Laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: Long-term oncologic outcomes after standard resection

Prognostic Factors for Early Recurrence After Resection of Pancreatic Cancer: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

More than half of pancreatic ductal adenocarcinomas (PDACs) recur within 12 months after curative-intent resection. This systematic review and meta-analysis was conducted to identify all reported prognostic factors for early recurrence in resected PDACs.

METHODS

After a systematic literature search, a meta-analysis was conducted using a random effects model. Separate analyses were performed for adjusted vs unadjusted effect estimates as well as reported odds ratios (ORs) and hazard ratios (HRs). Risk of bias was assessed using the Quality in Prognostic Studies tool, and evidence was rated according to Grading of Recommendations Assessment, Development and Evaluation recommendations.

RESULTS

After 2903 abstracts were screened, 65 studies were included. Of these, 28 studies (43.1%) defined early recurrence as evidence of recurrence within 6 months, whereas 34 (52.3%) defined it as evidence of recurrence within 12 months after surgery. Other definitions were uncommon. Analysis of unadjusted ORs and HRs revealed 41 and 5 prognostic factors for early recurrence within 6 months, respectively. When exclusively considering adjusted data, we identified 25 and 10 prognostic factors based on OR and HR, respectively. Using a 12-month definition, we identified 38 (OR) and 15 (HR) prognostic factors from unadjusted data and 38 (OR) and 30 (HR) prognostic factors from adjusted data, respectively. On the basis of frequency counts of adjusted data, preoperative carbohydrate antigen 19-9, N status, nondelivery of adjuvant therapy, grading, and tumor size based on imaging were identified as key prognostic factors for early recurrence.

CONCLUSIONS

Reported prognostic factors of early recurrence vary considerably. Identified key prognostic factors could aid in the development of a risk stratification framework for early recurrence. However, prospective validation is necessary.

Prognostic value of margin clearance in total and distal pancreatectomy specimens with pancreatic ductal adenocarcinoma in a Danish population-based nationwide study

BACKGROUND

The prognostic role of resection margin status following total (TP) and distal (DP) pancreatectomy for pancreatic ductal adenocarcinoma (PDAC) is insufficiently evaluated. In Denmark, pancreatic surgery, including the postoperative pathological examination of the resection specimens, is confined to four centres, all reporting to the Danish Pancreatic Cancer Database (DPCD). In this Danish population-based nationwide study on TP and DP for PDAC from 2015-2019, based on data from DPCD, we evaluated whether there is a prognostically relevant minimum margin clearance definition and whether certain margins hold independent prognostic information.

METHODS

Clinical and pathological data were retrieved from DPCD and supplemented by review of pathology reports and re-microscopy, if needed. One of the study pathologists performed all re-microscopy. The prognostic significance of margin status was evaluated by dichotomisation of the TP cohort (n = 101) and the DP cohort (n = 90) into involved and uninvolved groups, using different clearance definitions (0.5 - ≥3.0 mm).

RESULTS

Following TP, direct involvement of the superior mesenteric artery (SMA) margin had independent prognostic value. When using a clearance definition of ≥ 0.5 or ≥ 1.5 mm for SMA, median survival for R0 versus R1 was 19 (95% CI 14-26) versus 10 (95% CI 5-20) months (p = 0.010), and 21 (95% CI 15-30) versus 10 (95% CI 8-19) months (p = 0.011), respectively. Overall margin status was not of significant prognostic importance following neither DP nor TP.

CONCLUSION

In this Danish population-based nationwide study, SMA margin involvement was a significant isolated prognostic factor following TP, whereas combined assessment of all circumferential margins did not hold statistically significant prognostic information. Following DP, resection margin status did not affect survival.

Prognostic Impact of Resection Margin Status on Distal Pancreatectomy for Ductal Adenocarcinoma

Pancreatic cancer is associated with a poor prognosis. While surgical resection is the only treatment option with curative intent, most patients die of locoregional and/or distant recurrence. The prognostic impact of the resection margin status has received much attention. However, the evidence is almost exclusively related to pancreatoduodenectomies, while corresponding data for distal pancreatectomy specimens are limited. The key data, such as the rate of microscopic margin involvement (“R1”), the site of margin involvement, and the impact of R1 on patient outcome, are divergent between studies and do not currently allow any general conclusions. The main reasons for the variability in the published data are the small size of the study cohorts and their heterogeneity, as well as the marked divergence in pathology examination practices. The latter is a consequence of the lack of concrete guidance, both for grossing and microscopic examination. The increasing administration of neoadjuvant chemo(radio)therapy introduces a further factor of uncertainty as the conventional definition of a tumour-free margin (“R0”) based on 1 mm clearance is inadequate for these specimens. This review discusses the published data regarding the prognostic impact of margin status in distal pancreatectomy specimens along with the challenges and uncertainties that are related to the assessment of the margins.

