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Abe Y, Nabeshima T, Sakuta K, Nishise Y, Kuroki M. Hemorrhagic varices around the pancreatojejunostomy site due to left-sided portal hypertension after pancreaticoduodenectomy: A case report. DEN OPEN 2025; 5:e397. [PMID: 38895559 PMCID: PMC11182736 DOI: 10.1002/deo2.397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/10/2024] [Accepted: 06/03/2024] [Indexed: 06/21/2024]
Abstract
Pancreaticoduodenectomy (PD) with combined portal vein resection sometimes causes left-sided portal hypertension, which can be a problem. An appropriate treatment strategy for hemorrhagic ectopic varices due to left-sided portal hypertension after PD has not yet been determined. We report a case of repeated variceal rupture around the pancreatojejunostomy site. A 65-year-old woman with a history of PD for pancreatic head cancer was admitted with a chief complaint of bloody stools. She was diagnosed with pancreatojejunostomy variceal rupture, and an endoscopic cyanoacrylate injection was performed. As rebleeding occurred 2 weeks after the first treatment, endoscopic cyanoacrylate injection was repeated, and hemostasis was achieved. Additionally, she had esophageal, colonic, and gastrojejunostomy varices, and the future risk of these variceal ruptures was considered very high. Hence, a splenectomy was performed to prevent rebleeding or other variceal ruptures. Endoscopic cyanoacrylate injection is a useful treatment for hemorrhagic varices around the pancreatojejunostomy site. It is also necessary to understand portal vein hemodynamics and provide appropriate additional treatment in cases of recurrent variceal rupture due to left-sided portal hypertension after PD.
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Affiliation(s)
- Yasuaki Abe
- Department of GastroenterologyYamagata City Hospital SaiseikanYamagataJapan
| | | | - Kazuhiro Sakuta
- Department of GastroenterologyYamagata City Hospital SaiseikanYamagataJapan
| | - Yuko Nishise
- Department of GastroenterologyYamagata City Hospital SaiseikanYamagataJapan
| | - Michio Kuroki
- Department of GastroenterologyYamagata City Hospital SaiseikanYamagataJapan
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2
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Tidwell J, Thakkar B, Wu GY. Etiologies of Splenic Venous Hypertension: A Review. J Clin Transl Hepatol 2024; 12:594-606. [PMID: 38974953 PMCID: PMC11224904 DOI: 10.14218/jcth.2024.00054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/27/2024] [Accepted: 05/04/2024] [Indexed: 07/09/2024] Open
Abstract
Splenic venous hypertension or left-sided portal hypertension is a rare condition caused by an obstruction of the splenic vein. Usually, it presents with upper gastrointestinal bleeding in the absence of liver disease. Etiologies can be classified based on the mechanism of development of splenic vein hypertension: compression, stenosis, inflammation, thrombosis, and surgically decreased splenic venous flow. Diagnosis is established by various imaging modalities and should be suspected in patients with gastric varices in the absence of esophageal varices, splenomegaly, or cirrhosis. The management and prognosis vary depending on the underlying etiology but generally involve reducing splenic venous pressure. The aim of this review was to summarize the etiologies of splenic venous hypertension according to the mechanism of development.
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Affiliation(s)
- Jasmine Tidwell
- Department of Medicine, University of Connecticut Health Center, Farmington, CT, USA
| | - Bianca Thakkar
- Department of Medicine, University of Connecticut Health Center, Farmington, CT, USA
| | - George Y. Wu
- Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
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3
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Libia A, Marchese T, D’Ugo S, Piscitelli P, Castellana F, Clodoveo ML, Zupo R, Spampinato MG. Use of Vascular Shunt at the Time of Pancreatectomy with Venous Resection: A Systematic Review. Cancers (Basel) 2024; 16:2361. [PMID: 39001423 PMCID: PMC11240683 DOI: 10.3390/cancers16132361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 06/24/2024] [Accepted: 06/26/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND The rising diffusion of vascular resections during complex pancreatectomy for malignancy, for both oncological and technical matters, brought with it the use of vascular shunts, either temporary or definitive, to prevent bowel congestion and liver ischemia. This study aimed to systematically review the literature on the technical feasibility of vascular shunts during advanced pancreatic surgery, analyzing intraoperative and postoperative outcomes. METHODS A systematic literature search was performed on PubMed, Scopus, Web of Science, and the Cochrane Library Central, according to PRISMA guidelines. Studies published before 2006 were excluded, considering the lack of a standardized definition of locally advanced pancreatic cancer. The main outcomes evaluated were the overall complication rate and shunt patency. RESULTS Among 789 papers retrieved from the database search, only five fulfilled the inclusion criteria and were included in the review, amounting to a total of 145 patients undergoing a shunt creation at the time of pancreatectomy. Pancreatic adenocarcinoma (PDAC) was found to be the most common diagnosis and pancreaticoduodenectomy was the main surgical procedure, accounting for 88% and 83% of the overall cohort, respectively. The distal splenorenal shunt was the most performed. Overall, 44 out of 145 patients (30%) experienced postoperative complications; the long-term patency of definitive shunts was 83% (110 out of 120 patients). CONCLUSIONS An increasing number of patients with borderline resectable or locally advanced PDAC are becoming amenable to resection and shunt creation may facilitate vascular resection with clear margins, becoming a valid tool of modern pancreatic surgery.
