1 / 30

Major Venous Reconstruction in Pancreato-Biliary Surgery

Detailed overview of venous reconstruction during cancer surgery involving major veins, challenges for vascular surgeons, methods, and conduits used for reconstruction. Includes case studies and alternative methods for size matching in reconstruction.

paulacooper
Download Presentation

Major Venous Reconstruction in Pancreato-Biliary Surgery

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Major Venous Reconstruction during Pancreato-Biliary Surgery Seung-Kee Min Division of Vascular Surgery Seoul National University Hospital

  2. Cancer invasion to major veins during HBP surgery • Inferior vena cava, portal vein, or superior mesenteric vein • Venous reconstruction is required for complete resection. • A challenge for a vascular surgeon • Size mismatch • Lack of suitable autogenous conduit • Risk of infection

  3. Methods of PV reconstruction

  4. Methods of PV reconstruction (1) • End-to-End anastomosis • Patch angioplasty 3. Interposition graft No tension ! No stricture !

  5. Methods of PV reconstruction (2) • End-to-End anastomosis • Patch angioplasty 3. Interposition graft Lee et al. J Vasc Surg (2010)

  6. Methods of PV reconstruction (3) • End-to-End anastomosis • Patch angioplasty 3. Interposition graft Lee et al. J Vasc Surg (2010)

  7. Conduits for PV reconstruction 1. Autogenous vein • Femoral vein (SFV) • Left renal vein • Internal jugular vein • GSV • Gonadal vein 2. Homograft ; Cadaveric iliac vein (risk of degeneration and chronic rejection) 3. Bovine pericardium 4. Prosthetic graft ; ePTFE, Dacron (risk of infection) 5. Autogenous peritoneum (anecdotal use)

  8. Case 1. Pancreas cancer with PV/SMV invasion • Bovine patch angioplasty

  9. Case 2. Pancreas cancer with PV/SMV invasion • Patch angioplasty with bovine pericardium Portal vein Splenic vein IVC Bovine patch Lt. RV Rt. RV SMV

  10. Case 3. Pancreas cancer with SMV invasion • interposition graft with bovine pericardium

  11. Case 4. Pancreas cancer with SMV invasion • interposition graft with bovine pericardium

  12. Case 5. SMV Reconstruction with spiral graft • F/68, pancreatic cancer • CT: a mass at uncinate process of pancreas with SMV invasion

  13. Operation • PPPD • Segmental resection of PV/SMV & interposition graft with GSV • Small bowel edema due to size mismatch • PTFE interposition graft (10mm) • 2 days later, second-look operation was done • Total occlusion of PTFE graft Chiu et al. Vasc Endovasc Surg (2007)

  14. Spiral graft with GSV • To overcome the size mismatch & infection Chiu et al. Vasc Endovasc Surg (2007)

  15. Reconstruction with spiral vein graft v PV Spiral vein recon. SMV SMA SMV

  16. Follow-up CT scan Patent spiral graft at postoperative 3 months

  17. Spiral vein graft • Harvest of saphenous vein -- from groin to calf or ankle -- Length (D) = radius (R) / radius (D) x length (R) • Advantages -- can be tailored to fit a vessel of any size -- ease of handling and superficial dissection -- large vessel substitute without the drawbacks of prosthetic graft • Indications -- Major visceral vein reconstruction -- IJV reconstruction after RND -- Mesocaval shunts in children -- replacement of CFV after trauma -- After removal of infected prosthetic graft -- Axillary, subclavian or femoral artery reconstructions

  18. Other methods for size matching Yamamoto et al. Langenbecks Arch Surg 2009

  19. GSV longitudinal tailoring

  20. Case 6. Pancreas cancer with SMV & HA invasion • Portal vein; End-to-end anastomosis • Hepatic artery; interposition graft with GSV

  21. Complicated cases * Reconstructed later by spiral GSV graft Kim SM et al. J Korean Surg Soc 2013;84:346-52

  22. The fate of portal vein occlusion • Extrahepatic portal vein occlusion • Anomaly in children • After biliary operation in children • Portal vein invasion of malignancy • Pancreatic cancer • Colorectal cancer with liver metastasis • After liver transplantation  Variceal bleeding from the Hepatico-Jejunostomy

  23. Intervention first, but not always possible

  24. Intervention first, but not always possible Transhepatic or transsplenic Portal vein stent-graft H-J Varix embolization

  25. Endoscopic therapy for H-J stomy varix bleeding

  26. Endoscopic therapy with colonoscopy

  27. Rex shunt, revisited • Bypass between SMV-Lt portal vein in Rex recessus (umbilical fissure along umbilical vein in round ligament between segment III & IV) • Most physiologic • Limitation by the left PV status • Surgery of choice in extrahepatic portal vein occlusion, especially in children • Remained hepatopedal flow ; avoiding hepatic atrophy • No porto-systemic shunt ; minimizing hepatic encephalopathy • Conduit; autogenous vien – IJV, both GSV (1st done in 1992 , de Goyet, for EHPVO after LTPL)

  28. Meso-Rex shunt Meso-Rex shunt with transposed coronary vein Cho YP et al. ASTR 2014

  29. Take-home messages • Methods of PV reconstruction ; primary repair, patch angioplasty & interposition graft ; No tension & No stricture ! • Conduits of PV reconstruction ; autogenous vein ; tailored vein graft -- spiral graft ; bovine patch, cryopreserved vein, synthetic graft • Long-term fate of PV occlusion may result in fatal variceal bleeding from the hepatico-jejunostomy site.

  30. Thank you !

More Related