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Bernhardt M, Rühlmann F, Azizian A, Kölling MA, Beißbarth T, Grade M, König AO, Ghadimi M, Gaedcke J. Impact of Portal Vein Resection (PVR) in Patients Who Underwent Curative Intended Pancreatic Head Resection. Biomedicines 2023; 11:3025. [PMID: 38002027 PMCID: PMC10669675 DOI: 10.3390/biomedicines11113025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/25/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
The oncological impact of portal vein resection (PVR) in pancreatic cancer surgery remains contradictory. Different variables might have an impact on the outcome. The aim of the present study is the retrospective assessment of the frequency of PVR, histological confirmation of tumor infiltration, and comparison of oncological outcomes in PVR patients. We retrieved n = 90 patients from a prospectively collected data bank who underwent pancreas surgery between 2012 and 2019 at the University Medical Centre Göttingen (Germany) and showed a histologically confirmed pancreatic ductal adenocarcinoma (PDAC). While 50 patients (55.6%) underwent pancreatic resection combined with PVR, 40 patients (44.4%) received standard pancreatic surgery. Patients with distal pancreatectomy or a tumor other than PDAC were excluded. PVR was performed either as local excision or circular resection of the portal vein. Clinical/patient data and follow-ups were retrieved. The median follow-up period was 20.5 months. Regarding the oncological outcome, a statistically poorer CSS (p = 0.04) was observed in PVR patients. There was no difference (p = 0.18) in patients' outcomes between tangential and complete PVR, while n = 21 (42% of PVR patients) showed portal vein infiltration. The correlation between performed PVR and resection status was statistically significant: 48.6% of PVR patients achieved R0 resections compared to 75% in non-PVR patients (p = 0.03). Patients who underwent PDAC surgery with PVR show a significantly poorer outcome regardless of PVR type. Tumor size and R-status remain two important variables significantly associated with outcome. Since there is a lack of standardization for the indication of PVR, it remains unknown if the need for resection of vein structures during pancreatic resection represents the biological aggressiveness of the tumor or is biased by the experience of the surgeon.
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Affiliation(s)
- Markus Bernhardt
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Felix Rühlmann
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Azadeh Azizian
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Max Alexander Kölling
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Tim Beißbarth
- Institute of Medical Bioinformatics, University Medical Center, D-37075 Goettingen, Germany
| | - Marian Grade
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Alexander Otto König
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Center, D-37075 Goettingen, Germany
| | - Michael Ghadimi
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
| | - Jochen Gaedcke
- Department of General, Visceral and Pediatric Surgery, University Medical Center, D-37075 Goettingen, Germany (M.A.K.)
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Wang YL, Zhang HW, Lin F. Computed tomography combined with gastroscopy for assessment of pancreatic segmental portal hypertension. World J Clin Cases 2022; 10:8568-8577. [PMID: 36157801 PMCID: PMC9453378 DOI: 10.12998/wjcc.v10.i24.8568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 05/13/2022] [Accepted: 07/22/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Pancreatic segmental portal hypertension (PSPH) is the only type of portal hypertension that can be completely cured. However, it can easily cause varicose veins in the esophagus and stomach and hemorrhage in the digestive tract.
AIM To explore the application of computed tomography (CT) to examine the characteristics of PSPH and assess the risk level.
METHODS This was a retrospective analysis of CT images of 22 patients diagnosed with PSPH at our center. Spearman correlation analysis was performed using the range of esophageal and gastric varices (measured by the vertical gastric wall), the ratio of the width of the splenic portal vein to that of the compression site (S/C ratio), the degree of splenomegaly, and the stage determined by gastroscopy. This study examined whether patients experienced gastrointestinal bleeding within 2 wk and combined CT and gastroscopy to explore the connection between bleeding and CT findings.
RESULTS The range of esophageal and gastric varices showed the best correlation in the diagnosis of PSPH (P < 0.001), and the S/C ratio (P = 0.007) was correlated with the degree of splenomegaly (P = 0.021) and PSPH (P < 0.05). This study revealed that male patients were more likely than females to progress to grade 2 or grade 3 as determined by gastroscopy. CT demonstrated excellent performance, with an area under the curve of 0.879.
CONCLUSION CT can be used to effectively analyze the imaging signs of PSPH, and CT combined with gastroscopy can effectively predict the risk level of gastrointestinal bleeding.
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Affiliation(s)
- Yu-Li Wang
- Department of Radiology, The First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen 518035, Guangdong Province, China
| | - Han-Wen Zhang
- Department of Radiology, The First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen 518035, Guangdong Province, China
| | - Fan Lin
- Department of Radiology, The First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen Second People’s Hospital, Shenzhen 518035, Guangdong Province, China
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Gyoten K, Mizuno S, Nagata M, Ito T, Hayasaki A, Murata Y, Tanemura A, Kuriyama N, Kishiwada M, Sakurai H. Concomitant splenic artery ligation has no preventive effect on left‐sided portal hypertension following pancreaticoduodenectomy with the resection of the portal and superior mesenteric vein confluence for pancreatic ductal adenocarcinoma. Ann Gastroenterol Surg 2022; 6:420-429. [PMID: 35634189 PMCID: PMC9130910 DOI: 10.1002/ags3.12545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/30/2021] [Accepted: 12/27/2021] [Indexed: 11/13/2022] Open
Abstract
Background Left‐sided portal hypertension (LSPH) caused by splenic vein (SV) division in pancreaticoduodenectomy (PD) with portal vein (PV) resection remains challenging. The current study aimed to investigate the efficacy of splenic artery (SA) ligation in preventing LSPH. Methods One‐hundred thirty patients who underwent PD with PV resection for pancreatic ductal adenocarcinoma were classified into SV and SA preservation (SVP, n = 30), SV resection and SA preservation (SVR, n = 59), and SV resection and SA ligation (SAL, n = 41). The postoperative incidence of LSPH was assessed. Results The incidence of variceal formation in SVP, SVR, and SAL were 4.8%, 53.2%, and 46.4% at 3 mo, 13.0%, 71.2%, and 62.5% at 6 mo, and 25.0%, 87.5%, and 87.1% at 12 mo, respectively. The rate was significantly higher in SVR at 3 and 6 mo (P = .001 and P < .001, respectively) and in SVR and SAL (P < .001) at 12 mo. Variceal hemorrhage occurred only in SVR (n = 4). The platelet count ratio at 3, 6, and 12 mo began to significantly decrease from 3 mo in SVR (0.77, 0.67, and 0.60, respectively; P < .001) and 6 mo in SAL (0.91, 0.73, and 0.69, respectively; P < .001). The spleen volume ratio also showed significant increase from 3 mo in SVR (1.24, 1.34, and 1.42, respectively; P < .001) and 6 mo in SAL (1.31, 1.32, and 1.34, respectively; P < .001). SVR and SAL were significant risk factors for variceal formation at 12 mo (odds ratio, 21.0 and 20.3, respectively). Conclusion In PD with PV resection, SAL delayed LSPH but could not prevent its occurrence.
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Affiliation(s)
- Kazuyuki Gyoten
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
| | - Motonori Nagata
- Department of Radiology Mie University School of MedicineMie University School of Medicine Tsu Japan
| | - Takahiro Ito
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
| | - Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
| | - Hiroyuki Sakurai
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
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Oba A, Kato T, Inoue Y, Wu YHA, Ono Y, Sato T, Ito H, Saiura A, Takahashi Y. Extent of venous resection during pancreatectomy-finding the balance of technical possibility and feasibility. J Gastrointest Oncol 2021; 12:2495-2502. [PMID: 34790410 DOI: 10.21037/jgo-21-129] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 07/23/2021] [Indexed: 11/06/2022] Open
Abstract
The improvement of effective multidrug agents has allowed more patients to undergo resection for pancreatic cancer (PC). In the conversion cases of initially unresectable PC after induction chemotherapy, pancreatic surgeons often encounter challenging vein resections cases such as those of long-segment portal vein (PV)/superior mesenteric vein (SMV) encasement or occlusion of the distal (caudal) SMV. Given the lack of consensus for the optimal approach for major vein resections and reconstructions in these situations, this review summarizes the literature on this topic and provides the best currently available approaches for challenging vein reconstruction cases. For long-segment PV/SMV encasement, tips for direct end-to-end anastomosis without grafts and the splenic vein (SpV) reconstruction to prevent left-side portal hypertension will be introduced. For distal SMV encasement, several bypass techniques to deal with collateralizations will be introduced. Even though some high-volume PC centers are obtaining favorable outcomes for challenging vein resection cases, existing evidence on this topic is limited. It is essential to organize the well-designed international multicenter studies for the small population of challenging vein resection cases. With the emergence of effective chemotherapies, the number of PC patients who can undergo curative resection is increasing. Achieving more successful vessel resection and reconstruction in the treatment of PC is a common goal that pancreatic surgeons should focus on together.
