The Japanese Journal of Surgery (1992) 22:74-77
r
~
SUllGEI1YTODAY © Springer-Verlag 1992
Aggressive Resection for Advanced Pancreatic Carcinoma SHOJI SUNADA, MASAHIKOMIYATA,YASUHIROTANAKA, KENZOOKUMURA, MAKOTONAKAMURO, TORU KITAGAWA,RYOTASHIRAKURA,and YASUNARUKAWASHIMA The First Departmentof Surgery,Osaka UniversityMedicalSchool,Osaka, Japan
Abstract: An aggressive pancreatectomy was performed on a 53 year old Japanese man with advanced cancer of the pancreas. The tumor originated from the body of the pancreas and invaded the stomach, duodenum, left kidney, transverse colon and common hepatic artery. An unexpected cancer was also found in the head of the pancreas during the operation. Therefore, total pancreatectomy, total gastrectomy, left adrenonephrectomy, resection of the left transverse colon and dissection of the regional lymph nodes were performed. Resection of the common hepatic artery was also performed, followed by an end-to-end anastomosis between the common hepatic artery and celiac trunk. The postoperative course was uneventful and the patient was doing well until nine months after the operation when multiple metastatic lesions were noted in the liver. He died 391 days after the operation from hepatic failure. Key Words: pancreatic carcinoma, total pancreatectomy
Introduction The majority of pancreatic cancers are in an advanced stage at the time of diagnosis because our current diagnostic techniques are still inadequate for detecting early cancer of the pancreas. 1-3 Moreover, the prognosis of this cancer is still extremely poor 1-3 although despite this, the survival rate is relatively good following pancreatectomy even when the local findings of the cancer are extended. 4-6 Therefore, we have recently begun performing aggressive resection of pancreatic cancer, except in cases with distal metastasis. We present herein a case of pancreatic cancer in which most of the left upper abdominal organs were successfully resected with the entire pancreas.
Reprint Requests to: Masahiki Miyata MD, The First Department of Surgery, Osaka University Medical School, Fukushima-ku, Osaka 553, Japan (Received for publication on Aug. 2, 1990)
Case Report A 53 year old Japanese man presented with a history of upper abdominal discomfort since December, 1987. A 4 cm solid mass was detected by abdominal ultrasonography on April, 1988 and carcinoma of the body of the pancreas suspected. H e was transferred to the First Department of Surgery, Osaka University Medical School, on June 8, 1988 for an operation. On admission, he complained of back pain and nausea. An immovable goose egg sized hard mass was palpable in the left upper abdominal quadrant on physical examination. Ascites was not detected. Abdominal computerized tomography showed a 55 x 36 mm sized solid mass in the body of the pancreas, invading the common hepatic artery, celiac artery, splenic artery and left kidney (Fig. 1). An upper gastrointestinal series showed stenosis of the fourth portion of the duodenum and dilatation of the proximal duodenum. Gastroscopy revealed that the posterior wall of the stomach was pressed by the surrounding structures and barium enema showed stenosis of the splenic flexure of the transverse colon (Fig. 2). Celiac arteriography showed encasement of the splenic artery and dorsal pancreatic artery (Fig. 3). The serum level of CA19-9 was as high as 1,056U/ml, the normal value being less than 37 U/ml. There was no evidence suggesting hepatic or distant metastasis. From these findings, we diagnosed the lesion as a localized advanced pancreatic carcinoma invading the left upper abdominal organs. On July 13, 1988, a laparotomy was performed through a bilateral subcostal arched incision extending to the left l l t h rib. No metastatic lesions were seen over the peritoneum and abdominal organs. A hard mass, larger than a first, was palpable in the body of the pancreas with involvement of the stomach, fourth portion of the duodenum, splenic flexure of the transverse colon and left kidney. The celiac artery, common
S. Sunada et al. : Aggressive Pancreatectomy
75
Fig. 3. Preoperative celiac arteriography. Encasement of the splenic artery and dorsal pancreatic artery is shown by arrows
Common
hepatic A •
~,_"
_
.,,,,---.~-~Spleen
,-7~"~",...,4 ',
I
Fig. 1. An abdominal computerized tomography. The tumor in the pancreatic body was 55 × 36 mm in size. In the upper panel an arrow shows invasion of the celiac artery. In the lower panel the long arrow shows invasion of thee splenic artery and the short arrow shows invasion of the left kidney
