Is pancreaticoduodenectomy with mesentericoportal venous resection safe and worthwhile?

Pancreatoduodenectomy using a no-touch isolation technique

BACKGROUND

Pancreatoduodenectomy is the only effective treatment for cancers of the periampullary region. Because surgeons usually grasp tumors during pancreatoduodenectomy, this procedure may increase the risk of squeezing and shedding the cancer cells into the portal vein, retroperitoneum, and/or peritoneal cavity. In an effort to overcome these problems, we have developed a surgical technique for no-touch pancreatoduodenectomy.

METHODS

From March 2005 through May 2008, 42 patients have been operated on following this technique. Resected margins were microscopically analyzed.

RESULTS

We describe a technique for pancreatoduodenectomy using a no-touch isolation technique. We resect cancers with wrapping them within Gerota's fascia and transect the retroperitoneal margin along the right surface of the superior mesenteric artery and abdominal aorta without grasping tumors.

CONCLUSIONS

No-touch pancreatoduodenectomy has many potential advantages that merit further investigation in future randomized controlled trials.

Pancreaticoduodenectomy with vascular resection for local advanced pancreatic head cancer: a single center retrospective study

INTRODUCTION

Pancreaticoduodenectomy with vascular resection remains a controversial approach for patients with local advanced pancreatic head cancer for the lack of evidences of survival and quality of life benefits. The aim of this study was to evaluate whether patients of pancreatic head cancer benefit on quality of life, survival, and treatment cost from pancreaticoduodenectomy with vascular resection compared with palliative therapy.

MATERIALS AND METHODS

Two hundred fourteen patients of pancreatic head cancer whose pancreatic head could not be dissected free from adjacent vascular were involved in this study. Eighty of these patients underwent pancreaticoduodenectomy with vascular resection, whereas other patients underwent palliative therapy.

RESULTS

Pancreaticoduodenectomy with artery resection offered worse outcomes on almost all aspects of quality of life and survival compared with palliative therapy. Pancreaticoduodenectomy with vein resection offered better 5-year survival compared with palliative therapy, whereas palliative therapy offered better quality of life after surgery.

CONCLUSION

Pancreaticoduodenectomy with artery resection is nonsensical on treatment of pancreatic head cancer with artery adhesion/invasion. As for patients with vein adhesion/invasion, pancreaticoduodenectomy with vein resection should be performed cautiously. When actual vein invasion is very possible to have taken place, the choice of treatment strategy should be considered carefully by the pancreatic surgeons.

Therapeutic anticoagulant does not modify thromboses rate vein after venous reconstruction following pancreaticoduodenectomy

Recommendations for anticoagulation following major venous reconstruction for pancreatic adenocarcinoma (PA) are not clearly established. The aim of our study was to find out the relation between postoperative anticoagulant treatment and thrombosis rate after portal venous resection. Materials and methods. Between 1986 and 2006, twenty seven portal vein resections were performed associated with pancreaticoduodenectomies (n = 27) (PD).We defined four types of venous resection: type I was performed 1 cm above the confluent of the superior mesenteric vein (SMV) (n = 12); type II lateral resection and venorrhaphy at the level of the confluent SMV (n = 12); type III (n = 1) resulted from a primary end-to-end anastomosis above confluent and PTFE graph was used for reconstruction for type IV (n = 2). Curative anticoagulant treatment was always indicated after type IV (n = 2) resection, and after resection of type II when the length of venous resection was longer than ≥2 cm. Results. Venous thrombosis rate reached: 0%, 41%, and 100% for type I, II, IV resections, respectively. Among them four patients received curative anticoagulant treatment. Conclusion. After a portal vein resection was achieved in the course of a PD, curative postoperative anticoagulation does not prevent efficiently the onset of thrombosis.

Improving outcomes for operable pancreatic cancer: is access to safer surgery the problem?

Despite advances in the understanding and treatment of pancreatic cancer in the last two decades, there is a persisting nihilistic attitude among clinicians. An alarmingly high rate of under-utilization of surgical management for operable pancreatic cancer was recently reported in the USA, where more than half of patients with stage 1 operable disease and no other contraindications were not offered surgery as therapy, denying this group of patients a 20% chance of long-term survival. These data indicate that a nihilistic attitude among clinicians may be a significant and reversible cause of the persisting high mortality of patients with pancreatic cancer. This article examines the modern management of pancreatic cancer, in particular, the advances in surgical care that have reduced the mortality of pancreatectomy to almost that of colonic resection, and outlines a strategy for improving outcomes for patients with pancreatic cancer now and in the future.

Portal vein resection in surgery for cancer of biliary tract and pancreas: special reference to the relationship between the surgical outcome and site of primary tumor

BACKGROUND

Early and late outcomes after superior mesenteric-portal vein resection (VR) combined with pancreaticoduodenectomy, major hepatectomy, or both for pancreaticobiliary carcinoma were retrospectively evaluated. VR is the most frequently used vascular procedure in this field, but an exact role of VR has not been compared according to the primary site of tumor.

MATERIALS AND METHODS

Postoperative outcomes were compared between surgery with and without VR in each of the three disease-based groups: hilar cholangiocarcinoma and intrahepatic cholangiocarcinoma with hilar extension (HIC, 56), middle and distal cholangiocarcinoma and gallbladder carcinoma (DGC, 118), and pancreatic head adenocarcinoma (PHC, 77).

