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A simple technique of portal vein resection and reconstruction during pancreaticoduodenectomy
A Simple Technique of Portal Vein Resection and Reconstruction During Pancreaticoduodenectomy Pierre-Alain Clavien, MD, PhD, FACS, Hannes A Ru¨diger, MD
per gastrointestinal bleeding from hemorrhagic gastric varices.10 Currently, most surgeons recommend end-to-side reanastomosis of the splenic vein to the interposition graft. But this approach requires extensive dissection of the splenic vein and an additional anastomosis to the two anastomoses required for the interposition graft, each being a potential source of complications. In this report, we describe a simple technique of vascular reconstruction after resection of up to 5cm of the portal vein. The technique does not require an interposition or patch graft, or transection of the splenic vein.
Pancreaticoduodenectomy is the therapy of choice for resectable tumors located in the head of the pancreas. Among the many factors complicating this procedure is the proximity of major vessels, particularly the portal vein and its tributaries. Controversies exist regarding surgery for pancreatic or bile duct tumors invading the portal vein. Although a number of surgeons still consider vascular invasion as a contraindication for pancreatic surgery, several recent studies1–5 have suggested similar outcomes in patients undergoing pancreatectomy with portal vein resection as in those without tumor invasion of the portal vein. There is currently no consensus about the best technique for resection and reconstruction of the portal vein during pancreaticoduodenectomy. Most authors performed an end-to-end anastomosis either by direct suture6 or by using an interposition graft including the internal jugular,2,7 renal,3 saphenous,3 and external iliac1,8 veins, or a Gore-Tex (WL Gore, Flagstaff, AZ) interposition graft.4 Alternatively, a technique of autologous saphenous vein patch has been described for minimal tumor invasion into the portal vein.4,5 Direct closure with simple lateral venorrhaphy3,9 is indicated only for limited resection, and is associated with a significant risk of narrowing of the portal vein. Wide resection of the portal vein for tumors located in the head of the pancreas may require transection of the splenic vein. In the initial experience, the splenic vein was simply ligated without attempt at reconstruction, a procedure resulting in segmental portal hypertension and, in some patients, severe up-
TECHNIQUES OF PORTAL VEIN RESECTION AND RECONSTRUCTION The technique is applicable only for tumors partially invading the portal vein. The head of the pancreas is dissected in the standard fashion with preparation of the portal vein above the first part of the duodenum and the mesenteric vein below the pancreas. A Kelly clamp is carefully introduced along the vein between the neck of the pancreas and the mesenteric vein, and slowly brought to the porta hepatis. The neck of the pancreas is then divided with cautery, allowing complete visualization of the portal vein. The portal vein is clamped above and below the tumor, and this usually also occludes the splenic vein (Fig. 1A). The pancreaticoduodenectomy is performed in the usual fashion and the specimen containing part of the portal vein is then removed en bloc (Fig. 1B). After careful hemostasis of the pancreatic stump, two sponges are placed between the liver and the diaphragm, bringing the liver down and reducing tension of the portal vein. This simple maneuver greatly facilitates the portal vein reconstruction. A transverse reanastomosis (plication) of the portal vein is performed starting with running suture of 6.0 prolene (Ethicon Inc, Somerville, NJ) on the posterior wall, followed
No competing interests declared. Received July 2, 1999; Revised August 16, 1999; Accepted August 24, 1999. From the Section of Hepatobiliary Surgery and Transplantation, Department of Surgery, Duke University Medical Center, Durham, NC. Correspondence address: PA Clavien, MD, PhD, FACS, Box #3247, Duke University Medical Center, Durham, NC 27710. © 1999 by the American College of Surgeons Published by Elsevier Science Inc.
