R E S E C T I O N F O R C A R C I N O M A O F H E A D O F P A N C R E A S 489

RESECTION FOR CARCINOMA OF HEAD OF PANCREAS TWO 5-YEAR SURVIVALS

BY E. G. MUIR, LONDON

SINCE Whipple’s description in 1935 (Whipple, Parsons, and Mullins), the operation of pancreatico- duodenal resection has been widely used for carcinoma in the head of the pancreas, whether arising i n the ampulla, terminal common bile-duct, or pancreas itself. Enthusiasm for the operation has been some- what tempered by poor after-results and there are some who feel that it is seldom justified. I t is certainly true that 5-year survivals are rare and, though they have occurred, none has so far been recorded in this country. T w o such cases are here described and an attempt made to evaluate the operation.

CASE REPORTS Case r.-C. F., a man of 60, was admitted to hospital

on Aug. 20, 1949, with a history of many years indigestion and a diagnosis of chronic duodenal ulcer with duodenal deformity which had failed to respond to medical treat- ment. He had never been jaundiced. Laparotomy on Aug. 24, showed a mass the size of an orange in the head of the pancreas involving the first and second parts of the duodenum. There were no secondaries, the head of the pancreas was quite mobile and the tumour appeared localized. The head of the pancreas, together with the pyloric antrum and duodenum, was resected and the oversewn neck of the pancreas implanted into the first loop of the jejunum between the common bile-duct and the divided end of the stomach. Recovery was unevent- ful. Histology showed the growth to be a ‘ colloid ’ or mucinous adenocarcinoma of the pancreas. There were no glandular secondaries and the common bile-duct, though in contact with growth, had not been compressed. The patjent was discharged on a reduced-fat diet and pancreatin. Over the next two years he attended the hospital from time to time. He remained in fair health, but failed to gain weight, and there was evidence of a marked failure of fat absorption with loose pale stools. In May, 1952, he developed symptoms suggestive of mild obstruction, and a laparotomy showed an intussusception of the transverse colon caused by a small carcinoma. The growth was resected. No evidence of secondaries was found and the anastomoses of the previous operation appeared to be in good order. The patient made a good recovery. He continued to attend hospital from time to time, particularly when his loose stools became trouble- some. On several occasions he was admitted for a few days and usually improved rapidly on a reduced-fat diet and adequate proteins. On the last occasion a barium meal suggested compression of the stomach and on June 21, 1954, a small laparotomy incision was made. This showed no evidence of secondaries from either of his carcinomas and the appearance of the stomach on the barium meal was due to its position behind the transverse colon. At the present time, 5 years after the resection for a carcinoma of the head of the pancreas and 2 years after the resection for a carcinoma of the colon, this patient is free from recurrence. He is an elderly bachelor, living in lodgings, and his straitened circum- stances make an ideal diet sometimes difficult to obtain, but nevertheless his pancreatic insufficiency does not stop him from enjoying his life.

Case 2.-W. P., a man of 58, was admitted to hospital in December, 1947, with a four weeks history of jaundice. He was otherwise in good health. Laparotomy showed

a small growth at the ampulla of Vater. There were no secondaries and resection of the head of the pancreas and the duodenal loop was performed. The oversewn neck of the pancreas was implanted into the first jejunal loop between the common bile-duct and the divided end of the stomach. Recovery was uneventful. Histology showed that the growth, some 3 mm. in diameter, was a papillary adenocarcinoma of the ampulla of Vater. The patient made an uneventful recovery. He regained his normal weight, there was no diarrhea, and there was little evidence of fat wastage in his stools. Nine months after his operation he developed intermittent jaundice. Laparotomy was performed and this showed that his gall- bladder, which had previously appeared healthy, now contained gall-stones. There was no evidence of secondaries. The gall-bladder was removed, the common bile-duct explored, and some biliary debris and a small piece of silk suture removed from the region of the anastomosis to the jejunal loop. The patient made a good recovery and remains in good health. He earned his living as a coal-man and up till two years ago was still able to carry sacks of coal on his back. Now, 7 years after pancreatic resection, and 6 years after the subsequent cholecystectomy, he appears in good health and free from recurrence.

COMMENT One of these patients had the largest carcinoma

of the pancreas I have ever been able to resect : the other had the smallest. T h e y both underwent the same operative procedure but, while one has always shown evidence of pancreatic insufficiency, the other has remained on a normal diet, without weight loss, without pancreatin, without diarrhoea, and with little evidence of fat wastage. Both have undergone major operations at intervals after the pancreatic resection.

DISCUSSION Whipple (1951), in a n editorial review, stated

that until earlier operation was possible “ the cures with radical surgery in ampullary growths will remain few and in cancer of the pancreas will continue to be palliative ”. Brunschwig (1952) later reported 3 patients alive and well 84, 7, and over 5 years after pancreatico-duodenectomy, and Orr (1952) stated that there were then 17 cases which had lived 5-10 years after the operation. Child, Holswade, McClure, Gore, and O’Neil (I952), in an extensive review of some 150 cases submitted to resection, found only 3 known 5-year survivors and only 9 alive over eighteen months. T h e average survival period after radical resection was only 9 months, but in 1148 cases treated palliatively i t was only 5 months. T h e largest personal series is that of Cattell and Warren (1953), who stressed, as did Whipple and others, the difference-both in operative mortality and post-operative prognosis-between carcinoma of the pancreas itself and that of the ampulla of Vater. T h e resection operative mortality was 13.6 per cent. Of 38 survivors of resection for carcinoma of the pancreas only 2 (5 per cent) survived 5 years or more : of 28 survivors of ampullary carcinoma 3 (11 per

490 T H E B R I T I S H J O U R N A L O F S U R G E R Y

cent) were alive and well 9 years after operation, and 11 (40 per cent) lived 3 years or more. Thirty-two cases were available for a 5-year follow-up, and this showed an overall 5-year survival of 16 per cent. The same authors found that in 56 palliative opera- tions 75 per cent were dead in 6 months. Reviews of the subject by Rodney Smith (1953) and Moore and Younghusband (1954) give a similar impression. Though none of the cases recorded had survived 5 years, the results were definitely better in ampullary carcinoma, and palliative operations were disappoint- ing, with an average duration of life of 5-6 months.