RESULTS

VR was performed in 19.6% of HIC, 8.5% of DGC, and 45.5% of PHC. In-hospital death was 7.1% (4 of 56) patients with VR (3 of DGC and 1 of PHC). Operations with VR in DGC showed a larger amount of blood loss and more increased ratio of R1operation than those with no VR. In HIC, DGC, and PHC, median survival time of patients with VR was 37, 6.8, and 20 months and that of patients without VR was 42.9, 28.6, and 20.3 months, respectively. VR did not affect survival either in HIC or in PHC; however, in DGC, VR was accompanied with dismal outcome compared with no VR (p=0.001).

CONCLUSIONS

Aggressive surgery with VR can be justified both in HIC and in PHC but should not be recommended for DGC. Surgical outcomes of VR differed considerably, depending on the sites of the primary tumor.

Surgical management of carcinoma of the head of pancreas: extended lymphadenectomy or modified en bloc resection?

Pancreatoduodenectomy for the treatment of periampullary cancer was described over 70 years ago. The technique has evolved in an attempt to improve the dismal prognosis for patients with pancreatic cancers. Radical regional resection has been proposed to decrease the incidence of local recurrence as well as to improve survival. These extended resections have failed to show a significant survival benefit in prospective randomized controlled studies. Furthermore, extended pancreatic resections may be associated with increased morbidity. The concept of modified en bloc resection has been advocated and is soundly based on anatomical and pathological principals. This procedure is a modification of the radical regional resection previously described. It involves resection of the peripancreatic retroperitoneal tissue and lymph nodes en bloc with the head of pancreas, in order to achieve an R0 resection but without the morbidity associated with an extended lymphadenectomy. Conceptually, this procedure may be the most appropriate technique for the management of pancreatic head cancers although the ultimate effect on long-term survival can only be judged after further clinical studies.

En bloc vascular resection for locally advanced pancreatic malignancies infiltrating major blood vessels: perioperative outcome and long-term survival in 136 patients

BACKGROUND

To assess in-hospital complication rates and survival duration after en bloc vascular resection (VR) for infiltration of pancreatic malignancies in major vessels.

METHODS

Between 1994 and 2005, 585 patients underwent potentially curative pancreatic resection without adjuvant chemotherapy. Four hundred forty-nine patients (77%) underwent standard oncologic resection (VR-), whereas 136 (23%) received VR (VR+). For calculation of in-hospital morbidity and mortality rates, all 136 patients who underwent VR were considered. In contrast, for survival analysis, only pancreatic adenocarcinoma patients (n = 100) were included.

RESULTS

One hundred twenty-eight VR+ patients underwent portal or superior mesenteric vein resection and 13 hepatic artery (HA) or superior mesenteric artery (SMA) resection. In 5 patients, synchronous VR addressing both the mesenterico-portal axis and either the HA or SMA was performed. In-hospital morbidity and mortality rates of VR- patients (39.7%/4.0%) nearly equaled that of VR+ patients (40.3%/3.7%). From the 100 patients with pancreatic adenocarcinoma, histopathology confirmed "true" vascular invasion in 77 patients. Twenty-three patients had peritumoral inflammation, mimicking tumor invasion. Median survival was 15 months (11.2-18.8) in patients with histopathologic proven vascular invasion and 16 months (14.0-17.9) in those without (P = 0.86). Two-year survival probabilities were 36% (without) versus 34% (with vascular invasion; P = 0.9). Among VR+ patients with histopathologically evidenced vascular invasion, 19 survived longer than 30 months, and 6 were still alive 5 years after surgery. Multivariate modeling identified nodal involvement (N1) and poor grading (G3) as the only predictors of decreased survival. Evidence of vascular invasion had no adverse impact on survival.

CONCLUSION

Postoperative morbidity and mortality rates after en bloc VR are comparable with "standard" pancreatectomy procedures. Median survival of 15 months in patients with vascular invasion is superior to that of patients who undergo palliative therapy and nearly equals that of patients who are not in need for VR.

Surgical management of early-stage pancreatic cancer

BACKGROUND

Pancreatic cancer remains a difficult disease to treat. Diagnosis at an early stage may allow curative treatment with resection. In the past, the mortality associated with surgical treatment of pancreatic carcinoma was prohibitive but mortality associated with resection is now commensurate with all other major oncologic resections. Thus, the focus of surgical management has shifted to address several issues: the diagnosis and evaluation of patients with suspected pancreatic cancer, the role of preoperative endobiliary stenting, the role of laparoscopy, the extent of resection, the role of adjuvant and neoadjuvant treatment, and the role of specialized centers in treating the disease.

METHODS

The current literature is reviewed to address these issues and help guide physicians who first encounter patients with suspected pancreatic cancer as well as surgeons who ultimately resect them. Practical evidence-based information to guide the decision-making process is provided.

RESULTS

Surgical morbidity and mortality have achieved parity with other types of major oncologic resection, and a distinct survival advantage is possible when such therapy is applied early in the disease stage. Issues regarding the use of stents, extent of resection, and pre- vs post-operative chemoradiation therapy are becoming clearer as our collective experience broadens.

