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Libia A, Marchese T, D’Ugo S, Piscitelli P, Castellana F, Clodoveo ML, Zupo R, Spampinato MG. Use of Vascular Shunt at the Time of Pancreatectomy with Venous Resection: A Systematic Review. Cancers (Basel) 2024; 16:2361. [PMID: 39001423 PMCID: PMC11240683 DOI: 10.3390/cancers16132361] [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: 05/26/2024] [Revised: 06/24/2024] [Accepted: 06/26/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND The rising diffusion of vascular resections during complex pancreatectomy for malignancy, for both oncological and technical matters, brought with it the use of vascular shunts, either temporary or definitive, to prevent bowel congestion and liver ischemia. This study aimed to systematically review the literature on the technical feasibility of vascular shunts during advanced pancreatic surgery, analyzing intraoperative and postoperative outcomes. METHODS A systematic literature search was performed on PubMed, Scopus, Web of Science, and the Cochrane Library Central, according to PRISMA guidelines. Studies published before 2006 were excluded, considering the lack of a standardized definition of locally advanced pancreatic cancer. The main outcomes evaluated were the overall complication rate and shunt patency. RESULTS Among 789 papers retrieved from the database search, only five fulfilled the inclusion criteria and were included in the review, amounting to a total of 145 patients undergoing a shunt creation at the time of pancreatectomy. Pancreatic adenocarcinoma (PDAC) was found to be the most common diagnosis and pancreaticoduodenectomy was the main surgical procedure, accounting for 88% and 83% of the overall cohort, respectively. The distal splenorenal shunt was the most performed. Overall, 44 out of 145 patients (30%) experienced postoperative complications; the long-term patency of definitive shunts was 83% (110 out of 120 patients). CONCLUSIONS An increasing number of patients with borderline resectable or locally advanced PDAC are becoming amenable to resection and shunt creation may facilitate vascular resection with clear margins, becoming a valid tool of modern pancreatic surgery.
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Affiliation(s)
- Annarita Libia
- General Surgery Unit, Vito Fazzi Hospital, 73100 Lecce, Italy
| | | | - Stefano D’Ugo
- General Surgery Unit, Vito Fazzi Hospital, 73100 Lecce, Italy
| | - Prisco Piscitelli
- Department of Biological and Environmental Sciences and Biotechnologies, University of Salento, 73100 Lecce, Italy
- Local Health Authority, ASL LE, 73100 Lecce, Italy
| | - Fabio Castellana
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Maria Lisa Clodoveo
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Roberta Zupo
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy
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Ozsay O, Aydin MC, Karabulut K, Basoglu M, Dilek ON. Venous reconstruction thrombosis after pancreaticoduodenectomy with superior mesenteric/portal vein resection due to pancreatic cancer: an 8 years single institution experience. Acta Chir Belg 2024; 124:200-207. [PMID: 37767719 DOI: 10.1080/00015458.2023.2264630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 09/22/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Superior mesenteric/portal vein reconstruction (SMPVR) thrombosis remains a challenging complication following pancreaticoduodenectomy concomitant with venous resection. In this context, we aimed to present our SMPVR experiences and identify potential clinicopathological factors that increased SMPVR thrombosis. METHODS A total of 33 patients who underwent SMPVR during pancreaticoduodenectomy were analyzed. Of these, 26 patients who experienced pancreatic head ductal adenocarcinoma met our inclusion criteria. Patients' data were compared as classified by SMPVR type and the development of SMPVR thrombosis. All interposition grafts were Dacron in this cohort. RESULTS Types of SMPVR included: tangential resection with primary repair (n = 12); segmental resection with splenic vein preservation and either primary anastomosis (n = 8) or 14 mm tubular Dacron grafting (n = 1); segmental resection with splenic vein division either 14 mm tubular Dacron grafting (n = 2) or 14/7 mm 'Y'-shaped Dacron grafting (n = 3). A total of four patients having 14/7 mm 'Y'-shaped (n = 3) and 14 mm tubular Dacron (n = 1) developed SMPVR thrombosis (p = .001). Dacron grafting (p = .001) and splenic vein division (p = .010) were associated with SMPVR thrombosis. The median time to detection of SMPVR thrombosis was 4.3 months (2.5-21.0 months). The median follow-up time was 12.2 months (3.0-45 months). CONCLUSIONS During pancreaticoduodenectomy for pancreatic head ductal carcinoma, extended venous resection requiring SMPVR with 'Y'-shaped and use of Dacron interposition grafts appeared to be associated with the development of SMPVR thrombosis. This result warrants further investigations.
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Affiliation(s)
- Oguzhan Ozsay
- Department of Gastrointestinal Surgery, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Mehmet Can Aydin
- Department of Gastrointestinal Surgery, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Kagan Karabulut
- Department of General Surgery, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Mahmut Basoglu
- Department of General Surgery, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Osman Nuri Dilek
- Department of General Surgery, Katip Çelebi University School of Medicine, İzmir, Turkey
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Kim MK, Shin SH, Han IW, Heo JS, Lee SJ, Lee KW, Park JB, Woo SY, Park YJ, Yang SS. Cryopreserved allografts versus end-to-end anastomosis for the reconstruction of a segment-resected portomesenteric vein during advanced pancreatic cancer surgery. Asian J Surg 2023; 46:3741-3747. [PMID: 36813675 DOI: 10.1016/j.asjsur.2023.02.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 02/06/2023] [Accepted: 02/10/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Porto-mesenteric vein (PMV) infiltration of pancreatic cancer is classified as borderline resectable cancer. For en-bloc resectability, the probability of PMV resection and reconstruction is the most decisive factor. The purpose of this study was to compare and analyze PMV resection and reconstruction during pancreatic cancer surgery using end-to-end anastomosis (EA) and a cryopreserved allograft (AG) and to verify the effectiveness of reconstruction using an AG. METHODS Between May 2012 and June 2021, 84 patients (65 underwent EA, and 19 received AG reconstruction) underwent pancreatic cancer surgery with PMV reconstruction. An AG is a cadaveric graft with a diameter of 8-12 mm and is obtained from a liver transplant donor. Patency after reconstruction, disease recurrence, overall survival, and perioperative factors were assessed. RESULTS The median age was higher in EA patients (p = .022) and neoadjuvant therapy (p = .02) was more in AG patients. Upon histopathological examination, the R0 resection margin did not show a significant difference by reconstruction method. During a 36-month survival analysis, primary patency was significantly superior in EA patients (p = .004), and there was no significant difference in recurrence-free survival (p = .628) or overall survival (p = .638) rates. CONCLUSION Compared with EA, AG reconstruction after PMV resection during pancreatic cancer surgery showed a lower primary patency, but there was no difference in recurrence-free or overall survival rates. Therefore, the use of AG can be a viable option for borderline resectable pancreatic cancer surgery if the patient is properly followed-up postoperatively.
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Affiliation(s)
- Min-Kyu Kim
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang-Hyun Shin
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - In-Woong Han
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jin-Seok Heo
- Division of Hepatobiliary-Pancreatic Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Su-Jeong Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyo-Won Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae-Berm Park
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Shin-Young Woo
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yang-Jin Park
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Shin-Seok Yang
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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Jain AJ, Maxwell JE, Katz MHG, Snyder RA. Surgical Considerations for Neoadjuvant Therapy for Pancreatic Adenocarcinoma. Cancers (Basel) 2023; 15:4174. [PMID: 37627202 PMCID: PMC10453019 DOI: 10.3390/cancers15164174] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/04/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is a challenging disease process with a 5-year survival rate of only 11%. Neoadjuvant therapy in patients with localized pancreatic cancer has multiple theoretical benefits, including improved patient selection for surgery, early delivery of systemic therapy, and assessment of response to therapy. Herein, we review key surgical considerations when selecting patients for neoadjuvant therapy and curative-intent resection. Accurate determination of resectability at diagnosis is critical and should be based on not only anatomic criteria but also biologic and clinical criteria to determine optimal treatment sequencing. Borderline resectable or locally advanced pancreatic cancer is best treated with neoadjuvant therapy and resection, including vascular resection and reconstruction when appropriate. Lastly, providing nutritional, prehabilitation, and supportive care interventions to improve patient fitness prior to surgical intervention and adequately address the adverse effects of therapy is critical.
