1
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Asaoka T, Furukawa K, Mikamori M, Hyuga S, Ohashi T, Kazuya I, Nakahara Y, Naito A, Takahashi H, Moon J, Imasato M, Matsuda C, Nishikawa K, Mizushima T. Portal vein wedge resection and patch venoplasty with autologous vein grafts for hepatobiliary-pancreatic cancer. Surg Case Rep 2024; 10:27. [PMID: 38273043 PMCID: PMC10811310 DOI: 10.1186/s40792-024-01823-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/15/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Advanced hepatobiliary-pancreatic cancer often invades critical blood vessels, including the portal vein (PV) and hepatic artery. Resection with tumor-free resection margins is crucial to achieving a favorable prognosis in these patients. Herein, we present our cases and surgical techniques for PV wedge resection with patch venoplasty using autologous vein grafts during surgery for pancreatic ductal adenocarcinoma (PDAC) and perihilar cholangiocarcinoma (PhCC). CASE PRESENTATION Case 1: 73-year-old female patient with PDAC; underwent subtotal stomach-preserving pancreatoduodenectomy, with superior mesenteric vein wedge resection and venoplasty with the right gonadal vein. Case 2: 67-year-old male patient with PDAC; underwent distal pancreatectomy and celiac axis resection, with PV wedge resection and venoplasty with the middle colic vein. Case 3: 51-year-old female patient with type IV PhCC; underwent left hepatectomy with caudate lobectomy and bile duct resection, with hilar PV wedge resection and venoplasty with the inferior mesenteric vein (IMV). Case 4: 69-year-old male patient with type IIIA PhCC; underwent right hepatopancreatoduodenectomy, with hilar PV resection and patch venoplasty with the IMV. All patients survived for over 12 months after the surgery, without local recurrence. CONCLUSIONS PV wedge resection and patch venoplasty is a useful technique for obtaining tumor-free margins in surgeries for hepatobiliary-pancreatic cancer.
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Affiliation(s)
- Tadafumi Asaoka
- Department of Gastroenterological Surgery, Osaka Police Hospital, 10-31 Kitayamacho, Tennouji-Ku, Osaka, 543-0035, Japan.
| | - Kenta Furukawa
- Department of Gastroenterological Surgery, Osaka Police Hospital, 10-31 Kitayamacho, Tennouji-Ku, Osaka, 543-0035, Japan
| | - Manabu Mikamori
- Department of Gastroenterological Surgery, Osaka Police Hospital, 10-31 Kitayamacho, Tennouji-Ku, Osaka, 543-0035, Japan
| | - Satoshi Hyuga
- Department of Gastroenterological Surgery, Osaka Police Hospital, 10-31 Kitayamacho, Tennouji-Ku, Osaka, 543-0035, Japan
| | - Tomofumi Ohashi
- Department of Gastroenterological Surgery, Osaka Police Hospital, 10-31 Kitayamacho, Tennouji-Ku, Osaka, 543-0035, Japan
| | - Iwamoto Kazuya
- Department of Gastroenterological Surgery, Osaka Police Hospital, 10-31 Kitayamacho, Tennouji-Ku, Osaka, 543-0035, Japan
| | - Yujiro Nakahara
- Department of Gastroenterological Surgery, Osaka Police Hospital, 10-31 Kitayamacho, Tennouji-Ku, Osaka, 543-0035, Japan
| | - Atsushi Naito
- Department of Gastroenterological Surgery, Osaka Police Hospital, 10-31 Kitayamacho, Tennouji-Ku, Osaka, 543-0035, Japan
| | - Hidekazu Takahashi
- Department of Gastroenterological Surgery, Osaka Police Hospital, 10-31 Kitayamacho, Tennouji-Ku, Osaka, 543-0035, Japan
| | - Jeongho Moon
- Department of Gastroenterological Surgery, Osaka Police Hospital, 10-31 Kitayamacho, Tennouji-Ku, Osaka, 543-0035, Japan
| | - Mitsunobu Imasato
- Department of Gastroenterological Surgery, Osaka Police Hospital, 10-31 Kitayamacho, Tennouji-Ku, Osaka, 543-0035, Japan
| | - Chu Matsuda
- Department of Gastroenterological Surgery, Osaka Police Hospital, 10-31 Kitayamacho, Tennouji-Ku, Osaka, 543-0035, Japan
| | - Kazuhiro Nishikawa
- Department of Gastroenterological Surgery, Osaka Police Hospital, 10-31 Kitayamacho, Tennouji-Ku, Osaka, 543-0035, Japan
| | - Tsunekazu Mizushima
- Department of Gastroenterological Surgery, Osaka Police Hospital, 10-31 Kitayamacho, Tennouji-Ku, Osaka, 543-0035, Japan
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2
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Can E, Daum S, Lenk J, Paparoditis S, Hosse C, Elkilany A, de Bucourt M. Treatment of right hepatic artery stump bleeding after pylorus-preserving pancreaticoduodenectomy by covered stent endoprosthesis placement. Radiol Case Rep 2023; 18:1494-1497. [PMID: 36747908 PMCID: PMC9898279 DOI: 10.1016/j.radcr.2023.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 01/07/2023] [Indexed: 02/05/2023] Open
Abstract
Serious complications after pancreaticoduodenectomy include rupture of pseudoaneurysms arising from pancreatic fistula and pancreatojejunostomy leakage. We report a case of successful endovascular minimally invasive treatment using a covered stent endoprosthesis of a right hepatic artery stump bleeding following pylorus-preserving pancreaticoduodenectomy that was not suitable for coil or glue embolization due to an insufficiently short neck.
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Affiliation(s)
- Elif Can
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
- Corresponding author.
| | - Severin Daum
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department for Medicine (Gastroenterology, Infectious Diseases, Rheumatology), Hindenburgdamm 30, 12200, Berlin, Germany
| | - Julian Lenk
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Sophia Paparoditis
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Clarissa Hosse
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Aboelyazid Elkilany
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
| | - Maximilian de Bucourt
- Department of Diagnostic and Interventional Radiology, Charité-Universitätsmedizin Berlin, Hindenburgdamm 30, 12200, Berlin, Germany
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3
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Olakowski M, Grudzińska E. Pancreatic head cancer - Current surgery techniques. Asian J Surg 2023; 46:73-81. [PMID: 35680512 DOI: 10.1016/j.asjsur.2022.05.117] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/30/2022] [Accepted: 05/20/2022] [Indexed: 12/24/2022] Open
Abstract
Pancreatic head cancer is a highly fatal disease. For now, surgery offers the only potential long-term cure albeit with a high risk of complications. However, the progress of surgical technique during the past decade has resulted in 5-year survival approaching 30% after resection and adjuvant chemotherapy. This paper presents current data on the recommended extent of lymphadenectomy, the resection margin, on the definition of resectable and borderline resectable tumors and mesopancreas. Surgical techniques proposed to improve PD are presented: the artery first approach, the uncinate process first, the mesopancreas first approach, the triangle operation, periarterial divestment, and multiorgan resection.
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Affiliation(s)
- Marek Olakowski
- Department of Gastrointestinal Surgery, Medical University of Silesia, Medyków 14, 40-752, Katowice, Poland
| | - Ewa Grudzińska
- Department of Gastrointestinal Surgery, Medical University of Silesia, Medyków 14, 40-752, Katowice, Poland.
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4
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Conticchio M, Salloum C, Allard MA, Golse N, Pittau G, Ciacio O, Vibert E, Sa Cunha A, Cherqui D, Adam R, Azoulay D. The rex shunt for left portal vein reconstruction during hepatectomy for malignancy using of rex-shunt in adults for oncoliver surgery. Surg Endosc 2022; 36:8249-8254. [PMID: 35441315 DOI: 10.1007/s00464-022-09270-2] [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: 01/08/2022] [Accepted: 04/09/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Immediate portal reperfusion is mandatory following hepatectomy combined with portal vein (PV) resection. This retrospective study analyzes the feasibility and the outcomes of the Rex shunt (RS) for reconstruction of the left portal vein (LPV) and reperfusion of the remnant left liver or lobe following hepatectomy for cancer combined with resection of the PV in adult patients. METHODS From 2018 to 2021, an RS was used in the above setting to achieve R0 resection or when the standard LPV reconstruction failed or was deemed technically impossible. RESULTS There were 6 male and 5 female patients (median age, 58 years) with perihilar cancer (5 cases) or miscellaneous cancers invading the PV (6 cases). A major hepatectomy was performed in 10/11 patients. The RS was indicated to achieve R0 resection or for technical reasons in 8 and 3 cases, respectively, and was feasible in all consecutive attempts with (10 cases) or without an interposed synthetic graft (1 case). Two fatal complications (PV thrombosis and pulmonary embolism) and three non-severe complications occurred in four patients within 90 days of surgery. Two patients died of tumor recurrence with a patent RS at 13 and 29 months, and 7 were recurrence free with a patent shunt with a follow-up of 1 to 37 months (median, 15 months). CONCLUSION In case of remnant left liver or lobe following hepatectomy combined with resection of the PV, the RS may help to achieve R0 resection and is a valuable option to perform technically satisfying portal reperfusion of the remnant left liver or lobe.
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Affiliation(s)
- Maria Conticchio
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France
| | - Chady Salloum
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France
| | - Marc Antoine Allard
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 935, Villejuif, France
| | - Nicolas Golse
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 935, Villejuif, France
| | - Gabriella Pittau
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 935, Villejuif, France
| | - Oriana Ciacio
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 935, Villejuif, France
| | - Eric Vibert
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 935, Villejuif, France
| | - Antonio Sa Cunha
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 935, Villejuif, France
| | - Daniel Cherqui
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 935, Villejuif, France
| | - René Adam
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France.,Université Paris-Saclay, Saclay, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 935, Villejuif, France
| | - Daniel Azoulay
- Centre Hépato-Biliaire, Assistance Publique - Hôpitaux de Paris, Hôpital Universitaire Paul Brousse, 94000, Villejuif, France. .,Université Paris-Saclay, Saclay, France.
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5
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Alva-Ruiz R, Abdelrahman AM, Starlinger PP, Yonkus JA, Moravec DN, Busch JJ, Fleming CJ, Andrews JC, Mendes BC, Colglazier JJ, Smoot RL, Cleary SP, Nagorney DM, Kendrick ML, Truty MJ. Patency rates of hepatic arterial resection and revascularization in locally advanced pancreatic cancer. HPB (Oxford) 2022; 24:1957-1966. [PMID: 35780039 DOI: 10.1016/j.hpb.2022.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 05/02/2022] [Accepted: 06/13/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Arterial resection (AR) for pancreatic adenocarcinoma is increasingly considered at specialized centers. We aimed to examine the incidence, risk factors, and outcomes of hepatic artery (HA) occlusion after revascularization. METHODS We included patients undergoing HA resection with interposition graft (IG) or primary end-to-end anastomoses (EE). Complete arterial occlusion (CAO) was defined as "early" (EO) or "late" (LO) before/after 90 days respectively. Kaplan-Meier and change-point analysis for CAO was performed. RESULTS HA resection was performed in 108 patients, IG in 61% (66/108) and EE in 39% (42/108). An equal proportion (50%) underwent HA resection alone or in combination with celiac and/or superior mesenteric artery. CAO was identified in 18% of patients (19/108) with arterial IG least likely to occlude (p=0.019). Hepatic complications occurred in 42% (45/108) and correlated with CAO, symptomatic patients, venous resection, and postoperative portal venous patency. CAO-related operative mortality was 4.6% and significantly higher in EO vs LO (p = 0.046). Median CAO occlusion was 126 days. With change-point analysis, CAO was minimal beyond postoperative day 158. CONCLUSION CAO can occur in up to 18% of patients and the first 5-month post-operative period is critical for surveillance. LO is associated with better outcomes compared to EO unless there is inadequate portal venous inflow.