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Affiliation(s)
- Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomotaka Kato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Y H Andrew Wu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Ono Y, Inoue Y, Kato T, Matsueda K, Oba A, Sato T, Ito H, Saiura A, Takahashi Y. Sinistral Portal Hypertension after Pancreaticoduodenectomy with Splenic Vein Resection: Pathogenesis and Its Prevention. Cancers (Basel) 2021; 13:cancers13215334. [PMID: 34771498 PMCID: PMC8582504 DOI: 10.3390/cancers13215334] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 11/16/2022] Open
Abstract
To achieve curative resection for pancreatic cancer during pancreaticoduodenectomy (PD), extensive portal vein (PV) resection, including porto-mesenterico-splenic confluence (PMSC), may sometimes be necessary if the tumor is close to the portal venous system. Recently, this extended resection has been widely accepted in high-volume centers for pancreatic resection due to its favorable outcomes compared with non-operative treatment. However, in patients with long-term survival, sinistral portal hypertension (SPH) occurs as a late-onset postoperative complication. These patients present gastrointestinal varices due to congested venous flow from the spleen, which may cause critical variceal bleeding. Since the prognosis of patients with pancreatic cancer has improved, owing to the development of chemotherapy and surgical techniques, SPH is no longer a negligible matter in the field of pancreatic cancer surgery. This review clarifies the pathogenesis and frequency of SPH after PD through PMSC resection and discusses its prediction and prevention.
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Affiliation(s)
- Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
- Correspondence: ; Tel.: +81-3-3520-0111
| | - Tomotaka Kato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Kiyoshi Matsueda
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan;
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, School of Medicine, Juntendo University, Tokyo 113-0033, Japan;
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
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Mehrabi A, Loos M, Ramouz A, Dooghaie Moghadam A, Probst P, Nickel F, Schaible A, Mieth M, Hackert T, Büchler MW. Gastric venous reconstruction to reduce gastric venous congestion after total pancreatectomy: study protocol of a single-centre prospective non-randomised observational study (IDEAL Phase 2A) - GENDER study (Gastric v ENous Drainag E Reconstruction). BMJ Open 2021; 11:e052745. [PMID: 34675020 PMCID: PMC8532556 DOI: 10.1136/bmjopen-2021-052745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Total pancreatoduodenectomy (TP) is the standard surgical approach for treating extended pancreas tumours. If TP is performed with splenectomy, the left gastric vein (LGV) sometimes needs to be sacrificed for oncological or technical reasons, which can result in gastric venous congestion (GVC). GVC can lead to gastric venous infarction, which in turn causes gastric perforation with abdominal sepsis. To avoid gastric venous infarction, partial or total gastrectomy is usually performed if GVC occurs after TP. However, gastrectomy can be avoided by reconstructing the gastric venous outflow to overcome GVC and avoid gastric venous infarction. The current study aims to assess the role of gastric venous outflow reconstruction to prevent GVC after TP and avoid gastrectomy. METHODS AND ANALYSIS In the current single-centre observational pilot study, 20 patients will be assigned to study after intraoperative evaluation of gastric venous drainage after LGV resection during TP. During surgery, on-site evaluation by the surgeon, endoscopic examination, indocyanine green, gastric venous drainage flowmetry and spectral analysis will be performed. Postoperatively, patients will receive standard post-TP care and treatment. During hospitalisation, endoscopic examination with indocyanine green will be performed on the 1st, 3rd and 7th postoperative day to evaluate gastric ischaemia. Ischaemia markers will be evaluated daily after surgery. After discharge, patients will be followed-up for 90 days, during which mortality and morbidities will be recorded. The main endpoints of the study will include, rate of GVC, rate of gastric ischaemia, rate of postpancreatectomy gastrectomy, rate of reoperation, morbidity and mortality. ETHICS AND DISSEMINATION The study protocol has been reviewed and approved by the Ethics Committee of the University of Heidelberg. The results will be actively disseminated through peer-reviewed journals and conference presentations, and are expected in 2022. TRIAL REGISTRATION NUMBER NCT04850430.
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Affiliation(s)
- Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Martin Loos
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Ali Ramouz
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Arash Dooghaie Moghadam
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), Heidelberg University, Heidelberg, Germany
| | - Felix Nickel
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Anja Schaible
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Markus Mieth
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
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Splenorenal shunt for reconstruction of the gastric and splenic venous drainage during pancreatoduodenectomy with resection of the portal venous confluence. Langenbecks Arch Surg 2021; 406:2535-2543. [PMID: 34618219 PMCID: PMC8578106 DOI: 10.1007/s00423-021-02318-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/25/2021] [Indexed: 10/25/2022]
Abstract
BACKGROUND Resection of the portal venous confluence is frequently necessary for radical resection during pancreatoduodenectomy for cancer. However, ligation of the splenic vein can cause serious postoperative complications such as gastric/splenic venous congestion and left-sided portal hypertension. A splenorenal shunt (SRS) can maintain gastric and splenic venous drainage and mitigate these complications. PURPOSE This study describes the surgical technique, postoperative course, and surgical outcomes of SRS after pancreatoduodenectomy. METHODS Ten patients who underwent pancreatoduodenectomy and SRS between September 2017 and April 2019 were evaluated. After resection an end-to-side anastomosis between the splenic vein and the left renal vein was performed. Postoperative shunt patency, splenic volume, and any SRS-related complications were recorded. RESULTS The rates of short- and long-term shunt patency were 100% and 60%, respectively. No procedure-associated complications were observed. No signs of left-sided portal hypertension, such as gastrointestinal bleeding or splenomegaly, and no gastric/splenic ischemia were observed in patients after SRS. CONCLUSION SRS is a safe and effective measure to mitigate gastric congestion and left-sided portal hypertension after pancreatoduodenectomy with compromised gastric venous drainage after resection of the portal venous confluence.
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Zhang X, Wu Q, Fan H, He Q, Lang R. Reconstructing spleno-mesenterico-portal cofluence by bifurcated allogeneic vein in local advanced pancreatic cancer-a feasible method to avoid left-sided portal hypertension. Cancer Med 2021; 10:5448-5455. [PMID: 34190423 PMCID: PMC8366088 DOI: 10.1002/cam4.4093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 05/07/2021] [Accepted: 06/06/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Left-sided portal hypertension is usually found in patients undergoing pancreaticoduodenectomy (PD) with spleno-mesenterico-portal (S-M-P) confluence resection. This study is to explore the outcomes of S-M-P confluence reconstruction after resection by using bifurcated allogeneic vein. METHODS Clinicopathologic data of patients who underwent extensive PD with S-M-P confluence resection for carcinoma of pancreatic head/uncinate process in our hospital between December 2011 and August 2018 were retrospectively reviewed and clinical outcomes of vein reconstruction after resection were analyzed. RESULTS Of the 37 patients enrolled, S-M-P reconstruction by bifurcated allogeneic vein was performed in 24 cases (group 1) and simply splenic vein ligation in 13 cases (group 2). Items including pathological results, blood loss, and complications were comparable between the two groups, operation time was longer in group 1 (573.8 vs. 479.2 min, p = 0.018). Significantly decreased platelet count (205.9 vs. 133.1 × 109 /L, p = 0.001) and increased splenic volume (270.9 vs. 452.2 ml, p < 0.001) were observed in group 2 at 6 months after operation. The mean splenic hypertrophy ratio was 1.06 in group 1 and 1.63 in group 2, respectively (p < 0.001). There were four patients with varices were found in group 2, none in group 1. CONCLUSIONS Without increased complications, reconstructing S-M-P confluence by bifurcated allogeneic vein after resection may help to avoid left-sided portal hypertension.
