Clinical significance of combined pancreas and portal vein resection in surgery for pancreatic adenocarcinoma

BACKGROUND/AIMS: Surgical resection remains the only potentially curative treatment for pancreatic adenocarcinoma for which the resectability and prognosis are still poor. The aim of the present study was to evaluate the efficacy of portal vein resection for pancreatic adenocarcinoma. METHODOLOGY: Between August 1983 and December 2000, 69 patients with pancreatic ductal cell carcinoma underwent resection in our department; 22 of the 69 had combined resection of the pancreas and portal vein. When the pancreas could not be separated from the portal vein, the vein was judged to be invaded by cancer and resected. RESULTS: The mortality rate for portal vein resection was 4.5%, which was similar to that in 47 patients with no resection of the portal vein (2.1%). Postoperative histologic analysis showed that 8 (37%) of the patients who underwent portal vein resection did not have cancer invasion to the portal vein, and 3 of them remain disease free to date. The 3-year survival rate of patients undergoing portal vein resection was 21.3%, and that of patients without portal vein resection was 20.0%. CONCLUSIONS: Resection of the portal vein in cases of pancreatic ductal cell carcinoma has no adverse affect on long-term survival for selected patients.     

Monitoring hepatic venous hemoglobin oxygen saturation during Appleby operation for pancreatic cancer

BACKGROUND/AIMS: When an Appleby operation is performed for pancreatic body and tail carcinoma, it is necessary for prevention of hepatic ischemia to estimate accurately the hepatic circulation after resection of the celiac artery, the common hepatic artery and the portal vein. We studied the hepatic circulation by monitoring the ShvO2 (hepatic venous hemoglobin oxygen saturation) during an Appleby operation. METHODOLOGY: We performed an Appleby operation on 8 patients with pancreatic cancer. In 6 of 8 patients, a 7-Fr fiberoptic flow direct catheter was inserted in the right hepatic vein. The ShvO2 values were monitored continuously during surgery. RESULTS: The ShvO2 value was 76 +/- 3.5% just after laparotomy, and reduced to 61 +/- 13.2% after clamping the common hepatic artery. The values of the ShvO2 returned to 70.8 +/- 10.9% one hour after clamping. But, one patient underwent reconstruction of the common hepatic artery, because the ShvO2 value still stood at 50%. Combined resection of the portal vein was performed in 5 out of 8 patients. Two patients underwent resection of the portal vein without reconstruction due to the development of the collateral vein, one patients; resection of the portal vein with reconstruction, and two patients; wedge resection. In all 5 patients, the ShvO2 was stable during resection of the portal vein. CONCLUSIONS: Monitoring the ShvO2 is a useful method to evaluate at real time the hepatic circulation during the Appleby operation, and to decide if reconstruction of the common hepatic artery or the portal vein is needed or not.     

Pancreaticoduodenectomy with portal vein/superior mesenteric vein resection for patients with pancreatic cancer with venous invasion

BACKGROUND: With the development of new surgical techniques, pancreaticoduodenectomy(PD) with portal vein or superior mesenteric vein(PV/SMV) resection has been used in the treatment of patients with borderline resectable pancreatic cancer. However, opinions of surgeons differ in the effectiveness of this surgical technique. This study aimed to investigate the effectiveness of this approach in patients with pancreatic cancer.METHODS: Follow-up visits and retrospective analysis were carried out of 208 patients with pancreatic cancer who had undergone PD(PD group) and PD combined with PV/SMV resection and reconstruction(PDVR group) from June 2009 to May 2013 at our center. Statistical analysis was performed to compare the clinical features, the difference of survival time and risk factors of venous invasion in pancreatic cancer.Factors relating to postoperative survival time of pancreatic cancer were also investigated. RESULTS: In the PDVR group, which consisted of 42 cases, the 1-,2- and 3-year survival rates were 70%, 41% and 16%, respectively and the median survival time was 20.0 months. Among the 166 patients in the PD group, the 1-, 2- and 3-year survival rates were 80%, 52%, and 12%, respectively with the median survival time of 26.0 months. No significant difference in survival time and R0 resection ratio was found between the two groups. Lumbodorsal pain, tumor with pancreatic capsular invasion and bile duct infiltration were found to be independent risk factors for PV invasion in pancreatic cancer. In addition, non R0 resection,large tumor size(2 cm) and poorly differentiated tumor were independent risk factors for survival time in post-PD.CONCLUSIONS: The tumor has a higher chance of venous invasion if preoperative imagings indicate that it juxtaposes with the vessel. Lumbodorsal pain is the chief complaint. Patients with pancreatic cancer associated with PV involvement should receive PDVR for R0 resection when preoperational assessment shows the chance for eradication.     

