An Untapped Resource: Left Renal Vein Interposition Graft for Portal Vein Reconstruction During Pancreaticoduodenectomy

Excerpt

A 74-year-old female was initially evaluated for complaints of jaundice and vague abdominal pain. Preliminary assessment revealed an unremarkable past medical history and physical examination, with no abdominal tenderness noted. Laboratory studies were remarkable for an elevated total bilirubin of 8.3 mg/dL (normal < 1.4 mg/dL), AST of 218 U/L (normal < 40 U/L), ALT of 320 U/L (normal < 60 U/L), and alkaline phosphatase of 543 (normal < 130 U/L). Abdominal ultrasonography revealed a mass in the pancreatic head with proximal biliary dilation. Computed tomography (CT) confirmed a hypoattenuating mass in the head of the pancreas measuring 4 × 3.4 cm (Fig. 1). A 270 degree encasement of the portal vein (PV)–superior mesenteric vein (SMV) confluence by the tumor that did not involve the superior mesenteric artery (SMA) was noted radiographically, with no evidence of distant metastases. A stent placed by endoscopic retrograde cholangiopancreatography successfully relieved her biliary obstruction. Preoperative endoscopic ultrasound-guided biopsy revealed moderate-to-severe dysplasia, possibly in the setting of an intraductal papillary mucinous neoplasm, but no invasive carcinoma.

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