Pancreatoduodenectomy for bile duct and ampullary cancer

Pylorus-preserving pancreatoduodenectomy has become a standard operation for distal and middle bile duct cancers. Bile duct cancer typically extends longitudinally and invades vertically. It frequently metastasizes to the lymph nodes and infiltrates the perineural spaces. The presence of residual cancer in the bile duct stump and lymph node metastases are significant prognostic factors. Negative surgical margins and D2 lymph node dissection are necessary for curative resection. The clinical course after portal vein resection for bile duct cancer with portal vein invasion is better than that of non-resectable bile duct cancer. Portal vein resection can therefore be useful. The efficacy of prophylactic portal vein resection is unclear. We describe here our methods for performing pylorus-preserving pancreatoduodenectomy for bile duct cancer

Mesenteric-Portal Vein Resection during Pancreatectomy for Pancreatic Cancer

The aim of the present study was to determine the outcome of patients undergoing pancreatic resection with (VR+) or without (VR 12) mesenteric-portal vein resection for pancreatic carcinoma. Between January 1998 and December 2012, 241 patients with pancreatic cancer underwent pancreatic resection: in 64 patients, surgery included venous resection for macroscopic invasion of mesenteric-portal vein axis. Morbidity and mortality did not differ between the two groups (VR+: 29% and 3%; VR 12: 30% and 4.0%, resp.). Radical resection was achieved in 55/64 (78%) in the VR+ group and in 126/177 (71%) in the VR 12 group. Vascular invasion was histologically proven in 44 (69%) of the VR+ group. Survival curves were not statistically different between the two groups. Mean and median survival time were 26 and 15 months, respectively, in VR 12 versus 20 and 14 months, respectively, in VR+ group . In the VR+ group, only histologically proven vascular invasion significantly impacted survival , while, in the VR 12 group, R0 resection and tumor\u2019s grading significantly influenced long-term survival. Vascular resection during pancreatectomy can be performed safely, with acceptable morbidity and mortality. Long-term survival was the same, with or without venous resection. Survival was worse for patients with histologically confirmed vascular infiltration

Изолированная резекция вены в хирургическом лечении протоковой карциномы поджелудочной железы как фактор резектабельности

Background. Pancreatic ductal carcinoma (PDC) with involvement of the superior mesenteric vein (SMV) or/ and portal vein (PV) remains a discussible subject. We have evaluated vein invasion as a criterion of borderline resectability and long-term outcome. Material and methods. In our center, 68 patients underwent either 65 standard pancreatoduodenal resections or 3 pancreatoduodenectomies for PDC. Resection of SMV/PV was performed in 18 cases (26.5 %). Three patients received neoadjuvant chemotherapy (NACT), and adjuvant chemotherapy (ACT) was assigned to 37 patients (54.4 %). Results. Morbidity (42.0 vs 50.0 %, р=0.590) and mortality rates (4.0 vs 16.7 %, р=0.111) had no significant differences in groups of standard and angioplasty operations respectively. ACT was completed in 10 (16.7 %) patients only. There was true vein invasion in 12 of 18 patients with vein resection. рN+ (р=0.012) and angioplasty by itself (р<0.001) were found out as independent predictors of overall survival (OS). the median OS was 9.4 mo in patients with vein resection. in the group of standard operations, the median OS was 26.9 mo (р<0.001). The median OS in patients with vein resection and complete chemotherapy was 17.7 mo in contrast to 8.9 mo in those who did not receive chemotherapy (р=0.439). Conclusions. PDR with vein resection and incomplete chemotherapy cannot be regarded as a reasonable procedure. PDR with vein resection may be appropriate after efficient NACT.Лечение протоковой карциномы поджелудочной железы (ПКПЖ) с вовлечением верхней брыжеечной и/или воротной вены остается предметом дискуссий. Мы оценили венозную инвазию как критерий пограничной резектабельности и отдаленного прогноза заболевания. Материал и методы. В нашем центре 68 пациентов оперированы в объеме стандартной панкреатодуоденальной резекции (n=65) или панкреатодуоденэктомии (n=3) по поводу ПКПЖ. В 18 (26,5 %) наблюдениях выполнена резекция верхней брыжеечной и/или воротной вены. Неоадъювантную химиотерапию (НАХТ) получили 3 пациента, адъювантная химиотерапия (АХТ) начата у 37 (54,4 %) пациентов. Результаты. Частота послеоперационных осложнений в группе стандартных операций и ангиопластических операций (42,0 против 50,0 %, р=0,590), частота летальных исходов (4 против 16,7 %, р=0,111) значимо не отличались. АХТ закончена полностью у 10 (16,7 %) пациентов. Истинная инвазия опухоли отмечена у 12 из 18 пациентов с резекцией вены. Независимыми предикторами общей выживаемости (ОВ) были рN+ (р=0,012) и наличие ангиопластики (р=0,000). У пациентов с резекцией вены медиана ОВ составила 9,4 мес. В группе стандартных ПДР медиана ОВ была 26,9 мес (р=0,000). У пациентов с резекцией вены медиана ОВ при законченной химиотерапии составила 17,7 мес, без химиотерапии – 8,9 мес (р=0,439). Заключение. ПДР с резекцией вены и отсутствием или незавершенной химиотерапией может рассматриваться как неоправданная операция. Данную операцию целесообразно выполнять после эффективной НАХТ

