Major Vascular Resection Research Articles

Inferior vena cava resection without reconstruction for retroperitoneal malignancies

ABSTRACTInferior vena cava (IVC) involvement in retroperitoneal malignancies is a rare occurrence and radical surgery with major vascular resection represents the only potential curative treatment. IVC replacement after resection is still controversial and only small series and few prospective data are available. We report a series of three patients affected by retroperitoneal masses involving IVC treated with vena cava resection without replacement. All patients were treated by a radical R0 surgical procedure associated with infrarenal IVC resection and no reconstruction. Based on preoperative radiologic imaging and intraoperative findings, one patient also underwent right nephrectomy, while another patient underwent left renal vein ligation without nephrectomy. Neither early nor late severe post-operative complications related to the absence of IVC outflow were observed. Resection without replacement of the infrarenal IVC results in acceptable morbidity, thus specific risks related to the use of prosthetic grafts can be avoided.

How to simplify out-of-the-box surgery in recurrent gynecologic malignancies compromising iliac vessels: preoperative femorofemoral crossover bypass.

Pelvic side wall recurrences represent a challenge for oncologic surgeons, especially in cases requiring major vascular resections. Until the description of the out-of-the-box lateral resection surgical technique, lateral pelvic wall involvement was considered a contraindication for surgery.[1 2][1

Vascular Involvement in Primary Retroperitoneal Tumors

The retroperitoneum can host a wide variety of pathologies, including benign and malignant tumors. Primary retroperitoneal tumors are rare, usually large in size, more than half of them being larger than 20 cm at the time of diagnosis, due to their silent growth. They often present several therapeutic challenges because of their rarity, relatively late presentation and anatomical location, often in close relationship with several important structures in the retroperitoneal space. Extensive surgery is often required because of the intimate relationships with vital organs in the retroperitoneum. Retroperitoneal sarcomas frequently involve major vessels, originating from them or secondarily encase or invade them, requiring major vascular resections, with increasing morbidity. The main intervention that can increase the survival of patients with retroperitoneal tumors is radical resection. The involvement of large retroperitoneal vessels often makes impossible a radical intervention, usually because of the lack of an adequate material for ample and laborious vascular reconstruction. In this paper, a thorough search of the PubMed database was performed, to bring into the light the implications of vascular involvement in primary retroperitoneal tumors and the need of a strong cooperation between the urological or general surgeon and the vascular surgeon.

Perioperative blood transfusion is associated with poor long-term survival among patients with pancreatic adenocarcinoma

Background: Perioperative red blood cell transfusion (RBCT) can negatively affect the host’s immune system. This study investigated the effects of perioperative RBCT on long-term survival among patients with pancreatic ductal adenocarcinoma (PDAC). Methods: We retrospectively evaluated 148 patients with PDAC who underwent surgery with curative intent (33 patients received RBCTs and 115 patients did not receive RBCTs). Significant prognostic variables in the univariate analyses were subjected to multivariate analyses using a Cox proportional hazard regression model. We also adjusted for different covariate distributions in each group using inverse probability of treatment weighting, and the prognostic variables were re-analyzed. Results: Patients received and did not receive RBCT exhibited significant differences in age, preoperative hemoglobin levels, CA19-9 levels, maximum tumor size, tumor staging, operative time, intraoperative blood loss, major vascular resection, and the proportion of pancreaticoduodenectomy. In the unweighted analyses, patients with RBCT exhibited significantly poorer overall survival (P < 0.001) and recurrence-free survival (P < 0.001), compared to patients without RBCT. After adjusting for the different covariates, perioperative RBCT remained an independent risk factor for poorer long-term overall and recurrence-free survivals. Conclusion: Perioperative RBCT was associated with poorer long-term survival rates among patients with PDAC who underwent surgery with curative intent.

