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ORIGINAL ARTICLE
Splenic Vein–Inferior Mesenteric Vein Anastomosis
to Lessen Left-Sided Portal Hypertension After
Pancreaticoduodenectomy With Concomitant
Vascular Resection
Nélio Ferreira, MD; Elie Oussoultzoglou, MD; Pascal Fuchshuber, MD, PhD; Dimitrios Ntourakis, MD;
Masato Narita, MD, PhD; Mudassir Rather, MD; Edoardo Rosso, MD; Pietro Addeo, MD;
Patrick Pessaux, MD, PhD; Daniel Jaeck, MD, PhD, FRCS; Philippe Bachellier, MD, PhD
Hypothesis: A splenic vein (SV)–inferior mesenteric vein
(IMV) anastomosis reduces congestion of the stomach
and spleen after pancreaticoduodenectomy with resection of the SV–mesenteric vein confluence but carries a
risk of left-sided venous hypertension.
Design: Comparative retrospective study.
Setting: Department of Digestive Surgery and Trans-
plantation, University of Strasbourg, Strasbourg, France.
Patients: From January 1, 2002, to February 28, 2010, 39
patients underwent pancreaticoduodenectomy with resection of the SV–mesenteric vein confluence for pancreatic
adenocarcinoma. All patients had a terminoterminal portalvein–superiormesentericveinanastomosis.TheSVblood
flow into the portal vein was preserved in 11 patients by reimplantation of the SV into the portal vein. Sixteen patients
underwent surgical reconstruction of the SV-IMV confluence by anastomosis (group 1), and in 12 patients the natural SV-IMV confluence was preserved (group 2).
Main Outcome Measures: Preoperative and postoperative spleen volume and platelet count.
Author Affiliations: Centre de
Chirurgie Viscérale et de
Transplantation, Hôpital de
Hautepierre, Hôpitaux
Universitaires de Strasbourg,
Strasbourg, France
(Drs Ferreira, Oussoultzoglou,
Ntourakis, Narita, Rather,
Rosso, Addeo, Pessaux, Jaeck,
and Bachellier); and
Department of Surgical
Oncology, Permanente Medical
Group, Walnut Creek,
California (Dr Fuchshuber).
R
Results: Demographic characteristics, preoperative tumor staging, pathological outcome, and postoperative
complications were comparable in both groups. There
was no difference in platelet count between groups 1
and 2 preoperatively (mean [SD], 293.13 [125.37] vs
241.09 [49.12] ⫻ 103/µL [to convert to ⫻109/L, multiply by 1.0], respectively; P = .21) or postoperatively
(mean [SD], 231.75 [156.39] vs 164.31 [76.46]⫻ 103/
µL, respectively; P = .32). Likewise, no difference was
found in the spleen volume preoperatively (mean [SD],
258.96 [179.23] vs 237.31 [122.46] mL, respectively;
P = .76) and on postoperative day 15 (mean [SD],
279.08 [158.10] vs 299.12 [153.11] mL, respectively;
P =.78).
Conclusion: Early assessment shows that SV-IMV anas-
tomosis is as feasible and as safe as the preservation of a
natural SV-IMV confluence in patients undergoing pancreaticoduodenectomy with vascular resection for pancreatic head adenocarcinoma.
Arch Surg. 2011;146(12):1375-1381
ADICAL SURGERY REMAINS
the only curative treatment of pancreatic cancer.1-3 Portal vein (PV) and
superior mesenteric vein
(SMV) invasion is often present because
of the close relationship between these vessels and the pancreatic head as well as the
See Invited Critique
at end of article
uncinate process.4 For a long time, venous invasion was considered a contraindication to surgery. Recently, however, extensive vascular resection has gained
acceptance as it has been shown to improve the rates of R0 resection and surARCH SURG/ VOL 146 (NO. 12), DEC 2011
1375
vival5 without an increase in postoperative morbidity and mortality.6
Resection or division of the splenic vein
(SV) has been performed not only in cases
of vascular tumor invasion but also to
achieve a complete lymph node and neural dissection around the superior mesenteric artery (SMA).7 Potential risks of the
procedure include segmental left-sided venous hypertension with resulting splenomegaly, hypertensive gastropathy, esophageal varices, and hemorrhage.
