Adjunctive Superior Mesenteric-Portal Venous Reconstruction in the Treatment of Borderline Resectable Pancreatic Adenocarcinoma

Abstract

Pancreatic cancer is a leading cause of cancer death; it represents the ninth and tenth most common cancers in women and men, respectively, with only a 9% 5-year survival rate. Surgery remains the only potential curative therapy, but most patients present with advanced stage disease at the time of diagnosis. Patients with tumors that involve the superior mesenteric vein-portal vein (SMV-PV) confluence are considered “borderline resectable” and are at higher risk for perioperative complications and margin-positive resection. Regularly, neoadjuvant chemotherapy can be used to evaluate tumor behavior, to downstage tumors, to facilitate margin-negative resection, and to minimize the risk of recurrence. We present our single-institutional experience in the utility of adjunctive SMV-PV reconstruction for these tumors to assess viability and survival. A retrospective single-institution review identifying all patients who had a pancreaticoduodenectomy or total pancreatectomy during a 5-year period from January 2014 to December 2018 was completed. Multiplanar computed tomography angiography imaging was used to stage the tumors by objective radiologic classification determining extent of disease. Cases were presented preoperatively at a multidisciplinary tumor board. All vascular surgical reconstructions were performed by a multidisciplinary team approach with experienced hepatobiliary and vascular surgeons. During the 5-year period, 160 pancreatic resections (152 pancreaticoduodenectomies [95.0%] and 8 total pancreatectomies [(5.0%]) were performed, of which 85 (53.1%) were for pancreatic adenocarcinoma. The average age was 69.2 years (60.3% male, 39.7% female). Of the 85 operations for pancreatic adenocarcinoma, 35 (41.2%) underwent vascular reconstructions. Of these, 22 (62.9%) received neoadjuvant chemotherapy. Vascular reconstructions of the portal vein consisted of 16 (45.7%) primary repairs, 9 (25.7%) resections with cryopreserved vein allograft interposition grafting, 5 (14.3%) resections with primary end-to-end anastomosis, and 3 (8.6%) lateral venorrhaphy with patch angioplasty. There were also two (5.7%) concomitant arterial reconstructions (common hepatic artery). In the patients who underwent vascular reconstruction, margin-negative resection was achieved in 29 (85.3%). There were no in-hospital deaths; there was one (2.9%) 30-day death from a car accident. The 1-year survival was 74.3%. There were three (8.6%) thromboses requiring reintervention. This study validates a multidisciplinary surgical approach to the treatment of borderline resectable pancreatic cancers. When surgical treatment is deemed appropriate, adjunctive SMV-PV resection may further extend opportunity for a tumor-free margin (R0) of resection with comparable survival for stage II tumors. Vascular surgeons are being consulted to participate in these advanced vascular reconstructions with increased frequency and should be familiar with the various reconstruction techniques.