Extent of venous resection during pancreatectomy-finding the balance of technical possibility and feasibility

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.

Keywords: Pancreatic cancer (PC); left-side portal hypertension; locally advanced pancreatic cancer; neoadjuvant treatment; vein resection.

Figure 1

Long-segment PV/SMV encasement. (A) A tumor with proximal SMV involvement. (B) The Concept of “regional pancreaticoduodenectomy”. The retropancreatic segment of the porto-mesenterico-splenic confluence and surrounding soft tissue are resected en bloc. The pancreas is divided along the line above the superior mesenteric artery. (C) The parachute technique. The right and left walls are sutured by 5-0 Proline without tying. From left to right, the posterior wall is very loosely running sutured to minimize tension on the vein wall. After securing the posterior wall with adequate stitches, the anastomosis of the posterior wall would be accomplished by pulling each thread towards the other side along with the orifice. (D) An end-to-side anastomosis of the SpV to the LRV. PV, portal vein; SMV, superior mesenteric vein; SpV, splenic vein; LRV, left renal vein; SMA, superior mesenteric artery.

Figure 2

Distal SMV involvement. (A) A tumor involving distal SMV including the second jejunal vein or further branches. (B) The anthron bypass tube. One side of the catheter is inserted into the distal jejunal or ileal branches, while the other side is inserted into the round ligament that connects the umbilical portal vein. (C) The proximal and distal SMV and the SpV are clumped and divided, and the tumor is removed. Resection of the SpV can be performed to release the tension at the SMV anastomosis. (D) A single SMV lumen is created by unifying two or three of SMV side of branches by interrupted or continuous sutures. After performing the SMV anastomosis, the SpV is reconstructed to the PV or the LRV. SMV, superior mesenteric vein; LGV, left gastric vein; GCT, gastrocolic trunk; MCV, middle colic vein; J1V, the first jejunal vein; J2V, the second jejunal vein; J3V, the third jejunal vein; SpV, splenic vein; PV, portal vein; LRV, left renal vein.