When resection of the mesenteric
vein–PV confluence or division of the SV
is performed during pancreatic head resection, the presence of a natural SV–
inferior mesenteric vein (IMV) confluence can preserve the venous drainage of
the spleen and the gastric remnant and ob-
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A
PV
SV
SMV
11 Patients
B
PV
SV
IMV
SMV
tients (4.7%) had partial lateral venorrhaphy and 81 (95.3%)
had segmental venous resection, including PV resection in 12
patients, SMV resection in 30 patients, and SV–mesenteric vein
confluence resection in 39 patients with direct venovenous anastomosis without interposition. Figure 1 summarizes the vascular reconstruction after resection of the SV–mesenteric vein
confluence. Among these 39 patients, 11 received an end-toend anastomosis between the PV and the neoconfluence of the
SMV and SV (Figure 1A). These cases were excluded, leaving
a study population of 28 patients who underwent end-to-end
anastomosis between SMV and PV with either additional endto-end anastomosis between the SV and the IMV (group 1; n=16)
(Figure 1B) or preservation of a natural SV-IMV confluence
(group 2; n=12) (Figure 1C). The patients’ characteristics, preoperative imaging of venous invasion, preoperative serum tumor markers, preoperative biliary drainage, neoadjuvant treatment, blood transfusion, postoperative mortality and morbidity
including patency of the SV-IMV anastomosis, and histological results (venous tumor invasion, specimen margin invasion, TNM classification) were collected from the medical
records.
16 Patients (Group 1)
SURGICAL TECHNIQUES
C
PV
SV
SMV
IMV
12 Patients (Group 2)
Figure 1. Vascular reconstruction after resection of the splenic vein
(SV)–mesenteric vein confluence. Eleven patients received an end-to-end
anastomosis between the portal vein (PV) and the neoconfluence of the
superior mesenteric vein (SMV) and SV and were excluded from analysis
(A); the remaining 28 patients underwent end-to-end anastomosis between
the SMV and PV with either additional end-to-end anastomosis between the
SV and the inferior mesenteric vein (IMV) (group 1; n=16) (B) or
preservation of a natural SV-IMV confluence (group 2; n=12) (C).
viates the need for an additional anastomosis between the
SV and the PV.7,8 A natural SV-IMV confluence is absent
in about 30% of patients as the IMV drains either directly into the SMV or into the SV-SMV confluence.9 In
those cases or when a natural SV-IMV confluence cannot be preserved for technical reasons, construction of
an SV-IMV anastomosis may be of value to preserve
splenic and gastric venous drainage.
The aim of this study is to evaluate the feasibility and
function of an SV-IMV anastomosis during pancreaticoduodenectomy with SV–mesenteric vein confluence resection.
METHODS
STUDY POPULATION
Between January 1, 2002, and February 28, 2010, a total of 195
patients underwent a curative-intent pancreaticoduodenectomy for pancreatic head adenocarcinoma. Of these, 85 (43.5%)
with locally advanced disease had mesenteric vein–PV resection and reconstruction as part of their procedure. Four pa-
All patients underwent a standard Whipple pancreaticoduodenectomy without pylorus preservation and extended lymph
node dissection including the hepatic hilum, common hepatic
artery, celiac trunk, SMA, and para-aortic area above the left
renal vein. Intraoperative pathological analysis of the pancreatic margin was obtained in all cases. Technical highlights include the following: (1) early dissection of the origin of the SMA
above the left renal vein followed by sectioning of the retroportal pancreatic lamina10 to facilitate venous resection; (2) complete mobilization of the surgical specimen before removing the
involved venous segment; and (3) concomitant clamping of the
SMA during venous resection to prevent excessive intestinal
congestion11 prior to enteric anastomosis. The anastomosis between the SMV and PV was fashioned using a 6-0 nonabsorbable running suture impregnated with a growth factor. To facilitate a tension-free vascular anastomosis without graft
interposition, the right colon and the root of the mesentery were
completely mobilized.12 End-to-end anastomosis between the
SV and IMV was performed using an 8-0 nonabsorbable running suture. If the SV-IMV confluence was preserved, the SV
was ligated distally to this confluence (Figure 1C). A 2-layer
telescoped pancreaticogastrostomy was routinely used as previously reported.13 The reconstruction was completed by an endto-side choledochojejunostomy and a transmesocolic end-toside gastrojejunostomy.
