Posterior Superior Pancreaticoduodenal Vein Research Articles

Investigation of the variation of vessels around the pancreatic head based on the first jejunal vein anatomy at pancreaticoduodenectomy.

Pancreaticoduodenectomy (PD) for pancreatic cancer carries a high risk of massive intraoperative blood loss. The artery first approach (AFA) prevents blood loss during PD, but the optimal approach is unclear. The first jejunal vein (FJV) often comprises multiple veins and broadly supports venous drainage of the proximal jejunum. Its ligation carries a risk of proximal jejunum congestion. Here we investigated the anatomical characteristics of PD-associated vessels and AFA approach selection based on FJV anatomy. This study included 148 Japanese living donors for liver transplantation. We reviewed their computed tomography images and assessed the anatomical pattern of PD-associated vessels in terms of FJV anatomy. The FJV traveled posterior to the superior mesenteric artery in 128 patients (86.5%, dorsal group) and anterior in 20 (13.5%, ventral group). The predominant draining vein of the inferior pancreaticoduodenal vein was the superior mesenteric vein in the ventral group (87.5%) and the FJV in the dorsal group (97.9%). Compared with the dorsal group, the ventral group had a significantly greater percentage with the superior mesenteric vein ventral to the superior mesenteric artery (30.0% versus 10.9%) and a significantly larger posterior superior pancreaticoduodenal vein diameter (3.2 ± 0.9 versus 2.7 ± 0.6mm, p = 0.0029). These results were validated in patients with pancreatic head cancer. The anatomical characteristics of PD-associated vessels differed significantly between groups defined by FJV anatomy. Understanding the venous anatomy, especially the FJV, could support selection of the best approach in AFA for PD.

A case of pancreatic ductal adenocarcinoma with portal vein tumor thrombus continuously invading through the posterior superior pancreatico-duodenal vein

A case of pancreatic ductal adenocarcinoma with portal vein tumor thrombus continuously invading through the posterior superior pancreatico-duodenal vein

Three-Dimensional Reconstruction of the Peripancreatic Vascular System Based on Computed Tomographic Angiography Images and Its Clinical Application in the Surgical Management of Pancreatic Tumors

This study aimed to investigate the clinical significance of 3-dimensional (3D) reconstruction of peripancreatic vessels for patients with suspected pancreatic cancer (PC). A total of 89 patients with PC were included; 60 patients randomly underwent computed tomographic angiography. Based on the findings of 3D reconstruction of peripancreatic vessels, the appropriate method for individualized tumor resection was determined. These patients were compared with 29 conventionally treated patients with PC. The rate of visualization was 100% for great vessels around the pancreas. The detection rates for anterior superior pancreaticoduodenal artery, posterior superior pancreaticoduodenal artery, anterior inferior pancreaticoduodenal artery, posterior inferior pancreaticoduodenal artery, dorsal pancreatic artery, superior marginal arterial branch of the pancreatic head, anterior superior pancreaticoduodenal vein, posterior superior pancreaticoduodenal vein, anterior inferior pancreaticoduodenal vein, and posterior inferior pancreaticoduodenal vein were 86.6%, 85.0%, 76.6%, 71.6%, 91.6%, 53.3%, 61.6%, 55.0%, 43.3%, and 51.6%, respectively. Forty-three patients who had undergone 3D reconstruction underwent surgery. Of the 29 conventionally treated patients, 19 underwent surgery. The operative time, blood loss, length of hospital stay, and complication incidence of the 43 patients were superior to that of the 19 patients. A peripancreatic vascular reconstruction can reveal the vascular anatomy, variations of peripancreatic vascular, and tumor-induced vascular changes; the application of the simulation surgery platform could reduce surgical trauma and decrease operative time.

