Clinical significance of portal invasion by pancreatic head carcinoma

doi:10.1016/S0039-6060(05)80229-6

Surgery

Volume 117, Issue 1, January 1995, Pages 50-55

https://doi.org/10.1016/S0039-6060(05)80229-6 Get rights and content

Background. The purpose of the present study was to clarify the indication of aggressive surgery for panceatic head carcinoma.

Methods. Laparatomy was performed in 153 patients with carcinoma, 101 of whom underwent resection of the carcinoma. With histologic examination the degree of carcinoma invasion into the portal vein was classified into grades 0, I, or II according to the depth of invasion by the carcinoma. Macroscopic carcinoma invasion into portal vein was classified into types A, B, C, or D according to preoperative findings on the portal phase of superior mesenteric angiography or intraoperative portography.

Results. Macroscopic findings correlated with the histologic invasion grades. The 1-year survival rate was 39.6% in grade 0, 11.3% in grade I, and 5.5% in grade II cases. The survival rates of patients with type A (p<0.01), B (p<0.05), and C invasion (p<0.01) were higher than those of patients who did not undergo resection; however, no significant difference in the survival rates between patients who did not undergo resection and patients with type D invasion was observed.

Conclusions. For locally advanced carcinoma of the pancreatic head or entire pancreas, patients with type D invasion have no indication of aggressive surgery.