Major vascular resection and reconstruction combined with liver resection for primary and metastatic hepatic tumors

Major vascular resection and reconstruction combined with liver resection for primary and metastatic hepatic tumors

Vascular resection for locally advanced pancreatic malignancies: time-trend and outcome analysis from 100 consecutive resections at a high-HPB volume center

Introduction: Involvement of major vascular structures has been considered a limiting factor for resectable advanced tumors. The aim of this study is to investigate the clinical outcomes of patients with advanced APA with vascular resection and to identify significant survival predicting variables. Material and methods: We retrospectively reviewed our experience of consecutive pancreatic surgeries with VR, achieved at Sanchinarro University Hospital (Madrid, Spain) from 2007 to December 2017. Results: A total of 100 patients underwent VR for locally advanced pancreatic cancer. The average age of all patients was 60 years and the mean operating time (560 min, range 400–900). We performed 38 pancreaticoduodenectomies (PD), 20 distal-pancreatectomies (DP), 42 total pancreatectomy (TP). Furthermore, the patients were classified according to the type of VR: venous vascular resection (72 patients); arterial vascular resection (16 patients); arterial and venous vascular resection (12 patients)). The mean hospital stay was 16 days in PD group, 12 days in DP group and 15 days in TP group. Major vascular reconstruction was accomplished through Goretex® patch (n = 17), primary end-to-end anastomosis (n = 61), tangential resection (n = 22). In 30 % histopathologic examination revealed cancer invasion of the vessel, whereas the remainder had peritumoral inflammation extending to the vessel wall. Two-year survival rate were 22%. Conclusion: Major arterial vascular resection to achieve macroscopic tumor clearance can be performed safely with acceptable operative morbidity and mortality. Nevertheless it is justified only in carefully selected cases.

Postoperative Morbidity After Radical Resection of Primary Retroperitoneal Sarcoma: A Report From the Transatlantic RPS Working Group.

To investigate the safety of radical resection for retroperitoneal sarcoma (RPS). The surgical management of RPS frequently involves complex multivisceral resection. Improved oncologic outcomes have been demonstrated with this approach compared to marginal excision, but the safety of radical resection has not been shown in a large study population. The Transatlantic Retroperitoneal Sarcoma Working Group (TARPSWG) is an international collaborative of sarcoma centers. A combined experience of 1007 consecutive resections for primary RPS from January 2002 to December 2011 was studied retrospectively with respect to adverse events. A weighted organ score was devised to account for differences in surgical complexity. Univariate and multivariate logistic regression analyses were performed to investigate associations between adverse events and number and patterns of organs resected. Associations between adverse events and overall survival, local recurrence, and distant metastases were investigated. Severe postoperative adverse events (Clavien-Dindo ≥3) occurred in 165 patients (16.4%) and 18 patients (1.8%) died within 30 days. Significant predictors of severe adverse events were age (P = 0.003), transfusion requirements (P < 0.001), and resected organ score (P = 0.042). Resections involving pancreaticoduodenectomy, major vascular resection, and splenectomy/pancreatectomy were found to entail higher operative risk (odds ratio >1.5). There was no impact of postoperative adverse events on overall survival, local recurrence, or distant metastases. A radical surgical approach to RPS is safe when carried out at a specialist sarcoma center. High-risk resections should be carefully considered on an individual basis and weighed against anticipated disease biology. There appears to be no association between surgical morbidity and long-term oncologic outcomes.

Surgical Indication for Advanced Intrahepatic Cholangiocarcinoma According to the Optimal Preoperative Carbohydrate Antigen 19-9 Cutoff Value.

The indication of surgery in intrahepatic cholangiocarcinoma (ICC) patients with lymph node metastasis (LNM), macroscopic periductal infiltration (PI), and intrahepatic metastasis (IM) remains unclear. Patients who underwent resection for mass-forming (MF) dominant ICC and unresected patients caused by LNM, IM, or locally advanced tumors (UR group) were enrolled. The significance of CA19-9 was investigated in advanced ICC. Seventy-three patients who underwent resection and 20 UR patients were analyzed. Using the minimum p value approach based on the overall survival, the optimal CA19-9 cutoff value was 300U/mL. The OS of the patients with CA19-9 < 37U/mL (n = 26; MST, 49.6months) and 37-300U/mL (n = 28; MST, 45.1months) was comparable (P = 0.842); however, the OS of the patients with CA19-9 = 37-300U/mL was significantly better than that with CA19-9 ≥ 300U/mL (n = 19; MST, 15.3months; P < 0.001). CA19-9 > 300U/mL, MF + PI, and IM were independently associated with OS. The OS of the patients with CA19-9 < 300U/mL who developed LNM (MST, 34.0months), MF + PI (MST, 32.9months), or IM (MST, 35.2months), or who required major vascular resection (MST, 45.1months) was better than those with CA19-9 ≥ 300U/mL who developed LNM (MST, 8.7months; P = 0.005), MF + PI (MST, 7.5months; P = 0.040), or IM (MST, 8.7months; P = 0.001), or who required major vascular resection (MST, 14.8months; P = 0.015); their prognosis was similar with the UR group. Even if patients had ICC developing LNM, PI, or IM, or require major vascular resection, surgical resection can be indicated for patients with CA19-9 < 300U/mL. However, the indications for either adjuvant therapy or resection should be carefully determined in patients with CA19-9 ≥ 300U/mL.