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Affiliation(s)
- Annarita Libia
- General Surgery Unit, Vito Fazzi Hospital, 73100 Lecce, Italy
| | | | - Stefano D’Ugo
- General Surgery Unit, Vito Fazzi Hospital, 73100 Lecce, Italy
| | - Prisco Piscitelli
- Department of Biological and Environmental Sciences and Biotechnologies, University of Salento, 73100 Lecce, Italy
- Local Health Authority, ASL LE, 73100 Lecce, Italy
| | - Fabio Castellana
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Maria Lisa Clodoveo
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy
| | - Roberta Zupo
- Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Piazza Giulio Cesare 11, 70100 Bari, Italy
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Mansour N, Sirtl S, Angele MK, Wildgruber M. Management of Sinistral Portal Hypertension after Pancreaticoduodenectomy. Dig Dis 2024; 42:178-185. [PMID: 38185113 PMCID: PMC10997249 DOI: 10.1159/000535774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 12/08/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Sinistral, or left-sided, portal hypertension (SPH) is a rare cause of upper gastrointestinal (GI) hemorrhage resulting from obstruction of the splenic vein. Venous drainage from the spleen via collaterals can result in venous hemorrhage into both the retroperitoneal and intra-abdominal spaces due to increased venous blood pressure in peripancreatic and gastroduodenal vasculature. SPH can occur secondary to pancreatitis with thrombosis of the splenic vein. Another possible cause is the surgical ligation of the splenic vein as part of pancreaticoduodenectomy (PD). Although splenectomy has been traditionally considered as the treatment of choice to relieve venous hypertension, individual concepts for each patient have to be developed. Considering the venous collateral drainage pathways, a comprehensive approach involving surgical, endoscopic, and interventional radiology interventions may be necessary to address the underlying cause of variceal bleeding. Among these approaches, splenic artery embolization (SAE) has demonstrated efficacy in mitigating the adverse effects associated with elevated venous outflow pressure. SUMMARY This review summarizes key imaging findings in SPH patients after PD and highlights the potential of minimally invasive embolization for curative treatment of variceal hemorrhage. KEY MESSAGES (i) SPH is a potential consequence after major pancreas surgery. (ii) Collateral flow can lead to life-threatening abdominal bleeding. (iii) Depending on the origin and localization of the bleeding, a dedicated management is required, frequently involving interventional radiology techniques.
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Affiliation(s)
- Nabeel Mansour
- Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Simon Sirtl
- Department of Medicine II, LMU University Hospital, LMU Munich, Munich, Germany
| | - Martin K. Angele
- Department for General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | - Moritz Wildgruber
- Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany
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Hatai S, Kaku K, Kubo S, Sato Y, Noguchi H, Okabe Y, Ikenaga N, Nakata K, Nakamura M. Reconstruction with the right gastroepiploic vein during pancreaticoduodenectomy and total pancreatectomy to prevent left-sided portal hypertension: a report of two cases. Surg Case Rep 2023; 9:200. [PMID: 37982916 PMCID: PMC10660986 DOI: 10.1186/s40792-023-01773-x] [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: 08/22/2023] [Accepted: 10/25/2023] [Indexed: 11/21/2023] Open
Abstract
BACKGROUND Left-sided portal hypertension including gastric venous congestion may be caused by ligating the splenic vein during pancreaticoduodenectomy with portal vein resection or total pancreatectomy. The usefulness of reconstruction with the splenic vein has been reported in such cases. However, depending on the site of the tumor and other factors, it may be impossible to leave sufficient length of the splenic vein, making anastomosis difficult. We report two patterns of reconstruction with the right gastroepiploic vein during pancreaticoduodenectomy and total pancreatectomy to prevent left-sided portal hypertension. CASE PRESENTATION The first patient was a 79-year-old man who underwent pancreaticoduodenectomy for pancreatic cancer. The root of the splenic vein was infiltrated by the tumor, and we resected this vein at the confluence of the portal vein. Closure of the portal vein was performed without reconstruction of the splenic vein. To prevent left-sided portal hypertension, we anastomosed the right gastroepiploic vein to the middle colic vein. Postoperatively, there was no suggestion of left-sided portal hypertension, such as splenomegaly, varices, and thrombocytosis. The second case was a 63-year-old woman who underwent total pancreatectomy for pancreatic cancer. The splenic vein-superior mesenteric vein confluence was infiltrated by the tumor, and we resected the portal vein, including the confluence. End-to-end anastomosis was performed without reconstruction of the splenic vein. We also divided the left gastric vein, left gastroepiploic vein, right gastroepiploic vein, and right gastric vein, which resulted in a lack of drainage veins from the stomach and severe gastric vein congestion. We anastomosed the right gastroepiploic vein to the left renal vein, which improved the gastric vein congestion. Postoperatively, imaging confirmed short-term patency of the anastomosis site. Although the patient died because of tumor progression 8 months after the surgery, no findings suggested left-sided portal hypertension, such as varices. Reconstruction with the right gastroepiploic vein during pancreaticoduodenectomy and total pancreatectomy is useful to prevent left-sided portal hypertension.
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Affiliation(s)
- Sanshiro Hatai
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Keizo Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Shinsuke Kubo
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yu Sato
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Hiroshi Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Naoki Ikenaga
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
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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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Oba A, Del Chiaro M, Fujii T, Okano K, Stoop TF, Wu YHA, Maekawa A, Yoshida Y, Hashimoto D, Sugawara T, Inoue Y, Tanabe M, Sho M, Sasaki T, Takahashi Y, Matsumoto I, Sasahira N, Nagakawa Y, Satoi S, Schulick RD, Yoon YS, He J, Jang JY, Wolfgang CL, Hackert T, Besselink MG, Takaori K, Takeyama Y. "Conversion surgery" for locally advanced pancreatic cancer: A position paper by the study group at the joint meeting of the International Association of Pancreatology (IAP) & Japan Pancreas Society (JPS) 2022. Pancreatology 2023; 23:712-720. [PMID: 37336669 DOI: 10.1016/j.pan.2023.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 04/10/2023] [Accepted: 06/06/2023] [Indexed: 06/21/2023]
Abstract
Locally advanced pancreatic cancer (LAPC), which progresses locally and surrounds major vessels, has historically been deemed unresectable. Surgery alone failed to provide curative resection and improve overall survival. With the advancements in treatment, reports have shown favorable results in LAPC after undergoing successful chemotherapy therapy or chemoradiation therapy followed by surgical resection, so-called "conversion surgery", at experienced high-volume centers. However, recognizing significant regional and institutional disparities in the management of LAPC, an international consensus meeting on conversion surgery for LAPC was held during the Joint Congress of the 26th Meeting of the International Association of Pancreatology (IAP) and the 53rd Annual Meeting of Japan Pancreas Society (JPS) in Kyoto in July 2022. During the meeting, presenters reported the current best multidisciplinary practices for LAPC, including preoperative modalities, best systemic treatment regimens and durations, procedures of conversion surgery with or without vascular resections, biomarkers, and genetic studies. It was unanimously agreed among the experts in this meeting that "cancer biology is surpassing locoregional anatomical resectability" in the era of effective multiagent treatment. The biology of pancreatic cancer has yet to be further elucidated, and we believe it is essential to improve the treatment outcomes of LAPC patients through continued efforts from each institution and more international collaboration. This article summarizes the agreement during the discussion amongst the experts in the meeting. We hope that this will serve as a foundation for future international collaboration and recommendations for future guidelines.
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Affiliation(s)
- Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan; Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA.