Combined resection of the portal vein for pancreatic cancer: preoperative diagnosis of invasion by portography and prognosis

BACKGROUND/AIMS: Pancreatic cancer often invades the portal vein because of the anatomical position. Pancreatic cancer with portal vein invasion was not considered operable, and thus the resectability rate was low. METHODOLOGY: Between March 1976 and February 1994, 140 of 243 patients underwent resection, a resectability rate of 58%. A total of 81 (58%) of these patients underwent portal vein resection. We assessed 56 patients in whom the depth of invasion had already been determined histopathologically and whose superior mesenteric arterial portograms were readable. The 56 patients were classified into 4 groups: normal (Type I), stricture on one side of the portal vein (Type II), stricture on both sides of the portal vein (Type III), complete obstruction (Type IV). The length of the longitudinal lesions on portograms was also measured. RESULTS: In 93% (27/29 cases) of portographic Type I or II lesions with longitudinal lesions of 2 cm or less, portal vein invasion was limited to the tunica media. No patients with cancer invasion into the lumen survived more than 1 year. CONCLUSIONS: For patients with pancreatic cancer Type I or II, preoperative portography findings and longitudinal lesions of 2 cm or less, portal vein resection is indicated, and long-term survival can be expected.     

Pancreatic head tumors with portal vein involvement: an alternative surgical approach.

BACKGROUND/AIMS: One of the determining factors for the unresectability of pancreatic head tumors is the involvement of the portal venous system. Recent reports show that the resection of tumors with portal vein involvement has similar results to lesions with same stage without portal vein invasion. The aim of this study is to present a technique that allows the resection of portal vein segments without the use of grafts and with a shorter period of intraoperative venous occlusion. METHODOLOGY: Fifteen patients with pancreatic head tumors and portal vein involvement were submitted to pancreaticoduodenectomy according to this technique. The main feature of the technique is starting the pancreatic dissection at the posterior aspect of the head of the pancreas. The superior mesenteric artery is completely dissected from the pancreatic tissues leaving the section of the pancreas and the resection of the portal vein to the last step. RESULTS: Portal vein flow occlusion did not exceed 10 minutes. There were no major postoperative complications or mortality. CONCLUSIONS: This maneuver allows an easier resection of the mobilized portal vein with a shorter period of venous clamping and reconstruction without the need of venous graft.     

Postoperative portal vein thrombosis in patients with hepatosplenic mansonic schistosomiasis: relationship with intraoperative portal pressure and flow. A prospective study

BACKGROUND/AIMS: Portal vein thrombosis is a frequent postoperative complication after esophagogastric devascularization with splenectomy. The aim of this study was to analyze biochemical, hematological, coagulation blood tests and intraoperative portal vein hemodynamics after surgical treatment of hepatosplenic Mansonic schistosomal portal hypertension. METHODOLOGY: Forty patients with hepatosplenic schistosomiasis with indication for surgical treatment were prospectively studied. All patients underwent routine pre- and postoperative biochemical, hematologic, coagulation blood tests and intraoperative portal hemodynamic evaluation (portal pressure and portal flow) before and after esophagogastric devascularization and splenectomy using a 4-F thermodilution catheter introduced inside the portal vein. RESULTS: Portal vein thrombosis, diagnosed by routine postoperative Doppler ultrasonography was found in 22 patients (55%). It was partial in nineteen and total in three. In patients with postoperative portal thrombosis, we observed a reduction in portal flow of 971 +/- 592 mL/min (42 +/- 16%) at the end of the surgery, while this reduction was of 720 +/- 644mL/ min (33 +/- 30%) in those with postoperative pervious portal vein (p = 0.245). The decrease in portal pressure was the same in both groups: 7.2 +/- 3.0 mmHg (23 +/- 10%) and 7.6 +/- 3.8 mmHg (27 +/- 14%) with and without thrombosis respectively (p=0.759). There was also no significant difference between patients with and without portal vein thrombosis regarding pre- and postoperative hemoglobin level or platelet levels, coagulation tests, portal vein diameter and spleen's weight. CONCLUSIONS: Portal vein thrombosis was observed in 55% of the patients but this complication did not show any correlation with the decrease in portal flow or pressure or with biochemical, hematologic, coagulation blood tests, portal vein diameter or spleen's weight.     