DEFINITION OF POSTOPERATIVE
COMPLICATIONS
Postoperative complications were given Clavien classifications.14 Pancreatic fistula was defined as a drain output with
an amylase content greater than 3 times the serum amylase activity on or after postoperative day 3, according to the International Study Group on Pancreatic Fistula.15 Delayed gastric
emptying was defined as the inability to return to a standard
diet by the end of the first postoperative week, including prolonged nasogastric intubation, according to the International
Study Group of Pancreatic Surgery.16
MAIN OUTCOME MEASURES
All patients underwent computed tomography (CT) around
postoperative day 15, and the venous anastomosis outflow was
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evaluated. The occurrence of left-sided portal hypertension was
evaluated in both groups before and after surgery by assessing
the platelet count and spleen volume according to the Cavalieri method.17 In brief, the spleen surface was measured with
manual contouring on digitized CT using ImageJ version 1.42q
software (National Institutes of Health, Bethesda, Maryland).
Final spleen volume was calculated by adding all CT slices showing the spleen.18
STATISTICAL ANALYSIS
All values are expressed as mean (standard deviation). Pearson ␹2 test and independent t test were used appropriately. A
difference was considered significant at P⬍.05. Statistical analyses were performed using SPSS for Windows version 10.0 statistical software (SPSS Inc, Chicago, Illinois).
RESULTS
PATIENTS AND SURGICAL CHARACTERISTICS
There were 20 men and 8 women. Their mean (SD) age
was 63.2 (8.0) years (range, 43-80 years). The American Society of Anesthesiologists scores were 1 in 9 patients, 2 in 18 patients, and 3 in 1 patient. The mean (SD)
body mass index (calculated as weight in kilograms divided by height in meters squared) for all patients was
24.6 (3.5) (range, 16.6-31.9). Twenty-one patients had
preoperative weight loss ranging from 1.98 to 15.84 kg
(mean [SD], 6.84 [3.56] kg), and 6 patients received preoperative enteral nutritional support with ␻-3 fatty acids, arginine, ribonucleic acid, and soluble fiber (Oral Impact, Nestlé HealthCare Nutrition, Inc, Florham Park, New
Jersey). Preoperative biliary drainage was performed in
9 patients who presented with a total serum bilirubin level
higher than 11.69 mg/dL (to convert to micromoles per
liter, multiply by 17.104). Evaluation of vascular involvement was performed using the Nakao classification,19 with
6 patients showing grade A (normal), 11 patients grade
B (unilateral narrowing), 10 patients grade C (bilateral
narrowing), and 1 patient grade D (venous obstruction
and collateral circulation). The CA 19-9 serum level was
elevated in 19 patients, with a mean (SD) level of 772
(1327) kU/L (range, 48-6120 kU/L). Eight patients had
gemcitabine hydrochloride–based neoadjuvant chemotherapy with (n=5) or without (n=3) oxaliplatin. Twenty
patients received intraoperative red blood cell transfusion (mean [SD], 4.4 [2.8] units transfused).
PATHOLOGICAL RESULTS
The mean (SD) tumor size was 38.5 (13.6) mm (range,
15-70 mm). Tumor emboli within lymphatic and vascular spaces were encountered in 3 patients, and perineural invasion occurred in 18 patients. The mean (SD) numbers of overall dissected and involved lymph nodes were
35.7 (14.2) (range, 6-74) and 5.7 (10.3) (range, 1-50),
respectively. Pathological analysis of the specimen showed
that the mesenteric vein–PV wall was involved in 18 patients. The depth of invasion was limited to the adventitia in 4 patients, involved the tunica media in 7, and
reached the intima in 7. An R0 resection was achieved
in 18 patients (64.2%). Ten patients had microscopic positive margins (R1 resection) including the retroperitoneal margin alone (n = 5), the pancreatic stump alone
(n=3), and both the pancreatic stump and either the retroperitoneal margin (n=1) or PV (n=1). According to
the American Joint Committee on Cancer staging system, tumor was classified as pT1N0 (stage I) in 2 patients, T3N0 (stage IIA) in 4 patients, T3N1 (stage IIB)
in 16 patients, T4N1 (stage III) in 1 patient, and metastatic disease (stage IV) in distant lymph nodes in 5 patients.