629
ISSN 1072-7515/99/$21.00 PII S1072-7515(99)00214-8
630
Clavien and Ru¨diger
Portal Vein Resection and Reconstruction
J Am Coll Surg
Figure 1.Technique of portal vein resection and reconstruction during pancreaticoduodenectomy. (A) Tumor invasion of the portal vein is well visualized after transection of the neck of the pancreas. (B) The pancreaticoduodenectomy specimen containing part of the portal vein is resected en bloc. (C) The portal vein is reconstructed by direct running suture in a transverse fashion. (D) The use of a growth factor (loosely tied knot) is crucial to prevent significant stenosis after reperfusion of the portal vein.
by the anterior wall (Fig. 1C). The two sutures are loosely tied at about 1cm from the wall of the vein (nicknamed “growth factor knot”) to minimize the
risk of narrowing of the portal vein after reperfusion (Fig. 1D). The vessel clamps are then removed. The reconstruction of the duodenopancreatectomy is
Vol. 189, No. 6, December 1999
Clavien and Ru¨diger
performed as usual with or without preservation of the pylorus. CASE REPORTS This technique was used in three consecutive patients with pancreatic cancer (n⫽2) and distal cholangiocarcinoma (n⫽1). A pancreaticoduodenectomy and en bloc resection of the portal vein followed by a vascular reconstruction, as described above, was performed in each patient. The first patient was a 48-year-old AfricanAmerican man referred to us with a diagnosis of biliary stricture and a 10-kg weight loss. An ERCP, spiral CT scan, and endoscopic ultrasonography showed a heterogeneous, poorly defined mass in the head of the pancreas, with distal common bile duct obstruction. Brushing for cytology disclosed high grade dysplasia. At operation, the patient was found to have severe and diffuse sclerosing pancreatitis. After preparation of the portal vein at the level of the gastroduodenal artery and the superior mesenteric vein below the pancreas, a Kelly clamp was passed between the mesenteric-portal vein and the pancreas. Transection of the pancreas at this level revealed invasion of the tumor into the right side of the portal vein over a 3-cm length starting at the level of the splenic vein. En bloc resection of the pancreatic head was performed as shown in Figure 1A. Because frozen section examination of the pancreas margin was positive for cancer, the pancreas was transected again about 1cm distally to the initial cut. The new margin was negative for malignancy, and the portal vein was reconstructed as described above. The pancreatic and common bile duct stumps were anastomosed end-toside to the jejunum in a standardized fashion using a single layer of interrupted 3.0 silk and 5.0 PDS stitches (Ethicon Inc), respectively. A side-to-side gastrojejunostomy (no preservation of the pylorus) and feeding jejunostomy (Compat; Novartis Nutrition, Minneapolis, MN) were performed before closure of the abdomen. Pathologic examination of the specimen showed moderately differentiated adenocarcinoma with peripancreatic neural invasion. Two of seven nodes were positive for cancer. The postoperative course was complicated with wound infection. A CT scan performed 6 weeks after surgery demonstrated a patent and minimally narrowed portal vein (Fig. 2). Local management of the wound infection and social consideration delayed discharge from the hospital to postoperative day 28. Adjuvant
Portal Vein Resection and Reconstruction
631
radiation and chemotherapy were initiated 6 weeks postoperatively. The second patient was a 69-year-old Caucasian man presenting with jaundice and epigastric pain. An ultrasonography followed by a CT scan demonstrated a mass in the head of the pancreas obstructing the distal common bile and pancreatic ducts, and possible invasion of the portal vein a few millimeters above the insertion of the splenic vein. An ERCP examination with brushing for cytology confirmed the diagnosis of adenocarcinoma. A pancreaticoduodenectomy with en bloc partial resection of the portal vein was performed because of invasion of the tumor into the proximal portal vein. The vascular, pancreatic, and biliary reconstructions were performed as described above. Postoperative pathologic investigation revealed one of five peripancreatic lymph nodes to be positive for metastatic adenocarcinoma; biopsies taken at the resection margin showed no evidence of malignancy. The postoperative course