review of literature on clinical pancreatology - The Pancreapedia

hemoglobin A1c (HbA1c) level was 7.8 + 1.2 percent at 6 months and 7.8 + 1.5 percent at 12months after total pancreatectomy, respectively. It was concluded that total pancreatectomycan be safely performed and the treatment option for selectively limited pancreatic cancerand intraductal papillary mucinous neoplasm <strong>of</strong> the pancreas (IPMN), when the patientcondition permits and <strong>of</strong>fers a chance <strong>of</strong> cure, although careful long-term medical care andfollow-up are essential [478].With preserving stomach and spleenTotal pancreatectomy has been used to treat both benign and malignant diseases <strong>of</strong> thepancreas. The procedure <strong>of</strong> total pancreatectomy for invasive pancreatic cancer usuallyincludes distal gastrectomy and splenectomy to prevent ischemic changes due to decreasedblood supply. In one report, it was introduced a new technique <strong>of</strong> total pancreatectomy forinvasive pancreatic cancer preserving both the whole stomach and spleen. It was tried,initially to perform pylorus-preserving pancreatoduodenectomy (PPPD). Repeated frozensection examination <strong>of</strong> the pancreatic stumps, however, revealed persistent cancer infiltrationto the distal pancreas. Therefore, it was altered the planned PPPD to total pancreatectomypreserving the whole stomach and spleen with severing both the splenic artery and vein attheir origins. The postoperative course was uneventful. Enhanced CT following surgeryshowed sufficient blood supply to the whole stomach and spleen without any congestivechanges <strong>of</strong> blood flow. This method is considered safe and useful for patients with bothbenign and malignant disease <strong>of</strong> the pancreas [479].Portal vein reconstructionAggressive preoperative and intraoperative management may improve the resectability ratesand outcomes for locally advanced pancreatic adenocarcinoma with venous involvement.The efficacy and use <strong>of</strong> venous resection and especially arterial resection in themanagement <strong>of</strong> pancreatic adenocarcinoma remain, however, controversial. A retrospective<strong>review</strong> <strong>of</strong> 2 prospective databases <strong>of</strong> 593 consecutive pancreatic resections for pancreaticadenocarcinoma from 1999 through 2007 showed that 36 (6 %) underwent vascularresection at the time <strong>of</strong> pancreatectomy. Thirty-one <strong>of</strong> the 36 (88 %) underwent venousresection alone; 3 (8 %), combined arterial and venous resection; and 2 (6 %), arterialresection (superior mesenteric artery resection) alone. Patients included 18 men and 18women, with a median age <strong>of</strong> 62 (range, 42-82) years. The 90-day perioperative mortalityand morbidity rates were 0 and 35 percent, respectively, compared with 2 and 39 percent,respectively, for the group undergoing nonvascular pancreatic resection. Median survivalwas 18 (range, 8-42) months in the vascular resection group compared with 19 months in thenonvascular resection group. Multivariate analysis demonstrated node-positive disease,tumor location (other than head), and no adjuvant therapy as adverse prognostic variables.This means that in this combined experience, en bloc vascular resection consisting <strong>of</strong>venous resection alone, arterial resection alone, or combined vascular resection at the time<strong>of</strong> pancreatectomy for adenocarcinoma did not adversely affect postoperative mortality,morbidity, or overall survival. The need for vascular resection should not be acontraindication to surgical resection in the selected patient [480].Portal vein-superior mesenteric vein resection is frequently required after surgical resection<strong>of</strong> tumours <strong>of</strong> the pancreas head. Between 2000 and 2007, 28 patients had portal veinsuperiormesenteric vein resection and PVR during pancreaticoduodenectomy. Their clinicalreports were <strong>review</strong>ed retrospectively with specific attention to the methods <strong>of</strong> PVR andoutcomes. Ten patients had PVR with primary anastomosis, seven had PVR with autologousvein, one had a polytetrafluoroethylene (PTFE) patch, one did not have PVR and nine hadPVR with a PTFE interposition graft. There was no infection after PTFE grafting. Six patientshad PVR thrombosis after surgery: four after primary anastomosis, one after interpositionPTFE and one after vein repair. It was concluded that PTFE appeared to be an effective and