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Harrison JM, Li AY, Bergquist JR, Ngongoni F, Norton JA, Dua MM, Poultsides GA, Visser BC. Revascularization techniques for complete portomesenteric venous occlusion in patients undergoing pancreatic resection. HPB (Oxford) 2024:S1365-182X(24)02220-2. [PMID: 39060211 DOI: 10.1016/j.hpb.2024.07.408] [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: 07/02/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024]
Abstract
INTRODUCTION Pancreatic pathologies causing portomesenteric occlusion complicate extirpative pancreatic resection due to portomesenteric hypertension and collateral venous drainage. METHODS Patients with portomesenteric occlusion undergoing pancreatectomy were identified between 2007 and 2020 at Stanford University Hospital. Demographic and clinical data, technique and perioperative factors, and post-operative outcomes were analyzed. RESULTS Of twenty-seven (27) patients undergoing venous revascularization during pancreatectomy, most (15) were for pancreatic neuroendocrine tumor. Occlusions occurred mostly at the portosplenic confluence (15). Median occlusion length was 4.0 cm [3.1-5.8]. Regarding revascularization strategy, mesocaval shunting was used in 11 patients, in-line venous revascularization with internal jugular conduit in three patients, traditional venous resection and reconstruction in 9 patients, and thrombectomy in two patients. Median cohort operative time and estimated blood loss were 522 min [433-638] and 1000 mL [700-2500], respectively. Median length of stay was 10 days [8-14.5] with overall readmission rate of 37%. Significant complications occurred in 44% of patients despite only one (4%) perioperative mortality. DISCUSSION Despite the technical complexity for managing portomesenteric occlusions, early revascularization strategies including mesocaval shunting or in-line venous revascularization are feasible and facilitate a safe pancreatic resection for surgically fit patients.
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Affiliation(s)
- Jon M Harrison
- Section of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Amy Y Li
- Section of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - John R Bergquist
- Section of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Fari Ngongoni
- Section of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Jeffrey A Norton
- Section of Surgical Oncology, Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Monica M Dua
- Section of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - George A Poultsides
- Section of Surgical Oncology, Department of Surgery, Stanford University Hospital, Stanford, CA, USA
| | - Brendan C Visser
- Section of Hepatobiliary & Pancreatic Surgery, Department of Surgery, Stanford University Hospital, Stanford, CA, USA.
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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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Hatai S, Kaku K, Kubo S, Sato Y, Noguchi H, Okabe Y, Ikenaga N, Nakata K, Nakamura M. Reconstruction with the right gastroepiploic vein during pancreaticoduodenectomy and total pancreatectomy to prevent left-sided portal hypertension: a report of two cases. Surg Case Rep 2023; 9:200. [PMID: 37982916 PMCID: PMC10660986 DOI: 10.1186/s40792-023-01773-x] [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: 08/22/2023] [Accepted: 10/25/2023] [Indexed: 11/21/2023] Open
Abstract
BACKGROUND Left-sided portal hypertension including gastric venous congestion may be caused by ligating the splenic vein during pancreaticoduodenectomy with portal vein resection or total pancreatectomy. The usefulness of reconstruction with the splenic vein has been reported in such cases. However, depending on the site of the tumor and other factors, it may be impossible to leave sufficient length of the splenic vein, making anastomosis difficult. We report two patterns of reconstruction with the right gastroepiploic vein during pancreaticoduodenectomy and total pancreatectomy to prevent left-sided portal hypertension. CASE PRESENTATION The first patient was a 79-year-old man who underwent pancreaticoduodenectomy for pancreatic cancer. The root of the splenic vein was infiltrated by the tumor, and we resected this vein at the confluence of the portal vein. Closure of the portal vein was performed without reconstruction of the splenic vein. To prevent left-sided portal hypertension, we anastomosed the right gastroepiploic vein to the middle colic vein. Postoperatively, there was no suggestion of left-sided portal hypertension, such as splenomegaly, varices, and thrombocytosis. The second case was a 63-year-old woman who underwent total pancreatectomy for pancreatic cancer. The splenic vein-superior mesenteric vein confluence was infiltrated by the tumor, and we resected the portal vein, including the confluence. End-to-end anastomosis was performed without reconstruction of the splenic vein. We also divided the left gastric vein, left gastroepiploic vein, right gastroepiploic vein, and right gastric vein, which resulted in a lack of drainage veins from the stomach and severe gastric vein congestion. We anastomosed the right gastroepiploic vein to the left renal vein, which improved the gastric vein congestion. Postoperatively, imaging confirmed short-term patency of the anastomosis site. Although the patient died because of tumor progression 8 months after the surgery, no findings suggested left-sided portal hypertension, such as varices. Reconstruction with the right gastroepiploic vein during pancreaticoduodenectomy and total pancreatectomy is useful to prevent left-sided portal hypertension.
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Affiliation(s)
- Sanshiro Hatai
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Keizo Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Shinsuke Kubo
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yu Sato
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Hiroshi Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Naoki Ikenaga
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
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Karunakaran M, Barreto SG. Surgery for pancreatic cancer: current controversies and challenges. Future Oncol 2021; 17:5135-5162. [PMID: 34747183 DOI: 10.2217/fon-2021-0533] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Two areas that remain the focus of improvement in pancreatic cancer include high post-operative morbidity and inability to uniformly translate surgical success into long-term survival. This narrative review addresses specific aspects of pancreatic cancer surgery, including neoadjuvant therapy, vascular resections, extended pancreatectomy, extent of lymphadenectomy and current status of minimally invasive surgery. R0 resection confers longer disease-free survival and overall survival. Vascular and adjacent organ resections should be undertaken after neoadjuvant therapy, only if R0 resection can be ensured based on high-quality preoperative imaging, and that too, with acceptable post-operative morbidity. Extended lymphadenectomy does not offer any advantage over standard lymphadenectomy. Although minimally invasive distal pancreatectomies offers some short-term benefits over open distal pancreatectomy, safety remains a concern with minimally invasive pancreatoduodenectomy. Strict adherence to principles and judicious utilization of surgery within a multimodality framework is the way forward.
