The Clinical Study Of The Multidisciplinary Team Based On Minimally Invasive Surgeon In The Management Of Pancreatic Cancer

With the in-depth understanding of pancreatic cancer,from single department giving the diagnosis and treatment mode is turning to the MDT(Multi-Disciplinary Team,MDT)treatment model.In British 1994,Junor first came up with MDT,lay a foundation for further development.MDT gradually is popular in recent years,and has been reported articles regarding the effect of MDT,especially in the colorectal tumor.MDT based on minimally invasive surgeon different from the traditional one in this center is put forward in 2013,which gradually formed,fixed-point meeting regularly,become standardized model for the treatment of pancreatic cancer.In France 1987,Mouret physician first successful implementation of laparoscopic cholecystectomy,marked the era of minimally invasive surgery.Follow the steps of minimally invasive,surgeons gradually both have the ability to perform traditional surgery,and master minimally invasive techniques.On the basis of this,since January 2013 pancreatic cancer MDT was holded,gradually accumulated experience of management of pancreatic cancer.In this mode,minimally invasive surgery treatment,neoadjuvant therapy,HIPEC(Hyperthermic Intraperitoneal Chemotherapy,HIPEC)are fully used,and complement each other.Research through the retrospective analysis from January 2013 to December 2013 evaluate the effect of the MDT mode based on minimally invasive surgeon on diagnosis and treatment of pancreatic cancer,especially in borderline resectable pancreatic cancer and pancreatic body and tail carcinoma peritoneal metastasis.This clinical studuy was assessed the safety,feasibility,and tumor curative effect of minimally invasive surgery,neoadjuvant therapy,HIPEC in pancreatic caner.Part 1:The clinical study of the multidisciplinary team based on minimally invasive surgeon in the management of pancreatic cancerObjective:1.Understand MDT based on minimally invasive surgeon decision-making in the diagnosis and treatment of pancreatic cancer.2.Analyze MDT based on minimally invasive surgeon in the long-term curative effect of diagnosis and treatment of pancreatic cancer.3.Analyze MDT based on minimally invasive surgeon in the effect of patients with pancreatic cancer underwent operation.Methods:From January 2011 to December 2016,patients diagnosed of pancreatic ductal adenocarcinoma through pathology included in this study.In January 2013,this center began to practice the MDT discussion,patients through MDT discussion classified as MDT group,the rest of the patients in the NMDT(No MDT)group.According to whether the operation,subgroup analysis was further performed.Through analysis and comparison of the MDT group and NMDT group and operation subgroups regarding perioperative data and long-trem effect,this syudy was to assess the value of MDT based on minimally invasive surgeon.Results:Totally,130 cases included in the MDT group,192 cases in the NMDT group.66 cases included in the MDT operation subgroup,79 cases in NMDT operation subgroup.There was no significant difference in gender,age,BMI index,index of tumor,tumor location,surgical proportion,clinical symptoms,complications,TNM stage between MDT group and NMDT group.130 patients with pancreatic cancer through were hold 150 MDT discussion,20 cases went through two discussions.128 procedure fully implement MDT decision-making results(85.3%);7 Partial implement MDT decision-making(4.7%),completely does not perform in 15(10%).The reason for not performing the decision was the lack of the history data and the poor patient compliance.Intraoperative bleeding amount and operation time in MDT operation subgroups and the NMDT operation subgroup were statistically significant(273.3±51.4min vs 51.4±64.4 min,P=0.0001;137.9±145.8ml vs.145.8±166.6ml,P=0.002).Vascular resection,blood transfusion rate and mortality were no significant statistical difference(P=0.53,P=0.53,P=1.00).Postoperative anal exhaust time,postoperative liquid intake of MDT operation subgroup is better than that of the MDT operation subgroup,statistically significant(P=0.038,P=0.038,P=0.0416).The length of postoperative hospitalization of MDT operation subgroup was more than the MDT operation subgroups(10.3 vs.9.4±3.8±3.9 d d),but there was no statistically significant difference(P=0.1637).Overall postoperative complication rate of MDT operation subgroup was 48.5%,the MDT operation subgroup was 55.9%(P=0.836).There was no significant difference in pancreatic fistula(31.8%vs 30.4%,P=0.938).There were statistical