Jejunal vein tributary analysis and intraoperative clamp testing in avoiding congestion after pancreatoduodenectomy

Purpose Although venous drainage of the jejunal loop may be maintained after sacrifice of jejunal vein tributaries during pancreatoduodenectomy, risk of severe jejunal mesenteric congestion following division of these tributaries can be difficult to predict. This study considered how best to predict safety of jejunal vein tributary dissection. Methods Preoperative imaging findings and results of intraoperative clamp tests of jejunal vein tributaries during pancreatoduodenectomy were analyzed in 121 patients with hepatobiliary and pancreatic disease to determine whether this information adequately predicted safety of resecting superior mesenteric vein branches. Results Jejunal vein tributaries caudal to the inferior border of the pancreatic uncinate process tended to be fewer when tributaries cranial to this landmark were more numerous. Tributaries cranial to the border drained a relatively wide expanse of jejunal artery territory in the jejunal mesentery. The territory of jejunal tributaries cranial to the inferior border of the pancreas did not vary according to course of the first jejunal vein branch relative to the superior mesenteric artery. One patient among 30 (3%) who underwent intraoperative clamp tests of tributaries cranial to the border showed severe congestion in relation to a venous tributary coursing ventrally to the superior mesenteric artery. Conclusion Jejunal venous tributaries drained an extensive portion of jejunal arterial territory, but tributaries located cranially to the inferior border of the pancreas could be sacrificed without congestion in nearly all patients. Intraoperative clamp testing of these tributaries can identify patients whose jejunal veins must be preserved to avoid congestion.