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Zecchin Ferrara V, Martinino A, Toti F, Schilirò D, Pinto F, Giovinazzo F. Robotic Vascular Resection in Pancreatic Ductal Adenocarcinoma: A Systematic Review. J Clin Med 2024; 13:2000. [PMID: 38610766 PMCID: PMC11012275 DOI: 10.3390/jcm13072000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
(1) Background: This study comprehensively compared robotic pancreatic surgery with vascular resection (RPS-VR) to other surgical procedures in the treatment of pancreatic ductal adenocarcinoma (PDAC). (2) Methods: A systematic review of relevant literature was conducted to assess a range of crucial surgical and oncological outcomes. (3) Results: Findings indicate that robotic surgery with vascular resections (VRs) significantly prolongs the duration of surgery compared to other surgical procedures, and they notably demonstrate an equal hospital stay. While some studies reported a lower conversion rate and a higher rate of blood loss and blood transfusion in the RPS-VR group, others found no significant disparity. Furthermore, RPS-VR consistently correlated with comparable recurrence rates, free margins R0, postoperative mortality, and complication rates. Concerning the last one, certain reviews reported a higher rate of major complications. Overall survival and disease-free survival remained comparable between the RPS-VR and other surgical techniques in treating PDAC. (4) Conclusions: The analysis emphasizes how RPS-VR is a resembling approach in terms of surgical outcomes and aligns with existing literature findings in this field.
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Affiliation(s)
| | | | - Francesco Toti
- Department of Surgery, ASST Santi Paolo e Carlo, 20100 Milan, Italy
| | - Davide Schilirò
- Department of Surgery, Duke University, Durham, NC 27708, USA (D.S.)
| | - Federico Pinto
- Department of Surgery, University of Illinois at Chicago, Chicago, IL 60607, USA
| | - Francesco Giovinazzo
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00131 Rome, Italy
- Department of Health Sciences, UniCamillus-Saint Camillus International University, 00131 Rome, Italy
- Department of Surgery, Saint Camillus Hospital, 31100 Treviso, Italy
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2
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Ma MJ, Cheng H, Chen YS, Yu XJ, Liu C. Laparoscopic pancreaticoduodenectomy with portal or superior mesenteric vein resection and reconstruction for pancreatic cancer: A single-center experience. Hepatobiliary Pancreat Dis Int 2023; 22:147-153. [PMID: 36690522 DOI: 10.1016/j.hbpd.2023.01.004] [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: 11/09/2022] [Accepted: 12/29/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Open pancreaticoduodenectomy (OPD) with portal or superior mesenteric vein resection and reconstruction has been applied in pancreatic cancer patients with tumor infiltration or adherence. However, it is controversial whether laparoscopic pancreaticoduodenectomy (LPD) with major vascular resection and reconstruction is feasible. This study aimed to evaluate the safety and feasibility of LPD with major vascular resection compared with OPD with major vascular resection. METHODS We reviewed data for all pancreatic cancer patients undergoing LPD or OPD with vascular resection at Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, between February 2018 and May 2022. We compared the preoperative, intraoperative, and postoperative clinicopathological data of the two groups to conduct a comprehensive evaluation of LPD with major vascular resection. RESULTS A total of 63 patients underwent pancreaticoduodenectomy (PD) with portal or superior mesenteric vein resection and reconstruction, including 25 LPDs and 38 OPDs. The LPD group had less intraoperative blood loss (200 vs. 400 mL, P < 0.001), lower proportion of intraoperative blood transfusion (16.0% vs. 39.5%, P = 0.047), longer operation time (390 vs. 334 min, P = 0.004) and shorter postoperative hospital stay (11 vs. 14 days, P = 0.005). There was no perioperative death in all patients. There was no significant difference in the incidence of total postoperative complications, grade B/C postoperative pancreatic fistula, delayed gastric emptying and abdominal infection between the two groups. No postpancreatectomy hemorrhage nor bile leakage occurred during perioperative period. There was no significant difference in R0 resection rate and number of lymph nodes harvested between the two groups. Patency of reconstructed vessels in the two groups were 96.0% and 92.1%, respectively (P = 0.927). CONCLUSIONS LPD with portal or superior mesenteric vein resection and reconstruction was safe, feasible and oncologically acceptable for selected patients with pancreatic cancer, and it can achieve similar or even better perioperative results compared to open approach.
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Affiliation(s)
- Ming-Jian Ma
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan University, Shanghai 200032, China
| | - He Cheng
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan University, Shanghai 200032, China
| | - Yu-Sheng Chen
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan University, Shanghai 200032, China
| | - Xian-Jun Yu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan University, Shanghai 200032, China
| | - Chen Liu
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China; Shanghai Pancreatic Cancer Institute, Shanghai 200032, China; Pancreatic Cancer Institute, Fudan University, Shanghai 200032, China.
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3
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Sung MK, Song KB, Hong S, Park Y, Kwak BJ, Jun E, Lee W, Lee JH, Hwang DW, Kim SC. Laparoscopic versus open pancreaticoduodenectomy with major vein resection for pancreatic head cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023. [PMID: 36740999 DOI: 10.1002/jhbp.1317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 01/08/2023] [Accepted: 01/17/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND/PURPOSE Laparoscopic pancreaticoduodenectomy (PD) with major vein resection is a challenging procedure. Herein, we evaluated the feasibility and safety of laparoscopic vein resection in pancreatic head cancer with portal vein/superior mesenteric vein (PV/SMV) invasion, and compared the survival rate following laparoscopic surgery with that following open surgery. METHODS We retrospectively reviewed the electronic medical records of all patients with pancreatic head cancer who underwent surgery performed by a single surgeon from January 2015 to December 2017. Kaplan-Meier curves were plotted to compare the disease-free survival, while Cox-proportional hazard models were used to analyze prognostic factors for survival. RESULTS Among 76 patients, 63 underwent open PD and 13 underwent laparoscopic PD with PV/SMV resection. There was no significant difference in the rate of complications, including portal vein stenosis and portal vein thrombus, recurrence of tumors, or pathological outcomes after surgery between the groups. There was also no significant difference in disease-free survival (p = .803) between the two groups. Additionally, the surgical method was not an independent prognostic factor for disease-free survival. CONCLUSIONS Laparoscopic PD with major vein resection can be feasibly performed in select patients with abutment and focal narrowing of the PV/SMV in pancreatic head cancer.
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Affiliation(s)
- Min Kyu Sung
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sarang Hong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Yejong Park
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Bong Jun Kwak
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Eunsung Jun
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Woohyung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Roch AM, Kilbane EM, Nguyen T, Ceppa EP, Zyromski NJ, Schmidt CM, Nakeeb A, House MG. Portal Vein Thrombosis After Venous Reconstruction During Pancreatectomy: Timing and Risks. J Gastrointest Surg 2022; 26:2148-2157. [PMID: 35819666 DOI: 10.1007/s11605-022-05401-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/17/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Numerous studies have shown that portal vein resection during pancreatectomy can help achieve complete tumor clearance and long term-survival. While the safety of vascular resection during pancreatectomy is well documented, the risk of superior mesenteric vein/portal vein (SMV/PV) thrombosis after reconstruction remains unclear. This study aimed to describe the incidence and risk factors of SMV/PV thrombosis after vein reconstruction during pancreatectomy. METHODS All patients who underwent portal vein resection (PVR) during pancreatectomy (2007-2019) were identified from a single institution prospective clinical database. Demographic and clinical data, operative and pathological findings, and postoperative outcomes were analyzed. RESULTS Pancreatectomy with PVR was performed in 220 patients (mean age 65.1 years, male/female ratio 0.96). Thrombosis occurred in 36 (16.4%) patients after a median of 15.5 days [IQR 38.5, 1-786 days]. SMV/PV patency rates were 92.7% and 88.7% at 1 and 3 months, respectively. The rate of SMV/PV thrombosis varied according to SMV/PV reconstruction technique: 12.8% after venorrhaphy, 13.2% end-to-end anastomosis, 22.6% autologous vein, and 83.3% synthetic graft interposition (p < 0.0001). SMV/PV thrombosis was associated with increased 90-day mortality (16.7% vs 4.9%, p = 0.02) and overall 30-day complication rate (69.4% vs 42.9%, p = 0.006). Pancreatectomy type, neoadjuvant chemoradiation, pathologic tumor venous invasion, resection margin status, and manner of perioperative anticoagulation did not influence the incidence of PV thrombosis. SMV/PV thrombosis was associated with a nearly 5-times increased risk of postoperative sepsis after pancreatectomy. CONCLUSION Portal vein thrombosis developed in 16% of patients who underwent pancreatectomy with PVR at a median of 15 days. PVR with synthetic interposition graft carries the highest risk for thrombosis.
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Affiliation(s)
- Alexandra M Roch
- 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
| | - Trang Nguyen
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Attila Nakeeb
- 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.
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Li AY, Visser BC, Dua MM. Surgical Indications and Outcomes of Resection for Pancreatic Neuroendocrine Tumors with Vascular Involvement. Cancers (Basel) 2022; 14:cancers14092312. [PMID: 35565442 PMCID: PMC9103421 DOI: 10.3390/cancers14092312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 11/22/2022] Open
Abstract
Simple Summary Pancreatic neuroendocrine tumors (pNETs) are a heterogenous group of rare epithelial neoplasms. For most patients, surgery remains the only treatment modality to cure pNETs, and is recommended for patients with surgically resectable disease. Many of these tumors are non-functional tumors and do not produce clinical symptoms, so patients may present with locally advanced tumors, which invade surrounding organs or neighboring blood vessels. The presence of vascular involvement had previously been considered a contraindication to surgery, but, in recent years, at centers with considerable experience, aggressive surgery to remove pNETs with vascular reconstruction has been performed safely and with good long-term survival. In this review, we will discuss the considerations for resectability, review novel surgical approaches, and present the available evidence on the immediate and long-term postoperative outcomes. Abstract Complete surgical resection of pancreatic neuroendocrine tumors (pNETs) has been suggested as the only potentially curative treatment. A proportion of these tumors will present late during disease progression, and invade or encase surrounding vasculature; therefore, surgical treatment of locally advanced disease remains controversial. The role of surgery with vascular reconstruction in pNETs is not well defined, and there is considerable variability in the use of aggressive surgery for these tumors. Accurate preoperative assessment is critical to evaluate individual considerations, such as anatomical variants, areas and lengths of vessel involvement, proximal and distal targets, and collateralization secondary to the degree of occlusion. Surgical approaches to address pNETs with venous involvement may include thrombectomy, traditional vein reconstruction, a reconstruction-first approach, or mesocaval shunting. Although the amount of literature on pNETs with vascular reconstruction is limited to case reports and small institutional series, the last two decades of studies have demonstrated that aggressive resection of these tumors can be performed safely and with acceptable long-term survival.
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Bacalbasa N, Balescu I, Diaconu C, Socea B, Gherghiceanu F, Stiru O, Brasoveanu V. Portal vein reconstruction with interposition of cryopreserved aortic graft: A case report and literature review. Exp Ther Med 2021; 23:184. [DOI: 10.3892/etm.2021.11107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/05/2021] [Indexed: 11/05/2022] Open
Affiliation(s)
- Nicolae Bacalbasa
- Department of Visceral Surgery, Center of Excellence in Translational Medicine, ‘Fundeni’ Clinical Institute, 022328 Bucharest, Romania
| | - Irina Balescu
- Department of Surgery, ‘Ponderas’ Academic Hospital, 021188 Bucharest, Romania
| | - Camelia Diaconu
- Department of Internal Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Bogdan Socea
- Department of Surgery, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Florentina Gherghiceanu
- Department of Marketing and Medical Technology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Ovidiu Stiru
- Department of Cardiovascular Surgery, ‘Prof. Dr. C.C. Iliescu’ Emergency Institute for Cardiovascular Diseases, 022322 Bucharest, Romania
| | - Vladislav Brasoveanu
- Department of Visceral Surgery, Center of Excellence in Translational Medicine, ‘Fundeni’ Clinical Institute, 022328 Bucharest, Romania
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Wijetunga AR, Chua TC, Nahm CB, Pavlakis N, Clarke S, Chan DL, Diakos C, Maloney S, Ashrafi-Zadeh A, Kneebone A, Hruby G, Jamieson NB, Gill A, Mittal A, Samra JS. Survival in borderline resectable and locally advanced pancreatic cancer is determined by the duration and response of neoadjuvant therapy. Eur J Surg Oncol 2021; 47:2543-2550. [PMID: 33952409 DOI: 10.1016/j.ejso.2021.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 03/04/2021] [Accepted: 04/05/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Pancreatic cancer is the 8th commonest cancer and the 5th commonest cause of cancer-related death in Australia, with a 9% average 5-year survival. This study aims to investigate the effects of neoadjuvant treatment on overall survival (OS) and recurrence-free survival (RFS) in borderline resectable (BRPC) and locally advanced (LAPC) pancreatic adenocarcinoma followed by curative resection. MATERIALS AND METHODS Prospectively-collected demographic, medical, surgical and pathological data of patients with BRPC and LAPC treated with both neoadjuvant therapy (NAT) and surgery at a single tertiary referral centre in Australia were reviewed and analysed. RESULTS Between 2012 and 2018, 60 patients, 34 with BRPC and 26 with LAPC, were treated with NAT followed by curative resection. The commonest neoadjuvant chemotherapy regimens were Gemcitabine + Abraxane (51.7%) and FOLFIRINOX (35.0%), with 48.3% of patients additionally receiving neoadjuvant radiotherapy. Median RFS was 30 months and median OS was 35 months. On multivariable analysis, inferior OS was predicted by enlarged loco-regional lymph nodes on initial computed tomography (p = 0.032), larger tumour size post-NAT (p = 0.006) and Common Terminology Criteria for Adverse Events post-NAT toxicity greater than grade 2 (p = 0.015). LAPC patients received more neoadjuvant chemotherapy (p = 0.008) and radiotherapy (p = 0.021) than BRPC and achieved a superior pathological response (p = 0.010). CONCLUSION Patients who respond to NAT likely have a favourable disease biology and will progress well following resection. It is these patients who should be selected for more aggressive upfront management, and those with resistant disease should be spared from high-risk surgery.