was uncomplicated, and the patient was discharged 6 days after operation. The patient received postoperative radiation therapy (5,040 cGy in 28 fractions). A recent evaluation, including a spiral CT examination, 1 year after operation revealed the presence of hepatic metastasis without detectable abnormalities in the pancreas, and a patent portal vein without evidence of narrowing. The third patient was a 53-year-old Caucasian man who presented with painless jaundice and generalized pruritus. Abdominal ultrasonography and ERCP revealed a long stricture extending from the distal to the mid common bile duct with proximal ductal dilatation. Cytology of the material obtained by brushing demonstrated atypical cells. A spiral CT scan showed “fullness” in the head of the pancreas without clear evidence of tumor invasion into the portal vein. At the time of operation, a 3-cm mass was found in the head of the pancreas invading the lateral side of the portal vein from the level of the splenic vein up to 2cm proximally. The patient underwent a similar resection and reconstruction as presented above. Surgical pathology examination showed a moderately differentiated cholangiocarcinoma with no tumor shown at the pancreas margin and four of eight nodes positive for tumor invasion. The patient was discharged 7 days after operation and had an uneventful course at 8 months followup. He completed an adjuvant radiation therapy course. A CT scan performed 1 month after operation showed patency of the entire portal system with evi-
632
Clavien and Ru¨diger
Portal Vein Resection and Reconstruction
J Am Coll Surg
Figure 2. A contrast-enhanced spiral CT of the upper abdomen (section thickness 2.5 mm, spacing 1 mm) was performed 1 month after pancreaticoduodenectomy and partial resection of the portal vein. A volume-rendered curved multiplanar reformation in the coronal plane revealed patency of the splenic and portal systems. The portal vein was slightly narrowed just above the reconstruction site (arrow).
dence of mild narrowing at the site of portal vein reconstruction. Doppler ultrasonography further demonstrated patency of the portal vein with mild stenosis at 6 weeks after surgery (Fig. 3). DISCUSSION Although partial resection of the portal vein is increasingly used in some centers, few comprehensive descriptions of the technical aspect of the procedure are available.11 In many centers, a separate consultant “vascular” or “transplant” surgeon often performs the reconstruction of the portal vein. The new and simple technique described here may be useful in a number of clinical situations. A significant problem in currently used techniques of portal vein reconstruction is the reconstruction of the splenic vein. Failure to properly reconnect the splenic vein to the portal system may result in massive upper gastrointestinal bleeding from gastric varices.7,10 Additionally, Koike and asso-
ciates12 demonstrated in a dog model that the splenic vein plays a major role in maintaining gastric blood flow after pylorus-preserving pancreaticoduodenectomy. A consensus is emerging that preservation of the splenic-portal vein junction is critical during pancreas surgery.2 Although transection of the splenic vein can be sometimes avoided by using simple techniques of venorrhaphy, this approach is associated with a significant risk of narrowing of the portal vein.6 Venorrhaphy without the use of a patch should be strictly limited to very small resections. A wedge resection of the portal vein with lateral venorrhaphy and preservation of a small portion of the backwall was mentioned earlier by Harrison and colleagues,6 but no description of the technique was provided. The use of interposition2,3,7 or patch4,5 grafts using autologous vein1–3,7 grafts or Gore-Tex4 requires experience with this type of vascular reconstruction, and is time consuming. Additionally, the use of autologous grafts usually necessitates additional skin incisions, and
Vol. 189, No. 6, December 1999
Clavien and Ru¨diger
Portal Vein Resection and Reconstruction
633
Figure 3. Black and white print of a power Doppler ultrasound 4 weeks after pancreaticoduodenectomy and partial resection of the portal vein demonstrated patency of the splenic and portal systems. But a 30% to 50% stenosis of the portal vein was found at the anastomotic site associated with turbulent flow downstream (a). Hepatic artery (1).
