Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group

Graft choice in pancreatectomy with vascular resection: equivalent safety in selected patients

BACKGROUND

Pancreatic cancer is the third leading cause of cancer-related death in the United States, with surgical resection being the only option for long-term survival. The ability to manage vascular involvement has expanded the pool of patients who are able to undergo resection with curative intent. However, not all vascular involvements can be detected preoperatively. This study aimed to investigate the patterns of vascular resection and methods of repair or reconstruction METHODS: This was a single-center retrospective review of adult patients undergoing pancreatectomy with vascular involvement at a tertiary care referral hospital between 2010 and 2022. The primary endpoint was graft thrombosis within 90 days.

RESULTS

A total of 147 patients were included in the study. Of note, 21.8% of patients were not suspected of having vascular involvement preoperatively. Moreover, 68.0% of patients required vascular reconstruction, whereas the remaining 32.0% of patients underwent repair (either primary repair or patch angioplasty). Most patients who underwent reconstruction underwent primary end-to-end anastomosis (63.0%), with 19 patients requiring autologous interposition grafts and 16 patients requiring CryoVein interposition grafts. Univariate analysis found no clinical or technical predictors of early or 90-day thrombosis, including graft choice. In addition, 30- and 90-day mortalities occurred in 1 and 7 patients, respectively.

CONCLUSION

Pancreatectomy with vascular resection can be performed with low mortality in carefully selected patients. Unsuspected vascular involvement is relatively common (1 in 5). If autologous graft is not readily available, CryoVein is a safe alternative with similar perioperative outcomes.

Pancreatectomy with En Bloc Superior Mesenteric Vein and All Its Tributaries Resection without PV/SMV Reconstruction for "Low" Locally Advanced Pancreatic Head Cancer

The "vein definition" for locally advanced pancreatic ductal adenocarcinoma (LA PDAC) assumes portal-to-superior mesenteric vein (PV/SMV) unreconstructability due to tumor involvement or occlusion. Radical pancreatectomies with SMV resection without PV/SMV reconstruction are scarcely discussed in the literature. Retrospective analysis of 19 radical pancreatectomies for "low" LA PDAC with SMV and all its tributaries resection without PV/SMV reconstruction has shown zero mortality; overall morbidity-56%; Dindo-Clavien-3-10.5%; R0-rate-82%; mean operative procedure time-355 ± 154 min; mean blood loss-330 ± 170 mL; delayed gastric emptying-25%; and clinically relevant postoperative pancreatic fistula-8%. In three cases, surgery was associated with superior mesenteric (n2) and common hepatic artery (n1) resection. Surgery was completed without vein reconstruction (n13) and with inferior mesenteric-to-splenic anastomosis (n6). There were no cases of liver, gastric, or intestinal ischemia. A specific complication of the SMV resection without reconstruction was 2-3 days-long intestinal edema (48%). Median overall survival was 25 months, and median progression-free survival was 18 months. All the relapses, except two, were distant. The possibility of successful SMV resection without PV/SMV reconstruction can be predicted before surgery by CT-based reconstructions. The mandatory anatomical conditions for the procedure were as follows: (1) preserved SMV-SV confluence; (2) occluded SMV for any reason (tumor or thrombus); (3) well-developed inferior mesenteric vein collaterals with dilated intestinal veins; (4) no right-sided vein collaterals; and (5) no varices in the upper abdomen. Conclusion: "Low" LA PDACs involving SMV with all its tributaries can be radically and safely resected in highly and specifically selected cases without PV/SMV reconstruction with an acceptable survival rate.

Multimodal Approaches to Patient Selection for Pancreas Cancer Surgery

With an overall 5-year survival rate of 12%, pancreas ductal adenocarcinoma (PDAC) is an aggressive cancer that claims more than 50,000 patient lives each year in the United States alone. Even those few patients who undergo curative-intent resection with favorable pathology reports are likely to experience recurrence within the first two years after surgery and ultimately die from their cancer. We hypothesize that risk factors for these early recurrences can be identified with thorough preoperative staging, thus enabling proper patient selection for surgical resection and avoiding unnecessary harm. Herein, we review evidence supporting multidisciplinary and multimodality staging, comprehensive neoadjuvant treatment strategies, and optimal patient selection for curative-intent surgical resections. We further review data generated from our standardized approach at the Mayo Clinic and extrapolate to inform potential future investigations.

Innovative Imaging Techniques Used to Evaluate Borderline-Resectable Pancreatic Adenocarcinoma

A diagnosis of pancreatic cancer carries a 5-y survival rate of less than 10%. Furthermore, the detection of pancreatic cancer occurs most often in later stages of the disease due to its location in the retroperitoneum and lack of symptoms (in most cases) until tumors become more advanced. Once diagnosed, cross-sectional imaging techniques are heavily utilized to determine the tumor stage and the potential for surgical resection. However, a major determinant of resectability is the extent of local vascular involvement of the mesenteric vessels and critical tributaries; current imaging techniques have limited capacity to accurately determine vascular involvement. Surrounding inflammation and fibrosis can be difficult to discriminate from viable tumor, making determination of the degree of vascular involvement unreliable. New innovations in fluorescence and optoacoustic imaging techniques may overcome these limitations and make determination of resectability more accurate. These imaging modalities are able to more clearly discern between viable tumor tissue and non-neoplastic inflammation or desmoplasia, allowing clinicians to more reliably characterize vascular involvement and develop individualized treatment plans for patients. This review will discuss the current imaging techniques used to diagnose pancreatic cancer, the barriers that current techniques raise to accurate staging, and novel fluorescence and optoacoustic imaging techniques that may provide more accurate clinical staging of pancreatic cancer.

Laparoscopic pancreaticoduodenectomy with portal or superior mesenteric vein resection and reconstruction for pancreatic cancer: A single-center experience

BACKGROUND

Open pancreaticoduodenectomy (OPD) with portal or superior mesenteric vein resection and reconstruction has been applied in pancreatic cancer patients with tumor infiltration or adherence. However, it is controversial whether laparoscopic pancreaticoduodenectomy (LPD) with major vascular resection and reconstruction is feasible. This study aimed to evaluate the safety and feasibility of LPD with major vascular resection compared with OPD with major vascular resection.

METHODS

We reviewed data for all pancreatic cancer patients undergoing LPD or OPD with vascular resection at Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, between February 2018 and May 2022. We compared the preoperative, intraoperative, and postoperative clinicopathological data of the two groups to conduct a comprehensive evaluation of LPD with major vascular resection.

RESULTS

A total of 63 patients underwent pancreaticoduodenectomy (PD) with portal or superior mesenteric vein resection and reconstruction, including 25 LPDs and 38 OPDs. The LPD group had less intraoperative blood loss (200 vs. 400 mL, P < 0.001), lower proportion of intraoperative blood transfusion (16.0% vs. 39.5%, P = 0.047), longer operation time (390 vs. 334 min, P = 0.004) and shorter postoperative hospital stay (11 vs. 14 days, P = 0.005). There was no perioperative death in all patients. There was no significant difference in the incidence of total postoperative complications, grade B/C postoperative pancreatic fistula, delayed gastric emptying and abdominal infection between the two groups. No postpancreatectomy hemorrhage nor bile leakage occurred during perioperative period. There was no significant difference in R0 resection rate and number of lymph nodes harvested between the two groups. Patency of reconstructed vessels in the two groups were 96.0% and 92.1%, respectively (P = 0.927).

CONCLUSIONS

LPD with portal or superior mesenteric vein resection and reconstruction was safe, feasible and oncologically acceptable for selected patients with pancreatic cancer, and it can achieve similar or even better perioperative results compared to open approach.

