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01-04-2009 | Hepatobiliary and Pancreatic Tumors

Does Portal-Superior Mesenteric Vein Invasion Still Indicate Irresectability for Pancreatic Carcinoma?

Authors: Giovanni Ramacciato, MD, FACS, Paolo Mercantini, MD, PhD, Niccolò Petrucciani, MD, Valentina Giaccaglia, MD, Giuseppe Nigri, MD, Matteo Ravaioli, MD, Matteo Cescon, MD, Alessandro Cucchetti, MD, Massimo Del Gaudio, MD

Published in: Annals of Surgical Oncology | Issue 4/2009

Abstract

Background

Pancreatic carcinoma frequently infiltrates the portal vein or the superior mesenteric vein; pancreatectomy combined with portal vein/superior mesenteric vein resection represents a potentially curative treatment in these cases but is still a controversial procedure.

Methods

After performing a computerized Medline search, 12 series published during the last 8 years were selected, enrolling 399 patients who underwent pancreatectomy combined with portal vein/superior mesenteric vein resection for pancreatic carcinoma. Data were examined for information about indications, operation, adjuvant therapies, histopathology of resected specimens, perioperative results, and survival. Also, previous literature regarding the issue was extensively reviewed.

Results

Operative mortality and postoperative complication rates ranged from 0 to 7.7% and 16.7% to 54%, respectively. Median survival varied from 13 to 22 months; 5-year survival rate ranged from 9% to 18%.

Conclusions

The current literature suggests that portal vein/superior mesenteric vein resection combined with pancreatectomy is a safe and feasible procedure that increases the number of patients who undergo curative resection and, therefore, provides important survival benefits to selected groups of patients. This procedure should always be considered in case of suspected tumor infiltration of portal/superior mesenteric vein to achieve clear resection margins, in the absence of other contraindications for resection.

Jemal A, Siegel R, Ward E, Hao Y, Xu J, Murray T, Thun MJ. Cancer statistics, 2008. CA Cancer J Clin. 2008;58:71–96.PubMedCrossRef

Katz MH, Hwang R, Fleming JB, Evans DB. Tumor-node-metastasis staging of pancreatic adenocarcinoma. CA Cancer J Clin. 2008;58:111–25.PubMedCrossRef

Tseng JF, Tamm EP, Lee JE, Pisters PW, Evans DB. Venous resection in pancreatic cancer surgery. Best Pract Res Clin Gastroenterol. 2006;20:349–64.PubMedCrossRef

Shibata C, Kobari M, Tsuchiya T, Arai K, Anzai R, Takahashi M, et al. Pancreatectomy combined with superior mesenteric-portal vein resection for adenocarcinoma in pancreas. World J Surg. 2001;25:1002–5.PubMedCrossRef

Kawada M, Kondo S, Okushiba S, Morikawa T, Katoh H. Reevaluation of the indications for radical pancreatectomy to treat pancreatic carcinoma: is portal vein infiltration a contraindication? Surg Today. 2002;32:598–601.PubMedCrossRef

Nakagohri T, Kinoshita T, Konishi M, Inoue K, Takahashi S. Survival benefits of portal vein resection for pancreatic cancer. Am J Surg. 2003;186:149–53.PubMedCrossRef

Capussotti L, Massucco P, Ribero D, Viganò L, Muratore A, Calgaro M. Extended lymphadenectomy and vein resection for pancreatic head cancer: outcomes and implications for therapy. Arch Surg. 2003;138:1316–22.PubMedCrossRef

Howard TJ, Villanustre N, Moore SA, DeWitt J, LeBlanc J, Maglinte D, et al. Efficacy of venous reconstruction in patients with adenocarcinoma of the pancreatic head. J Gastrointest Surg. 2003;7:1089–95.PubMedCrossRef

Poon RT, Fan ST, Lo CM et al. Pancreaticoduodenectomy with en bloc portal vein resection for pancreatic carcinoma with suspected portal vein involvement. World J Surg. 2004;28:602–8.PubMedCrossRef

10.

Zhou GW, Wu WD, Xiao WD, Li HW, Peng CH. Pancreatectomy combined with superior mesenteric-portal vein resection: report of 32 cases. Hepatobiliary Pancreat Dis Int. 2005;4:130–4.PubMed

11.

Jain S, Sacchi M, Vrachnos P, Lygidakis NJ. Carcinoma of the pancreas with portal vein involvement: our experience with a modified technique of resection. Hepatogastroenterology. 2005;52:1596–600.PubMed

12.

