Superior Mesenteric-portal Vein Confluence Research Articles

Role of Collateral Venous Circulation in Prevention of Sinistral Portal Hypertension After Superior Mesenteric-Portal Vein Confluence Resection during Pancreaticoduodenectomy: a Single-Center Experience

BackgroundThe ligation of the splenic vein (SV) during pancreaticoduodenectomy (PD) may result in sinistral portal hypertension (SPH). This study aimed to identify the collateral pathways that formed postoperatively and evaluate the impact of omentum and arc of Barkow preservation in PD. MethodsPatients who underwent PD between January 2013 and May 2018 at the Second Affiliated Hospital of Zhejiang University were enrolled in this retrospective study. PD was performed with preservation of the greater omentum and arc of Barkow. Venous collaterals, spleen size, and platelet count were evaluated before and after surgery. ResultsIn total, 330 patients underwent PD, of whom, 43 patients who underwent superior mesenteric vein (SMV)/portal vein (PV) reconstruction and splenic vein (SV) ligation were selected. No patient developed severe gastrointestinal bleeding. Three collateral routes were identified: the left gastric route, the colic marginal route, and the first jejunal route. Seventeen patients developed splenomegaly. Twenty-three patients developed thrombocytopenia. However, none of them developed gastrointestinal bleeding or other clinical complaints. ConclusionAlthough subclinical SPH developed after SV ligation, postoperative gastrointestinal bleeding was uncommon.

Portal vein reconstruction using an autologous splenic vein graft at the superior mesenteric and portal vein confluence during pancreaticoduodenectomy

Introduction: Autologous vein graft reconstruction is needed in some cases following superior mesenteric portal vein (SMPV) resection during pancreatic cancer surgery. There have been no reports of reconstruction using a splenic vein autograft in a patient who underwent pancreaticoduodenectomy (PD). Methods: A 76-year-old woman was referred to our hospital for consultation based on a suspicion of pancreatic tumor. Computed tomography (CT) showed tumor in the uncinated process of the pancreas, approximately 40 x 30 mm in size, with narrowing of the superior mesenteric vein just below the SMPV confluence. Cytology of the pancreatic fluid revealed adenocarcinoma of the pancreas. She underwent PD and the mass was confirmed to have invaded the SMPV confluence. After clamping the splenic vein root with a vascular clamp, approximately 70 mm of the SMPV segment was resected. Then, the distal side of the pancreas with the splenic vein was raised and the splenic vein was dissected from the pancreas to harvest an autologous graft of the healthy splenic vein. Vascular reconstruction was performed using the 30-mm segment of the harvested splenic vein. The total time required for blocking and anastomosing the portal vein was 45 minutes. The final pathologic report revealed portal vein invasion, T4N0M0, and R0 resection. The patient received adjuvant chemotherapy. Follow-up CT at the 15th postoperative month showed a patent graft without evidence of recurrence. Conclusions: Splenic vein interposition grafting could be used in cases of PD with resection of the SMPV confluence, if the splenic vein is healthy.

脾静脈切離を伴う膵頭十二指腸切除術時の遠位脾腎静脈吻合による脾静脈再建

脾静脈切離を伴う膵頭十二指腸切除術時の遠位脾腎静脈吻合による脾静脈再建

Left-sided portal hypertension after pancreaticoduodenectomy with resection of superior mesenteric-portal vein confluence: Efficacy of concomitant splenic artery resection

Left-sided portal hypertension after pancreaticoduodenectomy with resection of superior mesenteric-portal vein confluence: Efficacy of concomitant splenic artery resection

Patency Rates of Portal Vein/Superior Mesenteric Vein Reconstruction After Pancreatectomy for Pancreatic Cancer