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Affiliation(s)
- Xingmao Zhang
- Department of hepatobiliary surgeryBeijing Chaoyang HospitalCapital Medical UniversityBeijingChina
| | - Qiao Wu
- Department of hepatobiliary surgeryBeijing Chaoyang HospitalCapital Medical UniversityBeijingChina
| | - Hua Fan
- Department of hepatobiliary surgeryBeijing Chaoyang HospitalCapital Medical UniversityBeijingChina
| | - Qiang He
- Department of hepatobiliary surgeryBeijing Chaoyang HospitalCapital Medical UniversityBeijingChina
| | - Ren Lang
- Department of hepatobiliary surgeryBeijing Chaoyang HospitalCapital Medical UniversityBeijingChina
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Ono Y, Takahashi Y, Tanaka M, Matsueda K, Hiratsuka M, Inoue Y, Ito H, Saiura A. Sinistral Portal Hypertension Prediction During Pancreatoduodenectomy With Splenic Vein Resection. J Surg Res 2020; 259:509-515. [PMID: 33160633 DOI: 10.1016/j.jss.2020.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 09/23/2020] [Accepted: 10/12/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy with porto-mesenterico-splenic confluence resection can cause sinistral portal hypertension (SPH), which may lead to gastrointestinal bleeding. Nevertheless, it remains difficult to predict SPH development during surgery. The aim of this study is to assess the feasibility of measuring splenic vein (SV) pressure to predict SPH. METHODS The patients who underwent pancreaticoduodenectomy with porto-mesenterico-splenic confluence resection between January 2016 and December 2017 were included in this study. SV pressure was measured before SV clamping (SVP1) and after SV clamping (SVP2). SPH was defined as varicose vein formation detected by follow-up computed tomography. Incidence of SPH was assessed in patients who had no SV drainage after surgery. RESULTS SV pressure was measured in 41 patients. Among them, 24 had no SV drainage (13 patients had occluded SV reconstruction, and 11 had SV ligation without an attempt at reconstruction) and were included for the analysis. SPH was observed in 16 of 24 patients (67%). The median ΔSVP (SPV2-SVP1) in patients with SPH was higher than that in patients without SPH (13.5 mmHg versus 7.5 mmHg, P = 0.0237). Most patients with SVP2 >20 mmHg (12/14 [86%]) or ΔSVP >10 mmHg (10/11 [91%]) developed SPH. CONCLUSIONS For the patients with SV resection, high SV pressure after clamping (≥20 mmHg) and a large SV pressure difference (≥10 mmHg) before and after clamping are feasible indication criteria for SV reconstruction to prevent SPH.
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Affiliation(s)
- Yoshihiro Ono
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Takahashi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masayuki Tanaka
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kiyoshi Matsueda
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Makiko Hiratsuka
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yosuke Inoue
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hiromichi Ito
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akio Saiura
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
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10
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Yu X, Bai X, Li Q, Gao S, Lou J, Que R, Yadav DK, Zhang Y, Li H, Liang T. Role of Collateral Venous Circulation in Prevention of Sinistral Portal Hypertension After Superior Mesenteric-Portal Vein Confluence Resection during Pancreaticoduodenectomy: a Single-Center Experience. J Gastrointest Surg 2020; 24:2054-2061. [PMID: 31468329 DOI: 10.1007/s11605-019-04365-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 08/12/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The 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. METHODS Patients 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. RESULTS In 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. CONCLUSION Although subclinical SPH developed after SV ligation, postoperative gastrointestinal bleeding was uncommon.
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Affiliation(s)
- Xiazhen Yu
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, Zhejiang Province, China
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, Zhejiang Province, China
| | - Qinghai Li
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shunliang Gao
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, Zhejiang Province, China
| | - Jianying Lou
- Department of Hepatobiliary and Pancreatic Surgery, School of Medicine, The Second Affiliated Hospital of Zhejiang University, Hangzhou, Zhejiang, China
| | - Risheng Que
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, Zhejiang Province, China
| | - Dipesh Kumar Yadav
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, Zhejiang Province, China
| | - Yun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, Zhejiang Province, China
| | - Haijun Li
- Department of General Surgery, Shenzhen Luohu People's Hospital, Shenzhen, Guangdong, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, 310003, People's Republic of China. .,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, China. .,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, Zhejiang Province, China.
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11
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Petrucciani N, Debs T, Rosso E, Addeo P, Antolino L, Magistri P, Gugenheim J, Ben Amor I, Aurello P, D'Angelo F, Nigri G, Di Benedetto F, Iannelli A, Ramacciato G. Left-sided portal hypertension after pancreatoduodenectomy with resection of the portal/superior mesenteric vein confluence. Results of a systematic review. Surgery 2020; 168:434-439. [PMID: 32600882 DOI: 10.1016/j.surg.2020.04.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/08/2020] [Accepted: 04/12/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatoduodenectomy with synchronous resection of the portal vein/superior mesenteric vein confluence may result in the development of left-sided portal hypertension. Left-sided portal hypertension presents with splenomegaly and varices and may cause severe gastrointestinal bleeding. The aim of the study is to review the incidence, treatment, and preventive strategies of left-sided portal hypertension. METHODS A systematic literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to identify all studies published up to September 30, 2019 reporting data on patients with left-sided portal hypertension after pancreatoduodenectomy with venous resection. RESULTS Eight articles including 829 patients were retrieved. Left-sided portal hypertension occurred in 7.7% of patients who had splenic vein preservation and 29.4% of those having splenic vein ligation. Fourteen cases of gastrointestinal bleeding owing to left-sided portal hypertension were reported at a mean interval of 28 months from pancreatoduodenectomy. Related mortality at 1 month was 7.1%. Treatment of left-sided portal hypertension consisted of splenectomy in 3 cases (21%) and colectomy in 1 (7%) case, whereas radiologic, endoscopic procedures or conservative treatments were effective in the other cases (71%). CONCLUSION Left-sided portal hypertension represents a potentially severe complication of pancreatoduodenectomy with venous resection occurring at greater incidence when the splenic vein is ligated and not reimplanted. Left-sided portal hypertension-related gastrointestinal bleeding although rare can be managed depending on the situation by endoscopic, radiologic procedures or operative intervention with low related mortality.
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Affiliation(s)
- Niccolo Petrucciani
- Department of Medical and Surgical Sciences and Translational Medicine, St Andrea University Hospital, Sapienza University, Rome, Italy.
