Portal-superior Mesenteric Vein Resection Research Articles

Laparoscopic Pancreaticoduodenectomy Combined With Portal-Superior Mesenteric Vein Resection and Reconstruction: Inferior-Posterior "Superior Mesenteric Artery-First" Approach.

Laparoscopic pancreaticoduodenectomy (LPD) with portal-superior mesenteric vein (PV/SMV) resection and reconstruction is increasingly performed. We aimed to introduce a safe and effective surgical approach and share our clinical experience with LPD with PV/SMV resection and reconstruction. We reviewed data for the patients undergoing LPD and open pancreaticoduodenectomy (OPD) combined with PV/SMV resection and reconstruction at the First Hospital of Jilin University between April 2021 and May 2023. The inferior-posterior "superior mesenteric artery-first" approach was used. We compared the preoperative, intraoperative, and postoperative clinicopathological data of the 2 groups to conduct a comprehensive evaluation of LPD with major vascular resection. A cohort of 37 patients with periampullary and pancreatic tumors underwent pancreaticoduodenectomy (PD) with major vascular resection and reconstruction, consisting of 21 LPDs and 16 OPDs. The LPD group had a longer operation time (322 vs. 235 min, P=0.039), reduced intraoperative bleeding (152 vs. 325mL, P=0.026), and lower intraoperative blood transfusion rates (19.0% vs. 50.0%, P=0.046) compared with the OPD group. The LPD group had significantly shorter operation times in end-to-end anastomosis (26 vs. 15 min, P=0.001) and artificial grafts vascular reconstruction (44 vs. 22 min, P=0.000) compared with the OPD group. There was no significant difference in the rate of R0 resection (100% vs. 87.5%, P=0.096). The length of hospital stay and ICU stay did not show significant differences between the 2 groups (15 vs. 18d, P=0.636 and 2.5 vs. 4.5d, P=0.726, respectively). However, the postoperative hospital stay in the LPD group was notably shorter compared with the OPD group (11 vs. 16d, P=0.007). Postoperative complication rates, including postoperative pancreatic fistula (POPF) Grade A/B, biliary leakage, and delayed gastric emptying (DGE), were similar between the two groups (38.1% vs. 43.8%, P=0.729). In addition, 1 patient in each group developed thrombosis, with vascular patency improving after anticoagulation treatment. LPD combined with PV/SMV resection and reconstruction can be easily and safely performed using the inferior-posterior "superior mesenteric artery-first" approach in cases of venous invasion. Further studies are required to evaluate the procedure's long-term outcomes.

Development and validation of risk prediction nomogram for pancreatic fistula and risk-stratified strategy for drainage management after pancreaticoduodenectomy.

Postoperative pancreatic fistula (POPF) is the major complication following pancreaticoduodenectomy (PD). We sought to develop and validate a risk prediction model for POPF after PD with the aim of determining personal risk probability and proposing a novel strategy for intraoperative placement and/or early-removal of prophylactic drainage. Data from 993 patients undergoing PD from January 2012 to December 2016 were retrospectively analyzed. Patients were randomly assigned to either training cohort or validation cohort. A nomogram was formulated based on the results from multivariable regression model for prediction of POPF. Internal and external validation were carried out with calibration plot respectively. POPF occurred in 162 (16.3%) patients. The final pre-/intra-operative prediction model included alanine transaminase level [odds ratio (OR) 1.00, 95% confidence interval (CI): 1.00-1.00, P=0.023], combined portal-superior mesenteric vein resection (OR 0.22, 95% CI: 0.05-0.95, P=0.043), pancreatic duct diameter (OR 1.48, 95% CI: 1.11-1.96, P=0.007), intraoperative colloid infusion (OR 1.00, 95% CI: 1.00-1.00, P=0.001), pathology (OR 1.71, 95% CI: 1.09-2.66, P=0.018). The area under the curve (AUC) was 0.667 in the training cohort and 0.621 in the validation cohort. The final postoperative prediction model included pancreatic duct diameter (OR 1.58, 95% CI: 1.14-2.19, P=0.006), intraoperative colloid infusion (OR 2.52, 95% CI: 1.26-5.06, P=0.009), drainage fluid amylase on postoperative day 3 (POD3) (OR 4.70, 95% CI: 3.30-6.70, P<0.001), and neutrophil count on POD3 (OR 2.83, 95% CI: 1.63-4.93, P<0.001). The AUC was 0.809 in the training cohort and 0.797 in the validation cohort. Based on these variables, two nomogram prediction models were developed respectively. The calibration plot of the two models showed a good correlation between the expected risk and the actual risk in the low-risk range. Our risk-stratified strategy for drain management according to nomograms may be beneficial for 34.5% of patients. Our study formulated and validated two nomogram models for predicting POPF that performed particularly well in the low-risk range. This tool may allow surgeons to propose a risk stratified strategy for intraoperative drain placement and early drain removal, which may be beneficial for a substantial proportion of patients.

