Clinical value of uncinate process resection combined with portal-superior mesenteric vein resection and end-to-end anastomosis in distal pancreatectomy / 中华消化外科杂志

ABSTRACT

Objective To explore the clinical value of uncinate process resection combined with portalsuperior mesenteric vein resection and end-to-end anastomosis in distal pancreatectomy.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 11 patients who underwent distal pancreatectomy combined with portal-superior mesenteric vein resection and end-to-end anastomosis in the Peking University Cancer Hospital (8 patients) and Jilin Guowen Hospital (3 patients) between January 2014 to April 2018 were collected.During the vascular reconstruction,uncinate process of the pancreas was first resected for reducing anastomotic tension,and then end-to-end anastomosis was done after portal-superior mesenteric vein resection.Observation indicators:(1) intraoperative situations;(2) postoperative recovery situations;(3) postoperative pathological examination situations;(4) follow-up and survival situations.Follow-up using outpatient examination and imaging examination was performed to detect patients' postoperative survival,tumor recurrence and metastasis and postoperative venous anastomotic patency up to May 2018.Measurement data with normal distribution were represented as x±s.Measurement data with skewed distribution were described as M (range).The non-recurrence and non-metastasis survival curve,overall survival curve and survival rate were respectively drawn and calculated by the Kaplan-Meier method.Results (1) Intraoperative situations:11 patients received uncinate process resection of the pancreas,and successfully underwent distal pancreatectomy combined with portal-superior mesenteric vein resection and end-to-end anastomosis.Eight patients underwent distal pancreatectomy + Appleby combined with celiac axis resection due to pancreatic tumor involving common hepatic artery,including 2 undergoing combined total gastrectomy due to gastric ischemia;2 patients underwent distal pancreatectomy;1 patient underwent distal pancreatectomy + distal gastrectomy due to blood supply obstacle of distal stomach.Operation time and volume of intraoperative blood loss of 11 patients were (5.8± 1.1) hours and 800 mL (range,200-2 500 mL).(2) Postoperative recovery situations:there was no grade C of pancreatic fistula of 11 patients.Four patients had grade B of pancreatic fistula,including 2 were cured by drainage-tube indwelling of pancreatic wound ＞ 3 weeks,1 was cured by continous washing due to pancreatic fistula combined with infection,and 1 was cured by the second abdominal puncture drainage due to pancreatic fistula with fever;1 of 4 patients was combined with grade C of delayed gastric emptying and cured by conservative treatment,and other 3 patients didn't occur postoperative complications.Of 5 patients diagnosed as biochemical fistula,1 had esophagus-jejunum anastomotic leakage,and 1 had changes of hepatic ischemia in S2,S3 and S4b segments by CT examination and recovered normal liver function at 2 weeks postoperatively,with long-term hepatatrophia in S2 and S3 segments.There was no postoperative death and reoperation in 11 patients.Duration of postoperative hospital stay of 11 patients was (22± 5) days.(3) Postoperative pathological examination results:tumors of 11 patients were located in neck and body of the pancreas,with a maximum diameter of (4.8± 1.7)cm.Among 11 patients,10 were confirmed with moderate-or low-differentiated ductal adenocarcinoma and 1 with anaplastic carcinoma.The length of portal-superior mesenteric vein resection of 11 patients was (2.6± 0.8) cm.Seven of 11 patients occurred different degrees of tumor infiltration in the portal-superior mesenteric vein,and other 4 patients occurred inflammatory adhesion,without tumor infiltration.(4) Follow-up and survival situations:11 patients were followed up for 3.0-37.6 months,with a median time of 15.7 months.During the follow-up,8 patients died of tumor recurrence and /or metastasis,and 3 survived;the non-recurrence and non-metastais survival time and overall survival time were respectively 9.0 months (range,3.0-37.6 months) and 24.6 months (range,3.0-37.6 months).One patient was complicated with anastomotic stenosis and surrounding varices of portal-superior mesenteric vein by postoperative half-year reexamination,anastomotic vein anomalies and venous thrombosis were not found in other patients before local tumor recurrence and / or death.Conclusion The combined uncinate process resection of the pancreas cannot increase the risk of postoperative pancreatic fistula,and it could effectively reduce the anastomotic tension in the distal pancreatectomy combined with portal-superior mesenteric vein resection and reconstruction,meanwhile,it can also achieve end-to-end anastomosis after longer vein resection.