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En bloc simultaneous pancreas and kidney composite graft transplant with limited vascular access
Abstracts / Pancreatology 14 (2014) S1eS129
F-028. En bloc simultaneous pancreas and kidney composite graft transplant with limited vascular access
S95
Conclusion: Our results suggest that preservation of the pyloric ring without vagal innervation has little significance, and that SSPPD with better perioperative and long-term outcomes is more suitable as a standard procedure for patients with pancreatic head cancer.
Yi-Ming Shyr, Shin-E. Wang Taipei Vaterans General Hospital, Taiwan, China F-030. Background: Limited vascular access could be encountered in an obese or re-transplant patient. Aims: An en bloc SPK composite graft transplant in an obese diabetic patient under hemodialysis was described. Patients & methods: At the back-table, SMA and SA of the pancreas graft were reconstructed with a long "Y" artery graft. The smaller left renal artery is anastomosed to thelonger common limb of the arterial Y graft and the shorter portal vein is to the longer graft left renal vein. This en bloc composite graft allowed to facilitate “real” SPK transplant using single common graft artery and vein for anastomosis to one recipient arterial and venous site. The en bloc pancreas and kidney composite graft was implanted by suturing the graft left renal vein to IVC and graft common iliac artery the recipient distal aorta. Results: The operative time was 7 hours with cold ischemic time of 6 hours and 25 min. and warm ischemic time of 47 min. The patient was discharged on postoperative day 20, with a serum creatinine level of 1.4 ng/ ml and a blood glucose level of 121 mg/dL. He has not had any rejection episodes or postoperative complications in the following 12 months after the en bloc SPK transplant. Conclusion: En bloc pancreas and kidney composite graft might be an option for patients with limited vascular access. This technique (1) facilitates “real” simultaneous pancreas and kidney (SPK) transplant with only single common artery and vein for implanting the composite graft; (2) minimizes dissection of vessels and conserves recipient vessels.
F-029. Preservation of the pyloric ring in surgery for pancreatic head cancer; PD vs PPPD vs SSPPD Tsutomu Fujii, Akimasa Nakao, Masashi Hattori, Dai Shimizu, Yasuhiro Kodera Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Japan Background: Pylorus-preserving pancreatoduodenectomy (PPPD) was developed in 1978, and has replaced conventional pancreatoduodenectomy with a distal gastrectomy (cPD) as the most commonly performed procedure. However, there has been no evidence from prospective studies to indicate the overwhelming superiority of PPPD over cPD. Subtotal stomach-preserving pancreatoduodenectomy (SSPPD), in which the pyloric ring and duodenum are removed and more than 90% of the stomach is preserved, has recently been performed in surgery for pancreatic head disease. Aims: In this study, three types of pancreatoduodenectomy: cPD, PPPD, and SSPPD were compared to assess the best option for PD in patients with cancer of the pancreatic head. Patients & methods: In 158 patients with pancreatic head cancer, the perioperative outcomes and long-term nutritional consequences were retrospectively compared. Results: The incidence of DGE was significantly higher in the PPPD group than in the cPD and SSPPD groups (27.3% versus 5.8% and 5.4%, respectively; P¼0.0012). The serum albumin concentration and total lymphocyte count at 1 year postoperatively were significantly higher in the SSPPD group than in the PPPD group (P¼0.0303 and P¼0.0203, respectively). The patients in the SSPPD group showed longer survival times than the patients in the cPD and PPPD groups (median survival times, 21.3, 17.1, and 17.7 months, respectively), although the differences did not reach statistical significance.