Robotic Versus Laparoscopic Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma: A Systematic Review and Meta-Analysis

Background

Robotic distal pancreatectomy (RDP) and laparoscopic distal pancreatectomy (LDP) are the two principal minimally invasive surgical approaches for patients with pancreatic body and tail adenocarcinoma. The use of RDP and LDP for pancreatic ductal adenocarcinoma (PDAC) remains controversial, and which one can provide a better R0 rate is not clear.

Methods

A comprehensive search for studies that compared robotic versus laparoscopic distal pancreatectomy for PDAC published until July 31, 2021, was conducted. Data on perioperative outcomes and oncologic outcomes (R0-resection and lymph node dissection) were subjected to meta-analysis. PubMed, Cochrane Central Register, Web of Science, and EMBASE were searched based on a defined search strategy to identify eligible studies before July 2021.

Results

Six retrospective studies comprising 572 patients (152 and 420 patients underwent RDP and LDP) were included. The present meta-analysis showed that there were no significant differences in operative time, tumor size, and lymph node dissection between RDP and LDP group. Nevertheless, compared with the LDP group, RDP results seem to demonstrate a possibility in higher R0 resection rate (p<0.0001).

Conclusions

This systematic review and meta-analysis suggest that RDP is a technically and oncologically safe and feasible approach for selected PDAC patients. Large randomized and controlled prospective studies are needed to confirm this data.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier [CRD42021269353].

Minimally Invasive Techniques for Pancreatic Resection

There is increasing interest in the role of minimally invasive surgery (MIS) for pancreatectomy. Prospective data indicate significant advantages for MIS when performed for left-sided pancreatic pathologies and may be deemed as the standard of care. However, there is reluctance in implementing this technique to pancreaticoduodenectomy because of the complexity of the operation and the mixed results from randomized trials. A detailed description of the technical aspects of robotic pancreaticoduodenectomy and distal pancreatectomy is presented in this article in addition to a summary of the most important prospective and cohort studies. We also provide insights into patient selection and the learning curve of MIS surgery for pancreatectomy.

Prognostic Impact of Resection Margin Status in Distal Pancreatectomy for Ductal Adenocarcinoma

Background

Resection margin status is considered one of the few surgeon-controlled parameters affecting prognosis in pancreatic ductal adenocarcinoma (PDAC). While studies mostly focus on resection margins in pancreatoduodenectomy, little is known about their role in distal pancreatectomy (DP). This study aimed to investigate resection margins in DP for PDAC.

Methods

Patients who underwent DP for PDAC between October 2004 and February 2020 were included (n = 124). Resection margins and associated parameters were studied in two consecutive time periods during which different pathology examination protocols were used: non-standardized (period 1: 2004–2014) and standardized (period 2: 2015–2020). Microscopic margin involvement (R1) was defined as ≤1 mm clearance.

Results

Laparoscopic and open resections were performed in 117 (94.4%) and 7 (5.6%) patients, respectively. The R1 rate for the entire cohort was 73.4%, increasing from 60.4% in period 1 to 83.1% in period 2 (p = 0.005). A significantly higher R1 rate was observed for the posterior margin (35.8 vs. 70.4%, p < 0.001) and anterior pancreatic surface (based on a 0 mm clearance; 18.9 vs. 35.4%, p = 0.045). Pathology examination period, poorly differentiated PDAC, and vascular invasion were associated with R1 in the multivariable model. Extended DP, positive anterior pancreatic surface, lymph node ratio, perineural invasion, and adjuvant chemotherapy, but not R1, were significant prognostic factors for overall survival in the entire cohort.

Conclusions

Pathology examination is a key determinant of resection margin status following DP for PDAC. A high R1 rate is to be expected when pathology examination is meticulous and standardized. Involvement of the anterior pancreatic surface affects prognosis.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-10464-6.

