Quoi de neuf dans le cancer du pancréas 2015 Pittau

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Quoi de neuf dans le cancer du pancréas 2015 Dr G. Pittau

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  • Early and late outcomes ofVR patients were compared with those of patients undergoing standard resection (SR
    The mean CA 19–9 level was more elevated in VR patients. Jaundice was less frequent in the VR patients, as tumors were more often located far from the main bile duct within the processus uncinatus. How- ever, similar rates of preoperative biliary drainage (25 %) were observed in both groups.Surgical
  • Reconstructions after segmental VR used primary end-to-end vascular anastomosis in 239 (92 %) of 261 patients. Interposition of autologous venous grafts (n = 15) or prosthetic grafts (n = 7) were rarely performed as a result of the full mobilization of the mesentery of the small bowel along with the right colon before reconstruction. Recon- structions after lateral VR used direct suture in 136 (96 %) of 141 patients or autologous venous patches in 5 patients
    VR did not increase overall postoperative morbidity,Clavien-Dindo grade III to IV morbidity (21 % in both groups), or 30-day mortality (5 vs. 3 % in SR patients) (Table 2).
  • In our study, the 56 %rate of venous invasion was most likely underestimated as a result of the retrospective design of the study, the non- standardized pathologic examination techniques in half of the patients, and surgeon failure to identify the vein on the surgical specimen.42,57 In case of lateral VR, pathologic examination of the vein is even more difficult in case of unmarked specimen.
    In VR patients, venous wall invasion (V?) was confirmed in 56 % of the studied veins (173 of 311); in contrast, 44 % (138 of 311) had tumor-mimicking lesions. V? was more frequent in segmental VR versus lateral VR (p = 0.016; Supplemen- tary Table 3). VR patients had significantly higher rates of poorly differentiated tumors, R1 resections and positive lymph nodes, whereas lymph node ratio remained com- parable in SR and VR patients independent of the selected cutoff values
    An up-front resection was performed in 1,251 (90 %) of1,399 patients, including 928 (93 %) of 997 SR patients and 323 (80 %) of 402 VR patients (p\0.01). Venous wall was abnormal on preoperative CT in 266 patients who underwent planned VR, while 166 patients underwent VR without any previous suggestive CT findings. One hundred forty-eight patients (148 of 1,399, 11 %)received preoperative chemotherapy (n = 28) or chemoradiotherapy (n = 51), including 79 (20 %) of 402 VR patients and 69 (0.7 %) of 997 SR patients (p\0.001). Preoperative treatment was performed due to borderline resectable tumors in 55 patients, locally advanced tumors in 47 patients, and inclusion in institutional phase II trials of preoperative chemoradiotherapy of resectable tumors in 46 patients. Adjuvant therapy was provided to 978 patients (70 %),including 289 (72 %) of 402 VR patients and 689 (69 %) of 997 SR patients.
    Moreover, the neoadjuvant treatment used in 20 %of VR patients may have decreased the rate of venous invasion
  • Après une suiviue de 20 mois, à difference par rapport aux papiers precedentes la survie des résection veineuses est infrior à la resection standard avec une survie médiane de 21 mois versus 29 mis eet 31 % à 3 ans vs 44%
    ). Survival was significantly inferior in VR patients with segmental VR (19 % for VR C2 cm vs. 33 % for VR B2 cm) vs. lateral VR (43 %; p = 0.016;
  • Survie à 3 ans
  • Survie à 3 ans
  • 25% grade 3-4 mais seulment 6% ont interrompu la cure
  • 28% de reponse partielle et 56% de stabilisation de la maladie qui fait Un contrôle de la maladie dans 84%
  • 25% grade 3-4 mais seulment 6% ont interrompu la cure
  • 44 pt folfirinox, la moitié cRT de consolidation
    Patients receiving neoadjuvant FOLFIRINOX had a decreasein pre- and posttreatment median Ca19-9 from 169 to 16. This resulted in aCa19-9 less than 40 Uin72%of patients compared with only31% of patients pretreatment. A significant decrease in tumor diameter on CT from a median of 3.6 cm to 2.2 cm was also observed
  • 44 pt folfirinox, la moitié cRT de consolidation
