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Hoffman D, Ashraf Ganjouei A, Romero Hernandez F, Ifuku K, Miller P, Glencer A, Corvera C, Kirkwood K, Alseidi A, Adam MA, Maker A, Hirose K, Hirose R, Nakakura E. Graft Choice in Pancreatectomy with Vascular Resection: Equivalent Safety in Selected Patients. J Gastrointest Surg 2024:S1091-255X(24)00585-7. [PMID: 39181231 DOI: 10.1016/j.gassur.2024.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 06/17/2024] [Accepted: 08/17/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Pancreatic cancer is the third leading cause of cancer related death in the US, with surgical resection being the only option for long term survival. The ability to manage vascular involvement has expanded the pool of patients who are able to undergo resection with curative intent. However, not all vascular involvement can be detected pre-operatively. We investigated patterns of vascular resection and methods of repair or reconstruction METHODS: Single center retrospective review of adult patients undergoing pancreatectomy with vascular involvement at a tertiary care referral hospital between 2010-2022. Our primary endpoint was graft thrombosis within 90 days. RESULTS 147 patients were included in the study. 21.8% of whom were not suspected of having vascular involvement pre-operatively. 68% of patients required vascular reconstruction (68%) with the remaining 32% undergoing repair (either primary repair or patch angioplasty). The majority undergoing reconstruction underwent primary end to end anastomosis (63%), with 19 patients requiring autogenous interposition grafts and 16 patients requiring Cryovein® interposition grafts. Univariate analysis found no clinical or technical predictors of early or 90 day thrombosis, including graft choice. 30 and 90 day mortality occurred in 1 and 7 patients respectively. CONCLUSION Pancreatectomy with vascular resection can be performed with low mortality in carefully selected patients. Unsuspected vascular involvement is relatively common (1 in 5). If autologous graft is not readily available, Cryovein® is a safe alternative with similar perioperative outcomes.
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Affiliation(s)
- D Hoffman
- Department of Surgery, University of California, San Francisco, CA, USA; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA
| | - A Ashraf Ganjouei
- Department of Surgery, University of California, San Francisco, CA, USA; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA
| | - F Romero Hernandez
- Department of Surgery, University of California, San Francisco, CA, USA; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA
| | - K Ifuku
- Department of Surgery, University of California, San Francisco, CA, USA; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA
| | - P Miller
- Department of Surgery, University of California, San Francisco, CA, USA; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA
| | - A Glencer
- Department of Surgery, University of California, San Francisco, CA, USA; Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, Department of Surgery, University of California, San Francisco, CA, USA; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA
| | - C Corvera
- Department of Surgery, University of California, San Francisco, CA, USA; Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, Department of Surgery, University of California, San Francisco, CA, USA; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA
| | - K Kirkwood
- Department of Surgery, University of California, San Francisco, CA, USA; Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, Department of Surgery, University of California, San Francisco, CA, USA; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA
| | - A Alseidi
- Department of Surgery, University of California, San Francisco, CA, USA; Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, Department of Surgery, University of California, San Francisco, CA, USA; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA
| | - M A Adam
- Department of Surgery, University of California, San Francisco, CA, USA; Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, Department of Surgery, University of California, San Francisco, CA, USA; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA
| | - A Maker
- Department of Surgery, University of California, San Francisco, CA, USA; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA
| | - K Hirose
- Department of Surgery, University of California, San Francisco, CA, USA; UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA
| | - R Hirose
- Department of Surgery, University of California, San Francisco, CA, USA; UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA
| | - E Nakakura
- Department of Surgery, University of California, San Francisco, CA, USA; Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, Department of Surgery, University of California, San Francisco, CA, USA; UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA; Division of Transplant Surgery, Department of Surgery, University of California, San Francisco, CA.
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Mansour N, Sirtl S, Angele MK, Wildgruber M. Management of Sinistral Portal Hypertension after Pancreaticoduodenectomy. Dig Dis 2024; 42:178-185. [PMID: 38185113 PMCID: PMC10997249 DOI: 10.1159/000535774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 12/08/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Sinistral, or left-sided, portal hypertension (SPH) is a rare cause of upper gastrointestinal (GI) hemorrhage resulting from obstruction of the splenic vein. Venous drainage from the spleen via collaterals can result in venous hemorrhage into both the retroperitoneal and intra-abdominal spaces due to increased venous blood pressure in peripancreatic and gastroduodenal vasculature. SPH can occur secondary to pancreatitis with thrombosis of the splenic vein. Another possible cause is the surgical ligation of the splenic vein as part of pancreaticoduodenectomy (PD). Although splenectomy has been traditionally considered as the treatment of choice to relieve venous hypertension, individual concepts for each patient have to be developed. Considering the venous collateral drainage pathways, a comprehensive approach involving surgical, endoscopic, and interventional radiology interventions may be necessary to address the underlying cause of variceal bleeding. Among these approaches, splenic artery embolization (SAE) has demonstrated efficacy in mitigating the adverse effects associated with elevated venous outflow pressure. SUMMARY This review summarizes key imaging findings in SPH patients after PD and highlights the potential of minimally invasive embolization for curative treatment of variceal hemorrhage. KEY MESSAGES (i) SPH is a potential consequence after major pancreas surgery. (ii) Collateral flow can lead to life-threatening abdominal bleeding. (iii) Depending on the origin and localization of the bleeding, a dedicated management is required, frequently involving interventional radiology techniques.
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Affiliation(s)
- Nabeel Mansour
- Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Simon Sirtl
- Department of Medicine II, LMU University Hospital, LMU Munich, Munich, Germany
| | - Martin K. Angele
- Department for General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | - Moritz Wildgruber
- Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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4
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Kurzversion 2.0 – Dezember 2021, AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:991-1037. [PMID: 35671996 DOI: 10.1055/a-1771-6811] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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Bratlie SO, Wennerblom J, Vilhav C, Persson J, Rangelova E. Resectable, borderline, and locally advanced pancreatic cancer-"the good, the bad, and the ugly" candidates for surgery? J Gastrointest Oncol 2021; 12:2450-2460. [PMID: 34790406 DOI: 10.21037/jgo-2020-slapc-04] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/10/2020] [Indexed: 12/31/2022] Open
Abstract
The possibility of surgical resection strongly overrules medical oncologic treatment and is the only modality, causa sine qua non, long-term survival can be achieved in patients with pancreatic cancer. For this reason, the clinical classification of local resectability, subdividing tumors into resectable, borderline resectable, and locally advanced cancer, that is very technical in nature, is the one most widely used and accepted. As multimodality treatment with potent agents, particularly in the neoadjuvant setting, seems to be stepping forward as the new standard of treatment of pancreatic cancer, the established technical surgical landmarks tend to get challenged. This review aims to highlight the grey zones in the current classifications for local tumor involvement with respect to the observed patient outcome in the current multimodality treatment era. It summarizes the latest reported series on the outcome of resected primary resectable, borderline and locally advanced pancreatic cancer, and particularly vascular resections during pancreatectomy, in the background of different types of neoadjuvant therapy. It also hints what the new horizons of cancer biology tend to reveal whenever the technical hinders start being pushed aside. The current calls for the necessity of re-classification of the clinical categories of pancreatic cancer, from technically oriented to biology-focused individualized approach, are being elucidated.
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Affiliation(s)
- Svein Olav Bratlie
- Section for Upper Abdominal Surgery, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Surgery, The Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johanna Wennerblom
- Section for Upper Abdominal Surgery, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Surgery, The Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Caroline Vilhav
- Section for Upper Abdominal Surgery, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Surgery, The Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan Persson
- Section for Upper Abdominal Surgery, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Surgery, The Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Elena Rangelova
- Section for Upper Abdominal Surgery, Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Surgery, The Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Ono Y, Inoue Y, Kato T, Matsueda K, Oba A, Sato T, Ito H, Saiura A, Takahashi Y. Sinistral Portal Hypertension after Pancreaticoduodenectomy with Splenic Vein Resection: Pathogenesis and Its Prevention. Cancers (Basel) 2021; 13:cancers13215334. [PMID: 34771498 PMCID: PMC8582504 DOI: 10.3390/cancers13215334] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 11/16/2022] Open
Abstract
To achieve curative resection for pancreatic cancer during pancreaticoduodenectomy (PD), extensive portal vein (PV) resection, including porto-mesenterico-splenic confluence (PMSC), may sometimes be necessary if the tumor is close to the portal venous system. Recently, this extended resection has been widely accepted in high-volume centers for pancreatic resection due to its favorable outcomes compared with non-operative treatment. However, in patients with long-term survival, sinistral portal hypertension (SPH) occurs as a late-onset postoperative complication. These patients present gastrointestinal varices due to congested venous flow from the spleen, which may cause critical variceal bleeding. Since the prognosis of patients with pancreatic cancer has improved, owing to the development of chemotherapy and surgical techniques, SPH is no longer a negligible matter in the field of pancreatic cancer surgery. This review clarifies the pathogenesis and frequency of SPH after PD through PMSC resection and discusses its prediction and prevention.
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Affiliation(s)
- Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
- Correspondence: ; Tel.: +81-3-3520-0111
| | - Tomotaka Kato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Kiyoshi Matsueda
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan;
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, School of Medicine, Juntendo University, Tokyo 113-0033, Japan;
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
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Addeo P, Bachellier P. Pancreaticoduodenectomy with Segmental Venous Resection: a Standardized Technique Avoiding Graft Interposition. J Gastrointest Surg 2021; 25:1925-1931. [PMID: 33904058 DOI: 10.1007/s11605-021-05012-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/08/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1, Avenue Molière, 67098, Strasbourg, France. .,ICube, Université de Strasbourg, CNRS UMR 7357, 67400, Illkirch, France.
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1, Avenue Molière, 67098, Strasbourg, France
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Garnier J, Traversari E, Ewald J, Marchese U, Delpero JR, Turrini O. Venous Reconstruction During Pancreatectomy Using Polytetrafluoroethylene Grafts: A Single-Center Experience with Standardized Perioperative Management. Ann Surg Oncol 2021; 28:5426-5433. [PMID: 33655364 DOI: 10.1245/s10434-021-09716-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/26/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although primary end-to-end anastomosis is preferred for portal vein-superior mesenteric vein (PV-SMV) reconstruction, interposition graft use may be required in some situations. We investigated the efficacy of polytetrafluoroethylene (PTFE) grafts when used during pancreatectomy in this context. METHODS From 2014 to 2019, 19 patients who underwent pancreatectomy requiring PV-SMV reconstruction using ringed PTFE grafts were entered prospectively into a clinical database (NCT02871336, CNIL No. Sy50955016U). Unfractionated heparin was used during the first 24 h postoperatively. The administration of low-molecular-weight heparin was initiated twice a day (two injections of 1 mg/kg enoxaparin) on postoperative day 2 and was continued until the first clinical follow-up. Patency was assessed by CT scan before home discharge. Patients were switched to antiplatelet therapy (75 mg of aspirin-based drug Kardegic®) without a deadline. RESULTS Pancreatoduodenectomy was the most commonly performed procedure (15 patients, 79%), and pancreatic duct adenocarcinoma was the predominant etiology (17 patients, 89%). The median PTFE graft diameter and length were 10 mm and 8 cm, respectively. The median clamping time was 25 min. The overall severe morbidity and 90-day mortality values were 21% and 10%, respectively. None of the patients experienced anticoagulation-related morbidity or PTFE graft-related infection. The 6-month PTFE graft patency rate was 68%. Patients who underwent distal pancreatectomy showed a higher late thrombosis rate than those who underwent a pancreaticoduodenectomy (50% vs. 8%, p = 0.049). The median long-term PTFE graft patency duration was 37 months. CONCLUSIONS PTFE reconstruction can be safely performed with simple perioperative management in cases requiring interposition graft use.
