Pancreatoduodenectomy with superior mesenteric vein resection and non-reconstruction for pancreatic head cancer paying particular attention to hemodynamics

Purpose Locally advanced pancreatic ductal adenocarcinoma (PDAC) with an unreconstructible superior mesenteric vein (SMV) invasion is one of the criteria of unresectability in the National Comprehensive Cancer Network guidelines. Advances in chemotherapy have improved downstaging and conversion surgery outcomes, thereby broadening surgical options for locally advanced PDAC. However, operations for PDAC with an unreconstructible SMV is less well-documented. If the collateral route is well-developed and can be preserved or reconstructed, SMV resection can be performed without reconstruction. In this paper, we detail our surgical technique and the outcomes for patients undergoing pancreatoduodenectomy with SMV resection and non-reconstruction (PD-SMVR-NR). Methods All consecutive patients with pancreatic head cancer who underwent PD at Juntendo University Hospital, Japan, between January 2019 and December 2022 were evaluated from a prospectively maintained preoperative database. Demographic data, clinical history, operative record, morbidity, mortality, and pathologic data were reviewed. Results Over four years at our Institute, 161 patients with pancreatic head cancer underwent PD, and 86 of these patients underwent PD with portal vein (PV) or SMV resection. There were three patients who underwent PD-SMVR-NR. Each patient had well-developed collateral vessels bypassing the obstructed segment of the SMV. All three patients had no hospital mortality with acceptable complications (Clavien-Dindo grade 2). Two patients achieved R0 resection. Conclusion By understanding the hemodynamics of venous flow and preserving collateral vessels, especially the superior right colic vein arcade and porto-mesenterico-splenic confluence, pancreatoduodenectomy with superior mesenteric vein resection and non-reconstruction can be performed safely.