P-P13 Long-term outcome after portal vein resection during pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a propensity score matched analysis

Background Portal vein resection (PVR) with pancreaticoduodenectomy (PD) is often performed to achieve clear margins for patients with vascular involvement in pancreatic ductal adenocarcinoma (PDAC). However, there is evidence to suggest that patients undergoing PVR often have more advanced cancers, therefore the impact of PVR on survival and recurrence remains unclear. The aim of this study is to assess overall (OS) and recurrence free (RFS) survival in patients who underwent PVR during PD, with particular attention to margin positivity. Methods A retrospective analysis was performed on 638 patients who underwent PD during a 12-year period. Exclusion criteria included PD for non-PDAC tumours, neoadjuvant chemotherapy or intra-operative radiotherapy. 374 patients were included in the study (90 PVR and 284 non-PVR). Patient characteristics and histopathological factors associated with OS and RFS were then evaluated using univariate and multivariate Cox regression analyses. 270 patients (90 PVR and 180 non-PVR), were matched by propensity score based on perineural invasion, pT and pN staging. The Kaplan-Meier method was used to calculate survival and log-rank tests. Results Resection margin positivity was associated with shorter OS and RFS (p < 0.0001), and the superior mesenteric vein (SMV) margin was the most significant risk factor for survival on competing risks analysis. Absent adjuvant chemotherapy, nodal metastasis and margin positivity were independent risk factors for OS and RFS on multivariate analysis. PVR was associated with higher intra-operative blood loss (p = 0.009), but was not associated with increased length of stay, complications or readmissions. PVR patients had increased pT staging, nodal metastasis and perineural invasion, however, there was no difference in OS (p = 0.551) or RFS (p = 0.256) between PVR and non-PVR after propensity matching. Conclusions Positive resection margins are associated with shorter survival times, and the SMV margin is the most significant prognostic indicator for overall survival and recurrence compared to other margins. PVR is a relatively safe procedure, however, it does not achieve the intended survival benefits of complete margin clearance. The impact on survival for margin positivity, particularly the SMV margin, and nodal metastasis should be considered when making decisions with regards to vein resection and adjuvant treatments.

Extended Venous Resections for Borderline Resectable Pancreatic Head Adenocarcinoma—A Retrospective Studies of Nine Cases

Background: pancreatic cancer is one of the most lethal malignancies and a leading cause of cancer-related death worldwide. The only chance to improve the long-term outcomes of patients with pancreatic cancer is surgery with radical intent. Methods: in the present paper, we aim to describe a case series of 9 patients submitted to radical surgery for borderline resectable pancreatic cancer. Results: in all cases, negative resection margins were achieved. The types of venous resection consisted of tangential portal vein resection in four cases, circumferential portal vein resection with direct reanastomosis in one case and circumferential resection with graft placement in another four cases; postoperatively, one patient developed a vascular surgery-related complication consisting of graft thrombosis and thus necessitated prolonged anticoagulant therapy. Conclusions: extended venous resections can be a safe and efficient way to maximize the benefits of radical surgery in locally advanced, borderline resectable pancreatic cancer.

Portal Vein Reconstruction during Pancreaticoduodenal Resection Using an Internal Jugular Vein as a Graft

Portal vein involvement by malignant tumours of the head of the pancreas is observed in almost 50% of the patients. In the past, this finding usually rendered the tumor inoperable. Over the past 30 years, the operative morbidity and mortality rate of pancreatectomy combined with portal vein resection has greatly decreased, and portal vein resection in pancreatic surgery has become a well-tolerated operative procedure in large-volume centres. Options for a venous reconstruction after SMV/PV resection include prosthetic, autologous or cryopreserved cadaveric vein grafts.Vascular resection and reconstruction provides great opportunity for R0 resection and improvement of oncological results in patients with pancreatic tumors and involvement of venous vessels, in the absence of distant metastases. If a longer graft length is required, there is the option of using either synthetic prosthesis or cryopreserved grafts. Their weak sides can be avoided by the use of jugular vein graft. Portal vein resection will be performed more often, safely and aggressively over the next years.

Eight-Year Survival Following Left Hepatic Trisectionectomy With Combined Hepatic Artery And Portal Vein Resection For Advanced Perihilar Cholangiocarcinoma

We report the case of a patient with exceptional survival over 8 years after left trisectionectomy combined with portal vein and hepatic artery resection and reconstruction for advanced perihilar cholangiocarcinoma. Such extended hepatectomy with vascular resection is the only way to obtain free tumor margin. It can be performed with acceptable morbidity and mortality and it is the only hope to prolong survival.