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Stoop TF, Theijse RT, Seelen LWF, Groot Koerkamp B, van Eijck CHJ, Wolfgang CL, van Tienhoven G, van Santvoort HC, Molenaar IQ, Wilmink JW, Del Chiaro M, Katz MHG, Hackert T, Besselink MG. Preoperative chemotherapy, radiotherapy and surgical decision-making in patients with borderline resectable and locally advanced pancreatic cancer. Nat Rev Gastroenterol Hepatol 2024; 21:101-124. [PMID: 38036745 DOI: 10.1038/s41575-023-00856-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2023] [Indexed: 12/02/2023]
Abstract
Surgical resection combined with systemic chemotherapy is the cornerstone of treatment for patients with localized pancreatic cancer. Upfront surgery is considered suboptimal in cases with extensive vascular involvement, which can be classified as either borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In these patients, FOLFIRINOX or gemcitabine plus nab-paclitaxel chemotherapy is currently used as preoperative chemotherapy and is eventually combined with radiotherapy. Thus, more patients might reach 5-year overall survival. Patient selection for chemotherapy, radiotherapy and subsequent surgery is based on anatomical, biological and conditional parameters. Current guidelines and clinical practices vary considerably regarding preoperative chemotherapy and radiotherapy, response evaluation, and indications for surgery. In this Review, we provide an overview of the clinical evidence regarding disease staging, preoperative therapy, response evaluation and surgery in patients with borderline resectable pancreatic cancer or locally advanced pancreatic cancer. In addition, a clinical work-up is proposed based on the available evidence and guidelines. We identify knowledge gaps and outline a proposed research agenda.
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Affiliation(s)
- Thomas F Stoop
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Rutger T Theijse
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands
- Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Leonard W F Seelen
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, Rotterdam, Netherlands
| | - Christopher L Wolfgang
- Division of Surgical Oncology, Department of Surgery, New York University Medical Center, New York City, NY, USA
| | - Geertjan van Tienhoven
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Radiation Oncology, Amsterdam, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht and St. Antonius Hospital Nieuwegein, Utrecht, Netherlands
| | - Johanna W Wilmink
- Cancer Center Amsterdam, Amsterdam, Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Medical Oncology, Amsterdam, Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam, Netherlands.
- Cancer Center Amsterdam, Amsterdam, Netherlands.
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Pande R, Liu W, Raza SS, Papamichail M, Suthananthan AE, Bartlett DC, Marudanayagam R, Dasari BVM, Sutcliffe RP, Roberts KJ, Wadhwani S, Chatzizacharias N. Staging Computed Tomography Parameters Predict the Need for Vein Resection during Pancreaticoduodenectomy in Resectable Pancreatic Ductal Adenocarcinoma. Diagnostics (Basel) 2024; 14:135. [PMID: 38248012 PMCID: PMC10814156 DOI: 10.3390/diagnostics14020135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 12/30/2023] [Accepted: 01/03/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Surgery-first approach is the current standard of care for resectable pancreatic ductal adenocarcinoma (PDAC), and a proportion of these cases will require venous resection. This study aimed to identify parameters on staging computed tomography (CT) that predict the need for venous resection during pancreaticoduodenectomy (PD) for resectable PDAC. METHODS We conducted a retrospective analysis of prospectively collected data on patients who underwent PD for resectable staged PDAC (as per NCCN criteria) between 2011 and 2020. Staging CTs were independently reviewed by two specialist radiologists blinded to the clinical outcomes. Univariate and multivariate risk analyses were performed. RESULTS In total, 296 PDs were included. Venous resection was performed in 62 (21%) cases. There was a higher rate of resection margin positivity in the vein resection group (72.6% vs. 48.7%, p = 0.001). Tumour at the neck of the pancreas, superior mesenteric vein involvement of ≥10 mm and pancreatic duct dilatation were identified as independent predictors for venous resection. DISCUSSION Staging CT parameters can predict the need for venous resection during PD for resectable cases of PDAC. This may assist in surgical planning, patient selection and counselling. Future efforts should concentrate on validating these results or identifying additional predictors in a multicentre and prospective setting.
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Affiliation(s)
- Rupaly Pande
- Department of HPB and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; (R.P.); (S.S.R.); (M.P.); (A.E.S.); (D.C.B.); (R.M.); (B.V.M.D.); (R.P.S.); (K.J.R.)
| | - Wingyan Liu
- Department of Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; (W.L.); (S.W.)
| | - Syed S. Raza
- Department of HPB and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; (R.P.); (S.S.R.); (M.P.); (A.E.S.); (D.C.B.); (R.M.); (B.V.M.D.); (R.P.S.); (K.J.R.)
| | - Michail Papamichail
- Department of HPB and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; (R.P.); (S.S.R.); (M.P.); (A.E.S.); (D.C.B.); (R.M.); (B.V.M.D.); (R.P.S.); (K.J.R.)