Fig. 4. Schema of the operative findings. The tumor in the pancreatic body invaded the stomach, duodenum, transverse colon, left kidney, celiac artery and splenic artery. The tumor in the head of the pancreas did not invade the surrounding structures
Fig. 2. Preoperative barium enema. Arrow show stenosis of the transverse colon
hepatic artery and splenic artery were also involved in the mass. Fortunately, the trunk of the celiac artery was free from cancerous invasion as expected preoperatively. A small tumor, 10 × 1 0 m m in size, was also palpable in the head of the pancreas, which had not been detected in the preoperative examinations (Fig. 4). A frozen section of the small tumor in the pancreatic head revealed adenocarcinoma. Total pancreatectomy, total gastrectomy, partial resection of the transverse colon, left adrenonephrectomy, resection of the c o m m o n hepatic and celiac arteries and dissection of the regional lymph nodes, with an R3 resection, as based on the the criteria of the Japanese Pancreas
76
S. Sunada et al.: Aggressive Pancreatectomy
Esophagojejunostomy C
°
m
~
a
c
A
Fig. 5. Schema of reconstruction following extended total pancreatectomy
Society, were performed. An end-to-end anastomosis of the common hepatic artery and celiac artery was first performed, the clamping time of the common hepatic artery being 30 rain. An end-to-side esophagojejunostomy and an end-to-side hepatico-jejunostomy in the Roux en Y fashion were performed (Fig. 5). The tumor in the pancreatic body measured 6 x 5 x 4cm, and the tumor in the pancreatic head measured 1 x 1 x 1 cm. Microscopically, the tumor in the pancreatic body invaded the stomach, duodenum, transverse colon, left kidney, common hepatic artery, celiac artery, left gastric artery and splenic artery. Metastasis to the regional lymph nodes was obvious and invasion of the retro-pancreatic region also noted. The tumor in the pancreatic head did not invade the surrounding structures and there was no continuity between the tumors. The findings of the tumor in the pancreatic body, based on the criteria of the Japanese Pancreas Society, 7 revealed Pb-t, T3, tumor forming, $3, Rp3, CH3, DU3, PVsp3, Ace3, Asp3, ASml, Plx.ce(+), Po, Ho, Ne(8,9,10,11,14), M0. The pathological diagnosis of the tumor was well-differentiated tubular adenocarcinoma, INFv, ly0, Vo, nee, si, rpi, due, pvsp3, ache, plx(+), b d w ( - ) , e w ( - ) , n 1 - 6 ( - ) , n 7(+), n 8a, 8 p ( - ) , n 9(+),n 10 - 12(-), n 13a(+), n 13b, 14 18(-). The findings of the tumor in the pancreatic head revealed Ph, T~, tumor forming, So, Rp0, CHo, DUo, PV0, A0, Plx(-), P0, H0, No, M0. The pathological diagnosis of the tumor was well-differentiated tubular adenocarcinoma, INFI3, ly0, Vo, ne0, so, rpo, duo, pvo, a0, plx(-), b d w ( - ) , e w ( - ) . The postoperative course was uneventful and the
patient was transferred to the Third Department of Medicine of the same institute for education regarding self-control of blood sugar and nutritional control 61 days after his operation. The serum level of CA19-9 was 70 U/ml at that time. Tegafur was given at a dose of 400mg per day for postoperative chemotherapy starting at 48 days after the operation, but was discontinued at 75 days due to nausea. His blood glucose level was controlled to within 80-300 mg/dl with 20-40 units of insulin per day. Oral intake was limited to within 600-800 Cal per day at the grated effort of the patient. The home parenteral nutrition (HPN) route was thus made 225 days after the operation and 900 Cal per day additionally infused at night. Metastasis of the liver was detected 212 days after the operation and the serum level of CA19-9 had escalated to 8200 U/ml, but the patient had no symptoms. He was discharged on March 19, 1989, 250 days after the operation. He complained of nausea 10 months after the operation, after which his general condition progressively deteriorated until he finally died 391 days after the operation from hepatic failure. Autopsy revealed metastasis to the liver which had been nearly replaced by multiple metastatic nodules. The metastatic nodules in the caudal lobe, 35mm in size, invaded the portal vein and jejunum at the portion of the hepatico-jejunostomy. There was no fatty change in the liver. There were four metastatic para-aortic lymph nodes, less than 10 mm in size as well as multiple metastatic nodules in the bilateral lungs.
