Portal vein reconstruction using an internal jugular vein as a graft: Report of a case

We report the case of a 41-year-old man with pancreatic carcinoma invading the portal vein who was successfully treated by portal vein resection combined with pancreatoduodenectomy and reconstruction using an autointernal jugular vein. The internal jugular vein is an ideal graft for portal vein replacement because it has sufficient length, a well-matched diameter, and there is no venous insufficiency after unilateral resection. Nevertheless, this is the first report of portal vein reconstruction using the internal jugular vein as a graft.     

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.     

胰头癌联合门静脉区域切除的临床价值

目的探讨胰腺癌联合门静脉区域切除的临床价值,及评价区域切除术中肿瘤侵犯门静脉后以颈内静脉替代门静脉的效果。方法回顾性分析2000年1月-2003年1月间天津医科大学附属肿瘤医院6例行胰头癌联合门静脉切除并用颈内静脉替代门静脉修复的患者的临床资料。结果本组6例行胰头癌联合门静脉切除并用颈内静脉替代门静脉修复,术后病理均证实肿瘤侵犯累及门静脉和／或肠系膜上静脉,术后生存时间17～49个月,平均23．2个月,其中2例存活超过3年,最长的1例术后无瘤生存达4年1个月。结论对于胰头癌局部浸润肠系膜上静脉和／或门静脉,但无远处转移的患者,应积极行手术切除。胰腺癌联合门静脉切除后,行颈内静脉替代门静脉修复是一种有效的方法,可以提高手术切除率,减少术后并发症,延长患者生存期。     

Leiomyosarcoma of the superior mesenteric vein: a diagnostic and therapeutic challenge

We report here a case of a very rare entity, a leiomyosarcoma of the mesentericoportal trunk, which was initially misdiagnosed as an unresectable pancreatic cancer invading the mesenteric vein, and which was finally treated by pancreatectomy with mesentericoportal reconstruction. The pitfalls of diagnosis and modalities of resection are discussed.     

Reconstruction of the iliofemoral venous circulation using internal jugular vein autograft.

Two patients with recurrent tumour masses in the groin which involved the common femoral vessels underwent en bloc resection of the tumour, vessels and adjacent anterior abdominal wall. Arterial reconstruction used autologous saphenous vein or polytetrafluorethylene graft. Venous reconstruction was with autologous internal jugular vein.     

The use of internal jugular vein as interposition graft for femoral vein reconstruction following traumatic venous injury: a useful approach in selected cases

Complex venous injuries remain a controversial and interesting challenge to the vascular and trauma surgeon. Data from the Vietnam Vascular Registry, combined with experience from recent civilian series, seem to indicate that the best results are obtained when venous repair is undertaken. This is especially true of combined arterial and venous injury where compromised venous outflow may lead to limb loss in spite of patent arterial reconstruction. The larger size of veins, however, has required the construction of complex and time-consuming panel and spiral-vein grafts. This makes them far from ideal in the trauma treatment setting, where minimization of blood loss and operating room time are high priorities. We present a case of combined injury to both femoral artery and vein, where the femoral vein injury was repaired using autologous internal jugular vein as interposition graft while the arterial injury was repaired with autologous saphenous vein from the opposite limb. The avoidance of prosthetics, ease of harvest, size match, and little associated morbidity all make a strong case for use of the internal jugular vein where speedy reconstruction of large venous conduits is indicated.     

Patency Rates of Portal Vein/Superior Mesenteric Vein Reconstruction After Pancreatectomy for Pancreatic Cancer

Background

Pancreatectomy with venous reconstruction (VR) for pancreatic cancer (PC) is occurring more commonly. Few studies have examined the long-term patency of the superior mesenteric-portal vein confluence following reconstruction.

Methods

From 2007 to 2013, patients who underwent pancreatic resection with VR for PC were classified by type of reconstruction. Patency of VR was assessed using surveillance computed tomographic imaging obtained from date of surgery to last follow-up.

Results

VR was performed in 43 patients and included the following: tangential resection with primary repair (7, 16 %) or saphenous vein patch (9, 21 %); segmental resection with splenic vein division and either primary anastomosis (10, 23 %) or internal jugular vein interposition (8, 19 %); or segmental resection with splenic vein preservation and either primary anastomosis (3, 7 %) or interposition grafting (6, 14 %). All patients were instructed to take aspirin after surgery; low molecular weight heparin was not routinely used. An occluded VR was found in four (9 %) of the 43 patients at a median follow-up of 13 months; median time to detection of thrombosis in the four patients was 72 days (range 16–238).

