Impact of radiological and pathological splenic vein involvement in patients with resectable pancreatic body or tail cancer.

PURPOSE: Several studies have reported a negative impact on survival associated with splenic vessel involvement, especially splenic artery (SpA) involvement, in patients diagnosed with pancreatic body or tail cancer. However, there is limited research on splenic vein (SpV) involvement. Therefore, we aimed to elucidate the significance of splenic vessel involvement, especially SpV involvement, in patients with resectable pancreatic body or tail cancer. METHODS: Between January 2007 and December 2021, 116 consecutive patients underwent distal pancreatectomies for pancreatic body or tail cancer. Among them, this study specifically examined 88 patients with resectable pancreatic body or tail cancer to elucidate prognostic factors using a multivariable Cox proportional analysis. The Kaplan-Meier method evaluated the impact of SpV involvement in terms of both radiological and pathological aspects and the efficacy of neoadjuvant therapy. RESULTS: Higher pre-operative carcinoembryonic antigen levels, larger tumour size, pathological SpV invasion, and non-completion of adjuvant therapy were identified as independent poor prognostic factors for overall survival (OS) and recurrence-free survival (RFS). Additionally, patients with radiological SpV encasement had significantly worse prognoses in terms of OS (p = 0.039) and RFS (p < 0.001). The sensitivity and specificity of multidetector-row computed tomography for detecting pathological SpV invasion were 81.0% and 61.2%, respectively. However, the prognostic impact of neoadjuvant therapy could not be determined, regardless of radiological SpV involvement. CONCLUSION: Radiological and pathological SpV involvement is a poor prognostic factor for patients with resectable pancreatic body or tail cancer. New innovative treatments and effective neoadjuvant therapy regimens are required for patients with SpV involvement.

The clinical applicability of percutaneous splenic vein stent implantation for pancreatic portal hypertension.

BACKGROUND: Pancreatic portal hypertension (PPH) is a type of extrahepatic portal hypertension. We compared the clinical efficacy of different treatment methods for PPH caused by splenic vein stenosis in chronic pancreatitis. METHODS: This article retrospectively analyzed the PPH cases that were caused by splenic vein stenosis after chronic pancreatitis. Patients were divided into three groups according to the different treatments: splenic vein stent implantation (stent group), splenectomy, and only medications (conservative group). The treatment effects from each group were compared. RESULTS: A total of 33 patients were retrospectively analyzed in this study (9, 12, and 12 patients in each group respectively). All the procedures were successful in the stent and splenectomy groups. During the follow-up, no patient had gastrointestinal bleeding recurrence in the stent and splenectomy groups. However, in the conservative group, the incidence of portal hypertensive gastropathy and upper gastrointestinal bleeding were 50% and 25%. In the stent group, all the varicose veins at the base of the stomach had shrunk by varying degrees, and the red color signs regressed. The stent patency rate was 100%. No major complication occurred. The average platelet count at 1, 3, 6-months postoperatively were all significantly higher than the preoperative value (P < 0.05). The average postoperative hospital stay duration was significantly shorter than that of the splenectomy group (3.1 ± 1.4 days vs. 16.1 ± 8.1 days; P < 0.05). In the splenectomy group, postoperative fever occurred in 4 patients. Postoperative infection occurred in 2 patients (one with abdominal cavity infection and the other with incision infection). Delayed abdominal bleeding occurred in one patient. Portal vein thrombosis occurred in 2 patients during follow up. CONCLUSION: Percutaneous splenic vein stent implantation for PPH treatment reduces the risk of gastrointestinal bleeding with minimal invasive. It has a high safety and reliable efficacy and is worthy of further clinical promotion.

A case of Vp4 hepatocellular carcinoma with tumor thrombosis extending into the confluence of the splenic/portal vein achieved a good prognosis with emergent hepatectomy and postoperative adjuvant therapy with lenvatinib.