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Affiliation(s)
- Roberto Alva-Ruiz
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Amro M Abdelrahman
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Patrick P Starlinger
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Jennifer A Yonkus
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - David N Moravec
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Joel J Busch
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Chad J Fleming
- Division of Vascular & Interventional Radiology, Department of Radiology, Mayo Clinic Rochester, MN, USA
| | - James C Andrews
- Division of Vascular & Interventional Radiology, Department of Radiology, Mayo Clinic Rochester, MN, USA
| | - Bernardo C Mendes
- Division of Vascular & Endovascular Surgery, Department of Surgery, Mayo Clinic Rochester MN, USA
| | - Jill J Colglazier
- Division of Vascular & Endovascular Surgery, Department of Surgery, Mayo Clinic Rochester MN, USA
| | - Rory L Smoot
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Sean P Cleary
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - David M Nagorney
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Michael L Kendrick
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA
| | - Mark J Truty
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Mayo Clinic Rochester, MN, USA.
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6
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Nakao A. Isolated pancreatectomy using mesenteric approach. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 29:293-300. [PMID: 34863031 PMCID: PMC9306750 DOI: 10.1002/jhbp.1092] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/19/2021] [Indexed: 01/02/2023]
Abstract
In 1981, we developed the first antithrombogenic bypass catheter for the portal system. This catheter‐bypass procedure relieved the time limitation caused by portal occlusion and facilitated safe and easy resection and reconstruction of the portal vein or hepatic artery. We thereafter explored isolated pancreatoduodenectomy, in which pancreatoduodenectomy is performed under non‐touch isolation techniques. It is difficult to perform isolated pancreatoduodenectomy because of the complex arterial anatomy of the peripancreatic head region. In 1992, a mesenteric approach was developed for pancreatoduodenectomy. This approach allows dissection from the non‐cancerous side and determination of both cancer‐free margins and resectability followed by systematic lymphadenectomy around the superior mesenteric artery. This approach also enables early ligation of the inferior pancreatoduodenal artery and dorsal pancreatic artery branches from the superior mesenteric artery, as well as complete excision of the total mesopancreas (which is thought to be the second portion of the pancreatic head nerve plexus). Through this development of the mesenteric approach and antithrombogenic catheter‐bypass procedure, our isolated pancreatoduodenectomy was finally established in 1992. This is the ideal surgery for pancreatic head cancer from both surgical and oncological aspects. We herein introduce the precise surgical techniques.
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Affiliation(s)
- Akimasa Nakao
- Department of Surgery, Nagoya Central Hospital, Nagoya, Japan
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7
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Khachfe HH, Habib JR, Harthi SA, Suhool A, Hallal AH, Jamali FR. Robotic pancreas surgery: an overview of history and update on technique, outcomes, and financials. J Robot Surg 2021; 16:483-494. [PMID: 34357526 DOI: 10.1007/s11701-021-01289-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 07/31/2021] [Indexed: 02/06/2023]
Abstract
The use robotics in surgery is gaining momentum. This approach holds substantial promise in pancreas surgery. Robotic surgery for pancreatic lesions and malignancies has become well accepted and is expanding to more and more center annually. The number of centers using robotics in pancreatic surgery is rapidly increasing. The most studied robotic pancreas surgeries are pancreaticoduodenectomy and distal pancreatectomy. Most studies are in their early phases, but they report that robotic pancreas surgery is safe feasible. Robotic pancreas surgery offers several advantages over open and laparoscopic techniques. Data regarding costs of robotics versus conventional techniques is still lacking. Robotic pancreas surgery is still in its early stages. It holds promise to become the new surgical standard for pancreatic resections in the future, however, more research is still needed to establish its safety, cost effectiveness and efficacy in providing the best outcomes.
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Affiliation(s)
- Hussein H Khachfe
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA. .,Division of GI Surgical Oncology, Department of Surgery, UPMC Pancreatic Cancer Center, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, Pittsburgh, PA, USA.
| | - Joseph R Habib
- Division of General Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| | - Salem Al Harthi
- Department of Surgery, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | - Amal Suhool
- Department of Surgery, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | - Ali H Hallal
- Department of Surgery, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
| | - Faek R Jamali
- Department of Surgery, Sheikh Shakhbout Medical City, Abu Dhabi, UAE
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8
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Liu L, Liu TX, Huang WX, Yang Z, Wang S, Da MX, Dong Y. Distal pancreatectomy with En-bloc celiac axis resection for locally advanced pancreatic body/tail cancer: A systematic review and meta-analysis. Asian J Surg 2021; 45:51-61. [PMID: 34187724 DOI: 10.1016/j.asjsur.2021.06.002] [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: 01/12/2021] [Revised: 04/09/2021] [Accepted: 06/02/2021] [Indexed: 11/02/2022] Open
Abstract
Distal pancreatectomy with En-bloc celiac axis resection (DP-CAR) is a challenging procedure that has yielded certain clinical efficacy in the treatment of locally advanced pancreatic body/tail cancer, especially in patients with invasion of abdominal vessels. However, the clinical efficacy and safety of DP-CAR remain controversial. The study aimed to systematically review efficacy and safety of DP-CAR in the treatment of locally advanced pancreatic body/tail cancer. We systematically searched PubMed, EMBASE, Cochrane Library, and Web of Science databases from inception to 1 October 2020. Two studiers independently accomplished the study selection, data extraction, and quality assessment. Initially, of 1032 studies were searched, among which 11 high quality studies including 1072 patients were finally identified. The pooled results showed that DP-CAR versus Distal pancreatectomy (DP), the rate of R0 resection (RR = 0.76; 95%CI: 0.66 to 0.88; p = 0.0002) and 3-year survival (RR = 0.65; 95%CI: 0.43 to 0.98; p = 0.04) was lower, postoperative mortality (RR = 2.48; 95%CI: 1.02 to 6.03; p = 0.04) was higher, the operation time (MD = 104.67; 95%CI: 84.70 to 124.64; p < 0.001) and hospital stay (MD = 3.94, 95% CI 1.35 to 6.53; p = 0.003) were longer. There was no statistical difference between the DP-CAR and DP group in 1-year, 2-year survival rate (RR = 0.84; 95%CI: 0.57 to 1.23; p = 0.37) (RR = 0.70; 95%CI: 0.45 to 1.10; p = 0.12). In conclusion, compared with DP, DP-CAR has worse efficacy and prognosis survival and is more dangerous, but it can obtain better survival benefit and quality of life than palliative treatment. We suggest that DP-CAR can be carefully attempted for effective margin-negative resection. However, surgeons and patients need to know its potential perioperative risk.
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Affiliation(s)
- Lu Liu
- College of Clinical Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou, China; Department of Surgical Oncology, Gansu Provincial Hospital, Lanzhou, China
| | - Tian-Xiang Liu
- Department of Surgical Oncology, Gansu Provincial Hospital, Lanzhou, China
| | - Wan-Xia Huang
- College of Clinical Medicine, Ningxia Medical University, Yinchuan, China
| | - Zhong Yang
- Department of Surgical Oncology, Gansu Provincial Hospital, Lanzhou, China
| | - Shang Wang
- College of Clinical Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou, China
| | - Ming-Xu Da
- Department of Surgical Oncology, Gansu Provincial Hospital, Lanzhou, China.
| | - Yang Dong
- The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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9
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Controlling the arterial supply into the pancreatic head region as a whole peripancreatic arterial arcade via a mesenteric approach during isolated pancreatoduodenectomy. Surg Today 2021; 51:1819-1827. [PMID: 34014389 DOI: 10.1007/s00595-021-02298-2] [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: 01/07/2021] [Accepted: 02/28/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The peripancreatic arterial system forms various arterial arcades and collateral branches; therefore, it stands to reason that the arterial supply into the pancreatic head region should be controlled as a whole peripancreatic arterial arcade rather than as the three major supplying arteries during isolated pancreatoduodenectomy (PD). We investigated the clinical importance of early control of the whole peripancreatic arterial arcade during PD. METHODS The subjects of this retrospective study were 63 consecutive patients who underwent PD via a mesenteric approach at our hospital between October, 2014 and February, 2017. The patients were divided into an early control group (n = 27) and a late control group (n = 36) for comparative analysis. RESULTS The peripancreatic arterial arcades and collateral branches were seen on preoperative multidetector row computed tomography (CT) images and during PD in all 63 patients. The early control group had significantly less intraoperative blood loss than the late control group. Early control of the whole peripancreatic arterial arcade was an independent factor associated with lower intraoperative blood loss in the multivariable analysis (P = 0.012). CONCLUSION The arterial supply into the pancreatic head region should be controlled as a whole peripancreatic arterial arcade rather than as the three major supplying arteries during isolated PD.
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10
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Radical Resection for Locally Advanced Pancreatic Cancers in the Era of New Neoadjuvant Therapy-Arterial Resection, Arterial Divestment and Total Pancreatectomy. Cancers (Basel) 2021; 13:cancers13081818. [PMID: 33920314 PMCID: PMC8068970 DOI: 10.3390/cancers13081818] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 12/20/2022] Open
Abstract
Simple Summary Aggressive arterial resection or total pancreatectomy in surgical treatment for locally advanced pancreatic cancer (LAPC) has gradually been encouraged thanks to new chemotherapy regimens such as FOLFIRINOX or Gemcitabine and nab-paclitaxel, which have provided more adequate patient selection and local tumor suppression, justifying aggressive local resection. The development of surgical techniques provides the safety of arterial resection (AR) for even major visceral arteries, such as the celiac axis or superior mesenteric artery. Total pancreatectomy has been re-evaluated as an effective option to balance both the local control and postoperative safety. In this review, we investigate the recent reports focusing on arterial resection and total pancreatectomy for locally advanced pancreatic cancer (LAPC) and discuss the rationale of such an aggressive approach in the treatment of PC. Abstract Aggressive arterial resection (AR) or total pancreatectomy (TP) in surgical treatment for locally advanced pancreatic cancer (LAPC) had long been discouraged because of their high mortality rate and unsatisfactory long-term outcomes. Recently, new chemotherapy regimens such as FOLFIRINOX or Gemcitabine and nab-paclitaxel have provided more adequate patient selection and local tumor suppression, justifying aggressive local resection. In this review, we investigate the recent reports focusing on arterial resection and total pancreatectomy for LAPC and discuss the rationale of such an aggressive approach in the treatment of PC. AR for LAPCs is divided into three, according to the target vessel. The hepatic artery resection is the simplest one, and the reconstruction methods comprise end-to-end, graft or transposition, and no reconstruction. Celiac axis resection is mainly done with distal pancreatectomy, which allows collateral arterial supply to the liver via the pancreas head. Resection of the superior mesenteric artery is increasingly reported, though its rationale is still controversial. Total pancreatectomy has been re-evaluated as an effective option to balance both the local control and postoperative safety. In conclusion, more and more aggressive pancreatectomy has become justified by the principle of total neoadjuvant therapy. Further technical standardization and optimal neoadjuvant strategy are mandatory for the global dissemination of aggressive pancreatectomies.
