Chapter 167 - Venous recon in non-vascular surgical oncology

Question 1

% of Pancreatic cancer with resectable disease at time of diagnosis

Answer 1

15-20%

Question 2

Factors involved in pancreatic cancer classification

Answer 2

1) resectable
2) locally irresectable
3) borderline resectable
4) metastatic

Question 3

Resectable pancreatic cancer definitiotn

Answer 3

1) no distant metastasis

2) no involvement of SMA or CA

Question 4

Locally unresectable pancreatic cancer definition

Answer 4

1) infiltration of SMA and CA

2) not amenable to pancreatectomy

Question 5

Borderline resectable pancreatic cancer definition

Answer 5

1) tumors abutment with SMA, CA and SMV, PV

Question 6

Signs on CT to demonstrate SMV/PV infiltration

Answer 6

1) portal venous phase
2) radiologic absense of fat plane
3) length of tumor involvement > 5 mm
4) venous occlusion with collateral vessels
5) teardrop sign in SMV (tethering by tumor)
6) irregularity of blood vessel wall
7) circumferential involvement of vessel > 180 degrees

Question 7

Most common tumor of the pancreas

Answer 7

Ductal adenocarcinoma

Question 8

Localization of ductal adenocarcinoma in pancreas

Answer 8

Head of pancreas 78% of time

Question 9

Pancreaticoduodenectomy steps

Answer 9

1) midline laparotomy or bilateral subcostal incision
2) Kocher maneuver to identify SMA and CA involvement
3) divide gastrocolic ligament to enter lesser sac
4) Mobilize hepatic flexure and ligate gastroepiploic vein before it enters the gastrocolic trunk
5) SMV identified and traced to inferior border of pancreas
6) Supraduodenal dissection include cholescystectomy, lymphadenectomy of hepatoduodenal ligament, CHA and CA
7) CBD dissected and isolated
8) ligate right gastric, GDA, right gastroepiploic artery
9) divide distal stomach/proximal duodenum
10) identify PV and dissect towards superior border of pancreas
11) Mobilize ligament of Treitz and divide proximal jejunum
12) Retrocolic window created in transverse mesocolon to right of middle colic artery
13) distal duodenum passed through window into lesser sac
14) specimen mobilized off SMV and SMA
15) divide pancreatic parenchyma

Question 10

Most common area of PV/SMV involvement

Answer 10

Right anterolateral wall

Question 11

Methods of PV reconstruction and % circumference recon needed as indication

Answer 11

1) primary venorrhaphy (30% circumference)
2) vein patch angioplasty (30-50% circumference; > 2cm)
3) primary end-to-end anastomosis (< 2cm excised)
4) interposition using autologous vein
5) interposition using prosthetic

Question 12

Splenic vein ligation required how often

Answer 12

33% if primary repair

78% with end-to-end recon

Question 13

Vessels needing control in PV/SMV reconstruction

Answer 13

Gastric vein

Splenic vein

Question 14

Rare complication after splenic vein ligation and rate of occurence

Answer 14

1) sinistral HTN
2) esophagitis
3) gastritis
4) GI bleed

3.8%

Question 15

Medial survival after PV/SMV reconstruction

Answer 15

15.5 months

not related to patency or the mode of reconstruction

Question 16

Type of PV/SMV tumor involvement

Answer 16

1) desmoplastic reaction at the interface only

2) actual tumor infiltration - much worse outcome

Question 17

Primary IVC tumor frequency

Answer 17

exceedingly rare <400 cases ever

Primary leiomyosarcoma (IVC is the most common vessel accounting for > 50% of all cases)