BackgroundPancreatectomy with venous reconstruction (VR) for pancreatic cancer (PC) is occurring more commonly. Few studies have examined the long-term patency of the superior mesenteric-portal vein confluence following reconstruction. MethodsFrom 2007 to 2013, patients who underwent pancreatic resection with VR for PC were classified by type of reconstruction. Patency of VR was assessed using surveillance computed tomographic imaging obtained from date of surgery to last follow-up. ResultsVR was performed in 43 patients and included the following: tangential resection with primary repair (7, 16 %) or saphenous vein patch (9, 21 %); segmental resection with splenic vein division and either primary anastomosis (10, 23 %) or internal jugular vein interposition (8, 19 %); or segmental resection with splenic vein preservation and either primary anastomosis (3, 7 %) or interposition grafting (6, 14 %). All patients were instructed to take aspirin after surgery; low molecular weight heparin was not routinely used. An occluded VR was found in four (9 %) of the 43 patients at a median follow-up of 13 months; median time to detection of thrombosis in the four patients was 72 days (range 16–238). ConclusionsPancreatectomy with VR can be performed with high patency rates. The optimal postoperative pharmacologic therapy to prevent thrombosis requires further investigation.

Use of the Left Renal Vein as a Practical Conduit in Superior Mesenteric Vein Reconstruction

Invasion of the superior mesenteric vein (SMV) or superior mesenteric-portal vein (SMPV) confluence, in pancreatic adenocarcinoma of the head and uncinate process, is the most common unexpected finding at the time of pancreaticoduodenectomy. Resection of the SMV or SMPV with reconstruction using autologous and synthetic conduits is well established. We describe the use of the left renal vein as a practical, easy, and durable alternative as an interposition graft after pancreaticoduodenectomy with en bloc segmental resection of the SMV. Involvement of the SMV by a pancreatic mass is resected en bloc with a standard pancreaticoduodenectomy. The left renal vein is then harvested from the junction with the IVC and proximal to the adrenal vein. This is then used as a vein graft for the resected portion of the SMV. Complete pancreatic cancer resection with grossly tumor-free margins provides the only chance for long-term cure. Isolated tumor involvement of the SMV or SMPV confluence is not associated with histopathological variables predictive of a poor prognosis and appears to be a function of tumor location rather than an indicator of biological aggressiveness. Recurrence and long-term survival following pancreaticoduodenectomy with and without vein resection are equivalent, provided grossly negative margins are achieved. We describe the use of the left renal vein as a technically feasible, easy, and durable conduit for SMV reconstruction in pancreaticoduodenectomy. After resection of the left renal vein, significant increase in postoperative serum creatinine has not been reported; collateral flow has been confirmed by radiological methods and severe renal dysfunction perioperatively, postoperatively, and during long-term follow-up has not been observed.

P179: The left renal vein as a practical conduit for superior mesenteric vein reconstruction

Background: Invasion of the superior mesenteric vein (SMV) or superior mesenteric-portal vein (SMPV) confluence in pancreatic adenocarcinoma of the head and uncinate process is a common finding at the time of pancreaticoduodenectomy. Recurrence and long-term survival following pancreaticoduodenectomy with and without vein resection are equivalent, provided grossly negative margins are achieved. Resection of the SMV or SMPV with reconstruction using autologous and synthetic conduits is well described. However, reconstruction with autologous vein can be laborious requiring harvest of internal jugular vein or paneling of saphenous vein, and synthetic reconstructions present a greater risk of infection. Here we describe the use of the left renal vein as a practical interposition graft after pancreaticoduodenectomy with en bloc segmental resection of the SMV. Methods: A 54 year old gentleman with a pancreatic head mass was found intraoperatively to be adherent to the SMV. A pancreaticoduodenectomy with en bloc right hemicolectomy and segmental resection of 3 cm of the SMV was performed. The left renal vein was harvested from the IVC to the confluence of the left adrenal and gonadal vein. The left renal vein was then used as a segmental interposition graft to reconstruct the SMV. Results: The patient was discharged home after 10 days postoperative stay with all drains removed prior to discharge. Pathology revealed a moderately differentiated pancreatic adenocarcinoma. All margins were tumor free. Metastasis was found in 1 of 37 nodes examined. BUN and creatinine were 6 and 0.6 at the time of discharge. Postoperative CT with contrast demonstrated a normal left kidney, and duplex demonstrated normal flow in the distal left renal vein. Conclusion: The left renal vein provides a technically feasible and practical conduit for SMV reconstruction in pancreaticoduodenectomy. With preservation of the gonadal and renal-azygous venous drainage no adverse effect on kidney function are seen. En bloc segmental resection of the SMV or SMPV confluence can be performed safely with no increase in perioperative morbidity or mortality rate compared with standard pancreaticoduodenectomy.

