Surgical outcomes in patients with pancreatic body and tail cancer invading the main veins

The aim of the study was to demonstrate the safety and satisfactory outcomes of surgical treatment in patients with ductal cancer of the body and tail of the pancreas with invasion of the main veins using distal subtotal resection of the pancreas with resection of the superior mesenteric and / or portal veins.
Materials and methods: Distal subtotal resection of the pancreas with resection of the superior mesenteric and / or portal veins was performed in 29 patients with ductal cancer of the body and tail of the pancreas. Parietal resection of the main veins with a length of 1.0 to 3.0 cm using a parietal suture was performed in 15 (51.7%) patients, and circular resection with a length of 1.5 to 5.0 cm was carried out in 14 (48.3%) patients. In the circular resection subset, 11 people had an end-to-end anastomosis, 2 had plastic surgery using a Gore-Tex synthetic graft, and 1    underwent an autologous vein plastic surgery. Compression of the portal vein during surgery lasted from 10 to 16 minutes with the creation of a direct end-to-end anastomosis and from 12 to 27 minutes with the use of a graft. Damage from the tumor to neighboring organs required a liver resection in 1 (3.5%) patient, wedge resection of the stomach wall in 3 (10.3 %) patients, adrenalectomy in 2 (6.9 %) subjects, small intestine resection in 2 (6.9 %) patients, one diaphragm resection, one nephrectomy, and one hemicolectomy. The duration of the operations ranged from 2 to 6.5 hours, and the volume ofblood loss ranged from 300 mL to 5.6 L. 
Results: R0 surgery was performed in 89.6 % of patients, R1 in 6.9 %, and R2 surgery in 3.5% of cases. Histopatho-logical examination of the surgical material revealed retroperitoneal invasion in 69.0% of patients, perineural invasion in 65.5%, and invasion of the superior mesenteric and/ or portal veins in 55.2% of cases. Complications occurred in 51.7% of patients, the incidence of Clavien-Dindo Grade III or higher complications was 34.5%. All complications were controlled with conservative treatment; there were no deaths. Long-term treatment outcomes: The one- and three-year overall survival rates were 74.6% and 14.9%, respectively (median 14.6 months), the progression-free survival rates were 31.0% and 15.5%, respectively (median 8.0 months). A comparison of results in 26 patients who underwent R0 surgery and 3 patients who underwent R+ surgery did not reveal statistically significant differences. 
Conclusion: Distal subtotal resection of the pancreas with resection of the superior mesenteric and / or portal veins is relatively safe and helps to improve the duration and quality of life of patients with ductal cancer of the body and tail of the pancreas.

1. Stoop T.F., Augustinus S., Bjornsson B., et al. Surgical outcome after distal pancreatectomy with and without porto-mesenteric venous resection in patients with pancreatic adenocarcinoma: a transatlantic evaluation (GAPASURG). Ann Surg Oncol 2024;31(12):8327-8339. https://doi.org/10.1245/sl0434-024-15932-3

2. Xu D., Wu P., Zhang K., et al. The short-term outcomes of distal pancreatectomy with portal vein/superior mesenteric vein resection. Langenbecks Arch Surg 2022;407(5):2161-2168. https://doi.org/10.1007/s00423-021-02382-8

3. Loos M., Mack C.E., Xu A.T.L., et al. Distal pancreatectomy: extent of resection determines surgical risk categories. Ann Surg 2024;279(3):479—485. https://doi.org/10.1097/SLA.0000000000005935

4. Hackert T., Klaiber U., Hinz U., et al. Portal vein resection in pancreatic cancer surgery: risk of thrombosis and radically determine survival. Ann Surg 2023;277(6):el291-el298. https://doi.org/10.1097/SLA.0000000000005444

5. Maekawa A., Oba A., Inoue Y., et al. Technical strategy for pancreatic body cancers: a raison d’etre of distal pancreatectomy with portal resection. Ann Surg Oncol 2024;31(2):1347—1357. https://doi.org/10.1245/sl0434-023-14554-5

6. Tanaka N., Yamada S., Sonohara F., et al. An outcome analysis of predictive factors for portal or splenic vein thrombosis after distal pancreatectomy. Surg Today 2020;50(10):1282-1289. https://doi.org/10.1007/s00595-020-02004-8

7. Ramacciato G, Nigri G, Petrucciani N, et al. Pancreatectomy with mesenteric and portal vein resection for borderline resectable pancreatic cancer: multicenter study of 406 patients. Ann Surg Oncol 2016;23(6):2028-37. doi: 10.1245/sl0434-016-5123-5

8. Nakao A., Takagi H. Isolated pancreatectomy for pancreatic head carcinoma using catheter bypass of the portal vein. Hepatogastroenterology 1993;40(5):426-429

9. Clavien P. A, Sanabria J. R, Strasberg S.M. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery 1992;lll(5):518-526

10. Bassi C., Marchegiani G., Dervenis C., et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery 2017;16l(3): 584—591. https://doi.Org/10.1016/j.surg.2016.11.014

11. Durin T., Chopinet S., Sauvanet A., et al. Defining benchmark outcomes for distal pancreatectomy in cancer: a multicenter, prospective cohort study. Ann Surg Oncol 2023;278(l):103-109. https://doi.org/10.1097/SLA.0000000000005539

12. Yamamoto Y., Sugiura T., Okamura Y., et al. Prognostic analysis of distal pancreatectomy for pancreatic body and/or tail cancer involving the portal vein: is it resectable? Pancreas 2022;5l(5):502-509. https://doi.org/10.1097/MPA.0000000000002058.