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A Modified Approach Pancreaticoduodenectomy Feasible A modied approach Pancreaticoduodenectomy feasible for recurrent cancer in No. 13 lymph node following gastrectomy Yechen Feng Aliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology Hang Zhang Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology Renyi Qin ( [email protected] ) https://orcid.org/0000-0001-8380-4538 Research article Keywords: pancreaticoduodenectomy, gastric cancer, recurrence, lymphadenectomy Posted Date: October 8th, 2019 DOI: https://doi.org/10.21203/rs.2.15708/v1 License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Page 1/17 Abstract Background In a proportion of patients with recurrence of gastric cancer after surgery, that recurrence is in the No. 13 lymph node group. The treatment of these patients are still controversal and challenging. Here we used a modied ‘Artery-rst’ approach technique and retrospective analysis the data to examined the ecacy and feasibility of reoperative pancreaticoduodenectomy for recurrent cancer in this lymph node group after initial subtotal gastrectomy. Methods From January 2011 to December 2015, 24 patients underwent pancreaticoduodenectomy with a modied ‘Artery-rst’ approach technique for recurrent gastric cancer in the No. 13 lymph node group at Tongji Hospital, Wuhan, China. Their medical records were retrospectively reviewed for relevant clinical characteristics, type of rst and second surgical procedures, TNM stage, adjuvant treatments, complications, and survival. Kaplan–Meier curves were used to analyze survival. Results The median interval between the rst and second operations was 7.5 (range 4.5–13.5) months and the median duration of follow-up 20.1 (range 5–58) months. The median operation time was 6.5 (range 5.0– 9.9) hours, and median blood loss 448 (range 110–1200) mL. The median intensive care unit stay was 1.5 (range 1–4) days and the median postoperative hospital stay 31.6 (range 15–55) days. No patient died. Two had serious complications. The median survival after pancreaticoduodenectomy was 28 (range 5–58) months. 13 patients had subsequent recurrence. T stage, N stage, and adequacy of resection inuenced survival. Conclusion s Pancreaticoduodenectomy with a modied ‘Artery-rst’ approach technique is a reasonable treatment option for recurrent remnant gastric cancer following unexpanded lymphadenectomy, particularly for patients with no distant metastases. Additionally, D2+ lymphadenectomy may be more effective than D2 lymphadenectomy in patients with locally advanced gastric cancer. Background Gastric cancer (GC) is the fourth most commonly diagnosed cancer and one of the most frequent causes of cancer death worldwide [1]. Its early detection and complete excision results in a 5-year survival rate of over 90% for patients with early-stage disease in Western countries [2]. Gastrectomy is necessary to cure patients with GC; however, recurrence can occur even after such [3–6]. Although gastrectomy with D1 or D2 lymphadenectomy is performed in most centers, recurrence in the lymph nodes can occur. Further problems can be expected in individuals with recurrence in the No. 13 lymph node group requiring pancreaticoduodenectomy for reoperation because of complicated operation and this procedure’s high mortality and morbidity rates. However, no studies have specically evaluated the outcomes of pancreaticoduodenectomy for recurrence in the No. 13 lymph node group after curative gastrectomy. As the only method of treatment for recurrent gastric cancer in No. 13 lymph node group, pancreaticoduodenectomy remains large number of diculties, including the progressive digestive tract reconstruction, the dissection of lymph node in hepatic portal area and the oppression or package around the PV/SMV by the recurrent area. Conventional surgical methods may induce incomplete in the dissection of lymph node and the massive hemorrhage in operation. ‘Artery-rst’ approach as a modication method with extensive attention, has the advantage of early detection to effective bleeding control. We have put forward to use devascularization-rst to pancreatic head (DFPH) method to improve the traditional ‘Artery- Page 2/17 rst’ approach [7]. Our preliminary data show the advantage of reducing intraoperative bleeding for the patients with the oppression or package around the SMV/PV by the recurrent area. Therefore, We will discuss the feasibility of modied ‘Artery-rst’ approach pancreaticoduodenectomy for curing recurrent gastric cancer. This study was designed to evaluate the ecacy of modied pancreaticoduodenectomy in subjects with recurrent GC after undergoing gastrectomy with D1 or D2 lymphadenectomy and the ecacy of gastrectomy with D2+ lymphadenectomy. Materials