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International Study Group of Pancreatic Surgery type 3 and 4 venous resections in patients with pancreatic adenocarcinoma:the Paoli-Calmettes Institute experience
2019, European Journal of Surgical Oncology
A new neoadjuvant regimen, together with more aggressive surgeries, appears to have increased the resectability rate in patients with pancreatic ductal adenocarcinoma (PDAC). Our study aimed to evaluate the outcomes of patients who underwent venous resection (VR) during pancreatectomies for PDAC.
Between 2005 and 2017, 130 patients underwent pancreatectomies with type 3 or 4 (i.e., segmental resection without or with graft interposition, respectively) VR for PDAC. Patients’ characteristics, surgical techniques, perioperative management, pathological findings, and outcomes were recorded and compared during 2 inclusion periods: the landmark year for the introduction of the FOLFIRINOX regimen and the hyperspecialization of our pancreatic-surgery team was 2010.
Performance of pancreatectomies with VR steadily increased through the 2 inclusion periods. In the overall series (n = 130), the median overall survival time and the 5-year survival proportion were 26.3 months and 21%, respectively. Upon multivariate analysis, ASA score 3 (P = 0.01) and R1 resection margins (P < 0.01) were found to be negative independent factors influencing survival. Patients who underwent upfront VR (n = 47) had survival rates similar to those of patients who received neoadjuvant treatment (n = 83). After 2010, more complex VR were performed; however, no difference was found between the 2 periods with respect to postoperative courses, pathologic findings, or survival after a matching process based on patients’ characteristics and tumor stages.
Over the last 2 decades, VR during pancreatectomy has been confirmed as a safe procedure despite the increase in technical complexity. Disappointingly, we did not observe any dramatic survival improvement.
Portal encasement: Significant CT findings to diagnose local recurrence after pancreaticoduodenectomy for pancreatic cancer
2018, Pancreatology
Citation Excerpt :
Pancreatic ductal adenocarcinoma (PDAC) recurs frequently in the early postoperative period even after curative resection [1–8].
To demonstrate the utility of portal encasement as a criterion for early diagnosis of local recurrence (LR) after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC).
A total of 61 patients who underwent PD for PDAC were included in this retrospective study. Portal stenosis was evaluated by sequential postoperative computed tomography (CT) scans and correlated with disease recurrence. In addition to the conventional LR diagnostic criterion of a growing soft tissue mass, LR was evaluated using portal encasement as an additional diagnostic criterion. Portal encasement was defined as progressive stenosis of the portal system accompanied by a soft tissue mass, notwithstanding the enlargement of the mass.
Benign portal stenosis was found on the first postoperative CT imaging in 16 patients. However, stenosis resolved a median of 81 days later in all but one patient whose stenosis was due to portal reconstruction during PD. Portal encasement could be distinguished from benign portal stenosis based on the timing of emergence of the portal stenosis. Portal encasement developed in 13 of the 19 patients with LR, including 6 patients in whom the finding of portal encasement led to the diagnosis of LR a median of 147 days earlier with our diagnostic criterion compared with the conventional diagnostic criteria.
Portal encasement should be considered as a promising diagnostic criterion for earlier diagnosis of LR after PD for PDAC.
The falciform ligament as a graft for portal–superior mesenteric vein reconstruction in pancreatectomy
2017, Journal of Surgical Research
Tumor invasion or adherence to the portal vein–superior mesenteric vein (PV/SMV) may be encountered during pancreatic surgery. In such cases, venous resection and reconstruction might be required for complete resection of the tumor. We report an innovative technique in which the graft for PV/SMV reconstruction was made with the falciform ligament.
Between May 2011 and July 2016, PV/SMV reconstruction with a falciform ligament graft was performed in 10 cases during pancreatectomy. Among these cases, including six cases with a patch graft and four cases with a conduit graft. Retrospective reviews of medical records and radiologic studies were performed.
Ten patients with pancreatobiliary cancer underwent en bloc tumor resection with concurrent PV/SMV resection and reconstruction with a falciform ligament graft. There were six males and four females, and the mean age was 65.3 ± 9.4 (48-80) y. Using Doppler ultrasound examination, all 10 grafts were shown to be patent at postoperative 2 wk. However, occlusion was found in one case with conduit graft and stenosis in the other three cases with conduit graft using enhanced computed tomography at postoperative 2 mo. Complete patency was shown in three of six cases with patch graft and stenosis in the other three cases at 2 mo after the operation. Although occlusion or stenosis of the grafts was observed, no severe adverse events occurred, and normal liver function was discovered in all 10 cases at postoperative 2 mo.
Falciform ligament grafts might be considered for reconstruction of PV/SMV in the absence of appropriate vascular grafts.
Splenic vein reconstruction is unnecessary in pancreatoduodenectomy combined with resection of the superior mesenteric vein–portal vein confluence according to short-term outcomes
2017, HPB
Citation Excerpt :
SMPV confluence resection combined with PD (SMPVrPD) without splenic vein (SV) reconstruction is considered to be associated with an increased risk of left-sided portal hypertension (LSPH) because of complications such as hemorrhage from the gastric remnant mucosa, esophageal and gastric varices, splenomegaly, and thrombocytopenia.11,12 Since the development of catheter bypass of the PV using antithrombogenic material in 1981,13 we have been performing SMPVrPD without SV reconstruction for more than 30 years and have experienced no severe clinical problems associated with LSPH.2,8,14,15 However, it remains controversial whether SV reconstruction is required during SMPVrPD to prevent LSPH.1,5–8,10–22