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Affiliation(s)
- Jonathan Garnier
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France.
| | - Eddy Traversari
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Jacques Ewald
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Ugo Marchese
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Jean-Robert Delpero
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Olivier Turrini
- Department of Surgical Oncology, CRCM, Institut Paoli-Calmettes, Aix-Marseille University, Marseille, France
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9
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Matsuki R, Momose H, Kogure M, Suzuki Y, Mori T, Sakamoto Y. Direct splenic vein reconstruction combined with resection of the portal vein/superior mesenteric vein confluence during pancreaticoduodenectomy. Langenbecks Arch Surg 2021; 406:1691-1695. [PMID: 33479791 DOI: 10.1007/s00423-020-02064-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Splenic vein (SV) ligation combined with portal vein (PV)/superior mesenteric vein (SMV) confluence resection during pancreaticoduodenectomy (PD) is reported to cause left-side portal hypertension (LPH). The purpose of this study was to present our technique of the SV reconstruction and to evaluate the surgical outcomes with/without SV ligation during PD. METHODS Twenty-four patients undergoing PD with PV and/or SMV resection and being followed over 4 months after surgery between March 2013 and December 2019 in our hospital were evaluated. Resection of the PV/SMV confluence were performed in 14, and SV reconstruction was successfully performed in 3. Presence of LPH was assessed by examining changes in splenic volume, newly venous collateral formation, and platelet counts before and 4-8 months after PD. Surgical technique is the direct anastomosis between SV and PV. RESULTS Splenic volume ratio was significantly higher in the SV ligation group (n = 11) than in the SV preservation group (n = 13) (median (range) 1.11 (0.57-1.62) vs. 1.68 (1.05-2.22), p < 0.01), but no significant differences were found in the incidence of newly formed venous collaterals or platelet counts between groups. CONCLUSION SV ligation may represent the cause of LPH after PD combined with resection of PV/SMV confluence. Our simple procedure may help decrease the incidence of LPH.
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Affiliation(s)
- Ryota Matsuki
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Hirokazu Momose
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Masaharu Kogure
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Yutaka Suzuki
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Toshiyuki Mori
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Yoshihiro Sakamoto
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan.
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10
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Bultmann U, Niedergethmann M, Gelos M. Postoperative results, pathologic outcome, and long-term patency rate of autologous vein reconstruction of the mesentericoportal axis after pancreatectomy. Langenbecks Arch Surg 2020; 406:1453-1460. [DOI: 10.1007/s00423-020-02026-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/04/2020] [Indexed: 12/17/2022]
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11
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Anger F, Döring A, Schützler J, Germer CT, Kunzmann V, Schlegel N, Lock JF, Wiegering A, Löb S, Klein I. Prognostic impact of simultaneous venous resections during surgery for resectable pancreatic cancer. HPB (Oxford) 2020; 22:1384-1393. [PMID: 31980308 DOI: 10.1016/j.hpb.2019.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/08/2019] [Accepted: 12/28/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the prognostic impact of simultaneous venous resection during pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) that was preoperatively staged resectable according to NCCN guidelines. METHODS A retrospective analysis of 153 patients who underwent PD for PDAC was performed. Patients were divided into standard PD and PD with simultaneous vein resection (PDVR). Groups were compared to each other in terms of postoperative morbidity and mortality, disease free (DFS) and overall survival (OS). RESULTS 114 patients received PD while 39 patients received PDVR. No differences in terms of postoperative morbidity and mortality between both groups were detected. Patients in the VR group presented with a significantly shorter OS in the median (13 vs. 21 months, P = 0.011). In subgroup analysis, resection status did not influence OS in the PDVR group (R0 13 vs. R1 12 months, P = 0.471) but in the PD group (R0 23 vs. R1 14 months, P = 0.043). PDVR was a risk factor of OS in univariate but not multivariable analysis. CONCLUSION PDVR for PDAC preoperatively staged resectable resulted in significantly shorter OS regardless of resection status. Patients who require PDVR should be considered for adjuvant chemotherapy in addition to other oncological indications.
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Affiliation(s)
- Friedrich Anger
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, Julius Maximilians University Wuerzburg, Wuerzburg, Germany.
| | - Anna Döring
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, Julius Maximilians University Wuerzburg, Wuerzburg, Germany
| | - Julia Schützler
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, Julius Maximilians University Wuerzburg, Wuerzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, Julius Maximilians University Wuerzburg, Wuerzburg, Germany; Comprehensive Cancer Centre Mainfranken, Julius Maximilians University Wuerzburg, Wuerzburg, Germany
| | - Volker Kunzmann
- Comprehensive Cancer Centre Mainfranken, Julius Maximilians University Wuerzburg, Wuerzburg, Germany; Department of Internal Medicine II, Julius Maximilians University Wuerzburg, Wuerzburg, Germany
| | - Nicolas Schlegel
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, Julius Maximilians University Wuerzburg, Wuerzburg, Germany
| | - Johan F Lock
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, Julius Maximilians University Wuerzburg, Wuerzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, Julius Maximilians University Wuerzburg, Wuerzburg, Germany; Comprehensive Cancer Centre Mainfranken, Julius Maximilians University Wuerzburg, Wuerzburg, Germany
| | - Stefan Löb
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, Julius Maximilians University Wuerzburg, Wuerzburg, Germany
| | - Ingo Klein
- Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, Julius Maximilians University Wuerzburg, Wuerzburg, Germany; Comprehensive Cancer Centre Mainfranken, Julius Maximilians University Wuerzburg, Wuerzburg, Germany
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Long-term outcomes following en bloc resection for pancreatic ductal adenocarcinoma of the head with portomesenteric venous invasion. Asian J Surg 2020; 44:313-320. [PMID: 32972828 DOI: 10.1016/j.asjsur.2020.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 07/05/2020] [Accepted: 07/20/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The aim of this study is to clarify the prognostic influence of venous resection of the portal vein (PV) or superior mesenteric vein (SMV) on long-term outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) of the head with suspected vascular invasion. METHODS From May 1995 to December 2014, a total of 557 patients underwent surgery with curative intent for pancreatic cancer of the head. RESULTS Among 557 patients, 106 (19%) underwent pancreaticoduodenectomy (PD) with PV-SMV resection and 89 (75.5%) of these patients were confirmed to have true pathological invasion. The 5-year overall survival rate in patients underwent PV-SMV resection was significantly lower compared with those who did not (18.7% versus 24.3%; p = 0.002). Patients with negative resection margins who underwent PV-SMV resection had a better prognosis than those with positive resection margins who did not undergo PV-SMV resection with positive resection margins (17% versus 6.3% in 5-year overall survival rate; p = 0.003). The overall morbidity rate was not significantly different between PV-SMV resection group and no PV-SMV resection group (p = 0.064). On multivariate analysis, margin status, advanced T stage (3 or 4), lymph node metastasis, and adjuvant therapy were independent prognostic factors for survival. CONCLUSION PV-SMV resection was related to lower overall survival. However, on multivariate analysis, margin status was a more important prognostic factor than PV-SMV resection and true pathological invasion for survival. Therefore, en bloc PV-SMV resection should be performed when PV-SMV invasion is suspected to achieve R0 resection.
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Comparing Pathology Report Quality Indicators in 2 Distinct Whipple Resection Specimen Protocols. Pancreas 2020; 49:788-792. [PMID: 32541634 DOI: 10.1097/mpa.0000000000001574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Pancreaticoduodenectomy specimens are complex, with varying gross examination techniques. In 2012, our institution began using axial sectioning. We sought to determine if this resulted in more complete pathology reporting. METHODS Quality indicators were analyzed for pathology reports from 2 cohorts: 2001 to 2009 grossed traditionally and 2012 to 2017 using an axial technique (n = 81 and 51). Continuous and categorical data were compared using 2-tailed t test and Fisher exact test, respectively. RESULTS The later cohort exhibited increased reporting of stage, lymphovascular invasion, margins/surfaces, mean number of lymph nodes, and mean number of slides (P < 0.01). No differences were seen in reporting of size, grade, or perineural invasion. In the later cohort, superior mesenteric vein/portal vein surface was positive in 17 cases (33%), showing strong correlation with superior mesenteric artery/uncinate margin involvement (13/17 cases; P = 0.0001). There was a higher rate of lymph node positivity (86% vs 65%, P < 0.01) in the later cohort. CONCLUSIONS There is a trend toward higher-quality pathology reports in 2012 to 2017. A possible drawback of the axial approach is increased histopathology slides. Potential additional contributors include College of American Pathologists protocols, increasing subspecialty practice, and updates to the American Joint Committee on Cancer staging criteria.
