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Pancreaticoduodenectomy with Major Vascular Resection: a Comparison of Laparoscopic Versus Open Approaches

  • 2014 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Major vascular resection when necessary for margin control during pancreaticoduodenectomy is relatively universal with perioperative and oncological outcomes that are similar to those of patients undergoing a PD without venous involvement. The present study compares total laparoscopic pancreaticoduodenectomy (TLPD) versus open pancreaticoduodenectomy (OPD) with major vascular resection.

Methods

We reviewed data for all patients undergoing TLPD or OPD with vascular resection at Mayo Clinic Rochester, between the dates of July 2007 and July 2013.

Results

A total of 31 patients undergoing TLPD and 58 patients undergoing OPD with major vascular resection were identified. Mean operative blood loss was significantly less in the laparoscopic (842 cc) compared to the open group (1,452 cc) (p < 0.001), as was median hospital stay, 6 (4–118) versus 9 (6–73) days, respectively (p = 0.006). There was no significant difference in the total number of complications (lap 35 %, open 48 %) (p = 0.24) or severe complications (≥III) (lap 6.4 %, open 3.4 %) (p = 0.51) in the two groups. In-hospital mortality or 30-day mortality was not statistically different between the laparoscopic and open groups, 3.2 and 3.4 %, respectively (p = 0.96). Patency of the reconstructed vessels on postoperative imaging was not significantly different between the TLPD (93 %) and OPD groups (91 %) (p = 0.76). In patients with a diagnosis of adenocarcinoma, there was no significant difference in overall survival between the two groups (p = 0.22).

Conclusion

The present study clearly demonstrates that not only is TLPD with major vascular resection feasible and safe but that it can achieve results that are similar in morbidity and mortality as well as oncologic outcome compared to patients undergoing OPD with major vascular resection.

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Abbreviations

TLPD:

Total laparoscopic pancreaticoduodenectomy

OPD:

Open pancreaticoduodenectomy

PD:

Pancreaticoduodenectomy

CI:

Confidence interval

CT:

Computed tomography

SD:

Standard deviation

PV:

Portal vein

SMV:

Superior mesenteric vein

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Conflict of Interest

None of the authors have any conflict of interest to disclose. The manuscript did not receive any funding.

Author information

Authors and Affiliations

  1. Division of Subspecialty General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA

    Kris P. Croome, Michael B. Farnell, Florencia G. Que, KMarie Reid-Lombardo, Mark J. Truty, David M. Nagorney & Michael L. Kendrick

  2. Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA

    Michael L. Kendrick

Authors
  1. Kris P. Croome
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Correspondence to Michael L. Kendrick.

Additional information

Discussant

Dr. R Matthew Walsh (Cleveland Heights, OH):

This study represents a great achievement in laparoscopic vein resection with laparoscopic Whipple procedure. It compares the results of one outstanding laparoscopic surgeon with his colleagues of equally outstanding success with open resections.

I have a few questions:

1. Can you readily tell that a vein resection needs to be done during laparoscopic dissection since imaging may be unreliable and some patients had neoadjuvant treatments? Did you compare pathologic vein involvement to be sure it is not over utilized?

2. Given the results of the NSQIP HPB demonstration project show nationally poor outcomes in adopting lap Whipple procedures, when in the learning curve should this be considered and what did you learn from the four patients you could not reconstruct as your own patient selection criteria?

3. The time to reconstruct in your expert hands was twice that of open. That did not change the outcomes here, but is that an important outcome measure for those embarking on this procedure?

Closing Discussant

Dr. Croome

Thank you Dr. Walsh for your comments and insightful questions.

It is our opinion that the magnification and fine dissection afforded by laparoscopic approaches enhances the intraoperative assessment of vascular involvement. Our pathologists do not consistently report confirmation of vascular invasion. Based on preoperative imaging and intraoperative assessment, we recommend vein resection for all patients with tumor adherence to avoid dissemination of tumor.

The learning curve for minimally invasive pancreaticoduodenectomy is quite long secondary to the advanced skills of resection and reconstruction required. The addition of a complex vascular resection and reconstruction certainly increases the difficulty. We recommend that laparoscopic major vascular resection be attempted only after considerable experience in open and laparoscopic pancreaticoduodenectomy as well as open major vascular resection and reconstruction. Conversion to an open approach should not be considered a complication, but rather sound clinical judgment to assure the best possible outcome for any given patient. In this study, the four patients were converted to open for either expected difficult reconstruction of the pancreatic anastomosis or vascular reconstruction and occurred at various stages of our learning curve.

The duration of reconstruction, and therefore clamp time, was longer for the laparoscopic group. This not only may be due to the learning curve of a new approach but also may be attributed to the greater time required to reconstruct using a long bovine pericardial patch venorrhaphy. We identified no complications that could be attributed to a longer clamp time.

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Croome, K.P., Farnell, M.B., Que, F.G. et al. Pancreaticoduodenectomy with Major Vascular Resection: a Comparison of Laparoscopic Versus Open Approaches. J Gastrointest Surg 19, 189–194 (2015). https://doi.org/10.1007/s11605-014-2644-8

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  • DOI: https://doi.org/10.1007/s11605-014-2644-8

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