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

Temporary mesenteric venous shunting for portal vein reconstruction: A novel technical adjunct

Pancreatic resection not infrequently requires portal vein (PV) repair or replacement. PV reconstruction often requires bypass grafting or patch venoplasty, and these grafts and patches require time to thaw or harvest. Mesenteric ischemia and congestion with associated bowel edema may result from prolonged venous occlusion during thawing, harvesting, and reconstructing. Temporary shunting of the mesenteric venous circulation may mitigate these adverse effects. Twenty-one patients were shunted using Argyle shunts during PV reconstruction from 2010 to 2020. Reconstructions in this series consisted of aortic homograft interposition grafts (52%), bovine pericardial patches (38%), internal jugular vein interposition grafts (5%), and internal jugular patches (5%). No intraoperative complications resulted from shunt placement; technical success of PV reconstruction was 100%. Temporary venous shunting during PV reconstruction is safe, technically straightforward, and may serve to decrease the duration of venous mesenteric occlusion.

Total portal vein replacement with peritoneal interposition graft during Whipple's procedure for extrahepatic cholangiocarcinoma: a technical report

BACKGROUND

Aggressive surgical resection in locally advanced hepatopancreatobiliary (HPB) malignancies is frequently advocated as the only potentially curative treatment. In recent years, advances in chemotherapy regimens and surgical techniques have led to improved oncologic outcomes and overall survival, by increasing the rates of radical (R0) resections. Vascular resections are increasingly reported to further increase disease clearance rates. Within this perspective, the issue of vascular reconstruction has raised growing interest, drawing particular attention to vascular substitutes and surgical techniques for reconstruction.

CASE PRESENTATION

A case of extrahepatic cholangiocarcinoma with high clinical suspicion of vascular infiltration of the portal trunk at preoperative assessment is reported. An autologous interposition graft, harvested from diaphragmatic peritoneum, was chosen as a vascular substitute leading to successful portal trunk reconstruction and overcoming all possible drawbacks associated with cadaveric and artificial grafts reconstructions.

CONCLUSION

This solution was strategic to ensure complete oncologic clearance averting the risk of positive margins (R1) at final pathology.

Tips and tricks for robotic pancreatoduodenectomy with superior mesenteric/portal vein resection and reconstruction

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.

Superior mesenteric vein reconstruction during pancreatoduodenectomy using a dilated right ovarian vein in a patient at future risk for pelvic congestion syndrome: a case report

BACKGROUND

Pancreatoduodenectomy including resection of the superior mesenteric vein (SMV) is increasingly performed for right-sided pancreatic ductal adenocarcinoma invading the wall of that vessel. Various venous grafts may be chosen for reconstruction. We present a woman with pancreatic cancer who underwent such a pancreatoduodenectomy with venous reconstruction using a dilated right ovarian vein.

CASE PRESENTATION

A 71-year-old woman with cancer involving the pancreatic head, uncinate process, and SMV underwent pancreatoduodenectomy with SMV resection. Reconstruction used a portion of the right ovarian vein that was markedly dilated and had placed her at risk for pelvic congestion syndrome (PCS). Graft patency was confirmed 8 months after surgery. She now finished receiving adjuvant chemotherapy and has no symptoms of PCS.

CONCLUSION

If an ovarian vein has sufficient diameter, it can be used to reconstruct the resected segment of the SMV during pancreatoduodenectomy in suitable patients.

Adult Human Vein Grafts Retain Plasticity of Vessel Identity

BACKGROUND

The spiral saphenous vein graft is an excellent choice for venous reconstruction after periphery vein injury, but only few cases have been reported. We implanted a segment of a single saphenous vein into both the popliteal vein as a venous vein graft and into the popliteal artery as an arterial vein graft at the same time in a trauma patient; we then had an extraordinary opportunity to harvest and examine both patent venous and arterial vein grafts at 2 weeks after implantation.

METHODS

A spiral saphenous vein graft was made as previously described and implanted into the popliteal vein and artery as interposition grafts; because of the patient's serious injuries, an amputation was performed at day 18 after vascular reconstruction. The grafts were harvested, fixed, and examined using histology and immunohistochemistry.