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Addeo P, De Mathelin P, Averous G, Tambou-Nguipi M, Terrone A, Schaaf C, Dufour P, Bachellier P. The left splenorenal venous shunt decreases clinical signs of sinistral portal hypertension associated with splenic vein ligation during pancreaticoduodenectomy with venous resection. Surgery 2020; 168:267-273. [PMID: 32536489 DOI: 10.1016/j.surg.2020.04.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/11/2020] [Accepted: 04/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The ligation of the splenic vein during pancreaticoduodenectomy with synchronous resection of the spleno-mesenteric-portal venous confluence has been associated with the development of left portal hypertension despite preservation of the natural confluence with the inferior mesenteric vein. This study aimed to assess whether a left splenorenal venous shunt might mitigate clinical signs of left portal hypertension associated with splenic vein ligation. METHODS We retrospectively evaluated the presence of left portal hypertension based on biologic and radiologic parameters in patients undergoing pancreaticoduodenectomy with synchronous resection of the spleno-mesentericoportal confluence between January 1, 2012, and December 31, 2018. We compared several parameters between patients undergoing splenic vein ligation with preservation of the inferior mesenteric vein confluence and a splenorenal venous shunt: the early and late spleen volumes and spleen volume ratios, an early and late platelet count, the presence of thrombocytopenia, the presence of varices, and digestive bleeding in the long-term. RESULTS There were 114 consecutive patients: 36 with splenic vein ligation and 78 with splenorenal venous shunt. All had a pancreaticogastrostomy. Patients with splenic vein ligation had a comparable baseline and early and late platelet counts. Although baseline splenic volumes were comparable between the 2 groups (242 ± 115 mL vs 261 ± 138 mL; P = .51), patients with splenic vein ligation showed a statistically significant greater splenic volume beyond the 6th postoperative months (334 ± 160 mL vs 241 ± 111 mL; P = .004), higher early and late spleen volume ratios (1.42 ± 0.67 vs 1.10 ± 0.3; P = .001 and 1.38 ± 0.38 vs 0.97 ± 0.4; P = .0001) than patients with splenorenal venous shunt. Splenic vein ligation was also associated with a higher rate of varices (81% vs 50%; P = .002) and more frequent varices with a caliber greater than 1 cm (57% vs 36%; P = .05) and more colonic varices (33% vs 12%; P = .01). Only 1 patient had long-term digestive bleeding (splenic vein ligation). CONCLUSION The left splenorenal shunt decreases clinical signs of left portal hypertension associated with splenic vein ligation and inferior mesenteric vein confluence preservation.
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Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.
| | - Pierre De Mathelin
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Gerlinde Averous
- Department of Pathology, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Marlene Tambou-Nguipi
- Department of Gastroenterology-Section of Oncology, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Alfonso Terrone
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Caroline Schaaf
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Patrick Dufour
- Department of Gastroenterology-Section of Oncology, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
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Kuwabara S, Matsumoto J, Tojima H, Wada H, Kato K, Tabata Y, Ichinokawa M, Yoshioka T, Murakawa K, Ikeda A, Ohtake S, Ono K. Colonic varices treated with embolization after pancreatoduodenectomy with portal vein resection: a case report. Surg Case Rep 2020; 6:126. [PMID: 32494925 PMCID: PMC7270471 DOI: 10.1186/s40792-020-00888-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/27/2020] [Indexed: 12/11/2022] Open
Abstract
Background Pancreatoduodenectomy with resection of the portal vein or superior mesenteric vein confluence has been safely performed in patients with pancreatic head cancer associated with infiltration of the portal vein or superior mesenteric vein. In recent years, left-sided portal hypertension, a late postoperative complication, has received focus owing to increased long-term survival with advances in chemotherapy. Left-sided hypertension may sometimes cause fatal gastrointestinal bleeding because of the rupture of gastrointestinal varices. Here, we present a case of colonic varices caused by left-sided portal hypertension after pancreatoduodenectomy with portal vein resection. Case presentation A 69-year-old man diagnosed with pancreatic head cancer was referred to our department for surgery after undergoing chemotherapy with nine courses of gemcitabine and nab-paclitaxel. Computed tomography showed a mass 25 mm in diameter and in contact with the portal vein. He had undergone subtotal stomach-preserving pancreatoduodenectomy with portal vein resection. Four centimeters of the portal vein had been resected, and end-to-end anastomosis was performed without splenic vein reconstruction. We had to completely resect the right colic vein, accessary right colic vein, and middle colic vein due to tumor invasion. The pathological diagnosis was ypT3, ypN1a, ypM0, and ypStageIIB, and he was administered TS-1 as postoperative adjuvant chemotherapy. Seven months after therapeutic radical surgery, he presented with melena with progressive anemia. Computed tomography revealed transverse colonic varices. He was offered interventional radiology. Trans-splenic arterial splenic venography showed that transverse colonic varices had developed as collateral circulation of the splenic vein and inferior mesenteric vein system. An embolic substance was injected into the transverse colonic varices, which halted the progression of the anemia caused by melena. Fifteen months after therapeutic radical surgery, local recurrence of the tumor occurred; he died 28 months after the surgery. Conclusions When subtotal stomach-preserving pancreatoduodenectomy with portal vein resection is performed without splenic vein reconstruction, colonic varices may result from left-sided portal hypertension. Interventional radiology is an effective treatment for gastrointestinal bleeding due to colonic varices, but it is important to be observant for colonic necrosis and new varices.
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Affiliation(s)
- Shota Kuwabara
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan.
| | - Joe Matsumoto
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Hiroyasu Tojima
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Hideyuki Wada
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Kohei Kato
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Yukiko Tabata
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Masaomi Ichinokawa
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Tatsuya Yoshioka
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Katsuhiko Murakawa
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Atsushi Ikeda
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Setsuyuki Ohtake
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Koichi Ono
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
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Pandé R, Roberts KJ. Determining Optimal Routes to Surgery for Borderline Resectable Venous Pancreatic Cancer-Where Is the Least Harm and Most Benefit? Front Oncol 2019; 9:1060. [PMID: 31681596 PMCID: PMC6811510 DOI: 10.3389/fonc.2019.01060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 09/30/2019] [Indexed: 11/13/2022] Open
Abstract
Surgery among patients with borderline resectable pancreatic cancer (BRPC) and venous disease has emerged as a viable strategy to achieve curative treatment. By definition, these patients are at increased risk of a positive resection margin, however, controversy exists with regards to necessity of radical surgery and optimum pathways with no consensus on definitive treatment. A surgery first approach is possible though outcomes vary but patients can have an efficient pathway to surgery, particularly if biliary drainage is avoided which limits overall complications. Neoadjuvant therapy (NAT) is emerging as a widely used strategy to improve oncological outcomes, including resection margin status. However, some patients progress on NAT whilst others suffer major complications whilst elderly patients are unlikely to be offered effective NAT limiting the widespread applicability of this therapy. In this article an overview of the entire pathway is presented along with assimilation of current best evidence to determine optimal routes to surgery for BRPC with venous involvement.
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Affiliation(s)
- Rupaly Pandé
- Department of HPB Surgery and Liver Transplant, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Keith J Roberts
- Department of HPB Surgery and Liver Transplant, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Department of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
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Ono Y, Tanaka M, Matsueda K, Hiratsuka M, Takahashi Y, Mise Y, Inoue Y, Sato T, Ito H, Saiura A. Techniques for splenic vein reconstruction after pancreaticoduodenectomy with portal vein resection for pancreatic cancer. HPB (Oxford) 2019; 21:1288-1294. [PMID: 30878491 DOI: 10.1016/j.hpb.2019.01.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 12/10/2018] [Accepted: 01/31/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) with splenic vein (SV) ligation may result in sinistral portal hypertension (SPH). The aim of this study was to compare the outcomes of various types of SV reconstruction to prevent SPH and to define the optimal reconstruction method. METHODS This study included patients who underwent PD with SV resection and reconstruction for pancreatic cancer between December 2013 and June 2017. The patency of various types of SV anastomosis and SPH was evaluated by follow up computed tomography. RESULTS The type of SV reconstruction was divided into two groups: (i) end-to-side anastomosis (n = 10), in which the SV was anastomosed with either the left renal vein (LRV; n = 8) or portal vein (n = 2); and (ii) end-to-end anastomosis (n = 20), in which the SV was anastomosed with another smaller vein or graft. The patency rate for Group 1 was 90% (9/10), compared with 45% (9/20) for Group 2 (P = 0.024). Half the patients in whom the SV anastomosis was occluded (6/12) developed gastrointestinal varices, whereas only 11% of patients with a patent SV anastomosis (2/9) had varices (P = 0.034). CONCLUSION SV-LRV reconstruction is widely applicable, effectively reduces the risk of SPH, and should be considered for the case of extended PD.
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Affiliation(s)
- Yoshihiro Ono
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Masayuki Tanaka
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Kiyoshi Matsueda
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Makiko Hiratsuka
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Yu Takahashi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Yoshihiro Mise
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Yosuke Inoue
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Takafumi Sato
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Hiromichi Ito
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Akio Saiura
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan.
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Al Faraï A, Garnier J, Ewald J, Marchese U, Gilabert M, Moureau-Zabotto L, Poizat F, Giovannini M, Delpero JR, Turrini O. International Study Group of Pancreatic Surgery type 3 and 4 venous resections in patients with pancreatic adenocarcinoma:the Paoli-Calmettes Institute experience. Eur J Surg Oncol 2019; 45:1912-1918. [DOI: 10.1016/j.ejso.2019.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/07/2019] [Accepted: 06/01/2019] [Indexed: 12/23/2022] Open
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Kushiya H, Noji T, Abo D, Soyama T, Tanaka K, Nakanishi Y, Asano T, Nakamura T, Tsuchikawa T, Okamura K, Hirano S. Treatment of bleeding from a portion of pancreatojejunostomy after pancreaticoduodenectomy with division of the splenic vein: two case reports. Surg Case Rep 2019; 5:128. [PMID: 31396775 PMCID: PMC6687795 DOI: 10.1186/s40792-019-0687-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/30/2019] [Indexed: 12/12/2022] Open
Abstract
Background There is no definitive strategy for gastrointestinal bleeding due to left-sided portal hypertension after pancreaticoduodenectomy (PD) for pancreatic cancer (PC) with concomitant portal vein resection (PVR). Case presentation Case 1: A 70-year-old woman underwent a PD for PC with PVR. Seven years after her surgery, she suffered severe anemia with suspected gastrointestinal bleeding. Computed tomography scan (CT) revealed varices at a portion of the pancreaticojejunostomy (PJ). Angiography revealed that splenic venous flow drained into the varices and then into the portal vein. A diagnosis of bleeding varices of the PJ due to left-sided portal hypertension was made. Following a partial splenic artery embolization, her anemia improved. Case 2: An 80-year-old male underwent a PD for pancreatic head cancer combined with resection of the confluence of the portal and splenic veins with a reconstruction between the portal and superior mesenteric veins. Eighteen months after his surgery, he developed melena with negative endoscopy findings in his large and small bowel. CT revealed varices at the site of the PJ that communicated with the jejunal and portal veins. He underwent obliteration of the varices via a trans-portal-venous approach. As a result, he remained without melena until he died of PC 17 months after the embolization. Conclusions Left-sided portal hypertension following a PD with bleeding varices can be treated by interventional radiology with minimal invasiveness.