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Affiliation(s)
| | | | | | - Rebecca A. Snyder
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (A.J.J.)
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Fogliati A, Fiorentini G, Alva-Ruiz R, Abdelrahman AM, Zironda A, Lynch IT, Smoot RL, Starlinger PP, Cleary SP, Kendrick ML, Truty MJ. Technical Outcomes of Porto-Mesenteric Venous Reconstruction in Pancreatic Resection Using Autologous Left Renal Vein Graft as Conduit. J Am Coll Surg 2023; 237:58-67. [PMID: 37158471 DOI: 10.1097/xcs.0000000000000744] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Portal or superior mesenteric vein (PV-SMV) resection and reconstruction is sometimes required during pancreatic tumor resection. In patients requiring segmental venous resection with interposition grafting, the left renal vein (LRV) is an accessible autologous solution. However, long-term patency outcomes of the LRV as an interposition conduit in this setting have not been analyzed. STUDY DESIGN We conducted a retrospective analysis of patients undergoing pancreatic resection with PV-SMV reconstruction using LRV between 2002 and 2022. The primary outcome was PV-SMV patency at last follow-up, assessed with postoperative CT scans and analyzed using Kaplan-Meier survival methods that account for variation in follow-up duration. Development of any postoperative acute kidney injury within 7 days of surgery and morbidity were secondary outcomes. RESULTS The study cohort includes 65 patients who underwent LRV harvest; 60 (92%) ultimately underwent successful reconstruction with harvested LRV graft. Kaplan-Meier 2-year estimated patency rate of the LRV graft was 88%, with no cases of complete occlusion. Six (10%) patients experienced graft stenosis. Nine of 61 (15%) patients experienced grade II or III acute kidney injury, 6 of 9 returning to normal renal function before discharge. No difference in median serum creatinine was observed at baseline, 6 and 12 months from surgery. LRV remnant thrombosis was seen in 7 of 65 (11%) patients. Only 3 of 61 (5%) patients had persistent acute kidney injury caused by complications unrelated to LRV harvesting. CONCLUSIONS Autologous LRV graft was a reliable conduit for segmental PV-SMV reconstruction, resulting in a high patency rate and marginal impact on renal function. LRV harvest is a safe and potentially ideal surgical option for PV-SMV reconstruction in pancreatic surgery.
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Affiliation(s)
- Alessandro Fogliati
- From the Division of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
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Hackert T, Klaiber U, Hinz U, Strunk S, Loos M, Strobel O, Berchtold C, Kulu Y, Mehrabi A, Müller-Stich BP, Schneider M, Büchler MW. Portal Vein Resection in Pancreatic Cancer Surgery: Risk of Thrombosis and Radicality Determine Survival. Ann Surg 2023; 277:e1291-e1298. [PMID: 35793384 DOI: 10.1097/sla.0000000000005444] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the outcomes of pancreatic cancer [pancreatic ductal adenocarcinoma (PDAC)] surgery with concomitant portal vein resection (PVR), focusing on the PVR type according to the International Study Group of Pancreatic Surgery (ISGPS). BACKGROUND Surgery offers the only chance for cure in PDAC. PVR is often performed for borderline or locally advanced tumors. METHODS Consecutive patients with PDAC operated between January 2006 and January 2018 were included. Clinicopathologic characteristics and outcomes were analyzed and tested for survival prediction. RESULTS Of 2265 PDAC resections, 1571 (69.4%) were standard resections and 694 (30.6%) were resections with PVR, including 149 (21.5%) tangential resections with venorrhaphy (ISGPS type 1), 21 (3.0%) resections with patch reconstruction (type 2), 491 (70.7%) end-to-end anastomoses (type 3), and 33 (4.8%) resections with graft interposition (type 4). The 90-day mortality rate was 2.6% after standard resection and 6.3% after resection with PVR ( P <0.0001). Postoperative portal vein thrombosis and pancreas-specific surgical complications most frequently occurred after PVR with graft interposition (21.2% and 48.5%, respectively). In multivariable analysis, age 70 years and above, ASA stages 3/4, increased preoperative serum carbohydrate antigen 19-9, neoadjuvant treatment, total pancreatectomy, PVR, higher UICC stage, and R+ resections were significant negative prognostic factors for overall survival. Radical R0 (>1 mm) resection resulted in 23.3 months of median survival. CONCLUSIONS This is the largest single-center, comparative cohort study of PVR in PDAC surgery, showing that postoperative morbidity correlates with the reconstruction type. When radical resection is achieved, thrombosis risk is outweighed by beneficial overall survival times of nearly 2 years.
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Affiliation(s)
- Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Tsiotos GG, Ballian N, Milas F, Ziogou P, Papaioannou D, Salla C, Athanasiadis I, Stavridi F, Strimpakos A, Psomas M, Kostopanagiotou G. Portal-mesenteric vein resection for pancreatic cancer: Results in par with the defined benchmark outcomes. Front Surg 2023; 9:1069802. [PMID: 36704507 PMCID: PMC9871782 DOI: 10.3389/fsurg.2022.1069802] [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: 10/14/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023] Open
Abstract
Background Patients with pancreatic cancer (PC), which may involve major peripancreatic vessels, have been generally excluded from surgery, as resection was deemed futile. The purpose of this study was to analyze the results of portomesenteric vein resection in borderline resectable or locally advanced PC. This study comprises the largest series of such patients in Greece. Materials and Methods Investigator-initiated, retrospective, noncomparative study of patients with borderline resectable or locally advanced adenocarcinoma undergoing pancreatectomy en-block with portal and/or superior mesenteric vein resection in a tertiary referral center in Greece between January 2014 and October 2021. Follow-up was complete up to December 2021. Operative and outcome measures were determined. Results Forty patients were included. Neoadjuvant therapy was administered to only 58% and was associated with smaller tumor size (median: 2.9 cm vs. 4.2 cm, p = 0.004), but not with increased survival. Though venous wall infiltration was present in 55%, it was not associated with tumor size, or Eastern Cooperative Oncology Group (ECOG) status. Resection was extensive: a median of 27 LNs were retrieved, R0 resection rate (≥1 mm) was 87%, and median length of resected vein segments was 3 cm, requiring interposition grafts in 40% (polytetrafluoroethylene). Median ICU stay was 0 days and length of hospitalization 9 days. Postoperative mortality was 2.5%. Median follow-up was 46 months and median overall survival (OS) was 24 months. Two-, 3- and 5-year OS rates were 49%, 33%, and 22% respectively. All outcomes exceeded benchmark cutoffs. Lower ECOG status was positively correlated with longer survival (ECOG-0: 32 months, ECOG-1: 24 months, ECOG-2: 12 months, p = 0.02). Conclusion This series of portomesenteric resection in borderline resectable or locally advanced PC demonstrated a median survival of 2 years, extending to 32 months in patients with good performance status, which meet or exceed current outcome benchmarks.