Gore-Tex grafts are inherently associated with an increased risk of infection and possibly thrombosis. In the three patients described here we used a simple technique allowing excellent control of the tumor margin with minimal risk of blood loss. The reconstruction in each case was possible without graft interposition and with preservation of the splenic flow. Placing one or two sponges on the posterior and superior aspect of the liver significantly decreased tension in the portal vein while performing the anastomosis. The use of a “growth factor tie” (Fig. 1D) prevented any major narrowing after removal of the sponges. Followup in each patient with CT scan demonstrated no or mild narrowing without any evidence of portal hypertension. No patient had complications related to the procedure with documented normal liver function test in each patient. Although this technique is clearly not applicable for tumors encasing the portal vein, it is probably applicable to most cases of partial invasion because up to 5cm of the portal vein can be partially resected. We now consider this approach to be the method of choice in most patients requiring portal vein resection, and consider complete encasement of the portal vein as a contraindication for pancreaticoduodenectomy.
In summary, we describe a simple technique of partial resection of the portal vein that does not require use of interposition or patch grafts. The splenic vein could also be spared in each of the three patients treated with this approach. We anticipate that this type of reconstruction will be applicable in most patients with tumor in the head of the pancreas invading, but not encasing, the portal vein. But the superiority of this simple technique over other types of reconstruction and the impact of portal vein resection on longterm outcomes after duodenopancreatectomy remain to be evaluated. References 1. Allema JH, Reinders ME, van Gulik TM, et al. Portal vein resection in patients undergoing pancreatoduodenectomy for carcinoma of the pancreatic head. Br J Surg 1994;81:1642–1646. 2. Fuhrman GM, Leach SD, Staley CA, et al. Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group. Ann Surg 1996;223: 154–162. 3. Harrison LE, Brennan MF. Portal vein involvement in pancreatic cancer: a sign of unresectability? Adv Surg 1997;31:375–394. 4. Leach SD, Lee JE, Charnsangavej C, et al. Survival following pancreaticoduodenectomy with resection of the superior mesenteric-portal vein confluence for adenocarcinoma of the pancreatic head. Br J Surg 1998;85:611–617.
634
Clavien and Ru¨diger
Portal Vein Resection and Reconstruction
5. Roder JD, Stein HJ, Siewert JR. Carcinoma of the periampullary region: who benefits from portal vein resection? Am J Surg 1996; 171:170–175. 6. Harrison LE, Klimstra DS, Brennan MF. Isolated portal vein involvement in pancreatic adenocarcinoma. A contraindication for resection? Ann Surg 1996;224:342–349. 7. Evans DB, Lee JE, Leach SD, et al. Vascular resection and intraoperative radiation therapy during pancreaticoduodenectomy: rationale and technique. Adv Surg 1996;29:235–262. 8. Nakamura S, Hachiya T, Oonuki Y, et al. A new technique for avoiding difficulty during reconstruction of the superior mesenteric vein. Surg Gyn Obst 1993;177:521–523. 9. Howard J. Pancreatoduodenectomy (Whipple Resection) with skeletonization of vessels for cancers of the pancreas and adjacent organs.
J Am Coll Surg
In: Howard JM, Ihse I, Prinz RA, eds. Surgical diseases of the pancreas. 3rd ed. Philadelphia: Williams & Wilkins; 1997:529–556. 10. Cusack JC Jr, Fuhrman GM, Lee JE, Evans DB. Managing unsuspected tumor invasion of the superior mesenteric-portal venous confluence during pancreaticoduodenectomy. Am J Surg 1994; 168:352–354. 11. Evans DB, Pisters PWT. Pancreaticoduodenectomy (Whipple Operation) and total pancreatectomy for cancer. In: Nyhus LM, Fischer JE, eds. Mastery of surgery. 3rd ed. Boston: Little, Brown and Co; 1997:1233–1249. 12. Koike M, Sumi S, Iwasaki S, et al. Experimental investigation of the role of the splenic vein in gastric venous obstruction after pylorus-preserving pancreatoduodenectomy in the dog. Int J Pancreatol 1997;22:45–50.
