title: Gastrectomy and lymphadenectomy for gastric cancer: is the pancreas safe?
abstract: BACKGROUND
  Resection of the capsule of the pancreas is part of the radical operation proposed by oriental authors for the treatment of gastric cancer. It is unclear; however, if resection of the capsule is a safe procedure or even if it is necessary. This study aims to assess in patients treated for gastric cancer the occurrence of: (a) pancreatic fistula and (b) metastasis to the pancreatic capsule.
  
  
  METHODS
  We studied 80 patients (mean age 61 years, 42 males) submitted to gastrectomy with resection of the pancreatic capsule by hydrodissection. Patients with pancreatic disease, tumoral invasion of the pancreas, submitted to concomitant splenectomy, or anastomotic leakage were excluded. The tumor was located in the distal third of the stomach in 60% of the patients, in the middle third in 27%, and proximally in 12%. Total gastrectomy was performed in 27% of the cases and partial gastrectomy in 73%. In all patients, amylase activity in the drainage fluid was measured on day 2. If initial measurement was abnormal, subsequent measurements were performed in alternated days until normalization. Pancreatic fistula was defined as amylase levels greater than 600. In 25 of these patients (mean age 53 years, 16 males), the pancreatic capsule was histologically analyzed for metastasis.
  
  
  RESULTS
  Pancreatic fistula was diagnosed in eight (10%) patients. The mean amylase level was 5,863. Normalization of amylase levels was achieved within 7 days in all patients. No patient developed clinical signs of fistula besides abnormal amylase levels in the drainage fluid, such as intra-abdominal abscesses. Pancreatic fistula was associated to younger age (p = 0.03) but not to gender (p = 0.1), tumor location (p = 0.6), and type of gastrectomy (p = 0.8). Metastasis to the pancreatic capsule was not identified.
  
  
  CONCLUSIONS
  In conclusion, resection of the pancreatic capsule must be discouraged due to subclinical pancreatic fistula in a significant number of the cases and absence of metastasis.
authors.affiliation: Department of Surgery, Division of Esophagus and Stomach, Federal University of Sao Paulo, Rua Napoleao de Barros, 715 2nd floor, Sao Paulo, Sao Paulo, 04024-002, Brazil. herbella.dcir@unifesp.epm.br
authors.forename: Fernando A
authors.initials: FA
authors.lastname: Herbella
authors.forename: Ana C
authors.initials: AC
authors.lastname: Tineli
authors.forename: Jorge L
authors.initials: JL
authors.lastname: Wilson
authors.forename: Jose C
authors.initials: JC
authors.lastname: Del Grande
mesh_terms: D000368:Aged; D001707:Biopsy, Needle; D016009:Chi-Square Distribution; D015331:Cohort Studies; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D005743:Gastrectomy / Q000379:methods*; D006801:Humans; D007150:Immunohistochemistry; D008197:Lymph Node Excision / Q000379:methods; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness / Q000473:pathology*; D009367:Neoplasm Staging; D010180:Pancreatectomy / Q000009:adverse effects* / Q000379:methods; D010185:Pancreatic Fistula / Q000453:epidemiology / Q000209:etiology*; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D011183:Postoperative Complications / Q000503:physiopathology; D011336:Probability; D018570:Risk Assessment; D017751:Safety Management; D013274:Stomach Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016019:Survival Analysis