Solid-pseudopapillary tumor of the pancreas: A single center experience

open6noAim of this study was to review the institutional experience of solid-pseudopapillary tumors of the pancreas with particular attention to the problems of preoperative diagnosis and treatment. From 1997 to 2013, SPT was diagnosed in 18 patients among 451 pancreatic cystic neoplasms (3.7%). All patients underwent preoperative abdominal ultrasound, computed assisted tomography, and tumor markers (CEA and CA 19-9) determinations. In some instances, magnetic resonance, positron emission tomography, and endoscopic ultrasound with aspiration cytology were performed. There were two males and 16 females. Serum CA 19-9 was slightly elevated in one case. Preoperative diagnosis was neuroendocrine tumor (n = 2), mucinous tumor (n = 2), and SPT (n = 14). Two patients underwent previous operation before referral to our department: one explorative laparotomy and one enucleation of SPT resulting in surgical margins involvement. All patients underwent pancreatic resection associated with portal vein resection (n = 1) or liver metastases (n = 1). One patient died of metastatic disease, 77 months after operation, and 17 are alive and free with a median survival time of 81.5 months (range 36-228 months). Most of SPT can be diagnosed by CT or MRI, and the role of other diagnostic tools is very limited. We lack sufficient information regarding clinicopathologic features predicting prognosis. Caution is needed when performing limited resection, and long and careful follow-up is required for all patients after surgery.openBeltrame, Valentina; Pozza, Gioia; Dalla Bona, Enrico; Fantin, Alberto; Valmasoni, Michele; Sperti, CosimoBeltrame, Valentina; Pozza, Gioia; DALLA BONA, Enrico; Fantin, Alberto; Valmasoni, Michele; Sperti, Cosim

Robot-assisted pancreaticoduodenectomy with vascular resection: technical details and results from a high-volume center