differences in incision and pulmonary infection,MDT operation subgroup was lower than that of MDT operation subgroup.There is no statistical difference in the deep vein thrombosis,reoperation,readmission rate,postoperative mortality.1 year,2 years,3 years survival rate of MDT group and the NMDT group were 61%,43.8%,26.7%and 48.4%,61%,19.4%,there was statistically significant difference(P=0.029).Cox regression analysis results showed that factors including TNM staging,surgery,MDT are associated with 3 year survival rate.1 year,2 years,3 years survival rate of MDT operation subgroup and the NMDT operation group were 67.2%,42.2%,29.7%and 54.3%,67.2%,20%,survival time,disease-free surial was statistically significant difference(P=0.046,P=0.046).Cox multiple factors regression analysis results show that the clinical T stage,tumor differentiation grade,MDT discussion,cutting edge,postoperative adjuvant are associated with survival rate and disease-free survival rate.Conclusion:1.MDT based on minimally invasive surgeon can offer patients with pancreatic cancer with standardization and individualization treatment,prolong survival time.2.MDT based on minimally invasive surgeon can increase the opportunity of minimally invasive treatment for patients with pancreatic cancer,without increasing the pancreatic fistula,bleeding and other complications and reduce postoperative incision,pulmonary infection,make the patients recover much fast.Part 2:The clinical study of neoadjuvant therapy based on the multidisciplinary team in the management of borderline resectable pancreatic cancerObjective:1.Evaluate the safety,feasibility of neoadjuvant therapy directed by MDT based on minimally invasive surgeon on BRPC patients.2.Evaluate the effect of RECIST 1.1 standards used by MDT based on minimally invasive surgeon on BRPC patients after neoadjuvant therapy.3.Evaluate the effect of directed by MDT based on minimally invasive surgeon on BRPC patients.Methods:From January 2013 to December 2016,BRPC patients were including in this study.BRPC patients receiving neoadjuvant therapy directed by MDT based on minimally invasive surgeon called NAT group;No neoadjuvant therapy and surgical radical excision were called NNAT group.Through analysis and comparison of two groups of short and the long-term effect,understand the value of neoadjuvant therapy directed by MDT based on minimally invasive surgeon on BRPC patients.Results:24 cases were including in the NAT group,17 cases in the NNAT operation subgroup,7 cases in the NNAT auxiliary treatment subgroup.The NAT group,the NNAT operation subgroup and the NNAT auxiliary treatment subgroup in gender,age,BMI index,index of tumor,tumor location,clinical symptoms,complications,tumor size,abdominal surgery history,ASA classification were no significant difference.CA19-9 and CEA in general is on the decline in BRPC patients after neoadjuvant therapy.RECIST1.1 standards:45.9%(11/24)PR,SD 25%(6/24),PD(7/24),29.1%efficient(RR)of 45.8%.The NAT operation subgroup and the NNAT operation subgroup was no statistical difference in intraoperative vascular resection and reconstruction(P=0.638).The operation time in NAT operation subgroup(269.5±50.4 min vs 50.4±61.4 min),intraoperative blood loss(172.9±135.5 mlvs 217.7±148.6 ml)were less than the NNAT operation subgroup,but there were no statistically significant difference(P=0.079,P=0.079).The two groups in transit operation circumstance there was no significant difference in intraoperative blood transfusion and the rate of conversion to laparotomy(P=0.818,P=0.818).Postoperative out of bed time(1.6 vs.1.9±1.6±1.4 d d,P=0.548),anal exhaust time(2.4 vs.2.8±1.2±1.1 d d,P=0.296),postoperative liquid intake(2.5 vs.2.8±1.7±1.2 d d,P=0.543),postoperative hospitalization days(9.5 vs.9.7±4.5±3.9 d d,P=0.886)between subgroup were no significant difference.Overall postoperative complication rate of the NAT operation subgroup was 38.1%,the NNAT operation subgroup was 29.4%.Postoperative pancreatic fistula in the NAT operation subgroup was 3 cases(17.6%),the NNAT operation subgroup 4 cases(19.1%).There was no significant difference in the overall complication rate,sever complications,pancreatic fistula,hemorrhage,pulmonary and incision infection,reoperation,readmission rate.3 years survival rate among the NAT group,the NNAT operation subgroup and the NNAT auxiliary treatment subgroup(35.3%,0%,19%)was statistical differences(P=0.003).3 years disease-free survival rate had statistical difference(P=0.047).Conclusion:1.Neoadjuvant therapy directed by MDT based on minimally invasive surgeon on BRPC patients