CONCLUSIONS

Surgical treatment of pancreatic cancer should be aggressively pursued given the clearly established survival advantage and relief of symptoms achieved when it is applied appropriately.

Guidelines for the Surgical Management of Pancreatic Adenocarcinoma

Pancreaticoduodenectomy remains the most formidable operative procedure for the surgical treatment of gastrointestinal malignancy. Improved outcomes after the Whipple procedure have been attributed to better preoperative patient selection, advances in three-dimensional radiographic imaging, and regionalization of referrals to high-volume, tertiary care centers. Despite these advances, morbidity and mortality after pancreaticoduodenectomy are not insignificant and the overall prognosis following resection for adenocarcinoma of the pancreas remains poor. Improvements in endoscopic decompression of malignant biliary obstruction have decreased the need for palliative bypass operations and have focused current surgical issues on ways to improve clinical outcomes following potentially curative resections. Controversies such as whether or not to perform extended lymph node dissections, and standard versus pylorus-preserving resections have been addressed by randomized, prospective clinical trials. Major venous resections secondary to local tumor extension are now performed without an increase in morbidity or mortality and with survival rates comparable to standard resections. This has led to even more aggressive resections following neoadjuvant therapy for lesions previously considered unresectable and now perhaps better categorized as borderline resectable. The impact of surgical specialization and regionalization of referrals to tertiary care centers is evident in markedly improved perioperative mortality rates. This article will attempt to describe current guidelines for the preoperative, intraoperative, and postoperative management of patients with localized pancreatic adenocarcinoma.

Extended Resection for Pancreatic Adenocarcinoma

Adenocarcinoma of the pancreas presents a number of therapeutic challenges. Given the poor long-term outcomes after pancreaticoduodenectomy (PD), many surgeons have sought to improve survival via a radical or "extended" pancreatectomy which may include (a) total pancreatectomy (TP), (b) extended lymph node dissection (ELND), and (c) portal/mesenteric vascular resections. These themes of "extended" resection are addressed in this review. TP should not be performed for most cases of adenocarcinoma of the pancreatic head because of the nominal incidence of lymph node involvement along the body and tail of the pancreas, the scarcity of multicentric disease, and the better management of pancreatic leaks after PD. Most studies show no difference in long-term survival and demonstrate greater postoperative morbidity after TP than after PD. Performing ELND in addition to PD is not worthwhile because most studies do not demonstrate any long-term benefits from ELND and the circumferential dissection around the mesenteric vessels required to harvest distant lymph nodes increases postoperative morbidity. Major arterial resection increases postoperative morbidity after PD and worsens long-term survival as the need for arterial resection to achieve negative resection margins indicates more aggressive disease. In contrast, portal and/or mesenteric venous resection does not increase the morbidity after PD or impact long-term survival as venous resection is often performed because of tumor location and not extent of disease. The disappointing experience with extended resections underscores the need for better adjuvant systemic strategies and the interdisciplinary care of patients with pancreatic adenocarcinoma.

Diagnostic accuracy of EUS for vascular invasion in pancreatic and periampullary cancers: a meta-analysis and systematic review

BACKGROUND

Vascular invasion (VI) in a patient with pancreatic or periampullary cancers precludes surgery and indicates a poor prognosis. Published data on the accuracy of EUS in diagnosing VI is varied.

OBJECTIVE

The aim of this meta-analysis was to evaluate the accuracy of EUS in diagnosing VI in patients with pancreatic and periampullary cancers.

DESIGN

Data from EUS studies were pooled according to the Mantel-Haenszel and DerSimonian Laird methods.

PATIENTS

EUS studies in which VI was confirmed by surgery or angiography were selected.

INTERVENTIONS

EUS.

MAIN OUTCOME MEASURES

Pooled estimates of sensitivity, specificity, likelihood ratios, and diagnostic odds ratio of EUS.

RESULTS

Data were extracted from 29 studies (N = 1308) that met the inclusion criteria. The pooled sensitivity of EUS in diagnosing VI was 73% (95% CI, 68.8-76.9) and the pooled specificity was 90.2% (95% CI, 87.9-92.2). The positive likelihood ratio for diagnosing VI by EUS was 9.1 (95% CI, 4.6-17.9) and the negative likelihood ratio was 0.3 (95% CI, 0.2-0.5). Diagnostic odds ratio, the odds of having VI in positive as compared with negative EUS studies, was 40.1 (95% CI, 16.1-99.9). The P value for chi(2) heterogeneity for all the pooled estimates was >.05.

CONCLUSIONS

Although EUS is the best noninvasive test to diagnose VI in pancreatic and periampullary cancers, this meta-analysis showed that the specificity (90%) is high but the sensitivity (73%) is not as high as suggested. Further refinements in EUS technologies and interpretation may improve the sensitivity for detecting VI.

Resection of the mesopancreas (RMP): a new surgical classification of a known anatomical space

Background

Prognosis after surgical therapy for pancreatic cancer is poor and has been attributed to early lymph node involvement as well as to a strong tendency of cancer cells to infiltrate into the retropancreatic tissue and to spread along the peripancreatic neural plexuses. The objective of our study was to classify the anatomical-surgical layer of the mesopancreas and to describe the surgical principles relevant for resection of the mesopancreas (RMP). Immunohistochemical investigation of the mesopancreatic-perineural lymphogenic structures was carried out with the purpose of identifying possible routes of metastatic spread.