Laparoscopic distal pancreatectomy in patients with poor physical status

BACKGROUND

Laparoscopic distal pancreatectomy (LDP) is advantageous over open surgery in the treatment of benign pancreatic lesions and low-grade malignancies. Yet the evidence on the relationship between comorbidities and the outcomes of LDP remains scarce.

METHODS

Patients who had undergone LDP for all indications between April 1997 and December 2019 were included. Preoperative physical status was defined according to the American Society of Anesthesiology (ASA) criteria. Perioperative outcomes were compared between the patients with high (ASA III-IV) and low/moderate anesthetic risk (ASA I-II).

RESULTS

A total of 605 patients were eligible for analysis including 190 with ASA III-IV and 415 with ASA I-II. The former was associated with older age, male gender, preexisting medical conditions, greater total number of comorbidities and red blood cell transfusion. The rate of medical complications was significantly higher in high-risk patients. Multivariable analysis identified ASA III-IV and operative time as independent predictors for medical complications. Overall/severe morbidity, surgical complications and mortality rates were similar.

CONCLUSIONS

Poor physical status defined as ASA grades III-IV predicts medical complications, but has a limited impact on surgical complications and severe morbidity of LDP. Thus, it should not be considered as a contraindication for LDP.

Oncologic Outcomes of Robotic Left Pancreatectomy for Pancreatic Adenocarcinoma: A Single-Center Comparison to Laparoscopic Resection

BACKGROUND

Feasibility and safety of robotic surgery for pancreatic disease has been well demonstrated; however, there is scarce literature on long-term oncologic outcomes. We compared perioperative and oncologic outcomes between robotic left pancreatectomy (RLP) and laparoscopic left pancreatectomy (LLP) for pancreatic adenocarcinoma.

METHODS

A retrospective review evaluated left pancreatectomies performed for pancreatic adenocarcinoma from 2009 to 2019 in a tertiary institution. Baseline characteristics, operative and oncologic outcomes were compared between RLP and LLP.

RESULTS

There were 75 minimally invasive left pancreatectomy cases for pancreatic adenocarcinoma identified of which 33 cases were done robotically and 42 laparoscopically. Baseline characteristics demonstrated no difference in gender, age, BMI, T stage, N stage, neoadjuvant, or adjuvant chemotherapy. An analysis of operative variables demonstrated no difference in blood loss, increased duration, and higher lymph node yield with RLP (20 vs 12; P = .0029). Postoperatively, both cohorts had 30% pancreatic fistulas and no difference in complications. There were no differences in length of stay (LOS), 30- or 90-day readmission rates, or 90-day mortality. The analysis of oncologic outcomes demonstrated similar R0 resections (RLP: 72% vs OLP: 67%), recurrence rates (RLP: 36% vs OLP: 41%), and time to recurrence (RLP: 324 vs OLP 218 days). There was increased survival in the RLP cohort that was not significant (32 vs 19 months).

CONCLUSION

This analysis demonstrates RLP is at least equivalent to LLP in perioperative and oncologic outcomes. The significantly higher lymph node yield and trend toward an improved survival suggests oncologic advantage. Randomized controlled studies are needed to clarify benefit.

Current statement and safe implementation of minimally invasive surgery in the pancreas

Minimally invasive pancreatic resection has become very popular in modern pancreatic surgery. Evidence of the benefits of a minimally invasive approach is accumulating thanks to prospective and randomized controlled studies. Minimally invasive surgery provides advantages to the surgeon due to the high definition of the surgical field and the freedom of fine movement of the robot, but should be considered only in selected patients and in high-volume centers. Minimally invasive distal pancreatectomy for benign and low-grade malignant tumors has established a secure position over open distal pancreatectomy, since it is associated with a shorter hospital stay, reduced blood loss, and equivalent complication rates. Minimally invasive distal pancreatectomy for pancreatic ductal adenocarcinoma appears to be a feasible, safe, and oncologically equivalent technique in experienced hands. On the other hand, the feasibility and safety of minimally invasive pancreaticoduodenectomy are still controversial compared with open pancreaticoduodenectomy. The choice of either technique among open, laparoscopic, and robotic approaches depends on surgeons' experience and hospital resources with a focus on patient safety. Further studies are needed to prove the perioperative and oncological advantages of minimally invasive surgery compared to open surgery in the pancreas. Here, we review the current status of minimally invasive pancreatic surgery and its safe implementation.

