Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1310_Библиотеки_им_академика_М_И_Перельмана.pdf
272 C.C. Jadlowiec and C.B. Rosen
References
1. American joint committee on cancer staging manual. 7th ed. New York: Springer; 2010.
p. 201.
2. Meyer CG, Penn I, James L. Liver transplantation for cholangiocarcinoma: results in 207
patients. Transplantation. 2000;69(8):1633–7.
3. Robles R, Figueras J, Turrión VS, Margarit C, Moya A, Varo E, et al. Spanish experience in
liver transplantation for hilar and peripheral cholangiocarcinoma. Ann Surg. 2004;39(2):
265–71.
4. Alessiani M, Tzakis A, Todo S, Demetris AJ, Fung JJ, Starzl TE. Assessment of five-year
experience with abdominal organ cluster transplantation. J Am Coll Surg. 1995;180(1):1–9.
5. Shimoda M, Farmer DG, Colquhoun SD, Rosove M, Ghobrial RM, Yersiz H, et al. Liver
transplantation for cholangiocellular carcinoma: analysis of a single-center experience and
review of the literature. Liver Transpl. 2001;7(12):1023–33.
6. Foo ML, Gunderson LL, Bender CE, Buskirk SJ. External radiation therapy and transcatheter
iridium in the treatment of extrahepatic bile duct carcinoma. Int J Radiat Oncol Biol Phys.
1997;39(4):929–35. Review.
7. Sudan D, DeRoover A, Chinnakotla S, Fox I, Shaw B Jr, McCashland T, et al.
Radiochemotherapy and transplantation allow long-term survival for nonresectable hilar
cholangiocarcinoma. Am J Transplant. 2002;2(8):774–9.
8. Rosen CB, Heimbach JK, Gores GJ. Liver transplantation for cholangiocarcinoma. Transpl
Int. 2010;23(7):692–7.
9. Rea DJ, Rosen CB, Nagorney DM, Heimbach JK, Gores GJ. Transplantation for
cholangiocarcinoma: when and for whom? Surg Oncol Clin N Am. 2009;18(2):325– 37.
10. Rea DJ, Heimbach JK, Rosen CB, Haddock HG, Alberts SR, Kremers WK, et al. Liver
transplantation with neoadjuvant chemoradiation is more effective than resection for hilar
cholangiocarcinoma. Ann Surg. 2005;242(3):451–61.
11. Burns JM, Rosen CB, Heimbach JK, Gores GJ. Blumgart’s surgery of the liver, biliary tract,
and pancreas. 5th ed. Philadelphia: Elsevier; 2012. p. 1712–21.
12. Heimbach JK, Gores GJ, Nagorney DM, Rosen CB. Liver transplantation for perihilar
cholangiocarcinoma after aggressive neoadjuvant therapy: a new paradigm for liver and
biliary malignancies? Surgery. 2006;140(3):331–4.
13. Lazaridis KN, Gores GJ. Lazaridis KN. Gores GJ Semin Liver Dis. 2006;26(1):42–51.
14. Croome KP, Rosen CB, Heimbach JK, Nagorney DM. Is liver transplantation appropriate for
patients with potentially resectable de novo hilar cholangiocarcinoma? J Am Coll Surg.
2015;221(1):130–9.
15. Mansour JC, Aloia TA, Crane CH, Heimbach JK, Nagino M, Vauthey JN. Hilar
cholangiocarcinoma: expert consensus statement. HPB (Oxford). 2015;17(8):691 – 9.
16. Darwish Murad S, Kim WR, Therneau T, Gores GJ, Rosen CB, Martenson JA, et al.
Predictors of pretransplant dropout and posttransplant recurrence in patients with perihilar
cholangiocarcinoma. Hepatology. 2012;56(3):972–81.
17. Taner CB, Bulatao IG, Willingham DL, Perry DK, Sibulesky L, Pungpapong S, et al. Events
in procurement as risk factors for ischemic cholangiopathy in liver transplantation using
donation after cardiac death donors. Liver Transpl. 2012;18(1):100–11.
18. Mathur AK, Heimbach J, Steffick DE, Sonnenday CJ, Goodrich NP, Merion RM. Donation
after cardiac death liver transplantation: predictors of outcome. Am J Transplant. 2010;10
(11):2512–9.