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Affiliation(s)
| | - Terence C Chua
- School of Medicine, Griffith University, Gold Coast, QLD, Australia; Department of Surgery, QE II Jubilee Hospital, Brisbane, QLD, Australia
| | - Christopher B Nahm
- Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Hepatopancreatobiliary Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - Nick Pavlakis
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Australian Pancreatic Centre, St Leonards, Sydney, NSW, Australia
| | - Stephen Clarke
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Australian Pancreatic Centre, St Leonards, Sydney, NSW, Australia
| | - David L Chan
- Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Australian Pancreatic Centre, St Leonards, Sydney, NSW, Australia
| | - Connie Diakos
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia; Australian Pancreatic Centre, St Leonards, Sydney, NSW, Australia
| | - Sarah Maloney
- Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Amir Ashrafi-Zadeh
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Andrew Kneebone
- Australian Pancreatic Centre, St Leonards, Sydney, NSW, Australia; Department of Radiation Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - George Hruby
- Australian Pancreatic Centre, St Leonards, Sydney, NSW, Australia; Department of Radiation Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Nigel B Jamieson
- Institute of Cancer Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Anthony Gill
- Sydney Medical School, The University of Sydney, Sydney, Australia; Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, NSW, Australia; NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Anubhav Mittal
- Sydney Medical School, The University of Sydney, Sydney, Australia; Australian Pancreatic Centre, St Leonards, Sydney, NSW, Australia; Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Jaswinder S Samra
- Sydney Medical School, The University of Sydney, Sydney, Australia; Australian Pancreatic Centre, St Leonards, Sydney, NSW, Australia; Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, NSW, Australia
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Fusai GK, Tamburrino D, Partelli S, Lykoudis P, Pipan P, Di Salvo F, Beghdadi N, Dokmak S, Wiese D, Landoni L, Nessi C, Busch ORC, Napoli N, Jang JY, Kwon W, Del Chiaro M, Scandavini C, Abu-Awwad M, Armstrong T, Hilal MA, Allen PJ, Javed A, Kjellman M, Sauvanet A, Bartsch DK, Bassi C, van Dijkum EJMN, Besselink MG, Boggi U, Kim SW, He J, Wolfgang CL, Falconi M. Portal vein resection during pancreaticoduodenectomy for pancreatic neuroendocrine tumors. An international multicenter comparative study. Surgery 2021; 169:1093-1101. [PMID: 33357999 DOI: 10.1016/j.surg.2020.11.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/18/2020] [Accepted: 11/02/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The role of portal vein resection for pancreatic cancer is well established but not for pancreatic neuroendocrine neoplasms. Evidence from studies providing information on long-term outcome after venous resection in pancreatic neuroendocrine neoplasms patients is lacking. METHODS This is a multicenter retrospective cohort study comparing pancreaticoduodenectomy with vein resection with standard pancreaticoduodenectomy in patients with pancreatic neuroendocrine neoplasms. The primary endpoint was to evaluate the long-term survival in both groups. Progression-free survival and overall survival were calculated using the method of Kaplan and Meier, but a propensity score-matched cohort analysis was subsequently performed to remove selection bias and improve homogeneity. The secondary outcome was Clavien-Dindo ≥3. RESULTS Sixty-one (11%) patients underwent pancreaticoduodenectomy with vein resection and 480 patients pancreaticoduodenectomy. Five (1%) perioperative deaths were recorded in the pancreaticoduodenectomy group, and postoperative clinically relevant morbidity rates were similar in the 2 groups (pancreaticoduodenectomy with vein resection 48% vs pancreaticoduodenectomy 33%). In the initial survival analysis, pancreaticoduodenectomy with vein resection was associated with worse 3-year progression-free survival (48% pancreaticoduodenectomy with vein resection vs 83% pancreaticoduodenectomy; P < .01) and 5-year overall survival (67% pancreaticoduodenectomy with vein resection vs 91% pancreaticoduodenectomy). After propensity score matching, no significant difference was found in both 3-year progression-free survival (49% pancreaticoduodenectomy with vein resection vs 59% pancreaticoduodenectomy; P = .14) and 5-year overall survival (71% pancreaticoduodenectomy with vein resection vs 69% pancreaticoduodenectomy; P = .98). CONCLUSION This study demonstrates no significant difference in perioperative risk with a similar overall survival between pancreaticoduodenectomy and pancreaticoduodenectomy with vein resection. Tumor involvement of the superior mesenteric/portal vein axis should not preclude surgical resection in patients with locally advanced pancreatic neuroendocrine neoplasms.
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Affiliation(s)
- Giuseppe K Fusai
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, United Kingdom
| | - Domenico Tamburrino
- Pancreatic Surgery Unit, Vita-Salute University, San Raffaele Hospital, Milan, Italy.
| | - Stefano Partelli
- Pancreatic Surgery Unit, Vita-Salute University, San Raffaele Hospital, Milan, Italy
| | - Panagis Lykoudis
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, United Kingdom
| | - Peter Pipan
- Department of HPB and Liver Transplant Surgery, Royal Free Hospital, London, United Kingdom
| | - Francesca Di Salvo
- Pancreatic Surgery Unit, Vita-Salute University, San Raffaele Hospital, Milan, Italy
| | - Nassiba Beghdadi
- Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de l'Appareil Digestif, Université de Paris-Paris Diderot, Beaujon Hospital, Clichy, France
| | - Safi Dokmak
- Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de l'Appareil Digestif, Université de Paris-Paris Diderot, Beaujon Hospital, Clichy, France
| | - Dominik Wiese
- Department of Visceral, Thoracic, and Vascular Surgery, Philipps University, Marburg, Germany
| | - Luca Landoni
- Unit of General and Pancreatic Surgery, University and Hospital Trust of Verona, Italy
| | - Chiara Nessi
- Unit of General and Pancreatic Surgery, University and Hospital Trust of Verona, Italy
| | - O R C Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Jin-Young Jang
- Department of Surgery, Seoul National University College of Medicine, South Korea
| | - Wooil Kwon
- Department of Surgery, Seoul National University College of Medicine, South Korea
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Denver, CO
| | - Chiara Scandavini
- Department of Clinical Science, Intervention, and Technology (CLINTEC), Karolinska Institute, Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Mahmoud Abu-Awwad
- Department of Surgery, University Hospital Southampton, United Kingdom
| | - Thomas Armstrong
- Department of Surgery, University Hospital Southampton, United Kingdom
| | - Mohamed Abu Hilal
- Department of Surgery, University Hospital Southampton, United Kingdom; Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Peter J Allen
- Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Surgical Oncology, Duke University, Durham, NC
| | - Ammar Javed
- Division of Surgical Oncology, Surgical Oncology, Pathology and Oncology, Johns Hopkins Medical Institution, Baltimore, MD
| | - Magnus Kjellman
- Department of Molecular Medicine and Surgery, Division of Endocrine Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Alain Sauvanet
- Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de l'Appareil Digestif, Université de Paris-Paris Diderot, Beaujon Hospital, Clichy, France
| | - Detlef K Bartsch
- Department of Visceral, Thoracic, and Vascular Surgery, Philipps University, Marburg, Germany
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, University and Hospital Trust of Verona, Italy
| | - E J M Nieveen van Dijkum
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Netherlands
| | - M G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Italy
| | - Sun-Whe Kim
- Department of Surgery, Seoul National University College of Medicine, South Korea
| | - Jin He
- Division of Surgical Oncology, Surgical Oncology, Pathology and Oncology, Johns Hopkins Medical Institution, Baltimore, MD
| | - Christofer L Wolfgang
- Division of Surgical Oncology, Surgical Oncology, Pathology and Oncology, Johns Hopkins Medical Institution, Baltimore, MD
| | - Massimo Falconi
- Pancreatic Surgery Unit, Vita-Salute University, San Raffaele Hospital, Milan, Italy
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Abstract
OBJECTIVE The aim of this study was to establish clinically relevant outcome benchmark values using criteria for pancreatoduodenectomy (PD) with portomesenteric venous resection (PVR) from a low-risk cohort managed in high-volume centers. SUMMARY BACKGROUND DATA PD with PVR is regarded as the standard of care in patients with cancer involvement of the portomesenteric venous axis. There are, however, no benchmark outcome indicators for this population which hampers comparisons of patients undergoing PD with and without PVR resection. METHODS This multicenter study analyzed patients undergoing PD with any type of PVR in 23 high-volume centers from 2009 to 2018. Nineteen outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of the centers (NCT04053998). RESULTS Out of 1462 patients with PD and PVR, 840 (58%) formed the benchmark cohort, with a mean age was 64 (SD11) years, 413 (49%) were females. Benchmark cutoffs, among others, were calculated as follows: Clinically relevant pancreatic fistula rate (International Study Group of Pancreatic Surgery): ≤14%; in-hospital mortality rate: ≤4%; major complication rate Grade≥3 and the CCI up to 6 months postoperatively: ≤36% and ≤26, respectively; portal vein thrombosis rate: ≤14% and 5-year survival for patients with pancreatic ductal adenocarcinoma: ≥9%. CONCLUSION These novel benchmark cutoffs targeting surgical performance, morbidity, mortality, and oncological parameters show relatively inferior results in patients undergoing vascular resection because of involvement of the portomesenteric venous axis. These benchmark values however can be used to conclusively assess the results of different centers or surgeons operating on this high-risk group.
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10
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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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11
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Weniger M, Miksch RC, Maisonneuve P, Werner J, D'Haese JG. Improvement of survival after surgical resection of pancreatic cancer independent of adjuvant chemotherapy in the past two decades – A meta-regression. Eur J Surg Oncol 2020; 46:1516-1523. [DOI: 10.1016/j.ejso.2020.02.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/30/2020] [Accepted: 02/14/2020] [Indexed: 02/07/2023] Open
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12
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Fancellu A, Petrucciani N, Porcu A, Deiana G, Sanna V, Ninniri C, Perra T, Celoria V, Nigri G. The Impact on Survival and Morbidity of Portal-Mesenteric Resection During Pancreaticoduodenectomy for Pancreatic Head Adenocarcinoma: A Systematic Review and Meta-Analysis of Comparative Studies. Cancers (Basel) 2020; 12:cancers12071976. [PMID: 32698500 PMCID: PMC7409306 DOI: 10.3390/cancers12071976] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/06/2020] [Accepted: 07/14/2020] [Indexed: 02/07/2023] Open
Abstract
Background: The literature is conflicting regarding oncological outcome and morbidity associated to portal–mesenteric resection during pancreaticoduodenectomy (PD) in patients with pancreatic head adenocarcinoma (PHAC). Methods: A meta-analysis of studies comparing PD plus venous resection (PD+VR) and standard PD exclusively in patients with adenocarcinoma of the pancreatic head was conducted. Results: Twenty-three cohort studies were identified, which included 6037 patients, of which 28.6% underwent PD+VR and 71.4% underwent standard PD. Patients who received PD+VR had lower 1-year overall survival (OS) (odds radio OR 0.79, 95% CI 0.67–0.92, p = 0.003), 3-year OS (OR 0.72, 95% CI 0.59–0.87, p = 0.0006), and 5-year OS (OR 0.57, 95% CI 0.39–0.83, p = 0.003). Patients in the PD+VR group were more likely to have a larger tumor size (MD 3.87, 95% CI 1.75 to 5.99, p = 0.0003), positive lymph nodes (OR 1.24, 95% CI 1.06–1.45, p = 0.007), and R1 resection (OR 1.74, 95% CI 1.37–2.20, p < 0.0001). Thirty-day mortality was higher in the PD+VR group (OR 1.93, 95% CI 1.28–2.91, p = 0.002), while no differences between groups were observed in rates of total complications (OR 1.07, 95% CI, 0.81–1.41, p = 0.65). Conclusions: Although PD+VR has significantly increased the resection rate in patients with PHAC, it has inferior survival outcomes and higher 30-day mortality when compared with standard PD, whereas postoperative morbidity rates are similar. Further research is needed to evaluate the role of PD+VR in the context of multimodality treatment of PHAC.