Methods

Resection of the mesopancreas (RMP) was performed in fresh corpses. Pancreas and mesopancreas were separated from each other and the mesopancreas was immunohistochemically investigated.

Results

The mesopancreas strains itself dorsally of the mesenteric vessels as a whitish-firm, fatty tissue-like layer. Macroscopically, in the dissected en-bloc specimens of pancreas and mesopancreas nerve plexuses were found running from the dorsal site of the pancreatic head to the mesopancreas to establish a perineural plane. Immunohistochemical examinations revealed the lymphatic vessels localized in direct vicinity of the neuronal plexuses between pancreas and mesopancreas.

Conclusion

The mesopancreas as a perineural lymphatic layer located dorsally to the pancreas and reaching beyond the mesenteric vessels has not been classified in the anatomical or surgical literature before. The aim to ensure the greatest possible distance from the retropancreatic lymphatic tissue which drains the carcinomatous focus can be achieved in patients with pancreatic cancer only by complete resection of the mesopancreas (RMP).

Tumour characteristics predictive of survival following resection for ductal adenocarcinoma of the head of pancreas

AIMS

We have maintained a highly conservative policy in selecting patients with carcinoma of the head of pancreas for resection. This has been based on tumour size, evidence of lymph node involvement or local invasion outside of the gland at laparotomy, laparoscopy or CT imaging. This study investigated our survival rates following pancreatic resection and examined clinicopathological predictors of survival.

METHODS

Sixty-two consecutive patients undergoing pancreatic resections for malignancy were identified from 1999 onwards. Thirty-three underwent resection for pancreatic ductal adenocarcinoma and were included in our analysis, the remainder included resections for ampullary adenocarcinoma (n=20) or other malignancies (n=9). Patient, tumour and operative characteristics were analysed to assess predictors of survival following resection (Kaplan-Meier survival curves).

RESULTS

Median survival following resection for ductal pancreatic adenocarcinoma was 54 months (ampullary adenocarcinomas achieved a median survival of 62 months) and thirty-day mortality was 2.7% (n=1). Survival was not associated with any demographic or intraoperative factors, such as blood loss, operative duration or anaesthetic technique. Survival curves were significantly worse when perineural or vascular invasion was evident histologically (p=0.023 and 0.0023 respectively). Patients with positive lymph nodes had a significantly shorter survival (p=0.0030) especially when lymph node status was expressed as a percentage of total lymph node yield. If more than 20% of retrieved lymph nodes were positive for tumour, this was a clear predictor of survival (p<0.0001). A positive resection margin was also associated with shortened survival (p=0.0291).

CONCLUSION

Despite the advances made in the management of pancreatic cancer, tumour biology still dictates long-term survival. A highly selective surgical approach to the management of these patients results in good long-term survival.

Impact of lymph node involvement on long-term survival after R0 pancreaticoduodenectomy for ductal adenocarcinoma of the pancreas

Pancreaticoduodenectomy remains the only potentially curative treatment for adenocarcinoma of the pancreas. The aim of this study was to analyze prognostic factors impacting survival after R0 pancreaticoduodenectomy for adenocarcinoma in the head of the pancreas. Between 1995 and 2002, a potentially curative (R0) pancreaticoduodenectomy with pancreatogastrostomy for ductal adenocarcinoma in the head of the pancreas was performed in 81 patients (42 women and 39 men) with a mean age of 64 years (range 35-84). Patients were identified from a prospective database and records were reviewed retrospectively. Postoperative mortality was 1%, and 40% of patients had complications. Median survival was 18 months, and the 5-year survival was 24%. Fifteen patients were alive at 5 years. Factors associated with poor survival in multivariate analysis were (1) two or more positive lymph nodes, (2) tumor diameter greater than 30 mm, and (3) age greater than 70 years. In patients with no or with one positive lymph node, the 5-year survival was 44%. On the other hand, in patients with two or more positive lymph nodes, both the 3- and 5-year survival was 5%. The main risk factor associated with poor survival after an R0 pancreaticoduodenectomy for adenocarcinoma in the head of pancreas was lymph node status: The presence of two or more positive lymph nodes was associated with decreased survival.

Clinical implications of combined portal vein resection as a palliative procedure in patients undergoing pancreaticoduodenectomy for pancreatic head carcinoma

BACKGROUND

The clinical implications of combined portal vein resections are controversial.

METHODS

One-hundred and forty-nine consecutive patients underwent macroscopically curative pancreatectomies for pancreatic head carcinoma between January 1, 1996 and December 31, 2004. Portal vein resection was performed in 86 patients (58%). Data on surgical mortality, morbidity, perioperative outcome, pathological factors, initial recurrence site, and survival were retrospectively compared between the patients with and without portal vein resection.

RESULTS

The incidence of postoperative pancreatic fistula was lower among patients who underwent portal vein resection. The median survival period was 14 months for the portal vein resection group and 35 months for the non-portal vein resection group, respectively. Combined portal vein resection was a significant predictor of poor survival using a multivariate analysis. Portal vein resection was strongly associated with larger tumor size, the degree of retropancreatic tissue invasion, the presence of extrapancreatic nerve plexus invasion, lymph node metastases, and positive cancer infiltration at the surgical margins.

