatectomy Total pancreatectomy
김송철 췌장암에서 췌장절제의 종류 및 범위 135 ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ 3) 확대 췌두부 십이지장 절제술(Extended pancreaticoduodenectomy): 수술자에 따라 그 범위에 차이는 있으나 표준적 췌두부 십이지장 절제술에서 절제될 수 없는 림프 절과 신경절 절제를 목적으로 한 수술로 기본적으로 표준 적 췌두부 십이지장 절제술의 절제에 다음의 절제를 더한 다(Fig. 3, 4). a) Gerota s fascia를 포함한 후복막 연부조직의 절제 b) SMV - PV junction의 왼쪽에서 췌장절제 c) Common & proper hepatic artery의 lymph node (8a, 8p) d) Celiac axis의 lymph node (9) e) hepatoduodenal ligament의 좌,우측 lymph node (12a1, 12a2, 12b1, 12b2, 12c, 12p1, 12p2, 12h) f) Aorta와 inferior PDA 사이의 lymph node (14a, b, c, d) g) 좌우로 Aorta와 IVC 사이, 상하로 celiac axis와 IMA 사 이의 lymph node (16a2, 16b1) h) 간동맥과 상장간맥 동맥 주변의 신경절 절제 4) 췌장절제술 및 주요 혈관 합병 절제: 비록 주요 혈관의 절제에는 아직 이견이 있는 실정이나 췌장암의 1/3에서 SMV (PV), SMA, CA, HA를 포함한 주요 혈관의 침범이 이 루어지므로 주요 혈관의 절제는 췌장절제술의 중요 부분 중 하나이며 혈관의 합병절제에는 SMV (PV)의 정맥 절제 와 SMA, CA, HA의 동맥절제로 나눌 수 있다. Fortner에 의 6 한 분류는 Table 2와 같다. SMV (또는 PV)의 침범의 그 범위가 혈관둘레의 경우 1/3 이하인 경우 primary wedge resection과 primary repair 또는 Standard lymphadenectomy Fig. 2. CT finding showing cancer of pancreas body involved the celiac axis. Arrow indicates celiac axis involved by tumor. a Extended lymphadenectomy Fig. 3. Diagram showing extent of standard lymphadenectomy and extended lymphadenectomy. b Fig. 4. Operative finding of standard dissection and extended dissection for cancer of the pancreas head. (a) standard lymphadenectomy (b) extended lymphadenectomy.
a b 100 80 Survival (%) 60 40 D+ 1 α 29.7% 29.7% 20 D1 18.0% 13.5% D 2 0 1 3 5 Years 10 Standard D 1 Modifiled D + 1 α