**7. Operative techniques**

femoral vein is an excellent size‐matched conduit for reconstruction of the SMV or PV without serious complications associated with venous insufficiency in the leg [32]. The patency of reconstruction of the PV or SMV using superficial femoral vein (GSV) reported by Lee et al. was 88% at mean follow‐up of 5 months with only a few patients developing mild lower leg edema. Chiba University's team [33] first reported the use of a left renal vein graft for reconstruction of the portal vein. No obvious left kidney dysfunction has been diagnosed after the removal of left renal vein graft [34]. This technique has the fol‐

Chiba et al. reported a 100% patency rate in a cohort of 35 patients using a left renal vein graft for portal vein reconstruction, even at long‐term follow‐up. Suzuki et al. [34] also dem‐ onstrated that reconstruction of the inferior vena cava (IVC) or PV with the left renal vein is a durable and safe method without adverse effects on early and long‐term renal function. Other veins with smaller diameters like external jugular vein also could be used. The vein is customized by cutting longitudinally and suturing it into a sheet or tube‐like graft in order to

Its recommended synthetic grafts need to be avoided because many resections may involve contaminated bile and postoperative infectious complications could occur. On the other hand, the placement of autologous graft prolongs operative time, which is a prerequisite for postoperative complications. Use of artificial vascular prosthesis also bear risks from throm‐ bosis, as well as infectious complications, which is the main reason for it not to be preferred by most of the medical specialists, although it decreases up to the minimum by the time of clamping of the portal blood flow and is completely justified in critical situation, accord‐ ing to us (**Figure 8**). No difference is observed regarding the hepatic function and hemo‐ dynamics of the portal blood flow in the postoperative period, compared to other patients.

lowing advantages compared with other substitutes:

**Figure 8.** Large resection of the portal vein with PTFE prosthesis replacement.

**2.** Usually harvesting takes only 5–10 min.

overcome size discrepancy.

206 Challenges in Pancreatic Pathology

**1.** No additional skin incision because the vein is in the same operative field.

**3.** Vein size is often suitable for the portal vein to be reconstructed.

Pancreaticoduodenectomy with or without vein resection should be performed in resect‐ able cases. A classical Whipple procedure or a pylorus preserving pancreaticoduodenec‐ tomy (PPPD) could be carried out. The preferred access is trough bi‐subcostal incision. The whole abdominal cavity is consecutively examined—the liver is palpated and intraoperative ultrasonography is performed for excluding metastatic lesions. The area around the celiac trunk is inspected for the presence of metastatic lymph nodes or local invasion. The parietal and visceral peritoneum are carefully examined for carcinosis. Mobilization of duodenum with Kocher maneuver ensures inspection of the head of pancreas and retroperitoneum in the area of the inferior vena cava. This is followed by dissection of the hepatoduodenal liga‐ ment. The suspected lesions are sent for express histological examination. Resectability is technically assessed based on the local status of the tumor and its relation to major blood vessels. If resectable, radical resection is undertaken. The type of the latter is determined by the anatomical localization of the process. If all resection margins are free of tumor invasion, the surgical operation is performed according to the standard approach, but if invasion is suspected, the course of operation may be changed by freeing the easier for dissection parts of the anatomical specimen at first, and proceeding to the most difficult for dissection areas at the end.

Vascular resections could be finished by primary closure of the vein, end‐to‐end anastomosis, or a segmental resection and reconstruction with interposition graft. Venous resections can be performed differently depending on the location and length of tumor adherence. In cases when the tumor infiltration reaches the vein from the right circumference and can be excised with a small patch and direct closure of the defect directly without a hemodynamically rel‐ evant stenosis, latero‐tangential resection of the portal vein could be done [31, 36, 37].