Background: Pancreaticoduodenectomy with vein resection (PD-VR) is widely accepted as a standard procedure to achieve a higher rate of R0 resections in borderline resectable pancreatic tumors. Thanks to the availability of newer technologies, such as the da Vinci Surgical System, several high-volume centers are reporting small series of minimally invasive PD-VR. Methods: A retrospective review of a prospectively maintained database was performed to identify patients who underwent robot-assisted PD-VR (RAPD-VR) between May 2011 and December 2019. The following factors were specifically analyzed: intraoperative results, post-operative complications, mortality at 90 days, patency of vascular reconstructions, overall survival (OS) and disease-free survival (DFS). Results: During the study period 184 patients underwent RAPD, including 22 who received a RAPDVR (12.0%). The superior mesenteric vein was resected in 9 patients (40.9%), the portal vein in 3 patients (13.6%) and the spleno-mesenteric junction in 10 patients (45.5%). Based on the classification provided by the International Study Group on Pancreatic Surgery these procedures were classified as follows: 1 type I (4.5%), 3 type II (13.6%), 10 type III (45.5%) and 8 type IV (36.4%). In no patient the splenic vein was ligated and left behind. The splenic vein was always reimplanted either on the porto-mesenteric axis or in the inferior vena cava. All but one procedure, were completed under robotic assistance (conversion rate 1/22; 4.5%) after a mean operative time of 610.0±83.5 minutes. Median estimated blood loss was 899.7 mL (719.4–1,430.2 mL), with 2 patients (9.1%) receiving intraoperative blood transfusions. Sixteen patients developed post-operative complications (72.7%), graded ≥III (according to Clavien-Dindo) in 5 patients (22.7%). Two patients died within 90 days, accounting for a postoperative mortality of 9.1%. Interestingly, post-operative pancreatic fistula (grade B) occurred in only 1 patient (4.5%). Repeat surgery was required in 4 patients (18.2%) and hospital readmission in 1 patient (4.5%). At the longest available follow-up, vein reconstruction was patent in 19 patients (86.4%). Eighteen patients had a final diagnosis of pancreatic ductal adenocarcinoma (81.8%). After circumferential study of resection margins, microscopic tumor residual ≤1 mm was found in 11 patients (50.0%). The mean number of examined lymph nodes was 42.2 (±16.3), and vascular infiltration was confirmed in 13 patients (59.1%). Median OS was 39.7 (27.5–not available) and DFS 32.9 (11.5–45.8). Tumor recurrence was identified in 6 patients (27.3%). One patient (4.5%) developed isolated local recurrence. Conclusions: We have shown the feasibility of RAPD-VR. The results reported herein need to be confirmed in larger series and their generalizability remains to be established

Standards of pancreaticoduodenectomy in a tertiary referral centre in Hong Kong: retrospective case series.

OBJECTIVE: To evaluate the perioperative outcomes of pancreaticoduodenectomy in a tertiary referral centre in Hong Kong. DESIGN: Retrospective case series. SETTING: University teaching hospital, Hong Kong. PATIENTS: One hundred and forty patients who underwent pancreaticoduodenectomy from July 1989 through June 2001. MAIN OUTCOME MEASURES: Mortality and morbidity. RESULTS: Overall hospital mortality among 140 patients was 2.9% (n=4), and 30-day operative mortality was 2.1% (n=3). There was no significant difference in the hospital mortality rate between 43 elderly patients aged 70 years or older and 97 younger patients (2.3% versus 3.1%). The overall morbidity rate was 38.6% (n=54). Intra-abdominal abscess (13.6%) and pancreaticojejunal anastomotic leakage (12.9%) were the two most common complications. Presence of co-morbid illness (risk ratio, 2.823; 95% confidence interval, 1.541-4.385; P=0.01), preoperative cholangitis (risk ratio, 2.565; 95% confidence interval, 1.166-5.643; P=0.02), and intra-operative blood loss >/=1.5 L (risk ratio, 2.236; 95% confidence interval, 1.132-6.213; P=0.03) were independent risk factors for postoperative morbidity. CONCLUSIONS: Pancreaticoduodenectomy is associated with a low risk of operative death when performed in a tertiary referral setting in Hong Kong. The postoperative morbidity rate remains high, however. Further improvement by reducing intra-operative blood loss may help curtail the high postoperative morbidity.published_or_final_versio

