Robotic Versus Open Pancreatoduodenectomy With Vein Resection and Reconstruction: A Propensity Score-Matched Analysis.

Objective: This study aimed to compare robotic pancreatoduodenectomy with vein resection (PD-VR) based on the incidence of severe postoperative complications (SPC). Background: Robotic pancreatoduodenectomy has been gaining momentum in recent years. Vein resection is frequently required in this operation, but no study has compared robotic and open PD-VR using a matched analysis. Methods: This was an intention-to-treat study designed to demonstrate the noninferiority of robotic to open PD-VR (2011-2021) based on SPC. To achieve a power of 80% (noninferiority margin:10%; α error: 0.05; ß error: 0.20), a 1:1 propensity score-matched analysis required 35 pairs. Results: Of the 151 patients with PD-VR (open = 115, robotic = 36), 35 procedures per group were compared. Elective conversion to open surgery was required in 1 patient with robotic PD-VR (2.9%). One patient in both groups experienced partial vein thrombosis. SPC occurred in 7 (20.0%) and 6 patients (17.1%) in the robotic and open PD-VR groups, respectively (P = 0.759; OR: 1.21 [0.36-4.04]). Three patients died after robotic PD-VR (8.6%) and none died after open PD-VR (P = 0.239). Robotic PD-VR was associated with longer operative time (611.1 ± 13.9 minutes vs 529.0 ± 13.0 minutes; P < 0.0001), more type 2 vein resection (28.6% vs 5.7%; P = 0.0234) and less type 3 vein resection (31.4% vs 71.4%; P = 0.0008), longer vein occlusion time (30 [25.3-78.3] minutes vs 15 [8-19.5] minutes; P = 0.0098), less blood loss (450 [200-750] mL vs 733 [500-1070.3] mL; P = 0.0075), and fewer blood transfusions (intraoperative: 14.3% vs 48.6%; P = 0.0041) (perioperative: 14.3% vs 60.0%; P = 0.0001). Conclusions: In this study, robotic PD-VR was noninferior to open PD-VR for SPC. Robotic and open PD-VR need to be compared in randomized controlled trials.

Short-term outcomes after liver resection with vascular reconstruction: Results from a study with the National Clinical Database of Japan.

BACKGROUND: Although curative resection with vascular reconstruction improves the prognosis of blood-invading locally advanced hepatobiliary tumors, the mortality and morbidity of the procedure remains unclear. This study aimed to clarify the risk factors associated with mortality and morbidity in patients undergoing liver resection with vascular reconstruction. METHODS: This retrospective observational study included 1215 patients undergoing hepatectomy of more than one section with vascular reconstruction, except for left lateral sectionectomy registered in the National Clinical Database (NCD) between 2015 and 2019. The rates of surgical mortality and relevant clinical factors were evaluated. RESULTS: Among the four types of vascular reconstruction, portal venous reconstruction was frequently performed in 724 patients (59.6% of the enrolled patients). Surgical mortality was 8.1%. Patients with hepatic artery reconstruction had the highest surgical mortality rate of 15.8%. In other types of reconstruction, surgical mortality was 9.1% in the portal vein, 5.2% in inferior vena cava, and 4.9% in hepatic vein. Factors significantly associated with surgical mortality include age, sex (male), preoperative comorbidity (American Society of Anesthesiologists grade >3, respiratory distress, diabetes, preoperative pneumonia, weight loss, and obstructive jaundice), poorer liver functional reserve (indocyanine green retention rate at 15 min and prothrombin time/international normalized ratio >1.1) and accompanying biliary reconstruction. CONCLUSIONS: The NCD revealed the detailed status of liver resection combined with vascular reconstruction in Japan. Based on the results of this analysis, understanding the factors that influence the outcome and postoperative course of each procedure will provide patients with accurate information and opportunities to improve future outcomes.

Highly complex liver resections: Exploring the boundaries of feasibility and safety.