EARLY POSTOPERATIVE OUTCOME
Complications included 1 cardiac complication managed with oral medications (Clavien grade II), 2 pancreatic fistulas treated successfully with octreotide acetate
(Clavien grade II), 2 cases of delayed gastric emptying
treated with prokinetic drugs (Clavien grade II), 1 case
of chylous ascites treated with diuretics (Clavien grade
II), 1 SV thrombosis treated with anticoagulation therapy
(Clavien grade II), 1 intra-abdominal abscess treated by
percutaneous drainage (Clavien grade IIIA), 2 reoperations (Clavien grade IIIB), and 2 in-hospital deaths within
30 days of surgery (Clavien grade V). Both reoperations
were because of postoperative hemorrhage: one for active abdominal bleeding from a branch of a midcolonic
artery on the second postoperative day and the other for
upper gastrointestinal tract bleeding from the pancreatic stump on postoperative day 7. Attempts at endoscopic treatment had failed and the patient required a salvage total pancreatosplenectomy. The first postoperative
death was caused by severe sepsis of undetermined origin 15 days after surgery. The second surgical mortality
was due to massive intra-abdominal hemorrhage complicating a pancreatic fistula on postoperative day 25.
EVALUATION OF LEFT-SIDED VENOUS
HYPERTENSION
The mean (SD) preoperative and postoperative (day 30)
platelet counts were 271.11 (102.24) and 200.13 (126.33)
⫻ 103/µL (to convert to ⫻109/L, multiply by 1.0), respectively. The mean (SD) preoperative and postoperative (day 15) spleen volumes were 249.22 (152.78) and
288.10 (152.09) mL, respectively.
COMPARABILITY OF BOTH GROUPS
As shown in Table 1, there were no differences between both groups regarding sex, age, American Society
of Anesthesiologists classification, body mass index, preoperative weight loss, degree of preoperative venous invasion, level of tumor markers (CA 19-9 level), preoperative biliary drainage, neoadjuvant chemotherapy, and
intraoperative blood transfusions. The final pathological examination of the resected specimens in both groups
showed no differences regarding tumor size, presence of
microvascular emboli and perineural invasion, numbers of dissected and involved lymph nodes, presence and
depth of PV invasion, number and site of positive surgical margins, and TNM classification (Table 2 and
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Table 1. Demographic and Surgical Characteristics
Characteristic
Sex, No.
Male
Female
Age, mean (SD), y
ASA score, No.
1
2
3
BMI, mean (SD)
Preoperative weight loss, No.
Yes
No
Nakao classification of preoperative
venous involvement, No.
A
B
C
D
Elevated CA 19-9 level, No.
Yes
No
Preoperative biliary drainage, No.
Yes
No
Neoadjuvant chemotherapy, No.
Yes
No
Received blood transfusion, No.
Yes
No
RBC units transfused, mean (SD)
Group 1
(n = 16)
Group 2
(n = 12)
11
5
63.0 (9.0)
9
3
63.5 (6.9)
4
12
0
24.6 (4.0)
5
6
1
24.5 (2.9)
13
3
8
4
Table 2. Pathological Data
P
Value
Variable
.72
Tumor size, mean (SD), mm
Microvascular emboli, No.
Yes
No
Perineural invasion, No.
Yes
No
Dissected lymph nodes, mean
(SD), No.
Involved lymph nodes, mean
(SD), No.
Portal vein infiltration, No.
No
Yes
Depth of venous wall invasion, No. a
Adventitia
Tunica media
Intima
Resection margin, No.
R0
R1
Site of positive margin, No. b
Pancreas
Retroperitoneum
Pancreas and retroperitoneum
Pancreas and portal vein
.94
.27
.96
.38
.82
3
6
6
1
3
5
4
0
9
7
10
2
6
10
3
9
6
10
2
10
11
5
5.0 (2.8)
9
3
3.7 (2.9)
.13
.48
.23
.72
Group 1
(n = 16)
Group 2
(n = 12)
P
Value
39.7 (14.0)
37.1 (13.7)
.49
.38
1
15
2
10
11
5
38.1 (15.6)
7
5
32.8 (12.4)
.97
7.4 (13.3)
3.4 (2.6)
.87
5
11
5
7
2
4
5
2
3
2
10
6
8
4
1
4
1
0
2
1
0
1
.57
.57
.75
.82
.27
a Eighteen patients had pathological venous involvement.
b Ten patients had positive resection margins.
