Anterior approach to the superior mesenteric artery by using nerve plexus hanging maneuver for borderline resectable pancreatic head carcinoma

Prognostic impacts of biological and conditional factors in patients with anatomically resectable pancreatic adenocarcinoma treated with preoperative chemoradiotherapy

The efficacy of preoperative chemoradiotherapy (CRT) for anatomically resectable pancreatic adenocarcinoma (R-PDAC) remains contentious. This study aims to elucidate the treatment outcomes of preoperative CRT for R-PDAC and to identify prognostic factors. This retrospective study included 109 R-PDAC patients treated with gemcitabine- or S-1 plus gemcitabine-based preoperative CRT from February 2005 to April 2023. Cox proportional hazards regression was employed to identify factors associated with worse overall survival (OS). Among the 109 cases, 90 patients (82.6%) underwent curative-intent resection following CRT. The median OS for the entire cohort was 36.5 months, significantly longer in resected cases than in unresected cases (40.6 vs 11.4 months). Multivariate analysis identified pretreatment serum levels of carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) and the Eastern Cooperative Oncology Group performance status ≥1 as independent prognostic factors. When these factors were scored (risk score 0-3) using pre-CRT serum CA19-9 level (≥640 U/mL) and CEA (≥6.1 ng/mL), OS for risk scores 1 (n = 41), 2 (n = 20) or 3 (n = 6) was significantly shorter than for risk score 0 (n = 42) (score 0 vs 1 vs 2 vs 3: 49.1 vs 33.8 vs 16.1 vs 16.8 months). The presence of portal vein invasion on imaging and post-CRT serum CA 19-9 level (≥111 U/mL) were independent prognostic factors in resected cases. Biological factors, including serum levels of CA19-9 and CEA, along with conditional factor of Eastern Cooperative Oncology Group performance status ≥1, were identified as independent prognostic factors for R-PDAC patients treated with preoperative CRT. Preoperative CRT is considered effective for cases lacking these risk factors.

Splenic vein resection is not a risk factor for delayed gastric emptying after pancreaticoduodenectomy with combined resection of the portal or superior mesenteric vein

PURPOSE

This study clarified the influence of the splenic vein (SV) on delayed gastric emptying (DGE) in patients who underwent pancreaticoduodenectomy (PD) combined with portal vein (PV) and superior mesenteric vein (SMV) resections.

METHODS

A total of 147 patients who underwent open subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) with PV/SMV resection were included in this study and classified into two groups: SV resection (n = 101) and preservation (n = 46). The incidence of DGE was compared between groups. Univariate and multivariate analyses were used to identify the risk factors for DGE.

RESULTS

There was no significant difference in the incidence of Grade B or C DGE between the SV resection and preservation groups (19.8 vs. 19.6%, respectively; p = 0.973). Multivariate analysis revealed that intra-abdominal abscess (odds ratio, 3.355; 95% confidence interval, 1.324-8.500; p = 0.011) was the only independent risk factor for DGE.

CONCLUSION

SV resection did not affect the incidence of DGE after SSPPD with PV/SMV resection. There may be no need to insist on preserving the veins associated with gastric venous flow out of concern for DGE.

Impact of Surgical Resection After Induction Gemcitabine Plus S-1-Based Chemoradiotherapy in Patients with Locally Advanced Pancreatic Ductal Adenocarcinoma: A Focus on UR-LA Cases

Background: This study aimed to assess the safety and efficacy of gemcitabine plus S-1-based chemoradiotherapy (GS-CRT) among patients with locally advanced pancreatic ductal adenocarcinoma (PDAC), especially among those with unresectable locally advanced (UR-LA) cases. Methods: A total of 351 consecutive PDAC patients were enrolled and prognostic predictors of disease-specific survival (DSS) were identified. Results: The treatment completion rate was 98.9% and Grade 3 or higher adverse events occurred in 181 cases (51.6%). Among 319 re-evaluated patients, pancreatectomy was performed in 184 (57.7%). Based on resectability, the 5-year DSS rates for the entire cohort were 39.6% (R), 43.8% (BR-PV), 21.2% (BR-A) and 13.3% (UR-LA), while the predictors of DSS were performance status (PS), hemoglobin (Hb) level, celiac artery (CA) involvement of ≥180 degrees and JPS 8th T category. In the resected cases, the predictors of DSS were preoperative PS, preoperative CA19-9 level, preoperative JPS-T factor, degree of histological response and adjuvant chemotherapy. In UR-LA resected patients, preoperative prognostic nutritional index (PNI), absence of pathological venous invasion and adjuvant chemotherapy were predictors of DSS. Conclusions: Even though Grade 3 or higher adverse events were encountered in about half of the cases, they were uneventfully managed. Therefore, GS-CRT is safe and highly tolerable with potential to improve patients' prognosis. Preoperative PS, CA19-9 levels and histological response are important prognostic factors, as well as adjuvant therapy. In UR-LA patients, prognostic nutritional index (PNI) and adjuvant chemotherapy were important for curative intent surgery.

Long-term survival analysis based on tumor location in patients with pancreatic ductal adenocarcinoma who underwent pancreatectomy following neoadjuvant chemoradiotherapy

BACKGROUND

The study aimed at assessing whether long-term survival outcomes were different based on tumor location in pancreatic ductal adenocarcinoma (PDAC) patients who underwent pancreatectomy following neoadjuvant chemoradiotherapy (CRT).

METHODS

Following CRT, resection rate was 60.5% (286/473) and the resected patients had pancreatic head (n = 218), body (n = 34) and tail (n = 34) tumors. Survival analyses were conducted, independent predictors of disease-free survival (DFS) and overall survival (OS) were identified, and then survival outcomes were stratified by the predictors of DFS and OS.

