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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%) | | POPF | | | Grade A | 4 (5.6%) | | | Grade B | 12 (16.9%) | | | Grade C | 3 (4.2%) | | PPH | | | Grade A | 1 (1.4%) | | | Grade B | 5 (7.0%) | | | Grade C | 6 (8.5%) | | DGE | | | 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 Outcome
(90-day)
| | 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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