Resection of portal and/or superior mesenteric vein and reconstruction by using allogeneic vein for pT3 pancreatic cancer

Utilizing bifurcated allogeneic vein grafts: a novel approach for preventing sinistral portal hypertension following pancreaticoduodenectomy. A 10-year before and after study

BACKGROUND

Sinistral portal hypertension (SPH) may occur in patients with pancreatic carcinoma after pancreaticoduodenectomy (PD) with spleno-mesenterico-portal (S-M-P) confluence resection. This study aimed to evaluate outcomes with bifurcated allogeneic vein replacement in the prevention of SPH in pancreatic carcinoma patients.

MATERIALS AND METHODS

A total of 81 patients were included. The authors retrospectively collected clinicopathological data from 66 patients underwent PD with S-M-P confluence resection in our hospital from January 2011 to December 2021, compared the correlation between different venous reconstruction methods using log-rank tests and clinical outcomes through univariate and multivariate analyses. Secondly, the authors prospectively collected clinical data and outcomes of 15 patients who underwent splenic vein reconstruction from January 2021 to January 2023.

RESULTS

In the retrospective study, 43 cases received reconstruction by bifurcated allogeneic vein (Reconstruction group) and 23 cases received simply SV ligation (Ligation group). The preoperative platelet counts and spleen volume were similar between two groups ( P >0.05). Nevertheless, at 1 month, 3 months and 6 months after operation, the related indexes of SPH such as platelet count, spleen volume, spleen volume ratio and esophagogastric varices (EGV) grade in Reconstruction group were better than those in Ligation group ( P <0.05). 6 months after surgery, the incidence of SPH in Ligation group was significantly higher than in Reconstruction group (36.4% vs. 8.1%, respectively). In the prospective study, the incidence of SPH in patients undergoing SV reconstruction was 6.7% (1/15).

CONCLUSIONS

Without compromising surgical outcomes, reconstruction of the S-M-P confluence by bifurcated allogeneic vein is a better method to avoid SPH in patients with advanced pancreatic carcinoma.

Cryopreserved allografts versus end-to-end anastomosis for the reconstruction of a segment-resected portomesenteric vein during advanced pancreatic cancer surgery

BACKGROUND

Porto-mesenteric vein (PMV) infiltration of pancreatic cancer is classified as borderline resectable cancer. For en-bloc resectability, the probability of PMV resection and reconstruction is the most decisive factor. The purpose of this study was to compare and analyze PMV resection and reconstruction during pancreatic cancer surgery using end-to-end anastomosis (EA) and a cryopreserved allograft (AG) and to verify the effectiveness of reconstruction using an AG.

METHODS

Between May 2012 and June 2021, 84 patients (65 underwent EA, and 19 received AG reconstruction) underwent pancreatic cancer surgery with PMV reconstruction. An AG is a cadaveric graft with a diameter of 8-12 mm and is obtained from a liver transplant donor. Patency after reconstruction, disease recurrence, overall survival, and perioperative factors were assessed.

RESULTS

The median age was higher in EA patients (p = .022) and neoadjuvant therapy (p = .02) was more in AG patients. Upon histopathological examination, the R0 resection margin did not show a significant difference by reconstruction method. During a 36-month survival analysis, primary patency was significantly superior in EA patients (p = .004), and there was no significant difference in recurrence-free survival (p = .628) or overall survival (p = .638) rates.

CONCLUSION

Compared with EA, AG reconstruction after PMV resection during pancreatic cancer surgery showed a lower primary patency, but there was no difference in recurrence-free or overall survival rates. Therefore, the use of AG can be a viable option for borderline resectable pancreatic cancer surgery if the patient is properly followed-up postoperatively.

Prognostic Value of Neoadjuvant Chemotherapy in Patients with Borderline Resectable Pancreatic Carcinoma Followed by Pancreatectomy with Portal Vein Resection and Reconstruction with Venous Allograft

BACKGROUND

Neo-adjuvant chemotherapy (NAC) represents one of the current research hotspots in the field of pancreatic ductal adenocarcinoma (PDAC). The aim of this study is to evaluate the prognostic value of NAC in patients with borderline resectable pancreatic cancer (BRPC) followed by pancreatectomy with portal vein (PV) resection and reconstruction with venous allograft (VAG).

