Vascular Resection in Pancreaticoduodenectomy: Is it Worthwhile?

Abstract

Pancreaticoduodenectomy (PD) is the gold standard treatment for cancer of pancreatic head in all the cases that are supposed to be resectable. Although the overall survival depends on many heterogeneous factors, the main aim of the treatment must be to achieve a R0 resection with microscopically and macroscopically free margins. As in recent reports vascular involvement does not represent anymore a technical limit, it is mandatory pointing out whether or not vascular resection modifies overall survival and if that is the case vascular invasion should not be considered as an exclusion criterion but as part of a standard resection. The review analysis demonstrated a progressive trend of inversion in the treatment of head pancreatic cancer over the last years. Recently, provided that a R0 resection may be performed, a more aggressive surgical approach has led to consider the possibility of venous and arterial resections. The basis for this new approach has been that the superior mesenteric vein or spleno-portal mesenteric vein invasion is not a measure of the tumor malignancy but merely a consequence of the tumor location. On the contrary, the controversial results in terms of overall survival and local recurrences achieved with major arterial resections are more likely due to a biological aggressivity than to the tumor site. The "artery first" technique seems to be the most promising approach to the problem although it needs further trials to determine whether or not this approach may be beneficial for patients in terms of overall survival and local recurrences.

Portal Vein Resection During Pancreatectomy for Pancreatic Head Adenocarcinoma. Scope of Current Opinions and own Experiences

“…PV invasion is not associated with histologic parameters suggesting a poor prognosis (14). These results support the hypothesis that the presence of vascular tumor involvement of the peripancreatic vessels seem to be an indicator of unfavorable tumor topography instead of being a sign of adverse tumor biology (15,16). Aggressive surgical resection should be attempted in cases with suspected portal vein invasion because 21.1% of patients had no ‚"true invasion'' (microscopically proven infiltration of the vein wall) and showed better survival than those with true invasion (17).…”

Meta-analysis of benefits of portal–superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma

“…In contrast, infiltration of the coeliac or superior mesenteric arteries rarely allows an R0 resection and is not considered an indication for surgery. In many centres a more aggressive approach to PV‐SMV resection has been adopted with the aim of improving life expectancy. In the light of this new approach, the present meta‐analysis evaluated the perioperative outcomes and overall survival of patients undergoing pancreatic resection combined with vein resection (VR), compared with those of patients without VR, with the aim of evaluating its feasibility and its influence on patients' outcomes.…”

Pancreaticoduodenectomy Combined with Vascular Resection and Reconstruction for Patients with Locally Advanced Pancreatic Cancer: A Multicenter, Retrospective Analysis

“…Several researchers have compared multiple aspects of PD combined with vascular reconstruction with PD surgery alone, including postoperative complications, mortality, survival, and surgery-related parameters. However, the existing data were mostly derived from single-center retrospective analyses, and the results obtained from different research centers are not exactly consistent with one another and sometimes even contradict one another [9], [10]. This study involved pancreatic cancer patients who were treated with PD combined with vascular resection in the pancreas treatment centers of multiple teaching hospitals in China.…”