PROCEDURES
AND
TECHNIQUES
Duodenum preserving pancreatic head resection (Beger procedure) for pancreatic trauma Brooke C. Bredbeck, Ernest E. Moore, MD, and Carlton C. Barnett, Jr., MD, Denver, Colorado
I
njury to the pancreatic head is a surgical challenge. A grading system for pancreatic trauma was developed by the American Association for the Surgery of Trauma (AAST) to aid in the management of such injuries.1 A key feature distinguishing whether surgical resection is required is the presence of injury to the pancreatic duct or ampulla. As previously described in the literature 20 years ago,2 we propose that a duodenumpreserving pancreatic head resection (DPPHR), otherwise known as a ‘‘Beger’’ procedure for injury to the head of the pancreas as described in 1980 by Hans Beger,3,4 should be within the armamentarium of the trauma surgeon. Although not applied for trauma at this point in our institution, the author’s familiarity with this technique leads us to believe that it has a role in management of selected injuries to the pancreatic head. Pancreatic injury is reported to occur in fewer than 2% of all abdominal injuries.5 In a multicenter study, AAST-OIS Grade II injuries were the most common (45%) followed by Grade I (25%), Grade III (22%), and Grade IV (7%), with no Grade V injuries reported.5 Depending on the grade of injury, patients may need no intervention, may require surgical repair, or may be so unstable as to only tolerate damage control with external drainage. If a proximal pancreatic resection is indicated, a trauma Whipple procedure or pancreaticoduodenectomy (PD) has been recommended even if the duodenum is reparable or uninjured. Initially pioneered to treat tumors of the head of the pancreas, the Whipple procedure is currently recommended in Grade V pancreatic injury.1 In cases of proximal transection alone (Grade III), a PD is not indicated; and in pancreatic duct injury without ampulla involvement (Grade IV), PD may be unnecessarily disruptive. PD as treatment of combined injury to the duodenum and pancreas may have decreased from approximately 10% to between 3% and 5% in recent years, but it has been suggested that this rate may be inappropriately high.1,6,7 Recent data from the National Trauma Data Bank show that far from being a procedure of last resort, approximately 20% of trauma PDs occurred in patients who did not have severe (Grade IV or V) injuries to either the pancreas or duodenum.8 Although patients surgically managed with an operation other than PD had significantly lower systolic blood pressures and Glasgow Coma Scale (GCS) scores, there was no significant difference between
From the Department of Surgery, Denver Health Medical Center, School of Medicine, University of Colorado at Denver, Denver, Colorado. Address for reprints: Carlton C. Barnett, Jr., MD, Department of Surgery, 777 Bannock St, Denver, CO 80204; email: [email protected]. DOI: 10.1097/TA.0000000000000544
morbidity and mortality in the PD- versus nonYPD-treated groups.8 These findings suggest two possible faults in reflexive treatment of combined pancreaticoduodenal trauma with PD. First, PD is performed in a significant minority of cases where it is not warranted. Second, it may be used in cases where its superiority as an operative intervention has not been fully established. Since the duodenum serves an important role as the ‘‘pacemaker’’ for the digestive system,9 an alternative procedure to PD such as a duodenum-sparing pancreatic head resection (DPPHR) may result in fewer long-term complications following surgery while obtaining control of the pancreatic injury. In 1994, a retrospective study of five patients with proximal main pancreatic duct injury and an intact duodenum found that three patients who underwent some form of duodenum-preserving pancreatic resection (one specifically received immediate DPPHR) survived compared with two deaths in patients who underwent PD.2 One patient likely received a delayed DPPHR, and one patient actually had a subtotal distal pancreatectomy. Although the study aimed to examine the feasibility of duodenum-preserving pancreatic resection in pancreatic trauma rather than to claim superiority over PD, the promise of DPPHR was clear. Despite this, the procedure remains exceedingly rare. In four publications between 1990 and 1997, a total of 399 cases of pancreatic injury were reported. Only 0.5% of these patients underwent a Rouxen-Y drainage of the distal segment of the transected pancreas, which is a component of the DPPHR.1,10Y13 Pancreatic trauma is often accompanied by injury to the duodenum. Duodenal trauma is potentially reparable except in cases of AAST-OIS Grade V injury.1 A DPPHR with duodenal repair in the setting of Grade IV or lower injury would obviate the long-term complications associated with duodenal resection as part of a PD. Importantly, the duodenum almost always has a longer basal electrical rhythm than the ileum and colon,9contributing to its role as the pacemaker of the gastrointestinal tract. The duodenum also secretes cholecystokinin, stimulating gallbladder contraction. In one meta-analysis of five randomized controlled trials studying outcomes of PD versus DPPHR for chronic pancreatitis, significant increases in reported diarrhea and fatigue along with lower global quality of life scores were reported in the PD group.14 This is of particular importance in the young trauma patient who will live with the long-term effects of a PD, longer than a middle-aged or elderly cancer patient. Another meta-analysis of 15 controlled experimental studies included comparisons between PD and DPPHR and showed not only a significant increase in relative risk for postoperative pain relief for the DPPHR but also significant decreases in acquired endocrine insufficiency, postoperative
J Trauma Acute Care Surg Volume 78, Number 3
649
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Trauma Acute Care Surg Volume 78, Number 3
Bredbeck et al.