Superior mesenteric vein resection without reconstruction in pylorus-preserving pancreatoduodenectomy for pancreatic head cancer

The prognosis of pancreatic cancer is poor, even in resectable patients. The reason for this poor prognosis is partly due to local invasion of the tumor into the tissues around the pancreas. Pancreatic head cancer usually invades the mesentericoportal veins, so the combined venous resection is usually performed during pancreatoduodenectomy for the purpose of obtaining a negative surgical margin. We performed pancreatoduodenectomy for lower pancreatic head cancer together with superior mesenteric vein resection without reconstruction in two patients, after confirming adequate portal venous flow and small intestinal congestion, This is the first report of pancreatoduodenectomy combined with superior mesenteric vein resection without reconstruction for the purpose of obtaining a wide surgical margin.     

Surgical treatment for hepatocellular carcinoma with portal vein tumor thrombus

BACKGROUND/AIMS: To study the value of surgical treatment for hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). METHODOLOGY: From January 1997 to December 2001, 63 cases of HCC with portal vein tumor thrombus underwent liver resection combined with PVTT removal (group 1). Between December 2001 and December 2003, 20 patients received adjuvant portal vein chemotherapy (PVC) after the surgical procedures mentioned above (group 2). Treatment outcome and the surgical features in these two groups were studied. RESULTS: The median overall survival in group 2 was significantly longer than that in group 1 (10.9 months vs. 7.8 months, p < 0.05). There were significant differences between the survival of the two groups (log-rank, p < 0.05). In group 1 the 1-, 3-, and 5-year survival rates were 18.0%, 14.8% and 1.6%, respectively. In group 2 the 1-year survival rate was 30%. CONCLUSIONS: Liver resection combined with PVTT removal and the postoperative PVC is beneficial to the survival of HCC patients with PVTT. Postoperative PVC might enhance the effect of these surgical approaches.     

Tips and tricks of surgical technique for pancreatic cancer: portal vein resection and reconstruction (with videos)

Surgical resection is the only hope for cure in patients with pancreatic cancer. To improve the resectability and achieve better prognosis of this lethal disease, extended resection for pancreatic cancer has been applied. We have performed portal vein resection aggressively for pancreatic cancer with portal vein invasion. We also established a method of portal vein reconstruction using the left renal vein graft for tumors widely extended to the portal vein. Our data show similar survival between patients with portal vein obstruction and those without invasion. We also show that portal vein reconstruction using the left renal vein graft can be performed safely without severe liver damage. With video, we introduce our surgical technique for portal vein resection and reconstruction, especially focusing on the usage of the left renal vein graft, providing several tips for a safe and successful procedure.     

