Abstract: Objective:To investigate the clinical efficacy of total pancreaticoduodenectomy combined with portal vein resection and allograft vascular grafts for pancreatic cancer with vascular invasion.
Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 9 patients with pancreatic cancer who underwent total pancreaticoduodenectomy combined with portal vein resection and allograft vascular grafts in the Beijing Chao Yang Hospital of Capital Medical University from January 2014 to September 2016 were collected. There were 4 males and 5 females, aged from 53 to 78 years, with a median age of 60 years. Involvement of portal vein (PV) and (or) superior mesenteric vein (SMV), splenic vein or convergence was detected in patients by preoperative evaluation, which indicated borderline resectable pancreatic cancer. Patients underwent complete surgical resection of tumor and involved portal veins, and then underwent vascular and digestive tract reconstruction. Observation indicators: (1) intraoperative situations; (2) postoperative situations; (3) followup. Patients were followed up by telephone interview and outpatient examination to detect survival of patients up to October 2018. Measurement data with normal distribution were represented as Mean±SD, measurement data with skewed distribution were expressed as M (range), and count data were expressed as absolute number.
Results: (1) Intraoperative situations: 9 patients underwent total pancreaticoduodenectomy combined with portal vein resection and allograft vascular grafts successfully, including 1 undergoing total pancreaticoduodenectomy due to positive margin of pancreatic neck during pancreaticoduodenectomy for pancreatic head carcinoma, 3 of pancreatic head carcinoma with portal vein involvement and atrophy of pancreatic body and tail, and 5 of carcinoma of pancreatic neck and body with portal vein involvement. The operation time, portal vein occlusion time, and volume of intraoperative blood loss were (573±19)minutes, (21±4)minutes, and (717±33)mL. (2) Postoperative situations: 4 of 9 patients had postoperative complications, including 2 with grade Ⅰ complication and 2 with grade Ⅱ complication. There was no grade Ⅲ or above complication. No anastomotic stenosis or thrombus formation after reconstruction for portal vein. The perioperative complications were cured after conservative treatment. Duration of postoperative hospital stay was 17 days (range, 10-25 days). Nine patients underwent subcutaneous injection of insulin to control blood glucose during the period fasting for solids and liquids. After resuming the semiliquid diet of diabetes, patients received subcutaneous injection of rapid acting insulin before meals combined with subcutaneous injection of longacting insulin before bedtime, with a insulin need of 24- 36 U/d. Patients had postprandial blood sugar level of 8-11 mmol/L, without unmanageable hyperglycemia or longterm application of insulin pump. Patients received oral trypsin pancreatin instead of trypsin, with no gastrointestinal symptoms such as bloating and steatorrhea, no malnutrition. Of 9 patients, 2 had welldifferentiated adenocarcinoma, 4 had moderately differentiated adenocarcinoma, and 3 had poordifferentiated adenocarcinoma. There were 3 patients with no vascular invasion, 1 with endangidic invasion, 5 with tumor infiltration of tunica adventitia vasorum. One of 9 patients was in IIA stage of TNM staging, 3 were in the II B stage, and 5 were in IIIB stage. The negative rate of pathological sections for excised specimen margin was 8/9. (3) Followup: 9 patients were followed up for 7-37 months, with a median followup time of 15 months. Four patients survived, 4 died of tumor recurrence and metastasis, and 1 died of cerebrovascular accident.
Conclusion:Total pancreaticoduodenectomy combined with portal vein resection and allograft vascular grafts is safe and feasible for pancreatic cancer involving portal vein, splenic vein or junction.