Masayuki Tanaka1, Hiromichi Ito2, Yoshihiro Ono1, Kiyoshi Matsueda3, Yoshihiro Mise1, Takeaki Ishizawa1, Yosuke Inoue1, Yu Takahashi1, Makiko Hiratsuka3, Toshiyuki Unno3, Akio Saiura4. 1. Department of 1Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan. 2. Department of 1Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan. Electronic address: hiromichi.ito@jfcr.or.jp. 3. Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan. 4. Department of 1Hepato-Biliary-Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan. Electronic address: akio.saiura@jfcr.or.jp.
Abstract
BACKGROUND: Resection of the porto-mesenterico-splenic confluence is at times necessary during pancreatoduodenectomy with portal vein resection for pancreatic cancer. Although splenic vein ligation can cause sinistral portal hypertension, the incidence of clinically relevant sinistral portal hypertension remains unknown, and the roles of the preservation of potential collateral veins and splenic vein reconstruction are controversial. METHODS: Patients with pancreatic cancer who underwent pancreatoduodenectomy with porto-mesenterico-splenic confluence resection were assessed for incidence of development of varices by computed tomography at 6 months after pancreatoduodenectomy. We evaluated the risk factors for sinistral portal hypertension and the impact of splenic vein reconstruction on sinistral portal hypertension. RESULTS: Of the 118 patients who underwent pancreatoduodenectomy with porto-mesenterico-splenic confluence resection, 31 (26%) underwent splenic vein reconstruction, 44 patients (37%) developed gastroesophageal varices, and 5 (11%) experienced varix rupture. Sacrifice of all 3 potential collateral veins (what we refer to as the critical veins: left gastric vein, middle colic vein, and superior right colic vein arcade) and absence of any spontaneous splenorenal shunt had a substantial impact on formation of varices. The risk of variceal formation could be stratified based on the number of preserved critical veins, and patent splenic vein reconstruction was associated with a decreased incidence of varices (60% versus 100%, P = .018) among the patients without preservation of the critical veins. In contrast, patients with multiple intact critical veins developed no varices, regardless of splenic vein reconstruction. CONCLUSIONS: Sinistral portal hypertension is not uncommon after pancreatoduodenectomy with porto-mesenterico-splenic confluence resection, and the number of preserved critical veins helps to predict the risk of sinistral portal hypertension. Thus, the indication for splenic vein reconstruction should be tailored according to individual risk factors.
BACKGROUND: Resection of the porto-mesenterico-splenic confluence is at times necessary during pancreatoduodenectomy with portal vein resection for pancreatic cancer. Although splenic vein ligation can cause sinistral portal hypertension, the incidence of clinically relevant sinistral portal hypertension remains unknown, and the roles of the preservation of potential collateral veins and splenic vein reconstruction are controversial. METHODS:Patients with pancreatic cancer who underwent pancreatoduodenectomy with porto-mesenterico-splenic confluence resection were assessed for incidence of development of varices by computed tomography at 6 months after pancreatoduodenectomy. We evaluated the risk factors for sinistral portal hypertension and the impact of splenic vein reconstruction on sinistral portal hypertension. RESULTS: Of the 118 patients who underwent pancreatoduodenectomy with porto-mesenterico-splenic confluence resection, 31 (26%) underwent splenic vein reconstruction, 44 patients (37%) developed gastroesophageal varices, and 5 (11%) experienced varix rupture. Sacrifice of all 3 potential collateral veins (what we refer to as the critical veins: left gastric vein, middle colic vein, and superior right colic vein arcade) and absence of any spontaneous splenorenal shunt had a substantial impact on formation of varices. The risk of variceal formation could be stratified based on the number of preserved critical veins, and patent splenic vein reconstruction was associated with a decreased incidence of varices (60% versus 100%, P = .018) among the patients without preservation of the critical veins. In contrast, patients with multiple intact critical veins developed no varices, regardless of splenic vein reconstruction. CONCLUSIONS: Sinistral portal hypertension is not uncommon after pancreatoduodenectomy with porto-mesenterico-splenic confluence resection, and the number of preserved critical veins helps to predict the risk of sinistral portal hypertension. Thus, the indication for splenic vein reconstruction should be tailored according to individual risk factors.
Authors: Mohammed Al-Saeedi; Leonie Frank-Moldzio; Pietro Contin; Philipp Mayer; Martin Loos; Thomas Schmidt; Martin Schneider; Beat P Müller-Stich; Christoph Berchtold; Arianeb Mehrabi; Thilo Hackert; Markus W Büchler; Oliver Strobel Journal: Langenbecks Arch Surg Date: 2021-10-07 Impact factor: 3.445