RESULTS

Resection rates were; 64.7% (head) vs. 46.6% (body) and 54.0% (tail) cases, p = 0.009. Among these cases, pancreatic head patients exhibited a higher incidence of initial clinical stage 3 tumors; 48.2% (head) vs. 29.4% (body) and 0% (tail) cases, p < 0.001 with more unresctable-locally advanced tumors; 22.0% (head) vs. 11.8% (body) and 0% (tail), p < 0.001, but demonstrated a better response to CRT; Evans grades 3/4 in 49.1% (head) vs. 23.5% (body) and 26.5% (tail), p = 0.012. Five-year DFS rates were; 19.9% (head) vs. 11.8% (body) vs. 24.6% (tail), p = 0.565 and OS rates; 25.4% (head) vs. 27.7% (body) vs. 32.0% (tail), p = 0.341. Significant predictors of DFS and OS included post-CRT CA19-9 levels, tumor differentiation, resection margins and pathological portal vein invasion. Based on these predictors, survival outcomes were also comparable. Pathological nodal invasion influenced DFS, while pathological stage impacted OS.

CONCLUSION

Pancreatic head patients had the best resection rate and long-term survival outcomes were comparable, attributable to the better response to CRT by pancreatic head than the body and tail PDAC patients.

Inverted Y-shaped technique for complex superior mesenteric / portal vein reconstruction in pancreatoduodenectomy for locally advanced pancreatic head ductal adenocarcinoma

Most pancreatoduodenectomy (PD) procedures for locally advanced pancreatic head adenocarcinoma (PDAC) require superior mesenteric/portal vein (SMV/PV) axis resection and reconstruction. Here we describe the inverted Y-shaped as a new technique for complex SMV/PV reconstruction and aimed at evaluating its safety and effectiveness. Among 287 patients who underwent PD for locally advanced PDAC from April, 2007 to December, 2020 at our hospital, 11 patients (3.8%) who underwent PV/SMV reconstruction with this technique were enrolled. Briefly, two distal veins were slit-wedged, sutured, resulting in one orifice, then reconstruction was completed with (n = 6) or without (n = 5) interposed autologous right external iliac vein (REIV) grafts, respectively. Operation time and blood loss were 649 (502-822) min and 1782 (475-6680) mL, respectively. The median length of resected SMV/PV was 40 (20-70) mm, 50 (50-70) mm for REIV grafts, and the splenic vein was resected in eight patients. No patient developed pancreatic fistula; mild leg edema was observed in the six graft patients and the median hospital stay was 36.0 d. PV patency rate at 2 mo after PD was 91% (10/11) and no 90-d mortality was recorded. R0 resection rate was 91% (10/11). It is feasible to safely reconstruct the SMV/PV using the inverted Y-shaped technique in appropriately selected PDAC patients.

Predictive risk factors for early recurrence in patients with localized pancreatic ductal adenocarcinoma who underwent curative-intent resection after preoperative chemoradiotherapy

Background

The optimal surgical indication after preoperative chemoradiotherapy (CRT) remains a subject of debate for patients with pancreatic ductal adenocarcinoma (PDAC) because early recurrence often occurs even after curative-intent resection. The present study aimed to identify perioperative risk factors of early recurrence for patients with PDAC who underwent curative-intent resection after preoperative CRT.

Methods

Two hundred three patients with PDAC who underwent curative-intent resection after preoperative CRT from February 2005 to December 2018 were retrospectively analyzed. The optimal threshold for differentiating between early and late recurrence was determined by the minimum p-value approach. Multivariate regression analysis was performed to identify predictive factors for early recurrence.

Results

In 130 patients who developed recurrence after resection, 52 who had an initial recurrence within 12 months were defined as the early recurrence group, and the remaining 78 were defined as the late recurrence group. The incidence of hepatic recurrence was significantly higher in the early recurrence group than in the late recurrence group (39.7 vs. 15.4%). The early recurrence group had significantly lower 3-year rates of post-recurrence and overall survival than the late recurrence group (4.0 and 10.7% vs. 9.8 and 59.0%, respectively). Serum level of CA19-9 before surgery ≥56.8 U/ml was identified as an independent risk factor for early recurrence (OR:3.07, 95%CI:1.65–5.73, p<0.001) and associated with a significantly higher cumulative incidence rate of hepatic recurrence and lower rates of recurrence-free and overall survival.

Conclusion

Serum level of CA19-9 before surgery after preoperative CRT was a strong predictive factor for early recurrence.

Retropancreatic Nerve Plexus Hanging Maneuver for Pancreatoduodenectomy for Cancer of the Head of the Pancreas

The efficacy of the hanging maneuver for the retropancreatic nerve plexus (RNP) to enhance the confirmation of the margin status and to facilitate en-bloc resection for pancreatoduodenectomy is studied. The exit of the hanging maneuver of the RNP is the left part of the superior mesenteric artery, and the entry is the cranial part of the celiac axis. The entry of the hanging maneuver was connected to the dissection line on the right side of the celiac axis. Thereafter, the tape of the hanging maneuver was pulled to the right side, and the RNP was deployed widely. Finally, the RNP was easily dissected using a sealing device other than inferior pancreaticoduodenal artery. With the correct implementation of the hanging maneuver, we believe that it would be possible to obtain reliable R0 resection as well as a reduction in blood loss and operation time.

Concomitant splenic artery ligation has no preventive effect on left‐sided portal hypertension following pancreaticoduodenectomy with the resection of the portal and superior mesenteric vein confluence for pancreatic ductal adenocarcinoma

Background

Left‐sided portal hypertension (LSPH) caused by splenic vein (SV) division in pancreaticoduodenectomy (PD) with portal vein (PV) resection remains challenging. The current study aimed to investigate the efficacy of splenic artery (SA) ligation in preventing LSPH.

Methods

One‐hundred thirty patients who underwent PD with PV resection for pancreatic ductal adenocarcinoma were classified into SV and SA preservation (SVP, n = 30), SV resection and SA preservation (SVR, n = 59), and SV resection and SA ligation (SAL, n = 41). The postoperative incidence of LSPH was assessed.

