Use of caudal pancreatectomy as a novel adjunct procedure to proximal splenorenal shunt in patients with noncirrhotic portal hypertension: A retrospective cohort study

Abstract

Backgrounds/aims: Proximal splenorenal shunt (PSRS) is considered a one-time treatment for noncirrhotic portal hypertension (NCPH) to prevent recurrent upper gastrointestinal (UGI) hemorrhage and long-term complications. Long-term shunt patency is necessary to achieve these. The lie of the shunt is a contributing factor to early shunt thrombosis. We investigated the role of resection of the distal tail of pancreas (caudal pancreatectomy [CP]) in improving the lie of shunt and decreasing shunt thrombosis.

Methods: This was a retrospective cohort study of patients with NCPH who underwent PSRS between 2014-2020 in JIPMER, Puducherry, India. CP was performed in patients with a long tail of pancreas, with the tip of pancreatic tail extending up to splenic hilum on preoperative CT. Perioperative parameters and shunt patency rate of patients who underwent PSRS with CP (Group A) were compared with patients undergoing conventional PSRS (Group B). Statistical analysis was performed using the Mann-Whitney U test and χ² test.

Results: Eighty four patients with NCPH underwent PSRS (extrahepatic portal vein obstruction = 39; noncirrhotic portal fibrosis = 45). Blood loss was lower (p = 0.002) and post-shunt fall in portal pressure higher (p = 0.002) in Group A. Shunt thrombosis rate was lower (p = 0.04) while rate of complete variceal regression (p = 0.03) and biochemical pancreatic leak (p = 0.01) were higher in Group A.There was no clinically relevant pancreatic fistula in either group.

Conclusions: CP is a safe and useful technique for reducing shunt thrombosis after PSRS in patients with NCPH by improving the lie of shunt.

Keywords: Caudal pancreatectomy; Lie of the shunt; Noncirrhotic portal hypertension; Proximal splenorenal shunt; Shunt thrombosis.

Fig. 1

Computed tomography portovenogram showing the long tail of pancreas with tip of pancreatic tail extending up to splenic hilum (arrow).

Fig. 2

Caudal pancreatectomy being performed using a laparoscopic linear cutter. The black line indicates the distal end of the pancreas. The splenic vein is looped (red loop).

Fig. 3

After caudal pancreatectomy. Long line indicates cut end of the pancreas. Short line indicates the adequate length of splenic vein.

Fig. 4

After caudal pancreatectomy and proximal splenorenal shunt, the satisfactory lie of the shunt. Black line shows the site of splenorenal anastomosis; arrow indicates the cut end of pancreas.

Fig. 5

Postoperative computed tomography portovenogram showing satisfactory lie of shunt after caudal pancreatectomy. Red arrow indicates the site of splenorenal anastomosis.

Fig. 6

Postoperative computed tomography portovenogram showing post-caudal pancreatectomy status. Red arrow indicates the cut edge of the pancreas; staples seen.