Vascular resection and reconstruction at pancreatico-duodenectomy: technical issues

With the improvement of perioperative management over the years, pancreatico-duodenectomy has become a safe operation despite its technical complexity. The presence of concomitant visceral artery occlusion unrelated to the underlying malignancy and concomitant major venous infiltration by tumor poses additional hazards to resection which could compromise the postoperative outcome.

A MEDLINE database search was performed to identify relevant articles using the key words "median arcuate ligament syndrome", "superior mesenteric artery", "replaced right hepatic artery", and "portal vein resection". Additional papers and book chapters were identified by a manual search of the references from the key articles.

Computed tomography with 3-dimensional reconstruction of the vascular anatomy provides most key information on the potential vascular problems encountered during surgery. A trial clamping of the gastroduodenal artery provides a simple intraoperative assessment for the presence of any significant visceral arterial occlusion. Depending on the timing of diagnosis, division of the median arcuate ligament, bypass or endovascular stenting should be considered. Portal and superior mesenteric vein resection had been used with increasing frequency and safety. The steps and methods taken to reconstruct the venous continuity vary with individual surgeons, and the anatomical variations encountered. With segmental loss of the portal vein, opinions differs with regard to the preservation of the splenic vein, and when divided, the necessity of restoring its continuity; source of the autologous vein graft when needed and whether the use of synthetic graft is a safe alternative.

During a pancreatico-duodenectomy, images of computed tomography must be carefully studied to appreciate the changes and variation of vascular anatomy. Adequate preoperative preparation, acute awareness of the probable arterial and venous anatomical variation and the availability of expertise, especially micro-vascular surgery, for vascular reconstruction would help to make the complex pancreatic resection a safer procedure.