Results

The incidence of variceal formation in SVP, SVR, and SAL were 4.8%, 53.2%, and 46.4% at 3 mo, 13.0%, 71.2%, and 62.5% at 6 mo, and 25.0%, 87.5%, and 87.1% at 12 mo, respectively. The rate was significantly higher in SVR at 3 and 6 mo (P = .001 and P < .001, respectively) and in SVR and SAL (P < .001) at 12 mo. Variceal hemorrhage occurred only in SVR (n = 4). The platelet count ratio at 3, 6, and 12 mo began to significantly decrease from 3 mo in SVR (0.77, 0.67, and 0.60, respectively; P < .001) and 6 mo in SAL (0.91, 0.73, and 0.69, respectively; P < .001). The spleen volume ratio also showed significant increase from 3 mo in SVR (1.24, 1.34, and 1.42, respectively; P < .001) and 6 mo in SAL (1.31, 1.32, and 1.34, respectively; P < .001). SVR and SAL were significant risk factors for variceal formation at 12 mo (odds ratio, 21.0 and 20.3, respectively).

Conclusion

In PD with PV resection, SAL delayed LSPH but could not prevent its occurrence.

Clinical significance and predictors of complete or near-complete histological response to preoperative chemoradiotherapy in patients with localized pancreatic ductal adenocarcinoma

BACKGROUND

The clinical value and predictors of a favorable histological response to preoperative chemoradiotherapy (CRT) in pancreatic ductal adenocarcinoma (PDAC) remains undefined.

OBJECTIVE

To assess the significance and predictors of a favorable histological response to preoperative CRT in patients with localized PDAC.

METHODS

The study included 203 patients with localized PDAC undergoing curative-intent resection after CRT. The rate of R0 resection and overall survival (OS) and recurrence-free survival (RFS) were correlated with the grading of histological response to determine optimal stratification. Clinical factors associated with a significant histological response were evaluated using multivariate regression analysis.

RESULTS

Among all patients, eight patients (3.9%) had a grade 4 (pCR); 40 (19.4%) had a grade 3 estimated rate of residual neoplastic cells <10% (near-pCR); and 155 (76.7%) had a grade 1/2 limited response. The 48 patients with pCR/near-pCR achieved significantly higher R0 resection rate (100%) than those with grade 1/2 (80.0%). The 5-year OS and RFS rates were significantly higher in the patients with pCR/near-pCR (45.3% and 36.5%) than in those with grade 1/2 (27.1% and 18.5%). Gemcitabine plus S-1 based CRT, serum CA19-9 level after CRT <83 U/mL, and interval from initial treatment to surgery ≥4.4 months were independent predictive factors for pCR/near-pCR.

CONCLUSIONS

pCR or near-pCR to preoperative CRT contributed to achieving a high rate of R0 resection and improving survival for localized PDAC. The use of gemcitabine plus S-1 as a radiosensitizer, lower serum CA19-9 level after CRT, and longer preoperative treatment duration were significantly associated with pCR or near-pCR.

Proximal subtotal pancreatectomy as an alternative to total pancreatectomy for malnourished patients

PURPOSE

To investigate whether proximal subtotal pancreatectomy (PSTP) is superior to total pancreatectomy (TP) for preserving postoperative endocrine function, and to identify the pre-operative risk factors influencing prognosis after TP and PSTP.

METHODS

The subjects of this retrospective study were patients who underwent TP (n = 15) or PSTP (n = 16) between 2008 and 2018 in our hospital. First, we compared the incidence of hypoglycemia within 30 days after surgery and the total daily amount of insulin needed in the 30 days after TP vs. PSTP. Then, we compared the prognoses between the groups.

RESULTS

The incidence of hypoglycemia in the 30 days after surgery was significantly lower in the PSTP group than in the TP group (n = 0 vs. n = 5; p < 0.001). The total amount of daily insulin given was also significantly lower after PSTP than after TP: (0 units vs. 18 units, p = 0.001). Lower lymphocyte counts (p = 0.014), lower cholinesterase (p = 0.021), and lower prognostic nutrition index (p = 0.021) were identified as significant risk factors for hypoglycemia in the TP group. Low cholinesterase (p = 0.015) and a low prognostic nutrition index (p = 0.048) were significantly associated with an unfavorable prognosis in the TP group, but not in the PSTP group.

CONCLUSIONS

PSTP may be a feasible alternative to TP to preserve endocrine function, especially for malnourished patients.

Anatomical change of SMV branches after the Cattell Braasch maneuver facilitates safe resection around the uncinated process in pancreatoduodenectomy

Background

The aims of the present study were to demonstrate the anatomical change of superior mesenteric vein (SMV) branches and to show how the Cattell Braasch maneuver facilitates a safer ligation of these venous branches during a pancreatoduodenectomy (PD).

Methods

Between January 2010 and December 2019, 97 patients with peripancreatic tumors underwent pancreatectomy. We retrospectively reviewed preoperative triple-phase enhanced computed tomography (CT) images and analyzed variations in SMV branches. Anatomical changes in SMV branches after the Cattell Braasch technique were observed using our operation video and illustrations.

Results

The first jejunal vein (J1v) in 75% of patients ran posterior to the superior mesenteric artery (SMA), while the remainder (25%) ran anterior to it. The inferior pancreatoduodenal vein (IPDV) was preoperatively detected in 91% of patients. The IPDV drained into the J1v in 74% of patients and into the SMV in 37%. After the Cattell Braasch maneuver, the J1v which ran posterior to the SMA now was found to lie to the right anterolateral side the SMA and the visualization of both the J1v and the IPDV were much more clearly visualized.

Conclusions

The most frequent venous variation was the IPDV draining into the J1v posterior to the SMA. After the Cattell Braasch maneuver, the IPDV was now located to the right anterolateral anterior aspect of the SMA which facilitates its visualization and should allow a safer ligation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01338-5.

Left-sided Portal Hypertension After Pancreaticoduodenectomy With Resection of the Portal Vein/Superior Mesenteric Vein Confluence in Patients With Pancreatic Cancer: A Project Study by the Japanese Society of Hepato-Biliary-Pancreatic Surgery

OBJECTIVE

The aim of this study was to evaluate how often left-sided portal hypertension (LPH) develops and how LPH affects the long-term outcomes of patients with pancreatic cancer treated with pancreaticoduodenectomy (PD) and resection of the portal vein (PV)/superior mesenteric vein (SMV) confluence.

SUMMARY BACKGROUND DATA

Little is known about LPH after PD with resection of the PV/SMV confluence.

