Pancreaticoduodenectomy with En Bloc Portal Vein Resection for Pancreatic Carcinoma with Suspected Portal Vein Involvement

Pancreaticoduodenectomy combined with portal vein resection is increasingly accepted as a viable treatment option for pancreatic carcinoma with suspected involvement of the portal vein.However, its clinical benefit remains controversial. This study evaluated the outcomes of pancreaticoduodenectomy with portal vein resection for pancreatic carcinoma in a group of Chinese patients operated on by a specialized team in a center with a low case volume of pancreatic cancer. The perioperative and long-term outcomes of 12 patients with portal vein resection for suspected involvement of the portal vein and 38 patients who underwent pancreaticoduodenectomy without portal vein resection during the same period were compared. In the former group, eight patients underwent segmental resection, and four patients underwent wedge resection of the portal vein. There were no significant differences in operative blood loss (median 0.8 vs. 0.8 liter, p = 0.313), hospital mortality (0% vs. 2.6%, p = 1.000), or operative morbidity (41.7% vs. 42.1%, p = 0.979) between the two groups. Patients who required portal vein resection had higher frequencies of microscopic lymphatic permeation (58.3% vs. 18.4%, p = 0.023) and vascular invasion (50.0% vs. 15.8%, p = 0.025). Long-term survival was comparable between patients with portal vein resection and those without it (median 19.5 vs. 20.7 months, p = 0.769). These findings suggest that pancreaticoduodenectomy combined with portal vein resection can be performed safely by a specialized team in a center with a low case volume of pancreatic carcinoma and that it may offer survival benefit in patients with suspected portal vein involvement.     

Pancreaticoduodenectomy with Mesentericoportal Vein Resection for Adenocarcinoma of the Pancreatic Head

Background The value of mesentericoportal vein resection (VR) associated with pancreaticoduodenectomy (PD) for pancreatic-head adenocarcinoma still remains controversial. Methods From 1989 to 2003, 45 consecutive patients with pancreatic-head adenocarcinoma underwent PD with mesentericoportal VR due to intraoperative macroscopic involvement of the superior mesenteric or portal vein (VR+ group). They were compared with 88 patients who underwent PD for adenocarcinoma without VR over the same time period (VR− group) and matched for age, American Society of Anesthesiologists (ASA) score, pathological diagnosis, and nodal involvement. Preoperative features, intraoperative parameters, postoperative course, and survival were compared between the VR+ group and VR− group. Factors that may influence survival were determined by univariate and multivariate analyses. Results Mortality, morbidity, and mean hospital stay did not differ between the two groups (VR+ 4.4%, 56%, and 22.6 days, respectively; VR− 5.7%, 64%, 24.6 days, respectively). In the group VR+, vein invasion was histologically proven in 29 (64%) patients. Three-year global survival and 3-year disease-free survival did not differ between the two groups: VR+ 22% and 14%, respectively; VR− 25% and 21%, respectively (log-rank: P = 0.69 and P = 0.39, respectively). Neither VR nor histologically proven vein involvement significantly impacted survival duration. On multivariate analysis, tumor-free margin was the most important prognostic factor. Conclusions Vein resection during PD can be performed safely. Patients with adenocarcinoma who require VR during PD have a survival not different from that of patients who undergo standard PD. Macroscopic isolated mesentericoportal vein involvement is not a contraindication for PD in patients with adenocarcinoma provided disease-free margins can be obtained.     

Improving Results of Pancreaticoduodenectomy for Pancreatic Cancer

This report from The Johns Hopkins Hospital reviews the results of pancreaticoduodenal resection during the decade of the 1990s, focusing on two recent publications. The first to be discussed involves a cohort of 650 consecutive patients undergoing pancreaticoduodenectomy (PD), with 443 patients having periampullary adenocarcinomas, 282 of whom had a pathologic diagnosis of pancreatic adenocarcinoma. The second report to be discussed involves the use of adjuvant chemoradiation therapy in a cohort of 174 patients who had successfully undergone PD for pancreatic adenocarcinoma. In both of these cohorts the operative mortality was less than 2%, and the median survival for resected pancreatic adenocarcinoma approximated 20 months.     