| | - Tarek Debs
- Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
| | - Edoardo Rosso
- Départment de Chirurgie Générale, Centre Hospitalier de Luxembourg, Luxembourg City, Luxembourg
| | - Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, France
| | - Laura Antolino
- Department of Medical and Surgical Sciences and Translational Medicine, St Andrea University Hospital, Sapienza University, Rome, Italy
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Italy
| | - Jean Gugenheim
- Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
| | - Imed Ben Amor
- Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France
| | - Paolo Aurello
- Department of Medical and Surgical Sciences and Translational Medicine, St Andrea University Hospital, Sapienza University, Rome, Italy
| | - Francesco D'Angelo
- Department of Medical and Surgical Sciences and Translational Medicine, St Andrea University Hospital, Sapienza University, Rome, Italy
| | - Giuseppe Nigri
- Department of Medical and Surgical Sciences and Translational Medicine, St Andrea University Hospital, Sapienza University, Rome, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Italy
| | - Antonio Iannelli
- Digestive Surgery and Liver Transplantation Unit, Archet 2 Hospital, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, France; INSERM U1065, Mediterranean Center for Molecular Medicine, Team 8 Hepatic Complications of Obesity, Nice, France
| | - Giovanni Ramacciato
- Department of Medical and Surgical Sciences and Translational Medicine, St Andrea University Hospital, Sapienza University, Rome, Italy
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12
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Addeo P, De Mathelin P, Averous G, Tambou-Nguipi M, Terrone A, Schaaf C, Dufour P, Bachellier P. The left splenorenal venous shunt decreases clinical signs of sinistral portal hypertension associated with splenic vein ligation during pancreaticoduodenectomy with venous resection. Surgery 2020; 168:267-273. [PMID: 32536489 DOI: 10.1016/j.surg.2020.04.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/11/2020] [Accepted: 04/16/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The ligation of the splenic vein during pancreaticoduodenectomy with synchronous resection of the spleno-mesenteric-portal venous confluence has been associated with the development of left portal hypertension despite preservation of the natural confluence with the inferior mesenteric vein. This study aimed to assess whether a left splenorenal venous shunt might mitigate clinical signs of left portal hypertension associated with splenic vein ligation. METHODS We retrospectively evaluated the presence of left portal hypertension based on biologic and radiologic parameters in patients undergoing pancreaticoduodenectomy with synchronous resection of the spleno-mesentericoportal confluence between January 1, 2012, and December 31, 2018. We compared several parameters between patients undergoing splenic vein ligation with preservation of the inferior mesenteric vein confluence and a splenorenal venous shunt: the early and late spleen volumes and spleen volume ratios, an early and late platelet count, the presence of thrombocytopenia, the presence of varices, and digestive bleeding in the long-term. RESULTS There were 114 consecutive patients: 36 with splenic vein ligation and 78 with splenorenal venous shunt. All had a pancreaticogastrostomy. Patients with splenic vein ligation had a comparable baseline and early and late platelet counts. Although baseline splenic volumes were comparable between the 2 groups (242 ± 115 mL vs 261 ± 138 mL; P = .51), patients with splenic vein ligation showed a statistically significant greater splenic volume beyond the 6th postoperative months (334 ± 160 mL vs 241 ± 111 mL; P = .004), higher early and late spleen volume ratios (1.42 ± 0.67 vs 1.10 ± 0.3; P = .001 and 1.38 ± 0.38 vs 0.97 ± 0.4; P = .0001) than patients with splenorenal venous shunt. Splenic vein ligation was also associated with a higher rate of varices (81% vs 50%; P = .002) and more frequent varices with a caliber greater than 1 cm (57% vs 36%; P = .05) and more colonic varices (33% vs 12%; P = .01). Only 1 patient had long-term digestive bleeding (splenic vein ligation). CONCLUSION The left splenorenal shunt decreases clinical signs of left portal hypertension associated with splenic vein ligation and inferior mesenteric vein confluence preservation.
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Affiliation(s)
- Pietro Addeo
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France.
| | - Pierre De Mathelin
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Gerlinde Averous
- Department of Pathology, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Marlene Tambou-Nguipi
- Department of Gastroenterology-Section of Oncology, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Alfonso Terrone
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Caroline Schaaf
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Patrick Dufour
- Department of Gastroenterology-Section of Oncology, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
| | - Philippe Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, Pôle des Pathologies Digestives, Hépatiques et de la Transplantation, Hôpital de Hautepierre-Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Strasbourg, France
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13
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Relationship Between Postoperative Pain and Overall 30-Day Complications in a Broad Surgical Population: An Observational Study. Ann Surg 2020; 269:856-865. [PMID: 29135493 DOI: 10.1097/sla.0000000000002583] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The aim of this study was to establish the relationship between postoperative pain and 30-day postoperative complications. BACKGROUND Only scarce data are available on the association between postoperative pain and a broad range of postoperative complications in a large heterogeneous surgical population. METHODS Having postoperative pain was assessed in 2 ways: the movement-evoked pain score on the Numerical Rating Scale (NRS-MEP) and the patients' opinion whether the pain was acceptable or not. Outcome was the presence of a complication within 30 days after surgery. We used binary logistic regression for the total population and homogeneous subgroups to control for case complexity. Results for homogeneous subgroups were summarized in a meta-analysis using inverse variance weighting. RESULTS In 1014 patients, 55% experienced moderate-to-severe pain on the first postoperative day. The overall complication rate was 34%. The proportion of patients experiencing postoperative complications increased from 0.25 [95% confidence interval (CI) = 0.21-0.31] for NRS-MEP = 0 to 0.45 (95% CI = 0.36-0.55) for NRS-MEP = 10. Patients who found their pain unacceptable had more complications (adjusted odds ratio = 2.17 (95% CI = 1.51-3.10; P < 0.001)). Summary effect sizes obtained with homogeneous groups were similar to those obtained from the total population who underwent very different types of surgery. CONCLUSIONS Higher actual postoperative pain scores and unacceptable pain, even on the first postoperative day, are associated with more postoperative complications. Our findings provide important support for the centrality of personalized analgesia in modern perioperative care.
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14
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Ono Y, Tanaka M, Matsueda K, Hiratsuka M, Takahashi Y, Mise Y, Inoue Y, Sato T, Ito H, Saiura A. Techniques for splenic vein reconstruction after pancreaticoduodenectomy with portal vein resection for pancreatic cancer. HPB (Oxford) 2019; 21:1288-1294. [PMID: 30878491 DOI: 10.1016/j.hpb.2019.01.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 12/10/2018] [Accepted: 01/31/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) with splenic vein (SV) ligation may result in sinistral portal hypertension (SPH). The aim of this study was to compare the outcomes of various types of SV reconstruction to prevent SPH and to define the optimal reconstruction method. METHODS This study included patients who underwent PD with SV resection and reconstruction for pancreatic cancer between December 2013 and June 2017. The patency of various types of SV anastomosis and SPH was evaluated by follow up computed tomography. RESULTS The type of SV reconstruction was divided into two groups: (i) end-to-side anastomosis (n = 10), in which the SV was anastomosed with either the left renal vein (LRV; n = 8) or portal vein (n = 2); and (ii) end-to-end anastomosis (n = 20), in which the SV was anastomosed with another smaller vein or graft. The patency rate for Group 1 was 90% (9/10), compared with 45% (9/20) for Group 2 (P = 0.024). Half the patients in whom the SV anastomosis was occluded (6/12) developed gastrointestinal varices, whereas only 11% of patients with a patent SV anastomosis (2/9) had varices (P = 0.034). CONCLUSION SV-LRV reconstruction is widely applicable, effectively reduces the risk of SPH, and should be considered for the case of extended PD.
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Affiliation(s)
- Yoshihiro Ono
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Masayuki Tanaka
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Kiyoshi Matsueda
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Makiko Hiratsuka
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Yu Takahashi
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Yoshihiro Mise
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Yosuke Inoue
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Takafumi Sato
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Hiromichi Ito
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan
| | - Akio Saiura
- Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Japan.
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15
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Distal splenorenal and mesocaval shunting at the time of pancreatectomy. Surgery 2019; 165:298-306. [DOI: 10.1016/j.surg.2018.10.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/02/2018] [Accepted: 10/08/2018] [Indexed: 12/12/2022]
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16
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Tanaka M, Ito H, Ono Y, Matsueda K, Mise Y, Ishizawa T, Inoue Y, Takahashi Y, Hiratsuka M, Unno T, Saiura A. Impact of portal vein resection with splenic vein reconstruction after pancreatoduodenectomy on sinistral portal hypertension: Who needs reconstruction? Surgery 2019; 165:291-297. [DOI: 10.1016/j.surg.2018.08.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/20/2018] [Accepted: 08/28/2018] [Indexed: 12/13/2022]
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17
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Nagai M, Sho M, Akahori T, Nishiwada S, Nakagawa K, Nakamura K, Tanaka T, Nishiofuku H, Kichikawa K, Ikeda N. Risk Factors for Late-Onset Gastrointestinal Hemorrhage After Pancreatoduodenectomy for Pancreatic Cancer. World J Surg 2018; 43:626-633. [PMID: 30225561 DOI: 10.1007/s00268-018-4791-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Late-onset gastrointestinal hemorrhage after pancreatoduodenectomy (PD) occasionally occurs repeatedly or leads to a serious condition. This retrospective study aimed to clarify its frequency and pathogenesis. METHODS A total of 147 consecutive patients who underwent PD for pancreatic cancer between 2006 and 2014 were evaluated. Patients were divided into two groups according to the occurrence of late-onset gastrointestinal hemorrhage on postoperative day 100 or later. Furthermore, recurrence and portal vein (PV) hemodynamics were thoroughly reevaluated by computed tomography. RESULTS Eleven patients experienced late-onset gastrointestinal hemorrhage. The bleeding sites were gastrojejunostomy in four patients, choledochojejunostomy in two, transverse colic marginal vein in one, and unknown in four. The median occurrence time of late-onset gastrointestinal hemorrhage was 13.3 months after PD. PV occlusion (63.6 vs. 8.9%; p < 0.001), no patency of PV-splenic vein (SPV) confluence (54.5 vs. 12.7%; p = 0.002), and SPV ligation (36.4 vs. 9.6%; p = 0.025) were found to be significant risk factors for late-onset gastrointestinal hemorrhage. Among 11 patients who experienced late-onset gastrointestinal hemorrhage, 7 had PV occlusion and 6 had local recurrence. CONCLUSIONS Our data suggested for the first time that both oncologic and non-oncologic factors might contribute to late-onset gastrointestinal hemorrhage after PD for pancreatic cancer. Furthermore, PV occlusion, no PV-SPV patency, and SPV ligation were found to be significant risk factors for late-onset gastrointestinal hemorrhage. Therefore, to prevent late-onset gastrointestinal hemorrhage, we must consider various approaches to maintain the patency of the PV and SPV.