Duodenopancreatectomía cefálica con reconstrucción venosa portomesentérica. Aspectos técnicos

Cephalic pancreaticoduodenectomy (CPD) with mesentericoportal venous resection increases the resectability rate of pancreatic tumors. When performed in selected patients and by experienced surgical teams, this technique shows the same long-term rates of morbidity, mortality and survival as CPD without vascular resection, provided that negative surgical margins are obtained. This procedure is contraindicated by complete thrombosis of the portal or superior mesenteric veins, invasion of the superior mesenteric artery or celiac trunk, and distant or periaortic lymph node involvement. Venous reconstruction can be performed through lateral suture, termino-terminal anastomosis, or by graft placement. We believe that intercalation of the autologous internal jugular vein facilitates resection and minimizes phenomena of venous stasis. We present a case of adenocarcinoma of the pancreatic head infiltrating the superior mesenteric-portal vein confluence that underwent surgery in our hospital. CPD with mesentericoportal venous resection and reconstruction using autologous internal jugular vein were performed. The most important technical features are discussed.

Survival following pancreaticoduodenectomy with resection of the superior mesenteric-portal vein confluence for adenocarcinoma of the pancreatic head.

The survival of patients who underwent pancreaticoduodenectomy with or without en bloc resection of the superior mesenteric-portal vein (SMPV) confluence for adenocarcinoma of the pancreatic head was compared. To be considered for surgery, patients were required to fulfil the following computed tomography criteria for resectability: (1) absence of extrapancreatic disease, (2) no evidence of tumour extension to the superior mesenteric artery (SMA) or coeliac axis, and (3) a patent SMPV confluence. Tumour adherence to the superior mesenteric vein (SMV) or SMPV confluence was assessed at operation and en bloc venous resection was performed when necessary to achieve complete tumour extirpation. Seventy-five consecutive patients underwent pancreaticoduodenectomy, 44 without venous resection and 31 with en bloc resection of the SMPV confluence. There were no perioperative deaths in either group; late (more than 6 months) occlusion of the reconstructed SMPV confluence contributed to the death of two patients. Median survival in the 31 patients who required venous resection at the time of pancreaticoduodenectomy was 22 months, and that for the 44 control patients was 20 months (P = 0.25). Patients with adenocarcinoma of the pancreatic head who require venous resection during pancreaticoduodenectomy for isolated tumour extension to the SMV or SMPV confluence (in the absence of tumour extension to the SMA or coeliac axis) have a duration of survival no different from that of patients who undergo standard pancreaticoduodenectomy. These data suggest that venous involvement is a function of tumour location rather than an indicator of aggressive tumour biology.

Primary pancreatic lymphoma

Background: Primary pancreatic lymphoma is a rare neoplasm that may be confused with pancreatic adenocarcinoma. We reviewed retrospectively our contemporary experience with this disease to define more clearly the clinical presentation of this disease and the proper role for percutaneous fine-needle aspiration biopsy and surgery. Methods: From 1980 to 1995, 11 patients with primary pancreatic lymphoma were treated at The University of Texas M. D. Anderson Cancer Center. Patient demographics, radiographic studies, fine-needle aspiration biopsy findings, operative procedures, and other treatment data were reviewed. Results: The median age of the 11 patients was 64 years (range, 37 to 74 years). Abdominal pain was the most common symptom at presentation. Five patients had an elevated lactate dehydrogenase level, and only two patients had hyperbilirubinemia. Computed tomography scan demonstrated encasement of the superior mesenteric artery or superior mesenteric–portal vein confluence in six patients. Seven patients underwent computed tomography–guided fine-needle aspiration; five had findings of lymphoma. Two patients underwent distal pancreatectomy and splenectomy, and one underwent pancreaticoduodenectomy. All patients were treated with combination chemotherapy, and seven received radiotherapy. Only two patients have died of disease (12 and 16 months after diagnosis) at a median follow-up time of 67 months. Conclusions: In the majority of patients, pancreatic lymphoma can be distinguished from pancreatic adenocarcinoma on the basis of symptoms, laboratory and radiographic findings, and fine-needle aspiration biopsy results. Once the diagnosis is established, all patients should undergo systemic chemotherapy followed by involved-field radiotherapy if the tumor has not been resected. (Surgery 1998;123:382-90.)