19. Mantel HT, Rosen CB, Heimbach JK, Nyberg SL, Ishitani MB, Andrews JC, et al. Vascular
complications after orthotopic liver transplantation after neoadjuvant therapy for hilar
cholangiocarcinoma. Liver Transpl. 2007;13(10):1372–81.
20 Transplantation for Hilar Cholangiocarcinoma 273
20. Kipp BR, Stadheim LM, Halling SA, Pochron NL, Harmsen S, Nagorney DM, et al.
A comparison of routine cytology and fluorescence in situ hybridization for the detection of
malignant bile duct strictures. Am J Gastroenterol. 2004;99(9):1675–81.
21. Nichols JC, Gores GJ, LaRusso NF, Wiesner RH, Nagorney DM, Ritts RE Jr. Diagnostic role
of serum CA 19-9 for cholangiocarcinoma in patients with primary sclerosing cholangitis.
Mayo Clin Proc. 1993;68(9):874–9.
Part III
Pancreas
Pancreatic Adenocarcinoma
in the Head of the Pancreas
21
with Portal Vein Involvement
Gyulnara G. Kasumova and Jennifer F. Tseng
Case Presentation
A 67-year-old male presented with new onset painless jaundice and hyperbilirubinemia. He underwent ERCP, where a biliary stricture was seen and a plastic
biliary stent placed. At the time of ERCP, bile duct brushings were obtained and
were negative. He underwent further evaluation with a CTA of the abdomen and
pelvis, which revealed a 2.1 cm hypodense lesion within the pancreatic head with
peri-portal and peri-pancreatic adenopathy.
Diagnosis and Workup
The patient demonstrated findings highly suspicious for pancreatic malignancy. His
case was presented at pancreaticobiliary multidisciplinary conference (MDC), which
includes surgical oncologists, medical oncologists, gastroenterologists, radiologists,
pathologists, and radiation oncologists. MDC has been shown to resolve staging and
treatment discrepancies, as well as to increase treatment rates, administration of
multimodality and neoadjuvant therapy, and decrease time to initiation of treatment.
Review of the scan demonstrated the mass to be in contact with the splenic/portal
G.G. Kasumova J.F. Tseng (&)
Department of Surgery, Beth Israel Deaconess Medical Center,
Harvard Medical School, 330 Brookline Avenue, Stoneman 9, Boston, MA 02215, USA
e-mail: jftseng@bidmc.harvard.edu
G.G. Kasumova
e-mail: gkasumov@bidmc.harvard.edu
© Springer International Publishing AG 2017
T.M. Pawlik et al. (eds.), Case-Based Lessons in the Management of Complex
Hepato-Pancreato-Biliary Surgery, DOI 10.1007/978-3-319-50868-9_21
277
278 G.G. Kasumova and J.F. Tseng
Fig. 21.1 Pre-operative imaging. Axial images of venous phase pancreatic protocol CT scan
demonstrating hypodense lesion in pancreatic head: a portal vein free of tumor; b abutment of the
portal vein with tumor; c tumor involvement of the splenic-portal vein confluence
vein confluence and adjacent superior mesenteric vein (Fig. 21.1). To obtain a tissue
diagnosis, the patient underwent endoscopic ultrasound with fine needle aspiration
(FNA) of the pancreatic mass and a porta hepatis lymph node. While the patient had
an elevated CA 19-9 level of 939 U/mL (normal: <34 U/mL), both FNA samples
were negative for malignant cells. The decision was made to proceed with open
pancreatic biopsy and simultaneous port-a-cath placement, due to the high suspicion
of malignancy. Open biopsy was performed using a Tru-Cut needle with three passes
through a small palpable mass in the head of the pancreas. Frozen section confirmed
pancreatic adenocarcinoma with duodenal invasion. The patient then underwent
a chest CT, which was negative for metastatic disease.
21 Pancreatic Adenocarcinoma in the Head of the Pancreas … 279
Management
The patient presented with borderline resectable pancreatic adenocarcinoma. He
received three cycles of neoadjuvant FOLFIRINOX (folinic acid, fluorouracil
[5-FU], irinotecan and oxaliplatin) chemotherapy followed by stereotactic body
radiotherapy (SBRT) with a cumulative dose of 2400 cGy. There was no progression of disease during treatment and, approximately 5 weeks after his last dose
of chemotherapy and 3.5 weeks after his last radiation treatment, he proceeded to
pancreaticoduodenectomy (PD) with venous resection and reconstruction with
interposition of the internal jugular vein and splenic vein preservation. The patient
is currently alive and well, undergoing workup for possible recurrence but presently
biopsy-negative, more than 2 years after PD with venous reconstruction.
