Jejunal vein tributary analysis and intraoperative clamp testing in avoiding congestion after pancreatoduodenectomy.

PURPOSE: Although venous drainage of the jejunal loop may be maintained after sacrifice of jejunal vein tributaries during pancreatoduodenectomy, risk of severe jejunal mesenteric congestion following division of these tributaries can be difficult to predict. This study considered how best to predict safety of jejunal vein tributary dissection. METHODS: Preoperative imaging findings and results of intraoperative clamp tests of jejunal vein tributaries during pancreatoduodenectomy were analyzed in 121 patients with hepatobiliary and pancreatic disease to determine whether this information adequately predicted safety of resecting superior mesenteric vein branches. RESULTS: Jejunal vein tributaries caudal to the inferior border of the pancreatic uncinate process tended to be fewer when tributaries cranial to this landmark were more numerous. Tributaries cranial to the border drained a relatively wide expanse of jejunal artery territory in the jejunal mesentery. The territory of jejunal tributaries cranial to the inferior border of the pancreas did not vary according to course of the first jejunal vein branch relative to the superior mesenteric artery. One patient among 30 (3%) who underwent intraoperative clamp tests of tributaries cranial to the border showed severe congestion in relation to a venous tributary coursing ventrally to the superior mesenteric artery. CONCLUSION: Jejunal venous tributaries drained an extensive portion of jejunal arterial territory, but tributaries located cranially to the inferior border of the pancreas could be sacrificed without congestion in nearly all patients. Intraoperative clamp testing of these tributaries can identify patients whose jejunal veins must be preserved to avoid congestion.

Investigation of the variation of vessels around the pancreatic head based on the first jejunal vein anatomy at pancreaticoduodenectomy.

PURPOSE: Pancreaticoduodenectomy (PD) for pancreatic cancer carries a high risk of massive intraoperative blood loss. The artery first approach (AFA) prevents blood loss during PD, but the optimal approach is unclear. The first jejunal vein (FJV) often comprises multiple veins and broadly supports venous drainage of the proximal jejunum. Its ligation carries a risk of proximal jejunum congestion. Here we investigated the anatomical characteristics of PD-associated vessels and AFA approach selection based on FJV anatomy. METHODS: This study included 148 Japanese living donors for liver transplantation. We reviewed their computed tomography images and assessed the anatomical pattern of PD-associated vessels in terms of FJV anatomy. RESULTS: The FJV traveled posterior to the superior mesenteric artery in 128 patients (86.5%, dorsal group) and anterior in 20 (13.5%, ventral group). The predominant draining vein of the inferior pancreaticoduodenal vein was the superior mesenteric vein in the ventral group (87.5%) and the FJV in the dorsal group (97.9%). Compared with the dorsal group, the ventral group had a significantly greater percentage with the superior mesenteric vein ventral to the superior mesenteric artery (30.0% versus 10.9%) and a significantly larger posterior superior pancreaticoduodenal vein diameter (3.2 ± 0.9 versus 2.7 ± 0.6 mm, p = 0.0029). These results were validated in patients with pancreatic head cancer. CONCLUSIONS: The anatomical characteristics of PD-associated vessels differed significantly between groups defined by FJV anatomy. Understanding the venous anatomy, especially the FJV, could support selection of the best approach in AFA for PD.

First jejunal vein, jejunal trunk, and pancreatico-duodenectomy: resolving the literature conundrum.

A detailed knowledge of the surgical anatomy of tributaries of the superior mesenteric vein, especially proximal jejunal venous anatomy (first jejunal vein and jejunal trunk), is a key prerequisite for performing a safe pancreatico-duodenectomy. However, the available literature on the anatomical course and surgical relevance of these vessels is scarce, the nomenclature across the articles is heterogeneous, and the resulting evidence is confusing to interpret. Standardized terminology and an in-depth review of these vessels with regard to their course, termination, vascular relations, and variations will help the surgeons in planning and performing this complex surgery safely, especially when a venous resection and reconstruction is planned in cases of borderline resectable pancreatic cancer. A uniform nomenclature and a unifying classification are proposed in this review for these two tributaries to help resolve the literature conundrum. This standardized terminology and anatomical description will assist the radiologists in reporting pancreatic protocol-computed tomography scans and surgeons in selecting the appropriate steps for the different anatomical orientations of these tributaries for the performance of safe pancreatic surgery. This will also help future researchers communicate in well-defined terms in reference to these tributaries so as to avoid confusion in future studies.

