Annals of Surgical Oncology

, Volume 21, Issue 6, pp 1937–1947 | Cite as

Adverse Tumor Biology Associated with Mesenterico-Portal Vein Resection Influences Survival in Patients with Pancreatic Ductal Adenocarcinoma

  • F. Wang
  • A. J. Gill
  • M. Neale
  • V. Puttaswamy
  • S. Gananadha
  • N. Pavlakis
  • S. Clarke
  • T. J. Hugh
  • J. S. Samra
Pancreatic Tumors



Although pancreatoduodenectomy (PD) with mesenterico-portal vein resection (VR) can be performed safely in patients with resectable pancreatic ductal adenocarcinoma (PDAC), the impact of this approach on long-term survival is controversial.

Patients and Methods

Analyses of a prospectively collected database revealed 122 consecutive patients with PDAC who underwent PD with (PD+VR) or without (PD−VR) VR between January 2004 and May 2012. Clinical data, operative results, and survival outcomes were analysed.


Sixty-four (53 %) patients underwent PD+VR. The majority (84 %) of the venous reconstructions were performed with a primary end-to-end anastomosis. Demographic and postoperative outcomes were similar between the two groups. American Society of Anesthesiologists (ASA) score, duration of operation, intraoperative blood loss, and blood transfusion requirement were significantly greater in the PD+VR group compared with the PD−VR group. Furthermore, the tumor size was larger, and the rates of periuncinate neural invasion and positive resection margin were higher in the PD+VR group compared with the PD−VR group. Histological venous involvement occurred in 47 of 62 (76 %) patients in the PD+VR group. At a median follow-up of 29 months, the median overall survival (OS) was 18 months for the PD+VR group, and 31 months for the PD−VR group (p = 0.016). ASA score, lymph node metastasis, neurovascular invasion, and tumor differentiation were predictive of survival. The need for VR in itself was not prognostic of survival.


PD with VR has similar morbidity but worse OS compared with a PD−VR. Although VR is not predictive of survival, tumors requiring a PD+VR have more adverse biological features.