exocrine insufficiency, and incidence of delayed gastric emptying postoperatively.15 Acquiring the knowledge to perform an adequate DPPHR in a trauma scenario along with proper preoperative imaging to confirm the extent of intra-abdominal injury will better ensure the safe use of DPPHR when indicated. As most trauma centers allow the opportunity to concomitantly treat chronic pancreatitis, we describe our modified DPPHR with considerations for the trauma patient. The reconstruction involves an end-to-end pancreaticojejunostomy to the body of the pancreas with the location determined by the need to resect the injured pancreatic parenchyma. An alternative procedure for the distal pancreas is a pancreaticogastrostomy. We favor the additional construction of an end-to-side pancreaticojejunostomy as described by Beger using the same Roux limb of the jejunum to the small remnant pancreatic tissue on the inner aspect of the duodenum with the possibility of a choledochojejunostomy completing the reconstruction3 (Figs. 1 and 2). We begin the procedure just as a standard PD16 with separation of the omental bursa from the transverse colon followed by a generous Cattell-Brasch and Kocher maneuver. At this point, a tunnel can be created inferiorly from the superior mesenteric-portal vein confluence to just beyond the superior border of the pancreas. Scoring the peritoneum along the inferior surface of the pancreas with care taken to avoid injury to the inferior mesenteric vein facilitates this maneuver. Once the pancreas has been mobilized off the superior mesenteric-portal vein confluence and the splenic vein, the transection line is determined by the extent of the injury to the head of the pancreas. The mesoduodenal vessels and the gastroduodenal artery should be preserved if possible, but this is not necessary for adequate duodenal perfusion. After the pancreas has been divided, we prefer to remove the pancreatic head with the harmonic scalpel (Fig. 3), but the use of ‘‘hemostatic’’ stay sutures and excision sharply or with electrocautery work equally well. We then create a 50-cm-long Roux limb for the creation of a duct-to-mucosa pancreatic jejunostomy. As the pancreatic duct is generally small in the young trauma patient, we generally
Figure 1. Subtotal resection of the head of the pancreas; portal vein, common hepatic artery, and common bile duct are dissected. These figures were published in Surgery (Beger et al.4). 650
Figure 2. Jejunum interposed between left side of the pancreas and the duodenal rim of pancreatic tissue. Duct-to-loop anastomosis. These figures were published in Surgery (Beger et al.4).
construct this with 4-6 interrupted 5-0 absorbable monofilament sutures. We usually use interrupted 3-0 nonabsorbable monofilament sutures between the pancreatic capsule and the serosa of the jejunum. The second anastomosis between the small remnant of the pancreatic head and the Roux limb is created with a single layer running 4-0 absorbable monofilament suture. The authors favor this technique to contain any of output from the pancreatic remnant as well as to potentially contain any bile leak that may arise secondary to occult bile duct injury during the procedure (from the use of thermal-based dissection). However, if the pancreatic duct is clearly visible or the remnant is small, one could consider oversewing and forego the second anastomosis. In summary, DPPHR is a viable option for Grade III or IV injuries to the head of the pancreas, either isolated or with duodenal injury that is amenable to primary repair. We do not recommend this technique in the setting of a Grade V duodenal injury, but in any lesser injury, duodenal repair should be considered with the addition of the DPPHR. Of note, this procedure may be ideal following a damage-control operation in the stable patient with more clearly demarcated injury.2 The advantage in a young otherwise healthy trauma patient includes
Figure 3. Final division of the head of the pancreas with harmonic scalpel. * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Trauma Acute Care Surg Volume 78, Number 3
Bredbeck et al.