.96
Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass
index (calculated as weight in kilograms divided by height in meters squared);
RBC, red blood cell.
Table 3). There were no differences in postoperative
complications between both groups (Table 4).
OCCURRENCE OF LEFT-SIDED PV
HYPERTENSION
[179.23] vs 279.08 [158.10] mL, respectively; P = .40;
group 2: mean [SD], 237.31 [122.46] vs 299.12 [153.11]
mL, respectively; P=.16). Furthermore, postoperative CT
showed patency of venous reconstruction (Figure 2)
in all patients except 1 patient from group 2 who developed SV thrombosis. Nevertheless, the thrombosis was
partial, there was no significant change in the spleen size,
and later CT showed complete recovery following anticoagulation therapy.
COMMENT
Between both groups (group 1 vs group 2), there was no
difference in the platelet count preoperatively (mean [SD],
293.13 [125.37] vs 241.09 [49.12] ⫻ 103/µL, respectively; P = .21) or postoperatively (mean [SD], 231.75
[156.39] vs 164.31 [76.46]⫻103/µL, respectively; P=.32).
Within group 2, the platelet count was significantly lower
after surgery compared with the preoperative count (mean
[SD], 164.31 [76.46] vs 241.09 [49.12]⫻103/µL, respectively; P=.02). In contrast, there was no difference within
group 1 between the preoperative and postoperative platelet counts (mean [SD], 293.13 [125.37] vs 231.75
[156.39]⫻103/µL, P=.32). Between groups 1 and 2, there
was also no difference in the preoperative and postoperative splenic volume (before surgery: mean [SD], 258.96
[179.23] vs 237.31 [122.46], respectively; P = .76; postoperative day 15: mean [SD], 279.08 [158.10] vs 299.12
[153.11] mL, respectively; P=.78). Splenic volume showed
no difference within each group on preoperative vs postoperative measurement (group 1: mean [SD], 258.96
This comparative retrospective study demonstrated the
safety of an SV-IMV anastomosis during pancreaticoduodenectomy with resection of the mesenteric vein–PV confluence. We did not observe additional specific vascularrelated postoperative complications from adding the
SV-IMV anastomosis to the procedure. The lack of a significant decrease in platelet count and the lack of a significant increase in spleen volume between both groups
before and after surgery suggest a protective function of
SV-IMV anastomosis from left-sided portal hypertension. Although a significant difference between preoperative and postoperative platelet counts was seen within
group 2, complications due to left-sided portal hypertension did not occur.
Pancreaticoduodenectomy has been regarded as the
standard operation for pancreatic head carcinoma and
can be performed safely with a mortality of 0.7% to 3%
and a morbidity of 36% to 41% in high-volume cen-
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Table 3. Tumor TNM Classification According to the American Joint Committee on Cancer
Patients, No.
TNM Classification
Stage
Group 1
I
IIA
IIB
III
IV
2
1
10
1
2
T1N0
T3N0
T3N1
T4N1
T3N1M1
P
Value
Group 2
0
3
6
0
3
.32
Table 4. Clavien Classification of Postoperative
Complications
Patients, No.
Clavien Grade
II
IIIA
IIIB
IV
V
Group 1
2
1
1
0
2
Group 2
5
0
1
0
0
P
Value
.23
PV
SV
IMV
ters.20,21 Radical resection is the single most important
factor determining outcome in these patients.2 To achieve
R0 resection, resection of the PV and/or SMV is necessary in 10% to 20% of cases and can be done successfully without increase in morbidity and mortality.1,6,22,23
It has been reported that venous resection provides the
same overall survival if it is R0 resection.5,13,24,25 Our policy
is to perform venous resection in all cases with preoperative or intraoperative suspicion of venous involvement, without dissection along the vein, to avoid tumor
dissemination.
Suspicion or diagnosis of vascular invasion is currently best assessed by CT.26 In this series, it occurred in
22 patients (78.6%). The degree of venous invasion was
evaluated according to the Nakao classification,19 which
assesses only the mesenteric-portal axis involvement.
