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

Abstract

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.

Keywords: gastrointestinal bleeding; gastrointestinal varices; pancreatic cancer; pancreaticoduodenectomy; sinistral portal hypertension; splenic vein ligation/resection.

Figure 1

Various venous flow form spleen after portal-superior mesenteric vein confluence resection. Brown arrows indicate the critical veins: (A-1) LGV, (A-2) MCV, (A-3) and SRCV arcade. (B) Pink arrows indicate the route from the SV to the PEV and the colonic marginal vein. (C) Red arrows indicate the route from the SV to the LGEV and the arc of Barkow; (C-1) the connection between the arc of Barkow and the colonic marginal vein at the left side of the transverse colon; (C-2) the connection between the arc of Barkow and the colonic marginal vein at the right side of the transverse colon. (D) Blue arrows indicate the route from the SV to the IMV and colonic marginal vein. IMV: inferior mesenteric vein; LEGV: left gastric epiploic vein; LGV: left gastric vein; MCV: middle colic vein; PEV: posterior epiploic vein; SV: splenic vein; SRCV: superior right colic vein.

Figure 2

Schematic drawings before and after superior mesenteric vein (SMV) or splenic vein (SV) reconstruction during pan-creaticoduodenectomy (PD). Red lines indicate cut lines of PV, SMV and SV. (A) Wide resection of the SMV under SV confluence was performed. IJV was used as the interposition graft. (B) Wedge resection of the SMV was performed, and the SMV was reconstructed by direct running suture in a transverse fashion. (C) The PV, SMV, and SV were cut as close to the specimen as possible, and SV-PV anastomosis (upper side) and SV-LRV anastomosis (lower side) were performed. IJV: internal jugular vein; IVC: inferior vena caca; LRV: left renal vein; PV: portal vein; SMV: superior mesenteric vein; SV: splenic vein.