Total pancreatoduodenectomy en bloc with superior mesenteric artery and vein resection after gemcitabine and nab-paclitaxel neoadjuvancy. (September 2017)

• Record Type: Journal Article
• Authors: Vicente, E.; Quijano, Y.; Ielpo, B.; Duran, H.
• Is Part Of: Surgical oncology. Volume 26:Number 3(2017)
• Page Start: 276
• Page End: 277
• Publication Date: 2017-09
• Subjects: Pancreatectomy -- Vascular resection -- Neoadjuvant treatment; Cancer -- Surgery -- Periodicals; Neoplasms -- surgery -- Periodicals; Cancer -- Chirurgie -- Périodiques; Electronic journals; 616.994059
• DOI: 10.1016/j.suronc.2017.05.002
• Languages: English
• ISSNs: 0960-7404

Abstract

Abstract: Background: Pancreatectomy for locally advanced adenocarcinoma affecting the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) is still under discussion[1] . However, in selected cases, in light of the advancement of recent neoadjuvant treatments, it must be taken into account[2, 3] . Thisvideo demonstrates some of the technical aspects of SMA and SMV resection as well as some tips of vascular reconstruction. Methods: A 48-year-old man with a large adenocarcinoma of the uncinated process affecting the SMA and SMV underwent 3 cycles of gemcitabine and nab-paclitaxel neoadjuvancy. Post chemotherapy studies showed no disease progression with a normalization of CA 19.9 and SUV of FDG PET CT scan and a downsizing of the tumor, as well. Therefore, an en bloc total spleno-pancreato-duodenectomy with resection of SMA and SMV was planned. Results: Through a bilateral subcostal incision, an "arterial first approach"[3] was performed. Considering the large length of the vascular resection, the replacement of the resected SMA and SMV was performed using two PTFE grafts, as showed in thevideo . Postoperative pathology showed margins free from disease with an important pathological response (grade 2 of Ryan classification adapted from rectal cancer)[4] . The post-operative course was uneventful and the patient is still free from disease at 31 months from surgery. Conclusions: This case is part of a large experience our group have acquired since we started neoadjuvancy in 2010. In our experience, we gathered 25 cases of locally advanced pancreatic tumors, of which 12 underwent to pancreatic resection after good response to the neoadjuvant treatment. In 5 of them concomitant SMA and SMV resection was required and post-operative mortality occurred in 1 of them. Morbidities and mortalities are higher compared with standard pancreatectomies, specially related to the vascular reconstruction (bleeding, graft thrombosis)[5] . However, in some circumstances like young age, great radiological and biological response to neoadjuvancy (such as the case herein presented), surgery might be considered the best option of care providing the only possibility to increase survival for these types of locally advanced tumors. However, further studies are needed to know which patients might benefit from this approach. En bloc total spleno-pancreato-duodenectomy with resection of SMA and SMV might be considered as an effective procedure in selected cases of pancreatic adenocarcinoma with good response to preoperative treatment. Highlights: Pancreatectomy including superior vein and artery resection is still under discussion. In selected cases surgery might be considered the best option of care. In light of recent treatment, further studies are required.