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Pancreatectomy with Concomitant / En Bloc Arterial Resection: Predictors of Morbidity and Mortality
May C. Tee*, Michael B. Farnell, Michael L. Kendrick, David M. Nagorney, Adam Krajewski, Ryan Groeschl, Kristopher P. Croome, Rory Smoot, Mark J. Truty
Department of Surgery, Mayo Clinic, Rochester, MN
Objective: Indications for pancreatectomy continue to expand with increased utilization of complex procedures including concurrent arterial resections. The aim of this study was to identify predictors of patient morbidity/mortality in such advanced cases.
Methods: Single institution review was conducted to identify all pancreatectomies performed (1/1988 to 11/2015) with concomitant/en bloc visceral arterial procedures (celiac, hepatic, and superior mesenteric artery/SMA). Patient demographics, co-morbidities, procedures, and peri-operative outcome data were collected. Univariate analyses were conducted identifying predictors of postoperative mortality, morbidity, re-operation, intensive care unit admission, length of stay, readmission, and overall survival.
Results: 71 patients underwent pancreatectomy with arterial resections that included: 28 (39%) with primary arteriorrhaphy or ligation alone and 43 (61%) with primary arterial anastomosis or complex graft/conduit reconstruction. Arteries involved included: 45 hepatic artery, 23 celiac trunk, 6 superior mesenteric artery, and 12 multi-vessel / other. Of these 71 patients, 38 (54%) underwent pancreatoduodenectomy, 21 (30%) subtotal pancreatectomy, and 12 (16%) total pancreatectomy. Concurrent venous resection/reconstruction was performed in 28 (39%) patients. 51 (72%) arterial resections were planned and 20 (28%) were unplanned. Outcomes and predictive factors are summarized (Table). Grade B/C post-pancreatectomy hemorrhage (PPH) was associated with a 13-fold greater risk (P<0.001) in 90-day mortality, 3-fold greater risk (P=0.003) in major morbidity, and almost 4-fold greater risk (P=0.016) in reoperation requiring a general anesthetic. Grade B/C postoperative pancreatic fistula (POPF) was associated with a 2.5-fold greater risk of major morbidity (P=0.006). Performing multi-vessel arterial procedures conferred a 4.5-fold greater risk of reoperation (P=0.013). 47 (66%) of cases were performed in last 5 years. Mortality decreased from 12.5% to 8.5% (P=0.68) and major morbidity decreased from 33.3% to 29.8% (P=0.79) since 2010 but was not statistically significant. Pathologically-confirmed malignancy was the indication for operation in 63 patients (89%). Patients with PDAC who underwent neoadjuvant therapy prior to operation had a median survival of 29.7 months compared to 14.8 months for those who underwent upfront resection (P=0.015).
Conclusions: Post-pancreatectomy mortality and morbidity remains substantial with concomitant/en bloc arterial resections with PPH/POPF the most significant predictors of poor outcome with multi-vessel resections/reconstructions conferring highest risk. Attempts at complication mitigation and utilization of neoadjuvant approach are required to justify the significantly increased perioperative risk in such cases.
Table 1: Peri-Operative Outcomes
|Operative Time (median)|| ||475 min|
|Estimated Blood Loss (median)|| ||750 mL|
|Transfusion|| ||59 (83.1%)|
|ICU|| ||26 (36.6%)|
|SSI|| ||15 (21.1%)|
|DVT/PE|| ||3 (4.2%)|
|LOS (median)|| ||10 days|
|Re-admission|| ||21 (30.0%)|
| ||Grade A||4 (5.6%)|
| ||Grade B||12 (16.9%)|
| ||Grade C||3 (4.2%)|
| ||Grade A||1 (1.4%)|
| ||Grade B||5 (7.0%)|
| ||Grade C||6 (8.5%)|
| ||Grade A||8 (11.3%)|
| ||Grade B||7 (9.9%)|
| ||Grade C||8 (11.3%)|
Legend: ICU = intensive care unit admission, SSI = surgical site infection, PE = pulmonary embolus, LOS = length of stay, POPF = Post-Operative Pancreatic Fistula; PPH = Post-Pancreatectomy Hemorrhage; DGE = Delayed Gastric Emptying
Table 2: Predictors of Peri-Operative Mortality and Major Morbidity
| ||Frequency (%)||Predictors||Relative Risk||P-Value|
|Mortality|| ||7 (9.9%)||PPH||13.6||0.0006|
| ||Pre-2010 / Post-2010||12.5% / 8.5%||CAD||4.98||0.0321|
| ||Unplanned / Planned||15.0% / 7.8%|| || || |
|Major Morbidity|| ||22 (31.0%)||PPH||3.12||0.0025|
| ||Pre-2010 / Post-2010||33.3%/29.8%||POPF||2.59||0.0062|
| ||Unplanned / Planned||40.0%/27.5%||DGE||2.13||0.0351|
|Re-Operation || ||12 (16.9%)||Multi-Vessel||4.57||0.0132|
| ||Pre-2010 / Post-2010||16.7%/17.0%||PPH||3.90||0.0159|
| ||Unplanned / Planned||20.0%/15.7%|| || || |
Legend:POPF = Post-Operative Pancreatic Fistula; PPH = Post-Pancreatectomy Hemorrhage; DGE = Delayed Gastric Emptying, Major Morbidity= Clavien-Dindo Grade 3b or higher complication, CAD=coronary artery disease, Multi-vessel = multiple arterial procedures.
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