Nonrecurrence-related patency failure following venous reconstruction during pancreaticoduodenectomy: Association with postoperative portal venous configuration

BACKGROUND Portal vein and superior mesenteric vein reconstruction can enable R0 pancreaticoduodenectomy; however, subsequent patency failure remains clinically important.Postoperative geometry may provide information beyond operative categories, although its association with preoperative anatomy and recurrencerelated vascular compromise requires clarification.AIM To determine whether postoperative venous geometry is associated with nonrecurrence-related portomesenteric patency failure.METHODS This single-center, retrospective cohort study included 183 patients undergoing R0 pancreaticoduodenectomy with four venous strategies during 2011-2025.Geometry was measured on the first technically adequate contrast-enhanced computed tomography (CT) within 14 days, with patency confirmed at cohort entry.Follow-up began at baseline CT acquisition.Fine-Gray regression assessed nonrecurrencerelated failure, with recurrence-related vascular events and death as competing events.Exploratory models incorporated preoperative angles.Postoperative interobserver agreement was assessed in 55 patients.RESULTS Nonrecurrence-related failure was observed in 49 (26.8%)patients, recurrencerelated vascular events in 34 (18.6%)patients, and death before failure in 76 (41.5%) patients.Baseline CT was obtained at a median of 7 (interquartile range, 6-9) days after surgery.Each 10-degree larger postoperative splenic vein-portal vein angle was associated with lower failure incidence [sub-distribution hazard ratio = 0.76; 95% confidence interval (CI): 0.65-0.89;P < 0.001].The association persisted after 4 / 44 corresponding preoperative-angle adjustment (0.76; 95%CI: 0.64-0.89;P < 0.001).Interobserver intraclass correlation coefficients ranged from 0.940 to 0.969. CONCLUSIONA wider postoperative splenic vein-portal vein angle remained associated with lower subsequent nonrecurrence-related patency failure after preoperative-angle adjustment.These findings support prospective evaluation as an imaging risk marker.