The quick, No-Twist, No-Kink portal confluence reconstruction

An aggressive surgical approach remains the best palliation and chance for 5-year survival in the treatment of locally advanced pancreatic cancer. Increasingly, this approach has involved partial or total resection of the portal vein (PV) or superior mesenteric vein (SMV) in combination with pancreaticoduodenectomy. Many studies have suggested that such resections done successfully are associated with an increased survival relative to nonresected patients, comparable with that of patients undergoing uncomplicated pancreaticoduodenectomy alone. Successful performance of portal resection remains extremely challenging because of the risk of uncontrolled bleeding and the difficulty encountered in preventing twisting or kinking of the reconstructed vessel. Prolonged partial or complete portal and mesenteric venous occlusion generally result in the development of bowel edema that makes the subsequent reconstruction more difficult. Recently, we and others have examined results of an aggressive surgical approach in the treatment of locally advanced pancreatic carcinoma. In our series, 43% of patients underwent partial portal vein resection with minimal additional blood loss, operative time, and postoperative complications, including pancreatic fistulae (unpublished observation). Our technique of portal vein resection, which preserves the anatomic relationship of the vessels in that region, allowing an easier reconstruction without kink or rotation of the portal-mesenteric confluence, is presented.