Setting up a division of HBP surgery at a local university hospital

Setting up a division of HBP surgery at a local university hospital

Pancreaticoduodenectomy for Retroperitoneal Sarcomas: A Mono-Institutional Experience in China.

BackgroundEn bloc resection of retroperitoneal sarcoma (RPS) with adjacent organs such as pancreatic head and duodenum is challenging for surgeons. This mono-institutional study aims to evaluate the feasibility, safety, and outcome of performing pancreaticoduodenectomy (PD) during RPS resection.MethodsThe clinical data of RPS patients who underwent PD at the Sarcoma Center of Peking University Cancer Hospital from January 2011 to December 2019 was collected and analyzed.ResultsTwenty-seven patients out of a total of 264 surgically treated RPS underwent PD. The main pathological subtype was liposarcoma. All patients received concomitant resection of a median of three additional organs (range: 1–5), including 11 patients (40.7%) who underwent inferior vena cava resection and one patient who underwent segmental superior mesenteric-portal vein resection. Microscopic tumor infiltration to the duodenum or pancreas was observed in 81.5% of patients. Major complications occurred in 40.7% of patients; the reoperation rate was 22.2%. One patient (3.7%) died from liver abscess postoperatively. During a median follow-up of 18.9 months, 15 patients (55.6%) developed locally recurrent disease; two patients (7.4%) also had pulmonary metastases additionally. Twelve patients (44.4%) died from local relapse eventually.ConclusionPD during RPS resection is feasible, and it may be necessary to achieve complete resection. However, considering the complexity and risk, it should be performed by an experienced surgical team. The long-term survival benefit of this procedure should be verified by further large-scale multi-institutional studies.

Clinical impact of pancreaticoduodenectomy for pancreatic cancer with resection of the secondary or later branches of the superior mesenteric vein.

To evaluate the feasibility of pancreaticoduodenectomy with resection of the second jejunal vein (J2V) for pancreatic ductal adenocarcinoma (PDAC). Among 114 patients with PDAC undergoing pancreaticoduodenectomy with portal-superior mesenteric vein resection (PVR), surgical outcomes, and prognoses of 10 patients with resection of J2V or later branches of the superior mesenteric vein (J2VR) were compared to 104 patients with PVR above J2V (standard PVR). The reconstruction methods in the J2VR group were reviewed. There were no significant differences in the operative time (470 vs 435min), morbidity (30% vs 27%), presence of portal vein stenosis (10% vs 5%) or thrombosis (10% vs 1%), and induction of adjuvant therapy (80% vs 88%) between the J2VR and standard PVR groups, although blood loss was higher in the J2VR group (1184 vs 494ml; P=.002). R0 proportion and 2-year survival rates were not significantly worse in the J2VR group compared to the standard PVR group (90 and 88%; 67 and 45%, respectively). At least one branch of the superior mesenteric vein was reconstructed in the J2VR group. Pancreaticoduodenectomy with J2VR for PDAC can be safely performed with a satisfactory overall survival rate.