A Paradigm Shifts: Neoadjuvant Therapy for Clearly Resectable Pancreatic Cancer

Over the past decade, neoadjuvant therapy has become the standard of care for patients with borderline resectable and locally advanced pancreatic cancer. The surgical community remains divided regarding the value of neoadjuvant therapy for patients who present with clearly resectable disease. Thus far, randomized controlled trials comparing neoadjuvant therapy with conventional upfront surgical strategies for patients with clearly resectable pancreatic cancer have been plagued by poor accrual, and are often underpowered. Nonetheless, meta-analyses of the results of these trials suggest that neoadjuvant therapy can be offered as an acceptable standard of care for patients with clearly resectable pancreatic cancer. Previous trials used neoadjuvant gemcitabine, but more recent studies have demonstrated superior survival for patients who were able to tolerate neoadjuvant FOLFIRINOX (leucovorin, 5-fluorouracil, irinotecan hydrochloride, and oxaliplatin). The increased utilization of FOLFIRINOX may be shifting the treatment paradigm in favor of neoadjuvant therapy among patients with clearly resectable disease. Randomized controlled trials assessing the value of neoadjuvant FOLFIRINOX in clearly resectable pancreatic cancer, which are expected to provide more conclusive recommendations, are still ongoing. This review outlines the rationale, considerations, and current level of evidence for the use of neoadjuvant therapy in patients with clearly resectable pancreatic cancer.

Comprehensive multimodal management of borderline resectable pancreatic cancer: Current status and progress

Borderline resectable pancreatic cancer (BRPC) is a complex clinical entity with specific biological features. Criteria for resectability need to be assessed in combination with tumor anatomy and oncology. Neoadjuvant therapy (NAT) for BRPC patients is associated with additional survival benefits. Research is currently focused on exploring the optimal NAT regimen and more reliable ways of assessing response to NAT. More attention to management standards during NAT, including biliary drainage and nutritional support, is needed. Surgery remains the cornerstone of BRPC treatment and multidisciplinary teams can help to evaluate whether patients are suitable for surgery and provide individualized management during the perioperative period, including NAT responsiveness and the selection of surgical timing.

Surgical Treatment of Pancreatic Cancer: Currently Debated Topics on Vascular Resection

Vascular resections involving the superior mesenteric and portal veins (SMV-PV), celiac axis (CA), superior mesenteric artery (SMA) and hepatic artery (HA) have multiplied in recent years, raising the resection rate for pancreatic cancer (PDAC) and the related morbidity and mortality rates. While resection is generally accepted for resectable SMV-PV, the usefulness of associated arterial resection in borderline resectable (BRPC) and locally-advanced PDAC (LAPC) is much debated. Careful selection of splenic vein reconstruction is very important to prevent left-sided portal hypertension (LSPH). During distal pancreatectomy (DP), CA and common HA resection is largely accepted, while there is debate on the value of SMA and proper HA resection and reconstruction. Their resection is useless according to several reviews and meta-analyses, and some international societies, although some high-volume centers have reported good results. Short- and long-term reconstructed vessel patency varies with the type of reconstruction, the material used, and the surgeon's experience. Laparoscopic and robotic pancreaticoduodenectomy and DP are generally accepted if done by surgeons performing at least 10 such procedures annually. The usefulness of associated vascular resection remains highly controversial. Surgeons need to complete numerous minimally-invasive procedures to overcome the learning curve, and prevent an increase in complications and surgical mortality. Higher resectability rates and satisfactory long-term results have been reported after neoadjuvant therapy (NAT) for BRPC and LAPC requiring vascular resection. It is essential to select the most appropriate NAT for a given patient and to assess PDAC resectability preoperatively.

The tentative application of en bloc concept in the pediatric brain tumor: Experience from a large pediatric center in china

Background

Children are more susceptible to the higher rate of massive blood transfusion because of the less allowable blood loss and lower intraoperative tolerance to blood loss during the resection of brain tumors. The surgical concept of en bloc resection, which is widely used in other tumors, may contribute to the improvement of brain tumor resection. However, there is still a lack of comprehensive research on its application in pediatric brain tumors.

Objective

The aim of this study is to investigate the outcomes of the en bloc concept and the factors associated with the application of the en bloc concept in pediatric brain tumors.

Methods

According to the surgical concept involved, the patients were divided into three subgroups: complete en bloc concept, partial en bloc concept, and piecemeal concept. The matching comparison (complete and partial en bloc concept groups vs. piecemeal concept group) was conducted to investigate the effect of the en bloc concept on the outcomes. Then, the patient data from January 2018, when the en bloc concept was routinely integrated into the brain tumor surgery in our medical center, were reviewed and analyzed to find out the predictors associated with the application of en bloc concept.

Results

In the en bloc group, the perioperative parameters, such as hospital stay (p = 0.001), pediatric intensive care unit (PICU) stay (p = 0.003), total blood loss (p = 0.015), transfusion rate (p = 0.005), and complication rate (p = 0.039), were all significantly improved. The multinomial logistic regression analysis showed that tumor volume, bottom vessel, and imaging features, such as encasing nerve or pass-by vessel, finger-like attachment, ratio of “limited line”, and ratio of “clear line”, were independent predictors for the application of the en bloc concept in our medical center.

Conclusion

This study supports the application of complete and partial en bloc concept in the pediatric brain tumor surgery based on the preoperative evaluation of imaging features, and compared with the piecemeal concept, the en bloc concept can improve the short outcomes without significant increases in the neurological complications. Large-series and additional supportive pieces of evidence are still warranted.

Clinical challenges associated with utility of neoadjuvant treatment in patients with pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is an increasingly common cancer with a persistently poor prognosis, and only approximately 20% of patients are clearly anatomically resectable at diagnosis. Historically, a paucity of effective therapy made it inappropriate to forego the traditional gold standard of upfront surgery in favour of neoadjuvant treatment; however, modern combination chemotherapy regimens have made neoadjuvant therapy increasingly viable. As its use has expanded, the rationale for neoadjuvant therapy has evolved from one of 'downstaging' to one of early treatment of micro-metastases and selection of patients with favourable tumour biology for resection. Defining resectability in PDAC is problematic; multiple differing definitions exist. Multidisciplinary input, both in initial assessment of resectability and in supervision of multimodality therapy, is therefore advised. European and North American guidelines recommend the use of neoadjuvant chemotherapy in borderline resectable (BR)-PDAC. Similar regimens may be applied in locally advanced (LA)-PDAC with the aim of improving potential access to curative-intent resection, but appropriate patient selection is key due to significant rates of recurrence after excision of LA disease. Upfront surgery and adjuvant chemotherapy remain standard-of-care in clearly resectable PDAC, but multiple trials evaluating the use of neoadjuvant therapy in this and other localised settings are ongoing.

Portalvein reconstruction with a cadaveric descending thoracic aortic homograft

Improvements in chemoradiotherapy have rendered complex pancreatic cancers involving the portal vein (PV) amenable to resection. PV reconstruction (PVR) is an essential component. Various conduits have been proposed; however, the optimal choice remains unknown. Fourteen patients underwent PVR with a cadaveric descending thoracic aortic homograft from 2014 to 2020. The primary diagnosis was pancreatic cancer. The splenic vein was ligated in seven patients (50%). The 30-day and 3-, 12-, and 24-month primary patency rates were 100%, 86%, 76%, and 76%, respectively. We found a cadaveric descending thoracic aortic homograft is an excellent conduit for PVR, given the optimal size, rapidly availability, favorable risk profile, and absence of harvest site complications.

AHPBA guidelines for managing VTE prophylaxis and anticoagulation for pancreatic surgery

BACKGROUND

Major abdominal surgery and malignancy lead to a hypercoagulable state, with a risk of venous thromboembolism (VTE) of approximately 3% after pancreatic surgery. No guidelines exist to assist surgeons in managing VTE prophylaxis or anticoagulation in patients undergoing elective pancreatic surgery for malignancy or premalignant lesions. A systematic review specific to VTE prophylaxis and anticoagulation after resectional pancreatic surgery is herein provided.