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Affiliation(s)
- Monish Karunakaran
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta-The Medicity, Gurugram 122001, India.,Department of Liver Transplantation & Regenerative Medicine, Medanta-The Medicity, Gurugram 122001, India
| | - Savio George Barreto
- College of Medicine & Public Health, Flinders University, South Australia, Australia.,Division of Surgery & Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia
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Ono Y, Inoue Y, Kato T, Matsueda K, Oba A, Sato T, Ito H, Saiura A, Takahashi Y. Sinistral Portal Hypertension after Pancreaticoduodenectomy with Splenic Vein Resection: Pathogenesis and Its Prevention. Cancers (Basel) 2021; 13:cancers13215334. [PMID: 34771498 PMCID: PMC8582504 DOI: 10.3390/cancers13215334] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 11/16/2022] Open
Abstract
To achieve curative resection for pancreatic cancer during pancreaticoduodenectomy (PD), extensive portal vein (PV) resection, including porto-mesenterico-splenic confluence (PMSC), may sometimes be necessary if the tumor is close to the portal venous system. Recently, this extended resection has been widely accepted in high-volume centers for pancreatic resection due to its favorable outcomes compared with non-operative treatment. However, in patients with long-term survival, sinistral portal hypertension (SPH) occurs as a late-onset postoperative complication. These patients present gastrointestinal varices due to congested venous flow from the spleen, which may cause critical variceal bleeding. Since the prognosis of patients with pancreatic cancer has improved, owing to the development of chemotherapy and surgical techniques, SPH is no longer a negligible matter in the field of pancreatic cancer surgery. This review clarifies the pathogenesis and frequency of SPH after PD through PMSC resection and discusses its prediction and prevention.
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Affiliation(s)
- Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
- Correspondence: ; Tel.: +81-3-3520-0111
| | - Tomotaka Kato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Kiyoshi Matsueda
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan;
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, School of Medicine, Juntendo University, Tokyo 113-0033, Japan;
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
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Splenorenal shunt for reconstruction of the gastric and splenic venous drainage during pancreatoduodenectomy with resection of the portal venous confluence. Langenbecks Arch Surg 2021; 406:2535-2543. [PMID: 34618219 PMCID: PMC8578106 DOI: 10.1007/s00423-021-02318-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/25/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND Resection of the portal venous confluence is frequently necessary for radical resection during pancreatoduodenectomy for cancer. However, ligation of the splenic vein can cause serious postoperative complications such as gastric/splenic venous congestion and left-sided portal hypertension. A splenorenal shunt (SRS) can maintain gastric and splenic venous drainage and mitigate these complications. PURPOSE This study describes the surgical technique, postoperative course, and surgical outcomes of SRS after pancreatoduodenectomy. METHODS Ten patients who underwent pancreatoduodenectomy and SRS between September 2017 and April 2019 were evaluated. After resection an end-to-side anastomosis between the splenic vein and the left renal vein was performed. Postoperative shunt patency, splenic volume, and any SRS-related complications were recorded. RESULTS The rates of short- and long-term shunt patency were 100% and 60%, respectively. No procedure-associated complications were observed. No signs of left-sided portal hypertension, such as gastrointestinal bleeding or splenomegaly, and no gastric/splenic ischemia were observed in patients after SRS. CONCLUSION SRS is a safe and effective measure to mitigate gastric congestion and left-sided portal hypertension after pancreatoduodenectomy with compromised gastric venous drainage after resection of the portal venous confluence.
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7
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Christians KK, Evans DB. Pancreaticoduodenectomy and Vascular Reconstruction: Indications and Techniques. Surg Oncol Clin N Am 2021; 30:731-746. [PMID: 34511193 DOI: 10.1016/j.soc.2021.06.011] [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] [Indexed: 10/20/2022]
Abstract
Pancreaticoduodenectomy with vascular resection/reconstruction can be safely completed following 6 standard steps plus basic principles of vascular surgery. Particular attention is paid to the location of the tumor relative to the 2 first-order vein branches, portal vein -splenic vein -superior mesenteric vein confluence, inferior mesenteric vein, and the presence of arterial perineural invasion. Successful resection following neoadjuvant therapy can result in median survival 3 times that of historical controls.
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Affiliation(s)
- Kathleen K Christians
- Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
| | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
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8
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Vascular resections in minimally invasive surgery for pancreatic cancer. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2021. [DOI: 10.1016/j.lers.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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9
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Zhang X, Wu Q, Fan H, He Q, Lang R. Reconstructing spleno-mesenterico-portal cofluence by bifurcated allogeneic vein in local advanced pancreatic cancer-a feasible method to avoid left-sided portal hypertension. Cancer Med 2021; 10:5448-5455. [PMID: 34190423 PMCID: PMC8366088 DOI: 10.1002/cam4.4093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 05/07/2021] [Accepted: 06/06/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Left-sided portal hypertension is usually found in patients undergoing pancreaticoduodenectomy (PD) with spleno-mesenterico-portal (S-M-P) confluence resection. This study is to explore the outcomes of S-M-P confluence reconstruction after resection by using bifurcated allogeneic vein. METHODS Clinicopathologic data of patients who underwent extensive PD with S-M-P confluence resection for carcinoma of pancreatic head/uncinate process in our hospital between December 2011 and August 2018 were retrospectively reviewed and clinical outcomes of vein reconstruction after resection were analyzed. RESULTS Of the 37 patients enrolled, S-M-P reconstruction by bifurcated allogeneic vein was performed in 24 cases (group 1) and simply splenic vein ligation in 13 cases (group 2). Items including pathological results, blood loss, and complications were comparable between the two groups, operation time was longer in group 1 (573.8 vs. 479.2 min, p = 0.018). Significantly decreased platelet count (205.9 vs. 133.1 × 109 /L, p = 0.001) and increased splenic volume (270.9 vs. 452.2 ml, p < 0.001) were observed in group 2 at 6 months after operation. The mean splenic hypertrophy ratio was 1.06 in group 1 and 1.63 in group 2, respectively (p < 0.001). There were four patients with varices were found in group 2, none in group 1. CONCLUSIONS Without increased complications, reconstructing S-M-P confluence by bifurcated allogeneic vein after resection may help to avoid left-sided portal hypertension.
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Affiliation(s)
- Xingmao Zhang
- Department of hepatobiliary surgeryBeijing Chaoyang HospitalCapital Medical UniversityBeijingChina
| | - Qiao Wu
- Department of hepatobiliary surgeryBeijing Chaoyang HospitalCapital Medical UniversityBeijingChina
| | - Hua Fan
- Department of hepatobiliary surgeryBeijing Chaoyang HospitalCapital Medical UniversityBeijingChina
| | - Qiang He
- Department of hepatobiliary surgeryBeijing Chaoyang HospitalCapital Medical UniversityBeijingChina
| | - Ren Lang
- Department of hepatobiliary surgeryBeijing Chaoyang HospitalCapital Medical UniversityBeijingChina
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10
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Fromer MW, Hawthorne J, Philips P, Egger ME, Scoggins CR, McMasters KM, Martin RCG. An Improved Staging System for Locally Advanced Pancreatic Cancer: A Critical Need in the Multidisciplinary Era. Ann Surg Oncol 2021; 28:6201-6210. [PMID: 34089107 DOI: 10.1245/s10434-021-10174-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/29/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Locally-advanced pancreatic cancer (LAPC) is traditionally considered stage III unresectable disease. Advances in induction systemic therapy regimens, surgical technique, and perioperative care have led to successful resection of an increasing number of these tumors with reasonable perioperative outcomes and disease-free intervals. Certain anatomic characteristics that meet criteria for locally-advanced disease, however, are more likely to result in a successful surgical outcome. METHODS A practical and consistent system is needed to communicate such nuance between surgical and nonsurgical oncologists for optimal treatment planning and to improve recording for cancer registries and research studies. RESULTS The present study proposes a novel subclassification system for stage III pancreatic cancers based on their pattern of vascular involvement and examines the current evidence for resection in each scenario. Introducing needed detail into the current catch-all stage III categorization will help to direct patient referrals and increase the body of knowledge about the variable presentations of this complex malignancy. CONCLUSION This proposed staging revision for LAPC is designed to convey more actionable tumor descriptions for treating oncologists, clinical trial eligibility, and surgical patient selection in the era of effective induction systemic therapy.