However, in our opinion, preoperative angiographic studies should also assess the relationship between the tumor and the SV as well as the anatomical position9 and
involvement of the IMV as insufficient venous drainage
of the spleen and gastric remnant can be a significant
source of postoperative complications after mesenteric
vein–PV confluence resection.7,27
For oncological reasons, wide vascular resection of the
SV–mesenteric vein confluence including the IMV is often necessary. Division and ligation of the SV carries a
theoretical risk of left-sided venous hypertension with
congestion of the stomach and spleen. It may induce hypertensive gastropathy with gastric mucosal hemorrhage27 as well as gastric variceal hemorrhage. Moreover, additional ligation of the left gastric vein during
lymph node dissection limits the gastric remnant drainage to the short gastric vessels. Therefore, many pancreatic surgeons avoid simple proximal ligation of the SV.
If the SV is ligated without reconstruction, the presence
of a natural SV-IMV confluence may provide sufficient
venous drainage of the spleen and gastric remnant. The
SMV
Figure 2. Representative postoperative computed tomographic scan of a
group 2 patient showing patent splenic vein (SV)–inferior mesenteric vein
(IMV) reconstruction. PV indicates portal vein; SMV, superior mesenteric
vein.
need for SV reconstruction is not universally accepted
because the venous drainage of the spleen and stomach
may reach the systemic circulation by drainage through
esophageal veins.28 If the SV-IMV confluence is absent
or impossible to preserve, drainage of the SV may be reestablished by construction of an anastomosis between
the SV and IMV to mitigate or completely avoid leftsided portal hypertension.
In 1997, Tamura et al8 reported 4 cases of SV-IMV anastomosis or preservation of a natural SV-IMV confluence
following pylorus-preserving pancreaticoduodenectomy for pancreatic cancer. Postoperative angiographic
studies showed adequate venous drainage from the spleen
and stomach into the portal circulation in all cases. In
2005, Misuta et al7 used the same technique in 12 cases.
Most patients again demonstrated adequate venous drainage of the spleen and stomach. Reversal of venous flow
toward the spleen was seen in only 3 patients (25%), 2
of whom developed splenomegaly and venous dilata-
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tion on postoperative CT imaging. These results raised
concerns about the safety of this anastomosis in some patients. However, Misuta and colleagues did not mention
the preoperative degree of venous invasion. It is possible that those patients might have already had some degree of left-sided portal hypertension prior to the operation. In the presence of severe preoperative venous stenosis
or occlusion due to tumor involvement, established collateral circulation may provide drainage of the spleen and
part of the stomach. In such cases, we do not advocate
construction of SV-IMV anastomosis.
Several methods are available to assess the immediate functionality of an SV-IMV anastomosis. They include clinical observation of the decrease of the gastric
congestion and color Doppler ultrasonography7 to demonstrate anastomotic patency and direction of venous
blood flow. The low rate of delayed gastric emptying, successfully managed with medication, suggests that there
were no additional negative effects on the postoperative
gastric motility.
Although feasible and reproducible, SV-IMV anastomosis may not be possible in all cases, for example, in
the presence of a very short SV stump. In these cases, an
interposition graft can be used29 either with an autologous vein (internal jugular, superficial femoral, gonadal, left renal, saphenous) or with prosthetic material. Venous grafts may require a second incision and
increase the operative time. Prosthetic material may not
be a good option in a contaminated and potentially infected operative field and carries a lower patency rate.11
Distal splenic-renal shunt has also been advocated by some
authors.30 If SV-IMV anastomosis is not possible, we try
to avoid the use of interposition graft by constructing an
anastomosis between the right gastroepiploic vein and
the IMV. Before division of the stomach, the right gastroepiploic vein is dissected and divided close to the pylorus along with the greater omentum. This anastomosis, however, is often performed at the end of the operation
after completion of the gastroenteric anastomosis to avoid
tension or kinking.
The decrease in the platelet count in the SV-IMV confluence preservation group suggests the presence of some
degree of hypersplenism. The occurrence of 1 case of postoperative SV thrombosis in this group suggests that the
confluence was not always functional. We hypothesize
venous traumatic injury31 as the possible cause of this complication and stress the importance of careful dissection
and meticulous use of vascular surgical techniques.