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11
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Sonohara F, Yamada S, Kurimoto K, Inokawa Y, Takami H, Hayashi M, Shimizu D, Hattori N, Kanda M, Tanaka C, Nakayama G, Koike M, Fujii T, Kodera Y. Age-Related Differences in the Prognosis of Pancreatic Cancer According to Perioperative Systemic Therapy. Pancreas 2021; 50:37-46. [PMID: 33370021 DOI: 10.1097/mpa.0000000000001712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES In this study, we retrospectively assessed the feasibility and prognostic efficacy of perioperative chemo(radio)therapy for pancreatic cancer (PC) patients according to age. METHODS A total of 556 consecutive patients who underwent curative-intent pancreatectomy for PC between 2000 and 2018 were enrolled. RESULTS Of the 556 patients who underwent resection, 95 (17%) were elderly (age, ≥75 years). Postoperative complications did not significantly differ between the 2 age groups, and postoperative prognoses were also similar (recurrence-free survival [RFS], P = 0.68; overall survival [OS], P = 0.28). In this cohort, 103 patients (19%) underwent preoperative chemo(radio)therapy, and 417 (77%) underwent postoperative chemotherapy. Perioperative therapy was found to be significantly beneficial for younger patients (preoperative therapy: RFS, P = 0.006; OS, P < 0.001; postoperative therapy: RFS, P < 0.001; OS, P < 0.001). Conversely, no significant survival benefit of perioperative therapy was found for the elderly (preoperative therapy: RFS, P = 0.28; OS, P = 0.44; postoperative therapy: RFS, P = 0.77; OS, P = 0.08). CONCLUSIONS This study demonstrated that, although perioperative therapy is feasible for selected elderly patients with PC, this approach might not be as beneficial as it is for younger PC patients.
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Affiliation(s)
- Fuminori Sonohara
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Suguru Yamada
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Keisuke Kurimoto
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Yoshikuni Inokawa
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Hideki Takami
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Masamichi Hayashi
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Dai Shimizu
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Norifumi Hattori
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Mitsuro Kanda
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Chie Tanaka
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Goro Nakayama
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Masahiko Koike
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Yasuhiro Kodera
- From the Department of Gastroenterological Surgery, Graduate School of Medicine, Nagoya University, Nagoya
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12
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Schmidt T, Strobel O, Schneider M, Diener MK, Berchtold C, Mihaljevic AL, Mehrabi A, Müller-Stich BP, Hackert T, Büchler MW. Cavernous transformation of the portal vein in pancreatic cancer surgery-venous bypass graft first. Langenbecks Arch Surg 2020; 405:1045-1050. [PMID: 32915294 PMCID: PMC7541372 DOI: 10.1007/s00423-020-01974-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/23/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND In recent years, several techniques have been introduced to allow safe oncologic resections of cancers of the pancreatic head. While resections of the mesenterico-portal axis became now a part of the routine treatment, patients with a cavernous transformation of the portal vein still pose a surgical challenge and are regularly deemed unresectable. OBJECTIVE Here, we describe a technique of initial venous bypass graft placement between the superior mesenteric vein or its tributaries and the portal vein before the resection of the pancreatic head. This approach avoids uncontrollable bleeding as well as venous congestion of the intestine with a continuous hepatic perfusion and facilitates oncologic resection of pancreatic head cancers. This technique, in combination with previously published resection strategies, enables tumor resection in locally advanced pancreatic head cancers. CONCLUSIONS Venous bypass graft first operations facilitate and enable the resection of the pancreatic head cancers in patients with a cavernous transformation of the portal vein thus rendering these patients resectable.
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Affiliation(s)
- Thomas Schmidt
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Christoph Berchtold
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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13
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Mizutani S, Taniai N, Furuki H, Shioda M, Ueda J, Aimoto T, Motoda N, Nakamura Y, Yoshida H. Treatment of Advanced Pancreatic Body and Tail Cancer by En Bloc Distal Pancreatectomy with Transverse Mesocolon Resection Using a Mesenteric Approach. J NIPPON MED SCH 2020; 88:301-310. [PMID: 32863347 DOI: 10.1272/jnms.jnms.2021_88-408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pancreatic body and tail cancer easily invades retroperitoneal tissue, including the transverse mesocolon. It is difficult to ensure a dissected peripancreatic margin with standard distal pancreatectomy for advanced pancreatic body and tail cancer. Thus, we developed a novel surgical procedure to ensure dissection of the peripancreatic margin. This involved performing dissection deeper than the fusion fascia of Toldt and further extensive en bloc resection of the root of the transverse mesocolon. We performed distal pancreatectomy with transverse mesocolon resection (DP-TCR) using a mesenteric approach and achieved good outcomes. METHODS There are two main considerations for surgical procedures using a mesenteric approach: 1) dissection deeper than the fusion fascia of Toldt (securing the vertical margin) and 2) modular resection of the pancreatic body and tail, with the root of the transverse mesocolon and adjacent organs in a horizontal direction (ensuring the caudal margin). RESULTS From 2017 to 2019, we performed DP-TCR using a mesenteric approach for six patients with advanced pancreatic body and tail cancer. Histopathological radical surgery was possible in all patients who underwent DP-TCR. No Clavien-Dindo grade IIIa or worse perioperative complications were observed in any patient. CONCLUSIONS We believe that DP-TCR is useful as a radical surgery for advanced pancreatic body and tail cancer with extrapancreatic invasion.
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Affiliation(s)
- Satoshi Mizutani
- Department of Digestive Surgery, Nippon Medical School Musashikosugi Hospital
| | - Nobuhiko Taniai
- Department of Digestive Surgery, Nippon Medical School Musashikosugi Hospital
| | - Hiroyasu Furuki
- Department of Digestive Surgery, Nippon Medical School Musashikosugi Hospital
| | - Mio Shioda
- Department of Digestive Surgery, Nippon Medical School Musashikosugi Hospital
| | - Junji Ueda
- Department of Digestive Surgery, Nippon Medical School Musashikosugi Hospital
| | - Takayuki Aimoto
- Department of Digestive Surgery, Nippon Medical School Musashikosugi Hospital
| | - Norio Motoda
- Department of Pathology, Nippon Medical School Musashikosugi Hospital
| | - Yoshiharu Nakamura
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Hospital
| | - Hiroshi Yoshida
- Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School Hospital
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14
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Małczak P, Sierżęga M, Stefura T, Kacprzyk A, Droś J, Skomarovska O, Krzysztofik M, Major P, Pędziwiatr M. Arterial resections in pancreatic cancer - Systematic review and meta-analysis. HPB (Oxford) 2020; 22:961-968. [PMID: 32360186 DOI: 10.1016/j.hpb.2020.04.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 02/20/2020] [Accepted: 04/09/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The number of pancreatic resections due to cancers is increasing. While concomitant venous resections are routinely performed in specialized centers, arterial resections are still controversial. Nevertheless they are performed in patients presenting with locally advanced tumors. Our aim was to summarize currently available literature comparing peri-operative and long-term outcomes of arterial and non-arterial pancreatic resections. METHODS We included studies comparing pancreatic operations with and without concomitant arterial resection. Inclusion criteria were morbidity or mortality. Studies additionally reporting venous resections with no possibility of excluding this data during the extraction were discarded. RESULTS The initial search yielded 1651 records. Finally, 19 studies were included in the analysis involving 2710 patients. Arterial resection was associated with a greater risk of death(RR: 4.09; p < 0.001) and complications (RR: 1.4; p = 0.01). There were no differences in the rate of pancreatic fistula, biliary fistula rate, cardiopulmonary complications, length of hospital stay and non-R0 rate. Oncologically, patients after arterial resection were at higher risk of worse 3-year survival. CONCLUSION Arterial resection in pancreatic cancer is associated with an increased risk of mortality and complications in comparison to standard non-arterial resections. Nevertheless, arterial resection may become a viable treatment for selected patients in high volume centers.
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Affiliation(s)
- Piotr Małczak
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland.
| | - Marek Sierżęga
- 1st Department of Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Tomasz Stefura
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Artur Kacprzyk
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Jakub Droś
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Oksana Skomarovska
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Marta Krzysztofik
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland
| | - Piotr Major
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
| | - Michał Pędziwiatr
- 2nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland; Centre for Research, Training and Innovation in Surgery (CERTAIN Surgery), Krakow, Poland
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15
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Kuwabara S, Matsumoto J, Tojima H, Wada H, Kato K, Tabata Y, Ichinokawa M, Yoshioka T, Murakawa K, Ikeda A, Ohtake S, Ono K. Colonic varices treated with embolization after pancreatoduodenectomy with portal vein resection: a case report. Surg Case Rep 2020; 6:126. [PMID: 32494925 PMCID: PMC7270471 DOI: 10.1186/s40792-020-00888-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/27/2020] [Indexed: 12/11/2022] Open
Abstract
Background Pancreatoduodenectomy with resection of the portal vein or superior mesenteric vein confluence has been safely performed in patients with pancreatic head cancer associated with infiltration of the portal vein or superior mesenteric vein. In recent years, left-sided portal hypertension, a late postoperative complication, has received focus owing to increased long-term survival with advances in chemotherapy. Left-sided hypertension may sometimes cause fatal gastrointestinal bleeding because of the rupture of gastrointestinal varices. Here, we present a case of colonic varices caused by left-sided portal hypertension after pancreatoduodenectomy with portal vein resection. Case presentation A 69-year-old man diagnosed with pancreatic head cancer was referred to our department for surgery after undergoing chemotherapy with nine courses of gemcitabine and nab-paclitaxel. Computed tomography showed a mass 25 mm in diameter and in contact with the portal vein. He had undergone subtotal stomach-preserving pancreatoduodenectomy with portal vein resection. Four centimeters of the portal vein had been resected, and end-to-end anastomosis was performed without splenic vein reconstruction. We had to completely resect the right colic vein, accessary right colic vein, and middle colic vein due to tumor invasion. The pathological diagnosis was ypT3, ypN1a, ypM0, and ypStageIIB, and he was administered TS-1 as postoperative adjuvant chemotherapy. Seven months after therapeutic radical surgery, he presented with melena with progressive anemia. Computed tomography revealed transverse colonic varices. He was offered interventional radiology. Trans-splenic arterial splenic venography showed that transverse colonic varices had developed as collateral circulation of the splenic vein and inferior mesenteric vein system. An embolic substance was injected into the transverse colonic varices, which halted the progression of the anemia caused by melena. Fifteen months after therapeutic radical surgery, local recurrence of the tumor occurred; he died 28 months after the surgery. Conclusions When subtotal stomach-preserving pancreatoduodenectomy with portal vein resection is performed without splenic vein reconstruction, colonic varices may result from left-sided portal hypertension. Interventional radiology is an effective treatment for gastrointestinal bleeding due to colonic varices, but it is important to be observant for colonic necrosis and new varices.