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Kagawa University School of Medicine, Kagawa, Japan
| | - Thomas F Stoop
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Y H Andrew Wu
- Department Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aya Maekawa
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuta Yoshida
- Department of Surgery, Kindai University, Osaka, Japan
| | | | - Toshitaka Sugawara
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Minoru Tanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | | | - Naoki Sasahira
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Sohei Satoi
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin He
- Department Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | | | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany; Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Germany
| | - Marc G Besselink
- Amsterdam UMC, Location University of Amsterdam, Department of Surgery, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
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Pedrazzoli S. Surgical Treatment of Pancreatic Cancer: Currently Debated Topics on Vascular Resection. Cancer Control 2023; 30:10732748231153094. [PMID: 36693246 PMCID: PMC9893105 DOI: 10.1177/10732748231153094] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Vascular resections involving the superior mesenteric and portal veins (SMV-PV), celiac axis (CA), superior mesenteric artery (SMA) and hepatic artery (HA) have multiplied in recent years, raising the resection rate for pancreatic cancer (PDAC) and the related morbidity and mortality rates. While resection is generally accepted for resectable SMV-PV, the usefulness of associated arterial resection in borderline resectable (BRPC) and locally-advanced PDAC (LAPC) is much debated. Careful selection of splenic vein reconstruction is very important to prevent left-sided portal hypertension (LSPH). During distal pancreatectomy (DP), CA and common HA resection is largely accepted, while there is debate on the value of SMA and proper HA resection and reconstruction. Their resection is useless according to several reviews and meta-analyses, and some international societies, although some high-volume centers have reported good results. Short- and long-term reconstructed vessel patency varies with the type of reconstruction, the material used, and the surgeon's experience. Laparoscopic and robotic pancreaticoduodenectomy and DP are generally accepted if done by surgeons performing at least 10 such procedures annually. The usefulness of associated vascular resection remains highly controversial. Surgeons need to complete numerous minimally-invasive procedures to overcome the learning curve, and prevent an increase in complications and surgical mortality. Higher resectability rates and satisfactory long-term results have been reported after neoadjuvant therapy (NAT) for BRPC and LAPC requiring vascular resection. It is essential to select the most appropriate NAT for a given patient and to assess PDAC resectability preoperatively.
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Affiliation(s)
- Sergio Pedrazzoli
- University of Padua, Padova, Italy,Sergio Pedrazzoli, University of Padua, Via Crescini, 39, Padova 35126, Italy.
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Kauffmann EF, Napoli N, Ginesini M, Gianfaldoni C, Asta F, Salamone A, Ripolli A, Di Dato A, Vistoli F, Amorese G, Boggi U. Tips and tricks for robotic pancreatoduodenectomy with superior mesenteric/portal vein resection and reconstruction. Surg Endosc 2023; 37:3233-3245. [PMID: 36624216 PMCID: PMC10082118 DOI: 10.1007/s00464-022-09860-0] [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: 08/28/2022] [Accepted: 12/27/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Open pancreatoduodenectomy with vein resection (OPD-VR) is now standard of care in patients who responded to neoadjuvant therapies. Feasibility of robotic pancreatoduodenectomy (RPD) with vein resection (RPD-VR) was shown, but no study provided a detailed description of the technical challenges associated with this formidable operation. Herein, we describe the trips and tricks for technically successful RPD-VR. METHODS The vascular techniques used in RPD-VR were borrowed from OPD-VR, as well as from our experience with robotic transplantation of both kidney and pancreas. Vein resection was classified into 4 types according to the international study group of pancreatic surgery. Each type of vein resection was described in detail and shown in a video. RESULTS Between October 2008 and November 2021, a total of 783 pancreatoduodenectomies were performed, including 233 OPDs-VR (29.7%). RPD was performed in 256 patients (32.6%), and RPDs-VR in 36 patients (4.5% of all pancreatoduodenectomies; 15.4% of all pancreatoduodenectomies with vein resection; 14.0% of all RPDs). In RPD-VR vein resections were: 4 type 1 (11.1%), 10 type 2 (27.8%), 12 type 3 (33.3%) and 10 type 4 (27.8%). Vascular patches used in type 2 resections were made of peritoneum (n = 8), greater saphenous vein (n = 1), and deceased donor aorta (n = 1). Interposition grafts used in type 4 resections were internal left jugular vein (n = 8), venous graft from deceased donor (n = 1) and spiral saphenous vein graft (n = 1). There was one conversion to open surgery (2.8%). Ninety-day mortality was 8.3%. There was one (2.8%) partial vein thrombosis, treated with heparin infusion. CONCLUSIONS We have reported 36 technically successful RPDs-VR. We hope that the tips and tricks provided herein can contribute to safer implementation of RPD-VR. Based on our experience, and according to data from the literature, we strongly advise that RPD-VR is performed by expert surgeons at high volume centers.
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Affiliation(s)
- Emanuele F Kauffmann
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
| | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Cesare Gianfaldoni
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Fabio Asta
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Alice Salamone
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Allegra Ripolli
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Armando Di Dato
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Fabio Vistoli
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - Gabriella Amorese
- Division of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
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Kim SH, Kim SS, Hwang HK, Lee WJ, Kang CM. Should the Splenic Vein Be Preserved-Fate of Sinistral Portal Hypertension after Pancreatoduodenectomy with Vascular Re-Section for Pancreatic Cancer. Cancers (Basel) 2022; 14:cancers14194853. [PMID: 36230776 PMCID: PMC9564260 DOI: 10.3390/cancers14194853] [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: 08/26/2022] [Revised: 09/29/2022] [Accepted: 09/30/2022] [Indexed: 11/16/2022] Open
Abstract
Background: This study aims to evaluate sinistral portal hypertension (SPH) development and its clinical impact on the long-term outcomes of patients with pancreatic cancer who underwent surgical resection with splenic vein (SV) ligation. Methods: Data from 94 consecutive patients who underwent pancreatoduodenectomy (PD) with vascular resection for pancreatic cancer from 2008 to 2019 were retrospectively collected. The patients were divided into two groups according to whether the SV was preserved or ligated during the surgery. Their computed tomography images were serially reviewed (preoperative, 6-, 12-, and 24-months postoperative) with clinical parameters. The degree of variceal formation (variceal score) and splenomegaly were assessed, and the oncologic outcomes were compared between the two groups. Variceal score in the SV ligation group was significantly higher than that in the SV saving group at the same postoperative periods (SV saving vs. ligation: 12 months, 0.9 ± 1.3 vs. 3.5 ± 2.2, p < 0.001; 24 months, 1.4 ± 1.8 vs. 4.0 ± 3.4, p = 0.009). Clinically relevant variceal bleeding was noted in one patient from the SV ligation group (SV saving vs. ligation: 0.0% vs. 3.1%, p = 0.953). In survival analysis, there was no significant difference between the two groups (DFS; SV saving vs. ligation: 13.0 (11.1−14.9) months vs. 13.0 (10.4−15.6) months, p = 0.969, OS; SV saving vs. ligation: 35.0 (19.9−50.1) months vs. 27.0 (11.6−42.4) months, p = 0.417). Although SV ligation induced SPH during PD for pancreatic cancer, it did not lead to clinically significant long-term complications. In addition, it did not impact the long-term survival of patients with resected pancreatic head cancer.