Discussion
There is no effective therapy for pancreatic cancer apart from surgical resection 4'6 which is why many surgeons aggressively resect advanced cancer of the pancreas. 4'8-15 The survival rate after resection, however, is still poor compared with cancers of the other abdominal organs, 16'17 the main reason for which being that in most cases, the stage of the pancreatic cancer is already very advanced at the time of surgical intervention. Recently, several reports have presented promising results of surgical therapy for pancreatic cancer. 4-6'11A3 Our continuing to perform resection of advanced pancreatic cancer is motivated by the fact that the 1 year survival rate of such patients is reportedly 30-50 per cent for resection and only 6-15 per cent for palliative procedures without resection. 4'6 The present case of advanced cancer of the pancreas showed extensive invasion of the surrounding structures but because distant metastasis was not detected, we attempted an extended caudal pancreatectomy before the operation. However, since an unexpected
S. Sunada et al.: Aggressive Pancreatectomy carcinoma was found in the head of the pancreas during the operation, a total pancreatectomy was performed. Otherwise, the preoperative evaluation of the extent of the cancer was confirmed to be correct during the operation. The success of taping the celiac trunk had been considered to be the determinant surgical point for resection in this patient and therefore, we approached the trunk first via the left retroperitoneal space. Division of the trunk was performed just before total pancreatectomy was carried out under systemic heparinization. Reconstruction of the hepatic arterial circulation was then performed within 30 rain. Postoperative pathological examination revealed that an absolutely curative resection had been performed in this patient. There was no continuity between the tumor in the pancreatic head and that in the pancreatic body and thus, we diagnosed this case as multiple cancer of the pancreas. Multiple pancreatic cancer is rare, with only 71 of a total 4,776 patients with pancreatic cancer being documented in the registry of pancreatic cancer in Japan. 3 In our case, hepatic metastasis was evident 7 months after the operation, and it was not able to be determined whether the cancer cells had already immigrated to the liver before surgery or during the operation with surgical manipulation. A n effective procedure for the control of such postoperative hepatic metastasis is one of the critical requirements for improving survival after resection of the pancreas. There were only a few metastatic para-aortic lymph nodes found at the level of origin of the superior mesenteric artery at autopsy. We tried to resect all the metastatic lymph nodes, but the operative procedure could not control local recurrence. Thus, radiotherapy or other additional therapy is necessary for control of advanced pancreatic cancer after resection. There was no fatty change in the liver on autopsy which showed that the control of metabolism of this patient was performed fairly well. This patient survived for 13 months after surgery which was an obviously longer period than the mean survival time for a palliative operation without resection for patients with the same stage of cancer. *-6 Our results showed that the mean survival time for palliative surgery and exploratory laparotomy for localized stage IV patients was 120 days and 33 days, respectively. 5 In this patient, the preoperative complaints completely disappeared and his quality of life remained fairly good until 1 month before his death. We conclude that the aggressive resection of advanced cancer of the pancreas was worthwhile in this patient. The series of regional pancreatectomy reported by Fortner et al. did not include any cases in which the left upper abdominal organs were completely removed with arterial reconstruction. 18,~9 Moreover, we found
77 no other cases of such aggressive pancreatectomy in the registry of pancreatic cancer in J a p a n ) Thus, the present case should encourage surgeons to perform extended resection for advanced cancer of the pancreas.