门静脉免疫化疗对原发性肝癌切除术后患者预后的影响

目的观察门静脉免疫化疗对原发性肝癌切除后患者预后的影响。方法收集湖北医药学院附属太和医院2010年1月-2013年6月住院的48例手术切除并行术后门静脉免疫化疗患者,对其临床资料进行回顾性分析,并与同期未行门静脉免疫化疗的59例患者进行对比。计量资料的分析采用两样本资料的t检验,率的检验采用卡方检验。生存分析采用Kaplan-Meirer法计算平均生存时间,采用log-rank检验分析不同组之间的差异性。将107例患者合并,采用Cox回归模型分析对可能影响预后的因素进行多因素分析。结果免疫化疗组和对照组的1、2、3年的无瘤生存率分别为87.5%(42/48)和67.8%(40/59)(χ2=5.739,P=0.017)、52.1%(25/48)和32.2%(19/59)(χ2=4.320,P=0.038)、16.7%(8/48)和10.2%(6/59)(χ2=0.982,P=0.322),平均生存时间分别为(32.4±2.3)个月和(24.7±2.3)个月(χ2=4.044,P=0.044)。合并门静脉癌栓者术后行门静脉免疫化疗其平均生存时间(12.4±1.3)个月,而未行门静脉免疫化疗者为(4.8±0.4)个月(χ2=15.535,P0.001)。经Cox回归分析显示,肿瘤的分化程度、肿瘤的大小、肝功能分级、是否存在门静脉癌栓是影响肝细胞切除术后复发的独立危险因素,而是否采用门静脉免疫化疗对影响肝癌术后的复发时间有重要影响,具有统计学意义(P0.001)。结论门静脉免疫化疗可改善原发性肝癌切除后的无瘤生存率和生存时间。     

Carcinoma of the pancreas with portal vein involvement--our experience with a modified technique of resection

BACKGROUND/AIMS: Up to 40% of the patients with pancreatic carcinoma are not fit for curative resection due to the locally advanced nature of the disease in the form of vascular involvement. In recent years a more aggressive approach of vascular resection with pancreaticoduodenectomy (PD) has resulted in the increase in resectability rate and survival in this group of patients. The most important determinant of survival in these patients is negative resection margins. The aim of the present study is to present our experience of vascular resection using a modified technique, in patients with pancreatic cancer. METHODOLOGY: This is a retrospective study of 48 patients who underwent portal vein/superior mesenteric vein (PV/SMV) resection along with PD using the modified technique of resection, during 1982-2004. The principle modification is the initial extensive retroperitoneal dissection for the assessment of the extent of tumor involvement of the superior mesenteric vessels and division of retroperitoneal margin before the division of the pancreas. All patients also underwent extended lymphadenectomy. RESULTS: The subtotal PD was done in 26 and total PD in 22 patients, with resection of the PV/SMV in all of them. The end-to-end anastomosis was possible after adequate mobilization of the PV and SMV in 40 patients. In 4 patients reconstruction was able to be done with the use of a graft. The portal vein occlusion time was 8-15 minutes. Histopathological examination showed negative margins in all the resected specimens. Postoperative complications occurred in 16.66% with reoperation rate of 8.33%, and mortality of 6.25%. After a mean follow-up of 110 months, mean survival was 40 months with the range of 18-250 months. The five-year and 10-year survival was 18% and 10% respectively. The venous patency rate was 100% at three years. CONCLUSIONS: In conclusion, PD with en bloc resection of the PV/SMV confluence can safely be done with morbidity and mortality similar to that of standard PD. The survival advantage is directly related to the attainment of negative resection margins. The modified technique is a useful way of doing vascular resection with the least amount of bowel congestion and securing negative resection margins.     

Autogenous vein graft from iliac artery to splenic artery for celiac occlusion in pancreaticoduodenectomy

This is a report of two patients with bile duct cancer and periampullary cancer with celiac axis occlusion who underwent pylorus-preserving pancreaticoduodenectomy and pancreaticoduodenectomy, respectively. Preoperative arteriography demonstrated complete obstruction of the celiac axis. The arterial blood flow to the liver, spleen, and stomach was sustained through the pancreaticoduodenal arcades and collaterals from the superior mesenteric artery. Therefore, reconstruction of the celiac axis circulation was required before division of the gastroduodenal artery. An autograft of the saphenous vein was placed between the iliac artery and the splenic artery, and subsequently pancreaticoduodenectomy was performed. The patients' postoperative courses were uneventful. Postoperative arteriography demonstrated patency of the grafts. When occlusion of the celiac axis exists, a bypass from the iliac artery to the splenic artery using a saphenous vein graft, may be safely and easily performed at the time of pancreaticoduodenal resection.     