METHODS

Six topic areas are reviewed: pre- and perioperative VTE prophylaxis, early postoperative VTE prophylaxis, extended outpatient VTE prophylaxis, management of chronic anticoagulation, anti-coagulation after vascular reconstruction, and treatment of VTE. A Medline and PubMED search was completed with systematic medical literature review for each topic. Level of evidence was graded and strength of recommendation ranked according to the GRADE (Grades of Recommendation Assessment, Development and Evaluation) system for practice guidelines.

RESULTS

Levels of evidence and strength of recommendations are presented.

DISCUSSION

While strong data exist to guide management of chronic anticoagulation and treatment of VTE, data for anticoagulation after reconstruction is inconclusive and support for perioperative chemoprophylaxis with pancreatic surgery is similarly limited. The risk of post-pancreatectomy hemorrhage often exceeds that of thrombosis. The role of universal chemoprophylaxis must therefore be examined critically, particularly in the preoperative setting.

Imaging Assessment of Pancreatic Cancer Resectability After Neoadjuvant Therapy: AJR Expert Panel Narrative Review

Despite important innovations in the treatment of pancreatic ductal adenocarcinoma (PDAC), PDAC remains a disease with poor prognosis and high mortality. A key area for potential improvement in the management of PDAC, aside from earlier detection in patients with treatable disease, is the improved ability of imaging techniques to differentiate treatment response after neoadjuvant therapy (NAT) from worsening disease. It is well established that current imaging techniques cannot reliably make this distinction. This narrative review provides an update on the imaging assessment of pancreatic cancer resectability after NAT. Current definitions of borderline resectable PDAC, as well as implications for determining likely patient benefit from NAT, are described. Challenges associated with PDAC pathologic evaluation and surgical decision making that are of relevance to radiologists are discussed. Also explored are the specific limitations of imaging in differentiating the response after NAT from stable or worsening disease, including issues relating to protocol optimization, tumor size assessment, vascular assessment, and liver metastasis detection. The roles of MRI as well as PET and/or hybrid imaging are considered. Finally, a short PDAC reporting template is provided for use after NAT. The highlighted methods seek to improve radiologists' assessment of PDAC treatment response after NAT.

Sinistral Portal Hypertension after Pancreaticoduodenectomy with Splenic Vein Resection: Pathogenesis and Its Prevention

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.

The impact of venous resection in pancreatoduodectomy: A systematic review and meta-analysis

BACKGROUND

Vein resection pancreatoduodenectomy (VRPD) may be performed in selected pancreatic cancer patients. However, the main risks and benefits related to VRPD remain controversial.

OBJECTIVE

This review aimed to evaluate the risks and survival benefits that the VRPD may add when compared with standard pancreatoduodenectomy (PD).

METHODS

A systematic review and meta-analysis of studies comparing VRPD and PD were performed.

RESULTS

VRPD was associated with a higher risk for postoperative mortality (risk difference: -0.01; 95% confidence interval [CI] -0.02 to -0.00) and complications (risk difference: -0.05; 95% CI -0.09 to -0.01) than PD. The length of hospital stay was not different between the groups (mean difference [MD]: -0.65; 95% CI -2.11 to 0.81). In the VRPD, the operating time was 69 minutes higher on average (MD: -69.09; 95% CI -88.4 to -49.78), with a higher blood loss rate (MD: -314.04; 95% CI -423.86 to -195.22). In the overall survival evaluation, the hazard ratio for mortality during follow-up on the group of VRPD was higher compared to the PD group (hazard ratio: 1.13; 95% CI 1.03-1.23).

CONCLUSION

VRPD is associated with a higher risk of short-term complications and mortality and a lower probability of survival than PD. Knowing the risks and potential benefits of surgery can help clinicians to properly manage pancreatic cancer patients with venous invasion. The decision for surgery with major venous resection should be shared with the patients after they are informed of the risks and prognosis.

Prognostic Value of Preoperative NLR and Vascular Reconstructive Technology in Patients With Pancreatic Cancer of Portal System Invasion: A Real World Study

The purpose was aimed to establish a simple computational model to predict tumor prognosis by combining neutrophil to lymphocyte Ratio (NLR) and biomarkers of oncological characteristics in patients undergoing vascular reconstructive radical resection of PDAC. The enrolled patients was divided into high or low NLR group with the cutoff value determined by the receiver operator characteristic (ROC) curve. Different vascular anastomoses were selected according to the Chaoyang classification of PDAC. Survival rates were calculated using the Kaplan-Meier and evaluated with the log-rank test. Cox risk regression model was used to analyze the independent risk factors for prognostic survival. The optimal cut-off value of NRL was correlated with the differentiation, tumor size, TNM stage and distant metastasis of advanced PDAC. A curative resection with vascular reconstructive of advanced PDAC according to Chaoyang classification can obviously improve the survival benefits. Cox proportional hazards demonstrated higher evaluated NLR, incisal margin R1 and lymphatic metastasis were the independent risk predictor for prognosis with the HR > 2, meanwhile, age beyond 55, TNM stage of III-IV or Tumor size > 4cm were also the obvious independent risk predictor for prognosis with the HR ≤ 2. The advanced PADC patients marked of RS group (3 < RS ≤ 6) showed no more than 24 months of survival time according to RS model based on the six independent risk predictors. Vascular reconstruction in radical resection of advanced PDAC improved survival, higher elevated NLR (>2.90) was a negative predictor of DFS and OS in those patients accompanying portal system invasion.

Preoperative assessment of the resectability of pancreatic ductal adenocarcinoma on CT according to the NCCN Guidelines focusing on SMA/SMV branch invasion

OBJECTIVES

For patients with pancreatic adenocarcinoma (PAC), adequate determination of disease extent is critical for optimal management. We aimed to evaluate diagnostic accuracy of CT in determining the resectability of PAC based on 2020 NCCN Guidelines.

METHODS

We retrospectively enrolled 368 consecutive patients who underwent upfront surgery for PAC and preoperative pancreas protocol CT from January 2012 to December 2017. The resectability of PAC was assessed based on 2020 NCCN Guidelines and compared to 2017 NCCN Guidelines using chi-square tests. Overall survival (OS) was estimated using the Kaplan-Meier method and compared using log-rank test. R0 resection-associated factors were identified using logistic regression analysis.

RESULTS

R0 rates were 80.8% (189/234), 67% (71/106), and 10.7% (3/28) for resectable, borderline resectable, and unresectable PAC according to 2020 NCCN Guidelines, respectively (p < 0.001). The estimated 3-year OS was 28.9% for borderline resectable PAC, which was significantly lower than for resectable PAC (43.6%) (p = 0.004) but significantly higher than for unresectable PAC (0.0%) (p < 0.001). R0 rate was significantly lower in patients with unresectable PAC according to 2020 NCCN Guidelines (10.7%, 3/28) than in those with unresectable PAC according to the previous version (31.7%, 20/63) (p = 0.038). In resectable PAC, tumor size ≥ 3 cm (p = 0.03) and abutment to portal vein (PV) (p = 0.04) were independently associated with margin-positive resection.

CONCLUSIONS

The current NCCN Guidelines are useful for stratifying patients according to prognosis and perform better in R0 prediction in unresectable PAC than the previous version. Larger tumor size and abutment to PV were associated with margin-positive resection in patients with resectable PAC.

KEY POINTS

• The updated 2020 NCCN Guidelines were useful for stratifying patients according to prognosis. • The updated 2020 NCCN Guidelines performed better in the prediction of margin-positive resection in unresectable cases than the previous version. • Tumor size ≥ 3 cm and abutment to the portal vein were associated with margin-positive resection in patients with resectable pancreatic adenocarcinoma.

Feasibility of mesentericoportal vein reconstruction by autologous falciform ligament during pancreaticoduodenectomy-cohort study

BACKGROUND

Mesentericoportal vein (MPV) resection in pancreatic ductal adenocarcinoma (PDAC) surgery has become a common procedure. A few studies had described the use of falciform ligament (FL) for MPV reconstruction and received encouraging preliminary effects.

AIMS

This study was designed to explore the feasibility and efficacy of this technique compared with others.

