Ann Hepatobiliary Pancreat Surg.  2023 Nov;27(4):423-427. 10.14701/ahbps.23-065.

Anticoagulation after pancreatic surgery with venous resection (TIGRESS): What should we do? Results from an international survey

• Russell TB
• Ciprani D
• Aroori S

• KMID: 2548509
• DOI: http://doi.org/10.14701/ahbps.23-065

Abstract

Backgrounds/Aims
Patients who undergo pancreatic surgery with venous resection have high rates of morbidity/mortality. Also, they are high-risk for postoperative venous thromboembolism. Whether this group should be routinely anticoagulated is unknown. This study aimed to establish current anticoagulation practices.
Methods
A survey (https://form.jotform.com/220242489107048) was sent out to pancreatic surgeons. Questions covered center volume, venous resection/reconstruction techniques and anticoagulation policies.
Results
Sixty-five centers from 17 countries responded. Following a “side-bite” venous resection with a patch repair, 40% used an autologous vein patch, 27% used peritoneum, and 27% used a bovine patch. After formally resecting a segment of vein, 17% of centers used an interposition graft (IG). Left renal vein (41%) and polytetrafluoroethylene (73%) grafts were the most commonly used autologous and prosthetic IGs, respectively. Following a prosthetic IG, an autologous IG, and a “side-bite” resection, 59%, 28%, and 19% of centers provided therapeutic anticoagulation, respectively (66% used low molecular-weight heparin). The duration of therapy provided varied from inpatient stay only (14%) to six months (32%).
Conclusions
Our global survey indicates that anticoagulation practices are highly variable. Centers do not agree on when to anticoagulate, how to anticoagulate, or the duration of therapy. A robust trial is required to provide clarity.

Keyword

Anticoagulants; Pancreaticoduodenectomy; Venous thromboembolism; Veins

Reference

1. Russell TB, Labib PLZ, Aroori S. 2023; Five-year follow-up after pancreatoduodenectomy performed for malignancy: a single-centre study. Ann Hepatobiliary Pancreat Surg. 27:76–86. DOI: 10.14701/ahbps.22-039. PMID: 36168824. PMCID: PMC9947371.

2. Filho JELP, Tustumi F, Coelho FF, Júnior SS, Honório FCC, Henriques AC, et al. 2021; The impact of venous resection in pancreatoduodectomy: a systematic review and meta-analysis. Medicine (Baltimore). 100:e27438. DOI: 10.1097/MD.0000000000027438. PMID: 34622858. PMCID: PMC8500612.

3. Russell TB, Labib PL, Aroori S. 2022; Selected intra-operative factors which affect pancreaticoduodenectomy outcomes: a narrative review. Ann Pancreat Cancer. 5:2. DOI: 10.21037/apc-21-16.

4. Wang X, Demir IE, Schorn S, Jäger C, Scheufele F, Friess H, et al. 2019; Venous resection during pancreatectomy for pancreatic cancer: a systematic review. Transl Gastroenterol Hepatol. 4:46. DOI: 10.21037/tgh.2019.06.01. PMID: 31304423. PMCID: PMC6624360.

5. Hackert T, Klaiber U, Hinz U, Strunk S, Loos M, Strobel O, et al. 2023; Portal vein resection in pancreatic cancer surgery: risk of thrombosis and radicality determine survival. Ann Surg. 277:e1291–e1298. DOI: 10.1097/SLA.0000000000005444. PMID: 35793384.

6. Peng C, Zhou D, Meng L, Cao Y, Zhang H, Pan Z, et al. 2019; The value of combined vein resection in pancreaticoduodenectomy for pancreatic head carcinoma: a meta-analysis. BMC Surg. 19:84. DOI: 10.1186/s12893-019-0540-6. PMID: 31286916. PMCID: PMC6615269.

7. Pan G, Xie KL, Wu H. 2013; Vascular resection in pancreatic adenocarcinoma with portal or superior mesenteric vein invasion. World J Gastroenterol. 19:8740–8744. DOI: 10.3748/wjg.v19.i46.8740. PMID: 24379594. PMCID: PMC3870522.

8. Navez J, Bouchart C, Lorenzo D, Bali MA, Closset J, van Laethem JL. 2021; What should guide the performance of venous resection during pancreaticoduodenectomy for pancreatic ductal adenocarcinoma with venous contact? Ann Surg Oncol. 28:6211–6222. DOI: 10.1245/s10434-020-09568-2. PMID: 33479866. PMCID: PMC8460578.

9. Chan KS, Srinivasan N, Koh YX, Tan EK, Teo JY, Lee SY, et al. 2020; Comparison between long and short-term venous patencies after pancreatoduodenectomy or total pancreatectomy with portal/superior mesenteric vein resection stratified by reconstruction type. PLoS One. 15:e0240737. DOI: 10.1371/journal.pone.0240737. PMID: 33151977. PMCID: PMC7644060.

10. Bergqvist D, Agnelli G, Cohen AT, Eldor A, Nilsson PE, Le Moigne-Amrani A, et al. 2002; Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N Engl J Med. 346:975–980. DOI: 10.1056/NEJMoa012385. PMID: 11919306.

11. Chandrasegaram MD, Eslick GD, Lee W, Brooke-Smith ME, Padbury R, Worthley CS, et al. 2014; Anticoagulation policy after venous resection with a pancreatectomy: a systematic review. HPB (Oxford). 16:691–698. DOI: 10.1111/hpb.12205. PMID: 24344986. PMCID: PMC4113250.