Intraoperative Peripherally Inserted Central Venous Catheter Central Venous Pressure Monitoring in Abdominal Aortic Aneurysm Reconstruction

Numerous studies have found no clinically significant benefit to the perioperative use of pulmonary artery catheters (PACs), and peripherally inserted central venous catheters (PICCs) have been reported to measure central venous pressure (CVP) accurately. The objective of this study was to determine whether the dynamic shifts in preload associated with elective reconstruction of abdominal aortic aneurysms (AAAs) are accurately reflected by CVP measurements from open-ended PICCs compared to CVP measurements from concomitant indwelling PACs. This is a retrospective review of prospectively collected data. PICCs and PACs were placed preoperatively in five patients undergoing elective AAA reconstruction. CVP measurements were recorded every 15 min during the operation. Bland-Altman statistical analysis was used to determine the degree of agreement in data collected by the two measurement devices. Seventy-three paired measurements of CVP from concomitant indwelling PICCs and PACs obtained from five patients undergoing elective AAA reconstruction revealed PICC measurements to be higher than PAC measurements by 0.6 mm Hg (overall correlation coefficient 0.92). The difference between the two measurement devices was expected to be <3.4 mm Hg at least 95% of the time. The findings of this pilot study indicate that PICCs are an effective method for CVP monitoring in situations of dynamic systemic compliance and preload, such as those observed during elective AAA reconstruction.     

Reconstruction of a Common Bile Duct Injury by Venous Bypass

Hepaticojejunostomy is the standard technique for the reconstruction of severe iatrogenic lesions of the common bile duct (CBD), although the technique itself is major surgery with a complication rate up to 30%. We report a case of a male patient with a iatrogenic complete transsection of the CBD. Due to multiple previous operations and the present inflammation a standard reconstruction technique was not possible to perform. A neo-bile duct was created using a segment of the Great Saphenous Vein (GSV) synchronously with an external biliary drainage by PTCA and biliary stenting (after 4 weeks). The stent was removed 8 months later. Cholangiography showed normal bile flow without occlusion. Blood tests normalised. We believe that using an autologous vein graft in combination with a removable or biodegradable stent is the right track for the reconstruction of the CBD in the future.     

Use of Cold-Stored Vein Allografts for Venous Reconstruction During Pancreaticoduodenectomy

Introduction

Venous resections and reconstructions of portal vein and/or superior mesenteric vein in course of pancreaticoduodenectomy are becoming a common practice and many surgical options have been described, from simple tangential resection and venorrhaphy to large segmental resections followed by interposition grafting. The aim of this study was to report the first experience of using fresh cadaveric vein allografts for venous reconstruction during pancreaticoduodenectomy focusing on technical feasibility and postoperative outcomes.

Methods

From January 2001 to October 2012, out of 151 patients undergoing pancreaticoduodenectomy for pancreatic head tumor, 22 (14.5 %) received a vascular resection of the mesentericoportal axis. In five of these patients, vascular reconstruction was accomplished by using cold-stored venous allografts of iliac and femoral veins from donor cadaver. Patients’ data, surgical techniques, and clinical outcomes were analyzed.

Results

Five patients undergoing pancreaticoduodenectomy were selected to receive a vascular reconstruction using a fresh venous allograft for patch closure in three cases, conduit interposition in one case and a Y-shaped graft in the last case. No graft thrombosis or stenosis occurred postoperatively and at long-term follow-up. Mortality rate was zero.

Conclusion

The use of fresh vein allografts is a feasible and effective technique for venous reconstruction during pancreaticoduodenectomy. However, prospective surveys including large cohorts of patients are necessary to confirm these results.     

Venous Reconstruction in Surgery of Meningiomas Invading the Sagittal and Transverse Sinuses

Surgery of meningiomas involving major dural sinuses leaves the surgeon confronted with a difficult dilemma: leave the fragment invading the sinus in place and have a higher risk of recurrence, or attempt a total removal with or without venous reconstruction and expose the patient to a potentially greater operative danger. The authors report a series of 47 meningiomas (41 of the sagittal sinus, 4 of the transverse sinus and 2 of the torcular) in whom gross total removal was achieved in all cases, and venous reconstruction (of various types) attempted in a majority. Thirty-nine patients had a good outcome and resumed their previous activities. There was a permanent neurological deficit in five due to infarction secondary to injury of central veins (all in the sagittal sinus midthird). Three patients died from brain swelling; all with meningioma totally occluding the sinus and in whom resection was achieved without sinus reconstruction. There were two recurrences in this series which has a mean follow-up of 7.5 years.

The authors' surgical experience led them to favor whenever possible, total removal with sinus reconstruction, using a patch for meningiomas with partial sinus invasion and a venous bypass for those with total sinus occlusion.

     

Recovery of Sensitivity in the Hand after Reconstruction with Arterialised Venous Flaps

Loss of soft tissues of the fingers were repaired in 22 patients using 25 arterialised venous flaps harvested from the thenar, hypothenar, or forearm regions. Twenty-one of the flaps survived completely, 16 of which were raised from the thenar or hypothenar region, and the other five from the forearm region. We studied the sensory recovery and skin characteristics of the flaps harvested from the three regions. Good sensory recovery was obtained for the thenar or hypothenar venous flaps, which were characterised by durable skin and suitable texture for replacement of defects in the finger pulp. On the other hand, no moving two-point discrimination was recorded during the follow-up period in the group given forearm venous flaps. These flaps showed instability during pinching and grasping. However, larger flaps and longer veins can be harvested from the forearm region. This type of flap is therefore considered useful for covering dorsal defects of the finger or large and multiple skin defects.     