Surgical management and pathological assessment of pancreatoduodenectomy with venous resection: an international survey among surgeons and pathologists

BackgroundThe aim of this survey was to gain insights in the current surgical management and pathological assessment of pancreatoduodenectomy with portal–superior mesenteric vein resection (VR). MethodsA systematic literature search was performed to identify international expert surgeons (N = 150) and pathologists (N = 40) who published relevant studies between 2009 and 2019. These experts and Dutch surgeons (N = 17) and pathologists (N = 20) were approached to complete an online survey. ResultsOverall, 76 (46%) surgeons and 37 (62%) pathologists completed the survey. Most surgeons (71%) estimated that preoperative imaging corresponded correctly with intraoperative findings of venous involvement in 50–75% of patients. An increased complication risk following VR was expected by 55% of surgeons, mainly after Type 4 (segmental resection-venous conduit anastomosis). Most surgeons (61%) preferred Type 3 (segmental resection-primary anastomosis). Most surgeons (75%) always perform the VR themselves. Standard postoperative imaging for patency control was performed by 54% of surgeons and 39% adjusted thromboprophylaxis following VR. Most pathologists (76%) always assessed tumor infiltration in the resected vein and only 54% of pathologists always assess the resection margins of the vein itself. Variation in assessment of tumor infiltration depth was observed. ConclusionThis international survey showed variation in the surgical management and pathological assessment of pancreatoduodenectomy with venous involvement. This highlights the lack of evidence and emphasizes the need for research on imaging modalities to improve patient selection for VR, surgical techniques, postoperative management and standardization of the pathological assessment.

Acute compartment syndrome of the lower leg causing cardiac arrest after resection of the right external iliac vein for autologous graft: a case report

BackgroundThe right external iliac vein (REIV) is often used for portal vein reconstruction in patients undergoing pancreatoduodenectomy with portal-superior mesenteric vein resection. We report a case of cardiac arrest caused by acute lower leg compartment syndrome as a result of REIV resection.Case presentationA 53-year-old man underwent pancreatoduodenectomy with portal vein resection. Hyperkalemia progressed during surgery due to intestinal reperfusion injury, which caused recurrent ventricular arrhythmia required for cardio-pulmonary resuscitation. The surgery was discontinued after resuscitation, and portal vein reconstruction using the REIV was performed 2 days post-operatively. Acute compartment syndrome was diagnosed immediately following the surgery. Hyperkalemia progressed, causing pulseless ventricular tachycardia. Emergent fasciotomy was performed, but right leg dysfunction persisted after discharge.ConclusionREIV resection can cause lower-extremity acute compartment syndrome. The status, including intracompartmental pressure, of the lower extremity should be carefully observed after REIV resection during and after surgery.

Laparoscopic pancreatoduodenectomy combined with portal-superior mesenteric vein resection and reconstruction with interposition graft: Case series.

Rationale:With the development of laparoscopic techniques, laparoscopic pancreatoduodenectomy was applied in various indications including pancreatic cancer. Here, we share our experience of venous resection and reconstruction with interposition graft in laparoscopic pancreatoduodenectomy in these patients.Patient concerns:We reviewed data of laparoscopic pancreatoduodenectomy with venous resection and reconstruction in patients with pancreatic cancer between the dates of October 2010 and November 2017.Outcomes:Ten patients underwent laparoscopic pancreatoduodenectomy with portal-superior mesenteric vein resection and reconstruction with interposition graft. The mean operative time was 547 min. The mean blood loss was 435 ml. The mean length of venous defect after resection was 5.4 cm. R0 resection was achieved in nine patients (90%). There was one patient who suffered from severe postoperative complication. There was no 30-day mortality in this study. The long-term patency was achieved in all patients.Conclusion:In this study, we demonstrate the initial experience of laparoscopic pancreaticoduodenectomy with long venous resection and reconstruction. Although applied in small number of patients, it could be another option for well-selected patients with reasonable morbidity and mortality as well as long-term outcomes in experienced minimally invasive surgical team.

