PMC4429856_01
CT in the portalvenous phase demonstrating the anatomic situation prior to revision surgery.. Axial maximum intensity projections of the upper abdomen at four different levels (A-D; (A) is below (D)). The SMV crosses the abdomen in front of the duodenum and the pancreas (A), reaching the liver at the site of the falciform ligament (B) and continuing into the left portal vein. The splenic vein runs behind the pancreas (C), reaching the liver hilum and continuing into the right portal vein (D). A filiform connection between the LPV and RPV is present at the liver hilum (black arrow in D). SMV = superior mesenteric vein; LPV = left portal vein, RPV = right portal vein; SV = splenic vein; P = pancreas.
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CT analysis revealed that the SMV ran ventrally of the duodenum into the left PV, draining the blood from the jejunum and ileum (Fig. 1A and B). The splenic vein (SV) ran underneath the pancreas and led directly into the right PV (Fig. 1C). A small intrahepatic connection between the right and left PV was present at the liver hilum (Fig. 1D), but SMV and SV drained separately into the liver without forming an anatomic PV (Fig. 2A).
Oblique coronal volume rendered images before (A) and after (B) revision surgery with insertion of a Gore-Tex prosthesis.. SMV and SV drain separately into the liver without forming an anatomic portal vein (A). Three months after surgery the prosthesis is occluded and newly formed collaterals can be observed draining blood from small mesenteric branches into the SV (B). SMV = superior mesenteric vein; SV = splenic vein.
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The patient's three-month follow-up showed a re-thrombosis of the prosthesis (Fig. 2B).
Intraoperative situs before resection of the preduodenal superior mesenteric vein (PDSMV).. The PDSMV was inseparable from the neck of pancreas and ran from the mesenteric root in front of the pancreas head (Phead) as well as the bulbus of duodenum (D) to feed the left portal vein via the falciform ligament. The splenic vein (SV) ran behind the body of the pancreas (Pbody), crossed ventrally the common hepatic artery (CHA) to reach the right portal vein dorsally the proper hepatic artery (PHA). The gastroduodenal artery (GDA) was already cut.
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After abdominal exploration and division of the adhesions, the PDSMV and the SV were identified (Fig. 3).
Intraoperative situs after the Whipple procedure and recontruction of the SMV using a PTFE graft in end-to-end technique.. The Whipple reconstruction was performed using a single jejunum loop, an end-to-side pancreaticojejunostomy and an end-to-side hepaticojejunostomy (BDA). The PTFE graft crossed the pancreaticojejunostomy ventrally.
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Treitz. The PPPD was finished, and the SMV reconstruction was performed with an 8 cm long 8 CH PTFE prosthesis in an end-to-end technique (Fig. 4).