References 1. Kalser MH, Smith FP, Schein P$, Zeppa R (1985) Exocrine tumors of the pancreas. Berk JE, ed. Gastroenterology. Fourth edition. Vol 6. Philadelphia: WB Saunders pp 4095-4121 2. Cello JP (1989) Carcinoma of the pancread. Sleisenger MH, Fordtran JS, eds. Gastronintestinal disease. Fourth edition. Philadelphia: WB Saunders pp 1872-1883 3. Annual Registry Reports of Cancer of the Pancreas (1988). (in Japanese) Registry Committee of Japan Pancreas Society. (1989) 4. Tajiri H, Yoshimori M, Nakamura K, Taylor WF, Go VW (1987) Clinicopathological study on carcinoma of the pancreas operated on at the Mayo clinic and the National Cancer Center Hospital. (in Japanese with an English Abst.) Nihon Ganchiryo Gakukai Zasshi (J Jpn Soc Cancer Ther) 23:566-572 5. Kuno N, Tanehira K, Kurimoto K, Kano T, Yasue M (1988) Combined modality therapy for advanced pancreatic cancer. Shokakigeka (in Japanese) (Gastroenterological Surgery) 11: 1491-1495 6. Miyata M, Nakao K, Takao T, Kuwata K, Nakashima N, Dousei T, Hayashi K, Kawashima Y (1990) An appraisal of pancreatectomy for advanced cancer of the pancreas based on survival rate and postoperative physical performance. J Surg Oncology45:33-39 7. Japan Pancreas Society (1986) General rules for cancer of the pancreas, The 3rd edition, Tokyo: Kanehara (in Japanese) 8. ReMine WH, Priestly JT, Judd ES, Jhon NK (1970) Total pancreatectomy. Ann Surg 172:595-604 9. Fortner JG, Kim DK, Cubilla A, Turnbull A, Pahnke LD, Shils ME (1977) Regionalpancreatectomy: En bloc pancreatic, portal vein and lymph node resection. Ann Surg 186:42-50 10. Ihse J, Liliya P, Arnesjo B. (1977) Total pancreatectomy for cancer. An appraisal of 65 cases. Ann Surg 186:675-685 11. SuzukiS, Manabe T, Tani T, Uchida K, Tobe R (1981) Rationale for total pancreatectomyfor cancerof the pancreas. (in Japanese) Tan To Sui (J Biliary Tract and Pancreas) 2:327-333 12. Moosa AR (1982) Pancreatic cancer. Approach to diagnosis, selection for surgery and choice of operation. Cancer 50:26892698 13. Nagakawa T, Kurachi M, Konishi K, Miyazaki I (1982) Translateral retroperitoneal approach in radical surgery for pancreatic carcinoma. Jpn J Surg 12:229-233 14. ImaizumiT, Hannyu F, Yoshikawa T, Nakasako T, Matsuyama H, Hasegawa M (1983) Relative non-curative resection of pancreatic cancer. (in Japanese) Rinshogeka (J Clinical Surgery) 43:1349-1356 15. Nagakawa T, Miyazaki I (1989) Extended pancreaticoduodenectomy for advanced pancreatic cancer. (in Japanese) Tan To Sui (J Biliary Tract and Pancreas) 10:151-158 16. Connolly MM, Dawson PJ, Michelassi F, Moosa AR, Lowenstein F (1989) Survivalin 1001 patients with carcinoma of the pancreas. Ann Surg 206:366-377 17. van Heerden JA, McIlrath DC, Ilstruo DM, Weiland LH (1989) Total pancreatectomy for ductal adenocarcinoma of the pancreas: An update. World J Surg 12:658-662 18. Fortner JG (1981) Surgical principles for pancreatic cancer: Regional total and subtotal pancreatectomy. Cancer 47:17121718 19. Fortner JG (1984) Regional pancreatectomy for cancer of the pancreas, ampulla, and other related sites. Ann Surg 199:418425
r
~
SUllGEI1YTODAY © Springer-Verlag 1992
Aggressive Resection for Advanced Pancreatic Carcinoma SHOJI SUNADA, MASAHIKOMIYATA,YASUHIROTANAKA, KENZOOKUMURA, MAKOTONAKAMURO, TORU KITAGAWA,RYOTASHIRAKURA,and YASUNARUKAWASHIMA The First Departmentof Surgery,Osaka UniversityMedicalSchool,Osaka, Japan
Abstract: An aggressive pancreatectomy was performed on a 53 year old Japanese man with advanced cancer of the pancreas. The tumor originated from the body of the pancreas and invaded the stomach, duodenum, left kidney, transverse colon and common hepatic artery. An unexpected cancer was also found in the head of the pancreas during the operation. Therefore, total pancreatectomy, total gastrectomy, left adrenonephrectomy, resection of the left transverse colon and dissection of the regional lymph nodes were performed. Resection of the common hepatic artery was also performed, followed by an end-to-end anastomosis between the common hepatic artery and celiac trunk. The postoperative course was uneventful and the patient was doing well until nine months after the operation when multiple metastatic lesions were noted in the liver. He died 391 days after the operation from hepatic failure. Key Words: pancreatic carcinoma, total pancreatectomy
