Additional Support for Neoadjuvant Therapy in the Management of Pancreatic Cancer

The relationship of a pancreatic head cancer to the superior mesenteric–portal vein (SMPV) confluence has intrigued and confused surgeons and oncologists for decades. The foundation for this ongoing debate began with Whipple, who described the operation of pancreaticoduodenectomy (PD) in 1935; Moore and colleagues, who first described resection and reconstruction of the superior mesenteric vein (SMV) in 1951; and Fortner, who reported his experience with regional pancreatectomy in 1973. Fortner routinely divided the distal splenic vein when performing segmental resection of the SMPV confluence, allowing for a primary end-to-end anastomosis of the SMV and portal vein (PV). However, the failure of regional pancreatectomy to positively influence survival duration caused most to dismiss venous resection as an ineffective, high-risk, and therefore overaggressive approach to a disease that is often metastatic at diagnosis. Adding to this controversy was the inability of preoperative imaging to predict the need for venous resection at the time of operation. In fact, despite the evolution of preoperative computed tomography (CT)-based staging in sophistication and objectivity, it remains inaccurate in predicting (preoperatively) the ability of the surgeon to separate the pancreatic head cancer from the lateral (or posterior) wall of the SMV, PV, or SMV-PV confluence at the time of surgery. The presence of tumor–artery (hepatic or superior mesenteric) abutment (loss of a normal tissue plane between the tumor and these vessels) is reliably defined by CT imaging, but in contrast, assessment of the tumor–vein relationship (in the absence of tumorinduced compression or narrowing) is not. Therefore, surgeons find themselves in the operating room with the pancreatic neck divided and the tumor adhered to the lateral or posterior wall of the SMV or SMPV confluence. In such a setting, the surgeon has three options: leave tumor behind as a grossly positive margin; perform a tangential or segmental venous resection and reconstruction as part of the PD; or persist in attempts to separate the tumor from the vein. This latter option is potentially dangerous, as it will often result in a small venotomy—which might quickly become a bigger venotomy. To facilitate venous repair, the surgeon may have to perform emergent removal of the specimen, often with a positive superior mesenteric artery (SMA) margin. This inability to accurately preoperatively predict who may require venous resection at the time of PD has led us to develop a series of techniques to better equip surgeons to manage both suspected and unsuspected venous abutment/ encasement at the time of PD. At present, there is evolving consensus that venous resection and reconstruction at the time of PD is becoming a more widespread and accepted management strategy, and one best performed in the setting of a multimodal approach including systemic therapy and often chemoradiation. In this context, in this issue, Delpero and colleagues from the Institut of Paoli Calmettes in Marseille, France, report a retrospective review of 1399 consecutive patients treated at 37 centers from 2004 to 2009 who underwent PD or total pancreatectomy for pancreatic adenocarcinoma with (n = 402) and without (n = 997) venous resection. Their definition of resectable and borderline resectable disease was based on the initial description by Varadhachary and colleagues, but the total number of patients with borderline resectable disease was not provided. They concluded that a surgery-first strategy for patients who required venous resection resulted in an inferior survival (median 21 months) compared to those who did not require Society of Surgical Oncology 2014