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Affiliation(s)
- Marc W Fromer
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Jenci Hawthorne
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Prejesh Philips
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Michael E Egger
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Charles R Scoggins
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Kelly M McMasters
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, USA.
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A Thought-Provoking Case of Successfully Treated Carcinoma of the Head of the Pancreas with Metachronous Lung Metastasis: Impact of Distal Spleno-Renal Shunt for Regional Invasion on Long-Term Period after Pancreaticoduodenectomy. Case Rep Surg 2021; 2021:6689419. [PMID: 34136302 PMCID: PMC8179775 DOI: 10.1155/2021/6689419] [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: 10/21/2020] [Accepted: 05/14/2021] [Indexed: 12/03/2022] Open
Abstract
When performing pancreaticoduodenectomy with resection of the confluence of the superior mesenteric vein and portal vein, division of the splenic vein may cause sinistral portal hypertension resulting in gastrointestinal bleeding, splenic congestion, and hypersplenism. To prevent these adverse events, it is important to intentionally decompress the splenic vein. This report is of a 68-year-old woman with stage IA carcinoma of the head of the pancreas who survived for more than six years following tumor resection and pancreaticoduodenectomy and distal splenorenal shunt. A 68-year-old woman was diagnosed with carcinoma of the head of the pancreas that involved the confluence of the superior mesenteric vein, portal vein, and splenic vein. No unresectable cancer sites or distant metastases were detected. Pancreaticoduodenectomy with resection of the confluence of the superior mesenteric vein and portal vein was performed. The superior mesenteric vein and portal vein were anastomosed in the end-to-end fashion, and the remnant splenic vein was anastomosed to the superior aspect of the left renal vein in the end-to-side fashion. At 22 months after the initial surgery, the patient underwent partial lung resection for a metachronous lung metastasis. For 6 years after the initial surgery, the venous reconstructions have maintained their patency without any obstruction of splenic venous flow, and the patient has remained in good health without further metastases or recurrences. This case has shown the importance of early diagnosis of carcinoma of the head of the pancreas, as appropriate and timely surgical management can result in good outcome. This patient responded well and remains alive six years following pancreaticoduodenectomy and preservation of the spleen with the use of a distal splenorenal shunt.
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12
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S GM, Gnanasekaran S, Raja K, Pottakkat B. Transient mesoportal shunt: An innovative technique for maintaining portal flow during pancreatoduodenectomy with portal vein resection. Ann Hepatobiliary Pancreat Surg 2021; 25:122-125. [PMID: 33649264 PMCID: PMC7952664 DOI: 10.14701/ahbps.2021.25.1.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 08/10/2020] [Accepted: 08/28/2020] [Indexed: 11/17/2022] Open
Abstract
Pancreatic cancers exhibit a surgical challenge, in light of frequent vascular involvement. In absence of metastatic spread, vascular invasion is the predominant limiting factor for determining the resectability. With progression of time vascular involvement is no longer considered a surgical contraindication. However these complex procedures are fraught with technical challenges. Portal clamping required for vascular resection and reconstruction results in hepatic ischemia and visceral congestion. In order to mitigate these untoward effects, surgeons have tried diverse techniques including venous shunts. Venous shunting facilitates the resection and allows for an enhanced exposure and a safe procedure. Previously described techniques were either cumbersome or failed to maintain portal flow. We present a technique of transient mesoportal shunt, to facilitate vascular resection during pancreatoduodenectomy. This technique is both simple and maintains portal flow throughout the procedure preventing both hepatic ischemia and visceral congestion.
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Affiliation(s)
- Gautham M S
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Senthil Gnanasekaran
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Kalayarasan Raja
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Biju Pottakkat
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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13
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Christians KK. Commentary: Venous resection and reconstruction at the time of pancreatectomy for cancer. Surgery 2020; 168:1058-1059. [DOI: 10.1016/j.surg.2020.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 08/14/2020] [Indexed: 01/30/2023]
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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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15
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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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16
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Evans DB. Commentary: Surgery for locally advanced pancreatic cancer after neoadjuvant therapy. Surgery 2020; 169:1032-1033. [PMID: 32868112 DOI: 10.1016/j.surg.2020.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/03/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Douglas B Evans
- The LaBahn Pancreatic Cancer Program, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.
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17
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Petrucciani N, Debs T, Rosso E, Addeo P, Antolino L, Magistri P, Gugenheim J, Ben Amor I, Aurello P, D'Angelo F, Nigri G, Di Benedetto F, Iannelli A, Ramacciato G. Left-sided portal hypertension after pancreatoduodenectomy with resection of the portal/superior mesenteric vein confluence. Results of a systematic review. Surgery 2020; 168:434-439. [PMID: 32600882 DOI: 10.1016/j.surg.2020.04.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/08/2020] [Accepted: 04/12/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatoduodenectomy with synchronous resection of the portal vein/superior mesenteric vein confluence may result in the development of left-sided portal hypertension. Left-sided portal hypertension presents with splenomegaly and varices and may cause severe gastrointestinal bleeding. The aim of the study is to review the incidence, treatment, and preventive strategies of left-sided portal hypertension. METHODS A systematic literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to identify all studies published up to September 30, 2019 reporting data on patients with left-sided portal hypertension after pancreatoduodenectomy with venous resection. RESULTS Eight articles including 829 patients were retrieved. Left-sided portal hypertension occurred in 7.7% of patients who had splenic vein preservation and 29.4% of those having splenic vein ligation. Fourteen cases of gastrointestinal bleeding owing to left-sided portal hypertension were reported at a mean interval of 28 months from pancreatoduodenectomy. Related mortality at 1 month was 7.1%. Treatment of left-sided portal hypertension consisted of splenectomy in 3 cases (21%) and colectomy in 1 (7%) case, whereas radiologic, endoscopic procedures or conservative treatments were effective in the other cases (71%). CONCLUSION Left-sided portal hypertension represents a potentially severe complication of pancreatoduodenectomy with venous resection occurring at greater incidence when the splenic vein is ligated and not reimplanted. Left-sided portal hypertension-related gastrointestinal bleeding although rare can be managed depending on the situation by endoscopic, radiologic procedures or operative intervention with low related mortality.