Major vascular resections in retroperitoneal sarcoma.

Retroperitoneal sarcomas (RPS) frequently involve major vessels, which either originate from them or secondarily encase or invade them. In this field, major vascular resections result in increased morbidity. However, survival does not seem to be affected by the need for vascular resection or by this higher morbidity. This paper aims to provide descriptions of the surgical strategy and outcomes for retroperitoneal sarcomas involving major vessels.

Laparoscopic pancreaticoduodenectomy combined with major vascular resection and reconstruction: an analysis of 7 patients

Objective To review our experience in laparoscopic pancreaticoduodenectomy combined with major vascular resection and reconstruction. Methods Of 183 patients who underwent laparoscopic pancreaticoduodenectomy in our department from November 2013 to January 2017, major vascular resection and reconstruction using the SMA first approach for total mesopancreas excision was performed in 7 patients. The clinical data of these 7 patients were retrospectively analyzed. Results Total 3D laparoscopic surgery was performed in all these 7 patients. The mean operation time, mean blood loss and blood flow occlusion time were (551.4±83.8) min, (671.3±256.3) ml and (45.8±6.7) min, respectively. Six out of 7 patients were pathologically diagnosed to have pancreatic adenocarcinoma with negative surgical margins. Two patients had lymphatic metastasis (the number of metastatic lymph node was 1 in each patient). The mean number of lymph nodes resected was (12.7±5.8). The portal vein-superior mesenteric vein (PV-SMV) was segmentally resected and reconstructed using an end to end anastomosis following the preoperative plan in 4 patients. These included 2 patients who underwent total pancreatectomy. The portal vein was wedge-resected and reconstructed by venorrhaphy in 2 patients. The remaining 1 patient was histopathologically diagnosed to have a mass-type chronic pancreatitis. Only 1 patient was treated in the ICU for 1 day after surgery. Post-operative complications occurred in 2 patients and they were managed with nonsurgical treatment (PV-SMV thrombosis and gastric emptying disorder in 1 and a pancreatic leakage (level A) in 1). The mean length of post-operative hospital stay was (13.7±3.2) days with no in-hospital mortality. Seven patients were alive by April 2017. The mean follow-up for the 6 patients with pancreatic adenocarcinoma was 4.5(3.5~9) months. Conclusions Based on our experience in skillful and masterly major vascular resection and reconstruction in open surgery and on our experience in standard laparoscopic pancreaticoduodenectomy, laparoscopic pancreaticoduodenectomy combined with major vascular resection and reconstruction was feasible and safe. This surgery requires very mature skills in laparoscopic surgery. Key words: Laparoscopic pancreaticoduodenectomy (LPD); Vascular resection; Vascular reconstruction; Total mesopancreas excision (TMpE)

Perioperative Red Blood Cell Transfusion Is Associated with Poor Long-term Survival in Pancreatic Adenocarcinoma.

Perioperative red blood cell transfusion (RBCT) can negatively affect the host's immune system. We investigated the effects of perioperative RBCT on long-term survival among patients with pancreatic ductal adenocarcinoma (PDAC). We retrospectively evaluated 148 patients with PDAC who underwent surgery with curative intent (33 who received RBCTs and 115 who did not). Significant prognostic variables on univariate analysis were subjected to multivariate analyses using a Cox proportional hazard regression model. Both groups exhibited significant differences in age, preoperative haemoglobin levels, carbohydrate antigen 19-9 levels, maximum tumour size, tumour staging, operative time, intraoperative blood loss, major vascular resection, and the proportion of pancreaticoduodenectomies performed. Patients who underwent RBCTs exhibited significantly poorer overall survival (p<0.001) and recurrence-free survival (p<0.001) compared to patients who did not. Perioperative RBCT was associated with poorer long-term survival among patients with PDAC who underwent surgery with curative intent.

Impact of major vascular resection on outcomes and survival in patients with intrahepatic cholangiocarcinoma: A multi-institutional analysis.