INTRODUCTION: In select clinical scenarios, advanced techniques for volume manipulation and vascular reconstruction are needed for complete hepatic tumor removal. These highly complex liver resections (HCLRs) entail a heightened risk of severe complications. Here, we describe the results of HCLR performed in a 3-year time period. MATERIALS AND METHODS: We conducted a retrospective analysis encompassing patients who underwent hepatic resections between June 15, 2020, and June 15, 2023. HCLR was defined according to previously established criteria, and included associating liver partition and portal vein ligation for staged hepatectomy. The outcomes of HCLR were compared to all non-HCLR performed within the same time frame. RESULTS: Among 167 hepatic resections, 26 were considered HCLR, and all were major resections. Five utilized total vascular exclusion, with venovenous bypass in three, and hypothermic liver perfusion in three. Five resections included vascular reconstructions, and one included hypothermic circulatory arrest for extraction of a tumor extending to the right atrium. Of the non-HCLR, 38 (26.9%) were major, and 49 (34.7%) were performed laparoscopically. The rates of overall major postoperative complications were comparable between those who underwent HCLR versus non-HCLR. HCLR was associated with increased rates of biliary complications, readmissions, and reoperation. However, no postoperative 90-day mortality was documented within patients that underwent HCLR compared to two in the non-HCLR group. CONCLUSIONS: In expert hands, HCLR can be performed with acceptable complication profile, akin to that of major non-HCLR. Those with questionable resectability should be referred to tertiary hepato-pancreato-biliary centers.

The role of vascular resection and reconstruction in pancreaticoduodenectomy.

Pancreaticoduodenectomy (PD) is one of the most difficult procedures in general surgery which involves the removal and reconstruction of many organs. PD is the standard surgical method for malignant tumors of the head, uncinate process and even the neck of the pancreas. During PD surgery, it often involves the removal and reconstruction of blood vessels. This is a clinical review about vascular resection and reconstruction in PD surgery.

Resección venosa en cirugía oncológica pancreática: opciones técnicas ante situaciones diversas / Venous resection in pancreatic oncologic surgery: Different techniques for different situations

Introducción: Análisis de los resultados de resección venosa en cirugía pancreática oncológica de 2 centros de referencia. Se analiza el tipo de intervención realizada, los tipos de reconstrucción vascular, el estudio anatomopatológico, la morbimortalidad postoperatoria y la supervivencia a 3 y 5 años. Métodos: Análisis retrospectivo, transversal y comparativo. Se incluyen 41 pacientes intervenidos de lesiones neoplásicas pancreáticas desde 2003 hasta 2021 que requirieron resección venosa por afectación vascular. Resultados: La técnica quirúrgica más frecuente fue la duodenopancreatectomía cefálica tipo Whipple, realizada en 35 de los 41 pacientes (85%). Uno de los casos se realizó por acceso laparoscópico. La reconstrucción vascular tipo 1 (sutura simple) se realizó en 11 pacientes (27%), la tipo 2 (patch de falciforme) en 4 casos (10%), la tipo 3 (sutura término-terminal) en 23 casos (56%) y la reconstrucción tipo 4 (injerto autógeno) en 3 casos (7%). La longitud media del segmento venoso resecado fue de 21mm (11-46) y el tiempo quirúrgico medio fue de 290min (220-360). El 90% (37/41) fueron adenocarcinoma de páncreas. El 83% se consideraron R0 y hubo afectación en el tramo vascular resecado en el 41% de los casos. Hubo morbilidad Clavien-Dindo>3 en 4 pacientes y no hubo ningún caso de mortalidad postoperatoria. La supervivencia a 3 años fue del 48% y a 5 años del 20%. Conclusiones: La resección venosa con reconstrucción para asegurar una resección R0 es una técnica factible, con una aceptable tasa de morbimortalidad y supervivencia global. (AU)