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Affiliation(s)
- Alessandro Fancellu
- Unit of General Surgery 2—Clinica Chirurgica, Department of Medical Surgical and Experimental Sciences, University of Sassari, V. le San Pietro 43, 07100 Sassari, Italy; (A.P.); (G.D.); (C.N.); (T.P.); (V.C.)
- Correspondence: ; Tel.: +39-079-22-8432
| | - Niccolò Petrucciani
- Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottarossa 1037, 00189 Rome, Italy; (N.P.); (G.N.)
| | - Alberto Porcu
- Unit of General Surgery 2—Clinica Chirurgica, Department of Medical Surgical and Experimental Sciences, University of Sassari, V. le San Pietro 43, 07100 Sassari, Italy; (A.P.); (G.D.); (C.N.); (T.P.); (V.C.)
| | - Giulia Deiana
- Unit of General Surgery 2—Clinica Chirurgica, Department of Medical Surgical and Experimental Sciences, University of Sassari, V. le San Pietro 43, 07100 Sassari, Italy; (A.P.); (G.D.); (C.N.); (T.P.); (V.C.)
| | - Valeria Sanna
- Unit of Medical Oncology, AOU Sassari, Via E. De Nicola, 07100 Sassari, Italy;
| | - Chiara Ninniri
- Unit of General Surgery 2—Clinica Chirurgica, Department of Medical Surgical and Experimental Sciences, University of Sassari, V. le San Pietro 43, 07100 Sassari, Italy; (A.P.); (G.D.); (C.N.); (T.P.); (V.C.)
| | - Teresa Perra
- Unit of General Surgery 2—Clinica Chirurgica, Department of Medical Surgical and Experimental Sciences, University of Sassari, V. le San Pietro 43, 07100 Sassari, Italy; (A.P.); (G.D.); (C.N.); (T.P.); (V.C.)
| | - Valentina Celoria
- Unit of General Surgery 2—Clinica Chirurgica, Department of Medical Surgical and Experimental Sciences, University of Sassari, V. le San Pietro 43, 07100 Sassari, Italy; (A.P.); (G.D.); (C.N.); (T.P.); (V.C.)
| | - Giuseppe Nigri
- Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea University Hospital, Sapienza University of Rome, Via di Grottarossa 1037, 00189 Rome, Italy; (N.P.); (G.N.)
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13
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Radiographic portal or superior mesenteric vein invasion is an independent prognostic factor in non-metastatic pancreatic ductal adenocarcinoma: A missing block of clinical T staging? Pancreatology 2020; 20:952-959. [PMID: 32561070 DOI: 10.1016/j.pan.2020.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 04/16/2020] [Accepted: 05/21/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Venous invasion is not included in the pancreatic ductal adenocarcinoma (PDAC) staging, and its correlation with prognosis remains unclear. We evaluated the prognostic impact of radiographic portal/superior mesenteric vein (PV/SMV) invasion, and its possibility of complementing T staging. METHODS We identified patients with non-metastatic PDAC using our institutional cohort, and divided them according to PV/SMV invasion at imaging, defined as >180-degree tumor-vessel interface or contour deformity. We conducted Cox proportional hazard regression, and compared survival in the original and 1:1 propensity score matched datasets. RESULTS We identified 454 patients [PV/SMV(+): 172; PV/SMV(-): 282]. In the multivariate analysis, PV/SMV invasion, age (≥70 years), performance status, tumor size (2-4, >4 cm), lymph nodes >4, and arterial invasion was correlated with prognosis. The PV/SMV(+) group had a shorter overall survival (OS) than the PV/SMV(-) group in the original (14.4 vs. 20.9 months; P < 0.001) and matched datasets (14.3 vs. 17.2 months; P = 0.009). Among patients without arterial invasion (cT1-cT3), the PV/SMV(+) group had a shorter OS (15.9 vs. 21.2 months; P = 0.002). Moreover, their OS did not differ from that of patients with arterial invasion (cT4) (15.9 vs. 14.4 months; P = 0.907). Patients with vessel (artery/vein) invasion had a shorter OS than those without vessel invasion (14.5 vs. 21.2 months; P < 0.001). CONCLUSIONS Radiographic PV/SMV invasion in non-metastatic PDAC was correlated with a poor prognosis. It could identify a group with shorter OS among patients without arterial invasion (cT1-cT3). It is suggested that inclusion of PV/SMV invasion in clinical T4 criteria should be considered.
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14
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Mathur A, Ross SB, Luberice K, Kurian T, Vice M, Toomey P, Rosemurgy AS. Margin Status Impacts Survival after Pancreaticoduodenectomy but Negative Margins Should Not be Pursued. Am Surg 2020. [DOI: 10.1177/000313481408000416] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Negative margins are the goal with pancreaticoduodenectomy for pancreatic adenocarcinoma. Thereby, margins are assessed intraoperatively with frozen section analysis and negative margins are pursued. This study was undertaken to determine the impact of margin status with pancreaticoduodenectomy for pancreatic adenocarcinoma and the value of extending resections to achieve negative margins. The intraoperative frozen section analysis and final margins for 448 patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma were assessed and their impact on survival was determined. Median data are presented. Two hundred ninety-eight (67%) patients had negative margins (R0), an additional 110 (25%) patients had microscopically positive and macroscopically negative margins (R1), and an additional 40 (9%) patients had initially positive microscopic margins, which became negative with further resection (R1 å R0). R0 resections were more likely to have smaller tumors, earlier T grade, earlier N grade, lower American Joint Committee on Cancer stage, and less frequent extrapancreatic extension ( P ≤ 0.03 for each). Survival was better with R0 resections than R1 resections (20 vs 12 months, P < 0.001); extending resections to achieve negative margins (i.e., R1 ! R0) did not improve survival beyond R1 resections (14 vs 12 months, P = 0.19). Survival after pancreaticoduodenectomy is disappointing. Patients with initial negative margins do best. Positive microscopic margins reflect more aggressive tumor-specific factors and lead to abbreviated survival even with extended resections to achieve negative margins (i.e., R1 ! R0). With an initial positive margin, pursuing negative margins does not improve survival and, thereby, negative margins should not be “chased.”
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Affiliation(s)
- Abhishek Mathur
- University of South Florida, Department of Surgery, Tampa, Florida
| | - Sharona B. Ross
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida; and
| | - Kenneth Luberice
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida; and
| | - Tony Kurian
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida; and
| | - Michelle Vice
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida; and
| | - Paul Toomey
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida; and
- University of South Florida, Department of Surgery, Tampa, Florida
| | - Alexander S. Rosemurgy
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, Tampa, Florida; and
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15
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Bacalbasa N, Balescu I, Dima S, Croitoru A, Brasoveanu V, Vilcu M, Brezean I. Pancreatoduodenectomy En Bloc With Vascular Resections in Borderline Resectable Pancreatic Cancer. In Vivo 2020; 33:2303-2308. [PMID: 31662572 DOI: 10.21873/invivo.11738] [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: 09/06/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND/AIM Pancreatic cancer remains asymptomatic for a long period of time, being frequently diagnosed when vascular invasion is already present. Such cases are widely known as borderline lesions. The aim of this study was to identify the effectiveness of vascular resection in this subgroup of patients. PATIENTS AND METHODS Fifteen such cases were submitted to surgery with curative intent. RESULTS Eight cases were diagnosed with borderline resectable lesions with portal vein invasion and were submitted to per primam resection and seven cases were initially diagnosed with arterial invasion and had been initially submitted to neoadjuvant chemotherapy followed by resection. In all cases portal vein resection was needed while in other four cases association of superior mesenteric artery resection was performed. Postoperatively, five patients developed complications requiring reoperation, three of whom died at the end of the first postoperative month. The histopathological studies confirmed the completeness of resection in all cases. CONCLUSION Vascular resections in pancreatic cancer resections remain demanding procedures, and are reserved for cases in which a radical resection is feasible.
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Affiliation(s)
- Nicolae Bacalbasa
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"I. Cantacuzino" Clinical Hospital, Bucharest, Romania.,"Fundeni" Clinical Institute - Center of Excellence in Translational Medicine, Bucharest, Romania
| | | | - Simona Dima
- "Fundeni" Clinical Institute - Center of Excellence in Translational Medicine, Bucharest, Romania
| | - Adina Croitoru
- "Fundeni" Clinical Institute - Center of Excellence in Translational Medicine, Bucharest, Romania.,"Titu Maiorescu" University, Bucharest, Romania
| | - Vladislav Brasoveanu
- "Fundeni" Clinical Institute - Center of Excellence in Translational Medicine, Bucharest, Romania.,"Titu Maiorescu" University, Bucharest, Romania
| | - Mihaela Vilcu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"I. Cantacuzino" Clinical Hospital, Bucharest, Romania
| | - Iulian Brezean
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,"I. Cantacuzino" Clinical Hospital, Bucharest, Romania
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16
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Zettervall SL, Ju T, Holzmacher JL, Huysman B, Werba G, Sidawy A, Lin P, Vaziri K. Arterial, but Not Venous, Reconstruction Increases 30-Day Morbidity and Mortality in Pancreaticoduodenectomy. J Gastrointest Surg 2020; 24:578-584. [PMID: 30945084 DOI: 10.1007/s11605-019-04211-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 03/11/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Vascular reconstruction during pancreaticoduodenectomy is increasingly utilized to improve pancreatic cancer resectability. However, few multi-institutional studies have evaluated the morbidity and mortality of arterial and venous reconstruction during this procedure. METHODS A retrospective analysis was performed utilizing the targeted pancreas module of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) for pancreaticoduodenectomy from 2014 to 2015. Demographics, comorbidities, and 30-day outcomes for patients who underwent venous or arterial reconstruction and both were compared to no reconstruction. RESULTS A total of 3002 patients were included in our study: 384 with venous reconstruction, 52 with arterial, 81 with both, and 2566 without. Compared to patients without reconstruction, those who underwent venous reconstruction had more congestive heart failure (1.8% vs 0.2%, P < 0.01), those with arterial reconstruction had higher rates of pulmonary disease (11.5% vs. 4.5%, P = 0.02), and neoadjuvant chemotherapy was more common in both venous (34% vs 12%, P < 0.01) and arterial reconstruction (21% vs 12%, P = 0.04). In multivariable analysis, there was no increase in morbidity or mortality following venous reconstruction. However, arterial reconstruction was associated with increased 30-day mortality with an odds ratio (OR): 6.7, 95%; confidence interval (CI): 1.8-25. Morbidity was increased as represented with return to the operating room (OR: 4.5, 95%; CI: 1.5-15), pancreatic fistula (OR: 4.4, 95%; CI: 1.7-11), and reintubation (OR: 3.9, 95%; CI: 1.1-14). CONCLUSIONS Venous reconstruction during pancreaticoduodenectomy does not increase perioperative morbidity or mortality and should be considered for patients previously considered to be unresectable or those where R0 resection would otherwise not be possible due to venous involvement. Careful consideration should be made prior to arterial reconstruction given the significant increase in perioperative complications and death within 30 days.