CONCLUSIONS

Portal vein resection at the time of pancreaticoduodenectomy can be safely performed. However, most of patients requiring portal vein resection do not achieve a potentially curative resection or a favorable survival term. As a result, the aggressive application and the strict selection of portal vein resection might reduce the incidence of positive surgical margins, enabling long-term survival in patients who do not require portal vein resection.

Leiomyosarcoma of the superior mesenteric vein: a diagnostic and therapeutic challenge

We report here a case of a very rare entity, a leiomyosarcoma of the mesentericoportal trunk, which was initially misdiagnosed as an unresectable pancreatic cancer invading the mesenteric vein, and which was finally treated by pancreatectomy with mesentericoportal reconstruction. The pitfalls of diagnosis and modalities of resection are discussed.

Pancreaticoduodenectomy with mesentericoportal vein resection for adenocarcinoma of the pancreatic head

BACKGROUND

The value of mesentericoportal vein resection (VR) associated with pancreaticoduodenectomy (PD) for pancreatic-head adenocarcinoma still remains controversial.

METHODS

From 1989 to 2003, 45 consecutive patients with pancreatic-head adenocarcinoma underwent PD with mesentericoportal VR due to intraoperative macroscopic involvement of the superior mesenteric or portal vein (VR+ group). They were compared with 88 patients who underwent PD for adenocarcinoma without VR over the same time period (VR- group) and matched for age, American Society of Anesthesiologists (ASA) score, pathological diagnosis, and nodal involvement. Preoperative features, intraoperative parameters, postoperative course, and survival were compared between the VR+ group and VR- group. Factors that may influence survival were determined by univariate and multivariate analyses.

RESULTS

Mortality, morbidity, and mean hospital stay did not differ between the two groups (VR+ 4.4%, 56%, and 22.6 days, respectively; VR- 5.7%, 64%, 24.6 days, respectively). In the group VR+, vein invasion was histologically proven in 29 (64%) patients. Three-year global survival and 3-year disease-free survival did not differ between the two groups: VR+ 22% and 14%, respectively; VR- 25% and 21%, respectively (log-rank: P=0.69 and P=0.39, respectively). Neither VR nor histologically proven vein involvement significantly impacted survival duration. On multivariate analysis, tumor-free margin was the most important prognostic factor.

CONCLUSIONS

Vein resection during PD can be performed safely. Patients with adenocarcinoma who require VR during PD have a survival not different from that of patients who undergo standard PD. Macroscopic isolated mesentericoportal vein involvement is not a contraindication for PD in patients with adenocarcinoma provided disease-free margins can be obtained.

[Cephalic pancreaticoduodenectomy with mesentericoportal venous reconstruction. Technical features]

Cephalic pancreaticoduodenectomy (CPD) with mesentericoportal venous resection increases the resectability rate of pancreatic tumors. When performed in selected patients and by experienced surgical teams, this technique shows the same long-term rates of morbidity, mortality and survival as CPD without vascular resection, provided that negative surgical margins are obtained. This procedure is contraindicated by complete thrombosis of the portal or superior mesenteric veins, invasion of the superior mesenteric artery or celiac trunk, and distant or periaortic lymph node involvement. Venous reconstruction can be performed through lateral suture, termino-terminal anastomosis, or by graft placement. We believe that intercalation of the autologous internal jugular vein facilitates resection and minimizes phenomena of venous stasis. We present a case of adenocarcinoma of the pancreatic head infiltrating the superior mesenteric-portal vein confluence that underwent surgery in our hospital. CPD with mesentericoportal venous resection and reconstruction using autologous internal jugular vein were performed. The most important technical features are discussed.

Oncological problems in pancreatic cancer surgery

Despite the development of more sophisticated diagnostic techniques, pancreatic carcinoma has not yet been detected in the early stage. Surgical resection provides the only chance for cure or long-term survival. The resection rate has increased due to recent advances in surgical techniques and the application of extensive surgery. However, the postoperative prognosis has been poor due to commonly occurring liver metastasis, local recurrence and peritoneal dissemination. Recent molecular-biological studies have clarified occult metastasis, micrometastasis and systemic disease in pancreatic cancer. Several oncological problems in pancreatic cancer surgery are discussed in the present review.

Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer

BACKGROUND

Tumour clearance during pancreatectomy may be facilitated by resection of the portal-superior mesenteric vein, but this is associated with increased perioperative risk. There is no consensus about which patients benefit from portal-superior mesenteric vein resection.

METHODS

A systematic appraisal was carried out of the literature on portal-superior mesenteric vein resection during pancreatectomy to identify recurrent themes to guide management. A computerized search of the Medline and Embase databases found 52 non-duplicated studies providing relevant data in 1646 patients. Pooled data were examined for information on outcome categories relating to operation, complications, histopathology and overall outcome.