Introduction: To report the clinical results of patients with malignant pancreatic lesions who underwent oncological surgery with vascular resection. The type of intervention performed, the types of vascular reconstruction, the pathological anatomy results, postoperative morbidity and mortality, and survival at 3 and 5 years were analysed. Methods: Retrospective, cross-sectional and comparative analysis. We include 41 patients with malignant pancreatic lesions who underwent surgery with vascular resection due to vascular involvement, from 2013 to 2021. Results: The most performed surgery was the cephalic pancreaticoduodenectomy (Whipple procedure) using median laparotomy, in 35 of the 41 patients (85%). One of the cases in the series was performed laparoscopically. Type 1 reconstruction (simple suture) was performed in 11 (27%) patients, type 2 in 4 (10%) cases, type 3 (T–T suture) in 23 (56%) cases, and type 4 reconstruction by autologous graft in 3 (7%) cases. The mean length of the resected venous segment was 21 (11–46)mm and the mean surgical time was 290 (220–360)min. 90% (37/41) were pancreatic adenocarcinoma. 83% were considered R0 and there was involvement in the resected vascular section in 41% of the cases. Four patients had Clavien-Dindo morbidity>3 and there were no cases of postoperative mortality. Survival at 3 years was 48% and at 5 years was 20%. Conclusions: The aggressive surgical treatment with venous resection in pancreatic malignant lesions to ensure R0 and its vascular reconstruction is a feasible technique, with an acceptable morbid-mortality rate and overall survival. (AU)

Surgical Planning for "Borderline Resectable" and "Locally Advanced" Pancreatic Cancer During Open Pancreatic Resection.

Pancreatic resection for pancreatic ductal adenocarcinoma (PDAC) is one of the most complex procedures in abdominal surgery due to the technical and oncological challenges given by its local aggressive growth. The improvement of new multidrug chemotherapy regimens and surgical techniques has increased the caseload of "borderline resectable" (BR) or even "locally advanced" (LA) PDAC candidates for surgical resection. As a result, the increased heterogeneity of surgical scenarios has made it essential to utilize a tailored surgical strategy for each individual case. Notably, the strategy employed to approach and assess the peripancreatic vessels should be weighted according to tumor's location and the site of suspected vascular infiltration. The aim of this paper is to describe the open surgical approach for "BR" or "LA" PDAC used at our Institution and summarizes a "step-up approach" to manage vascular infiltration.

Aggressive surgical approach with vascular resection and reconstruction for retroperitoneal sarcomas: a systematic review.

BACKGROUND AND AIM: Surgery is the mainstay of treatment and completeness of surgical resection is critical to achieve local control for retroperitoneal sarcoma (RPS). En-bloc resection of adjacent organs, including major abdominal vessels, is often required to achieve negative margins. The aim of this review was to summarise the available evidence to assess the relative benefits and disadvantages of an aggressive surgical approach with vascular resection in patients with retroperitoneal sarcoma (RPS). METHODS: We searched PubMed, the Cochrane Library, and EMBASE for relevant studies published from inception up to August 1, 2022. We performed a systematic review of the available studies to assess the safety and long-term survival results of vascular resection for RPS. RESULTS: We identified a total of 23 studies for our review. Overall postoperative in-hospital or 30-day mortality rate of patients with primary iliocaval leiomyosarcoma was 3% (11/359), and the major complication rate was 13%. The recurrence-free survival (RFS) rates after the follow-up period varied between 15% and 52%, and the 5-year overall survival (OS) rates ranged from 25 to 78%. Overall postoperative in-hospital or 30-day mortality rate of patients with RPSs receiving vascular resection was 3%, and the major complication rate was 27%. The RFS rates after the follow-up period were 18-86%, and the 5-year OS rates varied between 50% and 73%. There were no significant differences in the rates of RFS (HR: 0.97; 95% CI: 0.74-1.19; p = 0.945) and OS (HR: 1.01; 95% CI: 0.66-1.36; p = 0.774) between the extended resection group and tumour resection alone group. CONCLUSIONS: With adequate preparation and proper management, for patients with RPSs involving major vessels, aggressive surgical approach with vascular resection can achieve R0/R1 resection and improve survival.

