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

Y, Ono; Inoue, Yosuke; Kato, Takuya; Matsueda, Kiyoshi; Oba, Atsushi; Sato, Takafumi; Ito, Hiromichi; Saiura, Akio; Takahashi, Yu

doi:10.3390/cancers13215334

Cited by 14 publications

(12 citation statements)

References 47 publications

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“…Previous studies have consistently reported that SV ligation during PD was associated with the development of SPH [7][8][9][10][17][18][19][20][21][22][23]. However, the rate of variceal bleeding, the most critical complication of SPH, was variable among the authors (0~10%) [7,8,17,[19][20][21][22].…”

Section: Discussionmentioning

confidence: 96%

“…SPH may cause variceal formation, which can potentially lead to variceal rupture [8]. Therefore, some surgeons suggest several surgical techniques, such as interposition grafting or bypass, during vascular resection to prevent variceal formation [9]. However, only a few studies have evaluated the long-term follow-up of SPH after splenic vein ligation and its clinical significance in oncologic outcomes [10].…”

Section: Introductionmentioning

confidence: 99%

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Should the Splenic Vein Be Preserved—Fate of Sinistral Portal Hypertension after Pancreatoduodenectomy with Vascular Re-Section for Pancreatic Cancer

Kim

Hwang

et al. 2022

Cancers

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Background: This study aims to evaluate sinistral portal hypertension (SPH) development and its clinical impact on the long-term outcomes of patients with pancreatic cancer who underwent surgical resection with splenic vein (SV) ligation. Methods: Data from 94 consecutive patients who underwent pancreatoduodenectomy (PD) with vascular resection for pancreatic cancer from 2008 to 2019 were retrospectively collected. The patients were divided into two groups according to whether the SV was preserved or ligated during the surgery. Their computed tomography images were serially reviewed (preoperative, 6-, 12-, and 24-months postoperative) with clinical parameters. The degree of variceal formation (variceal score) and splenomegaly were assessed, and the oncologic outcomes were compared between the two groups. Variceal score in the SV ligation group was significantly higher than that in the SV saving group at the same postoperative periods (SV saving vs. ligation: 12 months, 0.9 ± 1.3 vs. 3.5 ± 2.2, p < 0.001; 24 months, 1.4 ± 1.8 vs. 4.0 ± 3.4, p = 0.009). Clinically relevant variceal bleeding was noted in one patient from the SV ligation group (SV saving vs. ligation: 0.0% vs. 3.1%, p = 0.953). In survival analysis, there was no significant difference between the two groups (DFS; SV saving vs. ligation: 13.0 (11.1–14.9) months vs. 13.0 (10.4–15.6) months, p = 0.969, OS; SV saving vs. ligation: 35.0 (19.9–50.1) months vs. 27.0 (11.6–42.4) months, p = 0.417). Although SV ligation induced SPH during PD for pancreatic cancer, it did not lead to clinically significant long-term complications. In addition, it did not impact the long-term survival of patients with resected pancreatic head cancer.

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Section: Discussionmentioning

confidence: 96%

Section: Introductionmentioning

confidence: 99%

Should the Splenic Vein Be Preserved—Fate of Sinistral Portal Hypertension after Pancreatoduodenectomy with Vascular Re-Section for Pancreatic Cancer

Kim

Hwang

et al. 2022

Cancers

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“…3). Whether the likelihood of GI bleeding events in SPH patients actually correlates strictly with the presence of varices alone cannot be answered unequivocally in view of the literature and is presumably subject to multiple hemodynamic factors, such as anatomy of the collaterals or pressure changes in the splenic collaterals [16].…”