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Affiliation(s)
- Minako Nagai
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.
| | - Takahiro Akahori
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Satoshi Nishiwada
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kenji Nakagawa
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kota Nakamura
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Toshihiro Tanaka
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Hideyuki Nishiofuku
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Kimihiko Kichikawa
- Department of Radiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
| | - Naoya Ikeda
- Department of Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan
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Tanaka H, Nakao A, Oshima K, Iede K, Oshima Y, Kobayashi H, Kimura Y. Splenic vein reconstruction is unnecessary in pancreatoduodenectomy combined with resection of the superior mesenteric vein-portal vein confluence according to short-term outcomes. HPB (Oxford) 2017. [PMID: 28629642 DOI: 10.1016/j.hpb.2017.02.438] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Superior mesenteric vein-portal vein confluence resection combined with pancreatoduodenectomy (SMPVrPD) is occasionally required for resection of pancreatic head tumors. It remains unclear whether such situations require splenic vein (SV) reconstruction for decompression of left-sided portal hypertension (LSPH). METHODS The data from 93 of 104 patients who underwent pancreatoduodenectomy (PD) for pancreatic head malignancies were reviewed. Surgical outcomes in three groups-standard PD (control group), PD combined with vascular resection and SV preservation (SVp group), and SMPVrPD with SV resection (SVr group)-were compared. The influence of division and preservation of the two natural confluences (left gastric vein-portal vein and/or inferior mesenteric vein-SV confluences) on portal hemodynamics were evaluated using three-dimensional computed tomographic portography. RESULTS No mortality occurred. The morbidity rates were not significantly different among the three groups (18/43, 8/21, and 7/29, respectively; p = 0.306). In the SVr group, three patients had gastric remnant venous congestion, and three had esophageal varices without hemorrhagic potential. No patients had splenomegaly, or severe or prolonged thrombocytopenia. These LSPH-associated findings were less frequently observed when the two confluences were preserved. CONCLUSIONS SMPVrPD without SV reconstruction can be safely conducted. Additionally, preservation of these two confluences may reduce the risk of LSPH.
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Affiliation(s)
| | - Akimasa Nakao
- Department of Surgery, Nagoya Central Hospital, Nagoya, Japan.
| | - Kenji Oshima
- Department of Surgery, Nagoya Central Hospital, Nagoya, Japan
| | - Kiyotsugu Iede
- Department of Surgery, Nagoya Central Hospital, Nagoya, Japan
| | - Yukiko Oshima
- Department of Surgery, Nagoya Central Hospital, Nagoya, Japan
| | | | - Yasunori Kimura
- Department of Surgery, Nagoya Central Hospital, Nagoya, Japan
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Clues to vascular disorders at non-contrast CT of the chest, abdomen, and pelvis. Abdom Radiol (NY) 2017; 42:2175-2187. [PMID: 28365786 DOI: 10.1007/s00261-017-1113-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Non-contrast chest CT scans are commonly performed while CT scans of the abdomen and pelvis are performed in a select subset of patients; those with limited renal function, an allergy to iodinated contrast, in the setting of suspected renal calculus, retroperitoneal hematoma, common duct calculus, abdominal aortic aneurysm with or without rupture, and in patients undergoing a PET-CT scan. In the absence of intravenous contrast, vascular structures may prove challenging to evaluate, yet their assessment is an important component of every non-contrast CT examination. We describe the key imaging features of both arterial and venous pathology, and review clues and common associated non-vascular findings, which can help the radiologist identify vascular disorders at non-contrast CT. Briefly, alternative imaging options are discussed.
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Gyoten K, Mizuno S, Nagata M, Ogura T, Usui M, Isaji S. Significance of Simultaneous Splenic Artery Resection in Left-Sided Portal Hypertension After Pancreaticoduodenectomy with Combined Portal Vein Resection. World J Surg 2017; 41:2111-2120. [PMID: 28258459 PMCID: PMC5504262 DOI: 10.1007/s00268-017-3916-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND In pancreaticoduodenectomy (PD) with resection of portal vein (PV)/superior mesenteric vein (SMV) confluence, the splenic vein (SV) division may cause left-sided portal hypertension (LPH). METHODS The 88 pancreatic ductal adenocarcinoma patients who underwent PD with PV/SMV resection after chemoradiotherapy were classified into three groups: both SV and splenic artery (SA) were preserved in Group A (n = 16), SV was divided and SA was preserved in Group B (n = 58), and both SV and SA were divided in Group C (n = 14). We evaluated the influence of resection of SV and/or SA on LPH after PD with resection of PV/SMV confluence. RESULTS The incidence of postoperative varices in Groups A, B and C was 6.3, 67.2 and 38.5%, respectively (p < 0.001), and variceal bleeding occurred only in Group B (n = 4: 6.8%). In multivariate analysis, Group B was the only significant risk factor for the development of postoperative varices (Groups B vs. A: odds ratio = 39.6, p = 0.001, Groups C vs. A: odds ratio = 8.75, p = 0.066). The platelet count ratio at 6 months after operation comparing to preoperative value was 0.93, 0.73 and 1.09 in Groups A, B and C, respectively (Groups B vs. C: p < 0.05), and spleen volume ratio at 6 months was 1.00, 1.37 and 0.96 in Groups A, B and C, respectively (Groups B vs. A and C: p < 0.01 and p < 0.05). CONCLUSION In PD with resection of PV-SMV confluence, the SV division causes LPH, but the concomitant division of SV and SA may attenuate it.
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Affiliation(s)
- Kazuyuki Gyoten
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Motonori Nagata
- Department of Radiology, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Toru Ogura
- Clinical Research Support Center, Mie University Hospital, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masanobu Usui
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Shuji Isaji
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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Surgical strategies and novel therapies for locally advanced pancreatic cancer. J Surg Oncol 2017; 116:16-24. [DOI: 10.1002/jso.24654] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 03/29/2017] [Indexed: 12/23/2022]
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Rosado ID, Bhalla S, Sanchez LA, Fields RC, Hawkins WG, Strasberg SM. Pattern of Venous Collateral Development after Splenic Vein Occlusion in an Extended Whipple Procedure (Whipple at the Splenic Artery) and Long-Term Results. J Gastrointest Surg 2017; 21:516-526. [PMID: 27921207 DOI: 10.1007/s11605-016-3325-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 11/14/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Extended Whipple procedures may require division of the splenic vein (SV). Controversy exists regarding the risk of sequelae of sinistral portal hypertension when the SV is ligated without reimplantation. The aim of this study was to identify postoperative venous collateral patterns and sequelae of SV ligation, as well as long-term results in an extended Whipple procedure. STUDY DESIGN Patients who had an extended Whipple procedure (Whipple at the Splenic Artery or WATSA) were entered in an institutional database. Evaluation of the venous collaterals was performed at least 5 months postoperatively by imaging. Spleen size and platelet counts were measured before and after operation. RESULTS Fifteen patients were entered from 2009 to 2014. SV was not reconstructed and the IMV-SV junction was always resected. Two collateral routes developed. An inferior route was present 14/15 patients. It connected the residual SV to the SMV via intermediate collateral veins in the omentum and along the colon. A superior route, present in 10/15 patients connected the residual SV to the portal vein via gastric, perigastric, and coronary veins. Gastrointestinal bleeding did not occur. Mean platelet count and spleen size were not affected significantly. Procedures were long, but few severe complications developed. In 12 patients with adenocarcinoma, the median survival has not been reached. CONCLUSIONS Patients who have SV ligation in an extended Whipple are protected against sequelae of sinestral portal hypertension by inferior collateral routes. The omentum and marginal veins of the colon are key links in this pathway.