The above patient case demonstrates the application of neoadjuvant therapy for
pancreatic adenocarcinoma, followed by restaging and pancreaticoduodenectomy
with vascular reconstruction. The first extended pancreaticoduodenectomy with
concomitant superior mesenteric vein (SMV) resection and reconstruction was
performed in 1951 [4].
Pancreaticoduodenectomy with portal vein (PV) resection and reconstruction as
part of an en bloc resection of the pancreas and surrounding structures to improve
survival was first described in Japan[5]. Nearly a decade later, a similar “regional
pancreatectomy” involving resection of the major peri-pancreatic vasculature with
wide soft tissue clearance was described by Fortner in the United States [6].
However, contrary to early beliefs, no survival benefit had been demonstrated for
patients undergoing radical or extended PD [7, 8]. It was not until recently that
venous resection (VR) has demonstrated more favorable results, with comparable
survival for patients with tumor involvement of major venous structures requiring
venous resection and reconstruction compared to standard PD [9].
Subsequent studies within the last decade have found that patients with locally
advanced disease requiring venous resection of the superior mesenteric and/or
portal veins demonstrated similar survival [10] and postoperative morbidity and
mortality [11] compared to patients who underwen t standard PD. Findings were
similar for those limited to tumors of the head [12–14]. Also, the results were not
affected when PD was performed for other indications (ampullary and distal
common bile duct cancers) [15]. One study [16] and several meta-analyses [17, 18]
evaluating mese nteric-portal vein resection for all pancreatectomy types found
similar results for survival, mortality, and morbidity. Multiple revie w articles have
also concluded that portal vein and/or superior mesenteric vein resection is safe and
confers a presumed survival advantage [19]. One study noted that patients who
underwent SMV/PV resection had decreased survival relative to patients without
resection; however, this study included a heterogeneous population of resectable
and borderline resectable patients [20]. Another large database retrospective review
found that patients undergoing pancreaticoduodenectomy with concomitant
280 G.G. Kasumova and J.F. Tseng
vascular resection had significantly increased rates of perioperative mortality and
morbidity compared to those who did not [21]; although the interpretation of these
results has been criticized, as large database work is limited by difficulty defining
entry criteria and venous resection procedures resulting in mixing of cases of
emergent versus planned reconstructions, as well as the inclusion of a potentially
heterogeneous patient population not described in the context of multimodality
cancer treatment [22]. Only one recent large meta-analysis demonstrated that
patients undergoing PV-SMV resection had increased mortality, higher rates of
R1/R2 resections, and worse survival [23]. Numerous studies have found that
tumor-free margins [10, 16, 23–27], as well as the presence of tumor infiltration on
venous resection [16, 17, 28, 29] were the most important prognostic factors. Only
one study found no survival difference in the presence or absence of venous tumor
infiltration [15] (Table 21.1).
Venous resection is often undertaken after neoadjuvant therapy. While neoadjuvant therapy for borderline resectable tumors has been subject to debate, the latest
National Comprehensive Cancer Network (NCCN) guidelines recommend neoadjuvant therapy prior to atte mpted surgical resection [26, 30–32]. However, the
International Study Group of Pancreatic Surgery (ISGPS) supports venous resection
for borderline tumors without necessitating neoadjuvant treatment [33, 34].
Pre-operative Planning
Appropriate patient selec tion is crucial for successful venous resection. Radiographic imaging should be reviewed to ensure that (1) no metastatic disease is
present; (2) there is no evidence of tumor involvement of the superior mesenteric
artery (SMA) or celiac axis; and (3) the SMV and PV are patent without evidence of
segmental or complete thrombosis [35].
The addition of vascular resection and reconstruction increases the complexity of
PD and should be performed in the setting of (1) a multidisciplinary evaluation of
the patient, with strong consideration of neoadjuvant treatment unless contraindicated; and (2) a high-volume surgical and perioperative team with extensive
experience in vascular reconstruction and vascular surgical expertise available for
preoperative and intraoperative consultation. Appropriate venous phase imaging
must be obtained preoperatively to appreciate tumor abutment of the lateral or
posterolateral wall of the SMV or superior mesenteric-portal vein (SMPV) confluence, the presence of which should indicate the need for venous resection [24].
