The remaining patients
are alive without evidence of recurrence on follow-up. Follow up period from 6-41 months with an overall free
survival rate of 66.6%.

Discussion:                       

IORT was first discovered in Japan during 1970s. It was
applied in patients with locally advanced malignancies (10). It involves the application of radiation beam from the radiation
machine in the operative field after tumor resection, directly on the suspected
tissues after exposure. This procedure guarantee the administration of high
doses of radiation to the affected areas. This increases the chance of killing
the tumor cells remaining after surgical resection. The unaffected tissues can
be shielded or placed away from the radiation beam which decreases the risk of
radiation complications on these organs (11). The earlier
studies performed to evaluate the effect of IORT on the affected patients
concluded that it is of great benefit for both local disease control and longer
disease free survival (12, 13). This was applicable
for resectable pancreatic and periampullary adenocarcinoma. Also, in cases of
unresectable tumors, IORT has the advantages of controlling the disease locally
and minimizing tumor pain (14).

Most of the studies regarding the effect of IORT after
complete resection of pancreatic and periampullary cancer are retrospective
studies (15-18). Many studies
have evaluated the results in patients who have undergone complete surgical resection
combined with IORT and who had surgical resection alone(4).  These studies
showed the reduction of local recurrence in the patient received IORT than in
patients who did not receive IORT (4). Zerbi et al. (15)  compared patients
who had complete surgical resection and receive IORT  and patients who underwent resection alone. They
found that there is no differences between the two groups regarding both operative
mortality and early postoperative complications. Regarding tumor recurrence,
they found that it was 56% in the group who had surgery alone and 26% in the
group who had complete surgical resection combined with IORT. Reni et al.(16) studied 127
patients who had complete surgical resection combined with IORT and compared
these patients with 76 patients with had complete surgical resection alone. They
did not find any difference in operative morbidity and mortality due to the
application of IORT. Moreover, they found that the application of IORT in patients
with stage I and II cancer significantly delays the local recurrence and prolongs
the overall survival. Another 2 different larger studies proved the benefit of
the IORT in the local control of the tumor without any increase in both
operative morbidity and mortality (17, 18).  Based on these reviews, we added IORT as part
of the management of pancreatic and periampullary cancers. Our results were in
agreement with most of the studies performed to investigate the role of IORT in
the management of pancreatic and periampullary adenocarcinoma.

Conclusion:

IORT is a feasible and safe procedure. It is well
tolerated and does not increase both the operative morbidity and mortality the
treated patients. Although our results are favorable, however, a larger number
of patients will be needed to get a clear conclusion.