Major vascular involvement (IVC or portal vein) for intrahepatic cholangiocarcinoma (ICC) has traditionally been considered a contraindication to resection. We sought to define perioperative outcomes and survival of ICC patients undergoing hepatectomy with major vascular resection in a large international multi-institutional database. A total of 1087 ICC patients who underwent curative-intent hepatectomy between 1990 and 2016 were identified from 13 institutions. Multivariable logistic and cox regressions were used to determine the impact of major vascular resection on perioperative and survival outcomes. Of 1087 patients who underwent resection, 128 (11.8%) also underwent major vascular resection (21 [16.4%] IVC resections, 98 [76.6%] PV resections, 9 [7.0%] combined resections). Despite more advanced disease, major vascular resection was not associated with the risk of any complication (OR = 0.68, 95%CI 0.32-1.45) or major complications (OR = 0.95, 95%CI 0.49-2.00). Post-operative mortality was also comparable between groups (OR = 1.05, 95%CI 0.32-3.47). In addition, median recurrence-free (14.0 vs 14.7 months, HR = 0.737, 95%CI 0.49-1.10) and overall (33.4 vs 40.2 months, HR = 0.71, 95%CI 0.359-1.40) survival were similar among patients who did and did not undergo major vascular resection (both P > 0.05). Among patients with ICC, major vascular resection was not associated with worse perioperative or oncologic outcomes. Concurrent major vascular resection should be considered in appropriately selected patients with ICC undergoing hepatectomy.

Prevention and nursing of complications for radical pancreaticoduodenectomy combined with major vascular resection and reconstruction

Objective To investigate the prevention and nursing of the complications of radical pancreaticoduodenectomy via artery approach under the colon area combined with portal vein and splenic vein resection and reconstruction. Methods A total of 13 cases of the radical pancreaticoduodenectomy via artery approach under the colon area combined with portal vein and splenic vein resection and reconstruction from March 2015 to June 2016 in Beijing Chao-Yang hospital were included in the study. Postoperative complications of patients were analyzed and effective nursing interventions were summarized. Results There was no patient with abdominal bleeding, gastrointestinal bleeding or portal vein thrombosis, 3 patients with pancreatic fistula and 1 patient suffering from delayed gastric emptying in total 13 cases. All of them were discharged after active treatment and nursing care. Conclusions Rigorous observation and effective preventive care on the patients of the radical pancreaticoduodenectomy via artery approach under the colon area combined with portal vein and splenic vein reconstruction could prevent, earlier observe and treat patients with complications to save their lives. Key words: Pancreaticoduodenectomy; Postoperative complications; Nursing care; Prevention

Impact of major vascular resection on short- and long-term outcomes in patients with intrahepatic cholangiocarcinoma.

275 Background: Major vascular (IVC or portal vein) resection for Intrahepatic Cholangiocarcinoma (ICC) has traditionally been considered a relative contraindication to resection. We sought to define perioperative outcomes and survival of ICC patients undergoing liver surgery with major vascular resection using a multi-institutional database. Methods: 1,087 ICC patients who underwent liver resection between 1990-2016 were identified from 13 participating institutions. Multivariable logistic and cox regressions were used to determine the impact of major vascular resection on perioperative outcomes and long-term overall survival. Results: Of 1,087 patients who underwent resection, 128(11.8%) also underwent major vascular resection [21(16.4%)IVC resections, 98(76.6%)PV resections, 9(7.0%)combined resections]. One hundred eighty-seven(17.2%) patients received neoadjuvant therapy. Most patients underwent a major hepatectomy involving ≥ 3 liver segments(n = 664,61.1%). On final pathology, the majority of patients had T1(40.4%) or T2(35.5%) tumors; 194(17.8%) had lymph node metastasis. Patients undergoing major vascular resection had more advanced T3/T4 tumors [44(34.4%) vs. 137(14.3%) without resection;P &lt; 0.001]. Of note, major vascular resection was not associated with the risk of any complication (OR .680,95%CI 0.32-1.45) or major complication (OR 0.69,95%CI 0.35-1.33); post-operative mortality was also comparable between groups (OR 1.06, 95%CI 0.32-3.48). In addition, median recurrence-free (14.0 months vs.14.7 months, HR.737,95%CI .49-1.10) and overall (33.4 months vs.40.2 months, HR .709,95%CI.36-1.40) survival were similar among patients who did and did not undergo major vascular resection, respectively(both P &gt; 0.05). Conclusions: Among patients with ICC, major vascular resection was not associated with increased peri-operative morbidity or mortality at major centers. Long-term outcomes following resection of ICC requiring vascular resection were also comparable to outcomes following resection of tumors without vascular involvement. Concurrent major vascular resection should be considered in appropriately selected ICC patients.