Clinical value of uncinate process resection combined with portal-superior mesenteric vein resection and end-to-end anastomosis in distal pancreatectomy

Objective To explore the clinical value of uncinate process resection combined with portal-superior mesenteric vein resection and end-to-end anastomosis in distal pancreatectomy. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 11 patients who underwent distal pancreatectomy combined with portal-superior mesenteric vein resection and end-to-end anastomosis in the Peking University Cancer Hospital (8 patients) and Jilin Guowen Hospital (3 patients) between January 2014 to April 2018 were collected. During the vascular reconstruction, uncinate process of the pancreas was first resected for reducing anastomotic tension, and then end-to-end anastomosis was done after portal-superior mesenteric vein resection. Observation indicators: (1) intraoperative situations; (2) postoperative recovery situations; (3) postoperative pathological examination situations; (4) follow-up and survival situations. Follow-up using outpatient examination and imaging examination was performed to detect patients′ postoperative survival, tumor recurrence and metastasis and postoperative venous anastomotic patency up to May 2018. Measurement data with normal distribution were represented as ±s. Measurement data with skewed distribution were described as M (range). The non-recurrence and non-metastasis survival curve, overall survival curve and survival rate were respectively drawn and calculated by the Kaplan-Meier method. Results (1) Intraoperative situations: 11 patients received uncinate process resection of the pancreas, and successfully underwent distal pancreatectomy combined with portal-superior mesenteric vein resection and end-to-end anastomosis. Eight patients underwent distal pancreatectomy + Appleby combined with celiac axis resection due to pancreatic tumor involving common hepatic artery, including 2 undergoing combined total gastrectomy due to gastric ischemia; 2 patients underwent distal pancreatectomy; 1 patient underwent distal pancreatectomy + distal gastrectomy due to blood supply obstacle of distal stomach. Operation time and volume of intraoperative blood loss of 11 patients were (5.8±1.1)hours and 800 mL (range, 200-2 500 mL). (2) Postoperative recovery situations: there was no grade C of pancreatic fistula of 11 patients. Four patients had grade B of pancreatic fistula, including 2 were cured by drainage-tube indwelling of pancreatic wound > 3 weeks, 1 was cured by continous washing due to pancreatic fistula combined with infection, and 1 was cured by the second abdominal puncture drainage due to pancreatic fistula with fever; 1 of 4 patients was combined with grade C of delayed gastric emptying and cured by conservative treatment, and other 3 patients didn′t occur postoperative complications. Of 5 patients diagnosed as biochemical fistula, 1 had esophagus-jejunum anastomotic leakage, and 1 had changes of hepatic ischemia in S2, S3 and S4b segments by CT examination and recovered normal liver function at 2 weeks postoperatively, with long-term hepatatrophia in S2 and S3 segments. There was no postoperative death and reoperation in 11 patients. Duration of postoperative hospital stay of 11 patients was (22±5)days. (3) Postoperative pathological examination results: tumors of 11 patients were located in neck and body of the pancreas, with a maximum diameter of (4.8±1.7)cm. Among 11 patients, 10 were confirmed with moderate- or low-differentiated ductal adenocarcinoma and 1 with anaplastic carcinoma. The length of portal-superior mesenteric vein resection of 11 patients was (2.6±0.8)cm. Seven of 11 patients occurred different degrees of tumor infiltration in the portal-superior mesenteric vein, and other 4 patients occurred inflammatory adhesion, without tumor infiltration. (4) Follow-up and survival situations: 11 patients were followed up for 3.0-37.6 months, with a median time of 15.7 months. During the follow-up, 8 patients died of tumor recurrence and / or metastasis, and 3 survived; the non-recurrence and non-metastais survival time and overall survival time were respectively 9.0 months (range, 3.0-37.6 months) and 24.6 months (range, 3.0-37.6 months). One patient was complicated with anastomotic stenosis and surrounding varices of portal-superior mesenteric vein by postoperative half-year reexamination, anastomotic vein anomalies and venous thrombosis were not found in other patients before local tumor recurrence and / or death. Conclusion The combined uncinate process resection of the pancreas cannot increase the risk of postoperative pancreatic fistula, and it could effectively reduce the anastomotic tension in the distal pancreatectomy combined with portal-superior mesenteric vein resection and reconstruction, meanwhile, it can also achieve end-to-end anastomosis after longer vein resection. Key words: Pancreatic neoplasms; Distal pancreatectomy; Vascular resection; End-to-end anastomosis; Uncinate process resection of the pancreas

Proposed Chaoyang vascular classification for superior mesenteric-portal vein invasion, resection, and reconstruction in patients with pancreatic head cancer during pancreaticoduodenectomy – A retrospective cohort study