The results obtained by Cattell and Warren (1953) are as yet unequalled and, while the number is small by comparison with other growths, it is interesting to compare their operative mortality of 13.6 per cent and 5-year survival of 16 per cent with the results of operations for cancer in other sites.

Cancer of Esophagus.-Sweet (1952) in a series of 254 patients with esophageal carcinoma treated by radical resection had an operative mortality of 11.6 per cent for low growths and 24.3 per cent for those in the mid-thoracic region. Of 211 cases available for post-operative follow-up 16 per cent were alive 3 years later and 5.7 per cent alive 5 years later.

Cancer of the Stomach.-Ransom (1953) reports a series of 1264 patients with cancer of the stomach with an overall operative mortality of 18.1 per cent in those resectable and a 5-year survival of 28 per cent.

Cancer of the Lung.-Price Thomas (1952) reports a 5-year survival rate of 21.15 per cent. Borrie (1952) reports 128 resections with an operative mortality of 22 per cent and considered that 20 per cent of resections were likely to be alive 3 years or more after resection.

The results of pancreatico-duodenectomy for carcinoma of the head of the pancreas are not good, but they can bear comparison with some recognized surgical procedures for cancer in other sites.

From inquiries in this country it is apparent that at least another 4 as yet unpublished cases have survived 5 years after operation and a considerable number have survived 3 years. One case of carcinoma of the common bile-duct died in the sixth post-operative year from hepatic secondaries and another of the ampulla of Vater is alive in the sixth year and free from metastases, but with a locally inoperable carcinoma of the rectum (d’Offay, 1954). A carcinoma of the pancreas died 5 $ years after operation from local recurrence (Rob) and an ampullary carcinoma is alive 5 years after resection (Rodney Smith, 1954).

As a supposed contrast to the radical operation, with its high mortality and poor survival rate, palliative short-circuits are favoured by some. Unfortunately in poor risks the operative mortality is not low and attention has already been drawn to the short survival rate obtained in most series with such operations. There are, however, occasionally surprising exceptions with a long survival, though there is seldom histological evidence of the condition found at the time of the palliative operation. A remarkable case is reported by Aird (1954). In

1938 a patient was explored by Vick and found to have an inoperable cancer of the head of the pancreas with twelve secondaries in the liver. A short-circuit was performed and the patient survived. In 1953 the anastomosis silted up and the patient was explored by Aird. There was an irremovable tumour in the head of the pancreas and twelve secondaries in the liver. The common bile-duct was greatly dilated and was anastomosed to the small intestine with such good effect that the patient is still alive sixteen years after the original palliative proceeding. Biopsy of the primary growth at the second operation suggested that it was a malignant ‘ carcinoid ’ tumour.

In general, the surgical opinion expressed has been in favour of radical resection for carcinoma of the ampulla of Vater, but considers operation unjustifiable for carcinoma of the pancreas itself unless the growth is small and easily operable. Difficult dissections around the superior mesenteric vein almost certainly indicate that a radical resection is unwise; there seems little justification for an attempt at resection of the involved portal vein and the division of the neck of the pancreas in cases of doubtful operability may spill cancer cells in the surrounding tissues and disseminate the disease. Operability is not always easy to assess, but ill-chosen cases almost certainly account for many of the early recurrences after radical resection and have given the operation a poor reputation. Radical resection is only indicated for the obviously operable case and, if it is reserved for this group, its after-results may be expected to improve.

SUMIMARY Two 5-year survivals are described following

pancreatico-duodenectomy for carcinoma of the head of the pancreas and the results of the operation are discussed.

I wish to acknowledge my grateful thanks to those surgeons who have helped me so readily with details of their cases.

REFERENCES AIRD, I. (1954), personal communication. BORRIE, J. (I952), Ann. R . Coll. Surg. Engl., 10, 165. BRUNSCHWIG, A. (1952)~ Ann. Surg., 136, 610. CATTELL, R. B., and WARREN, K. W. (1953), Surgery of

the Pancreas. Philadelphia : W. B. Saunders Co. CHILD, C. G., HOLSWADE, G. R., MCCLURE, R. D., GORE,

A. L., and O’NEILL, E. A. (1952), Surg. Gynec. Obstet., 94, 3 I .

D’OFFAY, T. M. (1954), personal communication. MOORE, R. G., and YOUNGHUSBAND, J. D. (1y54), Brit. J.

Surg., 41, 562. ORR, T. (1952), Ann. Surg., 136, 618. RANSOM, H. K. (1953), Surg. Gynec. Obstet., 96, 275. ROB, C. (1954), Brit. med. J., 2, 330. SMITH, RODNEY (1953), The Surgery of Pancreatic

Neoplasms. Edinburgh : E. & S . Livingstone. -- (1954)~ Brit. rned. J., 2, 330. SWEET, R. H. (1952), Surg. Gynec. Obszez., 94, 46. THOMAS, C. PRICE (I952), Ann. R. Coll. Surg. Engl., I I ,

WHIPPLE, A. 0. (1951), Surg. Gynec. Obstet., 93, IIZ. - _ PARSONS, W. B., and MULLINS, C. R. (1935)~ Ann.

205.

Surg., 102,!763.