Lecture : In surgery after preoperative treatment for UR-LA PDAC, inflammatory changes in the pancreatic parenchyma and peripancreatic tissues induced by chemotherapy or chemoradiation, resulting in the gradual disruption of natural tissue planes, made surgery more complicated in many cases. So far, 12 patients were considered PET responders with marked reduction of CA19-9 and received conversion surgery 3?9 months after the initiation of therapy (FOLFIRINOX, or 54Gy + S-1 or 5FU). Six patients received pancreatoduodenectomy (PD) and 6 did distal pancreatectomy (DP) with celiac axis resection. Portal vein resection was performed in 8 patients. Median intraoperative blood loss was 1378 mL and operation time was 543 min. R0 was achieved in 10 of 12 patients (83%). We are showing a couple of PD with the mesenteric approach (Nakao A, Dig Surg 2016) among such cases. There was no significant difference in R0 rates, morbidity, mortality and the overall survival (OS) compared to R and BR groups. The OS was better in the resected UR-LA group compared to unresected UR-LA.
In R and BR-PV PDAC patients, we have implemented nonrandomized prospective study of neoadjuvant chemoradiotherapy (NACRT). The short-NACRT group (n=53) received hypofractionated CRT (30Gy in 10 fractions) and the long-NACRT group (n=49) did standard CRT (50Gy in 25 fractions), both with concurrent S1. After restaging, the patients underwent surgery if eligible. The patient characteristics were well matched in terms of age, gender, tumor size and location, and R/BR-PV ratios between the groups. The completion rates of these NACRT protocols were high and similar between the groups (87% and 90%). Resection rate was significantly higher in the short-NACRT group (96% vs 84%, p=0.033) because distant metastasis was detected at restaging in 8 patients in the long-NACRT group (all liver metastasis) while only 2 (liver and peritoneal) in the short-NACRT group. Intraoperative variables including operation time and blood loss, as well as postoperative morbidity were also comparable between the groups. OS rates at 2 and 5 years were 66% and 41%, respectively, in the short-NACRT group. The 2-year OS in the long-NACRT group was 83% although the observation period is too short to make a comparison of the 2 groups.