BackgroundPatients with pancreatic head cancer involving the superior mesenteric-portal vein can benefit from vascular resection and reconstruction. We aimed to propose our vascular classification and assess its effect in this study. Material and methodsData of consecutive patients, who were diagnosed with pancreatic head cancer, and underwent radical pancreaticoduodenectomy combined with superior mesenteric-portal vein resection and reconstruction at our institute between October 2013 and August 2016, were retrospectively collected. On a scale of one to four, our classification was proposed. Perioperative parameters were then analyzed among the four types. ResultsThere were a total of 52 patients with 11 in type Ⅰ, 15 in type Ⅱ, 18 in type Ⅲ, 8 in type Ⅳ. The respective operative time and estimated blood loss of types Ⅲ (425–990 min, 265–1820 mL) and Ⅳ (480–1036 min, 330–1690 mL) were greater than those of types Ⅰ (300–824 min, 200–1255 mL) and Ⅱ (369–875 min, 305–1400 mL) (p < 0.05). Type Ⅳ had larger tumors (4–7 cm) than type Ⅰ (1.5–4 cm) (p < 0.05). Percentage of tunica intima involvement and the median survival time of type Ⅰ (9.1%, 22 months) were lower and longer than those of types Ⅱ (46.7%, 17 months) and Ⅲ (44.4%, 16 months; p < 0.05), and even lower and longer than those of type Ⅳ (87.5%, 10 months; p < 0.01), respectively. ConclusionsOur classification can provide a system to grade patients with venous invasion in order of surgical difficulty and survival.

Impact of the T and N stage in the American Joint Committee on Cancer (AJCC) 8th edition staging system for pancreatic cancer with curative resection.

261 Background: The 8th edition of the AJCC staging system for pancreatic cancer contains several changes. T and N classification incorporate tumor size and number of positive lymph node (LN). The aim of this study was to evaluate the impact on the outcomes of the new classification for the patients who underwent curative resection and received adjuvant treatment with S-1. Methods: We retrospectively reviewed 96 patients who underwent curative resection for pancreatic ductal adenocarcinoma and received adjuvant treatment with S-1 (40, 50, or 60 mg according to body-surface area, orally administered twice a day for 28 days followed by a 14-day rest, every 6 weeks [one cycle], for up to four cycles) at our institution between January 2007 and December 2015. Inclusion criteria were as follows: PS0/1, adequate-organ functions, no critical complication, start of adjuvant therapy within 10 weeks after resection, and no active concomitant malignancy. Results: 66 patients were satisfied with these criteria. Patients characteristics were as follows: median age 67 years (range, 43-83), male 40 (61%), Pancreatoduodenectomy / Distal / Total pancreatectomy 50/14/2, combined portal vein or superior mesenteric vein resection 25 (38%), no postoperative complication 25 (38%), Well/Moderately/Poorly differentiated type 23/41/2, the median tumor size 30mm (range, 13-130), the median number of dissected LN 25 (range, 10-60), the median number of positive LN 2 (range, 0-8), and the resection margin status (R0/1) 62/4. The distribution in the 8th edition (1A/1B/2A/2B/3) was 6(9%) / 10(15%) / 5(8%) / 36(54%) / 9(14%), respectively. 2-year overall survival (OS) and relapse-free survival (RFS) were 70% and 52%. In the 8th edition staging system (1A/1B/2A/2B/3), 2-year OS and RFS were 100/90/80/66/40% and 83/70/53/49/22%, respectively. 2-year OS and RFS by T classification according to AJCC 8th edition were 100/68/56% and 90/39/56% (T1/2/3), while those by N classification were 90/66/40% and 70/49/22% (N0/1/2), respectively. Conclusions: The survival was poor with progress of the stage in the new classification. Especially at N stage, it might be suggested an association with prognosis.