A Graded Evaluation of Outcomes Following Pancreaticoduodenectomy with Major Vascular Resection in Pancreatic Cancer

Previous studies examining short- and long-term outcomes of pancreaticoduodenectomy with vascular resection for pancreatic adenocarcinoma have not graded perioperative complication severity. These studies may provide incomplete assessments of the efficacy of vascular resection. In the current study, we evaluated 36 patients who had pancreaticoduodenectomy with major vascular resection. These were matched 1:3 by tumor stage and age to patients who had pancreaticoduodenectomy without vascular resection. Charts were reviewed to identify all complications and 90-day readmissions. Complications were graded as either severe or minor adverse postoperative outcomes, taking into account the total length of stay. There were no statistical differences in patient demographics, comorbidities, or symptoms between the groups. Patients who had vascular resection had significantly increased rates of severe adverse postoperative outcomes, readmissions, lengths of hospital stay, as well as higher hospital costs. Hypoalbuminemia and major vascular resection were independent predictors of severe adverse postoperative outcomes. On multivariate Cox-regression survival analysis, patients who had vascular resection had decreased recurrence-free (12 vs. 17 months) and overall (17 vs. 29 months) survival. Major vascular resection was a predictor of mortality, may be an independent prognostic factor for survival, and may warrant incorporation into future staging systems.     

胰头癌胰十二指肠切除术切缘癌细胞残留(R1)的研究和对临床实践的启示

目的探讨胰头癌胰十二指肠切除术切缘癌细胞残留(R1)的发生率及其对临床实践的启示。方法 2010年11月～2012年3月我科同一个手术组对28例胰头癌行根治性胰十二指肠切除(标准化组,n=28),标本除常规取胰腺颈部断端、胆总管断端、胃体空肠断端外,还常规标记和切取肠系膜上静脉沟切缘、钩突切缘与胰头后表面切缘,切缘表面有肿瘤细胞残留为R1。回顾分析我科同一个手术组2009年2月～2010年11月38例胰头癌行根治性胰十二指肠切除(非标准化组,n=38),比较2组R1发生率。结果标准化组R1发生率53.6%(15/28)显著高于非标准化组13.2%(5/38,χ2=12.467,P=0.000)。标准化组肠系膜上静脉沟切缘(9/15,60.0%)和钩突切缘(8/15,53.3%)是最常受累及的切缘,33.3%(5/15)的患者同时累及2个切缘。结论对胰十二指肠切除标本进行标准化取材能够显著提高R1的发生率,提供准确的病理信息。术中应该尽可能根治性切除钩突部,必要时联合切除肠系膜上静脉,以降低R1的发生率。     

Extended Pancreaticoduodenectomy with Vascular Resection for Pancreatic Cancer: A Systematic Review

Objectives  

This systematic review objectively evaluates the safety and outcomes of extended pancreaticoduodenectomy with vascular resection for pancreatic cancer involving critical adjacent vessels namely the superior mesenteric-portal veins, hepatic artery, superior mesenteric artery, and celiac axis.     

Impact of Obesity on Perioperative Outcomes and Survival Following Pancreaticoduodenectomy for Pancreatic Cancer: A Large Single-Institution Study

Background

To examine the effect of body mass index (BMI) on clinicopathologic factors and long-term survival in patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma.

Methods

Data on BMI, weight loss, operative details, surgical pathology, and long-term survival were collected on 795 patients who underwent pancreaticoduodenectomy. Patients were categorized as obese (BMI?>?30 kg/m²), overweight (BMI 25 to <30 kg/m²), or normal weight (BMI?<?25 kg/m²) and compared using univariate and multivariate analyses.

Results

At the time of surgery, 14% of patients were obese, 33% overweight, and 53% normal weight. Overall, 32% of patients had preoperative weight loss of >10%. There were no differences in operative times among the groups; however, higher BMI was associated with increased risk of blood loss (P?<?0.001) and pancreatic fistula (P?=?0.01). On pathologic analysis, BMI was not associated with tumor stage or number of lymph nodes harvested (both P?>?0.05). Higher BMI patients had a lower incidence of a positive retroperitoneal/uncinate margin versus normal weight patients (P?=?0.03). Perioperative morbidity and mortality were similar among the groups. Obese and overweight patients had better 5-year survival (22% and 22%, respectively) versus normal weight patients (15%; P?=?0.02). After adjusting for other prognostic factors, as well as preoperative weight loss, higher BMI remained independently associated with improved cancer-specific survival (overweight: hazard ratio, 0.68; obese: hazard ratio, 0.72; both P?<?0.05).

Conclusion

Obese patients had similar tumor-specific characteristics, as well as perioperative outcomes, compared with normal weight patients. However, obese patients undergoing pancreaticoduodenectomy for pancreatic cancer had an improved long-term survival independent of known clinicopathologic factors.     