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Affiliation(s)
- Ismael Dominguez Rosado
- Section of Hepato-Pancreato-Biliary Surgery, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 4990 Children's Place, Suite 1160, (Campus Box 8109), St Louis, MO, 63110, USA
- Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Vasco de Quiroga 15 Col, Tlalpan, 14000, Mexico City, Mexico
| | - Sanjeev Bhalla
- Mallinckrodt Institute of Radiology, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 660 S Euclid Ave Campus Box 8131, St Louis, MO, 63110, USA
| | - Luis A Sanchez
- Section of Vascular Surgery, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 660 S Euclid Ave Campus Box 8109, St Louis, MO, 63110, USA
| | - Ryan C Fields
- Section of Hepato-Pancreato-Biliary Surgery, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 4990 Children's Place, Suite 1160, (Campus Box 8109), St Louis, MO, 63110, USA
| | - William G Hawkins
- Section of Hepato-Pancreato-Biliary Surgery, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 4990 Children's Place, Suite 1160, (Campus Box 8109), St Louis, MO, 63110, USA
| | - Steven M Strasberg
- Section of Hepato-Pancreato-Biliary Surgery, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 4990 Children's Place, Suite 1160, (Campus Box 8109), St Louis, MO, 63110, USA.
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Addeo P, Nappo G, Felli E, Oncioiu C, Faitot F, Bachellier P. Management of the splenic vein during a pancreaticoduodenectomy with venous resection for malignancy. Updates Surg 2016; 68:241-246. [DOI: 10.1007/s13304-016-0396-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 09/07/2016] [Indexed: 12/24/2022]
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Kauffmann EF, Napoli N, Menonna F, Vistoli F, Amorese G, Campani D, Pollina LE, Funel N, Cappelli C, Caramella D, Boggi U. Robotic pancreatoduodenectomy with vascular resection. Langenbecks Arch Surg 2016; 401:1111-1122. [PMID: 27553112 DOI: 10.1007/s00423-016-1499-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 08/11/2016] [Indexed: 12/16/2022]
Abstract
PURPOSE This study aims to define the current status of robotic pancreatoduodenectomy (RPD) with resection and reconstruction of the superior mesenteric/portal vein (RPD-SMV/PV). METHODS Our experience on RPD, including RPD-SMV/PV, is presented along with a description of the surgical technique and a systematic review of the literature on RPD-SMV/PV. RESULTS We have performed 116 RPD and 14 RPD-SMV/PV. Seven additional cases of RPD-SMV/PV were identified in the literature. In our experience, RPD and RPD-SMV/PV were similar in all baseline variables, but lower mean body mass and higher prevalence of pancreatic cancer in RPD-SMV/PV. Regarding the type of vein resection, there were one type 2 (7.1 %), five type 3 (35.7 %) and eight type 4 (57.2 %) resections. As compared to RPD, RPD-SMV/PV required longer operative time, had higher median estimated blood loss, and blood transfusions were required more frequently. Incidence and severity of post-operative complications were not increased in RPD-SMV/PV, but post-pancreatectomy hemorrhage occurred more frequently after this procedure. In pancreatic cancer, RPD-SMV/PV was associated with a higher mean number of examined lymph nodes (60.0 ± 13.9 vs 44.6 ± 11.0; p = 0.02) and with the same rate of microscopic margin positivity (25.0 % vs 26.1 %). Mean length or resected vein was 23.1 ± 8.08 mm. Actual tumour infiltration was discovered in ten patients (71.4 %), reaching the adventitia in four patients (40.0 %), the media in two patients (20.0 %), and the intima in four patients (40.0 %). Literature review identified seven additional cases, all reported to have successful outcome. CONCLUSIONS RPD-SMV/PV is feasible in carefully selected patients. The generalization of these results remains to be demonstrated.
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Affiliation(s)
- Emanuele F Kauffmann
- Division of General and Transplant Surgery, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124, Pisa, Italy
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124, Pisa, Italy
| | - Francesca Menonna
- Division of General and Transplant Surgery, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124, Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124, Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Daniela Campani
- Division of Pathology, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Luca Emanuele Pollina
- Division of Pathology, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Niccola Funel
- Division of Pathology, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Carla Cappelli
- Division of Radiology, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Davide Caramella
- Division of Radiology, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa and Azienda Ospedaliero Universitaria Pisana, Via Paradisa 2, 56124, Pisa, Italy.
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Advances in the Surgical Management of Resectable and Borderline Resectable Pancreas Cancer. Surg Oncol Clin N Am 2016; 25:287-310. [PMID: 27013365 PMCID: PMC10181830 DOI: 10.1016/j.soc.2015.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Successful surgical resection offers the only chance for cure in patients with pancreatic cancer. However, pancreatic resection is feasible in less than 20% of the patients. In this review, the current state of surgical management of pancreatic cancer is discussed. The definition of resectability based on cross-sectional imaging and the technical aspects of surgery, including vascular resection and/or reconstruction, management of aberrant vascular anatomy and extent of lymphadenectomy, are appraised. Furthermore, common pancreatic resection-specific postoperative complications and their management are reviewed.
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26
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Ball CG, Dixon E, Vollmer CM, Howard TJ. The view from 10,000 procedures: technical tips and wisdom from master pancreatic surgeons to avoid hemorrhage during pancreaticoduodenectomy. BMC Surg 2015; 15:122. [PMID: 26608343 PMCID: PMC4660662 DOI: 10.1186/s12893-015-0109-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 11/10/2015] [Indexed: 12/30/2022] Open
Abstract
Pancreaticoduodenectomy remains the exclusive technique for surgical resection of cancers located within both the pancreatic head and periampullary region. Amongst peri-procedural complications, hemorrhage is particularly problematic given that allogenic blood transfusions are known to increase the risk of infection, acute lung injury, cancer recurrence and overall 30-day morbidity and mortality rates. Because blood loss can be considered a modifiable factor that reflects surgical technique, rates of perioperative blood loss and transfusion have been advocated as robust quality indicators. We present a correspondence manuscript that outlines peri-procedural concepts detailing a successful pancreaticoduodenectomy with minimal hemorrhage. These tips were collated from master pancreatic surgeons throughout the globe who have performed over 10,000 cumulative pancreaticoduodenectomies. At risk scenarios for hemorrhage include dissections of the superior mesenteric – portal vein, gastroduodenal artery, and retroperitoneal soft tissue margin. General principles in limiting slow continuous hemorrhage that may accumulate into larger total case losses are also discussed. While many of the techniques and tips proposed by master pancreas surgeons are intuitive and straight forward, when taken as a collective they represent a significant contribution to improved outcomes associated with the pancreaticoduodenectomy over the past 100 years.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, University of Calgary, Foothills Medical Centre, 1403-29 Street NW, Calgary, Alberta, T2N 2T9, Canada.
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Foothills Medical Centre, 1403-29 Street NW, Calgary, Alberta, T2N 2T9, Canada.
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
| | - Thomas J Howard
- Department of Surgery, Indiana University, Indianapolis, IN, USA.