The routine use of concomitant clamping of the SMA
during venous resection and reconstruction helps to decrease intestinal complications and reperfusion injury.11 Prolonged venous clamping of the main intestinal venous outflow can cause venous splanchnic stasis
and subsequent intestinal ischemia, coagulopathy, and
hemodynamic instability after declamping. Arterial clamping prevents intestinal venous congestion and thus facilitates biliary and gastric reconstruction.
Finally, the main limitations of this study are the short
period of observation and the use of surrogate markers
for the development of sinistral portal hypertension including platelet count and splenic volume.32,33 However, invasive measurements of portal pressure are not
routinely used in this clinical setting. Among noninvasive methods, both spleen volume and platelet count are
currently considered to be accurate predictive markers
of portal hypertension and the grade of hepatic sinusoidal injury, especially in patients treated with oxaliplatinbased chemotherapy.34,35
In conclusion, our data suggest that the SV-IMV anastomosis combined with venous resection in pancreaticoduodenectomy for pancreatic adenocarcinoma is feasible, safe, and functional as it promotes venous drainage
of the spleen and gastric remnant.
Accepted for Publication: July 19, 2011.
Correspondence: Philippe Bachellier, MD, PhD, Centre
de Chirurgie Viscérale et de Transplantation, Hôpital de
Hautepierre, Hôpitaux Universitaires de Strasbourg, Avenue Molière, 67098 Strasbourg CEDEX, France (philippe
[email protected]).
Author Contributions: Study concept and design: Oussoultzoglou and Fuchshuber. Acquisition of data: Ferreira and Ntourakis. Analysis and interpretation of data:
Ferreira, Oussoultzoglou, Fuchshuber, Narita, Rather,
Rosso, Addeo, Pessaux, Jaeck, and Bachellier. Drafting
of the manuscript: Ferreira, Oussoultzoglou, Ntourakis,
and Rather. Critical revision of the manuscript for important intellectual content: Oussoultzoglou, Fuchshuber,
Narita, Rosso, Addeo, Pessaux, Jaeck, and Bachellier. Statistical analysis: Oussoultzoglou, Ntourakis, and Narita.
Study supervision: Oussoultzoglou, Fuchshuber, Addeo,
Jaeck, and Bachellier.
Financial Disclosure: None reported.
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INVITED CRITIQUE
Safety and Effectiveness of Splenic Vein to Inferior
Mesenteric Vein Anastomosis During
Pancreaticoduodenectomy
R
adical resection is currently regarded as the standard operation for pancreatic cancer. Unfortunately, in 10% to 20% of patients, extension beyond the pancreas to involve contiguous major vascular
structures limits respectability and possible cure. Extending the scope of the operation to include segments
of the PV and/or SMV has proved to be safe, and immediate reconstruction is feasible using well-established vascular surgical techniques. In some instances, resection
of the SV–mesenteric vein confluence including the IMV
is necessary to achieve an R0 resection. If the SV-IMV
confluence remains intact, venous outflow from the spleen
is preserved, thereby avoiding the potential development of left-sided portal hypertension and hypertensive
gastropathy and/or gastric variceal hemorrhage. Ferreira et al1 have nicely demonstrated that if preservation
of the SV-IMV confluence is not possible, direct anastomosis between the remaining SV and IMV segments is
both feasible and safe. Furthermore, they have demon-
strated short-term anastomotic patency using clinical observation of gastric venous congestion as well as color
Doppler ultrasonography. The main limitations of the
study are the short observation and the use of surrogate
markers (platelet count and spleen volume) to assess gastric venous hypertension. While the validity of these surrogate markers of portal hypertension has been documented in patients with chemotherapy-induced hepatic
sinusoidal injury and generalized portal hypertension, it
is not clear whether they are equally applicable or reliable in the setting of pure left-sided portal hypertension. Other areas of concern involve the indications for
and the success of such extended venous resections. Twothirds of their patients who underwent venous resection had pathological venous involvement, and tumor involved the deeper aspects (tunica media and/or intima)
of the vein wall in 60% of these patients. It has been shown
elsewhere that deep invasion of the vein wall carries the
same dismal prognosis as noncurative resection. More-
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