Superior mesenteric-portal vein resection during laparoscopic pancreatoduodenectomy.

Laparoscopic pancreatoduodenectomy (LPD) with concomitant resection of major portal vessels has recently emerged as feasible and safe, with similar morbidity and mortality as well as oncologic outcome compared with patients undergoing open PD with major vascular resection. Of a consecutive series of 133 LPD, eight patients underwent concomitant superior mesenteric vein/portal vein (SMV/PV) resection and reconstruction with the intent of achieving a R0 resection. Four of these eight patients had tangential resection followed by lateral wall repair with Prolene 4.0. One patient had tangential resection with patch reconstruction. Three patients had circular venous resection: One had end-to-end primary venous reconstruction, and two patients had a prosthetic vascular graft interposition. There was no operative mortality. The SMV/PV was patent in all patients postoperatively on ultrasound Doppler or CT scans. Two patients (who underwent circular venous resection) had postoperative complications. One 77-year-old patient with preexisting cardiovascular disease died of heart failure on postoperative day 2, while another (undergoing prosthetic graft reconstruction) had postoperative bilioenteric anastomotic dehiscence and underwent immediate re-laparoscopy for repair. In our experience, LPD with concomitant major venous resection is feasible even in cases of longitudinal venous invasion. Further studies are needed to evaluate the role of laparoscopy in borderline pancreatic cancer.

Parenchyma-Sparing Hepatectomy with Vascular Reconstruction Techniques for Resection of Colorectal Liver Metastases with Major Vascular Invasion.

BackgroundResectability of colorectal liver metastasis (CRLM) depends on major vascular involvement and is affected by chemotherapy-induced liver injury. Parenchyma-sparing with combined resection and reconstruction of involved vessels may expand the indications and safety of hepatectomy.MethodsOf 92 patients who underwent hepatectomy for CRLM, 15 underwent major vascular resection and reconstruction. The reconstructed vessels were the portal vein (PV) in five cases, the major hepatic vein (HV) in nine cases, and the inferior vena cava in six cases.ResultsAll PV reconstructions were direct anastomoses. The HV was reconstructed with an autologous inferior mesenteric venous patch or an external iliac vein interposition graft. Total hepatic vascular exclusion was performed for six patients. Of nine patients with HV reconstruction, three had tumors involving all three major HVs, in whom the left HV was reconstructed as an only vein after extended right hepatectomy. In another six patients, multiple bilobar tumors or tumors in the liver that had chemotherapy-induced injury involved one or two HVs. Parenchyma-sparing by reconstruction of the HV was performed to secure the residual liver function. The patients with vascular reconstruction had an operative time of 462 ± 111 min and a blood loss of 1278 ± 528 mL. No complication classified as Clavien–Dindo 3 or more developed. The median hospital stay was 17 days (range 8–26 days). The cumulative 5-year survival rate for all the patients was 54.6 %, with no significant difference according to vascular reconstruction.ConclusionParenchyma-sparing hepatectomy combined with vascular reconstruction is a useful option to avoid major hepatectomy among various procedures for resection of CRLM with major vascular invasion.

A Graded Evaluation of Outcomes Following Pancreaticoduodenectomy with Major Vascular Resection in Pancreatic Cancer

Previous studies examining short- and long-term outcomes of pancreaticoduodenectomy with vascular resection for pancreatic adenocarcinoma have not graded perioperative complication severity. These studies may provide incomplete assessments of the efficacy of vascular resection. In the current study, we evaluated 36 patients who had pancreaticoduodenectomy with major vascular resection. These were matched 1:3 by tumor stage and age to patients who had pancreaticoduodenectomy without vascular resection. Charts were reviewed to identify all complications and 90-day readmissions. Complications were graded as either severe or minor adverse postoperative outcomes, taking into account the total length of stay. There were no statistical differences in patient demographics, comorbidities, or symptoms between the groups. Patients who had vascular resection had significantly increased rates of severe adverse postoperative outcomes, readmissions, lengths of hospital stay, as well as higher hospital costs. Hypoalbuminemia and major vascular resection were independent predictors of severe adverse postoperative outcomes. On multivariate Cox-regression survival analysis, patients who had vascular resection had decreased recurrence-free (12 vs. 17 months) and overall (17 vs. 29 months) survival. Major vascular resection was a predictor of mortality, may be an independent prognostic factor for survival, and may warrant incorporation into future staging systems.

