Abstract
Synchronous major vessel resection during pancreaticoduodenectomy (PD) for borderline resectable pancreatic adenocarcinoma remains controversial. In the 1970s, regional pancreatectomy advocated by Fortner was associated with unacceptably high morbidity and mortality rates, with no impact on long-term survival. With the establishment of a multidisciplinary approach, improvements in preoperative staging techniques, surgical expertise, and perioperative care reduced mortality rates and improved 5-year-survival rates are now achieved following resection in high-volume centres. Perioperative morbidity and mortality following PD with portal vein resection are comparable to standard PD, with reported 5-year-survival rates of up to 17%. Segmental resection and reconstruction of the common hepatic artery/proper hepatic artery (CHA/PHA) can be performed to achieve an R0 resection in selected patients with limited involvement of the CHA/PHA at the origin of the gastroduodenal artery (GDA). PD with concomitant major vessel resection for borderline resectable tumours should be performed when a margin-negative resection is anticipated at high-volume centres with expertise in complex pancreatic surgery. Where an incomplete (R1 or R2) resection is likely neoadjuvant treatment with systemic chemotherapy followed by chemoradiation as part of a clinical trial should be offered to all patients.
Highlights
Patients with pancreatic malignancy continue to have a dismal prognosis determined by the histological classification and extent of disease at the time of diagnosis [1]
Anderson criteria for borderline resectable tumours include those with encasement of a short segment of the hepatic artery (HA) amenable to resection and reconstruction without tumour extension to the coeliac axis, abutment of the superior mesenteric artery (SMA) involving ≤180◦ of the arterial circumference, or short-segment occlusion of the superior mesenteric vein (SMV), portal vein (PV), or superior mesenteric portal vein (SMPV) confluence with normal SMVbelow and normal PV above the area of tumour involvement amenable to resection and reconstruction (Table 2) [3]
To maximize the potential for an R0 resection, Varadhachary et al advocate neoadjuvant treatment with systemic chemotherapy followed by chemoradiation in patients with borderline resectable tumours defined by the extent of local tumour growth on multidetector computed tomography (CT) [3]
Summary
Patients with pancreatic malignancy continue to have a dismal prognosis determined by the histological classification and extent of disease at the time of diagnosis [1]. The prognosis for histologically proven invasive pancreatic cancer is poor, with a 5-year-survival rate of 9.7% following resection, and overall median survival time of 8.6 months [1]. Only 10–20% of patients are candidates for resection as approximately 50% present with metastatic, and 35% with locally advanced surgically unresectable disease. Surgically unresectable proximal pancreatic tumours are defined as those that encase adjacent arteries including the coeliac axis, superior mesenteric artery (SMA) or both, or that occlude the portal vein (PV), superior mesenteric vein (SMV), or superior mesenteric portal vein (SMPV) confluence (Tables 1 and 2). This paper reviews the literature on the management of borderline resectable proximal pancreatic cancers with vascular involvement with reference to assessment of resectability, staging investigations, survival, pancreaticoduodenectomy (PD) with major arterial and venous resection and the role of neoadjuvant therapy
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