Vascular resection in pancreatic cancer surgery: survival determinants

Pancreaticoduodenectomy (PD) is the standard operation for cancer of the pancreatic head. To achieve complete tumor resection and, thus, improve long-term survival, venous resection of the portal or superior mesenteric vein with reconstruction has become routine for advanced pancreatic adenocarcinoma (PDAC). However, its clinical benefit still remains controversial. The aim of this study was to investigate morbidity, mortality, and survival of patients with advanced PDAC following PD with venous resection and to identify significant survival determinants.

From October 2001 to December 2007, 488 patients with PDAC of the pancreatic head underwent PD at our department. Venous resection was performed in 110 patients (22.5%). Clinical data, surgical techniques, perioperative parameters, and histopathologic data were analyzed on a prospective database.

Major venous reconstruction was accomplished through primary lateral venorrhaphy in 18 patients (16.3%), polytetrafluoroethylene grafting (n = 14, 12.7%), primary end-to-end anastomosis (n = 72, 65.5%), an autologous saphenous venous graft patch (n = 4, 4.6%) or a Goretex(R) patch (n = 2, 2.3%). In 78.1% histopathologic examination revealed cancer invasion of the vein, whereas the remainder had peritumoral inflammation extending to the vessel wall. Perioperative morbidity rate was 41.8%; and the mortality rate 3.6%. The 1-, 2-, and 3-year survival rates were 55.2%, 23.1%, and 14.4%, respectively. Operating time (>420 min) and advanced age (>70 years) were the only prognostic variables, which significantly diminished survival on multivariate analysis.

Resection of the superior mesenteric or portal vein to achieve macroscopic tumor clearance can be performed safely with acceptable operative morbidity and mortality. However, improved local clearance in these patients cannot achieve a favorable long-term survival for all patients because distant metastases or local recurrence is frequent.