Laparoscopic pancreaticoduodenectomy with major venous resection and reconstruction: anterior superior mesenteric artery first approach

  • Yunqiang Cai
  • Pan Gao
  • Yongbin Li
  • Xin Wang
  • Bing Peng
Article
  • 52 Downloads

Abstract

Background

The en bloc resection of the superior mesenteric or portal vein with concomitant venous reconstruction may be required in patients with borderline resectable pancreatic cancer. However, performing laparoscopic pancreaticoduodenectomy (LPD) with major venous resection and reconstruction is technically challenging. Herein, we introduced a safe and feasible technique to perform LPD with major venous resection.

Methods

Over the period of November 2015 to November 2016, 18 patients underwent laparoscopic pancreaticoduodenectomy with major venous resection and reconstruction using the anterior superior mesenteric artery (SMA)-first approach at our institution. Demographic characteristics, intraoperative and postoperative variables, and follow-up outcomes were prospectively collected.

Results

Eighteen male and ten female patients were included in this study. The median age of the patients was 58 years (range 49–76 years). Eight cases of wage resections, six cases of end-to-end anastomosis, and four cases of artificial grafts were performed in our series. Only one patient (5.6%) required conversion because of uncontrolled bleeding from the splenic vein. The average operative time was 448 min (range 420–570 min). The mean time for blood occlusion was 32 min, including 17 min for wage resections, 28 min for end-to-end anastomosis, and 48 min for artificial grafts. Thirty-day mortality was not observed in our series. The median postoperative hospital stay was 13 days (range 9–18 days). Three patients suffered from pancreatic fistula (Grade A), and one suffered from abdominal bleeding after subcutaneous injection with low-molecular heparin. In this case, abdominal bleeding was stopped through conservative therapies.

Conclusion

Laparoscopic pancreaticoduodenectomy with major venous resection and reconstruction can be safely and feasibly performed. The anterior SMA-first approach can facilitate this procedure and decrease operative time and blood occlusion duration.

Keywords

Laparoscopic Minimal invasive surgery Pancreatectomy Pancreaticoduodenectomy Vascular resection 

Notes

Compliance with ethical standards

Disclosures

Dr. Yunqiang Cai, Pan Gao, Yongbin Li, Xin Wang, and Bing Peng have no conflicts of interest or financial ties to disclose.

Supplementary material

Supplementary material 1 (MP4 242747 KB)

