Bessere Therapie des Pankreaskarzinoms durch radikalere Chirurgie?

Zusammenfassung

Trotz Fortschritten in der Therapie des Pankreaskarzinoms bleibt das Überleben betroffener Patienten limitiert. Radikalere chirurgische Therapiekonzepte könnten helfen, die Prognose zu verbessern. Diese zielen insbesondere auf eine Senkung der Lokalrezidivrate ab, die bei Patienten mit reseziertem Pankreaskarzinom im weiteren Verlauf immerhin bei etwa 45% liegt. Zudem könnten auch Patienten mit oligometastasiertem Pankreaskarzinom von einer großzügigeren Indikationsstellung zur Resektion profitieren.

Vor diesem Hintergrund wurden wichtige Operations- und Indikationsprinzipien der Pankreaskarzinomchirurgie anhand einer Literaturanalyse und im Kontext eigener Erfahrungen auf den Prüfstand gestellt.

Auch wenn teilweise noch radikalere chirurgische Ansätze wie eine „erweiterte“ Lymphadenektomie oder eine standardmäßige komplette Pankreatektomie keinen Überlebensvorteil bringen, sollten im Rahmen von Pankreaskarzinomresektionen eine komplette Resektion des Tumors (R0), eine gründliche lokoregionäre Lymphadenektomie sowie eine adäquate radikale Dissektion im Bereich der peripankreatischen Gefäße unter Mitnahme der periarteriellen Nervenplexi der Standard sein. Wann immer zum Erreichen einer R0-Resektion erforderlich, sind Nachresektionen am Pankreas, zusätzliche venöse Gefäßresektionen und auch die Mitnahme von Nachbarorganen im Sinne einer multiviszeralen Resektion onkologisch sinnvoll. Simultane arterielle Gefäßresektionen im Rahmen von Pankreasresektionen wie auch chirurgische Resektionen bei oligometastasierten Patienten sollten hingegen selektionierten Patienten vorbehalten bleiben. Diese genannten Aspekte der chirurgischen Technik beim Pankreaskarzinom dürfen nicht unter dem Gesichtspunkt einer „sowieso bestehenden limitierten Prognose“ vernachlässigt werden. Im Gegenteil, sie bilden die absolut notwendige Grundlage, um beim Pankreaskarzinom in Kombination mit einer Systemtherapie gute Überlebensergebnisse zu erzielen. Es kann jedoch immer notwendig sein, diese Standards der Radikalität des chirurgischen Vorgehens unter Beachtung von Alter, Komorbiditäten und Wunsch der Patienten individuell anzupassen.

Abstract

Despite advances in the treatment of pancreatic cancer, the survival of affected patients remains limited. A more radical surgical therapy could help to improve the prognosis, in particular by reducing the local recurrence rate, which is around 45% in patients with resected pancreatic cancer. In addition, patients with oligometastatic pancreatic cancer could also benefit from a more radical indication for surgery.

Based on an analysis of the literature, important principles of pancreatic cancer surgery were examined.

Even if even more radical surgical approaches such as an “extended” lymphadenectomy or a standard complete pancreatectomy do not bring any survival advantage, complete resection of the tumour (R0), a thorough locoregional lymphadenectomy and an adequate radical dissection in the area of the peripancreatic vessels including periarterial nerve plexuses should be the standard of pancreatic carcinoma resections. Whenever necessary to achieve an R0 resection, resections of the pancreas have to be extended, as well as additional venous vascular resections and multivisceral resections had to be performed. Simultaneous arterial vascular resections as part of pancreatic resections as well as surgical resections in oligometastatic patients should, however, be reserved for selected patients. These aspects of the surgical technique in pancreatic carcinoma mentioned above must not be neglected from the point of view of an “existing limited prognosis”. On the contrary, they form the absolutely necessary basis in order to achieve good survival results in combination with system therapy. However, it may always be necessary to adapt these standards according to the age, comorbidities and wishes of the patient.

Schlüsselwörter

Pankreaskarzinom - Pankreaschirurgie - Lymphadenektomie - Gefäßresektion - Metastasenchirurgie - erweiterte Resektion

Keywords

pancreatic cancer - pancreatic surgery - lymphadenectomy - vascular resections - metastasis surgery - extended surgery

Publication History

Received: 05 January 2022

Accepted after revision: 07 February 2022

Article published online:
04 April 2022

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