Surgical treatment of the perihilar cholangiocarcinoma with portal vein invasion

Background. Perichilar cholangiocarcinoma is a rare type of malignant neoplasm and is 3-7 cases per 100,000 population. Surgical method is the only radical method of treatment, allowing to improve long-term survival results. One of the important and characteristic features of perihilar cholangiocarcinoma is tumor invasion to the area of the portal vein bifurcation, which occurs in 30–45% of cases. Portal vein invasion is the one of the main causes of perihilar cholangiocarcinoma irresectability. However, innovative surgical technologies allow resection of the liver with resection and reconstruction of the portal vein with acceptable mortality. The aim. The aim of our study was to asses results of surgical treatment of perihilar cholangiocarcinoma with (Group 1) and without (Group 2) portal vein invasion. Materials and methods. From 2003 to January 2023 in the Department of Surgery and Liver Transplantation of the Ukrainian National Institute of Surgery and Transplantation, 208 patients with perihilar cholangiocarcinoma underwent major extended liver resections. We compared 93 (46%) patients who received extended liver resection with portal vein resection (Group 1) with 115 (54%) patients who underwent liver resections without vascular reconstructions (Group 2). The average Ca 19–9 in the group 1 was 288 (8 – 1000) U/ml, in the group 2 –262 (10 – 612) U/ml. The level of total bilirubin in patients of the group 1 was 312 (43 – 621) mcmol/l, in the group 2 – 267 (10 – 612) mcmol/l. In view of this, in the preoperative period, 190 (91,3%) patients underwent decompression of the bile ducts, using percutaneous transhepatic cholangiostomy (PTBD) or retrograde endobiliary stenting. For patients with small remnant liver volume less than 40 %, in 80(38,5%) cases we did preoperative PVE of a resected part of the liver. In 9 cases we made simultaneous PVE and PTBD. When choosing the volume of surgical intervention, we proceeded from the tumor type of Bismuth-Corlette classification, invasion into the portal vessels and the depth of the liver lesion. The portal vein reconstruction was in all cases performed in an “end-to-end”. In all cases we made extended lymphadenectomy. Results. All complications were classified according to the Dindo-Clavien classification. Postoperative mortality in the main group was 11.5%. The overall 1, 3, 5-year survival in the group 1 was 96%, 68,3%, 57,4%, respectively. 1, 3, 5-year survival rate in the comparison group 2 was 98,4%, 76,7%, 47,3%, respectively. Conclusions. Aggressive tactics of surgical treatment of perihilar cholangiocarcinoma provides maximum radicality, allows to increase resectability in case of tumor invasion of the portal vein with acceptable mortality and long-term survival

The Role of Vascular Resection in Pancreatic Cancer Treatment

Currently, porto‐mesenteric vein resection is a standard procedure at high‐volume pancreatic centers. Experience in vascular surgery is indispensable for a modern pancreatic surgeon. Nowadays, only arterial resections still are a controversial issue. Nevertheless, attempts at resection involving reconstruction of the main arteries such as the coeliac axis, hepatic artery, and superior mesenteric artery (SMA) have been reported, although in small case series. An overview of the historical and contemporary methods for surgical management of superior mesenteric/portal vein involvement as well as arterial involvement by pancreatic cancer is presented. We compare the data from the literature with our data based on the examination and long‐term follow‐up of more than 300 radical pancreatic resections. Seventy‐two of the presented patients underwent pancreatic resection with simultaneous vascular resection—SMPV in 65 cases (44 with resection of the portal vein, 15 with resection of the superior mesenteric vein, 6 with resection of the porto‐mesenterial confluence), arterial in 2 and partial resections of IVC in 5 cases. Combined vascular resections were done in three cases. Both groups PVR and PR showed similarly close results in complication rates, mortality, and morbidity. Three and 5 years survival rates were 42 and 38% in PD group and 28 and 19% in the PVR group. The vascular resection must be performed only upon carefully selected patients with data for presence of resectable tumors or tumors with borderline resectability from the preoperative imaging studies. The prompt management of pancreatic cancer with vascular involvement should involve multidisciplinary consultation in high‐volume centers

The Impact on Survival and Morbidity of Portal-Mesenteric Resection During Pancreaticoduodenectomy for Pancreatic Head Adenocarcinoma. A Systematic Review and Meta-Analysis of Comparative Studies

