Venous Resection in Pancreatic Cancer Surgery

Abstract

Introduction: The clinical value of combined portal vein resection (PVR) during pancreatoduodenectomy (PD) for patients with pancreatic cancer has been discussed and many papers supporting this aggressive strategy have been published, however several controversies have remained insoluble. Recent progress in vascular surgical techniques enabled digestive surgeons to perform PVR safely.

Method: The indication of PVR is practically decided according to the intraoperative macroscopic findings and a type of PVR (wedge or segmental resection) is actually decided after detaching the uncinate process from the superior mesenteric artery during mesenteric root node dissection in many occasions. Reconstructive procedures after PVR have been developed and end-to-end anastomosis is commonly used. A transverse suture or an autologous vein patch closure should be used to prevent the portal vein stricture after wedge resection. An autologous vein graft (internal jugular vein, left renal vein, external iliac vein) is preferably used for interposition grafting because of low incidence of thrombosis than a synthetic graft.

Results: Although a PD with PVR is associated with longer operating time and more blood loss than a standard PD while providing R0 resection, no significant difference was found in morbidity and mortality between the two groups. Although different or similar survivals between the PD and PD with PVR groups were reported, depth of histological portal vein invasion and portographic findings of bilateral narrowing were poor prognostic factors.

Conclusions: Combined portal vein resection and reconstruction in R0 pancreatoduodenectomy provides acceptable morbidity, mortality and better survival than that of the unresected patients with locally advanced pancreatic cancer. PD with PVR should always be considered in case of pancreatic head cancer adherent to the portal vein in the absence of other contraindication for resection.