Predictors for Survival in an International Cohort of Patients Undergoing Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma

Background

Surgical factors, including resection of Gerota’s fascia, R0-resection, and lymph node yield, may be associated with survival after distal pancreatectomy (DP) for pancreatic ductal adenocarcinoma (PDAC), but evidence from large multicenter studies is lacking. This study aimed to identify predictors for overall survival after DP for PDAC, especially those related to surgical technique.

Patients and Methods

Data from an international retrospective cohort including patients from 11 European countries and the USA who underwent DP for PDAC (2007–2015) were analyzed. Cox proportional hazard analyses were performed and included Gerota’s fascia resection, R0 resection, lymph node ratio, extended resection, and a minimally invasive approach.

Results

Overall, 1200 patients from 34 centers with median follow-up of 15 months [interquartile range (IQR) 5–31 months] and median survival period of 30 months [95% confidence interval (CI), 27–33 months] were included. Gerota’s fascia resection [hazard ratio (HR) 0.74; p = 0.019], R0 resection (HR 0.70; p = 0.006), and decreased lymph node ratio (HR 0.28; p < 0.001) were associated with improved overall survival, whereas extended resection (HR 1.75; p < 0.001) was associated with worse overall survival. A minimally invasive approach did not improve survival as compared with an open approach (HR 1.14; p = 0.350). Adjuvant chemotherapy (HR 0.67; p = 0.003) was also associated with improved overall survival.

Conclusions

This international cohort identified Gerota’s fascia resection, R0 resection, and decreased lymph node ratio as factors associated with improved overall survival during DP for PDAC. Surgeons should strive for R0 resection and adequate lymphadenectomy and could also consider Gerota’s fascia resection in their routine surgical approach.

Electronic supplementary material

The online version of this article (10.1245/s10434-020-08658-5) contains supplementary material, which is available to authorized users.

Long-term oncologic outcomes of robotic and open pancreatectomy in a national cohort of pancreatic adenocarcinoma

BACKGROUND

Robotic pancreatectomy is gaining momentum; however, limited data exist on the long-term survival of this approach for pancreatic ductal adenocarcinoma (PDAC). The objective of this study is to compare the long-term oncologic outcomes of robotic pancreaticoduodenectomy (RPD) and robotic distal pancreatectomy (RDP) to open surgery in patients with PDAC.

STUDY DESIGN

Robotic and open pancreatectomy for stages I-III PDAC were obtained from the 2010 to 2016 National Cancer Database.

RESULTS

We identified 17 831 pancreaticoduodenectomies and 2718 distal pancreatectomies of which 626 (4%) and 332 (12%) were robotic, respectively. There was no difference in median overall survival between RPD (22.0 months) and open pancreatoduodenectomy (21.8 months; logrank P = .755). The adjusted hazard ratio [HR] was 1.014 (95% confidence interval [CI]: 0.903-1.139). The median overall survival for RDP (35.3 months) was higher than open distal pancreatectomy (ODP) (24.9 months; logrank P = .001). The adjusted HR suggests a benefit to RDP compared to ODP (HR, 0.744; 95% CI: 0.632-0.868) CONCLUSION: In a national cohort of resected pancreatic adenocarcinoma, the robotic platform was associated with similar long-term survival for pancreaticoduodenectomy, but improved survival for distal pancreatectomy.

Prediction of the Probability of Malignancy in Mucinous Cystic Neoplasm of the Pancreas With Ovarian-Type Stroma: A Nationwide Multicenter Study in Japan

OBJECTIVE

The aim of the study was to develop a formula for predicting the probability of malignancy of mucinous cystic neoplasm (MCN) of the pancreas with ovarian-type stroma.

METHODS

A total of 364 patients were enrolled. A total score was calculated as the sum of the approximate integers of the odds ratios of the predictive factors identified by multivariate analysis. The relationship between the total score and pathological results was assessed.

RESULTS

A total of 321 patients had benign MCN and 43 had malignant MCN. Five possible predictive factors were analyzed: 56 years or older, high serum carcinoembryonic antigen level, high carbohydrate antigen 19-9 level, tumor size of 51 mm or greater, and the presence of mural nodules. The total score was significantly higher in patients with malignant MCN (median, 24; range, 0-37) compared with benign MCN (median, 5; range, 0-33; P < 0.001). Receiver operating characteristic curve analysis demonstrated that the area under the curve was 0.86, and the sensitivity and specificity of the total score for discriminating malignant MCNs were 72% and 83%, respectively, using a cut-off value of 22.