Surgical Considerations for Neoadjuvant Therapy for Pancreatic Adenocarcinoma.

Pancreatic ductal adenocarcinoma (PDAC) is a challenging disease process with a 5-year survival rate of only 11%. Neoadjuvant therapy in patients with localized pancreatic cancer has multiple theoretical benefits, including improved patient selection for surgery, early delivery of systemic therapy, and assessment of response to therapy. Herein, we review key surgical considerations when selecting patients for neoadjuvant therapy and curative-intent resection. Accurate determination of resectability at diagnosis is critical and should be based on not only anatomic criteria but also biologic and clinical criteria to determine optimal treatment sequencing. Borderline resectable or locally advanced pancreatic cancer is best treated with neoadjuvant therapy and resection, including vascular resection and reconstruction when appropriate. Lastly, providing nutritional, prehabilitation, and supportive care interventions to improve patient fitness prior to surgical intervention and adequately address the adverse effects of therapy is critical.

Inverted Y-shaped technique for complex superior mesenteric / portal vein reconstruction in pancreatoduodenectomy for locally advanced pancreatic head ductal adenocarcinoma.

Most pancreatoduodenectomy (PD) procedures for locally advanced pancreatic head adenocarcinoma (PDAC) require superior mesenteric/portal vein (SMV/PV) axis resection and reconstruction. Here we describe the inverted Y-shaped as a new technique for complex SMV/PV reconstruction and aimed at evaluating its safety and effectiveness. Among 287 patients who underwent PD for locally advanced PDAC from April, 2007 to December, 2020 at our hospital, 11 patients (3.8%) who underwent PV/SMV reconstruction with this technique were enrolled. Briefly, two distal veins were slit-wedged, sutured, resulting in one orifice, then reconstruction was completed with (n = 6) or without (n = 5) interposed autologous right external iliac vein (REIV) grafts, respectively. Operation time and blood loss were 649 (502-822) min and 1782 (475-6680) mL, respectively. The median length of resected SMV/PV was 40 (20-70) mm, 50 (50-70) mm for REIV grafts, and the splenic vein was resected in eight patients. No patient developed pancreatic fistula; mild leg edema was observed in the six graft patients and the median hospital stay was 36.0 d. PV patency rate at 2 mo after PD was 91% (10/11) and no 90-d mortality was recorded. R0 resection rate was 91% (10/11). It is feasible to safely reconstruct the SMV/PV using the inverted Y-shaped technique in appropriately selected PDAC patients.

Venous resection in pancreatic oncologic surgery: Different techniques for different situations.

INTRODUCTION: To report the clinical results of patients with malignant pancreatic lesions who underwent oncological surgery with vascular resection. The type of intervention performed, types of vascular reconstruction, the pathological anatomy results, postoperative morbidity and mortality, and survival at 3 and 5 years were analyzed. METHODS: Retrospective, cross-sectional and comparative analysis. We include 41 patients with malignant pancreatic lesions who underwent surgery with vascular resection due to vascular involvement, from 2013 to 2021. RESULTS: The most performed surgery was pancreaticoduodenectomy (Whipple procedure) using median laparotomy, in 35 out of the 41 patients (85%). One of the cases in the series was performed laparoscopically. Type 1 reconstruction (simple suture) was performed in 11 (27%) patients, type 2 in 4 (10%) cases, type 3 (end-to-end) in 23 (56%) cases, and type 4 reconstruction by autologous graft in 3 (7%) cases. The mean length of the resected venous segment was 21 (11-46) mm, and mean surgical time was 290 (220-360) minutes. 90% (37/41) were pancreatic adenocarcinoma. 83% were considered R0, and there was involvement in the resected vascular section in 41% of the cases. Four patients had Clavien Dindo morbidity >3, and there were no cases of postoperative mortality. Survival at 3 years was 48% and at 5 years 20%. CONCLUSIONS: The aggressive surgical treatment with venous resection in pancreatic malignant lesions to ensure R0 and its vascular reconstruction is a feasible technique, with an acceptable morbid-mortality rate and overall survival.