RESULTS

The median (range) number of patients with portal-superior mesenteric vein resection per cohort was 23 (4-172). Median operating time was 513 (168-1740) min and blood loss 1750 (300-26000) ml. Postoperative morbidity ranged from 9 to 78 per cent with a median per cohort of 42 per cent. There were 73 perioperative deaths (5.9 per cent of 1235 for whom mortality data were provided). Median survival was 13 months, and 1-, 3- and 5-year survival rates were 50, 16 and 7 per cent respectively. Specimen histopathology confirmed positive nodes in 67.4 per cent.

CONCLUSIONS

This is the largest collective report to date on portal-superior mesenteric vein resection in pancreatectomy. The high rate of nodal metastases and low 5-year survival rates suggest that by the time of tumour involvement of the portal vein cure is unlikely, even with radical resection.

Risk factors for mortality and intra-abdominal complications after pancreatoduodenectomy: multivariate analysis in 300 patients

BACKGROUND

Studies of risk factors after pancreatoduodenectomy are few: some concern restricted populations and others are based on administrative data.

METHODS

Multicenter clinical data were collected for 300 patients undergoing pancreatoduodenectomy to determine (by univariate and multivariate analysis) preoperative and intraoperative risk factors for mortality and intra-abdominal complications (IACs), including pancreatic fistula. Fourteen factors including the center and volume effect were analyzed.

RESULTS

In univariate analysis, mortality was increased with age 70 years or more, extended resection(s), and volume and center effects. IACs occurred more often with main pancreatic duct diameter of 3 mm or less, normal parenchyma texture, extended resection(s), and the center effect. Pancreatic fistula was more frequent with main pancreatic duct diameter of 3 mm or less, normal parenchyma texture, and the center effect. In multivariate analysis, independent risk factor(s) for mortality were age greater than 70 years (odds ratio [OR], 3; 95% confidence interval [CI], 1.3-8) and extended resection (OR, 5; 95% CI, 1.2-22), risk factors for IACs were extended resection (OR, 5; 95% CI, 1.2-22) and main pancreatic duct diameter of 3 mm or less (OR, 2; 95% CI, 1.1-3), and the risk factor for pancreatic fistula was main pancreatic duct diameter of 3 mm or less (OR, 2.5; 95% CI, 1.2-4.6).

CONCLUSIONS

Age more than 70 years, extended resections, and main pancreatic duct diameter less than 3 mm are independent risk factors that should be considered in indications for and techniques of pancreatoduodenectomy.

Pancreatic cancer in sweden 1980-2000: a population-based study of hospitalized patients concerning time trends in curative surgery and other interventional therapies

Progress has been made during the last few decades in the treatment of patients with pancreatic cancer. In this population-based study, the time trends in curative surgery and the choice of palliative invasive therapies in Sweden over two decades are analyzed. Patients treated for pancreatic carcinoma in Sweden during 1980-2000 were identified in the Swedish Hospital Discharge Register and the Cancer Register. These data were matched with those in the Register of Causes of Death in Sweden. Data were identified and analyzed for 16,758 patients for three periods: 1980-1986 (n = 5775), 1987-1993 (n = 6096), and 1994-2000 (n = 4887). The rate of pancreatic resection increased 7.2%, 10.9%, and 15.1% (P < 0.0001) during the three respective periods. Palliative interventions decreased from 46.8% in the first period to 41.7% in the last period. On comparing the first and the last periods, biliary bypass operations were found to decrease (from 45.9% to 18.1%), as well as gastric bypass procedures (from 33.8% to 22.8%; P < 0.0001). Interventions by percutaneous transhepatic cholangiography (PTC) remained constant (10%-11%). Endoscopic therapy increased from 10.8% to 49.0%, as did the number of procedures per patient, from 1.3 to 1.7 (P < 0.0001) in the first and last periods, respectively. In 1980, the mean hospital stay was 40 days after resection and 30 days after palliative intervention. In 2000, the corresponding numbers were 26 days and 18 days (P < 0.001), respectively. During the past two decades, the rate of pancreatic resections in Sweden increased significantly. There was also a dramatic drop in palliative open surgery and a simultaneous increase in endoscopic interventions. Hospital stays decreased by more than a third.

Venous resection in pancreatic cancer surgery

Vascular resection and reconstruction at the time of pancreaticoduodenectomy (PD) adds complexity to an already demanding operation. In this chapter, we review the indications, surgical techniques, and most recent results of venous resection combined with PD. The need for venous resection may not always be apparent on preoperative imaging, and surgeons who perform PD should be familiar with standard techniques necessary for vascular resection and reconstruction. Recent data suggest that with proper patient selection and surgeon experience, vascular resection and reconstruction can be performed safely and does not impact survival duration even in patients with pancreatic ductal adenocarcinoma. The median survival of patients who underwent PD and required vascular resection was 23 months, approximately 1 year longer than the survival of patients with locally advanced, surgically unresectable pancreatic cancer who receive palliative chemotherapy or chemoradiation.

Current management of locally advanced pancreatic cancer

Almost 30% of patients with pancreatic cancer present with large, locally advanced tumors in the absence of distant metastases. Because surgical resection is frequently contraindicated by vascular invasion, locally advanced pancreatic cancer has a dismal prognosis with a 6-10-month median survival. Recent advances in the multimodality treatment of other gastrointestinal malignancies have not altered the management of patients with locally advanced pancreatic cancer, a clinical dilemma reflected by the number of nonrandomized trials and anecdotal reports addressing this difficult disease. Our review summarizes the current status of aggressive surgical resection and neoadjuvant chemoradiation for locally advanced pancreatic cancer and suggests a treatment algorithm for patients with this disease based upon published clinical evidence.