METHODS

Patients who underwent pancreaticoduodenectomy (PD) with MPV resection for PDAC from 2009 to 2018 were enrolled. Medical records were retrospectively reviewed, MPV reconstructions using FL were distinguished and compared with other techniques.

RESULTS

146 patients underwent MPV reconstruction, and 13 received FL venoplasty. Other reconstruction techniques included primary end-to-end anastomosis (primary, n = 30), lateral venorrhaphy (LV, n = 19), polytetrafluoroethylene conduit interposition (PTFE, n = 24), iliac artery (IA) allografts interposition (n = 47), and portal vein (PV) allografts interposition (n = 13). FL group holds the advantages of shortest operation time (p = 0.023), lowest blood loss (p = 0.109), and shortest postoperative hospital stay (p = 0.125). The grouped patency rates of FL, primary, LV, PTFE, IA, and PV were 100%, 90%, 68%, 54%, 68%, and 85% respectively. Comparison displayed that FL had the highest patency rate (p = 0.008) and lowest antiplatelet/anticoagulation proportion (p = 0.000). Complications and long-term survival were similar among different techniques. The median survival time of patent group (24.0 months, 95% CI: 22.0-26.0) was much longer than that of the thrombosed (17.0 months, 95% CI: 13.7-20.3), though without significant difference (P = 0.148).

CONCLUSIONS

PD with MPV resection and reconstruction by FL is safe, feasible, and efficacious, it might provide a potential benefit for patients.

Prognostic analysis of pancreatic carcinoma with portal system invasion following curative resection

Background

To analyze the related factors affecting the prognosis of pancreatic carcinoma with portal system invasion.

Methods

We retrospectively analyzed the clinical data of 118 patients with portal venous system invasion in Beijing Chaoyang Hospital between January 2011 and December 2018. Only patients with borderline resectable pancreatic cancer were included in this study. Borderline pancreatic cancer was defined according to NCCN (The National Comprehensive Cancer Network) guidelines. All patients underwent surgical treatment combined with vascular resection and reconstruction. The prognosis was evaluated according to the follow-up results, and the related risk factors for prognosis were analyzed. The survival curve was drawn by Kaplan-Meier method, and the survival rate was compared by log-rank test. Multivariate Cox regression was used to analyze the prognostic factors.

Results

In our research, all of 126 patients were successfully completed the operations. Complications occurred in 29.7% of patients and perioperative death in 4.0%. A total of 118 patients were followed up and the followed-up rate was 97.5% (118/121). The overall 1-year, 2-year and 3-year survival rates were 49.2%, 27.1% and 19.8%, And the median survival time was 20 months. Multivariate analysis showed that preoperative CA19-9 (RR 1.449, 95% CI: 1.053-1.994), N status (RR 2.533, 95% CI: 1.337-4.798), degree of tumor differentiation (RR 1.592, 95% CI: 1.064-2.381) and venous invasion depth (RR 2.03, 95% CI: 1.504-2.758) were independent risk factors for the prognosis.

Conclusions

The long-term prognosis of pancreatic carcinoma patients with portal system invasion is poor. The venous invasion depth is an independent risk factor for the prognosis of pancreatic carcinoma with portal system invasion, the deeper of venous invasion, the worse the prognosis, and poorly differentiated tumors have the worst prognosis. Other independent risk factors included N status and the preoperative CA19-9. Those may help with patients' selection for different treatment protocols.

Is Laparoscopic Pancreaticoduodenectomy Feasible for Pancreatic Ductal Adenocarcinoma?

Simple Summary

Pancreatic cancer is known to be one of the most lethal malignant diseases in gastrointestinal tract. Margin-negative pancreatectomy followed by postoperative adjuvant chemotherapy is essential treatment for long-term survival. Due to anatomical complexity and technical difficulty, laparoscopic pancreaticoduodenectomy is still controversial. However, with the advance of laparoscopic surgery, laparoscopic pancreatic resection of pancreatic head cancer has been carefully applied in well selected patients. The accumulating data are suggesting its technical feasibility, safety, and potential equivalent long-term oncologic outcome. In this review, the current status of laparoscopic pancreaticoduodenectomy for pancreatic head cancer is summarized. In addition, potential surgical indications and future perspectives of laparoscopic pancreaticoduodenectomy for pancreatic cancer are discussed for safe implementation in our clinical practice.

Abstract

Margin-negative radical pancreatectomy is the essential condition to obtain long-term survival of patients with pancreatic cancer. With the investigation for early diagnosis, introduction of potent chemotherapeutic agents, application of neoadjuvnat chemotherapy, advancement of open and laparoscopic surgical techniques, mature perioperative management, and patients’ improved general conditions, survival of the resected pancreatic cancer is expected to be further improved. According to the literatures, laparoscopic pancreaticoduodenectomy (LPD) is also thought to be good alternative strategy in managing well-selected resectable pancreatic cancer. LPD with combined vascular resection is also feasible, but only expert surgeons should handle these challenging cases. LPD for pancreatic cancer should be determined based on surgeons’ proficiency to fulfil the goals of the patient’s safety and oncologic principles.

Comparison between long and short-term venous patencies after pancreatoduodenectomy or total pancreatectomy with portal/superior mesenteric vein resection stratified by reconstruction type

Background

Venous reconstruction has been recently demonstrated to be safe for tumours with invasion into portal vein and/or superior mesenteric vein. This study aims to compare the patency between various venous reconstructions.

Methods

This is retrospective study of 76 patients who underwent pancreaticoduodenectomy or total pancreatectomy with venous reconstruction from 2006 to 2018. Patient demographics, tumour histopathology, morbidity, mortality and patency were studied. Kaplan-Meier estimates were performed for primary venous patency.

Results

Sixty-two patients underwent pancreaticoduodenectomy and 14 underwent total pancreatectomy. Forty-seven, 19 and 10 patients underwent primary repair, end-to-end anastomosis and interposition graft respectively. Major morbidity (Clavien-Dindo >grade 2) and 30-day mortality were 14/76(18.4%) and 1/76(1.3%) respectively. There were 12(15.8%) venous occlusion including 4(5.3%) acute occlusions. Overall 6-month, 1-year and 2-year primary patency was 89.1%, 92.5% and 92.3% respectively. 1-year primary patency of primary repair was superior to end-to-end anastomosis and interposition graft (primary repair 100%, end-to-end anastomosis 81.8%, interposition graft 66.7%, p = 0.045). Pairwise comparison also demonstrated superior 1-year patency of primary repair (adjusted p = 0.037). There was no significant difference between the cumulative venous patency for each venous reconstruction method: primary repair 84±6%, end-to-end anastomosis 75±11% and interposition graft 76±15% (p = 0.561).

Conclusion

1-year primary venous patency of primary repair is superior to end-to-end anastomosis and interposition graft.

The clinical impact of splenic artery ligation on the occurrence of digestive varices after pancreaticoduodenectomy with combined portal vein resection: a retrospective study in two institutes

PURPOSE

Pancreaticoduodenectomy (PD) concomitant with portal vein resection (PVR) often develops into digestive varices with an occurrence rate of 30-50%, and the variceal bleeding is sometimes untreatable and results in fatality. Against this issue, splenic artery (SpA) ligation during PD-PVR is emerging as an easy and effective prophylactic surgical option. The aim of this study was to investigate the significance of SpA ligation in the development of digestive varices in patients undergoing PD-PVR.

METHOD

We retrospectively investigated 97 patients with PDAC who received PD-PVR in two hospitals. Vascular reconstruction of the splenic vein (SpV) was not performed in either hospital. We assessed the occurrence rate of digestive varices in these patients in association with the performance of SpA ligation.

RESULTS

The occurrence rate of digestive varices was 23%. SpA ligation was the only significant decreasing factor for the development of digestive varices (odds ratio 0.3, p = 0.035). Although SpV resection was not a significant risk factor for the development of digestive varices in all patients, SpV resection was a significant risk factor for the development of digestive varices in patients without SpA ligation, as demonstrated in previous reports. SpA ligation did not increase surgical complications or impair pancreatic function.