Total pancreatectomy with segmental duodenectomy preserving right gastroepiploic vein

We performed total pancreatectomy with segmental duodenectomy preserving the gastrocolic trunk and right gastroepiploic vein, to prevent gastric venous congestion, for treatment of pancreatic tumor. This is believed to be the first report of such a procedure. The patient was a 58-year-old man with high serum levels of carbohydrate antigen 19-9 and carcinoembryonic antigen. He was examined by abdominal ultrasonography and computed tomography, and diagnosed with cancer of the pancreatic body. No distant metastasis was found. We decided to perform distal pancreatectomy. After surgery, the cut edge of the distal pancreas was subjected to frozen section examination, and there was carcinoma in situ in the stump of the main pancreatic duct. Therefore, we cut the pancreatic head partially, twice, but carcinoma in situ remained. We additionally performed pancreatic head resection with segmental duodenectomy, with preservation of the gastroduodenal artery, right gastroepiploic artery, gastrocolic trunk and right gastroepiploic vein to prevent gastric venous congestion. The postoperative course was uneventful and the patient remains in good condition. This surgical technique is considered feasible and safe for prevention of gastric venous congestion.     

Portal vein pulsatility index is a more important indicator than congestion index in the clinical evaluation of right heart function

AIM: To study the changes of portal blood flow in congestive heart failure. METHODS: We studied the congestion index (CI) and portal vein pulsatility index (PI) in patients with varied degrees of congestive heart failure using ultrasonic Doppler. Ten patients with (mean) right atrial pressure (RA) < 10 mmHg were classified as group 1 and the remaining 10 patients with RA > or = 10 mmHg as group 2. RESULTS: There were no difference on cardiac index (HI, P=0.28), aortic pressure (AO, P=0.78), left ventricular end-diastolic pressure (LVED, P=0.06), (max)imum portal blood velocity (Vmax, P=0.17), (mean) portal blood velocity (Vmean, P=0.15) and portal blood flow volume (PBF, P=0.95) between the two groups. Group 2 patients had higher pulmonary wedge pressure (PW, 29.9+/-9.3 mmHg vs 14.6+/-7.3 mmHg, P=0.002), pulmonary arterial pressure (PA, 46.3+/-13.2 mmHg vs 25.0+/-8.2 mmHg, P=0.004), RA (17.5+/-5.7 mmHg vs 4.7+/-2.4 mmHg, P<0.001), right ventricular end-diastolic pressure (RVED, 18.3+/-5.6 mmHg vs 6.4+/-2.7 mmHg, P<0.001), CI (8.7+/-2.4 vs 5.8+/-1.2, P=0.03), and PI (87.8+/-32.3% vs 27.0+/-7.4%, P<0.001) than Group 1. CI was correlated with PI (P<0.001), PW (P<0.001), PA (P<0.001), RA (P=0.043), RVED (P=0.005), HI (P<0.001), AO (P<0.001), CO (P<0.001), LVED (P<0.001), Vmax (P<0.001), Vmean (P<0.001), cross-sectional area of the main portal vein (P<0.001) and PBF (P<0.001). CI could be as high as 8.3 in patients with RA < 10 mmHg and as low as 5.9 in those with RA > or = 10 mmHg. CONCLUSION: Our data show that RI is a more significant indicator than CI in the clinical evaluation of high RA > or = 10 mmHg, whereas CI is better than PI in the assessment of left heart function.     

Preoperative predictors of portal vein thrombosis after splenectomy with periesophagogastric devascularization