Moving? Please send notice of your address change at least six weeks before you move to ensure continued service. Name Subscriber number Old Address
New Address
MAIL THIS FORM TO: JACS P.O. Box 2127 Marion, OH 43305-2127 Journal of the American College of Surgeons
OR FAX TO: (740) 382-5866 OR PHONE (tollfree) (800) 214-8489 (US) Outside the US call (740) 382-3322
per gastrointestinal bleeding from hemorrhagic gastric varices.10 Currently, most surgeons recommend end-to-side reanastomosis of the splenic vein to the interposition graft. But this approach requires extensive dissection of the splenic vein and an additional anastomosis to the two anastomoses required for the interposition graft, each being a potential source of complications. In this report, we describe a simple technique of vascular reconstruction after resection of up to 5cm of the portal vein. The technique does not require an interposition or patch graft, or transection of the splenic vein.
Pancreaticoduodenectomy is the therapy of choice for resectable tumors located in the head of the pancreas. Among the many factors complicating this procedure is the proximity of major vessels, particularly the portal vein and its tributaries. Controversies exist regarding surgery for pancreatic or bile duct tumors invading the portal vein. Although a number of surgeons still consider vascular invasion as a contraindication for pancreatic surgery, several recent studies1–5 have suggested similar outcomes in patients undergoing pancreatectomy with portal vein resection as in those without tumor invasion of the portal vein. There is currently no consensus about the best technique for resection and reconstruction of the portal vein during pancreaticoduodenectomy. Most authors performed an end-to-end anastomosis either by direct suture6 or by using an interposition graft including the internal jugular,2,7 renal,3 saphenous,3 and external iliac1,8 veins, or a Gore-Tex (WL Gore, Flagstaff, AZ) interposition graft.4 Alternatively, a technique of autologous saphenous vein patch has been described for minimal tumor invasion into the portal vein.4,5 Direct closure with simple lateral venorrhaphy3,9 is indicated only for limited resection, and is associated with a significant risk of narrowing of the portal vein. Wide resection of the portal vein for tumors located in the head of the pancreas may require transection of the splenic vein. In the initial experience, the splenic vein was simply ligated without attempt at reconstruction, a procedure resulting in segmental portal hypertension and, in some patients, severe up-
TECHNIQUES OF PORTAL VEIN RESECTION AND RECONSTRUCTION The technique is applicable only for tumors partially invading the portal vein. The head of the pancreas is dissected in the standard fashion with preparation of the portal vein above the first part of the duodenum and the mesenteric vein below the pancreas. A Kelly clamp is carefully introduced along the vein between the neck of the pancreas and the mesenteric vein, and slowly brought to the porta hepatis. The neck of the pancreas is then divided with cautery, allowing complete visualization of the portal vein. The portal vein is clamped above and below the tumor, and this usually also occludes the splenic vein (Fig. 1A). The pancreaticoduodenectomy is performed in the usual fashion and the specimen containing part of the portal vein is then removed en bloc (Fig. 1B). After careful hemostasis of the pancreatic stump, two sponges are placed between the liver and the diaphragm, bringing the liver down and reducing tension of the portal vein. This simple maneuver greatly facilitates the portal vein reconstruction. A transverse reanastomosis (plication) of the portal vein is performed starting with running suture of 6.0 prolene (Ethicon Inc, Somerville, NJ) on the posterior wall, followed
No competing interests declared. Received July 2, 1999; Revised August 16, 1999; Accepted August 24, 1999. From the Section of Hepatobiliary Surgery and Transplantation, Department of Surgery, Duke University Medical Center, Durham, NC. Correspondence address: PA Clavien, MD, PhD, FACS, Box #3247, Duke University Medical Center, Durham, NC 27710. © 1999 by the American College of Surgeons Published by Elsevier Science Inc.
