Abstract
Background
In pancreatic cancer, extensive tumor involvement of the mesenteric venous system
poses formidable challenges to operative resection. Such involvement can result from
cavernous collateral veins leading to increased intraoperative blood loss or long-segment
vascular defects of not only just the superior mesenteric vein but also even jejunal/ileal
branches. Strategies to facilitate margin-free resection and safe vascular reconstruction
in pancreatic surgery are important, particularly because systemic control of the
tumor is improving with multi-agent chemotherapy regimens.
Methods
We describe a systematic, multidisciplinary assessment for patients with pancreatic
cancer that involves the superior mesenteric vein, as well as the preoperative planning
of those undergoing operative resection. In addition, detailed descriptions of operative
approaches and technical strategies, which evolved with increasing experience at a
high-volume center, are presented.
Results
For the preoperative evaluation of tumor-free, vascular locations for potential reconstruction
and collateralization, computed tomographic imaging with high-resolution of vascular
structures (used with 3-dimensional or cinematic rendering) allows a precise calibration
of radiographic data with intraoperative findings. From an operative perspective,
we identified 5 potential strategies to consider for resection: collateral preservation,
mesoportal bypass (preresection), mesoportal interposition graft (postresection),
mesocaval shunt, and various combinations of these strategies. Many of these techniques
use interposition grafts, making it essential to assess autologous veins (preferred
conduit for reconstruction) or to prepare cryopreserved vascular allografts (an alternative
conduit, which must be thawed and should be matched for size and blood type).
Conclusion
Herein we share operative strategies to overcome involvement of the superior mesenteric
vein in pancreatic cancer. Improvements in preoperative planning and operative technique
can address common barriers to resection with curative intent.
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Article info
Publication history
Published online: September 17, 2020
Accepted:
July 30,
2020
Identification
Copyright
© 2020 Elsevier Inc. All rights reserved.
