The management of pancreatic tumor adherence to the lateral wall of the superior mesenteric and portal veins (SMPV) represents the most challenging technical aspect of pancreaticoduodenectomy (PD). Prior studies have demonstrated that partial or segmental venous resection and reconstruction is an ideal means of managing tumor adherence to the SMPV. Options for conduit during SMPV reconstruction include synthetic or autogenous vein grafts; however, the infectious risks of PD make autogenous tissue preferable. Our institution has extensive experience with use of the superficial femoral vein (SFV) for aortic and venous reconstruction. We describe herein the use of the SFV in the reconstruction of the SMPV in patients undergoing PD and vein resection for periampullary tumors. Our early experience with this specific technique has generated several observations. First, our experience has confirmed that safe performance of SMPV resection and graft placement requires complete dissection of the specimen and SMPV away from the superior mesenteric artery and retroperitoneal attachments. Second, we have found that harvesting of a short segment of SFV is easily achieved and safe in these patients if one adheres to the technique of SFV harvest as described by Clagett et al.1 Lastly, the SFV vein is an excellent size match for the SMPV, and its superior handling properties and durability make it our preferred conduit for SMPV reconstruction at the time of PD for cancer.
Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more
Subscribe for full-text access to content from 1998 forward and a host of useful features
Activate your current subscription (AMA members and current subscribers)
Purchase Online Access to this article for 24 hours
The operative view after transsection of the stomach and pancreas exposes a pancreatic head tumor with lateral involvement of the superior mesenteric vein confluence (SMV).
Reflection of the specimen medially (arrow) allows dissection of the retroperitoneal attachments from the superior mesenteric artery (SMA) to mobilize the specimen and attached superior mesenteric veins (SMV).
The medial-to-lateral view of the tumor and attached veins after dissection from surrounding structures. Note the divided pancreas (P) and superior mesenteric artery (SMA). SMV indicates superior mesenteric vein; PV, portal vein; and SV, splenic vein.
The lateral-to-medial view of the tumor and attached superior mesenteric vein (SMV) and portal vein (PV) after dissection from surrounding structures and the superior mesenteric artery (SMA).
These figures provide an anatomic basis for the surgical approach for superficial femoral vein harvest. A, The skin incision and soft-tissue dissection is performed over the lateral border of the middle third of the sartorious muscle. B, The vein lies within the Hunter canal along with the superficial femoral artery and saphenous nerve.
The superficial femoral popliteal vein (SFV) ready for harvest from the right leg. Multiple side branches have been divided from the SFV so that it is now separate from the superficial femoral artery (SFA) and saphenous nerve (SN) that have been reflected medially with the sartorious muscle.
Placement of the graft in the superior mesenteric portal vein (SMV) confluence. A, The proximal portion of the graft (closest to the heart) is used to reconstruct the portal vein (PV)–splenic vein confluence and preserve splenic flow. Note the Rumel tourniquet at the mesenteric root. P indicates pancreas; SMA, superior mesenteric artery. B, The SMV anastomosis is nearly complete in this photo; note the excellent size match of the SFV with the SMV. PV indicates portal vein; SV, splenic vein; and SFV, superficial femoral vein.
A typical superior mesenteric vein (SMV) and portal vein graft in place prior to reconstruction of the gastrointestinal tract.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
Instructions
Thank you for submitting a comment on this article. It will be reviewed by JAMA Surgery editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest* Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 11
Customize your page view by dragging & repositioning the boxes below.
More Listings atJAMACareerCenter.com >
and access these and other features:
Register Now
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Need assistance?
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.