The mesenteric root should be mobilized completely by resolving the attachment of the right hemicolon to the retroperitoneal adhesions in cases when tangential vein resection is not pos‐ sible [38]. In such a way, a greater flexibility of the mesenteric vein is achieved and this almost always allows approximation of the distal and proximal resection margins of the vein without any critical tension. A vascular graft needs to be inserted when the resected venous length

**Figure 9.** Resection of SMV/PV confluence with ligation of the splenic vein with preservation of the left gastric and inferior mesenteric veins.

**Figure 10.** Resection of the proximal part of the superior mesenteric vein followed by difficult anastomosis between portal vein and trifurcation of the distal superior mesenteric vein.

cannot be bridged by the direct anastomosis. A study, including a series of 110 patients under‐ going venous resection with different reconstruction techniques, revealed that no differences in surgical outcome were observed when different types of venous reconstruction (venorrha‐ phy, end‐to‐end anastomosis, or graft insertion) were performed [38].

Venous resection is also hampered by the need for preservation of the splenic vein, because this makes the direct approach to the most proximal 3–4 cm of the superior mesenteric artery much more difficult. Venous resection and reconstruction may be performed either before the separation of the specimen from the right lateral wall of the superior mesenteric artery, or after the accomplishment of the mesenteric dissection by separation of the superior mes‐ enteric artery at first. Both techniques require significant pancreatic surgery experience and must be performed only by surgeons who have enough experience in vascular resections and reconstructions during pancreatoduodenal resections. The patency of the venous gastric drainage is a special aspect in venous resections that has to be respected in certain situations. The splenic vein can be closed during venous resection as the stomach is usually drained sufficiently via the coronary vein (if preserved) and collaterals via the short gastric veins (**Figure 9**).

A plan for reconstruction must be preliminarily drawn if the proximal part of superior mes‐ enteric vein at the site where the three major veins join is involved. Major postoperative com‐ plications may result from the ligation of veins with no adequate collateral draining. Use of interpositional graft may become necessary for ensuring the possibility of lateral implantation of collaterals if reconstruction of more than one vein is needed. The first jejunal vein, which passes behind the superior mesenteric artery, could usually be ligated with no consequences. Despite that, every larger vein must at first be clamped for checking of presence of adequate collateral blood draining (**Figure 10**).

The temporary interruption of the portal blood flow could additionally damage the usually cholestatic liver. Data analysis shows a tendency for significant increase of the liver enzymes in patients with vascular resections, which is due to the clamping of the portal blood flow during the resection. However, this is observed only during the early postoperative period and does not influence liver function afterwards. The direct termino‐terminal reconstruction requires fast performing of the anastomosis, independently from the clamping of the supe‐ rior mesenteric vein. In cases of isolated involvement of superior mesenteric vein, the latter may be clamped proximally below the confluence with the splenic vein, which allows per‐ forming of anastomosis upon partially preserved portal blood flow through the splenic vein with intact inferior mesenteric vein. Portal blood flow is fully recovered through the created anastomosis after the specimen removal. Upon resection of the spleno‐portal confluence, the splenic vein could be anastomized termino‐laterally to the portal vein, while usually partial lateral clamping of the latter is performed. Avoidance of splanchnic stasis is exceptionally important upon performing of pancreatoduodenal resection combined with venous resection. The consequent intestinal and pancreatic edema hampers accomplishing of surgery and may have negative consequences regarding the digestive anastomosis.

Assessment of the specimen based on anatomical pathology is of considerable significance regarding size of the tumor, grade of invasion in the venous wall, as well as achievement of clear resection margins. Tumors' diameter is measured most precisely after its removal from the abdominal cavity. Resection lines are assessed during surgery with express histological examination after separation of 3–4 mm of the resection margin of pancreas. The presence of tumor cells in the vein, as well as growth of the process into the adventitia or media layer of venous wall reveals vascular infiltration.

cannot be bridged by the direct anastomosis. A study, including a series of 110 patients under‐ going venous resection with different reconstruction techniques, revealed that no differences in surgical outcome were observed when different types of venous reconstruction (venorrha‐

**Figure 10.** Resection of the proximal part of the superior mesenteric vein followed by difficult anastomosis between

**Figure 9.** Resection of SMV/PV confluence with ligation of the splenic vein with preservation of the left gastric and

inferior mesenteric veins.

