Thread by @Manishbhandare4

Portal Vein Resection (PVR) during Pancreatico-duodeneactomy (PD) for #PancreaticCancer

A thread..
ISGPS types, technical points, images, videos 1/9

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Type 1 PVR - sleeve resection of vein wall, less common. Most often site is at the PSPDV insertion in lateral PV border (during early phase of tumor extention in vein)
The other common situation is during distal resections,when SV is involved flush to its insertion.
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Type II PVR - Part of the wall is excised but primary closure (type I) is not feasible. The patch recon is more tedious than end to end recon. Hence most suitable cases are lateral/posterior wall involvements at the level of S-P confluence as splenic vein can be preserved.
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Type III PVR - Segmental resection with E-T-E recon, most common. Depending on the location and length of involvemnt, it could be SMV, PV or S-P confluence resection. Generally possible for upto 4-5 cm of length loss with adequate liver and mesentery mobilization.
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Type IV PVR - Segmental resection with interposition graft, when lengh loss of >5 cm. Graft can be seg of Lt renal v, tube made of free pariental peritoneum or a synthetic graft (high chances of long term thrombosis)
Therapeutic anticoagulation only for synthetic graft.
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Beyond ISGPS types, rarely when the vein involvement is chronic and the tumor location permits preservtion of developed collaterals, "Vein Resection withOut Reconstruction (VROR)" is possible. Detailed study of collateral anatomy on preop CT is crucial
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pubmed.ncbi.nlm.nih.gov/32776209/

Timing of vein resection during PD,
for simpler cases (better access, no artery involvement, smaller length involved) can be done in the very end when specimen is hanging on the vein.
Else, vein can be resected and joined in between f/b completion of rest of the dissection.
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Venous clamp duration, generally should be kept to minimum as possible but in difficult cases can extend upto 60mins (when vein is resected for better access to complete R0). To minimise bowel congestion intermittent SMA clamping to be done when vein clamp time exceeds 30min
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Temporary mesenterico-portal shunt can also be an option in few locally advanced cased with long seg/distal involvement in the mesenteric root.
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