AIM: To evaluate the predictive value of preoperative predictors for portal vein thrombosis (PVT) after splenectomy with periesophagogastric devascularization.METHODS: In this prospective study, 69 continuous patients with portal hypertension caused by hepatitis B cirrhosis underwent splenectomy with periesophagogastric devascularization in West China Hospital of Sichuan University from January 2007 to August 2010. The portal vein flow velocity and the diameter of portal vein were measured by Doppler sonography. The hepatic congestion index and the ratio of velocity and diameter were calculated before operation. The prothrombin time (PT) and platelet (PLT) levels were measured before and after operation. The patients’ spleens were weighed postoperatively.RESULTS: The diameter of portal vein was negatively correlated with the portal vein flow velocity (P < 0.05). Thirty-three cases (47.83%) suffered from postoperative PVT. There was no statistically significant difference in the Child-Pugh score, the spleen weights, the PT, or PLT levels between patients with PVT and without PVT. Receiver operating characteristic curves showed four variables (portal vein flow velocity, the ratio of velocity and diameter, hepatic congestion index and diameter of portal vein) could be used as preoperative predictors of postoperative portal vein thrombosis. The respective values of the area under the curve were 0.865, 0.893, 0.884 and 0.742, and the respective cut-off values (24.45 cm/s, 19.4333/s, 0.1138 cm/s^-1 and 13.5 mm) were of diagnostically efficient, generating sensitivity values of 87.9%, 93.9%, 87.9% and 81.8%, respectively, specificities of 75%, 77.8%, 86.1% and 63.9%, respectively.CONCLUSION: The ratio of velocity and diameter was the most accurate preoperative predictor of portal vein thrombosis after splenectomy with periesophagogastric devascularization in hepatitis B cirrhosis-related portal hypertension.     

Portal vein resection in pancreaticoduodenectomy (with video)

Superior mesenteric vein (SMV) resection during pancreaticoduodenectomy (PD) for pancreatic cancer was first reported by Moore in 1951. In Japan, utilization of portal vein resection (PVR) became popular beginning in the late 1970s and has resulted in an improved resection rate for pancreatic cancer. Outcomes of PVR differ according to the reported year and institution. In a recent report of meta-analysis, there was no difference in outcomes after PVR if R0 (negative surgical margins) resection was possible. Pancreatic surgery including vascular resection must be re-evaluated in light of recent advances in diagnostic imaging and surgical techniques, lower mortality and morbidity after PVR, and improvements in adjuvant and neo-adjuvant therapy. Isolated portal vein involvement should not be a contraindication to resection. Portal vein resection should be considered after appropriate patient selection based on an accurate diagnosis, provided that safe R0 resection is possible. We describe technical details and considerations for PVR during PD in this paper.     

Relationship between the diameter of the vein graft and postoperative ankle brachial pressure index following femoro-popliteal bypass

AIM: We studied whether the diameter of the saphenous vein graft affects the result of femoro-popliteal bypass surgery. METHODS: Thirty-eight patients with bypasses from the femoral artery to the above knee popliteal artery were studied. Bypasses without a patent anterior or posterior tibial artery were excluded. The great saphenous vein was used as a bypass graft in 20 extremities and Dacron grafts (6 mm or 8 mm diameter) were used in 18 arteries. The smallest diameter of the saphenous vein was measured preoperatively with ultrasonography. Vein grafts were divided into two groups: small vein graft (< or =3 mm) and large vein graft (> or =3.5 mm). The ankle brachial pressure index (ABI) was measured at 1 week and 3 months after operation. RESULTS: The diameter of the vein graft (2.5 to 4 mm, 3.4+/-0.5 mm) was positively correlated with postoperative ABI (R2 0.607, P<0.0001). The postoperative ABI at 1 week was significantly lower in the small vein graft group (0.72+/-0.09) than in the large vein graft group (0.95+/-0.11) and in the Dacron graft group (1.05+/-0.16). The ABI at 3 months was still significantly lower in small vein graft group (0.78+/-0.07). CONCLUSION: The diameter of the vein graft was positively correlated with postoperative ABI after femoro-popliteal above knee bypass. Postoperative ABI was lower using a vein graft with a diameter of < or =3 mm than that using a bigger vein graft or a Dacron graft.     

The significance of portal vein embolization in the treatment of colorectal liver metastases