METHODS

Overall, 536 patients who underwent PD with PV/SMV resection were enrolled. Among them, we mainly compared the SVp group [n=285; the splenic vein (SV) was preserved] and the SVr group (n = 227; the SV was divided and not reconstructed).

RESULTS

The incidence of variceal formation in the SVr group increased until 3 years after PD compared with that in the SVp group (38.7% vs 8.3%, P < 0.001). Variceal bleeding occurred in the SVr group (n = 9: 4.0%) but not in the SVp group (P < 0.001). In the multivariate analysis, the risk factors for variceal formation were liver disease, N factor, conventional PD, middle colic artery resection, and SV division. The only risk factor for variceal bleeding was SV division. The platelet count ratio at 6 months after PD was significantly lower in the SVr group than in the SVp group (0.97 vs 0.82, P < 0.001), and the spleen-volume ratios at 6 and 12 months were significantly higher in the SVr group than in the SVp group (1.38 vs 1.00 and 1.54 vs 1.09; P < 0.001 and P < 0.001, respectively).

CONCLUSIONS

PD with SV division causes variceal formation, bleeding, and thrombocytopenia.

[Definition and treatment of superior mesenteric artery revascularization and dissection-associated diarrhea (SMARD syndrome) in Germany]

Hintergrund

Die A. mesenterica superior (AMS) wird im Rahmen von Pankreasresektionen (PR) und mesenterialen Gefäßeingriffen (MG) freigelegt und disseziert. Eine dadurch entstandene Schädigung des umliegenden ex- und intrinsischen vegetativen Nervenplexus kann zu einer passageren oder therapierefraktären Diarrhö führen.

Fragestellung

Die vorliegende Studie soll einen Überblick über den derzeitigen Stellenwert der AMS-Revaskularisations- und -Dissektions-assoziierten Diarrhö („superior mesenteric artery revascularisation and dissection-associated diarrhea“[SMARD]-Syndrom) in Deutschland geben.

Material und Methoden

Nach selektiver Literaturrecherche (SLR) mit der Fragestellung, ob und wie häufig eine postoperativ neu aufgetretene Diarrhö nach PR und MG vorkommt, wurde eine Onlineumfrage versendet.

Ergebnisse

Die SLR (n = 4) bestätigte, dass eine postoperativ neu aufgetretene Diarrhö eine häufige Komplikation nach Präparation zur Revaskularisation (RV) bzw. Dissektion (DIS) der AMS ist (Inzidenz ca. 62 %). Therapierefraktäre Verläufe sind selten 14 %. 54 von 159 Zentren beteiligten sich an der Umfrage. 63 % gaben an, eine AMS-RV/-DIS im Rahmen von PR oder MG durchzuführen. Der Durchschnitt an PR pro Zentrum lag 2018 bei 47 und bei 49 im Jahr 2019. Fünf MG erfolgten durchschnittlich in beiden Jahren pro Zentrum. Drei Patienten litten durchschnittlich am SMARD-Syndrom.

Diskussion

Diese Umfrage erfasst erstmals den derzeitigen Stellenwert des SMARD-Syndroms in Deutschland. Bisher fehlen Empfehlungen zur Therapie einer solchen Diarrhö. Die Ergebnisse zeigen, dass zunächst eine symptomatische Therapie erfolgen sollte. Aufgrund der Komplexität der Pathophysiologie sind kausale Therapieansätze bislang nicht entwickelt.

Complete Lymphadenectomy Around the Entire Superior Mesenteric Artery Improves Survival in Artery-First Approach Pancreatoduodenectomy for T3 Pancreatic Ductal Adenocarcinoma

BACKGROUND

Artery-first approach pancreatoduodenectomy (AFA-PD) is an important technique for treating pancreatic ductal adenocarcinoma (PDAC). However, it remains unknown whether performing complete lymphadenectomy around the entire superior mesenteric artery (SMA) is associated with better outcomes. In this retrospective study, we aimed to investigate whether this approach improved overall and recurrence-free survival in patients with PDAC.

METHODS

We identified 88 patients with T3 PDAC who underwent PD at St. Marianna University School of Medicine, Kawasaki, Japan, between April 2005 and October 2017. Two groups were defined: an "AFA-PD group" (n = 45) who had undergone AFA-PD in addition to complete lymphadenectomy around the entire SMA, and a "conventional PD group" (n = 43) in whom complete lymphadenectomy had not been performed (conventional group). Univariate and multivariate survival analyses were performed to identify risk factors for overall and disease-free survival.

RESULTS

The AFA-PD group had a longer median survival time (40.3 vs. 22.6 months; p = 0.0140) and a higher 5-year survival rate (40.3% vs. 5.9%, p = 0.005) than the conventional PD group. Multivariate analysis showed that AFA-PD with complete lymphadenectomy around the entire SMA was an independent factor for improved overall survival (p = 0.022). Recurrences around the SMA were significantly less frequent in the AFA-PD group than in the conventional group (22.2% vs. 44.2%, p = 0.041).

CONCLUSIONS

AFA-PD with complete lymphadenectomy around the entire SMA can prevent recurrences around the SMA and may prolong overall survival in patients with PDAC.

The usefulness of modified splenic hilum hanging maneuver in laparoscopic splenectomy, especially for patients with huge spleen: a case-control study with propensity score matching

BACKGROUND

Although Laparoscopic splenectomy (LS) have been proven to the standard operation for removal of spleen, the rate of conversion to open surgery is still higher than those of other laparoscopic surgeries, especially for huge spleen. In order to reduce the rate of conversion to open surgery, we had developed LS using modified splenic hilum hanging (MSHH) maneuver: the splenic pedicle was transected en bloc using a surgical stapler after hanging splenic hilum with an atraumatic penrose drain tube.

METHODS

Between January 2005 and December 2019, we retrospectively assessed 94 patients who underwent LS. MSHH maneuver was performed in 37 patients (39.4%). We compared the intra- and postoperative outcomes between patients with or without MSHH maneuver. To adjust for differences in preoperative characteristics and blood examination, propensity score matching was used at a 1:1 ratio, resulting in a comparison of 29 patients per group. Predictive factors of conversion from LS to open surgery were elucidated using the uni- and multi-variate analyses.

