World Journal of Surgery

, Volume 34, Issue 11, pp 2648–2661 | Cite as

Vascular Reconstruction During Pancreatoduodenectomy for Ductal Adenocarcinoma of the Pancreas Improves Resectability but does not Achieve Cure

  • Mehdi Ouaissi
  • Catherine Hubert
  • Robert Verhelst
  • Parla Astarci
  • Christine Sempoux
  • Anne Jouret-Mourin
  • Anderson Loundou
  • Jean-François Gigot
  • The Multidisciplary HPB Group of Center of Cancer



Combined vascular and pancreatic resection improves long-term survival of patients suffering from ductal adenocarcinoma of the pancreatic head. This study was designed to compare the results of surgical resection in patients with pancreatic cancer with or without vascular resection. Late 10-year disease-free survival was considered as an indicator of patients’ disease cure.


A total of 149 consecutive patients have undergone pancreatoduodenectomy without vascular resection (group 1: 82 patients), with isolated venous resection (group B: 67 patients), or with arterial and/or venous resection (group C: 8 patients).


The duration of surgery and blood losses were significantly more important in groups B and C compared with group A; however, postoperative morbidity and mortality rates were similar. R1 resection was significantly more frequent in groups B (42%) and C (50%) compared with group A (13%; p = 0.0002), but there were more advanced tumors in these groups, as demonstrated by a lower Karnowsky index, higher Ca 19-9 plasmatic level, greater tumor size, more advanced stage in the AJCC classification, and more tumor location in the uncinate process of the pancreas. Ten-year overall and disease-free survivals were significantly better in group A (19 and 20%) compared with group B (2.8 and 0%) and group C (0% and 0%). Multivariate analysis proved vascular resection and metastatic nodal status as being independent predictive factors of disease-free survival.


Vascular resection combined to pancreatoduodenectomy for pancreatic cancer increases local resectability without increasing mortality and morbidity rates but does not improve patients’ disease cure rate.


Pancreatic Cancer Superior Mesenteric Artery Pancreatic Fistula Pancreatic Resection Superior Mesenteric Vein 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