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Affiliation(s)
- Sara L Zettervall
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
| | - Tammy Ju
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA.
| | - Jeremy L Holzmacher
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
| | - Bridget Huysman
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
| | - Gregor Werba
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
| | - Anton Sidawy
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
| | - Paul Lin
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
| | - Khashayar Vaziri
- Department of Surgery, George Washington University Medical Center, Washington, DC, USA
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17
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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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18
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Xie ZB, Li J, Gu JC, Jin C, Zou CF, Fu DL. Pancreatoduodenectomy with portal vein resection favors the survival time of patients with pancreatic ductal adenocarcinoma: A propensity score matching analysis. Oncol Lett 2019; 18:4563-4572. [PMID: 31611964 PMCID: PMC6781555 DOI: 10.3892/ol.2019.10822] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 07/18/2019] [Indexed: 01/27/2023] Open
Abstract
Portal vein (PV) involvement is common in patients with pancreatic ductal adenocarcinoma (PDAC). To the best of our knowledge, pancreatectomy combined with PV resection (PVR) is the only radical therapy for patients with PV involvement. However, there remains a debate on whether patients with PV involvement could benefit from PVR or not. The present study aimed to compare the survival outcomes between patients receiving pancreatoduodenectomy (PD) with PVR and those receiving PD alone. A total of 377 patients with PDAC were enrolled, 138 patients with PV involvement were placed in the PVR group, while the other 239 patients were in the non-PVR group. To reduce selection bias and estimate the causal effect, 123 pairs of propensity score matched (PSM) patients were selected and compared for the survival outcomes. Before PSM, the survival of patients in the PVR group was worse compared with those in the non-PVR group (mean survival, 25.1 vs. 29.3 months; P=0.038). After balancing the baseline characteristics using the PSM method, the significant survival difference between the two groups was insignificant (mean survival, 25.9 vs. 31.2 months; P=0.364). Tumor stage, body mass index, serum albumin, R1 resection, lymph node metastasis, carbohydrate antigen (CA)125 and CA19-9 were significant independent prognostic factors. The incidence of serious postoperative complications was similar between the two groups. PVR is safe and effective for patients with PDAC. Patients with PV involvement could achieve the similar survival outcome as patients without PV involvement, through radical resection combined with PVR, without increasing the risk of serious complications.
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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, P.R. China
| | - Ji Li
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, P.R. China
| | - Ji-Chun Gu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, P.R. China
| | - Chen Jin
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, P.R. China
| | - Cai-Feng Zou
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, P.R. China
| | - De-Liang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, P.R. China
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19
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Dolay K, Malya FU, Akbulut S. Management of pancreatic head adenocarcinoma: From where to where? World J Gastrointest Surg 2019; 11:143-154. [PMID: 31057699 PMCID: PMC6478601 DOI: 10.4240/wjgs.v11.i3.143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 02/06/2023] Open
Abstract
Pancreatic head adenocarcinoma (PHAC) is one of the most aggressive malignancies, and it has low long-term survival rates. Surgery is the only option for long-term survival. The difficulties associated with PHAC include higher frequencies of regional or distant lymph node metastases and vascular involvement, and positive resection margins in pancreatic and retroperitoneal tissues. Radical resections increase margin negativity and life expectancy; however, the extend of the surgery applied is controversial. Thus, western and eastern centers may use different approaches. Multiorgan, peripancreatic nerve plexus, and vascular resections have been discussed in relation to radical surgery for pancreatic cancer as have the roles of neoadjuvant and adjuvant therapy regimens. Determining the appropriate limits for surgery, standardizing definitions and surgical techniques according to guidelines, and centralizing pancreatic surgery within high-volume institutions to reduce mortality and morbidity rates are among the most important issues to consider. In this review, we evaluate the basic concepts underlying and the roles of radical surgery for PHAC, and lymphadenectomy, nerve plexus, retroperitoneal tissue, vascular, and multivisceral resections, total pancreatectomy, and liver metastases are discussed.
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Affiliation(s)
- Kemal Dolay
- Department of Surgery, Division of Hepato-Pancreato-Biliary Surgery, Istinye University, Liv Hospital, Istanbul 34340, Turkey
| | - Fatma Umit Malya
- Department of Surgery, Bezmialem Vakif University Faculty of Medicine, Istanbul 34093, Turkey
| | - Sami Akbulut
- Department of Surgery and Liver Transplant Institute, Inonu University Faculty of Medicine, Malatya 44280, Turkey
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20
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Kriger AG, Karmazanovsky GG, Smirnov AV, Kharazov AF, Gorin DS, Raevskaya MB, Galkin GV, Revishvili AS. [Diagnosis and treatment of pancreatic head cancer followed by mesenteric-portal vein invasion]. Khirurgiia (Mosk) 2018:21-29. [PMID: 30560841 DOI: 10.17116/hirurgia201812121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIM To evaluate the outcomes of pancreaticoduodenectomy with mesenteric-portal vein resection for pancreatic head cancer. MATERIAL AND METHODS Retrospective analysis included 124 patients with pancreatic head cancer for the period 2010-2017. Mesenteric-portal vein (MPV) invasion was diagnosed in 37 (29.8%) patients, tumor contact with superior mesenteric artery as a borderline resectable state was noted in 11 cases. All patients underwent pancreaticoduodenectomy with mesenteric-portal vein resection. RESULTS Vein invasion was histologically confirmed in 19 (51.3%) out of 37 patients. At the same time, arterial invasion was absent in 11 patients with a borderline resectable tumor. CT-associated overdiagnosis of venous wall invasion was 6.4%, intraoperative overdiagnosis - 87.5%. R0-resection was achieved in 88.5% after conventional pancreaticoduodenectomy and in 78.4% after pancreaticoduodenectomy followed by MPV resection. Median survival was 17 months, 2-year survival - 41%. Among 11 patients with a borderline resectable tumor median survival was 11 months. Pancreaticoduodenectomy without vein resection was followed by 2-year survival near 68.1%. Differences were significant (p=0.02). CONCLUSION Pancreaticoduodenectomy followed by MPV resection as the first stage of combined treatment of pancreatic head cancer is absolutely justified if circumferential involvement of the vein and contact with superior mesenteric artery or celiac trunk do not exceed 50%. Vein resection can provide R0-surgery in these cases.
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Affiliation(s)
- A G Kriger
- Vishnevsky National Medical Research Center of Surgery of Healthcare Ministry of Russia, Moscow, Russia
| | - G G Karmazanovsky
- Vishnevsky National Medical Research Center of Surgery of Healthcare Ministry of Russia, Moscow, Russia
| | - A V Smirnov
- Vishnevsky National Medical Research Center of Surgery of Healthcare Ministry of Russia, Moscow, Russia
| | - A F Kharazov
- Vishnevsky National Medical Research Center of Surgery of Healthcare Ministry of Russia, Moscow, Russia
| | - D S Gorin
- Vishnevsky National Medical Research Center of Surgery of Healthcare Ministry of Russia, Moscow, Russia
| | - M B Raevskaya
- Vishnevsky National Medical Research Center of Surgery of Healthcare Ministry of Russia, Moscow, Russia
| | - G V Galkin
- Vishnevsky National Medical Research Center of Surgery of Healthcare Ministry of Russia, Moscow, Russia
| | - A Sh Revishvili
- Vishnevsky National Medical Research Center of Surgery of Healthcare Ministry of Russia, Moscow, Russia
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21
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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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22
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Cai Y, Gao P, Li Y, Wang X, Peng B. Laparoscopic pancreaticoduodenectomy with major venous resection and reconstruction: anterior superior mesenteric artery first approach. Surg Endosc 2018; 32:4209-4215. [PMID: 29602996 DOI: 10.1007/s00464-018-6167-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 03/21/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND The en bloc resection of the superior mesenteric or portal vein with concomitant venous reconstruction may be required in patients with borderline resectable pancreatic cancer. However, performing laparoscopic pancreaticoduodenectomy (LPD) with major venous resection and reconstruction is technically challenging. Herein, we introduced a safe and feasible technique to perform LPD with major venous resection. METHODS Over the period of November 2015 to November 2016, 18 patients underwent laparoscopic pancreaticoduodenectomy with major venous resection and reconstruction using the anterior superior mesenteric artery (SMA)-first approach at our institution. Demographic characteristics, intraoperative and postoperative variables, and follow-up outcomes were prospectively collected. RESULTS Eighteen male and ten female patients were included in this study. The median age of the patients was 58 years (range 49-76 years). Eight cases of wage resections, six cases of end-to-end anastomosis, and four cases of artificial grafts were performed in our series. Only one patient (5.6%) required conversion because of uncontrolled bleeding from the splenic vein. The average operative time was 448 min (range 420-570 min). The mean time for blood occlusion was 32 min, including 17 min for wage resections, 28 min for end-to-end anastomosis, and 48 min for artificial grafts. Thirty-day mortality was not observed in our series. The median postoperative hospital stay was 13 days (range 9-18 days). Three patients suffered from pancreatic fistula (Grade A), and one suffered from abdominal bleeding after subcutaneous injection with low-molecular heparin. In this case, abdominal bleeding was stopped through conservative therapies. CONCLUSION Laparoscopic pancreaticoduodenectomy with major venous resection and reconstruction can be safely and feasibly performed. The anterior SMA-first approach can facilitate this procedure and decrease operative time and blood occlusion duration.
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Affiliation(s)
- Yunqiang Cai
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hospital, Chengdu, China
| | - Pan Gao
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hospital, Chengdu, China
| | - Yongbin Li
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hospital, Chengdu, China
| | - Xin Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Bing Peng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
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23
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Jouffret L, Guilbaud T, Turrini O, Delpero JR. Pancreaticoduodenectomy with combined superior mesenteric vein resection without reconstruction is possible: A case report and review of the literature. World J Clin Cases 2018; 6:214-218. [PMID: 30148150 PMCID: PMC6107530 DOI: 10.12998/wjcc.v6.i8.214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/10/2018] [Accepted: 06/08/2018] [Indexed: 02/05/2023] Open
Abstract
We report the case of a 56-year-old woman with pancreatic adenocarcinoma (PA) discovered during an episode of febrile jaundice. A computed tomography (CT) scan showed a mass in the head of the pancreas with circumferential infiltration of the superior mesenteric vein (SMV) and dilatation of the biliary and pancreatic ducts without metastases. The patient benefited from neoadjuvant chemotherapy (FOLFIRINOX) followed by radio-chemotherapy (45 Gy) and chemotherapy (LV5FU2). The revaluation CT revealed SMV thrombosis without portal vein (PV) thrombosis. There was no contact of the tumor with the PV. Pancreatoduodenectomy with combined resection of the SMV was performed with no reconstruction of this venous axis after confirmation of adequate PV, splenic, and left gastric venous flow and the absence of bowel ischemia. The pathological diagnosis was pT4N1R0 PA. There were no bowel angina issues during the follow-up period. At 15 mo after surgery, the patient died of metastatic recurrence.
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Affiliation(s)
- Lionel Jouffret
- Department of Surgical Oncology, Institut PaoliCalmettes, Marseille 13009, France
| | - Theophile Guilbaud
- Department of Surgical Oncology, Institut PaoliCalmettes, Marseille 13009, France
| | - Olivier Turrini
- Department of Surgical Oncology, Institut PaoliCalmettes, Marseille 13009, France
| | - Jean-Robert Delpero
- Department of Surgical Oncology, Institut PaoliCalmettes, Marseille 13009, France
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24
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Tee MC, Krajewski AC, Groeschl RT, Farnell MB, Nagorney DM, Kendrick ML, Cleary SP, Smoot RL, Croome KP, Truty MJ. Indications and Perioperative Outcomes for Pancreatectomy with Arterial Resection. J Am Coll Surg 2018; 227:255-269. [PMID: 29752997 DOI: 10.1016/j.jamcollsurg.2018.05.001] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 04/04/2018] [Accepted: 05/03/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pancreatectomy with arterial resection (AR) is performed infrequently. As indications evolve, we evaluated indications, outcomes, and predictors of mortality, morbidity, and survival after AR. STUDY DESIGN We performed a single-institution review of elective pancreatectomies with AR (from July1990 to July 2017). Univariate and multivariate analyses were performed for predictors of outcomes and survival. RESULTS A total of 111 patients underwent pancreatectomy with AR including any hepatic (54%), any celiac (44%), any superior mesenteric (14%), or multiple ARs (14%), with revascularization in 55%. The majority of cases were planned (77%) and performed post-2010 (78%). Overall 90-day major morbidity (≥grade III) and mortality were 54% and 13%, respectively, due to post-pancreatectomy hemorrhage (PPH), postoperative pancreatic fistula (POPF), or ischemia in the majority of cases. There was a significant decrease in mortality post-2010 (9% vs 29%, p = 0.02), and this was protective on multivariate analysis (odds ratio [OR] 0.1, p = 0.004); PPH increased mortality (OR 6.1, p < 0.001). Post-pancreatectomy hemorrhage was associated with major morbidity (OR 5.1, p = 0.005), reoperation (OR = 23.0, p = 0.004), ICU (OR 5.5, p < 0.001), and readmission (OR 2.6, p = 0.004). Other morbidity predictors were AR with graft (OR 4.0, p = 0.031) and POPF (OR 3.1, p = 0.003). Median survival was 28.5 months and improved for ductal adenocarcinoma after neoadjuvant chemotherapy (p = 0.038). There were no differences in survival based on AR type. CONCLUSIONS Regardless of indication or type, pancreatectomy with AR is associated with risks greater than standard resections. Mortality has decreased in the modern era; however, morbidity remains high from hemorrhagic, fistula, or ischemia-related complications. Mitigation measures are needed if advanced resections are considered with increasing frequency given the potential oncologic benefit of AR in selected cases after modern chemotherapy.
