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Annals of Surgical Oncology

, Volume 19, Issue 13, pp 4068–4077 | Cite as

The Impact of Vascular Resection on Early Postoperative Outcomes after Pancreaticoduodenectomy: An Analysis of the American College of Surgeons National Surgical Quality Improvement Program Database

  • Anthony W. CastleberryEmail author
  • Rebekah R. White
  • Sebastian G. De La Fuente
  • Bryan M. Clary
  • Dan G. BlazerIII
  • Richard L. McCann
  • Theodore N. Pappas
  • Douglas S. Tyler
  • John E. Scarborough
Pancreatic Tumors

Abstract

Background

Several single-center reports suggest that vascular resection (VR) during pancreaticoduodenectomy (PD) for patients with pancreatic adenocarcinoma is feasible without affecting early postoperative mortality or morbidity. Our objective is to review the outcomes associated with VR during PD using a large multicenter data source.

Methods

A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program Participant User Files for 2005–2009. All patients undergoing PD for a postoperative diagnosis of malignant neoplasm of the pancreas were included. Forward stepwise multivariate regression analysis was used to determine the association between VR during PD and 30-day postoperative mortality and morbidity after adjustment for patient demographics and comorbidities.

Results

3,582 patients were included for analysis, 281 (7.8 %) of whom underwent VR during PD. VR during PD was associated with significantly greater risk-adjusted 30-day postoperative mortality [5.7 % with VR versus 2.9 % without VR, adjusted odds ratio (AOR) 2.1, 95 % confidence interval (CI) 1.22–3.73, P = 0.008] and overall morbidity (39.9 % with VR versus 33.3 % without VR, AOR 1.36, 95 % CI 1.05–1.75, P = 0.02). There was no significant difference in risk-adjusted postoperative mortality or morbidity between those patients undergoing VR by the primary surgical team versus those patients undergoing VR by a vascular surgical team.

Conclusions

Contrary to the findings of several previously published single-center analyses, the current study demonstrates increased 30-day postoperative morbidity and mortality in PD with VR when compared with PD alone.

Keywords

National Surgical Quality Improvement Program Vascular Resection Current Procedural Terminology Code Surgeon National Surgical Quality Improvement National Surgical Quality Improvement Program Database 
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.

