Direct splenic vein reconstruction combined with resection of the portal vein/superior mesenteric vein confluence during pancreaticoduodenectomy

Comparison of prevention and treatment of portal vein thrombosis between proximal splenic vein ligation followed by postoperative transcatheter anticoagulant therapy and systemic anticoagulant therapy in patients with cirrhotic portal hypertension

Aims

Splenectomy combined with pericardial devascularization is one of the important methods to treat hypersplenism, gastrointestinal bleeding, and other complications caused by liver cirrhosis; however, it is accompanied by a high risk of portal vein thrombosis (PVT). This study aimed to explore the preventive and therapeutic effects of proximal splenic vein ligation (PSVL) with postoperative transcatheter anticoagulant therapy (TCAT) on PVT.

Methods

This study retrospectively selected 143 patients with liver cirrhosis and portal hypertension, who received splenectomy combined with pericardial devascularization from June 30, 2018 to June 30, 2021. According to computed tomography photography, within 1 week before the operation, the patients were divided into a prevention group (without preoperative PVT, n = 112) and a treatment group (preoperative PVT, n = 31). Then, each group was subdivided based on the treatment and prevention measures into PSVL + TCAT (n = 70) and systemic anticoagulant therapy (SAT) subgroups (n = 73). The preventive and therapeutic effects of PSVL followed by TCAT on PVT were analyzed.

Results

The operation time in the PSVL + TCAT subgroups was longer than that in the SAT subgroups (185 ± 76 min vs. 161 ± 55 min; p < 0.01). There was no difference between the two subgroups in terms of operative bleeding (345 ± 82 mL vs. 336 ± 65 mL; p > 0.50). There was no operative death, and all patients recovered uneventfully. In the prevention group, procedure‐related complications occurred in two patients in the PSVL + TCAT subgroup (3.7% [2/54]), including one patient with slight pancreatitis and one patient with chylous leakage, owing to mobilization of the pancreas. The PVT incidence in the prevention group was significantly different between the two subgroups at postoperative 7th day, 3rd month, and 6th month (PSVL + TCAT: 0%, 11.1%, and 5.6% vs. SAT: 39.7%, 31.0%, and 20.7%, respectively; all p < 0.05). In the treatment group, the thrombus regression rate at postoperative 7th day and disappearance rates at the 3rd month and the 6th month of the PSVL + TCAT subgroup were significantly higher than those in the SAT subgroup after anticoagulant and thrombolysis therapy (PSVL + TCAT: 75.0%, 68.8%, and 87.5% vs. SAT: 20.0%, 26.7%, and 40.0%; all p < 0.05).

Conclusions

PSVL + TCAT reduces the risk of PVT after splenectomy and is safe and effective in treating PVT during surgery for portal hypertension.

Inverted Y-shaped technique for complex superior mesenteric / portal vein reconstruction in pancreatoduodenectomy for locally advanced pancreatic head ductal adenocarcinoma

Most pancreatoduodenectomy (PD) procedures for locally advanced pancreatic head adenocarcinoma (PDAC) require superior mesenteric/portal vein (SMV/PV) axis resection and reconstruction. Here we describe the inverted Y-shaped as a new technique for complex SMV/PV reconstruction and aimed at evaluating its safety and effectiveness. Among 287 patients who underwent PD for locally advanced PDAC from April, 2007 to December, 2020 at our hospital, 11 patients (3.8%) who underwent PV/SMV reconstruction with this technique were enrolled. Briefly, two distal veins were slit-wedged, sutured, resulting in one orifice, then reconstruction was completed with (n = 6) or without (n = 5) interposed autologous right external iliac vein (REIV) grafts, respectively. Operation time and blood loss were 649 (502-822) min and 1782 (475-6680) mL, respectively. The median length of resected SMV/PV was 40 (20-70) mm, 50 (50-70) mm for REIV grafts, and the splenic vein was resected in eight patients. No patient developed pancreatic fistula; mild leg edema was observed in the six graft patients and the median hospital stay was 36.0 d. PV patency rate at 2 mo after PD was 91% (10/11) and no 90-d mortality was recorded. R0 resection rate was 91% (10/11). It is feasible to safely reconstruct the SMV/PV using the inverted Y-shaped technique in appropriately selected PDAC patients.

Concomitant splenic artery ligation has no preventive effect on left‐sided portal hypertension following pancreaticoduodenectomy with the resection of the portal and superior mesenteric vein confluence for pancreatic ductal adenocarcinoma

Background

Left‐sided portal hypertension (LSPH) caused by splenic vein (SV) division in pancreaticoduodenectomy (PD) with portal vein (PV) resection remains challenging. The current study aimed to investigate the efficacy of splenic artery (SA) ligation in preventing LSPH.

Methods

One‐hundred thirty patients who underwent PD with PV resection for pancreatic ductal adenocarcinoma were classified into SV and SA preservation (SVP, n = 30), SV resection and SA preservation (SVR, n = 59), and SV resection and SA ligation (SAL, n = 41). The postoperative incidence of LSPH was assessed.

Results

The incidence of variceal formation in SVP, SVR, and SAL were 4.8%, 53.2%, and 46.4% at 3 mo, 13.0%, 71.2%, and 62.5% at 6 mo, and 25.0%, 87.5%, and 87.1% at 12 mo, respectively. The rate was significantly higher in SVR at 3 and 6 mo (P = .001 and P < .001, respectively) and in SVR and SAL (P < .001) at 12 mo. Variceal hemorrhage occurred only in SVR (n = 4). The platelet count ratio at 3, 6, and 12 mo began to significantly decrease from 3 mo in SVR (0.77, 0.67, and 0.60, respectively; P < .001) and 6 mo in SAL (0.91, 0.73, and 0.69, respectively; P < .001). The spleen volume ratio also showed significant increase from 3 mo in SVR (1.24, 1.34, and 1.42, respectively; P < .001) and 6 mo in SAL (1.31, 1.32, and 1.34, respectively; P < .001). SVR and SAL were significant risk factors for variceal formation at 12 mo (odds ratio, 21.0 and 20.3, respectively).

Conclusion

In PD with PV resection, SAL delayed LSPH but could not prevent its occurrence.

Sinistral Portal Hypertension after Pancreaticoduodenectomy with Splenic Vein Resection: Pathogenesis and Its Prevention

To achieve curative resection for pancreatic cancer during pancreaticoduodenectomy (PD), extensive portal vein (PV) resection, including porto-mesenterico-splenic confluence (PMSC), may sometimes be necessary if the tumor is close to the portal venous system. Recently, this extended resection has been widely accepted in high-volume centers for pancreatic resection due to its favorable outcomes compared with non-operative treatment. However, in patients with long-term survival, sinistral portal hypertension (SPH) occurs as a late-onset postoperative complication. These patients present gastrointestinal varices due to congested venous flow from the spleen, which may cause critical variceal bleeding. Since the prognosis of patients with pancreatic cancer has improved, owing to the development of chemotherapy and surgical techniques, SPH is no longer a negligible matter in the field of pancreatic cancer surgery. This review clarifies the pathogenesis and frequency of SPH after PD through PMSC resection and discusses its prediction and prevention.