preservation of the physiologic function of the duodenum, which translates to better digestive function and quality of life for patients long term. REFERENCES 1. Biffl WL. Duodenum and pancreas. In: Mattox KL, Moore EE, Feliciano DV, eds. Trauma. 7th ed. New York, NY: McGraw-Hill; 2013:603Y631. 2. Leppaniemi AK, Haapiainen RK. Pancreatic trauma with proximal duct injury. Ann Chir Gynaecol. 1994;83:191Y195. 3. Beger HG, Witte C, Kraas E, Bittner R. Erfahrung mit einer das Duodenum erhaltenden Pankreaskopfresektion bei chronicscher Pankreatitis. Chirug. 1980;51:303Y309. 4. Beger HG, Krautzberger W, Bittner R, Buchler M, Limmer J. Duodenum preserving resection of the head of the pancreas in patients with severe chronic pancreatitis. Surgery. 1985;97(4):467Y473. 5. Akhrass R, Yaffe MB, Brandt CP, Reigle M, Fallon WF, Malangoni MA. Pancreatic trauma: a ten-year multi-institutional experience. Am Surg. 1997;63(7):598Y604. 6. Feliciano DV, Martin TD, Cruse PA, Graham JM, Burch JM, Mattox KL, Bitondo CG, Jordan GL Jr. Management of combined pancreaticoduodenal injuries. Ann Surg. 1987;205(6):673Y680. 7. Asensio JA, Petrone P, Rolda´n G, Kuncir E, Demetriades D. Pancreaticoduodenectomy: a rare procedure for the management of complex pancreaticoduodenal injuries. J Am Coll Surg. 2003;197(6):937Y942.
8. Van der Wilden GM, Yeh DD, Hwabejire JO, Klein EN, Fagenholz PJ, King DR, de Moya MA, Chang Y, Velmahos GC. Trauma Whipple: do or don’t after severe pancreaticoduodenal injuries? An analysis of the National Trauma Data Bank (NTDB). World J Surg. 2014;38:335Y340. 9. Itoh Z, Sekiguchi T. Interdigestive motor activity in health and disease. Scand J Gastroenterol Suppl. 1983;82:121Y134. 10. Patton JH, Jr. Lyden SP, Croce MA, Pritchard FE, Minard G, Kudsk KA, Fabian TC. Pancreatic trauma: a simplified management guideline. J Trauma. 1997;43: 234Y241. 11. Wisner DH, Wold RL, Frey CF. Diagnosis and treatment of pancreatic injuries. An analysis of management principles. Arch Surg. 1990;125(9):1109Y1113. 12. Ivatury RR, Nallathambi M, Rao P, Stahl WM. Penetrating pancreatic injuries. Analysis of 103 consecutive cases. Am Surg. 1990;56:90Y95. 13. Cogbill TH, Moore EE, Morris JA Jr, Hoyt DB, Jurkovich GJ, Mucha P. Jr, Ross SE, Feliciano DV, Shackford SR. Distal pancreatectomy for trauma: multicenter experience. J Trauma. 1991;31:1600Y1606. 14. Lu W, Shi Q, Zhang W, Cai S, Jiang K, Dong J. A meta-analysis of the long-term effects of chronic pancreatitis surgical treatments: duodenum-preserving pancreatic head resection versus pancreatoduodenectomy. Chin Med J (Engl). 2013; 126(1):147Y153. 15. Yin Z, Sun J, Yin D, Wang J. Surgical treatment strategies in chronic pancreatitis. A meta-analysis. Arch Surg. 2012;147(10):961Y968. 16. Katz MH, Fleming JB, Pisters PW, Lee JE, Evans DB. Anatomy of the superior mesenteric vein with special reference to the surgical management of first-order branch involvement at pancreaticoduodenectomy. Ann Surg. 2008;248(6):1098Y1102.
