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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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Sentí Farrarons S, Pardo Aranda F, Galofré Recasens M, Espin Álvarez F, Herrero Fonollosa E, García Domingo MI, Cremades Pérez M, Zárate Pinedo A, Camps Lassa J, Navinés López J, Cugat Andorra E. Venous resection in pancreatic oncologic surgery: Different techniques for different situations. Cir Esp 2023; 101:816-823. [PMID: 36706805 DOI: 10.1016/j.cireng.2023.01.001] [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: 02/23/2022] [Revised: 08/03/2022] [Accepted: 10/30/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION To report the clinical results of patients with malignant pancreatic lesions who underwent oncological surgery with vascular resection. The type of intervention performed, types of vascular reconstruction, the pathological anatomy results, postoperative morbidity and mortality, and survival at 3 and 5 years were analyzed. METHODS Retrospective, cross-sectional and comparative analysis. We include 41 patients with malignant pancreatic lesions who underwent surgery with vascular resection due to vascular involvement, from 2013 to 2021. RESULTS The most performed surgery was pancreaticoduodenectomy (Whipple procedure) using median laparotomy, in 35 out of the 41 patients (85%). One of the cases in the series was performed laparoscopically. Type 1 reconstruction (simple suture) was performed in 11 (27%) patients, type 2 in 4 (10%) cases, type 3 (end-to-end) in 23 (56%) cases, and type 4 reconstruction by autologous graft in 3 (7%) cases. The mean length of the resected venous segment was 21 (11-46) mm, and mean surgical time was 290 (220-360) minutes. 90% (37/41) were pancreatic adenocarcinoma. 83% were considered R0, and there was involvement in the resected vascular section in 41% of the cases. Four patients had Clavien Dindo morbidity >3, and there were no cases of postoperative mortality. Survival at 3 years was 48% and at 5 years 20%. CONCLUSIONS The aggressive surgical treatment with venous resection in pancreatic malignant lesions to ensure R0 and its vascular reconstruction is a feasible technique, with an acceptable morbid-mortality rate and overall survival.
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Affiliation(s)
- Sara Sentí Farrarons
- Departamento de Cirugía General, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - Fernando Pardo Aranda
- Unidad HPB, Departamento de Cirugía General, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain.
| | - Maria Galofré Recasens
- Departamento de Cirugía General, Hospital Universitari Mútua de Terrassa, Universitat de Barcelona, Terrassa, Barcelona, Spain
| | - Francesc Espin Álvarez
- Unidad HPB, Departamento de Cirugía General, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - Eric Herrero Fonollosa
- Unidad HPB, Departamento de Cirugía General, Hospital Universitari Mútua de Terrassa, Universitat de Barcelona, Terrassa, Barcelona, Spain
| | - Maria Isabel García Domingo
- Unidad HPB, Departamento de Cirugía General, Hospital Universitari Mútua de Terrassa, Universitat de Barcelona, Terrassa, Barcelona, Spain
| | - Manel Cremades Pérez
- Unidad HPB, Departamento de Cirugía General, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - Alba Zárate Pinedo
- Unidad HPB, Departamento de Cirugía General, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - Judith Camps Lassa
- Unidad HPB, Departamento de Cirugía General, Hospital Universitari Mútua de Terrassa, Universitat de Barcelona, Terrassa, Barcelona, Spain
| | - Jordi Navinés López
- Unidad HPB, Departamento de Cirugía General, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain
| | - Esteban Cugat Andorra
- Jefe Clínico de la Unidad HPB, Departamento de Cirugía General, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Jefe Clínico de la Unidad HPB, Departamento de Cirugía General, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain
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Hu H, Guo Q, Zhao J, Huang B, Du X. Aggressive surgical approach with vascular resection and reconstruction for retroperitoneal sarcomas: a systematic review. BMC Surg 2023; 23:275. [PMID: 37700246 PMCID: PMC10498574 DOI: 10.1186/s12893-023-02178-1] [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: 02/23/2023] [Accepted: 08/31/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND AND AIM Surgery is the mainstay of treatment and completeness of surgical resection is critical to achieve local control for retroperitoneal sarcoma (RPS). En-bloc resection of adjacent organs, including major abdominal vessels, is often required to achieve negative margins. The aim of this review was to summarise the available evidence to assess the relative benefits and disadvantages of an aggressive surgical approach with vascular resection in patients with retroperitoneal sarcoma (RPS). METHODS We searched PubMed, the Cochrane Library, and EMBASE for relevant studies published from inception up to August 1, 2022. We performed a systematic review of the available studies to assess the safety and long-term survival results of vascular resection for RPS. RESULTS We identified a total of 23 studies for our review. Overall postoperative in-hospital or 30-day mortality rate of patients with primary iliocaval leiomyosarcoma was 3% (11/359), and the major complication rate was 13%. The recurrence-free survival (RFS) rates after the follow-up period varied between 15% and 52%, and the 5-year overall survival (OS) rates ranged from 25 to 78%. Overall postoperative in-hospital or 30-day mortality rate of patients with RPSs receiving vascular resection was 3%, and the major complication rate was 27%. The RFS rates after the follow-up period were 18-86%, and the 5-year OS rates varied between 50% and 73%. There were no significant differences in the rates of RFS (HR: 0.97; 95% CI: 0.74-1.19; p = 0.945) and OS (HR: 1.01; 95% CI: 0.66-1.36; p = 0.774) between the extended resection group and tumour resection alone group. CONCLUSIONS With adequate preparation and proper management, for patients with RPSs involving major vessels, aggressive surgical approach with vascular resection can achieve R0/R1 resection and improve survival.
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Affiliation(s)
- Hankui Hu
- Division of Vascular Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Qiang Guo
- Division of Vascular Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China.
| | - Jichun Zhao
- Division of Vascular Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Bin Huang
- Division of Vascular Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Xiaojiong Du
- Division of Vascular Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan Province, China
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Radulova-Mauersberger O, Distler M, Riediger C, Weitz J, Welsch T, Kirchberg J. How we do it-the use of peritoneal patches for reconstruction of vena cava inferior and portal vein in hepatopancreatobiliary surgery. Langenbecks Arch Surg 2022; 407:3819-3831. [PMID: 36136152 DOI: 10.1007/s00423-022-02662-x] [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: 02/28/2022] [Accepted: 08/21/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Extended resections in hepatopancreatobiliary (HPB) surgery frequently require vascular resection to obtain tumor clearance. The use of alloplastic grafts may increase postoperative morbidity due to septic or thrombotic complications. The use of suitable autologous venous interponates (internal jugular vein, great saphenous vein) is frequently associated with additional incisions. The aim of this study was to report on our experience with venous reconstruction using the introperative easily available parietal peritoneum, focusing on key technical aspects. METHODS All patients who underwent HPB resections with venous reconstruction using peritoneal patches at our department between January 2017 and November 2021 were included in this retrospective analysis with median follow-up of 2 months (IQR: 1-8 months). We focused on technical aspects of the procedure and evaluated vascular patency and perioperative morbidity. RESULTS Parietal peritoneum patches (PPPs) were applied for reconstruction of the inferior vena cava (IVC) (13 patients) and portal vein (PV) (4 patients) during major hepatic (n = 14) or pancreatic (n = 2) resections. There were no cases of postoperative bleeding due to anastomotic leakage. Following PV reconstruction, two patients showed postoperative vascular stenosis after severe pancreatitis with postoperative pancreatic fistula and bile leakage, respectively. In patients with reconstruction of the IVC, no relevant perioperative vascular complications occurred. CONCLUSIONS The use of a peritoneal patch for reconstruction of the IVC in HPB surgery is a feasible, effective, and low-cost alternative to alloplastic, xenogenous, or venous grafts. The graft can be easily harvested and tailored to the required size. More evidence is still needed to confirm the safety of this procedure for the portal vein regarding long-term results.
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Affiliation(s)
- O Radulova-Mauersberger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - M Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - C Riediger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - J Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany. .,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany. .,German Cancer Research Center (DKFZ), Heidelberg, Germany. .,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany. .,Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.
| | - T Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - J Kirchberg
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.,National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.,German Cancer Research Center (DKFZ), Heidelberg, Germany.,Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
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Jin J, Yin SM, Weng Y, Chen M, Shi Y, Ying X, Gemenetzis G, Qin K, Zhang J, Deng X, Peng C, Shen B. Robotic versus open pancreaticoduodenectomy with vascular resection for pancreatic ductal adenocarcinoma: surgical and oncological outcomes from pilot experience. Langenbecks Arch Surg 2022; 407:1489-1497. [PMID: 35088144 DOI: 10.1007/s00423-021-02364-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 04/05/2021] [Accepted: 10/18/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE Venous resection and reconstruction (VR) is a feasible surgical technique to achieve optimal outcomes in selected patients with pancreatic ductal adenocarcinoma (PDAC) who undergo open pancreaticoduodenectomy (OPD). However, data regarding patient outcomes in patients who undergo VR in robotic-assisted pancreaticoduodenectomy (RPD) are scarce. METHODS All patients with a diagnosis of PDAC who underwent upfront open or robotic pancreatoduodenectomy with VR in a high-volume institution for pancreatic surgery between 2011 and 2019 were retrospectively reviewed. Perioperative and long-term outcomes were compared between the RPD and OPD cohorts. RESULTS A total of 84 patients were included in the final analysis, 14 patients underwent RPD with VR and 70 who had OPD with VR. Reconstructed venous patency, postoperative 30-day morbidity, and 90-day mortality were comparable; however, lymph node resection rates were lower in the RPC cohort (p = 0.029). No difference was identified in 3-year survival rates between the two groups (34.0% versus 25.7% respectively, p = 0.667). CONCLUSION RPD with VR is a feasible approach for patients with PDAC and venous invasion. Further studies are needed to assess long-term outcomes compared to the open approach.
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Affiliation(s)
- Jiabin Jin
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shih-Min Yin
- Division of General Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yuanchi Weng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengmin Chen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yusheng Shi
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiayang Ying
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - Kai Qin
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Zhang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaxing Deng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Chenghong Peng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Baiyong Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Research Institute of Pancreatic Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Department of Pancreatic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
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Bacalbasa N, Balescu I, Barbu I, Stiru O, Savu C, Pop L, Al Aloul A, Ursut B, Brasoveanu V, Petrea S. Vascular Resections in Association With Pancreatic Resections for Locally Advanced Pancreatic Cancer. In Vivo 2022; 36:1001-1006. [PMID: 35241562 DOI: 10.21873/invivo.12793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/28/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Locally advanced pancreatic cancer has been considered for a long period of time as an unresectable lesion and therefore, all patients have been traditionally addressed to the oncological services for palliative purposes. However, due to the wide usage of newer oncological agents in association with improved surgical techniques, radical surgical procedures became feasible. The aim of this study was to present the different surgical procedures that were performed in locally advanced pancreatic cancer patients in order to achieve radical resections. PATIENTS AND METHODS Between 2019 and 2020, six cases were submitted to pancreatic and vascular resections in Fundeni Clinical Hospital. RESULTS In all cases, surgery with curative intent was attempted; portal vein resection was performed in five cases, whereas arterial resection was performed in three cases. Reconstruction was performed by direct re-anastomosis, by placing cadaveric or synthetic grafts. The postoperative outcomes were favourable in all cases. CONCLUSION Vascular resections can be safely associated with pancreatic resections in cases presenting locally advanced pancreatic lesions, with acceptable morbidity rates.