Riediger H, Makowiec F, Fischer E, Adam U, Hopt UT. Postoperative morbidity and long-term survival after pancreaticoduodenectomy with superior mesenterico-portal vein resection. J Gastrointest Surg. 2006;10:1106–15.PubMedCrossRef

13.

Shimada K, Sano T, Sakamoto Y, Kosuge T. Clinical implications of combined portal vein resection as a palliative procedure in patients undergoing pancreaticoduodenectomy for pancreatic head carcinoma. Ann Surg Oncol. 2006;13:1569–78.PubMedCrossRef

14.

Al-Haddad M, Martin JK, Nguyen J et al. Vascular resection and reconstruction for pancreatic malignancy: a single center survival study. J Gastrointest Surg. 2007;11:1168–74.PubMedCrossRef

15.

Kurosaki I, Hatakeyama K, Minagawa M, Sato D. Portal vein resection in surgery for cancer of biliary tract and pancreas: special reference to the relationship between the surgical outcome and site of primary tumor. J Gastrointest Surg. 2008;12:907–18.PubMedCrossRef

16.

Tseng JF, Raut CP, Lee JE et al. Pancreaticoduodenectomy with vascular resection: margin status and survival duration. J Gastrointest Surg. 2004;8:935–49.PubMedCrossRef

17.

Li B, Chen FZ, Ge XH, Cai MZ, Jiang JS, Li JP, et al. Pancreatoduodenectomy with vascular reconstruction in treating carcinoma of the pancreatic head. Hepatobiliary Pancreat Dis Int. 2004;3:612–5.PubMed

18.

Aramaki M, Matsumoto T, Etoh T et al. Clinical significance of combined pancreas and portal vein resection in surgery for pancreatic adenocarcinoma. Hepatogastroenterology. 2003;50:263–6.PubMed

19.

Yoshimi F, Asato Y, Tanaka R, Nemoto K, Shioyama Y, Onaya H, et al. Reconstruction of the portal vein and the splenic vein in pancreaticoduodenectomy for pancreatic cancer. Hepatogastroenterology. 2003;50:856–60.PubMed

20.

Nakao A, Takeda S, Sakai M, Kaneko T, Inoue S, Sugimoto H, et al. Extended radical resection versus standard resection for pancreatic cancer: the rationale for extended radical resection. Pancreas. 2004;28:289–92.PubMedCrossRef

21.

Sasson AR, Hoffman JP, Ross EA, Kagan SA, Pingpank JF, Eisenberg BL. En bloc resection for locally advanced cancer of the pancreas: is it worthwhile? J Gastrointest Surg. 2002;6:147–57.PubMedCrossRef

22.

Yekebas EF, Bogoevski D, Cataldegirmen G et al. En bloc vascular resection for locally advanced pancreatic malignancies infiltrating major blood vessels: perioperative outcome and long-term survival in 136 patients. Ann Surg. 2008;247:300–9.PubMedCrossRef

23.

Adham M, Mirza DF, Chapuis F et al. Results of vascular resections during pancreatectomy from two European centres: an analysis of survival and disease-free survival explicative factors. HBP (Oxford). 2006;8:465–73.

24.

Van Geenen RC, ten Kate FJ, de Wit LT, van Gulik TM, Obertop H, Gouma DJ. Segmental resection and wedge excision of the portal or superior mesenteric vein during pancreatoduodenectomy. Surgery. 2001;129:158–63.PubMedCrossRef

25.

Bachellier P, Nakano H, Oussoultzoglou PD, Weber JC, Boudjema K, Wolf PD, et al. Is pancreaticoduodenectomy with mesentericoportal venous resection safe and worthwhile? Am J Surg. 2001;182:120–9.PubMedCrossRef

26.

Smoot RL, Christein JD, Farnell MB. Durability of portal venous reconstruction following resection during pancreaticoduodenectomy. J Gastrointest Surg. 2006;10:1371–5.PubMedCrossRef

27.

Carrère N, Sauvanet A, Goere D et al. Pancreaticoduodenectomy with mesentericoportal vein resection for adenocarcinoma of the pancreatic head. World J Surg. 2006;30:1526–35.PubMedCrossRef

28.

Fukuda S, Oussoultzoglou E, Bachellier P, Rosso E, Nakano H, Audet M, et al. Significance of the depth of portal vein wall invasion after curative resection for pancreatic adenocarcinoma. Arch Surg. 2007;142:172–9.PubMedCrossRef

29.