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27
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Hackert T, Weitz J, Büchler MW. Reinsertion of the gastric coronary vein to avoid venous gastric congestion in pancreatic surgery. HPB (Oxford) 2015; 17:368-70. [PMID: 25059096 PMCID: PMC4368403 DOI: 10.1111/hpb.12321] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 06/21/2014] [Indexed: 12/12/2022]
Affiliation(s)
- Thilo Hackert
- Department of Surgery, University of HeidelbergHeidelberg, Germany
| | - Jürgen Weitz
- Department of Surgery, University of DresdenDresden, Germany
| | - Markus W Büchler
- Department of Surgery, University of HeidelbergHeidelberg, Germany,Correspondence, Markus W. Büchler, Department of Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany. Tel: + 49 6221 566110. Fax: + 49 6221 565450. E-mail:
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28
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Ono Y, Matsueda K, Koga R, Takahashi Y, Arita J, Takahashi M, Inoue Y, Unno T, Saiura A. Sinistral portal hypertension after pancreaticoduodenectomy with splenic vein ligation. Br J Surg 2014; 102:219-28. [PMID: 25524295 DOI: 10.1002/bjs.9707] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 09/22/2014] [Accepted: 10/16/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Splenic vein ligation may result in sinistral (left-sided) portal hypertension and gastrointestinal haemorrhage. The aim of this study was to analyse the pathogenesis of sinistral portal hypertension following splenic vein ligation in pancreaticoduodenectomy. METHODS Patients who underwent pancreaticoduodenectomy for pancreatic cancer between January 2005 and December 2012 were included in this retrospective study. The venous flow pattern from the spleen and splenic hypertrophy were examined after surgery. RESULTS Of 103 patients who underwent pancreaticoduodenectomy with portal vein resection, 43 had splenic vein ligation. There were two predominant venous flow patterns from the spleen. In the varicose route (27 patients), flow from the spleen passed to colonic varices and/or other varicose veins. In the non-varicose route, flow from the spleen passed through a splenocolonic collateral (14 patients) or a spontaneous splenorenal shunt (2 patients). The varicose route was associated with significantly greater splenic hypertrophy than the non-varicose route (median splenic hypertrophy ratio 1·52 versus 0·94; P < 0·001). All patients with the varicose route had colonic varices, and none had a right colic marginal vein at the hepatic flexure. CONCLUSION Pancreaticoduodenectomy with splenic vein ligation may lead to sinistral portal hypertension. To avoid the development of varices, it is important to preserve the right colic marginal vein. Reconstruction of the splenic vein should be considered if the right colic marginal vein is divided.
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Affiliation(s)
- Y Ono
- Departments of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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29
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Yoon YS, Lee KH, Han HS, Cho JY, Jang JY, Kim SW, Lee WJ, Kang CM, Park SJ, Han SS, Ahn YJ, Yu HC, Choi IS. Effects of laparoscopic versus open surgery on splenic vessel patency after spleen and splenic vessel-preserving distal pancreatectomy: a retrospective multicenter study. Surg Endosc 2014; 29:583-8. [PMID: 25005018 DOI: 10.1007/s00464-014-3701-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 06/22/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND The aims of this study were to compare splenic vessel patency between laparoscopic and open spleen and splenic vessel-preserving distal pancreatectomy (SSVpDP), and to identify possible risk factors for poor splenic vessel patency. METHODS This retrospective multicenter study included 116 patients who underwent laparoscopic (n = 70) or open (n = 46) SSVpDP at seven Korean tertiary medical institutions between 2004 and 2011. Clinical parameters and the splenic vessel patency assessed by abdominal computed tomography were compared between the two surgical procedures. RESULTS The clinical parameters were not significantly different between both groups, except for postoperative hospital stay, which was significantly shorter in the laparoscopic group (10.4 vs. 13.5 days, P = 0.024). The splenic artery patency rate was similar in both groups (90.0 vs. 97.8 %), but the splenic vein patency rate was significantly lower in the laparoscopic group (64.3 vs. 87.0 %, P = 0.022). Univariate and multivariate analyses revealed surgical procedure [odds ratio (OR) 3.085, P = 0.043] and intraoperative blood loss (OR 4.624, P = 0.002) as independent risk factors for compromised splenic vein patency (partial or total occlusion). The splenic vein patency rate was significantly better in the late group (n = 34) than in the early period (n = 35) (79.4 vs. 48.6 %, P = 0.008). CONCLUSIONS Although laparoscopic SSVpDP had an advantage of shorter hospital stay compared with open surgery, it was associated with greater risk of poor splenic vein patency. However, this risk could decrease with increasing surgical experience and with efforts to minimize blood loss.
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Affiliation(s)
- Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Korea,
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30
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Liu Q, Song Y, Xu X, Jin Z, Duan W, Zhou N. Management of bleeding gastric varices in patients with sinistral portal hypertension. Dig Dis Sci 2014; 59:1625-9. [PMID: 24500452 DOI: 10.1007/s10620-014-3048-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Accepted: 01/23/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Sinistral portal hypertension (SPH) is a rare cause of upper gastrointestinal hemorrhage. Besides splenectomy, there is no consensus on the role of sclerotherapy and splenic embolization for bleeding gastric varices (GVs). This retrospective study summarizes our experience in managing GV bleeding from SPH in patients with pancreatic diseases. METHODS Patients with pancreatic diseases who had bleeding GVs from SPH in two tertiary hospitals were reviewed from January 2001 to December 2011. The etiology, clinical manifestations, diagnostic and therapeutic modalities were analyzed. RESULTS Twenty-one patients (15.2 %) complicating bleeding GVs among 139 patients with SPH secondary to pancreatic diseases were enrolled. The etiologies were acute pancreatitis in one patient, chronic pancreatitis in seven patients, and pancreatic tumors in 13 patients. Emergent endoscopic sclerotherapy was initially performed in five patients, and succeeded in two patients, while one patient died of massive hemorrhage. Initial transcatheter artery embolization using Gianturco coils was successfully performed in six patients. Splenectomy combined with other surgical procedures was undertaken for 15 patients. The patients undergoing artery embolization or splencetomy achieved hemostasis. The survivors had no recurrent bleeding during a median 72-month follow-up period. CONCLUSIONS The incidence of bleeding GVs from SPH is relatively rare. Splenic artery embolization could be selected as a first-line choice for bleeding SPH, especially for patients in poor conditions, and sclerotherapy may not be preferentially recommended. Further studies are required to evaluate the optimum treatment algorithm for bleeding GVs from SPH.
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Affiliation(s)
- Quanda Liu
- Department of Hepatobiliary Surgery, Second Artillery General Hospital PLA, Beijing, 100088, China,
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31
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Anterior approach to the superior mesenteric artery by using nerve plexus hanging maneuver for borderline resectable pancreatic head carcinoma. J Gastrointest Surg 2014; 18:1209-15. [PMID: 24664421 DOI: 10.1007/s11605-014-2495-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 03/03/2014] [Indexed: 01/31/2023]
Abstract
To achieve R0 resection for pancreatic ductal adenocarcinoma (PDAC) of the pancreatic head, complete resection of the retropancreatic nerve plexus around the superior mesenteric artery (SMA) is thought to be required. Twenty-five patients with borderline resectable right-sided PDAC were divided into two groups after neoadjuvant chemoradiotherapy: those with portal vein (PV) invasion alone (n = 12), and those with invasion of both PV and SMA (n = 13). A tape for guidance was passed in a space ventral to the SMA and behind the pancreatic parenchyma, followed by resection of the pancreatic parenchyma with the splenic vein. Another tape was passed behind the nerve plexus lateral to the hepatic artery and the SMA ventral to the inferior vena cava and the nerve plexus was dissected, resulting in complete resection of the nerve plexus around the SMA. Pathological findings revealed that the rates of R0, R01 (a margin less than 1 mm) and R1 were 58.3 %, 41.7 % and 0 % in PV group, and 53.8 %, 30.8 % and 15.4 % in PV/A group, respectively. The median survival time was 23.3 and 22.8 months in PV and PV/A groups, respectively. The plexus hanging maneuver for PDAC of the pancreatic head achieved complete resection of the retropancreatic nerve plexus around the SMA, helping to secure a negative surgical margin.