  1. 1.
    Winter JM, Cameron JL, Campbell KA, et al. 1423 pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg. 2006;10(9):1199–210; discussion 1210–1191.PubMedCrossRefGoogle Scholar
  2. 2.
    Tseng JF, Raut CP, Lee JE, et al. Pancreaticoduodenectomy with vascular resection: margin status and survival duration. J Gastrointest Surg. 2004;8(8):935–49; discussion 949–950.PubMedCrossRefGoogle Scholar
  3. 3.
    Kaneoka Y, Yamaguchi A, Isogai M. Portal or superior mesenteric vein resection for pancreatic head adenocarcinoma: prognostic value of the length of venous resection. Surgery. 2009;145(4):417–25.PubMedCrossRefGoogle Scholar
  4. 4.
    Verbeke CS, Leitch D, Menon KV, McMahon MJ, Guillou PJ, Anthoney A. Redefining the R1 resection in pancreatic cancer. Br J Surg. 2006;93(10):1232–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Samra JS, Gananadha S, Gill A, Smith RC, Hugh TJ. Modified extended pancreatoduodenectomy: en bloc resection of the peripancreatic retroperitoneal tissue and the head of pancreas. ANZ J Surg. 2006;76(11):1017–20.PubMedCrossRefGoogle Scholar
  6. 6.
    Sanjay P, Takaori K, Govil S, Shrikhande SV, Windsor JA. ‘Artery-first’ approaches to pancreatoduodenectomy. Br J Surg. 2012;99(8):1027–35.PubMedCrossRefGoogle Scholar
  7. 7.
    Wang F, Arianayagam R, Gill A, et al. Grafts for mesenterico-portal vein resections can be avoided during pancreatoduodenectomy. J Am Coll Surg. 2012;215(4):569–79.PubMedCrossRefGoogle Scholar
  8. 8.
    Gill AJ, Johns AL, Eckstein R, et al. Synoptic reporting improves histopathological assessment of pancreatic resection specimens. Pathology. 2009;41(2):161–7.PubMedCrossRefGoogle Scholar
  9. 9.
    Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–13.PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Castleberry AW, White RR, De La Fuente SG, et al. 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. Ann Surg Oncol. 2012;19(13):4068–77.PubMedCrossRefGoogle Scholar
  11. 11.
    Carrere N, Sauvanet A, Goere D, et al. Pancreaticoduodenectomy with mesentericoportal vein resection for adenocarcinoma of the pancreatic head. World J Surg. 2006;30(8):1526–35.PubMedCrossRefGoogle Scholar
  12. 12.
    Howard TJ, Krug JE, Yu J, et al. A margin-negative R0 resection accomplished with minimal postoperative complications is the surgeon’s contribution to long-term survival in pancreatic cancer. J Gastrointest Surg. 2006;10(10):1338–45; discussion 1345–1336.PubMedCrossRefGoogle Scholar
  13. 13.
    Esposito I, Kleeff J, Bergmann F, et al. Most pancreatic cancer resections are R1 resections. Ann Surg Oncol. 2008;15(6):1651–60.PubMedCrossRefGoogle Scholar
  14. 14.
    Nakao A, Kanzaki A, Fujii T, et al. Correlation between radiographic classification and pathological grade of portal vein wall invasion in pancreatic head cancer. Ann Surg. 2012;255(1):103–8.PubMedCrossRefGoogle Scholar
  15. 15.
    de Jong MC, Li F, Cameron JL, et al. Re-evaluating the impact of tumor size on survival following pancreaticoduodenectomy for pancreatic adenocarcinoma. J Surg Oncol. 2011;103(7):656–62.PubMedCrossRefGoogle Scholar
  16. 16.
    Shimada K, Nara S, Esaki M, Sakamoto Y, Kosuge T, Hiraoka N. Intrapancreatic nerve invasion as a predictor for recurrence after pancreaticoduodenectomy in patients with invasive ductal carcinoma of the pancreas. Pancreas. 2011;40(3):464–8.PubMedCrossRefGoogle Scholar
  17. 17.
    Noto M, Miwa K, Kitagawa H, et al. Pancreas head carcinoma: frequency of invasion to soft tissue adherent to the superior mesenteric artery. Am J Surg Pathol. 2005;29(8):1056–61.PubMedGoogle Scholar
  18. 18.
    Rehders A, Stoecklein NH, Guray A, Riediger R, Alexander A, Knoefel WT. Vascular invasion in pancreatic cancer: tumor biology or tumor topography? Surgery. 2012;152(3 Suppl 1):S143–51.PubMedCrossRefGoogle Scholar
  19. 19.
    Yekebas EF, Bogoevski D, Cataldegirmen G, et al. En bloc vascular resection for locally advanced pancreatic malignancies infiltrating major blood vessels: perioperative outcome and long-term survival in 136 patients. Ann Surg. 2008;247(2):300–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Muller SA, Hartel M, Mehrabi A, et al. Vascular resection in pancreatic cancer surgery: survival determinants. J Gastrointest Surg. 2009;13(4):784–92.PubMedCrossRefGoogle Scholar
  21. 21.
    Turrini O, Ewald J, Barbier L, Mokart D, Blache JL, Delpero JR. Should the portal vein be routinely resected during pancreaticoduodenectomy for adenocarcinoma? Ann Surg. 2013;257(4):726–30.PubMedCrossRefGoogle Scholar
  22. 22.
    Neoptolemos JP, Stocken DD, Friess H, et al. A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer. N Engl J Med. 2004;350(12):1200–10.PubMedCrossRefGoogle Scholar
  23. 23.
    Neoptolemos JP, Stocken DD, Bassi C, et al. Adjuvant chemotherapy with fluorouracil plus folinic acid vs gemcitabine following pancreatic cancer resection: a randomized controlled trial. JAMA. 2010;304(10):1073–81.PubMedCrossRefGoogle Scholar
  24. 24.
    Abrams RA, Lowy AM, O’Reilly EM, Wolff RA, Picozzi VJ, Pisters PW. Combined modality treatment of resectable and borderline resectable pancreas cancer: expert consensus statement. Ann Surg Oncol. 2009;16(7):1751–56.PubMedCrossRefGoogle Scholar
  25. 25.
    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(7):1736–44.PubMedCrossRefGoogle Scholar
  26. 26.
    Greer SE, Pipas JM, Sutton JE, et al. Effect of neoadjuvant therapy on local recurrence after resection of pancreatic adenocarcinoma. J Am Coll Surg. 2008;206(3):451–7.PubMedCrossRefGoogle Scholar
  27. 27.
    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(12):1569–78.PubMedCrossRefGoogle Scholar
  28. 28.
    Porembka MR, Hawkins WG, Linehan DC, et al. Radiologic and intraoperative detection of need for mesenteric vein resection in patients with adenocarcinoma of the head of the pancreas. HPB. 2011;13(9):633–42.PubMedCentralPubMedCrossRefGoogle Scholar
  29. 29.
    Turley RS, Peterson K, Barbas AS, et al. Vascular surgery collaboration during pancreaticoduodenectomy with vascular reconstruction. Ann Vasc Surg. 2012;26(5):685–92.PubMedCrossRefGoogle Scholar
  30. 30.
    Murakami Y, Uemura K, Sudo T, et al. Benefit of portal or superior mesenteric vein resection with adjuvant chemotherapy for patients with pancreatic head carcinoma. J Surg Oncol. 2013;107(4):414–21.PubMedCrossRefGoogle Scholar
  31. 31.
    Gong Y, Zhang L, He T, et al. Pancreaticoduodenectomy combined with vascular resection and reconstruction for patients with locally advanced pancreatic cancer: a multicenter, retrospective analysis. PLoS One. 2013;8(8):e70340.PubMedCentralPubMedCrossRefGoogle Scholar
  32. 32.
    Kelly KJ, Winslow E, Kooby D, et al. Vein involvement during pancreaticoduodenectomy: is there a need for redefinition of “borderline resectable disease”? J Gastrointest Surg. 2013;17(7):1209–17; discussion 1217.PubMedCrossRefGoogle Scholar
  33. 33.
    Wang J, Estrella JS, Peng L, et al. Histologic tumor involvement of superior mesenteric vein/portal vein predicts poor prognosis in patients with stage II pancreatic adenocarcinoma treated with neoadjuvant chemoradiation. Cancer. 2012;118(15):3801–11.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2014

Authors and Affiliations

  • F. Wang
    • 1
  • A. J. Gill
    • 2
  • M. Neale
    • 3
  • V. Puttaswamy
    • 3
  • S. Gananadha
    • 1
  • N. Pavlakis
    • 4
  • S. Clarke
    • 4
  • T. J. Hugh
    • 1
  • J. S. Samra
    • 1
  1. 1.Department of Gastrointestinal Surgery, Royal North Shore Hospital and North Shore Private HospitalUniversity of SydneySt LeonardsAustralia
  2. 2.Department of Anatomical Pathology, Royal North Shore Hospital and North Shore Private HospitalUniversity of SydneySt LeonardsAustralia
  3. 3.Department of Vascular Surgery, Royal North Shore Hospital and North Shore Private HospitalUniversity of SydneySt LeonardsAustralia
  4. 4.Department of Medical Oncology, Royal North Shore Hospital and North Shore Private HospitalUniversity of SydneySt LeonardsAustralia

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