AN EVALUATION OF SURGICAL TREATMENT OF CARCINOMA OF T H E HEAD OF THE PANCREAS

E. S. BRINTNALL, M.D.

PINION IS DIVIDED concerning the value of 0 pancreatic resections for cancer. Many sur- geons consider that resection of the head of pan- creas should be reserved for small ampullary lesions. They believe that survival after pallia- tive sidetracking procedures is as long as, or longer than, after resection; further, they con- tend that the palliative procedures carry a less formidable operative risk. The number of cases comprising this series is too small to make it a basis for valid statistical analysis. However, the obviously superior palliative results of resection as compared with biliary-tract diversion for resectable lesions justify publication of the study.

During the years 1947 to 1951 inclusive, ab- dominal exploratory operations were carried out at the University Hospital upon sixty-seven patients with carcinoma of the head of the pan- creas. The time span of 1947 to 1951 was selected because the author had first-hand in- formation and knowledge concerning these sixty-seven patients, although, in instances, the technical procedure may have been performed by other members of the University Hospital Staff. The time span of this study is brief, but the life history of pancreatic carcinoma is such that long-term survival is exceptional.

Table 1 indicates the surgical procedures per- formed upon the sixty-seven patients with neo- plastic lesions in the head of the pancreas. Histological proof was available on forty pa- tients; thirty-nine of these were adenocarcino- mas of ductal or acinar origin. One was an epidermoid carcinoma. An analysis to include histological grading was not carried out.

OPERATIVE PROCEDURES

The procedures carried out on these patients may be divided into four groups, as follows.

Exploration and Biopsy. In nine patients, extensive regional or diffuse abdominal carci- nomatosis precluded any attempt at a palliative

From the Department of Surgerv, College o f Medi-

Received for publication, March 3, 1952. cine, State University of Iowa, Iowa City, Iowa.

908

or therapeutic procedure. Of these patients, six died within one month after operation and three died two to two and one-half months postoperative.

Palliative Diversion of Biliary Flozu. The sidetracking procedures were carried out to alleviate the physiological deficits incident to biliary obstruction, to overcome jaundice, and to improve the patient’s sense of well-being. In the forty-two patients so treated, the procedures utilized were cholecystojejunostomy, twenty- seven patients; choledochojejunostomy, six; choledochoduodenostomy, five; cholecystogas- trostoniy, one: choledochostomy (external), two; and cholecystostomy (external), one. In- ternal drainage is definitely to be preferred, particularly choledochoduodenostomy or cho- lecystojejunostomy. External drainage is to be resorted to only in very exceptional circum- stances.

TABLE 1

TYPES OF SURGICAL PROCEDURES, CAR- CINOMA OF HEAD OF PANCREAS

Procedure Number of

patients

Biopsy only 9 Diversion of biliary flow 42 Resection of head of pancreas 15 Transduodenal ampullary resection 1

__

Palliative sidetracking procedures were car- 1 ied out in thirty-four patients because the neo- plasm had metastasized so as to be nonre- sectable or had spread to involve the regional major blood vessels. Howcver, in eight in- stances, palliative procedures were carried out for lesions that were technically resectable. These constituted a control group, in essence, horn which comparison? might be drawn. Pal- liative sidctiacking of the Iiiliary flow was e€- Eective in relieving jaundice and itching but seldom restored the patient to any semblance of general good health.

From the results recorded in Table 2, it can be seen that those patients with resectable le- sions upon whom palliative sidctracking pro- cedures were performed fared no better than

No. 5 SURGERY I N CARCINOMA OF HEAD OF PANCREAS . Brintnal l 909

TABLE 2

DIVERSIONS FOR CARCINOMA OF HEAD OF PANCREAS

ANALYSIS OF PALLIATIVE BILIARY-STREAM

Diversion for Inoperable Lesion 34 Living patients (at 18 mo. postoperative)

Patients deceased (1-7 mo. postoperative)

Operative deaths (within 1 mo. of operation)

2

24

8

1

5

2

Average survival time, 18 mo.