Outflow Reconstruction Using Cryopreserved Homologous Venous Grafts in Living Donor Liver Transplantation

Objectives

The techniques and outcomes of outflow reconstruction in living donor liver transplantation (LDLT) using cryopreserved homologous veins at the University of Tokyo Hospital are presented.

An Innovative Option for Venous Reconstruction After Pancreaticoduodenectomy: the Left Renal Vein

Introduction Pancreatic ductal adenocarcinoma has a high mortality rate with limited treatment options. One option is pancreaticoduodenectomy, although complete resection may require venous resection. Pancreaticoduodenectomy with venous resection and reconstruction is becoming a more common practice with many choices for venous reconstruction. We describe the technique of using the left renal vein as a conduit for venous reconstruction during pancreaticoduodenectomy. Methods The technique for use of the left renal vein as an interposition graft for venous reconstruction during pancreaticoduodenectomy is described as well as outcomes for nine patients that have undergone the procedure. Results Nine patients, seven men, with a mean age of 57 years, have undergone the operation. There were eight interposition grafts and one patch graft. Mean operating time was 7.8 hours, and mean tumor size was 3.4 cm. Eight patients had node-positive disease, and six had involvement of the vein. Mean hospital stay was 14 days and perioperative morbidity included a superficial wound infection, delayed gastric emptying, ascites, and gastrointestinal bleeding in one patient each. Creatinine ranged from 0.8–1.1 mg/dl preoperatively and from 0.7–1.3 mg/dl at discharge. Mean follow-up was 6.8 months with normal creatinine values noted through the follow-up period. Two patients had died during follow-up from recurrent disease at 8.3 and 18.2 months after the operation. Conclusions The left renal vein provides an additional choice for an autologous graft during pancreaticoduodenectomy with venous resection. The ease of harvesting the graft and maintenance of renal function distinguish its use.     

An Alternative Method of Reconstruction of Hepatic Venous Outflow in Domino Liver Transplantation

The double piggyback technique has been proposed for domino liver transplantation. To make this possible, it is necessary to reconstruct the venous outflow of the domino liver graft on the back table. We describe an alternative method of reconstruction of hepatic venous outflow, in which a neocaval segment is obtained using both common iliac veins from the cadaveric donor.     

胰腺癌患者术后静脉血栓栓塞症的发生率及其危险因素分析

目的分析胰腺癌患者术后静脉血栓栓塞症(VTE)的发生情况及其危险因素。方法:选取2017 年6 月—2021年12 月在安徽省庐江县人民医院及首都医科大学附属北京朝阳医院接受了根治性胰十二指肠切除术的346 例胰腺癌患者,回顾性分析其基本信息(年龄、性别、身高、体质量等)、实验室检查(白细胞计数、淋巴细胞计数、血小板计数、D- 二聚体、组织因子等)、手术的相关信息(血管重建方式、手术时长、出血量等)、肿瘤病理资料(肿瘤类型、分化程度等)。所有患者术前、术后均进行下肢静脉超声检查。根据作者术后是否新发VTE 组(41 例)和非VTE 组(305 例),比较两组患者的临床病例差异,采用多因素Logistic 回归分析胰腺癌患者术后新发VTE 的危险因素。结果:所有胰腺癌患者均顺利完成手术,术后共41 例发生VTE,发生率为11.8% ;余305 例为无VTE 组。两组患者淋巴细胞计数,组织因子,术前、术后第1 天、第3 天D- 二聚体水平及血管重建方式差异有统计学意义;VTE 组手术时长大于无VTE 组,差异有统计学意义(P ＜ 0.05)。本组所有患者术后病理结果均为胰腺导管腺癌,其中,中、高分化217 例,低分化129 例,两组的分化程度差异有统计学意义(P ＜ 0.05)。多因素Logistic 回归分析显示,高龄、组织因子升高、D- 二聚体(术后第1 天)升高、进行同种异体血管置换是胰腺癌术后发生VTE 的独立危险因素(P ＜ 0.05),淋巴细胞计数升高是其保护因素(P ＜ 0.05)。结论:胰腺癌术后VTE 发生率较高,高龄、组织因子升高、D- 二聚体(术后第1 天)升高及进行同种异体血管置换是胰腺癌术后发生VTE 的独立危险因素,而较高的淋巴细胞计数往往意味着更低的VTE 发生可能。     

Hepatic Venous Outflow Reconstruction in Right Lobe Living-Donor Liver Graft Using Recipient''s Superficial Femoral Vein

Venous congestion of a liver graft from a life donor is a disastrous complication with a high risk of graft failure. For safety reasons, the middle hepatic vein (MHV) is currently unanimously left with the donor. As this vessel provides major venous draining of the right anterior sector, reconstruction of significant MHV tributaries is controversial. We describe here successful venous outflow reconstruction in adult-to-adult right lobe living-donor liver transplantation (RL-LDLT) using the recipient's superficial femoral vein (SFV). Six months after transplantation, graft function and perfusion are excellent, and the patient is free of venous morbidity related to the harvest of the SFV.     

Gastric Venous Reconstruction After Radical Pancreatic Surgery: Case Report and Review of the Literature

Vascular resection during surgery for adenocarcinoma of the pancreas is being performed with increasing frequency in order to achieve an R0 resection. With increasingly radical operations come challenges for reconstruction. Generally, these are related to reconstruction of the portal vein; this is particularly true of long-segment vein involvement by the tumor, in which venous outflow from dependent organs can become compromised. We report the first case of left gastric vein to inferior mesenteric vein bypass during a radical total pancreatectomy with long-segment portal vein resection for pancreatic adenocarcinoma, performed to relieve severe gastric venous congestion.