    Patients receiving neoadjuvant FOLFIRINOX had a decreasein pre- and posttreatment median Ca19-9 from 169 to 16. This resulted in aCa19-9 less than 40 Uin72%of patients compared with only31% of patients pretreatment. A significant decrease in tumor diameter on CT from a median of 3.6 cm to 2.2 cm was also observed
  • This increase in operative timewas most likely due to the additional dissection of critical vessels such as the SMA.Five venous resectionswere performed.These more technically challenging operations resulted in a significant increase in blood loss. Despite the longer operation and increased blood loss, overall postoperative morbidity was decreased in the FOLFIRINOX group. Specifically, no patients in the FOLFIRINOXgroup developed a pancreatic fistula. In addition, length of stay, mortality, and read- missions were equivalent to those of the upfront resectable patient
  • 44 pt folfirinox, la moitié cRT de consolidation
    Patients receiving neoadjuvant FOLFIRINOX had a decreasein pre- and posttreatment median Ca19-9 from 169 to 16. This resulted in aCa19-9 less than 40 Uin72%of patients compared with only31% of patients pretreatment. A significant decrease in tumor diameter on CT from a median of 3.6 cm to 2.2 cm was also observed
  • This increase in operative timewas most likely due to the additional dissection of critical vessels such as the SMA.Five venous resectionswere performed.These more technically challenging operations resulted in a significant increase in blood loss. Despite the longer operation and increased blood loss, overall postoperative morbidity was decreased in the FOLFIRINOX group. Specifically, no patients in the FOLFIRINOXgroup developed a pancreatic fistula. In addition, length of stay, mortality, and read- missions were equivalent to those of the upfront resectable patient
  • Une approche chirurgicale plus invasive par biopsies répétées autour
    des vaisseaux est justifiée.
  • This meta-analysis suggests that the use of stapler or anastomotic closure for the pancreatic remnant after distal pancreatectomy is significantly better than suture closure. Stapler and anastomotic closures appear to be associated with a lower overall POPF rate after distal pancreatectomy. However, no differences were shown in the rates of clinically relevant POPF or abdomi- nal abscess, although there is a suggestion that stapler closure is superior to suture closure.
  • A total of 31 patients undergoing TLPD and 58 patients undergoing OPD with major vascular resection between the dates of July 2007 and July 2013 were identified. Patient demographics for the two groups can be seen in Table 1. Patients in the TLPD group were slightly older (69.5± 9.0 years) than those in the open group (63.6±11.3 years, p=0.01). The proportion of male patients was 54.8 % in the TLPD group and 56.9 % in the OPD group (p=0.85). There was no significant difference inBMI in the two groups, 26.1± 4.7 and 26.2±4.8, respectively (p=0.90).
  • Mean operative time for patients undergoing TLPD (465±86 min) was not significantly different from patients in the OPD group (465±98, p>0.99). Mean operative blood loss was significantly less in the TLPD (841.8±994.8 ml) com- pared to OPD group (1,452.1±1,966.7 ml, p<0.001).
    A lon- ger vascular clamp time was seen in patients undergoing TLPD, 46.8±30.8 and 25.1±16.2 min, respectively (p<0.001). Pylorus-preserving
    Tangential191resection was used more commonly in the TLPD group com- pared to the OPD group (p<0.001). One patient in the TLPD group had a tumor that involved a replaced right hepatic artery. The proximal right hepatic artery was ligated and a segmental resection performed; primary reconstruction of the distal right hepatic artery to the proximal gastroduodenal artery was performed laparoscopically. Operative variables can be seen in Table 2. The distribution of specific vessels involved by tumor was similar between groups. Vascular resection and reconstruction methods varied between groups based on surgeon preference of technique. Tangential resec- tions with lateral venorrhaphy or patch reconstruction were more common in the TLPD group
  • A significantly higher rate of complete macroscopic andmicroscopic margin-negative (R0) resection was obtained in the TLPD (93.5 %) compared to the OPD group (75.9 %, p= 0.038). The median number of lymph nodes harvested was higher in the TLPD group (20.0±8.6) compared to the OPD group (15.9±6.6. p=0.01).
