Regional pancreatoduodenectomy versus standard pancreatoduodenectomy with portal vein resection for pancreatic ductal adenocarcinoma with portal vein invasion

Abstract

Background: Pancreatoduodenectomy (PD) with portal vein resection (PVR) is a standard operation for pancreatic ductal adenocarcinoma (PDAC) with portal vein (PV) invasion, but positive margin rates remain high. It was hypothesized that regional pancreatoduodenectomy (RPD), in which soft tissue around the PV is resected en bloc, could enhance oncological clearance and survival.Methods: This retrospective study included consecutive patients who underwent PD with PVR between January 2005 and December 2016 in a single high-volume centre. In standard PD (SPD) with PVR, the PV was skeletonized and the surrounding soft tissue dissected. In RPD, the retropancreatic segment of the PV was resected en bloc with its surrounding soft tissue. The extent of lymphadenectomy was similar between the procedures.Results: A total of 268 patients were included (177 SPD, 91 RPD). Tumours were more often resectable in patients undergoing SPD (60⋅5 per cent versus 38 per cent in those having RPD; P = 0⋅014), and consequently they received neoadjuvant therapy less often (7⋅9 versus 25 per cent respectively; P < 0⋅001). R0 resection was achieved in 73 patients (80 per cent) in the RPD group, compared with 117 (66⋅1 per cent) of those in the SPD group (P = 0⋅016), although perioperative outcomes were comparable between the groups. Median recurrence-free (RFS) and overall (OS) survival were 17 and 32 months respectively in patients who had RPD, compared with 11 and 21 months in those who had SPD (RFS: P = 0⋅003; OS: P = 0⋅004).Conclusion: RPD is as safe and feasible as SPD, and may increase the survival of patients with PDAC with PV invasion.

Extent of venous resection during pancreatectomy—finding the balance of technical possibility and feasibility

“…Even though the rest three types seem to have a lower risk of early graft thrombosis (<30 days) (2.5-6.7%) than that of synthetic grafts (7.5%), thrombosis occurs with all types of grafts. Considering this concern, some surgeons might prefer to adopt the direct end-to-end anastomosis approach for 5 cm or more PV/SMV resections (5,(11)(12)(13). Zhang et al reported that direct end-to-end anastomosis for 5 to 7 cm of long-segment PV/SMV resection by performing tension-reducing liver mobilization and the Cattell-Braasch maneuver at the anastomotic site was possible without encountering complications (11).…”

“…Median length of resected vein was 40 mm (range, 20-80 mm). Antiplatelet or anticoagulation therapy was rarely used (5). We would like to present two approaches that aim for higher success in direct end-to-end anastomosing of long segmental veins.…”

“…tumors surrounding soft tissue. This aggressive strategy could be justified by the favorable short-term outcomes of low mortality, low rate of thrombosis, and better long-term prognosis (the median overall survival: 25.7 months) (5). Similarly, Terasaki and colleagues performed 135 concomitant vein resections out of 225 overall PDs for PC (60.0%) and reported excellent short-and long-term outcomes with only 0.8% of patient experiencing stenosis within 30 days postoperatively and 0.8% of mortality after vein resection (10).…”

“…Since Dr. Fortner and colleagues first reported the concept and results of "regional pancreatectomy", extensive pancreatectomies combined with major vascular resection and reconstruction have been gradually introduced and improved around the world (2,3). The introduction of effective multi-agent drugs, such as FOLFIRINOX or gemcitabine/nab-paclitaxel serves as a major turning point in modern treatment for PC as pancreatectomies with vein resections have become more actively adopted at high-volume centers, accomplishing low rates of mortality (0.7-5.2%) (4,5). According to the current Review Article…”

Radical Resection for Locally Advanced Pancreatic Cancers in the Era of New Neoadjuvant Therapy—Arterial Resection, Arterial Divestment and Total Pancreatectomy

“…The superiority of planned en-bloc portal vein resection in obtaining R0 to unplanned venous resection after a test dissection was recently documented [ 93 ]. The en-bloc approach is exactly the principle of regional pancreatectomy suggested by Fortner et al [ 7 ], and the reappraisal of regional en-bloc resection has been reported, such as for portal vein resection [ 94 ]. If the safety of AR is guaranteed, the same theory should be justified in SMA resection as well.…”