The first aim of the present paper was to evaluate hypertrophy of liver parenchyma after portal vein embolization in patients after systemic chemotherapy for colorectal carcinoma metastases and planned extensive liver resections. The second aim was to study whether hypertrophy of the liver parenchyma remnant after could influence the postoperative course large liver resections in long-term chemotherapy within complex therapy of colorectal carcinoma.The prospective study comprised of 43 patients with colorectal hepatic metastases in whom liver resections of 4-5 segments were planned (Table 1). All patients underwent complex therapy of colorectal carcinoma, including chemotherapy consisting of 6-12 therapeutic cycles. Time interval between chemotherapy and liver resection was 2-24 months (mean interval of 8 months). Twenty patients whose presumed liver parenchyma remnant was less than 40% of total liver volume were indicated for portal vein embolization (mean liver parenchyma remnant of 29%). This was always embolization of the right portal branch. Twenty-three patients were primarily indicated to liver resection. RESULTS: Hypertrophy of the left liver lobe occurred in all 20 patients. After portal vein embolization, the volume of left liver increased on average from 476 ml (282-754) to 584 ml (380-892) (P < 0.05). Mean hypertrophy of left liver lobe after portal vein embolization was 28.5%. The measured parenchyma remnant after tumor resection increased from 29% up to 38% by hypertrophy. Mean values of ALT and AST in the postoperative period were significantly different in the groups in this study. The values of alkaline phosphatase (ALP) and gamma glutamyl transpeptidase (GMT) were lower in patients after portal vein embolization (P < 0.05). Significant differences were in postoperative level of serum bilirubin, bilirubin levels in patients after portal vein embolization were 2-3 times lower than in the group of patients after immediate surgery (P < 0.05). he values of prothrombin time were also significantly lower in patients who underwent surgery without previous portal vein embolization (P < 0.05).     

Retrospective evaluation of risk factors of postoperative varices after pancreaticoduodenectomy with combined portal vein resection

BackgroundCombined portal vein (PV) resection is performed for pancreatic head cancer to achieve clear resection margins. This can be complicated by the formation of varices due to sinistral portal hypertension after pancreaticoduodenectomy (PD) with combined PV resection. However, clinical strategies to prevent varices formation due to sinistral portal hypertension remain controversial. Moreover, the critical vein among splenic vein (SPV), inferior mesenteric vein, left gastric vein, or middle colonic vein requiring preservation to prevent the development of varices remains unclear.MethodsWe retrospectively analyzed patients with pancreatic cancer who underwent PD with combined PV resection over 18 years at our institution. Varices were evaluated using enhanced computed tomography (CT) and endoscopy. Preoperative types of porto-mesenterico-splenic confluence, venous drainage, and venous resection types were determined by operative records and CT findings.ResultsOf the 108 subjects, the incidence of postoperative varices was observed in 24.1% of cases over 5.6 months. These varices were classified into five types based on location, as pancreaticojejunostomy anastomotic (11.5%), gastrojejunostomy anastomotic (11.5%), esophageal (11.5%), splenic hilar-gastric (23.1%), and right colonic (65.4%) varices. No case of variceal bleeding occurred. Multivariate analysis showed SPV ligation as the greatest risk factor of varices (P < 0.001), with a higher incidence of left-sided varices in patients with all the SPV venous drainage sacrificed (60%) than in the others (16.7%). Therefore, sacrificing all the SPV venous drainage was the only independent risk factor of varices (P = 0.049).ConclusionsPreservation of SPV venous drainage should be considered during SPV ligation to prevent post-PD varices.     

Comparison between portal vein pressure and wedged hepatic vein pressure in hepatitis B-related cirrhosis

Portal vein pressure and wedged hepatic vein pressure were measured simultaneously in 21 patients with hepatitis B-related cirrhosis of the liver and were compared to pressure measured in six patients with idiopathic portal hypertension. No significant difference in the portal venous pressure gradient was found between patients with cirrhosis and those with idiopathic portal hypertension (17.3 +/- 4.3 mmHg (mean +/- S.D.) vs. 19.7 +/- 3.1 mmHg, P greater than 0.05). However, the difference between the portal and the hepatic venous pressure gradient was significantly smaller in patients with cirrhosis than in idiopathic portal hypertension patients (1.3 +/- 1.7 vs. 10.8 +/- 2.1 mmHg, P less than 0.001). An excellent correlation was found between portal vein pressure and wedged hepatic vein pressure in hepatitis B-related cirrhosis (r = 0.94, P less than 0.001). There was no linear relationship between the portal venous pressure gradient and varix size or bleeding episodes. We concluded that a close agreement existed between portal vein pressure and wedged hepatic vein pressure in hepatitis B-related liver cirrhosis. Therefore, measurement of wedged hepatic vein pressure reliably reflects portal vein pressure in these patients.