    There was no significant difference in the total rate ofcomplications (lap 35 %, open 48 %) (p=0.24) or severe complications (≥III) (lap 6.4 %, open 3.4 %, p=0.51) in the two groups. In-hospital mortality or 30-day mortality was not statistically different between the TLPD and OPD groups, 3.2 and 3.4 %, respectively (p=0.96) (Table 4). Postoperative imaging was available for 28/31 patients inthe TLPD group and 55/58 patients in the OPD group. Paten- cy of the reconstructed vessels on postoperative imaging was not significantly different between the TLPD(93 %) andOPD groups (91%) (p=0.76). In
  • Median follow-upwas 15.2months in the TLPDgroup and14.8 months in the OPD group. When an intention-to-treat analysis was performed in patients with a diagnosis of adeno- carcinoma, there was no significant difference in overall sur- vival between the two groups (p=0.14; Fig. 1).Table
  • There was no significant differ-ence in patient age in theTLPDandOPDgroups (66.6±9.6 years and 65.4 ± 10.9 years, respectively; P = 0.35). The proportion of male patients was less in the TLPD group (47.2%) than in the OPD group(61.2%; P = 0.02).
  • Mean oper- ative time was not different between the TLPD and OPD groups(379.4 ± 93.5 and 387.6 ± 91.8 minutes, respectively; P = 0.45). Mean operative blood loss was significantly less in the TLPD group(492.4 ± 519.3 mL) than in the OPD group (866.7 ± 733.7 mL; P<0.001). Intraoperative transfusion occurred less frequently in theTLPD group (19%) than in the OPD group (33%; P = 0.01). There was no significant difference in mean tumor size between the TLPD(3.3 ± 1.0 cm) and OPD (3.3 cm ± 1.3) groups (P = 0.95). The proportion of patients classified by each respective T-stage (T1–T4) and the proportion of patients classified by each respective grade of tumor (well-differentiated, moderately differentiated, and poorly dif- ferentiated) were not different between groups. The rate of complete macroscopic and microscopicmargin-negative resection (R0) and the proportion of patients with node positivity were also not significantly different (Table 2). Perioperative
  • Perioperative outcomes are shown in Table 3. Occurrence ofsevere complications (≥IIIB) was not significantly different between the TLPD (5.6%) and OPD (13.6%) groups (P = 0.17). Pancreatic fistulae (gradeB/C) occurred in 12 patients (11%) in the TLPD groupand 26 patients (12%) in the OPD group (P = 0.79). Delayed gastric emptying (grade B/C) occurred less commonly in the TLPD group(9%) than in the OPD group (18%; P = 0.03). Postpancreatectomy hemorrhagewas not significantly different between the groups (7% vs6%; P = 0.65). Thirty-day or in-hospital mortality was also similar and occurred in 4 patients (2%) and 1 patient (1%), respectively(P = 0.50)
  • Median time until commencement of adju- vant chemotherapy was 48 days (range, 17–116 days) in the TLPD group and 59 days (range, 25–302 days) in the OPD group (P < 0.001). A significantly smaller proportion of patients in the TLPD group had a delay of greater than 56 days (8 weeks) between surgery and adjuvant chemotherapy than those in the OPD group (27% and41%, respectively; P=0.01). There were also a significantly smaller proportion of patients in the TLPD group (5% vs 12%; P = 0.04) who had a delay of greater than 90 days (12 weeks) or who didnot receive adjuvant chemotherapy at all secondary to complications
  • Median follow-up was 16.5 months in the TLPD group and15.1 months in theOPD group with amedian survival of 25.3 months and 21.8 months respectively. There was no significant difference inoverall survival between the 2 groups (P = 0.12) (Fig. 1); however, progression-free survival was longer in the TLPD group than in theOPD group (P = 0.03) (Fig. 2). A total of 46 patients (43%) in the TLPD group and 113 patients (53%) in the OPD group developed documented recurrence.
