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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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Manuscript Accepted Early View Article
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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
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31
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Manuscript Accepted Early View Article
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TITLE: Splenic vein turndown for vascular reconstruction following pancreatic cancer 33
resection in patients with high risk profile 34
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
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Manuscript Accepted Early View Article
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TITLE: Splenic vein turndown for vascular reconstruction following pancreatic cancer 65
resection in patients with high risk profile 66
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
Manuscript Accepted Early View Article
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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
Group 1 – substantial contributions to conception and design, acquisition of data 243
Group 2 – drafting the article, revising it critically for important intellectual content 244
Group 3 – final approval of the version to be published 245
246
Adeeb Majid 247
Group 1 – substantial contributions to conception and design, acquisition of data 248
Group 2 – drafting the article, revising it critically for important intellectual content 249
Group 3 – final approval of the version to be published 250
251
Ju-En Tan BMedSci 252
Group 1 – substantial contributions to conception and design, acquisition of data 253
Group 2 – drafting the article 254
Group 3 – final approval of the version to be published 255
256
Manuscript Accepted Early View Article
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Jim Iliopoulos 257
Group 1 – substantial contributions to conception and design, acquisition of data 258
Group 2 –revising the article critically for important intellectual content 259
Group 3 – final approval of the version to be published 260
261
Neil Merrett 262
Group 1 – substantial contributions to conception and design, acquisition of data 263
Group 2 –revising the article critically for important intellectual content 264
Group 3 – final approval of the version to be published 265
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
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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
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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
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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
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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
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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
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Figure 3: Splenic vein turn-down with anastomosis 380
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383
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Figure 4: Intraoperative photograph of splenic vein turndown technique with SMV 385
ligated, and splenic vein anastomosed to jejunal and ileal branches 386
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393
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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