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

Recurrence scoring system predicting early recurrence for patients with pancreatic ductal adenocarcinoma undergoing pancreatectomy and portomesenteric vein resection

BACKGROUND

Pancreatectomy with concomitant portomesenteric vein resection (PVR) enables patients with portomesenteric vein (PV) involvement to achieve radical resection of pancreatic ductal adenocarcinoma, however, early recurrence (ER) is frequently observed.

AIM

To predict ER and identify patients at high risk of ER for individualized therapy.

METHODS

Totally 238 patients undergoing pancreatectomy and PVR were retrospectively enrolled and were allocated to the training or validating cohort. Univariate Cox and LASSO regression analyses were performed to construct serum recurrence score (SRS) based on 26 serum-derived parameters. Uni- and multivariate Cox regression analyses of SRS and 18 clinicopathological variables were performed to establish a Nomogram. Receiver operating characteristic curve analysis was used to evaluate the predictive accuracy. Survival analysis was performed using Kaplan-Meier method and log-rank test.

RESULTS

Independent serum-derived recurrence-relevant factors of LASSO regression model, including postoperative carbohydrate antigen 19-9, postoperative carcinoembryonic antigen, postoperative carbohydrate antigen 125, preoperative albumin (ALB), preoperative platelet to ALB ratio, and postoperative platelets to lymphocytes ratio, were used to construct SRS [area under the curve (AUC): 0.855, 95%CI: 0.786–0.924]. Independent risk factors of recurrence, including SRS [hazard ratio (HR): 1.688, 95%CI: 1.075-2.652], pain (HR: 1.653, 95%CI: 1.052-2.598), perineural invasion (HR: 2.070, 95%CI: 0.827-5.182), and PV invasion (HR: 1.603, 95%CI: 1.063-2.417), were used to establish the recurrence nomogram (AUC: 0.869, 95%CI: 0.803-0.934). Patients with either SRS > 0.53 or recurrence nomogram score > 4.23 were considered at high risk for ER, and had poor long-term outcomes.

CONCLUSION

The recurrence scoring system unique for pancreatectomy and PVR, will help clinicians in predicting recurrence efficiently and identifying patients at high risk of ER for individualized therapy.

The combination of preoperative celiac axis stenting and neoadjuvant chemotherapy in an elderly patient with pancreatic cancer: a case report

BACKGROUND

Celiac axis stenosis (CAS) is frequently observed in patients undergoing pancreaticoduodenectomy (PD). This poses challenges because of the potential disruption of the hepatic arterial blood flow.

CASE PRESENTATION

We present the case of an 81-year-old woman diagnosed with pancreatic head cancer and severe CAS caused by calcification. The patient received neoadjuvant chemotherapy (NAC) and underwent preoperative endovascular stenting of the celiac axis to restore blood flow. After two cycles of NAC, subtotal stomach-preserving PD was performed. An intraoperative assessment of the hepatic arterial blood flow determined that it was well maintained. PD was performed using the standard technique; specialized techniques were not necessary. Importantly, no ischemic complications were encountered.

CONCLUSION

This case report describes the successful combination of preoperative celiac axis stenting, NAC, and surgical intervention for the management of CAS in an elderly patient with pancreatic cancer. This approach offers a potential solution for maintaining the hepatic arterial blood flow in the presence of CAS without vascular reconstruction, particularly in elderly individuals.

Developments in pancreatic cancer surgery

Pancreatic cancer surgery, with one of the worst prognoses in oncology, is a challenge to the surgical community. Centralization of pancreatic surgery has led to the foundation of high-volume centers, thereby greatly facilitating the successful performance of more radical approaches. This review spotlights on recent advances in surgical approaches to pancreatic cancer and the risks and benefits of vascular reconstruction to improve resectability. Surgery being the only modality to achieve cure, multivisceral and vascular resections are being incorporated to improve dismal operability rates of < 10%. Great leaps have been made in neoadjuvant and adjuvant treatment, as targeted and specific chemotherapeutic agents are being continually added. The concept of borderline and locally advanced pancreatic tumors and the use of neoadjuvant chemorad has extended the indications of oncological resection in such tumors. Venous resections are being routinely performed so as to facilitate en bloc removal of tumors, while arterial resections, owing to the increased morbidity and mortality, are offered to highly selective cases. New techniques like the triangle operation and periarterial divestment have opened new viable surgical options. Although laparoscopic approach is time consuming, it offers reduced operative blood loss and a shortened hospital stay at specialized centers. Robotic surgery may produce better results in patients needing vascular resection and reconstruction, but the expenses involved and limited availability are major deterrents. Advanced techniques of surgical resection and vessel reconstruction provide a repository for curative-intent surgery in borderline resectable and locally advanced pancreatic cancer.

Modern Treatment Strategies for Borderline Resectable Pancreatic Cancer

Pancreatic ductal adenocarcinoma (PDAC) continues to be a daunting clinical challenge. In 2023, it is estimated that 64,000 people will be newly diagnosed with PDAC and 51,000 people will die from PDAC. By 2030, PDAC is predicted to be the second leading cause of cancer-related death, second only to lung cancer (Siegel et al in, CA Cancer J Clin 73(1):17-48, 2023). It is a disease characterized by its late presentation, rapid demise thereafter, and, until recently, relatively ineffective systemic therapies. Despite this grim prognosis, appreciable progress has been made in the identification of patients with localized disease, who may be candidates for potentially curative resections, and in the understanding of the technical nuances and efficacy of aggressive surgical procedures. Currently, the overall 5-year survival rate is 15-25% for patients who undergo resection and receive adjuvant chemotherapy with or without chemoradiation therapy.

Changing Practice Patterns and Improving Survival for Patients with Pancreatic Ductal Adenocarcinoma

Over the last two decades, there have been many reported advances in the clinical management of pancreatic ductal adenocarcinoma (PDAC). We sought to evaluate changes in survival for patients diagnosed with PDAC between 2004 and 2017. The National Cancer Database was queried for patients diagnosed with PDAC between 2004 and 2017. There were 55,401 patients who underwent surgery and 109,477 patients who underwent non-surgical treatment for PDAC between 2004 and 2017. Patients were categorized into four groups by year of diagnosis. Median survival improved from 15.5 months to 25.3 months for patients treated with surgery between the years 2016 and 2017 compared with between 2004 and 2007 (p < 0.001). Median survival improved from 7.2 months to 10.1 months for patients treated without surgery during the same years (p < 0.001). On multivariable analysis, the hazard ratio for death was estimated to multiply by 0.975 per year for patients treated with surgery and 0.959 per year for patients treated without surgery (p < 0.001). This increase in survival in the setting of evolving care validates continued efforts aimed at improving survival for patients with this devastating disease.

Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years.

DATA SOURCES

A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression.

RESULTS

A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I² = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I² = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I²= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I² = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I² = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class.

CONCLUSIONS

Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.

Outcomes of pancreatectomy with portomesenteric venous resection and reconstruction for locally advanced pancreatic neuroendocrine neoplasms

BACKGROUND

While pancreatectomy with portomesenteric venous resection and reconstruction is commonly performed for locally advanced pancreatic adenocarcinoma, little is known regarding outcomes for pancreatic neuroendocrine neoplasms (panNENs).

METHODS

Patients who underwent non-parenchyma-sparing pancreatectomy for panNENs at Mayo Clinic from 2000 to 2020 were retrospectively reviewed. Propensity score matching was performed and patient characteristics and outcomes compared.