  • In those patients who developed recurrence, a smaller proportion of patients in the TLPD group (15%) developed local disease as the initial site of recurrence than those in the OPDgroup (27%) (P=0.04).
    On the univariate Cox proportional hazard model, significantpredictors of survival included tumor size [hazard ratio (HR) = 1.2; 95% confidence interval (CI), 1.1–1.4; P = 0.002), positive margin (HR = 1.7; 95% CI, 1.2–2.4; P = 0.004), positive nodal status (HR= 1.6; 95% CI, 1.1–2.4; P = 0.009), and not receiving adjuvant chemotherapy secondary to complications or delay beyond 90 days(HR = 5.1; 95% CI, 3.3–8.1; P < 0.001). Patient age more than 65 years, body mass index, and surgical procedure (TLPD vs OPD)were not significant predictors. On the multivariate Cox proportional model with backward stepwise selection, only positive nodal status(HR = 1.7; 95% CI, 0.94–3.2; P = 0.076) and not receiving adju- vant chemotherapy secondary to complications or delay beyond 90days (HR = 4.9; 95% CI, 3.0–7.8; P < 0.001) remained significant predictors
    In a recent evaluation of the European Study Group for Pancreatic Cancer- 3 (ESPAC-3), completion of all 6 cycles of adjuvant chemotherapy was predictive of overall survival whereas time to starting adjuvant chemotherapywas not if chemotherapywas started within 12weeks.25 In the present study, 75% of patients in both groups received adju- vant treatment, yet a significantly smaller proportion of patients in the TLPD group had a delay of greater than 56 days (8 weeks) be- tween surgery and adjuvant chemotherapy than those in the OPD group (27% and 41%, respectively). There were also a significantly smaller proportion of patients in the TLPD group (5% vs 12%) who had a delay of greater than 90 days or who did not receive adjuvant chemotherapy at all due to ongoing complications. This later finding may have importance in that delay beyond 12weekswas not addressed in the ESPAC-3 study.We suggest that the inability to initiate or com- plete chemotherapy will ultimately result in survival differences. The
  • Le dernier papier sortie en 2014 su JCO
    Est une analyse sur l’impact de la durée et du debur de la chimio adjuvante sur la survie
    Ils ont analysé les patients del acohorte prospectives de l’ESPAC 3
    Il n’ ya pas de difference dans la surviue globale selon le debut de la chimiotherapie avant ou apres 8 semaines de la chirurgie.
    Mais la difference est significative si on complete les 6 cycles de chlmio avec une survie mediane de 28 mois vs 14.6 aussi en terme de survie sans recidive 16.56 vs 10.35.
    Le debut de la chimiothérapie est un facteur significative seulement chez les patients qui n’ont pas completé les 36 cycles et il est en faveur d’un debut retardé plutot che precoce
  • The 46 patients who underwent LPD were comparedwith 46 matched patients who underwent OPD. To avoid a selection bias and improve the comparison, patients in the OPD group who were theoretically not suitable for LPD (vascular resection, neoadjuvant radio- chemotherapy, chronic or acute pancreatitis, suspected diffuse IPMN, and PD with division of a median arcuate ligament) were excluded from the analysis.
    The comparison of the LPD and OPD groups (Table 1) showed no difference in age, sex, tumor size, or associated comorbidities, but the BMI was lower in the LPD group (23 vs 27 kg/m2,p < 0.001).
    Surgery lasted longer in the LPD group (342 vs 264 mi- nutes, p < 0.001), but there was no difference in blood loss or transfusion rate (Table
  • Although the differ-ences were not significant for PF (48%vs 41%, p ¼ 0.52), gradeCPF (24%vs 6%, p¼0.007), bleeding (24%vs 7%, p¼ 0.02), and additional surgery (24%vs 11%, p¼ 0.09) weremore frequent in the LPDgroup. Although the differ- ence was not significant for Clavien IIIeIV complications(28% vs 20%, p ¼ 0.32), however the number of patients who presented at least 2 Clavien IIIeIV complications was higher in the LPD group.