| | - Arul E. Suthananthan
- Department of HPB and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; (R.P.); (S.S.R.); (M.P.); (A.E.S.); (D.C.B.); (R.M.); (B.V.M.D.); (R.P.S.); (K.J.R.)
| | - David C. Bartlett
- Department of HPB and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; (R.P.); (S.S.R.); (M.P.); (A.E.S.); (D.C.B.); (R.M.); (B.V.M.D.); (R.P.S.); (K.J.R.)
| | - Ravi Marudanayagam
- Department of HPB and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; (R.P.); (S.S.R.); (M.P.); (A.E.S.); (D.C.B.); (R.M.); (B.V.M.D.); (R.P.S.); (K.J.R.)
| | - Bobby V. M. Dasari
- Department of HPB and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; (R.P.); (S.S.R.); (M.P.); (A.E.S.); (D.C.B.); (R.M.); (B.V.M.D.); (R.P.S.); (K.J.R.)
| | - Robert P. Sutcliffe
- Department of HPB and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; (R.P.); (S.S.R.); (M.P.); (A.E.S.); (D.C.B.); (R.M.); (B.V.M.D.); (R.P.S.); (K.J.R.)
| | - Keith J. Roberts
- Department of HPB and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; (R.P.); (S.S.R.); (M.P.); (A.E.S.); (D.C.B.); (R.M.); (B.V.M.D.); (R.P.S.); (K.J.R.)
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2TT, UK
| | - Sharan Wadhwani
- Department of Radiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; (W.L.); (S.W.)
| | - Nikolaos Chatzizacharias
- Department of HPB and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK; (R.P.); (S.S.R.); (M.P.); (A.E.S.); (D.C.B.); (R.M.); (B.V.M.D.); (R.P.S.); (K.J.R.)
- College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
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Tamburrino D, De Stefano F, Belfiori G, Partelli S, Crippa S, Falconi M. Surgical Planning for "Borderline Resectable" and "Locally Advanced" Pancreatic Cancer During Open Pancreatic Resection. J Gastrointest Surg 2023; 27:3014-3023. [PMID: 37783912 DOI: 10.1007/s11605-023-05848-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/16/2023] [Indexed: 10/04/2023]
Abstract
Pancreatic resection for pancreatic ductal adenocarcinoma (PDAC) is one of the most complex procedures in abdominal surgery due to the technical and oncological challenges given by its local aggressive growth. The improvement of new multidrug chemotherapy regimens and surgical techniques has increased the caseload of "borderline resectable" (BR) or even "locally advanced" (LA) PDAC candidates for surgical resection. As a result, the increased heterogeneity of surgical scenarios has made it essential to utilize a tailored surgical strategy for each individual case. Notably, the strategy employed to approach and assess the peripancreatic vessels should be weighted according to tumor's location and the site of suspected vascular infiltration. The aim of this paper is to describe the open surgical approach for "BR" or "LA" PDAC used at our Institution and summarizes a "step-up approach" to manage vascular infiltration.
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Affiliation(s)
- Domenico Tamburrino
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Federico De Stefano
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Giulio Belfiori
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Crippa
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
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Ahuja M, Pandé R, Chugtai S, Brown RM, Cain O, Bartlett DC, Dasari BVM, Marudanayagam R, Roberts KJ, Isaac J, Sutcliffe RP, Chatzizacharias N. Vein Wall Invasion Is a More Reliable Predictor of Oncological Outcomes than Vein-Related Margins after Pancreaticoduodenectomy for Early Stages of Pancreatic Ductal Adenocarcinoma. Diagnostics (Basel) 2023; 13:3465. [PMID: 37998601 PMCID: PMC10670022 DOI: 10.3390/diagnostics13223465] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/11/2023] [Accepted: 11/14/2023] [Indexed: 11/25/2023] Open
Abstract
Pancreaticoduodenectomy (PD) with vein resection is the only potentially curative option for patients with pancreatic ductal adenocarcinoma (PDAC) with venous involvement. The aim of our study was to assess the oncological prognostic significance of the different variables of venous involvement in patients undergoing PD for resectable and borderline-resectable with venous-only involvement (BR-V) PDAC. We performed a retrospective analysis of prospectively acquired data over a 10-year period. Of the 372 patients included, 105 (28%) required vein resection and vein wall involvement was identified in 37% of those. A multivariable analysis failed to identify the vein-related resection margins as independent predictors for OS, DFS or LR. Vein wall tumour involvement was an independent predictor of OS (risk x1.7-2) and DFS (risk x1.9-2.2) in all models, while it replaced overall surgical margin positivity as the only parameter independently predicting LR during an analysis of separate resection margins (risk x2.4). Vein wall tumour invasion may be a more reliable predictor of oncological outcomes compared to traditionally reported parameters. Future studies should focus on possible pre-operative investigations that could identify these cases and management pathways that could yield a survival benefit, such as the use of neoadjuvant treatments.
