Splenic Vein as an Autologous Graft in Traumatic SMV Injuries: A Missed Valuable Alternative.

Traumatic superior mesenteric artery (SMA) and vein (SMV) injuries are rare but often lethal. The ideal management options of traumatic SMV injury are still controversial. Management options include venous repair and ligation. Splenic vein turndown procedure (SVTP) is a rare procedure that has been described in only 6 cases in the literature. Here, we reviewed the literature on the usage of the splenic vein turndown procedure (SVTP) as an alternative option in patients with traumatic SMV injury. METHODS: We performed a narrative review for the available literature on the usage of the splenic vein as an autologous graft in the management of the SMV injury. We included all studies of SVTP in traumatic SMV injuries only. RESULTS: We included only 5 studies. In total, 7 patients underwent SVTP. Five patients presented with a penetrating abdominal vascular trauma (AVT) and 2 patients with a blunt AVT. The advantages of the SVTP include no need for additional incisions to harvest potential autologous grafts, minimally increased operative time, and 1 less anastomotic site compared to other conduit options. CONCLUSIONS: In cases of traumatic SMV injuries with associated splenic or pancreatic injuries that need distal pancreatosplenectomy, surgeons may consider SVTP as an ideal management option rather than primary repair or ligation.

Splenic vein graft for the reconstruction of the mesenteric-portal trunk after gastroduodenopancreatectomy.

Resection of the confluence of the superior mesenteric and portal veins has been performed most frequently in the treatment of adenocarcinoma of the pancreas, in view of the reported positive results, but it can also be used in cases of benign pancreatic neolpasias when they are strongly adhered to the mesenteric-portal trunk. Nevertheless, there is no study on the best type of venous grafts for reconstruction of the mesenteric-portal trunk when required. The choice of graft depends on the preference of the surgeon or the institution. This technical note critically discusses the use of the splenic vein as an option for mesenteric-portal trunk reconstruction after gastroduodenopancreatectomy.

Partial splenectomy and use of splenic vein as an autograft for meso-Rex bypass: a clinical observational study.

BACKGROUND: Meso-Rex bypass (MRB) surgery is being increasingly used to treat chronic prehepatic portal hypertension secondary to extrahepatic portal vein thrombosis (EPVT) and cavernous transformation (EPVCT) in children. Rather than using the internal jugular vein (IJV, the traditional venous graft), we used an autogenous splenic vein segment graft for MRB. MATERIAL/METHODS: We examined 25 children with extrahepatic portal hypertension and a history of recurrent upper gastrointestinal (GI) variceal bleeding despite previous endoscopic sclerotherapy. All patients had melena, splenomegaly, hypersplenism, or some combination thereof. Left portal vein (LPV) patency was verified in 22 patients using intraoperative direct portography through the umbilical vein. Partial splenectomy was performed to enable the harvest of the splenic vein trunk, which was anastomosed between the superior mesenteric vein (SMV) and the left portal vein (LPV). All patients were followed for 12-48 months (mean=25.6 months) and no patients were lost to follow-up. RESULTS: Preoperative Doppler ultrasound (US) imaging indicated that 18/25 patients had adequate intrahepatic portal veins for shunting, with no blood flow in the LPVs of 7 patients. LPV patency in 22/25 patients was verified using intraoperative direct portography, with successful MRB. Shunting was converted into a portosystemic shunt in the remaining 3/25 patients with thrombosed LPVs. A Doppler US evaluation of the vein conduit revealed excellent postoperative flow. The patients' mean hemoglobin, platelet, and white blood cell counts increased significantly, and in all cases the endoscopic status obviously improved after shunting. Occlusion or narrowing occurred in 2/22 patients after discharge. At 12 months (for 1 patient) and 24 months (for 1 patient), the shunt was converted into a portosystemic shunt. The cumulative graft patency rate was 91% (20/22). CONCLUSIONS: Partial splenectomy and splenic vein autografting in MRB surgery can successfully resolve prehepatic portal hypertension and hypersplenism in children.

Total pancreaticoduodenectomy and segmental resection of superior mesenteric vein-portal vein confluence with autologous splenic vein graft in mucinous cystadenocarcinoma of the pancreas.