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Affiliation(s)
- Hiroki Kushiya
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan.
| | - Daisuke Abo
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Takeshi Soyama
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Toshimichi Asano
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
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Serenari M, Ercolani G, Cucchetti A, Zanello M, Prosperi E, Fallani G, Masetti M, Lombardi R, Cescon M, Jovine E. The impact of extent of pancreatic and venous resection on survival for patients with pancreatic cancer. Hepatobiliary Pancreat Dis Int 2019; 18:389-394. [PMID: 31230959 DOI: 10.1016/j.hbpd.2019.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/06/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Borderline resectable pancreatic cancer may require extended resections in order to achieve tumor-free margins, especially in the case of up-front resections, but it is important to know the limits of surgical therapy in this disease. This study aimed to investigate the impact of extent of pancreatic and venous resection on short- and long-term outcomes in patients with pancreatic adenocarcinoma (PDAC). METHODS This was a retrospective study from a prospectively maintained database of pancreatic resections for PDAC. Short- and long-term outcomes were analyzed in patients having borderline resectable PDAC submitted to up-front total pancreatectomy (TP) or pancreaticoduodenectomy (PD) with simultaneous portal vein (PV) and/or superior mesenteric vein (SMV) resection. Venous resections were carried out as tangential venous resection (TVR) or segmental venous resection (SVR). Patients were divided into 4 groups: (1) PD + TVR, (2) PD + SVR, (3) TP + TVR, (4) TP + SVR. Uni- and multivariate Cox regression analysis were performed to identify factors associated with survival. RESULTS Ninety-nine patients were submitted to simultaneous pancreatic and venous resection for PDAC. Among them, 25 were submitted to PD + TVR (25.3%), 12 to PD + SVR (12.1%), 23 to TP + TVR (23.2%), and 39 to TP + SVR (39.4%). Overall, major morbidity (Clavien-Dindo grade ≥ IIIA) was 26.3%. Thirty- and 90-day mortality were 3% and 11.1%, respectively. There were no significant differences among groups in terms of short-term outcomes. Median overall survival of patients submitted to PD + TVR was significantly higher than those to TP+SVR (29.5 vs 7.9 months, P = 0.001). Multivariate analysis identified TP (HR = 2.11; 95% CI: 1.31-3.44; P = 0.002) and SVR (HR = 2.01; 95% CI: 1.27-3.15; P = 0.003) as the only independent prognostic factors for overall survival. CONCLUSIONS Up-front TP associated to SVR was predictive of worse survival in borderline resectable PDAC. Perioperative treatments in high-risk surgical groups may improve such poor outcomes.
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Affiliation(s)
- Matteo Serenari
- Department of Medical and Surgical Sciences, S. Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences, S. Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy.
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences, S. Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Matteo Zanello
- Department of General Surgery, Maggiore Hospital - Bologna Local Health District, Bologna, Italy
| | - Enrico Prosperi
- Department of Medical and Surgical Sciences, S. Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Guido Fallani
- Department of Medical and Surgical Sciences, S. Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Michele Masetti
- Department of General Surgery, Maggiore Hospital - Bologna Local Health District, Bologna, Italy
| | - Raffaele Lombardi
- Department of General Surgery, Maggiore Hospital - Bologna Local Health District, Bologna, Italy
| | - Matteo Cescon
- Department of Medical and Surgical Sciences, S. Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Elio Jovine
- Department of General Surgery, Maggiore Hospital - Bologna Local Health District, Bologna, Italy
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Beane JD, Zenati M, Hamad A, Hogg ME, Zeh HJ, Zureikat AH. Robotic pancreatoduodenectomy with vascular resection: Outcomes and learning curve. Surgery 2019; 166:8-14. [DOI: 10.1016/j.surg.2019.01.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/09/2019] [Accepted: 01/10/2019] [Indexed: 12/19/2022]
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22
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Wang X, Demir IE, Schorn S, Jäger C, Scheufele F, Friess H, Ceyhan GO. Venous resection during pancreatectomy for pancreatic cancer: a systematic review. Transl Gastroenterol Hepatol 2019; 4:46. [PMID: 31304423 DOI: 10.21037/tgh.2019.06.01] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 06/04/2019] [Indexed: 12/11/2022] Open
Abstract
Pancreatic cancer is one of the most aggressive and lethal malignancies with a dismal prognosis and survival. The curative effects of venous resection (VR) in pancreatic cancer remain controversial. A systematic literature search was performed in PubMed, Embase and the Cochrane Library. The overall postoperative complications, perioperative mortality, histopathology, and long-term survival were compared between patients undergoing pancreatectomy combined with (VR+ group) or without (VR- group) VR. Forty-one studies were included in the systematic review. Pancreatectomy combined with VR required longer operation time and led to increased perioperative blood loss, whereas postoperative complications were similar. Patients in the VR+ group showed larger tumors and reduced R0 rates. Regarding long-term survival, patients with VR+ seemed to have impaired 1-, 3-, and 5-year survival. Based on our results, VR in pancreatic cancer is a safe and feasible procedure. Given the fact that patients have miserable outcomes and survival in the palliative setting alone, extended resection including VR is required for the purpose of achieving radical resection.
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Affiliation(s)
- Xiaobo Wang
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of General Surgery, School of Medicine, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Stephan Schorn
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Carsten Jäger
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Florian Scheufele
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Güralp O Ceyhan
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of General Surgery, School of Medicine, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
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Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains a dismal prognosis and surgery is the only chance for cure. However, only few of the patients have localized tumor eligible for curative complete resection. Preoperative management and well-staging of the disease are the cornerstone for appropriate surgery and major issues to define the best therapeutic strategy. This review focuses on the surgical and optimal perioperative management of PDAC and summarizes updates data on the subject.
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Jorgensen MS, Almerey T, Farres H, Oldenburg WA, Stauffer J, Hakaim AG. What to expect with major vascular reconstruction during Whipple procedures: a single institution experience and literature review. J Gastrointest Oncol 2019; 10:95-102. [PMID: 30788164 DOI: 10.21037/jgo.2018.10.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Major vascular reconstruction during a pancreaticoduodenectomy (PD), also known as a Whipple procedure, leads to controversial postoperative outcomes compared to conventional Whipple. Discussion with the patient regarding postoperative expectations is a crucial component of holistic surgical healthcare. The aim of this study was to report our 8-year experience of Whipple procedures involving vascular reconstruction and to review relevant literature to further evaluate expectant outcomes, therefore leading to more accurate discussion. Methods A retrospective review of patients undergoing Whipple procedures from January 2010, through December 2017 was performed. Patch, graft, and primary anastomosis during Whipple procedures were considered major vascular reconstruction. Literature on the current understanding of the outcomes associated with vascular reconstruction during Whipple procedures was reviewed. Results Twenty-nine from a total of 405 patients that met inclusion criteria had a Whipple procedure that involved major vascular reconstruction. Twelve patients were male and 17 were female (mean age, 65.2 years). Median hospital and intensive care unit (ICU) stay [range] of patients with vascular reconstruction was 12 [5-92] days and 3 [0-59] days, respectively. Thirty-day survival and 1-year survival of patients with vascular reconstruction was 93.1% and 55.2%, respectively, compared to non-vascular reconstruction patients 96.0% and 83.5%, respectively (P=0.35, P<0.001). Ninety-day readmission for vascular reconstruction patients was 31.0% compared to 14.6% in non-vascular reconstruction patients (P=0.03). The 1-year survival of those who had patch reconstruction, graft reconstruction, and primary anastomosis was 50.0%, 62.5%, 53.8%, respectively. Conclusions Compared to conventional Whipple procedures, those requiring major vascular reconstruction are associated with decreased survival. When vascular reconstruction is a valid option patients should be well aware of the associated outcomes.
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Affiliation(s)
| | - Tariq Almerey
- Department of Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Houssam Farres
- Division of Vascular Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - W Andrew Oldenburg
- Division of Vascular Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - John Stauffer
- Department of Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Albert G Hakaim
- Division of Vascular Surgery, Mayo Clinic Florida, Jacksonville, FL, USA
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25
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Comparison of end-to-end anastomosis and interposition graft during pancreatoduodenectomy with portal vein reconstruction for pancreatic ductal adenocarcinoma. Langenbecks Arch Surg 2019; 404:191-201. [DOI: 10.1007/s00423-019-01749-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 01/02/2019] [Indexed: 02/06/2023]
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26
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Park H, Kang I, Kang CM. Laparoscopic pancreaticoduodenectomy with segmental resection of superior mesenteric vein-splenic vein-portal vein confluence in pancreatic head cancer: can it be a standard procedure? Ann Hepatobiliary Pancreat Surg 2018; 22:419-424. [PMID: 30588536 PMCID: PMC6295366 DOI: 10.14701/ahbps.2018.22.4.419] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/25/2018] [Accepted: 07/26/2018] [Indexed: 12/20/2022] Open
Abstract
The feasibility of laparoscopic pancreaticoduodenectomy (LPD) in the treatment of pancreatic cancer is still disputed. However, advances in surgical technique and accumulating experience have led to the use of LPD with combined vascular resection and reconstruction as a safe and feasible procedure, especially in pancreatic cancer with major vascular involvement. A 64-year-old woman presented with obstructive jaundice secondary to pancreatic head cancer. Contrast abdominopelvic computed tomography revealed a pancreatic head tumor measuring approximately 22 mm in diameter that was abutting the first jejunal branch of the superior mesenteric vein at an angle of <180°. The patient underwent LPD, which failed to resect the pancreatic head tumor invading the superior mesenteric vein. Consequently, segmental resection of the confluence of the superior mesenteric vein, splenic vein, and portal vein (SMV/SV/PV) was completely performed in laparoscopic approach without complication. The patient recovered without any event and was discharged on postoperative day 9. LPD combined with vascular resection and reconstruction is feasible in cases involving major blood vessels. Further surgical expertise and education are required before LPD can be used as a standard procedure.
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Affiliation(s)
- Hyejin Park
- Department of Education and Training, Severance Hospital, Seoul, Korea
| | - Incheon Kang
- Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
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27
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Scholtz V, Meyer F, Schulz HU, Albrecht R, Halloul Z. [Vascular surgical aspects in abdominal surgery : Results from a tertiary care center over a 10-year time period]. Chirurg 2018; 90:307-317. [PMID: 30255373 DOI: 10.1007/s00104-018-0726-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
AIM To investigate the perioperative management and outcome of patients undergoing abdominal surgery with additional vascular (comorbid) alterations for internal quality assurance of the clinical results. METHODS Over a defined study period all consecutive cases of the aforementioned profile were documented and retrospectively analyzed as part of an ongoing prospective monocentric observational study to reflect the daily surgical practice. RESULTS Over 10 years (from January 1999 to December 2008), a total of 113 cases were registered. Pancreas resection including vascular reconstruction showed the highest percentage (30.1%). Within the target patient groups, similar outcome data were found compared with international reports. An exception was in the case of mesenteric ischemia, where open surgery was more frequently used in comparison to the study situation (included together were patients treated by surgery and interventions). The majority of vascular alterations during the postoperative course and iatrogenic lesions occurred following pancreas resection. In the therapeutic profile there are two particularly important measures, namely open surgery on one hand and image-guided radiology as well as endoscopy on the other hand. The majority of patients with a rare visceral artery aneurysm (considerable potential for rupture or erosion) were more frequently treated with image-guided interventional radiology versus open surgery. This conforms to the current well-established sequential patient (individual), results, and, in particular, risk-adapted staged treatment approach. CONCLUSION Additional vascular surgical treatment of problematic situations during abdominal surgery or in emergency cases is not daily routine; however, it is a challenging field including a considerable potential for complications (morbidity) and definitely mortality. This requires an experienced surgeon with high expertise, if possible in a center for vascular medicine.
