Vascular surgery collaboration during pancreaticoduodenectomy with vascular reconstruction.
BACKGROUND
Once thought to have unresectable disease, pancreatic cancer patients with portal venous involvement are now reported to have comparable survival after pancreaticoduodenectomy (PD) with vascular reconstruction (VR) as compared with patients without vascular involvement. We hypothesize that a multidisciplinary approach involving a vascular surgeon will minimize morbidity and improve patency of VRs.


METHODS
We identified 204 patients who underwent PD for pancreatic adenocarcinoma from 1997 to 2008. Patients who underwent PD with VR (N = 42) were compared with those who underwent standard PD (N = 162). VRs were performed by a vascular surgeon and involved primary repair (N = 8), vein patch (N = 25), or interposition grafting (N = 9) with femoral or other venous conduit.


RESULTS
Patients undergoing PD with VR had larger tumors (3.0 cm vs. 2.5 cm, P < 0.01) but did not have different rates of tumor-free margins (73% vs. 72%, P = 0.84) or lymph nodes metastases (50% vs. 38%, P = 0.14). The VR group had higher median blood loss (875 mL vs. 550 mL, P = 0<0.01), but no differences in mortality, complication rates, length of stay, or readmission rates were found in a median follow-up of 29 months. Overall survival rates were similar. Predictors of mortality on multivariate analysis included increasing histological grade (P = 0.01), positive lymph nodes (P = 0.01), and increasing tumor size (P = 0.01), but not VR (P = 0.28). When evaluated by computed tomography scans within 6 months postoperatively, 97% of reconstructions remained patent.


CONCLUSIONS
The need for VR is not a contraindication to potentially curative resection in patients with pancreatic adenocarcinoma. Assistance of a vascular surgeon during VR may allow moderate-volume centers to achieve outcomes comparable with high-volume centers.
Department of Surgery, Duke University, Durham, NC 27710, USA.
Ryan S
RS
Turley
Kirk
K
Peterson
Andrew S
AS
Barbas
Eugene P
EP
Ceppa
Erik K
EK
Paulson
Dan G
DG
Blazer
Bryan M
BM
Clary
Theodore N
TN
Pappas
Douglas S
DS
Tyler
Richard L
RL
McCann
Rebekah R
RR
White
D000230:Adenocarcinoma / Q000000981:diagnostic imaging / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016009:Chi-Square Distribution; D003299:Cooperative Behavior; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009361:Neoplasm Invasiveness; D009657:North Carolina; D010190:Pancreatic Neoplasms / Q000000981:diagnostic imaging / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000401:mortality; D010348:Patient Care Team; D018579:Patient Selection; D011169:Portal Vein / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D016016:Proportional Hazards Models; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality