Update: februari 2019

MULTIVERS

MULTI-disciplinary approach to VEnous ReSection during pancreatoduodenectomy for pancreatic adenocarcinoma

Background

Radical tumor resection followed by adjuvant chemotherapy is the current standard treatment of patients with resectable pancreatic cancer.(1) The pre- and intra-operative assessment of portal vein (PV) or superior mesenteric vein (SMV) involvement is particular important since this resection margin is among the most affected.(2) PV-SMV resection is indicated if required to aim for a radical resection, as stated by the International Study Group of Pancreatic Surgery.(3) A recent meta-analysis showed increased postoperative mortality and worse survival after PV-SMV resection.(4) The included studies were considered as low evidence and were quite heterogeneous (e.g. low -and high-volume hospitals, time-period: 2006-2014). The short- and long-term outcomes of PV-SMV resection in the Netherlands have not been reported, which will become more important in the near future due to the increasing use of neoadjuvant therapy in borderline and locally advanced pancreatic cancer. The evaluation of tumor extension and PV-SMV involvement on preoperative imaging is also becoming a clinical challenge since the growing use of neoadjuvant therapy.(5-7) Moreover, an absence of tumor invasion/approximation is reported in around half of the PV-SMV resections, indicating the difficulties of pre- and intra-operative assessment of PV-SMV involvement.(8-10)

The MULTI-VERS study platform provide an opportunity for a multidisciplinary approach to PV-SMV resections during pancreatoduodenectomy (PD), hereby ultimately improving the clinical outcomes of patients with pancreatic cancer.

Aim

To investigate 1)short- and long-term outcomes after PV-SMV resection and 2) discrepancies between pre- and intra-operative suspected PV-SMV involvement and histopathology findings in patients undergoing PD with(out) PV-SMV resection for pancreatic adenocarcinoma (PDAC)

Sample size

It is expected ±1200 PD’s were performed for PDAC in the Netherlands from 2013 through 201711 and that ±30% (±360 PD’s) included PV-SMV resection.

Study design

Retrospective multicenter cohort study.

Primary outcome measures

1) Complications Clavien-Dindo ≥III12, in-hospital-mortality, overall survival.

2) Discrepancies between pre- and intra-operative suspected PV-SMV involvement and histopathology findings.

Secondary outcome measures

Type of venous reconstruction, postoperative PV-SMV thrombosis, thromboprophylaxis, radical margins (R0).

In/exclusion criteria

All patients included in the Dutch Pancreatic Cancer Audit (DPCA) that underwent PD for PDAC from 2013 through 2017.

References

1. https://www.oncoline.nl/pancreascarcinoom.

2. van Roessel S, Kasumova GG, Tabatabaie O, et al. Pathological Margin Clearance and Survival After Pancreaticoduodenectomy in a US and European Pancreatic Center. Ann Surg Oncol 2018.

3. Bockhorn M, Uzunoglu FG, Adham M, et al. Borderline resectable pancreatic cancer: a consensus statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2014; 155(6):977-88.

4. Giovinazzo F, Turri G, Katz MH, et al. Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; 103(3):179-91.

5. Buchs NC, Chilcott M, Poletti PA, et al. Vascular invasion in pancreatic cancer: Imaging modalities, preoperative diagnosis and surgical management. World J Gastroenterol 2010; 16(7):818-31.

6. Ferrone CR, Marchegiani G, Hong TS, et al. Radiological and surgical implications of neoadjuvant treatment with FOLFIRINOX for locally advanced and borderline resectable pancreatic cancer. Ann Surg 2015; 261(1):12-7.

7. Versteijne E, Vogel JA, Besselink MG, et al. Meta-analysis comparing upfront surgery with neoadjuvant treatment in patients with resectable or borderline resectable pancreatic cancer. Br J Surg 2018.

8. 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.

9. Ravikumar R, Sabin C, Abu Hilal M, et al. Impact of portal vein infiltration and type of venous reconstruction in surgery for borderline resectable pancreatic cancer. Br J Surg 2017; 104(11):1539-1548.

10. Roch AM, House MG, Cioffi J, et al. Significance of Portal Vein Invasion and Extent of Invasion in Patients Undergoing Pancreatoduodenectomy for Pancreatic Adenocarcinoma. J Gastrointest Surg 2016; 20(3):479-87; discussion 487.