title: Ligation of superior mesenteric vein and portal to splenic vein anastomosis after superior mesenteric-portal vein confluence resection during pancreaticoduodenectomy - Case report.
abstract: 62 year old Caucasian female with pancreatic head mass abutting the superior mesenteric vein (SMV) presented with fine needle aspiration biopsy confirmed diagnosis of ductal adenocarcinoma. CT scan showed near complete obstruction of portal vein and large SMV collateral development. After 3 months of neoadjuvant therapy, her portal vein flow improved significantly, SMV collateral circulation was diminished. Pancreaticoduodenectomy (PD) and superior mesenteric portal vein (SMPV) confluence resection were performed; A saphenous vein interposition graft thrombosed immediately. The splenic vein remnant was distended and adjacent to the stump of the portal vein. Harvesting an internal jugular vein graft required extra time and using a synthetic graft posed a risk of graft thrombosis or infection. As a result, we chose to perform a direct anastomosis of the portal and splenic vein in a desperate situation. The anastomosis decompressed the mesenteric venous system, so we then ligated the SMV. The patient had an uneventful postoperative course, except transient ascites. She redeveloped ascites more than one year later. At that time a PET scan showed bilateral lung and right femur metastatic disease. She expired 15 months after PD.
  
  
  CONCLUSIONS
  The lessons we learned are (1) Before SMPV confluence resection, internal jugular vein graft should be ready for reconstruction. (2) Synthetic graft is an alternative for internal jugular vein graft. (3) Direct portal vein to SMV anastomosis can be achieved by mobilizing liver. (4) It is possible that venous collaterals secondary to SMV tumor obstruction may have allowed this patient's post-operative survival.
authors.affiliation: Department of Surgery, University of Toledo, College of Medicine, 3056 Arlington Avenue, Toledo, OH 43614, USA.
authors.forename: Jianlin
authors.initials: J
authors.lastname: Tang
authors.affiliation: Department of Surgery, University of Toledo, College of Medicine, 3056 Arlington Avenue, Toledo, OH 43614, USA.
authors.forename: Jihad
authors.initials: J
authors.lastname: Abbas
authors.affiliation: Department of Surgery, University of Toledo, College of Medicine, 3056 Arlington Avenue, Toledo, OH 43614, USA.
authors.forename: Katherine
authors.initials: K
authors.lastname: Hoetzl
authors.affiliation: Department of Surgery, University of Toledo, College of Medicine, 3056 Arlington Avenue, Toledo, OH 43614, USA.
authors.forename: David
authors.initials: D
authors.lastname: Allison
authors.affiliation: Department of Surgery, University of Toledo, College of Medicine, 3056 Arlington Avenue, Toledo, OH 43614, USA.
authors.forename: Mahamed
authors.initials: M
authors.lastname: Osman
authors.affiliation: Department of Surgery, University of Toledo, College of Medicine, 3056 Arlington Avenue, Toledo, OH 43614, USA.
authors.forename: Mallory
authors.initials: M
authors.lastname: Williams
authors.affiliation: Department of Surgery, University of Toledo, College of Medicine, 3056 Arlington Avenue, Toledo, OH 43614, USA.
authors.forename: Gerald B
authors.initials: GB
authors.lastname: Zelenock
keywords: Neoplasm; Pancreas; Pancreaticoduodenectomy; Reconstruction; Superior mesenteric vein