Journal Name: International Journal of Hepatobiliary and ... · Portal vein (PV) - superior mesenteric vein (SMV) ... 113 described for superior mesenteric vein trauma. ... 121 A

Manuscript Accepted Early View Article

Page 1 of 16

Early View Article: Online published version of an accepted article before publication in the

final form.

Journal Name: International Journal of Hepatobiliary and Pancreatic Diseases (IJHPD)

Type of Article: Case Report

Title: Splenic vein turndown for vascular reconstruction following pancreatic cancer

resection in patients with high risk profile

Authors: Emma Clout, James Wei Tatt Toh, Adeeb Majid, Ju-En Tan, Jim Iliopoulos, Neil

Merrett

doi: To be assigned

Early view version published: August 19, 2016

How to cite the article: Clout E, Toh JWT, Majid A, Tan J, Iliopoulos J, Merrett N. Splenic

vein turndown for vascular reconstruction following pancreatic cancer resection in patients

with high risk profile. International Journal of Hepatobiliary and Pancreatic Diseases

(IJHPD). Forthcoming 2016.

Disclaimer: This manuscript has been accepted for publication. This is a pdf file of the

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article before publication in the final form. The proof of this manuscript will be sent to the

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TYPE OF ARTICLE: Case Report 1

2

TITLE: Splenic vein turndown for vascular reconstruction following pancreatic cancer 3

resection in patients with high risk profile 4

5

AUTHORS: 6

Emma Clout B.Pharm, MBBS, MS, FRACS1 7

James Wei Tatt Toh BSc, MBBS, FRACS1 8

Adeeb Majid MBBS, MS, FRACS1 9

Ju-En Tan BMedSci, MBBS1 10

Jim Iliopoulos BSc (Med), MBBS (Hons 1), PhD, FRACS (Cardiothoracic), FRACS 11

(Vascular) 1 12

Neil Merrett MBBS, FRACS1 13

14

AFFILIATIONS: 15

1Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia 16

1University of Western Sydney, NSW, Australia 17

18

CORRESPONDING AUTHOR DETAILS 19

Emma Samantha Clout 20

C/- Bankstown-Lidcombe Hospital, Eldridge Rd, Bankstown, NSW, Australia 2200 21

Email: [email protected] 22

23

Short Running Title: Splenic vein turndown for reconstruction in pancreatic 24

resection 25

26

Guarantor of Submission : The corresponding author (Emma Clout) is the 27

guarantor of submission. 28

29

30

31

32


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35

ABSTRACT 36

37

Introduction 38

Vascular reconstruction is utilised following resections for pancreatic cancers with 39

borderline resectability. This is defined by venous or partial superior mesenteric 40

artery (SMA) involvement, where vessels are resected en-bloc to achieve an R0 41

resection. 42

There are many vascular reconstruction techniques post en-bloc R0 resection, each 43

with its own complication profile. The splenic turndown technique separates the 44

vascular anastomosis from the pancreatic anastomosis, reducing the risk of vascular 45

disruption should a pancreatic leak occur. 46

47

Case Report 48

This is the first report in the literature of the splenic vein turndown technique being 49

utilised for vascular reconstruction post pancreatic resection for borderline resectable 50

pancreatic cancer. To date, splenic vein turndown repair has only been described in 51

a trauma setting. In this case, splenic vein turndown was preferred as the patient 52

was on long-term corticosteroids with a high risk of anastomotic leak. 53

54

Conclusion 55

This case reports the technique of splenic vein turndown, showing that it is a feasible 56

option for vascular reconstruction post pancreatic resection. The main disadvantage 57

of this technique is high risk of segmental portal hypertension if the spleen is not 58

removed concomitantly. For this reason, its utility should be restricted to patients at 59

high risk of pancreatic leak. 60

61

Keywords: Pancreatic cancer, venous reconstruction 62

63

64


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67

INTRODUCTION 68

Patients with pancreatic cancer frequently have extra-pancreatic involvement at the 69

time of diagnosis[1]. Portal vein (PV) - superior mesenteric vein (SMV) involvement 70

is often seen on pre-operative imaging or at the time of resection. Surgical resection 71

remains the only definitive treatment, increasing median survival from five to ten 72