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Affiliation(s)
- Sung Hyun Kim
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea
- Pancreaticobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul 03722, Korea
| | - Seung-Seob Kim
- Pancreaticobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul 03722, Korea
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Ho Kyoung Hwang
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea
- Pancreaticobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul 03722, Korea
| | - Woo Jung Lee
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea
- Pancreaticobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul 03722, Korea
| | - Chang Moo Kang
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Seoul 03722, Korea
- Pancreaticobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul 03722, Korea
- Correspondence: ; Tel.: +82-2-2228-2100; Fax: +82-2-313-8289
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Feasibility and outcome of spleen and vessel preserving total pancreatectomy (SVPTP) in pancreatic malignancies - a retrospective cohort study. Langenbecks Arch Surg 2022; 407:3457-3465. [PMID: 36169725 DOI: 10.1007/s00423-022-02690-7] [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: 05/23/2022] [Accepted: 09/15/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Total pancreatectomy (TP) is most commonly performed to avoid postoperative pancreatic fistula (POPF) in patients with high-risk pancreas or to achieve tumor-free resection margins. As part of TP, a simultaneous splenectomy is usually performed primarily for the reason of oncologic radicality. However, the benefit of a simultaneous splenectomy remains unclear. Likewise, the technical feasibility as well as the safety of spleen and vessel preserving total pancreatectomy in pancreatic malignancies has hardly been evaluated. Thus, the aims of the study were to evaluate the feasibility as well as the results of spleen and vessel preserving total pancreatectomy (SVPTP). MATERIAL AND METHODS Patient characteristics, technical feasibility, perioperative data, morbidity, and mortality as well as histopathological results after SVPTP, mainly for pancreatic malignancies, from patient cohorts of two European high-volume-centers for pancreatic surgery were retrospectively analyzed. Mortality was set as the primary outcome and morbidity (complications according to Clavien-Dindo) as the secondary outcome. RESULTS A SVPTP was performed in 92 patients, predominantly with pancreatic adenocarcinoma (78.3%). In all cases, the splenic vessels could be preserved. In 59 patients, the decision to total pancreatectomy was made intraoperatively. Among these, the most common reason for total pancreatectomy was risk of POPF (78%). The 30-day mortality was 2.2%. Major complications (≥ IIIb according to Clavien-Dindo) occurred in 18.5% within 30 postoperative days. There were no complications directly related to the spleen and vascular preservation procedure. A tumor-negative resection margin was achieved in 71.8%. CONCLUSION We could demonstrate the technical feasibility and safety of SVPTP even in patients mainly with pancreatic malignancies. In addition to potential immunologic and oncologic advantages, we believe a major benefit of this procedure is preservation of gastric venous outflow. We consider SVPTP to be indicated in patients at high risk for POPF, in patients with multilocular IPMN, and in cases for extended intrapancreatic cancers.
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Vuorela T, Vikatmaa P, Kokkola A, Mustonen H, Salmiheimo A, Eurola A, Aho P, Haglund C, Kantonen I, Seppänen H. Long Term Results of Pancreatectomy With and Without Venous Resection: A Comparison of Safety and Complications of Spiral Graft, End-to-End and Tangential/Patch Reconstruction Techniques. Eur J Vasc Endovasc Surg 2022; 64:244-253. [PMID: 35462018 DOI: 10.1016/j.ejvs.2022.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/07/2022] [Accepted: 04/05/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Roughly 10% - 20% of pancreatic cancer patients are candidates for curative intent surgical treatment. In the 2000s, many studies showed similar survival rates comparing pancreatic surgery with or without vein resection and reconstruction. The aim was to identify the best method of venous reconstruction. METHODS This was a retrospective cohort study. A total of 1 375 patients undergoing pancreatectomy between 2005 and 2018 were identified. Patients undergoing a combined pancreatic resection and venous reconstruction were included retrospectively. When tumour infiltration to the portal/superior mesenteric vein was detected, excision and reconstruction with tangential suturing/patch, end to end anastomosis, or a spiral graft from the great saphenous vein was performed. Next, 90 day and long term survival and outcomes across reconstruction techniques were analysed. RESULTS Overall, 198 patients had venous involvement visible in pre-operative scans or detected during surgery, broken down as follows: 171 (86%) pancreaticoduodenectomy, 12 (6%) total pancreatectomy, and 15 (8%) distal pancreatectomy. In total, 69 (35%) spiral graft reconstructions, 77 (39%) end to end anastomoses, and 52 (26%) tangential/patch reconstructions were performed. Tumour histology revealed pancreatic adenocarcinomas in 162 (82%) patients, intraductal mucinous pancreatic neoplasia in 14 (7%), cholangiocarcinoma in five (3%), neuro-endocrine neoplasia in nine (5%), and eight other diagnoses. Overall, 183 (92%) were malignant and 15 (8%) benign. Two patients died within 90 days, one in hospital and one on post-operative day 38 due to thrombosis of the superior mesenteric vein and intestinal necrosis, a Clavien-Dindo grade 5 complication. In addition, 50 (23%) patients had Clavien-Dindo grade 3 - 4 complications. No differences in complications comparing vein reconstruction techniques or in the long term survival of pancreatectomy patients with or without venous reconstruction were detected. CONCLUSION The spiral graft technique, used when more advanced venous infiltration occurs, does not increase complications, with outcomes mirroring those accompanying shorter venous resections.
