Types of resection and reconstruction of the portal and superior mesenteric veins in surgical treatment of pancreatic head cancer with invasion of the major veins

Aim. To demonstrate feasibility, types and relative safety of resection and reconstruction of the portal and / or superior mesenteric veins invaded by tumor during surgical treatment of pancreatic head cancer.
Materials and methods. The study included patients with cancer of the pancreatic head and invasion of the portal and / or superior mesenteric veins who underwent thorough examination and surgical treatment at the N . N . Blokhin National Medical Research Center of Oncology in 2001–2023. Surgical volume depended on advancement of tumor invasion and included standard or extended Whipple’s procedure (WP), pylorus-preserving pancreaticoduodenectomy (PPPD) or pancreatomy. All surgical interventions included resection and reconstruction of the portal and / or superior mesenteric veins dependent on the advancement of tumor invasion. Surgical complications were evaluated per the Clavien–Dindo scale.
Results. Among 192 patients with pancreatic head cancer and invasion of the portal and / or superior mesenteric veins included in the study, 111 (57.8 %) were women and 81 (42.2 %) were men. Patient age varied between 31 and 77 years (median age 62 years, min–max 55–66). Standard WP was performed in 158 (82.3 %) patients, extended WP including aortocaval lymph node dissection in 6 (3.1 %) patients, PPP D in 6 (3.1 %) patients, and pancreatomy in 22 (11.5 %) patients. During surgery, all patients underwent resection of the major veins: only the portal vein was resected in 16 (8.3 %) cases (portal vein group), only the superior mesenteric vein in 83 (43.2 %) cases (superior mesenteric vein group), both veins in 93 (48.5 %) cases (portal and superior mesenteric veins group). In 48 (25 %) patients, tangential resection of the major veins of length between 0.5 and 3.5 cm with reconstruction using mural suture was performed; in the other 144 (75 %) patients, circular resection of length between 0.5 and 10.0 cm was performed. In the portal and superior mesenteric veins group, circular resection was significantly more common (89.3 %) than in the portal vein (62.5 %; р = 0.013) and superior mesenteric vein (61.5 %; р = 0.00001) groups. In 97 (50.5 %) patients with circular resection length below 4 cm, end-to-end anastomosis was constructed, in 6 (3.1 %) patients autologous vein was used, and in 41 (21.4 %) patients, synthetic Gore-Tex prosthesis was installed. Prosthesis was significantly more frequently used in the portal and superior mesenteric veins group (27.9 %) compared to the superior mesenteric vein group (14.5 %; р = 0.023). Three of 41 patients underwent prosthesis of the portal and / or superior mesenteric veins with a synthetic prosthesis with implanted splenic vein. Complications of surgical treatment were observed in 111 (57.8 %) patients, most commonly pancreatic fistula (18.8 %) and gastroparesis (17.7 %), bleeding from acute gastrointestinal ulcer (17.7 %) and pancreatic anastomosis failure (15.1 %). In 74 (38.5 %) patients, complication severity corresponded to grade III per the Clavien–Dindo classification. Bleeding from acute gastrointestinal ulcers was observed in 34 patients. The rate of bleeding complications in the portal and superior mesenteric veins group was 23.7 % which is significantly (р = 0.035) higher than in the portal vein group (12.5 %). After tangential resections bleeding rate was 18.8 %, after circular resections 17.4 %. The highest rate of bleeding (27.5 %) was observed in the portal and superior mesenteric veins group in patients after circular resection with ligation of the splenic vein, and it was significantly higher than in patients who underwent resection of only one of the two major veins (4.9 %). Additionally, bleedings were common in patients who underwent tangential vein resection (18.8 %), the rate was significantly higher than in patients who underwent circular resection of one of the major veins. Thrombosis of the portal or superior mesenteric vein developed in 11 (5.7 %) patients, thrombosis of the deep veins of the legs in 7 (3.7 %) patients.
Conclusion. Surgical treatment of patients with pancreatic head cancer and invasion of the portal and / or superior mesenteric veins is relatively safe and can include different types of vein resection and reconstruction. Depending on the indications, tangential resection with direct suture or circular resection can be performed using end-to-end anastomosis or synthetic prosthesis in which unaffected splenic vein can be implanted to prevent gastrointestinal bleeding in patients with portal hypertension or using a segment of autologous splenic vein. This allows to perform reconstruction of the major veins without a synthetic prosthesis.

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