METHODS

Medical records of patients with BPRC who underwent pancreatectomy with concomitant PV resection and reconstruction with VAG between April 2013 and March 2021 were analyzed retrospectively. Outcomes of patients with and without NAC (NAC, Group 1 vs. non-NAC, Group 2) were compared with focus on R0 resection rates, morbidity, and survival.

RESULTS

Of the 77 patients with pancreatectomy, PV resection and reconstruction with VAG were identified. Overall survival (OS) rates of 0.5-, 1-, and 2-year were 80.5%, 59.7%, and 31.2%, respectively (median survival time, MST, 14 months). Of these, 24 patients (Group 1) underwent operation following received NAC, and the remaining 53 patients did not (Group 2). The R0 resection rate of vascular margin was 100% vs. 84.9% (p = 0.04), respectively. Morbidity of post-operative pancreatic fistula (POPF) was 0% vs. 17.8% (p = 0.07), respectively. The OS of 0.5-, 1- and 2-year and MST of 2 groups were 83.3%, 66.7%, 41.7%, 16 months, and 79.2%, 55.6%, 26.4%, 13 months, respectively. Multivariate analysis revealed that carbohydrate antigen 19-9 (CA19-9) serum level and postoperative chemotherapy were independent prognostic factors in patients with BRPC after surgery.

CONCLUSION

NAC might improve the R0 resection rate and POPF in patients with BRPC who underwent pancreatectomy with concomitant PV resection and reconstruction with VAG. Survival benefit exists in patients with BRPC who received NAC before pancreatectomy. Postoperative chemotherapy also had a favorable effect on OS of BRPC patients. Elevated CA 19-9 serum level is associated with poor prognosis, even after NAC-combining operation.

Robotic versus open pancreaticoduodenectomy with vascular resection for pancreatic ductal adenocarcinoma: surgical and oncological outcomes from pilot experience

PURPOSE

Venous resection and reconstruction (VR) is a feasible surgical technique to achieve optimal outcomes in selected patients with pancreatic ductal adenocarcinoma (PDAC) who undergo open pancreaticoduodenectomy (OPD). However, data regarding patient outcomes in patients who undergo VR in robotic-assisted pancreaticoduodenectomy (RPD) are scarce.

METHODS

All patients with a diagnosis of PDAC who underwent upfront open or robotic pancreatoduodenectomy with VR in a high-volume institution for pancreatic surgery between 2011 and 2019 were retrospectively reviewed. Perioperative and long-term outcomes were compared between the RPD and OPD cohorts.

RESULTS

A total of 84 patients were included in the final analysis, 14 patients underwent RPD with VR and 70 who had OPD with VR. Reconstructed venous patency, postoperative 30-day morbidity, and 90-day mortality were comparable; however, lymph node resection rates were lower in the RPC cohort (p = 0.029). No difference was identified in 3-year survival rates between the two groups (34.0% versus 25.7% respectively, p = 0.667).

CONCLUSION

RPD with VR is a feasible approach for patients with PDAC and venous invasion. Further studies are needed to assess long-term outcomes compared to the open approach.

Use of the peritoneum or the round ligament of the liver in radical surgery for pancreatic cancer

BACKGROUND

At present, the materials commonly used for venous reconstruction in radical surgery for pancreatic cancer combined with vascular reconstruction include artificial blood vessels, autologous veins, and allogeneic blood vessels, but these materials all have their own disadvantages. In contrast, the use of the peritoneum and the round ligament of the liver for radical surgery for pancreatic cancer combined with vascular reconstruction provides new options.

METHODS

A retrospective descriptive study was performed. Clinical data were collected from 11 patients (5 males and 6 females with a median age of 62 years and an age range of 48-72 years) who underwent pancreatic cancer surgery combined with resection and reconstruction of the portal vein (PV) and superior mesenteric vein (SMV) using the peritoneum (including the round ligament of the liver) from November 2018 to November 2020 in the Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, and the Department of General Surgery, Affiliated Hospital of Shaoxing University. Intraoperative conditions and postoperative conditions were observed. Data were analyzed using SPSS 19.0 Normally distributed measurement data are expressed as the mean ± SD, whereas nonnormally distributed measurement data are expressed as the median (range). Count data are expressed as absolute numbers.