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Affiliation(s)
- Tiina Vuorela
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Finland.
| | - Pirkka Vikatmaa
- Department of Vascular Surgery, Abdominal Centre, University of Helsinki and Helsinki University Hospital, Finland
| | - Arto Kokkola
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Finland
| | - Harri Mustonen
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Finland; Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Aino Salmiheimo
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Finland
| | - Annika Eurola
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Finland
| | - Pekka Aho
- Department of Vascular Surgery, Abdominal Centre, University of Helsinki and Helsinki University Hospital, Finland
| | - Caj Haglund
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Finland; Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Finland
| | - Ilkka Kantonen
- Department of Vascular Surgery, Abdominal Centre, University of Helsinki and Helsinki University Hospital, Finland
| | - Hanna Seppänen
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Finland; Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Finland
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Vascular Resection in Pancreatectomy—Is It Safe and Useful for Patients with Advanced Pancreatic Cancer? Cancers (Basel) 2022; 14:cancers14051193. [PMID: 35267500 PMCID: PMC8909590 DOI: 10.3390/cancers14051193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease with poor prognosis and increased incidence. Surgical resection R0 remains the most important treatment to prolong survival in PDAC patients. In borderline and locally advanced cancer, vascular resection and reconstruction during pancreatectomy enables achieving R0 resection. This study is a comprehensive review of the literature regarding the role of venous and arterial resection with vascular reconstruction in the treatment of pancreatic cancer. Abstract Pancreatic ductal adenocarcinoma (PDAC) is a lethal disease with poor prognosis and increased incidence. Surgical resection R0 remains the most important treatment to prolong survival in PDAC patients. In borderline and locally advanced cancer, vascular resection and reconstruction during pancreatectomy enables achieving R0 resection. This study is a comprehensive review of the literature regarding the role of venous and arterial resection with vascular reconstruction in the treatment of pancreatic cancer. The literature review is focused on the use of venous and arterial resection with immediate vascular reconstruction in pancreaticoduodenectomy. Different types of venous and arterial resections are widely described. Different methods of vascular reconstructions, from primary vessel closure, through end-to-end vascular anastomosis, to interposition grafts with use autologous veins (internal jugular vein, saphenous vein, superficial femoral vein, external or internal iliac veins, inferior mesenteric vein, and left renal vein or gonadal vein), autologous substitute grafts constructed from various parts of parietal peritoneum including falciform ligament, cryopreserved and synthetic allografts. The most attention was given to the most common venous reconstructions, such as end-to-end anastomosis and interposition graft with the use of an autologous vein. Moreover, we presented mortality and morbidity rates as well as vascular patency and survival following pancreatectomy combined with vascular resection reported in cited articles.
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14
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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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15
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Hori T, Aoyama R, Yamamoto H, Harada H, Yamamoto M, Yamada M, Yazawa T, Zaima M. Sinistral portal hypertension and distal splenorenal shunt during pancreatic surgery. Hepatobiliary Pancreat Dis Int 2022; 21:73-75. [PMID: 34481759 DOI: 10.1016/j.hbpd.2021.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/20/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Tomohide Hori
- Department of Surgery, Shiga General Hospital, 5-4-30 Moriyama, Moriyama City, Shiga Prefecture, 524-8524, Japan.
| | - Ryuhei Aoyama
- Department of Surgery, Shiga General Hospital, 5-4-30 Moriyama, Moriyama City, Shiga Prefecture, 524-8524, Japan
| | - Hidekazu Yamamoto
- Department of Surgery, Shiga General Hospital, 5-4-30 Moriyama, Moriyama City, Shiga Prefecture, 524-8524, Japan
| | - Hideki Harada
- Department of Surgery, Shiga General Hospital, 5-4-30 Moriyama, Moriyama City, Shiga Prefecture, 524-8524, Japan
| | - Michihiro Yamamoto
- Department of Surgery, Shiga General Hospital, 5-4-30 Moriyama, Moriyama City, Shiga Prefecture, 524-8524, Japan
| | - Masahiro Yamada
- Department of Surgery, Shiga General Hospital, 5-4-30 Moriyama, Moriyama City, Shiga Prefecture, 524-8524, Japan
| | - Takefumi Yazawa
- Department of Surgery, Shiga General Hospital, 5-4-30 Moriyama, Moriyama City, Shiga Prefecture, 524-8524, Japan
| | - Masazumi Zaima
- Department of Surgery, Shiga General Hospital, 5-4-30 Moriyama, Moriyama City, Shiga Prefecture, 524-8524, Japan
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16
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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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17
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Karunakaran M, Barreto SG. Surgery for pancreatic cancer: current controversies and challenges. Future Oncol 2021; 17:5135-5162. [PMID: 34747183 DOI: 10.2217/fon-2021-0533] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Two areas that remain the focus of improvement in pancreatic cancer include high post-operative morbidity and inability to uniformly translate surgical success into long-term survival. This narrative review addresses specific aspects of pancreatic cancer surgery, including neoadjuvant therapy, vascular resections, extended pancreatectomy, extent of lymphadenectomy and current status of minimally invasive surgery. R0 resection confers longer disease-free survival and overall survival. Vascular and adjacent organ resections should be undertaken after neoadjuvant therapy, only if R0 resection can be ensured based on high-quality preoperative imaging, and that too, with acceptable post-operative morbidity. Extended lymphadenectomy does not offer any advantage over standard lymphadenectomy. Although minimally invasive distal pancreatectomies offers some short-term benefits over open distal pancreatectomy, safety remains a concern with minimally invasive pancreatoduodenectomy. Strict adherence to principles and judicious utilization of surgery within a multimodality framework is the way forward.
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Affiliation(s)
- Monish Karunakaran
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology & Bariatric Surgery, Medanta Institute of Digestive & Hepatobiliary Sciences, Medanta-The Medicity, Gurugram 122001, India.,Department of Liver Transplantation & Regenerative Medicine, Medanta-The Medicity, Gurugram 122001, India
| | - Savio George Barreto
- College of Medicine & Public Health, Flinders University, South Australia, Australia.,Division of Surgery & Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia
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18
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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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20
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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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21
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Garnier J, Ewald J, Marchese U, Delpero JR, Turrini O. Standardized salvage completion pancreatectomy for grade C postoperative pancreatic fistula after pancreatoduodenectomy (with video). HPB (Oxford) 2021; 23:1418-1426. [PMID: 33832833 DOI: 10.1016/j.hpb.2021.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/17/2021] [Accepted: 02/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Emergency completion pancreatectomy (CP) after pancreatoduodenectomy (PD) is a technically demanding procedure. We report our experiences with a four-step standardized technique used at our center since 2012. METHODS In the first step, the gastrojejunostomy is divided with a stapler to quickly access the pancreatic anastomosis and permit adequate exposure, especially in cases of active bleeding. Second, the bowel loops connected to the pancreatic anastomosis is divided in cases of pancreaticojejunostomy. Third, the pancreatectomy is completed with or without the splenic vessels and spleen conservation according to the local conditions. Finally, the fourth step reconstructs in a Roux-en-Y fashion and ensures drainage. RESULTS From January 2012 to December 2019, 450 patients underwent PD at our center. Reintervention for grade C postoperative pancreatic fistula was decided for 30 patients, and CP was performed in 21 patients. The mean intraoperative blood loss and operative duration were relatively low (600 ml and 240 min, respectively). During the perioperative period, three patients died from multiple organ failure, and two patients died intraoperatively from a cataclysmic hemorrhage originating from the superior mesenteric artery. DISCUSSION Our standardized procedure appears to be relatively safe, reproducible, and could be particularly useful for young surgeons.