Surgery for pancreatic cancer: recent controversies and current practice

Pancreatic duct carcinoma remains a common disease with a poor prognosis. More than 30,000 Americans will die of the disease in 2004, making it the fourth leading cause of cancer death. Despite significant advances in the treatment of many other human tumors, the 5-year survival rate for persons diagnosed with pancreatic cancer has not changed in decades and remains <5%. This is due both to the inherently aggressive biology of the disease and to its late diagnosis in most cases. Surgical resection of localized disease remains the only hope for cure of pancreatic cancer. Over the past 2 decades, significant advances in diagnostic imaging, staging, surgical technique, and perioperative care have led to marked improvement in the surgical management of pancreatic cancer patients. Operative mortality rates for pancreaticoduodenectomy are now <5% at major centers, and the average length of hospital stay has been reduced to <2 weeks. Improvements in patient outcome after pancreatic cancer surgery have made possible, for the first time, the design and conduct of large adjuvant therapy studies in pancreatic cancer. Such clinical trials are critical for improving outcomes for pancreatic cancer patients.

Early retropancreatic dissection during pancreaticoduodenectomy

BACKGROUND

During pancreaticoduodenectomy, early neck division may be inadequate, particularly in cases of replaced or accessory right hepatic artery (RHA) or diffuse intraductal papillary and mucinous neoplasm (IPMN) or when invasion of superior mesenteric artery is suspected.

METHODS

Modification of the technique of pancreaticoduodenectomy with dissection of the superior mesenteric vessels performed from behind the head of the pancreas before any pancreatic or digestive transection. The pancreas is divided later, after adequate mobilization of the specimen from the vessels, on either the neck or the body, according to underlying disease.

RESULTS

We used this technique successfully in 20 patients with a replaced or accessory RHA, which was successfully preserved in 19; one patient had inadvertent division of a 2-mm diameter accessory RHA that was ligated with no postoperative complications. Additionally, we used this technique in 18 patients with IPMN-14 pancreaticoduodenectomies extended to the body and 4 total pancreatectomies-and in 3 patients with adenocarcinoma involving the porto-mesenteric confluence and needing en-bloc vascular resection.

CONCLUSIONS

Early division of retroperitoneal margin is a useful technical variant of pancreaticoduodenectomy, which can be recommended in selective indications to improve safety and radicality of the procedure.

Current standards of surgery for pancreatic cancer

Background

Pancreatic cancer carries a dismal prognosis but there has been a vast increase in evidence on its management in the past decade.

Methods

An electronic and manual search was performed for articles on the surgical treatment of pancreatic cancer published in the past 10 years.

Results

Six major areas of advancement were identified. Groups at high risk of developing pancreatic cancer, notably those with chronic pancreatitis and hereditary pancreatitis, have been defined, raising the need for secondary screening. Methods of staging pancreatic cancer for resection have greatly improved but accuracy is still only 85–90 per cent. Pylorus-preserving partial pancreatoduodenectomy without extended lymphadenectomy is the simplest procedure; it does not compromise long-term survival. Adjuvant chemotherapy significantly improves long-term survival. Patients who are free from major co-morbidity have better palliation by surgery (with a double bypass) than by endoscopy. High-volume centres improve the results of surgery for all outcome measures including long-term survival.

Conclusion

The surgical management of pancreatic cancer has undergone a significant change in the past decade. It has moved away from no active treatment. The standard of care can now be defined as potentially curative resection in a specialist centre followed by adjuvant systemic chemotherapy.

[Surgical interdisciplinarity-abdomen excluding the pelvis]

Cooperation between different surgical disciplines arises from the employment of nonoperative procedures as a supplement to operative treatment (sequential multidisciplinary operations) and synchronized multidisciplinary or simultaneous operations. The objective is to ensure optimized treatment results. Complementary preoperative measures are the endoscopic removal of bile duct stones, interventional portal vein embolization, percutaneous abscess drainage, and so-called stenting in case of mechanical bowel obstruction. Intraoperative cooperation is advised in case of abdominal surgical diseases, especially with vascular surgery. Visceral surgeons should have a good command of vascular surgical techniques when performing corresponding operations. The aim of operative cooperation between different disciplines is to safeguard optimal treatment results. From this follows a right to and, for physicians, the duty of interdisciplinary cooperation. A prerequisite is the knowledge of the potentialities of the different disciplines as well as mutual respect for their limits. Intensive communication is an important aspect during the whole process of diagnostics, therapy, and postoperative care.

