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

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