References

  1. 1.
    Alexakis N, Halloran C, Raraty M, Ghaneh P, Sutton R, Neoptolemos JP. Current standards of surgery for pancreatic cancer. Br J Surg. 2004;91:1410–27.PubMedCrossRefGoogle Scholar
  2. 2.
    Glanemann M, Shi B, Liang F, et al. Surgical strategies for treatment of malignant pancreatic tumors: extended, standard or local surgery? World J Surg Oncol. 2008;6:123.PubMedCrossRefGoogle Scholar
  3. 3.
    Hidalgo M. Pancreatic cancer. N Engl J Med. 2010;362:1605–17.PubMedCrossRefGoogle Scholar
  4. 4.
    Katz MH, Wang H, Fleming JB, et al. Long-term survival after multidisciplinary management of resected pancreatic adenocarcinoma. Ann Surg Oncol. 2009;16:836–47.PubMedCrossRefGoogle Scholar
  5. 5.
    Shaib Y, Davila J, Naumann C, El-Serag H. The impact of curative intent surgery on the survival of pancreatic cancer patients: a U.S. Population-based study. Am J Gastroenterol. 2007;102:1377–82.PubMedCrossRefGoogle Scholar
  6. 6.
    Sohn TA, Yeo CJ, Cameron JL, et al. Resected adenocarcinoma of the pancreas-616 patients: results, outcomes, and prognostic indicators. J Gastrointest Surg. 2000;4:567–79.PubMedCrossRefGoogle Scholar
  7. 7.
    Stojadinovic A, Brooks A, Hoos A, Jaques DP, Conlon KC, Brennan MF. An evidence-based approach to the surgical management of resectable pancreatic adenocarcinoma. J Am Coll Surg. 2003;196:954–64.PubMedCrossRefGoogle Scholar
  8. 8.
    Wagner M, Redaelli C, Lietz M, Seiler CA, Friess H, Buchler MW. Curative resection is the single most important factor determining outcome in patients with pancreatic adenocarcinoma. Br J Surg. 2004;91:586–94.PubMedCrossRefGoogle Scholar
  9. 9.
    Evans DB, Farnell MB, Lillemoe KD, Vollmer C, Jr., Strasberg SM, Schulick RD. Surgical treatment of resectable and borderline resectable pancreas cancer: expert consensus statement. Ann Surg Oncol. 2009;16:1736–44.PubMedCrossRefGoogle Scholar
  10. 10.
    Ghaneh P, Costello E, Neoptolemos JP. Biology and management of pancreatic cancer. Gut. 2007;56:1134–52.PubMedCrossRefGoogle Scholar
  11. 11.
    Li D, Xie K, Wolff R, Abbruzzese JL. Pancreatic cancer. Lancet. 2004;363:1049–57.PubMedCrossRefGoogle Scholar
  12. 12.
    Orr RK. Outcomes in pancreatic cancer surgery. Surg Clin North Am. 2010;90:219–34.PubMedCrossRefGoogle Scholar
  13. 13.
    Wray CJ, Ahmad SA, Matthews JB, Lowy AM. Surgery for pancreatic cancer: recent controversies and current practice. Gastroenterology. 2005;128:1626–41.PubMedCrossRefGoogle Scholar
  14. 14.
    Allema JH, Reinders ME, van Gulik TM, et al. Portal vein resection in patients undergoing pancreatoduodenectomy for carcinoma of the pancreatic head. Br J Surg. 1994;81:1642–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Christians K, Evans DB. Pancreaticoduodenectomy and vascular resection: persistent controversy and current recommendations. Ann Surg Oncol. 2009;16:789–91.PubMedCrossRefGoogle Scholar
  16. 16.
    Harrison LE, Klimstra DS, Brennan MF. Isolated portal vein involvement in pancreatic adenocarcinoma. A contraindication for resection? Ann Surg. 1996;224:342–7; discussion 7–9.Google Scholar
  17. 17.
    Kawada M, Kondo S, Okushiba S, Morikawa T, Katoh H. Reevaluation of the indications for radical pancreatectomy to treat pancreatic carcinoma: is portal vein infiltration a contraindication? Surg Today. 2002;32:598–601.PubMedCrossRefGoogle Scholar
  18. 18.
    Nakao A, Harada A, Nonami T, Kaneko T, Inoue S, Takagi H. Clinical significance of portal invasion by pancreatic head carcinoma. Surgery. 1995;117:50–5.PubMedCrossRefGoogle Scholar
  19. 19.
    Ramacciato G, Mercantini P, Petrucciani N, et al. Does portal-superior mesenteric vein invasion still indicate irresectability for pancreatic carcinoma? Ann Surg Oncol. 2009;16:817–25.PubMedCrossRefGoogle Scholar
  20. 20.
    Roder JD, Stein HJ, Siewert JR. Carcinoma of the periampullary region: who benefits from portal vein resection? Am J Surg. 1996;171:170–4; discussion 4–5.PubMedCrossRefGoogle Scholar
  21. 21.
    Sasson AR, Hoffman JP, Ross EA, Kagan SA, Pingpank JF, Eisenberg BL. En bloc resection for locally advanced cancer of the pancreas: is it worthwhile? J Gastrointest Surg. 2002;6:147–57; discussion 57–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Shibata C, Kobari M, Tsuchiya T, et al. Pancreatectomy combined with superior mesenteric-portal vein resection for adenocarcinoma in pancreas. World J Surg. 2001;25:1002–5.PubMedCrossRefGoogle Scholar
  23. 23.
