Clinical implications of combined portal vein resection as a palliative procedure in patients undergoing pancreaticoduodenectomy for pancreatic head carcinoma

Venous resection for pancreatic cancer, a safe and feasible option? A systematic review and meta-analysis

BACKGROUND

In pancreatic ductal adenocarcinoma patients with suspected venous infiltration, a R0 resection is most of the time not possible without venous resection (VR). To investigate this special kind of patients, this meta-analysis was conducted to compare mortality, morbidity and long-term survival of pancreatic resections with (VR+) and without venous resection (VR-).

METHODS

A systematic search was performed in Embase, Pubmed and Web of Science. Studies which compared over twenty patients with VR + to VR-for PDAC with ≥1 year follow up were included. Articles including arterial resections were excluded. Statistical analysis was performed with the random effect Mantel-Haenszel test and inversed variance method. Individual patient data was compared with the log-rank test.

RESULTS

Following a review of 6403 papers by title and abstract and 166 by full text, a meta-analysis was conducted of 32 studies describing 2216 VR+ and 5380 VR-. There was significantly more post-pancreatectomy hemorrhage (6.5% vs. 5.6%), R1 resections (36.7% vs. 28.6%), N1 resections (70.3% vs. 66.8%) and tumors were significantly larger (34.6 mm vs. 32.8 mm) in patients with VR+. Of all VR + patients, 64.6% had true pathological venous infiltration. The 90-day mortality, individual patient data for overall survival and pooled multivariate hazard ratio for overall survival were similar.

CONCLUSION

VR is a safe and feasible option in patients with pancreatic cancer and suspicion of venous involvement, since VR during pancreatic surgery has comparable overall survival and complication rates.

What Are the Place and Modalities of Surgical Management for Pancreatic Neuroendocrine Neoplasms? A Narrative Review

Pancreatic neuroendocrine neoplasms (panNENs) are a heterogeneous group of tumors derived from cells with neuroendocrine differentiation. They are considered malignant by default. However, their outcomes are variable depending on their presentation in the onset of hereditary syndromes, hormonal secretion, grading, and extension. Therefore, although surgical treatment has long been suggested as the only treatment of pancreatic neuroendocrine neoplasms, its modalities are an evolving landscape. For selected patients (small, localized, non-functional panNENs), a "wait and see" strategy is suggested, as it is in the setting of multiple neuroendocrine neoplasia type 1, but the accurate size cut-off remains to be established. Parenchyma-sparring pancreatectomy, aiming to limit pancreatic insufficiency, are also emerging procedures, which place beyond the treatment of insulinomas and small non-functional panNENs (in association with lymph node picking) remains to be clarified. Furthermore, giving the fact that the liver is generally the only metastatic site, surgery keeps a place of choice alongside medical therapies in the treatment of metastatic disease, but its modalities and extensions are still a matter of debate. This narrative review aims to describe the current recommended surgical management for pancreatic NENs and controversies in light of the actual recommendations and recent literature.

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.

Proposal of a Clinically Useful Criterion for Early Drain Removal After Pancreaticoduodenectomy

PURPOSE

This study aimed to establish a reliable criterion for early drain removal after pancreaticoduodenectomy (PD) based on predictive factors of clinically relevant postoperative pancreatic fistula (CR-POPF) available on postoperative day 3 (POD3).

METHODS

A total of 300 consecutive patients who underwent PD with pancreaticojejunostomy at our hospital from 2011 to 2015 were analyzed retrospectively. CR-POPF was defined as POPF grade B or C according to the definition by ISGPF. Clinicopathological factors available on or before POD3 were analyzed to identify predictors of CR-POPF. Using obtained predictors, we developed a criterion for no CR-POPF and internally validated its relevance in 100 consecutive patients.

RESULTS

The incidence rates of CR-POPF, severe complications (Clavien-Dindo ≥ grade IIIa), and postoperative mortality were 35%, 9.6%, and 0.3%, respectively. Multivariate analysis showed that drain amylase (d-AMY) levels ≥ 350 IU/l on POD3, C-reactive protein (CRP) levels ≥ 14 mg/dl on POD3, preoperative endoscopic retrograde biliary drainage, and no portal vein resection were significant predictors of CR-POPF. Using the strongest predictors (i.e., d-AMY and CRP), we established a criterion for no CR-POPF: d-AMY levels < 350 IU/l and CRP levels < 14 mg/dl on POD3. The incidence rates of CR-POPF were 6%, 38%, and 88% in patients who fulfilled both of (n = 149), each of (n = 74), and none of (n = 77) the two factors, respectively. In the internal validation cohort, the positive predictive value of CR-POPF was 89%.

CONCLUSIONS

A simple two-factor criterion available on POD3 after PD has a reliable predictive ability. In patients who fulfill this criterion, early drain removal is considered safe.

Margin Status Impacts Survival after Pancreaticoduodenectomy but Negative Margins Should Not be Pursued

Negative margins are the goal with pancreaticoduodenectomy for pancreatic adenocarcinoma. Thereby, margins are assessed intraoperatively with frozen section analysis and negative margins are pursued. This study was undertaken to determine the impact of margin status with pancreaticoduodenectomy for pancreatic adenocarcinoma and the value of extending resections to achieve negative margins. The intraoperative frozen section analysis and final margins for 448 patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma were assessed and their impact on survival was determined. Median data are presented. Two hundred ninety-eight (67%) patients had negative margins (R0), an additional 110 (25%) patients had microscopically positive and macroscopically negative margins (R1), and an additional 40 (9%) patients had initially positive microscopic margins, which became negative with further resection (R1 å R0). R0 resections were more likely to have smaller tumors, earlier T grade, earlier N grade, lower American Joint Committee on Cancer stage, and less frequent extrapancreatic extension ( P ≤ 0.03 for each). Survival was better with R0 resections than R1 resections (20 vs 12 months, P < 0.001); extending resections to achieve negative margins (i.e., R1 ! R0) did not improve survival beyond R1 resections (14 vs 12 months, P = 0.19). Survival after pancreaticoduodenectomy is disappointing. Patients with initial negative margins do best. Positive microscopic margins reflect more aggressive tumor-specific factors and lead to abbreviated survival even with extended resections to achieve negative margins (i.e., R1 ! R0). With an initial positive margin, pursuing negative margins does not improve survival and, thereby, negative margins should not be “chased.”

The Impact of the Depth of Venous Invasion on Survival Following Pancreatoduodenectomy for Pancreatic Cancer: a Meta-analysis of Available Evidence

PURPOSE

The prognostic significance of portal/superior mesenteric vein (PV/SMV) invasion at the time of pancreatoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) is contentious. The aim of this meta-analysis was to compare the survival outcomes in patients with histologically proven adventitial (superficial) versus media/intimal (deep) PV/SMV invasion at the time of PD for PDAC.

METHODS

A systematic search of the PubMed, MEDLINE and SCOPUS databases were performed in accordance with PRISMA guidelines. All articles reporting outcomes specific to the depth of PDAC invasion into the PV/SMV wall were included. The primary outcome measure was overall survival.

RESULTS

Six studies including 310 patients who underwent pancreatic resection with PV/SMV resection for PDAC were included in this meta-analysis. There was no difference in overall survival comparing superficial vs deep invasion at 12 months (64% vs 58% respectively, risk difference, - 0.09; CI, - 0.21-0.04; P = 0.183), 36 months (22% vs 18% respectively, risk difference, - 0.05; CI, - 0.16-0.19; P = 0.857) and mean overall survival (42.8 months vs 25.7 months respectively, standard mean difference, - 0.27; CI, - 0.58, 0.03; P = 0.078). Although larger tumours were seen in those with confirmed deep vein wall invasion (P < 0.001), no difference was observed between the superficial and deep invasion groups with regard to age (P = 0.298), R1 resection (P = 0.896), nodal metastatic disease (P = 0.120) and perineural invasion (P = 0.609).

CONCLUSIONS

This meta-analysis suggests that the depth of PV/SMV wall invasion by PDAC may not impact survival after PD. However, given the limited sample size, further research is warranted with homogenous cohorts and longer follow-up.