Influence of the splenic vein and its branches in pancreatoduodenectomy with resection of the portal vein system Masashi Hattori, Tsutomu Fujii, Masaya Suenaga, Hideki Takami, Yoshikuni Inokawa, Mitsuro Kanda, Suguru Yamada, Hiroyuki Sugimoto, Shuji Nomoto, Yasuhiro Kodera Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Japan Background: Pancreatic head carcinoma frequently invades the superior mesenteric vein (SMV) and/or portal vein (PV), which complicates surgery. Patients with vascular invasion who undergo concurrent vascular resection sometimes achieve long-term survival equivalent to those without vascular invasion. Aims: The aims of this study were to categorize splenic vein (SV) dissection according to type of remnant SV branches, and to evaluate the consequence of dissection of the SV and its branches in pancreatoduodenectomy with SMV and/or PV resection. Patients & methods: We enrolled 129 patients who underwent pancreatectomy with SMV and/or PV resection for periampullary malignant neoplasms: 75 with SV dissection and 54 with SV preservation. White blood cell and platelet counts, hemoglobin, and spleen volume were measured before and after surgery. Patients were categorized according to types of remnant branches after SV dissection. Intraoperative gastric congestion and postoperative complications were evaluated. Results: Postoperative complications and white blood cell and hemoglobin counts were similar for SV resection and preservation. Postoperative platelet count was significantly lower and splenic volume was larger with SV dissection. SV dissection was categorized into six types. Splenic volume increased in the SV-dissected/inferior mesenteric vein (IMV)-preserved group. Platelet count decreased in the SV-dissected/IMV-preserved group and SV/IMV/left gastric vein (LGV)-dissected group. Intraoperative gastric congestion was seen in the SV/LGV-dissected group and SV-dissected/LGVpreserved on the remnant SV group. Conclusion: SV reconstruction might not be necessary when the SV needs to be dissected. Preservation of the IMV on remnant SV might not prevent sinistral portal hypertension. The LGV should be preserved to reduce the risk of gastric congestion.
F-031. Operative procedure and clinical features of left posterior approach pancreaticoduodenectomy with total mesopancreas excision for pancreatic head carcinoma Satoshi Mizutani a, Hideyuki Suzuki a, Takayuki Aimoto b, Akira Muraki a, Seiji Yamagishi a, Ryosuke Nakata a, Tadashi Kobayashi b, Masanori Watanabe a, Eiji Uchida c a
Institute of Gastroenterology, Nippon Medical School Musashikosugi Hospital, Japan b Kobayashi Hospital, Japan c Department of Surgery, Nippon Medical School, Japan Background: Mesopancreas is defined as the region including the area from exta-pancareatic plexus and regional lymphnodes to retroperitoneal fat tissue. The traditional pancreaticoduodenectomy(PD) procedure has a tendency to fail to dissect that region in its entirety especially the zone located on the left side of Superior Mesenteric Artery. Insufficient
F-028. En bloc simultaneous pancreas and kidney composite graft transplant with limited vascular access
S95
Conclusion: Our results suggest that preservation of the pyloric ring without vagal innervation has little significance, and that SSPPD with better perioperative and long-term outcomes is more suitable as a standard procedure for patients with pancreatic head cancer.
Yi-Ming Shyr, Shin-E. Wang Taipei Vaterans General Hospital, Taiwan, China F-030. Background: Limited vascular access could be encountered in an obese or re-transplant patient. Aims: An en bloc SPK composite graft transplant in an obese diabetic patient under hemodialysis was described. Patients & methods: At the back-table, SMA and SA of the pancreas graft were reconstructed with a long "Y" artery graft. The smaller left renal artery is anastomosed to thelonger common limb of the arterial Y graft and the shorter portal vein is to the longer graft left renal vein. This en bloc composite graft allowed to facilitate “real” SPK transplant using single common graft artery and vein for anastomosis to one recipient arterial and venous site. The en bloc pancreas and kidney composite graft was implanted by suturing the graft left renal vein to IVC and graft common iliac artery the recipient distal aorta. Results: The operative time was 7 hours with cold ischemic time of 6 hours and 25 min. and warm ischemic time of 47 min. The patient was discharged on postoperative day 20, with a serum creatinine level of 1.4 ng/ ml and a blood glucose level of 121 mg/dL. He has not had any rejection episodes or postoperative complications in the following 12 months after the en bloc SPK transplant. Conclusion: En bloc pancreas and kidney composite graft might be an option for patients with limited vascular access. This technique (1) facilitates “real” simultaneous pancreas and kidney (SPK) transplant with only single common artery and vein for implanting the composite graft; (2) minimizes dissection of vessels and conserves recipient vessels.
