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 (PD- MVR), 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 PD- MVR 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