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A Simple Technique of Portal Vein Resection andReconstruction During Pancreaticoduodenectomy

Pierre-Alain Clavien,MD, PhD, FACS, Hannes A Rudiger, MD

Pancreaticoduodenectomy is the therapy of choicefor resectable tumors located in the head of the pan-creas. Among the many factors complicating thisprocedure is the proximity of major vessels, particu-larly the portal vein and its tributaries. Controversiesexist regarding surgery for pancreatic or bile ducttumors invading the portal vein. Although a number

of surgeons still consider vascular invasion as a con-traindication for pancreatic surgery, several recentstudies15 have suggested similar outcomes in patientsundergoing pancreatectomy with portal vein resec-tion as in those without tumor invasion of the portalvein.

There is currently no consensus about the besttechnique for resection and reconstruction of theportal vein during pancreaticoduodenectomy. Mostauthors performed an end-to-end anastomosis eitherby direct suture6 or by using an interposition graft

including the internal jugular,

2,7

renal,

3

saphenous,

3

and external iliac1,8 veins, or a Gore-Tex (WL Gore,Flagstaff, AZ) interposition graft.4 Alternatively, atechnique of autologous saphenous vein patch hasbeen described for minimal tumor invasion into theportal vein.4,5 Direct closure with simple lateral ven-orrhaphy3,9 is indicated only for limited resection,and is associated with a significant risk of narrowingof the portal vein.

Wide resection of the portal vein for tumors lo-cated in the head of the pancreas may require tran-section of the splenic vein. In the initial experience,the splenic vein was simply ligated without attemptat reconstruction, a procedure resulting in segmentalportal hypertension and, in some patients, severe up-

per gastrointestinal bleeding from hemorrhagic gas-tric varices.10 Currently, most surgeons recommendend-to-side reanastomosis of the splenic vein to theinterposition graft. But this approach requires exten-sive dissection of the splenic vein and an additionalanastomosis to the two anastomoses required for theinterposition graft, each being a potential source ofcomplications.

In this report, we describe a simple technique ofvascular reconstruction after resection of up to 5cmof the portal vein. The technique does not require aninterposition or patch graft, or transection of thesplenic vein.

TECHNIQUES OF PORTAL VEINRESECTION AND RECONSTRUCTION

The technique is applicable only for tumors partiallyinvading the portal vein. The head of the pancreas is

dissected in the standard fashion with preparation ofthe portal vein above the first part of the duodenumand the mesenteric vein below the pancreas. A Kellyclamp is carefully introduced along the vein betweenthe neck of the pancreas and the mesenteric vein, andslowly brought to the porta hepatis. The neck of thepancreas is then divided with cautery, allowing com-plete visualization of the portal vein. The portal veinis clamped above and below the tumor, and this usu-ally also occludes the splenic vein (Fig. 1A). The pan-creaticoduodenectomy is performed in the usual

fashion and the specimen containing part of the por-tal vein is then removed en bloc (Fig. 1B). After care-ful hemostasis of the pancreatic stump, two spongesare placed between the liver and the diaphragm,bringing the liver down and reducing tension of theportal vein. This simple maneuver greatly facilitatesthe portal vein reconstruction. A transverse reanasto-mosis (plication) of the portal vein is performedstarting with running suture of 6.0 prolene (EthiconInc, Somerville, NJ) on the posterior wall, followed

No competing interests declared.

Received July 2, 1999; Revised August 16, 1999; Accepted August 24, 1999.From the Section of Hepatobiliary Surgery andTransplantation,Department ofSurgery, Duke University Medical Center, Durham, NC.Correspondence address: PA Clavien, MD, PhD, FACS, Box #3247, DukeUniversity Medical Center, Durham, NC 27710.