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Affiliation(s)
- Niccolo Petrucciani
- Department of Medical and Surgical Sciences and Translational Medicine, St Andrea University Hospital, Sapienza University, Rome, Italy.
| | - Tarek Debs
- Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
| | - Edoardo Rosso
- Départment de Chirurgie Générale, Centre Hospitalier de Luxembourg, Luxembourg City, Luxembourg
| | - 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, France
| | - Laura Antolino
- Department of Medical and Surgical Sciences and Translational Medicine, St Andrea University Hospital, Sapienza University, Rome, Italy
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Italy
| | - Jean Gugenheim
- Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
| | - Imed Ben Amor
- Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
| | - Paolo Aurello
- Department of Medical and Surgical Sciences and Translational Medicine, St Andrea University Hospital, Sapienza University, Rome, Italy
| | - Francesco D'Angelo
- Department of Medical and Surgical Sciences and Translational Medicine, St Andrea University Hospital, Sapienza University, Rome, Italy
| | - Giuseppe Nigri
- Department of Medical and Surgical Sciences and Translational Medicine, St Andrea University Hospital, Sapienza University, Rome, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Italy
| | - Antonio Iannelli
- Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France; INSERM U1065, Mediterranean Center for Molecular Medicine, Team 8 Hepatic Complications of Obesity, Nice, France
| | - Giovanni Ramacciato
- Department of Medical and Surgical Sciences and Translational Medicine, St Andrea University Hospital, Sapienza University, Rome, Italy
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18
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Addeo P, De Mathelin P, Averous G, Tambou-Nguipi M, Terrone A, Schaaf C, Dufour P, Bachellier P. The left splenorenal venous shunt decreases clinical signs of sinistral portal hypertension associated with splenic vein ligation during pancreaticoduodenectomy with venous resection. Surgery 2020; 168:267-273. [PMID: 32536489 DOI: 10.1016/j.surg.2020.04.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/11/2020] [Accepted: 04/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The ligation of the splenic vein during pancreaticoduodenectomy with synchronous resection of the spleno-mesenteric-portal venous confluence has been associated with the development of left portal hypertension despite preservation of the natural confluence with the inferior mesenteric vein. This study aimed to assess whether a left splenorenal venous shunt might mitigate clinical signs of left portal hypertension associated with splenic vein ligation. METHODS We retrospectively evaluated the presence of left portal hypertension based on biologic and radiologic parameters in patients undergoing pancreaticoduodenectomy with synchronous resection of the spleno-mesentericoportal confluence between January 1, 2012, and December 31, 2018. We compared several parameters between patients undergoing splenic vein ligation with preservation of the inferior mesenteric vein confluence and a splenorenal venous shunt: the early and late spleen volumes and spleen volume ratios, an early and late platelet count, the presence of thrombocytopenia, the presence of varices, and digestive bleeding in the long-term. RESULTS There were 114 consecutive patients: 36 with splenic vein ligation and 78 with splenorenal venous shunt. All had a pancreaticogastrostomy. Patients with splenic vein ligation had a comparable baseline and early and late platelet counts. Although baseline splenic volumes were comparable between the 2 groups (242 ± 115 mL vs 261 ± 138 mL; P = .51), patients with splenic vein ligation showed a statistically significant greater splenic volume beyond the 6th postoperative months (334 ± 160 mL vs 241 ± 111 mL; P = .004), higher early and late spleen volume ratios (1.42 ± 0.67 vs 1.10 ± 0.3; P = .001 and 1.38 ± 0.38 vs 0.97 ± 0.4; P = .0001) than patients with splenorenal venous shunt. Splenic vein ligation was also associated with a higher rate of varices (81% vs 50%; P = .002) and more frequent varices with a caliber greater than 1 cm (57% vs 36%; P = .05) and more colonic varices (33% vs 12%; P = .01). Only 1 patient had long-term digestive bleeding (splenic vein ligation). CONCLUSION The left splenorenal shunt decreases clinical signs of left portal hypertension associated with splenic vein ligation and inferior mesenteric vein confluence preservation.
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Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.
| | - Pierre De Mathelin
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Gerlinde Averous
- Department of Pathology, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Marlene Tambou-Nguipi
- Department of Gastroenterology-Section of Oncology, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Alfonso Terrone
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Caroline Schaaf
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Patrick Dufour
- Department of Gastroenterology-Section of Oncology, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
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19
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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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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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Oehme F, Distler M, Müssle B, Kahlert C, Weitz J, Welsch T. Results of portosystemic shunts during extended pancreatic resections. Langenbecks Arch Surg 2019; 404:959-966. [PMID: 31446472 DOI: 10.1007/s00423-019-01816-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 08/16/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Patients with borderline resectable pancreatic cancer are increasingly explored after neoadjuvant treatment protocols. A complete resection, then, frequently includes the resection of the mesentericoportal axis. Portosystemic shunting for advanced tumours with infiltration of the splenic vein or cavernous transformation of the portal vein can enable complete tumour resection and prevent portovenous congestion of the intestine. The aim of this study was to report the results of this technique for selected patients. METHODS Patients operated for pancreatic cancer at our department between September 2012 and December 2017 using intraoperative portosystemic shunting were included in this retrospective analysis. RESULTS Some 11 patients with pancreatectomy and simultaneous portosystemic shunting were included. The median age was 65.1 years. A distal splenorenal shunt and a temporary mesocaval shunt were accomplished in 5 and 4 cases, respectively. Two patients were operated using persistent mesocaval shunts (from the coronary, splenic or inferior mesenteric veins). The median operating time was 9.43 h. All but one patient were resected with tumour-negative resection margins; 5 patients had relevant complicated postoperative courses. There was one case of in-hospital mortality but no further 30- or 90-day mortality or graft-associated complications. Five patients were alive after a median follow-up of 24.6 months. The median postoperative survival was 12 months. CONCLUSION Portosystemic shunting at the time of extended pancreatectomy is technically challenging but feasible and enables complete tumour resection in cases in which standard vascular reconstruction is limited by cavernous transformation or to prevent sinistral portal hypertension with acceptable morbidity in selected cases. Considering the limited overall survival, the potential individual patient benefit needs to be weighed against the considerable morbidity of advanced tumour resections.