Surgical Treatment of Pancreatic Cancer: Currently Debated Topics on Vascular Resection.

Vascular resections involving the superior mesenteric and portal veins (SMV-PV), celiac axis (CA), superior mesenteric artery (SMA) and hepatic artery (HA) have multiplied in recent years, raising the resection rate for pancreatic cancer (PDAC) and the related morbidity and mortality rates. While resection is generally accepted for resectable SMV-PV, the usefulness of associated arterial resection in borderline resectable (BRPC) and locally-advanced PDAC (LAPC) is much debated. Careful selection of splenic vein reconstruction is very important to prevent left-sided portal hypertension (LSPH). During distal pancreatectomy (DP), CA and common HA resection is largely accepted, while there is debate on the value of SMA and proper HA resection and reconstruction. Their resection is useless according to several reviews and meta-analyses, and some international societies, although some high-volume centers have reported good results. Short- and long-term reconstructed vessel patency varies with the type of reconstruction, the material used, and the surgeon's experience. Laparoscopic and robotic pancreaticoduodenectomy and DP are generally accepted if done by surgeons performing at least 10 such procedures annually. The usefulness of associated vascular resection remains highly controversial. Surgeons need to complete numerous minimally-invasive procedures to overcome the learning curve, and prevent an increase in complications and surgical mortality. Higher resectability rates and satisfactory long-term results have been reported after neoadjuvant therapy (NAT) for BRPC and LAPC requiring vascular resection. It is essential to select the most appropriate NAT for a given patient and to assess PDAC resectability preoperatively.

Peritoneal patch in vascular reconstruction during pancreaticoduodenectomy for pancreatic cancer: a single Centre experience.

BACKGROUND: Concomitant venous resection during pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma with mesenterico-portal vein involvement is increasingly performed to achieve oncological resection. This study aims to report a single centre experience in peritoneal patch (PP) as autologous graft for vascular reconstruction (VR) during PD. METHODS: A retrospective analysis of all patients who underwent PD + VR with PP between December 2019 and September 2020 was performed, using a prospective collected database. Postoperative outcome and pathological margins were evaluated. Venous patency was assessed by computed tomography at day 7 and week 12 post surgery. RESULTS: Fifteen patients underwent PD + VR with PP reconstruction for pancreatic cancer, including one total pancreatectomy. VR consisted of lateral (n = 14) or tubular (n = 1) patch. The median PP length was 30 mm [26.3-33.8] and venous clamping time 30 min [27.5-39.0]. Computed tomography showed a patent VR in 93.3% and 53.3% after 7 days and 12 weeks, respectively; venous patency loss was always asymptomatic. The only postoperative VR-related complication was one mesenteric venous thrombosis. Five other patients experienced VR-unrelated complications: septic shock (n = 3), biliary fistula (n = 1) and post-traumatic subdural hematoma (n = 1). Mortality was nihil. At pathology, R0 resection (≥1 mm) was observed in 40.0% (6/15), venous margin was free in 46.7% (7/15), and venous wall was involved in 40.0% (6/15). CONCLUSIONS: Use of PP as venous substitute during PD + VR is safe and feasible with an acceptable postoperative morbidity, and a decreased but asymptomatic venous patency after 12 weeks which should question the role of anticoagulation therapy.

Clinical efficacy of radical resection of pancreatic cancer after neoadjuvant conversion therapy / 中华消化外科杂志

