vascular resection during resection during pancreaticoduodenectomy. ... smv and portal venous...

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  • Vascular resection during pancreaticoduodenectomy.

    Ryan Turley, MDResearch Fellow, Duke University

  • Vascular Resection during PD

    Outline

    Review of pancreatic adenocarcinoma

    Role of PD in treatment of pancreatic adenocarcinoma

    Theory for vascular resection for locally invasive disease

    Summary of current literature

    Types of reconstruction

    Duke experience

    Conclusions

  • Pancreatic Adenocarcinoma

  • Pancreatic Adenocarcinoma

    Classic Presentation

    Jaundice, sometimes painless

    Dark urine

    Light colored stool

    Labs

    Bilirubin

    Ca 19-9 (Normal < 37)

    37-100 less specific

    > 100 suggest malignancy

  • Pancreatic Adenocarcinoma

    Imaging Head mass with PV invasion

    Fine-cut CT scan

    High quality MRI scan

    Other

    EUS

    ERCP

  • Role

    of Pancreaticoduodenectomy (PD)

    PD is the only chance for cure.

    Mortality rates ranges from 0-8%.

    5 year survival after resection ranges from 7-

    25%.2

    Survival after surgery is worse for patients with positive margins.3

    2. Bachellier, et al. Is pancreaticoduodenectomy with mesentericoportal venous resection safe and worthwhile . Am J Surgery 2001;182: 120-9.

    3. Zervos EE et al. Surgical management of early-stage pancreatic cancer. Cancer Control. 2004; 11:23-31.

  • Pancreatic Adenocarcinoma

    SMV and Portal Venous Resection -

    Theory

    Grossly positive margins after resection associated with early recurrence.

    Close relationship between pancreatic head and superior mesenteric vein.

    Barriers to margin free resection include tumor involvement of SMV.

    Invasion of SMV can occur without retroperitoneal invasion.

    SMV not always accurately defined on pre-operative imaging.

  • Pancreatic Adenocarcinoma

    SMV/PV invasion

    Loss of the fat plane on CT

    Absence of normal pancreatic parenchyma between the low-density tumor and the vein wall

  • NCCN Practice Guidelines v.1.2009

    Resectable

    No distant metastases

    Clear fat plane around celiac and superior mesenteric artery.

    Patent SMV/PV

    Borderline Resectable

    Severe unilateral or bilateral SMV/portal impingement

    Less than 180 degree tumor abutment of SMA

    Abutment or enasement

    of hepatic artery, if reconstructible.

    SMV occlusion, if of a short segment, and reconstructible.

    SMA or celiac encasement < 180 degrees.

    Unresectable

    Distant Metastases

    Greater than 180 degree SMA encasement, any celiac abutment.

    Unreconstructible

    SMV/Portal Vein

    Aortic invasion or encasement.

    Metastases to lymph nodes beyond the field of resection.

  • Flow Diagram-

    NCCN GuidelinesPancreatic Protocol

    CT scan

    Resectable

    Resection Clinical Trial Neoadjuvant Therapy

    Borderline Unresectable

    Resection Neoadjuvant Therapy

    Chemotherapy/

    Radiation

    Restage

    ResectionSystemic Therapy

  • History

    First PD with SMV reconstruction by Moore et al. at the University of Minnesota in 1951.

    Symbas

    et al. concluded autologous grafts vein grafts remained patent while synthetic prosthesis had high rates of occlusion in 1961.

    Asada

    et al. in Japan reported radical pancreatectomy with PVR in 1963.

    First attempts in the 1970s by Fortner

    produced poor results with high morbidity and mortality.

    Reemergence in the 1990s by the MD Anderson group.

  • Current literature

    Modern debate is charged in comparing vascular resection for isolated invasion of SMV, PV, or SMV-PV confluence.

    Reported Morbidity

    25-55%

    PD with Vascular Resection has not yet been universally accepted due to failure to prove:

    (1) the procedure can be performed with acceptable morbidity and mortality even if margin free resections are increased.

    (2) PD with SM-PVR has survival similar characteristics as standard PD.

  • Reconstruction options

    V1

    Tangential resection with saphenous vein patch

    V2

    Segmental resection with splenic vein ligation and primary anastomosis

    V3

    Segmental resection with splenic vein ligation and interposition graft.

    V4

    Segmental resection without splenic vein ligation and primary anastomosis.

    V5

    Segmental resection without splenic vein ligation and interposition graft.

  • Available SMV-PVR techniques

    Vein Patch

    Greater Saphenous Vein

    Continuous 6-0 prolene

    Choice for less extensive tumor involvement

    < 1/3 vessel circumference

  • Interposition Grafting

    More extensive tumor involvement

    (> 1/3 vessel circumference)

    Interrupted 6-0 prolene

    Splenic vein can be ligated or reimplanted in side of interposition graft.

  • Interposition Graft

    Graft types

    Splenic vein

    Left Renal Vein

    Internal Jugular

    Ovarian Vein

    Femoral Vein*

  • Primary Reconstruction

    A.

    Pancreatic head tumor and involvement of the portal vein.