629
ISSN 1072-7515/99/$21.00 PII S1072-7515(99)00214-8
630
Clavien and Ru¨diger
Portal Vein Resection and Reconstruction
J Am Coll Surg
Figure 1.Technique of portal vein resection and reconstruction during pancreaticoduodenectomy. (A) Tumor invasion of the portal vein is well visualized after transection of the neck of the pancreas. (B) The pancreaticoduodenectomy specimen containing part of the portal vein is resected en bloc. (C) The portal vein is reconstructed by direct running suture in a transverse fashion. (D) The use of a growth factor (loosely tied knot) is crucial to prevent significant stenosis after reperfusion of the portal vein.
by the anterior wall (Fig. 1C). The two sutures are loosely tied at about 1cm from the wall of the vein (nicknamed “growth factor knot”) to minimize the
risk of narrowing of the portal vein after reperfusion (Fig. 1D). The vessel clamps are then removed. The reconstruction of the duodenopancreatectomy is
Vol. 189, No. 6, December 1999
Clavien and Ru¨diger
performed as usual with or without preservation of the pylorus. CASE REPORTS This technique was used in three consecutive patients with pancreatic cancer (n⫽2) and distal cholangiocarcinoma (n⫽1). A pancreaticoduodenectomy and en bloc resection of the portal vein followed by a vascular reconstruction, as described above, was performed in each patient. The first patient was a 48-year-old AfricanAmerican man referred to us with a diagnosis of biliary stricture and a 10-kg weight loss. An ERCP, spiral CT scan, and endoscopic ultrasonography showed a heterogeneous, poorly defined mass in the head of the pancreas, with distal common bile duct obstruction. Brushing for cytology disclosed high grade dysplasia. At operation, the patient was found to have severe and diffuse sclerosing pancreatitis. After preparation of the portal vein at the level of the gastroduodenal artery and the superior mesenteric vein below the pancreas, a Kelly clamp was passed between the mesenteric-portal vein and the pancreas. Transection of the pancreas at this level revealed invasion of the tumor into the right side of the portal vein over a 3-cm length starting at the level of the splenic vein. En bloc resection of the pancreatic head was performed as shown in Figure 1A. Because frozen section examination of the pancreas margin was positive for cancer, the pancreas was transected again about 1cm distally to the initial cut. The new margin was negative for malignancy, and the portal vein was reconstructed as described above. The pancreatic and common bile duct stumps were anastomosed end-toside to the jejunum in a standardized fashion using a single layer of interrupted 3.0 silk and 5.0 PDS stitches (Ethicon Inc), respectively. A side-to-side gastrojejunostomy (no preservation of the pylorus) and feeding jejunostomy (Compat; Novartis Nutrition, Minneapolis, MN) were performed before closure of the abdomen. Pathologic examination of the specimen showed moderately differentiated adenocarcinoma with peripancreatic neural invasion. Two of seven nodes were positive for cancer. The postoperative course was complicated with wound infection. A CT scan performed 6 weeks after surgery demonstrated a patent and minimally narrowed portal vein (Fig. 2). Local management of the wound infection and social consideration delayed discharge from the hospital to postoperative day 28. Adjuvant
Portal Vein Resection and Reconstruction
631
radiation and chemotherapy were initiated 6 weeks postoperatively. The second patient was a 69-year-old Caucasian man presenting with jaundice and epigastric pain. An ultrasonography followed by a CT scan demonstrated a mass in the head of the pancreas obstructing the distal common bile and pancreatic ducts, and possible invasion of the portal vein a few millimeters above the insertion of the splenic vein. An ERCP examination with brushing for cytology confirmed the diagnosis of adenocarcinoma. A pancreaticoduodenectomy with en bloc partial resection of the portal vein was performed because of invasion of the tumor into the proximal portal vein. The vascular, pancreatic, and biliary reconstructions were performed as described above. Postoperative pathologic investigation revealed one of five peripancreatic lymph nodes to be positive for metastatic adenocarcinoma; biopsies taken at the resection margin showed no evidence of malignancy. The postoperative course was uncomplicated, and the patient was discharged 6 days after operation. The patient received postoperative radiation therapy (5,040 cGy in 28 fractions). A recent evaluation, including a spiral CT examination, 1 year after operation revealed the presence of hepatic metastasis without detectable abnormalities in the pancreas, and a patent portal vein without evidence of narrowing. The third patient was a 53-year-old Caucasian man who presented with painless jaundice and generalized pruritus. Abdominal ultrasonography and ERCP revealed a long stricture extending from the distal to the mid common bile duct with proximal ductal