Living Donor Liver Transplantation for the Patients With Portal Vein Thrombosis: Use of an Interpositional Venous Graft Passed Posteriorly to the Pancreatic Parenchyma Without Using Jump Graft

BackgroundIt is difficult to reconstruct the portal vein (PV) using a long interpositional venous graft in living donor liver transplant (LDLT) patients with portal vein thrombosis (PVT), which involves the confluence of the superior mesenteric vein (SMV) and splenic vein (SV). We successfully performed LDLT for three patients with PVT using an interpositional vascular conduit passing posterior to the pancreas without a jump graft. MethodsThree of 130 patients who underwent LDLT in our hospital between March 2002 and June 2011 required this technique. After indentifying the location of the SMV, SV and gastrocolic trunk, we ligated and cut the posterior superior pancreaticoduodenal vein and other short branches from the PV. The PV was drawn inferiorly to the pancreas and transected at the confluence of SMV and SV. The external iliac vein or internal jugular vein was sacrificed as a graft for anastomosis to the cut end of the SMV using 6-0 polypropylene running sutures. Then the venous graft was drawn superiorly to the pancreas by passing it posterior to the pancreas parenchyma for anastomosis to the liver graft PV. The interpositional vein was placed posterior to the pancreas where the PV used to be. ResultsAll three patients displayed favorable postoperative courses with the Doppler ultrasound demonstrating good portal flow perioperatively. The postoperative portogram demonstrated patency of the vascular graft. ConclusionThis method is easy and helpful to treat portal vein thrombosis, by providing the shortest route between the PV of the donor and the SMV of the recipient.

Ruptured duodenal varices successfully treated with balloon-occluded retrograde transvenous obliteration : report of a case

A 66-year-old man with alcoholic cirrhosis was admitted to our hospital with fatigue and weakness for the last few days. He had recent on set of melena with severe anemia. Emergent upper gastrointestinal endoscopy revealed dark-red colored tense varices in the descending portion of duodenum. Multidimensional computed tomography (MDCT) demonstrated the duodenal varices (DV) supplied by the posterior superior pancreaticoduodenal vein (PSPDV) and drained into right testicular vein. We performed balloon-occluded retrograde transvenous obliteration (BRTO) because the ruptured DV were the cause of melena. A balloon catheter was inserted via the right femoral vein and wedged into the rt. testicular vein. Digital subtraction angiography showed DV supplied by the PSPDV and DV collaterals. The collateral veins were embolized with microcoils. The sclerosing agent, 5% solution of ethanolamine oleate with iopamidol (EOI), was continuously infused into DV under the ballon infration until DV were filled with screlosant completely. No major procedure-related complications occurred. Post-BRTO endoscopy and abdominal CT showed successful obliteration of DV. In conclusion, we report a case of DV successfully treated with BRTO. There is no established treatment of DV. Further studies are needed to clarify appropriate treatment for the eradication of DV.

Anatomical variations of peripancreatic veins and their intrapancreatic tributaries: multidetector-row CT scanning

To date the anatomy of the intrapancreatic and peripancreatic veins using multidetector-row CT (MDCT) was not assessed. The object of this study is to establish 3D CT anatomy of these veins. A total of 100 consecutive patients who underwent abdominal triple-phase CT using 16-detector MDCT were retrospectively reviewed. The anatomical variations of the peripancreatic and intrapancreatic veins were assessed. Among the 100 cases, 42 cases (42%) had a single posterior superior pancreaticoduodenal vein crossing the ventral side of the common bile duct, while 30 cases (30%) had an uncinate vein running upward behind the medial side of the pancreatic. In the pancreatic head and body/tail area, there were many small veins that directly entered the superior mesenteric or splenic vein. In 59 cases (59%), the centro-inferior pancreatic vein ran transversely along the inferior surface of the pancreatic body and drained the anterior or inferior parts of the pancreatic body, mainly into the splenic vein. Many variations exist in the running patterns of intrapancreatic veins as well as peripancreatic veins. Recognition of abnormalities of intrapancreatic veins on CT in the light of normal CT anatomy may contribute to the interpretation of pathological conditions of the pancreas.

Configuration of the straight veins and their intramural anastomoses in the human duodenum: an anatomical study using cast specimens.