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Affiliation(s)
- Gregory G. Tsiotos
- Departments of Surgery, Mitera-Hygeia Hospitals, Athens, Greece,Correspondence: Gregory G. Tsiotos
| | | | - Fotios Milas
- Departments of Surgery, Mitera-Hygeia Hospitals, Athens, Greece
| | - Panoraia Ziogou
- Departments of Surgery, Mitera-Hygeia Hospitals, Athens, Greece
| | | | - Charitini Salla
- Departments of Cytology, Mitera-Hygeia Hospitals, Athens, Greece
| | - Ilias Athanasiadis
- Departments of Medical Oncology, Mitera-Hygeia Hospitals, Athens, Greece
| | - Flora Stavridi
- Departments of Medical Oncology, Mitera-Hygeia Hospitals, Athens, Greece
| | - Alexios Strimpakos
- Departments of Medical Oncology, Mitera-Hygeia Hospitals, Athens, Greece
| | - Maria Psomas
- Departments of Anesthesiology, Mitera-Hygeia Hospitals, Athens, Greece
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Patency for autologous vein is superior to cadaveric vein in portal-mesenteric venous reconstruction. HPB (Oxford) 2022; 24:1326-1334. [PMID: 35135725 DOI: 10.1016/j.hpb.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/03/2022] [Accepted: 01/14/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Portal venous reconstruction (PVR) is often needed during resection of hepatopancreato-biliary (HPB) malignancies. Primary repair (PR), autologous vein (AV), or cryopreserved cadaveric vein (CCV) are frequently utilized, however relative patency is not well studied. METHODS All patients undergoing PVR between 2007-2019 at our center were identified. 3-year primary patency (PP), overall survival (OS), and survival-adjusted patency (SAP) were evaluated with Kaplan-Meier and Cox proportional hazards modeling. RESULTS One-hundred-twenty patients were identified with a median follow-up of 11 months. PR, AV, and CCV reconstruction were used in 28 (23%), 35 (29%), and 57 (48%) patients, respectively, with two (7%), four (11%), and 29 (51%) thromboses, respectively. 3-year PP was greater for both primary repair (90%) and AV (83%) compared to CCV (33%, both p<0.001). On multivariable analysis, CCV had worse 3-year PP (HR 7.89, p=0.005) and SAP (HR 2.09, p=0.02) compared to PR; AV reconstruction had equivalent oncologic and patency-related outcomes to PR (p>0.4 for both comparisons). CONCLUSIONS Primary patency for PR and AV reconstruction is superior to CCV for PVR during resection of HPB malignancies. AV conduit should be the preferred choice of reconstruction when PR is not achievable. Surgeons should only use CCV when factors preclude PR/AV reconstruction.
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Xu D, Wu P, Zhang K, Cai B, Yin J, Shi G, Yuan H, Miao Y, Lu Z, Jiang K. The short-term outcomes of distal pancreatectomy with portal vein/superior mesenteric vein resection. Langenbecks Arch Surg 2022; 407:2161-2168. [PMID: 35606575 DOI: 10.1007/s00423-021-02382-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/10/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Portal vein/superior mesenteric vein (PV/SMV) resection during distal pancreatectomy (DP) is often associated with technical difficulties due to the close anatomic relationship between pancreatic head and PV/SMV. In this paper, we present our operative technique and short-term outcomes of DP combined with venous resection (DP-VR) for left-sided pancreatic cancer (PC). METHODS We reviewed 368 consecutive cases of DP for PC from January 2013 to December 2018 in our institution, and identified 41 patients (11.1%) who had undergone DP-VR. The remaining 327 DP patients (88.9%) were matched to DP-VR using propensity scores in the proportion of 1:2. Demographics, intraoperative details, postoperative complications and the pathological results were compared between the two groups. RESULTS Out of the 41 DP-VR cases, in 14 (34.1%) venous resection with primary closure was performed, while the remaining 27 (65.9%) underwent end-to-end anastomosis without graft. A propensity-score-matched analysis revealed that DP-VR caused an increased risk of postoperative bleeding (17.1% vs. 3.7%, P = 0.016) and delayed gastric emptying (9.8% vs. 1.2%, P = 0.042) compared to standard DP. Overall morbidity (46.3% vs. 36.6%, P = 0.332), postoperative pancreatic fistula (31.7% vs. 26.8%, P = 0.672), R0 resection (58.5% vs. 67.1%, P = 0.223), 30-day reoperation (2.4% vs. 3.7%, P = 0.719), and 90-day mortality (0% vs. 2.5%, P = 0.550) were comparable between the two groups. In postoperative computed tomographic scans of 34 patients (82.9%) at a 90-day follow-up, PV/SMV stenosis was suggested in two patients (5.9%). CONCLUSION Despite the higher rates of postoperative bleeding, DP-VR was found to be a feasible and safe surgery with acceptable postoperative morbidity and mortality compared to standard DP for left-sided pancreatic cancer.
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Affiliation(s)
- Dong Xu
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Pengfei Wu
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Kai Zhang
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Baobao Cai
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Jie Yin
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Guodong Shi
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Hao Yuan
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Yi Miao
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Zipeng Lu
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
| | - Kuirong Jiang
- Pancreas Center & Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
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Vascular Resection in Pancreatectomy—Is It Safe and Useful for Patients with Advanced Pancreatic Cancer? Cancers (Basel) 2022; 14:cancers14051193. [PMID: 35267500 PMCID: PMC8909590 DOI: 10.3390/cancers14051193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease with poor prognosis and increased incidence. Surgical resection R0 remains the most important treatment to prolong survival in PDAC patients. In borderline and locally advanced cancer, vascular resection and reconstruction during pancreatectomy enables achieving R0 resection. This study is a comprehensive review of the literature regarding the role of venous and arterial resection with vascular reconstruction in the treatment of pancreatic cancer. Abstract Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease with poor prognosis and increased incidence. Surgical resection R0 remains the most important treatment to prolong survival in PDAC patients. In borderline and locally advanced cancer, vascular resection and reconstruction during pancreatectomy enables achieving R0 resection. This study is a comprehensive review of the literature regarding the role of venous and arterial resection with vascular reconstruction in the treatment of pancreatic cancer. The literature review is focused on the use of venous and arterial resection with immediate vascular reconstruction in pancreaticoduodenectomy. Different types of venous and arterial resections are widely described. Different methods of vascular reconstructions, from primary vessel closure, through end-to-end vascular anastomosis, to interposition grafts with use autologous veins (internal jugular vein, saphenous vein, superficial femoral vein, external or internal iliac veins, inferior mesenteric vein, and left renal vein or gonadal vein), autologous substitute grafts constructed from various parts of parietal peritoneum including falciform ligament, cryopreserved and synthetic allografts. The most attention was given to the most common venous reconstructions, such as end-to-end anastomosis and interposition graft with the use of an autologous vein. Moreover, we presented mortality and morbidity rates as well as vascular patency and survival following pancreatectomy combined with vascular resection reported in cited articles.
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Gemenetzis G, Blair AB, Nagai M, Groot VP, Ding D, Javed AA, Burkhart RA, Fishman EK, Hruban RH, Weiss MJ, Cameron JL, Narang A, Laheru D, Lafaro K, Herman JM, Zheng L, Burns WR, Wolfgang CL, He J. Anatomic Criteria Determine Resectability in Locally Advanced Pancreatic Cancer. Ann Surg Oncol 2022; 29:401-414. [PMID: 34448965 PMCID: PMC8688211 DOI: 10.1245/s10434-021-10663-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 08/01/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND The introduction of multi-agent chemotherapy and radiation therapy has facilitated potential resection with curative intent in selected locally advanced pancreatic cancer (LAPC) patients with excellent outcomes. Nevertheless, there remains a remarkable lack of consensus on the management of LAPC. We sought to describe the outcomes of patients with LAPC and objectively define the multidisciplinary selection process for operative exploration based on anatomical factors. METHODS Consecutive patients with LAPC were evaluated for pancreatic surgery in the multidisciplinary clinic of a high-volume institution, between 2013 and 2018. Prospective stratification (LAPC-1, LAPC-2, and LAPC-3), based on the involvement of regional anatomical structures, was performed at the time of presentation prior to the initiation of treatment. Resection rates and patient outcomes were evaluated and correlated with the initial anatomic stratification system. RESULTS Overall, 415 patients with LAPC were included in the study, of whom 84 (20%) were successfully resected, with a median overall survival of 35.3 months. The likelihood of operative exploration was associated with the pretreatment anatomic LAPC score, with a resection rate of 49% in patients classified as LAPC-1, 32% in LAPC-2, and 11% in LAPC-3 (p < 0.001). Resected patients with improvement of the LAPC score at the time of exploration had significantly longer median overall survival compared with those with no change or progression of LAPC score (60.7 vs. 29.8 months, p = 0.006). CONCLUSIONS Selected patients with LAPC can undergo curative-intent surgery with excellent outcomes. The proposed Johns Hopkins anatomic LAPC score provides an objective system to anticipate the probability of eventual surgical resection after induction therapy.
