Chapter 167 - Venous recon in non-vascular surgical oncology Flashcards
% of Pancreatic cancer with resectable disease at time of diagnosis
15-20%
Factors involved in pancreatic cancer classification
1) resectable
2) locally irresectable
3) borderline resectable
4) metastatic
Resectable pancreatic cancer definitiotn
1) no distant metastasis
2) no involvement of SMA or CA
Locally unresectable pancreatic cancer definition
1) infiltration of SMA and CA
2) not amenable to pancreatectomy
Borderline resectable pancreatic cancer definition
1) tumors abutment with SMA, CA and SMV, PV
Signs on CT to demonstrate SMV/PV infiltration
1) portal venous phase
2) radiologic absense of fat plane
3) length of tumor involvement > 5 mm
4) venous occlusion with collateral vessels
5) teardrop sign in SMV (tethering by tumor)
6) irregularity of blood vessel wall
7) circumferential involvement of vessel > 180 degrees
Most common tumor of the pancreas
Ductal adenocarcinoma
Localization of ductal adenocarcinoma in pancreas
Head of pancreas 78% of time
Pancreaticoduodenectomy steps
1) midline laparotomy or bilateral subcostal incision
2) Kocher maneuver to identify SMA and CA involvement
3) divide gastrocolic ligament to enter lesser sac
4) Mobilize hepatic flexure and ligate gastroepiploic vein before it enters the gastrocolic trunk
5) SMV identified and traced to inferior border of pancreas
6) Supraduodenal dissection include cholescystectomy, lymphadenectomy of hepatoduodenal ligament, CHA and CA
7) CBD dissected and isolated
8) ligate right gastric, GDA, right gastroepiploic artery
9) divide distal stomach/proximal duodenum
10) identify PV and dissect towards superior border of pancreas
11) Mobilize ligament of Treitz and divide proximal jejunum
12) Retrocolic window created in transverse mesocolon to right of middle colic artery
13) distal duodenum passed through window into lesser sac
14) specimen mobilized off SMV and SMA
15) divide pancreatic parenchyma
Most common area of PV/SMV involvement
Right anterolateral wall
Methods of PV reconstruction and % circumference recon needed as indication
1) primary venorrhaphy (30% circumference)
2) vein patch angioplasty (30-50% circumference; > 2cm)
3) primary end-to-end anastomosis (< 2cm excised)
4) interposition using autologous vein
5) interposition using prosthetic
Splenic vein ligation required how often
33% if primary repair
78% with end-to-end recon
Vessels needing control in PV/SMV reconstruction
Gastric vein
Splenic vein
Rare complication after splenic vein ligation and rate of occurence
1) sinistral HTN
2) esophagitis
3) gastritis
4) GI bleed
3.8%
Medial survival after PV/SMV reconstruction
15.5 months
not related to patency or the mode of reconstruction
Type of PV/SMV tumor involvement
1) desmoplastic reaction at the interface only
2) actual tumor infiltration - much worse outcome
Primary IVC tumor frequency
exceedingly rare <400 cases ever
Primary leiomyosarcoma (IVC is the most common vessel accounting for > 50% of all cases)
Secondary IVC tumor types
1) renal (RCC, transitional cell carcinoma, metastatic seminoma)
2) adrenal (lymphoma, malignant pheochromocytoma, paraganglioma)
3) retroperitoneal (liposarcoma, germ cell tumor, malignant fibrous histiocytoma, benign retroperitoneal neurofibroma, recurrent benign intravascular leiomyomatosis, Wilms tumor, teratoma, lymphadenopathy from metastatic melanoma, duodenal carcinoma)
4) abdominal
5) hepatic (hepaticellular carcinoma, cholangiocarcinoma, metastatic tumors from colon Ca)
Treatment of primary leiomyosarcoma
Complete en bloc resection only
no other non-surgical modalities help
Tumor thrombus of RCC
2-16%
tumor from renal vein lumen into the IVC
Neves and Zincke classification for tumor thrombus
LEVEL 1: IVC < 2cm from left renal vein
LEVEL 2: infrahepatic IVC > 2 cm above renal vein
LEVEL 3: retrohepatic IVC
LEVEL 4: supradiaphragmatic IVC and right atrium
IVC reconstruction surgical approach
1) midline laparotomy +/- sternotomy or right thoracoabdominal approach via 7-9th rib interspace
2) complete all aspects of nephrectomy except for renal vein ligation
3) gain control of IVC depending on extent of tumor
Retrohepatic IVC dissection
1) suprahepatic IVC and porta hepatis for Pringle maneuver
2) mobilize suspensory ligament of liver
3) control large lumbar veins
Methods to support CO in IVC clamping
1) trendelenburg position
2) extracorporeal support (VV bypass or CPB)
3) aortic clamping
Methods of IVC reconstruction
1) primary repair (< 50% narrowing only)
2) patch (>50% narrowing if just patch)
3) interposition graft
4) ligation
IVC graft size
14-20 mm
IVC graft material options
1) FV, IJ, GSV
2) aortic homograft
3) cryo IVC
4) prosthetic (dacron eptfe)
Rate of renal and hepatic vein reimplantation in IVC recon
Renal 24%
hepatic 2%
Reason for reimplanting renal vein
Help with graft flow
not usually necessary for renal function due to collaterals
Complications with IVC ligation
1) AKI
2) LE edema
3) LE DVT
reserved for chronic IVC obstruction with collateral
Palliative IVC bypass indication
1) disabling LE edema due to IVC occlusion
2) primary tumor/tumor thrombus unresectable
Palliative IVC bypass steps
1) right thoracoabdominal exposure
2) ePTFE 12-18 mm
3) inflow from IVC or iliac vein
4) distal anast at suprahepatic IVC or right atrium
5) place IVC filter
Venous venous bypass steps in extracorporeal bypass
1) 24Fr arterial perfusion cannula
2) outflow = infrarenal IVC or femoral vein
3) inflow = IJ
4) flow rate 750-1500 ml/min
5) systemic pressure 60-80 mmHg
Cardiopulmonary bypass steps
1) SVC, IVC and ascending aorta isolated
2) ascending aorta and SVC cannulated
3) relative hypothermia to 32 C
4) maintain perfusion 60-80 mmHg
IVC recon rate of VTE post-op
22% VTE
median time to VTE 6 days
lower with anticoagulation but bleeding risk higher
IVC recon patency
80-90% at 5 years
Risk factors for IVC graft infection
1) duodenal leak
2) bile leak
3) perforated diverticulitis
Risk factors for IVC graft thrombosis
Tumor recurrence
graft infection
Most common secondary tumor in IVC tumor
Renal Cell Carcinoma