RESULTS

Both grafts were patent, and there was a larger neointimal area in the venous graft compared to the arterial graft. There were CD31- and vWF-positive cells on both neointimal endothelia, with subendothelial deposition of α-actin-, CD3-, CD45-, and CD68-positive cells. There were fewer cells in the venous graft neointima compared to the arterial graft neointima; however, there were more inflammatory cells in the neointima of the venous graft. Some of the neointimal cells were PCNA-positive, whereas very few cells were cleaved caspase-3 positive. The venous graft neointimal endothelial cells were Eph-B4 and COUP-TFII positive, while the arterial graft neointimal endothelial cells were dll-4 and Ephrin-B2 positive.

CONCLUSIONS

The spiral saphenous vein graft remains a reasonable choice for vessel reconstruction, especially in the presence of diameter mismatch. Both the venous and arterial grafts showed similar re-endothelialization and cellular deposition; the venous graft had more neointimal hyperplasia and inflammation. At an early time, endothelial cells showed venous identity in the venous graft, whereas endothelial cells showed arterial identity in the arterial graft.

CLINICAL RELEVANCE

Veins can be used as venous or arterial vein grafts but venous grafts have more neointimal hyperplasia and inflammation; vein grafts acquire different vessel identity depending on the environment into which they are implanted.

Paneled Saphenous Vein Grafts Compared to Internal Jugular Vein Grafts in Venous Reconstruction after Pancreaticoduodenectomy

BACKGROUND

Venous resection during pancreaticoduodenectomy for the excision of pancreatic cancer allows for a more complete resection with negative margins, which increases survival. When the resected vein is greater than 3 cm, reconstruction with an interposition graft is recommended. However, consensus regarding the optimal venous conduit has not been reached. The objective of this study is to compare outcomes between the paneled saphenous vein graft (SVG) and internal jugular vein graft (IJVG) in portomesenteric venous reconstructions after pancreaticoduodenectomy.

METHOD

A retrospective review was performed of patients undergoing pancreaticoduodenectomy requiring an interposition graft for venous reconstruction between 2011 and 2019. Patients were stratified based on the type of conduit used (paneled SVG or IJVG). Preoperative patient characteristics, reconstruction details, and postoperative outcomes including graft patency were recorded.

RESULTS

During the study period, 18 patients met inclusion criteria (10 female, mean age: 63 years, age range: 41-82 years). Thirteen patients underwent reconstruction with paneled SVG and five with IJVG. Comparing SVG and IJVG groups, there were no significant differences in venous resection length, venous diameters at the resection margins, or splenic vein ligation rate. For the paneled SVG, the average length of harvested vein was 168 mm which rendered 3-paneled grafts with an average diameter of 12 mm. The time to complete the venous reconstructions did not differ between the two groups (SVG: 263+/-204 min, IJVG: 216+/-77 min, P = 0.63). There were five graft thrombosis, three in the SVG group (mean follow-up time of 17 months) and two in the IJVG group (mean follow-up time of 8 months). All but one of the graft thromboses occurred during the index hospitalization. There was one donor site seroma and wound dehiscence in the SVG group and none in the IJVG group. Hospital length of stay was longer for the IJVG group (IJVG: 15.2 days, SVG: 10.2 days, P = 0.03). However, in-hospital and late mortality did not differ between the groups.

CONCLUSIONS

Paneled SVG and IJVG are both versatile and durable conduits for venous reconstruction after pancreaticoduodenectomy, able to accommodate a wide range of venous defects. In this small series, SVG has comparable outcomes to IJVG. Paneled SVG is a suitable alternative to IJVG for portomesenteric reconstruction.

Autologous Saphenous Vein Panel Graft for Vascular Reconstruction

BACKGROUND

This study aims to present early and midterm results of vascular reconstruction with saphenous vein panel graft.

METHODS

Between August 2014 and August 2017, 11 saphenous vein panel grafts were used for vascular reconstruction in 10 patients. Patient data including age, gender, etiology of the vascular pathology, concomitant injury, site of injury, surgical procedure, additional surgical procedure, and hemodynamic status were retrospectively collected and analyzed. The Kaplan-Meier method was used to calculate the reintervention and patency rates.