There have, hitherto, been no anatomical investigations of the intramural venous system of the duodenum. Intramural longitudinal anastomoses of the straight veins in the human duodenum were investigated, using 15 latex resin cast specimens. The venous tree (with a straight vein as the trunk) was developed well, with numerous twigs (venules). We identified two types of longitudinal anastomoses between the straight veins; the direct and plexus-mediated types, with an equal incidence. The direct-type anastomosis was 0.1-0.5 mm in minimum diameter along the course and communicated in almost a straight line between the mother straight veins. In contrast, the plexus-mediated type was regarded as the thickest route (almost 0.1 mm) in the suggested submucosal venular network in the duodenal wall. These two types of anastomoses were distributed almost equally in most of the duodenum, although a relatively lower density was found in the superior portion. On the ventral side of the duodenum, the thicker straight veins had anastomotic branches significantly more frequently than the thinner ones (P = 0.0018). CONCLUSIONS; These results seemed to support the feasibility of Kocher mobilization, as well as the conventional poor preservation of the duodenal venous system during duodenum-preserving surgery. However, because the intramural longitudinal venous anastomoses were limited in number and location, we recommend preservation of the posterior superior pancreaticoduodenal vein and either of the inferior venous arcades, in combination with their concomitant arteries, in exchange for the unavoidable sacrifice of Henle's trunk and the dorsal pancreatic vein.

Surgical anatomy of the pancreas for limited resection.

The fusion fascia of the head of the pancreas is called the "fusion fascia of Treitz" and that of the body and tail of the pancreas is termed the "fusion fascia of Toldt". The fusion fascia is histologically composed of a loose connective tissue membrane. All of the important pancreaticoduodenal arcades of arteries and veins are situated on this membrane, i.e., between this membrane and the pancreatic parenchyma. The topography of the head of the pancreas shows that, after departing from the gastroducodenal artery, the anterior superior pancreaticoduodenal artery runs toward a point 1.5 cm below the papilla of Vater, then turns to the posterior aspect of the pancreas to join the anterior inferior pancreaticoduodenal artery. For preserving the duodenum, the artery toward the papilla is very important. The artery toward the papilla of Vater runs along the right side of the common bile duct after departing from the posterior superior pancreaticoduodenal artery. The gastrocolic trunk of Henle has been reported to be found in about 60% of individuals. It is possible that the gastroepiploic vein and anterior superior pancreaticoduodenal vein (ASPDV) can be divided at pancreaticoduodenectomy, with preservation of the superior right colic vein, if this area is free of carcinoma. The ASPDV and anterior inferior pancreaticoduodenal vein form an arcade on the anterior surface of the pancreas. However, arcade formation was not found between the posterior superior pancreaticoduodenal vein and posterior inferior pancreaticoduodenal vein in many of the individuals examined. The vein joined by the inferior mesenteric vein was also investigated.

Portal vein and its tributaries: evaluation with thin-section three-dimensional contrast-enhanced dynamic fat-suppressed MR imaging.

To evaluate the visibility of the main portal vein (MPV) and its tributaries in healthy subjects at thin-section three-dimensional (3D) contrast material-enhanced dynamic fat-suppressed magnetic resonance (MR) imaging and to determine whether this technique provides useful information in the evaluation of patients with cirrhosis. Seventy-two patients (37 control subjects, 35 patients with cirrhosis) underwent imaging with a high-performance-gradient (25 mT/m) system. In the 37 subjects in the control group, the MPV was visualized in 37; splenic vein (SV), in 37; superior mesenteric vein (SMV), in 37; inferior mesenteric vein (IMV), in 35; posterior superior pancreaticoduodenal vein (PSPDV), in 35; gastrocolic trunk (GT), in 34; right gastroepiploic vein (RGEV), in 31; right colic vein, in 30; anterior superior pancreaticoduodenal vein, in 22; middle colic vein (MCV), in 29; and first jejunal vein (FJV), in 36. Satisfactory visualization (mean ratings of 2 or higher) was achieved in the MPV, SV, SMV, IMV, PSPDV, GT, RGEV, and FJV in the control group. Mean diameters of the SV, SMV, MCV, and FJV were significantly larger in the cirrhosis group than in the control group (P <.001, P <.001, P =.048, and P =.002, respectively). Thin-section 3D contrast-enhanced dynamic fat-suppressed MR imaging can facilitate precise visualization of the MPV and its tributaries. Dilatation of the tributaries may be a nonspecific secondary finding that is suggestive of cirrhosis.