And Methods Patients This retrospective chart review and data collection study was approved by the Institutional Review Board of Huazhong University of Science and Technology. The data of 24 patients who had undergone pancreaticoduodenectomy for recurrent GC in the No. 13 lymph node group at the Tongji Hospital between January 2011 and December 2015 were reviewed. All patients had previously undergone surgery (8 open gastrectomy and 16 laparoscopic gastrectomy with D1 or D2 lymphadenectomy) for GC. Curative reoperation should only be considered for localized recurrent GC without major vascular invasion. If there is recurrence in the proximal No. 13 lymph nodes, modied pancreaticoduodenectomy should be considered even if vascular invasion is less than 180°. We chose DFPH surgical procedures to perform for reoperation after recurrence included pancreaticoduodenectomy, pancreaticoduodenectomy with SMV partial resection, and hepato-pancreaticoduodenectomy. The digestive reconstruction used the Roux-en-Y, pancreaticojejunostomy with the original stomach–jejunum anastomosis and choledochojejunostomy, which can segregate the bile and pancreatic juice. The radicality of surgery was classied as R0, R1, and R2 resection. R0 was dened as no visible gross or microscopic remnant cancer, R1 as no gross remnant cancer but visible microscopic remnant cancer on the incisional surface, and R2 as visible gross remnant cancer [8].The TNM stage of pathology was determined according to the American Joint Committee on Cancer (AJCC) 7th edition [9],and complications higher than grade III severity according to the Clavien-Dindo classication system were analyzed. [10]. Denitions According to both the seventh edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual [11] and the third edition of the Japanese Classication of Gastric Carcinoma by the Japanese Gastric Cancer Association) [12], the adequacy of resection was classied as R0, R1, and R2. R0 was dened as no visible gross or microscopic remnant cancer, R1 as no gross remnant cancer but visible microscopic remnant cancer on the incisional surface, and R2 as visible gross remnant cancer [13]. The TNM stage of pathology was determined according to the American Joint Committee on Cancer (AJCC) seventh edition [14]. Page 3/17 Operative procedures First operation Open or laparoscopic gastrectomy with D1 or D2 lymphadenectomy The resection procedure depended on whether the original tumor was located in the gastric body, pylorus or duodenal bulb. In patients undergoing distal subtotal gastrectomy, D1 lymphadenectomy, which includes No. 3, No. 4d, No. 5, No. 6 lymph node groups, or D2 lymphadenectomy, which includes of the No. 1, No. 3, No. 4sb, No. 4d, No. 5, No. 6, No. 7, No. 8a, No. 9, No. 11p, and No. 12a lymph node groups, was performed in accordance with the National Comprehensive Cancer Network guidelines for GC[15]. After distal subtotal gastrectomy, Billroth II anastomoses were constructed. Second operation Pancreaticoduodenectomy with the modied ‘Artery-rst’ approach technique An extended Kochermaneuver and hepatoduodenal ligament dissection were performed and the lymph nodes around the head of the pancreas and hepatoduodenal ligament, common hepatic artery, celiac axis, superior mesenteric artery, and para-aortic area dissected. As all of the recurrence tumor involved PV/SMV less than 180°, and did not invade and SMA, we took DFPH to control intraoperative bleeding. We priority interrupted the hepatic artery and splenic artery branches to pancreatic head, then resected the nerve elements and connective tissue form SMA and the roots of the celiac artery arteries. As all the blood ows is blocked, we took pretreatment blocking to venous system of pancreatic head. the distal common blie duct, head of the pancreas, duodenum and proximal jejunum, No. 7, No. 8a, No. 8p, No. 9, No. 12a, No. 12b, No. 12p, No. 13, and No. 14v lymph node groups were removed commonly. Additionally, No.16a and No.17 lymph node groups were included. SMV partial resection or hepatectomy would be performed if needed. The original stomach–jejunum anastomosis was retained. All resection margins (including the pancreatic duct, duodenal, biliary ducts, and retroperitoneal margins) were examined intraoperatively by frozen section. However, in two patients (Patients No. 4 and 6) a new Roux-en-Y limb was created because the original limb had been disrupted during dissection. The Roux-en-Y were reconstructed by pancreaticojejunostomy with the original stomach–jejunum anastomosis and choledochojejunostomy, described for our previous study.[16] Follow-up Patients were followed up 1 months after the second operation, and thereafter every 6 months with screening for CA19–9
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