New Conception for LA-PDAC Surgery, Increasing Ro-Rate and Minimizing Liver and Bowel Ischemia: Arterial Resection and Reconstruction First, R0-Pancreatectomy and Vein Resection Second

Abstract

Background: Modern results of neoadjuvant therapy have justified arterial resections for locally advanced pancreatic ductal adenocarcinoma(LA-PDAC). Restricted space and significant duration of arterial and portal clamping are challenging conditions as for R0-pancreatectomy, so as for prevention of severe liver or intestinal ischemia in simultaneous resections of the SMA or hepatic arteries and PV/SMV. The new approach “Arterial Resection and Reconstruction first, Ro-pancreatectomy and Vein Resection second”,АRR&(Ro+VR), can be a resolution of this problem in the majority of cases. On the background of untouched venous inflow, arterial resection and reconstruction are safer before mobilization of the pancreas due to collaterals, which are usually sacrificed during mobilization. Aim:To assess the safety and efficacy of АRR&(Ro+VR) approach for LA-PDAC. Method: Retrospective analysis of 76 arterial resections associated with pancreatectomies(2009-2021) and perioperative data of consecutive АRR&(Ro+VR) pancreatectomies(n20). Results: For 20 АRR&(Ro+VR) procedures mean OP time was 745±145min, mean blood loss - 570±320ml, rates of R0- vein resections -100%, pathological CA/CHA(16),/SMA(4) involvement– 85%(n17), PD/TP rate 4/16, morbidity 13(65%), DGE – 10(50%), mortality- n1(5%,bleeding). For 73 patients with 76 arterial resections (40 DPCARs,20 TP,13 PD) there were no liver ischemic complications, mortality-n5 (6,8%, bleeding(3),MI(1),sepsis(1)), gastric ischemia–5(6,8%), POPF B/C-21(39,6%). For PDAC(n56) median OS-28 months, median DFS-20 months, overall 5-year survival-38%, actual 5-y survival–15,3%. In all cases IOUS was an inspection technique for assessment of blood flow adequacy. All the relapses, except four, were distant. Conclusion: АRR&(Ro+VR) is a reasonable approach for R0-pancreatectomy with arterio-venous resections for LA-PDAC. Comparison with standard approach is coming.