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Affiliation(s)
- Manish Ahuja
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Rupaly Pandé
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Shafiq Chugtai
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Rachel M. Brown
- Department of Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (R.M.B.)
| | - Owen Cain
- Department of Pathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (R.M.B.)
| | - David C. Bartlett
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Bobby V. M. Dasari
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Ravi Marudanayagam
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Keith J. Roberts
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham B15 2SQ, UK
| | - John Isaac
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Robert P. Sutcliffe
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
| | - Nikolaos Chatzizacharias
- Department of HPB and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2GW, UK; (M.A.); (R.P.); (S.C.); (D.C.B.); (B.V.M.D.); (R.M.); (K.J.R.); (J.I.); (R.P.S.)
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Bernhardt M, Rühlmann F, Azizian A, Kölling MA, Beißbarth T, Grade M, König AO, Ghadimi M, Gaedcke J. Impact of Portal Vein Resection (PVR) in Patients Who Underwent Curative Intended Pancreatic Head Resection. Biomedicines 2023; 11:3025. [PMID: 38002027 PMCID: PMC10669675 DOI: 10.3390/biomedicines11113025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/25/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
The oncological impact of portal vein resection (PVR) in pancreatic cancer surgery remains contradictory. Different variables might have an impact on the outcome. The aim of the present study is the retrospective assessment of the frequency of PVR, histological confirmation of tumor infiltration, and comparison of oncological outcomes in PVR patients. We retrieved n = 90 patients from a prospectively collected data bank who underwent pancreas surgery between 2012 and 2019 at the University Medical Centre Göttingen (Germany) and showed a histologically confirmed pancreatic ductal adenocarcinoma (PDAC). While 50 patients (55.6%) underwent pancreatic resection combined with PVR, 40 patients (44.4%) received standard pancreatic surgery. Patients with distal pancreatectomy or a tumor other than PDAC were excluded. PVR was performed either as local excision or circular resection of the portal vein. Clinical/patient data and follow-ups were retrieved. The median follow-up period was 20.5 months. Regarding the oncological outcome, a statistically poorer CSS (p = 0.04) was observed in PVR patients. There was no difference (p = 0.18) in patients' outcomes between tangential and complete PVR, while n = 21 (42% of PVR patients) showed portal vein infiltration. The correlation between performed PVR and resection status was statistically significant: 48.6% of PVR patients achieved R0 resections compared to 75% in non-PVR patients (p = 0.03). Patients who underwent PDAC surgery with PVR show a significantly poorer outcome regardless of PVR type. Tumor size and R-status remain two important variables significantly associated with outcome. Since there is a lack of standardization for the indication of PVR, it remains unknown if the need for resection of vein structures during pancreatic resection represents the biological aggressiveness of the tumor or is biased by the experience of the surgeon.
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Affiliation(s)
- Markus Bernhardt
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Felix Rühlmann
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Azadeh Azizian
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Max Alexander Kölling
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Tim Beißbarth
- Institute of Medical Bioinformatics, University Medical Center, D-37075 Goettingen, Germany
| | - Marian Grade
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Alexander Otto König
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center, D-37075 Goettingen, Germany
| | - Michael Ghadimi
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Jochen Gaedcke
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
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Molnár A, Halimi A, Svensson J, Bayadsi H, Innala M, Hansén M, Hemmingsson O, Franklin O. Portomesenteric venous contact ≤180° and overall survival in resectable head and body pancreatic adenocarcinoma treated with upfront surgery. Eur J Surg Oncol 2023; 49:107097. [PMID: 37804583 DOI: 10.1016/j.ejso.2023.107097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/21/2023] [Accepted: 09/25/2023] [Indexed: 10/09/2023]
Abstract
INTRODUCTION Upfront surgery is the standard of care for resectable pancreatic cancer, defined as the absence of or ≤180° tumour contact with the portal/superior mesenteric vein. We hypothesized that portomesenteric venous tumour contact is prognostically unfavourable and aimed to assess whether it is associated with poorer survival compared with no venous contact in resectable head and body pancreatic cancer. METHODS This single-centre retrospective study included patients undergoing upfront surgery for resectable head and body pancreatic cancer in 2010-2020 at Umeå University Hospital, Sweden. No venous contact was compared with portomesenteric venous contact of ≤180° based on preoperative imaging. Overall survival on an intention-to-treat basis was compared with Kaplan-Meier curves, a log-rank test and Cox proportional hazards models. RESULTS The final study cohort included 39 patients with portomesenteric venous tumour contact and 144 patients without venous tumour contact. Patients with venous tumour contact had a median overall survival of 15.3 months compared to 23.0 months (log rank P = 0.059). Portomesenteric venous tumour contact was an independent negative prognostic factor for survival in the multivariable Cox model (HR 1.68; 95% CI 1.11-2.55, P = 0.014) and was associated with higher rates of microscopically non-radical resections (R1) (50% vs 26.1%, P = 0.012) and pathological lymph node metastasis (76.7% vs 56.8%, P = 0.012). There was no difference in adjuvant chemotherapy receipt or postoperative complications between the groups. CONCLUSIONS Portomesenteric venous tumour contact is associated with poorer overall survival and higher rates of R1 resections and lymph node metastasis in patients with resectable head and body pancreatic cancer treated with upfront surgery.