CONCLUSION

PD-PVR surgery was accompanied by a 23% incidence of digestive varices, and SpA ligation significantly decreased the development of digestive varices without causing clinically significant complications.

TRIAL REGISTRATION

No. 18196 (Osaka International Cancer Institute) and no. 19006 (National Hospital Organization Osaka National Hospital).

Long-term outcomes following en bloc resection for pancreatic ductal adenocarcinoma of the head with portomesenteric venous invasion

BACKGROUND

The aim of this study is to clarify the prognostic influence of venous resection of the portal vein (PV) or superior mesenteric vein (SMV) on long-term outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) of the head with suspected vascular invasion.

METHODS

From May 1995 to December 2014, a total of 557 patients underwent surgery with curative intent for pancreatic cancer of the head.

RESULTS

Among 557 patients, 106 (19%) underwent pancreaticoduodenectomy (PD) with PV-SMV resection and 89 (75.5%) of these patients were confirmed to have true pathological invasion. The 5-year overall survival rate in patients underwent PV-SMV resection was significantly lower compared with those who did not (18.7% versus 24.3%; p = 0.002). Patients with negative resection margins who underwent PV-SMV resection had a better prognosis than those with positive resection margins who did not undergo PV-SMV resection with positive resection margins (17% versus 6.3% in 5-year overall survival rate; p = 0.003). The overall morbidity rate was not significantly different between PV-SMV resection group and no PV-SMV resection group (p = 0.064). On multivariate analysis, margin status, advanced T stage (3 or 4), lymph node metastasis, and adjuvant therapy were independent prognostic factors for survival.

CONCLUSION

PV-SMV resection was related to lower overall survival. However, on multivariate analysis, margin status was a more important prognostic factor than PV-SMV resection and true pathological invasion for survival. Therefore, en bloc PV-SMV resection should be performed when PV-SMV invasion is suspected to achieve R0 resection.

Regional pancreatoduodenectomy versus standard pancreatoduodenectomy with portal vein resection for pancreatic ductal adenocarcinoma with portal vein invasion

Background

Pancreatoduodenectomy (PD) with portal vein resection (PVR) is a standard operation for pancreatic ductal adenocarcinoma (PDAC) with portal vein (PV) invasion, but positive margin rates remain high. It was hypothesized that regional pancreatoduodenectomy (RPD), in which soft tissue around the PV is resected en bloc, could enhance oncological clearance and survival.

Methods

This retrospective study included consecutive patients who underwent PD with PVR between January 2005 and December 2016 in a single high‐volume centre. In standard PD (SPD) with PVR, the PV was skeletonized and the surrounding soft tissue dissected. In RPD, the retropancreatic segment of the PV was resected en bloc with its surrounding soft tissue. The extent of lymphadenectomy was similar between the procedures.

Results

A total of 268 patients were included (177 SPD, 91 RPD). Tumours were more often resectable in patients undergoing SPD (60·5 per cent versus 38 per cent in those having RPD; P = 0·014), and consequently they received neoadjuvant therapy less often (7·9 versus 25 per cent respectively; P < 0·001). R0 resection was achieved in 73 patients (80 per cent) in the RPD group, compared with 117 (66·1 per cent) of those in the SPD group (P = 0·016), although perioperative outcomes were comparable between the groups. Median recurrence‐free (RFS) and overall (OS) survival were 17 and 32 months respectively in patients who had RPD, compared with 11 and 21 months in those who had SPD (RFS: P = 0·003; OS: P = 0·004).

Conclusion

RPD is as safe and feasible as SPD, and may increase the survival of patients with PDAC with PV invasion.

Significance of Cancer Cells at the Vein Edge in Patients with Pancreatic Adenocarcinoma Following Pancreatectomy with Vein Resection

BACKGROUND

Resection of the superior mesenteric and/or portal vein (SMV-PV) is increasingly performed with pancreatectomy for adenocarcinoma. We sought to analyze the impact of cancer at the transected edge(s) of the vein wall.

METHODS

Patients who underwent pancreatectomy with vein resection between 2003 and 2015 at a single center were evaluated. R1 resection was defined per guidelines from the American Joint Commission on Cancer and the College of American Pathologists. Specimens were also evaluated for the presence (V+) or absence (V-) of cancer cells at the transected edge(s) and depth of vein invasion.

RESULTS

Among 127 evaluated patients, 114 (90%) received preoperative therapy. R-status was categorized as margin-negative (R0)/V- (n = 72, 57%), R0/V+ (n = 19, 15%), margin-positive (R1)/V- (n = 24, 19%), and R1/V+ (n = 12, 9%). Patients with V- specimens had similar median durations of recurrence-free survival (RFS) (12 vs 9 months) and overall survival (OS) (30 vs 28 months) as did patients with V+ specimens (P > 0.05). In contrast, cancer invasion into the lumen was associated with RFS and OS (P < 0.05). Among patients who underwent R0 resection, V-status had no association with OS, RFS, or local control (P > 0.05).

CONCLUSION

Cancer invasion into the superior mesenteric and/or portal vein was adversely associated with survival, but cancer at the vein edge(s) was not. Transection of the SMV-PV through macroscopically normal vein may be performed to minimize resected vein length without fear of negatively affecting oncologic outcomes.

The past, present, and future status of multimodality treatment for resectable/borderline resectable pancreatic ductal adenocarcinoma

A multimodal approach to treating pancreatic ductal adenocarcinoma (PDAC) is now widely accepted. Improvements in radiological assessment have enabled us to define resectability in detail. Multimodality treatment is essential for patients, especially for those with PDAC in the borderline resectable (BR) stage. Even for disease in a resectable (R) stage, adjuvant and neoadjuvant therapies have demonstrated beneficial outcomes in several trials and analyses. Thus, there is growing interest in optimization of the perioperative therapeutic strategy. We discuss the transition of resectability criteria and the global standard of adjuvant and neoadjuvant treatments for patients with R/BR-PDAC.

Short-term outcomes after vascular resection for pancreatic tumors: Lessons learned from 72 cases from a single Brazilian Cancer Center

INTRODUCTION

Pancreatic malignant tumors are resectable at diagnosis in only 15% to 20% of cases and invasion of vascular structures is commonly present. Therefore, extended resections are needed for adequate local control and negative margins. However, morbidity and mortality associated with these enlarged resections are limiting factors. The aim of this study was to correlate demographic and technical aspects that influenced early and late outcomes.

MATERIALS AND METHODS

Between October 2007 and May 2019, 523 pancreatic surgeries were performed, of which 72 required vascular resections. Clinical and histopathological data, surgical techniques, and perioperative parameters were analyzed in a prospectively collected database.

RESULTS

Of the 72 cases of vascular resection, 31 were male and 41 females with a mean age of 60.9 years (34-81). The most commonly affected vascular structure was the portal vein (in 40.3%). Free margins were obtained in 77.8% of cases. Postoperative mortality rate at 60 days was 13.9%. American Society of Anesthesiologists (ASA) and age were the most important predictors of major complications.

CONCLUSION

Extended resections with vascular involvement in pancreatic surgeries are feasible and safe; furthermore, patient selection plays are key. ASA and age were the most important factors in the decision-making process for extended resections.

Acute compartment syndrome of the lower leg causing cardiac arrest after resection of the right external iliac vein for autologous graft: a case report

BACKGROUND

The right external iliac vein (REIV) is often used for portal vein reconstruction in patients undergoing pancreatoduodenectomy with portal-superior mesenteric vein resection. We report a case of cardiac arrest caused by acute lower leg compartment syndrome as a result of REIV resection.