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Affiliation(s)
- Shota Kuwabara
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan.
| | - Joe Matsumoto
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Hiroyasu Tojima
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Hideyuki Wada
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Kohei Kato
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Yukiko Tabata
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Masaomi Ichinokawa
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Tatsuya Yoshioka
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Katsuhiko Murakawa
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Atsushi Ikeda
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Setsuyuki Ohtake
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Koichi Ono
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
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16
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Shiihara M, Higuchi R, Izumo W, Yazawa T, Uemura S, Furukawa T, Yamamoto M. Retrospective evaluation of risk factors of postoperative varices after pancreaticoduodenectomy with combined portal vein resection. Pancreatology 2020; 20:522-528. [PMID: 32111565 DOI: 10.1016/j.pan.2020.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/23/2020] [Accepted: 02/19/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Combined portal vein (PV) resection is performed for pancreatic head cancer to achieve clear resection margins. This can be complicated by the formation of varices due to sinistral portal hypertension after pancreaticoduodenectomy (PD) with combined PV resection. However, clinical strategies to prevent varices formation due to sinistral portal hypertension remain controversial. Moreover, the critical vein among splenic vein (SPV), inferior mesenteric vein, left gastric vein, or middle colonic vein requiring preservation to prevent the development of varices remains unclear. METHODS We retrospectively analyzed patients with pancreatic cancer who underwent PD with combined PV resection over 18 years at our institution. Varices were evaluated using enhanced computed tomography (CT) and endoscopy. Preoperative types of porto-mesenterico-splenic confluence, venous drainage, and venous resection types were determined by operative records and CT findings. RESULTS Of the 108 subjects, the incidence of postoperative varices was observed in 24.1% of cases over 5.6 months. These varices were classified into five types based on location, as pancreaticojejunostomy anastomotic (11.5%), gastrojejunostomy anastomotic (11.5%), esophageal (11.5%), splenic hilar-gastric (23.1%), and right colonic (65.4%) varices. No case of variceal bleeding occurred. Multivariate analysis showed SPV ligation as the greatest risk factor of varices (P < 0.001), with a higher incidence of left-sided varices in patients with all the SPV venous drainage sacrificed (60%) than in the others (16.7%). Therefore, sacrificing all the SPV venous drainage was the only independent risk factor of varices (P = 0.049). CONCLUSIONS Preservation of SPV venous drainage should be considered during SPV ligation to prevent post-PD varices.
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Affiliation(s)
- Masahiro Shiihara
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Japan; Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Japan.
| | - Wataru Izumo
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Japan
| | - Takehisa Yazawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Japan
| | - Shuichiro Uemura
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Japan
| | - Toru Furukawa
- Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Japan
| | - Masakazu Yamamoto
- Department of Investigative Pathology, Tohoku University Graduate School of Medicine, Japan
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17
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Nakao mesenteric approach in pancreatoduodenectomy for pancreatic head cancer. JOURNAL OF PANCREATOLOGY 2019. [DOI: 10.1097/jp9.0000000000000031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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18
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Clinical impact of additional therapy for residual pancreatic cancer. Surg Today 2019; 50:440-448. [PMID: 31650262 DOI: 10.1007/s00595-019-01900-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/10/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE This study aimed to explore the prognostic significance of the resection margin (R) status of pancreatic ductal adenocarcinoma (PDAC) patients receiving neoadjuvant therapy (NAT) or adjuvant chemotherapy (AC). METHODS We retrospectively reviewed 427 consecutive patients, and the overall survival (OS) and disease-free survival (DFS) were analyzed based on the R status by a propensity score analysis (PSA). RESULTS The R0 ratio of the NAT (+) group was significantly higher than that of the NAT (-) group (97.2% vs. 69.6%, P < 0.0001). Local recurrence was well controlled in the NAT (+) group compared to the NAT (-) group (15.3% vs. 34.1%, P = 0.0013). The PSA revealed no significant survival difference between R0 and R1 resection among those treated with AC (median survival time [MST]: 43.0 vs. 33.3 months, matching hazard ratio [HR]: 1.212, P = 0.5708). Furthermore, the DFS in R0 and R1 resection followed by AC was identical (MST: 20.6 vs. 17.7 months, matching HR: 1.020, P = 0.9482). CONCLUSIONS NAT was a significant predictor of R0 resection. When patients completed AC, there were no marked differences in the OS or DFS between R0 and R1 resection. Our results demonstrated that the clinical impact of the R1 status has waned in the current era of PDAC management.
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19
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Biological and conditional factors should be included when defining criteria for resectability for patients with pancreatic cancer. HPB (Oxford) 2019; 21:1211-1218. [PMID: 30773450 DOI: 10.1016/j.hpb.2019.01.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/18/2019] [Accepted: 01/21/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aimed to evaluate novel resectability criteria for pancreatic ductal adenocarcinoma (PDAC) proposed by the International Association of Pancreatology (IAP) by comparing them with the National Comprehensive Cancer Network (NCCN) guidelines. METHODS 369 patients who underwent upfront surgery for PDAC were retrospectively analyzed. Overall survival (OS) of each group as defined by either of the guidelines were compared and preoperative prognostic factors for OS were identified. RESULTS Based on the IAP-criteria, 157 patients were classified as resectable (R), 192 as borderline resectable (BR) and 20 as unresectable (UR), with the median survival time (MST) of 40 months, 17 and 11, respectively. In contrast to the NCCN-criteria, BR demonstrated significantly better OS than UR (P = 0.023) under the IAP-criteria. Performance status ≥2 (hazard ratio [HR]: 2.47, P = 0.014) and lymph node metastasis suspected by imaging (HR: 1.55, P = 0.003) were identified as independent prognostic factors by the multivariate analysis along with portal or arterial invasion, while carbohydrate antigen 19-9 ≥ 500 U/ml was not (HR: 1.23, P = 0.190). CONCLUSION The IAP-criteria, which includes biological and conditional factors, resulted in superior separation of survival curves stratified by the resectablity when compared with the NCCN-criteria.
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20
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Conversion surgery for initially unresectable pancreatic cancer: current status and unresolved issues. Surg Today 2019; 49:894-906. [PMID: 30949842 DOI: 10.1007/s00595-019-01804-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/17/2019] [Indexed: 12/16/2022]
Abstract
Pancreatic cancer is one of the most lethal of all malignancies. One of the reasons for the dismal prognosis is that most diagnoses are made when the disease is either locally advanced or metastatic. Recent advances in chemotherapy and chemoradiotherapy (CRT) enable "conversion surgery" to be performed for selected patients with initially unresectable pancreatic cancer following favorable responses to preoperative treatment. Using FOLFIRINOX as preoperative treatment, the resection rate was reported as 6-44% of patients with locally advanced cancer and the prognosis of these patients was favorable. Even for metastasized cancer, recent reports show the effectiveness of conversion surgery, which has achieved 27-56 months of median overall survival. However, there are many unanswered questions about conversion surgery. The optimal regimen and duration of preoperative treatment remain unclear and there is still debate regarding the safety and effectiveness of vascular resection, which is often required for curative resection of locally advanced cancer. Accumulation of more data on conversion surgery is required to establish the safety and effectiveness of this treatment. In this review, we summarize the current status and unresolved issues about conversion surgery for initially unresectable pancreatic cancer.
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21
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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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Abstract
OBJECTIVES The aims of the study were to compare survival outcomes between patients with pancreatic ductal adenocarcinoma (PDAC) and invasive intraductal papillary mucinous neoplasms (IPMN) and to determine candidates for adjuvant chemotherapy. METHODS A total of 579 consecutive patients, including 375 PDAC and 204 IPMN patients, were reviewed. Stage-matched comparisons of survival data were conducted using the Cox proportional hazards model and propensity analysis. To evaluate prognostic factors, univariate and multivariate Cox regression analyses were performed. RESULTS The overall survival for invasive IPMN was significantly longer than that for PDAC (hazard ratio, 2.34; P = 0.0001). When the analysis was limited to stage I patients, the 5-year overall survival rate of invasive IPMN patients was significantly better than that of PDAC patients (100% vs 74.1%, P = 0.0092); however, no difference was observed between stage II patients with invasive IPMN and PDAC (hazard ratio, 1.49; P = 0.09). The Cox proportional hazards model and propensity analysis demonstrated no difference in stage-matched survival. Multivariate analysis revealed that only T (≥3) was an independent prognostic factor for invasive IPMN. CONCLUSIONS Stage-matched analysis did not show a significant survival difference between invasive IPMN and PDAC patients, and T3 or higher was an independent prognostic factor for invasive IPMN.
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23
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Kato Y, Yamada S, Suenaga M, Takami H, Niwa Y, Hayashi M, Iwata N, Kanda M, Tanaka C, Nakayama G, Koike M, Fujiwara M, Kodera Y. Impact of the Controlling Nutritional Status Score on the Prognosis After Curative Resection of Pancreatic Ductal Adenocarcinoma. Pancreas 2018; 47:823-829. [PMID: 29975352 DOI: 10.1097/mpa.0000000000001105] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The controlling nutritional status (CONUT) score is a useful tool to evaluate immune-nutritional status. This study aimed to investigate the impact of the CONUT score on short- and long-term outcomes after curative resection of pancreatic ductal adenocarcinoma (PDAC). METHODS Consecutive 344 PDAC patients receiving pancreatectomy without neoadjuvant therapy were examined retrospectively. After the best predictive value of the CONUT score for survival was identified, association between the CONUT score and long-term outcomes was evaluated using log-rank tests and a Cox regression model. Then correlations between the CONUT score and postoperative complications were analyzed. RESULTS The optimal cutoff value of the CONUT score was 4. The high CONUT score group showed significantly lower overall survival than the low CONUT score group (P = 0.002). In contrast, no significant difference in recurrence-free survival was found (P = 0.43). A multivariate analysis demonstrated that high CONUT score had an independent association with overall survival (hazard ratio, 1.64; P = 0.003). The CONUT score showed no association with postoperative pancreatic fistula, Clavien-Dindo grade, or postoperative hospital stay. CONCLUSION The CONUT score had an independent association with survival in patients with PDAC after pancreatectomy and was not associated with recurrence or postoperative complications.