RESULTS

(I) Intraoperative condition: all 11 patients completed the operation successfully, including total pancreatectomy (TP) in 4 patients and pancreatoduodenectomy (PD) in 7 patients. In the 11 patients, the duration of surgery was 503±183 min, and the volume of intraoperative bleeding was 332±268 mL. (II) Postoperative condition: of the 11 patients, 5 presented with complications, including pancreatic leak in 3 patients, bleeding in 1 patient, and thrombosis in 1 patient. Postoperative pathological examination showed that 10 of the 11 patients had adenocarcinoma, and 1 had a neuroendocrine tumor.

CONCLUSIONS

The peritoneum and the round ligament of the liver are feasible materials and provide clinical options for reconstruction of the PV and SMV.

Reconstructing spleno-mesenterico-portal cofluence by bifurcated allogeneic vein in local advanced pancreatic cancer-a feasible method to avoid left-sided portal hypertension

BACKGROUND

Left-sided portal hypertension is usually found in patients undergoing pancreaticoduodenectomy (PD) with spleno-mesenterico-portal (S-M-P) confluence resection. This study is to explore the outcomes of S-M-P confluence reconstruction after resection by using bifurcated allogeneic vein.

METHODS

Clinicopathologic data of patients who underwent extensive PD with S-M-P confluence resection for carcinoma of pancreatic head/uncinate process in our hospital between December 2011 and August 2018 were retrospectively reviewed and clinical outcomes of vein reconstruction after resection were analyzed.

RESULTS

Of the 37 patients enrolled, S-M-P reconstruction by bifurcated allogeneic vein was performed in 24 cases (group 1) and simply splenic vein ligation in 13 cases (group 2). Items including pathological results, blood loss, and complications were comparable between the two groups, operation time was longer in group 1 (573.8 vs. 479.2 min, p = 0.018). Significantly decreased platelet count (205.9 vs. 133.1 × 109 /L, p = 0.001) and increased splenic volume (270.9 vs. 452.2 ml, p < 0.001) were observed in group 2 at 6 months after operation. The mean splenic hypertrophy ratio was 1.06 in group 1 and 1.63 in group 2, respectively (p < 0.001). There were four patients with varices were found in group 2, none in group 1.

CONCLUSIONS

Without increased complications, reconstructing S-M-P confluence by bifurcated allogeneic vein after resection may help to avoid left-sided portal hypertension.

Periadventitial dissection of the superior mesenteric artery for locally advanced pancreatic cancer: Surgical planning with the "halo sign" and "string sign"

Most patients diagnosed with pancreatic cancer are classified as nonoperative candidates based on the contemporary guidelines of resectability. The advent of more potent control of systemic disease using neoadjuvant chemotherapy has enabled more aggressive operative interventions. In our multidisciplinary practice, patients with Stage III, locally advanced pancreatic cancer and superior mesenteric artery (SMA) encasement are now carefully triaged with high quality, preoperative imaging to determine if they can be considered candidates for operative resection with periadventitial dissection of the SMA. Patients displaying a "halo sign," where the encased SMA remains fully patent and free from arterial invasion, are now candidates for SMA periadventitial dissection. This procedure involves the surgical stripping of the infiltrated neurolymphatic tissue off the SMA leaving behind a bare "skeletonized artery." Alternatively, the "string sign" involving the SMA confers a more likely case of arterial invasion, where a complete oncologic resection cannot be achieved successfully. This method of patient selection in case of SMA involvement abandons the traditional metrics of circumferential degrees of the arterial encasement to guide surgical decisions. Our institutional approach has allowed us to meaningfully expand our operative methods of resection with the potential for improved longitudinal outcomes to pancreatic cancer patients who were deprived historically from the more effective and possibly curative treatment.

