Fujitani - Vasc Recon in Conjunc Panc Cancer Resec - VNVDA 2023

1. Vascular Reconstruction in Conjunction
with Pancreatic Cancer Resection
Roy M. Fujitani, MD, RVT, DFSVS, FACS
Professor of Surgery
Vice-Chair, Surgical Education and Faculty Development
Department of Surgery
Division of Vascular & Endovascular Surgery
University of California - Irvine

2. No Disclosures

3. Pancreatic Ductal Adenocarcinoma
• Worldwide annual incidence (2020): 495,773 patients
– 8th most common in women; 10th most common in men
• Third leading cause of cancer-related death (US)
– Incidence (2023 est): 64,050 patients
– Mortality: 50,550 patients (8.3% of all cancer deaths)
• Metastases occur very early in pathogenesis of
disease
– Most patients diagnosed at advanced stage

4. Pancreatic Ductal Adenocarcinoma
• Resection reserved for non-metastatic disease
• 5 year survival: 7-25%
• Median survival: 11-20 months
• High surgical morbidity rate
• 20% - 50%
• Recurrent disease: retroperitoneum ~ 34-87% of the time
• Immunotherapy-based strategies targeting stepwise events
required for tumor initiation & progression disappointing
• Combination therapies hold promise for enhancing immune
responses

5. Pancreatic Ductal Adenocarcinoma
Only curable option: Surgical resection
– Must have R0 (negative microscopic margin) resection for
best long-term cure

6. Therapeutic Sequencing for
Localized Pancreatic Cancer
• Treatment for pancreatic cancer is stage specific
• Multiplanar CT scanning
– Objective radiologic classification determines extent of
disease
• Resectable
• Borderline Resectable
• Locally Advanced (Nonresectable)

7. Adapted from: Appel BL, Tolat P, Evans DB, Tsai S. Cancer J 2012; 18(6):539-49

8. NCCN CT Staging: Resectable

9. NCCN CT Staging: Borderline Resectable

10. NCCN CT Staging:
Locally Advanced (Unresectable)

12. Who are candidates for concomitant vascular
reconstruction?
Borderline Resectable/Stage II
– Encasement of the portal vein, superior mesenteric vein, or PV/SMV
confluence (suitable proximal and distal targets)
– Less than 180° encasement of the common hepatic artery or right
hepatic artery
– Does NOT include superior mesenteric artery or celiac axis
Accounts for approximately 25% of cases in high volume
institutions1,2
Tseng JF, Raut CP, Lee JE, et al.J Gastrointest Surg 2004 Dec;8(8):935-49
Müller SA, Hartel M, Mehrabi A, et al. J Gastrointest Surg 2009 Apr;13(4):784-92

14. Vascular Reconstructions
Venous Reconstruction
• Primary direct repair
• Autologous conduit
• ePTFE conduit
• Cryovein conduit
• Autologous patch
Arterial Reconstruction
Primary direct repair
Autologous conduit

19. 270 Whipple Operations
60 vascular reconstructions
183 Whipple for adenocarcinoma
87 resections without
vascular reconstruction
49 Venous 11 Arterial
147 T3 lesions
Methods
36 T1 and T2 lesions
EXCLUDED
J Vasc Surg 2015;61(2):475-80
32.8%

20. Vascular
Reconstruction
(N=60)
No Vascular
Reconstruction
(N=87)
P-valuea
Age 64.5 ± 10.0 67.4 ± 9.7 0.081
Male 32 (53.3) 43 (49.4) 0.641
Race/Ethnicity 0.188
Non-Hispanic White 53 (88.3) 70 (80.5)
Non-Hispanic Black 0 (0) 2 (2.3)
Hispanic 5 (8.3) 5 (5.8)
Asian or Pacific Islander 2 (3.3) 10 (11.5)
Chronic Conditions 0.423
Hypertension 27 (45.0) 45 (51.7)
Diabetes Mellitus 7 (11.7) 27 (31.0)
Hyperlipidemia 7 (11.7) 15 (17.2)
Gastroesophageal Reflux 8 (13.3) 7 (9.2)
Hypothyroidism 7 (11.7) 4 (4.6)
NONE 13 (22) 20 (23)
Neoadjuvant Chemotherapy 23 (38.3) 8 (9.1) < 0.05
J Vasc Surg 2015;61(2):475-80

21. Venous (n=49)
Primary Repair
Vein Patch
Autologous Reconstruction
Cryovein
Portocaval shunts
37 (61.7%)
3 (5%)
3 (5%)
4 (6.7%)
2 (3.3%)
Arterial (n=11)
Primary Reconstruction (SMA)
Primary Reconstruction and
Reimplantation (Right Hepatic Artery)
4 (36.3%)
7 (63.6%)
Vascular Reconstructions
J Vasc Surg 2015;61(2):475-80

22. Whipple + Vascular
Reconstruction
(n=60)
Whipple
Resection
Only
(n=87)
P-value
Survival days
(months)
575.28 (18.9) 682.5 (22.4) 0.172
Intra-operative
Death
1/60 (1.6%) 0/87 (0%)
30-d mortality 3/60 (5%) 3/87 (3.4%) 0.699
1-year
survival
42 (71.1%) 61 (70.11%) 0.981
Results
J Vasc Surg 2015;61(2):475-80

23. Kaplan Meier Survival 5-year
p = 0.011
J Vasc Surg 2015;61(2):475-80

24. Prognostic Factors
Odd Ratio (CI)
Death at 30 days
Odds Ratio (CI)
Death at 1 year
Odds Ratio (CI)
Death at 5 years
Estimated Blood Loss 0.99 (0.99-1.01) 1.00 (1.00-1.00) 1.00 (1.00-1.00)
Lymph Nodes 0.05 (<0.1->1000.0) 3.06 (0.24-38.97) 40.96 (<0.1->1000.0)
Margin Status 8.18 (0.27-250.88) 0.77 (0.20-2.98) >1000.0 (<0.1->1000.0)
J Vasc Surg 2015;61(2):475-80

25. 5-year survival with neoadjuvant chemotherapy
P=0.017
P =0.017

26. Transfusion requirements
Average Units PRBC/case
(R=0.3)

27. Summary
• Pancreatic ductal adenocarcinoma continues to have a very
poor prognosis due to early metastases and late symptomatic
disease presentation
• Pancreaticoduodenectomy with concomitant vascular
reconstruction on borderline resectable T3 lesions with vascular
invasion may allow for increased R0 (microscopic margin
negative) surgical resections
• Equivalent survival outcomes may be achieved with
concomitant vascular reconstruction in carefully selected
patients.

28. Summary
• There are multiple options for vascular reconstruction for
mesenterico-portal venous and visceral arterial involvement to
maintain visceral perfusion
• A consistent team of experienced surgeons for complex
pancreaticoduodenal tumor resection and vascular reconstruction
is essential for successful outcomes

29. “
Division of Vascular and Endovascular Surgery
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