Pancreaticoduodenectomy for the resection of pancreatic adenocarcinoma may require portal vein resection to ensure disease-free resection margins.1 After division of the portal vein, the most frequent repair involves direct anastomosis or even insertion of a graft.2,3 We report a case treated with another surgical approach, including the insertion of an expanded polytetrafluoroethylene (PTFE) vascular graft inside the portal vein, which was subsequently affixed with external ligatures.
The patient is a 70-year-old insulin-dependent female, a current smoker, who had been diagnosed with pancreatic adenocarcinoma and was admitted for scheduled surgical resection after neoadjuvant treatment.
After identifying tumor invasion at the portal vein, we dissected and controlled the splenoportal axis, completely resecting its affected segment to ensure R0 resection margins, which resulted in insufficient vessel ends for direct reconstruction (Fig. 1A).
A. Intraoperative image after tumor resection.
Reconstruction with end-to-end anastomosis is not possible, as observed.
white arrowhead = portal end; black arrow = inferior mesenteric vein; white arrow = splenic vein; black arrowhead = end of superior mesenteric vein.
B. Diagram of the cannulation of the PTFE graft inside the portal vein with subsequent fixation using silk ligatures.
C. Final result after cannulation of the PTFE graft inside the portal vein.
The arrowheads indicate the silk ligatures.
To carry out the reconstruction as quickly as possible and reduce the morbidity associated with the procedure, we decided to use a ringed PTFE vascular graft (Gore Propaten Vascular Graft, GORE-TEX® Vascular Grafts, WL Gore & Associates, Inc, Flagstaff, AZ, USA) measuring 8 mm (to adapt it to the diameter of the superior mesenteric vein). Likewise, in order to reestablish venous flow as quickly as possible, avoid technical errors derived from the suture, and based on our previous experience with good results in the application of this technique in arteriovenous access for brachioaxillary hemodialysis, we decided to cannulate the ringed graft inside the portal vein. After systemic heparinization, the portal vein was clamped, leaving at least a 1.5-cm margin of healthy vein distal to the clamp. Next, we completely resected the affected venous segment and placed 3 interrupted traction sutures of 2/0 silk on the medial, lateral and superior margins of each venous end. Afterwards, traction was applied to the sutures described above, and we inserted the ringed vascular graft into the vein through both ends, leaving 3 rings inside the vein with 2 inter-ring spaces, where 2 external ligatures (2/0 silk) were placed at both ends, one in each inter-ring space (Fig. 1B). The presence of rings in the vascular graft provides support for adequate fixation of the ligatures (which can be verified by applying slight traction during surgery to confirm immobilization) as well as protection against graft stenosis. Finally, ligation of the inferior mesenteric and splenic veins was necessary, showing no signs of gastrointestinal congestion at the end of the operation (Fig. 1C).
During the procedure, an intra-arterial bolus of 5000 IU of heparin was administered, and simple antiplatelet treatment with aspirin (100 mg) was initiated on the first postoperative day.
CT angiography prior to hospital discharge showed bypass patency, with no signs of complications (Fig. 2). A follow-up venous Doppler ultrasound was performed in the first postoperative month, which also demonstrated patency of the bypass with no defects.
As previously published by Tseng et al.,2 resection and reconstruction of the portal vein during pancreaticoduodenectomy increases the complexity and duration of the procedure and may be associated with non-negligible morbidity and occasional mortality. With adequate surgeon experience, this maneuver can be performed safely, but it may become challenging when the free ends of the vein cannot be approximated without the need for graft interposition.
If graft placement is necessary, autologous veins have been the traditional choice, although in some cases venous allografts or PTFE grafts have been used.4,5,6,7 The literature on medium- to long-term patency rates is scarce. Some series describe graft thrombosis rates of up to 17% with a mean follow-up of 12.2 months, which is higher in PTFE grafts (33% vs 12%; P = 0.16) but not statistically significant.8 Other authors like Satauffer et al.9 have reported better results, with patency rates of 86% in the case of autologous vein grafts versus 100% for PTFE in follow-up studies one, 6 and 12 months after the intervention. The retrospective multicenter study by Chu et al.10 published PTFE graft patency rates of 76% with a mean follow-up of 14 months.
In this case report, we present another surgical solution to reestablish venous flow in these situations, which until now has not been published in the existing literature. The technique is technically less demanding than the classic reconstruction with the insertion of a graft with 2 vascular anastomoses. The aim is to reduce possible technical defects derived from the sutures as well as the reconstruction time.
The use of a cannulated PTFE prosthesis inside the portal vein can be a fast and safe alternative for the reconstruction of the affected segment of this vessel in oncological surgeries.
FundingThe authors have received no funding for the research, creation or publication of this article.
Declaration of conflicts of interestThe authors have no potential conflicts of interest to declare with regards to this present study.