    In the LPD group, postoperative bleeding was observedin 11 patients due to bleeding fromthe stump of theGDA(n ¼ 3), from a collateral of the SMA or the celiac trunk (n ¼ 7), and from adhesions in a patient with cirrhosis (n ¼ 1)
  • In our study, the postoperative outcomes for LPD inpatients with pancreatic adenocarcinoma were similar to those with the open approach. Based on the underlying disease, pancreatic adenocarcinoma had theoretically the lowest risk of PF because hard pancreas and dilated main pancreatic duct are more frequently encountered compared with other periampullary diseases. These results suggest that severe complications were related to the inci- dence and severity of PF and not specifically to the lapa- roscopic approach. Limiting LPD to selected patients with pancreatic adenocarcinoma is also supported by oncologic rules for laparoscopic approach determined by the mean number of harvested LN (20; range 8 to 59) or the rate of R0 resection (60%). A recent study in pancreatic ductal adenocarcinoma showed that LPD was better than OPD, with more rapid adjuvant therapy and a better progression free survival.37Therefore,limiting LPD to pancreatic adenocarcinoma does not seem to be related to oncologic considerations or postop- erative morbidity, but only to technical aspects including tumor size and vascular involvement. These aspects could evolve in the near because since LPD with venous resec- tion has been described.4
  • The first 20 LPD were compared with the last 26. Table 4 shows a significant decrease in the duration of surgery(367 vs 323 minutes, p ¼ 0.009) and blood loss (467 vs 291 mL, p ¼ 0.02), but no difference in major compli- cations including severe PF, bleeding, or additional sur-gery between the 2 groups. Although the rate of bleeding was similar, there was no bleeding from the stump of the GDA during the second period (60% vs 0%, p ¼ 0.001)
    clinically significant PF (44%), postoperative bleeding (24%), and reoperation (24%) were significantly more frequent after LPD than OPD. Moreover, we did not observe any reduction in the length of hospital stay compared with OPD. These results suggest that the lapa- roscopic approach does not improve the results of PD and should not be routinely indicated in patients at high risk of PF.
  • Single institutional data suggest that minimally invasive pancreaticoduodenectomy is feasible, with out- comes that are comparable to open pancreaticoduodenectomy for a select group of patients.5,7,12 However, it should be noted that these data are from high-volume institutions with highly experienced pan- creatic surgeons. It is well-known that increasing surgeon experience and hospital volume are significantly associated with reduced mor- bidity and mortality after open pancreaticoduodenectomy.
    53% of all minimally invasive pancreati- coduodenectomies were performed by hospitals in the low-volume group (≤10 cases/2 years); and only 27% of all open pancreaticoduodenectomies were performed by hospitals in the low-volume group (≤10 cases/2 years).?2015
  • Single institutional data suggest that minimally invasive pancreaticoduodenectomy is feasible, with out- comes that are comparable to open pancreaticoduodenectomy for a select group of patients.5,7,12 However, it should be noted that these data are from high-volume institutions with highly experienced pan- creatic surgeons. It is well-known that increasing surgeon experience and hospital volume are significantly associated with reduced mor- bidity and mortality after open pancreaticoduodenectomy.