CASE PRESENTATION

A 53-year-old man underwent pancreatoduodenectomy with portal vein resection. Hyperkalemia progressed during surgery due to intestinal reperfusion injury, which caused recurrent ventricular arrhythmia required for cardio-pulmonary resuscitation. The surgery was discontinued after resuscitation, and portal vein reconstruction using the REIV was performed 2 days post-operatively. Acute compartment syndrome was diagnosed immediately following the surgery. Hyperkalemia progressed, causing pulseless ventricular tachycardia. Emergent fasciotomy was performed, but right leg dysfunction persisted after discharge.

CONCLUSION

REIV resection can cause lower-extremity acute compartment syndrome. The status, including intracompartmental pressure, of the lower extremity should be carefully observed after REIV resection during and after surgery.

Portal-Mesenteric Vein Resection in Borderline Pancreatic Cancer; 33 Month-Survival in Patients with Good Performance Status

Background: Patients with pancreatic cancer (PC), which is not upfront resectable, but borderline, involving major peripancreatic vessels, have not been generally considered for surgery, considering that resection in such a setting may be futile.

Materials and Methods: Retrospective analysis of prospectively collected data on patients with borderline pancreatic adenocarcinoma undergoing pancreatectomy en-block with portal and/or superior mesenteric vein resection in a tertiary referral center in Greece between January 2012 and February 2017. Follow-up was complete up to January 2018.

Results: Twenty-four patients were included. Neoadjuvant therapy (NAT) was administered to only 38%, but more commonly in the second half of the group (58% vs. 17%, p = 0.035). It was associated with smaller tumor size (median: 2.5 vs. 4.2 cm, p < 0.001), fewer positive lymph nodes (LNs) in the resected specimen (median: 2 vs. 5, p = 0.04), and higher likelihood of adjuvant therapy (78% vs. 40%, p = 0.01), but not with survival. Resection was extensive: a median of 26 LNs were retrieved, R0 resection rate (≥1 mm) was 79%, and median length of vein segments was 4 cm, requiring interposition grafts in 58% (mostly polytetrafluoroethylene). Median intensive care unit stay was 0 days and length of hospital stay was 9 days. Post-operative mortality was 12.5%. Median overall survival was 24 months. Eastern Cooperative Oncology Group (ECOG) status was significantly associated with survival (p < 0.001) with ECOG-0: 33 months, ECOG-1: 12 months, and ECOG-2: 6 months.

Conclusion: This first Greek national series of portomesenteric vein resection in borderline PC demonstrates that it results to 2 years of median survival, extending to 33 months in patients with good performance status, especially if NAT is uniformly administered.

Contemporary Review of Borderline Resectable Pancreatic Ductal Adenocarcinoma

Borderline resectable pancreatic adenocarcinoma (PDAC) presents challenges in definition and treatment. Many different definitions exist for this disease. Some are based on anatomy alone, while others include factors such as disease biology and patient performance status. Regardless of definition, evidence suggests that borderline resectable PDAC is a systemic disease at the time of diagnosis. There is high-level evidence to support the use of neoadjuvant systemic therapy in these cases. Evidence to support the use of radiation therapy is ongoing. There are ongoing trials investigating the available neoadjuvant therapies for borderline resectable PDAC that may provide clarity in the future.

Treatment of bleeding from a portion of pancreatojejunostomy after pancreaticoduodenectomy with division of the splenic vein: two case reports

Background

There is no definitive strategy for gastrointestinal bleeding due to left-sided portal hypertension after pancreaticoduodenectomy (PD) for pancreatic cancer (PC) with concomitant portal vein resection (PVR).

Case presentation

Case 1: A 70-year-old woman underwent a PD for PC with PVR. Seven years after her surgery, she suffered severe anemia with suspected gastrointestinal bleeding. Computed tomography scan (CT) revealed varices at a portion of the pancreaticojejunostomy (PJ). Angiography revealed that splenic venous flow drained into the varices and then into the portal vein. A diagnosis of bleeding varices of the PJ due to left-sided portal hypertension was made. Following a partial splenic artery embolization, her anemia improved.

Case 2: An 80-year-old male underwent a PD for pancreatic head cancer combined with resection of the confluence of the portal and splenic veins with a reconstruction between the portal and superior mesenteric veins. Eighteen months after his surgery, he developed melena with negative endoscopy findings in his large and small bowel. CT revealed varices at the site of the PJ that communicated with the jejunal and portal veins. He underwent obliteration of the varices via a trans-portal-venous approach. As a result, he remained without melena until he died of PC 17 months after the embolization.

Conclusions

Left-sided portal hypertension following a PD with bleeding varices can be treated by interventional radiology with minimal invasiveness.

The impact of extent of pancreatic and venous resection on survival for patients with pancreatic cancer

BACKGROUND

Borderline resectable pancreatic cancer may require extended resections in order to achieve tumor-free margins, especially in the case of up-front resections, but it is important to know the limits of surgical therapy in this disease. This study aimed to investigate the impact of extent of pancreatic and venous resection on short- and long-term outcomes in patients with pancreatic adenocarcinoma (PDAC).

METHODS

This was a retrospective study from a prospectively maintained database of pancreatic resections for PDAC. Short- and long-term outcomes were analyzed in patients having borderline resectable PDAC submitted to up-front total pancreatectomy (TP) or pancreaticoduodenectomy (PD) with simultaneous portal vein (PV) and/or superior mesenteric vein (SMV) resection. Venous resections were carried out as tangential venous resection (TVR) or segmental venous resection (SVR). Patients were divided into 4 groups: (1) PD + TVR, (2) PD + SVR, (3) TP + TVR, (4) TP + SVR. Uni- and multivariate Cox regression analysis were performed to identify factors associated with survival.

RESULTS

Ninety-nine patients were submitted to simultaneous pancreatic and venous resection for PDAC. Among them, 25 were submitted to PD + TVR (25.3%), 12 to PD + SVR (12.1%), 23 to TP + TVR (23.2%), and 39 to TP + SVR (39.4%). Overall, major morbidity (Clavien-Dindo grade ≥ IIIA) was 26.3%. Thirty- and 90-day mortality were 3% and 11.1%, respectively. There were no significant differences among groups in terms of short-term outcomes. Median overall survival of patients submitted to PD + TVR was significantly higher than those to TP+SVR (29.5 vs 7.9 months, P = 0.001). Multivariate analysis identified TP (HR = 2.11; 95% CI: 1.31-3.44; P = 0.002) and SVR (HR = 2.01; 95% CI: 1.27-3.15; P = 0.003) as the only independent prognostic factors for overall survival.

CONCLUSIONS

Up-front TP associated to SVR was predictive of worse survival in borderline resectable PDAC. Perioperative treatments in high-risk surgical groups may improve such poor outcomes.

Cutting-edge strategies for borderline resectable pancreatic cancer

Worldwide, pancreatic ductal adenocarcinoma (PDAC) accounts for more than 400 000 deaths every year, being the 12th most common cancer and the seventh most frequent cause of death from cancer. Regardless of the advances in diagnosis and treatment, PDAC continues to have dismal outcomes and fewer than 25% of patients survive for 1 year. In the absence of metastatic disease, radical surgery remains the most important factor for improving survival and possibly offer cure. However, approximately 80% of patients cannot be offered surgery owing to locally advanced or metastatic disease at presentation. At presentation, only 10%-20% patients are eligible for resection, 30%-40% are unresectable/locally advanced and 50%-60% are metastatic. One promising development in recent years has been the inclusion of a new subgroup within the locally advanced tumors of borderline resectable pancreatic cancer (BRPC) comprising approximately 5%-10% of the total patient population. Although its exact definition has been refined over the past few years depending on the vascular involvement around the tumor, the term was initially proposed for tumors that are at a high risk of having margin positivity after resection. Various treatment approaches are still evolving for this entity. Herein, we reviewed the current status of different treatment modalities for BRPC.