Clinical efficacy of modified FOLFIRINOX as neoadjuvant chemotherapy for borderline resectable pancreatic cancer

Objective To investigate the clinical efficacy of modified FOLFIRINOX as neoadjuvant chemotherapy for borderline resectable pancreatic cancer. Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 28 patients diagnosed as borderline resectable pancreatic cancer who were admitted to the Tianjin Medical University Cancer Institute and Hospital between April 2013 and October 2015 were collected. Twenty-eight patients were treated with modified FOLFIRINOX( irinotecan 135 mg/m2, oxaliplatin 64 mg/m2, leucovorin 400 mg/m2, 5-FU 2 400 mg/m2, repeat the regimen every 2 weeks) as neoadjuvant chemotherapy. After the completion of neoadjuvant chemotherapy, patients were evaluated operation feasibility and developed surgical planning in 3 weeks. Observation indicators: (1) Efficacy of neoadjuvant chemotherapy; (2) adverse events of neoadjuvant chemotherapy; (3) surgical and postoperative situations; (4) follow-up situations. Follow-up using outpatient examination, telephone interview and we-chat was performed to etect survival of patients up to January 2017. Measurement data with skewed distribution were described as median (range). The survival curve was drawn by Kaplan-Meier method and the survival analysis was done by Log-rank test. Results (1) Efficacy of neoadjuvant chemotherapy: 28 patients received chemotherapy with a median cycle of 6 cycles (range, 3-12 cycles). Chemotherapy reaction of 28 patients: 14 had partial remission, 10 had stable disease and 4 had progressive disease. (2) Adverse events of neoadjuvant chemotherapy: there were 22 adverse events of 28 patients during chemotherapy, including 15 with grade1-2 and 7 with grade 3-4. (3) Surgical and postoperative situations: of 28 patients, 18 received radical resection for pancreatic cancer including 11 receiving pancreaticoduodenectomy, 7 receiving distal pancreatectomy with splenectomy. Surgeries included 6 with portal vein and superior mesenteric vein resection and reconstruction, 1 with coeliac trunk resection. Ten patients received R0 resection and 8 received R1 resection. Of 18 patients, 8 with postoperative complications were improved by conservative treatment, including 2 with pancreatic fistula, 1 with biliary fistula, 3 with delayed gastric empty, 1 with anastomotic hemorrhage, 1 with lympha fistula. No patient received re-operation or died within 30 days postoperatively. Pathological TNM staging: 2 patients were detected in stage Ⅰ-Ⅱ, 14 in stage Ⅲ and 2 in stage Ⅳ. All the 18 patients received chemotherapy after operation. Ten patients without operation continued chemotherapy. (4) Following up: 28 patients were followed up for 5-21 months with a median time of 13 months. Of the 15 died patients, 5 received operation and 10 received no operation. The median progression-free survival time and median overall survival time were 14 months and 19 months in the 18 operative patients, 7 months and 11 months in the 10 non-operative patients, respectively, with statistically significant differences (χ2=7.335, 9.950, P<0.05). Conclusions Modified FOLFIRINOX as neoadjuvant chemotherapy for borderline resectable pancreatic cancer is safe and effective, and patients can tolerate mild adverse reactions. Operable patients undergo surgeries after chemotherapy have relatively good outcome. Key words: Pancreatic neoplasm; Neoadjuvant chemotherapy; Modified FOLFIRINOX

Pancreatoduodenectomy combined with portal-superior mesenteric vein resection and reconstruction with interposition grafts for cancer: a meta-analysis.

The use of interposition grafts for portal-superior mesenteric vein (PV-SMV) reconstruction during pancreatoduodenectomy (PD) with venous resection (VR) for localized periampullary tumors is a controversial topic. The present meta-analysis aimed to evaluate the perioperative and long-term outcomes in patients who received interposition grafts for PV-SMV reconstruction after PD with VR. The correlative databases were systematically searched to identify relevant trials comparing vein grafts versus no vein grafts during PD with VR. 14 studies including 257 patients with vein grafts and 570 patients without vein grafts were extracted. The meta-analysis indicated no difference in perioperative morbidity, mortality, or thrombosis between the two groups, but the vein graft group was associated with a significantly increased venous thrombosis rate (≥ 6 months) (odds ratio [OR] = 2.75; 95% confidence interval [CI], 1.32–5.73; P = .007). The autologous vein group subgroup analysis also revealed a significantly increased vein thrombosis rate (OR = 3.13; 95% CI, 1.45–6.76; P = .004) between the two groups. Meanwhile, the prosthetic vein group subgroup analysis indicated no difference. Additionally, the oncological value of vein grafts during PD for pancreatic cancer survival was analyzed and revealed no difference in 1-year, 3-year, or 5-year survival between the two groups. Using interposition grafts for PV-SMV reconstruction is safe and effective, and has perioperative outcomes and long-term survival rates compared to those with no vein grafts during PD with VR. However, the lower long-term vein patency rate in patients with vein grafts indicate that interposition grafts may be more likely to lose function.