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Affiliation(s)
- Nicolae Bacalbasa
- Department of Visceral Surgery, Center of Excellence in Translational Medicine "Fundeni" Clinical Institute, Bucharest, Romania; .,Department of Obstetrics and Gynecology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Irina Balescu
- Department of Surgery, "Ponderas" Academic Hospital, Bucharest, Romania
| | - Ion Barbu
- Department of Visceral Surgery, Center of Excellence in Translational Medicine "Fundeni" Clinical Institute, Bucharest, Romania
| | - Ovidiu Stiru
- Emergency Institute for Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Bucharest, Romania.,Department of Cardiovascular Surgery, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Cornel Savu
- Department of Thoracic Surgery, "Marius Nasta" National Institute of Pneumology, Bucharest, Romania.,Department of Thoracic Surgery, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Lucian Pop
- Department of Obstetrics and Gynecology National Institute of Mother and Child Care Alessandrescu-Rusescu, Bucharest, Romania
| | - Adnan Al Aloul
- Department of Surgery, Ramnicu Sarat County Hospital, Buzau, Romania
| | - Bogdan Ursut
- Department of Surgery, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Surgery, "Agrippa Ionescu" Clinical Emergency Hospital, Bucharest, Romania
| | - Vladislav Brasoveanu
- Department of Visceral Surgery, Center of Excellence in Translational Medicine "Fundeni" Clinical Institute, Bucharest, Romania
| | - Sorin Petrea
- Department of Surgery, "Dr. I. Cantacuzino" Clinical Hospital, Bucharest, Romania
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Castillo Tuñón JM, Valle Rodas ME, Botello Martínez F, Rojas Holguín A, López Guerra D, Santos Naharro J, Jaén Torrejímeno I, Blanco Fernández G. Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures. Cir Esp 2021; 99:745-56. [PMID: 34794902 DOI: 10.1016/j.cireng.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/23/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The main objective of this study is to determine whether our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms. METHOD Descriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded. RESULTS 631 patients were analyzed. The values obtained in the quality standards are in range. The most frequent surgery was pancreaticoduodenectomy, which associated higher peri-operative morbidity and mortality rates (P ≤ .05). The extended vascular resections impacted the pancreaticoduodenectomy group, associating a longer mean stay (P = .01) and a higher rate of re-interventions (P = .02). CONCLUSIONS The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbidity and mortality.
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Blair AB, Krell RW, Ejaz A, Groot VP, Gemenetzis G, Padussis JC, Falconi M, Wolfgang CL, Weiss MJ, Are C, He J, Reames BN. Proclivity to Explore Locally Advanced Pancreas Cancer Is Not Associated with Surgeon Volume. J Gastrointest Surg 2021; 25:2562-2571. [PMID: 34027578 DOI: 10.1007/s11605-021-05034-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 02/05/2021] [Accepted: 04/28/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE There is limited high-level evidence to guide locally advanced pancreas cancer (LAPC) management. Recent work shows that surgeons' preferences in LAPC management vary broadly. We sought to examine whether surgeon volume was associated with attitudes regarding LAPC management. METHODS An electronic survey was distributed by email to an international cohort of pancreas surgeons to evaluate practice patterns regarding LAPC management. Clinical vignette-based questions evaluated surgeons' attitudes regarding patient eligibility and the proclivity to offer exploration. Surgeons were classified into "low-" or "high-volume" categories according to thresholds of self-reported annual pancreatectomy volume. Surgeon's attitudes regarding LAPC management and inclination to consider exploration were compared across annual volume categories. RESULTS A total of 153 eligible responses were received from 4 continents, for an estimated response rate of 10.6%. Median duration of practice was 12 years (IQR 6-20). Most respondents reported >25 cases/year (89, 58.2%), of which 34 (22.2%) reported >50. Compared to surgeons with <25 cases/year, surgeons with >25 cases/year practiced longer (median 15 vs. 7.5 years, P<0.001) and were more likely to "always" recommend neoadjuvant chemotherapy (83.2% vs. 56.3%, P=0.001). Surgeons performing >50 cases/year were more likely to offer arterial resection (70.6% vs. 43.7%, P=0.006). The willingness to offer (or defer) exploration did not differ across any categories of surgeons' annual case volume. CONCLUSIONS In an international survey of pancreas surgeons, the proclivity to consider exploration for LAPC was not associated with multiple categories of surgeon volume. Better evidence is needed to define the optimal management approach to LAPC.
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Affiliation(s)
- Alex B Blair
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Robert W Krell
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Aslam Ejaz
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | - Vincent P Groot
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Georgios Gemenetzis
- Department of Surgery, University of Glasgow School of Medicine, Glasgow, UK
| | - James C Padussis
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Massimo Falconi
- Department of Surgery, Università Vita-Salute, San Raffaele Hospital IRCCS, Milano, Italy
| | | | | | - Chandrakanth Are
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Jin He
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Bradley N Reames
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE, 68198, USA.
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Liu Y, Li G, Lu Z, Wang T, Yang Y, Wang X, Liu J. Effect of vascular resection for perihilar cholangiocarcinoma: a systematic review and meta-analysis. PeerJ 2021; 9:e12184. [PMID: 34631316 PMCID: PMC8466000 DOI: 10.7717/peerj.12184] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/29/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To evaluate the effect of vascular resection (VR), including portal vein resection (PVR) and hepatic artery resection (HAR), on short- and long-term outcomes in patients with perihilar cholangiocarcinoma (PHC). BACKGROUND Resection surgery and transplantation are the main treatment methods for PHC that provide a chance of long-term survival. However, the efficacy and safety of VR, including PVR and HAR, for treating PHC remain controversial. METHODS This study was registered at the International Prospective Register of Systematic Reviews (CRD42020223330). The EMBASE, PubMed, and Cochrane Library databases were used to search for eligible studies published through November 28, 2020. Studies comparing short- and long-term outcomes between patients who underwent hepatectomy with or without PVR and/or HAR were included. Random- and fixed-effects models were applied to assess the outcomes, including morbidity, mortality, and R0 resection rate, as well as the impact of PVR and HAR on long-term survival. RESULTS Twenty-two studies including 4,091 patients were deemed eligible and included in this study. The meta-analysis showed that PVR did not increase the postoperative morbidity rate (odds ratio (OR): 1.03, 95% confidenceinterval (CI): [0.74-1.42], P = 0.88) and slightly increased the postoperative mortality rate (OR: 1.61, 95% CI [1.02-2.54], P = 0.04). HAR did not increase the postoperative morbidity rate (OR: 1.32, 95% CI [0.83-2.11], P = 0.24) and significantly increased the postoperative mortality rate (OR: 4.20, 95% CI [1.88-9.39], P = 0.0005). Neither PVR nor HAR improved the R0 resection rate (OR: 0.70, 95% CI [0.47-1.03], P = 0.07; OR: 0.77, 95% CI [0.37-1.61], P = 0.49, respectively) or long-term survival (OR: 0.52, 95% CI [0.35-0.76], P = 0.0008; OR: 0.43, 95% CI [0.32-0.57], P < 0.00001, respectively). CONCLUSIONS PVR is relatively safe and might benefit certain patients with advanced PHC in terms of long-term survival, but it is not routinely recommended. HAR results in a higher mortality rate and lower overall survival rate, with no proven benefit.
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Affiliation(s)
- Yong Liu
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China
| | - Guangbing Li
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, China
| | - Ziwen Lu
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China
| | - Tao Wang
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China
| | - Yang Yang
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China
| | - Xiaoyu Wang
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China
| | - Jun Liu
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong Province, China
- Department of Liver Transplantation and Hepatobiliary Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province, China
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Abstract
Pancreaticoduodenectomy with vascular resection/reconstruction can be safely completed following 6 standard steps plus basic principles of vascular surgery. Particular attention is paid to the location of the tumor relative to the 2 first-order vein branches, portal vein -splenic vein -superior mesenteric vein confluence, inferior mesenteric vein, and the presence of arterial perineural invasion. Successful resection following neoadjuvant therapy can result in median survival 3 times that of historical controls.
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Affiliation(s)
- Kathleen K Christians
- Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
| | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
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11
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Spolverato G, Chiminazzo V, Lorenzoni G, Fiore M, Radaelli S, Sanfilippo R, Sangalli C, Barisella M, Callegaro D, Gronchi A. Oncological outcomes after major vascular resections for primary retroperitoneal liposarcoma. Eur J Surg Oncol 2021; 47:3004-3010. [PMID: 34364722 DOI: 10.1016/j.ejso.2021.06.035] [Citation(s) in RCA: 3] [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: 04/21/2021] [Revised: 06/15/2021] [Accepted: 06/29/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The surgical management of retroperitoneal sarcomas frequently involves complex multivisceral resections, however retroperitoneal liposarcoma (LPS) rarely invade major abdominal vessels. The aim of the study was to assess association of major vascular resections with outcome of primary LPS. METHODS All consecutive patients who underwent resection at our institutions for primary LPS between 2002 and 2019 were included. A propensity matched analysis was performed, adjusting the groups for the variables of Sarculator, to assess the effect of vascular resection on oncological outcomes. RESULTS Overall 425 patients were identified. Twenty-four (5%) patients had vascular resection. At final pathology 18 patients had vascular infiltration, 2 vascular encasement and 4 involvement without infiltration. Vascular resection was associated with longer operative time (480' vs. 330'; p < 0.001) and greater need for transfusions (4 vs. 0 units; p < 0.001), and was burdened by a higher rate of major complications (54% vs. 25%; p = 0.002). After propensity matched analysis, patients undergoing vascular resection had a lower 5-year OS (60% vs. 81%; p = 0.05), and a higher incidence of local and distant recurrence at 5 years (local: 45% vs. 24%, p = 0.05; distant: 20% vs. 0%, p = 0.04). CONCLUSIONS Vascular resection is feasible and safe even in the context of multivisceral resection for primary retroperitoneal liposarcomas, although associated to a higher complication rate. However, the independent association between vascular involvement and a higher risk of local recurrence, distant metastases and death may imply a more aggressive biology, which should be factored in the initial management of this complex disease.
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Affiliation(s)
- Gaya Spolverato
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy
| | - Valentina Chiminazzo
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy; Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Marco Fiore
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Stefano Radaelli
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Roberta Sanfilippo
- Department of Cancer Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Claudia Sangalli
- Department of Radiation Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Marta Barisella
- Department of Pathology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Dario Callegaro
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
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12
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S GM, Gnanasekaran S, Raja K, Pottakkat B. Transient mesoportal shunt: An innovative technique for maintaining portal flow during pancreatoduodenectomy with portal vein resection. Ann Hepatobiliary Pancreat Surg 2021; 25:122-125. [PMID: 33649264 PMCID: PMC7952664 DOI: 10.14701/ahbps.2021.25.1.122] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 08/10/2020] [Accepted: 08/28/2020] [Indexed: 11/17/2022] Open
Abstract
Pancreatic cancers exhibit a surgical challenge, in light of frequent vascular involvement. In absence of metastatic spread, vascular invasion is the predominant limiting factor for determining the resectability. With progression of time vascular involvement is no longer considered a surgical contraindication. However these complex procedures are fraught with technical challenges. Portal clamping required for vascular resection and reconstruction results in hepatic ischemia and visceral congestion. In order to mitigate these untoward effects, surgeons have tried diverse techniques including venous shunts. Venous shunting facilitates the resection and allows for an enhanced exposure and a safe procedure. Previously described techniques were either cumbersome or failed to maintain portal flow. We present a technique of transient mesoportal shunt, to facilitate vascular resection during pancreatoduodenectomy. This technique is both simple and maintains portal flow throughout the procedure preventing both hepatic ischemia and visceral congestion.
