Portal Vein Resection

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Principles of management

Accurately defining the extent of disease at the time of diagnosis (preoperative) and reserving surgery for those patients with localized, nonmetastatic pancreatic cancer who can undergo a complete gross resection of the primary tumor are critical elements to successful surgery for pancreatic adenocarcinoma.10 To achieve results equivalent to those for patients with tumors that do not involve adjacent vascular structures, the following principles of management11 must be adhered to when

Preoperative staging

Only patients characterized as resectable or borderline resectable are considered for PD. Staging should be established by a multidetector contrast-enhanced CT scan of the abdomen with 3-dimensional reconstruction,13 and by review in a multidisciplinary conference.12 The definitions of resectability are as follows:

  • 1.

    Resectable pancreatic cancer, defined as:

    • (a)

      The absence of extrapancreatic disease.

    • (b)

      No evidence of tumor extension to the SMA, celiac axis, or HA; as defined by the presence of a normal

“R” Factor

Three categories are used to describe the presence or absence of residual tumor following surgical resection:

  • 1.

    R0 is a grossly complete resection with microscopically negative margins.

  • 2.

    R1 is a grossly complete resection with microscopically positive margins.

  • 3.

    R2 is defined as a grossly incomplete resection.15

SMA Margin

The American Joint Committee on Cancer (AJCC) defined the soft tissue that contains autonomic nerves adjacent to the right lateral border of the proximal 3 to 4 cm of the SMA to be the

Neoadjuvant Therapy

Patients with borderline resectable disease based on anatomic criteria are at higher risk for a margin-positive resection with a surgery-alone approach. These patients also may be at higher risk for perioperative complications based on the complexity of the surgery, and at higher risk for systemic failure because of the advanced nature of their primary tumor. For these reasons, a neoadjuvant approach has been advocated including systemic chemotherapy, chemoradiation, or both, rather than

Standard Anatomy

The SMV drains the mid gut, which extends from the duodenum to the transverse colon. The SMA supplies arterial flow to the mid gut including the pancreatic head, duodenum, small bowel, and proximal colon. The SMA arises from the aorta and courses caudally, posterior to the pancreas. Proximal branches of the SMA include the inferior pancreaticoduodenal arteries (usually 2) and very small unnamed tributaries to the uncinate process. Several centimeters distal to its origin, the SMA gives off the

Types of venous resection

The different technical options for resection and reconstruction are illustrated in Fig. 7.

  • 1.

    VR1: Tangential resection of the SMV-PV confluence for tumor adherence limited to a small part of the lateral or posterior wall of the SMV-PV confluence. Repair is by greater saphenous vein patch. If isolated tumor involvement of the lateral SMV-PV confluence occurs directly opposite the SV entrance and a pie-shaped defect can be repaired transversely, a vein patch is not used.11

  • 2.

    VR2: Tumor involves the

Management of the splenic vein

The standard technique for segmental venous resection historically included transection of the SV (to release the PV).22 Division of the SV also allows complete exposure of the SMA medial to the SMV, and provides increased SMV and PV length to allow primary venous anastomosis. With the SV divided, the retroperitoneal dissection is then completed by dividing the tissues anterior to the aorta and to the right of the SMA, leaving the specimen only attached by the SMV-PV confluence. Vascular clamps

Management of jejunal and ileal branches

After transection of the pancreatic neck, the head and uncinate are separated from the SMV and PV when possible by dividing the small venous branches to the pancreas, including those from the jejunal branch to the uncinate. Isolated involvement of the jejunal branch of the SMV requires division of this branch and sometimes resection of a short segment. Reconstruction of the jejunal branch is not necessary if the ileal branch is intact and of reasonable diameter. The ileal branch is usually at

Other vascular resections

Hepatic artery resection and reconstruction is performed when limited tumor involvement of the GDA necessitates short segment resection of the common or proper HA. If a replaced right HA is inseparable from tumor, it is resected. The need for revascularization in this setting is based on back bleeding from the distal artery. The anterior wall of the inferior vena cava (IVC) can also be resected with vein patch reconstruction, when the posterior aspect of the tumor cannot be separated from the

Results of vascular resections

In 2004 Tseng and colleagues7 reported on 572 patients who underwent PD for all histologic diagnoses, of whom 141 (25%) required major vascular resections. Resection of the SMV, PV, or SMV-PV confluence was performed in 126 (89%) of 141 patients. Venous resections included 36 VR1, 24 VR2, 15 VR3, 11 VR4, and 40 VR5. In addition, 17 (12%) of 141 required segmental resection of the HA with or without interposition grafting, and 7 of these also had concomitant venous resection and reconstruction.

Summary

With proper patient selection, a detailed understanding of the anatomy of the root of mesentery, and adequate surgeon experience, vascular resection and reconstruction can be performed safely and does not impact survival duration. The median survival of patients with pancreatic ductal adenocarcinoma who underwent vascular resection was 23 months. This period was approximately 1 year longer than the expected survival of patients who did not have surgery because they were thought to have locally

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References (27)

  • J.F. Tseng et al.

    Pancreaticoduodenectomy with vascular resection: margin status and survival duration

    J Gastrointest Surg

    (2004)
  • C.P. Raut et al.

    Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma

    Ann Surg

    (2007)
  • D.B. Evans et al.

    Surgical treatment of resectable and borderline resectable pancreas cancer: expert consensus statement

    Ann Surg Oncol

    (2009)

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      Citation Excerpt :

      However, saphenous veins can be too small, and size mismatches to the drain portal inflow of the femoral vein (or external iliac vein) might lead to postoperative leg edema.7 The internal jugular vein might be a suitable replacement for PV/SMV because of the similar diameter, venous capacity, and length.22 However, the necessity for PV reconstruction is often not known until the last stage of the resection, and autograft harvesting is therefore associated with an additional surgical procedure carried out at another site of the body, disruption of the main operation, and prolonged operative time.

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