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Pilgrim CHC, Tsai S, Tolat P, Patel P, Rilling W, Evans DB, Christians KK. Optimal management of the splenic vein at the time of venous resection for pancreatic cancer: importance of the inferior mesenteric vein. J Gastrointest Surg 2014; 18:917-21. [PMID: 24347313 DOI: 10.1007/s11605-013-2428-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 11/27/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Resection of the superior mesenteric vein (SMV)-portal vein (PV)-splenic vein (SV) confluence during pancreatectomy for pancreatic cancer requires management of the SV. DISCUSSION Simple SV ligation can result in sinistral portal hypertension if the inferior mesenteric vein (IMV) enters the confluence and is thereby resected, or if the IMV is insufficient to drain the SV. We describe herein three patients whose clinical course confirms the importance of the IMV decompressing the SV to avoid sinistral hypertension.
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Affiliation(s)
- Charles H C Pilgrim
- Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, The Medical College of Wisconsin, 9200 W. Wisconsin Avenue, Milwaukee, WI, 53226, USA
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33
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Modified interventional obliteration for variceal hemorrhage from elevated jejunum after pylorus-preserving pancreatoduodenectomy. Jpn J Radiol 2014; 32:487-90. [DOI: 10.1007/s11604-014-0318-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 04/03/2014] [Indexed: 11/27/2022]
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34
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Zhang S, Wen DQ, Kong YL, Li YL, Zhang HY. Effects of secondary left-sided portal hypertension on the radical operation rate and prognosis in patients with pancreatic cancer. Asian Pac J Cancer Prev 2014; 15:2239-44. [PMID: 24716963 DOI: 10.7314/apjcp.2014.15.5.2239] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To investigate the effects of secondary left-sided portal hypertension (LSPH) on the radical operation rate of patients with pancreatic cancer and systemically evaluate the prognosis of patients with LSPH secondary to pancreatic cancer after radical surgery. MATERIALS AND METHODS The data of patients with pancreatic cancer who underwent laparotomy over a 15-year period in Department of Hepatobiliary Surgery of Chinese PLA Air Force General Hospital from Jan. 1, 1997, to Jun. 30, 2012 was retrospectively reviewed. RESULTS A total of 362 patients with pancreatic cancer after laparotomy were selected, including 73 with LSPH and 289 without LSPH. Thirty-five patients with LSPH (47.9%) and 147 without non-LSPH (50.9%) respectively underwent radical operations. No significant difference was found between these two groups regarding the total resection rate and stratified radical resection rate according to different pathological types and cancer locations. The mean and median survival time of patients after radical operation in LSPH group were 13.9 ± 1.3 months and 14.8 months, respectively, while those in non-LSPH group were 22.6 ± 1.4 months and 18.4 months, respectively(P<0.05). CONCLUSIONS Radical operations for pancreatic cancer and secondary LSPH are safe and effective. Because high-grade malignancy and poor prognosis are closely associated, the decision for radical surgery should be made more meticulously for the patients with pancreatic cancer.
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Affiliation(s)
- Shuo Zhang
- Department of Obstetrics and Gynecology, Chinese PLA Air Force General Hospital, Beijing, China E-mail : ,
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35
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Indication for the use of an interposed graft during portal vein and/or superior mesenteric vein reconstruction in pancreatic resection based on perioperative outcomes. Langenbecks Arch Surg 2014; 399:461-71. [DOI: 10.1007/s00423-014-1182-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 03/11/2014] [Indexed: 01/04/2023]
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36
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Chen Y, Tan C, Mai G, Ke N, Liu X. Resection of Pancreatic Tumors Involving the Anterior Surface of the Superior Mesenteric/Portal Veins Axis: An Alternative Procedure to Pancreaticoduodenectomy with Vein Resection. J Am Coll Surg 2013; 217:e21-8. [PMID: 24054418 DOI: 10.1016/j.jamcollsurg.2013.07.383] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 06/24/2013] [Accepted: 07/09/2013] [Indexed: 02/05/2023]
Affiliation(s)
- Yonghua Chen
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
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37
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Christians KK, Riggle K, Keim R, Pappas S, Tsai S, Ritch P, Erickson B, Evans DB. Distal splenorenal and temporary mesocaval shunting at the time of pancreatectomy for cancer: Initial experience from the Medical College of Wisconsin. Surgery 2013; 154:123-31. [DOI: 10.1016/j.surg.2012.11.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 11/16/2012] [Indexed: 01/24/2023]
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38
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Dokmak S. “Pattern of venous collateral development after splenic vein occlusion in an extended whipple procedure”. J Gastrointest Surg 2012; 16:2009-10. [PMID: 22836923 DOI: 10.1007/s11605-012-1976-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Accepted: 07/17/2012] [Indexed: 01/31/2023]
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39
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Lai ECS. Vascular resection and reconstruction at pancreatico-duodenectomy: technical issues. Hepatobiliary Pancreat Dis Int 2012; 11:234-42. [PMID: 22672815 DOI: 10.1016/s1499-3872(12)60154-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND With the improvement of perioperative management over the years, pancreatico-duodenectomy has become a safe operation despite its technical complexity. The presence of concomitant visceral artery occlusion unrelated to the underlying malignancy and concomitant major venous infiltration by tumor poses additional hazards to resection which could compromise the postoperative outcome. DATA SOURCES A MEDLINE database search was performed to identify relevant articles using the key words "median arcuate ligament syndrome", "superior mesenteric artery", "replaced right hepatic artery", and "portal vein resection". Additional papers and book chapters were identified by a manual search of the references from the key articles. RESULTS Computed tomography with 3-dimensional reconstruction of the vascular anatomy provides most key information on the potential vascular problems encountered during surgery. A trial clamping of the gastroduodenal artery provides a simple intraoperative assessment for the presence of any significant visceral arterial occlusion. Depending on the timing of diagnosis, division of the median arcuate ligament, bypass or endovascular stenting should be considered. Portal and superior mesenteric vein resection had been used with increasing frequency and safety. The steps and methods taken to reconstruct the venous continuity vary with individual surgeons, and the anatomical variations encountered. With segmental loss of the portal vein, opinions differs with regard to the preservation of the splenic vein, and when divided, the necessity of restoring its continuity; source of the autologous vein graft when needed and whether the use of synthetic graft is a safe alternative. CONCLUSIONS During a pancreatico-duodenectomy, images of computed tomography must be carefully studied to appreciate the changes and variation of vascular anatomy. Adequate preoperative preparation, acute awareness of the probable arterial and venous anatomical variation and the availability of expertise, especially micro-vascular surgery, for vascular reconstruction would help to make the complex pancreatic resection a safer procedure.
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Strasberg SM, Sanchez LA, Hawkins WG, Fields RC, Linehan DC. Resection of tumors of the neck of the pancreas with venous invasion: the "Whipple at the Splenic Artery (WATSA)" procedure. J Gastrointest Surg 2012; 16:1048-54. [PMID: 22399270 DOI: 10.1007/s11605-012-1841-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 02/07/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Tumors of the neck of the pancreas may involve the superior mesenteric and portal veins as well as the termination of the splenic vein. This presents a difficult problem since the pancreas cannot be transected through the neck as is standard in a Whipple procedure. Here, we present our method of resecting such tumors, which we term "Whipple at the Splenic Artery (WATSA)". METHODS The superior mesenteric and portal veins are isolated below and above the pancreas, respectively. The pancreas and splenic vein are divided just to the right of the point that the splenic artery contacts the superior border of the pancreas. This plane of transection is approximately 2 cm to the left of the pancreatic neck and away from the tumor. The superior mesenteric artery is cleared from the left side of the patient. With the specimen remaining attached only by the superior mesenteric and portal veins, these structures are clamped and divided. Reconstruction is performed with or without a superficial femoral vein graft. The splenic vein is not reconstructed. RESULTS Ten cases have been performed to date without mortality. We have previously shown that the pattern of venous collateral development following occlusion of the termination of the splenic vein in the manner described is not similar to that of cases of sinistral (left sided) portal hypertension. DISCUSSION Whipple at the splenic artery (WATSA) is a safe method for resection of tumors of the neck of the pancreas with vein involvement. It should be performed in high-volume pancreatic surgery centers.
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Affiliation(s)
- Steven M Strasberg
- HPB Surgery Section, Department of Surgery, Washington University in Saint Louis, 660 South Euclid Avenue, Box 8109, Saint Louis, MO 63110, USA.
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