629 1999 by the American College of Surgeons ISSN 1072-7515/99/$21.00

Published by Elsevier Science Inc. PII S1072-7515(99)00214-8

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by the anterior wall (Fig. 1C). The two sutures areloosely tied at about 1cm from the wall of the vein

(nicknamed growth factor knot) to minimize the

risk of narrowing of the portal vein after reperfusion(Fig. 1D). The vessel clamps are then removed. The

reconstruction of the duodenopancreatectomy is

Figure 1.Technique of portal vein resection and reconstruction during pancreaticoduodenectomy. (A) Tumor invasion ofthe portal vein is well visualized after transection of the neck of the pancreas. (B) The pancreaticoduodenectomyspecimen containing part of the portal vein is resected en bloc. (C) The portal vein is reconstructed by direct runningsuture in a transverse fashion. (D) The use of a growth factor (loosely tied knot) is crucial to prevent significant stenosisafter reperfusion of the portal vein.

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performed as usual with or without preservation ofthe pylorus.

CASE REPORTS

This technique was used in three consecutive pa-tients with pancreatic cancer (n2) and distal chol-angiocarcinoma (n1). A pancreaticoduodenec-tomy and en bloc resection of the portal veinfollowed by a vascular reconstruction, as describedabove, was performed in each patient.

The first patient was a 48-year-old African-American man referred to us with a diagnosis of bil-iary stricture and a 10-kg weight loss. An ERCP, spiralCT scan, and endoscopic ultrasonography showed aheterogeneous, poorly defined mass in the head of

the pancreas, with distal common bile duct obstruc-tion. Brushing for cytology disclosed high grade dys-plasia. At operation, the patient was found to havesevere and diffuse sclerosing pancreatitis. After prep-aration of the portal vein at the level of the gastrodu-odenal artery and the superior mesenteric vein belowthe pancreas, a Kelly clamp was passed between themesenteric-portal vein and the pancreas. Transectionof the pancreas at this level revealed invasion of thetumor into the right side of the portal vein over a3-cm length starting at the level of the splenic vein.

En bloc resection of the pancreatic head was per-formed as shown in Figure 1A. Because frozen sec-tion examination of the pancreas margin was positivefor cancer, the pancreas was transected again about1cm distally to the initial cut. The new margin wasnegative for malignancy, and the portal vein was re-constructed as described above. The pancreatic andcommon bile duct stumps were anastomosed end-to-side to the jejunum in a standardized fashion using asingle layer of interrupted 3.0 silk and 5.0 PDSstitches (Ethicon Inc), respectively. A side-to-sidegastrojejunostomy (no preservation of the pylorus)and feeding jejunostomy (Compat; Novartis Nutri-tion, Minneapolis, MN) were performed before clo-sure of the abdomen. Pathologic examination of thespecimen showed moderately differentiated adeno-carcinoma with peripancreatic neural invasion. Twoof seven nodes were positive for cancer. The postop-erative course was complicated with wound infec-tion. A CT scan performed 6 weeks after surgerydemonstrated a patent and minimally narrowed por-tal vein (Fig. 2). Local management of the woundinfection and social consideration delayed discharge

from the hospital to postoperative day 28. Adjuvant

radiation and chemotherapy were initiated 6 weekspostoperatively.

The second patient was a 69-year-old Caucasianman presenting with jaundice and epigastric pain.

An ultrasonography followed by a CT scan demon-

strated a mass in the head of the pancreas obstructingthe distal common bile and pancreatic ducts, andpossible invasion of the portal vein a few millimetersabove the insertion of the splenic vein. An ERCPexamination with brushing for cytology confirmedthe diagnosis of adenocarcinoma. A pancreaticoduo-denectomy with en bloc partial resection of the por-tal vein was performed because of invasion of thetumor into the proximal portal vein. The vascular,pancreatic, and biliary reconstructions were per-formed as described above. Postoperative pathologic

investigation revealed one of five peripancreaticlymph nodes to be positive for metastatic adenocar-cinoma; biopsies taken at the resection marginshowed no evidence of malignancy. The postopera-tive course was uncomplicated, and the patient wasdischarged 6 days after operation. The patient re-ceived postoperative radiation therapy (5,040 cGy in28 fractions). A recent evaluation, including a spiralCT examination, 1 year after operation revealed thepresence of hepatic metastasis without detectable ab-normalities in the pancreas, and a patent portal vein