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Affiliation(s)
- Gautham M S
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Senthil Gnanasekaran
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Kalayarasan Raja
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Biju Pottakkat
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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Gentile D, Donadon M, Civilini E, Torzilli G. Total upper transversal hepatectomy with outflow reconstruction for advanced mass-forming cholangiocarcinoma. Updates Surg 2021; 73:769-773. [PMID: 33625678 DOI: 10.1007/s13304-020-00946-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 07/03/2020] [Accepted: 12/08/2020] [Indexed: 10/22/2022]
Abstract
We describe a complex case of extended hepatectomy with venous outflow reconstruction for the treatment of advanced mass-forming cholangiocarcinoma (MFCCC) invading the three main hepatic veins (HVs). A 50-year-old woman who received a diagnosis of MFCCC and judged unresectable, was referred to our hospital. After multidisciplinary team evaluation, the patient underwent abdominal computed tomography, gadoxetic acid-enhanced magnetic resonance imaging, and fluorodeoxyglucose positron emission tomography. The radiological examinations showed a large mass located in S4s-8 and S1, in contact with the right hepatic vein (RHV), the inferior right hepatic vein, the anterior wall of the inferior vena cava (IVC), infiltrating the middle and left hepatic veins (MHV, LHV). Several communicating veins between the RHV, MHV and LHV were detected. The case was further investigated, and the surgical strategy planned by means of using three-dimensional simulation software. A total upper transversal hepatectomy with resection of the main HVs and outflow reconstruction was performed. The outflow of the remnant liver was restored performing a vascular anastomosis between the parenchymal stump of the RHV and the IVC. Meticulous review of pre-operative imaging techniques with three-dimensional simulation of hepatectomy together with advanced use of intra-operative ultrasound allowed us to offer the chance of cure to a patient otherwise considered unresectable.
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Affiliation(s)
- Damiano Gentile
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, Humanitas Clinical and Research Center - IRCCS, Via Manzoni, 56, 20089, Rozzano, Milano, Italy
| | - Matteo Donadon
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, Humanitas Clinical and Research Center - IRCCS, Via Manzoni, 56, 20089, Rozzano, Milano, Italy.,Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Efrem Civilini
- Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy.,Department of Vascular Surgery, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Guido Torzilli
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas University, Humanitas Clinical and Research Center - IRCCS, Via Manzoni, 56, 20089, Rozzano, Milano, Italy. .,Department of Biomedical Science, Humanitas University, Pieve Emanuele, Milan, Italy.
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Castillo Tuñón JM, Valle Rodas ME, Botello Martínez F, Rojas Holguín A, López Guerra D, Santos Naharro J, Jaén Torrejímeno I, Blanco Fernández G. Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures. Cir Esp 2020; 99:S0009-739X(20)30313-4. [PMID: 33342520 DOI: 10.1016/j.ciresp.2020.09.013] [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: 05/13/2020] [Revised: 09/14/2020] [Accepted: 09/23/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION The main objective of this study is to determine if our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms. METHOD Descriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded. RESULTS 631 patients were analyzed. The values ??obtained in the quality standards are in range. The most frequent surgery was cephalic duodenopancreatectomy, which associated higher peri-operative morbidity and mortality rates (p ≤ 0.05). The extended vascular resections impacted the cephalic duodenopancreatectomy group, associating a longer mean stay (p = 0.01) and a higher rate of re-interventions (p = 0.02). CONCLUSIONS The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbi-mortality.
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15
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Rosso E, Frey S, Zimmitti G, Manzoni A, Garatti M, Iannelli A. Laparoscopic Radical Antegrade Modular Pancreatosplenectomy with Vascular Resection for Pancreatic Cancer: Tips and Tricks. J Gastrointest Surg 2020; 24:2896-902. [PMID: 32666495 DOI: 10.1007/s11605-020-04695-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 06/04/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) with vascular resection for pancreatic cancer has been rarely reported in the literature. Several critical steps are required to achieve a safe radical resection under laparoscopy while respecting oncologic principles of radicality. METHODS Prospectively collected data on a consecutive series of patients undergoing radical antegrade modular pancreatosplenectomy (RAMPS) were retrospectively reviewed for the purpose of this study. Patients were divided into two groups based on the surgical approach and the need for vascular resection, and data were compared. The surgical technique is reported in detail focusing on the different modalities of vascular resection. RESULTS Twenty-three patients (male/female ratio, 12/11; mean age, 73 years) underwent RAMPS between July 2014 and October 2018 at our institution. Of these, 17 had a laparoscopic approach and six a standard open approach. All patients in the open group underwent complex vascular reconstructions while four out of 17 (23.5%) underwent laparoscopic vascular resection. One patient in the laparoscopic approach required a vascular reconstruction with graft interposition, which combined the two approaches. There was no mortality, and the complication rate and the duration of surgery were comparable between the two groups. CONCLUSION L-RAMPS with vascular resection is feasible and safe in selected cases when performed by advanced pancreatic surgeons with experience in laparoscopic surgery.
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Napoli N, Kauffmann E, Cacace C, Menonna F, Caramella D, Cappelli C, Campani D, Cacciato Insilla A, Vasile E, Vivaldi C, Fornaro L, Amorese G, Vistoli F, Boggi U. Factors predicting survival in patients with locally advanced pancreatic cancer undergoing pancreatectomy with arterial resection. Updates Surg 2021; 73:233-49. [PMID: 32978753 DOI: 10.1007/s13304-020-00883-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/03/2020] [Indexed: 02/07/2023]
Abstract
Pancreatectomy with arterial resection is a treatment option in selected patients with locally advanced pancreatic cancer. This study aimed to identify factors predicting cancer-specific survival in this patient population. A single-Institution prospective database was used. Pre-operative prognostic factors were identified and used to develop a prognostic score. Matching with pathologic parameters was used for internal validation. In a patient population with a median Ca 19.9 level of 19.8 U/mL(IQR: 7.1–77), cancer-specific survival was predicted by: metabolic deterioration of diabetes (OR = 0.22, p = 0.0012), platelet count (OR = 1.00; p = 0.0013), serum level of Ca 15.3 (OR = 1.01, p = 0.0018) and Ca 125 (OR = 1.02, p = 0.00000137), neutrophils-to-lymphocytes ratio (OR = 1.16; p = 0.00015), lymphocytes-to-monocytes ratio (OR = 0.88; p = 0.00233), platelets-to-lymphocytes ratio (OR = 0.99; p = 0.00118), and FOLFIRINOX neoadjuvant chemotherapy (OR = 0.57; p = 0.00144). A prognostic score was developed and three risk groups were identified. Harrell’s C-Index was 0.74. Median cancer-specific survival was 16.0 months (IQR: 12.3–28.2) for the high-risk group, 24.7 months (IQR: 17.6–33.4) for the intermediate-risk group, and 39.0 months (IQR: 22.7–NA) for the low-risk group (p = 0.0003). Matching the three risk groups against pathology parameters, N2 rate was 61.9, 42.1, and 23.8% (p = 0.04), median value of lymph-node ratio was 0.07 (IQR: 0.05–0.14), 0.04 (IQR:0.02–0.07), and 0.03 (IQR: 0.01–0.04) (p = 0.008), and mean value of logarithm odds of positive nodes was − 1.07 ± 0.5, − 1.3 ± 0.4, and − 1.4 ± 0.4 (p = 0.03), in the high-risk, intermediate-risk, and low-risk groups, respectively. An online calculator is available at www.survivalcalculator-lapdac-arterialresection.org. The prognostic factors identified in this study predict cancer-specific survival in patients with locally advanced pancreatic cancer and low Ca 19.9 levels undergoing pancreatectomy with arterial resection.
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17
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Conci S, Viganò L, Ercolani G, Gonzalez E, Ruzzenente A, Isa G, Salaris C, Fontana A, Bagante F, Pedrazzani C, Campagnaro T, Iacono C, De Santibanes E, Pinna DA, Torzilli G, Guglielmi A. Outcomes of vascular resection associated with curative intent hepatectomy for intrahepatic cholangiocarcinoma. European Journal of Surgical Oncology 2020; 46:1727-1733. [PMID: 32360063 DOI: 10.1016/j.ejso.2020.04.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 02/12/2020] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS We aimed to investigate the impact of vascular resection (VR) on postoperative outcomes and survival of patients undergoing hepatectomy for intrahepatic cholangiocarcinoma (ICC). METHODS A retrospective analysis of a multi-institutional series of 270 patients with resected ICC was carried out. Patients were divided into three groups: portal vein VR (PVR), inferior vena cava VR (CVR) and no VR (NVR). Univariate and multivariate analysis were applied to define the impact of VR on postoperative outcomes and survival. RESULTS Thirty-one patients (11.5%) underwent VR: 15 (5.6%) to PVR and 16 (5.9%) to CVR. R0 resection rates were 73.6% in NVR, 73.3% of PVR and 68.8% in CVR. The postoperative mortality rate was increased in VR groups: 2.5% in NVR, 6.7% in PVR and 12.5% in CVR. The 5-years overall survival (OS) rates progressively decreased from 38.4% in NVR, to 30.1% in CVR and to 22.2% in PVR, p = 0.030. However, multivariable analysis did not confirm an association between VR and prognosis. The following prognostic factors were identified: size ≥50 mm, patterns of distribution of hepatic nodules (single, satellites or multifocal), lymph-node metastases (N1) and R1 resections. In the VR group the 5-years OS rate in patients without lymph-node metastases undergoing R0 resection (VRR0N0) was 44.4%, while in N1 patients undergoing R1 resection was 20% (p < 0.001). CONCLUSION Vascular resection (PVR and CVR) is associated with higher operative risk, but seems to be justified by the good survival results, especially in patients without other negative prognostic factors (R0N0 resections).
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Affiliation(s)
- Simone Conci
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy.
| | - Luca Viganò
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas Clinical and Research Center - IRCCS, Humanitas University, Rozzano (Milan), Italy
| | - Giorgio Ercolani
- Department of General and Emergency Surgery and Organ Transplantation, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Esteban Gonzalez
- Department of Surgery, Division of General and Endocrine Surgery, University of Cagliari, Cagliari, Italy
| | - Andrea Ruzzenente
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - Giulia Isa
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - Claudia Salaris
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy; Department of Surgery, Division of General and Endocrine Surgery, University of Cagliari, Cagliari, Italy
| | - Andrea Fontana
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas Clinical and Research Center - IRCCS, Humanitas University, Rozzano (Milan), Italy
| | - Fabio Bagante
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - Corrado Pedrazzani
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - Tommaso Campagnaro
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - Calogero Iacono
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - Eduardo De Santibanes
- Department of Surgery, Division of HPB Surgery, Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Daniele Antonio Pinna
- Department of General and Emergency Surgery and Organ Transplantation, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Guido Torzilli
- Department of Surgery, Division of Hepatobiliary and General Surgery, Humanitas Clinical and Research Center - IRCCS, Humanitas University, Rozzano (Milan), Italy
| | - Alfredo Guglielmi
- Department of Surgery, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
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Marino MV, Latteri MA, Ahmad A. Tangential Venous Resections during Robotic-Assisted Pancreaticoduodenectomy: the Results of a Case Series (with Video). J Gastrointest Surg 2020; 24:1920-1921. [PMID: 32314236 DOI: 10.1007/s11605-020-04603-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/06/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Despite the potential advantages in terms of microdissection and microsuturing capabilites, the robotic approach for borderline resectable pancreatic cancer is scarcely reported. METHODS We report our technique for a robotic-assisted pancreaticoduodenectomy with tangential Portal/ Superior Mesenteric Vein resection/reconstruction (RPD PV/SMV).We also compared the surgical outcomes of eight consecutive patients undergoing RPD PV/SMV with that of sixty patients who underwent robotic-assisted pancreaticoduodenectomy (RPD) in the same period of time. RESULTS A total of eight consecutive patients underwent RPD PV/SMV. We observed an increased estimated blood loss (550 vs 280 mL, p = 0.003) and operative time (438 vs 350 min, p = 0.002) in the RPD PV/SMV group of patients compared with RPD group, whereas the complication rate (28% vs 31%, p = 0.726) was similar. No venous-congestion related complications were observed in the postoperative course. The median length of hospital stay was similar in the RPD group in comparison to that in the RPD PV/SMV group (10 vs 13 range 6-19 days, p = 0.313). CONCLUSION RPD PV/SMV is a challenging operation. It is associated with higher operative time and increased estimated blood loss in comparison to standard RPD.