RESULTS

Of 867 eligible patients, 41 (4.7%) required vascular resection, including 38 patients who underwent portomesenteric venous resection only. Of these, 23 underwent pancreaticoduodenectomy or total pancreatectomy and 15 distal pancreatectomy. Patients who required portomesenteric venous resection had larger tumors, higher tumor grade, and higher disease stage. After propensity score matching to patients undergoing standard resection, the portomesenteric venous resection group had longer operative times, greater blood loss, and higher transfusion rates. While portomesenteric venous thrombosis was more common after venous resection, major complication rates and perioperative mortality were similar between the two groups, as were 5-year overall and progression-free survival.

CONCLUSION

For patients with locally advanced panNENs, pancreatectomy with portomesenteric venous resection and reconstruction can be performed in selected patients at high-volume centers with acceptable perioperative morbidity and short- and long-term survival.

Robotic versus open pancreaticoduodenectomy with vascular resection for pancreatic ductal adenocarcinoma: surgical and oncological outcomes from pilot experience

PURPOSE

Venous resection and reconstruction (VR) is a feasible surgical technique to achieve optimal outcomes in selected patients with pancreatic ductal adenocarcinoma (PDAC) who undergo open pancreaticoduodenectomy (OPD). However, data regarding patient outcomes in patients who undergo VR in robotic-assisted pancreaticoduodenectomy (RPD) are scarce.

METHODS

All patients with a diagnosis of PDAC who underwent upfront open or robotic pancreatoduodenectomy with VR in a high-volume institution for pancreatic surgery between 2011 and 2019 were retrospectively reviewed. Perioperative and long-term outcomes were compared between the RPD and OPD cohorts.

RESULTS

A total of 84 patients were included in the final analysis, 14 patients underwent RPD with VR and 70 who had OPD with VR. Reconstructed venous patency, postoperative 30-day morbidity, and 90-day mortality were comparable; however, lymph node resection rates were lower in the RPC cohort (p = 0.029). No difference was identified in 3-year survival rates between the two groups (34.0% versus 25.7% respectively, p = 0.667).

CONCLUSION

RPD with VR is a feasible approach for patients with PDAC and venous invasion. Further studies are needed to assess long-term outcomes compared to the open approach.

Surgery for locally advanced pancreatic ductal adenocarcinoma-is it only about the vessels?

Pancreatic ductal adenocarcinoma (PDAC) is an oligosymptomatic disease, that is usually diagnosed in an advanced tumor stage. Traditionally, only the small subset of patients with tumors that showed no signs of vascular infiltration and distant metastases proceeded to surgery-still the only curative therapeutic modality to date. The remaining majority of patients received palliative chemotherapy or chemoradiation, usually with gemcitabine monotherapy. While gemcitabine monotherapy results in improved survival compared to best supportive care, most patients still succumb to the disease under therapy in a relatively short amount of time. Over the last years and decades, paradigms have shifted in PDAC treatment and potent multidrug chemotherapy protocols, including gemcitabine plus nab-paclitaxel and FOLFIRINOX, result in sufficient downstaging of advanced tumors in many patients. In this context, more and more patients are eligible for exploration and often resection. In this review we discuss the current state of the art in the clinical management and surgical treatment of patients with locally advanced pancreatic cancer, including classifications of locally advanced and borderline disease and surgical strategies for extended resections. An emphasis is put on arterial and venous resections and their outcome. In the end, we discuss current gaps in the literature and propose directions future research endeavors should focus on.

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.

Resection of the Portal-Superior Mesenteric Vein in Pancreatic Cancer: Pathological Assessment and Recurrence Patterns

OBJECTIVES

The portal vein (PV)-superior mesenteric vein (SMV) margin is the most affected margin in pancreatic cancer. This study investigates the association between venous resection, tumor invasion in the resected PV-SMV, recurrence patterns, and overall survival (OS).

METHODS

This multicenter cohort study included patients who underwent pancreatoduodenectomy for pancreatic cancer (2010-2017). In addition, a systematic literature search was performed.

RESULTS

In total, 531 patients were included, of which 149 (28%) underwent venous resection of whom 53% had tumor invasion in the resected PV-SMV. Patients with venous resection had a significant higher rate of R1 margins (69% vs 37%) and had more often multiple R1 margins (43% vs 16%). Patient with venous resection had a significant shorter time to locoregional recurrence and a shorter OS (15 vs 19 months). At multivariable analyses, venous resection and tumor invasion in the resected PV-SMV were not predictive for time to recurrence and OS. The literature overview showed that pathological assessment of the resected PV-SMV is not adequately standardized.

CONCLUSIONS

Only half of patients with venous resection had pathology confirmed tumor invasion in the resected PV-SMV, and both are not independently associated with time to recurrence and OS. The pathological assessment of the resected PV-SMV needs to be standardized.

The effect of preoperative chemotherapy and chemoradiotherapy on pancreatic fistula and other surgical complications after pancreatic resection: a systematic review and meta-analysis of comparative studies

BACKGROUND

Preoperative chemo- or chemoradiotherapy is recommended for borderline-resectable pancreatic cancer. The aim of this study was to determine the impact of preoperative therapy on surgical complications in patients with resected pancreatic cancer.

METHODS

This systematic review and meta-analysis included studies reporting on the rate of surgical complications after preoperative chemo- or chemoradiotherapy versus immediate surgery in pancreatic cancer patients. The primary endpoint was the rate of grade B/C POPF. Pooled odds ratios were calculated using random-effects models.

RESULTS

Forty-one comparative studies including 25,389 patients were included. Vascular resections were more often performed after preoperative therapy (29.4% vs. 15.7%, p < 0.001). Preoperative therapy was associated with a lower rate of grade B/C POPF as compared to immediate surgery (pooled OR 0.47, 95%CI 0.38-0.58). This reduction was mostly obtained by preoperative chemoradiotherapy (OR 0.46, 95%CI 0.29-0.73), but not by preoperative chemotherapy alone (OR 0.83, 95%CI 0.59-1.16). No difference was demonstrated for major morbidity, mortality, postpancreatectomy haemorrhage, delayed gastric emptying and overall morbidity.

CONCLUSION

Preoperative chemo- and chemoradiotherapy in patients with pancreatic cancer appears to be safe with respect to POPF and other surgical complications as compared to immediate surgery. The reduced rate of POPF appears to be attributable to preoperative chemoradiation.

Root-Cause Analysis of Mortality Following Pancreatic Resection (CARE Study): A Multicenter Cohort Study

OBJECTIVES

Analyze a multicenter cohort of deceased patients after pancreatectomy in high-volume centers in France by performing a root-cause analysis (RCA) to define the avoidable mortality rate.

BACKGROUND

Despite undeniable progress in pancreatic surgery for over a century, postoperative outcome remain particularly worse and could be further improved.

METHODS

All patients undergoing pancreatectomy between January 2015 and December 2018 and died post-operatively within 90 days after were included. RCA was performed in two stages: the first being the exhaustive collection of data concerning each patient from preoperative to death and the second being blind analysis of files by an independent expert committee. A typical root cause of death was defined with the identification of avoidable death.

RESULTS

Among the 3195 patients operated on in nine participating centers, 140 (4.4%) died within 90 days after surgery. After the exclusion of 39 patients, 101 patients were analyzed. The cause of death was identified in 90% of cases. After RCA, mortality was preventable in 30% of cases, mostly consequently to a preoperative assessment (disease evaluation) or a deficient postoperative management (notably pancreatic fistula and hemorrhage). An inappropriate intraoperative decision was incriminated in 10% of cases. The comparative analysis showed that young age and arterial resection, especially unplanned, were often associated with avoidable mortality.

