Reconstruction of the portal vein using a peritoneal patch-graft

How we do it-the use of peritoneal patches for reconstruction of vena cava inferior and portal vein in hepatopancreatobiliary surgery

PURPOSE

Extended resections in hepatopancreatobiliary (HPB) surgery frequently require vascular resection to obtain tumor clearance. The use of alloplastic grafts may increase postoperative morbidity due to septic or thrombotic complications. The use of suitable autologous venous interponates (internal jugular vein, great saphenous vein) is frequently associated with additional incisions. The aim of this study was to report on our experience with venous reconstruction using the introperative easily available parietal peritoneum, focusing on key technical aspects.

METHODS

All patients who underwent HPB resections with venous reconstruction using peritoneal patches at our department between January 2017 and November 2021 were included in this retrospective analysis with median follow-up of 2 months (IQR: 1-8 months). We focused on technical aspects of the procedure and evaluated vascular patency and perioperative morbidity.

RESULTS

Parietal peritoneum patches (PPPs) were applied for reconstruction of the inferior vena cava (IVC) (13 patients) and portal vein (PV) (4 patients) during major hepatic (n = 14) or pancreatic (n = 2) resections. There were no cases of postoperative bleeding due to anastomotic leakage. Following PV reconstruction, two patients showed postoperative vascular stenosis after severe pancreatitis with postoperative pancreatic fistula and bile leakage, respectively. In patients with reconstruction of the IVC, no relevant perioperative vascular complications occurred.

CONCLUSIONS

The use of a peritoneal patch for reconstruction of the IVC in HPB surgery is a feasible, effective, and low-cost alternative to alloplastic, xenogenous, or venous grafts. The graft can be easily harvested and tailored to the required size. More evidence is still needed to confirm the safety of this procedure for the portal vein regarding long-term results.

Complete and partial replacement of the inferior vena cava with autologous peritoneum in cancer surgery

Resection of the inferior vena cava may be required in the courses of oncological surgeries for the tumors originating from or invading it. Management of the remaining defect depends on the extension of the resection. Partial or complete replacement of the inferior vena cava, with a patch or interposition graft, may be required. Standard techniques for the reconstruction with a prosthetic material or the autologous veins can be associated with the prosthetic graft infection, high cost, long-standing anticoagulation, technical difficulties, and/or need for extra incisions. The use of the autologous peritoneum represents an easy and inexpensive alternative for the partial and complete inferior vena cava reconstructions.

Techniques for overcoming atretic changes of the portal vein in living donor liver transplantation

BACKGROUND

Spontaneous diversion of the portal flow through collateral vessels into the systemic circulation is frequently observed in liver transplant recipients with severe portal hypertension. This induces main portal vein atretic change and modifies flow into the collateral even after donor graft implantation. These atretic changes make liver transplantation challenging. In this article we described several methods for overcoming this challenge by appropriate surgical techniques.

METHODS

Three anastomotic techniques for living donor liver transplantation were performed in patients with atretic changes in the portal vein.

RESULTS

The three techniques were (1) venoplasty to widen the diameter by using the recipient's portal vein, and the diameter of the recipient's portal vein was enlarged using their own portal vein stump patch; (2) conduit with cryopreserved vessels, and we dissected around the superior mesenteric vein and splenic vein junction and a conduit was built using the cryopreserved vessels; and (3) left gastric varix to portal vein anastomosis, if the recipients had large gastric varix and variceal wall was sufficiently thick for anastomosis.

CONCLUSIONS

Selection of optimal methods for portal vein anastomosis is essential in patients with atrophic change on the portal vein. If these methods are used aptly, they can be considered as favorable methods for overcoming each situation.

Feasibility of bile duct as venous graft for venous reconstruction in pancreatic surgery: An animal experimental study

OBJECTIVE

Pancreatic cancer is a kind of high malignant tumor with a poor prognosis. The aim is to determine whether the dilated bile duct can be used to reconstruct the vessels.