References

  1. 1.
    Gagner M, Pomp A (1994) Laparoscopic pylorus-preserving pancreatoduodenectomy. Surg Endosc 8:408–410CrossRefPubMedGoogle Scholar
  2. 2.
    Subhas G, Mittal VK (2011) Training minimal invasive approaches in hepatopancreatobilliary fellowship: the current status. HPB 13:149–152CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Palanivelu C, Rajan PS, Rangarajan M, Vaithiswaran V, Senthilnathan P, Parthasarathi R, Praveen Raj P (2009) Evolution in techniques of laparoscopic pancreaticoduodenectomy: a decade long experience from a tertiary center. J Hepatobil Pancreat Surg 16:731–740CrossRefGoogle Scholar
  4. 4.
    Liao CH, Wu YT, Liu YY, Wang SY, Kang SC, Yeh CN, Yeh TS (2016) Systemic review of the feasibility and advantage of minimally invasive pancreaticoduodenectomy. World J Surg 40:1218–1225CrossRefPubMedGoogle Scholar
  5. 5.
    Awad ZT (2014) Totally laparoscopic pancreaticoduodenectomy for pancreatic head cancer with involvement of the superior mesenteric vein-portal vein confluence. Ann Surg Oncol 21:3439CrossRefPubMedGoogle Scholar
  6. 6.
    Palanisamy S, Deuri B, Naidu SB, Vaiyapurigoundar Palanisamy N, Natesan AV, Palanivelu PR, Parthasarathy R, Palanivelu C (2015) Major venous resection and reconstruction using a minimally invasive approach during laparoscopic pancreaticoduodenectomy: one step forward. Asian J Endosc Surg 8:468–472CrossRefPubMedGoogle Scholar
  7. 7.
    Croome KP, Farnell MB, Que FG, Reid-Lombardo KM, Truty MJ, Nagorney DM, Kendrick ML (2015) Pancreaticoduodenectomy with major vascular resection: a comparison of laparoscopic versus open approaches. J Gastrointest Surg 19:189–194 (discussion 194)CrossRefPubMedGoogle Scholar
  8. 8.
    Kendrick ML, Sclabas GM (2011) Major venous resection during total laparoscopic pancreaticoduodenectomy. HPB 13:454–458CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Dokmak S, Cherif R, Duquesne I, Delattre R, Aussilhou B, Soubrane O, Sauvanet A (2016) Laparoscopic pancreaticoduodenectomy with reconstruction of the portal vein with the parietal peritoneum. Ann Surg Oncol 23:2664CrossRefPubMedGoogle Scholar
  10. 10.
    Siriwardana HP, Siriwardena AK (2006) Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer. Br J Surg 93:662–673CrossRefPubMedGoogle Scholar
  11. 11.
    Asbun HJ, Stauffer JA (2012) Laparoscopic vs open pancreaticoduodenectomy: overall outcomes and severity of complications using the Accordion Severity Grading System. J Am Coll Surg 215:810–819CrossRefPubMedGoogle Scholar
  12. 12.
    Kantor O, Talamonti MS, Sharpe S, Lutfi W, Winchester DJ, Roggin KK, Bentrem DJ, Prinz RA, Baker MS (2017) Laparoscopic pancreaticoduodenectomy for adenocarcinoma provides short-term oncologic outcomes and long-term overall survival rates similar to those for open pancreaticoduodenectomy. Am J Surg 213:512–515CrossRefPubMedGoogle Scholar
  13. 13.
    Hakeem AR, Verbeke CS, Cairns A, Aldouri A, Smith AM, Menon KV (2014) A matched-pair analysis of laparoscopic versus open pancreaticoduodenectomy: oncological outcomes using Leeds Pathology Protocol. Hepatobil Pancreat Dis Int 13:435–441CrossRefGoogle Scholar
  14. 14.
    Khatkov IE, Izrailov RE, Khisamov AA, Tyutyunnik PS, Fingerhut A (2017) Superior mesenteric-portal vein resection during laparoscopic pancreatoduodenectomy. Surg Endosc 31:1488–1495CrossRefPubMedGoogle Scholar
  15. 15.
    Mollberg N, Rahbari NN, Koch M, Hartwig W, Hoeger Y, Buchler MW, Weitz J (2011) Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis. Ann Surg 254:882–893CrossRefPubMedGoogle Scholar
  16. 16.
    Amano H, Miura F, Toyota N, Wada K, Katoh K, Hayano K, Kadowaki S, Shibuya M, Maeno S, Eguchi T, Takada T, Asano T (2009) Is pancreatectomy with arterial reconstruction a safe and useful procedure for locally advanced pancreatic cancer? J Hepato-bil Pancreat Surg 16:850–857CrossRefGoogle Scholar
  17. 17.
    Weitz J, Rahbari N, Koch M, Buchler MW (2010) The “artery first” approach for resection of pancreatic head cancer. J Am Coll Surg 210:e1–e4CrossRefPubMedGoogle Scholar
  18. 18.
    Noto M, Miwa K, Kitagawa H, Kayahara M, Takamura H, Shimizu K, Ohta T (2005) Pancreas head carcinoma: frequency of invasion to soft tissue adherent to the superior mesenteric artery. Am J Surg Pathol 29:1056–1061PubMedGoogle Scholar
  19. 19.
    Gaedcke J, Gunawan B, Grade M, Szoke R, Liersch T, Becker H, Ghadimi BM (2010) The mesopancreas is the primary site for R1 resection in pancreatic head cancer: relevance for clinical trials. Langenbecks Arch Surg 395:451–458CrossRefPubMedGoogle Scholar
  20. 20.
    Kim PT, Temple S, Atenafu EG, Cleary SP, Moulton CA, McGilvray ID, Gallinger S, Greig PD, Wei AC (2014) Aberrant right hepatic artery in pancreaticoduodenectomy for adenocarcinoma: impact on resectability and postoperative outcomes. HPB 16:204–211CrossRefPubMedGoogle Scholar
  21. 21.
    Shrikhande SV, Barreto SG, Bodhankar YD, Suradkar K, Shetty G, Hawaldar R, Goel M, Shukla PJ (2011) Superior mesenteric artery first combined with uncinate process approach versus uncinate process first approach in pancreatoduodenectomy: a comparative study evaluating perioperative outcomes. Langenbecks Arch Surg 396:1205–1212CrossRefPubMedGoogle Scholar
  22. 22.
    Sanjay P, Takaori K, Govil S, Shrikhande SV, Windsor JA (2012) ‘Artery-first’ approaches to pancreatoduodenectomy. Br J Surg 99:1027–1035CrossRefPubMedGoogle Scholar
  23. 23.
    Pilgrim CH, Tsai S, Tolat P, Patel P, Rilling W, Evans DB, Christians KK (2014) Optimal management of the splenic vein at the time of venous resection for pancreatic cancer: importance of the inferior mesenteric vein. J Gastrointest Surg 18:917–921CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Yunqiang Cai
    • 1
    • 2
  • Pan Gao
    • 2
  • Yongbin Li
    • 2
  • Xin Wang
    • 1
  • Bing Peng
    • 1
  1. 1.Department of Pancreatic SurgeryWest China Hospital, Sichuan UniversityChengduChina
  2. 2.Department of Minimal Invasive SurgeryShangjin Nanfu HospitalChengduChina

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