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
651
AND
TECHNIQUES
Duodenum preserving pancreatic head resection (Beger procedure) for pancreatic trauma Brooke C. Bredbeck, Ernest E. Moore, MD, and Carlton C. Barnett, Jr., MD, Denver, Colorado
I
njury to the pancreatic head is a surgical challenge. A grading system for pancreatic trauma was developed by the American Association for the Surgery of Trauma (AAST) to aid in the management of such injuries.1 A key feature distinguishing whether surgical resection is required is the presence of injury to the pancreatic duct or ampulla. As previously described in the literature 20 years ago,2 we propose that a duodenumpreserving pancreatic head resection (DPPHR), otherwise known as a ‘‘Beger’’ procedure for injury to the head of the pancreas as described in 1980 by Hans Beger,3,4 should be within the armamentarium of the trauma surgeon. Although not applied for trauma at this point in our institution, the author’s familiarity with this technique leads us to believe that it has a role in management of selected injuries to the pancreatic head. Pancreatic injury is reported to occur in fewer than 2% of all abdominal injuries.5 In a multicenter study, AAST-OIS Grade II injuries were the most common (45%) followed by Grade I (25%), Grade III (22%), and Grade IV (7%), with no Grade V injuries reported.5 Depending on the grade of injury, patients may need no intervention, may require surgical repair, or may be so unstable as to only tolerate damage control with external drainage. If a proximal pancreatic resection is indicated, a trauma Whipple procedure or pancreaticoduodenectomy (PD) has been recommended even if the duodenum is reparable or uninjured. Initially pioneered to treat tumors of the head of the pancreas, the Whipple procedure is currently recommended in Grade V pancreatic injury.1 In cases of proximal transection alone (Grade III), a PD is not indicated; and in pancreatic duct injury without ampulla involvement (Grade IV), PD may be unnecessarily disruptive. PD as treatment of combined injury to the duodenum and pancreas may have decreased from approximately 10% to between 3% and 5% in recent years, but it has been suggested that this rate may be inappropriately high.1,6,7 Recent data from the National Trauma Data Bank show that far from being a procedure of last resort, approximately 20% of trauma PDs occurred in patients who did not have severe (Grade IV or V) injuries to either the pancreas or duodenum.8 Although patients surgically managed with an operation other than PD had significantly lower systolic blood pressures and Glasgow Coma Scale (GCS) scores, there was no significant difference between
From the Department of Surgery, Denver Health Medical Center, School of Medicine, University of Colorado at Denver, Denver, Colorado. Address for reprints: Carlton C. Barnett, Jr., MD, Department of Surgery, 777 Bannock St, Denver, CO 80204; email: [email protected]. DOI: 10.1097/TA.0000000000000544
morbidity and mortality in the PD- versus nonYPD-treated groups.8 These findings suggest two possible faults in reflexive treatment of combined pancreaticoduodenal trauma with PD. First, PD is performed in a significant minority of cases where it is not warranted. Second, it may be used in cases where its superiority as an operative intervention has not been fully established. Since the duodenum serves an important role as the ‘‘pacemaker’’ for the digestive system,9 an alternative procedure to PD such as a duodenum-sparing pancreatic head resection (DPPHR) may result in fewer long-term complications following surgery while obtaining control of the pancreatic injury. In 1994, a retrospective study of five patients with proximal main pancreatic duct injury and an intact duodenum found that three patients who underwent some form of duodenum-preserving pancreatic resection (one specifically received immediate DPPHR) survived compared with two deaths in patients who underwent PD.2 One patient likely received a delayed DPPHR, and one patient actually had a subtotal distal pancreatectomy. Although the study aimed to examine the feasibility of duodenum-preserving pancreatic resection in pancreatic trauma rather than to claim superiority over PD, the promise of DPPHR was clear. Despite this, the procedure remains exceedingly rare. In four publications between 1990 and 1997, a total of 399 cases of pancreatic injury were reported. Only 0.5% of these patients underwent a Rouxen-Y drainage of the distal segment of the transected pancreas, which is a component of the DPPHR.1,10Y13 Pancreatic trauma is often accompanied by injury to the duodenum. Duodenal trauma is potentially reparable except in cases of AAST-OIS Grade V injury.1 A DPPHR with duodenal repair in the setting of Grade IV or lower injury would obviate the long-term complications associated with duodenal resection as part of a PD. Importantly, the duodenum almost always has a longer basal electrical rhythm than the ileum and colon,9contributing to its role as the pacemaker of the gastrointestinal tract. The duodenum also secretes cholecystokinin, stimulating gallbladder contraction. In one meta-analysis of five randomized controlled trials studying outcomes of PD versus DPPHR for chronic pancreatitis, significant increases in reported diarrhea and fatigue along with lower global quality of life scores were reported in the PD group.14 This is of particular importance in the young trauma patient who will live with the long-term effects of a PD, longer than a middle-aged or elderly cancer patient. Another meta-analysis of 15 controlled experimental studies included comparisons between PD and DPPHR and showed not only a significant increase in relative risk for postoperative pain relief for the DPPHR but also significant decreases in acquired endocrine insufficiency, postoperative
J Trauma Acute Care Surg Volume 78, Number 3
649
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Trauma Acute Care Surg Volume 78, Number 3
Bredbeck et al.