months without surgery to twenty three months with a negative margin (R0) 73

resection[2]. The five year survival is approximately 20% when combined with 74

adjuvant therapy. Katz and colleagues[3] reported a median survival of forty months 75

for patients with borderline resectable disease who successfully completed 76

neoadjuvant therapy, R0 resection and adjuvant therapy. 77

Failure to achieve a clear margin (R1) resection produces similar survival rates to 78

chemo-radiation treatment alone with a median survival of eleven months[2]. 79

Benefits of surgery depend on clear margins being obtained. In order to achieve R0 80

status, en bloc resection of the SMV during the pancreatic resection may be required 81

followed by vascular reconstruction and gastrointestinal anastomoses. 82

Borderline resectability in pancreatic cancer is defined as no distant metastases, but 83

with venous involvement of the SMV/PV - abutment and/or narrowing or encasement 84

of the lumen but with suitable vessel proximal and distal to the area of vessel 85

involvement (to allow for reconstruction), no involvement of celiac axis and no more 86

than 180 degrees of circumferential involvement of SMA)[4]. 87

A consensus statement from the American Hepato-Pancreatico-Biliary Association 88

and Society of Surgical Oncology (AHPBA/SSO) in 2009 highlighted the importance 89

of R0/R1 resection for pancreatic adenocarcinomas with venous vascular 90

involvement of the PV/SMV[5], with little benefit from incomplete resections. The 91

AHPBA/SSO recommended these resections be performed in high volume 92

institutions with experience in resection and reconstruction of major mesenteric veins 93

[5]. 94

In this study, a case of a borderline resectable pancreatic adenocarcinoma has been 95

reported. The seventy five year old female required a pancreaticoduodenal resection 96


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with en bloc resection of major vasculature. However, she had significant 97

comorbidities and was on long-term high dose corticosteroids for polymyalgia 98

rheumatica (PMR). Because of her steroids, co-morbidities and age, there was 99

significant concerns of post-operative anastomotic leak, and a pancreatic leak 100

disrupting a vascular anastomosis would have been catastrophic. Furthermore, even 101

in the setting of neoadjuvant therapy, concern for pancreatic fistula was also 102

considered, with rates in the order of 3% found in systematic reviews [6]. 103

Following extensive discussions with upper gastrointestinal, vascular surgeons, 104

oncologists and radiologists, a decision was made to perform a pancreatic resection 105

and splenectomy with venous reconstruction using the splenic vein turndown 106

technique. 107

Final histopathology confirmed an R0 resection with negative margins and at one 108

year follow-up the patient had adequate flow and no evidence of recurrence. 109

This is the first report in the literature of the splenic vein turndown technique being 110

utilised for vascular reconstruction post pancreatic resection for borderline resectable 111

pancreatic cancer. Currently, the splenic vein turndown repair has only been 112

described for superior mesenteric vein trauma. This case shows that it may be 113

considered in patients who have a high risk of anastomotic leak in patients requiring 114

en block major vasculature resection in borderline resectable pancreatic cancer. 115

116

CASE REPORT 117

A seventy five year old female presented with abdominal pain and a new diagnosis 118

of insulin dependent diabetes mellitus (IDDM). She had polymyalgia rheumatica and 119

was on long-term steroids. 120

A triple phase Computed Tomography (CT) of the abdomen was performed 121

revealing a twenty three millimetre (mm) lesion in the pancreatic head with a mass 122

abutting the portal vein (PV). There was no thrombosis or encasement and no 123

arterial involvement or evidence of metastatic disease. Endoscopic ultrasound (EUS) 124

guided fine needle aspiration (FNA) biopsy confirmed the moderately differentiated 125

adenocarcinoma (22x24mm) with abutment of the SMV /PV over one centimetre, 126

associated with mild fusiform dilatation at the point of contact. She was assessed to 127

have borderline resectable disease and was commenced on neoadjuvant 128


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chemotherapy. 129

During the course of her treatment, she became jaundiced with a bilirubin of over two 130

hundred micromole per litre (mmol/L) and proceeded to endoscopic retrograde 131

cholangio pancreatography (ERCP) and stenting. Her Carbohydrate Antigen 19-9 132

(CA19-9) level was two hundred and sixty units per millilitre (U/mL). After 3 cycles of 133

gemcitabine based chemotherapy, repeat imaging with CT scan and EUS revealed 134

no progression or reduction in disease but her CA19-9 level decreased to 110 U/mL. 135