    53% of all minimally invasive pancreati- coduodenectomies were performed by hospitals in the low-volume group (≤10 cases/2 years); and only 27% of all open pancreaticoduodenectomies were performed by hospitals in the low-volume group (≤10 cases/2 years).?2015
    Factors independently associated with use of minimally inva- sive pancreaticoduodenectomy included fewer patient comorbidities[odds ratio (OR) = 1.45, P < 0.001], undergoing surgery in the Northeast [vs South] (OR = 1.47, P < 0.0001), treatment at an aca- demic center (OR = 2.06, P = 0.04), treatment in 2011 (OR = 1.43, P < 0.0001), and a diagnosis of a neuroendocrine tumor (NET) [vsadenocarcinoma] (OR = 1.64, P < 0.001 (Fig. 2)
  • Quoi de neuf dans le cancer du pancréas 2015 Pittau

    1. 1. Quoi de neuf en chirurgie pancréatique G. Pittau Journées du Centre Hépatobiliaire Paris 13/06/2015
    2. 2. Quoi de neuf en chirurgie du pancréas Chirurgie oncologique Chirurgie classique Chirurgie mini-invasive
    3. 3. Quoi de neuf en chirurgie du pancréas Chirurgie oncologique Chirurgie classique Chirurgie mini-invasive
    4. 4. Chirurgie- Résection veineuse Delpero ASO 2015 2015 Cohorte française 2004-2009 1399 PD Cohorte française 2004-2009 1399 PD 997 DPC sans résection997 DPC sans résection 402 DPC avec résection402 DPC avec résection
    5. 5. Chirurgie- Résection veineuse ChirurgieChirurgie Delpero ASO 2015 Mortalité/morbiditéMortalité/morbidité 2015
    6. 6. Chirurgie- Résection veineuse-Histopathologie Delpero ASO 2015 2015 Envahissement tumoral veineux: 56% TraitementTraitement Données Anatomo-pathologiquesDonnées Anatomo-pathologiques
    7. 7. Suivie 20 moisSuivie 20 mois Delpero ASO 2015 2015 Chirurgie- Résection veineuse-Survie Dans la population globale l’analyse multivariée a identifié la réséction veineuse comme un facteur indépendant négatif de survie (hazard ratio [HR] 1.75, 95 % CI : 1.28–2.40; p = 0.0005) Dans la population globale l’analyse multivariée a identifié la réséction veineuse comme un facteur indépendant négatif de survie (hazard ratio [HR] 1.75, 95 % CI : 1.28–2.40; p = 0.0005)
    8. 8. Delpero Ann Surg Onc 2015 Chirurgie- Résection veineuse- Facteurs associés à une meilleure survie Traitement néo-adjuvant ( HR 0.52, 95 % CI 0.29–0.94; p = 0.031) Traitement adjuvant ( HR 0.55, 95 % CI 0.35–0.85; p = 0.006) 2015
    9. 9. Delpero Ann Surg Onc 2015 Chirurgie- Résection veineuse- 2015 Les tumeurs qui nécessitent une RV sont très agressives avec un risque élevé de résection non R0 Toutes les tumeurs ayant un contact avec la veine doivent être considérées comme borderline et elles doivent avoir un traitement néo-adjuvant
    10. 10. Traitement neo-adjuvant FOLFIRINOX 2015 Marthey et al. Ann Surg Oncol 2015.
    11. 11. Traitement neo-adjuvant FOLFIRINOX 2015 Marthey et al. Ann Surg Oncol 2015.
    12. 12. Traitement neo-adjuvant FOLFIRINOX 2015 Marthey et al. Ann Surg Oncol 2015. Suivi 15 mois 70% Radiothérapie Médiane de Survie globale 22 mois Survie comparable aux Résécables d’emblée
    13. 13. Traitement neo-adjuvant FOLFIRINOX 2015 Marthey et al. Ann Surg Oncol 2015. Survie sans récidive: 22.5 mois Survie globale 24.9 mois FOLFIRINOX est un régime de chimiothérapie faisable avec une toxicité acceptable efficace sur le Borderline et LA Nécessité d’une étude randomisée FOLFIRINOX est un régime de chimiothérapie faisable avec une toxicité acceptable efficace sur le Borderline et LA Nécessité d’une étude randomisée
    14. 14. Ferrone et al Ann Surg 2015 2015 FOLFIRINOX- Evaluation de la résécabilité
    15. 15. Ferrone et al Ann Surg 2015 2015 FOLFIRINOX- Evaluation de la résécabilité