American Joint Committee on Cancer


American Society of Anesthesiology


Computed tomography


Endoscopic ultrasonography


18-Fluorodeoxyglucose positron emission tomography


Japanese Pancreas Society


Lymph nodes


Magnetic resonance imaging




Postoperative pancreatic fistula


Portal vein


Superior mesenteric artery


Superior mesenteric vein


Total pancreatectomy




  1. 1.
    Lowenfels AB, Maisonneuve P (2004) Epidemiology and prevention of pancreatic cancer. Jpn J Clin Oncol 34:238–244CrossRefPubMedGoogle Scholar
  2. 2.
    Jemal A, Thomas A, Murray T, Thun M (2002) Cancer statistics, 2002. CA Cancer J Clin 52:23–47CrossRefPubMedGoogle Scholar
  3. 3.
    Sohn TA, Yeo CJ, Cameron JL et al (2000) Resected adenocarcinoma of the pancreas-616 patients: results, outcomes, and prognostic indicators. J Gastrointest Surg 4:567–579CrossRefPubMedGoogle Scholar
  4. 4.
    Yeo CJ, Cameron JL, Sohn TA et al (1997) Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 226:248–257CrossRefPubMedGoogle Scholar
  5. 5.
    Trede M, Schwall G, Saeger HD (1990) Survival after pancreatoduodenectomy. 118 consecutive resections without an operative mortality. Ann Surg 211(4):447–458CrossRefPubMedGoogle Scholar
  6. 6.
    Neoptolemos JP, Stocken DD, Friess H et al (2004) A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer. N Engl J Med 350:1200–1210CrossRefPubMedGoogle Scholar
  7. 7.
    Oettle H, Post S, Neuhaus P et al (2007) Adjuvant chemotherapy with gemcitabine vs. observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial. JAMA 297:267–277CrossRefPubMedGoogle Scholar
  8. 8.
    Sa Cunha A, Rault A, Laurent C et al (2005) Surgical resection after radiochemotherapy in patients with unresectable adenocarcinoma of the pancreas. J Am Coll Surg 201(3):359–365CrossRefPubMedGoogle Scholar
  9. 9.
    Sultana A, Smith CT, Cunningham D et al (2007) Meta-analyses of chemotherapy for locally advanced and metastatic pancreatic cancer. J Clin Oncol 25(18):2607–2615CrossRefPubMedGoogle Scholar
  10. 10.
    Burris HA 3rd, Moore MJ, Andersen J et al (1997) Improvements in survival and clinical benefit with gemcitabine as first-line therapy for patients with advanced pancreas cancer: a randomized trial. J Clin Oncol 15:2403–2413PubMedGoogle Scholar
  11. 11.
    Berlin JD, Catalano P, Thomas JP et al (2002) Phase III study of gemcitabine in combination with fluorouracil versus gemcitabine alone in patients with advanced pancreatic carcinoma: Eastern Cooperative Oncology Group Trial E2297. J Clin Oncol 20:3270–3275CrossRefPubMedGoogle Scholar
  12. 12.
    Bramhall SR, Allum WH, Jones AG et al (1995) Treatment and survival in 13,560 patients with pancreatic cancer, and incidence of the disease, in the West Midlands: an epidemiological study. Br J Surg 82:111–115CrossRefPubMedGoogle Scholar
  13. 13.
    Wagner M, Redaelli C, Lietz M et al (2004) Curative resection is the single most important factor determining outcome in patients with pancreatic adenocarcinoma. Br J Surg 91:586–594CrossRefPubMedGoogle Scholar
  14. 14.
    Neoptolemos JP, Stocken DD, Dunn JA et al (2001) Influence of resection margins on survival for patients with pancreatic cancer treated by adjuvant chemoradiation and/or chemotherapy in the ESPAC-1 randomized controlled trial. Ann Surg 234:758–768CrossRefPubMedGoogle Scholar
  15. 15.
    Raut CP, Tseng JF, Sun CC et al (2007) Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma. Ann Surg 246:52–60CrossRefPubMedGoogle Scholar
  16. 16.
    Parker SL, Tong T, Bolden S, Wingo PA (1997) Cancer statistics, 1997. CA Cancer J Clin 47:5–27CrossRefPubMedGoogle Scholar
  17. 17.
    Allema JH, Reinders ME, van Gulik TM et al (1994) Portal vein resection in patients undergoing pancreatoduodenectomy for carcinoma of the pancreatic head. Br J Surg 81:1642–1646CrossRefPubMedGoogle Scholar
  18. 18.
    Bachellier P, Nakano H, Oussoultzoglou PD et al (2001) Is pancreaticoduodenectomy with mesentericoportal venous resection safe and worthwhile? Am J Surg 182:120–129CrossRefPubMedGoogle Scholar
  19. 19.
    Carrere N, Sauvanet A, Goere D et al (2006) Pancreaticoduodenectomy with mesentericoportal vein resection for adenocarcinoma of the pancreatic head. World J Surg 30:1526–1535CrossRefPubMedGoogle Scholar
  20. 20.
    Tseng JF, Raut CP, Lee JE et al (2004) Pancreaticoduodenectomy with vascular resection: margin status and survival duration. J Gastrointest Surg 8:935–949CrossRefPubMedGoogle Scholar
  21. 21.
    Nakao A, Takeda S, Inoue S et al (2006) Indications and techniques of extended resection for pancreatic cancer. World J Surg 30:976–982CrossRefPubMedGoogle Scholar
  22. 22.
    Martin RC 2nd, Scoggins CR, Egnatashvili V et al (2009) Arterial and venous resection for pancreatic adenocarcinoma: operative and long-term outcomes. Arch Surg 144:154–159CrossRefPubMedGoogle Scholar
