Do arterial resections improve survival in pancreatic cancer?—a narrative review

Abstract

In this article, we outline the important features of pancreatic cancer surgery in cases with visceral artery encasement.Background: Despite recent advances in diagnosis and treatment, pancreatic cancer continues to have a poor prognosis. Due to its limited response to chemotherapies, radiation, or targeted therapies, surgery (in combination with adjuvant chemotherapy) is the only potential way to treat pancreatic cancer in a curative manner. As only about 20% of the patients have surgically resectable disease at the time of diagnosis, the resection of encased visceral veins and arteries, along with neoadjuvant regimens, is one approach to treat otherwise palliative patients.Methods: Based on a selective literature review, we discuss the results of several studies and meta-analyses, comparing the mortality and morbidity, as well as long-term survival in patients undergoing arterial resection vs standard treatment. We conducted a selective literature review in PubMed without restrictions regarding time of publication or study design. Only articles in English language were selected.Conclusions: Several studies and meta-analyses comparing resection with and without arterial resection and reconstruction showed a significantly higher post-operative mortality and morbidity and shorter long-term survival in patients who required arterial resection. In patients with tumors initially considered irresectable, the approach of neoadjuvant chemotherapy followed by resection with arterial reconstruction showed a significantly increased survival compared to palliative chemotherapy alone with acceptable postoperative morbidity. Tumor resection with arterial reconstruction following intensive preoperative chemotherapy (plus radiochemotherapy in some cases) should be considered in selected patients, as it can prolong survival and potentially lead to sustained freedom from tumor recurrence.

Visceral debranching followed by chemotherapy and resection for locally advanced pancreatic cancer with arterial invasion: case report

“…This report illustrates that despite complications related to vascular reconstructions in pancreatic surgery such as graft thrombosis and anastomotic stricture, [5,7] an overall favorable and oncologically reasonable outcome can be achieved in select patients using an individualized bundle of vascular surgery, endovascular treatment, and pancreatic surgery as well as intensive neoadjuvant chemotherapy and specialized complication management. Therefore, patients qualifying for a complex sequence of treatments comprising major vascular surgery and multivisceral resection should not be automatically directed toward palliative treatment.…”

“…Autologous vein bypass from the right common iliac artery to the proper hepatic artery using the greater saphenous vein: (A) iliac anastomosis (white arrow), (B) hepatic anastomosis (blue arrow). Image adapted from Rebelo et al [5] treatments comprising major vascular surgery and multivisceral resection should not be automatically directed toward palliative treatment. Instead, a treatment approach in curative intention should be considered in mutual discussions carrying out a careful assessment of the expected risk-benefit ratio.…”

“…CT scan showing carcinoma of the pancreatic head and body with >180° encasement of the celiac trunk (red arrow), considered “irresectable” according to the consensus of the IAP. [6] Image adapted from Rebelo et al [5] CT = computed tomography, IAP = International Association of Pancreatology.…”

“…Autologous vein bypass from the right common iliac artery to the proper hepatic artery using the greater saphenous vein: (A) iliac anastomosis (white arrow), (B) hepatic anastomosis (blue arrow). Image adapted from Rebelo et al [5] …”

“…[3,4] Technically, resection of the tumor can be achieved by arterial resection and reconstruction, but the morbidity and mortality risk of such an approach is high, and it is therefore not considered standard practice but only done in highly selected patients or within clinical trials. [5] An alternative approach to overcome these limitations could be a therapeutic split, that is, performing an arterial reconstruction ("visceral debranching") as a first step followed by neoadjuvant chemotherapy and, last, tumor resection. Here, we present a case in which this novel therapeutic sequence has been followed.…”