    16. 16. Résultats post-opératoires FOLFIRINOX- Evaluation de la résécabilité Ferrone et al Ann Surg 2015 2015
    17. 17. 2015 FOLFIRINOX- Evaluation de la résécabilité Ferrone et al Ann Surg 2015
    18. 18. Histopathologie FOLFIRINOX- Evaluation de la résécabilité Ferrone et al Ann Surg 2015 2015
    19. 19. FOLFIRINOX- Evaluation de la résécabilité- Survie Ferrone et al Ann Surg 2015 Suivi 11 mois Survie médiane globale 34 mois FOLFIRINOX meilleur survie 2015 Le FOLFIRINOX est éfficace dans le traitement des bordeline et LA L’imagèrie traditionelle n’est pas efficace dans l’évaluation de la résécabilité après traitement néo-adjuvant. Place des biopsies répétées Le FOLFIRINOX est éfficace dans le traitement des bordeline et LA L’imagèrie traditionelle n’est pas efficace dans l’évaluation de la résécabilité après traitement néo-adjuvant. Place des biopsies répétées
    20. 20. Quoi de neuf en chirurgie du pancréas Chirurgie oncologique Chirurgie classique Chirurgie mini-invasive
    21. 21. Chirurgie- Prévention FP Zhang BJS 2015 2015
    22. 22. Chirurgie- Prévention FP Zhang BJS 2015 2015 Fistule pancréatique suture moignon vs agrafage OR 0 77 (95%CI) 0 61- 0 98; P=0 031)⋅ ⋅ ⋅ ⋅
    23. 23. Chirurgie- Prévention FP Zhang BJS 2015 2015 Définition ISGPF (OR 0 85( CI 95%) 0 53-1 38; P=0 517),⋅ ⋅ ⋅ ⋅ Pas de difference Fistule pancréatique suture moignon vs agrafage
    24. 24. Chirurgie- Prévention FP Zhang BJS 2015 2015 Anastomose P-J vs suture du moignon OR 0 55,(CI 95%) 0 31- 0 98; P=0 042)⋅ ⋅ ⋅ ⋅
    25. 25. Quoi de neuf en chirurgie du pancréas Chirurgie oncologique Chirurgie classique Chirurgie mini-invasive
    26. 26. Chirurgie mini-invasive- Résection veineuse Kendrick et al Ann Surg 2015 2015 USA 2007-2013 USA 2007-2013 58 DPC open + résection veineuse58 DPC open + résection veineuse 31 DPC coelio + résection veineuse31 DPC coelio + résection veineuse
    27. 27. Chirurgie mini-invasive- Résection veineuse Kendrick et al Ann Surg 2015 2015 Données per-opératoiresDonnées per-opératoires Résection vasculairesRésection vasculaires
    28. 28. Chirurgie mini-invasive- Résection veineuse Kendrick et al Ann Surg 2015 2015 Données anatomo-pathologiquesDonnées anatomo-pathologiques Morbidité- mortalitéMorbidité- mortalité Morbidité et mortalité identiquesMorbidité et mortalité identiques
    29. 29. Chirurgie mini-invasive- Résection veineuse Kendrick et al Ann Surg 2015 2015 Suivi médiane 15.2 mois DPC coelio 14.8 mois DPC open Survie identiques pour les adk de la tête du pancréas With the current level of experience there are no exclusion criteria for TLPD
    30. 30. Chirurgie mini-invasive- ADK du pancréas USA 2008-2013 USA 2008-2013 Kendrick et al Ann Surg 2015 214 DPC open214 DPC open 108 DPC coelio108 DPC coelio 2015
    31. 31. Chirurgie mini-invasive- ADK du pancréas Kendrick et al Ann Surg 2015 Données per-opératoires et anatomo-pathologiqueDonnées per-opératoires et anatomo-pathologique 2015
    32. 32. Chirurgie mini-invasive- ADK du pancréas Kendrick et al Ann Surg 2015 MorbiditéMorbidité 2015
    33. 33. Chirurgie mini-invasive- ADK du pancréas Kendrick et al Ann Surg 2015 Chimiothérapie adjuvanteChimiothérapie adjuvante Les patients opérés par coelio commencent la chimiothérapie plus précocement que les patients opérés par laparotomie Les patients opérés par coelio commencent la chimiothérapie plus précocement que les patients opérés par laparotomie 2015
    34. 34. Chirurgie mini-invasive- ADK du pancréas Kendrick et al Ann Surg 2015 SurvieSurvie P=0.12 Overall survivalOverall survival Progression free survivalProgression free survival P=0.03 Suivi médiane DPC coelio 16.5 mois DPC open 15.1 mois Survie médiane DPC coelio 25.3 mois DPC open 21.8 mois 2015