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Affiliation(s)
- Jonathan Garnier
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France.
| | - Jacques Ewald
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France
| | - Ugo Marchese
- Department of Surgery, Institut Paoli-Calmettes, Marseille, France
| | | | - Olivier Turrini
- Department of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, CRCM, Marseille, France
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22
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A Thought-Provoking Case of Successfully Treated Carcinoma of the Head of the Pancreas with Metachronous Lung Metastasis: Impact of Distal Spleno-Renal Shunt for Regional Invasion on Long-Term Period after Pancreaticoduodenectomy. Case Rep Surg 2021; 2021:6689419. [PMID: 34136302 PMCID: PMC8179775 DOI: 10.1155/2021/6689419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 05/14/2021] [Indexed: 12/03/2022] Open
Abstract
When performing pancreaticoduodenectomy with resection of the confluence of the superior mesenteric vein and portal vein, division of the splenic vein may cause sinistral portal hypertension resulting in gastrointestinal bleeding, splenic congestion, and hypersplenism. To prevent these adverse events, it is important to intentionally decompress the splenic vein. This report is of a 68-year-old woman with stage IA carcinoma of the head of the pancreas who survived for more than six years following tumor resection and pancreaticoduodenectomy and distal splenorenal shunt. A 68-year-old woman was diagnosed with carcinoma of the head of the pancreas that involved the confluence of the superior mesenteric vein, portal vein, and splenic vein. No unresectable cancer sites or distant metastases were detected. Pancreaticoduodenectomy with resection of the confluence of the superior mesenteric vein and portal vein was performed. The superior mesenteric vein and portal vein were anastomosed in the end-to-end fashion, and the remnant splenic vein was anastomosed to the superior aspect of the left renal vein in the end-to-side fashion. At 22 months after the initial surgery, the patient underwent partial lung resection for a metachronous lung metastasis. For 6 years after the initial surgery, the venous reconstructions have maintained their patency without any obstruction of splenic venous flow, and the patient has remained in good health without further metastases or recurrences. This case has shown the importance of early diagnosis of carcinoma of the head of the pancreas, as appropriate and timely surgical management can result in good outcome. This patient responded well and remains alive six years following pancreaticoduodenectomy and preservation of the spleen with the use of a distal splenorenal shunt.
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23
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Garnier J, Traversari E, Ewald J, Marchese U, Delpero JR, Turrini O. Venous Reconstruction During Pancreatectomy Using Polytetrafluoroethylene Grafts: A Single-Center Experience with Standardized Perioperative Management. Ann Surg Oncol 2021; 28:5426-5433. [PMID: 33655364 DOI: 10.1245/s10434-021-09716-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/26/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although primary end-to-end anastomosis is preferred for portal vein-superior mesenteric vein (PV-SMV) reconstruction, interposition graft use may be required in some situations. We investigated the efficacy of polytetrafluoroethylene (PTFE) grafts when used during pancreatectomy in this context. METHODS From 2014 to 2019, 19 patients who underwent pancreatectomy requiring PV-SMV reconstruction using ringed PTFE grafts were entered prospectively into a clinical database (NCT02871336, CNIL No. Sy50955016U). Unfractionated heparin was used during the first 24 h postoperatively. The administration of low-molecular-weight heparin was initiated twice a day (two injections of 1 mg/kg enoxaparin) on postoperative day 2 and was continued until the first clinical follow-up. Patency was assessed by CT scan before home discharge. Patients were switched to antiplatelet therapy (75 mg of aspirin-based drug Kardegic®) without a deadline. RESULTS Pancreatoduodenectomy was the most commonly performed procedure (15 patients, 79%), and pancreatic duct adenocarcinoma was the predominant etiology (17 patients, 89%). The median PTFE graft diameter and length were 10 mm and 8 cm, respectively. The median clamping time was 25 min. The overall severe morbidity and 90-day mortality values were 21% and 10%, respectively. None of the patients experienced anticoagulation-related morbidity or PTFE graft-related infection. The 6-month PTFE graft patency rate was 68%. Patients who underwent distal pancreatectomy showed a higher late thrombosis rate than those who underwent a pancreaticoduodenectomy (50% vs. 8%, p = 0.049). The median long-term PTFE graft patency duration was 37 months. CONCLUSIONS PTFE reconstruction can be safely performed with simple perioperative management in cases requiring interposition graft use.
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Affiliation(s)
- Jonathan Garnier
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France.
| | - Eddy Traversari
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Jacques Ewald
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Ugo Marchese
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Jean-Robert Delpero
- Department of Surgical Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Olivier Turrini
- Department of Surgical Oncology, CRCM, Institut Paoli-Calmettes, Aix-Marseille University, Marseille, France
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24
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Matsuki R, Momose H, Kogure M, Suzuki Y, Mori T, Sakamoto Y. Direct splenic vein reconstruction combined with resection of the portal vein/superior mesenteric vein confluence during pancreaticoduodenectomy. Langenbecks Arch Surg 2021; 406:1691-1695. [PMID: 33479791 DOI: 10.1007/s00423-020-02064-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/15/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Splenic vein (SV) ligation combined with portal vein (PV)/superior mesenteric vein (SMV) confluence resection during pancreaticoduodenectomy (PD) is reported to cause left-side portal hypertension (LPH). The purpose of this study was to present our technique of the SV reconstruction and to evaluate the surgical outcomes with/without SV ligation during PD. METHODS Twenty-four patients undergoing PD with PV and/or SMV resection and being followed over 4 months after surgery between March 2013 and December 2019 in our hospital were evaluated. Resection of the PV/SMV confluence were performed in 14, and SV reconstruction was successfully performed in 3. Presence of LPH was assessed by examining changes in splenic volume, newly venous collateral formation, and platelet counts before and 4-8 months after PD. Surgical technique is the direct anastomosis between SV and PV. RESULTS Splenic volume ratio was significantly higher in the SV ligation group (n = 11) than in the SV preservation group (n = 13) (median (range) 1.11 (0.57-1.62) vs. 1.68 (1.05-2.22), p < 0.01), but no significant differences were found in the incidence of newly formed venous collaterals or platelet counts between groups. CONCLUSION SV ligation may represent the cause of LPH after PD combined with resection of PV/SMV confluence. Our simple procedure may help decrease the incidence of LPH.