Venous resection during pancreatectomy for pancreatic cancer: a systematic review

Pancreatic cancer is one of the most aggressive and lethal malignancies with a dismal prognosis and survival. The curative effects of venous resection (VR) in pancreatic cancer remain controversial. A systematic literature search was performed in PubMed, Embase and the Cochrane Library. The overall postoperative complications, perioperative mortality, histopathology, and long-term survival were compared between patients undergoing pancreatectomy combined with (VR+ group) or without (VR- group) VR. Forty-one studies were included in the systematic review. Pancreatectomy combined with VR required longer operation time and led to increased perioperative blood loss, whereas postoperative complications were similar. Patients in the VR+ group showed larger tumors and reduced R0 rates. Regarding long-term survival, patients with VR+ seemed to have impaired 1-, 3-, and 5-year survival. Based on our results, VR in pancreatic cancer is a safe and feasible procedure. Given the fact that patients have miserable outcomes and survival in the palliative setting alone, extended resection including VR is required for the purpose of achieving radical resection.

[Diagnosis and treatment of pancreatic head cancer followed by mesenteric-portal vein invasion]

AIM

To evaluate the outcomes of pancreaticoduodenectomy with mesenteric-portal vein resection for pancreatic head cancer.

MATERIAL AND METHODS

Retrospective analysis included 124 patients with pancreatic head cancer for the period 2010-2017. Mesenteric-portal vein (MPV) invasion was diagnosed in 37 (29.8%) patients, tumor contact with superior mesenteric artery as a borderline resectable state was noted in 11 cases. All patients underwent pancreaticoduodenectomy with mesenteric-portal vein resection.

RESULTS

Vein invasion was histologically confirmed in 19 (51.3%) out of 37 patients. At the same time, arterial invasion was absent in 11 patients with a borderline resectable tumor. CT-associated overdiagnosis of venous wall invasion was 6.4%, intraoperative overdiagnosis - 87.5%. R0-resection was achieved in 88.5% after conventional pancreaticoduodenectomy and in 78.4% after pancreaticoduodenectomy followed by MPV resection. Median survival was 17 months, 2-year survival - 41%. Among 11 patients with a borderline resectable tumor median survival was 11 months. Pancreaticoduodenectomy without vein resection was followed by 2-year survival near 68.1%. Differences were significant (p=0.02).

CONCLUSION

Pancreaticoduodenectomy followed by MPV resection as the first stage of combined treatment of pancreatic head cancer is absolutely justified if circumferential involvement of the vein and contact with superior mesenteric artery or celiac trunk do not exceed 50%. Vein resection can provide R0-surgery in these cases.

Portal encasement: Significant CT findings to diagnose local recurrence after pancreaticoduodenectomy for pancreatic cancer

BACKGROUND/OBJECTIVES

To demonstrate the utility of portal encasement as a criterion for early diagnosis of local recurrence (LR) after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC).

METHODS

A total of 61 patients who underwent PD for PDAC were included in this retrospective study. Portal stenosis was evaluated by sequential postoperative computed tomography (CT) scans and correlated with disease recurrence. In addition to the conventional LR diagnostic criterion of a growing soft tissue mass, LR was evaluated using portal encasement as an additional diagnostic criterion. Portal encasement was defined as progressive stenosis of the portal system accompanied by a soft tissue mass, notwithstanding the enlargement of the mass.

RESULTS

Benign portal stenosis was found on the first postoperative CT imaging in 16 patients. However, stenosis resolved a median of 81 days later in all but one patient whose stenosis was due to portal reconstruction during PD. Portal encasement could be distinguished from benign portal stenosis based on the timing of emergence of the portal stenosis. Portal encasement developed in 13 of the 19 patients with LR, including 6 patients in whom the finding of portal encasement led to the diagnosis of LR a median of 147 days earlier with our diagnostic criterion compared with the conventional diagnostic criteria.

CONCLUSIONS

Portal encasement should be considered as a promising diagnostic criterion for earlier diagnosis of LR after PD for PDAC.

The Falciform Ligament for Mesenteric and Portal Vein Reconstruction in Local Advanced Pancreatic Tumor: A Surgical Guide and Single-Center Experience

Background

Since local tumor infiltration to the mesenteric-portal axis might represent a challenging assignment for curative intended resectability during pancreatic surgery, appropriate techniques for venous reconstruction are essential. In this study, we acknowledge the falciform ligament as a feasible and convenient substitute for mesenteric and portal vein reconstruction with high reliability and patency for local advanced pancreatic tumor.

Methods

A retrospective single-center analysis. Between June 2017 and January 2018, a total of eleven consecutive patients underwent pancreatic resections with venous reconstruction using falciform ligament. Among them, venous resection was performed in nine cases by wedge and in two cases by full segment. Patency rates and perioperative details were reviewed.

Results

Mean clamping time of the mesenteric-portal blood flow was 34 min, while perioperative mortality rate was 0%. By means of Duplex ultrasonography, nine patients were shown to be patent on the day of discharge, while two cases revealed an entire occlusion of the mesenteric-portal axis. Orthograde flow demonstrated a mean value of 34 cm/s. All patent grafts on discharge revealed persistent patency within various follow-up assessments.

Conclusion

The falciform ligament appears to be a feasible and reliable autologous tissue for venous blood flow reconstruction with high postoperative patency. Especially the possibility of customizing graft dimensions to the individual needs based on local findings allows an optimal size matching of the conduit. The risk of stenosis and/or segmental occlusion may thus be further reduced.

Vein resection in patients with adenocarcinoma of the head of pancreas adherent to the portomesenteric venous axis is beneficial despite a high rate of R1 resection

Backgrounds/Aims

En-bloc vein resection (VR) for pancreatic ductal adenocarcinoma (PDAC) of the head of pancreas adherent to the portomesenteric axis benefits patients when the vein wall is not infiltrated by tumour and an R0 resection is achieved, albeit at the expense of greater morbidity and mortality.

Methods

A retrospective review of pancreaticoduodenectomy for PDAC over 6 years was conducted. Patients were divided into a standard resection group (Group SR) and simultaneous vein resection group (Group VR) and compared for outcome.

Results

The study group consisted of 41 patients (Group SR 15, Group VR 26). VR was performed by end-to-end reconstruction in 12 patients and with interposition grafts in 13 cases (autologous vein in 10, PTFE in 3). R1 resections occurred in 49% patients, with the superior mesenteric artery margin most commonly involved. Patients with Ishikawa grade III and IV vein involvement were more likely to carry a positive SMA margin (p=0.04). Involvement of the splenoportal junction was associated with a significantly greater risk of pancreatic transection margin involvement. No difference in morbidity was seen between the groups. Median survival in the entire group of patients was 17 months and did not vary significantly between the groups. The only significant predictor of survival was lymph node status.

Conclusions

Venous involvement by proximal PDAC is indicative of tumor location rather than tumor biology. VR improves outcomes in patients with tumor adhesion to the portomesenteric venous axis despite a high incidence of R1 resections and greater operative mortality.

The Utility of Preoperative Vascular Grading in Patients Undergoing Surgery First for Pancreatic Cancer: Does Radiologic Arterial or Venous Involvement Predict Pathologic Margin Status?

Controversy exists on accurately grading vascular involvement on preoperative imaging for pancreatic ductal adenocarcinoma. We reviewed the association between preoperative imaging and margin status in 137 patients. Radiologists graded venous involvement based on the Ishikawa classification system and arterial involvement based on preoperative imaging. For patients with both classifications recorded, we categorized vascular involvement as "None," "Arterial only," "Venous only," or "Both" and examined the association of vascular involvement and pathologic margin status. Of 134 patients with Ishikawa classifications, 63%, 17%, 11%, and 9% were graded as I, II, III, and IV, respectively. Of 96 patients with arterial staging, 74%, 16%, and 10% were categorized as stages i, ii, and iii, respectively. Of 93 patients with both stagings, 61% had no vascular involvement, 7% had arterial only, 14% had venous only, and 17% had both involved. Ishikawa classification was strongly associated with a positive SMA and SMV margin (p<0.001). However, for arterial staging, there was no association with SMA or SMV margin. Overall, Ishikawa grading was more predicative of arterial involvement and remained significant on multivariate analysis. The use of diagnostic imaging in predicting positive margins is more accurate when using a venous grading system.