CONCLUSIONS

The current simple formula can predict the malignancy of MCN and may thus contribute to the adequate management of patients with MCN.

Downregulation of thymopoietin by miR-139-5p suppresses cell proliferation and induces cell cycle arrest/apoptosis in pancreatic ductal adenocarcinoma

MicroRNAs (miRNAs) serve a pivotal role in tumor development and progression, in which miRNA (miR)-139-5p functions as a tumor suppressor. However, the functions and mechanisms of miR-139-5p in pancreatic ductal adenocarcinoma (PDAC) remain unclear. In the present study, it was found that miR-139-5p was markedly decreased in PDAC tissues and cell lines. Noticeably, thymopoietin (TMPO) was predicted and confirmed as a direct target of miR-139-5p using a luciferase reporter system. The expression level of miR-139-5p was inversely associated with the expression of TMPO in PDAC specimens. A series of gain-of-function assays elucidated that the overexpression of miR-139-5p suppressed cell proliferation, and induced cell cycle arrest and cell apoptosis, determined with a Cell Counting Kit-8, colony formation assays and flow cytometry, respectively. Furthermore, the re-expression of TMPO eliminated the effects of miR-139-5p on cell proliferation, cell cycle progression and apoptosis. In summary, these findings demonstrated that miR-139-5p may be a tumor suppressor in PDAC, which may be useful in developing promising therapies for PDAC.

Variation in use of open and laparoscopic distal pancreatectomy and associated outcome metrics in a universal health care system

BACKGROUND

Universal health care (UHC) should ensure equal access to and use of surgery, but few studies have explored variation in UHC systems. The objective was to describe practice of distal pancreatectomy in Norway covered exclusively by an UHC.

METHODS

Data on all patients undergoing distal pancreatectomy from the Norwegian Patient Register over a 5-year period. Age- and gender-adjusted population-based resection rates (adj. per million/yr) for distal pancreatectomy were analysed across 4 regions and outcomes related to splenic salvage rate, hospital stay, reoperation, readmissions and 90-day mortality risk between regions. Risk is reported as odds ratio (OR) with 95% confidence interval (c.i.).

RESULTS

Regional difference exist in terms of absolute numbers, with the majority of procedures done in one region (n = 331; 59.7%). Regional variation persisted for age- and gender-adjusted population-rates, with highest rate at 23.8/million/yr and lowest rate at 13.5/mill/yr (for a 176% relative difference; or an absolute difference of +10.3 resections/million/yr). Overall, a lapDP instead of an open DP was 3.5 times more likely in SouthEast compared to all other regions combined (lapDP rate: 83% vrs 24%, respectively; OR 15.4, 95% c.i. 10.1-23.5; P < 0.001). The splenic salvage rate was lower in SouthEast (19.9%) compared to all other regions (average 26.5%; highest in Central-region at 37.0%; P = 0.010 for trend). Controlled for other factors in multivariate regression, 'region' of surgery remained significantly associated with laparoscopic access.

CONCLUSION

Despite a universal health care system, considerable variation exists in resection rates, use of laparoscopy and splenic salvage rates across regions.

Laparoscopic approach of the left side of the pancreas

INTRODUCTION

Laparoscopic left-sided pancreatectomy (LLP) is an increasingly used surgical technique for the treatment of benign and malignant lesions of the left side of the pancreas. The results of LLP as a treatment for primary pancreatic lesions of the head and tail of the pancreas were evaluated.

METHODS

From November 2011 to November 2017, 18 patients underwent surgery for primary lesions of the pancreas by means of a laparoscopic distal pancreatectomy. An intra-abdominal drain tube was used in all cases, and the recommendations of the International Study Group for Pancreatic Fistula (ISGPF) were followed.

RESULTS

The mean age was 66.5years (IQR 46-74). Among the 18 left pancreatectomies performed, four were with splenic preservation, and one was a central pancreatectomy. There were two conversions. The median surgical time was 247.5minutes (IQR 242-275). The median postoperative hospital stay was 7days (IQR 6-8). After 90days, complications were detected in five patients: three gradeII, one gradeIII and one gradeV according to the modified Clavien-Dindo classification. There was one gradeB pancreatic fistula, and four patients had to be readmitted to hospital because of peripancreatic collections. The anatomic pathology diagnosis was malignant neoplasm in 38.9% of cases, all of them with negative resection margins.

