Ann Hepatobiliary Pancreat Surg.  2021 Nov;25(4):509-516. 10.14701/ahbps.2021.25.4.509.

Portal vein wedge resection and patch venoplasty using autologous and homologous vein grafts during surgery for hepatobiliary malignancies

• Na BG
• Hwang S
• Jung DH
• Lee SG

• KMID: 2523055
• DOI: http://doi.org/10.14701/ahbps.2021.25.4.509

Abstract

Obtaining tumor-free resection margins is one of the most important factors for achieving favorable prognosis of patients undergoing resection for hepatobiliary malignancies. In this study, we present our experience of portal vein (PV) wedge resection and patch venoplasty using autologous or homologous vessel grafts for resecting perihilar cholangiocarcinoma, hepatocellular carcinoma, and distal bile duct cancer. Case 1 was 68-year-old male patient with type IV perihilar cholangiocarcinoma who underwent central bisectionectomy with caudate lobectomy and bile duct resection, and PV wedge resection and patch venoplasty with a cryopreserved iliac vein allograft patch. This patient survived 14 months after surgery. Case 2 was 77-year-old male patient with type IIIA perihilar cholangiocarcinoma who underwent left medial sectionectomy with caudate lobectomy, bile duct resection, and PV wedge resection and patch venoplasty with a cryopreserved iliac vein allograft patch. This patient survived 17 months after surgery. Case 3 was 54-year-old male patient with hepatitis B virus-associated liver cirrhosis and hepatocellular carcinoma with PV tumor thrombus who underwent left hepatectomy. The PV wall defect was repaired with an autologous greater saphenous vein patch. This patient survived 11 months after surgery. Case 4 was 65-year-old female patient with distal bile duct cancer who underwent pylorus-preserving pancreaticoduodenectomy, and main PV wedge resection and patch venoplasty with a cryopreserved iliac artery allograft patch. This patient survived 21 months after surgery. In conclusion, PV wedge resection and patch venoplasty can be used to facilitate complete tumor resection in patients undergoing various extents of surgical resection for hepatobiliary malignancies.

Keyword

Portal vein; Allograft; Autografts; Greater saphenous vein; Vascular reconstruction

Figure

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  Fig. 1 Perioperative findings of Case 1. (A) Preoperative computed tomography scan shows advanced perihilar cholangiocarcinoma (arrow). (B) Magnetic resonance cholangiopancreatography shows extensive involvement of the hilar bile duct (arrow), indicating Bismuth-Corlette type IV tumor. (C) Gross photograph of the surgical specimen is visible after central bisectionectomy, caudate lobectomy and bile duct resection. (D) Computed tomography scan taken at 2 weeks after surgery shows slightly stenotic portal vein reconstruction site (arrow) at the portal vein confluence portion.

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  Fig. 2 Intraoperative photographs in Case 1. (A) Tumor invades the confluence portion of the portal vein (PV) bifurcation and the right anterior PV branch (arrow). (B) The invaded PV confluence portion and the right anterior PV branch are elliptically excised and the wall defect is repaired with a cryopreserved iliac vein allograft patch. (C) The roofing patch venoplasty is fully expanded. (D) Central bisectionectomy with caudate lobectomy and bile duct resection are completed.

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  Fig. 3 Perioperative findings of Case 2. (A, B) Preoperative computed tomography scan shows advanced perihilar cholangiocarcinoma (arrows). (C) Gross photograph of the surgical specimen is visible after left medial sectionectomy, caudate lobectomy and bile duct resection. (D) Computed tomography scan taken at 2 weeks after surgery shows no abnormal findings. B2 and B3 indicate segment II and III ducts, respectively; LHD, left hepatic duct.

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  Fig. 4 Intraoperative photographs in Case 2. The tumor-invaded transverse portion of the left portal vein is elliptically excised and the wall defect is repaired with a cryopreserved iliac vein allograft patch (arrow).

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  Fig. 5 Perioperative findings of Case 3. (A, B) Preoperative computed tomography scan shows hepatocellular carcinoma and portal vein tumor thrombus (arrows) at the left liver. (C) Gross photograph of the surgical specimen is visible after left hepatectomy. (D) Computed tomography scan taken at 1 week after surgery shows no abnormal findings.

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  Fig. 6 Intraoperative photographs in Case 3. (A) Hepatocellular carcinoma is located at the left liver. (B) The left portal vein is transected at the confluence portion and intraluminal tumor thrombus is visible (arrow). (C, D) The portal vein wall defect is repaired with an autologous greater saphenous vein patch (arrows).

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  Fig. 7 Intraoperative photographs showing the greater saphenous vein patch in Case 3. Two greater saphenous vein segments are sutured (A) to make a 3 cm × 2 cm-sized rectangular patch (B).

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  Fig. 8 Perioperative findings of Case 4. (A) Preoperative computed tomography scan shows distal bile duct cancer (arrow). (B) Magnetic resonance cholangiopancreatography shows complete obstruction of the distal bile duct (arrow). (C) Gross photograph of the surgical specimen is visible after pylorus-preserving pancreaticoduodenectomy. (D) Computed tomography scan taken at 3 weeks after surgery shows a long stenosis at the site of portal vein reconstruction proximal to the superior mesenteric vein-splenic vein confluence portion (arrow).

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  Fig. 9 Intraoperative photographs in Case 4. (A, B) The main portal vein is invaded by the tumor (arrow). A cryopreserved iliac artery allograft is visible. (C, D) The tumor-invaded main portal vein wall is elliptically excised and the wall defect is repaired with a cryopreserved iliac artery allograft patch (arrow).

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