Positron Emission Tomography (PET) imaging revealed no evidence of metastatic 136

disease. Her case was referred to a high volume pancreatic surgery unit for 137

consideration of resectability. 138

With good premorbid performance status, no evidence of metastatic disease, no 139

disease progression while on neoadjuvant chemotherapy, and radiological evidence 140

of resectability, the patient was offered a pancreaticoduodenectomy. Intraoperatively, 141

the SMV and confluence of the jejunal and ileal venous tributaries was involved with 142

the tumour but the portal vein was relatively free (see Figure 1.). There was no 143

evidence of distant metastases. A decision was made to perform a total 144

pancreatectomy with venous resection and reconstruction. 145

Due to her chronic steroid use, the risk of leak was significantly higher. A decision 146

was made to perform a splenic vein turndown technique to reduce the risk of an 147

anastomotic leak disrupting the vascular reconstruction which would be catastrophic. 148

A splenectomy was also performed to reduce the risk of segmental portal 149

hypertension associated with the short gastric vessels in cases where the spleen is 150

preserved. 151

Following cholecystectomy, distal gastrectomy, end-side hepaticojejunostomy and 152

end-side antecolic gastrojejunostomy, a splenectomy was performed. The splenic 153

vein was isolated and prepared for the turndown technique. During the course of the 154

turndown technique, the PV, SV and 2 main tributaries of SMV (jejunal and ileal) 155

were clamped and divided. The two SMV tributaries were then re-anastomosed to 156

the mobilized and turned down splenic vein (see figure 2, 3 and 4.). 7-0 prolene 157

suture was used to perform the anatomosis of the splenic vein to ileal and jejunal 158

tributaries of the SMV, with a continuous end to side and end to end anastomosis 159

respectively. Even in this setting of neoadjuvant therapy, the caliber of these vessels 160


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were reasonable and formed part of the patient’s preoperative imaging assessment 161

with regards to options for venous reconstruction. This included vascular surgeon 162

review re suitability. This patient received 5000 international units (IU) of intravenous 163

(IV) heparin cover, and had a total ischaemia time of 17 minutes. No blood products 164

were used intraoperatively and the total operative time was 323 minutes. 165

Final pathology confirmed a poorly differentiated adenocarcinoma in the head of the 166

pancreas which was 35mm in diameter, extending to the anterior border. Tumour 167

was found invading the wall of the SMV. 2/26 lymph nodes were involved. The 168

pathological staging was pT3, pN1, Mx. The margin was negative and there was no 169

evidence of residual microscopic disease. The patient had an uneventful recovery 170

and proceeded to have adjuvant chemotherapy. Repeat imaging at three and six 171

months post-surgery revealed no evidence of recurrent disease. Furthermore, post 172

operative imaging revealed patent flow through her anastomosis, with no functional 173

limitation regarding the potential for angulation at the junction of the SV and SMV 174

with this turndown technique (see figure 5.) 175

The patient remains alive 42 months post resection. 176

177

DISCUSSION 178

There are many vascular reconstruction techniques including use of the splenic vein 179

post pancreatic resection including use of the splenic vein. When the splenic vein 180

has been used for reconstruction, it has been utilised as an autologous interposition 181

graft in cases of pancreatic adenocarcinoma. The IJV may also be used as an 182

autologous graft post pancreatic resection[7, 8]. There are a range of synthetic 183

grafts. 184

In this case, rather than using the splenic vein as an interposition graft, the splenic 185

vein turndown technique is a novel technique. Splenic vein turndown preserves the 186

splenic-PV confluence and utilizes the proximal splenic vein to anastomose the 187

jejunal and ileal tributaries, preserving intestinal venous drainage. 188

The use of a splenic vein turndown technique has been successfully described in 189

cases of SMV/PV trauma [9]. Phillips and colleagues reported the use of the 190

turndown technique in one patient to repair SMV traumatic avulsion, and in a 191

literature review of 56 articles, identified five other trauma cases where the splenic 192


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vein turndown repair was used. Of the six patients, four survived the procedure with 193

radiological evidence of portal venous flow post operatively[9]. 194

In a review of Pubmed, EMBASE and Google Scholar, using search terms including 195