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Affiliation(s)
- Adrienne Molnár
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Asif Halimi
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Johan Svensson
- Department of Statistics, Umeå School of Business, Economics and Statistics, Umeå University, Umeå, Sweden
| | - Haytham Bayadsi
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Marcus Innala
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Maria Hansén
- Oncology Clinic, Sundsvall Regional Hospital, Sundsvall, Sweden
| | - Oskar Hemmingsson
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Oskar Franklin
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden; Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
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7
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Groen JV, Michiels N, Besselink MG, Bosscha K, Busch OR, van Dam R, van Eijck CHJ, Koerkamp BG, van der Harst E, de Hingh IH, Karsten TM, Lips DJ, de Meijer VE, Molenaar IQ, Nieuwenhuijs VB, Roos D, van Santvoort HC, Wijsman JH, Wit F, Zonderhuis BM, de Vos-Geelen J, Wasser MN, Bonsing BA, Stommel MWJ, Mieog JSD. Practice variation in venous resection during pancreatoduodenectomy for pancreatic cancer: A nationwide cohort study. Surgery 2023; 174:924-933. [PMID: 37451894 DOI: 10.1016/j.surg.2023.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 04/19/2023] [Accepted: 06/18/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Practice variation exists in venous resection during pancreatoduodenectomy, but little is known about the potential causes and consequences as large studies are lacking. This study explores the potential causes and consequences of practice variation in venous resection during pancreatoduodenectomy for pancreatic cancer in the Netherlands. METHODS This nationwide retrospective cohort study included patients undergoing pancreatoduodenectomy for pancreatic cancer in 18 centers from 2013 through 2017. RESULTS Among 1,311 patients undergoing pancreatoduodenectomy, 351 (27%) had a venous resection, and the overall median annual center volume of venous resection was 4. No association was found between the center volume of pancreatoduodenectomy and the rate of venous resections, nor between patient and tumor characteristics and the rate of venous resections per center. Female sex, lower body mass index, neoadjuvant therapy, venous involvement, and stenosis on imaging were predictive for venous resection. Adjusted for these factors, 3 centers performed significantly more, and 3 centers performed significantly fewer venous resections than expected. In patients with venous resection, significantly less major morbidity (22% vs 38%) and longer overall survival (median 16 vs 12 months) were observed in centers with an above-median annual volume of venous resections (>4). CONCLUSION Patient and tumor characteristics did not explain significant practice variation between centers in the Netherlands in venous resection during pancreatoduodenectomy for pancreatic cancer. The clinical outcomes of venous resection might be related to the volume of the procedure.
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Affiliation(s)
- Jesse V Groen
- Department of Surgery, Leiden University Medical Center, The Netherlands.
| | - Nynke Michiels
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, The Netherlands; Cancer Center Amsterdam, The Netherlands
| | - Ronald van Dam
- Department of Surgery, Maastricht University Medical Center, The Netherlands
| | | | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands; Department of Epidemiology, Maastricht UMC+, The Netherlands
| | - Tom M Karsten
- Department of Surgery, Onze Lieve Vrouwe Gasthuis (loc. Oost), Amsterdam, The Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University of Groningen and University Medical Center Groningen, The Netherlands
| | - Isaac Q Molenaar
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein; Regional Academic Cancer Center Utrecht, The Netherlands
| | | | - Daphne Roos
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, UMC Utrecht Cancer Center, St Antonius Hospital Nieuwegein; Regional Academic Cancer Center Utrecht, The Netherlands
| | - Jan H Wijsman
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | - Babs M Zonderhuis
- Cancer Center Amsterdam, The Netherlands; Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, The Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht UMC+, The Netherlands
| | - Martin N Wasser
- Department of Radiology, Leiden University Medical Center, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, The Netherlands
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Oba A, Del Chiaro M, Fujii T, Okano K, Stoop TF, Wu YHA, Maekawa A, Yoshida Y, Hashimoto D, Sugawara T, Inoue Y, Tanabe M, Sho M, Sasaki T, Takahashi Y, Matsumoto I, Sasahira N, Nagakawa Y, Satoi S, Schulick RD, Yoon YS, He J, Jang JY, Wolfgang CL, Hackert T, Besselink MG, Takaori K, Takeyama Y. "Conversion surgery" for locally advanced pancreatic cancer: A position paper by the study group at the joint meeting of the International Association of Pancreatology (IAP) & Japan Pancreas Society (JPS) 2022. Pancreatology 2023; 23:712-720. [PMID: 37336669 DOI: 10.1016/j.pan.2023.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 04/10/2023] [Accepted: 06/06/2023] [Indexed: 06/21/2023]
