Vein resection without reconstruction (VROR) in pancreatoduodenectomy: expanding the surgical spectrum for locally advan
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ORIGINAL ARTICLE
Vein resection without reconstruction (VROR) in pancreatoduodenectomy: expanding the surgical spectrum for locally advanced pancreatic tumours Rugved V. Kulkarni 1,2 & Vijayraj Patil 1,2 & Manish S. Bhandare 1,2 & Vikram A. Chaudhari 1,2 & Shailesh V. Shrikhande 1,2 Received: 12 May 2020 / Accepted: 28 July 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Abstract Purpose Pancreatic malignancy with mesenterico-portal venous involvement can be safely managed with en bloc vein resection with comparable survival outcomes. Non-constructible venous encasement is regarded as criteria of unresectability in pancreatic cancer. In long-standing extra-hepatic venous obstruction, hepatopetal blood flow is established by collateralization in the hepatoduodenal and mesenteric region. Their importance in pancreatic malignancies is being recently acknowledged. Methods The records of patients undergoing pancreatoduodenectomies were retrospectively evaluated from 2012 to 2019. Pre and intraoperative records of patients undergoing concomitant vein resection were evaluated for the presence of venous collaterals, and its impact on oncological management was studied. Results Over a period of 7 years, 947 pancreatoduodenectomies were performed, of which 56 patients underwent concomitant vein resection. Among these, six patients had significant collaterals due to venous obstruction. They had pancreatic adenocarcinoma (2), neuroendocrine tumour (2) and solid pseudopapillary epithelial neoplasm (2) respectively. All these patients successfully underwent pancreatoduodenectomy with vein resection without vascular reconstruction. Superior mesenteric vein (SMV) was resected in four patients, whereas spleno-portal junction was resected in two patients. Dominant collaterals were preserved in all, without compromising oncological safety. Bowel congestion was checked by tolerability to 20-minute mesenteric venous clamping test. There was no major morbidity or hospital mortality following this surgical approach. Conclusion We recommend vein resection without reconstruction (VROR) as a novel approach in locally advanced pancreatic tumours (due to non-constructible vein involvement) with significant venous collaterals and emphasize the need to assess venous collateralization pre and intraoperatively. Keywords Pancreatic cancer . Portal vein involvement . Pancreatoduodenectomy . Vein resection . Collateral vessel . Portal hypertension
Introduction Pancreatic malignancy with mesenterico-portal venous involvement can be safely managed with vein resection with comparable survival outcomes [1, 2]. Non-constructible Rugved V. Kulkarni and Vijayraj Patil are shared first authors. * Shailesh V. Shrikhande [email protected] 1
GI and HPB Oncology Services, Department of Surgical Oncology, Tata Memorial Hospital, Dr. Ernest Borges Road, Parel, Mumbai, Maharashtra 400012, India
2
Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
venous involvement has been regarded as criteria of unresectability
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