Pancreatoduodenectomy with portal vein resection favors the survival time of patients with pancreatic ductal adenocarcinoma: A propensity score matching analysis

Portal vein (PV) involvement is common in patients with pancreatic ductal adenocarcinoma (PDAC). To the best of our knowledge, pancreatectomy combined with PV resection (PVR) is the only radical therapy for patients with PV involvement. However, there remains a debate on whether patients with PV involvement could benefit from PVR or not. The present study aimed to compare the survival outcomes between patients receiving pancreatoduodenectomy (PD) with PVR and those receiving PD alone. A total of 377 patients with PDAC were enrolled, 138 patients with PV involvement were placed in the PVR group, while the other 239 patients were in the non-PVR group. To reduce selection bias and estimate the causal effect, 123 pairs of propensity score matched (PSM) patients were selected and compared for the survival outcomes. Before PSM, the survival of patients in the PVR group was worse compared with those in the non-PVR group (mean survival, 25.1 vs. 29.3 months; P=0.038). After balancing the baseline characteristics using the PSM method, the significant survival difference between the two groups was insignificant (mean survival, 25.9 vs. 31.2 months; P=0.364). Tumor stage, body mass index, serum albumin, R1 resection, lymph node metastasis, carbohydrate antigen (CA)125 and CA19-9 were significant independent prognostic factors. The incidence of serious postoperative complications was similar between the two groups. PVR is safe and effective for patients with PDAC. Patients with PV involvement could achieve the similar survival outcome as patients without PV involvement, through radical resection combined with PVR, without increasing the risk of serious complications.

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.

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.

A Single-Institution Validation Study of Lymph Node Staging By the AJCC 8th Edition for Patients with Pancreatic Head Cancer: A Proposal to Subdivide the N2 Category

BACKGROUND

According to the revised staging of the American Joint Committee on Cancer, 8th edition (AJCC8), the N category in pancreatic ductal adenocarcinoma is classified as N0 (0), N1 (1-3), and N2 (≥ 4) based on the number of metastatic lymph nodes (LNs). This study aimed to validate this classification and analyze cutoff values of metastatic LN numbers.

METHODS

Patients with pancreatic head ductal adenocarcinoma who underwent pancreaticoduodenectomy at our institution between 2005 and 2016 without preoperative therapy were retrospectively analyzed. The patients were staged by AJCC8, and prognostic analyses were performed. The best cutoff value for the metastatic LN number was determined by the minimum P value approach.

RESULTS

In 228 of 309 patients, LN metastases were found (median number of examined LNs, 41). The median survival time (MST) was 56 months in the N0 group, 34 months in the N1 group, and 20 months in the N2 group (N0 vs N1: P = 0.023; N1 vs N2: P < 0.001). The best cutoff number of metastatic LNs was 4 for patients with LN metastases and 7 for patients with N2 disease. The MST for patients with four to six positive nodes (N2a) was significantly longer than for those with seven or more positive nodes (N2b) (24.0 vs 19.1 months: P = 0.012). For N2b patients, conventional adjuvant chemotherapy did not show survival benefits (P = 0.133), and overall survival did not differ significantly from that for patients with para-aortic LN metastasis (P = 0.562).

CONCLUSION

The N staging of AJCC8 was valid. Clinicians should regard N2b as similar to distant LN metastasis, and more intensive adjuvant therapy may be indicated for this group.

What to expect with major vascular reconstruction during Whipple procedures: a single institution experience and literature review

Background

Major vascular reconstruction during a pancreaticoduodenectomy (PD), also known as a Whipple procedure, leads to controversial postoperative outcomes compared to conventional Whipple. Discussion with the patient regarding postoperative expectations is a crucial component of holistic surgical healthcare. The aim of this study was to report our 8-year experience of Whipple procedures involving vascular reconstruction and to review relevant literature to further evaluate expectant outcomes, therefore leading to more accurate discussion.

Methods

A retrospective review of patients undergoing Whipple procedures from January 2010, through December 2017 was performed. Patch, graft, and primary anastomosis during Whipple procedures were considered major vascular reconstruction. Literature on the current understanding of the outcomes associated with vascular reconstruction during Whipple procedures was reviewed.

Results

Twenty-nine from a total of 405 patients that met inclusion criteria had a Whipple procedure that involved major vascular reconstruction. Twelve patients were male and 17 were female (mean age, 65.2 years). Median hospital and intensive care unit (ICU) stay [range] of patients with vascular reconstruction was 12 [5-92] days and 3 [0-59] days, respectively. Thirty-day survival and 1-year survival of patients with vascular reconstruction was 93.1% and 55.2%, respectively, compared to non-vascular reconstruction patients 96.0% and 83.5%, respectively (P=0.35, P<0.001). Ninety-day readmission for vascular reconstruction patients was 31.0% compared to 14.6% in non-vascular reconstruction patients (P=0.03). The 1-year survival of those who had patch reconstruction, graft reconstruction, and primary anastomosis was 50.0%, 62.5%, 53.8%, respectively.

Conclusions

Compared to conventional Whipple procedures, those requiring major vascular reconstruction are associated with decreased survival. When vascular reconstruction is a valid option patients should be well aware of the associated outcomes.

[Vascular surgical aspects in abdominal surgery : Results from a tertiary care center over a 10-year time period]

AIM

To investigate the perioperative management and outcome of patients undergoing abdominal surgery with additional vascular (comorbid) alterations for internal quality assurance of the clinical results.

METHODS

Over a defined study period all consecutive cases of the aforementioned profile were documented and retrospectively analyzed as part of an ongoing prospective monocentric observational study to reflect the daily surgical practice.

RESULTS

Over 10 years (from January 1999 to December 2008), a total of 113 cases were registered. Pancreas resection including vascular reconstruction showed the highest percentage (30.1%). Within the target patient groups, similar outcome data were found compared with international reports. An exception was in the case of mesenteric ischemia, where open surgery was more frequently used in comparison to the study situation (included together were patients treated by surgery and interventions). The majority of vascular alterations during the postoperative course and iatrogenic lesions occurred following pancreas resection. In the therapeutic profile there are two particularly important measures, namely open surgery on one hand and image-guided radiology as well as endoscopy on the other hand. The majority of patients with a rare visceral artery aneurysm (considerable potential for rupture or erosion) were more frequently treated with image-guided interventional radiology versus open surgery. This conforms to the current well-established sequential patient (individual), results, and, in particular, risk-adapted staged treatment approach.

CONCLUSION

Additional vascular surgical treatment of problematic situations during abdominal surgery or in emergency cases is not daily routine; however, it is a challenging field including a considerable potential for complications (morbidity) and definitely mortality. This requires an experienced surgeon with high expertise, if possible in a center for vascular medicine.

Histopathologic tumor invasion of superior mesenteric vein/ portal vein is a poor prognostic indicator in patients with pancreatic ductal adenocarcinoma: results from a systematic review and meta-analysis

Background

The impact of histopathologic tumor invasion of the superior mesenteric vein (SMV)/portal vein (PV) on prognosis in patients with pancreatic ductal adenocarcinoma (PDAC) after pancreatectomy remains controversial. A meta-analysis was performed to assess this issue.

Results

Eighteen observational studies comprising 5242 patients were eligible, of whom 2199 (41.9%) patients received SMV/PV resection. Histopathologic tumor invasion was detected in 1218 (58.1%) of the 2096 resected SMV/PV specimens. SMV/PV invasion was associated with higher rates of poor tumor differentiation (P = 0.002), lymph node metastasis (P < 0.001), perineural invasion (P < 0.001), positive resection margins (P = 0.004), and postoperative tumor recurrence (P < 0.001). SMV/PV invasion showed a significantly negative effect on survival in total patients who underwent pancreatectomy with and without SMV/PV resection (hazard ratio [HR]: 1.21, 95% confidence interval [CI]: 1.08–1.35; P = 0.001) and in patients who underwent pancreatectomy with SMV/PV resection (HR: 1.88, 95% CI, 1.48–2.39; P < 0.001).