Abstract
Locally advanced pancreatic cancer (LAPC), which progresses locally and surrounds major vessels, has historically been deemed unresectable. Surgery alone failed to provide curative resection and improve overall survival. With the advancements in treatment, reports have shown favorable results in LAPC after undergoing successful chemotherapy therapy or chemoradiation therapy followed by surgical resection, so-called "conversion surgery", at experienced high-volume centers. However, recognizing significant regional and institutional disparities in the management of LAPC, an international consensus meeting on conversion surgery for LAPC was held during the Joint Congress of the 26th Meeting of the International Association of Pancreatology (IAP) and the 53rd Annual Meeting of Japan Pancreas Society (JPS) in Kyoto in July 2022. During the meeting, presenters reported the current best multidisciplinary practices for LAPC, including preoperative modalities, best systemic treatment regimens and durations, procedures of conversion surgery with or without vascular resections, biomarkers, and genetic studies. It was unanimously agreed among the experts in this meeting that "cancer biology is surpassing locoregional anatomical resectability" in the era of effective multiagent treatment. The biology of pancreatic cancer has yet to be further elucidated, and we believe it is essential to improve the treatment outcomes of LAPC patients through continued efforts from each institution and more international collaboration. This article summarizes the agreement during the discussion amongst the experts in the meeting. We hope that this will serve as a foundation for future international collaboration and recommendations for future guidelines.
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Affiliation(s)
- Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan; Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Kagawa University School of Medicine, Kagawa, Japan
| | - Thomas F Stoop
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Y H Andrew Wu
- Department Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aya Maekawa
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuta Yoshida
- Department of Surgery, Kindai University, Osaka, Japan
| | | | - Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | | | - Naoki Sasahira
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Sohei Satoi
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin He
- Department Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany; Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
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Tamburrino D, Belfiori G, Andreasi V, Provinciali L, Cerchione R, De Stefano F, Fermi F, Gasparini G, Pecorelli N, Partelli S, Crippa S, Falconi M. Pancreatectomy with venous vascular resection for pancreatic cancer: Impact of types of vein resection on timing and pattern of recurrence. Eur J Surg Oncol 2023; 49:1457-1465. [PMID: 37088601 DOI: 10.1016/j.ejso.2023.03.229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/13/2023] [Accepted: 03/24/2023] [Indexed: 04/08/2023]
Abstract
INTRODUCTION Few studies analysed the impact of different venous resection techniques on recurrence in patients with pancreatic ductal adenocarcinoma (PDAC). Primary aim was to compare local recurrence rate and disease-free survival (DFS) between patients who underwent pancreatectomy with tangential versus segmental resection of portal vein/superior mesenteric vein. MATERIALS AND METHODS All consecutive patients who underwent pancreatectomy with venous resection for PDAC between 2009 and 2019 were included. A propensity score matching (PSM) was used to reduce the effect of treatment selection bias. RESULTS Overall, 120 patients (68%) underwent pancreatectomy with tangential venous resection and 57 patients (32%) were submitted to pancreatectomy with segmental venous resection. After a median follow-up of 24 months, local recurrence was comparable between the two groups (tangential: n = 32/120, 26.7% versus segmental: n = 10/57, 17.5%; p = 0.58). The median DFS was 17 months (IQR 9-31) in patients who underwent tangential resection, as compared to 12 months (IQR 5-21) in those who underwent segmental resection (p = 0.049). After PSM (n = 106), the median DFS was 18 months (IQR 9-26) in the tangential resection group, and 12 months (IQR 5-21) in the segmental resection group (p = 0.17). In the PSM population, lymph node ratio (HR 4.83; p = 0.028) and tumor size >25 mm (HR 3.26; p = 0.007) were identified as determinants of local recurrence. CONCLUSION Tangential venous resections are not associated with a higher rate of local recurrence. Long-term outcomes are more related to tumors characteristics than to venous resection techniques. A step-up approach to vein resection, with tangential resection being performed whenever technically feasible, should be strongly encouraged.
