Koichiro Misuta

The role of splenomesenteric vein anastomosis after division of the splenic vein in pancreatoduodenectomy

Division of the splenic vein was performed in 29 patients who underwent pancreatoduodenectomy to achieve lymph node dissection and neural resection around the superior mesenteric artery. The basic protocol for the splenic vein reconstruction to reduce congestion of the spleen and stomach is as follows. When the inferior mesenteric vein (IMV) drained into the splenic vein, the confluence was preserved without reconstruction of the splenic vein. When the IMV drained into the superior mesenteric vein (SMV) or the splenomesenteric angle, the division of the IMV and spleno-IMV anastomosis were performed. In postoperative venography, nine patients showed downward flow (from the splenic vein to the IMV) and three patients showed upward flow (from the IMV to the splenic vein). Postoperative computed tomography scans showed venous dilatation and splenomegaly in the upward flow group; there were no patients in the downward flow group. In selected patients, splenic vein reconstruction is necessary to reduce congestion of the spleen and stomach. When the flow is downward, spleno-IMV flow should be preserved. When the flow is upward, spleno-SMV anastomosis is necessary instead of spleno-IMV anastomosis.

Successful choledochojejunostomy for choledochal stricture with preservation of the collateral parabiliary venous system following iatrogenic portal occlusion

We surgically treated a patient with biliary stricture and portal vein occlusion, after operation for gastric cancer with lymphadenectomy along the hepatoduodenal ligament, that had led to choledochal stone formation and a dilatated parabiliary venous system. A 57-year-old man without hepatic dysfunction exhibited hepatic duct dilatation with choledochal stone on ultrasonography and percutaneous transhepatic cholangiography, respectively. Pharmacoportography revealed occlusion of the portal vein and dilatation of the parabiliary venous system. Of various preoperative imaging studies used, enhanced computed tomography was most useful for delineating the surgical anatomy of the hepatoduodenal ligament. Complete preservation of the dilatated vessels, which functioned as the main portal collateral pathway, resulted in a successful choledocho-jejunostomy, with an uneventful postoperative course.

Pancreatojejunostomy by Duct-Insertion Method: Clinical and Experimental Study

We have applied the duct-insertion method with complete drainage of pancreatic juice to patients with normal pancreatic tissue and an undilated pancreatic duct, and the duct-mucosal suture method to patients with hard pancreatic tissue and a dilated pancreatic duct. The safety and certainty of this duct-insertion method was examined by experiments with animals. There was no significant difference in bursting pressure of the anastomosis and hydroxyproline content between the two methods. In the histopathological findings, adhesion of the subserosal layer was found at 14 postoperative days and regenerative mucosa at 28 days after operation. In a clinical study, there was no significant difference in frequency of leakage. The value of pancreatic functional diagnostant (PFD) was maintained at a high rate 12 months after operation. It was considered that anastomotic patency was preserved. It is concluded the duct-insertion method is a safe and useful procedure, especially for patients with normal pancreatic tissue and an undilated pancreatic duct.