  23. 23.
    Adham M, Mirza DF, Chapuis F et al (2006) Results of vascular resections during pancreatectomy from two European centres: an analysis of survival and disease-free survival explicative factors. HPB 8:465–473CrossRefPubMedGoogle Scholar
  24. 24.
    Fortner JG, Kim DK, Cubilla A et al (1977) Regional pancreatectomy: en bloc pancreatic, portal vein and lymph node resection. Ann Surg 186:42–50CrossRefPubMedGoogle Scholar
  25. 25.
    Stitzenberg KB, Watson JC, Roberts A et al (2008) Survival after pancreatectomy with major arterial resection and reconstruction. Ann Surg Oncol 15:1399–1406CrossRefPubMedGoogle Scholar
  26. 26.
    Siriwardana HP, Siriwardena AK (2006) Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer. Br J Surg 93:662–673CrossRefPubMedGoogle Scholar
  27. 27.
    O’Toole DM, Golden AM (1991) Evaluating cancer patients for rehabilitation potential. West J Med 155:384–387PubMedGoogle Scholar
  28. 28.
    Owens WD, Felts JA, Spitznagel EL Jr (1978) ASA physical status classifications: a study of consistency of ratings. Anesthesiology 49:239–243CrossRefPubMedGoogle Scholar
  29. 29.
    Yoshida T, Matsumoto T, Sasaki A et al (2004) Outcome of paraaortic node-positive pancreatic head and bile duct adenocarcinoma. Am J Surg 187:736–740CrossRefPubMedGoogle Scholar
  30. 30.
    Doi R, Kami K, Ito D et al (2007) Prognostic implication of para-aortic lymph node metastasis in resectable pancreatic cancer. World J Surg 31:147–154CrossRefPubMedGoogle Scholar
  31. 31.
    Nakao A, Harada A, Nonami T et al (1995) Clinical significance of portal invasion by pancreatic head carcinoma. Surgery 117:50–55CrossRefPubMedGoogle Scholar
  32. 32.
    Willett CG, Czito BG, Bendell JC, Ryan DP (2005) Locally advanced pancreatic cancer. J Clin Oncol 23:4538–4544CrossRefPubMedGoogle Scholar
  33. 33.
    Pessaux P, Rosso E, Panaro F et al (2009) Preliminary experience with the hanging maneuver for pancreaticoduodenectomy. Eur J Surg Oncol 35:1006–1010PubMedGoogle Scholar
  34. 34.
    American Joint Commitee on Cancer, Greene FL PD, Fleming ID et al. (2002) AJCC cancer staging handbook, 6th ed. Springer-Verlag, New YorkGoogle Scholar
  35. 35.
    Society JP (2003) Classification of pancreatic carcinoma, 2nd edn. Kanehara and Co., Ltd., TokyoGoogle Scholar
  36. 36.
    Isaji S, Kawarada Y, Uemoto S (2004) Classification of pancreatic cancer: comparison of Japanese and UICC classifications. Pancreas 28:231–234CrossRefPubMedGoogle Scholar
  37. 37.
    Kawarada Y, Isaji S (1998) Stage classifications of pancreatic cancer: comparison of the Japanese and UICC classifications and proposal for a new staging system. Union Internationale Contre le Cancer. Pancreas 16:255–264CrossRefPubMedGoogle Scholar
  38. 38.
    Matsuno S, Egawa S, Fukuyama S et al (2004) Pancreatic Cancer Registry in Japan: 20 years of experience. Pancreas 28:219–230CrossRefPubMedGoogle Scholar
  39. 39.
    Wittekind C, Compton CC, Greene FL, Sobin LH (2002) TNM residual tumor classification revisited. Cancer 94:2511–2516CrossRefPubMedGoogle Scholar
  40. 40.
    Verbeke CS, Leitch D, Menon KV et al (2006) Redefining the R1 resection in pancreatic cancer. Br J Surg 93:1232–1237CrossRefPubMedGoogle Scholar
  41. 41.
    Luttges J, Vogel I, Menke M et al (1998) The retroperitoneal resection margin and vessel involvement are important factors determining survival after pancreaticoduodenectomy for ductal adenocarcinoma of the head of the pancreas. Virchows Arch 433:237–242CrossRefPubMedGoogle Scholar
  42. 42.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213CrossRefPubMedGoogle Scholar
  43. 43.
    Bassi C, Dervenis C, Butturini G et al (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138:8–13CrossRefPubMedGoogle Scholar
  44. 44.
    Wente MN, Veit JA, Bassi C et al (2007) Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 142:20–25CrossRefPubMedGoogle Scholar
  45. 45.
    Yeo CJ, Cameron JL, Lillemoe KD et al (1995) Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 Patients. Ann Surg 221:721–731CrossRefPubMedGoogle Scholar
  46. 46.
    Nakao A, Takeda S, Sakai M et al (2004) Extended radical resection versus standard resection for pancreatic cancer: the rationale for extended radical resection. Pancreas 28:289–292CrossRefPubMedGoogle Scholar
  47. 47.
    Nakagohri T, Kinoshita T, Konishi M et al (2003) Survival benefits of portal vein resection for pancreatic cancer. Am J Surg 186:149–153CrossRefPubMedGoogle Scholar
  48. 48.
    Howard TJ, Villanustre N, Moore SA et al (2003) Efficacy of venous reconstruction in patients with adenocarcinoma of the pancreatic head. J Gastrointest Surg 7:1089–1095CrossRefPubMedGoogle Scholar
  49. 49.