Nakao A, Takeda S, Inoue S, Nomoto S, Kanazumi N, Sugimoto H, et al. Indications and techniques of extended resection for pancreatic cancer. World J Surg. 2006;30:976–82.PubMedCrossRef

30.

Lygidakis NJ, Singh G, Bardaxoglou E, et al. Mono-bloc total spleno-pancreaticoduodenectomy for pancreatic head carcinoma with portal-mesenteric venous invasion. A prospective randomized study. Hepatogastroenterology. 2004;51:427–33.

31.

Nakao A, Kaneko T, Takeda S, Inoue S, Harada A, Nomoto S, et al. The role of extended radical operation for pancreatic cancer. Hepatogastroenterology. 2001;48:949–52.PubMed

32.

Ni QX, Zhang QH, Fu DL, Cao GH, Yao QY, Jin C, et al. Curative resection of pancreatic head carcinoma in recent 30 years: report of 377 cases. Hepatobiliary Pancreat Dis Int. 2002;1:126–8.PubMed

33.

Siriwardana HP, Siriwardena AK. Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer. Br J Surg. 2006;93:662–73.PubMedCrossRef

34.

Moore GE, Sako Y, Thomas LB. Radical pancreaticoduodenectomy with resection and reanastomosis of the superior mesenteric vein. Surgery. 1951;30:550–3.PubMed

35.

Asada S, Itaya H, Nakamura K et al. Radical pancreatectomy and portal vein resection. Report of two successful cases with transplantation of portal vein. Arch Surg. 1963;87:609–13.PubMed

36.

Fortner JG. Regional resection of cancer of the pancreas: a new surgical approach. Surgery. 1973;73:307–20.PubMed

37.

Sindelar WF. Clinical experience with regional pancreatectomy for adenocarcinoma of the pancreas. Arch Surg. 1989;1124:127–32.

38.

Yeo CJ, Cameron JL, Lillemoe KD et al. Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma. Part 2: randomized controlled trial evaluating survival, morbidity, and mortality. Ann Surg. 2002;236:355–68.PubMedCrossRef

39.

Fuhrman GM, Leach SD, Staley CA et al. Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group. Ann Surg. 1996;223:154–62.PubMedCrossRef

40.

Leach SD, Lee JE, Charnsangavej C et al. Survival following pancreaticoduodenectomy with resection of the superior mesenteric-portal vein confluence for adenocarcinoma of the pancreatic head. Br J Surg. 1998;85:611–7.PubMedCrossRef

41.

Harrison LE, Klimstra DS, Brennan MF. Isolated portal vein involvement in pancreatic adenocarcinoma A contraindication for resection?. Ann Surg. 1996;224:342–9.PubMedCrossRef

42.

Roder JD, Stein HJ, Siewert JR. Carcinoma of the periampullary region: who benefits from portal vein resection? Am J Surg. 1996;171:170–5.PubMedCrossRef

43.

Wray CJ, Ahmad SA, Matthews JB, Lowy AM. Surgery for pancreatic cancer: recent controversies and current practice. Gastroenterology. 2005;128:1626–41.PubMedCrossRef

44.

Sohn TA, Yeo CJ, Cameron JL et al. Resected adenocarcinoma of the pancreas - 616 patients: results, outcomes, and prognostic indicators. J Gastrointest Surg. 2000;4;567–79.PubMedCrossRef

45.

Nagakawa T, Sanada H, Inagaki M et al. Long-term survivors after resection of carcinoma of the head of the pancreas: significance of histologically curative resection. J Hepatobiliary Pancreat Surg. 2004;11:402–8.PubMedCrossRef

46.

Takai S, Satoi S, Toyokawa H et al. Clinicopathological evaluation after resection for ductal adenocarcinoma of the pancreas: a retrospective, single-institution experience. Pancreas. 2003;26:243–9.PubMedCrossRef

47.

Wagner M, Redaelli C, Lietz M, Seiler CA, Friess H, Büchler MW. Curative resection is the single most important factor determining outcome in patients with pancreatic adencarcinoma. Br J Surg. 2004;94:586–94.CrossRef

48.

Kuhlmann KF, de Castro SM, Wesseling JG et al. Surgical treatment of pancreatic adenocarcinoma: actual survival and prognostic factors in 343 patients. Eur J Cancer. 2004;40:549–58.PubMedCrossRef

49.

