Clinical efficacy of pancreaticoduodenectomy combined with venous resection via inferior mesenteric vein pathway for resectable pancreatic cancer

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Objective To investigate clinical efficacy of pancreaticoduodenectomy combined with venous resection via inferior mesenteric vein (IMV) pathway for resectable pancreatic cancer with superior mesenteric vein (SMV) and / or anterior wall of portal vein (PV) involvements. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 38 resectable pancreatic cancer patients who underwent pancreaticoduodenectomy with venous resection via IMV pathway in the West China Hospital of Sichuan University between January 2013 and January 2017 were collected. The tumors of 25 patients were BR-PV type (simplex SMV and / or PV involvements), and tumors of 13 patients were BR-A type (SMV, celiac trunk and / or hepatic artery involvements). The pancreaticoduodenectomy via IMV pathway was the same as traditional surgery in organs resection and lymph node dissection, the difference was cutting off the pancreas at a junction between IMV and splenic vein when using IMV pathway. Observation indicators: (1) intraoperative and postoperative situations; (2) results of postoperative pathological examination; (3) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative survival up to January 2018. Measurement data with skewed distribution were described as M (range). The survival curve was drawn by the Kaplan-Meir method, and Log-rank test was used for survival analysis. Results (1) Intraoperative and postoperative situations: 38 patients underwent intraoperative segmental resection of PV and / or SMV, including 30 with end-to-end anastomosis in situ and 8 with artificial vessel interposition anastomosis. Two of 38 patients were intraoperatively combined with common hepatic artery resection and end-to-end anastomosis in situ. There was no intraoperative celiac trunk resection. The operation time and volume of intraoperative blood loss of 38 patients were respectively 320 minutes (range, 280-520 minutes) and 530 mL (range, 420-650 mL). The incidence of total complications (Clavien-Dindo Ⅲ and above) of 38 patients was 18.4%(7/38), and some patients were combined with multiple complications, including 6 with pulmonary infection, 4 with pancreatic fistula (B and C grade), 4 with intra-abdominal infection, 3 with delayed gastric emptying, 2 with postoperative bleeding and 2 with venous thrombosis. Five patients were cured by postoperative symptomatic treatment, and 2 with postoperative bleeding died of worsened condition after reoperation. The mortality at 90 days postoperatively and duration of hospital stay were respectively 5.3%(2/38) and 12 days (range, 9-52 days). (2) Results of postoperative pathological examination: the R0 resection rate of 38 patients was 81.6%(31/38). The R0 resection rate of 25 patients in BR-PV type was 92.0%(23/25), and resection margin of pancreatic leading edge < 1 mm was in 2 patients without R0 resection; R0 resection rate of 13 patients in BR-A type was 8/13, and resection margin of pancreatic leading edge < 1 mm was in 2 patients and resection margin of SMV < 1 mm was in 4 patients (1 margined with resection margin of multiple sites < 1 mm) of patients without R0 resection. The resection margins of pancreatic trailing edge, venous cut edge and pancreatic cut edge in patients with BR-PV type and BR-A type were more than and equal to 1mm. The venous infiltration rate in patients with BR-PV type and BR-A type was respectively 100.0%(25/25) and 9/13. (3) Follow-up and survival situations: 38 patients were followed up for 6-40 months, with a median time of 15 months, and survival time was 18 months (range, 6-40 months). The survival time and 1-, 2- and 3-year cumulative survival rates were respectively 23 months (range, 8-40 months), 89.5%, 33.1%, 22.1% in 25 patients with BR-PV type and 16 months (range, 6-25 months), 83.9%, 16.8%, 0 in 13 patients with BR-A type. The tumor-free survival time and 1- and 2-year cumulative tumor-free survival rates were respectively 15 months (range, 5-30 months), 63.0%, 7.5% in patients with BR-PV type and 9 months (range, 4-18 months), 11.5%, 0 in patients with BR-A type. Conclusion For resectable pancreatic cancer with SMV and / or anterior wall of PV involvements, pancreaticoduodenectomy combined with venous resection via IMV pathway could avoid injury of SMV and / or PV, and increase negative rates of venous and pancreatic resection margins. Key words: Pancreatic neoplasms; Borderline resectable pancreatic cancer; Resectable pancreatic neoplasms; Pancreaticoduodenectomy; Combined venous resection; Inferior mesenteric vein pathway