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Perioperative and Long Term Outcome After Extended (Portal Vein, Multivisceral) Resection for Cancer of the Pancreatic Head
Birte Kulemann*1, Uwe a. Wittel1, Ulrich F. Wellner1, Tobias Keck1, Hryhoriy Lapshyn1, Peter Bronsert2, Jens Hoeppner1, Ulrich T. Hopt1, Frank Makowiec1
1Dept. of Surgery, University of Freiburg, Freiburg, Germany; 2Institute of Pathology, University of Freiburg, Freiburg, Germany
Introduction: Complete resection is established as the only potential chance for cure in patients with pancreatic cancer (PaCa). In contrast to extended lymphadenectomy, the influence of locally extended resection (portal vein, multivisceral) on perioperative morbidity and oncologic outcome remains less clear. We thus investigated perioperative and long-term outcome after standard pancreatic head resections (SPR), additional portal vein (PVR)- and multivisceral resections (MVR).
Methods: Clinicopathologic, perioperative and survival data from patients who underwent pancreatic head resection (PHR) for PaCa from 1994 to 2011 were analyzed (prospective pancreatic database).
Results: PHR for PaCa was performed in 291 patients. Of those, 170 (58%) underwent SPR, 103 (35%) additional PVR, and 18 (6%) had MVR. Additional organs resected were colon (n=7), liver (n=5), stomach (n=5), and small bowel (n=1). Operation time was significantly longer in MVR and PVR with a median time of 469 and 472 minutes, compared to SPR (428 min; p=0.01). Overall morbidity was slightly higher after MVR (72%) compared to PVR (55%) or SPR (50%; p=0.15). Patients who received MVR had a significantly higher in-hospital mortality of 11% compared to 4.7% in SPR and 0% in PVR (p=0.02). Nodal status did not differ in the three groups, whereas more patients in the MVR-group had tumor-negative resection margins (89% vs 65%/74%; p=0.06). The 3- and 5-year survival after SPR was 28% and 21%, respectively. Survival was slightly lower in PV with (19% and 10%) and lowest in MV (17% and 8%; p=0.15). Node negative patients with free margins survived substantially longer with a 3- and 5-year survival rate of 41% and 30% respectively (p=0.001 vs positive nodes or margins). Multivariate survival analysis identified margin positive resection, intraoperative blood transfusions and MVR as significant, independent risk factors for poorer overall survival.
Conclusion: Multivisceral pancreatic head resections imply increased perioperative morbidity, higher mortality and inferior survival. Portal vein resections however, can be performed safely to reach margin free resection, and its survival benefits.
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