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Affiliation(s)
- Marco Vito Marino
- Department of General Surgery, Hospital Universitario Marques de Valdecilla, Santander, Spain. .,Department of Emergency and General Surgery, Azienda Ospedaliera, Ospedali Riuniti Villa-Sofia Cervello, Palermo, Italy.
| | - Mario Adelfio Latteri
- Department of General Surgery and Oral Science, Paolo Giaccone University Hospital, Palermo, Italy
| | - Ali Ahmad
- Department of Surgical Oncology, University of Kansas, School of Medicine-Wichita, Kansas, USA
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Qureshi SS, M S, Dhareshwar J, Smriti V. Limb sparing surgery with vascular reconstruction for nonrhabdomyosarcoma soft tissue sarcoma in infants: A novel solution using allogenic vein graft from the parent. J Pediatr Surg 2020; 55:1673-1676. [PMID: 32409175 DOI: 10.1016/j.jpedsurg.2020.03.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/12/2020] [Accepted: 03/28/2020] [Indexed: 10/24/2022]
Abstract
Surgery continues to remain an integral component of treatment, especially for nonrhabdomyosarcoma soft tissue sarcoma as compared to rhabdomyosarcoma owing to their general insensitivity to chemotherapy. A key determinant of outcomes, particularly for extremity tumors includes complete tumor resection with negative margins; however, a significant limitation for limb salvage surgery is the adherence of sarcomas to vital vascular structures. Hitherto, vascular involvement constituted an adequate reason for amputation. However, modern reconstructive techniques and availability of prosthetic grafts in addition to autologous venous grafts have rendered limb salvage surgery possible in a substantial majority of patients. Vascular resection and reconstruction for extremity soft tissue sarcoma in children have not been used routinely for reasons like the small-caliber of native vessels, limited options for conduits and rapid somatic growth. The situation is inconceivable in infants owing to the contemporaneous diminutive caliber of the vessels. We report two infants with lower extremity nonrhabdomyosarcoma soft tissue sarcoma who underwent limb salvage surgery with resection of femoral vessels following which vascular reconstruction was successfully performed using the great saphenous vein allograft harvested from the father.
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Affiliation(s)
- Sajid S Qureshi
- Division of Paediatric Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Advanced Centre for Training Research and Education in Cancer (ACTREC), Tata Memorial Centre, Mumbai, India; Homi Bhabha National Institute (HBNI), Mumbai, India.
| | - Suresh M
- Division of Paediatric Surgical Oncology, Department of Surgical Oncology, Tata Memorial Hospital and Advanced Centre for Training Research and Education in Cancer (ACTREC), Tata Memorial Centre, Mumbai, India; Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Jayesh Dhareshwar
- Cardiovascular Surgeon, Department of Surgical Oncology, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
| | - Vasundhara Smriti
- Homi Bhabha National Institute (HBNI), Mumbai, India; Department of Radiology, Tata Memorial Hospital, Tata Memorial Centre, Mumbai, India
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Li CP, Liu BN, Wu JH, Hao CY. Contralateral internal iliac artery transposition for retroperitoneal sarcoma involving common iliac artery. Updates Surg 2020. [PMID: 32602011 DOI: 10.1007/s13304-020-00843-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/25/2020] [Indexed: 01/20/2023]
Abstract
Complete resection for retroperitoneal sarcoma (RPS) involving major vessels frequently requires vascular resection and reconstruction. The use of artificial grafts often leads to postoperative vascular graft infection (VGI), which usually requires reoperation and sometimes leads to death. In the present study, the data of RPS patients who underwent contralateral iliac artery (IIA) transposition for reconstruction of the common iliac artery (CIA) after RPS resection from 2015-2019 were retrospectively analyzed. Clinical, intraoperative, and postoperative outcomes were described. Contralateral IIA transposition was performed to reconstruct the CIA after segmental resection in three patients. All patients underwent concomitant organ resection. Colon resection was performed for all patients, nephrectomy was performed for two patients, and segmental resection of the left ureter with transurethral ureterostomy was performed for one patient. Complete resection was achieved in all patients, and microscopic tumor infiltration to the CIA was observed in all patients (tunica adventitia: 2, tunica media: 1). No major complications occurred during the hospital stay. During the follow-up period (6.0-29.1 months), one patient died from tumor recurrence, and the other two patients did not have any evidence of recurrence or metastatic disease at the latest follow-up. The level of lower limb function was favorable (MSTS93 scores: 28-30). The pelvic organ functions, including bowel, bladder, and sexual functions, were not impaired in any of the patients. This novel technique in which contralateral IIA transposition is performed to reconstruct the CIA after RPS resection is simple and reliable and may be a good alternative to artificial grafts.
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Jain S, Sharma G, Kaushik M, Upadhyayula R. Venous resection for adenocarcinoma of head of pancreas: Does extent of portal vein resection affect outcomes? Surgeon 2020; 18:129-136. [DOI: 10.1016/j.surge.2019.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/22/2019] [Accepted: 07/13/2019] [Indexed: 12/11/2022]
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Shi T, Huang Q, Liu K, Du S, Fan Y, Yang L, Peng C, Shen D, Wang Z, Gao Y, Gu L, Niu S, Ai Q, Li H, Liu F, Li Q, Wang H, Guo A, Fu B, Yang X, Zhang X, Wang D, Wang D, Guo H, Li H, Olivero A, Fam XI, Ma X, Wang B, Zhang X. Robot-assisted Cavectomy Versus Thrombectomy for Level II Inferior Vena Cava Thrombus: Decision-making Scheme and Multi-institutional Analysis. Eur Urol 2020; 78:592-602. [PMID: 32305170 DOI: 10.1016/j.eururo.2020.03.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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: 01/20/2020] [Accepted: 03/13/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Robot-assisted thrombectomy (RAT) for inferior vena cava (IVC) thrombus (RAT-IVCT) is being increasingly reported. However, the techniques and indications for robot-assisted cavectomy (RAC) for IVC thrombus are not well described. OBJECTIVE To develop a decision-making program and analyze multi-institutional outcomes of RAC-IVCT versus RAT-IVCT. DESIGN, SETTING, AND PARTICIPANTS Ninety patients with renal cell carcinoma (RCC) with level II IVCT were included from eight Chinese urological centers, and underwent RAC-IVCT (30 patients) or RAT-IVCT (60 patients) from June 2013 to January 2019. SURGICAL PROCEDURE The surgical strategy was based on IVCT imaging characteristics. RAT-IVCT was performed with standardized cavotomy, thrombectomy, and IVC reconstruction. RAC-IVCT was mainly performed in patients with extensive IVC wall invasion when the collateral blood vessels were well-established. For right-sided RCC, the IVC from the infrarenal vein to the infrahepatic veins was stapled. For left-sided RCC, the IVC from the suprarenal vein to the infrahepatic veins was removed and caudal IVC reconstruction was performed to ensure the right renal vein returned through the IVC collaterals. MEASUREMENTS Clinicopathological, operative, and survival outcomes were collected and analyzed. RESULTS AND LIMITATIONS All procedures were successfully performed without open conversion. The median operation time (268 vs 190 min) and estimated blood loss (1500 vs 400 ml) were significantly greater for RAC-IVCT versus RAT-IVCT (both p < 0.001). IVC invasion was a risk factor for progression-free and overall survival at midterm follow-up. Large-volume and long-term follow-up studies are needed. CONCLUSIONS RAC-IVCT or RAT-IVCT represents an alternative minimally invasive approach for selected RCC patients with level II IVCT. Selection of RAC-IVCT or RAT-IVCT is mainly based on preoperative IVCT imaging characteristics, including the presence of IVC wall invasion, the affected kidney, and establishment of the collateral circulation. PATIENT SUMMARY In this study we found that robotic surgeries for level II inferior vena cava thrombus were feasible and safe. Preoperative imaging played an important role in establishing an appropriate surgical plan.
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Affiliation(s)
- Taoping Shi
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Qingbo Huang
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Kan Liu
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Songliang Du
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Yang Fan
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Luojia Yang
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Cheng Peng
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Dan Shen
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Zhongxin Wang
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Yu Gao
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Liangyou Gu
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Shaoxi Niu
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Qing Ai
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Hongzhao Li
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Fengyong Liu
- Department of Interventional Radiology, Chinese PLA General Hospital, Beijing, China
| | - Qiuyang Li
- Department of Ultrasound, Chinese PLA General Hospital, Beijing, China
| | - Haiyi Wang
- Department of Radiology, Chinese PLA General Hospital, Beijing, China
| | - Aitao Guo
- Department of Pathology, Chinese PLA General Hospital, Beijing, China
| | - Bin Fu
- Department of Urology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xiaojian Yang
- Department of Urology, Xijing Hospital of Chinese PLA Air Force Medical University, Xi'an, China
| | - Xuepei Zhang
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Delin Wang
- Department of Urology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dongwen Wang
- Department of Urology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Hongqian Guo
- Department of Urology, Nanjing Drum Tower Hospital of Nanjing Medical school, Nanjing, China
| | - Hengping Li
- Department of Urology, Gansu Provincial Hospital, Lanzhou, China
| | - Alberto Olivero
- Department of Urology, San Martino Policlinico Hospital, University of Genova, Genoa, Italy
| | - Xeng Inn Fam
- Urology Unit, Surgery Department, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Xin Ma
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China.
| | - Baojun Wang
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China.
| | - Xu Zhang
- Department of Urology, Chinese PLA General Hospital/PLA Medical School, Beijing, China.
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Abstract
Cholangiocarcinoma is an aggressive malignancy of the extrahepatic bile ducts. Hilar lesions are most common. Patients present with obstructive jaundice and intrahepatic bile duct dilation. Cross-sectional imaging reveals local, regional, and distant extent of disease, with direct cholangiography providing tissue for diagnosis. The consensus of a multidisciplinary committee dictates treatment. Resection of the extrahepatic bile duct and ipsilateral hepatic lobe with or without vascular resection and transplantation after neoadjuvant protocol are options for curative treatment. The goal of surgery is to remove the tumor with negative margins. Patients with inoperable tumors or metastatic disease are best served with palliative chemoradiotherapy.
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Serenari M, Ercolani G, Cucchetti A, Zanello M, Prosperi E, Fallani G, Masetti M, Lombardi R, Cescon M, Jovine E. The impact of extent of pancreatic and venous resection on survival for patients with pancreatic cancer. Hepatobiliary Pancreat Dis Int 2019; 18:389-394. [PMID: 31230959 DOI: 10.1016/j.hbpd.2019.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/06/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Borderline resectable pancreatic cancer may require extended resections in order to achieve tumor-free margins, especially in the case of up-front resections, but it is important to know the limits of surgical therapy in this disease. This study aimed to investigate the impact of extent of pancreatic and venous resection on short- and long-term outcomes in patients with pancreatic adenocarcinoma (PDAC). METHODS This was a retrospective study from a prospectively maintained database of pancreatic resections for PDAC. Short- and long-term outcomes were analyzed in patients having borderline resectable PDAC submitted to up-front total pancreatectomy (TP) or pancreaticoduodenectomy (PD) with simultaneous portal vein (PV) and/or superior mesenteric vein (SMV) resection. Venous resections were carried out as tangential venous resection (TVR) or segmental venous resection (SVR). Patients were divided into 4 groups: (1) PD + TVR, (2) PD + SVR, (3) TP + TVR, (4) TP + SVR. Uni- and multivariate Cox regression analysis were performed to identify factors associated with survival. RESULTS Ninety-nine patients were submitted to simultaneous pancreatic and venous resection for PDAC. Among them, 25 were submitted to PD + TVR (25.3%), 12 to PD + SVR (12.1%), 23 to TP + TVR (23.2%), and 39 to TP + SVR (39.4%). Overall, major morbidity (Clavien-Dindo grade ≥ IIIA) was 26.3%. Thirty- and 90-day mortality were 3% and 11.1%, respectively. There were no significant differences among groups in terms of short-term outcomes. Median overall survival of patients submitted to PD + TVR was significantly higher than those to TP+SVR (29.5 vs 7.9 months, P = 0.001). Multivariate analysis identified TP (HR = 2.11; 95% CI: 1.31-3.44; P = 0.002) and SVR (HR = 2.01; 95% CI: 1.27-3.15; P = 0.003) as the only independent prognostic factors for overall survival. CONCLUSIONS Up-front TP associated to SVR was predictive of worse survival in borderline resectable PDAC. Perioperative treatments in high-risk surgical groups may improve such poor outcomes.