    B.

    En-bloc PD with Segmental portal venous resection.

    C.

    Reconstruction of the portal vein.

  • Previous StudiesAuthor Location N (%) Mortality

    30 days (%)

    Morbidity (%)

    Median Survival

    Neg

    Margins (%)

    Sindelar

    1989

    NCI 20 20 55 12

    Trede

    1990,97

    Mannheim 60 (10.7) 6.7 12

    Allema1994

    Amsterdam 20 (11.4) 15 55 8 15

    FortnerHarrison1996

    MSK 58 (17.5) 5 12 (Re-X-Lap)

    13 73

    Roder1996

    Munich 31 (10.4) 0 41.9 8 32

  • Previous StudiesAuthor Location N (%) Mortality

    30 days (%)

    Morbidity (%)

    Median Survival

    Neg

    Margins (%)

    Sindelar

    1989

    NCI 20 20 55 12

    Trede

    1990,97

    Mannheim 60 (10.7) 6.7 12

    Allema1994

    Amsterdam 20 (11.4) 15 55 8 15

    FortnerHarrison1996

    MSK 58 (17.5) 5 12 (Re-X-Lap)

    13 73

    Roder1996

    Munich 31 (10.4) 0 41.9 8 32

  • Previous StudiesAuthor Location N (%) Mort.

    30 days (%)

    Morbidity (%)

    Median Survival

    Neg

    Margins (%)

    LeachFurman1996, 98

    MD Anderson

    31 (41.7)

    0 30 22 87

    Tseng2004

    MD Anderson

    110 (38)

    1 18 23.43 78

    Imaizumi1998

    Tokyo 172 (69)

    5 23

    Nakao1993, 95

    Nagoya (Japan)

    104 (78)

    8 14% 5-year

    49

    Takahashi1994, 97

    Keio 107 (55.7)

    3.8 23.1 19 26.5

    Klempnauer1996

    Hannover 37 (19.6)

    13.5 35.1 (Re-X-Lap)

    9.0

  • Previous StudiesAuthor Location N (%) Mort.

    30 days (%)

    Morbidity (%)

    Median Survival

    Neg Margins (%)

    LeachFurman1996, 98

    MD Anderson

    31 (41.7)

    0 30 22 87

    Tseng2004

    MD Anderson

    110 (38)

    1 18 23.43 78

    Imaizumi1998

    Tokyo 172 (69)

    5 23

    Nakao1993, 95

    Nagoya (Japan)

    104 (78)

    8 14% 5-year

    49

    Takahashi1994, 97

    Keio 107 (55.7)

    3.8 23.1 19 26.5

    Klempnauer1996

    Hannover 37 (19.6)

    13.5 35.1 (Re-X-Lap)

    9.0

  • Previous StudiesAuthor Location N (%) Mort.

    30 days (%)

    Morbidity (%)

    Median Survival

    Neg Margins (%)

    LeachFurman1996, 98

    MD Anderson

    31 (41.7)

    0 30 22 87

    Tseng2004

    MD Anderson

    110 (38)

    1 18 23.43 78

    Imaizumi1998

    Tokyo 172 (69)

    5 23

    Nakao1993, 95

    Nagoya (Japan)

    104 (78)

    8 14% 5-year

    49

    Takahashi1994, 97

    Keio 107 (55.7)

    3.8 23.1 19 26.5

    Klempnauer1996

    Hannover 37 (19.6)

    13.5 35.1 (Re-X-Lap)

    9.0

  • Duke Experience Hypothesis

    Superior mesenterico-portal venous tumor invasion is function of location and not a harbinger of metastatic disease or worse outcome after resection.

    Combined pancreaticoduodenectomy with vascular resection offers previously unresectable patients a chance for cure without significant additional morbidity or mortality.

  • Duke Experience

    204 patients who underwent PD for pancreatic adenocarcinoma from 1997-2008.

    Patients who underwent PD with VR (N=42) were compared to patients who underwent standard PD (N=162).

    Vascular reconstructions were performed by a vascular surgeon using primary repair (N=7), vein patch (N=26), or interposition grafting (N=8) with saphenous or femoral vein conduit.

  • Inclusion Criteria

    All patients undergoing standard PD or PD with VR from 1997-2008 at Duke.

    Pathology confirming Pancreatic Ductal Adenocarcinoma.

  • Exclusion criteria

    Patients with significant missing clinicopathological data.

    All tumors not described in surgical pathology as pancreatic adenocarcinoma.

    Previous pancreas surgery.

  • Methods

    All available post-operative CT scans reviewed for patency by Duke radiology fellow KP.

    2 test was used to compare categorical variables.

    Independent t tests were used to evaluate continuous variables.

    Survival and follow-up were calculated from the time of surgery to date of death or last follow-up.

    Overall survival was estimated using the method of Kaplan and Meier.

    The log-rank test was used to evaluate differences between survival curves.

    Multivariate analyses of the effects of potential prognostic factors on survival were done using a Cox proportional hazards regression.

  • DemographicsPD + VRPD + VR(n=42)(n=42)

    Standard PDStandard PD(n