Materials And Methods

A systematic literature search was performed to identify articles published from January 2000 to August 2016. Data were pooled for meta-analysis using Review Manager 5.3.

Conclusions

Histopathologic tumor invasion of the SMV/PV is associated with more aggressive biologic behavior and could be used as an indicator of poor prognosis after PDAC resection.

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.

Non-invasively predicting differentiation of pancreatic cancer through comparative serum metabonomic profiling

BACKGROUND

The differentiation of pancreatic ductal adenocarcinoma (PDAC) could be associated with prognosis and may influence the choices of clinical management. No applicable methods could reliably predict the tumor differentiation preoperatively. Thus, the aim of this study was to compare the metabonomic profiling of pancreatic ductal adenocarcinoma with different differentiations and assess the feasibility of predicting tumor differentiations through metabonomic strategy based on nuclear magnetic resonance spectroscopy.

METHODS

By implanting pancreatic cancer cell strains Panc-1, Bxpc-3 and SW1990 in nude mice in situ, we successfully established the orthotopic xenograft models of PDAC with different differentiations. The metabonomic profiling of serum from different PDAC was achieved and analyzed by using 1H nuclear magnetic resonance (NMR) spectroscopy combined with the multivariate statistical analysis. Then, the differential metabolites acquired were used for enrichment analysis of metabolic pathways to get a deep insight.

RESULTS

An obvious metabonomic difference was demonstrated between all groups and the pattern recognition models were established successfully. The higher concentrations of amino acids, glycolytic and glutaminolytic participators in SW1990 and choline-contain metabolites in Panc-1 relative to other PDAC cells were demonstrated, which may be served as potential indicators for tumor differentiation. The metabolic pathways and differential metabolites identified in current study may be associated with specific pathways such as serine-glycine-one-carbon and glutaminolytic pathways, which can regulate tumorous proliferation and epigenetic regulation.

CONCLUSION

The NMR-based metabonomic strategy may be served as a non-invasive detection method for predicting tumor differentiation preoperatively.

Portal vein resection and reconstruction with artificial blood vessels is safe and feasible for pancreatic ductal adenocarcinoma patients with portal vein involvement: Chinese center experience

Evidence shows that portal vein resection (PVR) increase the resectability but does little benefit to overall survival in all pancreatic ductal adenocarcinoma (PDAC) patients. But for patients with portal vein involvement, PVR is the only radical choice. But whether the PDAC patients with portal vein involvement would benefit from radical pancreaticoduodenectomy with PVR or not is controversial. All 204 PDAC patients with portal vein involvement were enrolled in this study [PVR group, n=106; surgical bypass (SB) group, n=52; chemotherapy group, n=46]. Overall survival and prognostic factors were analyzed among three groups. Moreover, a literature review of 13 studies were also conducted. Among 3 groups, patients in PVR group achieved a significant longer survival (median survival: PVR group, 22.83 months; SB group, 7.26 months; chemotherapy group, 10.64 months). Therapy choice [hazard ratio (HR) =1.593, 95% confidence interval (CI) 1.323 to 1.918, P<0.001], body mass index (HR=0.772, 95% CI 0.559 to 0.994, P=0.044) and carbohydrateantigen 19-9 (HR=1.325, 95% CI 1.064 to 1.651, P=0.012) were independent prognostic factors which significantly affected overall survival. Pancreaticoduodenectomy combined with PVR and reconstruct with artificial blood vessels is a safe and an appropriate therapy choice for resectable PDAC patients with portal vein involvement.

Long-term outcomes after pancreaticoduodenectomy using pair-watch suturing technique: Different roles of pancreatic duct dilatation and remnant pancreatic volume for the development of pancreatic endocrine and exocrine dysfunction

BACKGROUND

We evaluated long-term outcomes including endo- and exocrine functions after pancreaticoduodenectomy (PD) with standardized pancreaticojejunostomy, paying attention to postoperative pancreatic duct dilatation (PDD) and remnant pancreatic volume (RPV), and examined whether postoperative pancreatic fistula (POPF) influenced the configuration of remnant pancreas.

METHODS

We analyzed the records of 187 patients with PD who could have RPV measured by CT volumetry at 1 month after operation and had been followed for more than 6 months. We assessed the risk factors of diabetes mellitus (DM) and PDD, and evaluated association between RPV and pancreatic endo- and exocrine functions assessed by several markers such as albumin, cholesterol, amylase and HbA1c.

RESULTS

Regarding RPV, pancreatic exocrine functions were significantly impaired in the small-volume group (SVG: less than 10 ml) than in the large-volume group (LVG: 10 ml or more). The incidence of new-onset or exacerbation of DM did not differ between SVG and LVG. PDD and the primary disease (pancreatic ductal adenocarcinoma compared to bile duct cancer) were selected as the independent risk factors of new-onset or exacerbation of DM by multivariate analysis. Unexpectedly, there was no significant association between POPF and PDD.

CONCLUSIONS

Early occurrence of POPF after PD did not influence the development of PDD in late period, and long-term follow-up should be made by paying attention to PDD and RPV, because PDD was recognized as the most important risk factor of new-onset or exacerbation of DM and the patients with small RPV suffered from prolonged exocrine dysfunction rather than endocrine dysfunction.

Vascular Reconstruction in Hepatic Malignancy

With surgery for hepatic malignancy, there are poor options for chemotherapy; many patients are deemed unresectable because of vascular involvement or location of tumors. Over the past few decades, advances in surgical technique have allowed resection of these tumors with vascular reconstruction to achieve negative margins and improve chances for survival. This article reviews those reconstruction techniques and outcomes in detail, including in situ perfusion and ex vivo liver surgery, and provides a discussion of implications and operative planning for patients with hepatic malignancy in order to provide surgeons with better understanding of these complicated operations.

Re-evaluation of classical prognostic factors in resectable ductal adenocarcinoma of the pancreas

Pancreatic ductal adenocarcinoma carries a poor prognosis with annual deaths almost matching the reported incidence rates. Surgical resection offers the only potential cure. Yet, even among patients that undergo tumor resection, recurrence rates are high and long-term survival is scarce. Various tumor-related factors have been identified as predictors of survival after potentially curative resection. These factors include tumor size, lymph node disease, tumor grade, vascular invasion, perineural invasion and surgical resection margin. This article will re-evaluate the importance of these factors based on recent publications on the topic, with potential implications for treatment and outcome in patients with pancreatic cancer.

Outcomes of Pancreaticoduodenectomy for Pancreatic Neuroendocrine Tumors: Are Combined Procedures Justified?

Efficacy and outcomes of resection for pancreatic neuroendocrine tumors (pNET) are well established; specific data on outcomes for pancreaticoduodenectomy (PD), either alone or with combined procedures, are limited. A retrospective review of PDs for pNET (1998-2014) at our institution was conducted. Patients were categorized into standard PD (SPD) alone or combined PD (CPD) defined as patients undergoing concurrent vascular reconstruction or additional organ resection for curative intent. Kaplan-Meier survival analyses were performed. PD for pNET was performed for 95 patients. Tumors were functional in 11 patients (9 %). Twenty-six patients (28 %) underwent CPD. The 30/90-day mortality was 1.1/5.3 % respectively and similar between SPD and CPD (p = 0.61/p = 0.24). Five-year overall survival after PD for pNET was 85.1/71.9 % and similar between SPD/CPD groups (p = 0.17). Recurrence-free and overall survival for low-grade tumors was 74.7/93.9 % at 5 years compared to only 14.8/49.7 % for high-grade tumors (p < 0.001) and not predicted by extent of resection (SPD/CPD, respectively). PD with or without concurrent resection provides an acceptable, perioperative and long-term oncologic, outcome for pNET. CPD is justified treatment modality, particularly for patients with low-grade tumors. The need for combinatorial procedures during PD is not contraindication alone for otherwise resectable patients with pNET.

