Surgical management and pathological assessment of pancreatoduodenectomy with venous resection: an international survey among surgeons and pathologists

Jesse V Groen,Martijn W.J Stommel,Arantza F Sarasqueta,Marc G Besselink,Lodewijk A.A Brosens,Casper H.J Van Eijck,Isaac Q Molenaar,Joanne Verheij,Judith De Vos-Geelen,Martin N Wasser,Bert A Bonsing,J Sven D Mieog

doi:10.1016/j.hpb.2020.04.015

Abstract

BackgroundThe aim of this survey was to gain insights in the current surgical management and pathological assessment of pancreatoduodenectomy with portal–superior mesenteric vein resection (VR). MethodsA systematic literature search was performed to identify international expert surgeons (N = 150) and pathologists (N = 40) who published relevant studies between 2009 and 2019. These experts and Dutch surgeons (N = 17) and pathologists (N = 20) were approached to complete an online survey. ResultsOverall, 76 (46%) surgeons and 37 (62%) pathologists completed the survey. Most surgeons (71%) estimated that preoperative imaging corresponded correctly with intraoperative findings of venous involvement in 50–75% of patients. An increased complication risk following VR was expected by 55% of surgeons, mainly after Type 4 (segmental resection-venous conduit anastomosis). Most surgeons (61%) preferred Type 3 (segmental resection-primary anastomosis). Most surgeons (75%) always perform the VR themselves. Standard postoperative imaging for patency control was performed by 54% of surgeons and 39% adjusted thromboprophylaxis following VR. Most pathologists (76%) always assessed tumor infiltration in the resected vein and only 54% of pathologists always assess the resection margins of the vein itself. Variation in assessment of tumor infiltration depth was observed. ConclusionThis international survey showed variation in the surgical management and pathological assessment of pancreatoduodenectomy with venous involvement. This highlights the lack of evidence and emphasizes the need for research on imaging modalities to improve patient selection for VR, surgical techniques, postoperative management and standardization of the pathological assessment.

Highlights

Pancreatic cancer infiltration in the portal or superior mesenteric vein (PV-SMV) is not considered a contra-indication for a resection as stated by the International Study Group of Pancreatic Surgery (ISGPS) in 2014.1 The assessment of venous involvement is important in surgical decision making since the resection margin on the level of the PV-SMV is among the most frequently affected.[2,3]
Fifteen (41%) pathologists estimated that a vein resection (VR) was performed in 5–10% of patients (Table 2)
Different perceptions exist between surgeons and pathologists regarding the estimated percentage of pancreatoduodenectomies with VR

Summary

Introduction

Pancreatic cancer infiltration in the portal or superior mesenteric vein (PV-SMV) is not considered a contra-indication for a resection as stated by the International Study Group of Pancreatic Surgery (ISGPS) in 2014.1 The assessment of venous involvement is important in surgical decision making since the resection margin on the level of the PV-SMV is among the most frequently affected.[2,3] In selected patients, it is possible to perform a venous resection (VR) to acquire a tumor-free resection margin on the level of the PV-SMV.[1]. The reported correspondence between preoperative imaging, findings during surgery and pathological assessment shows much variation and it remains challenging to select the right patients eligible for VR.[4,5,6] Despite criteria for assessment of vascular involvement on computed tomography exist,[7] absence of tumor infiltration in the resected vein in the final pathology is reported in 39% (range 17–78) of VR.[8] The surgeon has to rely on preoperative imaging, visual inspection, palpation and intraoperative frozen sections in order to distinguish tumor from normal tissue, peritumoral inflammation and fibrosis This is especially challenging after neoadjuvant chemo -and radiotherapy.[9,10,11] Routine VR and a ‘‘no-touch’’ technique, without breaching the ‘‘capsule’’ of the tumor at the venous margin, have been described earlier.[12,13] Some studies reported promising results of intraoperative ultrasound.[14,15,16,17] The direct contact with the operative field and real-time imaging provides feedback about the tumor and vascular involvement. This highlights the lack of evidence and emphasizes the need for research on imaging modalities to improve patient selection for VR, surgical techniques, postoperative management and standardization of the pathological assessment

Methods

Results

Conclusion