    Poon RT, Fan ST, Lo CM et al (2004) Pancreaticoduodenectomy with en bloc portal vein resection for pancreatic carcinoma with suspected portal vein involvement. World J Surg 28:602–608CrossRefPubMedGoogle Scholar
  50. 50.
    Shibata C, Kobari M, Tsuchiya T et al (2001) Pancreatectomy combined with superior mesenteric-portal vein resection for adenocarcinoma in pancreas. World J Surg 25:1002–1005CrossRefPubMedGoogle Scholar
  51. 51.
    van Geenen RC, ten Kate FJ, de Wit LT et al (2001) Segmental resection and wedge excision of the portal or superior mesenteric vein during pancreatoduodenectomy. Surgery 129:158–163CrossRefPubMedGoogle Scholar
  52. 52.
    Yekebas EF, Bogoevski D, Cataldegirmen G et al (2008) En bloc vascular resection for locally advanced pancreatic malignancies infiltrating major blood vessels: perioperative outcome and long-term survival in 136 patients. Ann Surg 247:300–309CrossRefPubMedGoogle Scholar
  53. 53.
    Kawada M, Kondo S, Okushiba S et al (2002) Reevaluation of the indications for radical pancreatectomy to treat pancreatic carcinoma: is portal vein infiltration a contraindication? Surg Today 32:598–601CrossRefPubMedGoogle Scholar
  54. 54.
    Nix GA, Dubbelman C, Srivastava ED et al (1991) Prognostic implications of the localization of carcinoma in the head of the pancreas. Am J Gastroenterol 86:1027–1032PubMedGoogle Scholar
  55. 55.
    Esposito I, Kleeff J, Bergmann F et al (2008) Most pancreatic cancer resections are R1 resections. Ann Surg Oncol 15:1651–1660CrossRefPubMedGoogle Scholar
  56. 56.
    Boggi U, Del Chiaro M, Croce C et al. (2009) Prognostic implications of tumor invasion or adhesion to peripancreatic vessels in resected pancreatic cancer. Surgery 146:869–881Google Scholar
  57. 57.
    Katz MH, Pisters PW, Evans DB et al (2008) Borderline resectable pancreatic cancer: the importance of this emerging stage of disease. J Am Coll Surg 206:833–846 (discussion 846–848)CrossRefPubMedGoogle Scholar
  58. 58.
    Takahashi S, Ogata Y, Tsuzuki T (1994) Combined resection of the pancreas and portal vein for pancreatic cancer. Br J Surg 81:1190–1193CrossRefPubMedGoogle Scholar
  59. 59.
    Kondo S, Katoh H, Hirano S et al (2003) Results of radical distal pancreatectomy with en bloc resection of the celiac artery for locally advanced cancer of the pancreatic body. Langenbecks Arch Surg 388:101–106CrossRefPubMedGoogle Scholar
  60. 60.
    Allendorf JD, Lauerman M, Bill A et al (2008) Neoadjuvant chemotherapy and radiation for patients with locally unresectable pancreatic adenocarcinoma: feasibility, efficacy, and survival. J Gastrointest Surg 12:91–100CrossRefPubMedGoogle Scholar
  61. 61.
    Greer SE, Pipas JM, Sutton JE et al (2008) Effect of neoadjuvant therapy on local recurrence after resection of pancreatic adenocarcinoma. J Am Coll Surg 206:451–457PubMedGoogle Scholar
  62. 62.
    Katz MH, Wang H, Fleming JB et al (2009) Long-term survival after multidisciplinary management of resected pancreatic adenocarcinoma. Ann Surg Oncol 16:836–847CrossRefPubMedGoogle Scholar
  63. 63.
    Turrini O, Viret F, Moureau-Zabotto L et al. (2009) Neoadjuvant chemoradiation and pancreaticoduodenectomy for initially locally advanced head pancreatic adenocarcinoma. Eur J Surg Oncol 35:1306–1311Google Scholar
  64. 64.
    Satoi S, Yanagimoto H, Toyokawa H et al (2009) Surgical results after preoperative chemoradiation therapy for patients with pancreatic cancer. Pancreas 38(3):282–288CrossRefPubMedGoogle Scholar
  65. 65.
    Evans DB, Varadhachary GR, Crane CH et al (2008) Preoperative gemcitabine-based chemoradiation for patients with resectable adenocarcinoma of the pancreatic head. J Clin Oncol 26:3496–3502CrossRefPubMedGoogle Scholar
  66. 66.
    Varadhachary GR, Wolff RA, Crane CH et al (2008) Preoperative gemcitabine and cisplatin followed by gemcitabine-based chemoradiation for resectable adenocarcinoma of the pancreatic head. J Clin Oncol 26:3487–3495CrossRefPubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2010

Authors and Affiliations

  • Mehdi Ouaissi
    • 1
  • Catherine Hubert
    • 1
  • Robert Verhelst
    • 2
  • Parla Astarci
    • 2
  • Christine Sempoux
    • 3
  • Anne Jouret-Mourin
    • 3
  • Anderson Loundou
    • 4
  • Jean-François Gigot
    • 1
  • The Multidisciplary HPB Group of Center of Cancer
  1. 1.Division of Hepato-Biliary and Pancreatic Surgery, Department of Abdominal Surgery and Transplantation, Cliniques Universitaires Saint-LucUniversité Catholique de Louvain (UCL)BrusselsBelgium
  2. 2.Department of Cardiovascular Surgery, Cliniques Universitaires Saint-LucUniversité Catholique de Louvain (UCL)BrusselsBelgium
  3. 3.Department of Pathology, Cliniques Universitaires Saint-LucUniversité Catholique de Louvain (UCL)BrusselsBelgium
  4. 4.Faculty of MedicineUniversity Aix-Marseille IIMarseilleFrance

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