title: Pancreatic adenocarcinoma with venous involvement: is up-front synchronous portal-superior mesenteric vein resection still justified? A survey of the Association Française de Chirurgie.
abstract: BACKGROUND
  Venous resection (VR) during pancreatectomy has been reported to neither increase mortality nor morbidity and to provide similar survival outcomes in same stage tumors. However, controversy remains regarding the indications for up-front surgery according to the degree of venous involvement.
  
  
  METHODS
  From 2004 to 2009, 1,399 patients included in a French multicenter survey underwent pancreaticoduodenectomy or total pancreatectomy for pancreatic adenocarcinoma, either without VR (997 standard resections [SR]) or with VR (402 patients; 29 %). Postoperative and long-term outcomes were compared in both groups.
  
  
  RESULTS
  VR was associated with the following factors: larger tumors (p < 0.001), poorly differentiated tumors (p = 0.004), higher numbers of positive lymph nodes (p = 0.042), and positive resection margins (R1; p < 0.001). Overall, VR increased neither postoperative morbidity nor postoperative mortality (5 vs. 3 % in SR patients; p = 0.16). The median and 3-year survival rates in VR patients versus SR patients were 21 months and 31 % vs. 29 months and 44 %, respectively (p = 0.0002). In the entire cohort, multivariate analysis identified VR as a significant poor prognostic factor for long-term survival (hazard ratio [HR] 1.75, 95 % confidence interval [CI] 1.28-2.40; p = 0.0005). In the VR patients, lymph node ratio, whatever the cutoff (<0.3: p = 0.093; ≥ 0.3: p = 0.0098), R1 resection (p = 0.010), and segmental resection (p = 0.016) were independent risk factors; neoadjuvant treatment (HR 0.52, 95 % CI 0.29-0.94; p = 0.031) and adjuvant treatment (HR 0.55, 95 % CI 0.35-0.85; p = 0.006) were significantly associated with improved long-term survival.
  
  
  CONCLUSIONS
  Long-term survival after pancreatectomy was significantly altered when up-front VR was performed. Neoadjuvant treatment may be a better strategy than up-front resection in patients with preoperative suspicion of venous involvement.
authors: Department of Surgical Oncology, Institut Paoli-Calmettes, Université de la Méditerranée, Marseille, France, jrdelpero@numericable.fr.
authors: Jean Robert
authors: JR
authors: Delpero
authors: Jean Marie
authors: JM
authors: Boher
authors: Alain
authors: A
authors: Sauvanet
authors: Yves Patrice
authors: YP
authors: Le Treut
authors: Antonio
authors: A
authors: Sa-Cunha
authors: Jean Yves
authors: JY
authors: Mabrut
authors: Laurence
authors: L
authors: Chiche
authors: Olivier
authors: O
authors: Turrini
authors: Philippe
authors: P
authors: Bachellier
authors: François
authors: F
authors: Paye
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008198:Lymph Nodes / Q000473:pathology*; D008297:Male; D008642:Mesenteric Veins / Q000473:pathology / Q000601:surgery*; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging; D010180:Pancreatectomy; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D011169:Portal Vein / Q000473:pathology / Q000601:surgery*; D011184:Postoperative Period; D011379:Prognosis; D011446:Prospective Studies; D012307:Risk Factors; D011795:Surveys and Questionnaires; D015996:Survival Rate