CONTEXT: Mucinous cystic tumors occur almost exclusively in middle-aged women and in the body or tail of the pancreas. Mucinous cystadenocarcinoma, a malignant sub-type of mucinous cystic tumors, in the head of the pancreas and in a middle-aged man is extraordinary, and the prognosis and proper management of mucinous cystadenocarcinoma has not been well documented. CASE REPORT: A 52-year-old male patient with a mucinous cystadenocarcinoma approximately 5.5 cm in size in the head of the pancreas underwent a total pancreaticoduodenectomy and segmental resection of the superior mesenteric vein-portal vein confluence with an autologous splenic vein graft due to tumor invasion. His postoperative course was uneventful and he received adjuvant chemotherapy. He has been followed-up periodically for more than 30 months after surgery without evidence of recurrence. CONCLUSION: Mucinous cystadenocarcinoma in the head of the pancreas in a middle-aged man is an extremely rare case. Because mucinous cystadenocarcinomas have a relatively good prognosis, an aggressive approach with major vascular resection is warranted in well-selected patients. Splenic vein interposition grafting could be used in cases which undergo total pancreaticoduodenectomy with segmental resection of the superior mesenteric vein-portal vein confluence if the splenic vein is healthy.

Managing unsuspected tumour invasion of the superior mesenteric-portal vein during surgery for pancreatic head cancer. A case report.

CONTEXT: In some cases, synchronous superior mesenteric-portal vein resection can be performed during pancreatic resection for cancer. The reconstruction technique is usually primary anastomosis; in only a few cases is an autologous vein graft needed. CASE REPORT: We report a case of reconstruction of the superior mesenteric-portal vein with a splenic vein autograft in a patient affected by pancreatic head adenocarcinoma who underwent a total pancreatectomy. CONCLUSIONS: The reconstruction of the superior mesenteric-portal vein with a splenic vein autograft should be performed in selected cases. It allows a reduction of operating time, it is a less invasive approach than reconstruction using an internal jugular vein autograft and it can be an oncologically correct approach.

Reconstruction of portal vein with an autograft of splenic vein.

To re-establish the portal circulation following extensive resection of the portal vein, we interposed an autograft of the splenic vein between the portal and superior mesenteric veins during total pancreatectomy in three patients with cancer of the pancreas. The postoperative course in two patients was uneventful, and patency of the graft was demonstrated angiographically on the 41st and 78th postoperative days, respectively. In the remaining patient an episode of postoperative peritonitis occurred with leakage of the gastrointestinal anastomosis. The patient died on the 78th postoperative day from a massive metastasis to the liver. Autopsy revealed a narrowing of the graft due to technical failure and inflammatory changes, but there was no evidence of cancer invasion. Thus, the autograft of the splenic vein proved useful to bridge the portal vein system.

Expanded microporous polytetrafluoroethylene as canine arterial bypass or replacement graft.

Expanded microporous polytetrafluoroethylene (PTFE) has been used experimentally and clinically for small-vessel bypass or replacement grafting; the results vary widely. This study assessed short (4--cm) femoral and carotid artery replacement PTFE grafts and longer (12--cm) femoral artery bypass PTFE grafts that crossed a flexion crease. Pore size at the blood-graft interface ranged from 10 to 30 mu. At the end of three months, overall patency rate was 22%. No long bypass grafts remained patent. The pore size and type of anastomosis did not affect patency. The occlusion was always thrombotic, associated with fibrin at the suture line. Nine of the 20 short carotid grafts (45%) and five of 22 short femoral grafts (22%) remained patent. These poor results indicate that further experimental studies are needed before PTFE is used clinically when an alternative exists.

Pancreatic autotransplantation following resection.

A patient with recurrent pancreatitis was treated by near-total pancreatectomy. The tail of the pancreas, together with the splenic artery and vein, was transplanted into the thigh, with anastomoses of the splenic vessels to the femoral vessels. Two months after operation simultaneously drawn blood samples from both femoral veins showed elevated insulin on the grafted side. Two years after operation the patient is free of symptoms and is not diabetic.