Anterior Tributaries of the Portal Vein at the Superior Margin of the Pancreas: Is "Tunneling" Procedure Safe During Pancreatic Surgery?

It is widely believed that using the "tunneling" procedure during pancreatoduodenectomy is a safe maneuver because the anterior tributaries of the portal vein (PV) are absent or very rare. The head of the pancreas with the duodenum and the common bile duct (CBD) was obtained from 22 autopsy cases. Three colors of silicon-polymerase dyes were injected into the pancreatic artery, PV, and bile duct. The tributaries of the PV at the superior margin of the pancreas were studied. There was no anterior branch of the intrapancreatic PV. The anterior superior pancreaticoduodenal vein (ASPDV) gave a definite branch to the anterior aspect of the PV at the superior margin of the pancreas in 4 of 22 cases. When the posterior superior pancreaticoduodenal vein (PSPDV) was located in front of the CBD (5 of 22 cases), the ASPDV and PSPDV had a thick common trunk at the right side of the PV. In these 5 cases, no individual branch from the ASPDV was found at the anterior aspect of the PV. PV sometimes has a definite anterior tributary at the superior margin of the pancreas; this must be kept in mind to perform the tunneling procedure during pancreatic surgery.

Small peripancreatic veins: improved assessment in pancreatic cancer patients using thin-section pancreatic phase helical CT.

Recent studies have shown evaluation of the small peripancreatic veins to have potential in improving pancreatic cancer staging. This study was performed to determine the effectiveness of thin-section pancreatic phase helical CT images in visualizing these veins. Seventy-two patients (30 with pancreatic adenocarcinoma and 42 with no pancreatic disease) underwent dual-phase helical CT with thin-section pancreatic phase acquisition (40-70 sec after i.v. contrast initiation at 3 ml/sec) and hepatic phase acquisition (70-100 sec). Visualization (with diameter measurement) or nonvisualization of the posterior superior pancreaticoduodenal vein (PSPDV), anterior superior pancreaticoduodenal vein (ASPDV), and gastrocolic trunk was recorded for both acquisitions. We also correlated surgical tumor resectability with the status of the small peripancreatic veins. Visualization of peripancreatic veins was significantly better on pancreatic phase images than on hepatic phase images for both healthy individuals (PSPDV, 88% of the veins visualized on the pancreatic phase images versus 50% on the hepatic phase images; ASPDV, 93% on the pancreatic phase images versus 48% on the hepatic phase images; gastrocolic trunk, 98% on the pancreatic phase images versus 76% on the hepatic phase images) and for pancreatic cancer patients (PSPDV, 97% on the pancreatic phase images versus 57% on the hepatic phase images; ASPDV, 77% on the pancreatic phase images versus 43% on the hepatic phase images) (p < .05). The exception was the gastrocolic trunk in cancer patients (83% on the pancreatic phase images versus 77% on the hepatic phase images) (p > .05). In pancreatic cancer patients, 11 dilated peripancreatic veins were identified on the pancreatic phase images compared with six on the hepatic phase images. However, only one of the 11 dilated peripancreatic veins was in a patient with surgically resectable disease. In a dual-phase helical CT protocol, thin-section pancreatic phase images provided visualization of the small peripancreatic veins that was superior to hepatic phase images, providing further support for the use of this protocol in pancreatic cancer evaluation.

Venous drainage from the posterior aspect of the pancreatic head and duodenum.

Eighty-three pancreatic head and duodenum specimens, selected from 214 specimens, were dissected minutely to clarify the configurations of the posterior superior pancreaticoduodenal vein (PSPDv) with special reference to its topographical relationship to the common bile duct (CBD) and to whether an artery accompanied the PSPDv. The PSPDv frequently (71.1%) ran postero-inferior to the CBD without the accompaniment of an artery. Moreover, several tributaries draining the second and third portions of the duodenum sometimes (28.9%) joined together without arterial association and formed a stem, the so-called dorsal pancreatic vein. Variations of PSPDv were discussed in relation to the general vascular configuration of the small intestine.

Peripancreatic veins on thin-section (3 mm) helical CT.