Question 18

Secondary IVC tumor types

Answer 18

1) renal (RCC, transitional cell carcinoma, metastatic seminoma)
2) adrenal (lymphoma, malignant pheochromocytoma, paraganglioma)
3) retroperitoneal (liposarcoma, germ cell tumor, malignant fibrous histiocytoma, benign retroperitoneal neurofibroma, recurrent benign intravascular leiomyomatosis, Wilms tumor, teratoma, lymphadenopathy from metastatic melanoma, duodenal carcinoma)
4) abdominal
5) hepatic (hepaticellular carcinoma, cholangiocarcinoma, metastatic tumors from colon Ca)

Question 19

Treatment of primary leiomyosarcoma

Answer 19

Complete en bloc resection only

no other non-surgical modalities help

Question 20

Tumor thrombus of RCC

Answer 20

2-16%

tumor from renal vein lumen into the IVC

Question 21

Neves and Zincke classification for tumor thrombus

Answer 21

LEVEL 1: IVC < 2cm from left renal vein
LEVEL 2: infrahepatic IVC > 2 cm above renal vein
LEVEL 3: retrohepatic IVC
LEVEL 4: supradiaphragmatic IVC and right atrium

Question 22

IVC reconstruction surgical approach

Answer 22

1) midline laparotomy +/- sternotomy or right thoracoabdominal approach via 7-9th rib interspace
2) complete all aspects of nephrectomy except for renal vein ligation
3) gain control of IVC depending on extent of tumor

Question 23

Retrohepatic IVC dissection

Answer 23

1) suprahepatic IVC and porta hepatis for Pringle maneuver
2) mobilize suspensory ligament of liver
3) control large lumbar veins

Question 24

Methods to support CO in IVC clamping

Answer 24

1) trendelenburg position
2) extracorporeal support (VV bypass or CPB)
3) aortic clamping

Question 25

Methods of IVC reconstruction

Answer 25

1) primary repair (< 50% narrowing only)
2) patch (>50% narrowing if just patch)
3) interposition graft
4) ligation

Question 26

IVC graft size

Answer 26

14-20 mm

Question 27

IVC graft material options

Answer 27

1) FV, IJ, GSV
2) aortic homograft
3) cryo IVC
4) prosthetic (dacron eptfe)

Question 28

Rate of renal and hepatic vein reimplantation in IVC recon

Answer 28

Renal 24%

hepatic 2%

Question 29

Reason for reimplanting renal vein

Answer 29

Help with graft flow

not usually necessary for renal function due to collaterals

Question 30

Complications with IVC ligation

Answer 30

1) AKI
2) LE edema
3) LE DVT

reserved for chronic IVC obstruction with collateral

Question 31

Palliative IVC bypass indication

Answer 31

1) disabling LE edema due to IVC occlusion

2) primary tumor/tumor thrombus unresectable

Question 32

Palliative IVC bypass steps

Answer 32

1) right thoracoabdominal exposure
2) ePTFE 12-18 mm
3) inflow from IVC or iliac vein
4) distal anast at suprahepatic IVC or right atrium
5) place IVC filter

Question 33

Venous venous bypass steps in extracorporeal bypass

Answer 33

1) 24Fr arterial perfusion cannula
2) outflow = infrarenal IVC or femoral vein
3) inflow = IJ
4) flow rate 750-1500 ml/min
5) systemic pressure 60-80 mmHg

Question 34

Cardiopulmonary bypass steps

Answer 34

1) SVC, IVC and ascending aorta isolated
2) ascending aorta and SVC cannulated
3) relative hypothermia to 32 C
4) maintain perfusion 60-80 mmHg

Question 35

IVC recon rate of VTE post-op

Answer 35

22% VTE
median time to VTE 6 days

lower with anticoagulation but bleeding risk higher

Question 36

IVC recon patency

Answer 36

80-90% at 5 years

Question 37

Risk factors for IVC graft infection

Answer 37

1) duodenal leak
2) bile leak
3) perforated diverticulitis

Question 38

Risk factors for IVC graft thrombosis

Answer 38

Tumor recurrence

graft infection

Question 39

Most common secondary tumor in IVC tumor

Answer 39

Renal Cell Carcinoma