Significance of Portal Vein Invasion and Extent of Invasion in Patients Undergoing Pancreatoduodenectomy for Pancreatic Adenocarcinoma

INTRODUCTION

Several studies have confirmed the safety of pancreatoduodenectomy with portal/mesenteric vein resection and reconstruction in select patients. The effect of vein invasion and extent of invasion on survival is less clear. The purpose of this study was to examine the association between tumor invasion of the portal/mesenteric vein and long-term survival.

METHODS

A retrospective review of a prospectively maintained database of patients who underwent pancreatoduodenectomy for pancreatic adenocarcinoma at a single academic medical center (2000-2014) was performed. Survival was compared using the Kaplan-Meier method and log-rank test. P < 0.05 was considered statistically significant.

RESULTS

After non-pancreatic periampullary adenocarcinomas and patients with non-segmental (lateral wall only) resection of portal/mesenteric vein were excluded, there were 567 eligible patients. Of these, segmental vein resection was performed in 90 (16 %) with end-to-end primary anastomosis (67) or interposition graft reconstruction (23). Patients with vein resection more likely received neoadjuvant systemic therapy (59 vs. 4 %, p < 0.0001). Histopathology of patients undergoing vein resection revealed a distribution of T stage toward larger tumors and higher rates of perineural invasion. Portal/mesenteric vein resection, however, was not associated with differences in hospital stay, postoperative complications, or operative mortality. Patients with or without vein resection had comparable overall survival rates at 1-, 3-, and 5-years. On final surgical histopathology, only 52 of 90 (58 %) vein resections had adenocarcinoma involvement of the venous wall. Of these, depth of invasion was at the level of the adventitia (9), media/intima (34), and full thickness/intraluminal (9). Venous wall invasion (52) did not significantly influence overall survival (14 vs. 21 months, p = 0.08) but was associated with significantly shorter median disease-free survival (11.3 vs. 15.8 months, p = 0.03), predominantly due to local recurrence. The extent of invasion (adventitia, media/intima, full thickness/intraluminal) did not impact overall survival or disease-free survival (14.4 vs. 15.5 vs. 7.4 months, p = 0.08 and 11.2 vs. 12.2 vs. 5 months, 0.59, respectively). Portal/mesenteric vein resection, histopathologic invasion, or the extent of invasion were not independent predictors of overall survival in Cox regression analysis.

CONCLUSION

Although Portal/mesenteric vein resection is associated with increased 90-day mortality, venous resection is not prognostic of overall survival. Although a subgroup analysis showed that a direct tumor invasion into the vein wall on final histopathology was associated with a higher rate of local recurrence but with no difference in overall survival (even when stratified according to extent of venous wall invasion), larger studies with an increased power will be needed to confirm these findings.

Delayed Gastric Emptying After Stapled Versus Hand-Sewn Anastomosis of Duodenojejunostomy in Pylorus-Preserving Pancreaticoduodenectomy: a Randomized Controlled trial

BACKGROUND

A retrospective analysis indicated that the incidence of delayed gastric emptying (DGE) was less after using a circular stapler (CS) for duodenojejunostomy than that after hand-sewn (HS) anastomosis in pylorus-preserving pancreaticoduodenectomy (PpPD). This randomized clinical trial compared the incidence of DGE postoperative after CS duodenojejunostomy with that of conventional HS anastomosis in PpPD.

METHODS

We randomly assigned 101 patients (age 20-80) undergoing PpPD to receive CS duodenojejunostomy (group CS, n = 50) or HS duodenojejunostomy (group HS, n = 51) in two Japanese cancer center hospitals between 2011 and 2013. The patients were stratified by institution and size of the main pancreatic duct (<3 or ≥3 mm). The primary endpoint was the incidence of grade B or C DGE according to the international definition with a non-inferiority margin of 5 %. This trial is registered with University hospital Medical Information Network (UMIN) Center: UMIN000005463.

RESULTS

Per-protocol analysis of data on 95 patients showed that grade B or C DGE was found in 4 (8.9 %) of 45 patients who underwent CS anastomosis and in 8 (16 %) of 50 patients who underwent HS anastomosis (P = 0.015). There were no differences in the overall incidence of DGE (P = 0.98), passage of the contrast medium through the anastomosis (P = 0.55), or hospital stays (P = 0.22).

CONCLUSIONS

CS duodenojejunostomy is not inferior to HS anastomosis with respect to the incidence of clinically significant DGE, justifying its use as treatment option.

Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma

BACKGROUND

Pancreatic ductal adenocarcinoma has a poor prognosis without surgery. No standard treatment has yet been accepted for patients with portal-superior mesenteric vein (PV-SMV) infiltration. The present meta-analysis aimed to compare the results of pancreatic resection with PV-SMV resection for suspected infiltration with the results of surgery without PV-SMV resection.

METHODS

A systematic search was performed of PubMed, Embase and the Cochrane Library in accordance with PRISMA guidelines from the time of inception to 2013. The inclusion criteria were comparative studies including patients who underwent pancreatic resection with or without PV-SMV resection. One, 3- and 5-year survival were the primary outcomes.

RESULTS

Twenty-seven studies were identified involving a total of 9005 patients (1587 in PV-SMV resection group). Patients undergoing PV-SMV resection had an increased risk of postoperative mortality (risk difference (RD) 0.01, 95 per cent c.i. 0.00 to 0.03; P = 0.2) and of R1/R2 resection (RD 0.09, 0.06 to 0.13; P < 0.001) compared with those undergoing standard surgery. One-, 3- and 5-year survival were worse in the PV-SMV resection group: hazard ratio 1.23 (95 per cent c.i. 1.07 to 1.43; P = 0.005), 1.48 (1.14 to 1.91; P = 0.004) and 3.18 (1.95 to 5.19; P < 0.001) respectively. Median overall survival was 14.3 months for patients undergoing pancreatic resection with PV-SMV resection and 19.5 months for those without vein resection (P = 0.063). Neoadjuvant therapies recently showed promising results.

CONCLUSION

This meta-analysis showed increased postoperative mortality, higher rates of non-radical surgery and worse survival after pancreatic resection with PV-SMV resection. This may be related to more advanced disease in this group.

National Comprehensive Cancer Network Resectability Status for Pancreatic Carcinoma Predicts Overall Survival

BACKGROUND

The aim of this study was to evaluate the validity of preoperative resectability status, as defined by the National Comprehensive Cancer Network (NCCN), from the viewpoint of overall survival.

METHODS

A total of consecutive 704 patients with pancreatic head carcinoma who underwent pancreatoduodenectomy with upfront surgery at seven Japanese hospitals between 2001 and 2012 were evaluated retrospectively. According to the NCCN definition of preoperative resectability status, tumors were divided into resectable tumors without vascular contact (R group), resectable tumors with portal or superior mesenteric vein (PV/SMV) contact of ≦180° (R-PV group), borderline resectable(BR) tumors with PV/SMV contact of >180° (BR-PV group), and BR tumors with arterial contact (BR-A group). The relationship between the NCCN definition of preoperative resectability status and overall survival was analyzed.

RESULTS

Of the 704 patients, 389, 114, 145, and 56 were classified into the R group, the R-PV group, the BR-PV group, and the BR-A group, respectively. Overall survival of the BR-PV and BR-A groups was significantly worse than that of the R group and R-PV groups (P < 0.05), although there was no significant difference in overall survival between the R group and the R-PV group (P = 0.310). Multivariate analysis revealed that PV/SMV contact of >180° (P = 0.008) and arterial contact (P < 0.001) were independent prognostic factors of overall survival.

CONCLUSION

From the viewpoint of overall survival, the NCCN definition of preoperative resectability status was valid.

Outcomes of resections for pancreatic adenocarcinoma with suspected venous involvement: a single center experience

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) patients frequently present with borderline resectable disease, which can be due to invasion of the portal/superior mesenteric vein (PV/SMV). Here, we analyzed this group of patients, with emphasis on short and long-term outcomes.

METHODS

156 patients who underwent a resection for PDAC were included in the analysis and sub-stratified into a cohort of patients with PV/SMV resection (n = 54) versus those with standard surgeries (n = 102).