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Affiliation(s)
- Florian Oehme
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Benjamin Müssle
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Christoph Kahlert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
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Ono Y, Tanaka M, Matsueda K, Hiratsuka M, Takahashi Y, Mise Y, Inoue Y, Sato T, Ito H, Saiura A. Techniques for splenic vein reconstruction after pancreaticoduodenectomy with portal vein resection for pancreatic cancer. HPB (Oxford) 2019; 21:1288-1294. [PMID: 30878491 DOI: 10.1016/j.hpb.2019.01.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 12/10/2018] [Accepted: 01/31/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) with splenic vein (SV) ligation may result in sinistral portal hypertension (SPH). The aim of this study was to compare the outcomes of various types of SV reconstruction to prevent SPH and to define the optimal reconstruction method. METHODS This study included patients who underwent PD with SV resection and reconstruction for pancreatic cancer between December 2013 and June 2017. The patency of various types of SV anastomosis and SPH was evaluated by follow up computed tomography. RESULTS The type of SV reconstruction was divided into two groups: (i) end-to-side anastomosis (n = 10), in which the SV was anastomosed with either the left renal vein (LRV; n = 8) or portal vein (n = 2); and (ii) end-to-end anastomosis (n = 20), in which the SV was anastomosed with another smaller vein or graft. The patency rate for Group 1 was 90% (9/10), compared with 45% (9/20) for Group 2 (P = 0.024). Half the patients in whom the SV anastomosis was occluded (6/12) developed gastrointestinal varices, whereas only 11% of patients with a patent SV anastomosis (2/9) had varices (P = 0.034). CONCLUSION SV-LRV reconstruction is widely applicable, effectively reduces the risk of SPH, and should be considered for the case of extended PD.
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Affiliation(s)
- Yoshihiro Ono
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Masayuki Tanaka
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Kiyoshi Matsueda
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Makiko Hiratsuka
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Yu Takahashi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Yoshihiro Mise
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Yosuke Inoue
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Takafumi Sato
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Hiromichi Ito
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Akio Saiura
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan.
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Macrovascular venous invasion of pancreatic neuroendocrine tumours: impact on surgical outcomes and survival. HPB (Oxford) 2019; 21:653-661. [PMID: 30522946 DOI: 10.1016/j.hpb.2018.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/03/2018] [Accepted: 10/25/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study evaluates the impact of macrovascular venous invasion (MVI) on surgical and survival outcomes of pancreatic neuroendocrine tumours (PNETs). METHODS We retrospectively reviewed data of 125 patients operated for PNETs. Operative, pathological,and survival outcomes were compared between PNETs with and without MVI. RESULTS Macrovascular venous invasion was detected in 25 of 125 PNETs (20%) presenting as tumour thrombi (n = 12) or venous wall invasion (n = 13). MVI was associated with larger tumours, a higher rate of lymph node involvement, less differentiated tumours, and a higher rate of perineural invasion. Resection of PNETS with MVI more often necessitated combined hepatic, venous and multivisceral resections, had a higher rate of intraoperative blood transfusion (p = 0.04) but similar morbidity (44% vs. 42%) and mortality (0 vs. 1%) as PNETs without MVI. PNETs with MVI had a lower median overall survival rate (60 vs. 149 months; p = 0.03). Multivariate analysis revealed that PNETs of the pancreatic head, synchronous liver metastases and higher tumour grade were prognostic factors for overall survival. CONCLUSIONS MVI is found in more advanced PNETs. Resection of PNETs with MVI is characterized by increased transfusion rate and reduced overall survival.
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Simoneau E, Katz MH, Lee JE, Tzeng CWD. ASO Author Reflections: Temporary Mesocaval Shunt: Indications and Technique for Safe Resection of Pancreatic Tumors With Mesenteric Venous Occlusion. Ann Surg Oncol 2019; 26:579-580. [PMID: 30859352 DOI: 10.1245/s10434-019-07290-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Eve Simoneau
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Division of Abdominal Organ Transplant and Hepatobiliary Surgery, Department of Surgery, Columbia University, New York, NY, USA
| | - Matthew H Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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25
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Distal splenorenal and mesocaval shunting at the time of pancreatectomy. Surgery 2019; 165:298-306. [DOI: 10.1016/j.surg.2018.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/02/2018] [Accepted: 10/08/2018] [Indexed: 12/12/2022]
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26
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Tanaka M, Ito H, Ono Y, Matsueda K, Mise Y, Ishizawa T, Inoue Y, Takahashi Y, Hiratsuka M, Unno T, Saiura A. Impact of portal vein resection with splenic vein reconstruction after pancreatoduodenectomy on sinistral portal hypertension: Who needs reconstruction? Surgery 2019; 165:291-297. [DOI: 10.1016/j.surg.2018.08.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/20/2018] [Accepted: 08/28/2018] [Indexed: 12/13/2022]
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Chatzizacharias NA, Tsai S, Griffin M, Tolat P, Ritch P, George B, Barnes C, Aldakkak M, Khan AH, Hall W, Erickson B, Evans DB, Christians KK. Locally advanced pancreas cancer: Staging and goals of therapy. Surgery 2018; 163:1053-1062. [PMID: 29331400 DOI: 10.1016/j.surg.2017.09.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/25/2017] [Accepted: 09/25/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients with locally advanced pancreatic cancer have historically been considered inoperable. The purpose of this report was to determine resectability rates for patients with locally advanced pancreatic cancer based on our recently described definitions of type A and type B locally advanced pancreatic cancer. METHODS An institutional prospective pancreas cancer database was queried for consecutive patients with locally advanced pancreatic cancer treated between January 2009 and June 2017. All pretreatment imaging was re-reviewed and patients were categorized as locally advanced pancreatic cancer type A or type B. Demographics, induction therapy, resection type, and outcomes were reviewed. RESULTS We identified 108 consecutive patients; 12 were excluded from analysis due to the absence of available pretreatment imaging or they had not yet completed all intended neoadjuvant therapy. Of the remaining 96 patients (45 type A, 51 type B), disease progression occurred in 19 (20%) during induction therapy and 30 (31%) were deemed inoperable at final preoperative restaging. Therefore, 47 (49%) of 96 patients were taken to surgery and 40 (42%) underwent successful resection (28 [62%] of 45 type A and 12 [24%] of 51 type B); an RO resection was achieved in 32 (80%). Metastatic disease was found intraoperatively (6 at laparoscopy, 1 at laparotomy) in 7 (15%) of 47 patients. There were no mortalities; 6 (15%) patients experienced major postoperative complications. Resected patients had a median overall survival of 38.9 months. CONCLUSION Locally advanced pancreatic cancer can be dichotomized into type A and B with distinctly different probabilities of completing all therapy to include surgery; thereby allowing goals of therapy to be established at the time of diagnosis. Multimodality therapy that includes surgery can be accomplished in selected patients with locally advanced pancreatic cancer and is associated with a median overall survival that approximates earlier stages of disease. (Surgery 2017;160:XXX-XXX.).
