Is there a role for arterial reconstruction in surgery for pancreatic cancer?

Abstract

Surgery remains the only potentially curative treatment for patients with pancreatic cancer. Locally advanced pancreatic cancer with vascular involvement remains a surgical challenge because high perioperative risk and the uncertainty of a survival benefit. Whilst portal vein resection has started to gather momentum because the perioperative morbidity and long term survival is comparable to standard pancreatectomy, there isn't yet a consensus on arterial resections. There have been various reports and case series of arterial resections in pancreatic cancer, with mixed survival results. Mollberg et al have appraised the heterogeneous published literature available on arterial resection in pancreatic cancer in an attempt to compare this to standard pancreatectomy. In this article, we discuss the results of this systematic review and meta-analysis, and the limitations associated with analysing results from heterogenous data. We have outlined the important features in surgery for pancreatic cancer and specifically to arterial resections, and compared arterial resections to the published literature on venous resections.

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

“…1. The invasion of the common hepatic artery (CHA) or the gastroduodenal artery (GDA) at its origin, of the superior mesenteric artery (SMA), or the celiac axis (CA) is usually considered as a contraindication for resection due to the risks of both morbidity and mortality, and poor oncological results (56,(110)(111)(112)(113) The report from the French Association of Surgery (41) (2004-2009) showed that in France AR was performed during pancreatectomy for PDAC in 2% of cases (37/1670, 27 + VR) with a morbidity rate of 54%, a 30-day mortality rate of 8% and a 3-year survival rate of 8% (median: 12.7 months, median survival rate without recurrence, 7 months). In a VR study in this series, AR significantly increased mortality (RR = 2.09; 95% CI = 0.99-4.38; p = 0.05) (LE 4).…”

Arterial resection and reconstruction in pancreatectomy: surgical technique and outcomes

“…Currently, surgical resection is considered the only possible curative approach for pancreatic tumors [1–3]. However, postsurgical outcomes remain poor as most patients present with advanced stage disease [4].…”

Segmental portal/superior mesenteric vein resection and reconstruction with the iliac vein after pancreatoduodenectomy

“… 2 – 4 VR is classified into four types: type 1 involves partial venous excision with direct closure, type 2 involves partial venous excision using a patch, type 3 involves segmental resection with primary venovenous anastomosis, and type 4 involves segmental resection with an interposed venous conduit. 5 In clinical practice, venous graft interposition following segmental resection of the PV/SMV remains only a small part of vascular reconstruction, 6 , 7 and the operative procedure, venous status, and long-term outcomes still require detailed evaluation. A recent report from the authors’ department presented a new venous reconstruction technique using the iliac vein harvested from donation after cardiac death (DCD) and addressed the feasibility of this method.…”