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Affiliation(s)
- May C Tee
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | - Rory L Smoot
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - Mark J Truty
- Department of Surgery, Mayo Clinic, Rochester, MN.
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25
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Routine portal vein resection for pancreatic adenocarcinoma shows no benefit in overall survival. Eur J Surg Oncol 2018; 44:1094-1099. [PMID: 29778616 DOI: 10.1016/j.ejso.2018.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 04/27/2018] [Accepted: 05/02/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Extended pancreatic resections including resections of the portal (PV) may nowadays be performed safely. Limitations in distinguishing tumor involvement from inflammatory adhesions however lead to portal vein resections (PVR) without evidence of tumor infiltration in the final histopathological examination. The aim of this study was to analyze the impact of these "false negative" resections on operative outcome and long-term survival. METHODS 40 patients who underwent pancreatic resection with PVR for pancreatic adenocarcinoma (PA) without tumor infiltration of the PV (PVR-group) were identified. In a 1:3 match these patients were compared to 120 patients after standard pancreatic resection without PVR (SPR-group) with regard to operative outcome and overall survival. RESULTS Survival analysis revealed that median survival was significantly shorter in the PVR group (311 days) as compared to the SPR group (558 days), (p = 0.0011, hazard ratio 1.98, 95% CI: 1.31-2.98). Also postoperative complications ≥ Clavien III occurred significantly more often in the PVR group (37.5% vs. 20.8%). CONCLUSIONS Radical resection affords the best chance for long-term survival in patients with PA. Based on the results of this study a routine resection of the PV as recently proposed may however not be recommended.
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26
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Negoi I, Beuran M, Hostiuc S, Negoi RI, Inoue Y. Surgical Anatomy of the Superior Mesenteric Vessels Related to Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis. J Gastrointest Surg 2018; 22:802-817. [PMID: 29363018 DOI: 10.1007/s11605-018-3669-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 01/02/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE Mesopancreas dissection with central vascular ligation and the superior mesenteric artery (SMA)-first approach represent the cornerstone of current principles for radical resection for pancreatic head cancer. The surgeon dissecting around the SMV and SMA should be aware regarding the anatomical variants in this area. The aims of this systematic review and meta-analysis are to detail the surgical anatomy of the superior mesenteric vessels and to propose a standardized terminology with impact in pancreatic cancer surgery. METHODS We conducted a systematic search to identify all published studies in PubMed/MEDLINE and Google Scholar databases from their inception up to March 2017. RESULTS Seventy-eight studies, involving a total of 18,369 specimens, were included. The prevalence of the mesenteric-celiac trunk, replaced/accessory right hepatic artery (RRHA), common hepatic artery, and SMV inversion was 2.8, 13.2, 2.6, and 4.1%, respectively. The inferior pancreaticoduodenal artery has its origin into the first jejunal artery, SMA, and RRHA, in 58.7, 35.8, and 1.2% of cases, respectively. The SMV lacks a common trunk in 7.5% of cases. The first jejunal vein has a trajectory posterior to the SMA in 71.8% of cases. The left gastric vein drains into the portal vein in 58%, in splenic vein (SV) in 35.6%, and into the SV-PV confluence in 5.8% of cases. CONCLUSIONS Complex pancreaticoduodenal resections require detailed knowledge of the superior mesenteric artery and vein, which is significantly different from the one presented in the classical textbooks of surgery. We are proposing the concept of the first jejunopancreatic vein which impacts the current oncological principles of pancreatic head cancer resection.
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Affiliation(s)
- Ionut Negoi
- Carol Davila University of Medicine and Pharmacy Bucharest, No. 8 Floreasca Street, Sector 1, 014461, Bucharest, Romania. .,Department of General Surgery, Emergency Hospital of Bucharest, Romania, Bucharest, Romania.
| | - Mircea Beuran
- Carol Davila University of Medicine and Pharmacy Bucharest, No. 8 Floreasca Street, Sector 1, 014461, Bucharest, Romania.,Department of General Surgery, Emergency Hospital of Bucharest, Romania, Bucharest, Romania
| | - Sorin Hostiuc
- Carol Davila University of Medicine and Pharmacy Bucharest, No. 8 Floreasca Street, Sector 1, 014461, Bucharest, Romania.,Department of Legal Medicine and Bioethics, National Institute of Legal Medicine Mina Minovici, Bucharest, Romania
| | - Ruxandra Irina Negoi
- Carol Davila University of Medicine and Pharmacy Bucharest, No. 8 Floreasca Street, Sector 1, 014461, Bucharest, Romania
| | - Yosuke Inoue
- Department of Gastrointestinal Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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27
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Zhu J, Li X, Kou J, Ma J, Li L, Fan H, Lang R, He Q. Proposed Chaoyang vascular classification for superior mesenteric-portal vein invasion, resection, and reconstruction in patients with pancreatic head cancer during pancreaticoduodenectomy – A retrospective cohort study. Int J Surg 2018; 53:292-297. [PMID: 29654962 DOI: 10.1016/j.ijsu.2018.04.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/21/2018] [Accepted: 04/01/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Jiqiao Zhu
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongtinan Road, Chaoyang District, Beijing 100020, China
| | - Xianliang Li
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongtinan Road, Chaoyang District, Beijing 100020, China
| | - Jiantao Kou
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongtinan Road, Chaoyang District, Beijing 100020, China
| | - Jun Ma
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongtinan Road, Chaoyang District, Beijing 100020, China
| | - Lixin Li
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongtinan Road, Chaoyang District, Beijing 100020, China
| | - Hua Fan
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongtinan Road, Chaoyang District, Beijing 100020, China
| | - Ren Lang
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongtinan Road, Chaoyang District, Beijing 100020, China
| | - Qiang He
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, No.8 Gongtinan Road, Chaoyang District, Beijing 100020, China.
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28
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Inthasotti W, Teepongkaruna SA, Chaibut K, Singhirunusorn J, Duriyaprapan P, Jantarateptewan N, Subwongcharoen S. Perioperative outcomes of pancreaticoduodenectomy: Superior mesenteric artery first approach in Rajavithi Hospital, Thailand. SURGICAL PRACTICE 2018. [DOI: 10.1111/1744-1633.12303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Wipawee Inthasotti
- Department of Surgery; Rajavithi Hospital, College of Medicine, Rangsit University; Bangkok Thailand
| | - Sa-ard Teepongkaruna
- Department of Surgery; Rajavithi Hospital, College of Medicine, Rangsit University; Bangkok Thailand
| | - Kittipong Chaibut
- Department of Surgery; Rajavithi Hospital, College of Medicine, Rangsit University; Bangkok Thailand
| | - Jumpol Singhirunusorn
- Department of Surgery; Rajavithi Hospital, College of Medicine, Rangsit University; Bangkok Thailand
| | - Pornchanan Duriyaprapan
- Department of Surgery; Rajavithi Hospital, College of Medicine, Rangsit University; Bangkok Thailand
| | - Natcha Jantarateptewan
- Department of Surgery; Rajavithi Hospital, College of Medicine, Rangsit University; Bangkok Thailand
| | - Somboon Subwongcharoen
- Department of Surgery; Rajavithi Hospital, College of Medicine, Rangsit University; Bangkok Thailand
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29
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Sheth RA, Sabir SH, Parmet P, Amin R, Kuban JD, Huang SY, Mahvash A, Fogelman D, Javle M, Wallace MJ. Portomesenteric Venous Stenting for Palliation of Ascites and Variceal Bleeding Caused by Prehepatic Portal Hypertension. Oncologist 2017; 23:712-718. [PMID: 29284759 DOI: 10.1634/theoncologist.2017-0337] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 11/09/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate percutaneous transhepatic portal vein stenting (PVS) for palliation of refractory ascites and/or variceal bleeding caused by extrahepatic portomesenteric venous stenosis in patients with pancreaticobiliary cancer. MATERIALS AND METHODS A single-institution, retrospective review of patients who underwent PVS between January 2007 and July 2015 was performed. A total of 38 patients were identified, of whom 28 met the inclusion criterion of PVS performed primarily for refractory ascites or variceal bleeding. In addition to technical success and overall survival, clinical success was measured by fraction of remaining life palliated. The palliative effect of PVS was also quantified by measuring changes in liver and ascites volumes after the procedure. RESULTS Technical success was 93% (26/28). Stent deployment involved more than one portomesenteric vessel in most patients (20/26). The cumulative probability of symptom recurrence at 6, 12, 18, and 24 months was 12%, 16%, 26%, and 40%, respectively. There was a significant difference (p < .001) in the probability of symptom recurrence, recurrence of abdominal ascites, and increase in liver volume between patients whose stents remained patent and those whose stents demonstrated partial or complete occlusion. The mean fraction of remaining life palliated was 87%. All but two patients were found to have improvement in clinical symptoms for the majority of their lives after the procedure. There were no major or minor complications. CONCLUSION As a low-risk procedure with a high clinical success rate, PVS can play a substantial role in improving quality of life in patients with portomesenteric stenoses. IMPLICATIONS FOR PRACTICE Portomesenteric venous stenosis is a challenging complication of pancreaticobiliary malignancy. Portomesenteric stenoses can lead to esophageal, gastric, and mesenteric variceal bleeding, as well as abdominal ascites. The purpose of this study was to evaluate the safety and efficacy of portal vein stenting (PVS) in patients with cancer who have symptomatic portal hypertension caused by portomesenteric venous compression. As a low-risk procedure with a high clinical success rate, PVS can play a substantial role in improving quality of life in patients with portomesenteric stenoses.
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Affiliation(s)
- Rahul A Sheth
- Department of Interventional Radiology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Sharjeel H Sabir
- Department of Interventional Radiology, MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Roshon Amin
- Department of Interventional Radiology, MD Anderson Cancer Center, Houston, Texas, USA
- Department of Radiology, University of Texas Medical School at Houston, Houston, Texas, USA
| | - Joshua D Kuban
- Department of Interventional Radiology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Steven Y Huang
- Department of Interventional Radiology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Armeen Mahvash
- Department of Interventional Radiology, MD Anderson Cancer Center, Houston, Texas, USA
| | - David Fogelman
- Department of Gastrointestinal Medical Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Milind Javle
- Department of Gastrointestinal Medical Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael J Wallace
- Department of Interventional Radiology, MD Anderson Cancer Center, Houston, Texas, USA
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30
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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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31
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Malleo G, Maggino L, Marchegiani G, Feriani G, Esposito A, Landoni L, Casetti L, Paiella S, Baggio E, Lipari G, Capelli P, Scarpa A, Bassi C, Salvia R. Pancreatectomy with venous resection for pT3 head adenocarcinoma: Perioperative outcomes, recurrence pattern and prognostic implications of histologically confirmed vascular infiltration. Pancreatology 2017; 17:847-857. [PMID: 28843714 DOI: 10.1016/j.pan.2017.08.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 07/20/2017] [Accepted: 08/18/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The outcomes of pancreatectomy with superior mesenteric vein (SMV) or portal vein (PV) resection have been mixed. This study investigated the morbidity and mortality profile after SMV-PV resection in comparison with standard pancreatectomy. Furthermore, we assessed whether tumors with histologically proven SMV-PV infiltration differ from other pT3 neoplasms in terms of recurrence pattern and survival. METHODS All patients with a pT3 head adenocarcinoma resected from 2000 to 2013 were analyzed retrospectively. In the SMV-PV resection group, information on venous wall status was obtained through pathologic reports. Standard statistical methods were used for data analysis. RESULTS The study population consisted of 651 patients, of whom 81 (12.4%) underwent synchronous SMV-PV resection. Venous resection was not associated with a higher rate of postoperative complications (60.5% versus 50.2%) and mortality (1.2% versus 1.1%) in comparison with standard pancreatectomy. Vascular infiltration was confirmed pathologically in 56/81 patients (69.1%). The median disease-specific survival of the entire population was 27 months (95% CI 24.6-29.3), with a 5-year survival rate of 20.5%. The median recurrence-free survival was 18 months (95% CI 15.0-20.9). On multivariate analysis, ASA score, preoperative pain, Ca 19-9 levels, tumor grade, R-status, lymph-vascular invasion, N-status, and adjuvant therapy resulted to be survival predictors. Similarly, Ca 19.9 levels, R-status, and N-status were predictors of recurrence. SMV-PV infiltration was not a significant prognostic factor. CONCLUSION Morbidity and mortality rates of pancreatectomy with SMV-PV resection are comparable with standard pancreatectomy. Pancreatic head adenocarcinoma with histologically confirmed SMV-PV infiltration does not segregate prognostically from other pT3 tumors.