RESULTS

Mean duration of follow-up was 16.5 ± 13.2 months (ranged, 2-39 months). The freedom from reintervention for any reason was 82% at 1 and 2 years. There was no evidence of arterial claudication or venous insufficiency in all patients. The primary patency rates were 82% at 1 and 2 years. There was no mortality, deep venous thrombosis, pulmonary embolism, graft thrombosis, anastomotic stenosis, diameter discrepancy, and aneurysm formation during late follow-up.

CONCLUSIONS

The autologous saphenous panel vein graft enables the surgeon to prepare suitable conduits easily with an appropriate diameter and length for vascular reconstruction. Although long-term results are unknown, this technique provides high patency rates in midterm follow-up, resistance to infection, and low reintervention rates. In conclusion, autologous saphenous vein panel grafts may well be preferred in various vascular disorders that require surgical reconstruction.

Autologous falciform ligament graft as A substitute for mesentericoportal vein reconstruction in pancreaticoduodenectomy

OBJECTIVE

To evaluate the falciform ligament as an autologous substitute for mesentericoportal vein reconstruction during pancreaticoduodenectomy.

BACKGROUND

Mesentericoportal vein reconstruction was needed in some certain cases during pancreaticoduodenectomy, and a rapidly available substitute was required.

METHODS

The falciform ligament was used as an autologous substitute during pancreaticoduodenectomy in 6 patients between June 2016 and May 2017. Anticoagulation was not performed at any stage and venous patency was estimated by Color-Doppler ultrasonography and contrast-enhanced computed tomography.

RESULTS

6 patients underwent vascular resection during pancreaticoduodenectomy for malignant tumors. The falciform ligament graft, with a mean length of 26 mm (10-40), was immediately harvested and used as a lateral patch for reconstruction of the mesentericoportal vein (n = 6). Severe morbidity included Clavien grade-III complications occurred in 1(16.7%) patients but there was no graft-related complications. Histological vascular invasion was present in all the patients (n = 6, 100%), and all had an R0 resection (100%). All venous reconstructions were patent (100%) after a mean follow-up of 12 (6-16) months.

CONCLUSIONS

An autologous falciform ligament graft can be safely used as a lateral substitute for mesentericoportal vein reconstruction during pancreaticoduodenectomy; this could help improve the radical resection rate of malignant tumors when oncologically required.

Domino Reconstruction of the Portal Vein Using the External Iliac Vein and an ePTFE Graft in Pancreatic Surgery

BACKGROUND

In the portal vein resection of long distance, an interposition by autologous vein is mandatory. External iliac vein (EIV) has been used, but harvesting the EIV is associated with severe venous congestion of the affected lower extremity. We have reconstructed the EIV using a ringed expanded polytetrafluoroethylene (ePTFE) graft.

METHODS

Thirteen patients underwent this surgery. The right EIV was used for reconstructing the portal vein, and the retrieved portion of EIV was interposed by the ePTFE graft. We evaluated size and length of the graft, graft patency, girth of thigh, time for reconstruction of EIV, and graft infection.

RESULTS

ePTFE grafts of 8 or 10 mm in diameter were used. The length of ePTFE graft used was 4.4 ± 0.5 cm. Graft patency was kept in 76.9% patients. Graft obstruction was encountered in three patients, and the girth of right thigh increased by about 10 cm. Time for reconstruction of EIV was 29.5 ± 6.8 min. Graft infection did not occur in any patients.

CONCLUSIONS

Reconstruction of the EIV using a ringed ePTFE graft seems to be a feasible option for preventing the swelling of the affected lower extremity after procurement of EIV for repairing the portal vein.

Comparison of patency rates and clinical impact of different reconstruction methods following portal/superior mesenteric vein resection during pancreatectomy

INTRODUCTION

Few studies have compared patency rates of the different methods of venous reconstruction (VR) during a pancreatectomy. This study aimed to evaluate the patency rates and the clinical impact of various reconstruction methods.

METHODS

For the meta-analysis, databases were systematically searched to identify studies reporting the outcomes of patients who underwent PVR/SMVR. For the retrospective study, clinical data were retrospectively analyzed from patients who underwent a pancreatectomy and VR between Feb. 2009 and Oct. 2015. Patency was assessed by CT and/or ultrasound.