Conclusions

Pancreatectomy with VR can be performed with high patency rates. The optimal postoperative pharmacologic therapy to prevent thrombosis requires further investigation.     

The cephalic and external jugular veins: important alternative recipient vessels in left-sided microvascular breast reconstruction

BACKGROUND: The internal mammary and thoracodorsal vessels are the standard recipient sites in microsurgical breast reconstruction. We review our series of venous outflow alternatives when these vessels are inadequate or unusable. MATERIALS AND METHODS: A retrospective review of all free breast reconstructions was performed from July 2003 through December 2005. Outcomes were measured with regard to re-exploration, flap failure, and fat necrosis, with attention to the timing and side of reconstruction, as well as the presence or absence of radiation therapy. RESULTS: A total of 141 free breast reconstructions were performed during the study period. In seven cases (5%), alternative venous outflow vessels were selected (cephalic or external jugular vein). Nine anastamotic complications occurred, all of which involved the left internal mammary group (statistically significant for venous thrombosis, P = 0.0063) and three flaps failed. All cephalic and external jugular veins remained patent with no flap failures or fat necrosis within this group. CONCLUSION: The cephalic vein and external jugular vein are excellent alternatives for venous outflow in free breast reconstruction if neither the internal mammary nor thoracodorsal veins are sufficient, especially in left-sided reconstruction.     

Indication for the use of an interposed graft during portal vein and/or superior mesenteric vein reconstruction in pancreatic resection based on perioperative outcomes

Purpose

Combined portal vein and/or superior mesenteric vein (PV/SMV) resection with pancreatic resection sometimes leads to prolonged survival for patients with pancreatic cancer. In this study, we evaluated perioperative outcomes of patients with PV/SMV reconstruction and considered indications for the use of a graft during this procedure.

Methods

We performed PV/SMV resection with pancreatic resection in 128 patients, including 14 using grafts. Complications associated with PV/SMV reconstruction and harvesting venous grafts and reconstructed PV/SMV patency during follow-up were assessed.

Results

Of the 128 patients, 5 underwent total pancreatectomy, 99 pancreaticoduodenectomy, and 24 distal pancreatectomy. In the 14 patients who underwent PV/SMV reconstruction with grafts, the grafts were harvested from the external iliac vein (EIV) in 10 patients and internal jugular vein (IJV) in the other 4. Five patients (3.9 %) had an intraoperative or postoperative acute thrombus or stenosis of reconstructed PV/SMV after direct end-to-end anastomosis. However, PV/SMV patency was excellent after reconstruction using grafts. There were no significant differences in other complications between groups with and without the use of grafts. Three patients (30 %) with EIV grafts had postoperative leg edema, and one of them required analgesics until his death because of leg pain caused by compartment syndrome, whereas no patients with IJV grafts had complications associated with sacrificing veins.

Conclusions

Depending on the length and/or position of the removed PV/SMV segment, interposed graft may be required for reconstruction in some patients, and the use of graft vein, particularly using IJV, is an appropriate procedure that is not associated with any complications.     

Bilateral resection and reconstruction of internal jugular vein for thyroid carcinoma

Two patients with thyroid carcinoma infiltrating bilateral internal jugular veins were treated. In reconstruction of the internal jugular vein by implantation of an autogenous venous segment or Gore-Tex artificial vessel, the repaired area soon became obstructed. The repaired area with the Impra-Flex artificial vessel became obstructed again one month after the implantation. In the reconstruction by ipsilateral end-to-end anastomosis between the internal and external jugular veins, good circulation was apparent even 2 years after the operation. The internal-external jugular vein anastomosis is expected to increase the safety of single-stage bilateral excision of the internal jugular vein, as an adjunct to total thyroidectomy, in the surgical treatment of thyroid carcinoma.     