without evidence of narrowing.The third patient was a 53-year-old Caucasianman who presented with painless jaundice and gen-eralized pruritus. Abdominal ultrasonography andERCP revealed a long stricture extending from thedistal to the mid common bile duct with proximalductal dilatation. Cytology of the material obtainedby brushing demonstrated atypical cells. A spiral CTscan showed fullness in the head of the pancreas

without clear evidence of tumor invasion into theportal vein. At the time of operation, a 3-cm mass

was found in the head of the pancreas invading thelateral side of the portal vein from the level of thesplenic vein up to 2cm proximally. The patient un-derwent a similar resection and reconstruction aspresented above. Surgical pathology examinationshowed a moderately differentiated cholangiocarci-noma with no tumor shown at the pancreas marginand four of eight nodes positive for tumor invasion.The patient was discharged 7 days after operationand had an uneventful course at 8 months followup.He completed an adjuvant radiation therapy course.

A CT scan performed 1 month after operation

showed patency of the entire portal system with evi-

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dence of mild narrowing at the site of portal veinreconstruction. Doppler ultrasonography furtherdemonstrated patency of the portal vein with mildstenosis at 6 weeks after surgery (Fig. 3).

DISCUSSION

Although partial resection of the portal vein is in-creasingly used in some centers, few comprehensivedescriptions of the technical aspect of the procedureare available.11 In many centers, a separate consultantvascular or transplant surgeon often performs thereconstruction of the portal vein. The new and sim-ple technique described here may be useful in a num-ber of clinical situations.

A significant problem in currently used tech-niques of portal vein reconstruction is the recon-struction of the splenic vein. Failure to properly re-connect the splenic vein to the portal system mayresult in massive upper gastrointestinal bleeding

from gastric varices.7,10Additionally, Koike and asso-

ciates12 demonstrated in a dog model that the splenicvein plays a major role in maintaining gastric bloodflow after pylorus-preserving pancreaticoduodenec-tomy. A consensus is emerging that preservation ofthe splenic-portal vein junction is critical duringpancreas surgery.2

Although transection of the splenic vein can besometimes avoided by using simple techniques ofvenorrhaphy, this approach is associated with a sig-

nificant risk of narrowing of the portal vein.6 Venor-rhaphy without the use of a patch should be strictlylimited to very small resections. A wedge resection ofthe portal vein with lateral venorrhaphy and preser-vation of a small portion of the backwall was men-tioned earlier by Harrison and colleagues,6 but nodescription of the technique was provided.The use ofinterposition2,3,7 or patch4,5 grafts using autologousvein13,7 grafts or Gore-Tex4 requires experience withthis type of vascular reconstruction, and is time con-suming. Additionally, the use of autologous grafts

usually necessitates additional skin incisions, and

Figure 2.A contrast-enhanced spiral CT of the upper abdomen (section thickness 2.5 mm, spacing 1 mm) was performed1 month after pancreaticoduodenectomy and partial resection of the portal vein. A volume-rendered curved multiplanarreformation in the coronal plane revealed patencyof the splenic and portal systems.The portal vein was slightly narrowed

just above the reconstruction site (arrow).


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Gore-Tex grafts are inherently associated with an in-creased risk of infection and possibly thrombosis.

In the three patients described here we used asimple technique allowing excellent control of thetumor margin with minimal risk of blood loss. Thereconstruction in each case was possible withoutgraft interposition and with preservation of thesplenic flow. Placing one or two sponges on the pos-terior and superior aspect of the liver significantlydecreased tension in the portal vein while performingthe anastomosis. The use of a growth factor tie (Fig.1D) prevented any major narrowing after removal ofthe sponges. Followup in each patient with CT scan

demonstrated no or mild narrowing without any ev-idence of portal hypertension. No patient had com-plications related to the procedure with documentednormal liver function test in each patient. Althoughthis technique is clearly not applicable for tumorsencasing the portal vein, it is probably applicable tomost cases of partial invasion because up to 5cm ofthe portal vein can be partially resected. We nowconsider this approach to be the method of choice inmost patients requiring portal vein resection, andconsider complete encasement of the portal vein as a

contraindication for pancreaticoduodenectomy.

