Extended lymphadenectomy in cephalic pancreatoduodenectomy. Personal observations.

BACKGROUND/AIMS: Long-term survival in patients with cancer of the pancreatic head is disappointing. Surgery is the only curative therapy. Unfortunately the prognosis of resected patients (10-15%) is extremely poor due to loco-regional cancer recurrence (50%). Lymphatic and perineural invasion may account for local recurrence. Japanese studies have reported the importance of an extended lymphadenectomy during the classic Whipple exeresis (40% of patients present lymph node metastases). METHODOLOGY: At the General Surgical Clinic of Pavia University 20 patients (14 men, 6 women, mean age 62.4 yr) with pancreatic head cancer (17 adenocarcinoma, 1 lymphoma, 2 carcinoma) underwent Whipple's exeresis with a regional (peripancreatic or R1) and juxta-regional (para-aortic or R2) lymphadenectomy according to the Ishikawa technique, between 1996-2000. R1 nodes consisted of lymph nodes at the pylorus, superior pancreatic head, common bile duct, anterior pancreaticoduodenal region, inferior pancreatic head and superior mesenteric vessels. R2 nodes consisted of lymph nodes at the superior and inferior pancreatic body, mid colic region, common hepatic duct, celiac axis and para-aortic region. RESULTS: The wide dissection was quite easy in patients with a serious cholestatic disease. Intraoperative mortality was 0%. Operative mortality was 5%. Postoperative complications (20%) consisted of 1 sepsis, 1 hepato-renal syndrome with hepatic coma, 1 intestinal obstruction by adhesive bands, and 1 wound infection. Eight patients (40%) died during a mean follow-up period of 6 months (neoplastic recurrence 50%). Notwithstanding the advanced disease (stage III 50%; N1+ 50%), 12 patients (60%) had a median postoperative survival rate of 18.4 months (range 1-48 months) without neoplastic recurrence. Tumor diameter was less than 4cm in 83.3% of cases. CONCLUSIONS: An earlier diagnosis (with tumor diameter <4 cm) can improve pancreatic head cancer prognosis. A wide surgical exeresis with R2 lymph nodes clearance together with surrounding connective and nervous tissue can remove micrometastases and better control local recurrence.