Superior mesenteric vein–portal vein confluence resection combined with pancreatoduodenectomy (SMPVrPD) is occasionally required for resection of pancreatic head tumors. It remains unclear whether such situations require splenic vein (SV) reconstruction for decompression of left-sided portal hypertension (LSPH).
The data from 93 of 104 patients who underwent pancreatoduodenectomy (PD) for pancreatic head malignancies were reviewed. Surgical outcomes in three groups—standard PD (control group), PD combined with vascular resection and SV preservation (SVp group), and SMPVrPD with SV resection (SVr group)—were compared. The influence of division and preservation of the two natural confluences (left gastric vein–portal vein and/or inferior mesenteric vein–SV confluences) on portal hemodynamics were evaluated using three-dimensional computed tomographic portography.
No mortality occurred. The morbidity rates were not significantly different among the three groups (18/43, 8/21, and 7/29, respectively; p = 0.306). In the SVr group, three patients had gastric remnant venous congestion, and three had esophageal varices without hemorrhagic potential. No patients had splenomegaly, or severe or prolonged thrombocytopenia. These LSPH-associated findings were less frequently observed when the two confluences were preserved.
SMPVrPD without SV reconstruction can be safely conducted. Additionally, preservation of these two confluences may reduce the risk of LSPH.
Surgical resection of pancreatic head cancer: What is the optimal extent of surgery?
2016, Cancer Letters
Extent of surgery should depend on curability. Improvements in surgical techniques have resulted in surgeons seeking to perform more radical surgery. To date, five randomized controlled trials (RCT) have analyzed the benefits of extended lymphadenectomy for pancreatic head cancer, but none has shown that extended lymphadenectomy enhances patient survival. As most patients with pancreatic cancer have microscopic, locally advanced disease that cannot be cured by surgery alone, local tumor control by extended lymphadenectomy cannot overcome the negative aspects of pre-existing lymph node metastasis. The most important factor improving overall survival following pancreatoduodenectomy in patients with pancreatic head cancer is proper systemic control of the disease rather than extensive local control. The long-term survival outcomes following adjuvant treatment in a large multi-center RCT suggest the need for aggressive systemic treatment. More attention must be paid to the benefits of adjuvant treatment, not only focusing on technical R0 resection. Surgical strategies for patients with pancreatic head cancer require more flexibility, with extent of surgery customized to individual patients, depending on tumor location and disease severity.
Technical risk factors for portal vein reconstruction thrombosis in pancreatic resection
2015, Journal of Vascular Surgery
Vascular reconstruction can facilitate pancreas tumor resection, but optimal methods of reconstruction are not well studied. We report our results for portal vein reconstruction (PVR) for pancreatic resection and determinants of postoperative patency.
We identified 173 patients with PVR in a prospective database of 6522 patients who underwent pancreatic resection at our hospital from 1970 to 2014. There were 128 patients who had >1 year of follow-up with computed tomography imaging. Preoperative, intraoperative, and postoperative factors were recorded. Patients with and without postoperative PVR thrombosis were compared by univariable, multivariable, and receiver operating characteristic curve analyses.
The survival of patients was 100% at 1 month, 88% at 6 months, 66% at 1 year, and 39% on overall median follow-up of 310 days (interquartile range, 417 days). Median survival was 15.5 months (interquartile range, 25 months); 86% of resections were for cancer. Four types of PVR techniques were used: 83% of PVRs were performed by primary repair, 8.7% with interposition vein graft, 4.7% with interposition prosthetic graft, and 4.7% with patch. PVR patency was 100% at 1 day, 98% at 1 month, 91% at 6 months, and 83% at 1 year. Patients with PVR thrombosis were not significantly different from patients with patent PVR in age, survival, preoperative comorbidities, tumor characteristics, perioperative blood loss or transfusion, or postoperative complications. They were more likely to have had preoperative chemotherapy (53% vs 9%; P < .0001), radiation therapy (35% vs 2%; P < .0001), and prolonged operative time (618 ± 57 vs 424 ± 20 minutes; P = .002) and to develop postoperative ascites (76% vs 22%; P < .001). Among patients who developed ascites, 38% of those with PVR thrombosis did so in the setting of tumor recurrence at the porta detected on imaging, whereas among patients with patent PVR, 50% did so (P = .73). Patients with PVR thrombosis were more likely to have had prosthetic graft placement compared with patients with patent PVRs (18% vs 2.7%; P = .03; odds ratio [OR], 7.7; 95% confidence interval [CI], 1.4-42). PVR patency overall was significantly worse for patients who had an interposition prosthetic graft reconstruction (log-rank, P = .04). On multivariable analysis, operative time (OR, 1.01; 95% CI, 1.01-1.02) and prosthetic graft placement (OR, 8.12; 95% CI, 1.1-74) were independent predictors of PVR thrombosis (C statistic = 0.88).
Long operative times and use of prosthetic grafts for reconstruction are risk factors for postoperative portal vein thrombosis. Primary repair, patch, or vein interposition should be preferentially used for PVR in the setting of pancreatic resection.

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View full text

Clinical significance of portal invasion by pancreatic head carcinoma

Am J Surg

Pancreatic diagnostic accuracy and survival statistics

Cancer

The annual report of pancreatic cancer

Pancreatic Cancer Register Committe. Japan Pancreas Society

Angiographic evaluation of pancreatic disease

Radiology

Temporal portosystemic bypass with the use of the heparinized hydrophilic catheter

Jpn J Artif Organs

Total pancreatectomy accompanied by portal vein resection using catheter-bypass of the portal vein

Shujutsu (Operation)

Isolated pancreatectomy for pancreatic head carcinoma using catheter bypass of the portal vein

Hepato-Gastroenterol

Portal vein resection with a new antithrombogenic catheter

Surgery

Surgical principle for pancreatic cancer: regional total and subtotal pancreatectomy

Cancer

General rules for surgical and pathological studies on cancer of the pancreas