Abstract
Simple SummaryAggressive arterial resection or total pancreatectomy in surgical treatment for locally advanced pancreatic cancer (LAPC) has gradually been encouraged thanks to new chemotherapy regimens such as FOLFIRINOX or Gemcitabine and nab-paclitaxel, which have provided more adequate patient selection and local tumor suppression, justifying aggressive local resection. The development of surgical techniques provides the safety of arterial resection (AR) for even major visceral arteries, such as the celiac axis or superior mesenteric artery. Total pancreatectomy has been re-evaluated as an effective option to balance both the local control and postoperative safety. In this review, we investigate the recent reports focusing on arterial resection and total pancreatectomy for locally advanced pancreatic cancer (LAPC) and discuss the rationale of such an aggressive approach in the treatment of PC.Aggressive arterial resection (AR) or total pancreatectomy (TP) in surgical treatment for locally advanced pancreatic cancer (LAPC) had long been discouraged because of their high mortality rate and unsatisfactory long-term outcomes. Recently, new chemotherapy regimens such as FOLFIRINOX or Gemcitabine and nab-paclitaxel have provided more adequate patient selection and local tumor suppression, justifying aggressive local resection. In this review, we investigate the recent reports focusing on arterial resection and total pancreatectomy for LAPC and discuss the rationale of such an aggressive approach in the treatment of PC. AR for LAPCs is divided into three, according to the target vessel. The hepatic artery resection is the simplest one, and the reconstruction methods comprise end-to-end, graft or transposition, and no reconstruction. Celiac axis resection is mainly done with distal pancreatectomy, which allows collateral arterial supply to the liver via the pancreas head. Resection of the superior mesenteric artery is increasingly reported, though its rationale is still controversial. Total pancreatectomy has been re-evaluated as an effective option to balance both the local control and postoperative safety. In conclusion, more and more aggressive pancreatectomy has become justified by the principle of total neoadjuvant therapy. Further technical standardization and optimal neoadjuvant strategy are mandatory for the global dissemination of aggressive pancreatectomies.
Highlights
Pancreatic cancer (PC) is a dismal clinical entity [1]
Recent reports have documented favorable short-term outcomes of venous resection in patients with localized PCs [10,11]; the R0 resection rate, as well as long-term survival, remained unsatisfactory, because the most frequent site of cancer-positive margin was located at the superior mesenteric artery (SMA) margin [12,13], which could not be overcome by venous resection alone
EEA, end-to-end anastomosis, ND, not described, PD, pancreaticoduodenectomy, Total pancreatectomy (TP), total pancreatectomy, DP, distal pancreatectomy, GDA, gastroduodenal artery and SpA, splenic artery. * The replaced hepatic artery was anastomosed to Cancerst2h0e21G, 1D3A, 1.8*1*8 The hepatic artery was anastomosed to the SpA with total pancreatectomy. † Incidences among all patient6sof 16 with arterial resection. ‡ Includes patients who had replaced HA. § Each number was not documented
Summary
Pancreatic cancer (PC) is a dismal clinical entity [1]. For localized PCs, resection is the only chance for cure. Total pancreatectomy (TP) is an option to achieve R0 resection in locally advanced PCs. The rationale of TP for PC, has long been in controversy due to complicated short-time outcomes, including malnutrition or brittle diabetes, along with unsatisfactory long-term survival [4]. Their results showed severe short-term outcomes and insufficient long-term survivals and was not accepted as a reasonable method to improve the treatment outcomes of LAPCs [2,7]. Recent reports have documented favorable short-term outcomes of venous resection in patients with localized PCs [10,11]; the R0 resection rate, as well as long-term survival, remained unsatisfactory, because the most frequent site of cancer-positive margin was located at the superior mesenteric artery (SMA) margin [12,13], which could not be overcome by venous resection alone. The necessity of more radical dissection, including arterial resection, remained and has become more prominent in the past two decades, recent meta-analyses concluded that pancreatectomy with ARs remained a challenge, because it increased the complexity of the procedure and was associated with increased morbidity and mortality in comparison to non-AR pancreatectomies [14,15]
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