
CHAPTER 49 • Pylorus-Saving Pancreaticoduodenectomy 563
STEP 5: PEARLS AND PITFALLS
◆ It is best to understand the potential for challenging anatomy. These circumstances include
patients with prior pancreatic surgery, patients with chronic infl ammation (chronic pancre-
atitis), patients with prior acute pancreatitis (seen in 37% of patients with IPMN), and
patients with tumor close to or invading the superior mesenteric vein and artery.
◆ If severe hemorrhage is encountered beneath the head of the pancreas in the superior mes-
enteric vein/portal vein or if it is encountered after division of the pancreas, several mea-
sures should be considered:
◆ Call for experienced help.
◆ Isolate and control the portal vein, superior mesenteric vein, and splenic vein, and place
either vessel loops or vascular clamps.
◆ Compression should always offer time to establish control and obtain help.
◆ Mobilize the pancreas to achieve the best exposure available.
◆ One potentially useful maneuver is to pass Fogarty catheters into the lumen of each
vein.
◆ If some length of vein is lost, it is possible to mobilize the vein to permit as much as a
3-cm defect to be repaired primarily.
SELECTED REFERENCES
1. Katz MH, Wang H, Fleming J, et al: Long-term survival after multidisciplinary management of resected
pancreatic adenocarcinoma. Ann Surg Oncol 2009;16:836-847.
2. Kow AW, Chan SP, Earnest A, et al: Striving for a better operative outcome: 101 pancreaticoduodenecto-
mies. HPB (Oxford) 2008;10:464-471.
3. Katz MH, Fleming JP, Pisters PW, et al: Anatomy of the superior mesenteric vein with special reference to
the surgical management of fi rst order branch involvement at pancreaticoduodenectomy. Ann Surg
2008;248:1094-1102.