Ann Hepatobiliary Pancreat Surg.  2018 Aug;22(3):261-268. 10.14701/ahbps.2018.22.3.261.

Vein resection in patients with adenocarcinoma of the head of pancreas adherent to the portomesenteric venous axis is beneficial despite a high rate of R1 resection

• Cherukuru
• Govil S
• Vij M
• Rela M

• KMID: 2420615
• DOI: http://doi.org/10.14701/ahbps.2018.22.3.261

Abstract

BACKGROUNDS/AIMS
En-bloc vein resection (VR) for pancreatic ductal adenocarcinoma (PDAC) of the head of pancreas adherent to the portomesenteric axis benefits patients when the vein wall is not infiltrated by tumour and an R0 resection is achieved, albeit at the expense of greater morbidity and mortality.
METHODS
A retrospective review of pancreaticoduodenectomy for PDAC over 6 years was conducted. Patients were divided into a standard resection group (Group SR) and simultaneous vein resection group (Group VR) and compared for outcome.
RESULTS
The study group consisted of 41 patients (Group SR 15, Group VR 26). VR was performed by end-to-end reconstruction in 12 patients and with interposition grafts in 13 cases (autologous vein in 10, PTFE in 3). R1 resections occurred in 49% patients, with the superior mesenteric artery margin most commonly involved. Patients with Ishikawa grade III and IV vein involvement were more likely to carry a positive SMA margin (p=0.04). Involvement of the splenoportal junction was associated with a significantly greater risk of pancreatic transection margin involvement. No difference in morbidity was seen between the groups. Median survival in the entire group of patients was 17 months and did not vary significantly between the groups. The only significant predictor of survival was lymph node status.
CONCLUSIONS
Venous involvement by proximal PDAC is indicative of tumor location rather than tumor biology. VR improves outcomes in patients with tumor adhesion to the portomesenteric venous axis despite a high incidence of R1 resections and greater operative mortality.

Keyword

Pancreatic cancer; Vein involvement; Borderline resectable; Vein resection; Survival

MeSH Terms

Adenocarcinoma*
Biology
Head*
Humans
Incidence
Lymph Nodes
Mesenteric Artery, Superior
Mortality
Pancreas*
Pancreatic Ducts
Pancreatic Neoplasms
Pancreaticoduodenectomy
Polytetrafluoroethylene
Retrospective Studies
Transplants
Veins*
Polytetrafluoroethylene

Figure

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  Fig. 1 Comparison of patient survival between the standard resection (SR) group and vein resection (VR) group.

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  Fig. 2 Comparison of patient survival according to lymph node involvement.

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  Fig. 3 Comparison of patient survival according to histological vein wall involvement.

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  Fig. 4 Comparison of patient survival following R0 vs. R1 resection.

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  Fig. 5 Comparison of patient survival according to type of vascular reconstruction.

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