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Invited Critique
February 1, 2007

Significance of the Depth of Portal Vein Wall Invasion After Curative Resection for Pancreatic Adenocarcinoma—Invited Critique

Arch Surg. 2007;142(2):180. doi:10.1001/archsurg.142.2.180

This study is a careful analysis of a superb clinical experience combining PV resection with pancreaticoduodenectomy in patients with pancreatic adenocarcinoma who underwent operation with curative intent. I make this distinction, rather than using curative resection, because resection of pancreatic cancer, even under ideal circumstances (small tumor, no involved lymph nodes, negative margins, and minimal blood loss), is a palliative exercise. Effective, durable, hope-restoring, often long-term, but palliative nonetheless. We as surgeons want desperately to believe that our knowledge, technical skills, temerity, intuition, and experience can somehow be leveraged against overwhelming odds to achieve the purity of a surgical cure. The corollary, of course, is that anything less is viewed as a therapeutic failure—a concept that I am unwilling to accept. Rather, I choose to view these data as further confirmation of the surgeon's central role in the effective treatment of patients with pancreatic cancer. The authors have done things right, achieving an overall 87.7% (121/138) margin-negative resection rate, a 36.4% (44/121) morbidity rate, and a 2.5% (3/121) mortality rate, with no significant differences between patients who required PV resection and those who did not. Their survival data are consistent with what we have come to expect, with poor survival in patients with deep venous wall invasion (overall 1-year survival of 21.5%) or positive surgical margins (overall 1-year survival of 34.4%). Unfortunately, preoperative prediction of deep venous invasion (tumor >45 mm or Nakao type C or type D on a portogram) or a positive retroperitoneal margin remains an inexact science, frequently requiring resection before the truth is accurately known. Cure of pancreatic cancer requires more than we currently have available. This glaring deficiency should not color the achievements of Fukuda and colleagues in providing effective surgical palliation with a low morbidity and mortality rate in patients with locally advanced pancreatic adenocarcinoma.

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