Mesoportal bypass, interposition graft, and mesocaval shunt: Surgical strategies to overcome superior mesenteric vein involvement in pancreatic cancer

BACKGROUND

In pancreatic cancer, extensive tumor involvement of the mesenteric venous system poses formidable challenges to operative resection. Such involvement can result from cavernous collateral veins leading to increased intraoperative blood loss or long-segment vascular defects of not only just the superior mesenteric vein but also even jejunal/ileal branches. Strategies to facilitate margin-free resection and safe vascular reconstruction in pancreatic surgery are important, particularly because systemic control of the tumor is improving with multi-agent chemotherapy regimens.

METHODS

We describe a systematic, multidisciplinary assessment for patients with pancreatic cancer that involves the superior mesenteric vein, as well as the preoperative planning of those undergoing operative resection. In addition, detailed descriptions of operative approaches and technical strategies, which evolved with increasing experience at a high-volume center, are presented.

RESULTS

For the preoperative evaluation of tumor-free, vascular locations for potential reconstruction and collateralization, computed tomographic imaging with high-resolution of vascular structures (used with 3-dimensional or cinematic rendering) allows a precise calibration of radiographic data with intraoperative findings. From an operative perspective, we identified 5 potential strategies to consider for resection: collateral preservation, mesoportal bypass (preresection), mesoportal interposition graft (postresection), mesocaval shunt, and various combinations of these strategies. Many of these techniques use interposition grafts, making it essential to assess autologous veins (preferred conduit for reconstruction) or to prepare cryopreserved vascular allografts (an alternative conduit, which must be thawed and should be matched for size and blood type).

CONCLUSION

Herein we share operative strategies to overcome involvement of the superior mesenteric vein in pancreatic cancer. Improvements in preoperative planning and operative technique can address common barriers to resection with curative intent.

Feasibility of bile duct as venous graft for venous reconstruction in pancreatic surgery: An animal experimental study

OBJECTIVE

Pancreatic cancer is a kind of high malignant tumor with a poor prognosis. The aim is to determine whether the dilated bile duct can be used to reconstruct the vessels.

METHODS

An animal model of jugular vein and portal vein reconstruction was established using the bile duct. A total of 20 landrace pigs were selected to undergo jugular vein reconstruction or portal vein reconstruction using the bile duct as a patch or bridge. The patency was evaluated by color Doppler, the reconstructed segments were removed and examined macroscopically and histologically at specified intervals, and the results were compared with synthetic vessels (IMPRA straight, 10s03-19).

RESULTS

The lumen was patent, although a low level thrombosis was observed when jugular or portal vein patching was used. For bridging, stenosis of the lumen was observed, and necrosis appeared when the bile duct was used for bridging, indicating that it is feasible to reconstruct the jugular vein and portal vein with a bile duct patch. However, the bridge was not feasible possibly due to loss of blood supply, and consequent necrosis and fibrosis.

CONCLUSION

The bile duct is technically feasible, but the outcomes are unsatisfactory.

Vascular Resections for Pancreatic Ductal Adenocarcinoma: Vascular Resections for PDAC

BACKGROUND AND AIMS

It has become clear that vein resection and reconstruction for pancreatic ductal adenocarcinoma (PDAC) is the standard of care as supported by multiple guidelines. However, resection of large peri-pancreatic arteries remains debatable.

MATERIALS AND METHODS

This review examines the current state of vascular resection with curative intent for PDAC in the last 5 years. Herein, we consider venous (superior mesenteric vein, portal vein), as well as arterial (superior mesenteric artery, celiac trunk, hepatic artery) resection or both with or without reconstruction.

RESULTS

Improvement of multidrug chemotherapy has revolutionized care for PDAC that should shift traditional surgical thinking from an anatomical classification of resectability to a prognostic and biological classification.

CONCLUSION

The present review gives an overview on the results of pancreatectomy associated with vascular resection, with consideration of new perspectives offered by the availability of better systemic therapies.