METHODS

An animal model of jugular vein and portal vein reconstruction was established using the bile duct. A total of 20 landrace pigs were selected to undergo jugular vein reconstruction or portal vein reconstruction using the bile duct as a patch or bridge. The patency was evaluated by color Doppler, the reconstructed segments were removed and examined macroscopically and histologically at specified intervals, and the results were compared with synthetic vessels (IMPRA straight, 10s03-19).

RESULTS

The lumen was patent, although a low level thrombosis was observed when jugular or portal vein patching was used. For bridging, stenosis of the lumen was observed, and necrosis appeared when the bile duct was used for bridging, indicating that it is feasible to reconstruct the jugular vein and portal vein with a bile duct patch. However, the bridge was not feasible possibly due to loss of blood supply, and consequent necrosis and fibrosis.

CONCLUSION

The bile duct is technically feasible, but the outcomes are unsatisfactory.

PARIETAL PERITONEUM GRAFT FOR DUODENUM INJURIES IN AN ANIMAL MODEL

Background:

Duodenal injuries and their surgical procedure cause a high morbidity and mortality.

Aim:

To assess the overall effectiveness of the auto-graft of peritoneum in the treatment of the perforation of the duodenum, aiming to reduce surgery time, costs, complexity and mortality.

Methods:

Twelve New Zealand rabbits, ages 4-6 months, both sexes, underwent designed surgical grade III duodenal injuries that were repaired 18 h after. Rabbits were surgically treated with the proposed auto-graft of peritoneum.

Results:

No postoperative deaths were observed; the animals presented corporal weight increase and were euthanized six months later. There was no significant difference between both groups relating to the postoperative evolution or in the histological changes.

Conclusion:

Auto-graft of the peritoneum and posterior fascia is a useful option for duodenal repair and that is worth of evaluation for humans.

The falciform ligament as a graft for portal-superior mesenteric vein reconstruction in pancreatectomy

BACKGROUND

Tumor invasion or adherence to the portal vein-superior mesenteric vein (PV/SMV) may be encountered during pancreatic surgery. In such cases, venous resection and reconstruction might be required for complete resection of the tumor. We report an innovative technique in which the graft for PV/SMV reconstruction was made with the falciform ligament.

METHODS

Between May 2011 and July 2016, PV/SMV reconstruction with a falciform ligament graft was performed in 10 cases during pancreatectomy. Among these cases, including six cases with a patch graft and four cases with a conduit graft. Retrospective reviews of medical records and radiologic studies were performed.

RESULTS

Ten patients with pancreatobiliary cancer underwent en bloc tumor resection with concurrent PV/SMV resection and reconstruction with a falciform ligament graft. There were six males and four females, and the mean age was 65.3 ± 9.4 (48-80) y. Using Doppler ultrasound examination, all 10 grafts were shown to be patent at postoperative 2 wk. However, occlusion was found in one case with conduit graft and stenosis in the other three cases with conduit graft using enhanced computed tomography at postoperative 2 mo. Complete patency was shown in three of six cases with patch graft and stenosis in the other three cases at 2 mo after the operation. Although occlusion or stenosis of the grafts was observed, no severe adverse events occurred, and normal liver function was discovered in all 10 cases at postoperative 2 mo.

CONCLUSIONS

Falciform ligament grafts might be considered for reconstruction of PV/SMV in the absence of appropriate vascular grafts.

Autologous Peritoneum Graft Repair of a Superior Mesenteric Vein Defect During Pancreaticoduodenectomy

Pancreatic cancers frequently invade the portomesenteric veins. Venous resection during pancreaticoduodenectomy with curative intent is more common now than it was in the past. Most venous resections can be repaired primarily, but some require vascular grafts. Here, we describe the use of an autologous parietal peritoneum graft instead of vascular grafts for repairing a superior mesenteric vein (SMV) defect. Pylorus-preserving pancreaticoduodenectomy combined with en bloc resection of the SMV lateral wall was performed in a 70-year-old woman with cancer of the pancreatic head. The SMV defect was 2 cm long and its width was half the SMV circumference. The defect was covered with a 3 × 2 cm parietal autologous peritoneum graft obtained from the left subcostal area and using running 6/0 polypropylene suture. Tension-free patching was performed, and we retained slight bulging of the graft. Her postoperative course was uneventful. She was discharged on Day 11 after computed tomography confirmed the patency of the SMV, despite slight narrowing. She was well after 10 months of follow-up. Autologous parietal peritoneum grafts can be used for repairing partial venous defects during pancreaticoduodenectomy. They are effective and are easy, fast, and cheap to obtain. 