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Affiliation(s)
- Ryota Matsuki
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Hirokazu Momose
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Masaharu Kogure
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Yutaka Suzuki
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Toshiyuki Mori
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan
| | - Yoshihiro Sakamoto
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan.
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25
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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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26
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Yamada D, Takahashi H, Hama N, Toshiyama R, Asukai K, Hasegawa S, Wada H, Sakon M, Ishikawa O. The clinical impact of splenic artery ligation on the occurrence of digestive varices after pancreaticoduodenectomy with combined portal vein resection: a retrospective study in two institutes. Langenbecks Arch Surg 2020; 406:1469-1479. [PMID: 33063227 DOI: 10.1007/s00423-020-02010-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 10/07/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Pancreaticoduodenectomy (PD) concomitant with portal vein resection (PVR) often develops into digestive varices with an occurrence rate of 30-50%, and the variceal bleeding is sometimes untreatable and results in fatality. Against this issue, splenic artery (SpA) ligation during PD-PVR is emerging as an easy and effective prophylactic surgical option. The aim of this study was to investigate the significance of SpA ligation in the development of digestive varices in patients undergoing PD-PVR. METHOD We retrospectively investigated 97 patients with PDAC who received PD-PVR in two hospitals. Vascular reconstruction of the splenic vein (SpV) was not performed in either hospital. We assessed the occurrence rate of digestive varices in these patients in association with the performance of SpA ligation. RESULTS The occurrence rate of digestive varices was 23%. SpA ligation was the only significant decreasing factor for the development of digestive varices (odds ratio 0.3, p = 0.035). Although SpV resection was not a significant risk factor for the development of digestive varices in all patients, SpV resection was a significant risk factor for the development of digestive varices in patients without SpA ligation, as demonstrated in previous reports. SpA ligation did not increase surgical complications or impair pancreatic function. CONCLUSION PD-PVR surgery was accompanied by a 23% incidence of digestive varices, and SpA ligation significantly decreased the development of digestive varices without causing clinically significant complications. TRIAL REGISTRATION No. 18196 (Osaka International Cancer Institute) and no. 19006 (National Hospital Organization Osaka National Hospital).
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Affiliation(s)
- Daisaku Yamada
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Hidenori Takahashi
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan.
| | - Naoki Hama
- Department of Surgery, National Hospital Organization Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka, 540-0006, Japan
| | - Reishi Toshiyama
- Department of Surgery, National Hospital Organization Osaka National Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka, 540-0006, Japan
| | - Kei Asukai
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Shinichiro Hasegawa
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Hiroshi Wada
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Masato Sakon
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
| | - Osamu Ishikawa
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, 3-1-69 Otemae, Chuo-ku, Osaka, 541-8567, Japan
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27
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Commentary: Complex venous resection and reconstruction for locally advanced pancreatic cancer: Our approach. Surgery 2020; 168:1056-1057. [PMID: 32928574 DOI: 10.1016/j.surg.2020.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 08/14/2020] [Indexed: 11/20/2022]
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28
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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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29
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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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30
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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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Oba A, Ito H, Ono Y, Sato T, Mise Y, Inoue Y, Takahashi Y, Saiura A. Regional pancreatoduodenectomy versus standard pancreatoduodenectomy with portal vein resection for pancreatic ductal adenocarcinoma with portal vein invasion. BJS Open 2020; 4:438-448. [PMID: 32191395 PMCID: PMC7260410 DOI: 10.1002/bjs5.50268] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/12/2019] [Accepted: 01/19/2020] [Indexed: 12/11/2022] Open
Abstract
Background Pancreatoduodenectomy (PD) with portal vein resection (PVR) is a standard operation for pancreatic ductal adenocarcinoma (PDAC) with portal vein (PV) invasion, but positive margin rates remain high. It was hypothesized that regional pancreatoduodenectomy (RPD), in which soft tissue around the PV is resected en bloc, could enhance oncological clearance and survival. Methods This retrospective study included consecutive patients who underwent PD with PVR between January 2005 and December 2016 in a single high‐volume centre. In standard PD (SPD) with PVR, the PV was skeletonized and the surrounding soft tissue dissected. In RPD, the retropancreatic segment of the PV was resected en bloc with its surrounding soft tissue. The extent of lymphadenectomy was similar between the procedures. Results A total of 268 patients were included (177 SPD, 91 RPD). Tumours were more often resectable in patients undergoing SPD (60·5 per cent versus 38 per cent in those having RPD; P = 0·014), and consequently they received neoadjuvant therapy less often (7·9 versus 25 per cent respectively; P < 0·001). R0 resection was achieved in 73 patients (80 per cent) in the RPD group, compared with 117 (66·1 per cent) of those in the SPD group (P = 0·016), although perioperative outcomes were comparable between the groups. Median recurrence‐free (RFS) and overall (OS) survival were 17 and 32 months respectively in patients who had RPD, compared with 11 and 21 months in those who had SPD (RFS: P = 0·003; OS: P = 0·004). Conclusion RPD is as safe and feasible as SPD, and may increase the survival of patients with PDAC with PV invasion.