Vascular variations encountered during laparoscopic surgery for transverse colon, splenic flexure, and descending colon cancer: a retrospective cohort study.

BACKGROUND: Laparoscopic surgery for cancer located in the transverse colon or splenic flexure is difficult because of vascular variability in this region and adjacent vital organs such as the pancreas, spleen, and duodenum. METHODS: This retrospective cohort study involved 51 patients who underwent laparoscopic surgery for colon cancer at Tokushima University Hospital from July 2015 to December 2020. Variations of the middle colic artery (MCA), left colic artery (LCA), middle colic vein (MCV), and first jejunal vein (FJV) and short-term outcomes of laparoscopic surgery in patients with each vascular variation were evaluated. RESULTS: Variations of the MCA, LCA, MCV, and FJV were classified into four, three, five, and three patterns, respectively. The short-term outcomes of laparoscopic surgery for transverse colon cancer in patients with MCA variations and those with FJV variations were evaluated, and no significant difference was found in the operation time, blood loss, postoperative complication rate, time from surgery to start of dietary intake, or time from surgery to discharge among the different variations. Additionally, no significant differences were found in the short-term outcomes of laparoscopic surgery for descending colon cancer in patients with LCA variations. CONCLUSION: Preoperative assessment of vascular variations may contribute to the stability of short-term outcomes of laparoscopic surgery for transverse colon, splenic flexure, and descending colon cancer.

Anatomical Study of the Duodenojejunal Uncinate Process Vein: A Key Landmark for Mesopancreatoduodenal Resection During Pancreaticoduodenectomy.

Background: The mesopancreas or mesopancreatoduodenum is an important anatomical concept during pancreaticoduodenectomy (PD) in patients with periampullary carcinoma. This study investigated whether the duodenojejunal uncinate process vein (DJUV), which is defined as the vein draining from the upper jejunum to the superior mesenteric vein adjacent to the uncinate process, is a useful anatomical landmark for the caudal border of mesopancreatoduodenum resection during PD. Methods: This study enrolled 100 adult patients with hepatobiliary pancreatic disease who underwent preoperative multidetector-computed tomography (CT). The anatomy of the key blood vessels involved during PD, and the relationship between these vessels and the DJUV, were analyzed by preoperative CT. Results: The first jejunal vein was the DJUV in 85 cases, whereas the second jejunal vein was the DJUV in 15 cases. Furthermore, the DJUV was classified into two subtypes depending on its positional relationship with the superior mesenteric artery (SMA). The inferior pancreaticoduodenal artery and vein were located on the cranial side of the DJUV in all cases. The distance between the middle colonic artery, used as a guide for regional lymph nodes, and the point where the DJUV intersected the SMA was within 10 mm in 80% of cases. These results imply that using the DJUV as a landmark for the caudal border of the mesopancreatoduodenum provides a safe approach and enables sufficient dissection of regional lymph nodes and tissues around the SMA. Conclusion: The DJUV may be a useful anatomical landmark for the caudal border of the mesopancreatoduodenum resection during PD.

Unusual contribution of the first jejunal vein in the formation of the portal vein.

Jejunum is drained into superior mesenteric vein through a series of jejunal veins. The way in which the first jejunal vein terminates is of great importance in upper abdominal surgery and radiological procedures. Knowledge of its variations is particularly important in surgical procedures like orthotropic hepatic transplantation, hepatic vein reconstruction, pancreatic surgery and surgical procedures of duodenojejunal junction. We saw a first jejunal vein opening directly into the portal vein. Further, the inferior mesenteric vein drained into the first jejunal vein. This case could be useful to gastroenterologists, general surgeons and radiologists.