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Affiliation(s)
- Nikolaos A Chatzizacharias
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Susan Tsai
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael Griffin
- Department of Radiology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Parag Tolat
- Department of Radiology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Paul Ritch
- Department of Medicine, Divisions of Medical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ben George
- Department of Medicine, Divisions of Medical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Chad Barnes
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mohammed Aldakkak
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Abdul H Khan
- Department of Gastroenterology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - William Hall
- Department of Radiation Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Beth Erickson
- Department of Radiation Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Douglas B Evans
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kathleen K Christians
- Department of Surgery, Division of Surgical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI, USA.
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Gyoten K, Mizuno S, Nagata M, Ogura T, Usui M, Isaji S. Significance of Simultaneous Splenic Artery Resection in Left-Sided Portal Hypertension After Pancreaticoduodenectomy with Combined Portal Vein Resection. World J Surg 2017; 41:2111-2120. [PMID: 28258459 PMCID: PMC5504262 DOI: 10.1007/s00268-017-3916-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND In pancreaticoduodenectomy (PD) with resection of portal vein (PV)/superior mesenteric vein (SMV) confluence, the splenic vein (SV) division may cause left-sided portal hypertension (LPH). METHODS The 88 pancreatic ductal adenocarcinoma patients who underwent PD with PV/SMV resection after chemoradiotherapy were classified into three groups: both SV and splenic artery (SA) were preserved in Group A (n = 16), SV was divided and SA was preserved in Group B (n = 58), and both SV and SA were divided in Group C (n = 14). We evaluated the influence of resection of SV and/or SA on LPH after PD with resection of PV/SMV confluence. RESULTS The incidence of postoperative varices in Groups A, B and C was 6.3, 67.2 and 38.5%, respectively (p < 0.001), and variceal bleeding occurred only in Group B (n = 4: 6.8%). In multivariate analysis, Group B was the only significant risk factor for the development of postoperative varices (Groups B vs. A: odds ratio = 39.6, p = 0.001, Groups C vs. A: odds ratio = 8.75, p = 0.066). The platelet count ratio at 6 months after operation comparing to preoperative value was 0.93, 0.73 and 1.09 in Groups A, B and C, respectively (Groups B vs. C: p < 0.05), and spleen volume ratio at 6 months was 1.00, 1.37 and 0.96 in Groups A, B and C, respectively (Groups B vs. A and C: p < 0.01 and p < 0.05). CONCLUSION In PD with resection of PV-SMV confluence, the SV division causes LPH, but the concomitant division of SV and SA may attenuate it.
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Affiliation(s)
- Kazuyuki Gyoten
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Motonori Nagata
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Toru Ogura
- Clinical Research Support Center, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masanobu Usui
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shuji Isaji
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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29
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Rosado ID, Bhalla S, Sanchez LA, Fields RC, Hawkins WG, Strasberg SM. Pattern of Venous Collateral Development after Splenic Vein Occlusion in an Extended Whipple Procedure (Whipple at the Splenic Artery) and Long-Term Results. J Gastrointest Surg 2017; 21:516-526. [PMID: 27921207 DOI: 10.1007/s11605-016-3325-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 11/14/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Extended Whipple procedures may require division of the splenic vein (SV). Controversy exists regarding the risk of sequelae of sinistral portal hypertension when the SV is ligated without reimplantation. The aim of this study was to identify postoperative venous collateral patterns and sequelae of SV ligation, as well as long-term results in an extended Whipple procedure. STUDY DESIGN Patients who had an extended Whipple procedure (Whipple at the Splenic Artery or WATSA) were entered in an institutional database. Evaluation of the venous collaterals was performed at least 5 months postoperatively by imaging. Spleen size and platelet counts were measured before and after operation. RESULTS Fifteen patients were entered from 2009 to 2014. SV was not reconstructed and the IMV-SV junction was always resected. Two collateral routes developed. An inferior route was present 14/15 patients. It connected the residual SV to the SMV via intermediate collateral veins in the omentum and along the colon. A superior route, present in 10/15 patients connected the residual SV to the portal vein via gastric, perigastric, and coronary veins. Gastrointestinal bleeding did not occur. Mean platelet count and spleen size were not affected significantly. Procedures were long, but few severe complications developed. In 12 patients with adenocarcinoma, the median survival has not been reached. CONCLUSIONS Patients who have SV ligation in an extended Whipple are protected against sequelae of sinestral portal hypertension by inferior collateral routes. The omentum and marginal veins of the colon are key links in this pathway.
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Affiliation(s)
- Ismael Dominguez Rosado
- Section of Hepato-Pancreato-Biliary Surgery, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 4990 Children's Place, Suite 1160, (Campus Box 8109), St Louis, MO, 63110, USA
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Vasco de Quiroga 15 Col, Tlalpan, 14000, Mexico City, Mexico
| | - Sanjeev Bhalla
- Mallinckrodt Institute of Radiology, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 660 S Euclid Ave Campus Box 8131, St Louis, MO, 63110, USA
| | - Luis A Sanchez
- Section of Vascular Surgery, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 660 S Euclid Ave Campus Box 8109, St Louis, MO, 63110, USA
| | - Ryan C Fields
- Section of Hepato-Pancreato-Biliary Surgery, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 4990 Children's Place, Suite 1160, (Campus Box 8109), St Louis, MO, 63110, USA
| | - William G Hawkins
- Section of Hepato-Pancreato-Biliary Surgery, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 4990 Children's Place, Suite 1160, (Campus Box 8109), St Louis, MO, 63110, USA
| | - Steven M Strasberg
- Section of Hepato-Pancreato-Biliary Surgery, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 4990 Children's Place, Suite 1160, (Campus Box 8109), St Louis, MO, 63110, USA.
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30
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Younan G, Tsai S, Evans DB, Christians KK. A Novel Reconstruction Technique During Pancreaticoduodenectomy After Roux-En-Y Gastric Bypass: How I do It. J Gastrointest Surg 2017; 21:1186-1191. [PMID: 28447199 PMCID: PMC5486682 DOI: 10.1007/s11605-017-3405-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/16/2017] [Indexed: 01/31/2023]
Abstract
The altered anatomy in patients after bariatric surgery who have undergone a Roux-en-Y gastric bypass may pose a technical challenge for surgical removal of the pancreatic head. We treat patients with pancreas cancer with multimodality therapy in a neoadjuvant fashion followed by pancreaticoduodenectomy (PD). In patients with Roux-en-Y gastric bypass anatomy, the gastric remnant is preserved and used for pancreaticogastrostomy reconstruction and subsequently drained by the same jejunal limb used for the hepaticojejunostomy. This method of reconstruction takes advantage of the previous surgically altered anatomy and avoids the morbidity of a gastric remnant resection at the time of PD.
