Advertisement

Arterial, but Not Venous, Reconstruction Increases 30-Day Morbidity and Mortality in Pancreaticoduodenectomy

  • Sara L. Zettervall
  • Tammy JuEmail author
  • Jeremy L. Holzmacher
  • Bridget Huysman
  • Gregor Werba
  • Anton Sidawy
  • Paul Lin
  • Khashayar Vaziri
Original Article
  • 29 Downloads

Abstract

Background

Vascular reconstruction during pancreaticoduodenectomy is increasingly utilized to improve pancreatic cancer resectability. However, few multi-institutional studies have evaluated the morbidity and mortality of arterial and venous reconstruction during this procedure.

Methods

A retrospective analysis was performed utilizing the targeted pancreas module of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) for pancreaticoduodenectomy from 2014 to 2015. Demographics, comorbidities, and 30-day outcomes for patients who underwent venous or arterial reconstruction and both were compared to no reconstruction.

Results

A total of 3002 patients were included in our study: 384 with venous reconstruction, 52 with arterial, 81 with both, and 2566 without. Compared to patients without reconstruction, those who underwent venous reconstruction had more congestive heart failure (1.8% vs 0.2%, P < 0.01), those with arterial reconstruction had higher rates of pulmonary disease (11.5% vs. 4.5%, P = 0.02), and neoadjuvant chemotherapy was more common in both venous (34% vs 12%, P < 0.01) and arterial reconstruction (21% vs 12%, P = 0.04). In multivariable analysis, there was no increase in morbidity or mortality following venous reconstruction. However, arterial reconstruction was associated with increased 30-day mortality with an odds ratio (OR): 6.7, 95%; confidence interval (CI): 1.8–25. Morbidity was increased as represented with return to the operating room (OR: 4.5, 95%; CI: 1.5–15), pancreatic fistula (OR: 4.4, 95%; CI: 1.7–11), and reintubation (OR: 3.9, 95%; CI: 1.1–14).

Conclusions

Venous reconstruction during pancreaticoduodenectomy does not increase perioperative morbidity or mortality and should be considered for patients previously considered to be unresectable or those where R0 resection would otherwise not be possible due to venous involvement. Careful consideration should be made prior to arterial reconstruction given the significant increase in perioperative complications and death within 30 days.

Keywords

Pancreaticoduodenectomy Vascular reconstruction Pancreatic cancer 

Notes

Acknowledgments

All authors have contributed significantly to this paper and meet the authorship guidelines as per the guidelines of the International Committee of Medical Journal Editors (ICMJE).