    35. 35. Chirurgie mini-invasive- ADK du pancréas Kendrick et al Ann Surg 2015 RécidiveRécidive p= 0.04 2015 La DPC coelio pour cancer n’est pas seulement faisable mais permet une récupération précoce et donc un début rapide de la chimiothérapie
    36. 36. Chirurgie mini-invasive- ADK du pancréas Valle et al et al JCO 2014 Pas de différence dans la survie globale selon le début de la chimiothérapie
    37. 37. Chirurgie mini-invasive France Cas-contrôle 2011-2014 France Cas-contrôle 2011-2014 Dokmak et al JACS 2015 2015 46 DPC open46 DPC open 46 DPC coelio46 DPC coelio
    38. 38. Chirurgie mini-invasive Dokmak et al JACS 2015 2015 MorbiditéMorbidité
    39. 39. Chirurgie mini-invasive Dokmak et al JACS 2015 2015 AdénocarcinomeAdénocarcinome Pas de différencePas de différence
    40. 40. Chirurgie mini-invasive Dokmak et al JACS 2015 2015 La DPC coelio est associée à un taux de morbidité élevée due à une augmentation de l’incidence et de la gravité de la FP. La DPC coelio n’est pas indiquée pour toutes les tumeurs peri-ampullaires mais seulement chez des patients sélectionnés avec moins de risque de développer une FP. Elle doit être réalisée dans des centres de référence par des chirurgiens pancréatiques. La DPC coelio est associée à un taux de morbidité élevée due à une augmentation de l’incidence et de la gravité de la FP. La DPC coelio n’est pas indiquée pour toutes les tumeurs peri-ampullaires mais seulement chez des patients sélectionnés avec moins de risque de développer une FP. Elle doit être réalisée dans des centres de référence par des chirurgiens pancréatiques.
    41. 41. Chirurgie mini-invasive USA 7061 National Cancer Database DPC 2010-2011 USA 7061 National Cancer Database DPC 2010-2011 La DPC coelio  du 45% du 2010 au 2011La DPC coelio  du 45% du 2010 au 2011 Adam et al Ann Surg 2015 2015 6078 open (86%)6078 open (86%) 983 mini-invasive (14%)983 mini-invasive (14%) 90% de DPC coelio sont faites dans des centres non expert!!! 90% de DPC coelio sont faites dans des centres non expert!!!
    42. 42. Chirurgie mini-invasive Adam et al Ann Surg 2015 2015 Facteurs indépendants associés à une DPC mini-invasive Facteurs indépendants associés à une DPC mini-invasive
    43. 43. Chirurgie mini-invasive Adam et al Ann Surg 2015 2015 Mortalité à 1 mois est plus élevée dans le groupe mini-invasive [OR = 1.87, (CI): 1.25–2.80, p = 0.002] Mortalité à 1 mois est plus élevée dans le groupe mini-invasive [OR = 1.87, (CI): 1.25–2.80, p = 0.002] DPC pour cancer (OR = 0.69, CI: 0.46–1.05, p = 0.09) Tendance inversée entre Hôpitaux à haut volume et mortalité La DPC coelio pour adénocarcinome est associée à un augmentation de la mortalité per-opératoire. La plus part des DPC coelio on été faites dans des centres non de référence.
    44. 44. À retenir L’imagerie traditionelle ne semble être pas efficace dans l’évaluation de la résécabilité après traitement neoadjuvant. Des biopsies per-opératoires autour des vaisseaux pourront être nécessaires pour juger la résécabilité Le FOLFIRINOX pour les tumeurs BD/LA est un traitement efficace qui permet un contrôle tumoral dans plus de 80% des cas, une chirurgie secondaire dans 36% avec une toxicité acceptable Les tumeurs ayant un contact avec la VP/VMS doivent être considérées comme borderline et avoir un traitement néo-adjuvant La DPC coelio reste un challenge en chirurgie, elle n’est pas validée et elle doit être réalisée par des chirurgiens experts dans de centres de référence

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