The purpose of this study was to evaluate thin-section helical CT for the frequency of visualization of the peripancreatic veins, the venous anatomy at the head of the pancreas, and variations of the venous anatomy. We performed 30-sec helical CT of the pancreas with one breath-hold and a 3-mm scanning collimation in 50 patients. The scan was started 60 sec after injection of an i.v. contrast medium at the rate of 2 ml/sec (total amount of contrast medium, 100 ml). The axial scan data were reviewed for the following information: the frequency of CT visualization of the peripancreatic veins (anterior superior pancreaticoduodenal vein, first jejunal vein, gastrocolic trunk, inferior mesenteric vein, left gastric vein, middle colic vein, posterior superior pancreaticoduodenal vein, right colic vein, and right gastroepipolic vein) and the anatomic relationship between the large portal venous system (portal vein, superior mesenteric vein, and splenic vein) and its tributaries. The frequency of visualization on CT of each vessel was gastrocolic trunk, 100%; right gastroepiploic vein, 100%; first jejunal vein, 96%; inferior mesenteric vein, 88%; left gastric vein, 80%; posterior superior pancreaticoduodenal vein, 72%; middle colic vein, 72%; right colic vein, 64%; and anterior superior pancreaticoduodenal vein, 50%. The anatomic relationship between the large portal venous system and its tributaries was as follows: The left gastric vein drained into the splenic vein-portal vein confluence (46%), into the splenic vein (32%), and into the portal vein (22%); the inferior mesenteric vein drained into the splenic vein (46%), the splenic vein-superior mesenteric vein confluence (25%), and the superior mesenteric vein (29%). The posterior superior pancreaticoduodenal vein drained into the portal vein above the splenic vein-portal vein confluence (mean distance, 0.3 cm). The middle colic vein, gastrocolic trunk, and first jejunal vein drained into the superior mesenteric vein below the splenic vein-portal vein confluence (mean distances of 2.4 cm, 3.0 cm, and 3.7 cm, respectively). Thin-section helical CT scans provide good visualization of the peripancreatic veins.

Carcinoma of the head of the pancreas: evaluation of the pancreaticoduodenal veins with dynamic CT--potential for improved accuracy in staging.

To determine if detection of abnormal dilatation of pancreaticoduodenal veins can improve the accuracy of computed tomographic (CT) staging of pancreatic adenocarcinoma. CT scans obtained during bolus administration of contrast material in 86 patients (aged 34-85 years) with pancreatic head carcinoma were reviewed. The diameter of the small veins that surround the head of the pancreas was measured (normal diameter of gastrocolic trunk, < or = 7 mm; of anterior superior pancreaticoduodenal vein, < or = 4 mm; of posterior superior pancreaticoduodenal vein, < or = 4 mm). Twenty-nine abnormally dilated peripancreatic veins were identified in 22 patients. Twenty-two of these dilated veins were in 16 patients with other CT criteria of tumor unresectability; seven dilated veins were in six patients with tumors deemed resectable at CT. All tumors in these latter six patients were unresectable at surgery. Although dilatation of these small peripancreatic veins without other CT criteria of tumor unresectability is an unusual finding, it may be a reliable sign of unresectable pancreatic carcinoma.

Posterior superior pancreaticoduodenal vein: mimic of distal common bile duct at sonography.

