Pancreaticoduodenectomy with vascular resection: Margin status and survival duration

Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
Journal of Gastrointestinal Surgery (Impact Factor: 2.39). 01/2005; 8(8):935-49; discussion 949-50. DOI: 10.1016/j.gassur.2004.09.046
Source: PubMed

ABSTRACT Major vascular resection performed at the time of pancreaticoduodenectomy (PD) for adenocarcinoma remains controversial. We analyzed all patients who underwent vascular resection (VR) at the time of PD for any histology at a single institution between 1990 and 2002. Preoperative imaging criteria for PD included the absence of tumor extension to the celiac axis or superior mesenteric artery (SMA). Tangential or segmental resection of the superior mesenteric or portal veins was performed when the tumor could not be separated from the vein. As a separate analysis, all patients who underwent PD with VR for pancreatic adenocarcinoma were compared to all patients who underwent standard PD for pancreatic adenocarcinoma. A total of 141 patients underwent VR with PD. Superior mesenteric-portal vein resections included tangential resection with vein patch (n=36), segmental resection with primary anastomosis (n=35), and segmental resection with autologous interposition graft (n=55). Hepatic arterial resections were performed in 10 patients, and resections of the anterior surface of the inferior vena cava were performed in 5 patients. PD was performed for pancreatic adenocarcinoma in 291 patients; standard PD was performed in 181 and VR in 110. Median survival was 23.4 months in the group that required VR and 26.5 months in the group that underwent standard PD (P=0.177). A Cox proportional hazards model was constructed to analyze the effects of potential prognostic factors (VR, tumor size, T stage, N status, margin status) on survival. The need for VR had no impact on survival duration. In conclusion, properly selected patients with adenocarcinoma of the pancreatic head who require VR have a median survival of approximately 2 years, which does not differ from those who undergo standard PD and is superior to historical patients believed to have locally advanced disease treated nonoperatively.

