A 52-year-old lady, a known diabetic, presented with steatorrhea, weight loss, and upper abdominal pain for 6 months. A triphasic computed tomography (CT) scan of the abdomen and magnetic resonance cholangiopancreatography showed a lesion with diffuse pancreatic involvement suggestive of intraductal papillary mucinous neoplasm (IPMN)-associated pathology. The serum CA 19-9 level at presentation was 89 IU/mL. She underwent a TP with splenectomy. Intraoperatively, the lesion involved the head and body of the pancreas. Dense peripancreatic inflammation due to prior episodes of pancreatitis made dissection of the splenic vessels and LGV difficult. LGV (draining into the SV in this case) had to be ligated because of dense adhesions around this area. A pylorus-resecting procedure was performed. At the end of resection, gastric congestion was evident. Therefore, a decision was taken to reimplant the LGV into the inferior mesenteric vein (IMV), as the SV was also ligated and the RGEV was reimplanted into a colic vein (Fig. 1). Help of the microvascular surgical team was sought in view of the narrow calibre of both the veins, and both anastomoses were performed under an operating microscope with a 9-0 Prolene suture. The operative time was 660 minutes, and the intraoperative blood loss was 2,000 mL. Post anastomosis, the congestion and colour of the stomach improved immediately. The remaining reconstruction was performed in a regular fashion. Precautionary upper GI endoscopy on the second postoperative day revealed a healthy pink gastric mucosa. Patient developed only mild (grade A) delayed gastric emptying in the post-operative period and recovered uneventfully. Histopathology revealed a moderately differentiated adenocarcinoma in the setting of IPMN (pT2N0). The patient is alive and is doing well 64 months after surgery with no evidence of recurrence.

A 66-year-old gentleman presented with a complaint of epigastric pain for 20 days. A triphasic CT scan (Fig. 2A) showed a borderline resectable pancreatic head tumour with deformed spleno-portal confluence and a luminal filling defect in the portal vein. The tumour was abutting the common hepatic artery and encasing the gastroduodenal artery (GDA). He received two cycles of chemotherapy (Gemcitabine and Paclitaxel) followed by concurrent Capecitabine-based radiotherapy at the previous treatment centre. A repeat CT scan at our centre showed stable disease. He was administered additional 2 cycles of FOLFIRINOX, and a reassessment CT scan was again suggestive of stable disease with 1 cm encasement of the GDA and a persistent deformity at the splenoportal confluence of approximately 2 cm in length. Occlusion of the confluence had resulted in omental venous collateral formation with significantly dilated RGEV carrying splenic drainage into the portal circulation. Intraoperatively, the splenoportal confluence and GDA were involved, but the latter was free at its origin. The RGEV was dilated to around 8 mm in diameter. The RGEV, which is usually sacrificed during pancreaticoduodenectomy, was preserved as it was the sole venous drainage for both the stomach and spleen in this case (Fig. 2B and 3), as SV reconstruction was not feasible due to the long length of SV involvement and coronary vein had to be sacrificed due to involvement by the tumour. The short gastric veins were patent; however, the entire gastric venous drainage was via the RGEV alone, as the SV had to be ligated and was unreconstructible due to long length involvement. Hence, SV ligation was performed after resection and the decision to preserve the RGEV was made intraoperatively after noticing gastric congestion after performing a bull-dog clamp test on this dilated vein. Pylorus-preserving pancreaticoduodenectomy was performed with 3 cm segmental portal vein resection and type III reconstruction (primary reconstruction with end-to-end anastomosis). The operative time was 540 minutes, and blood loss was 2,300 mL. The intraoperative course and postoperative recovery were uneventful. Postoperative CT showed normal gastric enhancement and mural thickness, indicating adequate venous outflow. Histopathology revealed moderately differentiated adenocarcinoma of the pancreatic head (pT4N1). On follow-up, the patient developed liver metastases 7 months after the surgery and he died 10 months after surgery.

A 49-year-old gentleman presented with a history of left-sided abdominal pain radiating to the back for 20 days. CECT of the abdomen and pelvis showed a hypodense lesion in the uncinate process and another hypodense lesion in the body extending to the pancreatic tail. The lesion was encasing the splenic artery and vein leading to formation of collaterals draining the spleen and stomach. Involvement of LGV insertion into the SV by the tumour was noted on the imaging along with dilated RGEV and LGEV. His CA-19.9 level was 16,742 U/mL and endoscopic ultrasound-guided fine needle aspiration was suggestive of adenocarcinoma. After receiving 5 cycles of FOLFIRINOX, reassessment CT showed a stable lesion with no evidence of disease spread and a declining CA-19.9 level (1,833 U/mL). In view of the multifocality of the tumour and stable disease on neoadjuvant chemotherapy, the decision to proceed with TP was taken. Intraoperatively, similar findings were confirmed as noted on the preoperative CT scan. The RGEV and LGEV were ligated, while keeping both the cut ends long with the intent of venous reconstruction, in case if gastric congestion would develop after LGV division. As the LGV was clamped with a bulldog, gastric congestion became evident. The LGV was divided with the decision to reconstruct the venous outflow. Gastric venous stasis was managed by first constructing an end-to-end LGV-RGEV anastomosis using a 7-0 prolene suture (Fig. 4A). This venous conduit, in turn, was drained into the MPV by means of a side-to-side anastomosis (Fig. 4B). Gastric congestion reverted soon after the release of vascular clamps and confirmed patency of the venous anastomosis (Fig. 5). Postoperatively, gastric function recovered well with the patient tolerating gradual diet escalation and nasogastric tube removal by POD2. CECT performed on POD6 showed that the venous conduit drained into the MPV with good opacification and no gastric wall oedema. The patient was discharged on POD14. The final histopathology showed a viable residual tumour (Evans grade 4) with two tumour epicenters, one in the head and another in the body of the pancreas extending into the tail. All margins were free. The final stage was ypT3ypN1, with 3 out of 38 lymph nodes being positive. On follow-up, the patient developed liver metastases six months post-surgery and is currently on palliative chemotherapy.

Gastric congestion secondary to compromised venous return can have deleterious consequences after TP. Detailed study of preoperative imaging is essential to plan the preservation of collaterals and/or the reconstruction of gastric veins to prevent an additional gastric resection during a major pancreatectomy.