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. 2020 Nov;405(7):1045-1050.
doi: 10.1007/s00423-020-01974-0. Epub 2020 Sep 11.

Cavernous transformation of the portal vein in pancreatic cancer surgery-venous bypass graft first

Thomas Schmidt  1 , Oliver Strobel  1 , Martin Schneider  1 , Markus K Diener  1 , Christoph Berchtold  1 , André L Mihaljevic  1 , Arianeb Mehrabi  1 , Beat P Müller-Stich  1 , Thilo Hackert  1 , Markus W Büchler  2
Affiliations

Cavernous transformation of the portal vein in pancreatic cancer surgery-venous bypass graft first

Thomas Schmidt et al. Langenbecks Arch Surg. 2020 Nov.

Abstract

Background: In recent years, several techniques have been introduced to allow safe oncologic resections of cancers of the pancreatic head. While resections of the mesenterico-portal axis became now a part of the routine treatment, patients with a cavernous transformation of the portal vein still pose a surgical challenge and are regularly deemed unresectable.

Objective: Here, we describe a technique of initial venous bypass graft placement between the superior mesenteric vein or its tributaries and the portal vein before the resection of the pancreatic head. This approach avoids uncontrollable bleeding as well as venous congestion of the intestine with a continuous hepatic perfusion and facilitates oncologic resection of pancreatic head cancers. This technique, in combination with previously published resection strategies, enables tumor resection in locally advanced pancreatic head cancers.

Conclusions: Venous bypass graft first operations facilitate and enable the resection of the pancreatic head cancers in patients with a cavernous transformation of the portal vein thus rendering these patients resectable.

Keywords: Cavernous transformation; Pancreatic cancer; Surgery; Venous bypass graft.

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Conflict of interest statement

The authors declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Preoperative imaging. a Preoperative MRI imaging of a patient with pancreatic cancer indicating a cavernous transformation of the portal vein in the hepatoduodenal ligament (indicated with arrows). b Patent extrahepatic portal vein in the same patients as in (a) (indicated by an asterisk). c, d Contrast-enhanced CT imaging of a patient with a pancreatic head adenocarcinoma and cavernous transformation of the portal vein (cavernous transformation indicated with arrows, patent extrahepatic portal vein (asterisk), site of portal vein occlusion (arrowhead))
Fig. 2
Fig. 2
Venous graft first placement. a Venous congestion and portal hypertension observed upon initial explorative laparotomy. An asterisk indicates congested varicose veins alongside the stomach and in the greater omentum due to portal hypertension. b Exploration and dissection of the hepatoduodenal ligament. Bile duct (bd) is tagged with a white vessel loop, the extrahepatic portal vein (pv) is tagged with a blue vessel loop, and the proper hepatic artery (pha) with a red vessel loop. c, d 12-mm ring-enforced polytetrafluoroethylene Gore-Tex prosthesis as venous bypass graft before pancreatic head (ph) resection between superior mesenteric vein and portal vein. Placement of the graft behind the ph in (d). cha, common hepatic artery
Fig. 3
Fig. 3
Extended resection and venous bypass graft shortening. a Intraoperative situs after total pancreatectomy. Venous bypass graft placed between superior mesenteric vein (smv) and portal vein. Anastomosis between left gastric vein (lgv) and left renal vein (lrv) to relief left-sided portal hypertension. Common hepatic artery (cha) and left gastric artery (lga) are tagged with vessel loops. Complete “triangle” lymphadenectomy between superior mesenteric artery (sma) and celiac trunk. b Shortening of the venous bypass graft before reconstruction to avoid kinking of the graft, pv, and smv as well as the sma. ivc, inferior vena cava
See this image and copyright information in PMC

References

    1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin. 2019;69(1):7–34. doi: 10.3322/caac.21551. - DOI - PubMed
    1. Strobel O, Hank T, Hinz U, Bergmann F, Schneider L, Springfeld C, Jager D, Schirmacher P, Hackert T, Buchler MW. Pancreatic cancer surgery: the new R-status counts. Ann Surg. 2017;265(3):565–573. doi: 10.1097/SLA.0000000000001731. - DOI - PubMed
    1. Hank T, Hinz U, Tarantino I, Kaiser J, Niesen W, Bergmann F, Hackert T, Buchler MW, Strobel O. Validation of at least 1 mm as cut-off for resection margins for pancreatic adenocarcinoma of the body and tail. Br J Surg. 2018;105(9):1171–1181. doi: 10.1002/bjs.10842. - DOI - PubMed
    1. Klaiber U, Schnaidt ES, Hinz U, Gaida MM, Heger U, Hank T, Strobel O, Neoptolemos JP, Mihaljevic AL, Buchler MW, Hackert T (2019) Prognostic factors of survival after neoadjuvant treatment and resection for initially unresectable pancreatic cancer. Ann Surg. 10.1097/SLA.0000000000003270 - PubMed
    1. Murphy JE, Wo JY, Ryan DP, Jiang W, Yeap BY, Drapek LC, Blaszkowsky LS, Kwak EL, Allen JN, Clark JW, Faris JE, Zhu AX, Goyal L, Lillemoe KD, DeLaney TF, Fernandez-Del Castillo C, Ferrone CR, Hong TS. Total neoadjuvant therapy with FOLFIRINOX followed by individualized chemoradiotherapy for borderline resectable pancreatic adenocarcinoma: a phase 2 clinical trial. JAMA Oncol. 2018;4(7):963–969. doi: 10.1001/jamaoncol.2018.0329. - DOI - PMC - PubMed