Splenorenal shunt for reconstruction of the gastric and splenic venous drainage during pancreatoduodenectomy with resection of the portal venous confluence

Abstract

Background Resection of the portal venous confluence is frequently necessary for radical resection during pancreatoduodenectomy for cancer. However, ligation of the splenic vein can cause serious postoperative complications such as gastric/splenic venous congestion and left-sided portal hypertension. A splenorenal shunt (SRS) can maintain gastric and splenic venous drainage and mitigate these complications. Purpose This study describes the surgical technique, postoperative course, and surgical outcomes of SRS after pancreatoduodenectomy. Methods Ten patients who underwent pancreatoduodenectomy and SRS between September 2017 and April 2019 were evaluated. After resection an end-to-side anastomosis between the splenic vein and the left renal vein was performed. Postoperative shunt patency, splenic volume, and any SRS-related complications were recorded. Results The rates of short- and long-term shunt patency were 100% and 60%, respectively. No procedure-associated complications were observed. No signs of left-sided portal hypertension, such as gastrointestinal bleeding or splenomegaly, and no gastric/splenic ischemia were observed in patients after SRS. Conclusion SRS is a safe and effective measure to mitigate gastric congestion and left-sided portal hypertension after pancreatoduodenectomy with compromised gastric venous drainage after resection of the portal venous confluence.

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

“…Additionally, pancreatic surgery leads to LSPH, and the mechanism underlying LSPH from pancreatic surgery is different from that of LSPH caused by pancreatitis. 43 , 44 Thus, the patients who underwent pancreatic surgery were excluded when a subgroup analysis was performed. The patients in the splenectomy group had a lower rate of GI bleeding than those in the non-splenectomy group (OR: 0.12; 95% CI: 0.04–0.39; p = 0.52; I 2 = 0%, Figure 2 ).…”

Risk Factors, Management, and Outcome of Gastric Venous Congestion After Total Pancreatectomy: An Underestimated Complication Requiring Standardized Identification, Grading, and Management

“…A patient reported by Sandroussi and McGilvray 16 underwent ligation of the inferior mesenteric vein (that drained into the superior mesenteric vein) so an end-to-end reconstruction could be created with the left coronary vein that managed the GVC successfully. The Heidelberg group published various reconstruction techniques including (1) end-to-side reconstruction of the left coronary vein on the portal vein, 33 (2) reconstruction of the splenic vein on either the portal vein, inferior caval vein, or left renal vein (splenorenal shunt) in case of spleen preservation, 34 , 35 (3) reconstruction of the left coronary vein on the left renal vein, and (4) reinsertion of the right gastroepiploic/coronary vein. 35 An observational bi-center study including 92 patients who underwent TP showed that spleen-preservation with its vasculature also could be considered, even in case of PVR, preserving the left gastroepiploic and short gastric veins.…”