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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 A4 (5.6%)
 Grade B12 (16.9%)
 Grade C3 (4.2%)
PPH
 Grade A1 (1.4%)
 Grade B5 (7.0%)
 Grade C6 (8.5%)
DGE
 Grade A8 (11.3%)
 Grade B7 (9.9%)
 Grade C8 (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 (%)PredictorsRelative RiskP-Value
Mortality 7 (9.9%)PPH13.60.0006
 Pre-2010 / Post-201012.5% / 8.5%CAD4.980.0321
 Unplanned / Planned15.0% / 7.8%   
Major Morbidity 22 (31.0%)PPH3.120.0025
 Pre-2010 / Post-201033.3%/29.8%POPF2.590.0062
 Unplanned / Planned40.0%/27.5%DGE2.130.0351
Re-Operation  12 (16.9%)Multi-Vessel4.570.0132
 Pre-2010 / Post-201016.7%/17.0%PPH3.900.0159
 Unplanned / Planned20.0%/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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