“splenic vein turndown” and “pancreatic cancer” or “pancreatic malignancy” or 196

“pancreatic resection”, there were no results. To the best of our knowledge, this is 197

the first report in the literature of the splenic vein turndown technique being utilized 198

for reconstruction post pancreatic resection for malignancy. 199

The splenic vein turndown technique has several limitations. Without a concomitant 200

splenectomy, there is a high risk of segmental portal hypertension and gastric 201

varices over time. Perigastric varices and submucosal varices detected by CT have 202

been reported to be as high as 70% and 20% respectively. It may also cause gastric 203

haemorrhage and intractable bleeding, although this is rare. Splenic vein obliteration 204

post spleen preserving distal pancreatectomy has also been described as a possible 205

complication [10]. 206

Although performing a splenectomy reduces the risk of segmental portal 207

hypertension, splenectomy is not without its own risks, including the risk of 208

overwhelming post splenectomy sepsis and the need for appropriate vaccinations 209

and long term antibiotics. 210

211

CONCLUSION 212

This case demonstrated the successful application of a splenic vein turndown 213

technique for SMV reconstruction following pancreaticoduodenectomy and venous 214

resection for pancreatic cancer. The technique may be considered in high risk 215

patients who are at significant risk of anastomotic leak such as for patients with long 216

term corticosteroids or immunosuppressants, as it separates the vascular 217

anastomosis from the pancreatic anastomosis, thus reducing the risk of a potential 218

pancreatic leak disrupting the vascular anastomosis. 219

220

CONSENT 221

Written informed consent was obtained from the patient prior to publication. 222

223

224


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CONFLICT OF INTEREST 225

The authors declare that there is no conflict of interests. 226

227

FUNDING 228

No sources of funding to declare. 229

230

AUTHOR’S CONTRIBUTIONS 231

232

EC and NM were involved in the preparation of the manuscript. JI, JT and AM were 233

involved in writing the discussion of this study. JWTT was responsible for reviewing 234

and main editing of the article. All authors approved the article prior to publication. 235

236

Emma Clout B.Pharm 237

Group 1 – substantial contributions to conception and design, acquisition of data 238

Group 2 – drafting the article, revising it critically for important intellectual content 239

Group 3 – final approval of the version to be published 240

241

James Wei Tatt Toh 242




246

Adeeb Majid 247




251

Ju-En Tan BMedSci 252


Group 2 – drafting the article 254


256


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Jim Iliopoulos 257


Group 2 –revising the article critically for important intellectual content 259


261

Neil Merrett 262


Group 2 –revising the article critically for important intellectual content 264


266

ACKNOWLEDGEMENTS 267

The authors would like to thank Catherine Keil and Lynne Roberts (SSWLHD library 268

network) for their support in the preparation of this manuscript. 269

270

List of Abbreviations 271

272

SMA superior mesenteric artery 273

274

PV portal vein 275

276

SMV superior mesenteric vein 277

278

HA hepatic artery 279

280

AHBA/SSO American Hepato-Pancreatico-Biliary Association and Society of 281

Surgical Oncology 282

283

IDDM insulin dependent diabetes mellitus 284

285

CT computed tomography 286

287

mm millimetres 288


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289

fig figure 290

291

FNA fine needle aspiration 292

293

EUS endoscopic ultrasound 294

295

mmol/L micromole per litre 296

297

ERCP endoscopic retrograde cholangio pancreatography 298

299

CA 19.9 carbohydrate antigen 19.9 300

301

U/mL units per millilitre 302

303

PET Positron Emission Tomography 304

305

IU international units 306

307

IV intravenous 308

309

IJV internal jugular vein 310

311

REFERENCES 312

1. Michalski CW, Weitz J, Buchler MW. Surgery insight: surgical management of 313

pancreatic cancer. Nature clinical practice Oncology. 2007; 4(9):526-35. Epub 314

2007/08/31. 315

2. Christians KK, Lal A, Pappas S, Quebbeman E, Evans DB. Portal vein 316

resection. The Surgical clinics of North America. 2010; 90(2):309-22. Epub 317

2010/04/07. 318

3. Katz MH, Pisters PW, Evans DB, Sun CC, Lee JE, Fleming JB, et al. 319

Borderline resectable pancreatic cancer: the importance of this emerging 320


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stage of disease. Journal of the American College of Surgeons. 2008; 321