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Affiliation(s)
- V Scholtz
- Klinik für Allgemein‑, Viszeral-, Gefäß- und Transplantationschirurgie, Universitätsklinikum Magdeburg A. ö. R., Magdeburg, Deutschland
| | - F Meyer
- Klinik für Allgemein‑, Viszeral-, Gefäß- und Transplantationschirurgie, Universitätsklinikum Magdeburg A. ö. R., Magdeburg, Deutschland.
| | - H-U Schulz
- Klinik für Allgemein- & Viszeralchirurgie, AMEOS Klinikum, Haldensleben, Deutschland
| | - R Albrecht
- Klinik für Allgemein‑, Viszeral- und minimal-invasive Chirurgie mit Thoraxchirurgie, Helios Klinikum, Aue, Deutschland
| | - Z Halloul
- Klinik für Allgemein‑, Viszeral-, Gefäß- und Transplantationschirurgie, Universitätsklinikum Magdeburg A. ö. R., Magdeburg, Deutschland
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28
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Garbarino GM, Fuks D, Cowan J, Ward M, Moisan F, Donatelli G, Beaussier M, Gayet B. Total Laparoscopic Pancreaticoduodenectomy with Venous Reconstruction for Pancreatic Head Cancer with Involvement of the Superior Mesenteric Vein–Portal Vein Confluence. Ann Surg Oncol 2018; 25:4035-4036. [DOI: 10.1245/s10434-018-6762-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Indexed: 01/15/2023]
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29
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Mohammed S, Mendez-Reyes JE, McElhany A, Gonzales-Luna D, Van Buren G, Bland DS, Villafane-Ferriol N, Pierzynski JA, West CA, Silberfein EJ, Fisher WE. Venous thrombosis following pancreaticoduodenectomy with venous resection. J Surg Res 2018; 228:271-280. [DOI: 10.1016/j.jss.2018.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 01/07/2018] [Accepted: 02/12/2018] [Indexed: 02/07/2023]
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30
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Sabater L, Muñoz E, Roselló S, Dorcaratto D, Garcés-Albir M, Huerta M, Roda D, Gómez-Mateo MC, Ferrández-Izquierdo A, Darder A, Cervantes A. Borderline resectable pancreatic cancer. Challenges and controversies. Cancer Treat Rev 2018; 68:124-135. [PMID: 29957372 DOI: 10.1016/j.ctrv.2018.06.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 12/18/2022]
Abstract
Pancreatic cancer is a dismal disease with an increasing incidence. Despite the majority of patients are not candidates for curative surgery, a subgroup of patients classified as borderline resectable pancreatic cancer can be selected in whom a sequential strategy of neoadjuvant therapy followed by surgery can provide better outcomes. Multidisciplinary approach and surgical pancreatic expertise are essential for successfully treating these patients. However, the lack of consensual definitions and therapies make the results of studies very difficult to interpret and hard to be implemented in some settings. In this article, we review the challenges of borderline resectable pancreatic cancer, the complexity of its management and controversies and point out where further research and international cooperation for a consensus strategy is urgently needed.
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Affiliation(s)
- Luis Sabater
- Department of Surgery, Liver-Biliary and Pancreatic Unit, Biomedical Research Institute INCLIVA, Hospital Clinico University of Valencia, Spain
| | - Elena Muñoz
- Department of Surgery, Liver-Biliary and Pancreatic Unit, Biomedical Research Institute INCLIVA, Hospital Clinico University of Valencia, Spain
| | - Susana Roselló
- CIBERONC Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Spain
| | - Dimitri Dorcaratto
- Department of Surgery, Liver-Biliary and Pancreatic Unit, Biomedical Research Institute INCLIVA, Hospital Clinico University of Valencia, Spain
| | - Marina Garcés-Albir
- Department of Surgery, Liver-Biliary and Pancreatic Unit, Biomedical Research Institute INCLIVA, Hospital Clinico University of Valencia, Spain
| | - Marisol Huerta
- CIBERONC Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Spain
| | - Desamparados Roda
- CIBERONC Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Spain
| | | | | | - Antonio Darder
- Department of Surgery, Liver-Biliary and Pancreatic Unit, Biomedical Research Institute INCLIVA, Hospital Clinico University of Valencia, Spain
| | - Andrés Cervantes
- CIBERONC Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Spain.
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31
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Song W, Yang Q, Chen L, Sun Q, Zhou D, Ye S, Hu Z, Wu L, Feng L, Zheng S, Wang W. Pancreatoduodenectomy combined with portal-superior mesenteric vein resection and reconstruction with interposition grafts for cancer: a meta-analysis. Oncotarget 2017; 8:81520-81528. [PMID: 29113411 PMCID: PMC5655306 DOI: 10.18632/oncotarget.20866] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 08/26/2017] [Indexed: 12/22/2022] Open
Abstract
The use of interposition grafts for portal-superior mesenteric vein (PV-SMV) reconstruction during pancreatoduodenectomy (PD) with venous resection (VR) for localized periampullary tumors is a controversial topic. The present meta-analysis aimed to evaluate the perioperative and long-term outcomes in patients who received interposition grafts for PV-SMV reconstruction after PD with VR. The correlative databases were systematically searched to identify relevant trials comparing vein grafts versus no vein grafts during PD with VR. 14 studies including 257 patients with vein grafts and 570 patients without vein grafts were extracted. The meta-analysis indicated no difference in perioperative morbidity, mortality, or thrombosis between the two groups, but the vein graft group was associated with a significantly increased venous thrombosis rate (≥ 6 months) (odds ratio [OR] = 2.75; 95% confidence interval [CI], 1.32–5.73; P = .007). The autologous vein group subgroup analysis also revealed a significantly increased vein thrombosis rate (OR = 3.13; 95% CI, 1.45–6.76; P = .004) between the two groups. Meanwhile, the prosthetic vein group subgroup analysis indicated no difference. Additionally, the oncological value of vein grafts during PD for pancreatic cancer survival was analyzed and revealed no difference in 1-year, 3-year, or 5-year survival between the two groups. Using interposition grafts for PV-SMV reconstruction is safe and effective, and has perioperative outcomes and long-term survival rates compared to those with no vein grafts during PD with VR. However, the lower long-term vein patency rate in patients with vein grafts indicate that interposition grafts may be more likely to lose function.
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Affiliation(s)
- Wei Song
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Qifan Yang
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Linghui Chen
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Qiang Sun
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Dongkai Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Song Ye
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Zhenhua Hu
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Liming Wu
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Liming Feng
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China
| | - Shusen Zheng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou 310003, China
| | - Weilin Wang
- Key Laboratory of Precision Diagnosis and Treatment for Hepatobiliary and Pancreatic Tumor of Zhejiang Province, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou 310003, China
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32
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Xie ZB, Gu JC, Zhang YF, Yao L, Jin C, Jiang YJ, Li J, Yang F, Zou CF, Fu DL. Portal vein resection and reconstruction with artificial blood vessels is safe and feasible for pancreatic ductal adenocarcinoma patients with portal vein involvement: Chinese center experience. Oncotarget 2017; 8:77883-77896. [PMID: 29100433 PMCID: PMC5652822 DOI: 10.18632/oncotarget.20847] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 08/17/2017] [Indexed: 12/19/2022] Open
Abstract
Evidence shows that portal vein resection (PVR) increase the resectability but does little benefit to overall survival in all pancreatic ductal adenocarcinoma (PDAC) patients. But for patients with portal vein involvement, PVR is the only radical choice. But whether the PDAC patients with portal vein involvement would benefit from radical pancreaticoduodenectomy with PVR or not is controversial. All 204 PDAC patients with portal vein involvement were enrolled in this study [PVR group, n=106; surgical bypass (SB) group, n=52; chemotherapy group, n=46]. Overall survival and prognostic factors were analyzed among three groups. Moreover, a literature review of 13 studies were also conducted. Among 3 groups, patients in PVR group achieved a significant longer survival (median survival: PVR group, 22.83 months; SB group, 7.26 months; chemotherapy group, 10.64 months). Therapy choice [hazard ratio (HR) =1.593, 95% confidence interval (CI) 1.323 to 1.918, P<0.001], body mass index (HR=0.772, 95% CI 0.559 to 0.994, P=0.044) and carbohydrateantigen 19-9 (HR=1.325, 95% CI 1.064 to 1.651, P=0.012) were independent prognostic factors which significantly affected overall survival. Pancreaticoduodenectomy combined with PVR and reconstruct with artificial blood vessels is a safe and an appropriate therapy choice for resectable PDAC patients with portal vein involvement.
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Affiliation(s)
- Zhi-Bo Xie
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Ji-Chun Gu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Yi-Fan Zhang
- Department of Plastic & Reconstructive Surgery, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200011, China
| | - Lie Yao
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Chen Jin
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Yong-Jian Jiang
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Ji Li
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Feng Yang
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Cai-Feng Zou
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - De-Liang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
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33
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Portal Vein Thrombosis After Splenic and Pancreatic Surgery. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 906:241-251. [PMID: 27638624 DOI: 10.1007/5584_2016_119] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The portal vein is formed by the confluence of the splenic and superior mesenteric veins, which drain the spleen and small intestine respectively. Occlusion of the portal vein by thrombus typically occurs in patients with cirrhosis and/or prothrombotic disorders. However, portal vein thrombosis (PVT) can also happen after determined surgeries. Moreover, PVT can have serious consequences depending on the location and extent of the thrombosis, including hepatic ischemia, intestinal ischemia, portal hypertension… In this chapter, we will review the incidence, management and prophylaxis of PVT after splenectomy, pancreas transplantation, pancreatic surgery and in the setting of acute and chronic pancreatitis.