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Affiliation(s)
- Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy.
| | - Laura Maggino
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giovanni Feriani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Alessandro Esposito
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Luca Landoni
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Luca Casetti
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Elda Baggio
- Unit of Vascular Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - Giovanni Lipari
- Unit of Vascular Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Italy
| | - Paola Capelli
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Italy
| | - Aldo Scarpa
- Department of Pathology and Diagnostics, University of Verona Hospital Trust, Italy; ARC-NET Research Center, University of Verona Hospital Trust, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
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Tanaka H, Nakao A, Oshima K, Iede K, Oshima Y, Kobayashi H, Kimura Y. Splenic vein reconstruction is unnecessary in pancreatoduodenectomy combined with resection of the superior mesenteric vein-portal vein confluence according to short-term outcomes. HPB (Oxford) 2017. [PMID: 28629642 DOI: 10.1016/j.hpb.2017.02.438] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Superior mesenteric vein-portal vein confluence resection combined with pancreatoduodenectomy (SMPVrPD) is occasionally required for resection of pancreatic head tumors. It remains unclear whether such situations require splenic vein (SV) reconstruction for decompression of left-sided portal hypertension (LSPH). METHODS The data from 93 of 104 patients who underwent pancreatoduodenectomy (PD) for pancreatic head malignancies were reviewed. Surgical outcomes in three groups-standard PD (control group), PD combined with vascular resection and SV preservation (SVp group), and SMPVrPD with SV resection (SVr group)-were compared. The influence of division and preservation of the two natural confluences (left gastric vein-portal vein and/or inferior mesenteric vein-SV confluences) on portal hemodynamics were evaluated using three-dimensional computed tomographic portography. RESULTS No mortality occurred. The morbidity rates were not significantly different among the three groups (18/43, 8/21, and 7/29, respectively; p = 0.306). In the SVr group, three patients had gastric remnant venous congestion, and three had esophageal varices without hemorrhagic potential. No patients had splenomegaly, or severe or prolonged thrombocytopenia. These LSPH-associated findings were less frequently observed when the two confluences were preserved. CONCLUSIONS SMPVrPD without SV reconstruction can be safely conducted. Additionally, preservation of these two confluences may reduce the risk of LSPH.
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Affiliation(s)
| | - Akimasa Nakao
- Department of Surgery, Nagoya Central Hospital, Nagoya, Japan.
| | - Kenji Oshima
- Department of Surgery, Nagoya Central Hospital, Nagoya, Japan
| | - Kiyotsugu Iede
- Department of Surgery, Nagoya Central Hospital, Nagoya, Japan
| | - Yukiko Oshima
- Department of Surgery, Nagoya Central Hospital, Nagoya, Japan
| | | | - Yasunori Kimura
- Department of Surgery, Nagoya Central Hospital, Nagoya, Japan
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Superior Mesenteric-Portal Vein Resection in Patients With Pancreatic Adenocarcinoma Is Safe and May Increase Survival. Int Surg 2017. [DOI: 10.9738/intsurg-d-15-00096.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Extension of pancreatic adenocarcinoma into adjacent vasculature often necessitates resection of the portal vein (PV) and or superior mesenteric vein (SMV) during pancreaticoduodenectomy (PD). Our study describes the surgical technique and results of PV/SMV resection in pancreatic adenocarcinoma patients. Between January 2008 and October 2013, 252 patients underwent PD for pancreatic malignancy. A total of 42 PV/SMV resections were performed (28 men, 14 women). Patients were categorized into 2 groups according to the degree of invasion into the portal vein wall: Group A (n = 16), extended compression of the portal vein wall by the surrounding carcinoma without true invasion, and Group B (n = 26), true invasion including intramural and transmural invasion. Morbidity of the 42 patients was 35%; there was no operative mortality, and overall 1-, 3-, and 5-year survival rates were 60%, 21%, and 12%, respectively. No differences in tumor size, margin positivity, nodal positivity, or survival rates were observed between groups. Resection of the PV/SMV is safe and does not increase morbidity or mortality. Tumor involvement of the PV/SMV is not associated with histopathologic signs that are predictive of a poor prognosis. The “artery first” approach should be considered as a means to facilitate safe venous resection and reconstruction.
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Abstract
Surgical resection is the only potentially curative option in the treatment of pancreatic ductal adenocarcinoma. Preoperative radiological imaging allows to rule out the presence of metastases. Three resectability categories are established based on the radiological findings depending on the degree of contact between the tumor and the blood vessels. Histological confirmation of malignancy is only required in cases of borderline or non-resectable tumors, prior to neoadjuvant treatment initiation. Diagnostic laparoscopy is recommended in the presence of large tumors of the body or tail and in borderline tumors to explore the possibility of resection and to apply treatment with curative intent, as well as in those cases with high level of biomarkers to rule out peritoneal involvement. Prior to surgery preoperative nutritional measures as well as endoscopic biliary drainage can be applied to optimize patient's conditions. Cephalic pancreaticoduodenectomy is the recommended surgical technique in tumors located in the head of the pancreas. The benefits from pyloric preservation, type or reconstruction (one vs. two loops), type of anastomosis (pancreaticojejunostomy vs. pancreaticogastrostomy), intraoperative biopsy of the pancreatic resection margin or the use of intraperitoneal drainages are inconclusive. Total pancreatectomy and/or portal resection should only be performed in particular cases; however, arterial resections have shown no benefits. Radical antegrade modular pancreaticosplenectomy, that can be performed laparoscopically, is the technique used for those tumors located in the pancreatic body-tail.
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Hidalgo M, Álvarez R, Gallego J, Guillén-Ponce C, Laquente B, Macarulla T, Muñoz A, Salgado M, Vera R, Adeva J, Alés I, Arévalo S, Blázquez J, Calsina A, Carmona A, de Madaria E, Díaz R, Díez L, Fernández T, de Paredes BG, Gallardo ME, González I, Hernando O, Jiménez P, López A, López C, López-Ríos F, Martín E, Martínez J, Martínez A, Montans J, Pazo R, Plaza JC, Peiró I, Reina JJ, Sanjuanbenito A, Yaya R, Carrato A. Consensus guidelines for diagnosis, treatment and follow-up of patients with pancreatic cancer in Spain. Clin Transl Oncol 2017; 19:667-681. [PMID: 27995549 PMCID: PMC5427095 DOI: 10.1007/s12094-016-1594-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/24/2016] [Indexed: 12/12/2022]
Abstract
The management of patients with pancreatic cancer has advanced over the last few years. We convey a multidisciplinary group of experts in an attempt to stablish practical guidelines for the diagnoses, staging and management of these patients. This paper summarizes the main conclusions of the working group. Patients with suspected pancreatic ductal adenocarcinoma should be rapidly evaluated and referred to high-volume centers. Multidisciplinary supervision is critical for proper diagnoses, staging and to frame a treatment plan. Surgical resection together with chemotherapy offers the highest chance for cure in early stage disease. Patients with advanced disease should be classified in treatment groups to guide systemic treatment. New chemotherapeutic regimens have resulted in improved survival. Symptomatic management is critical in this disease. Enrollment in a clinical trial is, in general, recommended.
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Affiliation(s)
- M Hidalgo
- Spanish National Cancer Centre, C/Melchor Fernández Almagro, 3, 28029, Madrid, Spain.
- Beth Israel Deaconess Medical Center, Boston, USA.
| | - R Álvarez
- Department of Medical Oncology, Centro Integral Oncológico Clara Campal, Madrid, Spain
| | - J Gallego
- University Hospital of Elche, Elche, Spain
| | - C Guillén-Ponce
- Hospital Universitario Ramón y Cajal, Ctra. de Colmenar Viejo km. 9,100, 28034, Madrid, Spain
| | - B Laquente
- Institut Català d´Oncologia, Duran y Reynals Hospital, Hospitalet Llobregat, Barcelona, Spain
| | - T Macarulla
- Vall d'Hebrón University Hospital, Barcelona, Spain
| | - A Muñoz
- University Hospital Gregorio Marañón, Madrid, Spain
| | - M Salgado
- University Hospital of Ourense, Ourense, Spain
| | - R Vera
- Complejo Hospitalario de Navarra, Pamplona, Spain
| | - J Adeva
- University Hospital 12 de Octubre, Madrid, Spain
| | - I Alés
- Hospital Carlos Haya, Málaga, Spain
| | - S Arévalo
- University Hospital Donostia, San Sebastián, Spain
| | - J Blázquez
- Department of Radiology, University Hospital Ramón y Cajal, Madrid, Spain
- MD Anderson Hospital, Madrid, Spain
| | - A Calsina
- Department of Palliative Care, Hospital Germans Trias I Pujol, Institut Catalá d´Oncologia, Badalona, Spain
| | - A Carmona
- Department of Medical Oncology and Hematology, University Hospital Morales Messeguer, Murcia, Spain
| | - E de Madaria
- Department of Gastroenterology, Hospital General Universitario de Alicante, Alicante, Spain
| | - R Díaz
- Department of Medical Oncology, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - L Díez
- Department of Surgery, Hospital Clínico San Carlos, Madrid, Spain
| | - T Fernández
- Department of Medical Oncology, Hospital Son Llàtzer, Palma de Mallorca, Spain
| | | | - M E Gallardo
- Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - I González
- Complejo Hospitalario de Granada, Granada, Spain
| | - O Hernando
- Department of Radiotherapy, University Hospital HM Sanchinarro, Madrid, Spain
- University Hospital HM Puerta del Sur, Madrid, Spain
| | - P Jiménez
- Department of Medical Oncology, Hospital Universitario Central de Asturias, Asturias, Spain
| | - A López
- Hospital Universitario de Burgos, Burgos, Spain
| | - C López
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - F López-Ríos
- Department of Pathology, University Hospital HM Sanchinarro, Madrid, Spain
| | - E Martín
- Department of Surgery, Hospital Universitario de la Princesa, Madrid, Spain
| | - J Martínez
- Department of Medical Oncology, University Hospital Virgen de las Nieves, Granada, Spain
| | | | - J Montans
- Department of Pathology, Centro Anatomopatológico, Madrid, Spain
| | - R Pazo
- Department of Medical Oncology, University Hospital Miguel Servet, Saragossa, Spain
| | - J C Plaza
- Department of Pathology, University Hospital HM Sanchinarro, Madrid, Spain
| | - I Peiró
- Department of Endocrinology, Instituto Catalán de Oncología, Hospital Duran I Reynals, Hospitalet de Llobregat, Barcelona, Spain
| | - J J Reina
- Department of Medical Oncology, University Hospital Virgen de la Macarena, Seville, Spain
| | - A Sanjuanbenito
- Department of Surgery, University Hospital Ramón y Cajal, Madrid, Spain
| | - R Yaya
- Department of Medical Oncology, Fundación Instituto Valenciano de Oncología, Valencia, Spain
| | - Alfredo Carrato
- Hospital Universitario Ramón y Cajal, Ctra. de Colmenar Viejo km. 9,100, 28034, Madrid, Spain.
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Percutaneous Pancreatic Biopsies-Still an Effective Method for Histologic Confirmation of Malignancy. Surg Laparosc Endosc Percutan Tech 2017; 26:334-7. [PMID: 27438169 DOI: 10.1097/sle.0000000000000288] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine the accuracy and safety of the percutaneous biopsy of pancreatic mass lesions. MATERIALS AND METHODS Over a 12-year period clinical parameters, imaging, pathologic results, and complications were assessed in patients undergoing percutaneous biopsies pancreatic lesions. RESULTS One hundred fifty-three patients underwent pancreatic biopsy. The preferred modality for performing the biopsy was ultrasound (93%, n=143) followed by computerized tomography (7%, n=10). Histologic diagnosis was achieved in 147 patients, of which 3 (2%) were benign and 144 (94%) were malignant. Complications included a single death from overwhelming hemorrhage and 2 patients with morbidity (hematoma and cerebrovascular accident). The sensitivity and specificity of percutaneous biopsies was 90% and 95%, respectively. CONCLUSIONS Ultrasound-guided and computerized tomographic-guided percutaneous biopsy of pancreatic lesions is an effective and safe method to confirm or refute malignancy in suspicious pancreatic lesions. Endoscopic ultrasound-guided Tru-Cut may have the added advantage of avoiding the risk of peritoneal soiling.
