Resection of Portovenous Structures to Obtain Microscopically Negative Margins during Pancreaticoduodenectomy for Pancreatic Adenocarcinoma is Worthwhile

Abstract

Locally advanced pancreatic adenocarcinoma may require resections of the portal vein and/or its major tributaries to achieve tumor extirpation, albeit with the potential for increased morbidity and mortality. However, major venous resections can impart complete tumor extirpation and thereby a survival advantage compared with resections with residual microscopic disease. This study was undertaken to determine if resection of the portal vein and/or its splenic or superior mesenteric venous (SMV) tributaries is a worthwhile endeavor. Since 1995, patients undergoing pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma have been prospectively followed. The impact of portovenous resections (portal vein, SMV, and/or splenic vein) on survival was evaluated using survival curve analysis (Mantel-Cox test). Margins were codified as R0 or R1 and data are presented as median, mean ± SD where appropriate. For 220 patients undergoing PD for pancreatic adenocarcinoma, survival was 17 months. Patients undergoing RO resections had improved survival relative to patients undergoing R1 resections (20 vs 13 months, P < 0.03). Concomitant portovenous resections were undertaken in 48 patients. There was no difference in survival after PD without portovenous resection (17 months) versus PD with portovenous resection (18 months). Resections with complete tumor extirpation (i.e., RO resections) provide superior long-term survival; all efforts to obtain RO resections should be undertaken. Portovenous resections during pancreaticoduodenectomy can be undertaken safely and are worthwhile when complete tumor extirpation is attainable.

Radiologic and intraoperative detection of need for mesenteric vein resection in patients with adenocarcinoma of the head of the pancreas

“…Many case series have documented the feasibility of MVR during a Whipple procedure to remove cancer invading the veins 1–18 . The approaches used to achieve these resections were developed independently within centres with specific interest in locally invasive cancers of the pancreas.…”

“…In addition, the literature is characterized by important differences in whether and how study variables are reported, in staging methods and in techniques of pathologic evaluation of specimens. For instance, many studies report the incidence of R1 resections, 5,9,10,13,14,16,23–29 but few report the method used to determine resection margin status 5,16,27–29 . Only a minority of papers report using a specific system to analyse pathology specimens.…”

“…In some cases, only the ‘retroperitoneal margin’ or area of pancreatic tissue adjacent to the small mesenteric artery was inked and analysed 5,27,28 . In other cases, intraoperative frozen sectioning was utilized to determine negative margins 5,16 . Very few groups report the status of all margins 9,16,28 and whether any patients had residual disease at the resected portal vein margin 13,16 .…”

“…In other cases, intraoperative frozen sectioning was utilized to determine negative margins 5,16 . Very few groups report the status of all margins 9,16,28 and whether any patients had residual disease at the resected portal vein margin 13,16 . None of this is surprising in what is essentially a case series literature.…”

“…Early in the evolution of the Whipple procedure, venous invasion was considered to be a contraindication to resection. However, during the last 20 years many case series have documented the feasibility of mesenteric venous resection (MVR) during a Whipple procedure to remove cancer invading the veins 1–18 . These studies have been summarized in three systematic reviews 19–21 .…”