Long-term Outcome after Proximal Gastrectomy with Jejunal Interposition for Gastric Cancer Compared with Total Gastrectomy

Background

Proximal gastrectomy (PG) has been widely accepted as treatment for early gastric cancer located in the upper third of the stomach. Reconstruction by jejunal interposition has been known to reduce reflux esophagitis for PG patients. The aim of this study was to compare the long-term outcomes of patients who underwent PG with jejunal interposition with those treated by total gastrectomy (TG).

Methods

Data on 102 cases of PG with jejunal interposition and 49 cases of TG with Roux-Y reconstruction for gastric cancer were analyzed retrospectively in terms of overall survival, weight maintenance, anemia and nutritional status, and endoscopic findings.

Results

Median follow-up time was 59 months in the both groups. There was no significant difference in the overall 5-year survival rate between the PG group (94 %) and the TG group (84 %). The PG group showed significantly better body weight maintenance at the first year. The laboratory blood tests showed that the PG group had a significantly better red blood cell count and hemoglobin and hematocrit levels at the second and third year. However, postoperative endoscopic surveillance detected reflux esophagitis (3 %), peptic ulcer (9 %), and metachronous gastric cancer (5 %) in the PG group.

Conclusions

Proximal gastrectomy maintains comparable oncological radicality to TG and is preferred over TG in terms of preventing postoperative anemia. However, periodic endoscopic follow-up is necessary to monitor the upper gastrointestinal tract.     

A Systematic Review and Meta-analysis of Survival and Surgical Outcomes Following Neoadjuvant Chemoradiotherapy for Pancreatic Cancer

Introduction  

This systematic review and meta-analysis aims to characterize the surgically important benefits and complications associated with the use of neoadjuvant chemoradiotherapy for the treatment of both resectable and initially unresectable pancreatic cancer. Studies were identified through a systematic literature search and analyzed by two independent reviewers. Survival, peri-operative complications, death rate, pancreatic fistula rate, and the incidence of involved surgical margins were analyzed and subject to meta-analysis.     

Surgical Outcomes of Gastrectomy for Elderly Patients with Gastric Cancer

Background

This study was designed to determine the surgical outcomes of gastric cancer in elderly patients. This information can help establish appropriate treatment for these patients.

Methods

A total of 1,193 patients with gastric cancer who underwent gastrectomy between 1995 and 2010 were enrolled in this retrospective study. The clinicopathologic features of 104 elderly patients (aged ≥80 years) were compared with those of 1,089 nonelderly patients.

Results

(1) Tumors located in the lower-third of the stomach, differentiated cancer, and surgery with limited lymph node dissection were more common in elderly patients. However, there was no difference in the proportion of laparoscopic gastrectomy between elderly and nonelderly patients. (2) Although surgical complication rates were similar in the two groups, the operative mortality rate was higher in elderly patients (1.9 %) than in nonelderly patients (0.7 %). (3) Elderly patients had a significantly poorer overall survival rate, whereas the disease-specific survival rates of the two groups were similar. Limited lymph node dissection did not influence the disease-specific survival rate of elderly patients. (4) The median life expectancy of elderly gastric cancer survivors was 9.8 years in patients aged 80–84 years and 6.0 years in those ≥85 years. The patients with limited lymph node dissection had slightly better prognosis.

Conclusions

The treatment results in elderly patients were comparable to those in nonelderly patients. These findings suggest that R0 resection with at least limited lymph node dissection according to Japanese guidelines should be considered, even for elderly patients.     

Pancreaticoduodenectomy with Vascular Resection for Local Advanced Pancreatic Head Cancer: A Single Center Retrospective Study

Introduction  Pancreaticoduodenectomy with vascular resection remains a controversial approach for patients with local advanced pancreatic head cancer for the lack of evidences of survival and quality of life benefits. The aim of this study was to evaluate whether patients of pancreatic head cancer benefit on quality of life, survival, and treatment cost from pancreaticoduodenectomy with vascular resection compared with palliative therapy. Materials and Methods  Two hundred fourteen patients of pancreatic head cancer whose pancreatic head could not be dissected free from adjacent vascular were involved in this study. Eighty of these patients underwent pancreaticoduodenectomy with vascular resection, whereas other patients underwent palliative therapy. Results  Pancreaticoduodenectomy with artery resection offered worse outcomes on almost all aspects of quality of life and survival compared with palliative therapy. Pancreaticoduodenectomy with vein resection offered better 5-year survival compared with palliative therapy, whereas palliative therapy offered better quality of life after surgery. Conclusion  Pancreaticoduodenectomy with artery resection is nonsensical on treatment of pancreatic head cancer with artery adhesion/invasion. As for patients with vein adhesion/invasion, pancreaticoduodenectomy with vein resection should be performed cautiously. When actual vein invasion is very possible to have taken place, the choice of treatment strategy should be considered carefully by the pancreatic surgeons.     