RESULTS

After the propensity score matching, blood loss (268 ml vs. 50 ml), the rate of conversion to open surgery (27.6% vs. 0%), and postoperative hospital stays (15 days vs. 10 days) were significantly decreased in patients with MSHH maneuver, respectively. Among 94 patients, 19 patients (20.2%) underwent conversion to open surgery. In multivariate analysis, spleen volume (SV) and LS without MSHH maneuver were independent predictive factors of conversion to open surgery, respectively. Additionally, cut-off value of SV for conversion to open surgery was 802 ml (sensitivity: 0.684, specificity: 0.827, p < 0.001).

CONCLUSIONS

LS using MSHH maneuver seems to be useful surgical technique to improve intraoperative outcomes and reduce the rate of conversion from LS to open surgery resulting in shorten postoperative hospital stay.

Prolonged operating time is a significant perioperative risk factor for arterial pseudoaneurysm formation and patient death following hemorrhage after pancreaticoduodenectomy

BACKGROUND

Arterial pseudoaneurysm is a rare but potentially fatal complication after pancreaticoduodenectomy (PD). This study aimed to evaluate the incidence and predictors associated with pseudoaneurysm formation and patient death caused by its rupture.

PATIENTS AND METHOD

We retrospectively reviewed the data of 453 patients who underwent PD from April 2007 to February 2019. Uni- and multivariate analysis and receiver operating characteristic (ROC) curve analysis were performed to identify risk factors and optimal cutoff values.

RESULTS

Among the 453 patients, 22 (4.9%) developed pseudoaneurysm after PD. Median duration from surgery to detection of pseudoaneurysm was 17.0 (1-51) days. The locations of pseudoaneurysms were hepatic artery in 8, splenic artery in 3, gastroduodenal artery in 4, gastric artery in 2 and others in 5 patients, and 72.7% (16/22) of patients presented with hemorrhage. All pseudoaneurysms were treated using angioembolization. Lower age (<65.5 years, p = 0.004), prolonged operation time (Cutoff ˃610 min, p = 0.026) and postoperative pancreatic fistula (POPF) (p = 0.013) were the independent risk factors for development of pseudoaneurysm. 6 (27.3%) patients died due to rupture of pseudoaneurysm and prolonged operation time (Cutoff ˃657 min, p = 0.043) was a significant risk factor for death related to pseudoaneurysm.

CONCLUSION

Prolonged operating time was identified as a risk factor for both pseudoaneurysm formation and patient death following pseudoaneurysm bleeding. Interventional radiology treatment offered a central role in the treatment of pseudoaneurysms after PD. Therefore, it is important to have a high index of suspicion in high risk patients of the possibility of pseudoaneurysm formation and bleeding.

An anatomical review of various superior mesenteric artery-first approaches during pancreatoduodenectomy for pancreatic cancer

When pancreatic head cancer invades the superior mesenteric artery (SMA), attempts at curative resection are aborted. Preoperative imaging diagnostics to determine the surgical curability have yet to surpass the intraoperative information acquired via inspection, palpation, and trial dissection. Pancreatoduodenectomy (PD) is a standard measure for treating periampullary cancers. In conventional PD, SMA invasion is usually identified by dissecting the retroportal lamina, which connects the uncinate process and SMA nerve plexus after dividing the neck of the pancreas. During PD for pancreatic head cancer, this retroperitoneal margin frequently vitiates surgical curability. SMA-first approaches during PD are methods where the SMA is dissected first by severing the posterior pancreatic capsule to assess the SMA involvement of pancreatic cancer early in the operation. The first report of such an approach prompted subsequent reports of various maneuvers that are now known collectively as "artery-first" approaches. We herein review those approaches by classifying them according to (1) the side of the mesocolon from where the SMA approach occurs (supracolic or infracolic) and (2) the direction of access (right or left and anterior or posterior). The steps of the reported PD procedures are numbered according to a timeline and summarized using anatomical division of the SMA.

Prognostic Nutritional Index After Chemoradiotherapy Was the Strongest Prognostic Predictor Among Biological and Conditional Factors in Localized Pancreatic Ductal Adenocarcinoma Patients

Background: In many malignancies, including pancreatic ductal adenocarcinoma (PDAC), host-related inflammatory/immunonutritional markers, such as the prognostic nutritional index (PNI), modified Glasgow prognostic score (mGPS), and C-reactive protein (CRP)/albumin ratio are reported to be prognostic factors. However, the prognostic influence of these factors before and after chemoradiotherapy (CRT) has not been studied in PDAC patients. Methods: Of 261 consecutive PDAC patients who were scheduled for CRT with gemcitabine or S1 plus gemcitabine between February 2005 and December 2015, participants in this study were 176 who completed CRT and had full data available on inflammatory/immunonutritional markers as well as on anatomical and biological factors for the investigation of prognostic/predictive factors. Results: In multivariate analysis, the significant prognostic factors were RECIST classification, cT category, performance status, post-CRT carcinoembryonic antigen, post-CRT C-reactive protein/albumin ratio, post-CRT mGPS, and post-CRT PNI. Post-CRT PNI (cut-off value, 39) was the strongest host-related prognostic factor according to the p-value. In the patients who underwent resection after CRT, median survival time (MST) was significantly shorter in the 12 patients with low PNI (<39) than in the 97 with high PNI (≥39), at 15.5 months versus 27.2 months, respectively (p = 0.0016). In the patients who did not undergo resection, MST was only 8.9 months in those with low PNI and 12.3 months in those with high PNI (p < 0.0001), and thus was similar to that of the resected patients with low PNI. Conclusions: Post-CRT PNI was the strongest prognostic/predictive indicator among the independent biological and conditional prognostic factors in PDAC patients who underwent CRT.

The clinical impact of portal venous patency ratio on prognosis of patients with pancreatic ductal adenocarcinoma undergoing pancreatectomy with combined resection of portal vein following preoperative chemoradiotherapy

We analyzed the significance of portal vein (PV) patency ratio (minimum diameter/maximum diameter) during preoperative chemoradiotherapy (CRT) on the outcomes of patients with pancreatic-ductal adenocarcinoma (PDAC).