RESULTS

While venous resections could be performed safely, there was a trend towards shorter median survival in the PV/SMV resection group (22.7 vs. 15.8 months, p = 0.157). These tumors were significantly larger (3.5 vs. 4.3 cm; p = 0.026) and margin-positivity was more frequent (30.4% vs. 44.4%, p = 0.046).

CONCLUSION

Venous resection was associated with a higher rate of margin positivity and a trend towards shorter survival. However, compared to non-surgical treatment, resection offers the best chance for long term survival.

Portal or superior mesenteric vein resection in pancreatoduodenectomy for pancreatic head carcinoma

BACKGROUND

The aim of this study was to determine the added value of portal or superior mesenteric vein (PV/SMV) resection during pancreatoduodenectomy for pancreatic head carcinoma.

METHODS

A multicentre observational study was conducted in patients with pancreatic head carcinoma who underwent pancreatoduodenectomy in seven Japanese hospitals between 2001 and 2012. Clinicopathological factors were compared between patients who did and did not undergo PV/SMV resection. Those with an impact on survival were identified by univariable and multivariable analysis.

RESULTS

Of the 937 patients who underwent pancreatoduodenectomy, 435 (46·4 per cent) had PV/SMV resection, whereas the remaining 502 (53·6 per cent) did not. Some 71·5 and 63·9 per cent of patients with and without PV/SMV resection respectively had lymph node-positive disease. Patients who underwent PV/SMV resection had more advanced tumours. Perioperative mortality and morbidity rates did not differ between the two groups. Multivariable analysis revealed that PV/SMV resection was not an independent prognostic factor for overall survival (P = 0·268). Among the 435 patients in whom the PV/SMV was resected, borderline resectable tumours with arterial abutment (P = 0·021) and absence of adjuvant chemotherapy (P < 0·001) were independent predictors of poor survival in multivariable analysis. Patients with resectable or borderline resectable tumours with PV/SMV involvement had a median survival time with additional adjuvant chemotherapy of 43·7 and 29·7 months respectively. Median survival time in patients with borderline resectable tumours with arterial abutment was 18·6 months despite adjuvant chemotherapy.

CONCLUSION

Pancreatoduodenectomy with PV/SMV resection and adjuvant chemotherapy in patients with pancreatic head carcinoma may provide good survival without increased mortality and morbidity.

Pancreatic adenocarcinoma with venous involvement: is up-front synchronous portal-superior mesenteric vein resection still justified? A survey of the Association Française de Chirurgie

BACKGROUND

Venous resection (VR) during pancreatectomy has been reported to neither increase mortality nor morbidity and to provide similar survival outcomes in same stage tumors. However, controversy remains regarding the indications for up-front surgery according to the degree of venous involvement.

METHODS

From 2004 to 2009, 1,399 patients included in a French multicenter survey underwent pancreaticoduodenectomy or total pancreatectomy for pancreatic adenocarcinoma, either without VR (997 standard resections [SR]) or with VR (402 patients; 29 %). Postoperative and long-term outcomes were compared in both groups.

RESULTS

VR was associated with the following factors: larger tumors (p < 0.001), poorly differentiated tumors (p = 0.004), higher numbers of positive lymph nodes (p = 0.042), and positive resection margins (R1; p < 0.001). Overall, VR increased neither postoperative morbidity nor postoperative mortality (5 vs. 3 % in SR patients; p = 0.16). The median and 3-year survival rates in VR patients versus SR patients were 21 months and 31 % vs. 29 months and 44 %, respectively (p = 0.0002). In the entire cohort, multivariate analysis identified VR as a significant poor prognostic factor for long-term survival (hazard ratio [HR] 1.75, 95 % confidence interval [CI] 1.28-2.40; p = 0.0005). In the VR patients, lymph node ratio, whatever the cutoff (<0.3: p = 0.093; ≥ 0.3: p = 0.0098), R1 resection (p = 0.010), and segmental resection (p = 0.016) were independent risk factors; neoadjuvant treatment (HR 0.52, 95 % CI 0.29-0.94; p = 0.031) and adjuvant treatment (HR 0.55, 95 % CI 0.35-0.85; p = 0.006) were significantly associated with improved long-term survival.

CONCLUSIONS

Long-term survival after pancreatectomy was significantly altered when up-front VR was performed. Neoadjuvant treatment may be a better strategy than up-front resection in patients with preoperative suspicion of venous involvement.

Vascular reconstruction plays an important role in the treatment of pancreatic adenocarcinoma

OBJECTIVE

Previous studies have proved the feasibility of performing a pancreaticoduodenectomy (Whipple operation) in patients with portal vein-superior mesenteric vein and hepatic artery invasion. We report our institutional experience with the use of a variety of vascular reconstructive methods during pancreatic resections for adenocarcinoma.

METHODS

A retrospective review was performed identifying all patients undergoing a Whipple operation or total pancreatectomy procedure from January 2003 to December 2013. All venous (portal vein-superior mesenteric vein) and arterial (superior mesenteric artery-hepatic artery) reconstructions were extracted and reviewed to determine survival and perioperative complications.

RESULTS

During the 10-year study period, 270 Whipple and total pancreatectomy procedures were performed, of which 183 were for adenocarcinoma of the pancreas. Of the 183 operations, a total of 60 (32.8%) vascular reconstructions were found, 49 venous and 11 arterial. Venous reconstruction included 37 (61.7%) primary repairs, four (6.7%) reconstructions with CryoVein (CryoLife, Inc, Kennesaw, Ga), three (5.0%) repairs with autologous vein patch, three (5.0%) autologous saphenous reconstructions, and two (3.33%) portacaval shunts. In addition, there were 11 (18.3%) arterial reconstructions (seven hepatic artery and four superior mesenteric artery). The 1-year survival for all reconstructions was 71.1%, which is equivalent to T3 lesions that did not receive vascular reconstruction (70.11%), with a median survival time of 575.28 days and 12 patients still alive. Survival time was comparable with each type of venous reconstruction, averaging 528 days (11 of 49 patients still alive). There was a total thrombosis rate of seven of 60 (11.6%), all of which were portal vein thrombosis: three in the primary repair group and four delayed thromboses seen in primary repair, CryoVein repair, and vein patch repair. There was no thrombosis in any patients after arterial reconstruction.

CONCLUSIONS

An aggressive approach for stage II pancreatic cancers with venous or arterial invasion can be performed with comparable results when it is executed by an experienced institution with skilled oncologic and vascular surgeons.

Vascular resection during radical resection of pancreatic adenocarcinomas: evolution over the past 15 years

This literature review aimed to critically analyze oncological results of vascular resection during pancreatectomy for adenocarcinoma in the light of the concept evolution of locally advanced tumors and microscopic complete resection. The literature search was conducted in PubMed and Medline for the period June 1994 to December 2012, retaining English as the language of publication. The review of 12 publications indicated that mortality and morbidity rates were not significantly different for pancreatectomy with or without venous resection (VR). Six comparative studies showed worse long-term survival in the VR group, though one meta-analysis, albeit with a significant population heterogeneity, demonstrated that the overall survival between VR and the control group was similar (12% vs. 17%). The compilation of 13 comparative studies showed a significantly lower rate of complete microscopic resection in the VR patient group compared to controls (63% vs. 77%; P = 0.001). Concerning pancreatectomy combined to arterial resection, the literature review indicated a significantly greater mortality and morbidity rate and a lower survival rate compared to pancreatic resection alone. Conflicting results concerning the long-term outcome of VR was due to the heterogeneity of the patient population. Since the only chance to cure patients of pancreatic adenocarcinoma is to obtain free resection margins, VR is a valid therapeutic option. But combined arterial resection to pancreatic resection does not appear to be recommended.

Pancreaticoduodenectomy with vascular resection for pancreatic head adenocarcinoma

Traditionally, pancreatic ductal adenocarcinoma with regional vascular involvement was thought to represent unresectable disease and was associated with disease progression and death within 1 year of diagnosis. Recent evidence demonstrates that pancreaticoduodenectomy with vascular resection and reconstruction can be safely performed in select patients with 5-year survival rates as high as 20%. In order to safely treat and to optimize survival in these complex patients, it is essential to accurately identify vascular involvement preoperatively, to utilize a multidisciplinary treatment approach, and to emphasize meticulous surgical technique with awareness of the critical margins of resection.

