P-P49 Predicting Future Pathological and Operative Complexity in Pancreatoduodenectomy: 30 Years of Experience

Background Patient selection for pancreatoduodenectomy (PD) is largely based upon local experience and established practice. This study sought to observe changes in complexity and patient cohort over time with the aim of predicting future cohort characteristic of patients undergoing PD. Methods All PDs at our institution between 1988 and 2020 were reviewed (n = 1,878) to observe changing trends in patient demographic, pathological diagnosis, operative factors and postoperative outcomes. Coefficients from regression models were reported as gradients per decade, to quantify the rate of change over time. The resulting models were then plotted to illustrate the trend across the study period, as well as forecasts for subsequent years. Results The annual volume (7 to 128) and proportion of pancreatic ductal adenocarcinoma (PDAC) (28 to 53%) increased at a linear rate. The proportion of associated vein resection (3 to 25%) and technical difficulty (type 2-4; 5 to 28%) increased in a nonlinear way, increasing more rapidly in later times. The average age (48 to 67) increased in a log linear trend. Length of stay reduced by 9.3%, whilst mortality reduced with an odds ratio of 0.69, per decade. Furthermore, When performance at our institution was compared to recently established benchmarks, it was shown that our institution regularly performed within these standards with few exceptions. By 2030 our predictions indicate that the average age will increase to 69, PDAC will comprise 62% of pathology, 40% will have an associated venous resection and 43% will be graded 2-4 in technical difficulty. Length of stay will have reduced to 9.6 days and mortality to 2%. Conclusions Despite increasing complexity of surgery and patient age, length of stay and mortality after PD are reducing. Understanding changes over time permits an estimation of a future surgical cohort where complexity will increase. It is important that surgeons continue to push boundaries. Patient selection, based upon prior experience may inhibit progression and development of services.

Extended Venous Resections for Borderline Resectable Pancreatic Head Adenocarcinoma—A Retrospective Studies of Nine Cases

Background: pancreatic cancer is one of the most lethal malignancies and a leading cause of cancer-related death worldwide. The only chance to improve the long-term outcomes of patients with pancreatic cancer is surgery with radical intent. Methods: in the present paper, we aim to describe a case series of 9 patients submitted to radical surgery for borderline resectable pancreatic cancer. Results: in all cases, negative resection margins were achieved. The types of venous resection consisted of tangential portal vein resection in four cases, circumferential portal vein resection with direct reanastomosis in one case and circumferential resection with graft placement in another four cases; postoperatively, one patient developed a vascular surgery-related complication consisting of graft thrombosis and thus necessitated prolonged anticoagulant therapy. Conclusions: extended venous resections can be a safe and efficient way to maximize the benefits of radical surgery in locally advanced, borderline resectable pancreatic cancer.

Prospective Evaluation of Resection Margins Using Standardized Specimen Protocol Analysis among Patients with Distal Cholangiocarcinoma and Pancreatic Ductal Adenocarcinoma

Purpose: Using a standardized specimen protocol analysis, this study aimed to evaluate the resection margin status of patients who underwent resection for either distal cholangiocarcinoma (DC) or pancreatic ductal adenocarcinoma (PDAC). This allowed a precise millimetric analysis of each inked margin. Methods: From 2010 to 2018, 355 consecutively inked specimens from patients with PDAC (n = 288) or DC (n = 67) were prospectively assessed. We assessed relationships between the tumor and the following margins: transection of the pancreatic neck, bile duct, posterior surface, margin toward superior mesenteric artery, and the surface of superior mesenteric vein/portal vein groove. Resection margins were evaluated using a predefined cut-off value of 1 mm; however, clearances of 0 and 1.5 mm were also evaluated. Results: Patients with DC were mostly men (64% vs. 49%, p = 0.028), of older age (68 yo vs. 65, p = 0.033), required biliary stenting more frequently (93% vs. 77%, p < 0.01), and received less neoadjuvant treatment (p < 0.001) than patients with PDAC. The venous resection rate was higher among patients with PDAC (p = 0.028). Postoperative and 90-day mortality rates were comparable. Patients with PDAC had greater tumor size (28.6 vs. 24 mm, p = 0.01) than those with DC. The R1 resection rate was comparable between the two groups, regardless of the clearance margin. Among the three types of resection margins, a venous groove was the most frequent in both entities. In multivariate analysis, the R1 resection margin did not influence patient survival in either PDAC or DC. Conclusion: Our standardized specimen protocol analysis showed that the R1 resection rate was comparable in PDAC and DC.

Superior vena cava resection and plastic repair as a part of surgical and combined treatment of lung cancer

This article summarizes our own experience of reconstructive operations with resection and plastic repair of the superior vena cava in the field of locally advanced lung cancer surgery. Both technical aspects and methodological approaches of this type of combined interventions are described in detail. Data from 45 patients who underwent wedge (21) and circular (24) superior vena cava resections were analyzed. In most (65%) cases, venous resection and reconstruction were combined with multi-organ resections of other anatomical structures of the chest cavity. 87% of patients received combined treatment in different directions. Postoperative complications were registered in 40% of cases, and the mortality rate was 13%. The unfavorable postoperative prognostic factors were followings: old age, pneumonectomy, combination of vein angioplasty with carinal resection. The 5-year survival rate was 18.5%, with a median survival of 19.4 + 4.6 months. The results allow us to recommend such operations in highly specialized clinics that have extensive experience in tracheobronchial angioplastic surgery and highly-qualified anesthesia care providers. Multimodal treatment allows to achieve satisfactory long-term results.

What Should Guide the Performance of Venous Resection During Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma with Venous Contact?

Complete surgical resection, most often associated with perioperative chemotherapy, is the only way to offer a chance of cure for patients with pancreatic cancer. One of the most important factors in determining survival outcome that can be influenced by the surgeon is the R0 resection. However, the proximity of mesenteric vessels in cephalic pancreatic tumors, especially the mesenterico-portal venous axis, results in an increased risk of vein involvement and/or the presence of malignant cells in the venous bed margin. A concomitant venous resection can be performed to decrease the risk of a positive margin. Given the additional technical difficulty that this implies, many surgeons seek a path between the tumor and the vein, hoping for the absence of tumor infiltration into the perivascular tissue on pathologic analysis, particularly in cases with administration of neoadjuvant therapy. The definition of optimal surgical margin remains a subject of debate, but at least 1 mm is an independent predictor of survival after pancreatic cancer surgical resection. Although preoperative radiologic assessment is essential for accurate planning of a pancreatic resection, intraoperative decision-making with regard to resection of the mesenterico-portal vein in tumors with a venous contact remains unclear and variable. Although venous histologic involvement and perivascular infiltration are not accurately predictable preoperatively, clinicians must examine the existing criteria and normograms to guide their surgical management according to the integration of new imaging techniques, preoperative chemotherapy use, tumor biology and molecular histopathology, and surgical techniques.