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Affiliation(s)
- Matteo Serenari
- Department of Medical and Surgical Sciences, S. Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Giorgio Ercolani
- Department of Medical and Surgical Sciences, S. Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy.
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences, S. Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Matteo Zanello
- Department of General Surgery, Maggiore Hospital - Bologna Local Health District, Bologna, Italy
| | - Enrico Prosperi
- Department of Medical and Surgical Sciences, S. Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Guido Fallani
- Department of Medical and Surgical Sciences, S. Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Michele Masetti
- Department of General Surgery, Maggiore Hospital - Bologna Local Health District, Bologna, Italy
| | - Raffaele Lombardi
- Department of General Surgery, Maggiore Hospital - Bologna Local Health District, Bologna, Italy
| | - Matteo Cescon
- Department of Medical and Surgical Sciences, S. Orsola - Malpighi Hospital, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Elio Jovine
- Department of General Surgery, Maggiore Hospital - Bologna Local Health District, Bologna, Italy
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Wang BS, Ma RZ, Liu YQ, Liu Z, Tao LY, Lu M, Wang GL, Zhang SD, Lu J, Ma LL. Body mass index as an independent risk factor for inferior vena cava resection during thrombectomy for venous tumor thrombus of renal cell carcinoma. World J Surg Oncol 2019; 17:17. [PMID: 30646899 PMCID: PMC6334420 DOI: 10.1186/s12957-019-1560-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/03/2019] [Indexed: 12/12/2022] Open
Abstract
Objective To define preoperative clinical and radiographic risk factors for the need of inferior vena cava (IVC) resection in patients with renal cell carcinoma (RCC) and IVC tumor thrombus. Methods We reviewed data of 121 patients with renal cell carcinoma and venous tumor thrombus receiving radical nephrectomy and thrombectomy at our institution between 2015 and 2017, and 86 patients with Mayo I–IV level tumor thrombus were included in the final analysis. Clinical features, operation details, and pathology data were collected. Preoperative images were reviewed separately by two radiologists. Univariable and multivariable logistic regression analyses were applied to evaluate clinical and radiographic risk factors of IVC resection. Results Of the 86 patients, 44 (51.2%) received IVC resection during thrombectomy. In univariate analysis, we found that body mass index (BMI) (odds ratio [OR] = 1.22, P = 0.003), primary tumor diameter (OR = 0.84, P = 0.022), tumor thrombus width (OR = 1.08, P = 0.037), tumor thrombus level (OR = 1.57, P = 0.030), and IVC occlusion (OR = 2.67, P = 0.038) were associated with the need for resection of the IVC. After adjusting for the other factors, BMI (OR = 1.18, P = 0.019) was the only significant risk factor for IVC resection. Multivariable analysis in Mayo II–IV subgroups confirmed BMI as an independent risk factor (OR = 1.26, P = 0.024). A correlation between BMI and the width (Pearson’s correlation coefficient [PCC] = 0.27, P = 0.014) and length (PCC = 0.23, P = 0.037) of the tumor thrombus was noticed. Conclusion We identified BMI as an independent risk factor for IVC resection during thrombectomy of RCC with tumor thrombus in a Chinese population. More careful preoperative preparation for the IVC resection and/or reconstruction is warranted in patients with higher BMI.
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Affiliation(s)
- Bin-Shuai Wang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Run-Zhuo Ma
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Yu-Qing Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Zhuo Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Li-Yuan Tao
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Min Lu
- Department of Pathology, Peking University Third Hospital, Beijing, China
| | - Guo-Liang Wang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Shu-Dong Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Jian Lu
- Department of Urology, Peking University Third Hospital, Beijing, China.
| | - Lu-Lin Ma
- Department of Urology, Peking University Third Hospital, Beijing, China.
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Park H, Kang I, Kang CM. Laparoscopic pancreaticoduodenectomy with segmental resection of superior mesenteric vein-splenic vein-portal vein confluence in pancreatic head cancer: can it be a standard procedure? Ann Hepatobiliary Pancreat Surg 2018; 22:419-424. [PMID: 30588536 PMCID: PMC6295366 DOI: 10.14701/ahbps.2018.22.4.419] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 07/25/2018] [Accepted: 07/26/2018] [Indexed: 12/20/2022] Open
Abstract
The feasibility of laparoscopic pancreaticoduodenectomy (LPD) in the treatment of pancreatic cancer is still disputed. However, advances in surgical technique and accumulating experience have led to the use of LPD with combined vascular resection and reconstruction as a safe and feasible procedure, especially in pancreatic cancer with major vascular involvement. A 64-year-old woman presented with obstructive jaundice secondary to pancreatic head cancer. Contrast abdominopelvic computed tomography revealed a pancreatic head tumor measuring approximately 22 mm in diameter that was abutting the first jejunal branch of the superior mesenteric vein at an angle of <180°. The patient underwent LPD, which failed to resect the pancreatic head tumor invading the superior mesenteric vein. Consequently, segmental resection of the confluence of the superior mesenteric vein, splenic vein, and portal vein (SMV/SV/PV) was completely performed in laparoscopic approach without complication. The patient recovered without any event and was discharged on postoperative day 9. LPD combined with vascular resection and reconstruction is feasible in cases involving major blood vessels. Further surgical expertise and education are required before LPD can be used as a standard procedure.
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Affiliation(s)
- Hyejin Park
- Department of Education and Training, Severance Hospital, Seoul, Korea
| | - Incheon Kang
- Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
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Cai Y, Gao P, Li Y, Wang X, Peng B. Laparoscopic pancreaticoduodenectomy with major venous resection and reconstruction: anterior superior mesenteric artery first approach. Surg Endosc 2018; 32:4209-4215. [PMID: 29602996 DOI: 10.1007/s00464-018-6167-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [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: 11/02/2017] [Accepted: 03/21/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND The en bloc resection of the superior mesenteric or portal vein with concomitant venous reconstruction may be required in patients with borderline resectable pancreatic cancer. However, performing laparoscopic pancreaticoduodenectomy (LPD) with major venous resection and reconstruction is technically challenging. Herein, we introduced a safe and feasible technique to perform LPD with major venous resection. METHODS Over the period of November 2015 to November 2016, 18 patients underwent laparoscopic pancreaticoduodenectomy with major venous resection and reconstruction using the anterior superior mesenteric artery (SMA)-first approach at our institution. Demographic characteristics, intraoperative and postoperative variables, and follow-up outcomes were prospectively collected. RESULTS Eighteen male and ten female patients were included in this study. The median age of the patients was 58 years (range 49-76 years). Eight cases of wage resections, six cases of end-to-end anastomosis, and four cases of artificial grafts were performed in our series. Only one patient (5.6%) required conversion because of uncontrolled bleeding from the splenic vein. The average operative time was 448 min (range 420-570 min). The mean time for blood occlusion was 32 min, including 17 min for wage resections, 28 min for end-to-end anastomosis, and 48 min for artificial grafts. Thirty-day mortality was not observed in our series. The median postoperative hospital stay was 13 days (range 9-18 days). Three patients suffered from pancreatic fistula (Grade A), and one suffered from abdominal bleeding after subcutaneous injection with low-molecular heparin. In this case, abdominal bleeding was stopped through conservative therapies. CONCLUSION Laparoscopic pancreaticoduodenectomy with major venous resection and reconstruction can be safely and feasibly performed. The anterior SMA-first approach can facilitate this procedure and decrease operative time and blood occlusion duration.
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Affiliation(s)
- Yunqiang Cai
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hospital, Chengdu, China
| | - Pan Gao
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hospital, Chengdu, China
| | - Yongbin Li
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hospital, Chengdu, China
| | - Xin Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Bing Peng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
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Zhang XM, Zhang J, Fan H, He Q, Lang R. Feasibility of portal or superior mesenteric vein resection and reconstruction by allogeneic vein for pancreatic head cancer-a case-control study. BMC Gastroenterol 2018; 18:49. [PMID: 29661201 PMCID: PMC5902870 DOI: 10.1186/s12876-018-0778-y] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 04/09/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There are few reports about resection of portal vein (PV)/superior mesenteric vein (SMV) and reconstruction by using allogeneic vein. This case-control study was designed to explore the feasibility and safety of this operation type in patients with T3 stage pancreatic head cancer. METHODS A total of 42 patients (Group A) underwent PV/SMV resection and reconstruction by using allogeneic vein were 1:1 matched to 42 controls (Group B) with other types of resection and reconstruction. The two groups were well matched. RESULTS There was no significantly prolonged total operation time (Group A vs. Group B [490.0 min vs. 470 min], P = 0.067) and increased intraoperative blood loss (Group A vs. Group B [650.0 min vs. 450 min], P = 0.108) was found between the two groups. R1 rate of PV/SMV was slightly reduced in group A compared to group B (4.8% vs. 14.3%, P = 0.137), although no significant difference was found. The incidences of main postoperative complications between the two groups were similar. A slightly increased 1-year and 2-year overall survival rate (OS) (Group A vs. Group B [1-year OS: 62.9% vs. 57.0%; 2-year OS: 31.5% vs. 25.6%], P = 0.501) and disease-free survival rate (DFS) (Group A vs. Group B [1-year DFS: 43.9% vs. 36.6%; 2-year DFS: 10.5% vs. 7.4%], P = 0.502) could be found in group A compared to group B, although the differences were not significant. CONCLUSIONS The operation types of PV/SMV resection and reconstruction by using allogeneic vein is safety and feasible, it might have a potential benefit for patients.
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Affiliation(s)
- Xing-mao Zhang
- Department of hepatobiliary surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongti South Street, Chaoyang District, Beijing, 100021 China
| | - Jie Zhang
- The First Hospital of Combination of the Western Medicine and Traditional Chinese Medicine, Xiaozhuang Hospital, Capital Medical University, 13 Jintai Street, Chaoyang District, Beijing, 100021 China
| | - Hua Fan
- Department of hepatobiliary surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongti South Street, Chaoyang District, Beijing, 100021 China
| | - Qiang He
- Department of hepatobiliary surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongti South Street, Chaoyang District, Beijing, 100021 China
| | - Ren Lang
- Department of hepatobiliary surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 Gongti South Street, Chaoyang District, Beijing, 100021 China
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Tinelli G, Cappuccio S, Parente E, Fagotti A, Gallotta V, Conte C, Costantini B, Gueli Alletti S, Scambia G, Vizzielli G. Resectability and Vascular Management of Retroperitoneal Gynecological Malignancies: A Large Single-institution Case-Series. Anticancer Res 2017; 37:6899-6906. [PMID: 29187471 DOI: 10.21873/anticanres.12153] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 09/02/2017] [Revised: 09/27/2017] [Accepted: 09/29/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM To report on morbidity and oncological outcomes in a consecutive series of gynecological malignancies involving the vascular district. PATIENTS AND METHODS We retrospectively evaluated a consecutive series between 1/2015 and 1/2017 with suspicious gynecological malignancies involving the vascular district. Peri-operative data and survival rates were computed. RESULTS Eight-hundred-four women with gynecological malignancies were admitted for major oncologic surgery during the study period, and among them, 50 cases (6.2%) showed vascular involvement. Twenty-seven and 23 patients were submitted to minor and major vascular procedures, respectively. R0 resection was achieved in 44 patients. There were no perioperative mortalities. Major postoperative complications occurred in 6 patients (12.0%). The 2-year disease free survival (DFS) was 67% if R0 resection was achieved. In patients with positive pathological margins (n=2), the 2-year DFS was 33%. CONCLUSION Vascular procedures can be safely performed with a proper pre-operative planning and may not be an impediment to major gynecological oncological surgery.