206(5):833-46; discussion 46-8. Epub 2008/05/13. 322

4. Callery MP, Chang KJ, Fishman EK, Talamonti MS, William Traverso L, 323

Linehan DC. Pretreatment assessment of resectable and borderline 324

resectable pancreatic cancer: expert consensus statement. Annals of surgical 325

oncology. 2009; 16(7):1727-33. Epub 2009/04/28. 326

5. Evans DB, Farnell MB, Lillemoe KD, Vollmer C, Jr., Strasberg SM, Schulick 327

RD. Surgical treatment of resectable and borderline resectable pancreas 328

cancer: expert consensus statement. Annals of surgical oncology. 2009; 329

16(7):1736-44. Epub 2009/04/24. 330

6. Verma V, Li J, Lin C. Neoadjuvant Therapy for Pancreatic Cancer: Systematic 331

Review of Postoperative Morbidity, Mortality, and Complications. American 332

journal of clinical oncology. 2016; 39(3):302-13. Epub 2016/03/08. 333

7. Casadei R, D'Ambra M, Freyrie A, Monari F, Alagna V, Ricci C, et al. 334

Managing unsuspected tumour invasion of the superior mesenteric-portal vein 335

during surgery for pancreatic head cancer. A case report. JOP : Journal of the 336

pancreas. 2009; 10(4):448-50. Epub 2009/07/08. 337

8. Miyata M, Nakao K, Hirose H, Hamaji M, Kawashima Y. Reconstruction of 338

portal vein with an autograft of splenic vein. The Journal of cardiovascular 339

surgery. 1987; 28(1):18-21. Epub 1987/01/01. 340

9. Phillips BT, Pasklinsky G, Watkins KT, Vosswinkel JA, Tassiopoulos AK. 341

Splenic vein turndown repair in superior mesenteric vein trauma: a reasonable 342

alternative. Vascular and endovascular surgery. 2011; 45(2):191-4. Epub 343

2010/12/16. 344

10. Yoon YS, Lee KH, Han HS, Cho JY, Ahn KS. Patency of splenic vessels after 345

laparoscopic spleen and splenic vessel-preserving distal pancreatectomy. The 346

British journal of surgery. 2009; 96(6):633-40. Epub 2009/05/13. 347

348

349

350

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FIGURE LEGENDS 353

354

Figure 1: Intraoperative photograph of venous structures encountered during splenic 355

vein turndown technique 356

357

Figure 2: Left – venous anatomy in pancreaduodenectomy. Right – venous anatomy 358

post splenic vein turndown with anastomosis of ileal and jejunal veins with total 359

pancreatectomy and splenectomy (PV = portal vein, SMV = superior mesenteric 360

vein, JB = jejunal branch, IC = ileocolic branch). 361

Figure 3: Splenic vein turn-down with anastomosis 362

Figure 4: Intraoperative photograph of splenic vein turndown technique with SMV 363

ligated, and splenic vein anastomosed to jejunal and ileal branches 364

365

FIGURES 366

367

368

Figure 1: Intraoperative photograph of venous structures encountered during splenic 369

vein turndown technique 370


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371

372

Figure 2: Left – venous anatomy in pancreaduodenectomy. Right – venous anatomy 373

post splenic vein turndown with anastomosis of ileal and jejunal veins with total 374

pancreatectomy and splenectomy (PV = portal vein, SMV = superior mesenteric 375

vein, JB = jejunal branch, IC = ileocolic branch). 376

377

378

379

Figure 3: Splenic vein turn-down with anastomosis 380

381

382


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383

384

Figure 4: Intraoperative photograph of splenic vein turndown technique with SMV 385

ligated, and splenic vein anastomosed to jejunal and ileal branches 386

387

388

389

390

391

392


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393

394

Figure 5: CT 3 months post total pancreatectomy and splenic turndown 395

reconstruction demonstrating patent flow through portal vein and ileal and jejunal 396

tributaries 397

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Journal Name: International Journal of Hepatobiliary and ... · Portal vein (PV) - superior mesenteric vein (SMV) ... 113 described for superior mesenteric vein trauma. ... 121 A