Pharmacokinetics of hydrogen after ingesting a hydrogen-rich solution: A study in pigs.

Drinking hydrogen (H2)-rich water is a common way to consume H2. Although many studies have shown efficacy of drinking H2-rich water in neuropsychiatric and endocrine metabolic disorders, their authenticity has been questioned because none examined the associated pharmacokinetics of H2. Therefore, we performed the first study to investigate the pharmacokinetics of H2 in pigs given an H2-rich glucose solution with the aim to extrapolate the findings to humans. We inserted blood collection catheters into the jejunal and portal veins, suprahepatic inferior vena cava, and carotid artery of 4 female pigs aged 8 weeks. Then, within 2 min we infused 500 ml of either H2-rich or H2-free glucose solution into the jejunum via a percutaneous gastrostomy tube and measured changes in H2 concentration in venous and arterial blood over 120 min. After infusion of the H2-rich glucose solution, H2 concentration in the portal vein peaked at 0.05 mg/L and remained at more than 0.016 mg/L (H2 saturation level, 1%) after 1 h; it also increased after infusion of H2-free glucose solution but remained below 0.001 mg/L (H2 saturation level, 0.06%). We assume that H2 was subsequently metabolized in the liver or eliminated via the lungs because it was not detected in the carotid artery. In conclusion, drinking highly concentrated H2-rich solution within a short time is a good way to increase H2 concentration in portal blood and supply H2 to the liver.

The Anatomical Pattern of the Proximal Jejunal Vein as a Prognostic Factor in Patients With Pancreatic Head Cancer Treated With Preoperative Chemoradiation Therapy.

BACKGROUND/AIM: The significance of the anatomical variations of proximal jejunal vein [the so-called 1st jejunal vein (J1v)] has been reported from a technical standpoint. The aim of this study was to retrospectively investigate the prognostic impact of the anatomical variations of J1v in the surgical treatment of resectable pancreatic cancer (PC). PATIENTS AND METHODS: A total of 49 patients with resectable PC located in the uncinate process were included in this study. The J1v converging pattern was divided into 2 groups in terms of its relation to the SMA (i.e., the J1v status): i) group D: the J1v travels posterior to the SMA; ii) group V: the J1v travels anterior to the SMA. The associations between the J1v status and surgical outcome were assessed. RESULTS: The 5-year survival rate after resection in group V (35%) was significantly lower than that in group D (70%) (p=0.029), and the J1v status of group V was the only independent negative prognostic factor (HR=5.49; 95% CI=1.69-19.3; p=0.005). CONCLUSION: The J1v converging pattern is a significant prognostic variable in patients with PC located in the uncinate process: the J1v status of group V was significantly associated with impaired survival.

Variant termination of first and second jejunal veins into a "pancreatic portal vein".

Jejunal veins usually terminate into the superior mesenteric vein. Here, an unusual termination of first and second jejunal veins into a pancreatic portal vein has been presented. The common vein formed by the first and second jejunal veins could be named as pancreatic portal vein because it divided into two branches in front of the third part of the duodenum and these two branches entered the head of the pancreas and further divided into smaller branches before anastomosing with the tributaries of pancreatico-duodenal veins. The knowledge of this rare vein could be useful to radiologists and surgeons.

Surgical Outcomes of Pancreaticoduodenectomy for Pancreatic Cancer with Proximal Dorsal Jejunal Vein Involvement.