Poor patient performance status and underlying organ system damage (especially
hepatic or renal insufficiency) may serve as relative contraindications for vascular
resection and consideration of other local therapies such as definitive SBRT may
apply.
21 Pancreatic Adenocarcinoma in the Head of the Pancreas … 281
%vein
infiltrate/
specimen
No. positive
margin
(R1/2)
No. positive
margin (R1/2)
(+VR) (%)
Median
survival
(mo) (−VR)
Median
survival
(mo) (+VR)
Morbidity
(−VR)
Morbidity
(+VR)
examined
38/62
(-VR) (%)
21/181
23.4 26.5 24/110
39
20
(61%)
(11.6%)
(21.8%)
(21.5%)
(18.2%)
(50%)
(55%)
22 15 13 (33%) 19 (24%) 16/29
81/169*
(47.9%)
22/53*
(41.5%)
15 19 8 (17.8%) 13 (14.8%) 29/45
56
(64%)
150
18.2 18.0 144/229 (62.9%) 423/820
(63.6%)
432/840
(55.6%)
–
(65.2%) #
11/45
(51.6%)
7/32
71.1%;
70.6%;
20/46
(51.4%)
10/32
(65.6%)
(24.4%)
(21.9%)
–––
±
23.6%***
25.8
±
33.3% ***
(43.5%)
(31.5%)
+
100%
36/166
(21.7%)
(19.0%)
20.0 26.0 8/42
50/166
(30.0%)
16/42
(38.1%)
–
49/208
(23.8%)
(35.4%)
21.6 19.7 46/131
104/208
(50%)
73/131
(55.7%)
Table 21.1 Pancreaticoduodenectomy for pancreatic adenocarcinoma with venous resection reported in the literature since 2004
% Operative
mortality
(−VR)
% Operative
mortality
(+VR)
No. patients
(−VR)
No. patients
(+VR)
No. patients
total (adeno)
First
author
(year)
(p = 0.86)
291 110 181 1 (0.9%) 2 (1.1%)
Tseng
(2004)
50 12 38 0 1 (2.6%) 5 (41.7%) 16 (42.1) 19.5 20.7 8.3% 15.8% 6/12
Poon
(2004)
7/169*
(4.1%)
(3.8%)
125 40 85 2/53*
Riediger
(2006)
133 45 88 2 (4.4%) 5 (5.7%) 25
Carrere
(2006)
2/46
1070 230 840 10 (4.6%) 26 (4.2%) 151/230
78 32^ 46 1/32
Ravikumar
(2014)
Cheung
(4.3%)
+
(3.1%)
(2014)
2/166
208 42 166 1/42
937** 435 502 –– ––18.5
Wang
Murakami
(2015)
(1.2%)
(2.4%)
(2015)
8/208
(3.8%)
(1.5%)
338 131 208 2/131
Kulemann
(2015)
PubMed was used to search the terms pancreatic + adenocarcinoma + venous resection + portal vein. Review studies were not included. Inclusion criteria were tumors of the head, pancreatic
adenocarcinoma, and PD. Studies that involved other pathologies were included if separate analyses were performed for head adenocarcinomas. A total of 18 full text articles were reviewed and
9 met inclusion criteria
+VR: venous resection; −VR: no venous resection; No.: number
*Includes pancreatic head cancer, ampullary cancer, bile duct cancer, and other
#Lymphovascular invasion
**Included patients who were resectable, borderline with venous involvement only, and borderline with arterial abutment
^Three pts also included resection of SMA
In-hospital mortality
+
***1 and 3-yr survival rates
±
p < 0.05
–Not reported
282 G.G. Kasumova and J.F. Tseng
Clinical Pearls
• Review patient imaging both preoperatively and intraoperatively to help
plan and direct dissection
• Obtain proximal and distal control of the splenic vein/SMV/PV early in
the operation prior to removing the tumor specimen
• If planning to use an interposition graft, prepare conduit (internal jugular
vein) early in the operat ion
• Make sure to correctly identify the specimen’s retroperitoneal margin
upon removal and determine R0/R1 vs. R2 resection status
Intra-operative Approach
In general, the need for vascular resection should be identified prior to operation
with preoperative imaging and discussed with the patient and family, and the
appropriate subspecialists, such as vascular surgery, should be alerted. Tumors of
the pancreatic head and uncinate process are in close proximity to the portal and
superior mesenteric veins and thereby place these vessels at risk of involvement and
need for resection and reconstruction. However, it should be noted that resection of
the SMV, PV, and SMPV confluence should only be performed when the vein
segment cannot be separated from the pancreatic tum or and never to improve R0
margin distance or lymphatic clearance [9]. The SMV, which drains the midgut,
runs posterior to the neck of the pancreas and joins the splenic vein to form the
portal vein. The superior mesenteric artery (SMA) courses posterior to the pancreas