exocrine insufficiency, and incidence of delayed gastric emptying postoperatively.15 Acquiring the knowledge to perform an adequate DPPHR in a trauma scenario along with proper preoperative imaging to confirm the extent of intra-abdominal injury will better ensure the safe use of DPPHR when indicated. As most trauma centers allow the opportunity to concomitantly treat chronic pancreatitis, we describe our modified DPPHR with considerations for the trauma patient. The reconstruction involves an end-to-end pancreaticojejunostomy to the body of the pancreas with the location determined by the need to resect the injured pancreatic parenchyma. An alternative procedure for the distal pancreas is a pancreaticogastrostomy. We favor the additional construction of an end-to-side pancreaticojejunostomy as described by Beger using the same Roux limb of the jejunum to the small remnant pancreatic tissue on the inner aspect of the duodenum with the possibility of a choledochojejunostomy completing the reconstruction3 (Figs. 1 and 2). We begin the procedure just as a standard PD16 with separation of the omental bursa from the transverse colon followed by a generous Cattell-Brasch and Kocher maneuver. At this point, a tunnel can be created inferiorly from the superior mesenteric-portal vein confluence to just beyond the superior border of the pancreas. Scoring the peritoneum along the inferior surface of the pancreas with care taken to avoid injury to the inferior mesenteric vein facilitates this maneuver. Once the pancreas has been mobilized off the superior mesenteric-portal vein confluence and the splenic vein, the transection line is determined by the extent of the injury to the head of the pancreas. The mesoduodenal vessels and the gastroduodenal artery should be preserved if possible, but this is not necessary for adequate duodenal perfusion. After the pancreas has been divided, we prefer to remove the pancreatic head with the harmonic scalpel (Fig. 3), but the use of ‘‘hemostatic’’ stay sutures and excision sharply or with electrocautery work equally well. We then create a 50-cm-long Roux limb for the creation of a duct-to-mucosa pancreatic jejunostomy. As the pancreatic duct is generally small in the young trauma patient, we generally
Figure 1. Subtotal resection of the head of the pancreas; portal vein, common hepatic artery, and common bile duct are dissected. These figures were published in Surgery (Beger et al.4). 650
Figure 2. Jejunum interposed between left side of the pancreas and the duodenal rim of pancreatic tissue. Duct-to-loop anastomosis. These figures were published in Surgery (Beger et al.4).
construct this with 4-6 interrupted 5-0 absorbable monofilament sutures. We usually use interrupted 3-0 nonabsorbable monofilament sutures between the pancreatic capsule and the serosa of the jejunum. The second anastomosis between the small remnant of the pancreatic head and the Roux limb is created with a single layer running 4-0 absorbable monofilament suture. The authors favor this technique to contain any of output from the pancreatic remnant as well as to potentially contain any bile leak that may arise secondary to occult bile duct injury during the procedure (from the use of thermal-based dissection). However, if the pancreatic duct is clearly visible or the remnant is small, one could consider oversewing and forego the second anastomosis. In summary, DPPHR is a viable option for Grade III or IV injuries to the head of the pancreas, either isolated or with duodenal injury that is amenable to primary repair. We do not recommend this technique in the setting of a Grade V duodenal injury, but in any lesser injury, duodenal repair should be considered with the addition of the DPPHR. Of note, this procedure may be ideal following a damage-control operation in the stable patient with more clearly demarcated injury.2 The advantage in a young otherwise healthy trauma patient includes
Figure 3. Final division of the head of the pancreas with harmonic scalpel. * 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
J Trauma Acute Care Surg Volume 78, Number 3
Bredbeck et al.