BACKGROUND/PURPOSE: The proximal jejunal vein which branches from the dorsal side of the superior mesenteric vein (SMV) usually drains the inferior pancreatoduodenal veins (IPDVs) and contacts the uncinate process of the pancreas. We focused on this vein, termed the proximal dorsal jejunal vein (PDJV), and evaluated the anatomical classification of the PDJV and surgical outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) with PDJV involvement (PDJVI). METHODS: The jejunal veins that branch from the dorsal side of the SMV above the inferior border of the duodenum are defined as PDJVs. We investigated 121 patients who underwent upfront pancreaticoduodenectomy for PDAC between 2011 and 2017; PDJVs were resected in all patients. The anatomical classification of PDJV was evaluated using multidetector computed tomography. Surgical and prognostic outcomes of pancreticoduodenectomy for PDAC with PDJVI were evaluated. RESULTS: The PDJVs were classified into seven types depending on the position of the first and second jejunal veins relative to the superior mesenteric artery. In all patients, the morbidity and mortality rates were 15.7 and 0.8%, respectively. The rates for parameters including SMV resection, presence of pathological T3-4, R0 resection, and 3-year survival were 46.2, 92.3, 92.3, and 61.1%, respectively, when there was PDJVI (n = 13). When there was no PDJVI (n = 108), the rates were 60.2, 93.5, 86.1, and 58.3%, respectively. Overall, there were no significant differences. CONCLUSIONS: Pancreaticoduodenectomy with PDJV resection is feasible for PDAC with PDJVI and satisfactory overall survival rates are achievable. It may be necessary to reconsider the resectability of PDAC with PDJVI.

Approaching the superior mesenteric artery from the right side using the proximal-dorsal jejunal vein preisolation method during laparoscopic pancreaticoduodenectomy.

BACKGROUND: Although the artery-first approach is widely used in open pancreaticoduodenectomy, it is difficult to laparoscopically expose the origin of the inferior pancreaticoduodenal artery (IPDA) from the left side of the superior mesenteric artery (SMA). By contrast, damaging the inferior pancreaticoduodenal veins (IPDVs) is possible when approaching the IPDA from the right side of the SMA. To facilitate the artery-first approach in laparoscopic pancreaticoduodenectomy (LPD), we focused on the proximal-dorsal jejunal vein (PDJV) that branched from the superior mesenteric vein (SMV) dorsal side and drained the IPDVs. This study aimed to clarify the usefulness of the right SMA approach using the PDJV preisolation method. METHODS: The PDJV was first isolated, and the IPDVs were divided along the PDJV on the right side of the SMA. Then, the IPDA was divided at the root without first separating the pancreatic head from the portal vein and the SMV. Overall, 21 patients underwent this approach, and the results were retrospectively compared with those of 21 patients who underwent the artery-first approach, which was performed on the left side of the SMA. Anatomical characteristics of the PDJV were evaluated using multidetector computed tomography for the two groups. RESULTS: Operative times and resection times were significantly lower for the PDJV preisolation group than for the conventional LPD group (489.3 vs. 541.7 min, respectively; p = 0.002). During anatomical evaluation, 41 patients (97.6%) had a PDJV that drained from the SMV dorsally and was in contact with the anterior aspect of the uncinate process. The PDJV was confirmed as the first jejunal vein in 31 patients (73.8%) and as the second jejunal vein in 10 patients (23.8%). CONCLUSIONS: This approach facilitates dissection of the IPDA on the right side of the SMA, thereby reducing operative times.

Vascular anatomy of the jejunal mesentery and complications associated with division of the first jejunal venous trunk during pancreaticoduodenectomy.

BACKGROUND: Little is known about the anatomy of the jejunal veins (JVs) flowing into the superior mesenteric vein (SMV), and whether they can be safely divided during pancreaticoduodenectomy. METHODS: Computed tomography was used to review the jejunal branches off the superior mesenteric artery (SMA) and into the SMV in 123 consecutive patients. The common trunk of the JVs (jejunal venous trunk, JVT) was classified as ventral or dorsal to the SMA. RESULTS: The first JVT involved multiple JVs in 108 (87.8%) cases. The first JVT diameter (≥7 or <7 mm) was significantly associated with the number of JVs (≥4 or <4; P < 0.05). Surgical outcomes were not significantly different between cases in which the first JVT was sacrificed (n = 32) or preserved (n = 91), except for operation time and portal venous resection frequency. One of the 32 cases (3.1%) with first JVT sacrifice showed severe congestion of the jejunal limb requiring emergency jejunal resection. CONCLUSIONS: The size and topology of the first JVT are associated with the number of JVs involved. This is important for understanding the resectional area of the mesojejunum and the pathogenesis of jejunal congestion.