Background: The literature is conflicting regarding oncological outcome and morbidity associated to portal-mesenteric resection during pancreaticoduodenectomy (PD) in patients with pancreatic head adenocarcinoma (PHAC). Methods: A meta-analysis of studies comparing PD plus venous resection (PD+VR) and standard PD exclusively in patients with adenocarcinoma of the pancreatic head was conducted. Results: Twenty-three cohort studies were identified, which included 6037 patients, of which 28.6% underwent PD+VR and 71.4% underwent standard PD. Patients who received PD+VR had lower 1-year overall survival (OS) (odds radio OR 0.79, 95% CI 0.67-0.92, p = 0.003), 3-year OS (OR 0.72, 95% CI 0.59-0.87, p = 0.0006), and 5-year OS (OR 0.57, 95% CI 0.39-0.83, p = 0.003). Patients in the PD+VR group were more likely to have a larger tumor size (MD 3.87, 95% CI 1.75 to 5.99, p = 0.0003), positive lymph nodes (OR 1.24, 95% CI 1.06-1.45, p = 0.007), and R1 resection (OR 1.74, 95% CI 1.37-2.20, p < 0.0001). Thirty-day mortality was higher in the PD+VR group (OR 1.93, 95% CI 1.28-2.91, p = 0.002), while no differences between groups were observed in rates of total complications (OR 1.07, 95% CI, 0.81-1.41, p = 0.65). Conclusions: Although PD+VR has significantly increased the resection rate in patients with PHAC, it has inferior survival outcomes and higher 30-day mortality when compared with standard PD, whereas postoperative morbidity rates are similar. Further research is needed to evaluate the role of PD+VR in the context of multimodality treatment of PHAC

Inferior mesenteric vein serves as an alternative guide for transection of the pancreatic body during pancreaticoduodenectomy with concomitant vascular resection: a comparative study evaluating perioperative outcomes

BACKGROUND: Tumors of the pancreatic head often involve the superior mesenteric and portal veins. The purpose of this study was to assess perioperative outcomes after pancreaticoduodenectomy (PD) with concomitant vascular resection using the inferior mesenteric vein (IMV) as a guide for transection of the pancreatic body (Whipple at IMV, WATIMV). METHODS: One hundred thirty-seven patients had segmental vein resection during PD between January 2006 and June 2013. Depending on whether the standard approach of creating a tunnel anterior to the mesenterico-portal vein (MPV) axis was achieved for pancreatic transection, patients were subjected to a standard PD with vein resection procedure (s-PD + VR, n = 75) or a modified procedure (m-PD + VR, n = 62). Within the m-PD + VR group, 28 patients underwent the WATIMV procedure, while 34 patients underwent the usual procedure of transection, or ‘central pancreatectomy’ (c-PD + VR). RESULTS: The volume of intraoperative blood loss and the blood transfusion requirements were significantly greater, and the venous wall invasion and neural invasion frequency were significantly higher in the m-PD + VR group compared with the s-PD + VR group. There were no significant differences in the length of hospitalization, postoperative morbidity, and grades of complications between the two groups. Multivariate logistic regression identified intraoperative blood transfusion (P = 0.004) and vascular invasion (P = 0.008) as the predictors of postoperative morbidity. Further stratification of the entire cohort of 62 (45%) patients who underwent m-PD + VR showed a higher rate of negative resection margins (96.4%) in the WATIMV group compared with the c-PD + VR group (76.5%) (P = 0.06). The volume of intraoperative blood loss (P = 0.013), and intraoperative blood transfusion requirements (P = 0.07) were significantly greater in the c-PD + VR group compared with the WATIMV group. Furthermore, high intraoperative blood loss and tumor stage were predictive of a positive resection margin. CONCLUSIONS: ‘Whipple at the IMV (WATIMV)’ has comparable postoperative morbidity with standard PD + VR. If IMV runs into the splenic vein, it could serve as an alternative guide for transection of the pancreatic body during PD + VR