Does Portal-Superior Mesenteric Vein Invasion Still Indicate Irresectability for Pancreatic Carcinoma?

Azienda Ospedaliera Sant'Andrea, UOC Hepatobiliary and Pancreatic Surgery, II Faculty of Medicine, University of Rome La Sapienza, Via di Grottarossa 1035-1039, Rome, Italy.
Annals of Surgical Oncology (Impact Factor: 3.93). 02/2009; 16(4):817-25. DOI: 10.1245/s10434-008-0281-8
Source: PubMed


Pancreatic carcinoma frequently infiltrates the portal vein or the superior mesenteric vein; pancreatectomy combined with portal vein/superior mesenteric vein resection represents a potentially curative treatment in these cases but is still a controversial procedure.
After performing a computerized Medline search, 12 series published during the last 8 years were selected, enrolling 399 patients who underwent pancreatectomy combined with portal vein/superior mesenteric vein resection for pancreatic carcinoma. Data were examined for information about indications, operation, adjuvant therapies, histopathology of resected specimens, perioperative results, and survival. Also, previous literature regarding the issue was extensively reviewed.
Operative mortality and postoperative complication rates ranged from 0 to 7.7% and 16.7% to 54%, respectively. Median survival varied from 13 to 22 months; 5-year survival rate ranged from 9% to 18%.
The current literature suggests that portal vein/superior mesenteric vein resection combined with pancreatectomy is a safe and feasible procedure that increases the number of patients who undergo curative resection and, therefore, provides important survival benefits to selected groups of patients. This procedure should always be considered in case of suspected tumor infiltration of portal/superior mesenteric vein to achieve clear resection margins, in the absence of other contraindications for resection.

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Available from: Valentina Giaccaglia, May 22, 2015
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    • "The most common unexpected finding at the time of pancreaticoduodenectomy in pancreatic carcinoma of the head and uncinate process is the invasion of the superior mesenteric vein (SMV) or superior mesenteric portal vein (SMV/PV) confluence, located anteriorly, laterally, or posterolaterally [3,4]. The current literature suggests that portal vein and/or SMV invasion is not a contraindication to pancreatic resection, provided that these veins are not occluded [5]. In this report, we describe a case of resection of the SMV and restoration of its continuity by inter-position of an autologous superficial femoral vein (SFV) graft, since few data exist about SMV reconstruction with a SFV graft during pancreatectomy. "
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    ABSTRACT: This systematic review objectively evaluates the safety and outcomes of extended pancreaticoduodenectomy with vascular resection for pancreatic cancer involving critical adjacent vessels namely the superior mesenteric-portal veins, hepatic artery, superior mesenteric artery, and celiac axis. Electronic searches were performed on two databases from January 1995 to August 2009. The end points were: firstly, to evaluate the safety through reporting the mortality rate and associated complications and, secondly, the outcome by reporting the survival after surgery. This was synthesized through a narrative review with full tabulation of results of all included studies. Twenty-eight retrospective studies comprising of 1,458 patients were reviewed. Vein thrombosis and arterial involvement were reported as contraindications to surgery in 62% and 71% of studies, respectively. The median mortality rate was 4% (range, 0% to 17%). The median R0 and R1 rates were 75% (range, 14% to 100%) and 25% (range, 0% to 86%), respectively. In high volume centers, the median survival was 15 months (range, 9 to 23 months). Nine of 10 (90%) studies comparing the survival after extended pancreaticoduodenectomy with vascular resection versus standard pancreaticoduodenectomy reported statistically similar (p > 0.05) survival outcomes. Undertaking vascular resection was not associated with a poorer survival. The morbidity, mortality, and survival outcome after undertaking extended pancreaticoduodenectomy with vascular resection for pancreatic cancer with venous involvement and/or limited arterial involvement is acceptable in the setting of an expert referral center and should not be a contraindication to a curative surgery.
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