Patency rates of portal vein/superior mesenteric vein reconstruction after pancreatectomy for pancreatic cancer

BACKGROUND

Pancreatectomy with venous reconstruction (VR) for pancreatic cancer (PC) is occurring more commonly. Few studies have examined the long-term patency of the superior mesenteric-portal vein confluence following reconstruction.

METHODS

From 2007 to 2013, patients who underwent pancreatic resection with VR for PC were classified by type of reconstruction. Patency of VR was assessed using surveillance computed tomographic imaging obtained from date of surgery to last follow-up.

RESULTS

VR was performed in 43 patients and included the following: tangential resection with primary repair (7, 16%) or saphenous vein patch (9, 21%); segmental resection with splenic vein division and either primary anastomosis (10, 23%) or internal jugular vein interposition (8, 19%); or segmental resection with splenic vein preservation and either primary anastomosis (3, 7%) or interposition grafting (6, 14%). All patients were instructed to take aspirin after surgery; low molecular weight heparin was not routinely used. An occluded VR was found in four (9%) of the 43 patients at a median follow-up of 13 months; median time to detection of thrombosis in the four patients was 72 days (range 16-238).

CONCLUSIONS

Pancreatectomy with VR can be performed with high patency rates. The optimal postoperative pharmacologic therapy to prevent thrombosis requires further investigation.

Use of cold-stored vein allografts for venous reconstruction during pancreaticoduodenectomy

INTRODUCTION

Venous resections and reconstructions of portal vein and/or superior mesenteric vein in course of pancreaticoduodenectomy are becoming a common practice and many surgical options have been described, from simple tangential resection and venorrhaphy to large segmental resections followed by interposition grafting. The aim of this study was to report the first experience of using fresh cadaveric vein allografts for venous reconstruction during pancreaticoduodenectomy focusing on technical feasibility and postoperative outcomes.

METHODS

From January 2001 to October 2012, out of 151 patients undergoing pancreaticoduodenectomy for pancreatic head tumor, 22 (14.5 %) received a vascular resection of the mesentericoportal axis. In five of these patients, vascular reconstruction was accomplished by using cold-stored venous allografts of iliac and femoral veins from donor cadaver. Patients' data, surgical techniques, and clinical outcomes were analyzed.

RESULTS

Five patients undergoing pancreaticoduodenectomy were selected to receive a vascular reconstruction using a fresh venous allograft for patch closure in three cases, conduit interposition in one case and a Y-shaped graft in the last case. No graft thrombosis or stenosis occurred postoperatively and at long-term follow-up. Mortality rate was zero.

CONCLUSION

The use of fresh vein allografts is a feasible and effective technique for venous reconstruction during pancreaticoduodenectomy. However, prospective surveys including large cohorts of patients are necessary to confirm these results.

Use of autologous renal capsule grafts for venous repair

OBJECTIVE

To evaluate the efficacy of the renal capsule for reconstruction of the inferior vena cava in a canine model.

MATERIALS AND METHODS

The present study was conducted on 10 dogs; an oval window (2-8 cm long, mean 6.5 cm) was made in the inferior vena cava and then repaired using the autologous renal capsule patch. The patency and functionality of the graft were assessed macroscopically and microscopically 3 months postoperatively.

RESULTS

All the dogs were killed at 3 months, showing excellent patency of the vena cava macroscopically and in the venography. In the microscopic examination, all the patches were completely endothelialized. No evidence of infection or thrombosis was noted.

CONCLUSION

A renal capsule patch can be used for reconstruction of the inferior vena cava. Patency appears to be good, and the risk of infection is low. Moreover, this is an accessible material.