METHODS

The 261 PDAC patients had been prospectively registered to our CRT protocol (Gemcitabine or S1+Gemcitabine) from 2005 to 2015. Among them, the subjects were the 84 PDAC- patients with preoperative PV contact who underwent pancreatectomy with PV resection.

RESULTS

The 3- and 5-year disease-specific survival (DSS) rates of all 84 patients were 44% and 39%, respectively. Pathological PV invasion (pPV) was seen in 22, and PV patency ratio after CRT (cut-off:0.62) was most relevant factor to predict pPV (sensitivity:54.8%, specificity:91.9%, accuracy:81.5%). Multivariate analysis revealed that PV patency ratio after CRT and improvement of PV patency ratio were selected as independent prognostic indicators. The 3- and 5-year DSS in 39 patients with PV patency ratio after CRT >0.6 were significantly higher than those in 45 patients <0.6: 65% and 60% vs. 24% and 20% (p = 0.0001). The patients with PV patency ratio >0.6, were significantly associated with the lower incidence of pPV, higher response for CRT, and better R0 resection rate. Even when severe PV strictures were seen before CRT, DSS of the patients whose PV patency ratio had recovered after CRT was excellent compared with those without improvement.

CONCLUSIONS

The PV patency ratio and its improvement are new prognostic indicators for PDAC treated with preoperative CRT. Even when PV was severely constricted, patients could obtain favorable outcomes, if its patency had recovered after CRT.

Comparative Study Between Gemcitabine-Based and Gemcitabine Plus S1-Based Preoperative Chemoradiotherapy for Localized Pancreatic Ductal Adenocarcinoma, With Special Attention to Initially Locally Advanced Unresectable Tumor

OBJECTIVES

To evaluate clinical/histological response and prognosis between preoperative gemcitabine-based chemoradiation therapy (G-CRT) and gemcitabine plus S1-based CRT (GS-CRT) for localized pancreatic ductal adenocarcinoma patients according to the 3 resectability groups.

METHODS

Among 199 patients who had 90% or more relative dose intensity of chemotherapy and completion of radiotherapy preoperatively (G-CRT: 98 and GS-CRT: 101), the subjects were 113 patients (G-CRT: 60 and GS-CRT: 53) who underwent curative-intent resection, and we compared clinical and histological effects between the 2 regimens.

RESULTS

There is a significant improvement in clinical and histological responses as assessed by reduction rate in tumor size, post-CRT serum level of carbohydrate antigen 19-9, and the ratio of histological high responder according to the Evans grading system in GS-CRT, as compared with G-CRT, which in turn significantly increased R0 resection rate (P = 0.013). These effects of GS-CRT resulted in significant improvement of disease-specific survival (median survival time, 36.0 vs 27.2 months; P = 0.042), especially in patients with unresectable locally advanced disease (36.0 vs 18.1 months, P = 0.014).

CONCLUSIONS

For localized pancreatic ductal adenocarcinoma patients, GS-CRT, as compared with G-CRT, provides significant improvement in clinical and histological response as well as long-time survival, especially in patients with unresectable locally advanced disease.

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

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.

Clinical Significance of Histological Effect and Intratumor Stromal Expression of Tenascin-C in Resected Specimens After Chemoradiotherapy for Initially Locally Advanced Unresectable Pancreatic Ductal Adenocarcinoma

OBJECTIVES

Tenascin-C (TN-C) is an extracellular matrix protein that is up-regulated in pancreatic ductal adenocarcinoma (PDAC) stroma and associated with tumor invasion. We examined intratumor stromal expression of TN-C in resected specimens and the histologic effect of chemoradiotherapy (CRT) as prognostic indicators in initially locally advanced unresectable (UR-LA) PDAC.

METHODS

Among 110 UR-LA PDAC patients enrolled in the CRT protocol from February 2005 to December 2015, 46 who underwent curative-intent resection were classified as high (tumor destruction >50%) and low (≤50%) responders according to the Evans grading system. Tenascin-C expression was immunohistologically evaluated in all patients except one with complete response.

RESULTS

The 12 high responders achieved a significantly higher R0 rate than did the 34 low responders (83.3 vs 47.1%), but disease-specific survival (DSS) time was not significantly different (median survival time, 29.8 vs 21.0 months). Tenascin-C expression was inversely correlated with histologic effect of CRT. The 22 patients with negative TN-C had significantly longer DSS time than did the 23 with positive TN-C (29.3 vs 17.1 months). In multivariate analysis, only TN-C expression was a significant prognostic factor for DSS.

CONCLUSIONS

Intratumor stromal expression of TN-C is a strong prognostic indicator in UR-LA PDAC patients with resection after CRT.

Survival Analysis in Patients with Pancreatic Ductal Adenocarcinoma Undergoing Chemoradiotherapy Followed by Surgery According to the International Consensus on the 2017 Definition of Borderline Resectable Cancer

Background: The aim of this study was to validate a new definition of borderline resectable pancreatic ductal adenocarcinoma (PDAC) provided by the 2017 international consensus on the basis of three dimensions of anatomical (A), biological (B), and conditional (C) factors, using the data of the patients who had been registered for our institutional protocol of chemoradiotherapy followed by surgery (CRTS) for localized patients with PDAC. Methods: Among 307 consecutive patients pathologically diagnosed with localized PDAC who were enrolled in our CRTS protocol from February 2005 to December 2016, we selected 285 patients who could be re-evaluated after CRT. These 285 patients were classified according to international consensus A definitions as follows: R (resectable; n = 62), BR-PV (borderline resectable, superior mesenteric vein (SMV)/portal vein (PV) involvement alone; n = 27), BR-A (borderline resectable, arterial involvement; n = 50), LA (locally advanced; n = 146). Disease-specific survival (DSS) was analyzed according to A, B (serum CA 19-9 levels and lymph node metastasis diagnosed by computed tomography findings before CRT), and C factors (performance status (PS)) factors. Results: The rates of resection and R0 resection were similar between R (83.9 and 98.0%) and BR-PV (85.2 and 95.5%), but much lower in BR-A (70.0 and 84.8%) and LA (46.6 and 62.5%). DSS evaluated by median survival time (months) showed a similar trend to surgical outcomes: 33.7 in R, 27.3 in BR-PV, 18.9 in BR-A and 19.3 in LA, respectively. DSS in R patients with CA 19-9 levels > 500 U/mL was significantly poorer than in patients with CA 19-9 levels ≤ 500 U/mL, but there were no differences in DSS among BR-PV, BR-A, and LA patients according to CA 19-9 levels. Regarding lymph node metastasis, there was no significant difference in DSS according to each resectability group. DSS in R patients with PS ≥ 2 was significantly worse than in patients with PS 0-1. Conclusions: The international consensus on the definition of BR-PDAC based on three dimensions of A, B, and C is useful and practicable because prognosis of PDAC patients is influenced by anatomical factors as well as biological and conditional factors, which in turn may help to decide treatment strategy.