CONCLUSIONS

LLP can be considered the technique of choice in the treatment of primary benign pancreatic lesions and an alternative to the open approach in selected patients diagnosed with malignant pancreatic lesions.

Laparoscopic Distal Pancreatectomy: Our Experience in a Tertiary Referral Center

BACKGROUND

Despite an increase in the number of laparoscopic distal pancreatectomy (LDP) procedures being performed, the long-term oncology and operative results are still unclear. The aim of this study was to present the surgical and long-term results of patients undergoing LDP for the treatment of distal pancreatic tumors.

MATERIALS AND METHODS

A retrospective review was made of patients who underwent LDP in our clinic, between 2006 and 2018, and who were diagnosed with pancreas tail, neck, and corpus tumors. For the purposes of this study, the data related to the preoperative, operative, and postoperative characteristics of the patients were determined.

RESULTS

A total of 46 patients were identified as suitable for inclusion in the study. Of these, 52.1% were female individuals, and the average age of the whole group was 63 years. Previous surgery for malignant diseases was recorded for 54.3% of the patients, due to premalignant diseases in 13% and benign diseases in 32.7%. On average, 10 lymph nodes were removed from patients diagnosed with malignant tumors. The conversion rate was found to be 2.1%. The postoperative pancreatic fistula rate was 26%, and there was 1 complication each of grades III and IV according to the Clavien-Dindo classification. The mortality rate was 0%.

CONCLUSIONS

It was concluded that LDP of distal pancreas tumors seems to be both safe and effective in respect of the long-term results in addition to the early results of the operation.

Long term oncological outcome of laparoscopic techniques in pancreatic cancer

The laparoscopic technique in distal pancreatic resection (LDP) has been widely accepted, and outcome data support the hypothesis that survival is improved, partly due to improved postoperative safety and recovery, thus optimizing treatment with adjuvant chemotherapy. But laparoscopic pancreaticoduodenectomy (LPD or Whipple-procedures) has spread more slowly, due to the complexity of the procedure. Surgical safety has been a problem in hospitals with low patient volume, resulting in raised postoperative mortality, requiring careful monitoring of outcome during the surgical learning curve. Robotic assistance is expected to improve surgical safety, but data on long term oncological outcome of laparoscopic Whipple procedures with or without robotic assistance is scarce. Future research should still focus surgical safety, but most importantly long term outcome, recorded as recurrence at maximal follow up or - at best - overall long term survival (OS). Available data show median survival above 2.5 years, five year OS more than 30% after LDP even in series with suboptimal adjuvant chemotherapy. Also after LPD, long term survival is reported equal to or longer than open resection. However, surgical safety during the learning curve of LPD is a problem, which hopefully can be facilitated by robotic assistance. Patient reported outcome should also be an endpoint in future trials, including patients with pancreatic ductal adenocarcinoma.

Incidence and management of arterial injuries during pancreatectomy

PURPOSE

The incidence of intraoperative arterial injury during pancreatectomy is not well described. This study aims to evaluate the incidence, management, and outcome of arterial injuries during pancreatectomy.

METHODS

This is a retrospective study of 1535 consecutive patients undergoing pancreatectomy between 2006 and 2016 at Oslo University Hospital. The type of arterial injury and potential contributing factors were analyzed. Short-term outcomes were compared between patients with arterial injury and patients undergoing a planned arterial resection due to tumor involvement.

RESULTS

Arterial injury was diagnosed in 14 patients (incidence 0.91%), while planned arterial resection was performed in 22 patients. The injuries were located in the superior mesenteric artery (n = 5), right hepatic artery (n = 5), common hepatic artery (n = 2), left hepatic artery (n = 1), and celiac trunk (n = 2). The artery was reconstructed in all except one patient. In 11 patients with injury, peripancreatic inflammation, aberrant arterial anatomy, close relationship between tumor and injured artery, or a combination of the three were found. Median estimated blood loss was 1100 ml in both groups. Rate of severe complications (≥ Clavien grade IIIa), comprehensive complication index, and 90-day mortality for patients with intraoperative arterial injury vs planned arterial resection were 43 vs 45% (p = 0.879), median 35.9 vs 21.8 (p = 0.287), and 14.3 vs 4.5% (p = 0.551), respectively.

CONCLUSION

Arterial injury during pancreatectomy is an infrequent and manageable complication. Early recognition and primary repair in order to restore arterial liver perfusion may improve outcome. However, the morbidity is high and comparable to patients undergoing a planned arterial resection.