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Major Venous Reconstruction during Pancreato-Biliary Surgery

Major Venous Reconstruction during Pancreato-Biliary Surgery. Seung-Kee Min Division of Vascular Surgery Seoul National University Hospital. Cancer invasion to major veins during HBP surgery. Inferior vena cava, portal vein, or superior mesenteric vein

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Major Venous Reconstruction during Pancreato-Biliary Surgery

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  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 !

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