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Affiliation(s)
- Georgios Gemenetzis
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Surgery, Royal Infirmary Edinburgh, Edinburgh, Scotland, UK
| | - Alex B Blair
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Minako Nagai
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Vincent P Groot
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ding Ding
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ammar A Javed
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard A Burkhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elliot K Fishman
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Cancer Research Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Weiss
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Surgery, Northwell Health, Manhasset, NY, USA
| | - John L Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amol Narang
- Department of Radiation Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel Laheru
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly Lafaro
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph M Herman
- Department of Radiation Oncology, Northwell Health, Manhasset, NY, USA
| | - Lei Zheng
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William R Burns
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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12
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Aras O, Gömceli İ. Can the Falciform Ligament Be the Most Ergonomic Patch in Portal Vein Reconstruction? Indian J Surg 2021. [DOI: 10.1007/s12262-020-02532-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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13
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Addeo P, Bachellier P. Pancreaticoduodenectomy with Segmental Venous Resection: a Standardized Technique Avoiding Graft Interposition. J Gastrointest Surg 2021; 25:1925-1931. [PMID: 33904058 DOI: 10.1007/s11605-021-05012-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/08/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1, Avenue Molière, 67098, Strasbourg, France. .,ICube, Université de Strasbourg, CNRS UMR 7357, 67400, Illkirch, France.
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, 1, Avenue Molière, 67098, Strasbourg, France
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14
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Labori KJ, Kleive D, Khan A, Farnes I, Fosby B, Line PD. Graft type for superior mesenteric and portal vein reconstruction in pancreatic surgery - A systematic review. HPB (Oxford) 2021; 23:483-494. [PMID: 33288403 DOI: 10.1016/j.hpb.2020.11.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/27/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Contemporary practice for superior mesenteric/portal vein (SMV-PV) reconstruction during pancreatectomy with vein resection involves biological (autograft, allograft, xenograft) or synthetic grafts as a conduit or patch. The aim of this study was to systematically review the safety and feasibility of the different grafts used for SMV-PV reconstruction. METHODS A systematic search was performed in PubMed and Embase according to the PRISMA guidelines (January 2000-March 2020). Studies reporting on ≥ 5 patients undergoing reconstruction of the SMV-PV with grafts during pancreatectomy were included. Primary outcome was rate of graft thrombosis. RESULTS Thirty-four studies with 603 patients were included. Four graft types were identified (autologous vein, autologous parietal peritoneum/falciform ligament, allogeneic cadaveric vein/artery, synthetic grafts). Early and overall graft thrombosis rate was 7.5% and 22.2% for synthetic graft, 5.6% and 11.7% for autologous vein graft, 6.7% and 8.9% for autologous parietal peritoneum/falciform ligament, and 2.5% and 6.2% for allograft. Donor site complications were reported for harvesting of the femoral, saphenous, and external iliac vein. No cases of graft infection were reported for synthetic grafts. CONCLUSION In selected patients, autologous, allogenic or synthetic grafts for SMV-PV reconstruction are safe and feasible. Synthetic grafts seems to have a higher incidence of graft thrombosis.
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Affiliation(s)
- Knut J Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
| | - Dyre Kleive
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Ammar Khan
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ingvild Farnes
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bjarte Fosby
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Pål-Dag Line
- Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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15
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Shao Y, Feng J, Jiang Y, Hu Z, Wu J, Zhang M, Shen Y, Zheng S. Feasibility of mesentericoportal vein reconstruction by autologous falciform ligament during pancreaticoduodenectomy-cohort study. BMC Surg 2021; 21:4. [PMID: 33397346 PMCID: PMC7783990 DOI: 10.1186/s12893-020-01019-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 12/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mesentericoportal vein (MPV) resection in pancreatic ductal adenocarcinoma (PDAC) surgery has become a common procedure. A few studies had described the use of falciform ligament (FL) for MPV reconstruction and received encouraging preliminary effects. AIMS This study was designed to explore the feasibility and efficacy of this technique compared with others. METHODS Patients who underwent pancreaticoduodenectomy (PD) with MPV resection for PDAC from 2009 to 2018 were enrolled. Medical records were retrospectively reviewed, MPV reconstructions using FL were distinguished and compared with other techniques. RESULTS 146 patients underwent MPV reconstruction, and 13 received FL venoplasty. Other reconstruction techniques included primary end-to-end anastomosis (primary, n = 30), lateral venorrhaphy (LV, n = 19), polytetrafluoroethylene conduit interposition (PTFE, n = 24), iliac artery (IA) allografts interposition (n = 47), and portal vein (PV) allografts interposition (n = 13). FL group holds the advantages of shortest operation time (p = 0.023), lowest blood loss (p = 0.109), and shortest postoperative hospital stay (p = 0.125). The grouped patency rates of FL, primary, LV, PTFE, IA, and PV were 100%, 90%, 68%, 54%, 68%, and 85% respectively. Comparison displayed that FL had the highest patency rate (p = 0.008) and lowest antiplatelet/anticoagulation proportion (p = 0.000). Complications and long-term survival were similar among different techniques. The median survival time of patent group (24.0 months, 95% CI: 22.0-26.0) was much longer than that of the thrombosed (17.0 months, 95% CI: 13.7-20.3), though without significant difference (P = 0.148). CONCLUSIONS PD with MPV resection and reconstruction by FL is safe, feasible, and efficacious, it might provide a potential benefit for patients.
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Affiliation(s)
- Yi Shao
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Jiaojiao Feng
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, 310006, China
| | - Yuancong Jiang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Zhenhua Hu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Jian Wu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Min Zhang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Yan Shen
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Shusen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China. .,Key Laboratory of Organ Transplantation, Research Center for Diagnosis and Treatment of Hepatobiliary Diseases, No. 79 QingChun Road, Hangzhou, 310003, Zhejiang, People's Republic of China.