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Affiliation(s)
- George Younan
- 0000 0001 2111 8460grid.30760.32Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226 USA
| | - Susan Tsai
- 0000 0001 2111 8460grid.30760.32Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226 USA
| | - Douglas B. Evans
- 0000 0001 2111 8460grid.30760.32Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226 USA
| | - Kathleen K. Christians
- 0000 0001 2111 8460grid.30760.32Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226 USA
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31
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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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32
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Addeo P, Nappo G, Felli E, Oncioiu C, Faitot F, Bachellier P. Management of the splenic vein during a pancreaticoduodenectomy with venous resection for malignancy. Updates Surg 2016; 68:241-246. [DOI: 10.1007/s13304-016-0396-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 09/07/2016] [Indexed: 12/24/2022]
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33
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Christians KK, Heimler JW, George B, Ritch PS, Erickson BA, Johnston F, Tolat PP, Foley WD, Evans DB, Tsai S. Survival of patients with resectable pancreatic cancer who received neoadjuvant therapy. Surgery 2016; 159:893-900. [PMID: 26602840 DOI: 10.1016/j.surg.2015.09.018] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 09/20/2015] [Accepted: 09/21/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enthusiasm for neoadjuvant therapy is growing from the emerging consensus that pancreatic cancer is a systemic disease at the time of diagnosis. Those who remain in favor of upfront surgery often cite the lack of reported data to support alternative treatment sequencing. We therefore report the results of all patients treated outside of a clinical trial under the direction of a multidisciplinary pancreatic cancer working group. METHODS We reviewed all patients with resectable pancreatic cancer treated with neoadjuvant therapy (NeoTx) from 2009 to 2013; we excluded those patients treated on prospective clinical trials as they will be the subject of subsequent reports. Data regarding demographics, NeoTx, operative outcomes, pathology, and survival data were abstracted from a prospective database. RESULTS NeoTx was initiated in 69 patients; median age was 65 years (interquartile range [IQR]: 11) and median carbohydrate antigen 19-9 at diagnosis was 96.5 (IQR 210). NeoTx consisted of chemotherapy alone (n = 10, 14%), chemotherapy and radiation (chemoradiation, n = 53, 77%), or both (n = 6, 9%). Median carbohydrate antigen 19-9 after NeoTx was 39 (IQR 104) corresponding to a median decrease of 60%. Operative resection was completed in 60 (87%) of the 69 patients. At restaging after NeoTx, 5 (7%) of 69 patients were not considered candidates for surgery because of the development of metastatic disease (n = 4) or an inadequate performance status (n = 1). At the time of surgery, 4 (6%) of 64 patients had metastatic disease found at laparoscopy. Of the 60 patients who underwent surgical resection, a complete pathologic response was observed in 2 (3%) patients; 20 (33%) had positive lymph nodes, and the median number of positive lymph nodes was 2 (IQR 3). R0 resections were achieved in 58 (97%) of the 60 patients. Additional postoperative adjuvant therapy was administered to 37 (62%) of the 60 patients. Median survival of all 69 patients was 31.5 months; 44.9 months for the 60 patients who completed all NeoTx and resection compared with 8.1 months for the 9 patients who were not resected (log rank P < .001). CONCLUSION NeoTx for resectable pancreatic cancer was associated with a median overall survival of 32 months; something not reported for patients treated with surgery first if based on intent-to-treat analysis. Treatment sequencing may provide an oncologic benefit beyond that of the selection bias afforded surgery after a period of induction therapy.
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Affiliation(s)
- Kathleen K Christians
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI.
| | - Jonathan W Heimler
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Ben George
- Department of Medical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Paul S Ritch
- Department of Medical Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Beth A Erickson
- Department of Radiation Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Fabian Johnston
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Parag P Tolat
- Department of Diagnostic Radiology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - William D Foley
- Department of Diagnostic Radiology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Douglas B Evans
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Susan Tsai
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
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34
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Ono Y, Matsueda K, Koga R, Takahashi Y, Arita J, Takahashi M, Inoue Y, Unno T, Saiura A. Sinistral portal hypertension after pancreaticoduodenectomy with splenic vein ligation. Br J Surg 2014; 102:219-28. [PMID: 25524295 DOI: 10.1002/bjs.9707] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 09/22/2014] [Accepted: 10/16/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Splenic vein ligation may result in sinistral (left-sided) portal hypertension and gastrointestinal haemorrhage. The aim of this study was to analyse the pathogenesis of sinistral portal hypertension following splenic vein ligation in pancreaticoduodenectomy. METHODS Patients who underwent pancreaticoduodenectomy for pancreatic cancer between January 2005 and December 2012 were included in this retrospective study. The venous flow pattern from the spleen and splenic hypertrophy were examined after surgery. RESULTS Of 103 patients who underwent pancreaticoduodenectomy with portal vein resection, 43 had splenic vein ligation. There were two predominant venous flow patterns from the spleen. In the varicose route (27 patients), flow from the spleen passed to colonic varices and/or other varicose veins. In the non-varicose route, flow from the spleen passed through a splenocolonic collateral (14 patients) or a spontaneous splenorenal shunt (2 patients). The varicose route was associated with significantly greater splenic hypertrophy than the non-varicose route (median splenic hypertrophy ratio 1·52 versus 0·94; P < 0·001). All patients with the varicose route had colonic varices, and none had a right colic marginal vein at the hepatic flexure. CONCLUSION Pancreaticoduodenectomy with splenic vein ligation may lead to sinistral portal hypertension. To avoid the development of varices, it is important to preserve the right colic marginal vein. Reconstruction of the splenic vein should be considered if the right colic marginal vein is divided.
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Affiliation(s)
- Y Ono
- Departments of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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35
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Krepline AN, Christians KK, Duelge K, Mahmoud A, Ritch P, George B, Erickson BA, Foley WD, Quebbeman EJ, Turaga KK, Johnston FM, Gamblin TC, Evans DB, Tsai S. Patency rates of portal vein/superior mesenteric vein reconstruction after pancreatectomy for pancreatic cancer. J Gastrointest Surg 2014; 18:2016-25. [PMID: 25227638 DOI: 10.1007/s11605-014-2635-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 08/18/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreatectomy with venous reconstruction (VR) for pancreatic cancer (PC) is occurring more commonly. Few studies have examined the long-term patency of the superior mesenteric-portal vein confluence following reconstruction. METHODS From 2007 to 2013, patients who underwent pancreatic resection with VR for PC were classified by type of reconstruction. Patency of VR was assessed using surveillance computed tomographic imaging obtained from date of surgery to last follow-up. RESULTS VR was performed in 43 patients and included the following: tangential resection with primary repair (7, 16%) or saphenous vein patch (9, 21%); segmental resection with splenic vein division and either primary anastomosis (10, 23%) or internal jugular vein interposition (8, 19%); or segmental resection with splenic vein preservation and either primary anastomosis (3, 7%) or interposition grafting (6, 14%). All patients were instructed to take aspirin after surgery; low molecular weight heparin was not routinely used. An occluded VR was found in four (9%) of the 43 patients at a median follow-up of 13 months; median time to detection of thrombosis in the four patients was 72 days (range 16-238). CONCLUSIONS Pancreatectomy with VR can be performed with high patency rates. The optimal postoperative pharmacologic therapy to prevent thrombosis requires further investigation.