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34
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Zervos EE, Rosemurgy AS, Al-Saif O, Durkin AJ. Surgical Management of Early-Stage Pancreatic Cancer. Cancer Control 2017. [DOI: 10.1177/107327480401100204] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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35
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Ravikumar R, Sabin C, Abu Hilal M, Al-Hilli A, Aroori S, Bond-Smith G, Bramhall S, Coldham C, Hammond J, Hutchins R, Imber C, Preziosi G, Saleh A, Silva M, Simpson J, Spoletini G, Stell D, Terrace J, White S, Wigmore S, Fusai G. Impact of portal vein infiltration and type of venous reconstruction in surgery for borderline resectable pancreatic cancer. Br J Surg 2017; 104:1539-1548. [PMID: 28833055 DOI: 10.1002/bjs.10580] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 12/29/2016] [Accepted: 04/04/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND The International Study Group of Pancreatic Surgery (ISGPS) recommends operative exploration and resection of pancreatic cancers in the presence of reconstructable mesentericoportal axis involvement. However, there is no consensus on the ideal method of vascular reconstruction. The effect of depth of tumour invasion of the vessel wall on outcome is also unknown. METHODS This was a retrospective cohort study of pancreaticoduodenectomy with vein resection for T3 adenocarcinoma of the head of the pancreas across nine centres. Outcome measures were overall survival based on the impact of the depth of tumour infiltration of the vessel wall, and morbidity, in-hospital mortality and overall survival between types of venous reconstruction: primary closure, end-to-end anastomosis and interposition graft. RESULTS A total of 229 patients underwent portal vein resection; 129 (56·3 per cent) underwent primary closure, 64 (27·9 per cent) had an end-to-end anastomosis and 36 (15·7 per cent) an interposition graft. There was no difference in overall morbidity (26 (20·2 per cent), 14 (22 per cent) and 9 (25 per cent) respectively; P = 0·817) or in-hospital mortality (6 (4·7 per cent), 2 (3 per cent) and 2 (6 per cent); P = 0·826) between the three groups. One hundred and six patients (47·5 per cent) had histological evidence of vein involvement; 59 (26·5 per cent) had superficial invasion (tunica adventitia) and 47 (21·1 per cent) had deep invasion (tunica media or intima). Median survival was 18·8 months for patients who had primary closure, 27·6 months for those with an end-to-end anastomosis and 13·0 months among patients with an interposition graft. There was no significant difference in median survival between patients with superficial, deep or no histological vein involvement (20·8, 21·3 and 13·3 months respectively; P = 0·111). Venous tumour infiltration was not associated with decreased overall survival on multivariable analysis. CONCLUSION In this study, there was no difference in morbidity between the three modes of venous reconstruction, and overall survival was similar regardless of tumour infiltration of the vein.
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Affiliation(s)
- R Ravikumar
- Department of Hepatopancreatobiliary (HPB) and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - C Sabin
- Research Department of Infection and Population Health, Royal Free Campus, University College London, London, UK
| | - M Abu Hilal
- Department of HPB Surgery, Southampton General Hospital, Southampton, UK
| | - A Al-Hilli
- Department of HPB Surgery, Southampton General Hospital, Southampton, UK
| | - S Aroori
- Department of HPB Surgery, Plymouth Hospitals, Plymouth, UK
| | - G Bond-Smith
- Department of HPB Surgery, Royal London Hospital, London, UK
| | - S Bramhall
- Liver Unit, University Hospital Birmingham, Birmingham, UK
| | - C Coldham
- Liver Unit, University Hospital Birmingham, Birmingham, UK
| | - J Hammond
- Department of HPB, Nottingham University Hospitals, Nottingham, UK
| | - R Hutchins
- Department of HPB Surgery, Royal London Hospital, London, UK
| | - C Imber
- Department of Hepatopancreatobiliary (HPB) and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - G Preziosi
- Department of Hepatopancreatobiliary (HPB) and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - A Saleh
- Department of HPB and Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - M Silva
- Department of HPB Surgery, Churchill Hospital, Oxford, UK
| | - J Simpson
- Department of HPB, Nottingham University Hospitals, Nottingham, UK
| | - G Spoletini
- Department of HPB Surgery, Churchill Hospital, Oxford, UK
| | - D Stell
- Department of HPB Surgery, Plymouth Hospitals, Plymouth, UK
| | - J Terrace
- Department of HPB and Liver Transplant Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S White
- Department of HPB and Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - S Wigmore
- Department of HPB and Liver Transplant Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - G Fusai
- Department of Hepatopancreatobiliary (HPB) and Liver Transplant Surgery, Royal Free Hospital, London, UK
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Domino Reconstruction of the Portal Vein Using the External Iliac Vein and an ePTFE Graft in Pancreatic Surgery. J Gastrointest Surg 2017; 21:1278-1286. [PMID: 28378316 DOI: 10.1007/s11605-017-3413-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 03/26/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND In the portal vein resection of long distance, an interposition by autologous vein is mandatory. External iliac vein (EIV) has been used, but harvesting the EIV is associated with severe venous congestion of the affected lower extremity. We have reconstructed the EIV using a ringed expanded polytetrafluoroethylene (ePTFE) graft. METHODS Thirteen patients underwent this surgery. The right EIV was used for reconstructing the portal vein, and the retrieved portion of EIV was interposed by the ePTFE graft. We evaluated size and length of the graft, graft patency, girth of thigh, time for reconstruction of EIV, and graft infection. RESULTS ePTFE grafts of 8 or 10 mm in diameter were used. The length of ePTFE graft used was 4.4 ± 0.5 cm. Graft patency was kept in 76.9% patients. Graft obstruction was encountered in three patients, and the girth of right thigh increased by about 10 cm. Time for reconstruction of EIV was 29.5 ± 6.8 min. Graft infection did not occur in any patients. CONCLUSIONS Reconstruction of the EIV using a ringed ePTFE graft seems to be a feasible option for preventing the swelling of the affected lower extremity after procurement of EIV for repairing the portal vein.
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Zhiying Y, Haidong T, Xiaolei L, Yongliang S, Shuang S, Liguo L, Li X, Atyah M. The falciform ligament as a graft for portal-superior mesenteric vein reconstruction in pancreatectomy. J Surg Res 2017; 218:226-231. [PMID: 28985853 DOI: 10.1016/j.jss.2017.05.090] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 04/30/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Tumor invasion or adherence to the portal vein-superior mesenteric vein (PV/SMV) may be encountered during pancreatic surgery. In such cases, venous resection and reconstruction might be required for complete resection of the tumor. We report an innovative technique in which the graft for PV/SMV reconstruction was made with the falciform ligament. METHODS Between May 2011 and July 2016, PV/SMV reconstruction with a falciform ligament graft was performed in 10 cases during pancreatectomy. Among these cases, including six cases with a patch graft and four cases with a conduit graft. Retrospective reviews of medical records and radiologic studies were performed. RESULTS Ten patients with pancreatobiliary cancer underwent en bloc tumor resection with concurrent PV/SMV resection and reconstruction with a falciform ligament graft. There were six males and four females, and the mean age was 65.3 ± 9.4 (48-80) y. Using Doppler ultrasound examination, all 10 grafts were shown to be patent at postoperative 2 wk. However, occlusion was found in one case with conduit graft and stenosis in the other three cases with conduit graft using enhanced computed tomography at postoperative 2 mo. Complete patency was shown in three of six cases with patch graft and stenosis in the other three cases at 2 mo after the operation. Although occlusion or stenosis of the grafts was observed, no severe adverse events occurred, and normal liver function was discovered in all 10 cases at postoperative 2 mo. CONCLUSIONS Falciform ligament grafts might be considered for reconstruction of PV/SMV in the absence of appropriate vascular grafts.
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Affiliation(s)
- Yang Zhiying
- Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing, China.
| | - Tan Haidong
- Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Liu Xiaolei
- Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Sun Yongliang
- Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Si Shuang
- Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Liu Liguo
- Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xu Li
- Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Manar Atyah
- Department of Hepatobiliary Surgery, China-Japan Friendship Hospital, Beijing, China
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Gilabert M, Boher JM, Raoul JL, Paye F, Bachellier P, Turrini O, Delpero JR. Comparison of preoperative imaging and pathological findings for pancreatic head adenocarcinoma: A retrospective analysis by the Association Française de Chirurgie. Medicine (Baltimore) 2017; 96:e7214. [PMID: 28614269 PMCID: PMC5478354 DOI: 10.1097/md.0000000000007214] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 04/27/2017] [Accepted: 05/19/2017] [Indexed: 12/22/2022] Open
Abstract
Initial imaging of pancreatic ductal adenocarcinoma is of crucial importance in the decision-making process. The aim of this study was to compare preoperative imaging, pathological data, and outcomes in a series of patients who underwent resection for pancreatic head cancer.From January 2004 to December 2009, data were collected by the Association Française de Chirurgie on 1044 patients who received first-line R0 resection of pancreatic head cancer.On imaging (computed tomography scan 97%, echoendoscopic ultrasound 61.3%, magnetic resonance imaging 46.5%), arterial, venous, or lymph node invasion was suspected in 20, 161, and 197 patients, respectively; arterial, venous, or lymph node invasion was observed histologically in 11, 116, and 736 cases, respectively. In the patients for whom both imaging and pathological data were available, the concordance, sensitivity, specificity, positive predictive value, and negative predictive value were as follows: 97.5%, 27.3%, 98%, 20%, and 99%, for arterial invasion; 86.5%, 54%, 91%, 47.8%, and 93.2%, for venous invasion; and 38%, 21%, 86%, 78%, and 41%, respectively, for lymph node invasion. Imaging of arterial invasion had no prognostic value, while histological evidence of invasion was associated with a poor prognosis. Venous and lymph node invasion, as demonstrated by imaging and by pathological analysis, had an adverse prognostic value.Imaging gives a fair positive predictive value for venous or arterial invasion; venous invasion on imaging and histology was associated with a poor prognosis; arterial invasion on imaging does not have any significant prognostic value.
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Affiliation(s)
| | - Jean-Marie Boher
- Clinical Trial Office and Biostatistics Unit, Paoli-Calmettes Institute, Marseille
| | - Jean-Luc Raoul
- Department of Medical Oncology, Paoli-Calmettes Institute
| | - François Paye
- Department of Digestive Surgery, Hôpital Saint-Antoine, Paris
| | - Philippe Bachellier
- Hepatobiliary Surgery and Liver Transplantation, Hôpital Universitaire de Strasbourg, Strasbourg
| | - Olivier Turrini
- Department of Digestive Surgery, Paoli-Calmettes Institute, Marseille, France
| | - Jean Robert Delpero
- Department of Digestive Surgery, Paoli-Calmettes Institute, Marseille, France
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Jegatheeswaran S, Baltatzis M, Jamdar S, Siriwardena AK. Superior mesenteric artery (SMA) resection during pancreatectomy for malignant disease of the pancreas: a systematic review. HPB (Oxford) 2017; 19:483-490. [PMID: 28410913 DOI: 10.1016/j.hpb.2017.02.437] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/01/2017] [Accepted: 02/16/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Resection of the superior mesenteric artery (SMA) during pancreatectomy is performed infrequently and is undertaken with the aim of removing non-metastatic locally advanced pancreatic tumours. SMA resection reports also encompass resection of other visceral vessels. The consequences of resection of these different arteries are not necessarily equivalent. This is a focused systematic review of the outcome of SMA resection during pancreatectomy for cancer. METHODS A computerized search of the English language literature was undertaken for the period 1st January 2000 through 30th April 2016. The keywords "Pancreatic surgery" and "Vascular resections" were used. Thirteen studies reported 70 patients undergoing pancreatectomy with SMA resection from 10,726 undergoing pancreatectomy. Individual patient-level outcome data were available for 25. RESULTS Median (range) accrual period was 132 (48-372) months. Reported peri-operative morbidity ranged from 39% to 91%. There were 5 peri-operative deaths in the 25 patients with individual-outcome data. Median survival was 11 months (95% Confidence interval 9.5-12.5 months; standard error 0.8 months). CONCLUSIONS SMA resection during pancreatectomy is undertaken infrequently incurring high peri-operative morbidity and mortality. Median survival is 11 (95% CI 9.5-12.5) months. In contemporary practice there is no evidence to support SMA resection during pancreatectomy.