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Affiliation(s)
- Yoshiyasu Kato
- From the Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
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24
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Einama T, Kamachi H, Tsuruga Y, Sakata T, Shibuya K, Sakamoto Y, Shimada S, Wakayama K, Orimo T, Yokoo H, Kamiyama T, Katoh N, Uchinami Y, Mitsuhashi T, Taketomi A. Optimal resection area for superior mesenteric artery nerve plexuses after neoadjuvant chemoradiotherapy for locally advanced pancreatic carcinoma. Medicine (Baltimore) 2018; 97:e11309. [PMID: 30075497 PMCID: PMC6081073 DOI: 10.1097/md.0000000000011309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 05/26/2018] [Indexed: 02/05/2023] Open
Abstract
Recently, several reports demonstrated the efficacy of neoadjuvant chemotherapy (NAC) or chemoradiotherapy (NACRT) for patients with borderline resectable (BRPC) and locally advanced unresectable pancreatic carcinoma (LAPC). The aim of this study was to evaluate the treatment response after NACRT, especially for nerve plexuses, and the optimal resection area for superior mesenteric artery nerve plexuses in BRPC and LAPC patients after NACRT.A total of 17 patients with BRPC and LAPC received preoperative gemcitabine-based NACRT. The numbers of BRPC and LAPC patients were 13 and 4, respectively. We evaluated nerve plexus invasion by CT before and after NACRT, decided on the resection area of plexus invasion in SMA before NACRT, and compared the preoperative evaluation and clinicopathological findings.In the plexus of the supra-mesenteric artery (pl-SMA), arterial nerve plexus invasion, in cases <90°, all patients showed the absence of residual cancer in the resected specimen after NACRT. In cases between 90° and 180°, 1 of 2 patients (50%) showed nerve plexus invasion. In cases over 180°, all patients showed nerve plexus invasion. We could perform R0 resection in all 10 cases, and pl-SMA invasion disappeared in 6 of 7 BRPC patients.We demonstrated the relationship between the angle of nerve plexus tumor invasion and treatment effect after NACRT. We could perform R0 resection in all pl-SMA invasion cases, deciding on the resection area of pl-SMA based on CT before NACRT.
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Affiliation(s)
- Takahiro Einama
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
- Department of Surgery, National Defense Medical College, Saitama, Japan
| | - Hirofumi Kamachi
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Yosuke Tsuruga
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Toshihiro Sakata
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Kazuaki Shibuya
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Yuzuru Sakamoto
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Shingo Shimada
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Kenji Wakayama
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Tatsuya Orimo
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Hideki Yokoo
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Toshiya Kamiyama
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
| | - Norio Katoh
- Department of Radiation Oncology, Hokkaido University Graduate School of Medicine, Sapporo
| | - Yusuke Uchinami
- Department of Radiation Oncology, Hokkaido University Graduate School of Medicine, Sapporo
| | - Tomoko Mitsuhashi
- Department of Surgical Pathology, Hokkaido University Hospital Sapporo, Hokkaido
| | - Akinobu Taketomi
- Gastroenterological Surgery I, Hokkaido University Graduate School of Medicine, Sapporo
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25
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Iede K, Nakao A, Oshima K, Suzuki R, Yamada H, Oshima Y, Kobayashi H, Kimura Y. Early ligation of the dorsal pancreatic artery with a mesenteric approach reduces intraoperative blood loss during pancreatoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:329-334. [PMID: 29747222 DOI: 10.1002/jhbp.562] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Early ligation of the inferior pancreatoduodenal artery has been advocated to reduce blood loss during pancreatoduodenectomy. However, the impact of early ligation of the dorsal pancreatic artery (DPA) remains unclear. This study was performed to investigate the clinical implications of early ligation of the DPA. METHODS From October 2014 to April 2017, 34 consecutive patients underwent pancreatoduodenectomy using a mesenteric approach. The patients were divided into the early DPA ligation group (n = 15) and late DPA ligation group (n = 19). The clinical features were retrospectively compared between the two groups (H29-044). RESULTS Preoperative multidetector row computed tomography and intraoperative findings revealed that the right branch of the DPA supplied the pancreatic head region in all cases. Intraoperative blood loss was significantly lower in the early than late ligation group (median 609 ml [range 94-1,013 ml] vs. 764 ml [range 367-1,828 ml], respectively; P = 0.008). Multivariable analysis revealed that early DPA ligation was independently associated with blood loss (P = 0.023). The DPAs arising from the superior mesenteric artery underwent early ligation at a significantly higher rate. CONCLUSIONS Early ligation of the DPA during pancreaticoduodenectomy with a mesenteric approach could reduce intraoperative blood loss.
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Affiliation(s)
- Kiyotsugu Iede
- Department of Surgery, Nagoya Central Hospital, 3-7-7 Taiko, Nakamura-ku, Nagoya, 453-0801, Japan
| | - Akimasa Nakao
- Department of Surgery, Nagoya Central Hospital, 3-7-7 Taiko, Nakamura-ku, Nagoya, 453-0801, Japan
| | - Kenji Oshima
- Department of Surgery, Nagoya Central Hospital, 3-7-7 Taiko, Nakamura-ku, Nagoya, 453-0801, Japan
| | - Ryota Suzuki
- Department of Surgery, Nagoya Central Hospital, 3-7-7 Taiko, Nakamura-ku, Nagoya, 453-0801, Japan
| | - Hironori Yamada
- Department of Surgery, Nagoya Central Hospital, 3-7-7 Taiko, Nakamura-ku, Nagoya, 453-0801, Japan
| | - Yukiko Oshima
- Department of Surgery, Nagoya Central Hospital, 3-7-7 Taiko, Nakamura-ku, Nagoya, 453-0801, Japan
| | - Hironobu Kobayashi
- Department of Surgery, Nagoya Central Hospital, 3-7-7 Taiko, Nakamura-ku, Nagoya, 453-0801, Japan
| | - Yasunori Kimura
- Department of Surgery, Nagoya Central Hospital, 3-7-7 Taiko, Nakamura-ku, Nagoya, 453-0801, Japan
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26
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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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27
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Evaluation and proposal of novel resectability criteria for pancreatic cancer established by the Japan Pancreas Society. Surgery 2017; 162:784-791. [DOI: 10.1016/j.surg.2017.04.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/11/2017] [Accepted: 04/14/2017] [Indexed: 01/08/2023]
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28
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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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29
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Maeta T, Ebata T, Hayashi E, Kawahara T, Mizuno S, Matsumoto N, Ohta S, Nagino M. Pancreatoduodenectomy with portal vein resection for distal cholangiocarcinoma. Br J Surg 2017; 104:1549-1557. [PMID: 28782798 DOI: 10.1002/bjs.10596] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 04/07/2017] [Accepted: 04/12/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Little is known about the value of portal vein (PV) resection in distal cholangiocarcinoma. The aim of this study was to evaluate the clinical significance of PV resection in distal cholangiocarcinoma. METHODS Patients who underwent pancreatoduodenectomy (PD) for distal cholangiocarcinoma between 2001 and 2010 at one of 31 hospitals in Japan were reviewed retrospectively with special attention to PV resection. Short- and long-term outcomes were evaluated. RESULTS In the study interval, 453 consecutive patients with distal cholangiocarcinoma underwent PD, of whom 31 (6·8 per cent) had combined PV resection. The duration of surgery (510 versus 427 min; P = 0·005) and incidence of blood transfusion (48 versus 30·7 per cent; P = 0·042) were greater in patients who had PV resection than in those who did not. Postoperative morbidity and mortality were no different in the two groups. Several indices of tumour progression, including high T classification, lymphatic invasion, perineural invasion, pancreatic invasion and lymph node metastasis, were more common in patients who had PV resection. Consequently, the incidence of R1/2 resection was higher in this group (32 versus 11·8 per cent; P = 0·004). Survival among the 31 patients with PV resection was worse than that for the 422 patients without PV resection (15 versus 42·4 per cent at 5 years; P < 0·001). Multivariable analyses revealed that age, blood loss, histological grade, perineural invasion, pancreatic invasion, lymph node metastasis and surgical margin were independent risk factors for overall survival. PV resection was not an independent risk factor. CONCLUSION PV invasion in distal cholangiocarcinoma is associated with locally advanced disease and several negative prognostic factors. Survival for patients who have PV resection is poor even after curative resection.
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Affiliation(s)
- T Maeta
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - T Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - E Hayashi
- Department of Surgery, Japan Community Health Care Organization Chukyo Hospital, Nagoya, Japan
| | - T Kawahara
- Department of Surgery, Daido Hospital, Nagoya, Japan
| | - S Mizuno
- Department of Surgery, Shizuoka Kosei Hospital, Shizuoka, Japan
| | - N Matsumoto
- Department of Surgery, Hekinan Municipal Hospital, Hekinan, Japan
| | - S Ohta
- Department of Surgery, Kani Tono Hospital, Kani, Japan
| | - M Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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30
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Jegatheeswaran S, Baltatzis M, Jamdar S, Siriwardena AK. Superior mesenteric artery (SMA) resection during pancreatectomy for malignant disease of the pancreas: a systematic review. HPB (Oxford) 2017; 19:483-490. [PMID: 28410913 DOI: 10.1016/j.hpb.2017.02.437] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 02/01/2017] [Accepted: 02/16/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Resection of the superior mesenteric artery (SMA) during pancreatectomy is performed infrequently and is undertaken with the aim of removing non-metastatic locally advanced pancreatic tumours. SMA resection reports also encompass resection of other visceral vessels. The consequences of resection of these different arteries are not necessarily equivalent. This is a focused systematic review of the outcome of SMA resection during pancreatectomy for cancer. METHODS A computerized search of the English language literature was undertaken for the period 1st January 2000 through 30th April 2016. The keywords "Pancreatic surgery" and "Vascular resections" were used. Thirteen studies reported 70 patients undergoing pancreatectomy with SMA resection from 10,726 undergoing pancreatectomy. Individual patient-level outcome data were available for 25. RESULTS Median (range) accrual period was 132 (48-372) months. Reported peri-operative morbidity ranged from 39% to 91%. There were 5 peri-operative deaths in the 25 patients with individual-outcome data. Median survival was 11 months (95% Confidence interval 9.5-12.5 months; standard error 0.8 months). CONCLUSIONS SMA resection during pancreatectomy is undertaken infrequently incurring high peri-operative morbidity and mortality. Median survival is 11 (95% CI 9.5-12.5) months. In contemporary practice there is no evidence to support SMA resection during pancreatectomy.
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Affiliation(s)
| | - Minas Baltatzis
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK
| | - Saurabh Jamdar
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK; Faculty of Medicine, University of Manchester, Manchester, England, UK
| | - Ajith K Siriwardena
- Regional Hepato-Pancreato-Biliary Surgery Unit, Manchester Royal Infirmary, Manchester, UK; Faculty of Medicine, University of Manchester, Manchester, England, UK.
