Extended resection of the pancreas with portal system resection can lead to R0 resection [3]. However, TP is complicated by permanent pancreatic endocrine and exocrine deficiencies, such as postoperative diabetes mellitus and digestion disorders. Medications for controlling pancreatic secretory function have improved TP safety.
In our case, the right gastric vein and right gastroepiploic vein (RGEV) were removed during the initial surgery. The left gastroepiploic vein and short and posterior gastric veins were removed during the second operation. However, blood flow from the LGV to the SpV was insufficient owing to stenosis during the operation. The IMV and middle colic vein were preserved at the initial and second surgery. However, the arc of Barkow, which supplies the transverse colon via multiple ascending branches, was lost during splenectomy. This phenomenon is similar to sinistral portal hypertension, which causes gastrointestinal hemorrhage. Gastric congestion in our case can be attributed to the stenosis by the iatrogenic maneuver. Distal splenorenal and mesocaval shunting have been performed during complex pancreatectomy for the patients with border-line resectable or locally advanced pancreatic cancer. These techniques provide operative resection to patients with complex vascular involvement and prevent long-term potential consequences of gastric venous congestion [4].
Nakao et al. recommended TPDG to prevent venous congestion [1]. However, extended resection of the stomach with TP involves functional and structural dysfunction, resulting in worsening of the patient’s nutritional status. Tanaka et al. reported the risk for varices is dependent on the number of the gastric drainage veins preserved [5]. At least one gastric draining vein must be preserved to avoid venous congestion of the subtotal or whole stomach when performing TP. In many cases, TP loses all drainage veins to the stomach. The addition of distal pancreatectomy leads to avoid venous congestion around the lower body of the stomach. In the upper body of the stomach, venous congestion and bleeding are often avoidable because well-developed submucosal venous plexus in esophago-gastric junctions are sometimes observed.
Careful preoperative assessment for the drainage veins and meticulous operative planning and techniques to preserve them are important to minimize the risk of venous congestion in patients with locally advanced pancreatic cancer. LGV or RGEV preservation is deemed particularly important [2]. However, it may be difficult to use the RGEV in case of remnant TP because it is always removed during PD. Therefore, preserving the LGV is more important.
We are sometimes obliged to remove all draining veins from the stomach depending on the tumor size, tumor location, and invasion depth. RGEV and left ovarian vein anastomosis and LGV and IMV anastomosis were performed to effectively reduce gastric congestion. Unfortunately, the RGEV was already removed during the initial surgery in our case. The ideal anastomosis in our case was that between the LGV and stump of the SpV. The advantage of this was the short distance of each vein without tension of the anastomosis.
Our experience suggests that LGV and SpV anastomosis prevents gastric venous congestion and that gastric outflow preservation is important. It is vital that suitable revascularization be performed to avoid sinistral portal hypertension. To conclude, LGV and SpV anastomosis can be an effective option to prevent gastric venous congestion when performing TP.