RESULTS

For the meta-analysis, the long-term patency rates of the primary repair group and the autologous graft group were significantly higher than that of the synthetic graft group. For the retrospective study, the reconstruction consisted of primary repair in 62 cases (89.8%) and synthetic grafting in 7 cases (10.1%). Synthetic grafting was more likely to cause acute thrombosis compared with primary repair for PVR/SMVR (85.7% versus 16.7%). Acute thrombosis was associated with decreased median survival (12 versus 6 months) and increased hazard of death. Late thrombosis and stenosis were not associated with survival or serious clinical impact. Median survival for the primary repair group and the synthetic grafting group was 12 and 7 months, respectively.

CONCLUSION

Primary repair following PVR/SMVR is preferred and can be achieved in most situations. Stenosis should be noted when with risk factors (long segmental and tension), but it produced little clinical impact. Synthetic grafting was associated with a higher thrombosis rate. Acute thrombosis is associated with increased mortality and decreased survival.

Parietal Peritoneum as an Autologous Substitute for Venous Reconstruction in Hepatopancreatobiliary Surgery

OBJECTIVE

To evaluate the parietal peritoneum (PP) as an autologous substitute for venous reconstruction during hepatopancreatobiliary (HPB) surgery.

BACKGROUND

Venous resection during liver or pancreatic resection may require a rapidly available substitute especially when the need for venous resection is unforeseen.

METHODS

The PP was used as an autologous substitute during complex liver and pancreatic resections. Postoperative anticoagulation was standard and venous patency was assessed by routine computed tomographic scans.

RESULTS

Thirty patients underwent vascular resection during pancreatic (n = 18) or liver (n = 12) resection, mainly for malignant tumors (n = 29). Venous resection was an emergency procedure in 4 patients due to prolonged vascular occlusion. The PP, with a mean length of 22 mm (15-70), was quickly harvested and used as a lateral (n = 28) or a tubular (n = 2) substitute for reconstruction of the mesentericoportal vein (n = 24), vena cava (n = 3), or hepatic vein (n = 3). Severe morbidity included Clavien grade-III complications in 4 (13%) patients but there was no PP-related or hemorrhagic complications. Histological vascular invasion was present in 18 (62%) patients, and all had an R0 resection (100%). After a mean follow-up of 14 (7-33) months, all venous reconstructions were patent except for 1 tubular graft (97%).

CONCLUSIONS

A PP can be safely used as a lateral patch for venous reconstruction during HPB surgery; this could help reduce reluctance to perform vascular resection when oncologically required. Clinical trials identification: NCT02121886.

Bovine pericardium for portal vein reconstruction in abdominal surgery: a surgical guide and first experiences in a single center

BACKGROUND

Resection and reconstruction of infiltrated vessels achieve resectability of extended pancreatic tumors. The aim of the present study was to assess the feasibility of bovine pericardium as graft material for the individualised portal vein reconstruction and demonstrate a surgical technique for abdominal vein repair.

METHODS

We performed a MEDLINE search to review the methods for complex abdominal vein reconstruction in the course of extended pancreatectomy. Moreover, clinical data of patients receiving portal vein reconstruction using a bovine pericardial patch at our institution were retrospectively analyzed.

RESULTS

Based on the results of a review of the literature, autologous venous grafts using the internal jugular vein represent the most popular option for segmental portal vein reconstruction in case of impossible direct suture. At our center, segmental portal vein reconstruction with bovine pericardial patch in course of pancreatic surgery was performed in 4 patients. No case of vascular complications such as occlusion, segmental stenosis or thrombosis occurred.

CONCLUSIONS

Our experience suggests a surgical procedure for an individual size-matched portal vein reconstruction using bovine pericardium. Although first results appear promising, prospective studies are required to objectively assess the patency of bovine pericardium compared with autologous and synthetic interposition grafts for portal vein reconstruction.

Spiral saphenous vein graft for major pelvic vessel reconstruction during exenteration surgery

This article describes a great saphenous vein spiral graft technique for reconstruction of iliac vessels after en bloc resection during pelvic exenteration. Use of different size syringes as a scaffold allows the surgeon to construct autologous vascular interposition conduits of variable diameter to match the luminal size of the vessel requiring reconstruction. Autologous vascular grafts are preferred in exenteration surgery in which the operative field is commonly contaminated by concomitant bowel resection, which carries an increased risk of graft infection.

