Pancreatectomy with and without venous resection: TTFM to assess portal flow and HFUS as routine imaging

Case

Long-Term Results of Pancreatectomy With and Without Venous Resection: A Comparison of Safety and Complications of Spiral Graft, End-to-End and Tangential/Patch Reconstruction Techniques 

The Medistim Transit Time Flow Measurement (TTFM) provides objective and reliable data that is robust and user-independent. With established numeric indices such as mean flow volume and pulsatility index, TTFM offers an accurate insight into the dynamics of graft function. ​The Medistim High-Frequency Ultrasound (HFUS) probe is specifically designed to provide high-resolution, near-field images during surgery.  

 In this study, the portal flow was controlled with TTFM and later in the series (circa 2015 onwards) the reconstruction was routinely visualized by HFUS. 

Quote from the publication:
This is the largest study yet published comparing the short and long term outcomes for different venous reconstruction techniques together with radical intent pancreatic resection. The technique of spiral interposition graft from the patient’s own great saphenous vein was standardized for use in pancreatectomy when longer venous resections were needed. This retrospective study aimed to determine its safety and feasibility. 

Abstract

Objective:
Roughly 10%20% of pancreatic cancer patients are candidates for curative intent surgical treatment. In the 2000s, many studies showed similar survival rates comparing pancreatic surgery with or without vein resection and reconstruction. The aim was to identify the best method of venous reconstruction.

Methods:
This was a retrospective cohort study. A total of 1375 patients undergoing pancreatectomy between 2005 and 2018 were identified. Patients undergoing a combined pancreatic resection and venous reconstruction were included retrospectively. When tumor infiltration to the portal/superior mesenteric vein was detected, excision and reconstruction with tangential suturing/patch, end-to-end anastomosis, or a spiral graft from the great saphenous vein were performed. Next, 90-day and long term survival and outcomes across reconstruction techniques were analysed 

Results:
Overall, 198 patients had venous involvement visible in pre-operative scans or detected during surgery, broken down as follows: 171 (86%) pancreaticoduodenectomy, 12 (6%) total pancreatectomy, and 15 (8%) distal pancreatectomy. In total, 69 (35%) spiral graft reconstructions, 77 (39%) end-to-end anastomoses, and 52 (26%) tangential/patch reconstructions were performed. Tumour histology revealed pancreatic adenocarcinomas in 162 (82%) patients, intraductal mucinous pancreatic neoplasia in 14 (7%), cholangiocarcinoma in five (3%), neuroendocrine neoplasia in nine (5%), and eight other diagnoses. Overall, 183 (92%) were malignant and 15 (8%) benign. Two patients died within 90 days, one in the hospital and one on postoperative day 38 due to thrombosis of the superior mesenteric vein and intestinal necrosis, a ClavienDindo grade 5 complication. In addition, 50 (23%) patients had ClavienDindo grade 34 complications. No differences in complications comparing vein reconstruction techniques or in the long term survival of pancreatectomy patients with or without venous reconstruction were detected.  

Conclusion:
The spiral graft technique, used when more advanced venous infiltration occurs, does not increase complications, with outcomes mirroring those accompanying shorter venous resections. 

Illustrations:
The illustrations below are copied from the publication showing the preparation of the spiral venous graft (Figure 1) and how the splenic vein is sutured when performing spiral graft reconstruction (Figure 2). 

Figure 1. (A, B) Representation of the technical preparation of a spiral venous graft using the great saphenous vein, with the aid of a 5 or 10 mL syringe, and (C) end result with extra vein for subsequent lengthening if needed.

Figure 2. Visual representation of the splenic vein sutured (A) to the side of the graft and (B) to the side of the portal vein. 

Reference:
Long Term Results of Pancreatectomy With and Without Venous Resection: A Comparison of Safety and Complications of Spiral Graft, End-to-End and Tangential/Patch Reconstruction Techniques. Vuorelaa T, Vikatmaa P, Kokkolaa A, Mustonena H, Salmiheimoa A, Eurolaa A, Ahob P, Haglunda C, Kantonen I, Seppänen H. Eur J Vasc Endovasc Surg (2022) 64, 244-253.  

DOI: https://doi.org/10.1016/j.ejvs.2022.04.006