Introduction The majority of pancreatic cancers are in an advanced stage at the time of diagnosis because our current diagnostic techniques are still inadequate for detecting early cancer of the pancreas. 1-3 Moreover, the prognosis of this cancer is still extremely poor 1-3 although despite this, the survival rate is relatively good following pancreatectomy even when the local findings of the cancer are extended. 4-6 Therefore, we have recently begun performing aggressive resection of pancreatic cancer, except in cases with distal metastasis. We present herein a case of pancreatic cancer in which most of the left upper abdominal organs were successfully resected with the entire pancreas.
Reprint Requests to: Masahiki Miyata MD, The First Department of Surgery, Osaka University Medical School, Fukushima-ku, Osaka 553, Japan (Received for publication on Aug. 2, 1990)
Case Report A 53 year old Japanese man presented with a history of upper abdominal discomfort since December, 1987. A 4 cm solid mass was detected by abdominal ultrasonography on April, 1988 and carcinoma of the body of the pancreas suspected. H e was transferred to the First Department of Surgery, Osaka University Medical School, on June 8, 1988 for an operation. On admission, he complained of back pain and nausea. An immovable goose egg sized hard mass was palpable in the left upper abdominal quadrant on physical examination. Ascites was not detected. Abdominal computerized tomography showed a 55 x 36 mm sized solid mass in the body of the pancreas, invading the common hepatic artery, celiac artery, splenic artery and left kidney (Fig. 1). An upper gastrointestinal series showed stenosis of the fourth portion of the duodenum and dilatation of the proximal duodenum. Gastroscopy revealed that the posterior wall of the stomach was pressed by the surrounding structures and barium enema showed stenosis of the splenic flexure of the transverse colon (Fig. 2). Celiac arteriography showed encasement of the splenic artery and dorsal pancreatic artery (Fig. 3). The serum level of CA19-9 was as high as 1,056U/ml, the normal value being less than 37 U/ml. There was no evidence suggesting hepatic or distant metastasis. From these findings, we diagnosed the lesion as a localized advanced pancreatic carcinoma invading the left upper abdominal organs. On July 13, 1988, a laparotomy was performed through a bilateral subcostal arched incision extending to the left l l t h rib. No metastatic lesions were seen over the peritoneum and abdominal organs. A hard mass, larger than a first, was palpable in the body of the pancreas with involvement of the stomach, fourth portion of the duodenum, splenic flexure of the transverse colon and left kidney. The celiac artery, common
S. Sunada et al. : Aggressive Pancreatectomy
75
Fig. 3. Preoperative celiac arteriography. Encasement of the splenic artery and dorsal pancreatic artery is shown by arrows
Common
hepatic A •
~,_"
_
.,,,,---.~-~Spleen
,-7~"~",...,4 ',
I
Fig. 1. An abdominal computerized tomography. The tumor in the pancreatic body was 55 × 36 mm in size. In the upper panel an arrow shows invasion of the celiac artery. In the lower panel the long arrow shows invasion of thee splenic artery and the short arrow shows invasion of the left kidney
Fig. 4. Schema of the operative findings. The tumor in the pancreatic body invaded the stomach, duodenum, transverse colon, left kidney, celiac artery and splenic artery. The tumor in the head of the pancreas did not invade the surrounding structures
Fig. 2. Preoperative barium enema. Arrow show stenosis of the transverse colon