Objective:To investigate the clinical efficacy of radical resection of pancreatic cancer after neoadjuvant conversion therapy.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 23 patients who underwent radical resection of pancreatic cancer after neoadjuvant conversion therapy in Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School from January 2019 to May 2022 were collected. There were 17 males and 6 females, aged 58(range, 33-73)years. After neoadjuvant conversion therapy, the three-dimensional (3D) visualization was used to evaluate and classify tumor vascular invasion, and surgical plan was planned and implemented. Observation indicators: (1) situations of neoadjuvant conversion therapy; (2) surgical situations; (3) postoperative histopathological examination; (4) postoperative recovery; (5) follow-up. Measurement data with normal distribution were represen-ted as Mean± SD, and measurement data with skewed distribution were represented as M(range) or M( Q1, Q3). Count data were described as absolute numbers. Results:(1) Situations of neoadjuvant conversion therapy. All 23 patients received the AG combination chemotherapy (albumin-paclitaxel+gemcitabine), including 14 patients combined with stereotactic body radiation therapy. Of the 23 patients, 22 cases achieved partial response, and 1 case showed stable disease. The CA19-9 of the 23 patients was 85.06(29.74,634.5)U/mL and 13.96(9.74,25.02)U/mL before and after neoadjuvant conversion therapy, respectively. (2) Surgical situations. According to the results of preoperative 3D visualization of tumor vascular invasion, 7 of the 23 patients were evaluated as arterial invasion, 8 cases were evaluated as venous invasion, 5 cases were evaluated as arterial and venous invasion, and there were 3 cases showing negative of vascular invasion. Of the 23 patients, 12 cases underwent pancreaticoduodenectomy, 4 cases underwent radical antegrade modular pancreatosplenectomy, 7 cases underwent total pancreaticoduodenectomy. For vascular reconstruction, there were 10 patients without vascular reconstruction, and there were 13 patients undergoing artificial vascular vein reconstruction. The operation time and volume of intraoperative blood loss of the 23 patients was (524±171)minutes and 1 000(400,1 600)mL, respectively. (3) Postoperative histopathological exami-nation. Results of postoperative histopathological examination in 23 patients showed that there were 2 cases with moderate-well differentiated tumor, 10 cases with moderate differentiated tumor, 7 cases with moderate-poorly differentiated tumor, 2 cases with poorly differentiated tumor, and 2 cases negative of tumor. The number of lymph node dissected in 23 patients was 16±7. There were 5 cases with lymph node metastasis and 18 cases without lymph node metastasis. There were 17 cases with nerve invasion and 6 cases without nerve invasion. All 23 patients were negative of vascular invasion. Of the 23 patients, there were 21 cases with R 0 resection and 2 cases with R 1 resection. For pathological TNM staging, there were 2 cases with 0 stage, 13 cases with Ⅰ stage, 7 cases with Ⅱ stage, and 1 case with Ⅳ stage. For postoperative pathological scoring, there were 2 cases achieved 0 point (complete pathological remission), 16 cases achieved 2 points (partial remission), and 5 cases achieved 3 points (no significant effect). (4) Postoperative recovery. The postoperative duration of hospital stay of 23 patients was 19(14,31)days. There were 17 of 23 patients underwent postoperative complications, including 11 cases with Clavien-Dindo Ⅱ stage complications, 3 cases with Clavien-Dindo Ⅲa stage complications, 1 case with Clavien-Dindo Ⅲb stage complication, 1 case with Clavien-Dindo Ⅳ stage complication, and 1 case with Clavien-Dindo Ⅴ stage complica-tion. (5) Follow-up. There were 22 patients underwent follow-up, with follow-up time as 12(9,23)months. There were 9 patients underwent postoperative recurrence and metastasis, with recurrence and metastasis time as 7.8(range, 6.0-12.0)months. During the follow-up, 15 of the 22 patients survived. Conclusion:Radical resection of pancreatic cancer after neoadjuvant conversion therapy is feasible.

How we do it-the use of peritoneal patches for reconstruction of vena cava inferior and portal vein in hepatopancreatobiliary surgery.

