the role of surgeon in advanced pancreaticobiliary cancers

The role of surgeon in advancedpancreaticobiliary cancers

A Sa Cunha

Disclosure

• Merck

• Sanofi

• Roche

• Baxter

• Biomup

• Intuitiv

Distal extrahepatic cholangiocarcinoma

Peripheral or intrahepaticcholangiocarcinoma

Perihilar cholangiocarcinoma

EXTRAHEPATIC CHOLANGIOCARCINOMAS

Gallbladder cholangiocarcinoma

Pancreatic adenocarcinoma

Pancreaticobiliary cancers

Surgery remains the only chance of cure

• Low rate of resectability

• Major resection

• High rate of R1 Resection

• High rate of morbimortality


Mortality cut-offs

Pancreaticoduodenectomy 9.2% 16 and 40 per yearDistal pancreatectomy 6.2% 15 and 25 per year


Evaluation of resectability

Principles of curative surgery

Place of palliative surgery

Place of transplantation

(SMA or CA) ≥180°Unreconstructible SMV/PV

No arterial contactVein < 180°

arterial contact < 180°Vein ≥ 180° orUnilateral narrowing

Resectable Bordeline Locally advanced


Resecability Curative surgery Palliative surgery Transplantation

Intra-hepatic cholangiocarcinoma

Vascular involvment


Peri-hilar cholangiocarcinoma

Bismuth, Corlette et al. Surg Gyn Obs 1975

De Oliviera et al. Hepatology 2011



Peri-hilar cholangiocarcinoma

B4

B3

B2

B4

B3

B2

No resectable or Difficult….« Easy »….

Boudjema et al. J Gastrointest Surg 2013


Boudjema et al. J Gastrointest Surg 2013


Goals of surgery

R0 resection

Low rate of morbidity-mortality


Pre operative work up• Jaundice

• Pre operative biliary drain ?

• Duodenal obstruction• Duodenal stent

• Evaluation of the futur remnant liver• Portal vein embolisation ?

• Nutrition


Gallbladder cancer

2/3 of gallbladder cancers are discovered on the resected specimenof a cholecystectomy T N+

Epithelium Tis 0 %

Lamina propria T1a 2 %

Muscularis T1b 15 - 25 %

Subserosal T2 20 - 60 %

Beyond serosa T3 > 70 %

PV / HA T4

Cholecystectomy

ExtendedCholecystectomy


Gallbladder cancer


Intra hepatic cholangiocarcinoma

AFC-2009 Published series 1998-2009

survey Occident Japan

Major resection 82 % 77 % 76 %

≥ 4 segments 53 % 63 % 49 %

with segment 1 32 % 27 % 48 %

with common BD 19 % 20 % 39 %

vascular resection 9 % 12 % 21 %


Intra hepatic cholangiocarcinoma

100 operated

20 % non resectable

80 resected

55 survivors

6 % mortality

25 % R1 resection

60 R0

40 % N+

AFC series, 2010


Peri hilar cholangiocarcinoma

- R0 resection on biliary and peri-biliary margin

- Biliary resection + major hepatectomy

- Systematic resection of segment 1

- Portal resection if necessary but not systematic

- Analysis of the confluent B2-B3 to plan the surgical strategy

- Right sided hepatectomies if possible B4

B3

B2

B4

B3

B2



Pancreaticoduodenectomy

• Lymphadenectomy ≥ 15 ganglions

• Lymphadenectomy N15,6,8a, 12b1, 12b2, 12c, 13a, 13b,

14a,14b, 17a, 17b

21

Resectable pancreatic cancer

Sanjeevi S et al. BJS 2014

No resectable at laparotomy13%

22

Résultats de la chirurgie


23



11% de N+

24



MortalityDPC

Mortality 2 %

France 2009-2010

PD: 9%

25



≈ 40% No CTn=2047

Adjuvant CT (%) 57,7

Merkow, et al., Ann Surg 2014

26



ESPAC 4 GEM GEMCAP

6 cycles 65% 54%

Prodige 24 GEM FOLFIRINOX

6 cycles 79,% 66,4%

27



ESPAC 4 GEM GEMCAP

6 cycles 65% 54%

Prodige 24 GEM FOLFIRINOX

6 cycles 79,% 66,4%

All treatment completed30-35 % of patients


Pancreatic adenocarcinomaR1

Verbeke et al.BJS 2006

57%

Esposito et al.Ann Surg Oncol 2008

14%

R1

85%

76%

Incrément % MR+

0 mm* 23 %

1 mm ° 61 %

1,5 mm £ 63 %

2 mm 71 %Delpero et al. HPB 2012



Distal pancreatectomy

• Lymphadenectomy 15- 20 ganglions

• Lymphadenectomy N110,11,18,


Minimally invasive approach

No randomized trial

Laparoscopic PDPLOT Trial

Palanivelu CBr J Surg 2017

PADULAP TrialPoves I

Ann Surg 2018

LEOPARD 2 TrialVan Hilst J

Lancet GastroenterolHepatol 2019

n 64 66 105

Conversion rate 3% 23,5% 20%

MorbidityDindo- Clavien ≥ 3

6% (Lap) VS 9% (O) 15% (Lap) VS 38% (O)

P=0.0450% (Lap) VS 39% (O)

Mortality 3% (Lap) VS 3% (O) 0% (Lap) VS 6,9% (O) 10% (Lap) VS 2% (O)


Biliary drainage

• Endoscopy vs surgical bypass

Endoscopic stenting is associated with lower procedure morbidity and mortality than surgery, with no significant difference in overall survival

(meta-analysis Taylor Liver Transpl 2000;6:302)


Duodenal obstruction

⚫ Endoscopy*– Feasibility 96% – Efficacy 88%

⚫ Endoscopy/surgery– Reprise alimentation plus rapide– Morbidity and in hospital stay reduced**

*Maire et al.Am J Gastroenterol 2006** Maetani et al. Endoscopy 2004

Mittal et al. Br J Surg 2004Nuzzo et al. Hepatogastroenterol Y2004


Peri hilar cholangiocarcinoma

Neoadjuvant chemoradiotherapy45 Gy Radiotherapy5-FU

Transluminal boost: Iridium 192 brachytherapy (20-30 Gy)

Survival 1-Year 3-Year 5-Year

Resection 82% 48% 21%

TH 92% 82% 82%



Very early IHC = Single tumor ≤2

Cirrhotic patients



5-Year survival 83.3%5-Year recurrence-free survival 50%



Unresectable IHC

• Tumor < 3cm

• Radiochemotherapy (Protocol Mayo)

• N0 at staging laparotomy

Liver transplantation



Resectable IHCTransphil Trial

• Tumor < 3cm• N0 at staging exploration

➢ Resection vs Transplantation (Mayo protocol)

Conclusions

Discussion in MDT

Extended surgeryPre operative work-upHigh rate of morbimortalityHigh volumes centers

Liver transplantationUnresectable peri hilar CC ( Mayo clinic protocol)Resectable peri hilar CC : Transphil trial

the role of surgeon in advanced pancreaticobiliary cancers

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