Progress in research of vascular grafts for portal vein/superior mesenteric vein reconstruction

Portal vein/superior mesenteric vein reconstruction is applied more and more broadly in abdominal surgery. This reconstructive surgery can improve radical resection rate and prolong survival in patients with abdominal carcinoma, expand the indications for liver transplantation, and increase the success rate of liver transplantation. Selection of a suitable vascular graft is key to the success of the surgery. Currently available vascular grafts include autogenous veins, ligamentum teres hepatis, artificial blood vessels, allograft veins, peritoneal patch, and pericardiac patch. This review aims to summarize recent progress in basic research, clinical application of vascular grafts for portal vein/superior mesenteric vein.

Experimental results of using autologous rectus fascia sheath for venous patch grafts in dogs

Autologous vascular patch grafts developed from the internal rectus sheath were implanted onto the bilateral common iliac vein and jugular vein of 4 experimental beagle dogs. During the development and implanting of the grafts no technical difficulties or perioperative complications were encountered. The follow-up lasted 6 months and 3 months in the case of the common iliac vein grafts and the jugular grafts, respectively. In the postoperative period, the morphological and functional characteristics of the implanted venous sections were examined by Doppler ultrasonography and CT angiography. Normal patency was detected, and none of these check-ups showed obturation or stenosis. The histological survey showed no mesothelial cell layer, but the insides of the grafts showed total restructuring and were covered by a normal endothelial layer. No difference could be detected between samples harvested 3 and 6 months after implanting. The immunohistochemical examinations using anti-claudin-5 and anti-CD31 antibodies confirmed the preliminary results of the histological examinations that the luminal surfaces of the implanted grafts developed a differentiated monolayer endothelium which was free of degenerative and inflammatory signs. The control examinations show the suitability of the internal rectus sheath as a venous wall donor.

Portomesenteric reconstruction during Whipple procedures: review and report of a case

A 60-year-old man undergoing a Whipple procedure to treat a pancreatic cancer was found to have tumor adherence to the portal vein. An en block pancreaticoduodenectomy with segmental portal vein resection (PVR) was performed. A primary portal vein anastomosis was initially attempted but failed. Hemodynamic deterioration led the authors to perform a temporary prosthetic portal vein interposition graft and abdominal closure. The following morning, once stable, the patient was brought back to the operating room for autologous reconstruction with femoral vein and completion of the pancreaticoduodenectomy. The role of PVR for vein invasion or tumor adherence during a Whipple procedure is still under debate. However, there is growing evidence that the perioperative morbidity and long-term survival in patients who undergo a pancreaticoduodenectomy with PVR are similar to those of patients without vein resection. Therefore a combined resection of the pancreatic head and the portal vein has been suggested in the absence of other contraindications for resection to be able to offer a curative surgical intervention to a larger number of patients. The authors herein report the details of a patient's case and also review the currently available methods for PVR and reconstruction.

Spiral saphenous vein graft for portal vein reconstruction in pancreatic cancer surgery

The curative strategy for most pancreatic cancer is surgical resection. Extensive resection with lymph node dissection is the key to providing long-term survival. However, early diagnosis of pancreatic cancer is not always possible (ie, resectability is limited). One reason for such a nonresectable condition is vascular invasion or encasement. Portal vein involvement has been a contraindication for pancreatic cancer surgery for most general surgeons. Combining oncologic and vascular surgeons in the procedure has been a good solution. A multidisciplinary approach that includes general and vascular surgeons is appropriate in selected patients requiring vascular reconstruction at the time of pancreatectomy. The objective of this paper is to report a case in which spiral saphenous vein was used for portal vein reconstruction during pancreatic cancer resection.

The rectus abdominis musculoperitoneal (RAMP) flap for the reconstruction of complicated pharyngoesophageal defects

In the advanced stage of hypopharyngeal cancer, extensive resection may sometimes leave both the cervical soft tissue and pharyngoesophageal defects that must be reconstructed at the same time. In this study, a new reconstructive method using the rectus abdominis musculoperitoneal flap is described. Three patients underwent pharyngoesophageal reconstruction by this method. Complete survival of the flaps was seen in all patients, but one patient developed a fistula due to rapid local recurrence of the tumour. We believe that the rectus abdominis musculoperitoneal flap can be an alternative choice for reconstruction of pharyngoesophageal defect, especially when there is a large area of cervical soft tissue defect at the same time.

