Meta-analysis and cost effective analysis of portal-superior mesenteric vein resection during pancreatoduodenectomy: Impact on margin status and survival.
BACKGROUND
The benefit of portal-superior mesenteric vein resection (PSMVR) with pancreatoduodenectomy (PD) remains controversial. This study assesses the impact of PSMVR on resection margin status and survival.


METHODS
An electronic search was performed to identify relevant articles. Pooled odds ratios were calculated for outcomes using the fixed or random-effects models for meta-analysis. A decision analytical model was developed for estimating cost effectiveness.


RESULTS
Sixteen studies with 4145 patients who underwent pancreatoduodenectomy were included: 1207 patients had PSMVR and 2938 patients had no PSMVR. The R1 resection rate and post-operative mortality was significantly higher in PSMVR group (OR1.59[1.35, 1.86] p=<0.0001, and OR1.72 [1.02,2.92] p = 0.04 respectively). The overall survival at 5-years was worse in the PSMVR group (HR0.20 [0.07,0.55] P = 0.020). Tumour size (p = 0.030) and perineural invasion (P = 0.009) were higher in the PSMVR group. Not performing PSMVR yielded cost savings of $1617 per additional month alive without reduction in overall outcome.


CONCLUSIONS
On the basis of retrospective data this study shows that PD with PSMVR is associated with a higher R1 rate, lower 5-year survival and is not cost-effective. It appears that PD with PSMVR can only be justified if R0 resection can be achieved. The continuing challenge is accurate selection of these patients.
Department of HPB and Transplant Surgery, St James Hospital, Leeds, UK.
Richard
R
Bell
Department of Biostatistics and Epidemiology, Auckland University of Technology, Auckland, New Zealand.
Braden Te
BT
Ao
HPB/Upper GI Unit, Department of Hepatobiliary and Pancreatic Surgery, Auckland City Hospital, New Zealand.
Natasha
N
Ironside
HPB/Upper GI Unit, Department of Hepatobiliary and Pancreatic Surgery, Auckland City Hospital, New Zealand; Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
Adam
A
Bartlett
HPB/Upper GI Unit, Department of Hepatobiliary and Pancreatic Surgery, Auckland City Hospital, New Zealand; Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
John A
JA
Windsor
HPB/Upper GI Unit, Department of Hepatobiliary and Pancreatic Surgery, Auckland City Hospital, New Zealand; Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand. Electronic address: spandanaboyana@adhb.govt.nz.
Sanjay
S
Pandanaboyana
D006801:Humans; D008642:Mesenteric Veins / Q000473:pathology* / Q000601:surgery; D010190:Pancreatic Neoplasms / Q000191:economics / Q000401:mortality* / Q000473:pathology* / Q000601:surgery; D016577:Pancreaticoduodenectomy / Q000401:mortality*; D011169:Portal Vein / Q000473:pathology* / Q000601:surgery; D011379:Prognosis; D015996:Survival Rate
Margins; Pancreatoduodenectomy; Survival; Venous resection