is safe and feasible.2.The RECIST1.1 standard used by MDT based on minimally invasive surgeon was accurate to assess the BRPC after neoadjuvant therapy.3.Neoadjuvant therapy directed by MDT based on minimally invasive surgeon on BRPC patients can urge cancer down-staging,increase the rate of R0 resection and the percentage of minimally invasive,reduce postoperative pain,fast recovery.4.Neoadjuvant therapy directed by MDT based on minimally invasive surgeon can extend the lifetime of BRPC patient.Part 3:The clinical study of HIPEC based on the multidisciplinary team in the management of pancreatic body and tail cancer with peritoneal metastasisObjective:1.Evaluate the value of MDT based on minimally invasive surgeon on pancreatic body and tail carcinoma with peritoneal metastasis.2.Evaluate the safety,feasibility and clinical value of HIPEC directed by MDT based on minimally invasive surgeon in pancreatic body and tail carcinoma.Methods:From December 2007 to November 2016,patients with pancreatic body and tail carcinoma were selected.There are two groups,CRS + HIPEC group and CRR group.Results:From October 2007 to December 2016,74 cases were enrolled in CRR group,19 cases in CRS + HIPEC group.CRR and CRS + HIPEC group in gender,age,BMI,tumor index(CA19-9,CEA,CA125),abdominal surgery history,preoperative ASA classification were no significant difference.PCI scores were statistical difference between two groups(P = 0.00).Operation time in CRS + HIPEC group was obviously longer than the CRR group(232.9±49.6 min vs 49.6±34.8 min),with statistical significance(P=0.0001).On the implementation of extensive surgery,CRS + HIPEC group has higher proportion(P=0.022).CRS + HIPEC group and CRR group in bleeding amount,the rate of conversion to open and intraoperative mortality no significant difference(P=0.577,P=0.577,P=0.725).Postoperative out of bed time(P=0.564),postoperative anal exhaust time(P=0.185),postoperative into liquid time of CRR group(P=0.098)compared with them in CRS + HIPEC group,no statistical difference.Postoperative hospitalization days of CRS + HIPEC group was longer than the CCR group,but no statistically significant difference(P=0.157).The rate of overall postoperative complication in CRS+HIPEC group was 57.9%,the CCR group was 32.4%;7 cases in CRS+HIPEC group occurred postoperative pancreatic fistula(36.8%),grade A 4 cases,grade B 2 cases,grade C 1 case.Postoperative pancreatic fistula in CCR group was 19 cases(25.7%),grade A 8 cases,grade B 11 cases.CRS+HIPEC groups associated with a higher incidence of postoperative lavage drainage pipe incision infection has statistical differences compared with CRR group(P=0.0027).Chemotherapy toxicity reaction exists in CRS +HIPEC group,but mainly grade I and II level(P=0.0007).Two groups have no perioperative death;There is no statistical difference in the overall complication rate,complications,pancreatic fistula,bleeding,gastric paralysis,acute renal insufficiency,incision infection,and readmission rate.1 year,2 year overall survival rate in CRS + HIPEC groups was 68.4%and 36.8%and 1 year,2 years disease-free survival rate were 61%and 32%:1 year,2 year overall survival rate in CRR groups was 83.3%and63.9%and 1 year,2 years disease-free survival rate were 79%and 57.7%.Between two groups,2 year overall survival rate was statistically significant difference(P=0.474).Based on PCI value,PCI≤10 and PCI>10 were compared with CRR group regarding 2 years survival rate(PCI≤10 and CRR,P=0.724;PCI>10 with CRR,P=0.007).In 2 disease-free survival rate,CRR group is higher than the CRS + HIPEC group.PCI≤10 and PCI>10 were compared with CRR group in 2 year disease-free survival rate(PCI≤10 and CRR,P=0.695;PCI group>10 with CRR,P=0.002).The quality of life of CRS + HIPEC group was assessed by SF-36 scale,evaluation time includes:1 week before treatment,after treatment in first,three,six,twelve months.The RP,BP,GH,VT,SF,RE,MH were significantly lower than the preoperative baseline,but after six months recovery to preoperative baseline.In terms of physical pain,vitality,emotional function,the scores after twelve months were improved.Conclusion:1.MDT based on minimally invasive surgeon can accurately evaluate the resectability of pancreatic body and tail carcinoma with peritoneal metastasis and precisely guide postoperative adjuvant therapy.2.CRS + HIPEC is safe and feasible in treatment of pancreatic body and tail carcinoma with peritoneal metastasis,not increase complications such as postoperative pancreatic fistula,and can improve the quality of life,prolong lifetime,especially in patients with PCI ≤ 10.