Primary pancreatic lymphoma

Background: Primary pancreatic lymphoma is a rare neoplasm that may be confused with pancreatic adenocarcinoma. We reviewed retrospectively our contemporary experience with this disease to define more clearly the clinical presentation of this disease and the proper role for percutaneous fine-needle aspiration biopsy and surgery. Methods: From 1980 to 1995, 11 patients with primary pancreatic lymphoma were treated at The University of Texas M. D. Anderson Cancer Center. Patient demographics, radiographic studies, fine-needle aspiration biopsy findings, operative procedures, and other treatment data were reviewed. Results: The median age of the 11 patients was 64 years (range, 37 to 74 years). Abdominal pain was the most common symptom at presentation. Five patients had an elevated lactate dehydrogenase level, and only two patients had hyperbilirubinemia. Computed tomography scan demonstrated encasement of the superior mesenteric artery or superior mesenteric–portal vein confluence in six patients. Seven patients underwent computed tomography–guided fine-needle aspiration; five had findings of lymphoma. Two patients underwent distal pancreatectomy and splenectomy, and one underwent pancreaticoduodenectomy. All patients were treated with combination chemotherapy, and seven received radiotherapy. Only two patients have died of disease (12 and 16 months after diagnosis) at a median follow-up time of 67 months. Conclusions: In the majority of patients, pancreatic lymphoma can be distinguished from pancreatic adenocarcinoma on the basis of symptoms, laboratory and radiographic findings, and fine-needle aspiration biopsy results. Once the diagnosis is established, all patients should undergo systemic chemotherapy followed by involved-field radiotherapy if the tumor has not been resected. (Surgery 1998;123:382-90.)

Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group.

Tumor invasion of the superior mesenteric-portal vein (SMPV) confluence is often considered a contraindication to pancreaticoduodenectomy for patients with malignant tumors of the pancreas or periampullary region. The authors sought to determine whether pancreaticoduodenectomy with en bloc resection of the SMPV confluence could be safely performed and whether tumors involving the SMPV confluence were associated with pathologic parameters suggesting poor prognosis. Several centers have reported high rates of retroperitoneal margin positivity after pancreaticoduodenectomy for tumors of the pancreatic head and periampullary region. Positive-margin or incomplete resection is associated with early tumor recurrence and no survival benefit compared with palliative therapy. Tumor adherence to the lateral of posterior wall of the SMPV confluence often represents the only barrier to complete tumor resection at the time of pancreaticoduodenectomy. Data on all patients undergoing pancreaticoduodenectomy for adenocarcinoma of the pancreas or periampullary region over a 3.5-year period were entered prospectively in a pancreatic tumor database. To be considered for surgery, patients were required to fulfill the following computed tomography criteria for resectability: 1) the absence of extrapancreatic disease, 2) no tumor encasement of the superior mesenteric artery or celiac axis, and 3) a patent SMPV confluence. Tumor adherence to the superior mesenteric vein or SMPV confluence was assessed intraoperatively, and en bloc venous resection was performed when necessary to achieve complete tumor extirpation. Data on operative characteristics, morbidity, mortality, tumor size, nodal metastases, margin positivity, perineural invasion, and tumor DNA content were compared for patients who did and did not receive venous resection. Fifty-nine patients underwent pancreaticoduodenectomy, 36 without venous resection and 23 with en bloc resection of the SMPV confluence. No differences in median hospital stay, morbidity, mortality, tumor size, margin positivity, nodal positivity, or tumor DNA content were observed between groups. When necessary, segmental resection of the SMPV confluence may be performed safely during pancreaticoduodenectomy for periampullary malignant tumors. Tumors invading the SMPV confluence are not associated with histologic parameters suggesting a poor prognosis. Our data suggest that venous involvement is a function of tumor location rather than an indicator of aggressive tumor biology.

Pancreatic malignancy involving the superior mesenteric-portal vein confluence is not a contraindication to pancreaticoduodenectomy

Pancreatic malignancy involving the superior mesenteric-portal vein confluence is not a contraindication to pancreaticoduodenectomy