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Is Partial Resection of Portal or Superior Mesenteric Vein Justified for Patients With Pancreatic Head Carcinoma?
Yoshiaki Murakami*1, Kenichiro Uemura1, Sohei Satoi2, Masayuki Sho4, Fuyuhiko Motoi7, Goro Honda6, Manabu Kawai5, Ippei Matsumoto3, Seiko Hirono5, Masanao Kurata6, Hiroaki Yanagimoto2, Takahiro Akahori4, Makoto Shinzeki3, Michiaki Unno7
1Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan; 2Department of Surgery, Kansai Medical University, Hirakata, Japan; 3Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan; 4Department of Surgery, Nara Medical University, Nara, Japan; 5Second Department of Surgery, Wakayama Medical University, Wakayama, Japan; 6Department of Surgery, Komagome Hospital, Tokyo, Japan; 7Department of Surgery, Tohoku University, Sendai, Japan
Introduction. The prognostic impact of PV/SMV resection for pancreatic head carcinoma is still controversial. The aim of this study was to determine whether portal or superior mesenteric vein (PV/SMV) resection is justified for patients with pancreatic carcinoma who underwent pancreatoduodenectomy.
Methods. Of 1,451 consecutive patients with pancreatic carcinoma underwent tumor resection at 7 high-volume surgical institutions between 2001 and 2012, 937 patients who underwent pancreatoduodenectomy were analyzed retrospectively. These patients were classified into three groups according to preoperative multi-detector row computed tomography (MDCT) findings reported by National Comprehensive Cancer Network; resectable tumor (R group), borderline resectable tumor of PV/SMV involvement (BR-P group), and borderline resectable tumor of arterial abutment (BR-A group). Clinicopathological factors were compared between patients who did and did not undergo PV/SMV resection using univariate and multivariate analysis.
Results. Of the 937 patients, 435 patients (46%) underwent partial resection of the PV/SMV and the remaining 501 patients (54%) did not. Patients who underwent PV/SMV resection had more advanced tumor and required more operative time and more blood loss for tumor resection. However, the frequency of mortality and morbidity did not differ between the two groups. Univariate survival analysis revealed that there was a significant difference in overall survival between the two groups (P < 0.001). However, no significant differences of overall survival between the two groups were found among the subgroup of R group, BR-P group, and BR-A group and PV/SMV resection was not an independent prognostic factor of overall survival by multivariate analysis. Among 435 patients who underwent PV/SMV resection, multivariate analysis demonstrated that preoperative MDCT findings BR-A (P = 0.021), preoperative serum CA19-9 level (P < 0.001), blood transfusion (P = 0.020), postoperative complication (P < 0.001), use of postoperative adjuvant chemotherapy (P < 0.001), pathological PV/SMV invasion (P = 0.048), and lymph node status (P = 0.041) was independent prognostic factors. R group and BR-P group had a favorable median survival time with additional adjuvant chemotherapy (median survival time 43.7 months and 29.7 months, respectively). However, median survival time of BR-A group was only 18.6 months despite of administration of adjuvant chemotherapy.
Conclusion. Resection of the PV/SMV, if no arterial abutment is found, provides an adequate survival benefit to patients with pancreatic head carcinoma without increased mortality and morbidity. Subsequent adjuvant chemotherapy is mandatory for patients who undergo PV/SMV resection.
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