Download full-text


Available from: Eddie K Abdalla, Jul 28, 2015
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: С 2000�го по 2006 г. 36 больным выполнена гастропанкреатодуоденальная резекция по поводу злокачествен� ных опухолей поджелудочной железы, терминального отдела общего желчного протока, большого сосочка двенадцатиперстной кишки. В 8 наблюдениях выявлено распространение опухоли на верхнюю брыжеечную вену, что потребовало выполнения ее резекции и реконструктивной операции. При необходимости удаления части воротной и верхней брыжеечной вен на большом протяжении в 2 наблюдениях применен способ не� стандартного восстановления кровотока в системе воротной вены, который включал на начальном этапе со� судистой реконструкции формирование спленопортального анастомоза и последующее создание мезентери� кокавального анастомоза. Несмотря на необходимость выполнения резекции сосудов в системе воротной ве� ны, способ позволяет сократить время ишемии печени за счет раннего восстановления воротного кровотока, избежать использования аутовенозных вставок, сосудистых протезов и временных обходных шунтов, а также уменьшить вероятность тромбоза брыжеечных вен. During 2000�2006 we performed 36 gastropancreatoduodenectomies in pancreatic, distal common bile duct and papil� lary cancer patients. Tumor involved the superior mesenteric vein in 8 cases, requiring its resection and vascular recon� structions. When resected portion of portal and superior mesenteric veins was too long, we used the technique of the por� tal vein system blood supply nonstandard restoration in 2 cases. The technique included formation of splenoportal anas� tomosis at the initial stage of vascular reconstruction followed by mesentericocaval anastomosis. Regardless of portal vein system reconstruction necessity, a liver ischemia period is reduced at the account of portal vein blood supply early restoration. There is no need to use autovenous insets, vascular prostheses and temporary collateral bypasses. Probability of mesenteric veins thrombosis is reduced.
  • Source
  • [Show abstract] [Hide abstract]
    ABSTRACT: Die Inzidenz des Pankreaskarzinoms nimmt zu, und der Krankheitsverlauf zeichnet sich durch ausgesprochene Aggressivität aus, so dass das Pankreaskarzinom heute die vierthäufigste krebsbedingte Todesursache darstellt. Die Grundvoraussetzung für eine kurative Therapie ist die chirurgische R0-Resektion. Aufgrund multimodaler Therapieansätze konnte vor allem in Kombination mit adjuvanten Chemotherapien die 5-Jahres-Überlebensrate auf 20–30% gesteigert werden. Auch bei primär nicht operablen Tumoren ist eine sekundäre Operabilität nach neoadjuvanter Therapie in einigen Fällen möglich, so dass die Therapie des Pankreaskarzinoms heute interdisziplinär und multimodal erfolgen sollte. Die Standardoperation für Raumforderungen des Pankreaskopfs ist die pyloruserhaltende partielle Pankreatikoduodenektomie, für Raumforderungen des Pankreaskorpus oder -schwanzes die Pankreaslinksresektion. Die routinemäßige erweiterte Lymphadenektomie ist nicht indiziert. Pankreasresektionen mit Resektionen der Pfortader und der V. mesenterica superior sowie multiviszerale Resektionen sollten durchgeführt werden, da eine erzielte R0-Resektion in dieser Situation die gleiche Prognose wie nach einer Standardoperation hat und der palliativen Therapie somit überlegen ist. Die Operation von Lokalrezidiven kann im Einzelfall sinnvoll sein. Arterielle Resektionen und Resektionen von Metastasen sind als experimentell anzusehen und sollten nur in begründeten Einzelfällen durchgeführt werden. Palliative Resektionen, die einen Residualtumor belassen, sollten nicht vorgenommen werden. An spezialisierten Zentren werden aufgrund hoher Fallzahlen eine Abnahme der perioperativen Letalität und Morbidität sowie eine Zunahme des Langzeitüberlebens von Patienten mit Pankreaskarzinomen erzielt. Ziel einer Pankreasresektion muss immer die R0-Situation sein, da dies der wichtigste Prognosefaktor für Langzeitüberleben ist. Die Chirurgie nimmt die zentrale Rolle in der kurativen Therapie des Pankreaskarzinoms ein, muss aber zur Erzielung eines optimalen Ergebnisses in ein multimodales Therapiekonzept eingebettet sein. The incidence of pancreatic ductal adenocarcinoma is increasing and its aggressive and devastating course makes it the fourth leading cause of cancer- related deaths. The basis for curative therapy is the radical surgical resection. Multimodal therapy including adjuvant chemotherapy improved the 5-year survival rates up to 20–30%. In primary nonresectable cancer, resectionoris sometimes possible after neoadjuvant treatment. This underlines the importance of interdisciplinary and multimodal treatment. The standard operation for tumors of the pancreatic head is the pylorus-preserving partial pancreaticoduodenectomy, for tumors of the pancreatic body or tail the distal pancreatectomy. The extended lymphadenectomy is not routinely indicated. Resection of the portal vein, the superior mesenteric vein and multivisceral resections should be performed if the tumor can be removed completely. The outcome is comparable to standard resections and superior to palliative treatment. Resection of a local recurrence might be reasonable in individual cases. Resections in case of arterial involvement or metastatic disease are experimental and should only be performed as an individualized treatment concept. Palliative resections with gross tumor residues should not be performed. Due to high case load, specialized centers generate a significantly decreased risk of perioperative mortality and morbidity and an increased long-term survival. The main aim of pancreatic resection is to remove the tumor completely (R0) because curative tumor resection has been demonstrated to be the single most important factor for long-term survival. Surgery plays the central role in curative treatment of pancreatic cancer, but should be embedded in multimodal therapy concepts to achieve optimal results.
    Onkopipeline 01/2008; 1(2):63-68. DOI:10.1007/s15035-008-0123-y
Show more