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Affiliation(s)
| | - Minas Baltatzis
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK
| | - Saurabh Jamdar
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK; Faculty of Medicine, University of Manchester, Manchester, England, UK
| | - Ajith K Siriwardena
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK; Faculty of Medicine, University of Manchester, Manchester, England, UK.
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Addeo P, Velten M, Averous G, Faitot F, Nguimpi-Tambou M, Nappo G, Felli E, Fuchshuber P, Bachellier P. Prognostic value of venous invasion in resected T3 pancreatic adenocarcinoma: Depth of invasion matters. Surgery 2017; 162:264-274. [PMID: 28576385 DOI: 10.1016/j.surg.2017.03.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/20/2017] [Accepted: 03/02/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Incomplete evaluation of venous invasion has led to conflicting results regarding the prognosis of patients undergoing pancreatectomy with a synchronous venous resection. This study evaluates the prognostic value associated with the presence and the depth of venous invasion in T3 pancreatic adenocarcinoma. METHODS This study evaluated retrospectively 181 consecutive pancreatoduodenectomies performed for T3N0M0 and T3N1M0 pancreatic adenocarcinomas (stages IIA and IIB) from January 2006 to December 2014. Univariate and multivariate Cox analyses were performed to assess survival prognostic factors. RESULTS Pancreatoduodenectomies with a segmental venous resection was performed on 91 patients, while 90 other patients had a standard pancreatoduodenectomies without venous resection. Pathologic venous invasion was detected in 68 (74%) of the 91 venous resection patients. Depth of venous invasion was into the adventitia (n = 25), media (n = 28), and intima (n = 15). The overall survival rates at 1, 3, 5, and 10 years were 75%, 33%, 21%, and 6%, respectively. There were no differences in survival between patients undergoing standard pancreatoduodenectomies and pancreatoduodenectomies with venous resection (27 vs 22 months; P = .28) or between patients with and without venous invasion (20 vs 27 months; P = .08). In multivariate analysis, depth of venous invasion into the intima (hazard ratio, 2.25; 95% confidence interval, 1.16-4.34; P = .0001) and adjuvant chemotherapy (hazard ratio, 0.16; 95% confidence interval, 0.09-0.43; P ≤ .0001) were identified as independent prognostic factors of overall survival. CONCLUSION Depth of venous invasion into the intima indicates poor survival in pancreatic T3 adenocarcinoma. Preoperative identification of this factor could be helpful for better selection of patients for curative operation.
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Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France; Cancer Registry of Bas-Rhin, Faculty of medicine, University of Strasbourg, Strasbourg, France
| | - Michel Velten
- Cancer Registry of Bas-Rhin, Faculty of medicine, University of Strasbourg, Strasbourg, France
| | - Gerlinde Averous
- Department of Pathology, University of Strasbourg, Strasbourg, France
| | - François Faitot
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Marlene Nguimpi-Tambou
- Department of Hepatogastroenterology, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Gennaro Nappo
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Emanuele Felli
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Pascal Fuchshuber
- Department of Surgery, The Permanente Medical Group, Kaiser Medical Center Walnut Creek, Walnut Creek, CA
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.
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Beane JD, House MG, Pitt SC, Zarzaur B, Kilbane EM, Hall BL, Riall TS, Pitt HA. Pancreatoduodenectomy with venous or arterial resection: a NSQIP propensity score analysis. HPB (Oxford) 2017; 19:254-263. [PMID: 28038967 DOI: 10.1016/j.hpb.2016.11.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 10/19/2016] [Accepted: 11/30/2016] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Vascular resection during pancreatoduodenectomy (PD) is being performed more frequently. Our aim was to analyze the outcomes of PD with and without vascular resection in a large, multicenter cohort. METHODS Patient data were gathered from 43 institutions as part of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Pancreatectomy Demonstration Project. Over a 14-month period, 1414 patients underwent PD without (82.2%) or with major venous (PD + V; 13.7%) or arterial (PD + A; 4.0%) vascular resection. RESULTS Postoperative morbidity and mortality following PD + A (51.0% and 3.6%) was comparable to PD + V (46.9% and 3.6%) and PD (44.3 and 1.5%, p = 0.50 and 0.43). A propensity score matched analysis revealed that vascular resection was associated with significant increases (p ≤ 0.05) in operative time (7:37 vs 6:11), need for blood transfusion (42.2% vs 18.1%), deep venous thromboembolism (6.9% vs 0.9%), postoperative septic shock (6.9% vs 1.7%), and length of stay (12.2 vs 10 days) while overall morbidity (45.7% vs 46.6) and mortality (1.0% vs 0%) were comparable. CONCLUSIONS Compared to PD alone, PD + VR was associated with increased operative time, perioperative transfusions, deep venous thrombosis, septic shock, as well as length of stay, but overall morbidity and mortality were not increased.
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Affiliation(s)
- Joal D Beane
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Susan C Pitt
- University of Wisconsin School of Medicine, Madison, WI, USA
| | - Ben Zarzaur
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - E Molly Kilbane
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Bruce L Hall
- Washington University School of Medicine, St. Louis, MO, USA
| | - Taylor S Riall
- University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Henry A Pitt
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.
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Zhang XM, Fan H, Kou JT, Zhang XX, Li P, Dai Y, He Q. Resection of portal and/or superior mesenteric vein and reconstruction by using allogeneic vein for pT3 pancreatic cancer. J Gastroenterol Hepatol 2016; 31:1498-503. [PMID: 26825612 DOI: 10.1111/jgh.13299] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/20/2016] [Accepted: 01/22/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM There is still controversy on the outcomes of portal vein (PV) and/or superior mesenteric vein (SMV) resection in pancreatic cancer, and there are few reports about pancreaticoduodenectomy (PD) with PV/SMV resection and reconstruction by using allogeneic vein. This study is to explore the outcomes of PD with PV/SMV resection and reconstruction by using allogeneic vein for pT3 pancreatic cancer with venous invasion. METHODS Clinicopathological data of patients underwent PD with en bloc resection of PV/SMV and reconstruction by using internal iliac from August 20, 2013 to July 25, 2015 were collected and the data of patients with pT3 stage pancreatic head cancer with PV/SMV invasion were analyzed. The short- and long-term outcomes were presented. RESULTS Thirty patients met the criteria of this study. PV resection and reconstruction were performed for 12 patients, SMV for 9 patients, and PV + SMV for 9 patients, respectively. The median operation time was 460 min, and the median intraoperative blood loss was 450 mL. R0 resection rate was 93.3%, total incidence of complications was 23.3%, and incidence of pancreatic fistula was 10%. The 1-year and 2-year overall survival rates were 68.6% and 39.2%, 1-year and 2-year disease free survival rates were 44.8% and 17.1%. CONCLUSIONS PD with en bloc resection of PV/SMV and reconstruction by using allogeneic vein was safe and feasible for patients with pT3 stage pancreatic head cancer with PV/SMV invasion. A large-scale research with longer follow-up time is required to draw a significant conclusion.
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Affiliation(s)
- Xing-Mao Zhang
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Hua Fan
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jian-Tao Kou
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xin-Xue Zhang
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Ping Li
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yang Dai
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Qiang He
- Department of Hepatobiliary Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Marsoner K, Langeder R, Csengeri D, Sodeck G, Mischinger HJ, Kornprat P. Portal vein resection in advanced pancreatic adenocarcinoma: is it worth the risk? Wien Klin Wochenschr 2016; 128:566-72. [PMID: 27363995 PMCID: PMC5010594 DOI: 10.1007/s00508-016-1024-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 05/25/2016] [Indexed: 01/29/2023]
Abstract
Introduction Portal vein resection represents a viable add-on option in standard pancreaticoduodenectomy for locally advanced ductal pancreatic adenocarcinoma, but is often underused as it may set patients at additional risk for perioperative and postoperative morbidity and mortality. We aimed to review our long-term experience to determine the additive value of this intervention for locally advanced pancreatic adenocarcinoma. Patients and methods Single, university surgical center audit over a 13-year period; cohort comprised 221 consecutive patients undergoing pancreatic resection; in 47 (21 %) including portal vein resection. Predictors for short- and long-term survival were assessed via multivariate logistic and Cox regression. Results Baseline and perioperative characteristics were similar between the two groups. However, overall skin-to-skin times, intraoperative transfusion requirements as the need for medical inotropic support were higher in patients undergoing additional portal vein resection (p < 0.0001; p = 0.001 and p = 0.03). Postoperative complication rates were 34 vs. 35 % (p = 0.89), 14 patients (5 % vs. 11 %; p = 0.18) died in-hospital. An American Society of Anesthesiologists Score >2 was the only independent predictor for in-hospital mortality (OR 10.66, 95 % CI 1.24–91.30). Follow-up was complete in 99.5 %, one-year survival was 59 % vs. 70 % and five-year overall survival 15 % vs. 12 % with and without portal vein resection, respectively (Log rank: p = 0.25). For long-term outcome, microvascular invasion (HR 2.03, 95 % CI 1.10–3.76) and preoperative weight loss (HR 2.17, 95 % CI 1.31–3.58) were independent predictors. Conclusion Despite locally advanced disease, patients who underwent portal vein resection had no worse perioperative and overall survival than patients with lower staging and standard pancreaticoduodenectomy only. Therefore, the feasibility of portal vein resection should be evaluated in every potential candidate at risk.
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Affiliation(s)
- Katharina Marsoner
- Department of General Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036, Graz, Austria
| | - Rainer Langeder
- Department of General Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036, Graz, Austria
| | - Dora Csengeri
- Department of General Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036, Graz, Austria
| | - Gottfried Sodeck
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Hans Jörg Mischinger
- Department of General Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036, Graz, Austria
| | - Peter Kornprat
- Department of General Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036, Graz, Austria.