Free peritoneal graft for repair of severe seromuscular defect of bowel: from experiment to clinical practice

BACKGROUND

Severe seromuscular tear of the bowel with impending perforation following enterolysis or trauma is not uncommon in gastrointestinal surgery. It is sometimes complicated with enterocutaneous fistula, intra-abdominal abscess or free perforation, especially of the ileus. In addition, direct serosal repair is often impossible, or complicated by lumen compromise. Serosal patch repair also reportedly is also associated with complications such as dislodgement of the sutured bowel loop, fistula formation, adhesion ileus, or volvulus. Free peritoneal graft (FPG), as in split-thickness skin graft (STSG), can be taken by underlying healthy tissue within 24 to 48 h and used for repair of such defect.

PATIENTS AND METHODS

In this study, FPG was used as an alternative to serosal patch repair or resection to cover severe defects of the colon, rectum, duodenum, or small bowel in 30 consecutive patients. All defects were over 8 x 4 cm in size and involved 30 to 80% of the circumference of the bowel wall. Each defect was deep enough to expose the thin mucosal layer, with the intestinal content visible through it. These defects could have been successfully treated by resection or repair using a serosal or mucosal patch instead of FPG. After making sure that the mucosa associated with the defect was alive and not perforated, a patch of intact peritoneum with pre-peritoneal tissue from the lateral abdominal wall (slightly smaller than the defect) was superimposed, with the edges simply sewn to the margin of the defect.

RESULTS

All patients recovered uneventfully, with no untoward effects determined, even after long-term follow-up.

CONCLUSION

We believe that FPG provides a feasible, simple, effective, economic, and safe alternative for repair of severe seromuscular defects; potentially making it widely applicable in clinical practice.

[Peritoneal-fascia-muscle autologous graft in the inguinal canal of rats]

PURPOSE

To study the fragment of the autologous tissue, built by a peritoneum-fascia-muscle, implanted on the level of the wall of inguinal canal and the spermatic cord of rats aiming to verify the histological behavior of the survive and the tissue incorporation.

METHODS

Thirty-six rats were distributed into four groups. The rats of the group A, B, C and D were submitted to the median laparotomy to obtain the species to be implanted. On the group A, was implanted a tissue compounded by peritoneum and transversal fascia on the wall of the inguinal canal. On the B, the tissue implanted was added a part of rectum muscle of the abdomen and implanted on the wall of the inguinal canal. On the C, the tissue grafted was similar to the groupA, now grafted into the spermatic cord. On the D, the tissue was similar to the group B, now grafted into the spermatic cord.

RESULTS

After 21 days of implant, these tissues presented the following histological alteration: the group A and C, fibroadipous tissue with dilated vessel, Focus of fibrosis' and limphoplasmocitary infiltrated and the groups B and D, fibroadipous tissue with dilated vessels, skeletal muscle and focus of fibrosis. The fibrosis displayed on the groups B and D was more intensive. On the group B, we almost always find the skeletal muscle, while on the group D this tissue was presented in six animals, almost replaced by fibrosis in two and not present in one.

CONCLUSION

All the implanted grafts displayed survive and local incorporation, what could be useful on the correction of defects on the inguinal canal, on situations when the autologous tissue was indicated.

Reconstruction of portal vein using a hepatic vein patch graft after combined hepatectomy and portal vein resection

BACKGROUND

Surgical resection is the only treatment modality that ensures complete tumor removal in patients with liver tumors involving a major portal vein branch or its bifurcation. Restoration of good portal blood flow is essential for recovery in the early postoperative period and for long-term survival. However, such extended resections often result in large defects at the bifurcation of the portal vein that are not amenable to suturing or end-to-end anastomosis.

METHODS

A patch graft technique is very useful for reconstruction of long and elongated defects when other methods are not technically appropriate. We describe a simple technique for reconstructing the portal vein using a patch graft obtained from the hepatic vein stump of the resected specimen.

CONCLUSIONS

This technique permits surgeons to reconstruct the portal vein without any need for harvesting another vein and with no need for an additional incision.