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16
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Bultmann U, Niedergethmann M, Gelos M. Postoperative results, pathologic outcome, and long-term patency rate of autologous vein reconstruction of the mesentericoportal axis after pancreatectomy. Langenbecks Arch Surg 2020; 406:1453-1460. [DOI: 10.1007/s00423-020-02026-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/04/2020] [Indexed: 12/17/2022]
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17
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Chan KS, Srinivasan N, Koh YX, Tan EK, Teo JY, Lee SY, Cheow PC, Jeyaraj PR, Chow PKH, Ooi LLPJ, Chan CY, Chung AYF, Goh BKP. Comparison between long and short-term venous patencies after pancreatoduodenectomy or total pancreatectomy with portal/superior mesenteric vein resection stratified by reconstruction type. PLoS One 2020; 15:e0240737. [PMID: 33151977 PMCID: PMC7644060 DOI: 10.1371/journal.pone.0240737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 09/20/2020] [Indexed: 02/07/2023] Open
Abstract
Background Venous reconstruction has been recently demonstrated to be safe for tumours with invasion into portal vein and/or superior mesenteric vein. This study aims to compare the patency between various venous reconstructions. Methods This is retrospective study of 76 patients who underwent pancreaticoduodenectomy or total pancreatectomy with venous reconstruction from 2006 to 2018. Patient demographics, tumour histopathology, morbidity, mortality and patency were studied. Kaplan-Meier estimates were performed for primary venous patency. Results Sixty-two patients underwent pancreaticoduodenectomy and 14 underwent total pancreatectomy. Forty-seven, 19 and 10 patients underwent primary repair, end-to-end anastomosis and interposition graft respectively. Major morbidity (Clavien-Dindo >grade 2) and 30-day mortality were 14/76(18.4%) and 1/76(1.3%) respectively. There were 12(15.8%) venous occlusion including 4(5.3%) acute occlusions. Overall 6-month, 1-year and 2-year primary patency was 89.1%, 92.5% and 92.3% respectively. 1-year primary patency of primary repair was superior to end-to-end anastomosis and interposition graft (primary repair 100%, end-to-end anastomosis 81.8%, interposition graft 66.7%, p = 0.045). Pairwise comparison also demonstrated superior 1-year patency of primary repair (adjusted p = 0.037). There was no significant difference between the cumulative venous patency for each venous reconstruction method: primary repair 84±6%, end-to-end anastomosis 75±11% and interposition graft 76±15% (p = 0.561). Conclusion 1-year primary venous patency of primary repair is superior to end-to-end anastomosis and interposition graft.
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Affiliation(s)
- Kai Siang Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Singapore Health Services Pte Ltd, Singapore, Singapore
| | - Nandhini Srinivasan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Ye Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Ek Khoon Tan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Jin Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-National University of Singapore Medical School Singapore, Singapore, Singapore
| | - Ser Yee Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-National University of Singapore Medical School Singapore, Singapore, Singapore
| | - Peng Chung Cheow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-National University of Singapore Medical School Singapore, Singapore, Singapore
| | - Prema Raj Jeyaraj
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-National University of Singapore Medical School Singapore, Singapore, Singapore
| | - Pierce Kah Hoe Chow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-National University of Singapore Medical School Singapore, Singapore, Singapore
| | - London Lucien Peng Jin Ooi
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-National University of Singapore Medical School Singapore, Singapore, Singapore
| | - Chung Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-National University of Singapore Medical School Singapore, Singapore, Singapore
| | - Alexander Yaw Fui Chung
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-National University of Singapore Medical School Singapore, Singapore, Singapore
| | - Brian Kim Poh Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Singapore Health Services Pte Ltd, Singapore, Singapore
- Duke-National University of Singapore Medical School Singapore, Singapore, Singapore
- * E-mail:
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18
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Affiliation(s)
- Kristin N Kelly
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, CRB, 4th Floor, Miami, FL 33136, USA
| | - Francisco I Macedo
- Department of Surgery, North Florida Regional Medical Center, University of Central Florida College of Medicine, Gainesville, FL, USA
| | - Nipun B Merchant
- Division of Surgical Oncology, Dewitt-Daughtry Department of Surgery, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1120 Northwest 14th Street, CRB, 4th Floor, Miami, FL 33136, USA.
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19
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Yu X, Bai X, Li Q, Gao S, Lou J, Que R, Yadav DK, Zhang Y, Li H, Liang T. Role of Collateral Venous Circulation in Prevention of Sinistral Portal Hypertension After Superior Mesenteric-Portal Vein Confluence Resection during Pancreaticoduodenectomy: a Single-Center Experience. J Gastrointest Surg 2020; 24:2054-2061. [PMID: 31468329 DOI: 10.1007/s11605-019-04365-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 08/12/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The ligation of the splenic vein (SV) during pancreaticoduodenectomy (PD) may result in sinistral portal hypertension (SPH). This study aimed to identify the collateral pathways that formed postoperatively and evaluate the impact of omentum and arc of Barkow preservation in PD. METHODS Patients who underwent PD between January 2013 and May 2018 at the Second Affiliated Hospital of Zhejiang University were enrolled in this retrospective study. PD was performed with preservation of the greater omentum and arc of Barkow. Venous collaterals, spleen size, and platelet count were evaluated before and after surgery. RESULTS In total, 330 patients underwent PD, of whom, 43 patients who underwent superior mesenteric vein (SMV)/portal vein (PV) reconstruction and splenic vein (SV) ligation were selected. No patient developed severe gastrointestinal bleeding. Three collateral routes were identified: the left gastric route, the colic marginal route, and the first jejunal route. Seventeen patients developed splenomegaly. Twenty-three patients developed thrombocytopenia. However, none of them developed gastrointestinal bleeding or other clinical complaints. CONCLUSION Although subclinical SPH developed after SV ligation, postoperative gastrointestinal bleeding was uncommon.
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Affiliation(s)
- Xiazhen Yu
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, Zhejiang Province, China
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, Zhejiang Province, China
| | - Qinghai Li
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shunliang Gao
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, Zhejiang Province, China
| | - Jianying Lou
- Department of Hepatobiliary and Pancreatic Surgery, School of Medicine, The Second Affiliated Hospital of Zhejiang University, Hangzhou, Zhejiang, China
| | - Risheng Que
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, Zhejiang Province, China
| | - Dipesh Kumar Yadav
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, Zhejiang Province, China
| | - Yun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, Zhejiang Province, China
| | - Haijun Li
- Department of General Surgery, Shenzhen Luohu People's Hospital, Shenzhen, Guangdong, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China. .,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China. .,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, Zhejiang Province, China.
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20
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Delpero JR, Sauvanet A. Vascular Resection for Pancreatic Cancer: 2019 French Recommendations Based on a Literature Review From 2008 to 6-2019. Front Oncol 2020; 10:40. [PMID: 32117714 PMCID: PMC7010716 DOI: 10.3389/fonc.2020.00040] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/10/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction: Vascular resection remains a subject of debate in the management of Pancreatic Ductal Adenocarcinoma (PDAC). These French recommendations were drafted on behalf of the French National Institute of Cancer (INCA-2019). Material and Methods: A systematic literature search, with PubMed, Medline® (OvidSP), EMBASE, the Cochrane Library, was performed for abstracts published in English from January 2008 to June 2019, and identified systematic reviews/metaanalyses, retrospective analyses and case series dedicated to vascular resections in the setting of PDAC. All selected articles were graded for level of evidence and strength of recommendation was given according to the GRADE system. Results: Neoadjuvant treatment should be performed rather than direct surgery in borderline and locally advanced non-metastatic PDAC with venous and/or arterial infiltration (T4 stage). Patients who respond or those with stable disease and good performance status should undergo surgical exploration to assess resectability because cross-sectional imaging often fails to identify the extent of the remaining viable tumor. Combining vascular resection with pancreatectomy in these cases increases the feasibility of curative resection which is still the only option to improve long-term survival. Venous resection (VR) is recommended if resection is possible in the presence of limited lateral or circumferential involvement but without venous occlusion and in the absence of arterial contact with the celiac axis (CA; cephalic tumors) or the superior mesenteric artery (SMA; all tumor locations) (Grade B). The patients should be in good general condition because mortality and morbidity are higher than following pancreatectomy without VR (Grade B). In case of planned VR, neoadjuvant treatment is recommended since it improves both rate of R0 resections and survival compared to upfront surgery (Grade B). Due to their complexity and specificities, arterial resection (AR; mainly the hepatic artery (HA) or the CA) must be discussed in selected patients, in multidisciplinary team meetings in tertiary referral centers, according to the tumor location and the type of arterial extension. In case of invasion of a short segment of the common HA, resection with arterial reconstruction may be proposed after neoadjuvant therapy. In case of SMA invasion, neoadjuvant therapy may be followed by laparotomy with dissection and biopsy of peri-arterial tissues. A pancreaticoduodenectomy (PD) with SMA-resection is not recommended if the frozen section examination is positive (Grade C). In case of distal PDAC with invasion of the CA, a distal pancreatectomy with CA-resection without arterial reconstruction may be proposed after neoadjuvant therapy and radiologic embolization of the CA branches (expert opinion). Conclusion: For PDAC with vascular involvement, neoadjuvant treatment followed by pancreatectomy with venous resection or even arterial resection can be proposed as a curative option in selected patients with selected vascular involvement.