Pancreatoduodenectomy with portal vein resection favors the survival time of patients with pancreatic ductal adenocarcinoma: A propensity score matching analysis

Portal vein (PV) involvement is common in patients with pancreatic ductal adenocarcinoma (PDAC). To the best of our knowledge, pancreatectomy combined with PV resection (PVR) is the only radical therapy for patients with PV involvement. However, there remains a debate on whether patients with PV involvement could benefit from PVR or not. The present study aimed to compare the survival outcomes between patients receiving pancreatoduodenectomy (PD) with PVR and those receiving PD alone. A total of 377 patients with PDAC were enrolled, 138 patients with PV involvement were placed in the PVR group, while the other 239 patients were in the non-PVR group. To reduce selection bias and estimate the causal effect, 123 pairs of propensity score matched (PSM) patients were selected and compared for the survival outcomes. Before PSM, the survival of patients in the PVR group was worse compared with those in the non-PVR group (mean survival, 25.1 vs. 29.3 months; P=0.038). After balancing the baseline characteristics using the PSM method, the significant survival difference between the two groups was insignificant (mean survival, 25.9 vs. 31.2 months; P=0.364). Tumor stage, body mass index, serum albumin, R1 resection, lymph node metastasis, carbohydrate antigen (CA)125 and CA19-9 were significant independent prognostic factors. The incidence of serious postoperative complications was similar between the two groups. PVR is safe and effective for patients with PDAC. Patients with PV involvement could achieve the similar survival outcome as patients without PV involvement, through radical resection combined with PVR, without increasing the risk of serious complications.

International consensus statement on robotic pancreatic surgery

The robotic surgical system has been applied to various types of pancreatic surgery. However, controversies exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness of robotic surgery. This study aimed to evaluate the current status of robotic pancreatic surgery and put forth experts' consensus and recommendations to promote its development. Based on the WHO Handbook for Guideline Development, a Consensus Steering Group* and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 19 topics were analyzed. The first 16 recommendations were generated by GRADE using an evidence-based method (EBM) and focused on the safety, feasibility, indication, techniques, certification of the robotic surgeon, and cost-effectiveness of robotic pancreatic surgery. The remaining three recommendations were based on literature review and expert panel opinion due to insufficient EBM results. Since the current amount of evidence was low/meager as evaluated by the GRADE method, further randomized controlled trials (RCTs) are needed in the future to validate these recommendations.

Risk factors related to metastasis of para-aortic lymph nodes in pancreatic ductal adenocarcinoma: A retrospective observational study

This study was designed to explore the risk factors related to metastasis of para-aortic lymph node (PALN).Clinicopathologic data of 241 patients with resectable or borderline resectable pancreatic cancer who underwent pancreaticoduodenectomy with extended lymphadenectomy between January 2008 and December 2015 were collected, potential factors related to metastasis of PALN were analyzed.Positive rate of PALN was 19.5% (47/241). Univariate analysis showed that back pain (P = .028), preoperative CA19-9 level (P < .001), tumor size (P < .001), portal vein (PV)/superior mesenteric vein (SMV) invasion (P < .001), superior mesenteric artery (SMA) invasion (P < .001), and diameter > 1.0 cm were in correlation with PALN involvement, multivariate analysis revealed that preoperative CA19-9 level, PV/SMV invasion, SMA invasion and diameter > 1.0 cm were independent risk factors to metastasis of PALN. Patients with LN8+ had a higher positive rate of PALN than with LN8- (38.1% vs 15.6%, P = .001), similar results could be found when LN12+ (35.8% vs 13.2%, P < .001) and LN14+ (41.2% vs 11.0%, P < .001), multivariate analysis showed that LN8+ and LN14+ were closely in correlation with PALN metastasis.Several factors were related to the status of PALN, preoperative CA19-9 level, PV/SMV invasion, SMA invasion and diameter > 1.0 cm were 4 independent risk factors to PALN metastasis. LN8+ and LN14+ were 2 strong predictors of PALN metastasis. A comprehensive analysis covering all possible risk factors related to metastasis of PALN should be given before design of treatment plan whenever involvement of PALN was suspected.

Proposed Chaoyang vascular classification for superior mesenteric-portal vein invasion, resection, and reconstruction in patients with pancreatic head cancer during pancreaticoduodenectomy - A retrospective cohort study

BACKGROUND

Patients with pancreatic head cancer involving the superior mesenteric-portal vein can benefit from vascular resection and reconstruction. We aimed to propose our vascular classification and assess its effect in this study.