Borderline resectable pancreatic cancer. Challenges and controversies

Pancreatic cancer is a dismal disease with an increasing incidence. Despite the majority of patients are not candidates for curative surgery, a subgroup of patients classified as borderline resectable pancreatic cancer can be selected in whom a sequential strategy of neoadjuvant therapy followed by surgery can provide better outcomes. Multidisciplinary approach and surgical pancreatic expertise are essential for successfully treating these patients. However, the lack of consensual definitions and therapies make the results of studies very difficult to interpret and hard to be implemented in some settings. In this article, we review the challenges of borderline resectable pancreatic cancer, the complexity of its management and controversies and point out where further research and international cooperation for a consensus strategy is urgently needed.

Resection of retroperitoneal sarcoma en-bloc with inferior vena cava: 20 year outcomes of a single institution

BACKGROUND

Margin negative resection offers the best chance of long-term survival in retroperitoneal sarcoma (RPS). En-bloc resection of adjacent structures, including the inferior vena cava (IVC), is often required to achieve negative margins. We review our 20-year experience of en-bloc IVC and RPS resection.

METHODS

Retrospective review of patients with RPS resection involving the IVC were matched 1:3 by age and histology to RPS without IVC resection. Prognostic factors for overall survival (OS) and disease free survival (DFS) were assessed.

RESULTS

Thirty-two patients underwent RPS resection en-bloc with IVC. They were matched with 96 cases of RPS without IVC resection. Median OS of 59 months and DFS 18 months in IVC resection group was comparable to RPS resection without vascular involvement: median OS 65 months, DFS 18 months (P = 0.519, P = 0.604). On multivariate analyses, R2 margin (OS: HR = 6.52 [95%CI: 1.18-36.09], P = 0.032) was associated with inferior OS. R2 margin and increased number of organs resected (DFS: HR = 5.07, [1.15-22.27], P = 0.031, HR = 1.28 [1.01-1.62], P = 0.014) were associated with inferior DFS. Reconstructions included graft (n = 19, 59%), patch (n = 4, 13%), primary repair (n = 6, 19%), and ligation (n = 4, 13%).

CONCLUSIONS

RPS resection en-bloc with IVC can achieve equivalent rates of DFS and OS to patients without vascular involvement.

Prediction and clinical implications of portal vein/superior mesenteric vein invasion in patients with resected pancreatic head cancer: the significance of preoperative CT parameters

AIM

To determine the preoperative computed tomography (CT) parameters that predict portal vein/superior mesenteric vein (PV-SMV) invasion in patients with pancreatic head cancer, and to assess whether PV-SMV invasion affects patient survival.

MATERIALS AND METHODS

Sixty patients with PV-SMV invasion, and 60 randomly selected patients without it, who had undergone preoperative CT and subsequent surgery for pancreatic head cancer were enrolled. The following CT parameters were evaluated using multivariate logistic regression and receiver operating characteristic analyses to predict vessel invasion (tumour size and margin, length of involved vessel, distance from the tumour to the vessel, vessel irregularity, the teardrop sign, and tumour-vein interface [TVI]). The Cox proportional hazard model was used to evaluate the effects of PV-SMV invasion on survival.

RESULTS

In multivariate analysis, tumour size (odds ratio [OR]=1.99) and TVI (OR=3.79 [≤90°], 20.66 [>90°, ≤180°], and 47.24 [>180°]) were independent CT predictors of PV-SMV invasion (p<0.05); they achieved a sensitivity of 87%, a specificity of 75%, and an accuracy of 81%; however, PV-SMV invasion did not affect patient survival after surgery (p=0.374).

CONCLUSION

In patients with pancreatic head cancer, preoperative CT parameters can predict PV-SMV invasion with high accuracy. PV-SMV invasion did not affect treatment outcome after surgery.

Evolution of pancreatectomy with en bloc venous resection for pancreatic cancer in Italy. Retrospective cohort study on 425 cases in 10 pancreatic referral units

INTRODUCTION

The aim of this study is to analyze the evolution of pancreatectomy with venous resection in 10 referral Italian centers in the last 25 years.

METHODS

A multicenter database of 425 patients submitted to pancreatectomy with venous resection between 1991 and 2015 was retrospectively analyzed. Patients were classified in 5 periods: 1 (1991-1995); 2 (1996-2000); 3 (2001-2005); 4 (2006-2010); 5 (2011-2015). Indications and outcomes were compared according to the period of surgery.

RESULTS

Nineteen patients were operated in period 1, 28 in period 2, 91 in period 3, 140 in period 4, and 147 in period 5. Use of neoadjuvant therapy increased from 0% in period 1 and 2-12.1% in period 5. Postoperative complications ranged from 46.3% to 67.8%, and mortality from 5.3% to 9.2%. Median survival progressively increased, from 6 months in period 1-16 months in period 2, 24 months in period 3 and 4 and 35 months in period 5 (p = 0.004). Period, venous and nodal invasion were significant prognostic factors for survival.

CONCLUSION

Management and outcomes of pancreatectomy with venous resection have evolved in the last 25 years in Italy. Improvement in patients' multidisciplinary management has lead to significant improvement of median survival.

Clinical significance of defining borderline resectable pancreatic cancer

Since the introduction of the concept of borderline resectable pancreatic cancer (BRPC), various definitions of this disease entity have been suggested. However, there are several obstacles in defining this disease category. The current diagnostic criteria of BRPC mainly focuses on its expanded 'technical resectability'; however, they are difficult to interpret because of their ambiguity using potential subjective or arbitrary terminology, In addition, limitations in current imaging technology and a lack of evidence in radiological-pathological-clinical correlation make it difficult to refine the criteria. On the other hand, neoadjuvant treatment is usually applied to increase the R0 resection rate of BRPC focusing on the 'oncological curability'. However, evidence is needed concerning the effect of neoadjuvant treatment by quality-controlled prospective randomized clinical trials based on a standardized radiologic and pathologic reporting system. In conclusion, there are two aspects in the current concept of BRPC, which are technical resectability and oncological curability. Although the recent evolution of surgical techniques is expanding the scope of technical resectability, it should not be overlooked that the disease entity must be defined based on the evidence of oncological curability.

Pancreatoduodenectomy combined with portal-superior mesenteric vein resection and reconstruction with interposition grafts for cancer: a meta-analysis

The use of interposition grafts for portal-superior mesenteric vein (PV-SMV) reconstruction during pancreatoduodenectomy (PD) with venous resection (VR) for localized periampullary tumors is a controversial topic. The present meta-analysis aimed to evaluate the perioperative and long-term outcomes in patients who received interposition grafts for PV-SMV reconstruction after PD with VR. The correlative databases were systematically searched to identify relevant trials comparing vein grafts versus no vein grafts during PD with VR. 14 studies including 257 patients with vein grafts and 570 patients without vein grafts were extracted. The meta-analysis indicated no difference in perioperative morbidity, mortality, or thrombosis between the two groups, but the vein graft group was associated with a significantly increased venous thrombosis rate (≥ 6 months) (odds ratio [OR] = 2.75; 95% confidence interval [CI], 1.32–5.73; P = .007). The autologous vein group subgroup analysis also revealed a significantly increased vein thrombosis rate (OR = 3.13; 95% CI, 1.45–6.76; P = .004) between the two groups. Meanwhile, the prosthetic vein group subgroup analysis indicated no difference. Additionally, the oncological value of vein grafts during PD for pancreatic cancer survival was analyzed and revealed no difference in 1-year, 3-year, or 5-year survival between the two groups. Using interposition grafts for PV-SMV reconstruction is safe and effective, and has perioperative outcomes and long-term survival rates compared to those with no vein grafts during PD with VR. However, the lower long-term vein patency rate in patients with vein grafts indicate that interposition grafts may be more likely to lose function.