Pancreaticoduodenectomy with Venous Resection: How I Do It

Abstract

The establishment of tertiary referral centers and the well timely management of postoperative complications have largely contributed to the reduction of postoperative mortality of pancreatic resections. These improvements combined with the advances in chemotherapy regimens have let pancreatic surgeons to the development of extensive resection in case of pancreatic tumors abutting or infiltrating the major peripancreatic vessels. In case of pancreatic adenocarcinoma, a local extension with a various degree of infiltration to the superior mesenteric and/or coeliac venous and arterial vessels is a common finding in about one-third of the newly diagnosed cases. The infiltration of the coeliac trunk and the superior mesenteric artery is classically considered as a synonymous of unresectable locally advanced disease. In such circumstances various combinations of neoadjuvant chemotherapy or radiochemotherapy regimens are used for tumor’s downstaging. In these circumstances resection will be therefore considered only in some selected patients showing stable or responding disease [1]. On the contrary the infiltration of the spleno-mesenterico-portal (SMP) venous axis is nowadays no more considered as contraindication to a curative resection [2, 3]. The rationale behind such extensive resection is to obtain a margin-free resection without additional postoperative morbidity and mortality compared with a standard pancreatectomy. Whether patients with venous infiltration should undergo upfront resection or neoadjuvant treatment with secondary resection in case of good response to preoperative treatment remains at the moment debated [4]. It is more likely that with the advent of FOLFIRINOX^® regimens which showed a higher rate of pathological response compared with previous gemcitabine-based chemotherapy, all patients presenting with resectable or locally advanced pancreatic cancer will receive preoperative chemotherapy in the near future [5]. Nevertheless the prognostic value related to the presence of a histologically proven venous invasion remains unclear because of the small size of the cohort analyzed, heterogeneity in patients’ population, and the lack of information regarding the presence and/or the depth of the venous wall invasion in different comparative studies reported [4, 6]. Some authors identified venous invasion as a consequence of pure tumor localization [7], while others identified venous invasion as a poor prognostic factor [4, 6]. Other studies pointed out the importance of tumor depth infiltration into the venous wall, identifying intimal invasion as a poor prognostic factor [8]. In the modern era of pancreatic surgery, different single-center and multicenter studies have shown the safety of pancreatectomy with venous resection. Morbidity and mortality of pancreatectomy with venous resection are not different from those of standard resection in pair comparison [2, 4]. However there is still a lack of a standardized surgical technique described that may limit the diffusion and reproducibility of the good results reported by tertiary centers in different environments. The present chapter will describe a standardized surgical technique used to perform a “safe” pancreaticoduodenectomy with venous resection.