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Affiliation(s)
- Giovanni Tinelli
- Division of Vascular Surgery, "Agostino Gemelli" Foundation University Hospital, Catholic University, Rome, Italy
| | - Serena Cappuccio
- Department of Women's and Children's Health, "Agostino Gemelli" Foundation University Hospital, Catholic University, Rome, Italy
| | - Ezio Parente
- Division of Vascular Surgery, "Agostino Gemelli" Foundation University Hospital, Catholic University, Rome, Italy
| | - Anna Fagotti
- Department of Women's and Children's Health, "Agostino Gemelli" Foundation University Hospital, Catholic University, Rome, Italy
| | - Valerio Gallotta
- Department of Women's and Children's Health, "Agostino Gemelli" Foundation University Hospital, Catholic University, Rome, Italy
| | - Carmine Conte
- Department of Women's and Children's Health, "Agostino Gemelli" Foundation University Hospital, Catholic University, Rome, Italy
| | - Barbara Costantini
- Department of Women's and Children's Health, "Agostino Gemelli" Foundation University Hospital, Catholic University, Rome, Italy
| | - Salvatore Gueli Alletti
- Department of Women's and Children's Health, "Agostino Gemelli" Foundation University Hospital, Catholic University, Rome, Italy
| | - Giovanni Scambia
- Department of Women's and Children's Health, "Agostino Gemelli" Foundation University Hospital, Catholic University, Rome, Italy
| | - Giuseppe Vizzielli
- Department of Women's and Children's Health, "Agostino Gemelli" Foundation University Hospital, Catholic University, Rome, Italy
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Low TY, Koh YX, Teo JY, Goh BKP. Short-Term Outcomes of Extended Pancreatectomy: A Single-Surgeon Experience. Gastrointest Tumors 2017; 4:72-83. [PMID: 29594108 DOI: 10.1159/000484523] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 10/23/2017] [Indexed: 12/13/2022] Open
Abstract
Background/Aims The International Study Group of Pancreatic Surgery recently published a consensus statement on the definition of extended pancreatectomy (EP). We aimed to determine the safety profile and short-term outcomes of EP compared to standard pancreatectomy (SP). To mitigate surgeon bias, only pancreatectomies performed by a single surgeon were included. Methods Ninety consecutive patients who underwent pancreatectomy by a single surgeon over a period of 5 years and who met our study criteria were classified into an SP or an EP group. Sixty-two patients underwent pancreaticoduodenectomy (PD), including total pancreatectomy, and 28 patients underwent distal pancreatectomy. Results The 25 patients who underwent EP had significantly increased operation time, estimated blood loss, postoperative intensive care unit (ICU) transfer, and postoperative stay compared to the 65 patients who underwent SP. There was 1 (1.1%) 30-day mortality and 4 (4.4%) in-hospital mortalities. Postoperative morbidity and mortality were similar between both groups. Subgroup analysis of the patients who underwent PD demonstrated that the EP group (n = 22) had significantly increased operation time and postoperative ICU transfers. Conclusion Although patients who underwent EP experienced significantly increased operative time, blood loss, and postoperative stay, they did not experience significantly higher postoperative morbidity or mortality compared to patients who underwent SP.
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Affiliation(s)
- Tze-Yi Low
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore, Singapore
| | - Ye-Xin Koh
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore, Singapore
| | - Jin-Yao Teo
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore, Singapore
| | - Brian K P Goh
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore, Singapore.,Duke-National University of Singapore Medical School, Singapore, Singapore
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31
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Affiliation(s)
- Warren R Maley
- Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, College 605, Philadelphia, PA 19107, USA
| | - Charles J Yeo
- Department of Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, 1015 Walnut Street, Curtis 620, Philadelphia, PA 19107, USA.
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Vicente E, Quijano Y, Ielpo B, Duran H. Total pancreatoduodenectomy en bloc with superior mesenteric artery and vein resection after gemcitabine and nab-paclitaxel neoadjuvancy. Surg Oncol 2017; 26:276-277. [PMID: 29804945 DOI: 10.1016/j.suronc.2017.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 01/09/2017] [Revised: 04/23/2017] [Accepted: 05/10/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pancreatectomy for locally advanced adenocarcinoma affecting the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) is still under discussion [1]. However, in selected cases, in light of the advancement of recent neoadjuvant treatments, it must be taken into account [2,3]. This video demonstrates some of the technical aspects of SMA and SMV resection as well as some tips of vascular reconstruction. METHODS A 48-year-old man with a large adenocarcinoma of the uncinated process affecting the SMA and SMV underwent 3 cycles of gemcitabine and nab-paclitaxel neoadjuvancy. Post chemotherapy studies showed no disease progression with a normalization of CA 19.9 and SUV of FDG PET CT scan and a downsizing of the tumor, as well. Therefore, an en bloc total spleno-pancreato-duodenectomy with resection of SMA and SMV was planned. RESULTS Through a bilateral subcostal incision, an "arterial first approach" [3] was performed. Considering the large length of the vascular resection, the replacement of the resected SMA and SMV was performed using two PTFE grafts, as showed in the video. Postoperative pathology showed margins free from disease with an important pathological response (grade 2 of Ryan classification adapted from rectal cancer) [4]. The post-operative course was uneventful and the patient is still free from disease at 31 months from surgery. CONCLUSIONS This case is part of a large experience our group have acquired since we started neoadjuvancy in 2010. In our experience, we gathered 25 cases of locally advanced pancreatic tumors, of which 12 underwent to pancreatic resection after good response to the neoadjuvant treatment. In 5 of them concomitant SMA and SMV resection was required and post-operative mortality occurred in 1 of them. Morbidities and mortalities are higher compared with standard pancreatectomies, specially related to the vascular reconstruction (bleeding, graft thrombosis) [5]. However, in some circumstances like young age, great radiological and biological response to neoadjuvancy (such as the case herein presented), surgery might be considered the best option of care providing the only possibility to increase survival for these types of locally advanced tumors. However, further studies are needed to know which patients might benefit from this approach. En bloc total spleno-pancreato-duodenectomy with resection of SMA and SMV might be considered as an effective procedure in selected cases of pancreatic adenocarcinoma with good response to preoperative treatment.
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Affiliation(s)
- E Vicente
- Madrid Norte Sanchinarro San Pablo University Hospital, General Surgery Department, Calle Oña 10, 28050 Madrid, Spain
| | - Y Quijano
- Madrid Norte Sanchinarro San Pablo University Hospital, General Surgery Department, Calle Oña 10, 28050 Madrid, Spain
| | - B Ielpo
- Madrid Norte Sanchinarro San Pablo University Hospital, General Surgery Department, Calle Oña 10, 28050 Madrid, Spain.
| | - H Duran
- Madrid Norte Sanchinarro San Pablo University Hospital, General Surgery Department, Calle Oña 10, 28050 Madrid, Spain
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33
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Kaiser J, Hackert T, Büchler MW. Extended Pancreatectomy: Does It Have a Role in the Contemporary Management of Pancreatic Adenocarcinoma? Dig Surg 2017; 34:441-446. [PMID: 28700995 DOI: 10.1159/000478539] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 06/08/2017] [Indexed: 12/10/2022]
Abstract
BACKGROUND Pancreatic cancer is a low-incident but highly mortal disease. Surgery is still the preferred treatment option for resectable pancreatic cancer as it offers the only realistic chance for cure. As many patients present with locally advanced disease, which is generally considered as not amenable to surgical treatment, it is important to know the limits of surgical therapy in this disease. METHODS In this review, the indication and outcomes of extended pancreatectomies as well as the alternative treatment options for locally advanced pancreatic cancer are described. Furthermore, controversies as well as ongoing and future directions for the treatment options of locally advanced pancreatic cancer are discussed. RESULTS Extended pancreatectomy can be performed with higher morbidity and mortality rates in patients with locally advanced pancreatic cancer compared to patients undergoing formal pancreatic resections. These procedures offer significant advantages with respect to both perioperative results and to long-term outcome when compared to chemotherapy. CONCLUSION Due to the higher morbidity and mortality rates, these operations should be limited to specialist units with great experience in pancreatic surgery as well as experience in peri- and post-operative management of patients with pancreatic diseases.
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Affiliation(s)
- Joerg Kaiser
- Department of General, Visceral and Transplantation Surgery, Heidelberg, Germany
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34
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Podda M, Thompson J, Kulli CTG, Tait IS. Vascular resection in pancreaticoduodenectomy for periampullary cancers. A 10 year retrospective cohort study. Int J Surg 2017; 39:37-44. [PMID: 28110027 DOI: 10.1016/j.ijsu.2017.01.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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: 11/11/2016] [Revised: 01/04/2017] [Accepted: 01/10/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is the only chance of cure for periampullary cancers. This study aims to evaluate survival and complication rates for PD with additional vascular resection performed for local vascular involvement and compare to standard PD. MATERIALS AND METHODS A retrospective cohort analysis of a departmental hepato-pancreatobiliary database from 2004 to 2014 was performed. All patients (n = 92) who underwent PD without vascular resection (n = 72), with venous resection (n = 16), with both arterial and venous resection (n = 4) were included in the study. Patients who received palliative double bypass (n = 6) were also included for survival analysis. Survival and post-operative complications were assessed. RESULTS Median survival for standard PD and PD with venous resection was 21 months and 18 months respectively (P = 0.588). Patients who received PD with venous and arterial resection had a median survival of 7 months, significantly less than standard PD (P = 0.044). Median survival in the palliative bypass group was 4 months, comparable to PD with venous and arterial resection (P = 0.191). There was a significant survival advantage in patients who received an R0 resection (median survival 24 months) compared to those who received an R1 resection (median survival 18 months) (P < 0.02). Patients with a lymph node ratio <0.2 had a median survival of 25 months, which was significantly higher than that of patients who had a lymph node ratio ≥0.2 (9 months) (P < 0.005). CONCLUSION PD with venous resection has similar survival to standard PD with no increased risk of procedure specific post-operative complications. On the other hand, PD with venous resection and additional arterial resection has no survival benefit and may be a step too far in our experience.
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Affiliation(s)
- Mauro Podda
- San Francesco Hospital, General, Minimally Invasive and Robotic Surgery Unit, 08100 Nuoro, Italy; Ninewells Hospital and Medical School, HPB and UpperGI Surgery Unit, DD1 9SY Dundee, United Kingdom.
| | - Jessica Thompson
- Ninewells Hospital and Medical School, HPB and UpperGI Surgery Unit, DD1 9SY Dundee, United Kingdom.
| | | | - Iain Stephen Tait
- Ninewells Hospital and Medical School, HPB and UpperGI Surgery Unit, DD1 9SY Dundee, United Kingdom.
