title: Direct percutaneous transhepatic portomesenteric venous stenting in management of locally advanced pancreatic cancer.
abstract: OBJECTIVE
  Pancreatectomy with portal and/or superior mesenteric vein resection remains a controversial procedure because of high complexity and morbidity. Neoadjuvant chemotherapy has been shown to increase resectability of these locally advanced lesions. We aimed to assess the utility and efficacy of direct percutaneous transhepatic portomesenteric venous stenting (THVS) with neoadjuvant chemotherapy in increasing surgical resectability of locally advanced pancreatic carcinoma.
  
  
  METHODS
  Forty pancreatic carcinoma patients with tumor thrombus involving the portal vein and superior mesenteric vein were identified. Patients underwent THVS followed by neoadjuvant chemotherapy. Whipple procedure was offered to responders.
  
  
  RESULTS
  THVS was attempted in all. The tumor thrombus could not be crossed in 2 patients (95% technical success rate). All patients underwent 3 cycles of neoadjuvant gemcitabine, paclitaxel, and capecitabine. Disease progression was noted in 16 patients and surgery was not offered. Twenty-two patients were explored with intent-to-perform a Whipple procedure. In 7 of these (32%), extensive disease precluding surgical resection was identified and the procedure was abandoned. Whipple procedure without vascular resection was performed successfully in 15 patients (68%). There were no perioperative deaths. Negative vascular margins were noted in 3 patients and negative peripancreatic lymph nodes in 5 patients. Median survival was 17 months (range, 5 to 70 mo). In the stented nonoperative group, median survival was 9 months (range, 3 to 19 mo). The stented and resected group achieved a statistically significant (P=0.0422) survival advantage.
  
  
  CONCLUSIONS
  THVS in combination with neoadjuvant chemotherapy can increase tumor resectability and survival in a select group of locally advanced pancreatic cancer patients.
authors.affiliation: *Department of Surgery, Lenox Hill Hospital ‡Lenox Hill Heart and Vascular Institute, New York †Department of Surgery, Vassar Brothers Medical Center §Interventional Radiology, DRA Imaging, Poughkeepsie, NY.
authors.forename: Dimitri
authors.initials: D
authors.lastname: Alden
authors.forename: Yuriy
authors.initials: Y
authors.lastname: Dudiy
authors.forename: Naiem
authors.initials: N
authors.lastname: Nassiri
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Friedland
authors.forename: Philip
authors.initials: P
authors.lastname: Amatulle
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Rosen
mesh_terms: D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage; D002277:Carcinoma / Q000188:drug therapy / Q000401:mortality / Q000601:surgery*; D003131:Combined Modality Therapy; D006801:Humans; D053208:Kaplan-Meier Estimate; D008642:Mesenteric Veins / Q000601:surgery*; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation / Q000379:methods; D020360:Neoadjuvant Therapy; D010190:Pancreatic Neoplasms / Q000188:drug therapy / Q000401:mortality / Q000601:surgery*; D011169:Portal Vein / Q000601:surgery*; D012189:Retrospective Studies; D015607:Stents; D014656:Vascular Surgical Procedures / Q000295:instrumentation / Q000379:methods