Adverse tumor biology associated with mesenterico-portal vein resection influences survival in patients with pancreatic ductal adenocarcinoma

BACKGROUND

Although pancreatoduodenectomy (PD) with mesenterico-portal vein resection (VR) can be performed safely in patients with resectable pancreatic ductal adenocarcinoma (PDAC), the impact of this approach on long-term survival is controversial.

PATIENTS AND METHODS

Analyses of a prospectively collected database revealed 122 consecutive patients with PDAC who underwent PD with (PD+VR) or without (PD-VR) VR between January 2004 and May 2012. Clinical data, operative results, and survival outcomes were analysed.

RESULTS

Sixty-four (53 %) patients underwent PD+VR. The majority (84 %) of the venous reconstructions were performed with a primary end-to-end anastomosis. Demographic and postoperative outcomes were similar between the two groups. American Society of Anesthesiologists (ASA) score, duration of operation, intraoperative blood loss, and blood transfusion requirement were significantly greater in the PD+VR group compared with the PD-VR group. Furthermore, the tumor size was larger, and the rates of periuncinate neural invasion and positive resection margin were higher in the PD+VR group compared with the PD-VR group. Histological venous involvement occurred in 47 of 62 (76 %) patients in the PD+VR group. At a median follow-up of 29 months, the median overall survival (OS) was 18 months for the PD+VR group, and 31 months for the PD-VR group (p = 0.016). ASA score, lymph node metastasis, neurovascular invasion, and tumor differentiation were predictive of survival. The need for VR in itself was not prognostic of survival.

CONCLUSIONS

PD with VR has similar morbidity but worse OS compared with a PD-VR. Although VR is not predictive of survival, tumors requiring a PD+VR have more adverse biological features.

Benefit from synchronous portal-superior mesenteric vein resection during pancreaticoduodenectomy for cancer: a meta-analysis

BACKGROUND

Pancreaticoduodenectomy combined with portal-superior mesenteric vein synchronous resection for cancer remains a hot debate topic. The present study used meta-analytical technique to provide update information and an evidence-based evaluation on both the perioperative benefit and long-term survival.

METHODS

A meta-analysis was performed to evaluate studies comparing venous resection (VR) versus without venous resection (WVR) groups. 22 retrospective studies including 2890 patients were eligible for an analysis of perioperative morbidity, mortality, and long-term survival. Furthermore, subgroup analysis was made according to histopathology and resection margin status respectively for the purpose of survival assessment.

RESULTS

There was no difference in perioperative morbidity, mortality and 1-year, 3-year survival between two groups, but showed differences in median tumor size (P < 0.001), R0 resection rate (P < 0.001), lymph node metastasis (P = 0.03), pancreatic fistula (P = 0.01), and 5-year survival (P = 0.03). In subgroup analysis, patients in venous resection group received R0 resection had a significantly better survival comparing with who received R1 resection both at 2-year (P < 0.001) and 5-year (P = 0.00002). In histopathology subgroup, patients in venous resection groups who had true tumor infiltration had a significantly bad survival comparing with whom only with inflammation pathology.

CONCLUSION

Pancreaticoduodenectomy combined with venous resection can achieve equal perioperative morbidity and mortality as standard resection. However, in order to obtain an optimal survival outcome, surgeons should make an R0 resection as far as possible, especially in cases need synchronous venous resection.

Evolving role of vascular resection and reconstruction in hepatic surgery for malignancy

Primary and secondary hepatic malignancies, including hepatocellular cancer, cholangiocarcinoma and metastatic disease from colorectal cancer continue to increase in incidence worldwide, and remain diseases with a high mortality. Liver resection, with negative margins, is associated with improved survival and better quality of life over nonoperative treatment. As liver resection continues to evolve, aggressive centers are increasingly using vascular resection and reconstruction to achieve negative margins and improve outcomes. As these resections become more common, the morbidity and mortality associated with these complex surgical procedures is decreasing. Currently, resections of the portal vein are becoming routine in major liver and pancreatic resections, and experience with hepatic artery, hepatic vein and inferior vena cava resections is increasing. This review paper looks at the current indications, techniques and outcomes for major vascular resection in hepatic malignancy.

Margin status, recurrence pattern, and prognosis after resection of pancreatic cancer

BACKGROUND

Controversy persists as to whether positive operative margins are an independent prognostic factor for resected pancreatic cancer. This study evaluated the impact of the resection margin status on the patterns of recurrence and prognosis after resection for pancreatic cancer.

METHODS

A total of 208 patients with pancreatic cancer who underwent resection with curative intent were studied retrospectively. All patients underwent pancreatectomy (164 pancreatoduodenectomies, 42 distal pancreatectomies, and 2 total pancreatectomies) intended to achieve R0 resection. They were divided into three groups on the basis of the following margin status: R(>1 mm), R(0-1 mm), and R(0 mm). The postoperative survival and recurrence patterns were evaluated in relation to the margin status. Multivariate analyses were performed to evaluate the factors influencing the overall survival.

RESULTS

The resection margin was R(>1 mm) in 134 patients (65%), R(0-1 mm) in 40 (19%), and R(0 mm) in 34 patients (16%). The margin status correlated with the rate of local recurrence; 8% in R(>1 mm), 20% in R(0-1 mm), and 50% in R(0 mm) patients. In contrast, the incidence of recurrence at other sites, such as the lymph nodes, peritoneum, liver and other distant organs, were almost identical among the three groups. The median survival time was 26 months in R(>1 mm), 30 months in R(0-1 mm), and 23 months in R(0 mm) patients (P = not significant). The multivariate analyses revealed that lymph node metastases and poor differentiation were correlated with poor survival.

CONCLUSION

In the setting of pancreatectomy, when we evaluated the definitions of R0 resection, the margin status influenced the local recurrence rate but had no impact on the patients' survival.

Vein involvement during pancreaticoduodenectomy: is there a need for redefinition of "borderline resectable disease"?

INTRODUCTION

Current National Comprehensive Cancer Network guidelines recommend neoadjuvant therapy for borderline resectable pancreatic adenocarcinoma to increase the likelihood of achieving R0 resection. A consensus has not been reached on the degree of venous involvement that constitutes borderline resectability. This study compares the outcome of patients who underwent pancreaticoduodenectomy with or without vein resection without neoadjuvant therapy.

METHODS

A multi-institutional database of patients who underwent pancreaticoduodenectomy was reviewed. Patients who required vein resection due to gross vein involvement by tumor were compared to those without evidence of vein involvement.

RESULTS

Of 492 patients undergoing pancreaticoduodenectomy, 70 (14 %) had vein resection and 422 (86 %) did not. There was no difference in R0 resection (66 vs. 75 %, p = NS). On multivariate analysis, vein involvement was not predictive of disease-free or overall survival.

CONCLUSION

This is the largest modern series examining patients with or without isolated vein involvement by pancreas cancer, none of whom received neoadjuvant therapy. Oncological outcome was not different between the two groups. These data suggest that up-front surgical resection is an appropriate option and call into question the inclusion of isolated vein involvement in the definition of "borderline resectable disease."