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Affiliation(s)
- Jean Robert Delpero
- Institut Paoli-Calmettes (IPC), Marseille, France.,Faculté de Médecine, Aix Marseille Université, Marseille, France
| | - Alain Sauvanet
- Hôpital Beaujon, Clichy, France.,Université Paris VII - Denis Diderot, Paris, France
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21
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Oba A, Bao QR, Barnett CC, Al-Musawi MH, Croce C, Schulick RD, Del Chiaro M. Vascular Resections for Pancreatic Ductal Adenocarcinoma: Vascular Resections for PDAC. Scand J Surg 2020; 109:18-28. [PMID: 31960765 DOI: 10.1177/1457496919900413] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS It has become clear that vein resection and reconstruction for pancreatic ductal adenocarcinoma (PDAC) is the standard of care as supported by multiple guidelines. However, resection of large peri-pancreatic arteries remains debatable. MATERIALS AND METHODS This review examines the current state of vascular resection with curative intent for PDAC in the last 5 years. Herein, we consider venous (superior mesenteric vein, portal vein), as well as arterial (superior mesenteric artery, celiac trunk, hepatic artery) resection or both with or without reconstruction. RESULTS Improvement of multidrug chemotherapy has revolutionized care for PDAC that should shift traditional surgical thinking from an anatomical classification of resectability to a prognostic and biological classification. CONCLUSION The present review gives an overview on the results of pancreatectomy associated with vascular resection, with consideration of new perspectives offered by the availability of better systemic therapies.
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Affiliation(s)
- A Oba
- Department of Surgery, Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Denver, CO, USA.,Department of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Q R Bao
- Department of Surgery, Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Denver, CO, USA.,Department of Surgery, Oncology, and Gastroenterology, University of Padua, Padua, Italy
| | - C C Barnett
- Department of Surgery, Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Denver, CO, USA.,Department of Surgery, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - M H Al-Musawi
- Department of Surgery, Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - C Croce
- Department of Surgery, Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - R D Schulick
- Department of Surgery, Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Denver, CO, USA.,University of Colorado Cancer Center, Denver, CO, USA
| | - M Del Chiaro
- Department of Surgery, Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Denver, CO, USA.,University of Colorado Cancer Center, Denver, CO, USA
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22
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Howe JR, Merchant NB, Conrad C, Keutgen XM, Hallet J, Drebin JA, Minter RM, Lairmore TC, Tseng JF, Zeh HJ, Libutti SK, Singh G, Lee JE, Hope TA, Kim MK, Menda Y, Halfdanarson TR, Chan JA, Pommier RF. The North American Neuroendocrine Tumor Society Consensus Paper on the Surgical Management of Pancreatic Neuroendocrine Tumors. Pancreas 2020; 49:1-33. [PMID: 31856076 PMCID: PMC7029300 DOI: 10.1097/mpa.0000000000001454] [Citation(s) in RCA: 198] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This manuscript is the result of the North American Neuroendocrine Tumor Society consensus conference on the surgical management of pancreatic neuroendocrine tumors from July 19 to 20, 2018. The group reviewed a series of questions of specific interest to surgeons taking care of patients with pancreatic neuroendocrine tumors, and for each, the available literature was reviewed. What follows are these reviews for each question followed by recommendations of the panel.
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Affiliation(s)
- James R. Howe
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Claudius Conrad
- Department of Surgery, St. Elizabeth Medical Center, Tufts University School of Medicine, Boston, MA
| | | | - Julie Hallet
- Department of Surgery, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jeffrey A. Drebin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rebecca M. Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Herbert J. Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Steven K. Libutti
- §§ Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Gagandeep Singh
- Department of Surgery, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Jeffrey E. Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas A. Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Michelle K. Kim
- Department of Medicine, Mt. Sinai Medical Center, New York, NY
| | - Yusuf Menda
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Jennifer A. Chan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Rodney F. Pommier
- Department of Surgery, Oregon Health & Sciences University, Portland, OR
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Tsiotos GG, Ballian N, Michelakos T, Milas F, Ziogou P, Papaioannou D, Salla C, Athanasiadis I, Razis E, Stavridi F, Psomas M. Portal-Mesenteric Vein Resection in Borderline Pancreatic Cancer; 33 Month-Survival in Patients with Good Performance Status. J Pancreat Cancer 2019; 5:43-50. [PMID: 31559380 PMCID: PMC6761582 DOI: 10.1089/pancan.2019.0013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Patients with pancreatic cancer (PC), which is not upfront resectable, but borderline, involving major peripancreatic vessels, have not been generally considered for surgery, considering that resection in such a setting may be futile. Materials and Methods: Retrospective analysis of prospectively collected data on patients with borderline pancreatic adenocarcinoma undergoing pancreatectomy en-block with portal and/or superior mesenteric vein resection in a tertiary referral center in Greece between January 2012 and February 2017. Follow-up was complete up to January 2018. Results: Twenty-four patients were included. Neoadjuvant therapy (NAT) was administered to only 38%, but more commonly in the second half of the group (58% vs. 17%, p = 0.035). It was associated with smaller tumor size (median: 2.5 vs. 4.2 cm, p < 0.001), fewer positive lymph nodes (LNs) in the resected specimen (median: 2 vs. 5, p = 0.04), and higher likelihood of adjuvant therapy (78% vs. 40%, p = 0.01), but not with survival. Resection was extensive: a median of 26 LNs were retrieved, R0 resection rate (≥1 mm) was 79%, and median length of vein segments was 4 cm, requiring interposition grafts in 58% (mostly polytetrafluoroethylene). Median intensive care unit stay was 0 days and length of hospital stay was 9 days. Post-operative mortality was 12.5%. Median overall survival was 24 months. Eastern Cooperative Oncology Group (ECOG) status was significantly associated with survival (p < 0.001) with ECOG-0: 33 months, ECOG-1: 12 months, and ECOG-2: 6 months. Conclusion: This first Greek national series of portomesenteric vein resection in borderline PC demonstrates that it results to 2 years of median survival, extending to 33 months in patients with good performance status, especially if NAT is uniformly administered.
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Affiliation(s)
| | | | | | - Fotios Milas
- Department of Surgery, Mitera-Hygeia Hospitals, Marousi, Greece
| | - Panoraia Ziogou
- Department of Surgery, Mitera-Hygeia Hospitals, Marousi, Greece
| | | | - Charitini Salla
- Department of Cytology, Mitera-Hygeia Hospitals, Marousi, Greece
| | - Ilias Athanasiadis
- Department of Medical Oncology, Mitera-Hygeia Hospitals, Marousi, Greece
| | - Evangelia Razis
- Department of Medical Oncology, Mitera-Hygeia Hospitals, Marousi, Greece
| | - Flora Stavridi
- Department of Medical Oncology, Mitera-Hygeia Hospitals, Marousi, Greece
| | - Maria Psomas
- Department of Anesthesiology, Mitera-Hygeia Hospitals, Marousi, Greece
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The Falciform Ligament for Mesenteric and Portal Vein Reconstruction in Local Advanced Pancreatic Tumor: A Surgical Guide and Single-Center Experience. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2018; 2018:2943879. [PMID: 30364084 PMCID: PMC6188775 DOI: 10.1155/2018/2943879] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 09/03/2018] [Indexed: 12/16/2022]
Abstract
Background Since local tumor infiltration to the mesenteric-portal axis might represent a challenging assignment for curative intended resectability during pancreatic surgery, appropriate techniques for venous reconstruction are essential. In this study, we acknowledge the falciform ligament as a feasible and convenient substitute for mesenteric and portal vein reconstruction with high reliability and patency for local advanced pancreatic tumor. Methods A retrospective single-center analysis. Between June 2017 and January 2018, a total of eleven consecutive patients underwent pancreatic resections with venous reconstruction using falciform ligament. Among them, venous resection was performed in nine cases by wedge and in two cases by full segment. Patency rates and perioperative details were reviewed. Results Mean clamping time of the mesenteric-portal blood flow was 34 min, while perioperative mortality rate was 0%. By means of Duplex ultrasonography, nine patients were shown to be patent on the day of discharge, while two cases revealed an entire occlusion of the mesenteric-portal axis. Orthograde flow demonstrated a mean value of 34 cm/s. All patent grafts on discharge revealed persistent patency within various follow-up assessments. Conclusion The falciform ligament appears to be a feasible and reliable autologous tissue for venous blood flow reconstruction with high postoperative patency. Especially the possibility of customizing graft dimensions to the individual needs based on local findings allows an optimal size matching of the conduit. The risk of stenosis and/or segmental occlusion may thus be further reduced.