Bilateral resection and reconstruction of internal jugular vein for thyroid carcinoma

Two patients with thyroid carcinoma infiltrating bilateral internal jugular veins were treated. In reconstruction of the internal jugular vein by implantation of an autogenous venous segment or Gore-Tex artificial vessel, the repaired area soon became obstructed. The repaired area with the Impra-Flex artificial vessel became obstructed again one month after the implantation. In the reconstruction by ipsilateral end-to-end anastomosis between the internal and external jugular veins, good circulation was apparent even 2 years after the operation. The internal-external jugular vein anastomosis is expected to increase the safety of single-stage bilateral excision of the internal jugular vein, as an adjunct to total thyroidectomy, in the surgical treatment of thyroid carcinoma.     

Results of a pancreatectomy with a limited venous resection for pancreatic cancer

PURPOSE: The indications for a pancreatectomy with a partial resection of the portal or superior mesenteric vein for pancreatic cancer, when the vein is involved by the tumor, remain controversial. It can be assumed that when such involvement is not extensive, resection of the tumor and the involved venous segment, followed by venous reconstruction will extend the potential benefits of this resection to a larger number of patients. The further hypothesis of this study is that whenever involvement of the vein by the tumor does not exceed 2 cm in length, this involvement is more likely due to the location of the tumor being close to the vein rather than because of its aggressive biological behavior. Consequently, in these instances a pancreatectomy with a resection of the involved segment of portal or superior mesenteric vein for pancreatic cancer is indicated, as it will yield results that are superposable to those of a pancreatectomy for cancer without vascular involvement. METHODS: Twenty-nine patients with carcinoma of the pancreas involving the portal or superior mesenteric vein over a length of 2 cm or less underwent a macroscopically curative resection of the pancreas en bloc with the involved segment of the vein. The venous reconstruction procedures included a tangential resection/lateral suture in 15 cases, a resection/end-to-end anastomosis in 11, and a resection/patch closure in 3. RESULTS: Postoperative mortality was 3.4%; morbidity was 21%. Local recurrence was 14%. Cumulative (standard error) survival rate was 17% (9%) at 3 years. CONCLUSION: A pancreatectomy combined with a resection of the portal or superior mesenteric vein for cancer with venous involvement not exceeding 2 cm is indicated in order to extend the potential benefits of a curative resection.     

Centrifugal pump-assisted venous bypass between the superior mesenteric vein and the umbilical vein during portal vein resection

We describe herein our method of performing centrifugal pump-assisted venous bypass between the superior mesenteric vein and the umbilical vein, developed with the aim of preventing congestion of the small intestine and promoting strong and constant hepatic blood flow during portal vein resection. By using this bypass method, portal vein resection and reconstruction was able to be carried out with ease and safety in six patients undergoing surgery for a pancreatic mass or cancer. No coagulation abnormalities, thrombocytopenia, leukocytopenia, severe liver dysfunction, or portal vein thrombosis developed in any of the patients postoperatively. Thus, we highly recommend this simple and reliable method of bypass when portal vein resection is being performed.     

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.     

Surgical treatment of congenital spindle-shaped aneurysms of the internal jugular vein]

In 6 of 12 investigated patients resection of a congenital aneurysms of the internal jugular vein was accomplished. In 2 of them venous patency was restored by means of a longitudinal-lateral suture after resection of a sac-shaped aneurysm, while in 4--following circular resection of a spindle-shaped aneurysm the vein was reconstructed by an end- to-end anastomosis. Phlebographic studies in 2 patients 10 and 12 months after reconstruction of the internal jugular vein have demonstrated great perspectives of employing such operation in clinical practice.     

Early Vein Reconstruction and Right-to-Left Dissection for Left-Sided Pancreatic Tumors with Portal Vein Occlusion

Large left-sided pancreatic tumors are frequently associated with portal vein (PV) and/or superior mesenteric vein (SMV) occlusion. Traditionally, vein reconstruction is deferred until after removal of the tumor. However, division of venous collaterals, as is done in a typical left-to-right fashion, leads to progressive portal hypertension and increased risk of variceal hemorrhage during the dissection. Conversely, early PV/SMV resection and reconstruction restores mesenteric-portal flow and decompresses varices, thereby enabling a safer and easier right-to-left pancreatic resection. This “How I Do It” report describes the technique and advantages of a “reconstruction-first” approach for large left-sided pancreatic tumors with venous involvement and left-sided portal hypertension.     