CONCLUSION

One third of postoperative mortality after pancreatectomy seems to be avoidable, even if the surgery is performed in high volume centers. These data suggest that improving postoperative pancreatectomy outcome requires a multidisciplinary, rigorous and personalized management.

Risk factors for early morbidity and mortality following pancreatoduodenectomy with concomitant vascular reconstruction

Background

Locally advanced pancreatic tumors may require vascular reconstruction for complete resection. However, pancreatoduodenectomy with vascular resection (PDVR) remains a subject of debate due to increased complications.

Methods

Patients were identified using the ACS NSQIP Participant User Data Files from 2014 to 2019.

Results

The 30-day mortality rate was 2.7%; major complications occurred in 32.2%. There is an increasing trend of PDVR in patients requiring pancreatectomy. There were no significant differences in mortality between PDVR with vein, artery, or venous and arterial resections. High BMI and postoperative biliary stent were risk factors for early complications. High BMI and COPD increased risk of early mortality. Chemotherapy and chemoradiotherapy were negative predictors for early morbidities and mortality, respectively.

Conclusion

This study identifies the predictors of early morbidity and mortality in PDVR. The results of this study may assist decision making in perioperative management to optimize overall survival and guide additional research.

•

Pancreaticoduodenectomy with concomitant vascular reconstruction (PDVR) for carcinoma is increasing in frequency for locally advanced pancreatic neoplasms.

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Early morbidity and mortality rates are acceptable.

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Patients with elevated body mass index (BMI) and underlying COPD have a higher mortality.

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Elevated BMI and preoperative biliary stenting are associated with a higher incidence of early complications.

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Neoadjuvant chemotherapy and chemoradiation may also improve resectability and post-operative outcomes.

The Current Treatment Paradigm for Pancreatic Ductal Adenocarcinoma and Barriers to Therapeutic Efficacy

Pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis, with a median survival time of 10-12 months. Clinically, these poor outcomes are attributed to several factors, including late stage at the time of diagnosis impeding resectability, as well as multi-drug resistance. Despite the high prevalence of drug-resistant phenotypes, nearly all patients are offered chemotherapy leading to modest improvements in postoperative survival. However, chemotherapy is all too often associated with toxicity, and many patients elect for palliative care. In cases of inoperable disease, cytotoxic therapies are less efficacious but still carry the same risk of serious adverse effects, and clinical outcomes remain particularly poor. Here we discuss the current state of pancreatic cancer therapy, both surgical and medical, and emerging factors limiting the efficacy of both. Combined, this review highlights an unmet clinical need to improve our understanding of the mechanisms underlying the poor therapeutic responses seen in patients with PDAC, in hopes of increasing drug efficacy, extending patient survival, and improving quality of life.

Portal vein resection during pancreaticoduodenectomy for pancreatic neuroendocrine tumors. An international multicenter comparative study

BACKGROUND

The role of portal vein resection for pancreatic cancer is well established but not for pancreatic neuroendocrine neoplasms. Evidence from studies providing information on long-term outcome after venous resection in pancreatic neuroendocrine neoplasms patients is lacking.

METHODS

This is a multicenter retrospective cohort study comparing pancreaticoduodenectomy with vein resection with standard pancreaticoduodenectomy in patients with pancreatic neuroendocrine neoplasms. The primary endpoint was to evaluate the long-term survival in both groups. Progression-free survival and overall survival were calculated using the method of Kaplan and Meier, but a propensity score-matched cohort analysis was subsequently performed to remove selection bias and improve homogeneity. The secondary outcome was Clavien-Dindo ≥3.

RESULTS

Sixty-one (11%) patients underwent pancreaticoduodenectomy with vein resection and 480 patients pancreaticoduodenectomy. Five (1%) perioperative deaths were recorded in the pancreaticoduodenectomy group, and postoperative clinically relevant morbidity rates were similar in the 2 groups (pancreaticoduodenectomy with vein resection 48% vs pancreaticoduodenectomy 33%). In the initial survival analysis, pancreaticoduodenectomy with vein resection was associated with worse 3-year progression-free survival (48% pancreaticoduodenectomy with vein resection vs 83% pancreaticoduodenectomy; P < .01) and 5-year overall survival (67% pancreaticoduodenectomy with vein resection vs 91% pancreaticoduodenectomy). After propensity score matching, no significant difference was found in both 3-year progression-free survival (49% pancreaticoduodenectomy with vein resection vs 59% pancreaticoduodenectomy; P = .14) and 5-year overall survival (71% pancreaticoduodenectomy with vein resection vs 69% pancreaticoduodenectomy; P = .98).

CONCLUSION

This study demonstrates no significant difference in perioperative risk with a similar overall survival between pancreaticoduodenectomy and pancreaticoduodenectomy with vein resection. Tumor involvement of the superior mesenteric/portal vein axis should not preclude surgical resection in patients with locally advanced pancreatic neuroendocrine neoplasms.

Evaluation of Outcomes Following Surgery for Locally Advanced Pancreatic Neuroendocrine Tumors

IMPORTANCE

Although outcome of surgical resection of liver metastases from pancreatic neuroendocrine tumors (PNETs) has been extensively studied, little is known about surgery for locally advanced PNETs; it was listed recently by the European neuroendocrine tumor society as a major unmet need.

OBJECTIVE

To evaluate the outcome of patients who underwent surgery for locally aggressive PNETs.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective single-center case series reviewed consecutive patients who underwent resection of T3/T4 PNETs at a single academic institution. Data collection occurred from 2003 to 2018. Data analysis was performed in August 2019.

MAIN OUTCOMES AND MEASURES

Disease-free survival (primary outcome) and overall mortality (secondary outcome) were assessed with Kaplan-Meier analysis. Recurrence risk (secondary outcome, defined as identification of tumor recurrence on imaging) was assessed with Cox proportional hazard models adjusting for covariates.

RESULTS

In this case series, 99 patients with locally advanced nondistant metastatic PNET (56 men [57%]) with a mean (SEM) age of 57.0 (1.4) years and a mean (SEM) follow-up of 5.3 (0.1) years underwent surgically aggressive resections. Of those, 4 patients (4%) underwent preoperative neoadjuvant treatment (including peptide receptor radionuclide therapy and chemotherapy); 18 patients (18%) underwent pancreaticoduodenectomy, 68 patients (69%) had distal or subtotal pancreatic resection, 10 patients (10%) had total resection, and 3 patients (3%) had other pancreatic procedures. Additional organ resection was required in 86 patients (87%): spleen (71 patients [71%]), major blood vessel (17 patients [17%]), bowel (2 patients [2%]), stomach (4 patients [4%]), and kidney (2 patients [2%]). Five-year disease-free survival was 61% (61 patients) and 5-year overall survival was 91% (91 patients). Of those living, 75 patients (76%) had an Eastern Cooperative Oncology Group score of less than or equal to 1 at last followup. Lymph node involvement (HR, 7.66; 95% CI, 2.78-21.12; P < .001), additional organ resected (HR, 6.15; 95% CI, 1.61-23.55; P = .008), and male sex (HR, 3.77; 95% CI, 1.68-8.97; P = .003) were associated with increased risk of recurrence. Functional tumors had a lower risk of recurrence (HR, 0.23; CI, 0.06-0.89; P = .03). Required resection of blood vessels was not associated with a significant increase recurrence risk.