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Affiliation(s)
- Warren R Maley
- Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, College 605, Philadelphia, PA 19107, USA
| | - Charles J Yeo
- Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, 1015 Walnut Street, Curtis 620, Philadelphia, PA 19107, USA.
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Ravikumar R, Sabin C, Abu Hilal M, Al-Hilli A, Aroori S, Bond-Smith G, Bramhall S, Coldham C, Hammond J, Hutchins R, Imber C, Preziosi G, Saleh A, Silva M, Simpson J, Spoletini G, Stell D, Terrace J, White S, Wigmore S, Fusai G. Impact of portal vein infiltration and type of venous reconstruction in surgery for borderline resectable pancreatic cancer. Br J Surg 2017; 104:1539-1548. [PMID: 28833055 DOI: 10.1002/bjs.10580] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 12/29/2016] [Accepted: 04/04/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND The International Study Group of Pancreatic Surgery (ISGPS) recommends operative exploration and resection of pancreatic cancers in the presence of reconstructable mesentericoportal axis involvement. However, there is no consensus on the ideal method of vascular reconstruction. The effect of depth of tumour invasion of the vessel wall on outcome is also unknown. METHODS This was a retrospective cohort study of pancreaticoduodenectomy with vein resection for T3 adenocarcinoma of the head of the pancreas across nine centres. Outcome measures were overall survival based on the impact of the depth of tumour infiltration of the vessel wall, and morbidity, in-hospital mortality and overall survival between types of venous reconstruction: primary closure, end-to-end anastomosis and interposition graft. RESULTS A total of 229 patients underwent portal vein resection; 129 (56·3 per cent) underwent primary closure, 64 (27·9 per cent) had an end-to-end anastomosis and 36 (15·7 per cent) an interposition graft. There was no difference in overall morbidity (26 (20·2 per cent), 14 (22 per cent) and 9 (25 per cent) respectively; P = 0·817) or in-hospital mortality (6 (4·7 per cent), 2 (3 per cent) and 2 (6 per cent); P = 0·826) between the three groups. One hundred and six patients (47·5 per cent) had histological evidence of vein involvement; 59 (26·5 per cent) had superficial invasion (tunica adventitia) and 47 (21·1 per cent) had deep invasion (tunica media or intima). Median survival was 18·8 months for patients who had primary closure, 27·6 months for those with an end-to-end anastomosis and 13·0 months among patients with an interposition graft. There was no significant difference in median survival between patients with superficial, deep or no histological vein involvement (20·8, 21·3 and 13·3 months respectively; P = 0·111). Venous tumour infiltration was not associated with decreased overall survival on multivariable analysis. CONCLUSION In this study, there was no difference in morbidity between the three modes of venous reconstruction, and overall survival was similar regardless of tumour infiltration of the vein.
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Affiliation(s)
- R Ravikumar
- Department of Hepatopancreatobiliary (HPB) and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - C Sabin
- Research Department of Infection and Population Health, Royal Free Campus, University College London, London, UK
| | - M Abu Hilal
- Department of HPB Surgery, Southampton General Hospital, Southampton, UK
| | - A Al-Hilli
- Department of HPB Surgery, Southampton General Hospital, Southampton, UK
| | - S Aroori
- Department of HPB Surgery, Plymouth Hospitals, Plymouth, UK
| | - G Bond-Smith
- Department of HPB Surgery, Royal London Hospital, London, UK
| | - S Bramhall
- Liver Unit, University Hospital Birmingham, Birmingham, UK
| | - C Coldham
- Liver Unit, University Hospital Birmingham, Birmingham, UK
| | - J Hammond
- Department of HPB, Nottingham University Hospitals, Nottingham, UK
| | - R Hutchins
- Department of HPB Surgery, Royal London Hospital, London, UK
| | - C Imber
- Department of Hepatopancreatobiliary (HPB) and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - G Preziosi
- Department of Hepatopancreatobiliary (HPB) and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - A Saleh
- Department of HPB and Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - M Silva
- Department of HPB Surgery, Churchill Hospital, Oxford, UK
| | - J Simpson
- Department of HPB, Nottingham University Hospitals, Nottingham, UK
| | - G Spoletini
- Department of HPB Surgery, Churchill Hospital, Oxford, UK
| | - D Stell
- Department of HPB Surgery, Plymouth Hospitals, Plymouth, UK
| | - J Terrace
- Department of HPB and Liver Transplant Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S White
- Department of HPB and Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - S Wigmore
- Department of HPB and Liver Transplant Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - G Fusai
- Department of Hepatopancreatobiliary (HPB) and Liver Transplant Surgery, Royal Free Hospital, London, UK
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An Untapped Resource: Left Renal Vein Interposition Graft for Portal Vein Reconstruction During Pancreaticoduodenectomy. Dig Dis Sci 2017; 62:68-71. [PMID: 26825845 DOI: 10.1007/s10620-016-4050-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 01/19/2016] [Indexed: 01/07/2023]
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28
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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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29
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Younan G, Tsai S, Evans DB, Christians KK. Techniques of Vascular Resection and Reconstruction in Pancreatic Cancer. Surg Clin North Am 2016; 96:1351-1370. [PMID: 27865282 DOI: 10.1016/j.suc.2016.07.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Multimodality therapy has become the standard approach for the treatment of pancreatic cancer. With improved response rates to newer chemotherapeutic agents, tumors that used to be considered unresectable are now being considered for operation. Neoadjuvant therapy for borderline resectable pancreatic cancer is considered standard of care and venous resection/reconstruction is no longer controversial. Arterial resection and reconstruction in select patients has also proven to be safe when done in highly specialized centers by high-volume surgeons. This article reviews indications for, and technical aspects of, vascular resection/reconstruction and shunting procedures during pancreatectomy, including critical elements of perioperative care.
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Affiliation(s)
- George Younan
- Pancreatic Cancer Program, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226, USA
| | - Susan Tsai
- Pancreatic Cancer Program, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226, USA
| | - Douglas B Evans
- Pancreatic Cancer Program, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226, USA
| | - Kathleen K Christians
- Pancreatic Cancer Program, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226, USA.