Pancreaticoduodenectomy with En Bloc Portal Vein Resection for Pancreatic Carcinoma with Suspected Portal Vein Involvement

Pancreaticoduodenectomy combined with portal vein resection is increasingly accepted as a viable treatment option for pancreatic carcinoma with suspected involvement of the portal vein.However, its clinical benefit remains controversial. This study evaluated the outcomes of pancreaticoduodenectomy with portal vein resection for pancreatic carcinoma in a group of Chinese patients operated on by a specialized team in a center with a low case volume of pancreatic cancer. The perioperative and long-term outcomes of 12 patients with portal vein resection for suspected involvement of the portal vein and 38 patients who underwent pancreaticoduodenectomy without portal vein resection during the same period were compared. In the former group, eight patients underwent segmental resection, and four patients underwent wedge resection of the portal vein. There were no significant differences in operative blood loss (median 0.8 vs. 0.8 liter, p = 0.313), hospital mortality (0% vs. 2.6%, p = 1.000), or operative morbidity (41.7% vs. 42.1%, p = 0.979) between the two groups. Patients who required portal vein resection had higher frequencies of microscopic lymphatic permeation (58.3% vs. 18.4%, p = 0.023) and vascular invasion (50.0% vs. 15.8%, p = 0.025). Long-term survival was comparable between patients with portal vein resection and those without it (median 19.5 vs. 20.7 months,p = 0.769). These findings suggest that pancreaticoduodenectomy combined with portal vein resection can be performed safely by a specialized team in a center with a low case volume of pancreatic carcinoma and that it may offer survival benefit in patients with suspected portal vein involvement.

Portal vein resection: A modified technique for reconstruction after pancreaticoduodenectomy

Pancreaticoduodenectomy is the only curative treatment for pancreatic head tumors. The possibility to achieve a potentially curative surgical treatment is limited to patients in which a complete tumor resection can be performed with free surgical margins. In a small number of patients with localized pancreatic cancer, negative margins are only accomplished with portal vein resection. Pancreaticoduodenectomy is often avoided in these patients due to the mistaken concept that venous resection may be followed by higher mortality and carries poorer survival. Actually, these patients present the same survival rate as patients similarly staged in whom portal vein resection was not performed. Therefore, venous resection is worthwhile. The authors describe an alternative technique for venous reconstruction after resection of a long segment of portal or superior mesenteric vein. The use of a venous graft as proposed in this study is feasible, easy to perform, and may simplify the venous reconstruction even in extensive mesentericoportal venous resection.

Efficacy of venous reconstruction in patients with adenocarcinoma of the pancreatic head

Pancreaticoduodenectomy is often avoided in patients with portal or superior mesenteric venous involvement due to the perception that venous resection is complex, morbid, and carries a poor long-term survival. Our recent experience using state-of-the-art imaging and strict resection criteria show that venous reconstruction increases operative time, transfusion requirements, intensive care unit stay, and total hospital length of stay, but has no significant impact on operative morbidity rates, mortality rates, or the incidence of positive histologic margins. Kalpan-Meier life table analysis shows similar survival curves when compared to a contemporary cohort of patients who do not undergo venous reconstruction.

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Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis

OBJECTIVE

To review the current status of pancreatoduodenectomy for pancreatic cancer and chronic pancreatitis using evidence-based methodology.

SUMMARY BACKGROUND DATA

Despite improved results of pancreatoduodenectomy over the recent years, the reputation of the Whipple procedure and its main modifications has remained poor. In addition, the current status of newer modifications of standard pancreatoduodenectomy is still under debate.

METHODS

Medline search and manual cross-referencing were performed to identify all relevant articles for classification and analysis according to their quality of evidence. The search was limited to articles published between 1990 and 2001.

RESULTS

The mortality rate of pancreatoduodenectomy has declined to less than 5% for chronic pancreatitis and 3% to 8% for pancreatic cancer. In contrast, overall morbidity rates remain high, ranging between 20% and 70%. Delayed gastric emptying represents almost half of all complications. The overall 5-year survival rate for patients with pancreatic cancer remains poor, ranging between 5% and 15%, with a median survival of 13 to 17 months. Mortality and morbidity are not related to the type of pancreatoduodenectomy; however, patients with pancreatic cancer tend to be at increased risk for complications. Extended lymph node dissection and portal vein resection can be performed with similar mortality and morbidity rates as standard procedures, but without apparent survival benefits in the long term. Major relief of pain is achieved in 70% to 100% of patients with chronic pancreatitis.

CONCLUSIONS

Pancreatoduodenectomy and its main modifications are safe and effective treatment modalities, especially in experienced centers with a high patient volume. For chronic pancreatitis, surgical resection provides major relief of pain and thus increased quality of life. Overall survival for patients with pancreatic cancer is determined predominantly by the pathology within the resected specimen.

Magnifying endoscopic observation of the gastric mucosa, particularly in patients with atrophic gastritis

The gastric mucosal surface was observed using the magnifying fibergastroscope (FGS-ML), and the fine gastric mucosal patterns, which were even smaller than one unit of gastric area, were examined at a magnification of about 30. For simplicification, we classified these patterns by magnifying endoscopy in the following ways; FP, FIP, FSP, SP and MP, modifying Yoshii's classification under the dissecting microscope. The FIP, which was found to have round and long elliptical gastric pits, is a new addition to our endoscopic classification. The relationship between the FIP and the intermediate zone was evaluated by superficial and histological studies of surgical and biopsy specimens. The width of the band of FIP seems to be related to the severity of atrophic gastritis. Also, the transformation of FP to FIP was assessed by comparing specimens taken from the resected and residual parts of the stomach, respectively. Moreover, it appears that severe gastritis occurs in the gastric mucosa which shows a FIP. Therefore, we consider that the FIP indicates the position of the atrophic border.