hepatic artery and splenic artery were also involved in the mass. Fortunately, the trunk of the celiac artery was free from cancerous invasion as expected preoperatively. A small tumor, 10 × 1 0 m m in size, was also palpable in the head of the pancreas, which had not been detected in the preoperative examinations (Fig. 4). A frozen section of the small tumor in the pancreatic head revealed adenocarcinoma. Total pancreatectomy, total gastrectomy, partial resection of the transverse colon, left adrenonephrectomy, resection of the c o m m o n hepatic and celiac arteries and dissection of the regional lymph nodes, with an R3 resection, as based on the the criteria of the Japanese Pancreas
76
S. Sunada et al.: Aggressive Pancreatectomy
Esophagojejunostomy C
°
m
~
a
c
A
Fig. 5. Schema of reconstruction following extended total pancreatectomy
Society, were performed. An end-to-end anastomosis of the common hepatic artery and celiac artery was first performed, the clamping time of the common hepatic artery being 30 rain. An end-to-side esophagojejunostomy and an end-to-side hepatico-jejunostomy in the Roux en Y fashion were performed (Fig. 5). The tumor in the pancreatic body measured 6 x 5 x 4cm, and the tumor in the pancreatic head measured 1 x 1 x 1 cm. Microscopically, the tumor in the pancreatic body invaded the stomach, duodenum, transverse colon, left kidney, common hepatic artery, celiac artery, left gastric artery and splenic artery. Metastasis to the regional lymph nodes was obvious and invasion of the retro-pancreatic region also noted. The tumor in the pancreatic head did not invade the surrounding structures and there was no continuity between the tumors. The findings of the tumor in the pancreatic body, based on the criteria of the Japanese Pancreas Society, 7 revealed Pb-t, T3, tumor forming, $3, Rp3, CH3, DU3, PVsp3, Ace3, Asp3, ASml, Plx.ce(+), Po, Ho, Ne(8,9,10,11,14), M0. The pathological diagnosis of the tumor was well-differentiated tubular adenocarcinoma, INFv, ly0, Vo, nee, si, rpi, due, pvsp3, ache, plx(+), b d w ( - ) , e w ( - ) , n 1 - 6 ( - ) , n 7(+), n 8a, 8 p ( - ) , n 9(+),n 10 - 12(-), n 13a(+), n 13b, 14 18(-). The findings of the tumor in the pancreatic head revealed Ph, T~, tumor forming, So, Rp0, CHo, DUo, PV0, A0, Plx(-), P0, H0, No, M0. The pathological diagnosis of the tumor was well-differentiated tubular adenocarcinoma, INFI3, ly0, Vo, ne0, so, rpo, duo, pvo, a0, plx(-), b d w ( - ) , e w ( - ) . The postoperative course was uneventful and the
patient was transferred to the Third Department of Medicine of the same institute for education regarding self-control of blood sugar and nutritional control 61 days after his operation. The serum level of CA19-9 was 70 U/ml at that time. Tegafur was given at a dose of 400mg per day for postoperative chemotherapy starting at 48 days after the operation, but was discontinued at 75 days due to nausea. His blood glucose level was controlled to within 80-300 mg/dl with 20-40 units of insulin per day. Oral intake was limited to within 600-800 Cal per day at the grated effort of the patient. The home parenteral nutrition (HPN) route was thus made 225 days after the operation and 900 Cal per day additionally infused at night. Metastasis of the liver was detected 212 days after the operation and the serum level of CA19-9 had escalated to 8200 U/ml, but the patient had no symptoms. He was discharged on March 19, 1989, 250 days after the operation. He complained of nausea 10 months after the operation, after which his general condition progressively deteriorated until he finally died 391 days after the operation from hepatic failure. Autopsy revealed metastasis to the liver which had been nearly replaced by multiple metastatic nodules. The metastatic nodules in the caudal lobe, 35mm in size, invaded the portal vein and jejunum at the portion of the hepatico-jejunostomy. There was no fatty change in the liver. There were four metastatic para-aortic lymph nodes, less than 10 mm in size as well as multiple metastatic nodules in the bilateral lungs.
