Pancreaticoduodenectomy and Vascular Resection: Persistent Controversy and Current Recommendations

Most physicians do not understand the difference between the historical experience with regional pancreatectomy and isolated tumor resection of the SMV, PV or superior mesenteric–portal vein (SMPV) confluence performed as part of a gross complete resection of the primary tumor. Vascular resection at the time of PD was initially performed in an attempt to improve survival duration by performing an en bloc resection of the pancreas and surrounding structures.2 This concept of regional pancreatectomy involved the systematic resection of major peripancreatic vascular structures together with wide soft tissue clearance. Contrary to the beliefs of Fortner and others, radical PD has not been demonstrated to confer a survival benefit.3,4 Most physicians and many surgeons assume that the negative experience with regional pancreatectomy also applies to patients with isolated tumor extension that involves a short segment of the SMV or PV.

The addition of vascular resection and reconstruction to PD increases the complexity of the operation and is not something that all pancreatic surgeons feel capable of performing. This issue may be amplified by the limited experience of many surgeons with the technical aspects of vascular surgery and the potential for perioperative death and major morbidity that exists with pancreatic surgery for cancer.

The published data which examines vascular resection as a prognostic factor for survival duration is of poor quality. The majority of such reports (including those analyzed by Giovanni and colleagues) did not contain a description of the process used to differentiate complete (R0/R1) from incomplete (R2) gross resections. Even in those patients who may have undergone a complete gross resection, most manuscripts failed to incorporate prospective standardized pathologic evaluation and reporting of the PD specimen to differentiate R0 from R1 resections. This is a critically important consideration because the intraoperative finding of venous adherence to the tumor is often unexpected and the surgeon may then attempt to separate the SMPV confluence from the pancreatic head. When this maneuver is unsuccessful, the surgeon is left with either a grossly positive margin or an inadvertent venotomy. Venous injury often results in uncontrolled hemorrhage and the necessity for rapid removal of the tumor without proper attention to the SMA dissection; it is easy to appreciate how such cases may result in an R2 resection. In patients with grossly incomplete resections, and without any form of preoperative therapy, it is likely that their poor survival is due to the persistent adenocarcinoma at the SMA or celiac origin, not the presence of a vascular reconstruction. In the absence of prospective evaluation of the SMA margin (performed by very few of the papers analyzed by Giovanni and colleagues), reports of venous resection during PD are impossible to interpret. Further, even if the SMA margin is assessed accurately, the pathologist cannot differentiate an R2 from an R1 resection; the surgeon’s operative note must state whether or not a gross complete resection was performed.5