Pancreatic surgery: beyond the traditional limits

Pancreatic cancer is one of the five leading causes of cancer death for both males and females in the western world. More than 85 % pancreatic tumors are of ductal origin but the incidence of cystic tumors such as intrapapillary mucinous tumors (IPMN) or mucinous cystic tumors (MCN) and other rare tumors is rising. Complete surgical resection of the tumor is the mainstay of any curative therapeutic approach, however, up to 40 % of patients with potentially resectable pancreatic cancer are not offered surgery. This is despite 5-year survival rates of up to 40 % or even higher in selected patients depending on tumor stage and histology. Standard procedures for pancreatic tumors include the Kausch-Whipple- or pylorus-preserving Whipple procedure, and the left lateral pancreatic resection (often with splenectomy), and usually include regional lymphadenectomy. More radical or extended pancreatic operations are becoming increasingly utilised however and we examine the data available for their role. These operations include major venous and arterial resection, multivisceral resections and surgery for metastatic disease, or palliative pancreatic resection. Portal vein resection for local infiltration with or without replacement graft is now well established and does not deleteriously affect perioperative morbidity or mortality. Arterial resection, however, though often technically feasible, has questionable oncologic impact, is not without risk and is usually reserved for isolated cases. The value of extended lymphadenectomy is frequently debated; the recent level I evidence demonstrates no advantage. Multivisceral resections, i.e. tumors, often in the tail of the pancreas, with invasion of the colon or stomach or other surrounding tissues, while associated with an increased morbidity and a longer hospital stay, do however show comparable mortality-and survival rates to those without such infiltration and therefore should be performed if technically feasible. Routine resection for metastatic disease however does not seem to show any advantage over palliative treatment but may be an option in selected patients with easily removable metastases. In conclusion pancreatic surgery beyond the traditional limits is established in tumors infiltration the venous system and may be a considered approach in selected patients with locally infiltrating pancreatic cancer or metastasis.

Is extended hemihepatectomy plus pancreaticoduodenectomy justified for advanced bile duct cancer and gallbladder cancer?

BACKGROUND

Major hepatopancreaticoduodenectomy (HPD) is an extensive surgical procedure offering the highest curability for patients with advanced biliary cancer. However, surgical morbidity associated with major HPD is high, and optimal indications for this procedure remain unclear.

METHODS

Between 1989 and 2010, 14 patients with widespread bile duct cancer and 5 with gallbladder cancer having biliary infiltration underwent major HPD at our hospital. Preoperative portal vein embolization was performed in 17 patients undergoing right HPD. Clinicopathologic factors and survivals following HPD were compared between patients with bile duct cancer and those with gallbladder cancer.

RESULTS

One patient who underwent right HPD for gallbladder cancer died of hepatic failure (5.3%) and 18 of the 19 patients (95%) developed postoperative pancreatic fistulas. The median hospital stay was 47 days. Depth of invasion was T3 in 1 patient and T4 in 2 patients with bile duct cancer and was T4 in all 5 patients with gallbladder cancer (P = .002). The clinical stage was IV in 3 patients (21%) with bile duct cancer and in all 5 patients with gallbladder cancer (P = .002). The 5-year survival rates and median survival rates of patients with bile duct cancer and gallbladder cancer were 45% vs 0 and 3.3 years vs 8 months, respectively (P < .001).

CONCLUSION

HPD can be an acceptable treatment option for widespread bile duct cancer. However, the indication for HPD in advanced-stage gallbladder cancer should be considered carefully, considering the high morbidity rate and the advanced stage of the disease.

The impact of vascular resection on early postoperative outcomes after pancreaticoduodenectomy: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database

BACKGROUND

Several single-center reports suggest that vascular resection (VR) during pancreaticoduodenectomy (PD) for patients with pancreatic adenocarcinoma is feasible without affecting early postoperative mortality or morbidity. Our objective is to review the outcomes associated with VR during PD using a large multicenter data source.

METHODS

A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program Participant User Files for 2005-2009. All patients undergoing PD for a postoperative diagnosis of malignant neoplasm of the pancreas were included. Forward stepwise multivariate regression analysis was used to determine the association between VR during PD and 30-day postoperative mortality and morbidity after adjustment for patient demographics and comorbidities.

RESULTS

3,582 patients were included for analysis, 281 (7.8 %) of whom underwent VR during PD. VR during PD was associated with significantly greater risk-adjusted 30-day postoperative mortality [5.7 % with VR versus 2.9 % without VR, adjusted odds ratio (AOR) 2.1, 95 % confidence interval (CI) 1.22-3.73, P = 0.008] and overall morbidity (39.9 % with VR versus 33.3 % without VR, AOR 1.36, 95 % CI 1.05-1.75, P = 0.02). There was no significant difference in risk-adjusted postoperative mortality or morbidity between those patients undergoing VR by the primary surgical team versus those patients undergoing VR by a vascular surgical team.

CONCLUSIONS

Contrary to the findings of several previously published single-center analyses, the current study demonstrates increased 30-day postoperative morbidity and mortality in PD with VR when compared with PD alone.

Vascular invasion in pancreatic cancer: tumor biology or tumor topography?

BACKGROUND

Although vascular resection in pancreatic adenocarcinoma increases the resection rate, involvement of the vascular structures frequently is assumed to be associated with a more aggressive tumor biology and tumor cell dissemination. Our study's aim was to assess the correlation of vascular tumor involvement with adverse, clinicopathologic prognosticators and with the extent of tumor cell dissemination.

METHODS

We studied 108 patients who had undergone pancreatic resection, of whom 39 underwent vascular resection. Clinical parameters and the postoperative course were recorded. Formalin-embedded lymph node samples as well as bone marrow aspirates were screened immunohistochemically for disseminated tumor cells. Univariate and multivariate analyses were performed using the log-rank test and the Cox proportional-hazard models.

RESULTS

Overall, 2,388 lymph nodes and bone marrow aspirates from 49 matched patients were screened immunohistochemically. Fully 50% of the patients had disseminated tumor cells in lymph nodes and 27% in bone marrow. The mean observation period in cohort was 28 months. Vascular resection did not correlate with prognostically relevant parameters. Disseminated tumor cells in lymph nodes were associated with a decrease in relapse-free survival (P = .016) and were confirmed as independent indicators for a decrease in metastasis-free survival at multivariate analysis. There was no adverse prognostic influence of vascular resection, and there was no increased frequency of disseminated tumor cells in patients undergoing vascular resection.

CONCLUSION

These results support the hypothesis that the presence of vascular tumor involvement of peripancreatic vessels seems to be an indicator of unfavorable tumor topography, instead of being a sign of adverse tumor biology. Thus, vascular resection in pancreatic cancer appears to be warranted to achieve tumor-free margins.

Pancreatectomy combined with superior mesenteric vein-portal vein resection for pancreatic cancer: a meta-analysis

BACKGROUND

Pancreatectomy combined with superior mesenteric vein-portal vein resection (VR) for pancreatic cancer remains a matter of debate. The present study is a meta-analysis of the available evidence.

METHODS

Articles published until end of March 2011, comparing the results of pancreatic resections with VR versus without VR, were searched. Pooled odds ratios (OR) and weighted mean differences (WMD; with 95% Confidence Intervals [95% CI]) were calculated using either the fixed effects model or the random effects model.

RESULTS

Nineteen nonrandomized studies met the inclusion criteria, comprising 2,247 patients. There was no difference in perioperative morbidity (OR: 0.95; 95% CI: 0.74-1.21; P = 0.67), mortality (OR: 1.19; 95% CI: 0.73-1.96; P = 0.48), or 5-year overall survival (OR: 0.57; 95% CI: 0.32-1.02; P = 0.06) between patients with VR and those without VR.

CONCLUSIONS

Pancreatectomy combined with VR resection for pancreatic cancer is justified because it can result in good perioperative outcome and long-term survival comparable to that obtained with standard resection. Owing to the selection bias and low level of clinical evidence available so far, the results should be interpreted with caution.

Benefit of portal or superior mesenteric vein resection with adjuvant chemotherapy for patients with pancreatic head carcinoma

BACKGROUND AND OBJECTIVES

The aim of this study was to evaluate the efficacy of portal or superior mesenteric vein (PV/SMV) resection for patients with pancreatic carcinoma who underwent pancreatoduodenectomy.

METHODS

Medical records of 125 patients with pancreatic head carcinoma who underwent pancreatoduodenectomy were reviewed retrospectively. Sixty-one patients underwent PV/SMV resection and 64 patients did not. Clinicopathological factors were compared between the two groups and the prognostic impact of PV/SMV resection was evaluated using univariate and multivariate survival analysis.