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Affiliation(s)
- A Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - H Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Y Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - T Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Y Mise
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Y Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Y Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - A Saiura
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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Surgical treatment of gastric venous congestion in association with extended resection of pancreas: a case report. BMC Surg 2020; 20:28. [PMID: 32041579 PMCID: PMC7011434 DOI: 10.1186/s12893-020-0692-4] [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: 11/06/2019] [Accepted: 02/03/2020] [Indexed: 11/30/2022] Open
Abstract
Background Total pancreatectomy is performed for chronic pancreatitis, tumors involving the entire pancreas or remnant pancreas after pancreatectomy. Gastric venous congestion and bleeding may be associated with total pancreatectomy. We report the case of a patient who underwent left gastric vein to splenic vein bypass to relieve gastric venous congestion during total pancreatectomy for remnant pancreatic cancer. Case presentation A 60-year-old woman underwent subtotal stomach-preserving pancreaticoduodenectomy for cancer of the pancreatic head. A follow-up computed tomography revealed a low-density tumor of the remnant pancreas. The pathological diagnosis was adenocarcinoma on endoscopic ultrasound-fine needle aspiration. Total resection of the remnant pancreas was performed for the tumor 3 years after the initial surgery. We ligated the splenic vein at the point of distal side of the left gastric vein confluent. Immediately, the vein congestion around the stomach was confirmed. We found the stenosis of the confluent between the left gastric vein and splenic vein. We subsequently anastomosed the left gastric vein and splenic vein, following which the gastric venous congestion was relieved. Conclusion In cases wherein all the drainage veins from the stomach are removed, an anastomosis between the left gastric vein and splenic vein can be effectively used to prevent gastric venous congestion and bleeding after total pancreatectomy.
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Delpero JR, Sauvanet A. Vascular Resection for Pancreatic Cancer: 2019 French Recommendations Based on a Literature Review From 2008 to 6-2019. Front Oncol 2020; 10:40. [PMID: 32117714 PMCID: PMC7010716 DOI: 10.3389/fonc.2020.00040] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/10/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction: Vascular resection remains a subject of debate in the management of Pancreatic Ductal Adenocarcinoma (PDAC). These French recommendations were drafted on behalf of the French National Institute of Cancer (INCA-2019). Material and Methods: A systematic literature search, with PubMed, Medline® (OvidSP), EMBASE, the Cochrane Library, was performed for abstracts published in English from January 2008 to June 2019, and identified systematic reviews/metaanalyses, retrospective analyses and case series dedicated to vascular resections in the setting of PDAC. All selected articles were graded for level of evidence and strength of recommendation was given according to the GRADE system. Results: Neoadjuvant treatment should be performed rather than direct surgery in borderline and locally advanced non-metastatic PDAC with venous and/or arterial infiltration (T4 stage). Patients who respond or those with stable disease and good performance status should undergo surgical exploration to assess resectability because cross-sectional imaging often fails to identify the extent of the remaining viable tumor. Combining vascular resection with pancreatectomy in these cases increases the feasibility of curative resection which is still the only option to improve long-term survival. Venous resection (VR) is recommended if resection is possible in the presence of limited lateral or circumferential involvement but without venous occlusion and in the absence of arterial contact with the celiac axis (CA; cephalic tumors) or the superior mesenteric artery (SMA; all tumor locations) (Grade B). The patients should be in good general condition because mortality and morbidity are higher than following pancreatectomy without VR (Grade B). In case of planned VR, neoadjuvant treatment is recommended since it improves both rate of R0 resections and survival compared to upfront surgery (Grade B). Due to their complexity and specificities, arterial resection (AR; mainly the hepatic artery (HA) or the CA) must be discussed in selected patients, in multidisciplinary team meetings in tertiary referral centers, according to the tumor location and the type of arterial extension. In case of invasion of a short segment of the common HA, resection with arterial reconstruction may be proposed after neoadjuvant therapy. In case of SMA invasion, neoadjuvant therapy may be followed by laparotomy with dissection and biopsy of peri-arterial tissues. A pancreaticoduodenectomy (PD) with SMA-resection is not recommended if the frozen section examination is positive (Grade C). In case of distal PDAC with invasion of the CA, a distal pancreatectomy with CA-resection without arterial reconstruction may be proposed after neoadjuvant therapy and radiologic embolization of the CA branches (expert opinion). Conclusion: For PDAC with vascular involvement, neoadjuvant treatment followed by pancreatectomy with venous resection or even arterial resection can be proposed as a curative option in selected patients with selected vascular involvement.
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Affiliation(s)
- Jean Robert Delpero
- Institut Paoli-Calmettes (IPC), Marseille, France.,Faculté de Médecine, Aix Marseille Université, Marseille, France
| | - Alain Sauvanet
- Hôpital Beaujon, Clichy, France.,Université Paris VII - Denis Diderot, Paris, France
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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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Kushiya H, Noji T, Abo D, Soyama T, Tanaka K, Nakanishi Y, Asano T, Nakamura T, Tsuchikawa T, Okamura K, Hirano S. Treatment of bleeding from a portion of pancreatojejunostomy after pancreaticoduodenectomy with division of the splenic vein: two case reports. Surg Case Rep 2019; 5:128. [PMID: 31396775 PMCID: PMC6687795 DOI: 10.1186/s40792-019-0687-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/30/2019] [Indexed: 12/12/2022] Open
Abstract
Background There is no definitive strategy for gastrointestinal bleeding due to left-sided portal hypertension after pancreaticoduodenectomy (PD) for pancreatic cancer (PC) with concomitant portal vein resection (PVR). Case presentation Case 1: A 70-year-old woman underwent a PD for PC with PVR. Seven years after her surgery, she suffered severe anemia with suspected gastrointestinal bleeding. Computed tomography scan (CT) revealed varices at a portion of the pancreaticojejunostomy (PJ). Angiography revealed that splenic venous flow drained into the varices and then into the portal vein. A diagnosis of bleeding varices of the PJ due to left-sided portal hypertension was made. Following a partial splenic artery embolization, her anemia improved. Case 2: An 80-year-old male underwent a PD for pancreatic head cancer combined with resection of the confluence of the portal and splenic veins with a reconstruction between the portal and superior mesenteric veins. Eighteen months after his surgery, he developed melena with negative endoscopy findings in his large and small bowel. CT revealed varices at the site of the PJ that communicated with the jejunal and portal veins. He underwent obliteration of the varices via a trans-portal-venous approach. As a result, he remained without melena until he died of PC 17 months after the embolization. Conclusions Left-sided portal hypertension following a PD with bleeding varices can be treated by interventional radiology with minimal invasiveness.
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Affiliation(s)
- Hiroki Kushiya
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Takehiro Noji
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan.
| | - Daisuke Abo
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Takeshi Soyama
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Kita 15 Nishi 7, Kita-ku, Sapporo, 060-8638, Japan
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Yoshitsugu Nakanishi
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Toshimichi Asano
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Toru Nakamura
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Takahiro Tsuchikawa
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Keisuke Okamura
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery 2, Hokkaido University Faculty of Medicine, Kita 15 Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
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