Severe morbidity following pancreatectomy with vascular reconstruction: impact of intraoperative vascular events and grafted venous reconstructions

Abstract

Background: Vascular resection and reconstruction during pancreatic surgery has become increasingly common in high-volume centers. However, the impact of intraoperative vascular events and complex venous reconstructions on severe morbidity remains understudied.

Methods: We conducted a retrospective cohort study including 77 patients who underwent pancreatic resection with vascular reconstruction at a high-volume tertiary care center between January 2010 and December 2024. Perioperative factors were evaluated through univariate and multivariate analyses.

Results: Intraoperative events occurred in 25 % of the patients; severe morbidity (≥ IIIb according to the Clavien-Dindo classification) was observed in 31 %, and the mortality rate was 3.9 %. Severe morbidity was significantly influenced by intraoperative events (OR=4.3, 95 % CI 1.3-14.6, p = 0.016) and type 4 venous reconstruction (OR=12.7, 95 % CI 1.5-280, p = 0.037). Despite the increasing proportion of type 3 and type 4 venous reconstructions performed over the years, the rates of severe morbidity have remained stable. A notable improvement in the R0 resection rate for pancreatic ductal adenocarcinoma was observed after 2019, with a significant shift toward more complex venous reconstructions.

Conclusion: Intraoperative events and type 4 venous reconstruction significantly increase the risk of severe morbidity in pancreatic surgery. These findings underscore the importance of surgical planning, expertise in vascular procedures, and multidisciplinary care to improve outcomes.

Keywords: Distal pancreatectomy; Pancreaticoduodenectomy; Vascular resection; Venous reconstruction.

Fig. 1

VenR types 1–3 (ISGPS classification) during pancreaticoduodenectomy. (a) Type 1 - primary venorraphy. (b) Type 2 - Peritoneal patch. (c) Segmental resection of the superior mesenteric vein with preservation of the splenoportal junction. (d) Portomesenteric anastomosis with concomitant splenorenal shunt.

Fig. 2

VenR type 4 (ISGPS classification) after (a) distal pancreatectomy with left hepatectomy and total gastrectomy for an 18 cm solid pseudopapillary tumor (PTFE graft). (b) Pancreatoduodenectomy for a solid pseudopapillary tumor (internal jugular vein graft) and reimplantation of the splenic vein with the left gastric vein.

Fig. 3

Flowchart illustrating the patient selection for the present study. DP-CAR = distal pancreatectomy with celiac artery resection/LAPDAC = locally advanced pancreatic ductal adenocarcinoma.

Fig. 4

VenR types (ISGPS classification) clustered by periods.