Average survival time, 2% mo.

Diversion f o r Resectable Lesions 8 Living patients (4 mo. postoperative)

Average survival time, 4 mo.

Average survival time, 8 mo. I’atients deceased 2-22 mo. postoperative)

Operative death (within 1 mo. of operation) TOTAL 42 -~ ~~

those patients with nonresectable carcinomas. Resections of Head of Pancreas. Therapeutic

resections were carried out in fifteen patients. In five patients, the carcinoma was ampullary in type, in four it was histologically of ductal origin, and in the remaining six the carcinoma was of the parenchymal (acinar) variety. The method of reconstruction is illustrated in Fig. 1. This technique was used in fourteen instances, and, in the other, the gallbladder was substi- tuted for the common duct in the anastomosis of the biliary tree to the jejunum. A one-stage resection was used in every instance.

In those patients who survived operation, the postoperative course was free of serious compli- cations. The surviving patients quickly recov- ered from the major operative procedure and lived comfortably until such time as pain, diges- tive disturbance, recurrent jaundice, or loss of weight indicated the presence of recurrent car- cinoma. The terminal illness in those patients who died of recurrent and metastatic cancer was brief. Good palliation was afforded the patients during the time interval between oper- ation and final illness. No instance of steator- rhea or recurring cholangitis was observed, and the patients were not prone to digestive dis- turbances. Gain of weight and strength was con- stant among surviving patients.

TABLE 3

ANALYSIS O F THERAPErJTIC RESECTIONS OF HEAD OF PANCREAS FOR CANCER

Patients now living (5-26 mo. postoperative)

Patients deceased (4-32 mo. postoperative)

Operative deaths (within 1 mo. postoperative)

7

6

2

Average survival time, 19 mo.

Average survival time, 17 mo. -

TOTAL 15 - -~

There were two operative deaths incident to injury inflicted upon major blood vessels. In one patient (M. P.) a segment of the common hepatic artery was resected because of neo- plastic invasion and an end-to-end anastomosis of the vessel was performed. The patient died one month after operation as a result of liver necrosis incident to hepatic-artery thrombosis. The other death (A. C. ) occurred ten days after operation from massive venous mesenteric thrombosis subsequent to operative injury that was inflicted upon the superior inesenteric vein.

Table 3 records the survival data on the f i f - teen patients subjected to resections of the head of the pancreas.

FIG. 1. Diagrammatic illustration of the method o[ reconstruction used after resection of the head of the pancreas: “telescopic” end-to-end pancreaticojejunos- tomy, end-to-side choledochojejunostomy, and retro- colic gastrojejunostomy.

Transduodenal Resection of the Ampul la . This procedure was carried out in a single in- stance upon a poor-risk patient. The ainpullary lesion was small and extremely pedunculated. This patient is living and well, without evi- dence of the disease, seven months follow- ing operation. T h e author does not subscribe to this limited resection except in unusual circumstances.

DISCUSSIGN

From our recent experience with carcinoma of the head of the pancreas, it is our opinion that the procedure of choice is resection with reconstruction of the gastrointestinal tract as

910 CANCEK September 1952 Vol. 5

illustrated in Fig. 1. The patients undergoing resection were unselected. The operative mor- tality of 13 per cent does not appear prohibi- tive.

An appraisal of the two mortalities reveals that the patients were inoperable at the time of exploration. In reviewing the palliative pro- cedures, it is of particular interest to note that palliative sidetracking procedures in resectable lesions offered no more benefit than did similar procedures in those patients with spread be-

yond the scope of resection or involvement of adjacent major blood vessels.

SUMMARY

The results ol resection of the head of the pancreas for cancer indicate that this procedure is of greater palliative benefit than diversion of the biliary flow, whether such diversion is performed Eor resectable or nonresectable cancers.