208 Challenges in Pancreatic Pathology

Venous resection is also hampered by the need for preservation of the splenic vein, because this makes the direct approach to the most proximal 3–4 cm of the superior mesenteric artery

phy, end‐to‐end anastomosis, or graft insertion) were performed [38].

portal vein and trifurcation of the distal superior mesenteric vein.

#### **8. Outcome**

The overview of literature revealed that the resection and reconstruction of porto‐mesenteric vein in case of pancreatoduodenal resection does not change the percentage of complica‐ tions and mortality compared to the standard surgical operation. By excluding the first series with regional pancreatectomy, vein resection does not have prognostic significance regarding the survival. Large series with radical surgical resection showed that surgical morbidity and mortality rates are comparable to standard pancreatic head resections [38–40]. Comparable complication rates between standard pancreaticoduodenectomy (PD) and pancreaticoduode‐ nectomy with vascular resection (PDVR) were reported by some studies [12, 13]. Tseng et al. from the MD Anderson Centre, found no survival difference in patients undergoing PD and PDVR [29]. Yekebas et al. found similar postoperative morbidity and mortality rates between PD and PDVR [41]. There are also studies that have reported increased morbidity with no survival benefit in PDVR [38]. The analysis of our data showed that the total level of complica‐ tions in both groups of patients does not show statistical difference, while the present one is due mainly to patients with venous resection and interposition of artificial graft. In patients with vascular resection there is higher rate of early and late bleeding and a tendency for more frequent need for hemotransfusions. This is especially emphasized in patients with segmen‐ tal resection and reconstruction with an artificial prosthesis. This fact is explained with the advanced stage of the disease, involving a larger portion of the vein and the more technically difficult destructive stage of surgical operation, related with higher volume of blood loss. The rate of relaparotomies in patients with vascular resections is not greater as compared to patients with no vascular resections. Regarding the porto‐mesenteric invasion, the analysis of the literature and our experience leads to the following conclusions:


Ishikawa et al. reported of 3‐year survival in 59% of the cases with unilateral invasion and 18‐month survival in patients with bilateral invasion of the process [19]. A systematic review by Siriwardena suggested that PDVR was associated with a high rate of nodal metastases and low survival rates [42]. There is also some evidence of better survival outcomes with PDVR over palliative treatment [36–38]. Recently, a meta‐analysis by Zhou et al. [43] compared 19 studies and 661 patients with venous resections during PDAC with 2247 patients undergoing similar operation but without vessel resection. The surgical outcome of the two groups was comparable. No difference in overall survival between both patient groups was found, the 5‐year survival rate being 12.3%—superior compared with palliative treatment. Bachellier et al. reported 22% and 2‐year survival in 31 patients with pancreatoduodenectomy and resec‐ tion of porto‐mesenteric vein, which is close to the 24% reported for the conventional surgical