International consensus on definition and criteria of borderline resectable pancreatic ductal adenocarcinoma 2017

This statement was developed to promote international consensus on the definition of borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC) which was adopted by the National Comprehensive Cancer Network (NCCN) in 2006, but which has changed yearly and become more complicated. Based on a symposium held during the 20th meeting of the International Association of Pancreatology (IAP) in Sendai, Japan, in 2016, the presenters sought consensus on issues related to BR-PDAC. We defined patients with BR-PDAC according to the three distinct dimensions: anatomical (A), biological (B), and conditional (C). Anatomic factors include tumor contact with the superior mesenteric artery and/or celiac artery of less than 180° without showing stenosis or deformity, tumor contact with the common hepatic artery without showing tumor contact with the proper hepatic artery and/or celiac artery, and tumor contact with the superior mesenteric vein and/or portal vein including bilateral narrowing or occlusion without extending beyond the inferior border of the duodenum. Biological factors include potentially resectable disease based on anatomic criteria but with clinical findings suspicious for (but unproven) distant metastases or regional lymph nodes metastases diagnosed by biopsy or positron emission tomography-computed tomography. This also includes a serum carbohydrate antigen (CA) 19-9 level more than 500 units/ml. Conditional factors include the patients with potentially resectable disease based on anatomic and biologic criteria and with Eastern Cooperative Oncology Group (ECOG) performance status of 2 or more. The definition of BR-PDAC requires one or more positive dimensions (e.g. A, B, C, AB, AC, BC or ABC). The present definition acknowledges that resectability is not just about the anatomic relationship between the tumor and vessels, but that biological and conditional dimensions are also important. The aim in presenting this consensus definition is also to highlight issues which remain controversial and require further research.

Superiority of stapled side-to-side gastrojejunostomy over conventional hand-sewn end-to-side gastrojejunostomy for reducing the risk of primary delayed gastric emptying after subtotal stomach-preserving pancreaticoduodenectomy

BACKGROUND AND PURPOSE

Delayed gastric emptying (DGE) is the most common complication following pancreaticoduodenectomy (PD). The clinical efficacy of stapled side-to-side anastomosis using a laparoscopic stapling device during alimentary reconstruction in PD is not well understood and its superiority over conventional hand-sewn end-to-side anastomosis remains controversial. The objective of this study was to evaluate the effectiveness of the stapled side-to-side anastomosis in preventing the development of DGE after PD.

METHODS

The subjects of this retrospective study were 137 patients who underwent pancreaticoduodenectomy, as subtotal stomach-preserving pancreaticoduodenectomy (SSPPD; n = 130), or conventional whipple procedure (n = 7) with Child reconstruction, between January 2010 and May 2014. The patients were divided into two groups according to whether they had had a stapled side-to-side anastomosis (SA group; n = 57) or a conventional hand-sewn end-to-side anastomosis (HA group; n = 80).

RESULTS

SA reduced the operative time (SA vs. HA: 508 vs. 557 min, p = 0.028) and the incidence of delayed gastric emptying (SA vs. HA: 21.1 vs. 46.3%, p = 0.003) and was associated with shorter hospitalization (SA vs. HA: 33 vs. 39.5 days, p = 0.007). In this cohort, SA was the only significant factor contributing to a reduction in the incidence of DGE (p = 0.002).

CONCLUSIONS

Stapled side-to-side gastrojejunostomy reduced the operative time and the incidence of DGE following PD with Child reconstruction, thereby also reducing the length of hospitalization.

Significance of Simultaneous Splenic Artery Resection in Left-Sided Portal Hypertension After Pancreaticoduodenectomy with Combined Portal Vein Resection

BACKGROUND

In pancreaticoduodenectomy (PD) with resection of portal vein (PV)/superior mesenteric vein (SMV) confluence, the splenic vein (SV) division may cause left-sided portal hypertension (LPH).

METHODS

The 88 pancreatic ductal adenocarcinoma patients who underwent PD with PV/SMV resection after chemoradiotherapy were classified into three groups: both SV and splenic artery (SA) were preserved in Group A (n = 16), SV was divided and SA was preserved in Group B (n = 58), and both SV and SA were divided in Group C (n = 14). We evaluated the influence of resection of SV and/or SA on LPH after PD with resection of PV/SMV confluence.

RESULTS

The incidence of postoperative varices in Groups A, B and C was 6.3, 67.2 and 38.5%, respectively (p < 0.001), and variceal bleeding occurred only in Group B (n = 4: 6.8%). In multivariate analysis, Group B was the only significant risk factor for the development of postoperative varices (Groups B vs. A: odds ratio = 39.6, p = 0.001, Groups C vs. A: odds ratio = 8.75, p = 0.066). The platelet count ratio at 6 months after operation comparing to preoperative value was 0.93, 0.73 and 1.09 in Groups A, B and C, respectively (Groups B vs. C: p < 0.05), and spleen volume ratio at 6 months was 1.00, 1.37 and 0.96 in Groups A, B and C, respectively (Groups B vs. A and C: p < 0.01 and p < 0.05).

CONCLUSION

In PD with resection of PV-SMV confluence, the SV division causes LPH, but the concomitant division of SV and SA may attenuate it.