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Yamamoto M, Akamatsu N, Aoki T, Sakamoto Y, Tamura S, Hasegawa K, Kokudo N. Safety and efficacy of cryopreserved homologous veins for venous reconstruction in pancreatoduodenectomy. Surgery 2016; 161:385-393. [PMID: 27726914 DOI: 10.1016/j.surg.2016.08.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 05/23/2016] [Accepted: 08/02/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND There are several techniques for reconstructing the portal vein-superior mesenteric vein during pancreatoduodenectomy. The aim of the present study was to present our results with portal vein-superior mesenteric vein reconstruction using cryopreserved homologous veins during pancreatoduodenectomy for patients with pancreatic head cancer. METHODS Patients who underwent pancreatoduodenectomy for pancreatic head cancer were reviewed retrospectively. In patients with portal vein-superior mesenteric vein resection, the detailed method of reconstruction and clinical outcomes were reviewed. Clinical characteristics, patient survival, and portal vein-superior mesenteric vein patency were compared between those with and without homologous vein grafts. Factors affecting the patency of reconstructed veins were assessed by univariate analysis. RESULTS Among 144 patients undergoing pancreatoduodenectomy, portal vein-superior mesenteric vein resection was performed in 36 patients (25%); 18 (50%) underwent reconstruction with homologous veins, and the other 18 (50%) underwent reconstruction without homologous veins. The extent of portal vein-superior mesenteric vein involvement, operative time, duration of clamping of portal vein-superior mesenteric vein, intraoperative blood loss, and length of the venous resection were greater (P ≤ .013 each) in those with homologous vein grafts. There was no significant difference in postoperative morbidity/mortality, patient survival, or portal vein-superior mesenteric vein patency. The 1- and 2-year overall patency of portal vein-superior mesenteric vein was 76% and 71%, respectively, while the 2-year patencies were 67% and 67% in those with homologous veins and 87% and 73% in those without homologous veins without difference between the groups. Circumferential resection and pathologic portal vein-superior mesenteric vein involvement were associated with the patency of the reconstructed vein (P = .002 and P = .028, resp). CONCLUSION Use of homologous venous grafts for portal vein-superior mesenteric vein reconstruction are feasible alternatives during pancreatoduodenectomy for advanced pancreatic head cancer.
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Affiliation(s)
- Masaki Yamamoto
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
| | - Taku Aoki
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Sumihito Tamura
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division and Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
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Gao W, Dai X, Dai C, Jiang K, Wu J, Li Q, Guo F, Chen J, Wei J, Lu Z, Tu M, Miao Y. Comparison of patency rates and clinical impact of different reconstruction methods following portal/superior mesenteric vein resection during pancreatectomy. Pancreatology 2016; 16:1113-1123. [PMID: 27707648 DOI: 10.1016/j.pan.2016.09.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 08/29/2016] [Accepted: 09/20/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Few studies have compared patency rates of the different methods of venous reconstruction (VR) during a pancreatectomy. This study aimed to evaluate the patency rates and the clinical impact of various reconstruction methods. METHODS For the meta-analysis, databases were systematically searched to identify studies reporting the outcomes of patients who underwent PVR/SMVR. For the retrospective study, clinical data were retrospectively analyzed from patients who underwent a pancreatectomy and VR between Feb. 2009 and Oct. 2015. Patency was assessed by CT and/or ultrasound. RESULTS For the meta-analysis, the long-term patency rates of the primary repair group and the autologous graft group were significantly higher than that of the synthetic graft group. For the retrospective study, the reconstruction consisted of primary repair in 62 cases (89.8%) and synthetic grafting in 7 cases (10.1%). Synthetic grafting was more likely to cause acute thrombosis compared with primary repair for PVR/SMVR (85.7% versus 16.7%). Acute thrombosis was associated with decreased median survival (12 versus 6 months) and increased hazard of death. Late thrombosis and stenosis were not associated with survival or serious clinical impact. Median survival for the primary repair group and the synthetic grafting group was 12 and 7 months, respectively. CONCLUSION Primary repair following PVR/SMVR is preferred and can be achieved in most situations. Stenosis should be noted when with risk factors (long segmental and tension), but it produced little clinical impact. Synthetic grafting was associated with a higher thrombosis rate. Acute thrombosis is associated with increased mortality and decreased survival.
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Affiliation(s)
- Wentao Gao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, PR China.
| | - Xinglong Dai
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, PR China
| | - Cuncai Dai
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, PR China
| | - Kuirong Jiang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, PR China
| | - Junli Wu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, PR China
| | - Qiang Li
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, PR China
| | - Feng Guo
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, PR China
| | - Jianmin Chen
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, PR China
| | - Jishu Wei
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, PR China
| | - Zipeng Lu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, PR China
| | - Min Tu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, PR China
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, PR China.
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Advances in the Surgical Management of Resectable and Borderline Resectable Pancreas Cancer. Surg Oncol Clin N Am 2016; 25:287-310. [PMID: 27013365 PMCID: PMC10181830 DOI: 10.1016/j.soc.2015.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Successful surgical resection offers the only chance for cure in patients with pancreatic cancer. However, pancreatic resection is feasible in less than 20% of the patients. In this review, the current state of surgical management of pancreatic cancer is discussed. The definition of resectability based on cross-sectional imaging and the technical aspects of surgery, including vascular resection and/or reconstruction, management of aberrant vascular anatomy and extent of lymphadenectomy, are appraised. Furthermore, common pancreatic resection-specific postoperative complications and their management are reviewed.
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Dua MM, Tran TB, Klausner J, Hwa KJ, Poultsides GA, Norton JA, Visser BC. Pancreatectomy with vein reconstruction: technique matters. HPB (Oxford) 2015; 17. [PMID: 26223388 PMCID: PMC4557658 DOI: 10.1111/hpb.12463] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND A variety of techniques have been described for portal vein (PV) and/or superior mesenteric vein (SMV) resection/reconstruction during a pancreatectomy. The ideal strategy remains unclear. METHODS Patients who underwent PV/SMV resection/reconstruction during a pancreatectomy from 2005 to 2014 were identified. Medical records and imaging were retrospectively reviewed for operative details and outcomes, with particular emphasis on patency. RESULTS Ninety patients underwent vein resection/reconstruction with one of five techniques: (i) longitudinal venorrhaphy (LV, n = 17); (ii) transverse venorrhaphy (TV, n = 9); (iii) primary end-to-end (n = 28); (iv) patch venoplasty (PV, n = 17); and (v) interposition graft (IG, n = 19). With a median follow-up of 316 days, thrombosis was observed in 16/90 (18%). The rate of thrombosis varied according to technique. All patients with primary end-to-end or TV remained patent. LV, PV and IG were all associated with significant rates of thrombosis (P = 0.001 versus no thrombosis). Comparing thrombosed to patent, there were no differences with respect to pancreatectomy type, pre-operative knowledge of vein involvement and neoadjuvant therapy. Prophylactic aspirin was used in 69% of the total cohort (66% of patent, 81% of thrombosed) and showed no protective benefit. CONCLUSIONS Primary end-to-end and TV have superior patency than the alternatives after PV/SMV resection and should be the preferred techniques for short (<3 cm) reconstructions.
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Affiliation(s)
- Monica M Dua
- Department of Surgery, Division of Surgical Oncology, Stanford University School of MedicineStanford, CA, USA
| | - Thuy B Tran
- Department of Surgery, Division of Surgical Oncology, Stanford University School of MedicineStanford, CA, USA
| | - Jill Klausner
- Department of Surgery, University of CaliforniaLos Angeles, CA, USA
| | - Kim J Hwa
- Department of Surgery, Division of Surgical Oncology, Stanford University School of MedicineStanford, CA, USA
| | - George A Poultsides
- Department of Surgery, Division of Surgical Oncology, Stanford University School of MedicineStanford, CA, USA
| | - Jeffrey A Norton
- Department of Surgery, Division of Surgical Oncology, Stanford University School of MedicineStanford, CA, USA
| | - Brendan C Visser
- Department of Surgery, Division of Surgical Oncology, Stanford University School of MedicineStanford, CA, USA
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Christians KK, Evans DB. Additional Support for Neoadjuvant Therapy in the Management of Pancreatic Cancer. Ann Surg Oncol 2014; 22:1755-8. [DOI: 10.1245/s10434-014-4307-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Indexed: 12/20/2022]
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