and, in the majority of cases, will be located posteromedial to the SMV. The close
relationship of the artery and vein makes involvement of the SMA without the
SMV unlikely, only occurring if there is a posteriorly located tumor of the uncinate
process; similarly, complete occlusion of the SMPV confluence often indicates
tumor involvement of the SMA [35]. The SMA is surrounded by a perineural
plexus that extends into pancreatic parenchyma and is a potential conduit for tumor
extension [35]. While the clearance of the retroperitoneal margin and SMA dissection should be optimized, the surgeon must be wary of circumferential skeletonization of the vessel, which can result in denervation of the small bowel and
increased transit time with increased risk of subsequent malnutrition [24].
If the PV and SMV are unable to be dissected free of tumor and grossly negative
margins achieved, then venous resection and reconstruction is indicated. Segmental
venous resection can be accomplished with or without division of the splenic vein.
However, division of the splenic vein allows complete SMA exposure medial to the
SMV and separation of the SMV and PV from the splenic vein, allowing for
increased vein length for resection and primary anastomosis without the need for
21 Pancreatic Adenocarcinoma in the Head of the Pancreas … 283
interposition grafting. To free the tumor from attachment at the SMPV confluence
after division of the splenic vein, vascular clamps are placed 2–3 cm proximal (on
the PV) and distal (on the SMV) to the involved segment and the vein is transected.
A common practice for any anticipated lengthy (>30 min) occlusion of the portal
vein is to perform SMA inflow occlusion after systemic heparinization and prior to
SMV/PV occlusion to prevent small bowel edema impairing anastomosis.
Ideally, the splenic vein should be preserved when tumor involvement is limited
to the PV and/or SMV. In cases of segmental involvemen t of the PV/SMV, splenic
vein preservati on limits mobilization of the PV and may require interposition
grafting following SMV resection. Furthermore, preservation of the splenic vein
can limit access to the proximal SMA [35]. For interposition grafting, we prefer to
use internal jugular vein as the conduit. The conduit should be harvested early, prior
to venous resection, and be prepared before vascular clamping for efficient anas-
tomosis and minimal ischemia time.
As described in 2004, five general types of venous resection and reconstruction
can be performed [35] (Fig. 21.2). When only a small portion of the SMPV confluence is involved by tumor, a tangential resection followed by vein patch repair
(commonly from the greater saphenous vein) may be performed (Fig. 21.2, V1). If
splenic vein ligation is necessary due to tumor involvement at the confluence,
approximation of the superior mesenteric and portal veins may be either through a
primary anastomosis without tension in an end-to-end fashion (Fig. 21.2, V2) or
using an internal jugular vein interposition graft (Fig. 21.2, V3). If the splenic vein
can be preserved in the setting of isolated tumor involvement of the PV or SMV,
reconstruction may be similarly performed either as a tensionless primary
end-to-end anastomosis (Fig. 21.2, V4) or with the use of an interposition graft
(Fig. 21.2, V5).
After removal of the specimen, the surgeon must identify and ink the
retroperitoneal margin for pathologic evaluation by permanent section [35]. Possible R1 versus R2 resection must also be determined by the surgeon at the time
of operation; for clinically margin-negative resections as documented by the surgeon, microscopic pathological analysis will differentiate between R0 and R1
resection [35].
Controversies Around Management
• Whether or not to clamp the superior mesenteric artery prior to portal
vein-superior mesenteric vein resection
• Whether the splenic vein can be ligated or reimplantation is necessary
• Whether or not to administer systemic heparin