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Molina V, Sampson J, Ferrer J, Díaz A, Ayuso JR, Sánchez-Cabús S, Fuster J, García-Valdecasas JC. Surgical treatment of perihilar cholangiocarcinoma: early results of en bloc portal vein resection. Langenbecks Arch Surg 2017; 402:95-104. [PMID: 28012034 DOI: 10.1007/s00423-016-1542-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/13/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The objective of this study was to analyse the safety, feasibility and survival outcomes of our treatment of perihilar cholangiocarcinoma (PHC) since the introduction of more aggressive approaches (en bloc, vascular and extended liver resections) in 2007. PATIENTS AND METHODS From July 2007 to December 2014, 32 consecutive patients with PHC underwent surgery with curative intent. Surgery with resection and reconstruction of the portal vein bifurcation and right hepatic artery was performed if necessary for a complete removal of the tumour. Perioperative data and postoperative histological findings, tumour recurrence rates and survival rates were recorded. Seventeen (53%) of the patients presented with stage IIIb or IV according to the UICC classification system. RESULTS The 5-year survival rate in our series was 45%, and this percentage increased to 65% when patients with advanced stage cancer (stage IIIb or higher) were excluded. We performed 3 arterials and 23 portal vein reconstruction. Twelve patients underwent extended hemihepatectomy. We achieved cancer-free margins in 19 patients (60%). Tumour stage and nodal involvement were the most important prognostic factors. The perioperative morbidity and mortality rates of this cohort were 72% (23) and 15.6% (5), respectively; these results were similar to data published by other groups. CONCLUSIONS An aggressive approach involving en bloc or extended liver resection combined with vascular reconstruction provides acceptable morbidity and mortality and increases the 5-year survival rate of PHC.
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Abstract
BACKGROUND Due to their size or location liver tumors can infiltrate important vascular structures, which are essential for postoperative liver function. OBJECTIVE To present the technical possibilities and results of current concepts of vascular resection and reconstruction in liver surgery. MATERIAL AND METHODS A literature search of the Medline and Cochrane databases was performed regarding currently available studies on vascular resection and reconstruction in liver surgery. RESULTS Portal vein resections are routinely performed by many institutions and can be performed as an end-to-end anastomosis or graft interposition. This is the basis of the en bloc resection concept, especially for Klatskin tumors. Reconstruction of the inferior vena cava as well as the hepatic arteries is technically feasible and is increasingly being reported in smaller series. In particular, the resection of tumors near the hepatic veins may require total vascular exclusion for complete interruption of liver perfusion, which enables resection in the non-perfused liver and by this reduced blood loss. Furthermore, in situ cooling, ante situm and ex situ resections increase both technical resectability and the ischemic tolerance of the liver to more than 60 min. The majority of vascular reconstructions can be performed without a significant increase in morbidity; however, vascular tumor infiltration is associated with impaired long-term survival. CONCLUSION Based on the experience of transplantation surgery concepts for vascular reconstruction can be safely applied to liver surgery. These concepts contribute to increasing the resectability of liver tumors. Due to the often impaired prognosis of vascular tumor infiltration, the use of these concepts should be individually assessed by weighing the prognosis against the morbidity.
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Abstract
Multimodality therapy has become the standard approach for the treatment of pancreatic cancer. With improved response rates to newer chemotherapeutic agents, tumors that used to be considered unresectable are now being considered for operation. Neoadjuvant therapy for borderline resectable pancreatic cancer is considered standard of care and venous resection/reconstruction is no longer controversial. Arterial resection and reconstruction in select patients has also proven to be safe when done in highly specialized centers by high-volume surgeons. This article reviews indications for, and technical aspects of, vascular resection/reconstruction and shunting procedures during pancreatectomy, including critical elements of perioperative care.
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Affiliation(s)
- George Younan
- Pancreatic Cancer Program, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226, USA
| | - Susan Tsai
- Pancreatic Cancer Program, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226, USA
| | - Douglas B Evans
- Pancreatic Cancer Program, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226, USA
| | - Kathleen K Christians
- Pancreatic Cancer Program, Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226, USA.
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Westermark S, Rangelova E, Ansorge C, Lundell L, Segersvärd R, Del Chiaro M. Cattell-Braasch maneuver combined with local hypothermia during superior mesenteric artery resection in pancreatectomy. Langenbecks Arch Surg 2016; 401:1241-7. [PMID: 27562317 DOI: 10.1007/s00423-016-1501-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 08/19/2016] [Indexed: 01/01/2023]
Abstract
Background The recent development of new neo-adjuvant treatment regimens associated with a higher success rate of down-staging has increased the interest of pancreatic surgeons on the role of extended surgery for patients affected by locally advanced pancreatic cancer. Pancreatectomy together with resection of the portal/superior mesenteric vein is considered nowadays standard of care for patients affected by pancreatic cancer. However, the resection of major abdominal arteries is still debatable. In particular, the short- and long-term results after resection of the superior mesenteric artery (SMA) remain controversial and only few cases have been described in literature. The present paper describes a new, quick, and easy technique for resection of the SMA. Clinical case A 71-year-old patient affected by IPMN cancer with infiltration of the SMA received FOLFIRINOX-based neo-adjuvant treatment. After 4 months of treatment, the patient underwent total pancreatectomy with en bloc resection of the SMA and direct end-to-end anastomosis. The vascular resection was performed combining a complete Cattell-Braasch maneuver with local bowel hypothermia in an attempt to avoid graft interposition by facilitating an end-to-end anastomosis and to reduce the warm ischemia time. The post-operative course was uneventful and the patient was discharged 8 days post-operatively.
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39
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Perinel J, Nappo G, El Bechwaty M, Walter T, Hervieu V, Valette PJ, Feugier P, Adham M. Locally advanced pancreatic duct adenocarcinoma: pancreatectomy with planned arterial resection based on axial arterial encasement. Langenbecks Arch Surg 2016; 401:1131-42. [PMID: 27476146 DOI: 10.1007/s00423-016-1488-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/21/2016] [Indexed: 12/22/2022]
Abstract
Pancreatectomy with arterial resection for locally advanced pancreatic duct adenocarcinoma (PDA) is associated with high morbidity and is thus considered as a contraindication. The aim of our study was to report our experience of pancreatectomy with planned arterial resection for locally advanced PDA based on specific selection criteria. MATERIAL AND METHODS All patients receiving pancreatectomy for PDA between October 2008 and July 2014 were reviewed. The patients were classified into group 1, pancreatectomy without vascular resection (66 patients); group 2, pancreatectomy with isolated venous resection (31 patients), and group 3, pancreatectomy with arterial resection for locally advanced PDA (14 patients). The primary selection criteria for arterial resection was the possibility of achieving a complete resection based on the extent of axial encasement, the absence of tumor invasion at the origin of celiac trunk (CT) and superior mesenteric artery (SMA), and a free distal arterial segment allowing reconstruction. Patient outcomes and survival were analyzed. RESULTS Six SMA, two CT, four common hepatic artery, and two replaced right hepatic artery resections were undertaken. The preferred arterial reconstruction was splenic artery transposition. Group 3 had a higher preoperative weight loss, a longer operative time, and a higher incidence of intraoperative blood transfusion. Ninety-day mortality occurred in three patients in groups 1 and 2. There were no statistically significant differences in the incidence, grade, and type of complications in the three groups. Postoperative pancreatic fistula and postpancreatectomy hemorrhage were also comparable. In group 3, none had arterial wall invasion and nine patients had recurrence (seven metastatic and two loco-regional). Survival and disease-free survival were comparable between groups. CONCLUSION Planned arterial resection for PDA can be performed safely with a good outcome in highly selected patients. Key elements for defining the resectability is based on the extent of the axial arterial encasement with two criteria: the origin of the CT and SMA are free from tumor invasion and the possibility of distal reconstruction.
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40
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Thiels CA, Bergquist JR, Laan DV, Croome KP, Smoot RL, Nagorney DM, Thompson GB, Kendrick ML, Farnell MB, Truty MJ. Outcomes of Pancreaticoduodenectomy for Pancreatic Neuroendocrine Tumors: Are Combined Procedures Justified? J Gastrointest Surg 2016; 20:891-8. [PMID: 26925796 DOI: 10.1007/s11605-016-3102-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 02/02/2016] [Indexed: 01/31/2023]
Abstract
Efficacy and outcomes of resection for pancreatic neuroendocrine tumors (pNET) are well established; specific data on outcomes for pancreaticoduodenectomy (PD), either alone or with combined procedures, are limited. A retrospective review of PDs for pNET (1998-2014) at our institution was conducted. Patients were categorized into standard PD (SPD) alone or combined PD (CPD) defined as patients undergoing concurrent vascular reconstruction or additional organ resection for curative intent. Kaplan-Meier survival analyses were performed. PD for pNET was performed for 95 patients. Tumors were functional in 11 patients (9 %). Twenty-six patients (28 %) underwent CPD. The 30/90-day mortality was 1.1/5.3 % respectively and similar between SPD and CPD (p = 0.61/p = 0.24). Five-year overall survival after PD for pNET was 85.1/71.9 % and similar between SPD/CPD groups (p = 0.17). Recurrence-free and overall survival for low-grade tumors was 74.7/93.9 % at 5 years compared to only 14.8/49.7 % for high-grade tumors (p < 0.001) and not predicted by extent of resection (SPD/CPD, respectively). PD with or without concurrent resection provides an acceptable, perioperative and long-term oncologic, outcome for pNET. CPD is justified treatment modality, particularly for patients with low-grade tumors. The need for combinatorial procedures during PD is not contraindication alone for otherwise resectable patients with pNET.
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Affiliation(s)
- Cornelius A Thiels
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA.,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - John R Bergquist
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA.,Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Danuel V Laan
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | | | - Rory L Smoot
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - David M Nagorney
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Geoffrey B Thompson
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Michael L Kendrick
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Michael B Farnell
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA
| | - Mark J Truty
- Department of Surgery, Mayo Clinic Rochester, 200 First St. Southwest, Rochester, MN, 55905, USA.
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41
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Pessaux P, Méméo R, Ferreira N, Hargat J, Mutter D, Marescaux J. Pancreaticoduodenectomy with mesenterico-portal vein resection (with video). J Visc Surg 2016; 153:227-8. [PMID: 27032317 DOI: 10.1016/j.jviscsurg.2016.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- P Pessaux
- Hepato-Biliary and Pancreatic surgical unit, IRCAD-IHU, University of Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France.
| | - R Méméo
- Hepato-Biliary and Pancreatic surgical unit, IRCAD-IHU, University of Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
| | - N Ferreira
- Hepato-Biliary and Pancreatic surgical unit, IRCAD-IHU, University of Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
| | - J Hargat
- Hepato-Biliary and Pancreatic surgical unit, IRCAD-IHU, University of Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
| | - D Mutter
- Hepato-Biliary and Pancreatic surgical unit, IRCAD-IHU, University of Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
| | - J Marescaux
- Hepato-Biliary and Pancreatic surgical unit, IRCAD-IHU, University of Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
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Abstract
BACKGROUND Vascular resection interventions and the associated necessity of a reconstruction for maintenance particularly of hepatic and small intestinal perfusion are important aspects especially for the surgical treatment of pancreatic cancer. An R0 resection is the only curative treatment option for patients with pancreatic cancer. Venous or arterial vascular infiltration by the tumor and the associated resection and reconstruction for complete tumor removal and establishment of a sufficient perfusion of the dependent organs represents one of the greatest challenges in pancreatic surgery. In addition the oncological significance with respect to arterial vascular resections is controversial. OBJECTIVE In this review article the indications and technical aspects of vascular resection and reconstruction in the therapy of pancreatic cancer are presented and discussed based on the current literature. MATERIAL AND METHODS A systematic search of Medline, Embase and the Cochrane Library was carried out to identify studies reporting the results of venous or arterial vascular resection techniques, postoperative morbidity, mortality and patient survival after surgery for pancreatic cancer. Results Pancreatic cancer with vascular infiltration should not principally be seen as non-resectable but must always be checked for the possibility of a curative resection. A decisive factor is the differentiation between venous and arterial vascular involvement. Various safe technical options are available for venous vascular resection, depending on the extent of tumor infiltration. Arterial vascular resections are associated with an increased morbidity and mortality. In selected patients a complete tumor resection and prolonged survival can be achieved by arterial vascular resection.