Surgical pitfalls of jejunal vein anatomy in pancreaticoduodenectomy.

BACKGROUND: Pancreaticoduodenectomy (PD) is the standard surgical procedure for treating pancreatic head cancers. Considerable knowledge of proximal jejunal and pancreatic vein anatomy is a prerequisite for performing PD surgery safely, yet there appear to be no detailed descriptions of first and second jejunal vein (J1V, J2V) anatomy available in the literature. STUDY DESIGN: Adults with hepatobiliary-pancreatic disease underwent multidetector-row computed tomography with intravenous contrast (n = 155), and SYNAPSE 3D (Fujifilm Medical, Tokyo, Japan) was used to generate 3D-CT images. RESULTS: In 84% of patients, J1V and J2V formed a common trunk (FJT). There were three patterns of branches, related to the presence or absence of FJT formation and the anatomical relationships between the superior mesenteric artery (SMA) and the jejunal veins, as follows: Type 1 (n = 98, 63%) characterized by an FJT located dorsal to SMA; Type 2 (n = 32, 21%), where the FJT was located ventral to the SMA; and Type 3 (n = 25, 16%), where J1V and J2V each drained separately into the SMV. CONCLUSIONS: J1V and J2V usually formed an FJT, and separate J1V and J2V drainage into the SMV was uncommon. Preoperative information on individual patient venous anatomy would increase the safety of the PD procedure.

A strange case of superior mesenteric venous collar around the superior mesenteric artery.

During our dissection classes, we saw a venous collar formed around the superior mesenteric artery (SMA) by the jejunal tributaries of superior mesenteric vein in an adult male cadaver. The jejunal tributaries united themselves to form two common jejunal veins. Upper common jejunal vein crossed superficial to SMA and opened into the SMV in front of the uncinate process of pancreas. The inferior common jejunal vein crossed behind the SMA from left to right and opened into the SMV, 4 cm below this level. A communicating vein connected the two common jejunal veins with each other.

Biliary tract anatomy and its relationship with venous drainage.

Portal cavernoma develops as a bunch of hepatopetal collaterals in response to portomesenteric venous obstruction and induces morphological changes in the biliary ducts, referred to as portal cavernoma cholangiopathy. This article briefly reviews the available literature on the vascular supply of the biliary tract in the light of biliary changes induced by portal cavernoma. Literature pertaining to venous drainage of the biliary tract is scanty whereas more attention was focused on the arterial supply probably because of its significant surgical implications in liver transplantation and development of ischemic changes and strictures in the bile duct due to vasculobiliary injuries. Since the general pattern of arterial supply and venous drainage of the bile ducts is quite similar, the arterial supply of the biliary tract is also reviewed. Fine branches from the posterior superior pancreaticoduodenal, retroportal, gastroduodenal, hepatic and cystic arteries form two plexuses to supply the bile ducts. The paracholedochal plexus, as right and left marginal arteries, run along the margins of the bile duct and the reticular epicholedochal plexus lie on the surface. The retropancreatic, hilar and intrahepatic parts of biliary tract has copious supply, but the supraduodenal bile duct has the poorest vascularization and hence susceptible to ischemic changes. Two venous plexuses drain the biliary tract. A fine reticular epicholedochal venous plexus on the wall of the bile duct drains into the paracholedochal venous plexus (also called as marginal veins or parabiliary venous system) which in turn is connected to the posterior superior pancreaticoduodenal vein, gastrocolic trunk, right gastric vein, superior mesenteric vein inferiorly and intrahepatic portal vein branches superiorly. These pericholedochal venous plexuses constitute the porto-portal collaterals and dilate in portomesenteric venous obstruction forming the portal cavernoma.