PURPOSE: Extended resections in hepatopancreatobiliary (HPB) surgery frequently require vascular resection to obtain tumor clearance. The use of alloplastic grafts may increase postoperative morbidity due to septic or thrombotic complications. The use of suitable autologous venous interponates (internal jugular vein, great saphenous vein) is frequently associated with additional incisions. The aim of this study was to report on our experience with venous reconstruction using the introperative easily available parietal peritoneum, focusing on key technical aspects. METHODS: All patients who underwent HPB resections with venous reconstruction using peritoneal patches at our department between January 2017 and November 2021 were included in this retrospective analysis with median follow-up of 2 months (IQR: 1-8 months). We focused on technical aspects of the procedure and evaluated vascular patency and perioperative morbidity. RESULTS: Parietal peritoneum patches (PPPs) were applied for reconstruction of the inferior vena cava (IVC) (13 patients) and portal vein (PV) (4 patients) during major hepatic (n = 14) or pancreatic (n = 2) resections. There were no cases of postoperative bleeding due to anastomotic leakage. Following PV reconstruction, two patients showed postoperative vascular stenosis after severe pancreatitis with postoperative pancreatic fistula and bile leakage, respectively. In patients with reconstruction of the IVC, no relevant perioperative vascular complications occurred. CONCLUSIONS: The use of a peritoneal patch for reconstruction of the IVC in HPB surgery is a feasible, effective, and low-cost alternative to alloplastic, xenogenous, or venous grafts. The graft can be easily harvested and tailored to the required size. More evidence is still needed to confirm the safety of this procedure for the portal vein regarding long-term results.

Minimally-invasive versus open pancreatoduodenectomies with vascular resection: A 1:1 propensity-matched comparison study.

Background: Minimally invasive pancreatic pancreatoduodenectomy (MIPD) is increasingly adopted worldwide and its potential advantages include reduced hospital stay and decrease pain. However, evidence supporting the role of MIPD for tumours requiring vascular reconstruction remains limited and requires further evaluation. This study aims to investigate the safety and efficacy of MIPD with vascular resection (MIPDV) by performing a 1:1 propensity-score matched (PSM) comparison with open pancreatoduodenectomy with vascular resection (OPDV) based on a single surgeon's experience. Methods: This is a retrospective review of 41 patients who underwent PDV between 2011 and 2020 by a single surgeon. After PSM, the comparison was made between 13 MIPDV and 13 OPDV. Results: Thirty-six patients underwent venous reconstruction (VR) only and 5 underwent arterial reconstruction of which 4 had concomitant VR. The types of VR included 22 wedge resections with primary repair, 8 segmental resections with primary anastomosis and 11 requiring interposition grafts. Post-operative pancreatic fistula (POPF) occurred in 3 (7.3%) patients. Major complications (>Grade 2) occurred in 16 (39%) patients, of which 7 were due to delayed gastric emptying requiring nasojejunal tube placement. There was 1 (2.4%) 30-day mortality (OPDV). Of the 13 MIPDV, there were 3 (23.1%) open conversions. PSM comparison demonstrated that MIPDV was associated with longer median operative time (720 min vs. 485 min (P = 0.018). There was no statistically significant difference in other key perioperative outcomes such as intra-operative blood loss, overall morbidity, major morbidity rate, POPF and length of stay. Conclusion: Our initial experience with the adoption MIPDV has demonstrated it to be safe with comparable outcomes to OPDV despite the longer operation time.

Case Report: Retroperitoneal Sarcoma in Six Operations: Our Experience in Operative Management of Blood Vessels.

Here we introduce a case of retroperitoneal liposarcoma, which is characterized by repeated recurrences after surgery, and has undergone a total of 6 operations. The diameter of the tumor was about 26 cm at the time of the patient's diagnosis. The imaging examination revealed that the surrounding organs and blood vessels were invaded, which brought great challenges to radical resection. The postoperative pathology of the patient's first operation was dedifferentiated liposarcoma, and some areas showed myxofibrosarcoma differentiation. With the recurrence of sarcoma, myxofibrosarcoma dedifferentiated into rhabdomyosarcoma, and malignant fibrous histiocytoma appeared in some areas. How to treat this type of patient after recurrence? How to deal with blood vessels wrapped by sarcoma during surgery? The medical community has not yet reached the same conclusion. We describe the process of treating the patient and the experience of dealing with blood vessels during surgery.