dilatation. Cytology of the material obtained by brushing demonstrated atypical cells. A spiral CT scan showed “fullness” in the head of the pancreas without clear evidence of tumor invasion into the portal vein. At the time of operation, a 3-cm mass was found in the head of the pancreas invading the lateral side of the portal vein from the level of the splenic vein up to 2cm proximally. The patient underwent a similar resection and reconstruction as presented above. Surgical pathology examination showed a moderately differentiated cholangiocarcinoma with no tumor shown at the pancreas margin and four of eight nodes positive for tumor invasion. The patient was discharged 7 days after operation and had an uneventful course at 8 months followup. He completed an adjuvant radiation therapy course. A CT scan performed 1 month after operation showed patency of the entire portal system with evi-
632
Clavien and Ru¨diger
Portal Vein Resection and Reconstruction
J Am Coll Surg
Figure 2. A contrast-enhanced spiral CT of the upper abdomen (section thickness 2.5 mm, spacing 1 mm) was performed 1 month after pancreaticoduodenectomy and partial resection of the portal vein. A volume-rendered curved multiplanar reformation in the coronal plane revealed patency of the splenic and portal systems. The portal vein was slightly narrowed just above the reconstruction site (arrow).
dence of mild narrowing at the site of portal vein reconstruction. Doppler ultrasonography further demonstrated patency of the portal vein with mild stenosis at 6 weeks after surgery (Fig. 3). DISCUSSION Although partial resection of the portal vein is increasingly used in some centers, few comprehensive descriptions of the technical aspect of the procedure are available.11 In many centers, a separate consultant “vascular” or “transplant” surgeon often performs the reconstruction of the portal vein. The new and simple technique described here may be useful in a number of clinical situations. A significant problem in currently used techniques of portal vein reconstruction is the reconstruction of the splenic vein. Failure to properly reconnect the splenic vein to the portal system may result in massive upper gastrointestinal bleeding from gastric varices.7,10 Additionally, Koike and asso-
ciates12 demonstrated in a dog model that the splenic vein plays a major role in maintaining gastric blood flow after pylorus-preserving pancreaticoduodenectomy. A consensus is emerging that preservation of the splenic-portal vein junction is critical during pancreas surgery.2 Although transection of the splenic vein can be sometimes avoided by using simple techniques of venorrhaphy, this approach is associated with a significant risk of narrowing of the portal vein.6 Venorrhaphy without the use of a patch should be strictly limited to very small resections. A wedge resection of the portal vein with lateral venorrhaphy and preservation of a small portion of the backwall was mentioned earlier by Harrison and colleagues,6 but no description of the technique was provided. The use of interposition2,3,7 or patch4,5 grafts using autologous vein1–3,7 grafts or Gore-Tex4 requires experience with this type of vascular reconstruction, and is time consuming. Additionally, the use of autologous grafts usually necessitates additional skin incisions, and
Vol. 189, No. 6, December 1999
Clavien and Ru¨diger
Portal Vein Resection and Reconstruction
633
Figure 3. Black and white print of a power Doppler ultrasound 4 weeks after pancreaticoduodenectomy and partial resection of the portal vein demonstrated patency of the splenic and portal systems. But a 30% to 50% stenosis of the portal vein was found at the anastomotic site associated with turbulent flow downstream (a). Hepatic artery (1).
Gore-Tex grafts are inherently associated with an increased risk of infection and possibly thrombosis. In the three patients described here we used a simple technique allowing excellent control of the tumor margin with minimal risk of blood loss. The reconstruction in each case was possible without graft interposition and with preservation of the splenic flow. Placing one or two sponges on the posterior and superior aspect of the liver significantly decreased tension in the portal vein while performing the anastomosis. The use of a “growth factor tie” (Fig. 1D) prevented any major narrowing after removal of the sponges. Followup in each patient with CT scan demonstrated no or mild narrowing without any evidence of portal hypertension. No patient had complications related to the procedure with documented normal liver function test in each patient. Although this technique is clearly not applicable for tumors encasing the portal vein, it is probably applicable to most cases of partial invasion because up to 5cm of the portal vein can be partially resected. We now consider this approach to be the method of choice in most patients requiring portal vein resection, and consider complete encasement of the portal vein as a contraindication for pancreaticoduodenectomy.