Trends in indications, complications and outcomes for venous resection during pancreatoduodenectomy.

Pancreatoduodenectomy with superior mesenteric-portal vein resection has become a common procedure in pancreatic surgery. The aim of this study was to compare standard pancreatoduodenectomy with pancreatoduodenectomy plus venous resection at a high-volume centre, and to examine trends in management and outcome over a decade for the latter procedure. This retrospective observational study included all patients undergoing pancreatoduodenectomy with or without venous resection at Oslo University Hospital between January 2006 and December 2015. Trends were evaluated by assessing preoperative clinical and radiological characteristics, as well as perioperative outcomes in three time intervals (early, intermediate and late). A total of 784 patients had a pancreatoduodenectomy, of whom 127 (16·2 per cent) underwent venous resection. Venous resection resulted in a longer operating time (median 422 versus 312 min; P = 0·001) and greater estimated blood loss (EBL) (median 700 versus 500 ml; P = 0·004) than standard pancreatoduodenectomy. The rate of severe complications was significantly higher for pancreatoduodenectomy with venous resection (37·0 versus 26·3 per cent; P = 0·014). The overall burden of complications, evaluated using the Comprehensive Complication Index (CCI), did not differ (median score 8·7 versus 8·7; P = 0·175). Trends in venous resection over time showed a significant reduction in EBL (median 1050 versus 375 ml; P = 0·001) and duration of hospital stay (median 14 versus 9 days; P = 0·011) between the early and late periods. However, despite an improvement in the intermediate period, severe complication rates returned to baseline in the late period (18 of 43 versus 9 of 42 versus 20 of 42 patients in early, intermediate and late periods respectively; P = 0·032), as did CCI scores (median 20·9 versus 0 versus 20·9; P = 0·041). Despite an initial improvement in severe complications for venous resection during pancreatoduodenectomy, this was not maintained over time. Every fourth patient with venous resection needed relaparotomy, most frequently for bleeding.

Combination therapy of portal vein resection and adjuvant gemcitabine improved prognosis of advanced pancreatic cancer.

Although adjuvant chemotherapy (AC) using gemcitabine improves the prognosis of patients with resectable pancreatic cancer, the effect of gemcitabine AC on the prognosis of patients with borderline resectable pancreatic cancer is not clear. We analyzed the prognosis of patients with pancreatic cancer who underwent curative pancreatoduodenectomy or total pancreatectomy in combination with portal/superior mesenteric vein resection (PVR) [PVR (+) group] or without PVR [PVR(-) group]. MST of the PVR (+) group was significantly shorter than that of the PVR(-) group (p=0.017). In contrast, when we focused on the patients with gemcitabine AC, there was no significant difference in MST between the PVR (+) and the PVR (-) groups (p=0.247). Furthermore, we compared MST of two subgroups in the PVR (+) group depending on gemcitabine AC status. In the PVR (+) group, MST of the patients with gemcitabine AC was significantly longer than that without gemcitabine AC (p=0.003). This was also true for the patients with pancreatic cancer which had histologically proven invasion to portal/superior mesenteric vein (PV/SMV) (p=0.001). The prognosis of patients with pancreatic cancer invading PV/SMV can be improved by combination therapy with PVR and gemcitabine adjuvant chemotherapy.

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.

Pancreaticoduodenectomy for ductal adenocarcinoma of the pancreatic head with venous resection.