preservation of the physiologic function of the duodenum, which translates to better digestive function and quality of life for patients long term. REFERENCES 1. Biffl WL. Duodenum and pancreas. In: Mattox KL, Moore EE, Feliciano DV, eds. Trauma. 7th ed. New York, NY: McGraw-Hill; 2013:603Y631. 2. Leppaniemi AK, Haapiainen RK. Pancreatic trauma with proximal duct injury. Ann Chir Gynaecol. 1994;83:191Y195. 3. Beger HG, Witte C, Kraas E, Bittner R. Erfahrung mit einer das Duodenum erhaltenden Pankreaskopfresektion bei chronicscher Pankreatitis. Chirug. 1980;51:303Y309. 4. Beger HG, Krautzberger W, Bittner R, Buchler M, Limmer J. Duodenum preserving resection of the head of the pancreas in patients with severe chronic pancreatitis. Surgery. 1985;97(4):467Y473. 5. Akhrass R, Yaffe MB, Brandt CP, Reigle M, Fallon WF, Malangoni MA. Pancreatic trauma: a ten-year multi-institutional experience. Am Surg. 1997;63(7):598Y604. 6. Feliciano DV, Martin TD, Cruse PA, Graham JM, Burch JM, Mattox KL, Bitondo CG, Jordan GL Jr. Management of combined pancreaticoduodenal injuries. Ann Surg. 1987;205(6):673Y680. 7. Asensio JA, Petrone P, Rolda´n G, Kuncir E, Demetriades D. Pancreaticoduodenectomy: a rare procedure for the management of complex pancreaticoduodenal injuries. J Am Coll Surg. 2003;197(6):937Y942.
8. Van der Wilden GM, Yeh DD, Hwabejire JO, Klein EN, Fagenholz PJ, King DR, de Moya MA, Chang Y, Velmahos GC. Trauma Whipple: do or don’t after severe pancreaticoduodenal injuries? An analysis of the National Trauma Data Bank (NTDB). World J Surg. 2014;38:335Y340. 9. Itoh Z, Sekiguchi T. Interdigestive motor activity in health and disease. Scand J Gastroenterol Suppl. 1983;82:121Y134. 10. Patton JH, Jr. Lyden SP, Croce MA, Pritchard FE, Minard G, Kudsk KA, Fabian TC. Pancreatic trauma: a simplified management guideline. J Trauma. 1997;43: 234Y241. 11. Wisner DH, Wold RL, Frey CF. Diagnosis and treatment of pancreatic injuries. An analysis of management principles. Arch Surg. 1990;125(9):1109Y1113. 12. Ivatury RR, Nallathambi M, Rao P, Stahl WM. Penetrating pancreatic injuries. Analysis of 103 consecutive cases. Am Surg. 1990;56:90Y95. 13. Cogbill TH, Moore EE, Morris JA Jr, Hoyt DB, Jurkovich GJ, Mucha P. Jr, Ross SE, Feliciano DV, Shackford SR. Distal pancreatectomy for trauma: multicenter experience. J Trauma. 1991;31:1600Y1606. 14. Lu W, Shi Q, Zhang W, Cai S, Jiang K, Dong J. A meta-analysis of the long-term effects of chronic pancreatitis surgical treatments: duodenum-preserving pancreatic head resection versus pancreatoduodenectomy. Chin Med J (Engl). 2013; 126(1):147Y153. 15. Yin Z, Sun J, Yin D, Wang J. Surgical treatment strategies in chronic pancreatitis. A meta-analysis. Arch Surg. 2012;147(10):961Y968. 16. Katz MH, Fleming JB, Pisters PW, Lee JE, Evans DB. Anatomy of the superior mesenteric vein with special reference to the surgical management of first-order branch involvement at pancreaticoduodenectomy. Ann Surg. 2008;248(6):1098Y1102.
* 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
651