Vascular Resections in Association With Pancreatic Resections for Locally Advanced Pancreatic Cancer.

BACKGROUND/AIM: Locally advanced pancreatic cancer has been considered for a long period of time as an unresectable lesion and therefore, all patients have been traditionally addressed to the oncological services for palliative purposes. However, due to the wide usage of newer oncological agents in association with improved surgical techniques, radical surgical procedures became feasible. The aim of this study was to present the different surgical procedures that were performed in locally advanced pancreatic cancer patients in order to achieve radical resections. PATIENTS AND METHODS: Between 2019 and 2020, six cases were submitted to pancreatic and vascular resections in Fundeni Clinical Hospital. RESULTS: In all cases, surgery with curative intent was attempted; portal vein resection was performed in five cases, whereas arterial resection was performed in three cases. Reconstruction was performed by direct re-anastomosis, by placing cadaveric or synthetic grafts. The postoperative outcomes were favourable in all cases. CONCLUSION: Vascular resections can be safely associated with pancreatic resections in cases presenting locally advanced pancreatic lesions, with acceptable morbidity rates.

Robotic versus open pancreaticoduodenectomy with vascular resection for pancreatic ductal adenocarcinoma: surgical and oncological outcomes from pilot experience.

PURPOSE: Venous resection and reconstruction (VR) is a feasible surgical technique to achieve optimal outcomes in selected patients with pancreatic ductal adenocarcinoma (PDAC) who undergo open pancreaticoduodenectomy (OPD). However, data regarding patient outcomes in patients who undergo VR in robotic-assisted pancreaticoduodenectomy (RPD) are scarce. METHODS: All patients with a diagnosis of PDAC who underwent upfront open or robotic pancreatoduodenectomy with VR in a high-volume institution for pancreatic surgery between 2011 and 2019 were retrospectively reviewed. Perioperative and long-term outcomes were compared between the RPD and OPD cohorts. RESULTS: A total of 84 patients were included in the final analysis, 14 patients underwent RPD with VR and 70 who had OPD with VR. Reconstructed venous patency, postoperative 30-day morbidity, and 90-day mortality were comparable; however, lymph node resection rates were lower in the RPC cohort (p = 0.029). No difference was identified in 3-year survival rates between the two groups (34.0% versus 25.7% respectively, p = 0.667). CONCLUSION: RPD with VR is a feasible approach for patients with PDAC and venous invasion. Further studies are needed to assess long-term outcomes compared to the open approach.

Contralateral internal iliac artery transposition for retroperitoneal sarcoma involving common iliac artery.

Complete resection for retroperitoneal sarcoma (RPS) involving major vessels frequently requires vascular resection and reconstruction. The use of artificial grafts often leads to postoperative vascular graft infection (VGI), which usually requires reoperation and sometimes leads to death. In the present study, the data of RPS patients who underwent contralateral iliac artery (IIA) transposition for reconstruction of the common iliac artery (CIA) after RPS resection from 2015-2019 were retrospectively analyzed. Clinical, intraoperative, and postoperative outcomes were described. Contralateral IIA transposition was performed to reconstruct the CIA after segmental resection in three patients. All patients underwent concomitant organ resection. Colon resection was performed for all patients, nephrectomy was performed for two patients, and segmental resection of the left ureter with transurethral ureterostomy was performed for one patient. Complete resection was achieved in all patients, and microscopic tumor infiltration to the CIA was observed in all patients (tunica adventitia: 2, tunica media: 1). No major complications occurred during the hospital stay. During the follow-up period (6.0-29.1 months), one patient died from tumor recurrence, and the other two patients did not have any evidence of recurrence or metastatic disease at the latest follow-up. The level of lower limb function was favorable (MSTS93 scores: 28-30). The pelvic organ functions, including bowel, bladder, and sexual functions, were not impaired in any of the patients. This novel technique in which contralateral IIA transposition is performed to reconstruct the CIA after RPS resection is simple and reliable and may be a good alternative to artificial grafts.