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Título

Pancreatoduodenectomy with vascular resection or no resection: what is the best approach when pancreas cancer invades the portomesenteric venous axis? A systematic review and meta-analysis.

Resumo

INTRODUCTION Pancreatoduodenectomy for pancreatic cancer is technically demanding, with a high risk for perioperative morbidity, especially when the superior mesenteric/portal vein is involved by the tumor. Vascular resection may offer patients with vascular involvement a chance of cure since the R0 surgery is achieved. The aim of this review was to compare the pancreatoduodenectomy associated with venous resection with palliative therapy (no resection) for the treatment of patients with periampullary neoplasms. METHODS A systematic search was performed in Embase, Medline, Cochrane, and Lilacs. Inclusion criteria were studies comparing palliation therapy with pancreatoduodenectomy with major venous resection (portal vein, superior mesenteric vein, or portomesenteric confluence) in patients with periampullary tumor. Combined arterial resection was excluded. RESULTS Ten studies were included in the meta-analysis, comprising 1,533 individuals. The difference in overall survival was statistically significant, with higher overall survival in the pancreatic resection group (HR 4.00; 95% CI 2.8 to 5.2). There was no difference in postoperative mortality rates (RD: 0.00; 95% CI -0.03 to 0.03). The palliative group had fewer complications (RD -0.17; 95% CI -0.26 to -0.07). As expected, the rate of the pancreatic leak was higher in the resection group (RD -0.10; 95% CI -0.15 to -0.04). The estimated difference in the length of total hospital stay between the two groups was shorter in the palliative group (MD -4.06 days; 95% CI -5.24 to -2.87). DISCUSSION This systematic review and meta-analysis showed that pancreatic resection increases survival in patients with locally advanced periampullary cancer compared to palliative surgery. However, more extensive resection implies more significant morbidity with more extended hospital stays, bleeding, and higher postoperative complications, including pancreatic leaks. The higher long-term survival rate in the resection group compared with the palliation implies that pancreatoduodenectomy with vein resection should be the first-line therapy. Risks and benefits should be shared with the patient and family before any decision. CONCLUSION In centers with experience in pancreatic surgery, venous resection may be considered for patients with locally advanced cancer who are willing to accept the potentially increased morbidity associated with this type of surgery.