Discussion
There is no effective therapy for pancreatic cancer apart from surgical resection 4'6 which is why many surgeons aggressively resect advanced cancer of the pancreas. 4'8-15 The survival rate after resection, however, is still poor compared with cancers of the other abdominal organs, 16'17 the main reason for which being that in most cases, the stage of the pancreatic cancer is already very advanced at the time of surgical intervention. Recently, several reports have presented promising results of surgical therapy for pancreatic cancer. 4-6'11A3 Our continuing to perform resection of advanced pancreatic cancer is motivated by the fact that the 1 year survival rate of such patients is reportedly 30-50 per cent for resection and only 6-15 per cent for palliative procedures without resection. 4'6 The present case of advanced cancer of the pancreas showed extensive invasion of the surrounding structures but because distant metastasis was not detected, we attempted an extended caudal pancreatectomy before the operation. However, since an unexpected
S. Sunada et al.: Aggressive Pancreatectomy carcinoma was found in the head of the pancreas during the operation, a total pancreatectomy was performed. Otherwise, the preoperative evaluation of the extent of the cancer was confirmed to be correct during the operation. The success of taping the celiac trunk had been considered to be the determinant surgical point for resection in this patient and therefore, we approached the trunk first via the left retroperitoneal space. Division of the trunk was performed just before total pancreatectomy was carried out under systemic heparinization. Reconstruction of the hepatic arterial circulation was then performed within 30 rain. Postoperative pathological examination revealed that an absolutely curative resection had been performed in this patient. There was no continuity between the tumor in the pancreatic head and that in the pancreatic body and thus, we diagnosed this case as multiple cancer of the pancreas. Multiple pancreatic cancer is rare, with only 71 of a total 4,776 patients with pancreatic cancer being documented in the registry of pancreatic cancer in Japan. 3 In our case, hepatic metastasis was evident 7 months after the operation, and it was not able to be determined whether the cancer cells had already immigrated to the liver before surgery or during the operation with surgical manipulation. A n effective procedure for the control of such postoperative hepatic metastasis is one of the critical requirements for improving survival after resection of the pancreas. There were only a few metastatic para-aortic lymph nodes found at the level of origin of the superior mesenteric artery at autopsy. We tried to resect all the metastatic lymph nodes, but the operative procedure could not control local recurrence. Thus, radiotherapy or other additional therapy is necessary for control of advanced pancreatic cancer after resection. There was no fatty change in the liver on autopsy which showed that the control of metabolism of this patient was performed fairly well. This patient survived for 13 months after surgery which was an obviously longer period than the mean survival time for a palliative operation without resection for patients with the same stage of cancer. *-6 Our results showed that the mean survival time for palliative surgery and exploratory laparotomy for localized stage IV patients was 120 days and 33 days, respectively. 5 In this patient, the preoperative complaints completely disappeared and his quality of life remained fairly good until 1 month before his death. We conclude that the aggressive resection of advanced cancer of the pancreas was worthwhile in this patient. The series of regional pancreatectomy reported by Fortner et al. did not include any cases in which the left upper abdominal organs were completely removed with arterial reconstruction. 18,~9 Moreover, we found
77 no other cases of such aggressive pancreatectomy in the registry of pancreatic cancer in J a p a n ) Thus, the present case should encourage surgeons to perform extended resection for advanced cancer of the pancreas.
