Total Gastrectomy Secondary to Gastric Venous Congestion After Total Pancreatectomy and Splenectomy with Portal Vein Res
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CASE REPORT
Total Gastrectomy Secondary to Gastric Venous Congestion After Total Pancreatectomy and Splenectomy with Portal Vein Resection: a Case Report Mehmet Akif Üstüner 1 & Erol Aksoy 1 & Orhan Aras 1 & Erdal Birol Bostancı 1 Received: 9 June 2019 / Accepted: 21 February 2020 # Association of Surgeons of India 2020
Abstract Portal vein resection is a frequently used method for obtaining R0 resection in pancreatic adenocarcinoma cases. However, portal vein resection may disrupt venous outflow of other organs, especially in long segment involvement. In this study, we present a case of gastric venous congestion following portal vein reconstruction during total pancreatectomy. Keywords Total pancreatectomy . Gastric venous congestion . Portal vein resection
İntroduction Management of pancreatic head cancer with vascular invasion was difficult until the 1980s. Vascular resection combined with pancreaticoduodenectomy have enabled operations performed safely in the last 2 decades. Although vascular resection results are still controversial, many studies have shown that their long-term prognosis can be better than those without vascular resection [1].
Case A 65-year-old woman who presented to our clinic with abdominal pain had epigastric tenderness. Abdominal tomography revealed a pancreatic head mass of 3 cm, surrounding portal vein 180°, with a suspicion of malignancy. * Mehmet Akif Üstüner [email protected] Erol Aksoy [email protected] Orhan Aras [email protected] Erdal Birol Bostancı [email protected] 1
Deparmant of Gastroenterolojıc Surgery, Ankara City Hospital, Ankara, Turkey
In the surgical exploration, invasion of the mass from the SMV to the portal vein was observed. Pancreaticoduodenectomy was performed, pancreas head was resected en bloc, clamping portal vein proximally and distally. Malignancy was assessed also in the remaining pancreas tissue and the surface of portal vein confluence according to frozen section analysis results (Fig. 1). Upon this, the pancreas was resected distally two times more and specimens were sent for frozen section analysis. Total pancreatectomy was decided based on frozen section analysis displaying malignancy again. A 5-cm section of portal vein was resected where the splenic vein and the coronary vein were also invaded. The liver was released and the portal vein was anastomosed end-to-end to ensure a loose anastomosis (Fig. 2). The splenic artery was sutured and then cut. Short gastric vessels in the gastrosplenic ligament were ligated and cut. Total pancreatectomy + splenectomy was performed by splenectomy including distal pancreas. During the operation, congestion-related edema developed in the remaining gastric tissue and bleeding started from nasogastric tube. The remaining esophageal-gastric venous plexus and left phrenic vein were found to be inadequate in providing venous return, after the resection of the right gastric artery/vein (RGA, RGV), gastroepiploic artery/vein (GEA, GEV), left gastric artery/vein (LGA, LGV), and short gastric vessels.
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