MATERIAL AND METHODS

Data of consecutive patients, who were diagnosed with pancreatic head cancer, and underwent radical pancreaticoduodenectomy combined with superior mesenteric-portal vein resection and reconstruction at our institute between October 2013 and August 2016, were retrospectively collected. On a scale of one to four, our classification was proposed. Perioperative parameters were then analyzed among the four types.

RESULTS

There were a total of 52 patients with 11 in type Ⅰ, 15 in type Ⅱ, 18 in type Ⅲ, 8 in type Ⅳ. The respective operative time and estimated blood loss of types Ⅲ (425-990 min, 265-1820 mL) and Ⅳ (480-1036 min, 330-1690 mL) were greater than those of types Ⅰ (300-824 min, 200-1255 mL) and Ⅱ (369-875 min, 305-1400 mL) (p < 0.05). Type Ⅳ had larger tumors (4-7 cm) than type Ⅰ (1.5-4 cm) (p < 0.05). Percentage of tunica intima involvement and the median survival time of type Ⅰ (9.1%, 22 months) were lower and longer than those of types Ⅱ (46.7%, 17 months) and Ⅲ (44.4%, 16 months; p < 0.05), and even lower and longer than those of type Ⅳ (87.5%, 10 months; p < 0.01), respectively.

CONCLUSIONS

Our classification can provide a system to grade patients with venous invasion in order of surgical difficulty and survival.

Feasibility of portal or superior mesenteric vein resection and reconstruction by allogeneic vein for pancreatic head cancer-a case-control study

BACKGROUND

There are few reports about resection of portal vein (PV)/superior mesenteric vein (SMV) and reconstruction by using allogeneic vein. This case-control study was designed to explore the feasibility and safety of this operation type in patients with T3 stage pancreatic head cancer.

METHODS

A total of 42 patients (Group A) underwent PV/SMV resection and reconstruction by using allogeneic vein were 1:1 matched to 42 controls (Group B) with other types of resection and reconstruction. The two groups were well matched.

RESULTS

There was no significantly prolonged total operation time (Group A vs. Group B [490.0 min vs. 470 min], P = 0.067) and increased intraoperative blood loss (Group A vs. Group B [650.0 min vs. 450 min], P = 0.108) was found between the two groups. R1 rate of PV/SMV was slightly reduced in group A compared to group B (4.8% vs. 14.3%, P = 0.137), although no significant difference was found. The incidences of main postoperative complications between the two groups were similar. A slightly increased 1-year and 2-year overall survival rate (OS) (Group A vs. Group B [1-year OS: 62.9% vs. 57.0%; 2-year OS: 31.5% vs. 25.6%], P = 0.501) and disease-free survival rate (DFS) (Group A vs. Group B [1-year DFS: 43.9% vs. 36.6%; 2-year DFS: 10.5% vs. 7.4%], P = 0.502) could be found in group A compared to group B, although the differences were not significant.

CONCLUSIONS

The operation types of PV/SMV resection and reconstruction by using allogeneic vein is safety and feasible, it might have a potential benefit for patients.

Portal vein reconstruction using primary anastomosis or venous interposition allograft in pancreatic surgery

OBJECTIVE

Superior mesenteric vein/portal vein (SMV/PV) resection and reconstruction during pancreatic surgery are increasingly common. Several reconstruction techniques exist. The aim of this study was to evaluate characteristics of patients and clinical outcomes for SMV/PV reconstruction using interposed cold-stored cadaveric venous allograft (AG+) or primary end-to-end anastomosis (AG-) after segmental vein resections during pancreatic surgery.

METHODS

All patients undergoing pancreatic surgery with SMV/PV resection and reconstruction from 2006 to 2015 were identified. Clinical and histopathologic outcomes as well as preoperative and postoperative radiologic findings were assessed.