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Tajima H, Makino I, Ohbatake Y, Nakanuma S, Hayashi H, Nakagawara H, Miyashita T, Takamura H, Ohta T. Neoadjuvant chemotherapy for pancreatic cancer: Effects on cancer tissue and novel perspectives. Oncol Lett 2017; 13:3975-3981. [PMID: 28599404 DOI: 10.3892/ol.2017.6008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 02/17/2017] [Indexed: 01/05/2023] Open
Abstract
Chemotherapy for pancreatic cancer has diversified following the addition of more treatment regimens; however, in spite of this, pancreatic cancer remains a fatal disease. Preoperative (neoadjuvant) chemotherapy (NAC) or neoadjuvant chemoradiation therapy (NACRT) has been developed and implemented. For patients with borderline resectable pancreatic cancer (BRPC) and locally advanced pancreatic cancer (LAPC), a number of clinical trials have been conducted; NACRT was demonstrated to improve resectability, R0 resection rate, overall survival rate, disease-free survival rate and even an LAPC and BRPC survival advantage over NAC. However, from the knowledge obtained from resected specimens following preoperative treatment, residual pancreatic cancer tissues following NAC are rich in chemoresistant cancer stem-like cells and epithelial-mesenchymal transition (EMT) markers. Conversely, metformin, angiotensin receptor blocker, statins and low-dose paclitaxel are well-known as drugs that inhibit EMT, which is associated with cancer stem cell-like characteristics. Although clinical effectiveness is unlikely to be achieved using one of these as an anticancer agent, it is reasonable to use these drugs for patients with comorbidities in the treatment of pancreatic cancer. Furthermore, gemcitabine (GEM) affects antitumor immunity by stimulating the expression of major histocompatibility complex class I-related chain A on the surface of cancer cells to enhance the cytotoxicity of natural killer cells. Considering EMT and antitumor immunity, there is a possibility that GEM and nanoparticle albumin-bound paclitaxel therapy is the most suitable regimen for treating pancreatic cancer. However, even as preoperative treatment progresses, R0 resection is the most important factor for the long-term survival of pancreatic cancer patients.
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Affiliation(s)
- Hidehiro Tajima
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
| | - Isamu Makino
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
| | - Yoshinao Ohbatake
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
| | - Shinichi Nakanuma
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
| | - Hironori Hayashi
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
| | - Hisatoshi Nakagawara
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
| | - Tomoharu Miyashita
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
| | - Hiroyuki Takamura
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
| | - Tetsuo Ohta
- Department of Gastroenterological Surgery, Division of Cancer Medicine, Graduate School of Medicine Science, Kanazawa University, Kanazawa 920-8641, Japan
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Wang M, Zhang H, Zhu F, Peng F, Wang X, Shen M, Qin RY. Pancreaticoduodenectomy for borderline resectable pancreatic head cancer with a modified artery-first approach technique. Hepatobiliary Pancreat Dis Int 2017; 16:215-221. [PMID: 28381388 DOI: 10.1016/s1499-3872(16)60171-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The treatment of borderline resectable pancreatic head cancer (BRPHC) is still controversial and challenging. The artery-first approaches are described to be the important options for the early determination. Whether these approaches can achieve an increase R0 rate, better bleeding control and increasing long-term survival for BRPHC are still controversial. We compared a previously reported technique, a modified artery-first approach (MAFA), with conventional techniques for the surgical treatment of BRPHC. METHODS A total of 117 patients with BRPHC undergone pancreaticoduodenectomy (PD) from January 2013 to June 2015 were included. They were divided into an MAFA group (n=78) and a conventional-technique group (n=39). Background characteristics, operative data and complications were compared between the two groups. RESULTS Mean operation time was significantly shorter in the MAFA group than that in the conventional-technique group (313 vs 384 min; P=0.014); mean volume of intraoperative blood loss was significantly lower in the MAFA group than that in the conventional-technique group (534 vs 756 mL; P=0.043); and mean rate of venous resection was significantly higher in the conventional-technique group than that in the MAFA group (61.5% vs 35.9%; P=0.014). Pathologic data, early mortality and morbidity were not different significantly between the two groups. CONCLUSIONS MAFA is safe, simple, less time-consuming, less intraoperative blood loss and less venous resection, and therefore, may become a standard surgical approach to PD for BRPHC with the superior mesenteric vein-portal vein involvement but without superior mesenteric artery invasion.
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Affiliation(s)
- Min Wang
- Department of Pancreatic-Biliary Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
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Silvestris N, Brunetti O, Vasile E, Cellini F, Cataldo I, Pusceddu V, Cattaneo M, Partelli S, Scartozzi M, Aprile G, Casadei Gardini A, Morganti AG, Valentini V, Scarpa A, Falconi M, Calabrese A, Lorusso V, Reni M, Cascinu S. Multimodal treatment of resectable pancreatic ductal adenocarcinoma. Crit Rev Oncol Hematol 2017; 111:152-165. [PMID: 28259290 DOI: 10.1016/j.critrevonc.2017.01.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 01/11/2017] [Accepted: 01/24/2017] [Indexed: 01/17/2023] Open
Abstract
After a timing preoperative staging, treatment of resectable pancreatic adenocarcinoma (PDAC) includes surgery and adjuvant therapies, the former representing the initial therapeutic option and the latter aiming to reduce the incidence of both distant metastases (chemotherapy) and locoregional failures (chemoradiotherapy). Herein, we provide a critical overview on the role of multimodal treatment in PDAC and on new opportunities related to current more active poli-chemotherapy regimens, targeted therapies, and the more recent immunotherapy approaches. Moreover, an analysis of pathological markers and clinical features able to help clinicians in the selection of the best therapeutic strategy will be discussed. Lastly, the role of neoadjuvant treatment of initially resectable disease will be considered mostly in patients whose malignancy shows morphological but not clinical or biological criteria of resectability. Depending on the results of these investigational studies, today a multidisciplinary approach can offer the best address therapy for these patients.
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Affiliation(s)
- Nicola Silvestris
- Medical Oncology Unit, Cancer Institute "Giovanni Paolo II", Bari, Italy.
| | - Oronzo Brunetti
- Medical Oncology Unit, Cancer Institute "Giovanni Paolo II", Bari, Italy.
| | - Enrico Vasile
- Department of Oncology, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
| | - Francesco Cellini
- Radiation Oncology Department, Gemelli ART, Università Cattolica del Sacro Cuore, Roma, Italy.
| | - Ivana Cataldo
- ARC-NET Research Centre, University of Verona, Verona, Italy.
| | | | - Monica Cattaneo
- Department of Medical Oncology, University and General Hospital, Udine, Italy.
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy.
| | - Mario Scartozzi
- Medical Oncology Unit, University of Cagliari, Cagliari, Italy.
| | - Giuseppe Aprile
- Department of Medical Oncology, University and General Hospital, Udine, Italy; Department of Medical Oncology, General Hospital of Vicenza, Vicenza, Italy.
| | | | - Alessio Giuseppe Morganti
- Radiation Oncology Center, Dept. of Experimental, Diagnostic and Specialty Medicine - DIMES, University of Bologna, Italy.
| | - Vincenzo Valentini
- Radiation Oncology Department, Gemelli ART, Università Cattolica del Sacro Cuore, Roma, Italy.
| | - Aldo Scarpa
- ARC-NET Research Centre, University of Verona, Verona, Italy.
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, 'Vita-Salute' University, Milan, Italy.
| | - Angela Calabrese
- Radiology Unit, Cancer Institute "Giovanni Paolo II", Bari, Italy.
| | - Vito Lorusso
- Medical Oncology Unit, Cancer Institute "Giovanni Paolo II", Bari, Italy.
| | - Michele Reni
- Medical Oncology Department, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Stefano Cascinu
- Modena Cancer Center, Policlinico di Modena Università di Modena e Reggio Emilia, Italy.
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Bell R, Ao BT, Ironside N, Bartlett A, Windsor JA, Pandanaboyana S. Meta-analysis and cost effective analysis of portal-superior mesenteric vein resection during pancreatoduodenectomy: Impact on margin status and survival. Surg Oncol 2017; 26:53-62. [PMID: 28317585 DOI: 10.1016/j.suronc.2016.12.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 11/21/2016] [Accepted: 12/29/2016] [Indexed: 12/25/2022]
Abstract
INTRODUCTION The benefit of portal-superior mesenteric vein resection (PSMVR) with pancreatoduodenectomy (PD) remains controversial. This study assesses the impact of PSMVR on resection margin status and survival. METHOD An electronic search was performed to identify relevant articles. Pooled odds ratios were calculated for outcomes using the fixed or random-effects models for meta-analysis. A decision analytical model was developed for estimating cost effectiveness. RESULTS Sixteen studies with 4145 patients who underwent pancreatoduodenectomy were included: 1207 patients had PSMVR and 2938 patients had no PSMVR. The R1 resection rate and post-operative mortality was significantly higher in PSMVR group (OR1.59[1.35, 1.86] p=<0.0001, and OR1.72 [1.02,2.92] p = 0.04 respectively). The overall survival at 5-years was worse in the PSMVR group (HR0.20 [0.07,0.55] P = 0.020). Tumour size (p = 0.030) and perineural invasion (P = 0.009) were higher in the PSMVR group. Not performing PSMVR yielded cost savings of $1617 per additional month alive without reduction in overall outcome. CONCLUSION On the basis of retrospective data this study shows that PD with PSMVR is associated with a higher R1 rate, lower 5-year survival and is not cost-effective. It appears that PD with PSMVR can only be justified if R0 resection can be achieved. The continuing challenge is accurate selection of these patients.
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Affiliation(s)
- Richard Bell
- Department of HPB and Transplant Surgery, St James Hospital, Leeds, UK
| | - Braden Te Ao
- Department of Biostatistics and Epidemiology, Auckland University of Technology, Auckland, New Zealand
| | - Natasha Ironside
- HPB/Upper GI Unit, Department of Hepatobiliary and Pancreatic Surgery, Auckland City Hospital, New Zealand
| | - Adam Bartlett
- HPB/Upper GI Unit, Department of Hepatobiliary and Pancreatic Surgery, Auckland City Hospital, New Zealand; Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - John A Windsor
- HPB/Upper GI Unit, Department of Hepatobiliary and Pancreatic Surgery, Auckland City Hospital, New Zealand; Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Sanjay Pandanaboyana
- HPB/Upper GI Unit, Department of Hepatobiliary and Pancreatic Surgery, Auckland City Hospital, New Zealand; Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
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Amico EC, Alves JR, João SA. Splenic vein graft for the reconstruction of the mesenteric-portal trunk after gastroduodenopancreatectomy. Rev Col Bras Cir 2016; 41:381-3. [PMID: 25467106 DOI: 10.1590/0100-69912014005015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 11/15/2013] [Indexed: 12/22/2022] Open
Abstract
Resection of the confluence of the superior mesenteric and portal veins has been performed most frequently in the treatment of adenocarcinoma of the pancreas, in view of the reported positive results, but it can also be used in cases of benign pancreatic neolpasias when they are strongly adhered to the mesenteric-portal trunk. Nevertheless, there is no study on the best type of venous grafts for reconstruction of the mesenteric-portal trunk when required. The choice of graft depends on the preference of the surgeon or the institution. This technical note critically discusses the use of the splenic vein as an option for mesenteric-portal trunk reconstruction after gastroduodenopancreatectomy.