F-029. Preservation of the pyloric ring in surgery for pancreatic head cancer; PD vs PPPD vs SSPPD Tsutomu Fujii, Akimasa Nakao, Masashi Hattori, Dai Shimizu, Yasuhiro Kodera Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Japan Background: Pylorus-preserving pancreatoduodenectomy (PPPD) was developed in 1978, and has replaced conventional pancreatoduodenectomy with a distal gastrectomy (cPD) as the most commonly performed procedure. However, there has been no evidence from prospective studies to indicate the overwhelming superiority of PPPD over cPD. Subtotal stomach-preserving pancreatoduodenectomy (SSPPD), in which the pyloric ring and duodenum are removed and more than 90% of the stomach is preserved, has recently been performed in surgery for pancreatic head disease. Aims: In this study, three types of pancreatoduodenectomy: cPD, PPPD, and SSPPD were compared to assess the best option for PD in patients with cancer of the pancreatic head. Patients & methods: In 158 patients with pancreatic head cancer, the perioperative outcomes and long-term nutritional consequences were retrospectively compared. Results: The incidence of DGE was significantly higher in the PPPD group than in the cPD and SSPPD groups (27.3% versus 5.8% and 5.4%, respectively; P¼0.0012). The serum albumin concentration and total lymphocyte count at 1 year postoperatively were significantly higher in the SSPPD group than in the PPPD group (P¼0.0303 and P¼0.0203, respectively). The patients in the SSPPD group showed longer survival times than the patients in the cPD and PPPD groups (median survival times, 21.3, 17.1, and 17.7 months, respectively), although the differences did not reach statistical significance.
Influence of the splenic vein and its branches in pancreatoduodenectomy with resection of the portal vein system Masashi Hattori, Tsutomu Fujii, Masaya Suenaga, Hideki Takami, Yoshikuni Inokawa, Mitsuro Kanda, Suguru Yamada, Hiroyuki Sugimoto, Shuji Nomoto, Yasuhiro Kodera Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Japan Background: Pancreatic head carcinoma frequently invades the superior mesenteric vein (SMV) and/or portal vein (PV), which complicates surgery. Patients with vascular invasion who undergo concurrent vascular resection sometimes achieve long-term survival equivalent to those without vascular invasion. Aims: The aims of this study were to categorize splenic vein (SV) dissection according to type of remnant SV branches, and to evaluate the consequence of dissection of the SV and its branches in pancreatoduodenectomy with SMV and/or PV resection. Patients & methods: We enrolled 129 patients who underwent pancreatectomy with SMV and/or PV resection for periampullary malignant neoplasms: 75 with SV dissection and 54 with SV preservation. White blood cell and platelet counts, hemoglobin, and spleen volume were measured before and after surgery. Patients were categorized according to types of remnant branches after SV dissection. Intraoperative gastric congestion and postoperative complications were evaluated. Results: Postoperative complications and white blood cell and hemoglobin counts were similar for SV resection and preservation. Postoperative platelet count was significantly lower and splenic volume was larger with SV dissection. SV dissection was categorized into six types. Splenic volume increased in the SV-dissected/inferior mesenteric vein (IMV)-preserved group. Platelet count decreased in the SV-dissected/IMV-preserved group and SV/IMV/left gastric vein (LGV)-dissected group. Intraoperative gastric congestion was seen in the SV/LGV-dissected group and SV-dissected/LGVpreserved on the remnant SV group. Conclusion: SV reconstruction might not be necessary when the SV needs to be dissected. Preservation of the IMV on remnant SV might not prevent sinistral portal hypertension. The LGV should be preserved to reduce the risk of gastric congestion.
F-031. Operative procedure and clinical features of left posterior approach pancreaticoduodenectomy with total mesopancreas excision for pancreatic head carcinoma Satoshi Mizutani a, Hideyuki Suzuki a, Takayuki Aimoto b, Akira Muraki a, Seiji Yamagishi a, Ryosuke Nakata a, Tadashi Kobayashi b, Masanori Watanabe a, Eiji Uchida c a
Institute of Gastroenterology, Nippon Medical School Musashikosugi Hospital, Japan b Kobayashi Hospital, Japan c Department of Surgery, Nippon Medical School, Japan Background: Mesopancreas is defined as the region including the area from exta-pancareatic plexus and regional lymphnodes to retroperitoneal fat tissue. The traditional pancreaticoduodenectomy(PD) procedure has a tendency to fail to dissect that region in its entirety especially the zone located on the left side of Superior Mesenteric Artery. Insufficient