BackgroundRecent reports have shown that patients with vascular tumour invasion who undergo concurrent vascular resection can achieve long-term survival rates equivalent to those without vascular involvement requiring pancreaticoduodenectomy alone. There is no consensus about which patients benefit from the portal-superior mesenteric vein resection and there is no consensus about the best surgical technique of vessel reconstruction (resection with or without graft reconstruction). As published series are small the aim of this study was to evaluate our experience in pancreatectomies with en bloc vascular resection and reconstruction of vessels.MethodsReview of database at University Clinical Centre Maribor identified 133 patients (average age 65.4 ± 8.6 years, 69 female patients) who underwent pancreatoduodenectomy between January 2006 and August 2014. Clinical data, operative results, pathological findings and postoperative outcomes were collected prospectively and analyzed. Current literature and our experience in pancreatectomies with en bloc vascular resection and reconstruction of portal vein are reviewed.ResultsTwenty-two patients out of 133 (16.5%) had portal vein-superior mesenteric vein resection and portal vein reconstruction (PVR) during pancreaticoduodenectomy. In fourteen patients portal vein was reconstructed without the use of synthetic vascular graft. In these series two types of venous reconstruction were performed. When tumour involvement was limited to the superior mesenteric vein (SPV) or portal vein (PV) such that the splenic vein could be preserved, and vessels could be approximated without tension a primary end-to-end anastomosis was performed. When tumour involved the SMV-splenic vein confluence, splenic vein ligation was necessary. In the remaining eight procedures interposition graft was needed. Dacron grafts with 10 mm diameter were used. There was no infection after dacron grafting. One patient had portal vein thrombosis after surgery: it was thrombosis after primary reconstruction. There were no thromboses in patients with synthetic graft interposition. There were no significant differences in postoperative morbidity, mortality or grades of complication between groups of patients with or without a PVR. Median survival time in months was in a group with vein resection 16.13 months and in a group without vein resection 15.17 months. Five year survival in the group without vein resection was 19.5%. Comparison of survival curves showed equal hazard rates with log-rank p = 0.090.ConclusionsSurvival of patients with pancreatic cancer who undergo an R0 resection with reconstruction was comparable to those who have a standard pancreaticoduodenectomy with no added mortality or morbidity. Synthetic graft appeared to be an effective and safe option as an interposition graft for portomesenteric venous reconstruction after pancreaticoduodenectomy.

Meta-Analysis of Benefits of Portal-Superior Mesenteric Vein Resection in Pancreatic Resection for Ductal Adenocarcinoma

There are increased postoperative mortality rates, higher rates of non-R0, positive margins, resection and worse survival after pancreatic resection with portal vein superior mesenteric vein (PV/SMV) resection.

Superior Mesenteric-Portal Vein Resection in Patients With Pancreatic Adenocarcinoma Is Safe and May Increase Survival

Extension of pancreatic adenocarcinoma into adjacent vasculature often necessitates resection of the portal vein (PV) and or superior mesenteric vein (SMV) during pancreaticoduodenectomy (PD). Our study describes the surgical technique and results of PV/SMV resection in pancreatic adenocarcinoma patients. Between January 2008 and October 2013, 252 patients underwent PD for pancreatic malignancy. A total of 42 PV/SMV resections were performed (28 men, 14 women). Patients were categorized into 2 groups according to the degree of invasion into the portal vein wall: Group A (n = 16), extended compression of the portal vein wall by the surrounding carcinoma without true invasion, and Group B (n = 26), true invasion including intramural and transmural invasion. Morbidity of the 42 patients was 35%; there was no operative mortality, and overall 1-, 3-, and 5-year survival rates were 60%, 21%, and 12%, respectively. No differences in tumor size, margin positivity, nodal positivity, or survival rates were observed between groups. Resection of the PV/SMV is safe and does not increase morbidity or mortality. Tumor involvement of the PV/SMV is not associated with histopathologic signs that are predictive of a poor prognosis. The “artery first” approach should be considered as a means to facilitate safe venous resection and reconstruction.

Synchronous superior mesenteric-portal vein resection during pancreatectomy for T3 head adenocarcinoma: Perioperative outcomes and prognostic implications of histologically confirmed venous infiltration

Synchronous superior mesenteric-portal vein resection during pancreatectomy for T3 head adenocarcinoma: Perioperative outcomes and prognostic implications of histologically confirmed venous infiltration