Section: Introductionmentioning

confidence: 99%

Management of Sinistral Portal Hypertension after Pancreaticoduodenectomy

Mansour,

Sirtl,

Angele

et al. 2024

Dig Dis

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Background: Sinistral or left-sided portal hypertension (SPH) is a rare cause of upper gastrointestinal hemorrhage resulting from obstruction of the splenic vein. Venous drainage from the spleen via collaterals can result in venous hemorrhage both into the retroperitoneal and intraabdominal space due to increased venous blood pressure in peripancreatic and gastroduodenal vasculature. SPH can occur secondary to pancreatitis with thrombosis of the splenic vein. Another possible cause is the surgical ligation of the splenic vein as part of pancreaticoduodenectomy (PD). Although splenectomy has been traditionally considered as the treatment of choice to relieve venous hypertension, individual concepts for each patient have to be developed. Considering the venous collateral drainage pathways, a comprehensive approach involving surgical, endoscopic, and interventional radiology interventions may be necessary to address the underlying cause of variceal bleeding. Among these approaches, splenic artery embolization (SAE) has demonstrated efficacy in mitigating the adverse effects associated with elevated venous outflow pressure. Summary: This review summarizes key imaging findings in SPH patients after pancreaticoduodenectomy and highlights the potential of minimally invasive embolization for curative treatment of variceal hemorrhage. Key Messages: • sinistral portal hypertension is a potential consequence after major pancreas surgery • collateral flow can lead to life threatening abdominal bleeding • depending on the origin and localization of the bleeding a dedicated management is required, frequently involving interventional radiology techniques

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“… 4 , 5 Isolated gastric varices are a typical manifestation of LSPH, which results in severe or persistent gastrointestinal (GI) bleeding. 5 – 7 …”

Section: Introductionmentioning

confidence: 99%

Splenectomy versus non-splenectomy for gastrointestinal bleeding from left-sided portal hypertension: a systematic review and meta-analysis

Liu,

Wei,

Song

2024

Therap Adv Gastroenterol

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Objectives: Left-sided portal hypertension (LSPH) leads to life-threatening gastrointestinal (GI) bleeding. There are no recommendations or consensus about the management of GI bleeding caused by LSPH. This systematic review and meta-analysis were conducted to evaluate the incidence of GI bleeding and the mortality of patients with LSPH receiving different therapeutic strategies. Design: A systematic review and meta-analysis were performed to determine the efficacy of different therapeutic strategies for GI bleeding caused by LSPH. Data sources and methods: All relevant studies were searched from PubMed, Embase, Web of Science, Cochrane Library, Scopus, ScienceDirect, MEDLINE, Google Scholar, CNKI, and Wanfang Data without language restriction through 15 November 2023. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated through RevMan5.3 software. (The Cochrane Collaboration, Copenhagen, Denmark). Results: Seventeen retrospective studies and one prospective study involving 624 patients were included. This systematic review and meta-analysis found that: (1) splenectomy was more effective than non-splenectomy therapeutic strategies in reducing the incidence of GI bleeding caused by LSPH (OR: 0.12; 95% CI: 0.06–0.27); (2) splenectomy was superior to partial splenic artery embolism (PSAE) (OR: 0.06; 95% CI: 0.01–0.62) or endoscopic interventions (OR: 0.04; 95% CI: 0.01–0.19) in the prevention of GI bleeding, respectively; (3) no significant difference in the mortality was observed between splenectomy and non-splenectomy therapeutic strategies (OR: 0.46; 95% CI: 0.20–1.08); and (4) patients receiving preoperative PSAE followed by splenectomy had less intraoperative bleeding and shorter operative time than those receiving splenectomy. Conclusion: This meta-analysis demonstrated that splenectomy is superior to non-splenectomy therapeutic strategies in reducing the incidence of GI bleeding from LSPH, which revealed that splenectomy should be recommended in the management of these patients. Trial registration: This study has been registered on the PROSPERO database with the registration number CRD42023483764.

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

Cited by 14 publications

References 47 publications

Should the Splenic Vein Be Preserved—Fate of Sinistral Portal Hypertension after Pancreatoduodenectomy with Vascular Re-Section for Pancreatic Cancer

Should the Splenic Vein Be Preserved—Fate of Sinistral Portal Hypertension after Pancreatoduodenectomy with Vascular Re-Section for Pancreatic Cancer

Management of Sinistral Portal Hypertension after Pancreaticoduodenectomy

Splenectomy versus non-splenectomy for gastrointestinal bleeding from left-sided portal hypertension: a systematic review and meta-analysis

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