CONCLUSIONS AND RELEVANCE

In this case series, positive lymph node involvement and resection of organs with tumor involvement were associated with an increased recurrence risk. These subgroups may require adjuvant systemic treatment. These findings suggest that patients with locally advanced PNETs who undergo surgical resection have excellent disease-free and overall survival.

Prognostic impact of simultaneous venous resections during surgery for resectable pancreatic cancer

BACKGROUND

The aim of this study was to evaluate the prognostic impact of simultaneous venous resection during pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC) that was preoperatively staged resectable according to NCCN guidelines.

METHODS

A retrospective analysis of 153 patients who underwent PD for PDAC was performed. Patients were divided into standard PD and PD with simultaneous vein resection (PDVR). Groups were compared to each other in terms of postoperative morbidity and mortality, disease free (DFS) and overall survival (OS).

RESULTS

114 patients received PD while 39 patients received PDVR. No differences in terms of postoperative morbidity and mortality between both groups were detected. Patients in the VR group presented with a significantly shorter OS in the median (13 vs. 21 months, P = 0.011). In subgroup analysis, resection status did not influence OS in the PDVR group (R0 13 vs. R1 12 months, P = 0.471) but in the PD group (R0 23 vs. R1 14 months, P = 0.043). PDVR was a risk factor of OS in univariate but not multivariable analysis.

CONCLUSION

PDVR for PDAC preoperatively staged resectable resulted in significantly shorter OS regardless of resection status. Patients who require PDVR should be considered for adjuvant chemotherapy in addition to other oncological indications.

Cavernous transformation of the portal vein in pancreatic cancer surgery-venous bypass graft first

BACKGROUND

In recent years, several techniques have been introduced to allow safe oncologic resections of cancers of the pancreatic head. While resections of the mesenterico-portal axis became now a part of the routine treatment, patients with a cavernous transformation of the portal vein still pose a surgical challenge and are regularly deemed unresectable.

OBJECTIVE

Here, we describe a technique of initial venous bypass graft placement between the superior mesenteric vein or its tributaries and the portal vein before the resection of the pancreatic head. This approach avoids uncontrollable bleeding as well as venous congestion of the intestine with a continuous hepatic perfusion and facilitates oncologic resection of pancreatic head cancers. This technique, in combination with previously published resection strategies, enables tumor resection in locally advanced pancreatic head cancers.

CONCLUSIONS

Venous bypass graft first operations facilitate and enable the resection of the pancreatic head cancers in patients with a cavernous transformation of the portal vein thus rendering these patients resectable.

Fifty Years of Surgery for Pancreatic Cancer

The surgical treatment of pancreatic cancer (PDAC) has seen sweeping changes during the past 5 decades. Up to the middle of the 20th century resection rates were below 5%, but the numbers of curative resections for PDAC are now continuously increasing due to improved neoadjuvant treatment concepts as well as progress in surgical techniques and perioperative management. During the same period, mortality rates after pancreatic surgery have decreased considerably and are now less than 5%. One of the most important cornerstones of reduced mortality has been the concentration of PDAC surgery in specialized centers. In addition, the management of postoperative complications has improved greatly as a result of optimized interdisciplinary teamwork. Adjuvant chemotherapy has become the reference treatment in resected PDAC, achieving significantly prolonged survival. Moreover, the concept of borderline resectable PDAC has emerged to characterize tumors with increased risk for tumor-positive resection margins or worse outcome. The best treatment strategy for borderline resectable PDAC is currently under debate, whereas neoadjuvant therapy has become established as a beneficial treatment option for patients with locally advanced PDAC, enabling conversion surgery in up to 60% of cases. This review article summarizes the principal changes in PDAC surgery during the past 50 years.

Robotic-assisted pancreaticoduodenectomy with vascular resection. Description of the surgical technique and analysis of early outcomes

BACKGROUND

Despite the potential benefits, the adoption of the minimally invasive surgery for the treatment of borderline resectable pancreatic cancer is still in the initial phase. We investigated the safety and feasibility of the robotic pancreaticoduodenectomy with venous resection/reconstruction (RPD SMV/PV).

METHODS

Since March 2013 to October 2019, a total of 73 RPD and 10 RPD SMV/PV were performed. The two groups were case-matched according to the preoperative characteristics.

RESULTS

Mean operative times and estimated blood loss were less in the RPD group in comparison to that in the RPD with SMV-PV group (525 vs 642 min, p = 0.003 and 290 vs 620 ml, p = 0.002, respectively). The mean length of hospital stay was similar in the RPD group in comparison to that in the RPD with SMV-PV group (10 days vs 13 days, p = 0.313). The two groups had similar overall postoperative morbidity rate (57.5% vs 60%, p = 0.686), although the severe complication rate was lower in the RPD group (11% vs 40%, p = 0.004).

CONCLUSIONS

RPD with SMV-PV is associated with increased operative time, estimated blood loss, higher major complication rate compared with RPD.

The Impact on Survival and Morbidity of Portal-Mesenteric Resection During Pancreaticoduodenectomy for Pancreatic Head Adenocarcinoma: A Systematic Review and Meta-Analysis of Comparative Studies

Background: The literature is conflicting regarding oncological outcome and morbidity associated to portal–mesenteric resection during pancreaticoduodenectomy (PD) in patients with pancreatic head adenocarcinoma (PHAC). Methods: A meta-analysis of studies comparing PD plus venous resection (PD+VR) and standard PD exclusively in patients with adenocarcinoma of the pancreatic head was conducted. Results: Twenty-three cohort studies were identified, which included 6037 patients, of which 28.6% underwent PD+VR and 71.4% underwent standard PD. Patients who received PD+VR had lower 1-year overall survival (OS) (odds radio OR 0.79, 95% CI 0.67–0.92, p = 0.003), 3-year OS (OR 0.72, 95% CI 0.59–0.87, p = 0.0006), and 5-year OS (OR 0.57, 95% CI 0.39–0.83, p = 0.003). Patients in the PD+VR group were more likely to have a larger tumor size (MD 3.87, 95% CI 1.75 to 5.99, p = 0.0003), positive lymph nodes (OR 1.24, 95% CI 1.06–1.45, p = 0.007), and R1 resection (OR 1.74, 95% CI 1.37–2.20, p < 0.0001). Thirty-day mortality was higher in the PD+VR group (OR 1.93, 95% CI 1.28–2.91, p = 0.002), while no differences between groups were observed in rates of total complications (OR 1.07, 95% CI, 0.81–1.41, p = 0.65). Conclusions: Although PD+VR has significantly increased the resection rate in patients with PHAC, it has inferior survival outcomes and higher 30-day mortality when compared with standard PD, whereas postoperative morbidity rates are similar. Further research is needed to evaluate the role of PD+VR in the context of multimodality treatment of PHAC.