Mesenteric approach during pancreaticoduodenectomy for pancreatic ductal adenocarcinoma

Mesenteric approach is an artery‐first approach during pancreaticoduodenectomy (PD). In the present study, we evaluated clinical and oncological benefits of this procedure for pancreatic ductal adenocarcinoma (PDAC) of the pancreas head. Between 2000 and 2015, 237 consecutive PDAC patients underwent PD. Among them, 72 experienced the mesenteric approach (mesenteric group) and 165 the conventional approach (conventional group). A matched‐pairs group consisted of 116 patients (58 patients in each group) matched for age, gender, resectability status, and neoadjuvant therapy. Surgical and oncological outcomes were compared between the two groups in unmatched‐ and matched‐pair analyses. Intraoperative blood loss was lower in the mesenteric group than in the conventional group in both resectable PDAC (R‐PDAC) and borderline resectable PDAC (BR‐PDAC) on unmatched‐ and matched‐pairs analyses (R‐PDAC, unmatched: 312.5 vs 510 mL, P=.008; matched: 312.5 vs 501.5 mL, P=.023; BR‐PDAC, unmatched: 507.5 vs 935 mL, P<.001; matched: 507.5 vs 920 mL, P=.003). Negative surgical margins (R0) and overall survival (OS) rates in the mesenteric group were better in R‐PDAC patients (R0 rates, unmatched: 100% vs 87.7%, P=.044; matched: 100% vs 86.7%, P=.045; OS, unmatched: P=.008, matched: P=.021), although there were no significant differences in BR‐PDAC patients. Mesenteric approach might reduce blood loss by early ligation of the vessels to the pancreatic head. Furthermore, it might increase R0 rate, leading to improvement of survival for R‐PDAC patients. However, R0 and survival rates could not be improved only by the mesenteric approach for BR‐PDAC patients. Therefore, effective multidisciplinary treatment is essential to improve survival in BR‐PDAC patients.

Superior mesenteric artery first approach versus standard pancreaticoduodenectomy: a systematic review and meta-analysis

BACKGROUND

The superior mesenteric artery (SMA) first approach was proposed recently as a new modification of the standard pancreaticoduodenectomy. Increasing evidence showed that a periadventiceal dissection of the SMA with early transection of the inflow during pancreaticoduodenectomy associates better early perioperative results, and setup the scene for long-term oncological benefits. The objectives of the current study are to compare the operative results and long-term oncological outcomes of SMA first approach pancreaticoduodenectomy (SMA-PD) with standard pancreaticoduodenectomy (S-PD).

DATA SOURCES

Electronic search of the PubMed/MEDLINE, EMBASE, Web of Science and Cochrane Library was performed until July 2015. We considered randomized controlled trials (RCTs) and non-randomized comparative studies (NRCSs) comparing SMA-PD with S-PD to be eligible if they included patients with periampullary cancers.

RESULTS

A total of one RCT and thirteen NRCSs met the inclusion criteria, involving 640 patients with SMA-PD and 514 patients with S-PD. The SMA-PD was associated with less intraoperative bleeding, less blood transfusions and higher rate of associated venous resections. The pancreatic fistula and delayed gastric emptying had a significantly lower rate in the SMA-PD group. There were no differences between the two approaches regarding overall complications, major complication rates and in-hospital mortality. There was no difference regarding R0 resection rate, and one-, two- or three-year overall survival. The SMA-PD was associated with a lower local, hepatic and extrahepatic metastatic rate.

CONCLUSIONS

The SMA-PD is associated with better perioperative outcomes, such as blood loss, transfusion requirements, pancreatic fistula, and delayed gastric emptying. Although the one-, two- or three-year overall survival rate is not superior, the SMA-PD has a lower local and metastatic recurrence rate.

Top-down approach to the superior mesenteric artery and the mesopancreas during pancreatoduodenectomy for pancreatic cancer

Complete surgical resection with microscopically tumor-free resection margins (R0) is the most important survival determinant for patients with localized pancreatic cancer. The medial and posterior resection margins are the dominant sites of microscopic tumor involvement, and outline the so-called mesopancreas. In this study, we present a modified surgical approach to the superior mesenteric artery, celiac trunc, and mesopancreas during pancreatoduodenectomy, which enables a comfortable exposure and radical en bloc clearance of the mesopancreas and the tissue adjacent to the superior mesenteric artery. The dissection of the mesopancreas is directed from the ventral aspect of the portal vein downward along the superior mesenteric artery and the celiac trunc, before the transection of the duodenal mesentery is accomplished. The described technique complements the established surgical approaches to pancreatic head tumors, and is indicated in the absence of portal vein infiltration. J. Surg. Oncol. 2016;113:668-671. © 2016 Wiley Periodicals, Inc.

A new surgical technique of pancreaticoduodenectomy with splenic artery resection for ductal adenocarcinoma of the pancreatic head and/or body invading splenic artery: impact of the balance between surgical radicality and QOL to avoid total pancreatectomy

For pancreatic ductal adenocarcinoma (PDAC) of the head and/or body invading the splenic artery (SA), we developed a new surgical technique of proximal subtotal pancreatectomy with splenic artery and vein resection, so-called pancreaticoduodenectomy with splenic artery resection (PD-SAR). We retrospectively reviewed a total of 84 patients with curative intent pancreaticoduodenectomy (PD) for PDAC of the head and/or body. These 84 patients were classified into the two groups: conventional PD (n=66) and PD-SAR (n=18). Most patients were treated by preoperative chemoradiotherapy (CRT). Postoperative MDCT clearly demonstrated enhancement of the remnant pancreas at 1 and 6 months in all patients examined. Overall survival rates were very similar between PD and PD-SAR (3-year OS: 23.7% versus 23.1%, P=0.538), despite the fact that the tumor size and the percentages of UICC-T4 determined before treatment were higher in PD-SAR. Total daily insulin dose was significantly higher in PD-SAR than in PD at 1 month, while showing no significant differences between the two groups thereafter. PD-SAR with preoperative CRT seems to be promising surgical strategy for PDAC of head and/or body with invasion of the splenic artery, in regard to the balance between operative radicality and postoperative QOL.