References

  1. 1.
    Christians KK, Heimler JW, George B, et al. Survival of patients with resectable pancreatic cancer who received neoadjuvant therapy. Surgery. 2016;159(3):893–900. doi: https://doi.org/10.1016/j.surg.2015.09.018 CrossRefGoogle Scholar
  2. 2.
    Mollberg N, Rahbari NN, Koch, et al. Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis. Annals of Surgery. 2011; 254(6), 882–893.  https://doi.org/10.1097/SLA.0b013e31823ac299 CrossRefGoogle Scholar
  3. 3.
    Tummala P, Howard, T, Agarwal B. Dramatic Survival Benefit Related to R0 Resection of Pancreatic Adenocarcinoma in Patients With Tumor </=25 mm in Size and </=1 Involved Lymph Nodes. Clinical and Translational Gastroenterology. 2013;4,e33.  https://doi.org/10.1038/ctg.2013.4 CrossRefGoogle Scholar
  4. 4.
    Evans DB, Farnell MB, Lillemoe KD, Vollmer C, Strasberg SM, Schulick RD. Surgical treatment of resectable and borderline resectable pancreas cancer: expert consensus statement. Ann Surg Oncol. 2009;16(7):1736–1744. doi: https://doi.org/10.1245/s10434-009-0416-6.CrossRefGoogle Scholar
  5. 5.
    Siriwardana HPP, Siriwardena AK. Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer. Br J Surg. 2006;93(6):662–673. doi: https://doi.org/10.1002/bjs.5368.CrossRefGoogle Scholar
  6. 6.
    Network NCCN. Clinical Practice Guidelines in Oncology: Pancreatic Adenocarcinoma Version 2.2017. 2017 [cited 2018 14 April]; Available from: https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf.
  7. 7.
    Bockhorn M, Uzunoglu FG, Adham M, et al. Borderline resectable pancreatic cancer: a consensus statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2014;155(6):977–88.CrossRefGoogle Scholar
  8. 8.
    Hoshimoto S, Hishinuma S, Shirakawa H, et al. Reassessment of the clinical significance of portal-superior mesenteric vein invasion in borderline resectable pancreatic cancer. Eur J Surg Oncol. 2017;43(6):1068–75.CrossRefGoogle Scholar
  9. 9.
    Worni M, Castleberry AW, Clary BM, et al. Concomitant vascular reconstruction during pancreatectomy for malignant disease: a propensity score-adjusted, population-based trend analysis involving 10,206 patients. JAMA Surgery. 2013;148(4):331–8.CrossRefGoogle Scholar
  10. 10.
    Castleberry AW, White RR, De La Fuente SG, et al. The impact of vascular resection on early postoperative outcomes after pancreaticoduodenectomy: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database. Ann Surg Oncol. 2012;19(13):4068–77.CrossRefGoogle Scholar
  11. 11.
    Levey AS, Coresh J, Greene T, et al. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med. 2006;145(4):247–54.CrossRefGoogle Scholar
  12. 12.
    Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med. 2003;139(2):137–47.CrossRefGoogle Scholar
  13. 13.
    KDIGO 2012 clinical practice guidelines for the evaluation and management of chronic kidney disase. Kidney inter. 2012;2:1–138CrossRefGoogle Scholar
  14. 14.
    Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Critical Care. 2007;11(2), R31.  https://doi.org/10.1186/cc5713 CrossRefGoogle Scholar
  15. 15.
    Bursac Z, Gauss CH, Williams DK, Hosmer DW. Purposeful selection of variables in logistic regression. Source Code Biol Med. 2008;3:17. doi: https://doi.org/10.1186/1751-0473-3-17.CrossRefGoogle Scholar
  16. 16.
    Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg. 2016;103(3):179–191. doi: https://doi.org/10.1002/bjs.9969.CrossRefGoogle Scholar
  17. 17.
    Martin RCG, Scoggins CR, Egnatashvili V, Staley CA, McMasters KM, Kooby DA. Arterial and venous resection for pancreatic adenocarcinoma: operative and long-term outcomes. Arch Surg Chic Ill 1960. 2009;144(2):154–159. doi: https://doi.org/10.1001/archsurg.2008.547.Google Scholar
  18. 18.
    Kelly KJ, Winslow E, Kooby D, et al. Vein involvement during pancreaticoduodenectomy: is there a need for redefinition of “borderline resectable disease”? J Gastrointest Surg Off J Soc Surg Aliment Tract. 2013;17(7):1209–1217; discussion 1217. doi: https://doi.org/10.1007/s11605-013-2178-5 CrossRefGoogle Scholar
  19. 19.
    Riediger H, Makowiec F, Fischer E, Adam U, Hopt UT. Postoperative morbidity and long-term survival after pancreaticoduodenectomy with superior mesenterico-portal vein resection. J Gastrointest Surg Off J Soc Surg Aliment Tract. 2006;10(8):1106–1115. doi: https://doi.org/10.1016/j.gassur.2006.04.002.CrossRefGoogle Scholar
  20. 20.
    Ramacciato G, Mercantini P, Petrucciani N, et al. Does portal-superior mesenteric vein invasion still indicate irresectability for pancreatic carcinoma? Ann Surg Oncol. 2009;16(4):817–825. doi: https://doi.org/10.1245/s10434-008-0281-8.CrossRefGoogle Scholar
  21. 21.
    Yu XZ, Li J, Fu DL, et al. Benefit from synchronous portal-superior mesenteric vein resection during pancreaticoduodenectomy for cancer: a meta-analysis. Eur J Surg Oncol J Eur Soc Surg Oncol Br Assoc Surg Oncol. 2014;40(4):371–378. doi: https://doi.org/10.1016/j.ejso.2014.01.010 Google Scholar
  22. 22.
    Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer Jr CM. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. Journal of the American College of Surgeons. 2013;216:114.CrossRefGoogle Scholar
  23. 23.
    Greenblatt DY, Kelly KJ, Rajamanickam V, et al. Preoperative Factors Predict Perioperative Morbidity and Mortality After Pancreaticoduodenectomy. Annals of Surgical Oncology. 2011;18(8), 2126–2135.  https://doi.org/10.1245/s10434-011-1594-6 CrossRefGoogle Scholar
  24. 24.
    Sandini M, Malleo G, Gianotti L. Scores for Prediction of Fistula after Pancreatoduodenectomy: A Systematic Review. Digestive Surgery. 2016;33(5), 392–400.  https://doi.org/10.1159/000445068 CrossRefGoogle Scholar
  25. 25.
    Hu BY, Wan T, Zhang WZ, Dong JH. Risk factors for postoperative pancreatic fistula: analysis of 539 successive cases of pancreaticoduodenectomy. World Journal of Gastroenterology. 2016;22:7797–805.CrossRefGoogle Scholar
  26. 26.
    Graham JA, Kayser R, Smirniotopoulos J, Nusbaum JD, Johnson LB. Probability prediction of a postoperative pancreatic fistula after a pancreaticoduodenectomy allows for more transparency with patients and can facilitate management of expectations. Journal of Surgical Oncology. 2013;108:137–8.CrossRefGoogle Scholar
  27. 27.
    Kawai M, Kondo S, Yamaue H et al. Predictive risk factors for clinically relevant pancreatic fistula analyzed in 1239 patients with pancreaticoduodenectomy: multicenter data collection as a project study of pancreatic surgery by the Japanese Society of Hepato-Biliary-Pancreatic Surgery. Journal of Hepato-Biliary-Pancreatic Sciences. 2011;18:601–8.CrossRefGoogle Scholar
  28. 28.
    Glebova NO, Hicks CW, Tosoian JJ, et al. Outcomes of arterial resection during pancreatectomy for tumor. J Vasc Surg. 2016;63(3):722–729.e1. doi: https://doi.org/10.1016/j.jvs.2015.09.042 Google Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  1. 1.Department of SurgeryGeorge Washington University Medical CenterWashingtonUSA

Personalised recommendations