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Affiliation(s)
- Domenico Tamburrino
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Belfiori
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Valentina Andreasi
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Lorenzo Provinciali
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Raffaele Cerchione
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Federico De Stefano
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Francesca Fermi
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Giulia Gasparini
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Nicolò Pecorelli
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Crippa
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic and Transplant Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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10
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Michiels N, Doppenberg D, Groen JV, van Veldhuisen E, Bonsing BA, Busch OR, Crobach ASLP, van Delden OM, van Dieren S, Farina A, de Hingh IHJT, Hurks R, Nederend J, Shahbazi Feshtali S, Tank Y, Vahrmeijer AL, Wasser M, Besselink MG, Mieog JSD. Intraoperative Ultrasound During Surgical Exploration in Patients with Pancreatic Cancer and Vascular Involvement (ULTRAPANC): A Prospective Multicenter Study. Ann Surg Oncol 2023; 30:3455-3463. [PMID: 36774435 PMCID: PMC10175412 DOI: 10.1245/s10434-023-13112-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 01/02/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Determining the resectability of pancreatic cancer with vascular involvement on preoperative computed tomography imaging remains challenging, especially following preoperative chemotherapy and chemoradiotherapy. Intraoperative ultrasound (IOUS) may provide real-time additional information, but prospective multicenter series confirming its value are lacking. PATIENTS AND METHODS This prospective multicenter study included patients undergoing surgical exploration for pancreatic cancer with vascular involvement. All patients underwent IOUS at the start of explorative laparotomy. Primary outcomes were resectability status as defined by the National Comprehensive Cancer Network and the extent of vascular involvement. RESULTS Overall, 85 patients were included, of whom 74 (87%) were post preoperative chemotherapy, and mostly following FOLFIRINOX regimen (n = 57; 76%). On the basis of preoperative imaging, 34 (40%) patients were staged as resectable (RPC), 32 (38%) borderline resectable (BRPC), and 19 (22%) locally advanced pancreatic cancer (LAPC). IOUS changed the resectability status in 32/85 (38%) patients (p < 0.001), including 8/19 (42%) patients with LAPC who were downstaged (4 to BRPC, 4 to RPC), and 22/32 (69%) patients with BRPC who were downstaged to RPC. Among patients with presumed superior mesenteric artery (SMA) involvement, 20/28 (71%) had no SMA involvement on IOUS. In 15 of these 20 patients a pancreatic resection was performed, all with R0 SMA margin. CONCLUSION IOUS during surgical exploration for pancreatic cancer and vascular involvement downstaged the resectability status in over one-third of patients, which could facilitate progress during surgical exploration. This finding should be confirmed by larger studies, including detailed pathology assessment. Trial Registration www.trialregister.nl (NL7621).
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Affiliation(s)
- Nynke Michiels
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Deesje Doppenberg
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jesse V. Groen
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Eran van Veldhuisen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Otto M. van Delden
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Interventional Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Susan van Dieren
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Arantza Farina
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Rob Hurks
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Interventional Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joost Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Yeliz Tank
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - A. L. Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin Wasser
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - J. Sven D. Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - for the Dutch Pancreatic Cancer Group
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Interventional Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
- Department of Radiology, Catharina Hospital, Eindhoven, The Netherlands
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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11
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de Santibañes M, Pekolj J, Sanchez Claria R, de Santibañes E, Mazza OM. Technical Implications for Surgical Resection in Locally Advanced Pancreatic Cancer. Cancers (Basel) 2023; 15:cancers15051509. [PMID: 36900300 PMCID: PMC10000506 DOI: 10.3390/cancers15051509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 03/08/2023] Open
Abstract
Pancreatic ductal adenocarcinoma remains a global health challenge and is predicted to soon become the second leading cause of cancer death in developed countries. Currently, surgical resection in combination with systemic chemotherapy offers the only chance of cure or long-term survival. However, only 20% of cases are diagnosed with anatomically resectable disease. Neoadjuvant treatment followed by highly complex surgical procedures has been studied over the last decade with promising short- and long-term results in patients with locally advanced pancreatic ductal adenocarcinoma (LAPC). In recent years, a wide variety of complex surgical techniques that involve extended pancreatectomies, including portomesenteric venous resection, arterial resection, or multi-organ resection, have emerged to optimize local control of the disease and improve postoperative outcomes. Although there are multiple surgical techniques described in the literature to improve outcomes in LAPC, the comprehensive view of these strategies remains underdeveloped. We aim to describe the preoperative surgical planning as well different surgical resections strategies in LAPC after neoadjuvant treatment in an integrated way for selected patients with no other potentially curative option other than surgery.
