Mesoportal bypass, interposition graft, and mesocaval shunt: Surgical strategies to overcome superior mesenteric vein involvement in pancreatic cancer

Kinny‐Köster, Benedict; Oosten, Floortje van; Javed, Ammar A.; Cameron, John L.; Lafaro, Kelly J.; Burkhart, Richard A.; Burns, William R.; He, Jin; Fishman, Elliot K.; Wolfgang, Christopher L.

doi:10.1016/j.surg.2020.07.054

Cited by 25 publications

(21 citation statements)

References 27 publications

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“…National Comprehensive Cancer Network guidelines, the cases of technically challenging vein reconstruction are categorized as borderline resectable or locally advanced PCs (6). Recently, Kinny-Köster et al from the Johns Hopkins group categorized two challenging situations: long-segment portal vein (PV)/superior mesenteric vein (SMV) encasement, occlusion of the distal (caudal) SMV even with involvement of the jejunal and ileal branches (7). In these situations, cavernous transformation and venous collateralization often introduces surgical challenges due to the high likelihood of encountering increased blood loss and congestion of the intestinal veins and small bowel (Figures 1,2).…”

Section: Extent Of Venous Resection During Pancreatectomy-finding the Balance Of Technical Possibility And Feasibilitymentioning

confidence: 99%

“…The cases of distal (caudal) SMV involvement are more challenging than those of the porto-mesentericosplenic confluence involvement (7,25). First, there are fewer distal SMV involvement cases than the portomesenterico-splenic confluence involvement cases.…”

Section: Distal Smv Involvementmentioning

confidence: 99%

“…Finally, the reconstruction of distal SMV, which is smaller and thinner than proximal SMV, is technically demanding. The John Hopkins team introduced several bypass reconstructions such as mesoportal bypass, interposition graft, and mesocaval shunt during resection (7). Similarly, Oehme et al reported the usefulness of portosystemic shunts (a splenorenal shunt or a temporary mesocaval shunt) during extended pancreatectomy.…”

Section: Distal Smv Involvementmentioning

confidence: 99%

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Extent of venous resection during pancreatectomy—finding the balance of technical possibility and feasibility

Oba¹,

Kato²,

Inoue³

et al. 2021

J Gastrointest Oncol

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The improvement of effective multidrug agents has allowed more patients to undergo resection for pancreatic cancer (PC). In the conversion cases of initially unresectable PC after induction chemotherapy, pancreatic surgeons often encounter challenging vein resections cases such as those of long-segment portal vein (PV)/superior mesenteric vein (SMV) encasement or occlusion of the distal (caudal) SMV. Given the lack of consensus for the optimal approach for major vein resections and reconstructions in these situations, this review summarizes the literature on this topic and provides the best currently available approaches for challenging vein reconstruction cases. For long-segment PV/SMV encasement, tips for direct end-to-end anastomosis without grafts and the splenic vein (SpV) reconstruction to prevent left-side portal hypertension will be introduced. For distal SMV encasement, several bypass techniques to deal with collateralizations will be introduced. Even though some high-volume PC centers are obtaining favorable outcomes for challenging vein resection cases, existing evidence on this topic is limited. It is essential to organize the well-designed international multicenter studies for the small population of challenging vein resection cases. With the emergence of effective chemotherapies, the number of PC patients who can undergo curative resection is increasing. Achieving more successful vessel resection and reconstruction in the treatment of PC is a common goal that pancreatic surgeons should focus on together.

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Section: Extent Of Venous Resection During Pancreatectomy-finding the Balance Of Technical Possibility And Feasibilitymentioning

confidence: 99%

Section: Distal Smv Involvementmentioning

confidence: 99%

Section: Distal Smv Involvementmentioning

confidence: 99%

See 1 more Smart Citation

Extent of venous resection during pancreatectomy—finding the balance of technical possibility and feasibility

Oba¹,

Kato²,

Inoue³

et al. 2021

J Gastrointest Oncol

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“…Therefore it is imperative that patient selection should be based not only on the feasibility of a successful oncological resection, but also on tumor biology. Currently, limited tools are available to predict patient's specific tumor biology (12,13).…”

Section: Review Articlementioning

confidence: 99%

Favorable tumor biology in locally advanced pancreatic cancer—beyond CA19-9

Kinny‐Köster¹,

Wolfgang²,

He³

et al. 2021

J Gastrointest Oncol

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Patients with pancreatic ductal adenocarcinoma (PDAC) are frequently staged as unresectable locally advanced pancreatic cancer (LAPC) at the time of diagnosis. Recently, the administration of multi-agent induction chemotherapy has resulted in treatment response in up to 60% of these patients rendering their tumors technically resectable. Operative strategies have evolved to allow for successful oncologic resection of LAPC. These technically complex procedures involving vascular resections and reconstructions are now being performed with increasing safety at high-volume centers. However, even after induction therapy and successful resection, disease recurrence sometimes occurs early on, limiting the benefit of resecting the local tumor.Therefore, selection of surgical candidates should factor in each patient's tumor biology which could result in accurate treatment guidance to improve patient outcomes while avoiding overtreatment. Well-informed patient selection is critical to improve outcomes in LAPC. Multidisciplinary teams have to determine the appropriate care for LAPC patients at the time of reevaluation after administration of induction chemotherapy. At this point the concept of favorable vs. unfavorable tumor biology becomes highly relevant and having access to biomarkers that are predictive of tumor behavior are of paramount importance. Currently, CA19-9 remains the only clinically utilized biomarker for PDAC, however, its use is limited by factors discussed in this review.While CA19-9 holds value in patient assessment, additional biomarkers are required that could supplement and improve the current ability to classify tumor biology and predict behavior in individual patients. Recent investigations on the use of circulating tumor DNA (ctDNA) and circulating tumor cells (CTCs) using liquid biopsies, as well as patient-derived organoids to characterize tumor biology have shown promise in achieving precise tumor biology-based patient stratification. Serial assessment of these biomarkers throughout therapy could supplement or even replace the anatomic criteria for resectability in the future.

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“…Furthermore, three-dimensional (3D) reconstruction of the scans are routinely performed at our PMDC which can provide additional valuable information such as the degree of tumor-vessel relationship, aberrant anatomy through vascular mapping, and more sensitive assessment of occult metastatic disease. 26 , 27 , 28 Given that our PMDC is commonly comprised of patients with borderline and locally advanced disease having access to complete and accurate radiological information becomes exceedingly valuable.…”

Section: Introductionmentioning

confidence: 99%

The Impact of the COVID-19 Pandemic on Multidisciplinary Clinics: A High-Volume Pancreatic Cancer Center Experience

Javed

Kinny‐Köster

Hodgin

et al. 2022

Current Problems in Diagnostic Radiology

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Mesoportal bypass, interposition graft, and mesocaval shunt: Surgical strategies to overcome superior mesenteric vein involvement in pancreatic cancer

Cited by 25 publications

References 27 publications

Extent of venous resection during pancreatectomy—finding the balance of technical possibility and feasibility

Extent of venous resection during pancreatectomy—finding the balance of technical possibility and feasibility

Favorable tumor biology in locally advanced pancreatic cancer—beyond CA19-9

The Impact of the COVID-19 Pandemic on Multidisciplinary Clinics: A High-Volume Pancreatic Cancer Center Experience

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