Outcomes of Vascular Resection in Pancreaticoduodenectomy: Single-surgeon Experience

Extension of pancreatic adenocarcinoma into adjacent vasculature often necessitates resection of the portal vein (PV) and/or superior mesenteric vein (SMV) during pancreaticoduodenectomy (PD). The vein is reconstructed primarily by end-to-end anastomosis of vein remnants or venoplasty or by use of autologous or synthetic vein grafts. The objective of this study was to review outcomes in patients undergoing PD for pancreatic adenocarcinoma, specifically comparing the short- and long-term outcomes between the patients undergoing vascular resection and those undergoing standard PD. All patients undergoing PD for pancreatic adenocarcinoma by a single surgeon between 2007 and 2012 were reviewed. Of the 61 patients identified, 18 patients underwent vascular resection of the PV (four patients), SMV (10 patients), or both (four patients). The remaining 43 patients had standard PD. Demographic, perioperative, pathological, and long-term outcomes data were collected and both vascular and standard groups were compared. Both groups had similar demographics. The vascular group had significantly longer operative times (529 vs 406 minutes; P < 0.01) with a trend to greater estimated blood loss (0.64 vs 0.53 L; P = 0.06). Pathological analysis showed no difference between the two groups with regard to lymph node status/ratio and rate of R0 resection (94 vs 91%; P = 0.57); however, the size of the tumor was significantly greater in the vascular group (4.2 vs 3 cm; P < 0.01). Short-term outcomes were similar in the vascular group and standard group, respectively, with no difference in pancreatic fistula rate (6 vs 7%; P = 1.0), transfusion rate (44 vs 35%; P = 0.57), and median length of stay (8 vs 7 days; P = 0.10), and there was no 30-day mortality in either group. Based on Kaplan-Meier methods, the median recurrence-free survival was 18 versus 23 months ( P = 0.37) in the vascular and standard groups, respectively, and the overall survival was almost identical in both groups, each with a median of 31 months ( P = 0.91). In our experience, mesenteric and PV resection during PD was performed safely and without compromise of short- or longer-term outcomes. It can be performed safely and patients have no significant difference in perioperative outcomes or overall survival.

Autologous peritoneal graft for venous vascular reconstruction after tumor resection in abdominal surgery: a systematic review

Radical surgical resection (R0) is the only option to cure patients with borderline resectable or multivisceral intraabdominal malignancies involving major vessels. Autologous peritoneal flap has been described as a safe and versatile option for vascular reconstruction, but still limited experience exists regarding its use. An extensive literature review was performed to analyze results of vascular reconstruction with an autologous peritoneal graft. Fifteen reports were found for a total of 94 patients. No cases of arterial vascular reconstruction were found. Two different types of peritoneal patch have been described, backed (APFG, 30 patients) or not backed (ANFP, 64 patients) by posterior rectus sheath. A patch type of reconstruction was adopted in 70 patients (74.5%), while a tubular reconstruction in 24 (25.5%). Postoperative mortality was 5.3% (5 cases). Graft outcomes with very heterogeneous follow-ups (7 days-47 months) were available only in 85 patients (90.4%). Among them, a graft patency was documented in 80 patients (94.1%), while a stenotic graft was reported in 5 patients (5.9%). No differences in graft outcomes were observed between the patch and tubular groups (p = 0.103), nor between the ANFP and APFG groups (p = 0.625). In reported experiences, autologous peritoneal graft seems to represent a safe and versatile option for functional restoration of venous vascular anatomy after resection, especially in operations with high risk of contamination, trauma, liver transplantation and unplanned vascular resection. Unfortunately, the data available in the literature do not make it possible to draw any evidence-based conclusions on these considerations.

Arterial, but Not Venous, Reconstruction Increases 30-Day Morbidity and Mortality in Pancreaticoduodenectomy

BACKGROUND

Vascular reconstruction during pancreaticoduodenectomy is increasingly utilized to improve pancreatic cancer resectability. However, few multi-institutional studies have evaluated the morbidity and mortality of arterial and venous reconstruction during this procedure.

METHODS

A retrospective analysis was performed utilizing the targeted pancreas module of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) for pancreaticoduodenectomy from 2014 to 2015. Demographics, comorbidities, and 30-day outcomes for patients who underwent venous or arterial reconstruction and both were compared to no reconstruction.

RESULTS

A total of 3002 patients were included in our study: 384 with venous reconstruction, 52 with arterial, 81 with both, and 2566 without. Compared to patients without reconstruction, those who underwent venous reconstruction had more congestive heart failure (1.8% vs 0.2%, P < 0.01), those with arterial reconstruction had higher rates of pulmonary disease (11.5% vs. 4.5%, P = 0.02), and neoadjuvant chemotherapy was more common in both venous (34% vs 12%, P < 0.01) and arterial reconstruction (21% vs 12%, P = 0.04). In multivariable analysis, there was no increase in morbidity or mortality following venous reconstruction. However, arterial reconstruction was associated with increased 30-day mortality with an odds ratio (OR): 6.7, 95%; confidence interval (CI): 1.8-25. Morbidity was increased as represented with return to the operating room (OR: 4.5, 95%; CI: 1.5-15), pancreatic fistula (OR: 4.4, 95%; CI: 1.7-11), and reintubation (OR: 3.9, 95%; CI: 1.1-14).

CONCLUSIONS

Venous reconstruction during pancreaticoduodenectomy does not increase perioperative morbidity or mortality and should be considered for patients previously considered to be unresectable or those where R0 resection would otherwise not be possible due to venous involvement. Careful consideration should be made prior to arterial reconstruction given the significant increase in perioperative complications and death within 30 days.

Vascular Resection for Pancreatic Cancer: 2019 French Recommendations Based on a Literature Review From 2008 to 6-2019

Introduction: Vascular resection remains a subject of debate in the management of Pancreatic Ductal Adenocarcinoma (PDAC). These French recommendations were drafted on behalf of the French National Institute of Cancer (INCA-2019).

Material and Methods: A systematic literature search, with PubMed, Medline® (OvidSP), EMBASE, the Cochrane Library, was performed for abstracts published in English from January 2008 to June 2019, and identified systematic reviews/metaanalyses, retrospective analyses and case series dedicated to vascular resections in the setting of PDAC. All selected articles were graded for level of evidence and strength of recommendation was given according to the GRADE system.

Results: Neoadjuvant treatment should be performed rather than direct surgery in borderline and locally advanced non-metastatic PDAC with venous and/or arterial infiltration (T4 stage). Patients who respond or those with stable disease and good performance status should undergo surgical exploration to assess resectability because cross-sectional imaging often fails to identify the extent of the remaining viable tumor. Combining vascular resection with pancreatectomy in these cases increases the feasibility of curative resection which is still the only option to improve long-term survival. Venous resection (VR) is recommended if resection is possible in the presence of limited lateral or circumferential involvement but without venous occlusion and in the absence of arterial contact with the celiac axis (CA; cephalic tumors) or the superior mesenteric artery (SMA; all tumor locations) (Grade B). The patients should be in good general condition because mortality and morbidity are higher than following pancreatectomy without VR (Grade B). In case of planned VR, neoadjuvant treatment is recommended since it improves both rate of R0 resections and survival compared to upfront surgery (Grade B). Due to their complexity and specificities, arterial resection (AR; mainly the hepatic artery (HA) or the CA) must be discussed in selected patients, in multidisciplinary team meetings in tertiary referral centers, according to the tumor location and the type of arterial extension. In case of invasion of a short segment of the common HA, resection with arterial reconstruction may be proposed after neoadjuvant therapy. In case of SMA invasion, neoadjuvant therapy may be followed by laparotomy with dissection and biopsy of peri-arterial tissues. A pancreaticoduodenectomy (PD) with SMA-resection is not recommended if the frozen section examination is positive (Grade C). In case of distal PDAC with invasion of the CA, a distal pancreatectomy with CA-resection without arterial reconstruction may be proposed after neoadjuvant therapy and radiologic embolization of the CA branches (expert opinion).

Conclusion: For PDAC with vascular involvement, neoadjuvant treatment followed by pancreatectomy with venous resection or even arterial resection can be proposed as a curative option in selected patients with selected vascular involvement.