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Affiliation(s)
- Enio Campos Amico
- Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte State, Brazil
| | - José Roberto Alves
- Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte State, Brazil
| | - Samir Assi João
- Universidade Federal do Rio Grande do Norte, Natal, Rio Grande do Norte State, Brazil
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Takahashi H, Akita H, Tomokuni A, Kobayashi S, Ohigashi H, Fijiwara Y, Yano M, Sakon M, Ishikawa O. Preoperative Gemcitabine-based Chemoradiation Therapy for Borderline Resectable Pancreatic Cancer. Ann Surg 2016; 264:1091-1097. [DOI: 10.1097/sla.0000000000001547] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Yamamoto M, Akamatsu N, Aoki T, Sakamoto Y, Tamura S, Hasegawa K, Kokudo N. Safety and efficacy of cryopreserved homologous veins for venous reconstruction in pancreatoduodenectomy. Surgery 2016; 161:385-393. [PMID: 27726914 DOI: 10.1016/j.surg.2016.08.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 05/23/2016] [Accepted: 08/02/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND There are several techniques for reconstructing the portal vein-superior mesenteric vein during pancreatoduodenectomy. The aim of the present study was to present our results with portal vein-superior mesenteric vein reconstruction using cryopreserved homologous veins during pancreatoduodenectomy for patients with pancreatic head cancer. METHODS Patients who underwent pancreatoduodenectomy for pancreatic head cancer were reviewed retrospectively. In patients with portal vein-superior mesenteric vein resection, the detailed method of reconstruction and clinical outcomes were reviewed. Clinical characteristics, patient survival, and portal vein-superior mesenteric vein patency were compared between those with and without homologous vein grafts. Factors affecting the patency of reconstructed veins were assessed by univariate analysis. RESULTS Among 144 patients undergoing pancreatoduodenectomy, portal vein-superior mesenteric vein resection was performed in 36 patients (25%); 18 (50%) underwent reconstruction with homologous veins, and the other 18 (50%) underwent reconstruction without homologous veins. The extent of portal vein-superior mesenteric vein involvement, operative time, duration of clamping of portal vein-superior mesenteric vein, intraoperative blood loss, and length of the venous resection were greater (P ≤ .013 each) in those with homologous vein grafts. There was no significant difference in postoperative morbidity/mortality, patient survival, or portal vein-superior mesenteric vein patency. The 1- and 2-year overall patency of portal vein-superior mesenteric vein was 76% and 71%, respectively, while the 2-year patencies were 67% and 67% in those with homologous veins and 87% and 73% in those without homologous veins without difference between the groups. Circumferential resection and pathologic portal vein-superior mesenteric vein involvement were associated with the patency of the reconstructed vein (P = .002 and P = .028, resp). CONCLUSION Use of homologous venous grafts for portal vein-superior mesenteric vein reconstruction are feasible alternatives during pancreatoduodenectomy for advanced pancreatic head cancer.
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Affiliation(s)
- Masaki Yamamoto
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
| | - Taku Aoki
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Sumihito Tamura
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
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Zhu J, Han D, Li X, Pan F, Ma J, Kou J, Fan H, Lang R, He Q. Inferior Infracolic 'Superior Mesenteric Artery First' Approach with a No-Touch Isolation Surgical Technique in Patients with a Borderline Resectable Cancer of the Pancreatic Head. Ann Surg Oncol 2016; 23:976-980. [PMID: 27600620 DOI: 10.1245/s10434-016-5542-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Early diagnosis of superior mesenteric artery (SMA) involvement is vital for patients with a borderline resectable cancer of the pancreatic head to achieve an R0 resection. We aimed to detect the effect of the inferior infracolic 'superior mesenteric artery first' approach with a no-touch isolation surgical technique in these patients. METHODS The data of 21 patients who were consecutively diagnosed with a borderline resectable cancer of the pancreatic head and treated with our technique between July 2014 and September 2015 were analyzed. RESULTS During the exploration, five patients were confirmed to have invasion to the SMA. Fourteen patients underwent a pancreaticoduodenectomy, and two patients underwent a total pancreatectomy due to a positive margin at the pancreatic neck on frozen sections. Ten men and six women, with a mean age of 64.1 years, were included in the study. Pathologic stage was T1, T2, and T3 in 1, 3, and 12 patients, respectively. Venous resection was performed in 8 patients, and an R0 resection was achieved in all patients (16/16). The mean intraoperative blood loss was 532 ml (range 200-1800 ml). At median follow-up time after surgery (12.8 months; range 4.5-18 months), two patients had a recurrence in the liver. The 1-year survival rate was 75 %, and the 1-year tumor-free survival rate was 62.5 %. CONCLUSIONS Our technique facilitates early diagnosis of arterial involvement and the achievement of an R0 resection. This technique allows the tumor to be resected in situ, and removed en bloc, and is associated with decreased blood loss.
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Affiliation(s)
- Jiqiao Zhu
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Dongdong Han
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xianliang Li
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Fei Pan
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jun Ma
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jiantao Kou
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Hua Fan
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Ren Lang
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Qiang He
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Organ Transplant Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
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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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Superior mesenteric-portal vein resection during laparoscopic pancreatoduodenectomy. Surg Endosc 2016; 31:1488-1495. [PMID: 27444832 DOI: 10.1007/s00464-016-5115-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 07/12/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Laparoscopic pancreatoduodenectomy (LPD) with concomitant resection of major portal vessels has recently emerged as feasible and safe, with similar morbidity and mortality as well as oncologic outcome compared with patients undergoing open PD with major vascular resection. MATERIALS AND METHODS Of a consecutive series of 133 LPD, eight patients underwent concomitant superior mesenteric vein/portal vein (SMV/PV) resection and reconstruction with the intent of achieving a R0 resection. RESULTS Four of these eight patients had tangential resection followed by lateral wall repair with Prolene 4.0. One patient had tangential resection with patch reconstruction. Three patients had circular venous resection: One had end-to-end primary venous reconstruction, and two patients had a prosthetic vascular graft interposition. There was no operative mortality. The SMV/PV was patent in all patients postoperatively on ultrasound Doppler or CT scans. Two patients (who underwent circular venous resection) had postoperative complications. One 77-year-old patient with preexisting cardiovascular disease died of heart failure on postoperative day 2, while another (undergoing prosthetic graft reconstruction) had postoperative bilioenteric anastomotic dehiscence and underwent immediate re-laparoscopy for repair. CONCLUSIONS In our experience, LPD with concomitant major venous resection is feasible even in cases of longitudinal venous invasion. Further studies are needed to evaluate the role of laparoscopy in borderline pancreatic cancer.
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Flis V, Potrc S, Kobilica N, Ivanecz A. Pancreaticoduodenectomy for ductal adenocarcinoma of the pancreatic head with venous resection. Radiol Oncol 2016; 50:321-8. [PMID: 27679549 PMCID: PMC5024653 DOI: 10.1515/raon-2015-0017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 03/26/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Recent reports have shown that patients with vascular tumour invasion who undergo concurrent vascular resection can achieve long-term survival rates equivalent to those without vascular involvement requiring pancreaticoduodenectomy alone. There is no consensus about which patients benefit from the portal-superior mesenteric vein resection and there is no consensus about the best surgical technique of vessel reconstruction (resection with or without graft reconstruction). As published series are small the aim of this study was to evaluate our experience in pancreatectomies with en bloc vascular resection and reconstruction of vessels. METHODS Review of database at University Clinical Centre Maribor identified 133 patients (average age 65.4 ± 8.6 years, 69 female patients) who underwent pancreatoduodenectomy between January 2006 and August 2014. Clinical data, operative results, pathological findings and postoperative outcomes were collected prospectively and analyzed. Current literature and our experience in pancreatectomies with en bloc vascular resection and reconstruction of portal vein are reviewed. RESULTS Twenty-two patients out of 133 (16.5%) had portal vein-superior mesenteric vein resection and portal vein reconstruction (PVR) during pancreaticoduodenectomy. In fourteen patients portal vein was reconstructed without the use of synthetic vascular graft. In these series two types of venous reconstruction were performed. When tumour involvement was limited to the superior mesenteric vein (SPV) or portal vein (PV) such that the splenic vein could be preserved, and vessels could be approximated without tension a primary end-to-end anastomosis was performed. When tumour involved the SMV-splenic vein confluence, splenic vein ligation was necessary. In the remaining eight procedures interposition graft was needed. Dacron grafts with 10 mm diameter were used. There was no infection after dacron grafting. One patient had portal vein thrombosis after surgery: it was thrombosis after primary reconstruction. There were no thromboses in patients with synthetic graft interposition. There were no significant differences in postoperative morbidity, mortality or grades of complication between groups of patients with or without a PVR. Median survival time in months was in a group with vein resection 16.13 months and in a group without vein resection 15.17 months. Five year survival in the group without vein resection was 19.5%. Comparison of survival curves showed equal hazard rates with log-rank p = 0.090. CONCLUSIONS Survival of patients with pancreatic cancer who undergo an R0 resection with reconstruction was comparable to those who have a standard pancreaticoduodenectomy with no added mortality or morbidity. Synthetic graft appeared to be an effective and safe option as an interposition graft for portomesenteric venous reconstruction after pancreaticoduodenectomy.
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Affiliation(s)
- Vojko Flis
- Department of Vascular Surgery, Surgical clinics, University Clinical Centre Maribor, Slovenia
| | - Stojan Potrc
- Department of Vascular Surgery, Surgical clinics, University Clinical Centre Maribor, Slovenia
| | - Nina Kobilica
- Department of Vascular Surgery, Surgical clinics, University Clinical Centre Maribor, Slovenia
| | - Arpad Ivanecz
- Department of Vascular Surgery, Surgical clinics, University Clinical Centre Maribor, Slovenia
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Kleive D, Berstad AE, Verbeke CS, Haugvik SP, Gladhaug IP, Line PD, Labori KJ. Cold-stored cadaveric venous allograft for superior mesenteric/portal vein reconstruction during pancreatic surgery. HPB (Oxford) 2016; 18:615-22. [PMID: 27346143 PMCID: PMC4925797 DOI: 10.1016/j.hpb.2016.05.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 05/08/2016] [Accepted: 05/21/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND SMV/PV resection has become common practice in pancreatic surgery. The aim of this study was to evaluate the technical feasibility and surgical outcome of using cold-stored cadaveric venous allografts (AG) for superior mesenteric vein (SMV) and portal vein (PV) reconstruction during pancreatectomy. METHODS Patients who underwent pancreatic resection with concomitant vascular resection and reconstruction with AG between January 2006 and December 2014 were identified from our institutional prospective database. Medical records and pre- and postoperative CT-images were reviewed. RESULTS Forty-five patients underwent SMV/PV reconstruction with AG interposition (n = 37) or AG patch (n = 8). The median operative time and blood loss were 488 min (IQR: 450-551) and 900 ml (IQR: 600-2000), respectively. Major morbidity (Clavien ≥ III) occurred in 16 patients. Four patients were reoperated (thrombosis n = 2, graft kinking/low flow n = 2) and in-hospital mortality occurred in two patients. On last available CT scan, 3 patients had thrombosis, all of whom also had local recurrence. Estimated cumulative patency rate (reduction in SMV/PV luminal diameter <70% and no thrombosis) at 12 months was 52%. CONCLUSION Cold-stored cadaveric venous AG for SMV/PV reconstruction during pancreatic surgery is safe and associated with acceptable long-term patency.
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Affiliation(s)
- Dyre Kleive
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway,Correspondence: Dyre Kleive, Nydalen, 0424, Oslo, Norway. Tel: +47 23070000. Fax: +47 23072526.NydalenOslo0424Norway
| | | | - Caroline S. Verbeke
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway,Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Sven P. Haugvik
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway,Department of Surgery, Drammen Hospital, Vestre Viken Hospital Trust, Drammen, Norway
| | - Ivar P. Gladhaug
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Pål-Dag Line
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway,Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Knut J. Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
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Advances in the Surgical Management of Resectable and Borderline Resectable Pancreas Cancer. Surg Oncol Clin N Am 2016; 25:287-310. [PMID: 27013365 PMCID: PMC10181830 DOI: 10.1016/j.soc.2015.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Successful surgical resection offers the only chance for cure in patients with pancreatic cancer. However, pancreatic resection is feasible in less than 20% of the patients. In this review, the current state of surgical management of pancreatic cancer is discussed. The definition of resectability based on cross-sectional imaging and the technical aspects of surgery, including vascular resection and/or reconstruction, management of aberrant vascular anatomy and extent of lymphadenectomy, are appraised. Furthermore, common pancreatic resection-specific postoperative complications and their management are reviewed.
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Folkert IW, Hernandez P, Roses RE. Multidisciplinary management of nonfunctional neuroendocrine tumor of the pancreas. World J Gastroenterol 2016; 22:3105-3116. [PMID: 27003988 PMCID: PMC4789986 DOI: 10.3748/wjg.v22.i11.3105] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 01/05/2016] [Accepted: 01/11/2016] [Indexed: 02/06/2023] Open
Abstract
Pancreatic neuroendocrine tumors (PNETs) are a rare and diverse group of tumors; nonfunctional (NF) PNETs account for the majority of cases. Most patients with NF-PNETs have metastatic disease at the time of presentation. A variety of treatment modalities exist, including medical, liver directed, and surgical treatments. Aggressive surgical management is associated with prolonged survival, however available data are limited by selection bias and the frequent combination of PNETs with carcinoid tumors. Although few patients with metastatic disease will be cured, application of currently available therapies in a multidisciplinary setting can lead to excellent outcomes with prolonged patient survival.
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