RESULTS

A total of 171 patients were identified. The study included 42 and 71 patients reconstructed with AG+ and AG-, respectively. Patients in the AG+ group had longer mean operative time (506 minutes [standard deviation, 83 minutes] for AG+ vs 420 minutes [standard deviation, 91 minutes] for AG-; P < .01) and more intraoperative bleeding (median, 1000 mL [interquartile range (IQR), 650-2200 mL] for AG+ vs 600 mL [IQR, 300-1000 mL] for AG-; P < .01). Neoadjuvant therapy was administered more frequently for patients in the AG+ group (23.8% vs 8.5%; P = .02). Patients with AG+ had a longer length of tumor-vein involvement (median, 2.4 cm [IQR, 1.6-3.0 cm] for AG+ vs 1.8 cm [IQR, 1.2-2.4 cm] for AG-; P = .01), and a higher number of patients had a tumor-vein interface >180 degrees (35.7% for AG+ vs 21.1% for AG-; P = .02). There was no difference in number of patients with major complications (42.9% for AG+ vs 36.6% for AG-; P = .51) or early failure at the reconstruction site (9.5% for AG+ vs 8.5% for AG-; P = 1). A subgroup analysis of 10 patients in the AG+ group revealed the presence of donor-specific antibodies in all patients.

CONCLUSIONS

The short-term outcome of SMV/PV reconstruction with interposed cold-stored cadaveric venous allografts is comparable to that of reconstruction with primary end-to-end anastomosis. Graft rejection could be a contributing factor to severe stenosis in patients reconstructed with allograft.

Radical antegrade modular pancreatosplenectomy versus standard procedure in the treatment of left-sided pancreatic cancer: A systemic review and meta-analysis

BACKGROUND

Radical antegrade modular pancreatosplenectomy (RAMPS), first reported by Strasberg in 2003, has attracted increasing attention in the treatment of left-sided pancreatic cancer. The limited number of cases eligible for RAMPS makes it difficult to perform any prospective randomized trial of RAMPS versus the standard procedure. Therefore, we performed this systemic review and meta-analysis of the current data to clarify the role of the RAMPS procedure.

METHODS

A literature search was performed in electronic databases, including PubMed, Medline, Embase, CNKI and the Cochrane Library. Studies comparing RAMPS with the standard procedure were included in this meta-analysis. R0 resection rate, recurrence rate at the end of the follow-up, overall survival (OS) and disease-free survival (DFS) were measured as primary outcomes. Revman 5.3 was used to perform the analysis.

RESULTS

Six retrospective cohort studies with a total number of 378 patients were included in our analysis. Meta-analysis revealed that RAMPS was correlated with higher R0 resection rates [Odds Ratio (OR) 95% confidence interval (CI), 2.19 (1.16 ~ 4.13); P = 0.02] and successful harvest of more lymph nodes [weighted mean difference (WMD) 95% CI, 7.06 (4.52 ~ 9.60); P < 0.01] compared with the standard procedure. However, no statistically significant difference was found between the procedures with respect to recurrence rates [OR 95% CI, 0.66 (0.40 ~ 1.09); P = 0.10], OS [Hazard ratio (HR) 95% CI, 0.65 (0.42 ~ 1.00); P = 0.05] or DFS [HR 95% CI, 1.02 (0.62 ~ 1.68); P = 0.93].

CONCLUSIONS

RAMPS is safe and oncologically superior to the standard procedure for the treatment of left-sided pancreatic cancer. However, high-grade evidence will be necessary to confirm the potential survival benefits of RAMPS.

Segmental portal/superior mesenteric vein resection and reconstruction with the iliac vein after pancreatoduodenectomy

Objective The results of segmental venous resection (VR) combined with pancreatoduodenectomy (PD) are controversial but may be promising. Few studies have described reconstruction of the portal/superior mesenteric vein (PV/SMV) with the iliac vein harvested from donation after cardiac death (DCD). Methods From January 2014 to April 2016, PD combined with segmental excision of the PV/SMV (VR group) was performed in 21 patients with adenocarcinoma of the head of the pancreas (ADHP). The authors established a new technique of venous reconstruction using the iliac vein from DCD and analysed patients' long-term survival. Results The tumour dimensions and tumour staging were greater and the operation time was longer in the VR than PD group; however, no differences in the resection degree, blood loss, complications, reoperation rate, or mortality rate were found. The median survival was similar between the VR and PD groups. The long-term patency of the donor iliac vein was 90%. The degree of resection was a strong predictor of long-term survival. Conclusion Segmental PV/SMV resection combined with PD is applicable to selective patients with venous invasion by ADHP if R0 resection has probably been achieved. An iliac vein obtained by DCD provides an effective graft for venous reconstruction.