864 A Graded Evaluation of Outcomes Following Pancreaticoduodenectomy With Major Vascular Resection in Pancreatic Cancer: Major Vascular Resection Is Associated With Severe Adverse Postoperative Outcome and Early Recurrence

864 A Graded Evaluation of Outcomes Following Pancreaticoduodenectomy With Major Vascular Resection in Pancreatic Cancer: Major Vascular Resection Is Associated With Severe Adverse Postoperative Outcome and Early Recurrence

Pancreaticoduodenectomy with Major Vascular Resection: a Comparison of Laparoscopic Versus Open Approaches

BackgroundMajor vascular resection when necessary for margin control during pancreaticoduodenectomy is relatively universal with perioperative and oncological outcomes that are similar to those of patients undergoing a PD without venous involvement. The present study compares total laparoscopic pancreaticoduodenectomy (TLPD) versus open pancreaticoduodenectomy (OPD) with major vascular resection. MethodsWe reviewed data for all patients undergoing TLPD or OPD with vascular resection at Mayo Clinic Rochester, between the dates of July 2007 and July 2013. ResultsA total of 31 patients undergoing TLPD and 58 patients undergoing OPD with major vascular resection were identified. Mean operative blood loss was significantly less in the laparoscopic (842 cc) compared to the open group (1,452 cc) (p < 0.001), as was median hospital stay, 6 (4–118) versus 9 (6–73) days, respectively (p = 0.006). There was no significant difference in the total number of complications (lap 35 %, open 48 %) (p = 0.24) or severe complications (≥III) (lap 6.4 %, open 3.4 %) (p = 0.51) in the two groups. In-hospital mortality or 30-day mortality was not statistically different between the laparoscopic and open groups, 3.2 and 3.4 %, respectively (p = 0.96). Patency of the reconstructed vessels on postoperative imaging was not significantly different between the TLPD (93 %) and OPD groups (91 %) (p = 0.76). In patients with a diagnosis of adenocarcinoma, there was no significant difference in overall survival between the two groups (p = 0.22). ConclusionThe present study clearly demonstrates that not only is TLPD with major vascular resection feasible and safe but that it can achieve results that are similar in morbidity and mortality as well as oncologic outcome compared to patients undergoing OPD with major vascular resection.

En bloc vascular resection for the treatment of borderline resectable pancreatic head carcinoma.

Borderline resectable (BR) pancreatic head carcinoma (PhC) is an advanced disease, presenting with infiltration of major vessels. Major vascular resection (VR), particularly arterial resection, to achieve microscopic no residual tumor (R0) is a controversial approach, due to the potential complications. In this study, we aimed to clarify the benefit of en bloc R0 resection with VR for PhC by retrospectively evaluating 78 PhC patients who underwent pancreatoduodenectomy at our institute. The patients were divided into 4 groups as follows: R, resectable (n=20); BR-V, BR involving the superior mesenteric vein or portal vein (PV) (n=28); BR-SMA, BR involving the superior mesenteric artery (n=21); and BR-HA, BR involving the hepatic artery (n=9). In total, 65 patients underwent VR, with 63, 21 and 9 patients undergoing PV, SMA and HA resection, respectively. The R0 rates were as follows: R group, 85%; BR-V, 82%; BR-SMA, 71%; and BR-HA, 33%. The median survival time and 5-year survival rate for R0 resection were 31 months and 25% in the R group, 22 months and 28% in the BR-V group, 17 months and 27% in the BR-SMA group and 10 months and 0% in the BR-HA group, respectively. The prognosis was comparable among the BR-V, BR-SMA and R groups, but was significantly poorer in the BR-HA group. In total, 5 patients (6.4%) died perioperatively (4 from postoperative hemorrhage and 1 from suffocation due to failure of expectoration, without pneumonia or asthma). Of the 4 patients who succumbed to hemorrhage, 3 had undergone arterial resection. Therefore, en bloc resection with major VR for R0 may be suitable for BR-V and BR-SMA PhC patients.