In summary, we describe a simple technique ofpartial resection of the portal vein that does not re-

quire use of interposition or patch grafts. The splenicvein could also be spared in each of the three patientstreated with this approach. We anticipate that thistype of reconstruction will be applicable in most pa-tients with tumor in the head of the pancreas invad-ing, but not encasing, the portal vein. But the supe-riority of this simple technique over other types ofreconstruction and the impact of portal vein resec-tion on longterm outcomes after duodenopancreate-ctomy remain to be evaluated.

References

1. Allema JH, Reinders ME, van Gulik TM, et al. Portal vein resec-tion in patients undergoing pancreatoduodenectomy for carci-noma of the pancreatic head. Br J Surg 1994;81:16421646.

2. Fuhrman GM, Leach SD, Staley CA, et al. Rationale for enbloc vein resection in the treatment of pancreatic adenocarci-noma adherent to the superior mesenteric-portal vein conflu-ence. Pancreatic Tumor Study Group. Ann Surg 1996;223:154162.

3. Harrison LE, Brennan MF. Portal vein involvement in pancreaticcancer: a sign of unresectability? Adv Surg 1997;31:375394.

4. Leach SD, Lee JE, Charnsangavej C, et al. Survival followingpancreaticoduodenectomy with resection of the superiormesenteric-portal vein confluence for adenocarcinoma of the pan-

creatic head. Br J Surg 1998;85:611617.

Figure 3. Black and white print of a power Doppler ultrasound 4 weeks after pancreaticoduodenectomy and partialresection of the portal vein demonstrated patency of the splenic and portal systems. But a 30% to 50% stenosis of theportal vein was found at the anastomotic site associated with turbulent flow downstream (a). Hepatic artery (1).

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5. Roder JD, Stein HJ, Siewert JR. Carcinoma of the periampullaryregion: who benefits from portal vein resection? Am J Surg 1996;171:170175.

6. Harrison LE, Klimstra DS, Brennan MF. Isolated portal vein in-volvement in pancreatic adenocarcinoma. A contraindication forresection? Ann Surg 1996;224:342349.

7. Evans DB, Lee JE, Leach SD, et al. Vascular resection and intra-

operative radiation therapy during pancreaticoduodenectomy: ra-tionale and technique. Adv Surg 1996;29:235262.8. Nakamura S, Hachiya T, Oonuki Y, et al. A new technique for

avoiding difficulty during reconstruction of the superior mesen-teric vein. Surg Gyn Obst 1993;177:521523.

9. Howard J. Pancreatoduodenectomy (Whipple Resection) with skel-etonization of vessels for cancers of the pancreas and adjacent organs.

In: Howard JM, Ihse I, Prinz RA, eds. Surgical diseases of the pan-creas. 3rd ed. Philadelphia: Williams & Wilkins; 1997:529556.

10. Cusack JC Jr, Fuhrman GM, Lee JE, Evans DB. Managing unsus-pected tumor invasion of the superior mesenteric-portal venousconfluence during pancreaticoduodenectomy. Am J Surg 1994;168:352354.

11. Evans DB, Pisters PWT. Pancreaticoduodenectomy (Whipple

Operation) and total pancreatectomy for cancer. In: Nyhus LM,Fischer JE, eds. Mastery of surgery. 3rd ed. Boston: Little, Brownand Co; 1997:12331249.

12. Koike M, Sumi S, Iwasaki S, et al. Experimental investigation ofthe role of the splenic vein in gastric venous obstruction afterpylorus-preserving pancreatoduodenectomy in the dog. Int J Pan-creatol 1997;22:4550.

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