We reviewed our 25-year long experience on cPD for locally advanced colon cancer. The procedure of cPD is rarely performed procedure in gastrointestinal surgery. A nationwide survey in Netherland showed that the most common indication of cPD is locally advanced pancreatic head cancer (23) directly invading colon or mesocolon, followed by locally invaded colon cancer with duodenum and/or pancreatic head.
In 1998, surgeons in Sloan-kattering memorial cancer center commented that esophagectomy, hepatectomy, pancreatectomy and total pelvic exenteration are the most complex surgical procedures in cancer surgery (45). These procedures are recommended to be done in high-volume well-experienced medical centers. From our findings, we found that the postoperative courses of cPD were very similar to those after PD. Therefore, achieving a successful emergent cPD may be similar to ensuring a successful emergent PD. Emergent PD is associated with high postoperative morbidity and a high mortality usually > 30% (30–33).
However, Gulle et al (29) operated on 10 patients with emergent PD to treat complex pancreaticoduodenal trauma with zero death. All their patients were relatively young and healthy without associated troublesome co-morbidities. The risks of emergent PD for non-trauma patients are usually higher than trauma cases, because these patients usually have unrecognized preoperative poor conditions and ill-controlled co-existed inflammation or organ dysfunction that resulted in a failed emergent PD (30, 31, 33).
Managing postoperative complications after emergent cPD equally important as treating complication after emergent PD. The cPD is a challenging procedure, and is highly technique-demanded and time-consuming. It requires meticulous and experienced care during the periperative period in order to reduce complication and death rates. Thus, the general preoperative conditions of patients should be well-surveyed to cope with potential postoperative adverse events. Therefore, criteria of preoperative patient selection are key to the cPD success.
Patients of older age, poorly controlled comorbidities, or obesity which typically are risks of PD were therefore excluded from our emergent cPD_surgery in treating bowel obstruction or perforation. Moreover, if the perforation time is long (> 6 hours), severe intra-abdominal contamination could lead to edematous and fragile conditions. Long periods of generalized peritonitis may cause easily breakdown of sutures in early postoperative period of cPD. Such patients are therefore not recommended for emergent cPD.
Acute massive bleeding from gastrointestinal malignancies is very rare but grave. Once that occurs, emergent resection to stop bleeding is likely the only life-saving option. The aforementioned patient selection criteria for obstruction and perforation cannot be totally applied indiscriminately in bleeding cases. Trans-arterial embolization may be transiently helpful for hemostasis (29, 46). However, due to abundant vascular collaterals in pancreaticoduodenal regions, total hemostasis is challenging. Bleeding tumor resection is still mandatory after hemostasis controlled by embolization.
Tsai et al. reported that intraperitoneal infections worse outcomes more than bleeding in emergent PD (33). In this series, we recommended 2 stage PJ after cPD.
PJ has been considered as the Achilles tendon of PD. For success of cPD, the management of PJ is also important. At the early period of our study (March, 1996), we had a case of grade C catastrophic POPF with PPH (disruption of PJ with massive internal bleeding). The patient fortunately survived after timely and appropriate management to overcome this diasterouse complication.
Intraoperative management for technique-related and technique-unrelated adverse events of cPD should be also be great concerns, to reduce chances of operative mortality.
Staged PJ was routinely used for all PD after this case when the pancreatic duct diameter is small (< 2 mm), pancreatic parenchyma is soft or associated with large vessel resection or controlled troublesome comorbidity. Staged PJ was firstly propose by Japanese surgeons, Miyagawa and Makuuchi in 1994 (39). They covered the common hepatic each proper hepatic arteries, and gastroduodenal artery stump using a sheet of pedicled greater omentum or liver falciform ligament (35, 36). Then, a thin plastic tube was inserted into the main pancreatic duct to totally exteriorize the pancreatic juice. The pancreatic juices was fed into intestine lumen through another tube jejunostomy. The seromuscular sutured to the posterior wall of the pancreatic stump. PJ was performed three months later by inserting the aforementionally placed plastic tube into the neighboring jejuna lumen.
The pedicled falciform ligament of the liver, or greater omentum is able to cover the transected stump of gastroduodenal artery (the most common site of PPH after PD). These vessels can be protected from erosion of leaked pancreatic juice. Actually, PJ is not the end of PD. No catastrophic complication had occurred in our patients after using 2-stage PJ procedures quaranteeing the safety of cPD.
The experience of treating acute necrotizing pancreatitis is also useful for treating POPF after PD (46). An appropriate and timely managements of complications after PD could improve healing and avoid operative death. The procedure of completion pancreatectomy for disruptured PJ (28) has high death rate (28, 40). Even with the development of chronic pancreatic fistula, treatment by fistulojejutnosomy can be effective without sequelae (44).
DGE is also a trouble adverse event of PD or cPD. The problem is likely due to the destruction of upper abdominal autonomic nerve fibers during the lymphadenectomy. The condition often requires prolonged hospitalization, long-term nasogastric decompression and total parenteral nutrition support. These managements could cause other systemic problems, such as catheter sepsis, electrolyte unbalance, trace elements deficiency, aspiration pneumonia and hepatic dysfunction. Some of them are fatal. To avoid such formidable complications, efforts to preserve the upper abdominal vagus nerve and sympathetic nerve plexus, can minimize chances of DGE. Upper abdominal lymphadenectomy, which is typically carried out for periampillar or pancreatic cancer, is not needed in CRC patients.
The 5-years OS for locally advanced CRC is 51%. The reported 5-year OS rate after cPD for locally advanced CRC is around 50–60% (26). Our non-e group patients prognosis is comparable to other literatures (4–11). Because of the high incidence of lymph node metastasis, e-group patients prognosis is somewhat poorer. Nevertheless, both groups had insignificantly different OS. Histological TNM staging, lymph involvement and cancer cell differentiation are prognostic factors (5–12, 14, 15, 17–21, 23–25). The cancer condition of our patients who undergoing cPD were similar to other literatures on patients of colon cancer. Development of new target agents or chemotherapeutic drugs may be helpful to prolong survival time after cPD.
Several limitations of current study are listed below.
First, this is a long-duration observational cohort study. It is not a randomized-controlled trial because of the small sample size. The CRC which involves duodenum and /or pancreas is a unique presentation. During the 25-year long duration of our study, diagnosis tools, surgical techniques, operative equipments, and peri-preoperative assessments have markedly improved. Thus, our initial case-selection criteria in the e-group may have been too conservative. For example, the patient age can be extended as the life expectancy of the general population has increased by 5 years during this study period (47). The safety range of emergent cPD may also be extended.
Second, treatment strategies for locally advanced CRC were decided by experienced colorectal and hepato-pancreatico-biliary surgeons, and oncologists. These staff have turned over during this period. Although a senior surgeon (CCW) constantly has led the treatment strategy of individual patients, discrepancy in management in this complex disease remains. For example, the adjuvant therapies after elective or emergent cPD may differ because of different postoperative course.
Third, although staged PJ may ensure the safety of cPD, additional admission and operations are needed to complete PJ of patients. If we have had new safe guarded techniques on PJ, the safety of cPD with one single operation could have been developed, reducing both hospital costs and anesthetic risks.
Despite high complication rates, our reviewed experiences supported that emergent cPD is a feasible procedure on the highly selected patients with locally advanced CRC presenting as acute abdomen. The long-term outcomes after emergent and non-emergent cPD are comparable.