Graft reconstruction in pancreaticoduodenectomy: outcomes and survival

One discussion this week included use of prosthetic graft reconstruction …


Reference: Chu CK, et al. Prosthetic graft reconstruction after portal vein resection in pancreaticoduodenectomy: a multicenter analysis. Journal of the American College of Surgeons. 2010 Sep;211(3):316-324. doi: 10.1016/j.jamcollsurg.2010.04.005

Summary: Use of prosthetic grafts for reconstruction after portal vein (PV) resection during pancreaticoduodenectomy is controversial. This paper (by Emory authors) review 33 patients who underwent pancreaticoduodenectomy (PD) with vein resection and reconstruction using PTFE grafts between 1994 and 2009. Patient, operative, and outcomes variables were studied. Graft patency and survival were assessed using the Kaplan-Meier technique.

Most operations were performed for pancreatic adenocarcinoma (n = 28, 85%); 96% were T3 lesions or greater.

Standard PD was performed in 12 (36%) patients, pylorus-preservation in 17 (52%), and total pancreatectomy in 4 (12%).

Combined resection of portal and superior mesenteric veins (SMV) was required in 49%, with resection isolated to PV in 12% and SMV in 39%. Splenic vein ligation was necessary in 30%.

  • Median graft diameter = 12 mm (range 8 to 20 mm), ring-enforced = 73%.
  • Median operative time = 463 minutes
  • Vascular clamp times = 41 minutes
  • Median blood loss = 1,500 mL.
  • Irreversible hepatic necrosis or graft infection = 0
  • With mean follow-up of 14 months, overall graft patency = 76%
  • Estimated median duration of graft patency = 21 months
  • Median survival = 12 months for pancreatic adenocarcinoma.

Perioperative outcomes (Table 3, p.320):

graft

CONCLUSION: PTFE grafts may provide a safe and effective option in venous reconstruction after PD with en-bloc portomesenteric venous resection in selected patients. Although uniformity in technique and management are lacking, long-term patency is achievable with minimal hepatic morbidities and, importantly, infrequent infectious complications. Optimal selection criteria for use of prosthetic grafts in portal vein reconstruction remain to be established.

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