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

Abstract

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.

Keywords: Pancreatoduodenectomy; Pelvic congestion syndrome; Superior mesenteric vein resection and reconstruction.

Fig. 1

Computed tomographic findings concerning the pancreatic tumor. The pancreatic tumor is in contact with the right side of the superior mesenteric vein (SMV) at the level of confluence of the first jejunal vein tributary, involving less than 180 degrees of the vein’s circumference (A). Longitudinal extent of the tumor along the SMV is about 20 mm (C). The tumor also has spread along the retropancreatic nerve plexus to a point near the superior mesenteric artery (B, D)

Fig. 2

Computed tomographic appearances of the right ovarian vein (A, C) and the superior mesenteric vein invaded by the tumor (B, D). The right ovarian vein shows dilation to a diameter of about 10 mm, approximating the dimensions of the portion of the superior mesenteric vein to be resected

Fig. 3

Intraabdominal findings during the operation. A and B Dilated right ovarian vein to be used for the graft. C Superior mesenteric vein invaded by the pancreatic tumor. D Superior mesenteric vein after reconstruction using the right ovarian venous graft

Fig. 4

Three-dimensional images of the superior mesenteric vein (SMV) before (A) and after (B) combined resection and reconstruction. The purple shading represents the ovarian vein graft in place after ligation and division of the first jejunal vein tributary and segmental resection of the SMV followed by SMV reconstruction. C and D Computed tomographic findings after reconstruction (coronal view)