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Chirurgie des Pankreaskarzinoms: Techniken zur Vermeidung des Lokalrezidivs

Surgery of pancreatic cancer: techniques to avoid local recurrence

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Zusammenfassung

Hintergrund

Neben dem prognostisch führenden systemischen Rezidiv ist eine hohe Rate an Lokalrezidiven ein relevantes Problem in der Chirurgie des Pankreaskarzinoms. Anspruch der chirurgischen Resektion als Grundlage eines kurativen Therapiekonzepts muss die Verbesserung der lokalen Kontrolle sein.

Ziel der Arbeit

Die aktuelle Datenlage bezüglich Häufigkeit, Relevanz und Risikofaktoren des Lokalrezidivs wird zusammengefasst und daran abgeleitet werden Strategien zur Reduktion des Lokalrezidivs unter besonderer Berücksichtigung chirurgischer Resektionstechniken dargestellt.

Material und Methoden

Es erfolgte eine Analyse und Bewertung aktueller wissenschaftlichen Literatur zum Thema.

Ergebnisse und Diskussion

Ein Lokalrezidiv tritt nach Resektion eines Pankreaskarzinoms als erste Rezidivmanifestation bei 20–50 % der Patienten auf. Die erhebliche Variation der Lokalrezidivraten hängt von chirurgischer Qualität, (neo)adjuvantem Therapieregime sowie von Design der Nachsorge und Dauer der Nachbeobachtung ab. Ein R1-Status ist ein wichtiger Risikofaktor für das Lokalrezidiv und deutet auf die Relevanz der lokal radikalen Resektion hin. Bei den meisten Lokalrezidiven handelt es sich um perivaskuläre Rezidive oder Lymphknotenrezidive. Chirurgisch technische Ansatzpunkte zur Verbesserung der Lokalrezidivrate betreffen daher die Lymphadenektomie, die Dissektion direkt an den Oberbauchgefäßen unter Mitnahme der periarteriellen Gefäßplexus und die Gefäßresektion. Die Sicherheit und onkologische Effektivität der radikalen Resektionstechniken beim Pankreaskarzinom im Kontext der multimodalen Therapie muss in prospektiven Studien weiter evaluiert werden.

Abstract

Background

In addition to the prognostically important systemic recurrence, a high rate of local recurrence is a relevant problem of pancreatic cancer surgery. Improvement of local control is a requirement for surgical resection as a prerequisite for a potentially curative treatment.

Objectives

Summary of the current evidence on frequency, relevance, and risk factors of local recurrence. Presentation of strategies for reduction of local recurrence with a special focus on surgical resection techniques.

Material and methods

Analysis and appraisal of currently available scientific literature on the topic.

Results and conclusion

Local recurrences occur as the first manifestation of tumor recurrence in 20–50% of patients after resection of pancreatic cancer. The considerable variations of reported local recurrence rates depend on the quality of surgery, regimens of (neo)adjuvant therapy as well as the design of surveillance and duration of follow-up. An R1 status is an important risk factor for local recurrence highlighting the relevance of a local radical resection. The majority of local recurrences consist of perivascular and lymph node recurrences. Therefore, lymphadenectomy, radical dissection directly at the celiac and mesenteric vessels including resection of the periarterial nerve plexus and vascular resection are starting points for improving surgical resection techniques. The safety and efficacy of radical resection techniques in the context of multimodal treatment of pancreatic cancer have to be further evaluated in prospective studies.

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Authors and Affiliations

  1. Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland

    O. Strobel & M. W. Büchler

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  1. O. Strobel
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  2. M. W. Büchler
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Correspondence to O. Strobel.

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Interessenkonflikt

O. Strobel und M.W. Büchler geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Strobel, O., Büchler, M.W. Chirurgie des Pankreaskarzinoms: Techniken zur Vermeidung des Lokalrezidivs. Chirurg 91, 615–627 (2020). https://doi.org/10.1007/s00104-020-01196-6

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