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31
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Miyazaki M, Yoshitomi H, Takano S, Shimizu H, Kato A, Yoshidome H, Furukawa K, Takayashiki T, Kuboki S, Suzuki D, Sakai N, Ohtuka M. Combined hepatic arterial resection in pancreatic resections for locally advanced pancreatic cancer. Langenbecks Arch Surg 2017; 402:447-456. [PMID: 28361216 DOI: 10.1007/s00423-017-1578-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 03/21/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Arterial involvement in advanced pancreatic cancer generally defines local unresectability. This study was aimed to evaluate the clinical outcomes of combined common hepatic arterial resection with pancreaticoduodenectomy or total pancreatectomy in patients with locally advanced pancreatic cancer involving the hepatic artery. METHODS Of 348 patients with pancreatic head cancers who underwent surgical resection between June 1999 and September 2015, 21 underwent combined common hepatic arterial resection with pancreaticoduodenectomy (17) or total pancreatectomy (4). Preoperative common hepatic arterial embolization was performed in 12 patients. Preoperative CT findings of hepatic arterial involvement, postoperative complications, survival rates, and prognostic factors for survival were analyzed. Twenty-one unresectable patients with locally advanced pancreatic cancer who underwent laparotomy in this study period were selected as the control group. RESULTS Rates of pathological arterial invasion were significantly higher in patients with level III (>1800) CT findings (90%,9/10) than in patients with levels I and II (<1800) (27%, 3/11) (p < 0.01). No surgical deaths occurred. Survival after surgical resection in all 21 patients was 47.6%, 6.6%, and 6.6% at 1, 3, and 5 years, and median survival was 11 months. The preoperative serum CA19-9 level was a significant prognostic factor for overall survival, median survivals were 21.5 and 8.3 months in the low CA19-9 and high CA19-9 groups, respectively. No significant difference in survival between the high-CA19-9 group and the unresectable group was found. CONCLUSIONS Combined common hepatic arterial resection in pancreaticoduodenectomy or total pancreatectomy might be feasible with an acceptable rate of surgical complications, and may have a beneficial effect on the prognosis only in patients with low preoperative serum CA19-9 levels.
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Affiliation(s)
- Masaru Miyazaki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan.
| | - Hideyuki Yoshitomi
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Shigetsugu Takano
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Hiroaki Shimizu
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Atsushi Kato
- International University of Health & Welfare Mita Hospital, Tokyo, Japan
| | - Hiroyuki Yoshidome
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Katunori Furukawa
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Tsukasa Takayashiki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Satoshi Kuboki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Daisuke Suzuki
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Nozomu Sakai
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
| | - Masayuki Ohtuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, 260-0856, Japan
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Asano T, Yamada S, Fujii T, Yabusaki N, Nakayama G, Sugimoto H, Koike M, Fujiwara M, Kodera Y. The Charlson age comorbidity index predicts prognosis in patients with resected pancreatic cancer. Int J Surg 2017; 39:169-175. [PMID: 28161529 DOI: 10.1016/j.ijsu.2017.01.115] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND The Charlson age comorbidity index (CACI) is a useful measure of comorbidity to standardize the evaluation of surgical patients and has been reported to predict postoperative mortality in various cancers. METHOD A total of 379 patients who underwent R0/R1 resection for pancreatic cancer between 2003 and 2014 were enrolled in this study. According to the CACI, the age-adjusted comorbidity index was calculated by weighting individual comorbidities; CACI<4 was considered the low-CACI group, whereas CACI≥4 was considered the high-CACI group. The correlations between the CACI and clinicopathologic features and survival outcomes were statistically analyzed. RESULTS The patients with a high CACI were more likely to be old and had higher CA19-9 levels and lower incidences of portal vein resection and blood transfusion. The rate of patients who received chemotherapy was significantly higher in the low-CACI group than in the high-CACI group (87% vs. 69%, P < 0.0001). The overall survival (OS) rate was significantly higher in the low-CACI group than in the high-CACI group (P = 0.047). Multivariable analysis showed that a high CACI was a predictor of poor survival (P = 0.024). In the high-CACI group, patients with high relative dose intensity (RDI) for postoperative adjuvant chemotherapy had significantly better relapse-free survival (RFS) and OS than those with low RDI (both P < 0.0001). CONCLUSIONS The CACI was a significant independent predictor of prognosis and compliance for postoperative adjuvant chemotherapy in the resected pancreatic cancer.
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Affiliation(s)
- Tomonari Asano
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Suguru Yamada
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Tsutomu Fujii
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Norimitsu Yabusaki
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Goro Nakayama
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroyuki Sugimoto
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiko Koike
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Michitaka Fujiwara
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan
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Kasumova GG, Conway WC, Tseng JF. The Role of Venous and Arterial Resection in Pancreatic Cancer Surgery. Ann Surg Oncol 2016; 25:51-58. [DOI: 10.1245/s10434-016-5676-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Indexed: 12/19/2022]
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34
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Tsuchikawa T, Takeuchi S, Nakamura T, Shichinohe T, Hirano S. Clinical impact of chemotherapy to improve tumor microenvironment of pancreatic cancer. World J Gastrointest Oncol 2016; 8:786-792. [PMID: 27895816 PMCID: PMC5108980 DOI: 10.4251/wjgo.v8.i11.786] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 07/19/2016] [Accepted: 09/18/2016] [Indexed: 02/05/2023] Open
Abstract
A perioperative multimodal strategy including combination chemotherapy and radiotherapy, in addition to surgical resection, has been acknowledged to improve patient prognosis. However chemotherapy has not been actively applied as an immunomodulating modality because of concerns about various immunosuppressive effects. It has recently been shown that certain chemotherapeutic agents could modify tumor microenvironment and host immune responses through several underlying mechanisms such as immunogenic cell death, local T-cell infiltration and also the eradication of immune-suppressing regulatory cells such as regulatory T cells (Tregs) and myeloid-derived suppressor cells. With the better understanding of the cell components in the tumor microenvironment and the effect of chemotherapy to improve tumor microenvironment, it has been gradually clear that the chemotherapeutic agents is two-edged sword to have both immune promoting and suppressing effects. The cellular components of the tumor microenvironment include infiltrating T lymphocytes, dendritic cells, regulatory T cells, tumor associated macrophages, myeloid derived suppressor cells and cancer associated fibroblasts. Based on the better understanding of tumor microenvironment following chemotherapy, the treatment protocol could be modified as personalized medicine and the prognosis of pancreas cancer would be more improved utilizing multimodal chemotherapy. Here we review the recent advances of chemotherapy to improve tumor microenvironment of pancreatic cancer, introducing the unique feature of tumor microenvironment of pancreatic cancer, interaction between anti-cancer reagents and these constituting cells and future prospects.
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Pancreatic Cancer: 80 Years of Surgery-Percentage and Repetitions. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2016; 2016:6839687. [PMID: 27847403 PMCID: PMC5099466 DOI: 10.1155/2016/6839687] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 06/01/2016] [Indexed: 12/18/2022]
Abstract
Objective. The incidence of pancreatic cancer is estimated to be 48,960 in 2015 in the US and projected to become the second and third leading causes of cancer-related deaths by 2030. The mean costs in 2015 may be assumed to be $79,800 per patient and for each resection $164,100. Attempt is made to evaluate the results over the last 80 years, the number of survivors, and the overall survival percentage. Methods. Altogether 1230 papers have been found which deal with resections and reveal survival information. Only 621 of these report 5-year survivors. Reservation about surgery was first expressed in 1964 and five-year survival of nonresected survivors is well documented. Results. The survival percentage depends not only on the number of survivors but also on the subset from which it is calculated. Since the 1980s the papers have mainly reported the number of resections and survival as actuarial percentages, with or without the actual number of survivors being reported. The actuarial percentage is on average 2.75 higher. Detailed information on the original group (TN), number of resections, and actual number of survivors is reported in only 10.6% of the papers. Repetition occurs when the patients from a certain year are reported several times from the same institution or include survivors from many institutions or countries. Each 5-year survivor may be reported several times. Conclusion. Assuming a 10% resection rate and correcting for repetitions and the life table percentage the overall actual survival rate is hardly more than 0.3%.
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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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Locally advanced pancreatic duct adenocarcinoma: pancreatectomy with planned arterial resection based on axial arterial encasement. Langenbecks Arch Surg 2016; 401:1131-1142. [PMID: 27476146 DOI: 10.1007/s00423-016-1488-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/21/2016] [Indexed: 12/22/2022]
Abstract
Pancreatectomy with arterial resection for locally advanced pancreatic duct adenocarcinoma (PDA) is associated with high morbidity and is thus considered as a contraindication. The aim of our study was to report our experience of pancreatectomy with planned arterial resection for locally advanced PDA based on specific selection criteria. MATERIAL AND METHODS All patients receiving pancreatectomy for PDA between October 2008 and July 2014 were reviewed. The patients were classified into group 1, pancreatectomy without vascular resection (66 patients); group 2, pancreatectomy with isolated venous resection (31 patients), and group 3, pancreatectomy with arterial resection for locally advanced PDA (14 patients). The primary selection criteria for arterial resection was the possibility of achieving a complete resection based on the extent of axial encasement, the absence of tumor invasion at the origin of celiac trunk (CT) and superior mesenteric artery (SMA), and a free distal arterial segment allowing reconstruction. Patient outcomes and survival were analyzed. RESULTS Six SMA, two CT, four common hepatic artery, and two replaced right hepatic artery resections were undertaken. The preferred arterial reconstruction was splenic artery transposition. Group 3 had a higher preoperative weight loss, a longer operative time, and a higher incidence of intraoperative blood transfusion. Ninety-day mortality occurred in three patients in groups 1 and 2. There were no statistically significant differences in the incidence, grade, and type of complications in the three groups. Postoperative pancreatic fistula and postpancreatectomy hemorrhage were also comparable. In group 3, none had arterial wall invasion and nine patients had recurrence (seven metastatic and two loco-regional). Survival and disease-free survival were comparable between groups. CONCLUSION Planned arterial resection for PDA can be performed safely with a good outcome in highly selected patients. Key elements for defining the resectability is based on the extent of the axial arterial encasement with two criteria: the origin of the CT and SMA are free from tumor invasion and the possibility of distal reconstruction.
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Abstract
Isolated pancreatoduodenectomy (PD) is an ideal surgery for pancreatic head cancer. In cancer surgery, 'isolated' means en bloc resection using a non-touch isolation technique. I have been developing isolated PD for pancreatic cancer since 1981. In this operation, the most important and first step is to use a mesenteric approach instead of Kocher's maneuver. The precise surgical techniques of the mesenteric approach are introduced in this paper.
