Inferior mesenteric vein serves as an alternative guide for transection of the pancreatic body during pancreaticoduodenectomy with concomitant vascular resection: a comparative study evaluating perioperative outcomes

Abstract

Background: Tumors of the pancreatic head often involve the superior mesenteric and portal veins. The purpose of this study was to assess perioperative outcomes after pancreaticoduodenectomy (PD) with concomitant vascular resection using the inferior mesenteric vein (IMV) as a guide for transection of the pancreatic body (Whipple at IMV, WATIMV).

Methods: One hundred thirty-seven patients had segmental vein resection during PD between January 2006 and June 2013. Depending on whether the standard approach of creating a tunnel anterior to the mesenterico-portal vein (MPV) axis was achieved for pancreatic transection, patients were subjected to a standard PD with vein resection procedure (s-PD + VR, n = 75) or a modified procedure (m-PD + VR, n = 62). Within the m-PD + VR group, 28 patients underwent the WATIMV procedure, while 34 patients underwent the usual procedure of transection, or 'central pancreatectomy' (c-PD + VR).

Results: The volume of intraoperative blood loss and the blood transfusion requirements were significantly greater, and the venous wall invasion and neural invasion frequency were significantly higher in the m-PD + VR group compared with the s-PD + VR group. There were no significant differences in the length of hospitalization, postoperative morbidity, and grades of complications between the two groups. Multivariate logistic regression identified intraoperative blood transfusion (P = 0.004) and vascular invasion (P = 0.008) as the predictors of postoperative morbidity. Further stratification of the entire cohort of 62 (45%) patients who underwent m-PD + VR showed a higher rate of negative resection margins (96.4%) in the WATIMV group compared with the c-PD + VR group (76.5%) (P = 0.06). The volume of intraoperative blood loss (P = 0.013), and intraoperative blood transfusion requirements (P = 0.07) were significantly greater in the c-PD + VR group compared with the WATIMV group. Furthermore, high intraoperative blood loss and tumor stage were predictive of a positive resection margin.

Conclusions: 'Whipple at the IMV (WATIMV)' has comparable postoperative morbidity with standard PD + VR. If IMV runs into the splenic vein, it could serve as an alternative guide for transection of the pancreatic body during PD + VR.

Figures

Figure 1

Magnetic resonance imaging (MRI) of a patient with segmental vein occlusion. A) A mass with complete occlusion of the superior mesenteric vein (SMV) (arrow); B) A multiple planar volume reconstruction image showed complete occlusion of the SMV with a venous collateral (arrow); the inferior mesenteric vein (IMV) inserted into the splenic vein (SV). PV, portal vein.

Figure 2

Schematic diagram. A) Pancreatic tumors involving the anterior of the mesenterico-portal vein (MPV) axis (circles); line A indicates the usual plane of transection of the neck of the pancreas in a standard Whipple procedure; line B indicates the plane of transection in an interior mesenteric vein (IMV) procedure; line C indicates the plane of transaction as in the ‘central pancreatectomy’ approach. B) The pancreas is transected just to the right of the plane through which the IMV enters the inferior border of the pancreas. (PV, portal vein; HA, hepatic artery; SA, splenic artery; SMV, superior mesenteric vein; SMA, superior mesenteric artery; SV, splenic vein).

Figure 3

Intraoperative photographs. A) creating the tunnel between the anterior surface of the splenic vein (SV) and the posterior surface of the pancreas; the body of the pancreas was encircled with a vessel loop; B) The superior mesenteric vein (SMV) has been anastomosed to the portal vein (PV) without a graft. (Reprinted from: Chen YH et al., J Am Coll Surg 2013, 217(4):E21-E28., with permission).