Vascular Resection in Pancreatic Cancer Surgery: Survival Determinants

Introduction

Pancreaticoduodenectomy (PD) is the standard operation for cancer of the pancreatic head. To achieve complete tumor resection and, thus, improve long-term survival, venous resection of the portal or superior mesenteric vein with reconstruction has become routine for advanced pancreatic adenocarcinoma (PDAC). However, its clinical benefit still remains controversial. The aim of this study was to investigate morbidity, mortality, and survival of patients with advanced PDAC following PD with venous resection and to identify significant survival determinants.

Material and Methods

From October 2001 to December 2007, 488 patients with PDAC of the pancreatic head underwent PD at our department. Venous resection was performed in 110 patients (22.5%). Clinical data, surgical techniques, perioperative parameters, and histopathologic data were analyzed on a prospective database.

Results

Major venous reconstruction was accomplished through primary lateral venorrhaphy in 18 patients (16.3%), polytetrafluoroethylene grafting (n?=?14, 12.7%), primary end-to-end anastomosis (n?=?72, 65.5%), an autologous saphenous venous graft patch (n?=?4, 4.6%) or a Goretex® patch (n?=?2, 2.3%). In 78.1% histopathologic examination revealed cancer invasion of the vein, whereas the remainder had peritumoral inflammation extending to the vessel wall. Perioperative morbidity rate was 41.8%; and the mortality rate 3.6%. The 1-, 2-, and 3-year survival rates were 55.2%, 23.1%, and 14.4%, respectively. Operating time (>420 min) and advanced age (>70 years) were the only prognostic variables, which significantly diminished survival on multivariate analysis.

Conclusion

Resection of the superior mesenteric or portal vein to achieve macroscopic tumor clearance can be performed safely with acceptable operative morbidity and mortality. However, improved local clearance in these patients cannot achieve a favorable long-term survival for all patients because distant metastases or local recurrence is frequent.     

Prosthetic replacement of the inferior vena cava. Current controversies

A ringed polytetrafluoroethylene (PTFE) graft is currently the most widely used replacement for the inferior vena cava, although clinical studies comparing this technique with non-ringed prostheses are lacking. There is no consensus on the need to use an anticoagulant or associate a temporary distal arteriovenous fistula to increase venous flow. At present, the best therapeutic strategy cannot be determined. We present a case of retroperitoneal sarcoma infiltrating the infrarenal vena cava, right colon and ureter that was surgically treated in our hospital. En bloc resection was performed and the vena cava was reconstructed using a non-ringed PTFE graft associated with systemic anticoagulation.     

Portomesenteric reconstruction during Whipple procedures: review and report of a case

A 60-year-old man undergoing a Whipple procedure to treat a pancreatic cancer was found to have tumor adherence to the portal vein. An en block pancreaticoduodenectomy with segmental portal vein resection (PVR) was performed. A primary portal vein anastomosis was initially attempted but failed. Hemodynamic deterioration led the authors to perform a temporary prosthetic portal vein interposition graft and abdominal closure. The following morning, once stable, the patient was brought back to the operating room for autologous reconstruction with femoral vein and completion of the pancreaticoduodenectomy. The role of PVR for vein invasion or tumor adherence during a Whipple procedure is still under debate. However, there is growing evidence that the perioperative morbidity and long-term survival in patients who undergo a pancreaticoduodenectomy with PVR are similar to those of patients without vein resection. Therefore a combined resection of the pancreatic head and the portal vein has been suggested in the absence of other contraindications for resection to be able to offer a curative surgical intervention to a larger number of patients. The authors herein report the details of a patient's case and also review the currently available methods for PVR and reconstruction.     

胰十二指肠切除联合肠系膜上-门静脉切除后无需血管替代进行端端吻合

目的探讨胰十二指肠切除联合大段肠系膜上-门静脉切除后不用血管替代进行端端吻合的可行性和安全性。方法对北京大学临床肿瘤学院自2006年8月至2007年2月采用联合肝脏游离及Cattell-Braasch手法施行胰十二指肠联合5cm以上门静脉-肠系膜上静脉的切除,未采用替代血管而直接行端端吻合的5例胰头癌病人的临床资料进行总结。结果术后所有病人均恢复顺利,无严重手术并发症和围手术期死亡。结论胰十二指肠切除联合大段门静脉-肠系膜上静脉切除后直接进行端端吻合,是安全、可行的一种方法。