Postoperative Outcomes of Tangential versus Segmental Resection and End-to-end Reconstruction of the Superior Mesenterico-Portal Vein During Pancreatoduodenectomy for Pancreatic Adenocarcinoma: A Single-Center Experience

Abstract

Background/Aim: The impact of venous resections and reconstruction techniques on morbidity after surgery for pancreatic cancer (PDAC) remains controversial. Patients and Methods: A total of 143 patients receiving pancreatoduodenectomy (PD) for PDAC between 2013 and 2018 were identified from a prospective database. Morbidity and mortality after PD with tangential resection versus endto-end reconstruction were assessed. Results: Fifty-two of 143 (36.4%) patients underwent PD with portal venous resection (PVR), which was associated with longer operation times [398 (standard error (SE) 12.01) vs. 306 (SE 13.09) min, p<0.001]. PVR was associated with longer intensivecare-unit stay (6.3 vs. 3.8 days, p=0.054); morbidity (Clavien-Dindo classification (CDC) grade p>0.99) were not different. Tangential venous resection was associated with similar CDC grade IIIa-IV (42.9% vs. 50.0%, p=0.781) and 30-day mortality rates (3.5% vs. 4.1%, p=0.538) as segmental resection and end-to-end venous reconstruction. Conclusion: Both tangential and segmental PVR appear feasible and can be safely performed to achieve negative resection margins.Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive gastrointestinal tumors and associated with dismal prognosis. PDAC is expected to be in the top three causes of cancer-related deaths by 2030 (1-4). Five-year overall survival rates are as low as 6% for all PDAC patients (5). Surgical resection remains the only curative treatment, and tumors of the pancreatic head undergo pancreatoduodenectomy (PD) (1-3). About 20% of patients with PDAC are unresectable at the time of initial diagnosis presenting with distant metastasis or major arterial involvement (1, 2). While arterial resections during PD are associated with increased morbidity and mortality (3), resection of the superior mesenterico-portal vein (SMPV) has become a standard procedure (4). The guidelines of the National Comprehensive Cancer Network (NCCN) define involvement of the SMPV as borderline resectable PDAC if safe reconstruction is deemed feasible (5-7). Large studies of PD for PDAC reported PVR rates of about 30% (2, 3). Although PVR is increasingly considered a standard procedure at "high-volume" centers of pancreatic surgery, heterogeneous results have been reported regarding perioperative morbidity and mortality (4, 8) as well as longterm outcomes (4, 9-12). Venous resections can be performed as tangential or segmental resections with end-to-end 5123