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 value of combined vein resection in pancreaticoduodenectomy for pancreatic head carcinoma: a meta-analysis

Background

Although pancreaticoduodenectomy with vein resection (PDVR) is widely performed in selected patients with indications, its benefits remain controversial. In this meta-analysis, we evaluate the safety and efficacy of PDVR in comparison to standard pancreaticoduodenectomy (PD).

Methods

We searched PubMed, Embase, and Cochrane as well as the Chinese National Knowledge Infrastructure, Weipu, and Wanfang databases for studies that evaluate the value of PVDR. The data of the patients who underwent PD or PDVR were analyzed using Review Manager and STATA software.

Results

In comparison with the PD group, the PDVR group had a lower R0 resection rate and higher rates of complications such as biliary fistula, reoperation rate, delayed gastric emptying, cardiopulmonary abnormalities, hemorrhage, in-hospital mortality, 30-day mortality. The blood loss, duration of operation, total hospital stay is higher in PDVR group.

Conclusions

Compared to standard PD, PDVR was associated with a greater risk of some specific complications and increase the mortality rate, total hospital stay time, combine with vein resection have a lower R0 resection rate. Therefore, combine with vascular resection for pancreatic cancer needs to be carefully selected by the surgeon.

Can post-hoc video review of robotic pancreaticoduodenectomy predict portal/superior mesenteric vein margin status in pancreatic adenocarcinoma?

BACKGROUND

Achieving margin negative resection is a significant determinant of outcome in pancreatic adenocarcinoma (PDA). However, because of the fibrotic nature of PDA, it can be difficult to discriminate fibrosis from active disease intra-operatively. We sought to determine if post-hoc video review of robotic pancreatico-duodenectomy (RPD) could predict the portal/superior mesenteric vein (PV/SMV) margin status on final pathology.

METHODS

Experienced pancreatic surgeons, blinded to patient and operative variables, reviewed the PV/SMV margin for available RPD videos of consecutive PDA patients from 9/2012 through 6/2017.

RESULTS

107 RPD videos were reviewed. Of 76 patients (71%) predicted to have a negative vein margin on video review, 20 patients (26%) had a pathologic positive margin. 25 of 31 patients (81%) predicted to have positive margin on video review were positive on pathology. The specificity of video prediction was 90.3% with a sensitivity of 55.6% and an accuracy of 75.7%.

CONCLUSION

Post-hoc video review prediction is unable to reliably predict a positive (R1) margin at the portal vein/SMV, suggesting that intra-operative clinical assessment may be suboptimal in determining the need for more extensive resections.

Surgical, survival, and oncological outcomes after vascular resection in robotic and open pancreaticoduodenectomy

BACKGROUND

To evaluate the surgical, oncological, and survival outcomes after pancreaticoduodenectomy (PD) with superior mesenteric vein (SMV)/portal vein (PV) resection by either robotic PD (RPD) or open PD (OPD).

METHODS

Data of patients with periampullary lesions undergoing PD were retrieved from a prospectively collected computer database. Surgical risks as well as oncological and survival outcomes were compared between patients with (vein resection group) and without SMV/PV resection (without vein resection group).

RESULTS

A total of 391 patients undergoing pancreaticoduodenectomy were enrolled, including 43 (11.0%) and 384 (89.0%) patients with and without vein resection, respectively. Eleven (25.6%) of PDs with vein resection were performed using the robotic approach. Operation time in the vein resection group was significantly longer (median of 8 vs. 7 h). Blood loss, curative resection (R0) rate, and harvested lymph node number were similar between these two groups. Surgical outcomes including postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), chyle leakage, wound infection, and hospital stay were not significantly different between the two groups. There was no survival difference between these groups, with 1- and 3-year survival rates of 92.6% and 26.5%, respectively, for vein resection group, vs. 70.3% and 37.2%, respectively, for the without vein resection group.

CONCLUSIONS

PD with vein resection is technically feasible by OPD and RPD in selected patients. Additional SMV/PV would not increase the surgical risks of PD and could achieve similar survival outcomes for pancreatic head adenocarcinoma when compared to PD without vein resection.

Pancreatic cancer – What's next?

This chapter focuses on the most recent advantages in the medical treatment of localized pancreatic cancer.

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.

The importance of assessing the SMA margin in patients undergoing pancreaticoduodenectomy

Aim: The purpose of this study is to examine the true incidence of superior mesenteric artery (SMA) positivity in patients who have superior mesenteric vein (SMV) positivity while undergoing pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PDAC). Methods: All patients who underwent PD for PDAC between January 2005 and December 2011 were retrospectively identified from our database. Patients deemed resectable by NCCN guidelines, protocol CT scans, and endoscopic ultrasound were included. The PD specimen was inked using five colors to specifically identify and study the SMV and SMA margins. We also analyzed and compared R1-sub groups (R1A group- SMA and SMV positive; R1B group - SMV positive, SMA negative). Results: 98 patients underwent PD for resectable pancreatic adenocarcinoma. 75 patients (76.5%) were found to have negative surgical margin on final pathology (R0 group) while 23 patients (23.4%) had positive SMV margins (R1 group). In the R1 group, 11 patients (47.8%) were found to have positive SMA margin (R1A group) and 12 patients were SMV positive and SMA negative (R1B group). No statistically significant survival difference was noted between R0 and R1 or between R1-A and R1-B. Conclusion: This study demonstrates that with careful inking of the SMA and SMV margins, there is a high rate of concurrent SMA positivity in those patients that are SMV positive. There was no impact on survival. Accurate margin assessment is critical by careful examination and inking of the SMA and SMV margin.

Pancreatoduodenectomy without Vascular Resection in Patients with Primary Resectable Adenocarcinoma and Unilateral Venous Contact: A Matched Case Study

PURPOSE

To investigate the oncological outcome and survival of patients following a conservative approach on the portal-mesenteric axis, in an intraoperative ultrasound-selected group of pancreatoduodenectomy (PD), performed on patients with primary resectable with vascular contact (prVC) pancreatic ductal adenocarcinoma (PDAC).

METHODS

A consecutive series of patients who underwent PD for PDAC at our tertiary care center, between 2008 and 2017, were reviewed. A total of 156 PDs and 88 total pancreatectomies were performed during the study period, including 35 vascular resections. We identified a group of 40 (25.6%) patients with prVC-PDAC in whom after checking the feasibility with intraoperative ultrasound, we were able to perform PD by separation of the tumor from the portomesenteric axis avoiding vascular resection, without residual macroscopic disease (no vascular resection, nvrPD), and compared this group, using case-matched methodology, with the standard PD (sPD) group of primary resectable without vascular contact- (prwVC-) PDAC.

RESULTS

The median follow-up was 28.5 ± 23.2 months in the sPD group and 23.8 ± 20.8 months in the nvrPD group (p = 0.35). Isolated local recurrence rate was 2/40 (5%) in both groups. Additionally, there were no statistical differences in the systemic progression of the disease (42.5% sPD vs. 45% nvrPD, p = 0.82) or local plus synchronous systemic disease rates (2.5% sPD vs. 7.5% nvrPD, p = 0.30). The median survival was 22 months for the sPD group and 23 months for the nvrPD group, p = 0.86. The overall survival was similar in the two groups (1 y: 76.3% sPD vs. 70.0% nvrPD; 3 y: 35.6% vs. 31.6%; and 5 y: 28.5% vs. 25.3%; p = 0.80). Conclusions. PD without vascular resection can be considered safe and oncologically acceptable in selected patients with preoperative diagnosis of prVC-PDAC. The poor prognosis of PDAC is related to the aggressive biology and systemic spread of the tumor, rather than the local control of the disease.

