Laparoscopic Pancreaticoduodenectomy with Major Vein Resection: Single Institutional Experience

Abstract

Pancreatic cancer is a common tumor of the digestive system with high malignancy, and the incidence is increasing annually. Approximately 40% of pancreatic cancer patients have a locally advanced disease at the first diagnosis. The safety and feasibility of laparoscopic pancreaticoduodenectomy (LPD) has been established in recent years. Pancreatic cancer with major vein involvement, once considered an absolute contraindication of surgical treatment, is now also a potential candidate for LPD. This study aims to describe the detailed surgical procedures (standard procedure and retrocolonic approach in LPD) and provide the short-term outcomes of patients receiving this challenging operation. From August 2016 to November 2017, among 137 patients undergoing LPD at our center, 8 patients received LPD with major vein resection and reconstruction. The patients’ general data, intraoperative parameters, postoperative morbidity, pathological outcomes, and specific information related to SMV/PV resection and reconstruction were extracted and analyzed. The median age of all patients was 53 (range 49–67) years. The median body mass index (kg/m²) and American Society of Anesthesiologists score were 22.7 (range 18.9–30.2) and 2 (range 2–3), respectively. One patient received tangential resection and primary suture reconstruction, 5 patients underwent segmental resection and end-to-end anastomoses, and 2 patients had a segmental resection and prosthetic vein interposition graft. The median duration of operation and total SMV/PV clamping time were 570 (range 440–640) min and 45 (range 30–60) min, respectively. The median intraoperative estimated blood loss was 630 (range 100–1500) ml. Postoperative pathological outcomes revealed pancreatic ductal adenocarcinoma in 7 patients and chronic pancreatitis in 1 patient. Negative margin was obtained in 6 of 7 patients suffering from pancreatic cancer. One positive margin was found due to local cancer infiltration at the retroperitoneal margin. Median lymph node harvest was 13 (range 6–20), and lymph node metastasis was confirmed in 3 patients. No severe complications after LPD were detected. No 30-day or in-hospital mortality occurred. To date, all patients involved in this study were alive without evidence of tumor recurrence except one patient undergoing R1 resection. LPD with major vein resection and reconstruction is safe and feasible in high-volume tertiary centers. Substantial experience in laparoscopic operations and advanced skills of intracorporal vascular suture in open surgeries should be obtained before attempting LPD with major vein resection. A standard LPD procedure and retrocolonic approach should be adopted appropriately according to the results of preoperative imaging studies.