    Tucker ON, Rela M. Controversies in the management of borderline resectable proximal pancreatic adenocarcinoma with vascular involvement. HPB Surg. 2008;2008:839503.PubMedCrossRefGoogle Scholar
  24. 24.
    van Geenen RC, ten Kate FJ, de Wit LT, van Gulik TM, Obertop H, Gouma DJ. Segmental resection and wedge excision of the portal or superior mesenteric vein during pancreatoduodenectomy. Surgery. 2001;129:158–63.PubMedCrossRefGoogle Scholar
  25. 25.
    Bachellier P, Nakano H, Oussoultzoglou PD, et al. Is pancreaticoduodenectomy with mesentericoportal venous resection safe and worthwhile? Am J Surg. 2001;182:120–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Capussotti L, Massucco P, Ribero D, Vigano L, Muratore A, Calgaro M. Extended lymphadenectomy and vein resection for pancreatic head cancer: outcomes and implications for therapy. Arch Surg. 2003;138:1316–22.PubMedCrossRefGoogle Scholar
  27. 27.
    Fuhrman GM, Leach SD, Staley CA, et al. Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group. Ann Surg. 1996;223:154–62.Google Scholar
  28. 28.
    Launois B, Stasik C, Bardaxoglou E, et al. Who benefits from portal vein resection during pancreaticoduodenectomy for pancreatic cancer? World J Surg. 1999;23:926–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Takahashi S, Ogata Y, Tsuzuki T. Combined resection of the pancreas and portal vein for pancreatic cancer. Br J Surg. 1994;81:1190–3.PubMedCrossRefGoogle Scholar
  30. 30.
    Toomey P, Hernandez J, Morton C, et al. Resection of portovenous structures to obtain microscopically negative margins during pancreaticoduodenectomy for pancreatic adenocarcinoma is worthwhile. Amer Surg. 2009;75:804–9; discussion 9–10.Google Scholar
  31. 31.
    Turley RS, Peterson K, Ceppa EP, et al. Vascular surgery collaboration during pancreaticoduodenectomy with vascular reconstruction. Ann Vascular Surgery. 2012;(in press).Google Scholar
  32. 32.
    Fink AS, Campbell DA, Jr., Mentzer RM, Jr., et al. The National Surgical Quality Improvement Program in non-veterans administration hospitals: initial demonstration of feasibility. Ann Surg. 2002;236:344–53; discussion 53–4.PubMedCrossRefGoogle Scholar
  33. 33.
    Khuri SF, Daley J, Henderson W, et al. The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Ann Surg. 1998;228:491–507.PubMedCrossRefGoogle Scholar
  34. 34.
    Siriwardana HP, Siriwardena AK. Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer. Br J Surg. 2006;93:662–73.PubMedCrossRefGoogle Scholar
  35. 35.
    Fernandez-del Castillo C, Rattner DW, Warshaw AL. Standards for pancreatic resection in the 1990 s. Arch Surg. 1995;130:295–9; discussion 9–300.PubMedCrossRefGoogle Scholar
  36. 36.
    Fortner JG. Regional pancreatectomy for cancer of the pancreas, ampulla and other related sites. Jpn J Surg. 1983;13:385–94.PubMedCrossRefGoogle Scholar
  37. 37.
    Fortner JG. Regional pancreatectomy for cancer of the pancreas, ampulla, and other related sites. Tumor staging and results. Ann Surg. 1984;199:418–25.Google Scholar
  38. 38.
    Fortner JG, Klimstra DS, Senie RT, Maclean BJ. Tumor size is the primary prognosticator for pancreatic cancer after regional pancreatectomy. Ann Surg. 1996;223:147–53.PubMedCrossRefGoogle Scholar
  39. 39.
    Horvath KD, Chabot JA. An aggressive resectional approach to cystic neoplasms of the pancreas. Am J Surg. 1999;178:269–74.PubMedCrossRefGoogle Scholar
  40. 40.
    Howard TJ, Villanustre N, Moore SA, et al. Efficacy of venous reconstruction in patients with adenocarcinoma of the pancreatic head. J Gastrointest Surg. 2003;7:1089–95.PubMedCrossRefGoogle Scholar
  41. 41.
    Leach SD, Lee JE, Charnsangavej C, et al. Survival following pancreaticoduodenectomy with resection of the superior mesenteric-portal vein confluence for adenocarcinoma of the pancreatic head. Br J Surg. 1998;85:611–7.PubMedCrossRefGoogle Scholar
  42. 42.
    Machado MC, Penteado S, Cunha JE, et al. Pancreatic head tumors with portal vein involvement: an alternative surgical approach. Hepato-gastroenterology. 2001;48:1486–7.PubMedGoogle Scholar
  43. 43.
    Sindelar WF. Clinical experience with regional pancreatectomy for adenocarcinoma of the pancreas. Arch Surg. 1989;124:127–32.PubMedCrossRefGoogle Scholar
  44. 44.
    Tsao JI, Rossi RL, Lowell JA. Pylorus-preserving pancreatoduodenectomy. Is it an adequate cancer operation. Arch Surg. 1994;129:405–12.PubMedCrossRefGoogle Scholar
  45. 45.