Benassai G, Mastrorilli M, Quarto G, Cappiello A, Giani U, Forestieri P, et al. Factors influencing survival after resection for ductal adenocarcinoma of the head of the pancreas. J Surg Oncol. 2000;73:212–8.PubMedCrossRef

50.

Espat NJ. “Aggressive” operations for pancreatic cancer: technical and biologic challenges. World J Surg. 2006;30:983–4.CrossRef

51.

Smith SL, Rajan PS. Imaging of pancreatic adenocarcinoma with emphasis on multidetector CT. Clin Radiol. 2004;59:26–38.PubMedCrossRef

52.

Furukawa H, Kosuge T, Mukai K et al. Helical computed tomography in the diagnosis of portal vein invasion by pancreatic head carcinoma. Usefulness for selecting surgical procedures and predicting the outcome. Arch Surg. 1998;133:61–5.PubMedCrossRef

53.

Brügel M, Link TM, Rummeny EJ, Lange P, Theisen J, Dobritz M. Assessment of vascular invasion in pancreatic head cancer with multislice spiral CT: value of multiplanar reconstructions. Eur Radiol. 2004;14:1188–95.PubMedCrossRef

54.

Soriano A, Castells A, Ayuso C et al. Preoperative staging and tumor resectability assessment of pancreatic cancer: prospective study comparing endoscopic ultrasonography, helical computed tomography, magnetic resonance imaging, and angiography. Am J Gastroenterol. 2004;99:492–501.PubMedCrossRef

55.

Lu DS, Reber HA, Krasny RM, Kadell BM, Sayre J. Local staging of pancreatic cancer: criteria for unresectability of major vessels as revealed by pancreatic-phase, thin-section helical CT. Am J Roentgenol. 1997;168:1439–43.

56.

Kulig J, Popiela T, Zajac A, Kłek S, Kołodziejczyk P. The value of imaging techniques in the staging of pancreatic cancer. Surg Endosc. 2005;19:361–5.PubMedCrossRef

57.

Megibow AJ, Zhou XH, Rotterdam H et al. Pancreatic adenocarcinoma: CT versus MR imaging in the evaluation of resectability - Report of the Radiology Diagnostic Oncology Group. Radiology. 1995;195:327–32.PubMed

58.

Fritscher-Ravens A, Knoefel WT, Krause C, Swain CP, Brandt L, Patel K. Three-dimensional linear endoscopic ultrasound-feasibility of a novel technique applied for detection of vessel involvement of pancreatic masses. Am J Gastroenterol. 2005;100:1296–302.PubMedCrossRef

59.

Varadhachary GR, Tamm EP, Abbruzzese JL et al. Borderline resectable pancreatic cancer: definitions, management, and role of preoperative therapy. Ann Surg Oncol. 2006;13:1035–46.PubMedCrossRef

60.

Machado MC, Figueira ER, Machado MA, Jukemura J, Cunha JE, Perini MV, Bacchella T. Portal vein resection: a modified technique for reconstruction after pancreaticoduodenectomy. J Surg Oncol. 2004;88:52–4.PubMedCrossRef

61.

Koniaris LG, Schoeniger LO, Kovach S, Sitzmann JV. The quick, no-twist, no-kink portal confluence reconstruction. J Am Coll Surg. 2003;196:490–4.PubMedCrossRef

62.

Fujisaki S, Tomita R, Fukuzawa M. Utility of mobilization of the right colon and the root of the mesentery for avoiding vein grafting during reconstruction of the portal vein. J Am Coll Surg. 2001;193:576–78.PubMedCrossRef

63.

Misuta K, Shimada H, Miura Y et al. The role of splenomesenteric vein anastomosis after division of the splenic vein in pancreatoduodenectomy. J Gastrointest Surg. 2005;9:245–53.PubMedCrossRef

64.

Chiu KM, Chu SH, Chen JS, Li SJ, Chan CY, Chen KS. Spiral saphenous vein graft for portal vein reconstruction in pancreatic cancer surgery. Vasc Endovasc Surg. 2007;41:149–52.CrossRef

65.

Ohwada S, Hamada K, Kawate S et al. Left renal vein graft for vascular reconstruction in abdominal malignancy. World J Surg. 2007;31:1215–20.PubMedCrossRef

66.

Smoot RL, Christein JD, Farnell MB. An innovative option for venous reconstruction after pancreaticoduodenectomy: the left renal vein. J Gastrointest Surg. 2007;11:425–31.PubMedCrossRef

67.

