Vein resection in patients with adenocarcinoma of the head of pancreas adherent to the portomesenteric venous axis is beneficial despite a high rate of R1 resection

Abstract

Backgrounds/AimsEn-bloc vein resection (VR) for pancreatic ductal adenocarcinoma (PDAC) of the head of pancreas adherent to the portomesenteric axis benefits patients when the vein wall is not infiltrated by tumour and an R0 resection is achieved, albeit at the expense of greater morbidity and mortality.MethodsA retrospective review of pancreaticoduodenectomy for PDAC over 6 years was conducted. Patients were divided into a standard resection group (Group SR) and simultaneous vein resection group (Group VR) and compared for outcome.ResultsThe study group consisted of 41 patients (Group SR 15, Group VR 26). VR was performed by end-to-end reconstruction in 12 patients and with interposition grafts in 13 cases (autologous vein in 10, PTFE in 3). R1 resections occurred in 49% patients, with the superior mesenteric artery margin most commonly involved. Patients with Ishikawa grade III and IV vein involvement were more likely to carry a positive SMA margin (p=0.04). Involvement of the splenoportal junction was associated with a significantly greater risk of pancreatic transection margin involvement. No difference in morbidity was seen between the groups. Median survival in the entire group of patients was 17 months and did not vary significantly between the groups. The only significant predictor of survival was lymph node status.ConclusionsVenous involvement by proximal PDAC is indicative of tumor location rather than tumor biology. VR improves outcomes in patients with tumor adhesion to the portomesenteric venous axis despite a high incidence of R1 resections and greater operative mortality.

The Impact on Survival and Morbidity of Portal–Mesenteric Resection During Pancreaticoduodenectomy for Pancreatic Head Adenocarcinoma: A Systematic Review and Meta-Analysis of Comparative Studies

“…The PRISMA flow diagram for systematic review is presented in Figure 1 . Twenty-three studies comparing PD+VR and standard PD for patients with PHAC, published between May 1998 and November 2019, were considered suitable for the meta-analysis [ 8 , 12 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ]. On review of the data extraction, there was 100% agreement between the three reviewers.…”

“…Long-term survival outcome after PD is related to several factors that remain to be better established; among them, the local extension of the primary tumor, lymph node infiltration status, tumor differentiation, and involvement of surgical margins seem to play a prominent role [ 15 , 16 ]. To date, it is not clear whether portal–venous infiltration is a consequence of local tumor progression or if it can be considered as an expression of aggressive tumor biology [ 15 , 23 , 25 ]. However, the current meta-analysis demonstrates that PD+VR does not improve patients’ long-term prognosis when compared with standard PD.…”

Prognostic impact of simultaneous venous resections during surgery for resectable pancreatic cancer

“…Several studies argue that venous involvement might be a consequence of tumour location rather than tumour biology. 3,12,32,33 However, histologically proven SMV/PV invasion by carcinoma cells is associated with a poorer survival and CA19-9 levels were shown to be significantly higher in patients who underwent VR during PD. 6,34,35 Furthermore, CA19-9 was defined as an additional negative predictor for postoperative survival.…”

Vascular Resections for Pancreatic Ductal Adenocarcinoma: Vascular Resections for PDAC

“…Furthermore, the morbidity and mortality rate is not different from that reported for “conventional pancreatectomies.” Interestingly, 13 out of 43 papers published in the past 5 years report a mortality rate below 1% (Table 1). Survival data were available in a limited number of studies; however, even there, the 5-year survival rate varies from 0% to 39%, which is not different from studies published for pancreatectomy without vein resection (17–59). The overall picture as demonstrated in Table 1 shows that vein resections are commonly done in experienced centers, and that short- and long-term results are comparable with these of “conventional” pancreatic surgery.…”