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43
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Del Chiaro M, Segersvärd R, Rangelova E, Coppola A, Scandavini CM, Ansorge C, Verbeke C, Blomberg J. Cattell-Braasch Maneuver Combined with Artery-First Approach for Superior Mesenteric-Portal Vein Resection During Pancreatectomy. J Gastrointest Surg 2015; 19:2264-8. [PMID: 26423804 DOI: 10.1007/s11605-015-2958-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 09/15/2015] [Indexed: 01/31/2023]
Abstract
Pancreatectomy associated with superior mesenteric-portal vein (SMPV) resection is currently considered the standard of care for patients with pancreatic tumors involving the major peripancreatic veins. However, a standard approach for resection and reconstruction is not defined yet. The aim of this study is to analyze the feasibility and short-term results of an original Cattell-Braasch artery-first approach (CBAF) for the resection of SMPV during pancreatectomy. Of 144 pancreatectomies with vascular resection undertaken from 2008 to 2013 at Karolinska University Hospital, 45 (31.2 %) were performed combining a Cattell-Braasch maneuver with an artery-first approach (from 2011 to 2013). The mean patient age was 65.2 years. Thirty-seven (82.2 %) patients underwent pancreatoduodenectomy and 8 (17.8 %) total pancreatectomy. Histology showed pancreatic ductal adenocarcinoma in 42 patients (93.3 %). The median length of the resected SMPV segment was 4.6 cm (range 3-7). In all patients, a direct end-to-end anastomosis was performed without graft interposition. In nine cases (20 %), an arterial resection was also performed. There was no mortality in this series, and the morbidity rate was 35.5 %. Combined CBAF for the resection of SMPV during pancreatectomy seems to be safe and effective. The reconstruction of the resected vessels is possible in many cases without graft interposition, even if the resected vein segment is of considerable length.
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Affiliation(s)
- Marco Del Chiaro
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden.
| | - Ralf Segersvärd
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Elena Rangelova
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Alessandro Coppola
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Chiara Maria Scandavini
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Christoph Ansorge
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Caroline Verbeke
- Department of Pathology, Karolinska Institute, Stockholm, Sweden
| | - John Blomberg
- Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
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Abstract
Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive malignant tumors and represents the fifth most common cause of cancer-related deaths. It is associated with a poor prognosis, likely due to the tendency of the tumor for early local and distant spread. One of the major obstacles of effectively treating PDAC is the often late diagnosis. Among all options currently available for PDAC, surgical resection offers the only potential cure with 5-year survival rate of approximately 15-20 %. However, in the absence of metastatic disease, which precludes resection, assessment of vascular invasion is an important parameter for determining resectability for pancreatic cancer. The vascular involvement in patients with pancreatic carcinoma ranges between 21 and 64 %. Historically, vascular involvement has been considered a contraindication to resective cure. Meanwhile, the surgical approach of pancreatoduodenectomy (PD) combined with vascular resection and reconstruction has been widely applied in clinical practice to remove the tumor completely. Therefore, vascular invasion is no longer a surgical contraindication and the rate of surgical resection has greatly increased. Moreover, PD combined with vascular resection can account for 20 to 25 % of the total cases of PD surgery in a number of the larger pancreas treatment centers. The aim of this review is to provide an overview of management and outcome of vascular resection in PDAC surgery.
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Álamo JM, Marín LM, Suarez G, Bernal C, Serrano J, Barrera L, Gómez MA, Muntané J, Padillo FJ. Improving outcomes in pancreatic cancer: Key points in perioperative management. World J Gastroenterol 2014; 20:14237-14245. [PMID: 25339810 PMCID: PMC4202352 DOI: 10.3748/wjg.v20.i39.14237] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 02/14/2014] [Accepted: 06/23/2014] [Indexed: 02/06/2023] Open
Abstract
This review focused in the perioperative management of patients with pancreatic cancer in order to improve the outcome of the disease. We consider that the most controversial points in pancreatic cancer management are jaundice management, vascular resection and neo-adjuvant therapy. Preoperative biliary drainage is recommended only in patients with severe jaundice, as it can lead to infectious cholangitis, pancreatitis and delay in resection, which can lead to tumor progression. The development of a phase III clinical trial is mandatory to clarify the role of neo-adjuvant radiochemotherapy in pancreatic adenocarcinoma. Venous resection does not adversely affect postoperative mortality and morbidity, therefore, the need for venous resection should not be a contraindication to surgical resection in selected patients. The data on arterial resection alone, or combined with vascular resection at the time of pancreatectomy are more heterogeneous, thus, patient age and comorbidity should be evaluated before a decision on operability is made. In patients undergoing R0 resection, arterial resection can also be performed.
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46
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Abstract
Optimal treatment of hilar cholangiocarcinoma depends on location of the cancer and extent of biliary and vascular involvement. Candidates for resection or transplantation must be evaluated and managed by a multidisciplinary team at a high-volume hepatobiliary center. Success requires absence of distant nodal or extrahepatic metastases and an adequate functional liver remnant with a negative ductal margin. Ipsilateral portal vein resection and reconstruction should be performed in patients with venous involvement. Neoadjuvant chemoradiation and liver transplantation is the best treatment option for patients with unresectable hilar cholangiocarcinoma without nodal or distant metastases and for patients with underlying chronic liver disease.
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Affiliation(s)
- Victor M Zaydfudim
- Department of Surgery, University of Virginia, 1300 Jefferson Park Avenue, Charlottesville, VA 22908, USA
| | - Charles B Rosen
- Division of Transplantation Surgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - David M Nagorney
- Department of Surgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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47
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Lopez NE, Prendergast C, Lowy AM. Borderline resectable pancreatic cancer: Definitions and management. World J Gastroenterol 2014; 20:10740-10751. [PMID: 25152577 PMCID: PMC4138454 DOI: 10.3748/wjg.v20.i31.10740] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 01/06/2014] [Accepted: 03/19/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is the fourth leading cause of cancer death in the United States. While surgical resection remains the only curative option, more than 80% of patients present with unresectable disease. Unfortunately, even among those who undergo resection, the reported median survival is 15-23 mo, with a 5-year survival of approximately 20%. Disappointingly, over the past several decades, despite improvements in diagnostic imaging, surgical technique and chemotherapeutic options, only modest improvements in survival have been realized. Nevertheless, it remains clear that surgical resection is a prerequisite for achieving long-term survival and cure. There is now emerging consensus that a subgroup of patients, previously considered poor candidates for resection because of the relationship of their primary tumor to surrounding vasculature, may benefit from resection, particularly when preceded by neoadjuvant therapy. This stage of disease, termed borderline resectable pancreatic cancer, has become of increasing interest and is now the focus of a multi-institutional clinical trial. Here we outline the history, progress, current treatment recommendations, and future directions for research in borderline resectable pancreatic cancer.
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48
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Ebata T, Ito T, Yokoyama Y, Igami T, Sugawara G, Mizuno T, Nagino M. Surgical technique of hepatectomy combined with simultaneous resection of hepatic artery and portal vein for perihilar cholangiocarcinoma (with video). J Hepatobiliary Pancreat Sci 2014; 21:E57-61. [PMID: 24912472 DOI: 10.1002/jhbp.121] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Perihilar cholangiocarcinomas often involve the bifurcation of the portal vein and the hepatic artery at initial presentation. Previously, vascular invasion was a major obstacle for R0 resection; therefore, such tumors were regarded as locally advanced, unresectable disease. Recently, in leading centers, these tumors have been resected using a specific technique, vascular resection and reconstruction. Vascular resection is classified into three types: portal vein resection alone, hepatic artery resection alone, and simultaneous resection of both the portal vein and hepatic artery. Of these, portal vein resection is widely performed, whereas hepatic artery resection remains controversial. Therefore, hepatectomy combined with simultaneous resection of the portal vein and hepatic artery represents one of the most complicated and challenging procedures in hepatobiliary surgery. The survival benefit of this extended procedure remains unproven, and there is only a single study reporting an unexpectedly favorable outcome in 50 patients. Considering the dismal survival in patients with unresectable disease, hepatic artery resection and/or portal vein resection may be a promising option of choice. However, the technique is highly demanding and has not been standardized. Therefore, this extended surgery may be allowed only in selected hepatobiliary centers.
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Affiliation(s)
- Tomoki Ebata
- Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Ouaïssi M, Turrini O, Hubert C, Louis G, Gigot JF, Mabrut JY. Vascular resection during radical resection of pancreatic adenocarcinomas: evolution over the past 15 years. J Hepatobiliary Pancreat Sci 2014; 21:623-38. [PMID: 24890182 DOI: 10.1002/jhbp.122] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
This literature review aimed to critically analyze oncological results of vascular resection during pancreatectomy for adenocarcinoma in the light of the concept evolution of locally advanced tumors and microscopic complete resection. The literature search was conducted in PubMed and Medline for the period June 1994 to December 2012, retaining English as the language of publication. The review of 12 publications indicated that mortality and morbidity rates were not significantly different for pancreatectomy with or without venous resection (VR). Six comparative studies showed worse long-term survival in the VR group, though one meta-analysis, albeit with a significant population heterogeneity, demonstrated that the overall survival between VR and the control group was similar (12% vs. 17%). The compilation of 13 comparative studies showed a significantly lower rate of complete microscopic resection in the VR patient group compared to controls (63% vs. 77%; P = 0.001). Concerning pancreatectomy combined to arterial resection, the literature review indicated a significantly greater mortality and morbidity rate and a lower survival rate compared to pancreatic resection alone. Conflicting results concerning the long-term outcome of VR was due to the heterogeneity of the patient population. Since the only chance to cure patients of pancreatic adenocarcinoma is to obtain free resection margins, VR is a valid therapeutic option. But combined arterial resection to pancreatic resection does not appear to be recommended.
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Affiliation(s)
- Mehdi Ouaïssi
- Department of Digestive Surgery, Timone Hospital, Marseille, France
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50
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Pan G, Xie KL, Wu H. Vascular resection in pancreatic adenocarcinoma with portal or superior mesenteric vein invasion. World J Gastroenterol 2013; 19:8740-8744. [PMID: 24379594 PMCID: PMC3870522 DOI: 10.3748/wjg.v19.i46.8740] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Revised: 09/20/2013] [Accepted: 10/14/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate long-term survival after the Whipple operation with superior mesenteric vein/portal vein resection (SMV/PVR) in relation to resection length.
METHODS: We evaluated 118 patients who underwent the Whipple operation for pancreatic adenocarcinoma at our Department of Hepatobiliary Pancreatic Surgery between 2005 and 2010. Fifty-eight of these patients were diagnosed with microscopic PV/SMV invasion by frozen-section examination and underwent SMV/PVR. In 28 patients, the length of SMV/PVR was ≤ 3 cm. In the other 30 patients, the length of SMV/PVR was > 3 cm. Clinical and survival data were analyzed.
RESULTS: SMV/PVR was performed successfully in 58 patients. There was a significant difference between the two groups (SMV/PVR ≤ 3 cm and SMV/PVR > 3 cm) in terms of the mean survival time (18 mo vs 11 mo) and the overall 1- and 3-year survival rates (67.9% and 14.3% vs 41.3% and 5.7%, P < 0.02). However, there was no significant difference in age (64 years vs 58 years, P = 0.06), operative time (435 min vs 477 min, P = 0.063), blood loss (300 mL vs 383 mL, P = 0.071) and transfusion volume (85.7 mL vs 166.7 mL, P = 0.084) between the two groups.
CONCLUSION: Patients who underwent the Whipple operation with SMV/PVR ≤ 3 cm had better long-term survival than those with > 3 cm resection.
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