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Affiliation(s)
- Akimasa Nakao
- Professor Emeritus, Nagoya University, President Nagoya Central Hospital, Nagoya, Japan
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Yamada S, Fujii T, Yabusaki N, Murotani K, Iwata N, Kanda M, Tanaka C, Nakayama G, Sugimoto H, Koike M, Fujiwara M, Kodera Y. Clinical Implication of Inflammation-Based Prognostic Score in Pancreatic Cancer: Glasgow Prognostic Score Is the Most Reliable Parameter. Medicine (Baltimore) 2016; 95:e3582. [PMID: 27149487 PMCID: PMC4863804 DOI: 10.1097/md.0000000000003582] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
A variety of systemic inflammation-based prognostic scores have been explored; however, there has been no study to clarify which score could best reflect survival in resected pancreatic cancer patients.Between 2002 and 2014, 379 consecutive patients who underwent curative resection of pancreatic cancer were enrolled. The Glasgow Prognostic Score (GPS), modified GPS (mGPS), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), prognostic index (PI), and prognostic nutritional index (PNI) scores for each patient were calculated. Survival of each score was evaluated, and correlations between the score selected on the basis of the prognostic significance and various clinicopathological factors were analyzed.In the analysis of the GPS, the median survival time (MST) was 28.1 months for score 0, 25.6 for score 1, and 17.0 for score 2. As for mGPS, the MST was 25.8 months for score 0, 27.7 for score 1, and 17.0 for score 2. Both scores were found to be significant. On the contrary, there were no statistical differences in MST between various scores obtained using the NLR, PLR, PI, or PNI. Multivariate analysis revealed that lymph node metastasis, positive peritoneal washing cytology, and a GPS score of 2 were significant prognostic factors. There was also statistically significant correlation between the GPS score and tumor location (head), tumor size (≥2.0 cm), bile duct invasion, and duodenal invasion.Our study demonstrated that the GPS could be an independent predictive marker and was superior to other inflammation-based prognostic scores in patients with resected pancreatic cancer.
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Affiliation(s)
- Suguru Yamada
- From the Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine (SY, TF, NY, NI, MK, CT, GN, HS, MK, MF, YK), and Center for Advanced Medicine and Clinical Research (KM), Nagoya University Hospital, Aichi, Japan
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Affiliation(s)
- Thilo Hackert
- Department of Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
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Yamada S, Fujii T, Hirakawa A, Kanda M, Sugimoto H, Kodera Y. Lymph node ratio as parameter of regional lymph node involvement in pancreatic cancer. Langenbecks Arch Surg 2016; 401:1143-1152. [PMID: 27048402 DOI: 10.1007/s00423-016-1412-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 03/17/2016] [Indexed: 12/23/2022]
Abstract
PURPOSE To determine which indicators, anatomical nodal metastasis (Japan Pancreas Society, JPS), number of positive lymph nodes (PLN), or lymph node ratio (LNR), is the best means of assessing lymph node involvement in pancreatic cancer. METHODS This retrospective study analyzed 275 patients with pancreatic cancer treated at a single institution. Survival curves according to the JPS, PLN, or LNR were assessed by the Kaplan-Meier method. Prognostic value of each classification was explored by Cox regression analysis after adjustments for clinical factors. RESULTS Multivariate analysis showed that, relative to n0 in the JPS, hazard ratios (HR) in n1, n2, and n3 were 1.72, 1.73, and 2.75, respectively, with no difference in survival between n1 and n2. Relative to PLN of 0, the HR in the PLN categories of 1∼2, 3, and >3 were 1.39, 1.65, and 3.03, respectively. Relative to LNR of 0, the HR in the categories of 0 < LNR ≤ 0.1, 0.1 < LNR ≤ 0.2, and LNR > 0.2 were 1.27, 2.00, and 5.58, respectively. An incremental increase in the HR was observed as the LNR category progressed, and differences between the survivals were distinct when stratified by the LNR. CONCLUSIONS The LNR was an accurate predictor of survival among three assessment strategies and could be proposed as a candidate for use as N categories, pending validation studies.
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Affiliation(s)
- Suguru Yamada
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Tsutomu Fujii
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Akihiro Hirakawa
- Biostatistics Section, Center for Advanced Medicine and Clinical Research, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Mitsuro Kanda
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hiroyuki Sugimoto
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
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Fernandes E, Giulianotti PC. Robotic-assisted pancreatic surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 20:583-9. [PMID: 23588851 DOI: 10.1007/s00534-013-0615-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Pancreatic surgery is a challenging application of minimally invasive surgery. Due to the complexity of the surgical technique, requiring dissection along major abdominal vessels as well as delicate reconstruction involving biliary, pancreatic and enteric anastomoses, reports on laparoscopic pancreatic surgery have been scanty. With the advent of robotic-assisted surgery, however, the increased dexterity granted by endo-wristed instruments, the improved three-dimensional vision and the computer filtration of the surgeon's movements have brought minimally invasive pancreatic surgery into a new era. METHODS As the surgical group which has performed the highest number of robotic-assisted pancreatic procedures worldwide, we review the state of the art of minimally invasive robotic-assisted pancreatic surgery. Clinical results from all major robotic-assisted pancreatic surgery series are considered. RESULTS Preliminary reports from the published major pancreatic surgery series show encouraging results, with morbidity and mortality comparable to open surgery. Preliminary data on cancer survival rates also appear to be similar to open series. CONCLUSION Robotic-assisted pancreatic surgery is safe and feasible for all pancreatic diseases. The complexity of pancreatic procedures warrant them to be carried out in specialised centres, where short- and long-term outcomes seem to be similar to the ones achieved in open surgery.
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Affiliation(s)
- E Fernandes
- Division of General, Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 South Wood Street, Chicago, IL, 60612, USA.
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Fujii T, Yamada S, Murotani K, Kanda M, Sugimoto H, Nakao A, Kodera Y. Inverse Probability of Treatment Weighting Analysis of Upfront Surgery Versus Neoadjuvant Chemoradiotherapy Followed by Surgery for Pancreatic Adenocarcinoma with Arterial Abutment. Medicine (Baltimore) 2015; 94:e1647. [PMID: 26426657 PMCID: PMC4616842 DOI: 10.1097/md.0000000000001647] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Combined arterial resection during pancreatectomy can be a challenging treatment, and outcome would be more favorable if the tumor becomes technically removable from the artery. Neoadjuvant chemoradiotherapy (NACRT) is expected to achieve locoregional control and enable margin-negative resection. To investigate the effects of NACRT in patients with pancreatic adenocarcinoma (PDAC) which were deemed borderline resectable through preoperative imaging due to abutment of the major artery, including the superior mesenteric artery (SMA) or common hepatic artery (CHA), but were still considered to be technically removable. In the current study, comparisons were make between 71 patients who underwent upfront surgery and 21 patients who underwent NACRT followed by surgery in the strategy to preserve the artery, using unmatched and inverse probability of treatment weighting analysis (UMIN000017115). Fifty patients in the upfront surgery group and 18 in the NACRT group underwent curative resection (70% vs 86%, respectively; P = 0.16). The results of the propensity score weighted logistic regressions indicated that the incidences of pathological lymph node metastasis and a pathological positive resection margin were significantly lower in the NACRT group (odds ratio, 0.006; P < 0.001 and odds ratio, 0.007; P < 0.001, respectively). Among the propensity-score matched patients, the estimated 1- and 2-year survival rates in the upfront surgery group were 66.7% and 16.0%, respectively, and those in the NACRT group were 80.0% and 65.2%, respectively. In conclusion, it was suggested that chemoradiotherapy followed by surgery provided clinical benefits in patients with PDACs in contact with the SMA or CHA.
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Affiliation(s)
- Tsutomu Fujii
- From the Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine (TF, SY, MK, HS, AN, YK), and Center for Clinical Research, Aichi Medical University, Nagakute, Japan (KM)
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Azagra JS, Arru L, Estévez S, Silviu-Tiberiu MP, Poulain V, Goergen M. Pure laparoscopic pancreatoduodenectomy with initial approach to the superior mesenteric artery. Wideochir Inne Tech Maloinwazyjne 2015; 10:450-7. [PMID: 26649095 PMCID: PMC4653251 DOI: 10.5114/wiitm.2015.54040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 06/05/2015] [Accepted: 07/15/2015] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION The "artery-first approach" (AFA) to the superior mesenteric artery allows an early assessment of resectability of pancreatic tumours and could improve the benefits of laparoscopy, reducing invasiveness, especially for unresectable tumours. AIM To describe our technique of pure laparoscopic pancreatoduodenectomy (PLPD) with the AFA, and to report the surgical outcomes of this procedure in a small series of 12 patients through a retrospective analysis of a prospectively collected database. MATERIAL AND METHODS Twelve selected patients underwent elective full laparoscopic pancreatoduodenectomy with the AFA. The technical aspects of the procedure are described in detail and the included images facilitate the understanding of the procedure. RESULTS The mean operative time was 300 min (range: 250-540 min). No intraoperative complications were observed. No conversion to laparotomy was necessary. The mean postoperative hospital stay was 18 days (range: 8-42). Mortality was null. There were 3 major complications at the 3rd post-operative month follow-up: 2 patients reporting a grade A pancreatic fistula and one biliary fistula. CONCLUSIONS Our work shows that pure laparoscopic pancreatoduodenectomy (PLPD) with the AFA is feasible, in selected patients. The AFA could improve on the advantages of laparoscopy in the identification of unresectable patients, and it also allows early control of vascular structures.
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Affiliation(s)
- Juan Santiago Azagra
- Centre Hospitalier de Luxembourg, Service de Chirurgie Générale et Mini-invasive, Luxembourg City, Luxembourg GD
| | - Luca Arru
- Centre Hospitalier de Luxembourg, Service de Chirurgie Générale et Mini-invasive, Luxembourg City, Luxembourg GD
| | - Sergio Estévez
- Centre Hospitalier de Luxembourg, Service de Chirurgie Générale et Mini-invasive, Luxembourg City, Luxembourg GD
| | - Makkai-Popa Silviu-Tiberiu
- Centre Hospitalier de Luxembourg, Service de Chirurgie Générale et Mini-invasive, Luxembourg City, Luxembourg GD
| | - Virginie Poulain
- Centre Hospitalier de Luxembourg, Service de Chirurgie Générale et Mini-invasive, Luxembourg City, Luxembourg GD
| | - Martine Goergen
- Centre Hospitalier de Luxembourg, Service de Chirurgie Générale et Mini-invasive, Luxembourg City, Luxembourg GD
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Murakami Y, Satoi S, Sho M, Motoi F, Matsumoto I, Kawai M, Honda G, Uemura K, Yanagimoto H, Shinzeki M, Kurata M, Kinoshita S, Yamaue H, Unno M. National Comprehensive Cancer Network Resectability Status for Pancreatic Carcinoma Predicts Overall Survival. World J Surg 2015; 39:2306-14. [PMID: 26013206 DOI: 10.1007/s00268-015-3096-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the validity of preoperative resectability status, as defined by the National Comprehensive Cancer Network (NCCN), from the viewpoint of overall survival. METHODS A total of consecutive 704 patients with pancreatic head carcinoma who underwent pancreatoduodenectomy with upfront surgery at seven Japanese hospitals between 2001 and 2012 were evaluated retrospectively. According to the NCCN definition of preoperative resectability status, tumors were divided into resectable tumors without vascular contact (R group), resectable tumors with portal or superior mesenteric vein (PV/SMV) contact of ≦180° (R-PV group), borderline resectable(BR) tumors with PV/SMV contact of >180° (BR-PV group), and BR tumors with arterial contact (BR-A group). The relationship between the NCCN definition of preoperative resectability status and overall survival was analyzed. RESULTS Of the 704 patients, 389, 114, 145, and 56 were classified into the R group, the R-PV group, the BR-PV group, and the BR-A group, respectively. Overall survival of the BR-PV and BR-A groups was significantly worse than that of the R group and R-PV groups (P < 0.05), although there was no significant difference in overall survival between the R group and the R-PV group (P = 0.310). Multivariate analysis revealed that PV/SMV contact of >180° (P = 0.008) and arterial contact (P < 0.001) were independent prognostic factors of overall survival. CONCLUSION From the viewpoint of overall survival, the NCCN definition of preoperative resectability status was valid.