Reconstruction of portal vein and superior mesenteric vein after extensive resection for pancreatic cancer

PURPOSE

Tumor invasion to the portal vein (PV) or superior mesenteric vein (SMV) can be encountered during the surgery for pancreatic cancer. Venous reconstruction is required, but the optimal surgical methods and conduits remain in controversies.

METHODS

From January 2007 to July 2012, 16 venous reconstructions were performed during surgery for pancreatic cancer in 14 patients. We analyzed the methods, conduits, graft patency, and patient survival.

RESULTS

The involved veins were 14 SMVs and 2 PVs. The operative methods included resection and end-to-end anastomosis in 7 patients, wedge resection with venoplasty in 2 patients, bovine patch repair in 3 patients, and interposition graft with bovine patch in 1 patient. In one patient with a failed interposition graft with great saphenous vein (GSV), the SMV was reconstructed with a prosthetic interposition graft, which was revised with a spiral graft of GSV. Vascular morbidity occurred in 4 cases; occlusion of an interposition graft with GSV or polytetrafluoroethylene, segmental thrombosis and stenosis of the SMV after end-to-end anastomosis. Patency was maintained in patients with bovine patch angioplasty and spiral vein grafts. With mean follow-up of 9.8 months, the 6- and 12-month death-censored graft survival rates were both 81.3%.

CONCLUSION

Many of the involved vein segments were repaired primarily. When tension-free anastomosis is impossible, the spiral grafts with GSV or bovine patch grafts are good options to overcome the size mismatch between autologous vein graft and portomesenteric veins. Further follow-up of these patients is needed to demonstrate long-term patency.

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.

A cylindrical femoral vein panel graft for caval reconstructions

This report describes a simple venous reconstructive technique that results in an autogenous vascular graft with sufficient luminal diameter for replacing the vena cava. The majority of vena caval reconstructions are performed using prosthetic grafts; however, graft infection is a concern in clean-contaminated hepatobiliary and retroperitoneal resections.

Does portal-superior mesenteric vein invasion still indicate irresectability for pancreatic carcinoma?

BACKGROUND

Pancreatic carcinoma frequently infiltrates the portal vein or the superior mesenteric vein; pancreatectomy combined with portal vein/superior mesenteric vein resection represents a potentially curative treatment in these cases but is still a controversial procedure.

METHODS

After performing a computerized Medline search, 12 series published during the last 8 years were selected, enrolling 399 patients who underwent pancreatectomy combined with portal vein/superior mesenteric vein resection for pancreatic carcinoma. Data were examined for information about indications, operation, adjuvant therapies, histopathology of resected specimens, perioperative results, and survival. Also, previous literature regarding the issue was extensively reviewed.

RESULTS

Operative mortality and postoperative complication rates ranged from 0 to 7.7% and 16.7% to 54%, respectively. Median survival varied from 13 to 22 months; 5-year survival rate ranged from 9% to 18%.

CONCLUSIONS

The current literature suggests that portal vein/superior mesenteric vein resection combined with pancreatectomy is a safe and feasible procedure that increases the number of patients who undergo curative resection and, therefore, provides important survival benefits to selected groups of patients. This procedure should always be considered in case of suspected tumor infiltration of portal/superior mesenteric vein to achieve clear resection margins, in the absence of other contraindications for resection.

Magnifying endoscopic observation of the gastric mucosa, particularly in patients with atrophic gastritis

The gastric mucosal surface was observed using the magnifying fibergastroscope (FGS-ML), and the fine gastric mucosal patterns, which were even smaller than one unit of gastric area, were examined at a magnification of about 30. For simplicification, we classified these patterns by magnifying endoscopy in the following ways; FP, FIP, FSP, SP and MP, modifying Yoshii's classification under the dissecting microscope. The FIP, which was found to have round and long elliptical gastric pits, is a new addition to our endoscopic classification. The relationship between the FIP and the intermediate zone was evaluated by superficial and histological studies of surgical and biopsy specimens. The width of the band of FIP seems to be related to the severity of atrophic gastritis. Also, the transformation of FP to FIP was assessed by comparing specimens taken from the resected and residual parts of the stomach, respectively. Moreover, it appears that severe gastritis occurs in the gastric mucosa which shows a FIP. Therefore, we consider that the FIP indicates the position of the atrophic border.