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Affiliation(s)
- Martín de Santibañes
- Liver Transplant Unit, Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, Buenos Aires C1181ACH, Argentina
- Correspondence: ; Tel.: +54-11-4981-4501
| | - Juan Pekolj
- Liver Transplant Unit, Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, Buenos Aires C1181ACH, Argentina
| | - Rodrigo Sanchez Claria
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1181ACH, Argentina
| | - Eduardo de Santibañes
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1181ACH, Argentina
| | - Oscar Maria Mazza
- Department of Surgery, Division of HPB Surgery, Hospital Italiano de Buenos Aires, Buenos Aires C1181ACH, Argentina
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Ouyang G, Zhong X, Cai Z, Liu J, Zheng S, Hong D, Yin X, Yu J, Bai X, Liu Y, Liu J, Huang X, Xiong Y, Xu J, Cai Y, Jiang Z, Chen R, Peng B. The short- and long-term outcomes of laparoscopic pancreaticoduodenectomy combining with different type of mesentericoportal vein resection and reconstruction for pancreatic head adenocarcinoma: a Chinese multicenter retrospective cohort study. Surg Endosc 2023:10.1007/s00464-023-09901-2. [PMID: 36759356 DOI: 10.1007/s00464-023-09901-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 01/18/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND The results of laparoscopic pancreaticoduodenectomy combining with mesentericoportal vein resection and reconstruction (LPD-MPVRs) for pancreatic head adenocarcinoma are rarely reported. The aim of present study was to explore the short- and long-term outcomes of different type of LPD-MPVRs. METHODS Patients who underwent LPD-MPVRs in 14 Chinese high-volume pancreatic centers between June 2014 and December 2020 were selected and compared. RESULTS In total, 142 patients were included and were divided into primary closure (n = 56), end-end anastomosis (n = 43), or interposition graft (n = 43). Median overall survival (OS) and median progress-free survival (PFS) between primary closure and end-end anastomosis had no difference (both P > 0.05). As compared to primary closure and end-end anastomosis, interposition graft had the worst median OS (12 months versus 19 months versus 17 months, P = 0.001) and the worst median PFS (6 months versus 15 months versus 12 months, P < 0.000). As compared to primary closure, interposition graft had almost double risk in major morbidity (16.3 percent versus 8.9 percent) and about triple risk (10 percent versus 3.6 percent) in 90-day mortality, while End-end anastomosis had only one fourth major morbidity (2.3 percent versus 8.9 percent). Multivariate analysis revealed postoperation hospital stay, American Society of Anesthesiologists (ASA) score, number of positive lymph nodes had negative impact on OS, while R0, R1 surgical margin had protective effect on OS. Postoperative hospital stay had negative impact on PFS, while primary closure, end-end anastomosis, short-term vascular patency, and short-term vascular stenosis positively related to PFS. CONCLUSIONS In LPD-MPVRs, interposition graft had the worst OS, the worst PFS, the highest rate of major morbidity, and the highest rate of 90-day mortality. While there were no differences in OS and PFS between primary closure and end-end anastomosis.
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Affiliation(s)
- Guoqing Ouyang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, Sichuan, 610041, People's Republic of China
| | - Xiaosheng Zhong
- Department of Pancreatic Surgery, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, People's Republic of China
| | - Zhiwei Cai
- Department of Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, People's Republic of China
| | - Jianhua Liu
- Department of Hepato-Pancreato-Biliary Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, People's Republic of China
| | - Shangyou Zheng
- Department of Pancreas Center, Department of General Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Science, Guangzhou, Guangdong, People's Republic of China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Defei Hong
- Department of General Surgery, Sir Run Run Shaw Hospital, The Medicine School of Zhejiang University, Hangzhou, Zhejiang, China
| | - Xinmin Yin
- Department of Hepatobiliary Surgery, The People's Hospital of Hunan Province, Changsha, Hunan, People's Republic of China
| | - Jian Yu
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Yahui Liu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, People's Republic of China
| | - Jun Liu
- Department of Live Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital, Shandong University, Jinan, Shandong, People's Republic of China.,Department of Live Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, People's Republic of China
| | - Xiaobing Huang
- Department of Hepatobiliary Surgery, The Second Affiliated Army Medical University, Chongqing, People's Republic of China
| | - Yong Xiong
- Department of Hepatobiliary Surgery, Panzhihua Central Hospital, Panzhihua, Sichuan, People's Republic of China
| | - Jie Xu
- Department of Hepatobiliary Surgery, Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Yunqiang Cai
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, Sichuan, 610041, People's Republic of China.
| | - Zhongyi Jiang
- Department of Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, People's Republic of China.
| | - Rufu Chen
- Department of Pancreas Center, Department of General Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Science, Guangzhou, Guangdong, People's Republic of China. .,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.
| | - Bing Peng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, Sichuan, 610041, People's Republic of China.