Fleming JB, Barnett CC, Clagett P. Superficial femoral vein as a conduit for portal vein reconstruction during pancreaticoduodenectomy. Arch Surg. 2005;140:698–701.PubMedCrossRef

68.

Tashiro S, Uchino R, Hiraoka T et al. Surgical indication and significance of portal vein resection in biliary and pancreatic cancer. Surgery. 1991;109:481–7.PubMed

69.

Tuech JJ, Pessaux P, Arnaud JP. Portal vein resection in pancreatic head carcinoma. Part 1: technical considerations. Hepatogastroenterology. 2001;48:884–7.PubMed

70.

Bold RJ, Charnsangavej C, Cleary KR et al. Major vascular resection as part of pancreaticoduodenectomy for cancer: radiologic, intraoperative, and pathologic analysis. J Gastrointest Surg. 1999;3:233–43.PubMedCrossRef

71.

Yeo CJ, Cameron JL, Lillemoe KD et al. Pancreaticoduodenectomy for cancer of the head of the pancreas 201 patients. Ann Surg. 1995;221:721–31.PubMedCrossRef

72.

Winter JM, Cameron JL, Campbell KA et al. 1423 Pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg. 2006;10:1199–211.PubMedCrossRef

73.

Balcom JH, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg. 2001;136:391–8.PubMedCrossRef

74.

Cameron JL, Riall TS, Coleman J, Belcher KA. One thousand consecutive pancreaticoduodenectomies. Ann Surg. 2006;244:10–5.PubMedCrossRef

75.

Yeo CJ, Cameron JL, Sohn TA et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg. 1997;226:248–57.PubMedCrossRef

76.

Büchler MW, Wagner M, Schmied BM, Uhl W, Friess H, Z’graggen K. Changes in morbidity after pancreatic resection. Toward the end of completion pancreatectomy. Arch Surg. 2003;138:1310–4.PubMedCrossRef

77.

Richter A, Niedergethmann M, Sturm JW, Lorenz D, Post S, Trede M. Long-term results of partial pancreaticoduodenectomy for ductal adenocarcinoma of the pancreatic head: 25-year experience. World J Surg. 2003;27:324–9.PubMedCrossRef

78.

Gouma DJ, van Geenen RC, van Gulik TM, de Haan RJ, de Wit LT, Busch OR, et al. Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume: toward the end of completion pancreatectomy. Ann Surg. 2000;232:786–95.PubMedCrossRef

79.

McPhee JT, Hill JS, Whalen GF et al. Perioperative mortality for pancreatectomy: a national perspective. Ann Surg. 2007;246:246–53.PubMedCrossRef

80.

Adam U, Makowiec F, Riediger H et al. Risk factors for complications after pancreatic head resection. Am J Surg. 2004;187:201–8.PubMedCrossRef

81.

Leon LR Jr, Hughes JD, Psalms SB, Guerra R, Biswas A, Prasad A, et al. Portomesenteric reconstruction during Whipple procedures: review and report of a case. Vasc Endovasc Surg. 2008;41:537–46.CrossRef

82.

National Cancer Institute, Pancreatic Cancer Treatment. http://www.cancer.gov/cancertopics/pdq/treatment/pancreatic/HealthProfessional. Accessed 7 Sept 2008.

83.

National Comprehensive Cancer Network (NCCN) clinical practice guidelines in oncology. Pancreatic adenocarcinoma. http://www.nccn.org/professionals/physician_gls/PDF/pancreatic.pdf. Accessed 7 Sept 2008.

Title: Does Portal-Superior Mesenteric Vein Invasion Still Indicate Irresectability for Pancreatic Carcinoma?
Authors: Giovanni Ramacciato, MD, FACS
Paolo Mercantini, MD, PhD
Niccolò Petrucciani, MD
Valentina Giaccaglia, MD
Giuseppe Nigri, MD
Matteo Ravaioli, MD
Matteo Cescon, MD
Alessandro Cucchetti, MD
Massimo Del Gaudio, MD
Publication date: 01-04-2009
Publisher: Springer-Verlag
Published in: Annals of Surgical Oncology / Issue 4/2009
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI: https://doi.org/10.1245/s10434-008-0281-8

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Does Portal-Superior Mesenteric Vein Invasion Still Indicate Irresectability for Pancreatic Carcinoma?

Abstract

Background

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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