PMC8179775_01
Pancreatic cancer with regional invasion into vessels. (a, b) Enhanced computed tomography shows a hypovascular mass in the pancreatic head (red arrow) and marked dilation of the main pancreatic duct of the distal pancreatic parenchyma (yellow arrows). (c) The pancreatic tumor (red area) markedly involves the confluence of the superior mesenteric vein, portal venous trunk, and splenic vein. (d) The inferior mesenteric vein flows into the superior mesenteric vein, not the splenic vein. There is no evidence of cancer at unresectable sites or distant metastases. GB: gallbladder; IMV: inferior mesenteric vein; LGV: left gastric vein; LRV: left renal vein; IVC: inferior vena cava; MCV: middle colic vein; SMA: superior mesenteric artery; SMV: superior mesenteric vein; SpA: splenic artery; SpV: splenic vein.
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fig1
Enhanced computed tomography (CT) detected a hypovascular mass (18 mm diameter) in the pancreatic head (Figures 1(a) and 1(b)). The main pancreatic duct of the distal pancreatic parenchyma was substantially dilated (Figures 1(a) and 1(b)). Dynamic CT clearly demonstrated that the carcinoma of the head of the pancreas had invaded the superior mesenteric vein, portal venous trunk, and splenic vein (Figure 1(c)). The inferior mesenteric vein flowed into the superior mesenteric vein rather than the splenic vein (Figure 1(d)), suggesting that the inferior mesenteric vein was not a viable splenic venous drainage route. As imaging examinations revealed that the tumor involved the confluence of the superior mesenteric vein, portal venous trunk, and splenic vein (Figures 1(c) and 1(d)), en bloc resection of the confluence of these veins was performed, with simultaneous venous reconstructions (Figure 2).
The distal splenorenal shunt. The confluence of the superior mesenteric vein, portal vein, and splenic vein are resected en bloc. The superior mesenteric vein and portal venous trunk are anastomosed in the end-to-end fashion. The remnant splenic vein is anastomosed to the superior aspect of the left renal vein in the end-to-side fashion. CA: celiac artery; CHA: common hepatic artery; IMV: inferior mesenteric vein; LAdV: left adrenal vein; LGA: left gastric artery; LGV: left gastric vein; LOV: left ovarian vein; LRA: left renal artery; LRV: left renal vein; IVC: inferior vena cava; MCV: middle colic vein; MPD: main pancreatic duct; PV: portal vein; SMA: superior mesenteric artery; SMV: superior mesenteric vein; SpA: splenic artery; SpV: splenic vein.
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fig2
As imaging examinations revealed that the tumor involved the confluence of the superior mesenteric vein, portal venous trunk, and splenic vein (Figures 1(c) and 1(d)), en bloc resection of the confluence of these veins was performed, with simultaneous venous reconstructions (Figure 2).
Surgical procedures. (a) The splenic vein is ligated and cut, and the splenic vein is temporarily clamped. The left renal vein is partially clamped. (b) A venous orifice is made on the superior aspect of the LRV. The splenic vein and left renal vein are set in the end-to-side fashion by bilateral fixation sutures. (c, d) The splenic vein is anastomosed to the left renal vein in the end-to-side fashion by unabsorbable polypropylene. LAdV: left adrenal vein; LOV: left ovarian vein; LRV: left renal vein; SpV: splenic vein.
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fig3
The splenic vein was divided as near as possible to the junction of the superior mesenteric vein and portal vein and temporarily clamped (Figure 3(a)). The left renal vein was then prepared for anastomosis on the left side of the superior mesenteric artery and partially clamped (Figure 3(a)). An anastomosis orifice was created on the superior aspect of the left renal vein rather than the ventral aspect (Figure 3(b)). After widening the cut end of the splenic vein by making a small slit in its heel side, the splenic vein and left renal vein were anastomosed in the end-to-side fashion by bilateral fixation sutures (6-0 Prolene; Ethicon, Inc., Cincinnati, USA) (Figure 3(b)). Subsequently, the remnant splenic vein was anastomosed to the superior aspect of the left renal vein in the end-to-side fashion by unabsorbable polypropylene (6-0 Prolene) (Figures 3(c) and 3(d)).
Long-term patency of the distal splenorenal shunt. (a) Schemas for venous reconstructions during pancreaticoduodenectomy. (b) Three-dimensional imagery at 5 years and 6 months after the initial surgery shows that the distal splenorenal shunt has maintained good patency. The estimated splenic volume is 35 mL. LRV: left renal vein; IVC: inferior vena cava; PV: portal vein; SMA: superior mesenteric artery; SMV: superior mesenteric vein; SpA: splenic artery; SpV: splenic vein.
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fig4
Dynamic CT and upper esophagogastric endoscopy performed 5 years and 6 months after the initial surgery revealed that all venous reconstructions had maintained good patency (Figure 4), and there were no esophageal varices or congestive gastropathy.