Pylorus-preserving Pancreaticoduodenectomy with External Pancreatic Remnant Drainage

Background : Pancreaticoduodenectomy is the mainstay of surgical treatment for various benign and malignant diseases of the head of the pancreas and the periampullar region. The incidence of postoperative morbidity remains significantly high. Various modifications have been advocated for the restoration of the digestive continuity and drainage of bile and pancreatic ducts in order to diminish this high morbidity rate.

Methods : A new modification with the combination of an end-to-end duodenojejunal anastomosis and creation of an external pancreatic fistula following pylorus-preserving pancreaticoduodenectomy is described. Our initial experience with this modification in seven patients is reported and its advantages are discussed.

Results : There was no mortality, while morbidity was 29%, including postoperative pneumonia and psychosis in one patient, and intra-abdominal abscess in another patient. No significantly delayed gastric emptying was observed and no patient developed diabetes, anastomotic ulcer or reflux cholangitis postoperatively.

Conclusions : The reported technique seems to be a safe modification of restoration after pancreaticoduodenectomy, with maintenance of anatomical gastrointestinal continuity, avoidance of complications from anastomosis with the pancreatic remnant, as well as maintenance of endocrine pancreatic function. However, long-term follow-up and larger comparative studies are needed to evaluate the impact of this modification on morbidity and mortality, including longterm nutritional complications.     

Patency Rates of Portal Vein/Superior Mesenteric Vein Reconstruction After Pancreatectomy for Pancreatic Cancer

Background

Pancreatectomy with venous reconstruction (VR) for pancreatic cancer (PC) is occurring more commonly. Few studies have examined the long-term patency of the superior mesenteric-portal vein confluence following reconstruction.

Methods

From 2007 to 2013, patients who underwent pancreatic resection with VR for PC were classified by type of reconstruction. Patency of VR was assessed using surveillance computed tomographic imaging obtained from date of surgery to last follow-up.

Results

VR was performed in 43 patients and included the following: tangential resection with primary repair (7, 16 %) or saphenous vein patch (9, 21 %); segmental resection with splenic vein division and either primary anastomosis (10, 23 %) or internal jugular vein interposition (8, 19 %); or segmental resection with splenic vein preservation and either primary anastomosis (3, 7 %) or interposition grafting (6, 14 %). All patients were instructed to take aspirin after surgery; low molecular weight heparin was not routinely used. An occluded VR was found in four (9 %) of the 43 patients at a median follow-up of 13 months; median time to detection of thrombosis in the four patients was 72 days (range 16–238).

Conclusions

Pancreatectomy with VR can be performed with high patency rates. The optimal postoperative pharmacologic therapy to prevent thrombosis requires further investigation.     

Variations in Surgical Treatment and Outcomes of Patients With Pancreatic Cancer: A Population-Based Study

Background There is ongoing debate on how variations in surgical technique affect outcomes in pancreatic cancer. This population-based study examines current surgical practice and outcomes for cancer of the pancreatic head. Methods All patients 18 to 85 years old diagnosed with nonmetastatic adenocarcinoma of the pancreatic head from 1998 through 2003 were identified from the Surveillance, Epidemiology and End Results (SEER) Program registry. Multivariable regression was used to elucidate factors associated with the type of pancreaticoduodenectomy performed, extent of lymph node (LN) assessment, early mortality, and late survival. Results Overall, 2111 patients were included in the study, with 83.7% treated with a standard Whipple pancreaticoduodenectomy (PD). However, there was marked regional variation in the use of pylorus-preserving pancreaticoduodenectomy (PPPD; range, .03%–32.0%; P < .0001) and total pancreatectomy (TP; range, .04%–19.5%; P < .0001). TP was associated with significantly higher early mortality (odds ratio, 2.6; 95% confidence interval, 1.6 to 4.1; P < .0001), but late survival did not differ significantly between TP, PPPD, and PD (P = .69). Significant variation was also seen in the number of LN assessed (range across SEER regions, 7.3–13.5; P < .0001). Decreased LN assessment reduced the odds of diagnosing a patient as node positive and was associated with worse late survival. Conclusions In this population-based study, we found marked clinically important variability in the surgical treatment of adenocarcinoma of the pancreatic head, with respect to the use of TP, PPPD, or PD, and the extent of LN assessment. Further research is warranted to elucidate the underlying reasons, and to clarify the role of adequate lymphadenectomy.