RESULTS

The frequency of mortality and morbidity did not differ between the two groups. Univariate analysis revealed that a significant difference in overall survival was found between patients who did and did not undergo PV/SMV resection (P = 0.046) as well as between patients with and without pathological PV/SMV invasion (P = 0.012). However, PV/SMV resection and pathological PV/SMV invasion were not independent prognostic factors by multivariate survival analysis. Among patients with PV/SMV resection, the use of adjuvant chemotherapy was the only independent prognostic factor of overall survival (P = 0.003).

CONCLUSIONS

Resection of the PV/SMV with adjuvant chemotherapy may provide an acceptable survival benefit to patients with pancreatic head carcinoma, which involves the PV/SMV without additional mortality and morbidity.

Serum CA19-9 is a significant predictor among preoperative parameters for early recurrence after resection of pancreatic adenocarcinoma

OBJECTIVE

To evaluate the preoperative factors predictive of postoperative early recurrence in patients with resected pancreatic cancer focusing on the serum CA19-9 value.

METHODS

One hundred fifty-four patients undergoing surgical resection for pancreatic cancer were enrolled in this study. Univariate and multivariate analyses were performed to determine the predictors of early recurrence which was defined as relapse within 6 months after surgery.

RESULTS

On ROC curve analysis, the cutoff value of CA19-9 was determined to be 100 U/ml. Of 73 patients with CA19-9 value ≥ 100 U/ml, 39 (53 %) had early recurrence. In contrast, only 9 of 81 patients (11 %) with CA19-9 value < 100 U/ml developed a recurrence at an early period (p < 0.001). Multivariate analysis revealed that CA19-9 value ≥ 100 U/ml (odds ratio, 11.2) were significant predictors of early recurrence. The overall 3- and 5-year survival rates and median survival times were 47.3 %, 40.1 %, and 31 months in patients with CA19-9 value < 100 U/ml and 21.2 %, 9.4 %, and 16 months in patients with CA19-9 value ≥ 100 U/ml (p < 0.001).

CONCLUSIONS

A preoperative CA19-9 value ≥ 100 U/ml was a significant predictor of early recurrence and a poor prognosis after resection for pancreatic adenocarcinoma.

A preoperative predictive scoring system for postoperative pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) remains a leading cause of morbidity after pancreaticoduodenectomy (PD). In the present study we sought to establish a preoperative scoring system with which to predict this complication.

PATIENTS AND METHODS

The clinical records of 387 consecutive patients who underwent PD for periampullary tumor between 2004 and 2009 were reviewed retrospectively. Patients were divided into two groups; 279 consecutive patients constituted the study group and the next 108 patients constituted the validation group. Univariate and multivariate logistic regression analyses were performed using preoperative and surgical factors potentially influencing grade B or C POPF in the study group, and a score to predict POPF was constructed. This score was confirmed in the validation group.

RESULTS

In the study group, grade A POPF was recognized in 45 patients (16%), grade B in 98 (35%), and grade C in 5 (2%). A preoperative predictive scoring system for POPF (0-7 points) was constructed using the following 5 factors; main pancreatic duct index <0.25 (2 points), away from portal vein on computed tomography (2 points), disease other than pancreatic cancer (1 point), male (1 point), and intra-abdominal thickness >65 mm (1 point). The nomogram showed an area under the curve (AUC) of 0.808. This scoring system was highly predictive for grade B or C POPF in the validation group (AUC = 0.834).

CONCLUSIONS

The present scoring system satisfactorily predicted the occurrence of POPF and thus will be useful for the perioperative risk management of patients undergoing PD in a high-volume center hospital.

Clinical significance of portal-superior mesenteric vein resection in pancreatoduodenectomy for pancreatic head cancer

OBJECTIVES

The purpose of this study was to determine the significance of portal vein-superior mesenteric vein (PV-SMV) invasion on survival in patients who underwent margin-negative pancreatoduodenectomy (PD) with PV-SMV resection for pancreatic adenocarcinoma.

METHODS

We retrospectively reviewed the records of 60 patients who underwent margin-negative PD with or without PV-SMV resection for pancreatic adenocarcinoma between August 2001 and December 2007. The depth of vessel invasion was investigated and was categorized into 3 groups: tunica adventitia, media, and intima. Clinicopathologic factors and survival were analyzed.

RESULTS

Portal vein-superior mesenteric vein resection was performed on 19 patients, but only 15 patients (78.9%) had histologically true invasion and showed poorer survival (median survival, 14 vs 9 months; P < 0.05). Univariate analysis revealed that poorly differentiated tumor, lymphatic invasion, endovascular invasion, PV-SMV invasion, and invasion into the intima of PV-SMV were statistically significant. Poorly differentiated tumor and invasion into the intima of PV-SMV were significant in multivariate analysis.

CONCLUSIONS

Aggressive surgical resection should be attempted in cases with suspected PV-SMV invasion because 21.1% of patients had no true invasion and showed better survival than those with true invasion. However, invasion into the tunica intima may be a poor prognostic factor for survival even after margin-negative PD for pancreatic adenocarcinoma.

Histologic tumor involvement of superior mesenteric vein/portal vein predicts poor prognosis in patients with stage II pancreatic adenocarcinoma treated with neoadjuvant chemoradiation

BACKGROUND

Studies have shown that superior mesenteric vein (SMV)/portal vein (PV) resection with pancreaticoduodenectomy (PD) is safe and feasible for patient with pancreatic adenocarcinoma (PAC). However, the prognostic significance of tumor involvement of the resected vein in patients who received neoadjuvant therapy is unclear.

METHODS

The authors evaluated 225 consecutive patients with stage II PAC who received neoadjuvant therapy and PD with or without SMV/PV resection. The resected SMV/PV was entirely submitted for histologic assessment and reviewed in all cases. Tumor involvement of the SMV/PV was correlated with clinicopathologic features and survival.

RESULTS

Among the 225 patients, SMV/PV resection was performed in 85 patients. Histologic tumor involvement of the resected SMV/PV was identified in 57 patients. Histologic tumor involvement of the SMV/PV was associated with larger tumor size, higher rates of positive margin, and local/distant recurrence. By multivariate analysis, tumor involvement of the SMV/PV was an independent predictor of both disease-free survival (DFS) and overall survival (OS). However, addition of venous resection to PD itself had no impact on either DFS or OS compared with those with PD alone.

CONCLUSIONS

Histologic tumor involvement of the SMV/PV is an independent predictor of both DFS and OS in patients with stage II PAC treated with neoadjuvant therapy and PD. Complete histologic evaluation of the resected SMV/PV is important for the prognosis in patients with PAC who received neoadjuvant therapy and PD.

Analysis of risk factors for delayed gastric emptying (DGE) after 387 pancreaticoduodenectomies with usage of 70 stapled reconstructions

BACKGROUND

Delayed gastric emptying (DGE) is one of the most troublesome complications after pancreaticoduodenectomy (PD).

METHODS

Between 2004 and 2009, 387 patients underwent PD and of these, 302 patients (78%) underwent pylorus-preserving PD. The stapled reconstruction of duodeno- or gastrojejunostomy was introduced in 2006, and 70 patients (18%) underwent stapled Roux-en-Y reconstruction. Postoperative DGE was defined based on the International Study Group on Pancreatic Surgery classification, and grade B or C DGE was considered to be clinically relevant. Risk factors for DGE were evaluated using univariate and multivariate analyses.

RESULTS

Four patients died in the hospital (1.0%). Postoperative DGE was found in 70 patients (18%). DGE was less frequently seen in stapled reconstruction than in hand-sewn reconstruction (7.2% vs. 21%, P < 0.001), and in single-layer anastomosis than in double-layer anastomosis (12% vs. 24%, P = 0.02). The multivariate logistic regression analysis revealed that the independent risk factors for DGE were postoperative pancreatic fistula (risk ratio [RR] 2.4, P = 0.002), hand-sewn reconstruction (RR 2.9, P = 0.03) and male (RR 2.2, P = 0.02).

CONCLUSION

The method of alimentary reconstruction affected the occurrence of DGE. The incidence of DGE was less in stapled reconstruction than in hand-sewn reconstruction.