Venous Reconstruction During Pancreatectomy in Borderline Resectable Pancreatic Cancer

Pancreaticoduodenectomy with complete resection of disease is the sole curative treatment of pancreatic cancer. The number of patients undergoing resection for disease invading the portal vein (PV) or superior mesenteric vein (SMV) is increasing. We aimed to describe our experience with PV or SMV reconstruction during pancreaticoduodenectomy for borderline resecTable pancreatic ductal adenocarcinoma. We performed a single-institution, retrospective review of all consecutive pancreaticoduodenectomies performed with PV/SMV reconstruction between January 2013 and October 2019. Exclusion criteria were: lack of preoperative computed tomography scan, lack of at least one postoperative follow-up computed tomography scan/magnetic resonance imaging within 6 months, or indications for surgery other than pancreatic ductal adenocarcinoma. We analyzed demographics, comorbidities, type of procedure performed, granular intraoperative data, and medication usage. The primary outcomes were 1-year mortality and thrombosis/occlusion. Sixty-six patients were included. The mean age was 65.5 years, 35 (53%) were female, 58 (88%) were white and the majority of patients were either overweight or obese. The proportion of pancreaticoduodenectomies performed with venous reconstruction has increased from 17% in 2013 to 31% in 2019 (Figure). Thirty-five (52%) patients underwent planned venous reconstruction and 33 (50%) had a preoperative internal jugular duplex performed. Four types of reconstruction were performed: 27 (42%) interposition grafts, 21 (32%) primary repairs, 13 (20%) end-to-end anastomosis, and 4 (6%) patch repair. Overall, 14 (23%) required intraoperative transfusion. Postoperatively, 51 (77%) were started on aspirin and 12 (18%) were started on therapeutic anticoagulation. Of the 15 (23%) patients that had PV/SMV thrombosis or occlusion, 47% were thrombosed within 30 days. One-year mortality was 16.7%. The interposition graft group had the most planned venous reconstructions compared to primary repair, end-to-end, and patch (74% vs 19% vs 62% vs 25%; P < .01), longest vascular surgeon operative time (137 minutes vs 52.5 minutes vs 43 minutes vs 105.5 minutes; P < .01), second longest total operative time (625 minutes vs 516 minutes vs 560 minutes vs 637 minutes ; P < .01). Interposition grafts were more likely to involve both PV and SMV (89% vs 0% vs 23% vs 100%; P < .01) and involve splenic reimplantation (44% vs 0% vs 8% vs 30%; P < .01) than end-to-end or primary repair. Interposition grafts trended toward having longer PV/SMV resections than end-to-end (2 cm vs 0.9 cm; P = .15). Patch repair was associated with higher thrombosis rates and higher rates of postoperative pancreatic fistula and major postoperative complications (Table). Venous reconstruction during pancreaticoduodenectomy is associated with accepTable postoperative morbidity and mortality. This allows treatment of patients previously considered unresecTable.TableUnivariate demographics, comorbidities, intraoperative details, medications, and outcomes compared between interposition graft, primary repair, end-to-end, and patch repairInterposition graft (n = 27)Primary repair (n = 21)End-to-end (n = 13)Patch (n = 4)P valueDemographics Age, years, median (IQR)63 (61-67)63 (61-67)67 (61-76)69 (64-76).26 Female sex14 (52%)10 (48%)7 (54%)3 (75%).87 White race24 (89%)18 (86%)11 (85%)4 (100%)1BMI.19 Normal (BMI 18.5-25)8 (30%)3 (14%)6 (46%)1 (33%) Overweight (BMI 25-30)13 (48%)11 (52%)3 (23%)0 (0%) Obese (BMI 30-40)6 (22%)7 (33%)4 (31%)2 (67%)Charlson Comorbidity Index, median (IQR)6 (6, 7)7 (6, 7)6 (6, 7)8 (7, 9.5).1History of VTE4 (15%)0 (0%)2 (15%)0 (0%).17Intraoperative details Planned venous reconstruction20 (74%)4 (19%)8 (62%)1 (25%)