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Thiels CA, Bergquist JR, Laan DV, Croome KP, Smoot RL, Nagorney DM, Thompson GB, Kendrick ML, Farnell MB, Truty MJ. Outcomes of Pancreaticoduodenectomy for Pancreatic Neuroendocrine Tumors: Are Combined Procedures Justified? J Gastrointest Surg 2016; 20:891-8. [PMID: 26925796 DOI: 10.1007/s11605-016-3102-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 02/02/2016] [Indexed: 01/31/2023]
Abstract
Efficacy and outcomes of resection for pancreatic neuroendocrine tumors (pNET) are well established; specific data on outcomes for pancreaticoduodenectomy (PD), either alone or with combined procedures, are limited. A retrospective review of PDs for pNET (1998-2014) at our institution was conducted. Patients were categorized into standard PD (SPD) alone or combined PD (CPD) defined as patients undergoing concurrent vascular reconstruction or additional organ resection for curative intent. Kaplan-Meier survival analyses were performed. PD for pNET was performed for 95 patients. Tumors were functional in 11 patients (9 %). Twenty-six patients (28 %) underwent CPD. The 30/90-day mortality was 1.1/5.3 % respectively and similar between SPD and CPD (p = 0.61/p = 0.24). Five-year overall survival after PD for pNET was 85.1/71.9 % and similar between SPD/CPD groups (p = 0.17). Recurrence-free and overall survival for low-grade tumors was 74.7/93.9 % at 5 years compared to only 14.8/49.7 % for high-grade tumors (p < 0.001) and not predicted by extent of resection (SPD/CPD, respectively). PD with or without concurrent resection provides an acceptable, perioperative and long-term oncologic, outcome for pNET. CPD is justified treatment modality, particularly for patients with low-grade tumors. The need for combinatorial procedures during PD is not contraindication alone for otherwise resectable patients with pNET.
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Affiliation(s)
- Cornelius A Thiels
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA.,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - John R Bergquist
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA.,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Danuel V Laan
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | | | - Rory L Smoot
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - David M Nagorney
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Geoffrey B Thompson
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Michael L Kendrick
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Michael B Farnell
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Mark J Truty
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA.
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Implantation of radioactive (125)I seeds improves the prognosis of locally advanced pancreatic cancer patients: A retrospective study. ACTA ACUST UNITED AC 2016; 36:205-210. [PMID: 27072963 DOI: 10.1007/s11596-016-1567-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/16/2016] [Indexed: 12/18/2022]
Abstract
Locally advanced pancreatic cancer is associated with a very poor prognosis. This study was performed to evaluate whether patients with locally advanced pancreatic cancer benefit from (125)I seed implantation. This retrospective study included 224 patients with locally advanced pancreatic cancer, with 137 patients (61.2%) in the implantation (IP) group and 87 (38.9%) in the non-implantation (NIP) group. The survival status, complications and objective curative effects were compared between the groups. The average operative time in the IP group was significantly longer than that in the NIP group (243±51 vs. 214±77 min). The tumor response rates were 9.5% and 0 at the 2nd month after surgery in the IP and NIP groups, respectively (P<0.05). The IP group exhibited a trend toward pain relief at the 6th month after surgery. The global health status scores of the IP group were higher than those of the NIP group at the 3rd and 6th month after surgery. The median survival time in the IP group was significantly longer than that in the NIP group. In conclusion, patients with locally advanced pancreatic cancer can benefit from (125)I seed implantation in terms of local tumor control, survival time, pain relief and quality of life.
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Barreto SG, Windsor JA. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17:e118-e124. [DOI: 10.1016/s1470-2045(15)00463-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 10/21/2015] [Accepted: 10/27/2015] [Indexed: 12/13/2022]
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47
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Eskander MF, Bliss LA, Tseng JF. Pancreatic adenocarcinoma. Curr Probl Surg 2016; 53:107-54. [DOI: 10.1067/j.cpsurg.2016.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 01/04/2016] [Indexed: 12/17/2022]
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Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2015; 103:179-91. [PMID: 26663252 DOI: 10.1002/bjs.9969] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 08/27/2015] [Accepted: 09/15/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma has a poor prognosis without surgery. No standard treatment has yet been accepted for patients with portal-superior mesenteric vein (PV-SMV) infiltration. The present meta-analysis aimed to compare the results of pancreatic resection with PV-SMV resection for suspected infiltration with the results of surgery without PV-SMV resection. METHODS A systematic search was performed of PubMed, Embase and the Cochrane Library in accordance with PRISMA guidelines from the time of inception to 2013. The inclusion criteria were comparative studies including patients who underwent pancreatic resection with or without PV-SMV resection. One, 3- and 5-year survival were the primary outcomes. RESULTS Twenty-seven studies were identified involving a total of 9005 patients (1587 in PV-SMV resection group). Patients undergoing PV-SMV resection had an increased risk of postoperative mortality (risk difference (RD) 0.01, 95 per cent c.i. 0.00 to 0.03; P = 0.2) and of R1/R2 resection (RD 0.09, 0.06 to 0.13; P < 0.001) compared with those undergoing standard surgery. One-, 3- and 5-year survival were worse in the PV-SMV resection group: hazard ratio 1.23 (95 per cent c.i. 1.07 to 1.43; P = 0.005), 1.48 (1.14 to 1.91; P = 0.004) and 3.18 (1.95 to 5.19; P < 0.001) respectively. Median overall survival was 14.3 months for patients undergoing pancreatic resection with PV-SMV resection and 19.5 months for those without vein resection (P = 0.063). Neoadjuvant therapies recently showed promising results. CONCLUSION This meta-analysis showed increased postoperative mortality, higher rates of non-radical surgery and worse survival after pancreatic resection with PV-SMV resection. This may be related to more advanced disease in this group.
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Affiliation(s)
- F Giovinazzo
- Hepatobiliary and Pancreatic Surgical Unit, NHS Grampian, Aberdeen, UK
| | - G Turri
- Hepatobiliary and Pancreatic Surgical Unit, NHS Grampian, Aberdeen, UK
| | - M H Katz
- MD Anderson Cancer Center, Houston, Texas, USA
| | - N Heaton
- Institute of Liver Studies, King's College Hospital, London, UK
| | - I Ahmed
- Hepatobiliary and Pancreatic Surgical Unit, NHS Grampian, Aberdeen, UK
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Seufferlein T, Porzner M, Heinemann V, Tannapfel A, Stuschke M, Uhl W. Ductal pancreatic adenocarcinoma. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:396-402. [PMID: 24980565 DOI: 10.3238/arztebl.2014.0396] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 03/12/2014] [Accepted: 03/12/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Ductal adenocarcinoma of the pancreas is the fourth most common cause of death from cancer in men and women in Germany: about 15 000 persons die of this disease each year. METHOD The S3 guideline on exocrine pancreatic carcinoma was updated with the aid of systematic literature reviews on the surgical, neoadjuvant, and adjuvant treatment of ductal pancreatic carcinoma, and on treatment in the metastatic stage. These reviews covered the periods 2002 to February 2012 (for radiotherapy) and 2006 to August 2011 (for all other topics). RESULTS The criteria for borderline resectable pancreatic tumors are the same as those of the guidelines of the National Comprehensive Cancer Network. Preoperative biliary drainage with a stent is recommended only if cholangitis is present or if a planned operation cannot be performed soon after the diagnosis is made. When a pancreatic carcinoma is resected, at least 10 regional lymph nodes should be excised, and the ratio of affected to excised nodes should be documented in the pathology report. Gemcitabine and 5-fluorouracil are recommended for adjuvant therapy. Neither of these drugs is preferred over the other; if the one initially given is poorly tolerated, the other one should be given instead. When gemcitabine and erlotinib are given for palliative treatment, erlotinib should be given for no longer than 8 weeks if no skin rash develops. In selected patients, the folfirinox protocol yields markedly better results than gemcitabin. Moreover, the new combination of nab-paclitaxel and gemcitabine can be used as first-line treatment. In the event of disease progression under first-line treatment, second-line treatment should be initiated. CONCLUSION In recent years, new chemotherapeutic protocols have brought about marked improvement in palliative care. Further trials are needed to determine whether the perioperative or adjuvant use of these protocols might also improve the outcome of surgical treatment with curative intent.
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Affiliation(s)
- Thomas Seufferlein
- Ulm University Hospital Medical Center, Department of Internal Medicine I, Medical Clinic III, Department of Hematology & Oncology, Großhadern Hospital, Ludwig-Maximilian-¬Universität, Munich, Institute of Pathology, Ruhr-University Bochum, Radiation and Tumor Clinic, University Hospital of Duisburg-Essen, Surgical Clinic at the St. Josef-Hospital, Ruhr-University Bochum
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Höing K, Ringe KI, Bektas H, Klempnauer J, Jäger MD. Preduodenal superior mesenteric vein and Whipple procedure with vascular reconstruction-A case report. Int J Surg Case Rep 2015; 10:107-10. [PMID: 25853842 PMCID: PMC4429856 DOI: 10.1016/j.ijscr.2015.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 03/03/2015] [Indexed: 11/26/2022] Open
Abstract
A preduodenal superior mesenteric vein (SMV) is a rare portal vein disorder. Correct assessment of portal vein disorders can allow for hepato-pancreatic surgery. A preduodenal SMV does not contradict a Whipple procedure. Resection of a preduodenal SMV required a PTFE prosthesis. Preserved venous collateral pathways compensate late thrombosis of PTFE prosthesis.
Introduction Portal vein (PV) disorders are various, but rare. Here, we report a preduodenal superior mesenteric vein (PDSMV) in a patient who underwent a pancreaticoduodenectomy. Presentation of case A 67-year old woman with familial adenomatosis polyposis was suspicious for cancer of the papilla of vater and scheduled for surgery. Pre-operative diagnostic revealed a PDSMV continuing into the left PV. The splenic vein (SV) continued directly into the right PV without forming ananatomic PV confluence. Eight centimetre of the PDSMV were resected during the pancreaticoduodenectomy and reconnected using a polytetrafluoroethylene prosthesis. On day 1, early graft thrombosis was treated by thrombectomy and change to a larger graft. Pathology confirmed a R0-resection of the adenocarcinoma of the papilla of vater (pTis pN0,G2). At three-month follow-up, the patient was cancer-free and clinically asymptomatic, although, a late graft thrombosis with accompanying newly build venous collaterals passing mesenteric blood to the SV were found. Discussion Rare PV disorders like a PDSMV do not contradict pancreatic surgery, but should be treated in experienced centres. Skills of SMV/PV reconstruction and its peri-operative management might be beneficial for successful outcome. Despite late graft thrombosis no clinical disadvantage occurred most likely due to preservation of the SV and of potential venous collateral pathways. Conclusion Extended surgical procedures like a pancreaticoduodenectomy are realisable in patients with PV disorders, but require awareness, adequate radiological interpretation and specific surgical experience for secure treatment.
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Affiliation(s)
- Kristina Höing
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany.
| | - Kristina I Ringe
- Institut für Diagnostische und Interventionelle Radiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Hüseyin Bektas
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Jürgen Klempnauer
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Mark D Jäger
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany.
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