Routine portal vein resection for pancreatic adenocarcinoma shows no benefit in overall survival

BACKGROUND

Extended pancreatic resections including resections of the portal (PV) may nowadays be performed safely. Limitations in distinguishing tumor involvement from inflammatory adhesions however lead to portal vein resections (PVR) without evidence of tumor infiltration in the final histopathological examination. The aim of this study was to analyze the impact of these "false negative" resections on operative outcome and long-term survival.

METHODS

40 patients who underwent pancreatic resection with PVR for pancreatic adenocarcinoma (PA) without tumor infiltration of the PV (PVR-group) were identified. In a 1:3 match these patients were compared to 120 patients after standard pancreatic resection without PVR (SPR-group) with regard to operative outcome and overall survival.

RESULTS

Survival analysis revealed that median survival was significantly shorter in the PVR group (311 days) as compared to the SPR group (558 days), (p = 0.0011, hazard ratio 1.98, 95% CI: 1.31-2.98). Also postoperative complications ≥ Clavien III occurred significantly more often in the PVR group (37.5% vs. 20.8%).

CONCLUSIONS

Radical resection affords the best chance for long-term survival in patients with PA. Based on the results of this study a routine resection of the PV as recently proposed may however not be recommended.

Pancreaticoduodenectomy with venous resection and reconstruction: current surgical techniques and associated postoperative imaging findings

PURPOSE

Introduction of effective neoadjuvant therapy for pancreas cancer has resulted in complex and aggressive operations involving vasculature resection. This results in complicated postoperative CT appearance of vasculature, which in addition to high rate of recurrence makes interpretation of imaging difficult. The aim of this study was to identify patterns of postoperative appearance of portal vein-superior mesenteric vein complex (PV-SMV).

METHODS

A retrospective study was conducted on patients undergoing pancreaticoduodenectomy with PV-SMV resection and reconstruction (PVR) between 2004 and 2014. Clinicopathological data were collected from a prospectively maintained database. Postoperative CT scans were reviewed to identify patterns of venous and perivenous features.

RESULTS

The mean age, of 70 patients included in the study, was 63.0 ± 12.2 years and 37 (52.9%) were males. The median time between surgery and postoperative scan was 10 days (IQR 7-25). Tangential resection with PVR via primary closure or use of a patch was performed in 37 (52.9%) patients while the rest underwent segmental resection with PVR via end-to-end anastomosis or use of a graft. Postoperative patterns of PV-SMV included concentric narrowing (N = 40, 57.1%), eccentric narrowing (N = 19, 27.1%) or partial venous thrombosis (N = 7, 10.0%). Perivenous features included perivenous fluid collection and induration (N = 57, 81.4%) and mass-like soft tissue thickening (N = 13, 18.6%). Long-term follow-up was available on 44 (62.9%) patients of which 28 (63.6%) demonstrated no recurrence of disease.

CONCLUSION

This is a novel study that identifies and categorizes postoperative features of PV-SMV after PVR. These features overlap with those of disease recurrence and their better understanding can results in an accurate interpretation of postoperative imaging.

The extent of vascular resection is associated with perioperative outcome in patients undergoing pancreaticoduodenectomy

BACKGROUND

Few studies have examined the relation between extent of vascular resection and morbidity following pancreaticoduodenectomy (PD) with vein resection (PDVR).

METHODS

Patients undergoing PD for malignancy were identified using the American College of Surgeons National Surgical Quality Improvement Project from 2006 to 2013. Current procedural terminology codes were used to characterize PDVR.

RESULTS

9235 patients underwent PD, 977 (10.6%) had PDVR - 640 with direct and 224 with graft repair. PDVR had longer operative times (456 ± 136 vs 374 ± 128 min, p < 0.05) and higher intraoperative transfusions (1.8 ± 3.4 vs 4.3 ± 4.9 units, p < 0.05) than PD alone. On adjusted multivariable regression, PDVR with either direct or graft repairs was associated with higher rates of overall morbidity (OR [odds ratio] 1.50 for direct, 1.74 for graft, p < 0.05), bleeding (OR 2.18 for direct, 3.26 for graft, p < 0.05), and DVT (OR 2.12 for direct, 2.62 for graft, p < 0.05) compared to PD alone. Graft repair was further associated with increased risk of reoperation (OR 1.59), septic shock (OR 2.77) and 30-day mortality (OR 2.72), all p < 0.05.

DISCUSSION

The risk of significant morbidity and mortality for PDVR is associated with the extent of vascular resection, with graft repairs having increased morbidity and mortality rates.

Randomized clinical trial of duct-to-mucosa versus invagination pancreaticojejunostomy after pancreatoduodenectomy

BACKGROUND

The postoperative pancreatic fistula (POPF) rate for duct-to-mucosa and invagination anastomosis after pancreatoduodenectomy is still debated. The aim of this RCT was to investigate the POPF rate for duct-to-mucosa versus invagination pancreaticojejunostomy.

METHODS

Patients were stratified by pancreatic texture and diameter of the main pancreatic duct and randomized to the duct-to-mucosa or invagination group. The primary endpoint was the rate of clinically relevant POPF (defined as grade B or C). Secondary endpoints were suture material cost for pancreaticojejunostomy, drain insertion duration and duration of postoperative hospital stay.

RESULTS

Some 120 patients undergoing pancreatoduodenectomy were included following consent. Clinically relevant POPF developed in six of 59 patients (10 per cent) in the invagination group and in 14 of 61 patients (23 per cent) in the duct-to-mucosa group (P = 0·077). Duration of drain insertion (6 versus 7 days respectively; P = 0·027) and postoperative hospital stay (19 versus 24 days; P = 0·015) were shorter in the invagination group. Subgroup analysis for 61 patients with a soft pancreas revealed a lower rate of clinically relevant POPF in the invagination group (10 per cent versus 42 per cent in the duct-to-mucosa group; P = 0·010). Among 20 patients with a clinically relevant POPF, the six patients in the invagination group had a shorter duration of drain insertion (38·5 days versus 49 days for 14 patients in the duct-to-mucosa group; P = 0·028) and postoperative hospital stay (42 versus 54·5 days respectively; P = 0·028).

CONCLUSION

This study did not demonstrate a superiority of invagination over duct-to-mucosa pancreaticojejunostomy in the risk of POPF. However, in high-risk patients with a soft pancreas, invagination may reduce the risk of clinically relevant POPF compared with duct-to-mucosa. Registration number: UMIN000005890 (http://www.umin.ac.jp).

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.

Pancreatectomy with venous resection for pT3 head adenocarcinoma: Perioperative outcomes, recurrence pattern and prognostic implications of histologically confirmed vascular infiltration

BACKGROUND

The outcomes of pancreatectomy with superior mesenteric vein (SMV) or portal vein (PV) resection have been mixed. This study investigated the morbidity and mortality profile after SMV-PV resection in comparison with standard pancreatectomy. Furthermore, we assessed whether tumors with histologically proven SMV-PV infiltration differ from other pT3 neoplasms in terms of recurrence pattern and survival.

METHODS

All patients with a pT3 head adenocarcinoma resected from 2000 to 2013 were analyzed retrospectively. In the SMV-PV resection group, information on venous wall status was obtained through pathologic reports. Standard statistical methods were used for data analysis.