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Affiliation(s)
- Yoshiaki Murakami
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan,
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Lee JH, Kang CM, Bang SM, Choi JY, Seong JS, Hwang HK, Choi SH, Lee WJ. The Role of Neoadjuvant Chemoradiation Therapy in Patients With Borderline Resectable Pancreatic Cancer With Isolated Venous Vascular Involvement. Medicine (Baltimore) 2015; 94:e1233. [PMID: 26252282 PMCID: PMC4616587 DOI: 10.1097/md.0000000000001233] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The rationale for neoadjuvant chemoradiation therapy (Neo-CRT) and the definition of borderline resectable pancreatic cancer (BRPC) are still controversial. In particular, surgical treatment of BRPC with isolated venous vascular involvement (IVVI) is debatable.From January 2000 to December 2013, 84 patients diagnosed with BRPC according to NCCN guidelines were identified, and 70 patients were found to have BRPC with IVVI. We divided all 70 patients into 3 groups: surgery first without Neo-CRT (Group 1); pancreatectomy following Neo-CRT (Group 2); and no operation following Neo-CRT (Group 3). Patient characteristics including oncologic outcomes were analyzed for each of the 3 patients groups.Thirty-seven patients were female and 33 were male, with a mean age of 61.7 ± 9.74 years. Among the 70 BRPC patients with IVVI, 28 patients (40%) belonged to Group 1, 30 patients (42.9%) belonged to Group 2, and 12 patients (17.1%) belonged to Group 3. Pathological tumor size (P < 0.001), pT stage (P = 0.001), pTNM stage (P=0.002), combined vascular resection (P = 0.003), completeness of adjuvant therapy (P = 0.004) were found to be statistically significantly different between Groups 1 and 2. In addition, disease-free survival (P = 0.055) and disease-specific survival (DSS) (P=0.006) were improved in Group 2. Interestingly, when comparing DSS, there was no statistically significant difference between Groups 1 and 3 (P = 0.991).The clinical practice of pancreatectomy following Neo-CRT in BRPC with IVVI provided favorable oncologic outcomes. The effect of Neo-CRT in BRPC with IVVI may be multifactorial, providing proper patient selection, complete adjuvant chemotherapy, and potential therapeutic (downstaging) effect.
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Affiliation(s)
- Jin Ho Lee
- From the Division of Pancreaticobiliary Cancer Clinic, Department of Surgery, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (JHL, CMK, HKH, WJL); Division of Gastroenterology, Department of Internal Medicine and Yonsei Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (SMB); Department of Radiology, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (JYC); Department of Radiation Oncology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (JSS); and Division of Hepatobiliary and Pancreas, Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea (SHC)
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Takano H, Tsuchikawa T, Nakamura T, Okamura K, Shichinohe T, Hirano S. Potential risk of residual cancer cells in the surgical treatment of initially unresectable pancreatic carcinoma after chemoradiotherapy. World J Surg Oncol 2015; 13:209. [PMID: 26113164 PMCID: PMC4482054 DOI: 10.1186/s12957-015-0617-3] [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: 02/09/2015] [Accepted: 06/03/2015] [Indexed: 11/11/2022] Open
Abstract
Background With development of chemoradiotherapy for pancreatic carcinoma, borderline resectable or initially unresectable cases sometimes become operable after long-term intensive chemoradiotherapy. However, there is no established strategy for adjuvant surgery with respect to whether the surgical resection should be extensive or downsized accordingly with diminished disease areas following response to chemoradiotherapy. Methods The clinical and pathological aspects of 18 patients with initially unresectable pancreatic cancer who underwent adjuvant surgery after chemo(radio)therapy in our department from 2007 were evaluated. Results Overall survival from initial treatment was much better for patients with R0 resection than for patients with R1/2 resection. In two of three patients who had complete improvement of plexus (PL) invasion after chemo(radio)therapy, there had still remained pathological plexus invasion. It was shown that tumors did not shrink continuously from the tumor front, but parts remained discontinuously at the distal portion in the process of tumor regression by chemo(radio)therapy. Conclusions In adjuvant surgery for patients with locally advanced pancreatic cancer, the potential risk of residual cancer in the regression area following chemoradiotherapy should be considered. Achieving R0 resection will lead to an improved prognosis, and it is necessary to consider how well the extent of resection is after a favorable response to chemoradiotherapy.
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Affiliation(s)
- Hironobu Takano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, Hokkaido, 060-8638, Japan.
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, Hokkaido, 060-8638, Japan.
| | - Toru Nakamura
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, Hokkaido, 060-8638, Japan.
| | - Keisuke Okamura
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, Hokkaido, 060-8638, Japan.
| | - Toshiaki Shichinohe
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, Hokkaido, 060-8638, Japan.
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15 W-7, Sapporo, Hokkaido, 060-8638, Japan.
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Technical risk factors for portal vein reconstruction thrombosis in pancreatic resection. J Vasc Surg 2015; 62:424-33. [PMID: 25953018 DOI: 10.1016/j.jvs.2015.01.061] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 01/22/2015] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Vascular reconstruction can facilitate pancreas tumor resection, but optimal methods of reconstruction are not well studied. We report our results for portal vein reconstruction (PVR) for pancreatic resection and determinants of postoperative patency. METHODS We identified 173 patients with PVR in a prospective database of 6522 patients who underwent pancreatic resection at our hospital from 1970 to 2014. There were 128 patients who had >1 year of follow-up with computed tomography imaging. Preoperative, intraoperative, and postoperative factors were recorded. Patients with and without postoperative PVR thrombosis were compared by univariable, multivariable, and receiver operating characteristic curve analyses. RESULTS The survival of patients was 100% at 1 month, 88% at 6 months, 66% at 1 year, and 39% on overall median follow-up of 310 days (interquartile range, 417 days). Median survival was 15.5 months (interquartile range, 25 months); 86% of resections were for cancer. Four types of PVR techniques were used: 83% of PVRs were performed by primary repair, 8.7% with interposition vein graft, 4.7% with interposition prosthetic graft, and 4.7% with patch. PVR patency was 100% at 1 day, 98% at 1 month, 91% at 6 months, and 83% at 1 year. Patients with PVR thrombosis were not significantly different from patients with patent PVR in age, survival, preoperative comorbidities, tumor characteristics, perioperative blood loss or transfusion, or postoperative complications. They were more likely to have had preoperative chemotherapy (53% vs 9%; P < .0001), radiation therapy (35% vs 2%; P < .0001), and prolonged operative time (618 ± 57 vs 424 ± 20 minutes; P = .002) and to develop postoperative ascites (76% vs 22%; P < .001). Among patients who developed ascites, 38% of those with PVR thrombosis did so in the setting of tumor recurrence at the porta detected on imaging, whereas among patients with patent PVR, 50% did so (P = .73). Patients with PVR thrombosis were more likely to have had prosthetic graft placement compared with patients with patent PVRs (18% vs 2.7%; P = .03; odds ratio [OR], 7.7; 95% confidence interval [CI], 1.4-42). PVR patency overall was significantly worse for patients who had an interposition prosthetic graft reconstruction (log-rank, P = .04). On multivariable analysis, operative time (OR, 1.01; 95% CI, 1.01-1.02) and prosthetic graft placement (OR, 8.12; 95% CI, 1.1-74) were independent predictors of PVR thrombosis (C statistic = 0.88). CONCLUSIONS Long operative times and use of prosthetic grafts for reconstruction are risk factors for postoperative portal vein thrombosis. Primary repair, patch, or vein interposition should be preferentially used for PVR in the setting of pancreatic resection.
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Murakami Y, Satoi S, Motoi F, Sho M, Kawai M, Matsumoto I, Honda G. Portal or superior mesenteric vein resection in pancreatoduodenectomy for pancreatic head carcinoma. Br J Surg 2015; 102:837-46. [PMID: 25877050 DOI: 10.1002/bjs.9799] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Revised: 12/22/2014] [Accepted: 02/04/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND The aim of this study was to determine the added value of portal or superior mesenteric vein (PV/SMV) resection during pancreatoduodenectomy for pancreatic head carcinoma. METHODS A multicentre observational study was conducted in patients with pancreatic head carcinoma who underwent pancreatoduodenectomy in seven Japanese hospitals between 2001 and 2012. Clinicopathological factors were compared between patients who did and did not undergo PV/SMV resection. Those with an impact on survival were identified by univariable and multivariable analysis. RESULTS Of the 937 patients who underwent pancreatoduodenectomy, 435 (46·4 per cent) had PV/SMV resection, whereas the remaining 502 (53·6 per cent) did not. Some 71·5 and 63·9 per cent of patients with and without PV/SMV resection respectively had lymph node-positive disease. Patients who underwent PV/SMV resection had more advanced tumours. Perioperative mortality and morbidity rates did not differ between the two groups. Multivariable analysis revealed that PV/SMV resection was not an independent prognostic factor for overall survival (P = 0·268). Among the 435 patients in whom the PV/SMV was resected, borderline resectable tumours with arterial abutment (P = 0·021) and absence of adjuvant chemotherapy (P < 0·001) were independent predictors of poor survival in multivariable analysis. Patients with resectable or borderline resectable tumours with PV/SMV involvement had a median survival time with additional adjuvant chemotherapy of 43·7 and 29·7 months respectively. Median survival time in patients with borderline resectable tumours with arterial abutment was 18·6 months despite adjuvant chemotherapy. CONCLUSION Pancreatoduodenectomy with PV/SMV resection and adjuvant chemotherapy in patients with pancreatic head carcinoma may provide good survival without increased mortality and morbidity.
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Affiliation(s)
- Y Murakami
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Vein resections >3 cm during pancreatectomy are associated with poor 1-year patency rates. Surgery 2015; 157:708-15. [DOI: 10.1016/j.surg.2014.12.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 11/19/2014] [Accepted: 12/03/2014] [Indexed: 01/24/2023]
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