In summary, we describe a simple technique of partial resection of the portal vein that does not require use of interposition or patch grafts. The splenic vein could also be spared in each of the three patients treated with this approach. We anticipate that this type of reconstruction will be applicable in most patients with tumor in the head of the pancreas invading, but not encasing, the portal vein. But the superiority of this simple technique over other types of reconstruction and the impact of portal vein resection on longterm outcomes after duodenopancreatectomy remain to be evaluated. References 1. Allema JH, Reinders ME, van Gulik TM, et al. Portal vein resection in patients undergoing pancreatoduodenectomy for carcinoma of the pancreatic head. Br J Surg 1994;81:1642–1646. 2. Fuhrman GM, Leach SD, Staley CA, et al. Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group. Ann Surg 1996;223: 154–162. 3. Harrison LE, Brennan MF. Portal vein involvement in pancreatic cancer: a sign of unresectability? Adv Surg 1997;31:375–394. 4. Leach SD, Lee JE, Charnsangavej C, et al. Survival following pancreaticoduodenectomy with resection of the superior mesenteric-portal vein confluence for adenocarcinoma of the pancreatic head. Br J Surg 1998;85:611–617.
634
Clavien and Ru¨diger
Portal Vein Resection and Reconstruction
5. Roder JD, Stein HJ, Siewert JR. Carcinoma of the periampullary region: who benefits from portal vein resection? Am J Surg 1996; 171:170–175. 6. Harrison LE, Klimstra DS, Brennan MF. Isolated portal vein involvement in pancreatic adenocarcinoma. A contraindication for resection? Ann Surg 1996;224:342–349. 7. Evans DB, Lee JE, Leach SD, et al. Vascular resection and intraoperative radiation therapy during pancreaticoduodenectomy: rationale and technique. Adv Surg 1996;29:235–262. 8. Nakamura S, Hachiya T, Oonuki Y, et al. A new technique for avoiding difficulty during reconstruction of the superior mesenteric vein. Surg Gyn Obst 1993;177:521–523. 9. Howard J. Pancreatoduodenectomy (Whipple Resection) with skeletonization of vessels for cancers of the pancreas and adjacent organs.
J Am Coll Surg
In: Howard JM, Ihse I, Prinz RA, eds. Surgical diseases of the pancreas. 3rd ed. Philadelphia: Williams & Wilkins; 1997:529–556. 10. Cusack JC Jr, Fuhrman GM, Lee JE, Evans DB. Managing unsuspected tumor invasion of the superior mesenteric-portal venous confluence during pancreaticoduodenectomy. Am J Surg 1994; 168:352–354. 11. Evans DB, Pisters PWT. Pancreaticoduodenectomy (Whipple Operation) and total pancreatectomy for cancer. In: Nyhus LM, Fischer JE, eds. Mastery of surgery. 3rd ed. Boston: Little, Brown and Co; 1997:1233–1249. 12. Koike M, Sumi S, Iwasaki S, et al. Experimental investigation of the role of the splenic vein in gastric venous obstruction after pylorus-preserving pancreatoduodenectomy in the dog. Int J Pancreatol 1997;22:45–50.
Moving? Please send notice of your address change at least six weeks before you move to ensure continued service. Name Subscriber number Old Address
New Address
MAIL THIS FORM TO: JACS P.O. Box 2127 Marion, OH 43305-2127 Journal of the American College of Surgeons
OR FAX TO: (740) 382-5866 OR PHONE (tollfree) (800) 214-8489 (US) Outside the US call (740) 382-3322