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Affiliation(s)
- A N Krepline
- Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI, 53226, USA
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Conway WC, Bolton JS. Mesocaval Shunt to Facilitate Complex Venous Resection during Pancreaticoduodenectomy. Am Surg 2014. [DOI: 10.1177/000313481408001141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - John S. Bolton
- Surgical Oncology Ochsner Medical Center New Orleans, Louisiana
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Pilgrim CHC, Tsai S, Tolat P, Patel P, Rilling W, Evans DB, Christians KK. Optimal management of the splenic vein at the time of venous resection for pancreatic cancer: importance of the inferior mesenteric vein. J Gastrointest Surg 2014; 18:917-21. [PMID: 24347313 DOI: 10.1007/s11605-013-2428-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 11/27/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Resection of the superior mesenteric vein (SMV)-portal vein (PV)-splenic vein (SV) confluence during pancreatectomy for pancreatic cancer requires management of the SV. DISCUSSION Simple SV ligation can result in sinistral portal hypertension if the inferior mesenteric vein (IMV) enters the confluence and is thereby resected, or if the IMV is insufficient to drain the SV. We describe herein three patients whose clinical course confirms the importance of the IMV decompressing the SV to avoid sinistral hypertension.
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Affiliation(s)
- Charles H C Pilgrim
- Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, The Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI, 53226, USA
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Christians KK, Pilgrim CHC, Tsai S, Ritch P, George B, Erickson B, Tolat P, Evans DB. Arterial resection at the time of pancreatectomy for cancer. Surgery 2014; 155:919-26. [PMID: 24787115 DOI: 10.1016/j.surg.2014.01.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 01/16/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Tumor-induced arterial abutment/encasement has been traditionally a contraindication to surgery in patients with localized pancreatic cancer (PC). One recent meta-analysis reported greater mortality rates in this setting. We report herein a series of planned arterial resections in carefully selected patients who responded favorably to combined modality therapy for localized PC. METHODS We reviewed all patients with PC and arterial encasement treated between May 2011 and September 2013; all patients received an extensive course of neoadjuvant therapy before surgery. RESULTS Of 15 patients taken to surgery, 2 had peritoneal disease at laparoscopy, and therefore, laparotomy was not performed. Pancreatectomy (pancreaticoduodenectomy, 3; distal, 8; central pancreatectomy, 1; total, 1) was performed in the remaining 13, 10 of whom required arterial resection. The most common operation was an Appleby procedure. Of 10 patients who underwent combined pancreatectomy and arterial resection, their median age was 62 years (range, 33-75), median operative time was 7.5 hours, and median blood loss was 725 mL. Complications occurred in 3 of 15 patients with no perioperative mortality. Median duration of hospital stay was 9 days (range, 5-19). An R0 resection was achieved in 11 (85%) of 13 patients. At a median follow-up of 21 months, 8 of these 13 resected patients (62%) are alive without disease. CONCLUSION Planned arterial resection at the time of pancreatectomy can be performed with acceptable morbidity and mortality; patient selection and induction therapy are likely critically important variables that seem to impact patient outcome. Those patients with stable or responding disease after induction therapy represent the subset of patients with potentially favorable tumor biology in whom extended resections may enhance survival duration.
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Affiliation(s)
- Kathleen K Christians
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI.
| | - Charles H C Pilgrim
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Susan Tsai
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Paul Ritch
- Department of Medicine, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Ben George
- Department of Medicine, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Beth Erickson
- Department of Radiation Oncology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Parag Tolat
- Department of Radiology, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
| | - Douglas B Evans
- Department of Surgery, Pancreatic Cancer Program, Medical College of Wisconsin, Milwaukee, WI
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Bachellier P, Rosso E, Fuchshuber P, Addeo P, David P, Oussoultzoglou E, Lucescu I. Use of a temporary intraoperative mesentericoportal shunt for pancreatic resection for locally advanced pancreatic cancer with portal vein occlusion and portal hypertension. Surgery 2014; 155:449-56. [PMID: 24462078 DOI: 10.1016/j.surg.2013.09.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 09/12/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Our aim was to evaluate the perioperative morbidity and survival of a selected group of patients with locally advanced pancreatic ductal adenocarcinoma (PDAC) and malignant obstruction of portal axis inducing portal hypertension (PH) who underwent a curative intent pancreatic resection, after neoadjuvant chemotherapy, adopting a new type of temporary intraoperative mesentericoportal shunt (TMPS). METHODS We analyzed the perioperative data and survival outcome of 15 patients with locally advanced PDAC and PH who underwent pancreatoduodenectomy combined with vascular resections between October 2008 and October 2012 using this TMPS. RESULTS There was no perioperative mortality. Postoperative morbidity occurred in 7 patients without any postoperative liver failure. All patients underwent mesentericoportal venous resection, 11 of whom had a concomitant arterial resection. The mean ± SD follow-up was 16 ± 10 months (range, 4-40; median 15). Overall survival rates of patients were 78% and 11% at 1 and at 3 years, respectively. Median survival was 17 months. The 1-year disease-free survival was 36%. CONCLUSION The use of this form of TMPS allowed us to achieve PD or total pancreatectomy in patients with locally advanced PDAC and PH without postoperative mortality but with increased morbidity. The relevance of such an aggressive approach is yet to be determined.
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Affiliation(s)
- Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.
| | - Edoardo Rosso
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Pascal Fuchshuber
- Department of Surgical Oncology, The Permanente Medical Group, Walnut Creek, CA
| | - Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Patrice David
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Elie Oussoultzoglou
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Ionut Lucescu
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
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Pilgrim CH, Tsai S, Evans DB, Christians KK. Mesocaval Shunting: A Novel Technique to Facilitate Venous Resection and Reconstruction and Enhance Exposure of the Superior Mesenteric and Celiac Arteries during Pancreaticoduodenectomy. J Am Coll Surg 2013; 217:e17-20. [DOI: 10.1016/j.jamcollsurg.2013.05.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 05/21/2013] [Accepted: 05/22/2013] [Indexed: 01/14/2023]
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