**Figure 11.** Survival rates depending on the type of intervention.

**8. Outcome**

210 Challenges in Pancreatic Pathology

The overview of literature revealed that the resection and reconstruction of porto‐mesenteric vein in case of pancreatoduodenal resection does not change the percentage of complica‐ tions and mortality compared to the standard surgical operation. By excluding the first series with regional pancreatectomy, vein resection does not have prognostic significance regarding the survival. Large series with radical surgical resection showed that surgical morbidity and mortality rates are comparable to standard pancreatic head resections [38–40]. Comparable complication rates between standard pancreaticoduodenectomy (PD) and pancreaticoduode‐ nectomy with vascular resection (PDVR) were reported by some studies [12, 13]. Tseng et al. from the MD Anderson Centre, found no survival difference in patients undergoing PD and PDVR [29]. Yekebas et al. found similar postoperative morbidity and mortality rates between PD and PDVR [41]. There are also studies that have reported increased morbidity with no survival benefit in PDVR [38]. The analysis of our data showed that the total level of complica‐ tions in both groups of patients does not show statistical difference, while the present one is due mainly to patients with venous resection and interposition of artificial graft. In patients with vascular resection there is higher rate of early and late bleeding and a tendency for more frequent need for hemotransfusions. This is especially emphasized in patients with segmen‐ tal resection and reconstruction with an artificial prosthesis. This fact is explained with the advanced stage of the disease, involving a larger portion of the vein and the more technically difficult destructive stage of surgical operation, related with higher volume of blood loss. The rate of relaparotomies in patients with vascular resections is not greater as compared to patients with no vascular resections. Regarding the porto‐mesenteric invasion, the analysis of

the literature and our experience leads to the following conclusions:

of patients with standard pancreatoduodenectomy.

ity rates, compared to those of standard pancreatoduodenectomy.

**1.** Involvement of superior mesenteric artery or celiac trunk usually means mesenteric nerve plexus involvement, which makes impossible the achievement of clear resection lines. **2.** In portal and mesenteric venous resections there is no increase of the morbidity or mortal‐

**3.** The survival of patients with resection of portal vein does not differ significantly from that

Ishikawa et al. reported of 3‐year survival in 59% of the cases with unilateral invasion and 18‐month survival in patients with bilateral invasion of the process [19]. A systematic review by Siriwardena suggested that PDVR was associated with a high rate of nodal metastases and low survival rates [42]. There is also some evidence of better survival outcomes with PDVR over palliative treatment [36–38]. Recently, a meta‐analysis by Zhou et al. [43] compared 19 studies and 661 patients with venous resections during PDAC with 2247 patients undergoing similar operation but without vessel resection. The surgical outcome of the two groups was comparable. No difference in overall survival between both patient groups was found, the 5‐year survival rate being 12.3%—superior compared with palliative treatment. Bachellier et al. reported 22% and 2‐year survival in 31 patients with pancreatoduodenectomy and resec‐ tion of porto‐mesenteric vein, which is close to the 24% reported for the conventional surgical operation [35]. Nakagohri et al. reported absence of significant difference in the survival of 33 patients with porto‐mesenteric venous resection compared to 48 conventional pancreato‐ duodenectomies (15 vs. 10 months; *p* > 0.05) [44]. Other researchers present similar results: Leach et al.—average survival of 20 vs. 22 months, Harrison et al.—average survival of 13 vs. 17 months, Tseng et al.—average survival of 23.43 vs. 26.5 months, and Hartel et al.—5‐year survival of 22 vs. 24%. Moreover, in cases of resection of the vein and absence of histological verification of invasion, improvement of survival was observed, but these observations of Nakagohri and Hartel are still not confirmed and remain controversial [44].

Based on our experience with 356 patients with pancreatic cancer radically operated in our department for a 10‐year period (2006–2016)—285 pancreatoduodenectomies and 71 distal pancreatectomies, we could point the level of combined vascular resections of 20.2%. Seventy‐ two of the presented patients underwent pancreatic resection with simultaneous vascular resection—SMPV in 65 cases (44 with resection of the portal vein, 15 with resection of the superior mesenteric vein, 6 with resection of the porto‐mesenterial confluence), arterial in 2 and partial resections of IVC in five cases. Combined vascular resections were done in three cases. Twenty‐eight segmental (21 end‐to‐end anastomosis and seven interposition grafts) and 37 partial wedge venous resections of SMPV were done. Both groups PVR and PR showed similarly close results in complication rates, mortality, and morbidity. Three‐ and 5‐year sur‐ vival rates were 42 and 38% in the PD group and 28 and 19% in the PVR group (**Figure 11**).
