Download pancreatoduodenectomy + multivisceral resection yes/no

PANCREATODUODENECTOMY
+ MULTIVISCERAL RESECTION
YES/NO
JM RAMIA
SERVICIO DE CIRUGIA
HOSPITAL DE GUADALAJARA
INTRODUCTION
Pancreatic cancer has a dismal prognosis.
Surgical resection with negative margins is the
best and only curative treatment option, but only
obtained a 15-25% survival at 5 years.
 When tumor is located in the pancreatic head,
pancreaticoduodenectomy (PD) is the surgical
technique that is performed, includes the
resection of several organs (pancreatic head,
duodenum, bile duct, gallbladder and distal
stomach).
 The PD presents, in specialized centers, a
postoperative mortality of 5% and a morbidity
approaching 50%.


DEFINITION OF MVR RESECTION
More than 40% of pancreatic tumors, when
they are diagnosed, present locally advanced
disease with infiltration of adjacent organs
and/or vascular structures.
 The need to resect other organs not
included in the PD, to perform an
oncologically correct surgery (R0), is usually
called PD with Multivisceral resection (PDMVR), and is considered to have a higher
postoperative risk than PD.

BACKGROUND
Publications on PD-MVR are very infrequent and
heterogeneous because they include:
 Different types of surgery: PD, distal pancreatectomy
and total pancreatectomy, with/without portal or
arterial resection
 Several indications by different pathologies:

◦ Hepatopancreaduodenectomy performed in Asia for the
treatment of cholangiocarcinoma.
◦ Right hemicolectomy plus PD done in patients with colon
cancer located in hepatic flexure that invades duodenum
and pancreas.
◦ PD-MVR due to pancreatic rare tumors (neuroendocrine,
sarcomas, metastases, ..)
◦ PD-MVR for pancreatic cancer covered by this lecture.
PRO/CON
The PD-MVR for pancreatic cancer is a controversial
procedure.
 CON: The invasion of neighboring organs is
considered by some authors a contraindication for
PD based on the aggressiveness of the surgery,
possible postoperative complications, poor
oncological benefit obtained and short survival.
 PRO: Conversely, others authors argue that when
tumor invades neighboring organs, the only
oncological surgical valid resection is PD-MVR.
Kulemann et al obtains a higher rate of R0 in the PDMVR group than conventional PD, but curiously the
survival of PD-MVR group was worse.
ORGANS RESECTED
The organs most often resected in PD-MVR are right
colon and liver.
 COLON: When colon resection is performed may be
due to direct invasion or vascular involvement of
mesocolon. Anastomotic dehiscence rate is variable
(0 to 16%) and a high percentage of postoperative
intestinal obstruction also occurs.
 LIVER: could be affected by direct invasion or liver
metastases, treated by minor hepatectomies. In the
series of Hartwig et al, liver resection has lower
complication rate than resections of other organs.
 Other organs removed in the PD-MVR are: kidney,
adrenal gland, entire stomach, diaphragm, small
intestine, and a combined resection of various organs.
DATA FROM SERIES
Percentage of PD-MVR over total number of reviewed
cases ranges between 2.75-18%
 The diagnosis of pancreatic cancer from 36-75%
 Percentage of males between 47-64.4%
 Average age between 62 and 67 years.
 Except in one series, the most frequently resected
organ is colon.
 The most frequently performed surgery is PD and some
papers include vascular resections.
 The morbidity of the PD-MVR ranges between 50-69%,
 Mortality between 0 – 10%
 Survival is between 12 and 20 months.

PD VS PD-MVR
Preoperative: diagnosis of pancreatic cancer is higher
or less depending on the series, more preoperative
diabetes mellitus, higher percentage of men, older
patients and more ASA III cases.
 Intraoperative: more operating time, less PD with
pyloric preservation, more total pancreatectomies,
more venous resection, more perioperative blood
loss and greater intraoperative transfusion.
 Postoperative: longer stay in ICU , more
postoperative major complications, more
relaparotomies, more episodes of postoperative
bleeding, higher mortality and hospital stay.
 - Stadium: worse TNM, less and more R0, most
patients with stage IVB.

STATISTICAL ANALYSIS
MORBIDITY
 In univariate: Intraoperative transfusion, colon resection,
kidney and liver resection were predictors of morbidity.
 In multivariate, only transfusion and nephrectomy were
predictors of morbidity.
 Resection of two or more organs has been associated
with increased relaparotomies.
SURVIVAL
 Univariate analysis: T stage, nephrectomy, resect 4 or
more additional organs and postoperative transfusion
have a predictive value for survival.
 Multivariate analysis, tumor stage was only predictor of
survival.
CONCLUSIONS
The few series published on PD-MVR are
very heterogeneous.
PD-MVR has a higher morbidity and
mortality comparing to PD, but obtains
similar oncologic results.
The absence of RCT does not let to
recommend PD-MVR systematically but it
cannot be totally discouraged