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13
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Kauffmann EF, Napoli N, Ginesini M, Gianfaldoni C, Asta F, Salamone A, Ripolli A, Di Dato A, Vistoli F, Amorese G, Boggi U. Tips and tricks for robotic pancreatoduodenectomy with superior mesenteric/portal vein resection and reconstruction. Surg Endosc 2023; 37:3233-3245. [PMID: 36624216 PMCID: PMC10082118 DOI: 10.1007/s00464-022-09860-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 12/27/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Open pancreatoduodenectomy with vein resection (OPD-VR) is now standard of care in patients who responded to neoadjuvant therapies. Feasibility of robotic pancreatoduodenectomy (RPD) with vein resection (RPD-VR) was shown, but no study provided a detailed description of the technical challenges associated with this formidable operation. Herein, we describe the trips and tricks for technically successful RPD-VR. METHODS The vascular techniques used in RPD-VR were borrowed from OPD-VR, as well as from our experience with robotic transplantation of both kidney and pancreas. Vein resection was classified into 4 types according to the international study group of pancreatic surgery. Each type of vein resection was described in detail and shown in a video. RESULTS Between October 2008 and November 2021, a total of 783 pancreatoduodenectomies were performed, including 233 OPDs-VR (29.7%). RPD was performed in 256 patients (32.6%), and RPDs-VR in 36 patients (4.5% of all pancreatoduodenectomies; 15.4% of all pancreatoduodenectomies with vein resection; 14.0% of all RPDs). In RPD-VR vein resections were: 4 type 1 (11.1%), 10 type 2 (27.8%), 12 type 3 (33.3%) and 10 type 4 (27.8%). Vascular patches used in type 2 resections were made of peritoneum (n = 8), greater saphenous vein (n = 1), and deceased donor aorta (n = 1). Interposition grafts used in type 4 resections were internal left jugular vein (n = 8), venous graft from deceased donor (n = 1) and spiral saphenous vein graft (n = 1). There was one conversion to open surgery (2.8%). Ninety-day mortality was 8.3%. There was one (2.8%) partial vein thrombosis, treated with heparin infusion. CONCLUSIONS We have reported 36 technically successful RPDs-VR. We hope that the tips and tricks provided herein can contribute to safer implementation of RPD-VR. Based on our experience, and according to data from the literature, we strongly advise that RPD-VR is performed by expert surgeons at high volume centers.
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Affiliation(s)
- Emanuele F Kauffmann
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Cesare Gianfaldoni
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Fabio Asta
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Alice Salamone
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Allegra Ripolli
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Armando Di Dato
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
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14
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Sillesen M, Hansen CP, Dencker EE, Burgdorf SK, Krohn PS, Stender MT, Fristrup CW, Storkholm JH. Long-Term Outcomes of Venous Resections in Pancreatic Ductal Adenocarcinoma Patients: A Nationwide Cohort Study. Ann Surg Open 2022; 3:e219. [PMID: 37600295 PMCID: PMC10406038 DOI: 10.1097/as9.0000000000000219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 09/25/2022] [Indexed: 03/05/2023] Open
Abstract
To investigate whether pancreatic resections (PR) for pancreatic ductal adenocarcinoma (PDAC) is associated with worse survival when resection of the superior mesenteric vein/portal vein (SMV/PV) is required. Background PR for PDAC with resection of the superior mesenteric vein/portal vein (SMV/PV, PR+V resection) may be associated with inferior overall survival (OS) compared with PR without the need for SMV/PV resection (PR-V). We hypothesized that PR+V results in lower OS compared with PR-V. Method Retrospective study using data from the nationwide Danish Pancreatic Cancer Database from 2011 to 2020. Data on patients who underwent PR for PDAC were extracted. A group of PR patients found nonresectable on exploratory laparotomy (EXP) was also included. OS was assessed using Kaplan-Meier and Cox proportional hazards models adjusting for confounders (age, sex, R-resection level, chemotherapy, comorbidities, histology T and N classification, procedure subtype as well as tumor distance to the SMV/PV). Results Overall, 2403 patients were identified. Six hundred two underwent exploration only (EXP group), whereas 412 underwent pancreatic resection with (PR+V group) and 1389 (PR-V) without SMV/PV resection. Five-year OS for the PR+V group was lower (20% vs 30%) compared with PR-V, although multivariate Cox proportional hazards modeling could not associate PR+V status with OS (Hazard ratio 1.11, P = 0.408). Conclusion When correcting for confounders, PR+V was not associated with lower OS compared with PR-V.
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Affiliation(s)
- Martin Sillesen
- From the Department of Organ Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Denmark
- Center for Surgical Translation and Artificial Intelligence Research (CSTAR), Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Carsten Palnæs Hansen
- From the Department of Organ Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Emilie Even Dencker
- From the Department of Organ Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Denmark
- Center for Surgical Translation and Artificial Intelligence Research (CSTAR), Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Stefan Kobbelgaard Burgdorf
- From the Department of Organ Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Paul Suno Krohn
- From the Department of Organ Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | | | - Jan Henrik Storkholm
- From the Department of Organ Surgery and Transplantation, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Surgery, Imperial College NHS Trust, Hammersmith Hospital, London, United Kingdom
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15
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Groen JV, Michiels N, Mieog JSD. Author response to: Venous wedge and segment resection during pancreatoduodenectomy for pancreatic cancer: impact on short- and long-term outcomes in a nationwide cohort analysis. Br J Surg 2022; 109:e88. [PMID: 35416240 PMCID: PMC10364705 DOI: 10.1093/bjs/znac060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/02/2022] [Indexed: 08/02/2023]
Affiliation(s)
- Jesse V Groen
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Nynke Michiels
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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16
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Wang X, Wang Z, Ke N. Comment on: Venous wedge and segment resection during pancreatoduodenectomy for pancreatic cancer: impact on short- and long-term outcomes in a nationwide cohort analysis. Br J Surg 2022; 109:e87. [PMID: 35416254 DOI: 10.1093/bjs/znac058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 02/02/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Xing Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Ziyao Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Nengwen Ke
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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