    Tseng JF, Raut CP, Lee JE, et al. Pancreaticoduodenectomy with vascular resection: margin status and survival duration. J Gastrointest Surg. 2004;8:935–49; discussion 49–50.PubMedCrossRefGoogle Scholar
  46. 46.
    Wanebo HJ, Glicksman AS, Vezeridis MP, et al. Preoperative chemotherapy, radiotherapy, and surgical resection of locally advanced pancreatic cancer. Arch Surg. 2000;135:81–7; discussion 8.PubMedCrossRefGoogle Scholar
  47. 47.
    Yeo CJ, Cameron JL, Lillemoe KD, et al. Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients. Ann Surg. 1995;221:721–31; discussion 31–3.PubMedCrossRefGoogle Scholar
  48. 48.
    Al-Haddad M, Martin JK, Nguyen J, et al. Vascular resection and reconstruction for pancreatic malignancy: a single center survival study. J Gastrointest Surg. 2007;11:1168–74.PubMedCrossRefGoogle Scholar
  49. 49.
    Jain S, Sacchi M, Vrachnos P, Lygidakis NJ. Carcinoma of the pancreas with portal vein involvement—our experience with a modified technique of resection. Hepato-gastroenterology. 2005;52:1596–600.PubMedGoogle Scholar
  50. 50.
    Kurosaki I, Hatakeyama K, Minagawa M, Sato D. Portal vein resection in surgery for cancer of biliary tract and pancreas: special reference to the relationship between the surgical outcome and site of primary tumor. J Gastrointest Surg. 2008;12:907–18.PubMedCrossRefGoogle Scholar
  51. 51.
    Nakagohri T, Kinoshita T, Konishi M, Inoue K, Takahashi S. Survival benefits of portal vein resection for pancreatic cancer. Am J Surg. 2003;186:149–53.PubMedCrossRefGoogle Scholar
  52. 52.
    Poon RT, Fan ST, Lo CM, et al. Pancreaticoduodenectomy with en bloc portal vein resection for pancreatic carcinoma with suspected portal vein involvement. World J Surg. 2004;28:602–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Riediger H, Makowiec F, Fischer E, Adam U, Hopt UT. Postoperative morbidity and long-term survival after pancreaticoduodenectomy with superior mesenterico-portal vein resection. J Gastrointest Surg. 2006;10:1106–15.PubMedCrossRefGoogle Scholar
  54. 54.
    Shimada K, Sano T, Sakamoto Y, Kosuge T. Clinical implications of combined portal vein resection as a palliative procedure in patients undergoing pancreaticoduodenectomy for pancreatic head carcinoma. Ann Surg Oncol. 2006;13:1569–78.PubMedCrossRefGoogle Scholar
  55. 55.
    Zhou GW, Wu WD, Xiao WD, Li HW, Peng CH. Pancreatectomy combined with superior mesenteric-portal vein resection: report of 32 cases. Hepatobiliary Pancreat Dis Int. 2005;4:130–4.PubMedGoogle Scholar
  56. 56.
    Syin D, Woreta T, Chang DC, Cameron JL, Pronovost PJ, Makary MA. Publication bias in surgery: implications for informed consent. J Surg Res. 2007;143:88–93.PubMedCrossRefGoogle Scholar
  57. 57.
    Rodgers M, Jobe BA, O’Rourke RW, Sheppard B, Diggs B, Hunter JG. Case volume as a predictor of inpatient mortality after esophagectomy. Arch Surg. 142(9):829–39.Google Scholar
  58. 58.
    Dimick JB, Wainess RM, Upchurch GR Jr, Iannettoni MD, Orringer MB. National trends in outcomes for esophageal resection. Ann Thorac Surg. 2005;79(1):212–6; discussion 217–8.Google Scholar
  59. 59.
    Chowdhury MM, Dagash H, Pierro A. A systematic review of the impact of volume of surgery and specialization on patient outcome. Br J Surg. 2007;94:145–61.PubMedCrossRefGoogle Scholar
  60. 60.
    Golledge J, Wiggins JE, Callam MJ. Effect of surgical subspecialization on breast cancer outcome. Br J Surg. 2000;87:1420–5.PubMedCrossRefGoogle Scholar
  61. 61.
    Hall BL, Hsiao EY, Majercik S, Hirbe M, Hamilton BH. The impact of surgeon specialization on patient mortality: examination of a continuous Herfindahl-Hirschman index. Ann Surg. 2009;249:708–16.PubMedCrossRefGoogle Scholar
  62. 62.
    Solomon MJ, Thomas RJ, Gattellari M, Ward JE. Does type of surgeon matter in rectal cancer surgery? Evidence, guideline consensus and surgeons’ views. ANZ J Surg. 2001;71:711–4.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2012

Authors and Affiliations

  • Anthony W. Castleberry
    • 1
    Email author
  • Rebekah R. White
    • 1
  • Sebastian G. De La Fuente
    • 2
  • Bryan M. Clary
    • 1
  • Dan G. BlazerIII
    • 1
  • Richard L. McCann
    • 1
  • Theodore N. Pappas
    • 1
  • Douglas S. Tyler
    • 1
  • John E. Scarborough
    • 1
  1. 1.Department of SurgeryDuke University Medical CenterDurhamUSA
  2. 2.Department of SurgeryH. Lee Moffitt Cancer CenterTampaUSA

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