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


METHODS
Review 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.


RESULTS
Twenty-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.


CONCLUSIONS
Survival 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.
Department of Vascular Surgery, Surgical clinics, University Clinical Centre Maribor, Slovenia.
Vojko
V
Flis
Department of Vascular Surgery, Surgical clinics, University Clinical Centre Maribor, Slovenia.
Stojan
S
Potrc
Department of Vascular Surgery, Surgical clinics, University Clinical Centre Maribor, Slovenia.
Nina
N
Kobilica
Department of Vascular Surgery, Surgical clinics, University Clinical Centre Maribor, Slovenia.
Arpad
A
Ivanecz
pancreatic cancer; pancreaticoduodenectomy; vein resection
Eur J Surg Oncol. 2011 Sep;37(9):791-7
21741199
Ann Surg. 1973 Aug;178(2):209-14
4269229
J Gastrointest Surg. 2004 Dec;8(8):935-49; discussion 949-50
15585381
J Gastrointest Surg. 2003 Dec;7(8):1089-95
14675720
J Korean Surg Soc. 2013 Jun;84(6):346-52
23741692
Hepatobiliary Pancreat Dis Int. 2012 Jun;11(3):234-42
22672815
Br J Surg. 2009 Mar;96(3):247-52
19224515
J Am Coll Surg. 2012 Oct;215(4):569-79
22762991
J Am Coll Surg. 2014 Mar;218(3):401-11
24484730
J Gastrointest Surg. 2006 Dec;10(10):1371-5
17175456
Surgeon. 2012 Apr;10(2):102-6
22209537
Ann Surg Oncol. 2008 Jun;15(6):1651-60
18351300
Arch Surg. 2009 Feb;144(2):154-9
19221327
Am Surg. 1995 Jul;61(7):607-11
7793742
Ann Surg Oncol. 2014 Jun;21(6):1927-8
24370905
World J Surg. 2010 Nov;34(11):2648-61
20607257
Ann Surg Oncol. 2009 Apr;16(4):789-91
19169752
J Surg Oncol. 2013 Jan;107(1):33-8
22711619
J Gastrointest Surg. 2011 Dec;15(12):2187-92
21997435
J Gastrointest Surg. 2009 Apr;13(4):784-92
19137380
Br J Surg. 2006 Jun;93(6):662-73
16703621
J Am Coll Surg. 2008 May;206(5):833-46; discussion 846-8
18471707
J Am Coll Surg. 2010 Sep;211(3):316-24
20800187
World J Surg. 2012 Apr;36(4):884-91
22350478
J Vasc Surg. 2012 May;55(5):1386-93; discussion 1393
22386140
Ann Surg. 2001 Dec;234(6):758-68
11729382
Arch Surg. 2002 Aug;137(8):901-6; discussion 906-7
12146988
Ann Surg. 2008 Feb;247(2):300-9
18216537
Langenbecks Arch Surg. 2014 Oct;399(7):801-10
25173359
Ann Surg. 2009 Aug;250(2):187-96
19638912
J Gastrointest Surg. 2007 Sep;11(9):1168-74
17632763