Previous investigators have noted that the common bile duct may appear to merge with the portal vein on sagittal sonograms, mimicking a venous structure. The posterior superior pancreaticoduodenal vein courses adjacent to the distal part of the common bile duct within the pancreatic head. A prospective study was performed to assess the sonographic appearance of the posterior superior pancreaticoduodenal vein. The study included 50 consecutive subjects in whom the pancreatic head was well seen. Anatomic characteristics of the posterior superior pancreaticoduodenal vein were noted with gray-scale, duplex Doppler, and color Doppler sonography. The site of insertion of the posterior superior pancreaticoduodenal vein into the portal vein was noted. The posterior superior pancreaticoduodenal vein was visualized in all 50 cases. Although it usually (82% of cases) inserted into the posterior aspect of the portal vein, the posterior superior pancreaticoduodenal vein inserted into the anterior aspect of the portal vein in nine cases (18%), resulting in an appearance mimicking the common bile duct on sagittal sonograms. Doppler examination showed flow toward the portal vein in all obliquely oriented posterior superior pancreaticoduodenal veins, and in 40% overall. The common bile duct could always be followed into the porta hepatis and was anterior to the posterior superior pancreaticoduodenal vein in 49 cases (98%). The posterior superior pancreaticoduodenal vein can be seen routinely on sonograms when the pancreatic head is unobscured, and it can mimic the common bile duct in a significant number of cases. These structures can be distinguished by noting continuation of the common bile duct into the porta hepatis, the generally anterior position of the common bile duct, and flow in the posterior superior pancreaticoduodenal vein on Doppler examination. Awareness of the existence and anatomy of the posterior superior pancreaticoduodenal vein minimizes its confusion with the common bile duct at sonographic examination.

Venous anatomy of the pancreatic head: normal CT appearance in cadavers and patients.

This study was conducted to define the normal CT appearance of the four pancreaticoduodenal veins (anterior and posterior superior, and anterior and posterior inferior) in the head of the pancreas in injected cadaveric specimens and to assess the frequency with which these normal vessels are seen on dynamic contrast-enhanced CT scans. The appearance of the four pancreaticoduodenal veins was studied on CT scans of four cadavers in which the portal veins were injected in situ with radiopaque solutions. A computer-generated three-dimensional model of the pancreatic head and its venous drainage was then produced from one cadaveric examination to show the venous anatomy. After definition of the venous anatomy in the cadaveric specimen, the anterior superior pancreaticoduodenal vein, posterior superior pancreaticoduodenal vein, and gastrocolic trunk were analyzed retrospectively on dynamic bolus contrast-enhanced abdominal CT scans of 100 consecutive patients who had no evidence of pancreatic disease. The anterior and posterior superior pancreaticoduodenal veins were seen on 98% and 88% of scans, respectively. The veins had mean diameters of 2.1 mm. The gastrocolic trunk was seen on 89% of scans and had a mean diameter of 4.7 mm. The inferior pancreaticoduodenal veins are small and were not identified definitively. The anterior and posterior superior pancreaticoduodenal veins and gastrocolic trunk are routinely visualized on CT scans of patients without pancreatic disease. Consequently, assessment of the veins may be useful in staging pancreatic carcinoma.

Dilated posterior superior pancreaticoduodenal vein: recognition with CT and clinical significance in patients with pancreaticobiliary carcinomas.

The authors retrospectively reviewed computed tomographic (CT) scans, angiograms, and surgical-pathologic records of 226 patients without and 64 patients with pathologically proved pancreaticobiliary carcinoma to evaluate frequency of depiction, normal range of size, and causes of dilatation of the posterior superior pancreaticoduodenal vein (PSPDV) at CT. Among the patients with pancreaticobiliary carcinoma, CT demonstrated enlarged PSPDVs (diameter, greater than or equal to 8 mm) in seven patients. CT and angiography showed that the portal-superior mesenteric vein (P-SMV) was occluded or stenotic at its confluence in three patients and was normal in four patients. Among the latter four patients, localized tumor invasion was found surgically-pathologically along the right lateral wall of the P-SMV in three. A dilated PSPDV with obliteration of the P-SMV at CT may confirm tumor extension to the P-SMV. In patients with a normal P-SMV at CT, a dilated PSPDV indicates that the tumor has extended beyond the pancreatic parenchyman and occluded other pancreaticoduodenal veins or extended to the wall of the P-SMV.

Anatomy of the pancreatic veins. A post mortem and clinical phlebographic investigation.

The venous anatomy of 22 autopsy specimens of human pancreas was examined by dissection and radiography after injection of gelatin agent. The most constant findings were the posterior superior pancreaticoduodenal vein draining to the portal vein and the anterior superior pancreaticoduodenal vein draining to the gastrocolic trunk and superior mesenteric vein. Both veins were identified in 21 and 20 of 22 cases, respectively. All other pancreatic veins varied considerably in their course. The normal findings in clinical selective pancreatic phlebography based on 148 examinations are described.