Left gastric vein to adrenal vein anastomosis: intraoperative solution for gastric venous congestion following extended distal pancreatectomy

Abstract

Extended distal pancreatectomy often requires resection of vascular structures and adjacent organs, potentially leading to gastric venous congestion. This case report describes a 49-year-old female who underwent radical antegrade modular pancreatosplenectomy for pancreatic ductal adenocarcinoma. During the procedure, segmental gastric venous congestion was observed and resolved by anastomosing the left gastric vein to the left adrenal vein. The in-hospital postoperative recovery was initially uneventful; however, the patient was readmitted because of intra-abdominal fluid collection that was managed with antibiotics. Pathological examination confirmed moderately differentiated ductal adenocarcinoma with lymphovascular invasion. The patient received adjuvant mFOLFIRINOX therapy and remains disease-free 12 months after surgery with adequate patency of the anastomosis. This case highlights the importance of recognizing and addressing gastric venous congestion during radical antegrade modular pancreatosplenectomy to prevent complications, such as delayed gastric emptying or gastric necrosis, and proposes left gastric vein to left adrenal vein anastomosis as an effective intraoperative solution.

Keywords: extended distal pancreatectomy; gastric venous congestion; left gastric vein; venous reconstruction.

Figure 1

Preoperative CT scan (coronal view, portal phase) shows a 25 mm spiculated mass with hypoattenuation observed after the administration of IV contrast (white asterisk). The lesion encases the splenic artery (black asterisk), extends to the retroperitoneal fat (white arrowhead), and shows mesogastric distortion (black arrowhead).

Figure 2

Final intraoperative view after the RAMPS procedure. Left gastric vein [1], left adrenal vein [2], and vascular anastomosis (white arrowhead). Variceal veins at the level of the lesser curvature (*). Left renal vein (**).

Figure 3

CT scan taken 12 months after surgery, displayed from upper to lower in a left to right sequence, showing the anastomosis between the left gastric vein (LGV, 1) and left adrenal vein (LAV, 2). The left renal vein is indicated by ‘^**’.