References 1. Kalser MH, Smith FP, Schein P$, Zeppa R (1985) Exocrine tumors of the pancreas. Berk JE, ed. Gastroenterology. Fourth edition. Vol 6. Philadelphia: WB Saunders pp 4095-4121 2. Cello JP (1989) Carcinoma of the pancread. Sleisenger MH, Fordtran JS, eds. Gastronintestinal disease. Fourth edition. Philadelphia: WB Saunders pp 1872-1883 3. Annual Registry Reports of Cancer of the Pancreas (1988). (in Japanese) Registry Committee of Japan Pancreas Society. (1989) 4. Tajiri H, Yoshimori M, Nakamura K, Taylor WF, Go VW (1987) Clinicopathological study on carcinoma of the pancreas operated on at the Mayo clinic and the National Cancer Center Hospital. (in Japanese with an English Abst.) Nihon Ganchiryo Gakukai Zasshi (J Jpn Soc Cancer Ther) 23:566-572 5. Kuno N, Tanehira K, Kurimoto K, Kano T, Yasue M (1988) Combined modality therapy for advanced pancreatic cancer. Shokakigeka (in Japanese) (Gastroenterological Surgery) 11: 1491-1495 6. Miyata M, Nakao K, Takao T, Kuwata K, Nakashima N, Dousei T, Hayashi K, Kawashima Y (1990) An appraisal of pancreatectomy for advanced cancer of the pancreas based on survival rate and postoperative physical performance. J Surg Oncology45:33-39 7. Japan Pancreas Society (1986) General rules for cancer of the pancreas, The 3rd edition, Tokyo: Kanehara (in Japanese) 8. ReMine WH, Priestly JT, Judd ES, Jhon NK (1970) Total pancreatectomy. Ann Surg 172:595-604 9. Fortner JG, Kim DK, Cubilla A, Turnbull A, Pahnke LD, Shils ME (1977) Regionalpancreatectomy: En bloc pancreatic, portal vein and lymph node resection. Ann Surg 186:42-50 10. Ihse J, Liliya P, Arnesjo B. (1977) Total pancreatectomy for cancer. An appraisal of 65 cases. Ann Surg 186:675-685 11. SuzukiS, Manabe T, Tani T, Uchida K, Tobe R (1981) Rationale for total pancreatectomyfor cancerof the pancreas. (in Japanese) Tan To Sui (J Biliary Tract and Pancreas) 2:327-333 12. Moosa AR (1982) Pancreatic cancer. Approach to diagnosis, selection for surgery and choice of operation. Cancer 50:26892698 13. Nagakawa T, Kurachi M, Konishi K, Miyazaki I (1982) Translateral retroperitoneal approach in radical surgery for pancreatic carcinoma. Jpn J Surg 12:229-233 14. ImaizumiT, Hannyu F, Yoshikawa T, Nakasako T, Matsuyama H, Hasegawa M (1983) Relative non-curative resection of pancreatic cancer. (in Japanese) Rinshogeka (J Clinical Surgery) 43:1349-1356 15. Nagakawa T, Miyazaki I (1989) Extended pancreaticoduodenectomy for advanced pancreatic cancer. (in Japanese) Tan To Sui (J Biliary Tract and Pancreas) 10:151-158 16. Connolly MM, Dawson PJ, Michelassi F, Moosa AR, Lowenstein F (1989) Survivalin 1001 patients with carcinoma of the pancreas. Ann Surg 206:366-377 17. van Heerden JA, McIlrath DC, Ilstruo DM, Weiland LH (1989) Total pancreatectomy for ductal adenocarcinoma of the pancreas: An update. World J Surg 12:658-662 18. Fortner JG (1981) Surgical principles for pancreatic cancer: Regional total and subtotal pancreatectomy. Cancer 47:17121718 19. Fortner JG (1984) Regional pancreatectomy for cancer of the pancreas, ampulla, and other related sites. Ann Surg 199:418425