RESULTS

The study population consisted of 651 patients, of whom 81 (12.4%) underwent synchronous SMV-PV resection. Venous resection was not associated with a higher rate of postoperative complications (60.5% versus 50.2%) and mortality (1.2% versus 1.1%) in comparison with standard pancreatectomy. Vascular infiltration was confirmed pathologically in 56/81 patients (69.1%). The median disease-specific survival of the entire population was 27 months (95% CI 24.6-29.3), with a 5-year survival rate of 20.5%. The median recurrence-free survival was 18 months (95% CI 15.0-20.9). On multivariate analysis, ASA score, preoperative pain, Ca 19-9 levels, tumor grade, R-status, lymph-vascular invasion, N-status, and adjuvant therapy resulted to be survival predictors. Similarly, Ca 19.9 levels, R-status, and N-status were predictors of recurrence. SMV-PV infiltration was not a significant prognostic factor.

CONCLUSION

Morbidity and mortality rates of pancreatectomy with SMV-PV resection are comparable with standard pancreatectomy. Pancreatic head adenocarcinoma with histologically confirmed SMV-PV infiltration does not segregate prognostically from other pT3 tumors.

Splenic vein reconstruction is unnecessary in pancreatoduodenectomy combined with resection of the superior mesenteric vein-portal vein confluence according to short-term outcomes

BACKGROUND

Superior mesenteric vein-portal vein confluence resection combined with pancreatoduodenectomy (SMPVrPD) is occasionally required for resection of pancreatic head tumors. It remains unclear whether such situations require splenic vein (SV) reconstruction for decompression of left-sided portal hypertension (LSPH).

METHODS

The data from 93 of 104 patients who underwent pancreatoduodenectomy (PD) for pancreatic head malignancies were reviewed. Surgical outcomes in three groups-standard PD (control group), PD combined with vascular resection and SV preservation (SVp group), and SMPVrPD with SV resection (SVr group)-were compared. The influence of division and preservation of the two natural confluences (left gastric vein-portal vein and/or inferior mesenteric vein-SV confluences) on portal hemodynamics were evaluated using three-dimensional computed tomographic portography.

RESULTS

No mortality occurred. The morbidity rates were not significantly different among the three groups (18/43, 8/21, and 7/29, respectively; p = 0.306). In the SVr group, three patients had gastric remnant venous congestion, and three had esophageal varices without hemorrhagic potential. No patients had splenomegaly, or severe or prolonged thrombocytopenia. These LSPH-associated findings were less frequently observed when the two confluences were preserved.

CONCLUSIONS

SMPVrPD without SV reconstruction can be safely conducted. Additionally, preservation of these two confluences may reduce the risk of LSPH.

Trends in indications, complications and outcomes for venous resection during pancreatoduodenectomy

Background

Pancreatoduodenectomy with superior mesenteric–portal vein resection has become a common procedure in pancreatic surgery. The aim of this study was to compare standard pancreatoduodenectomy with pancreatoduodenectomy plus venous resection at a high-volume centre, and to examine trends in management and outcome over a decade for the latter procedure.

Methods

This retrospective observational study included all patients undergoing pancreatoduodenectomy with or without venous resection at Oslo University Hospital between January 2006 and December 2015. Trends were evaluated by assessing preoperative clinical and radiological characteristics, as well as perioperative outcomes in three time intervals (early, intermediate and late).

Results

A total of 784 patients had a pancreatoduodenectomy, of whom 127 (16·2 per cent) underwent venous resection. Venous resection resulted in a longer operating time (median 422 versus 312 min; P = 0·001) and greater estimated blood loss (EBL) (median 700 versus 500 ml; P = 0·004) than standard pancreatoduodenectomy. The rate of severe complications was significantly higher for pancreatoduodenectomy with venous resection (37·0 versus 26·3 per cent; P = 0·014). The overall burden of complications, evaluated using the Comprehensive Complication Index (CCI), did not differ (median score 8·7 versus 8·7; P = 0·175). Trends in venous resection over time showed a significant reduction in EBL (median 1050 versus 375 ml; P = 0·001) and duration of hospital stay (median 14 versus 9 days; P = 0·011) between the early and late periods. However, despite an improvement in the intermediate period, severe complication rates returned to baseline in the late period (18 of 43 versus 9 of 42 versus 20 of 42 patients in early, intermediate and late periods respectively; P = 0·032), as did CCI scores (median 20·9 versus 0 versus 20·9; P = 0·041).

Conclusion

Despite an initial improvement in severe complications for venous resection during pancreatoduodenectomy, this was not maintained over time. Every fourth patient with venous resection needed relaparotomy, most frequently for bleeding.

Venous occlusion test applied to the tributaries of the superior mesenteric veins of the pancreas head infiltrated by tumor

A 64-year-old white woman presented with cholestatic jaundice, weight loss and a solid lesion in the pancreas head. At multislice computed tomography, a superior mesenteric vein (SMV) and one of it tributaries showed signs of tumor infiltration. At surgery, a venous occlusion test applied to the infiltrated tributary of the SMV showed immediate venous congestion in two-thirds of the distal small intestine. No reconstruction attempt was made due to the small size of the vessel. A biliodigestive anastomosis and lymph node biopsy was performed. The herein assessed case report suggests that the ileal tributary occlusion test applied to patients presenting pancreatic adenocarcinoma, with invasion of the tributaries of the SMV, may be effective in contraindicating resection procedures.

A Multidisciplinary Approach to Pancreas Cancer in 2016: A Review

In this article, we review our multidisciplinary approach for patients with pancreatic cancer. Specifically, we review the epidemiology, diagnosis and staging, biliary drainage techniques, selection of patients for surgery, chemotherapy, radiation therapy, and discuss other palliative interventions. The areas of active research investigation and where our knowledge is limited are emphasized.

The Impact of Increasing Hospital Volume on 90-Day Postoperative Outcomes Following Pancreaticoduodenectomy

BACKGROUND

Performance of pancreaticoduodenectomy (PD) in high-volume centers has been posited to improve postoperative morbidity and mortality, consistent with the volume-outcomes hypothesis. We sought to evaluate the impact of hospital volume on 90-day PD outcomes at hepatopancreatobiliary (HPB) centers within a regionalized system.

METHODS

A retrospective population-based observational cohort study was performed, using administrative records of patients undergoing PD between 2005 and 2013 in Ontario, Canada. Postoperative administrative codes were used to define complications. Patients' 90-day postoperative outcomes were compared between center-volume categories using chi-square tests and multivariable regression. Volume cutoffs were defined using minimal regional standards (20PD/year), with assessment of the impact of further volume increases.

RESULTS

Of 2660 patients, 2563 underwent PD at HPB centers. Of these, 38.9% underwent surgery at higher-volume centers (>40 PD/year), 36.9% at medium-volume centers (20-39 PD/year), and 24.1% at lower-volume centers (10-19 PD/year). Mortality (30- and 90-day) was lowest at higher-volume hospitals (1.5%, 2.7%, respectively) compared to medium-volume (3.9%, 6.3%) and lower-volume hospitals (2.9%, 5.2%) (p < 0.01). Patients treated at higher- and medium-volume centers had lower reoperation rates (10.3%, 10.7% vs. 16.7%, p = 0.0002) and less prolonged length of stay (23.2%, 22.0% vs. 31.6%, p < 0.0001) compared to lower-volume centers.

CONCLUSION

Progressive increases in hospital volume correspond to improved 90-day outcomes following PD.