In this report, we describe a case of highly advanced hepatocellular carcinoma with tumor thrombosis extending into the main portal vein of the pancreas that was successfully treated with adjuvant lenvatinib after right hepatic resection with thrombectomy. A 70-year-old woman was referred from the clinic because of elevated hepatobiliary enzymes. The patient was positive for the hepatitis B virus antigen at our hospital. The tumor markers were highly elevated with alpha-fetoprotein (14.5 U/mL) and protein induced by vitamin K absence (PIVKAII) (1545 ng/mL), suggesting hepatocellular carcinoma. Dynamic abdominal computed tomography showed an early enhanced tumor approximately 6 cm in size and portal vein tumor thrombosis filling the main portal vein, but not extending into the splenic or superior mesenteric vein (SMV). On magnetic resonance imaging 1 week after CT, portal vein tumor thrombosis had extended to the confluence of the splenic vein with the SMV, indicating rapid tumor growth. Thus, we performed emergent right hepatectomy with tumor thrombectomy. Postoperatively, we treated the patient with lenvatinib for a tumor reduction surgery. Fortunately, the patient was alive 2 years postoperatively without recurrence. This case report suggests that a favorable outcome may be achieved with multidisciplinary treatment including resection and postoperative treatment with lenvatinib.

Coincidence of splenic vein aneurysm and haemorrhagic cyst of the pancreas.

Pseudoaneurysm of the splenic vein is a rare entity which is associated with pancreatitis in 52 % cases. Pseudocysts of the pancreas create approximately 70 % of all cystic lesions of the pancreas. One of the most dangerous complications of pancreatic pseudocysts is bleeding into the cystic lumen. This is caused by perforation of the pseudoaneurysm of the splenic vein. Enzymatic damage of the splenic vein´s wall is the cause of pseudoaneurysm. The clinical condition varies. It can be asymptomatic or bring about haemodynamic instability. The diagnostic process of pseudoaneurysm of the splenic vein is difficult. This case study introduces a case of a 50­year­old man with the anamnesis of recurrent pancreatitis caused by alcoholism. He had abdominal pain and was diagnosed with a pseudocyst of the pancreas. Abdominal CT showed an extensive capsulated collection in the left subphrenic space, 23cm in diameter, with serosanguineous content and coagulations. The CT visualised the mass effect on the surrounding tissues and a complete deformation of the spleen. Between the collection and partially oppressed tail of the pancreas there was a venous pseudoaneurysm, 3.5cm in diameter. Considering its localization, it most probably originated from the splenic vein. Surgery was done. We did distal resection of the pancreas with a complete removal of the pseudocyst and spleen (Fig. 7, Ref. 11). Keywords: splenic vein, pseudoaneurysm, pancreatitis, pancreatic pseudocysts.

Left-sided Portal Hypertension After Pancreaticoduodenectomy With Resection of the Portal Vein/Superior Mesenteric Vein Confluence in Patients With Pancreatic Cancer: A Project Study by the Japanese Society of Hepato-Biliary-Pancreatic Surgery.

OBJECTIVE: The aim of this study was to evaluate how often left-sided portal hypertension (LPH) develops and how LPH affects the long-term outcomes of patients with pancreatic cancer treated with pancreaticoduodenectomy (PD) and resection of the portal vein (PV)/superior mesenteric vein (SMV) confluence. SUMMARY BACKGROUND DATA: Little is known about LPH after PD with resection of the PV/SMV confluence. METHODS: Overall, 536 patients who underwent PD with PV/SMV resection were enrolled. Among them, we mainly compared the SVp group [n=285; the splenic vein (SV) was preserved] and the SVr group (n = 227; the SV was divided and not reconstructed). RESULTS: The incidence of variceal formation in the SVr group increased until 3 years after PD compared with that in the SVp group (38.7% vs 8.3%, P < 0.001). Variceal bleeding occurred in the SVr group (n = 9: 4.0%) but not in the SVp group (P < 0.001). In the multivariate analysis, the risk factors for variceal formation were liver disease, N factor, conventional PD, middle colic artery resection, and SV division. The only risk factor for variceal bleeding was SV division. The platelet count ratio at 6 months after PD was significantly lower in the SVr group than in the SVp group (0.97 vs 0.82, P < 0.001), and the spleen-volume ratios at 6 and 12 months were significantly higher in the SVr group than in the SVp group (1.38 vs 1.00 and 1.54 vs 1.09; P < 0.001 and P < 0.001, respectively). CONCLUSIONS: PD with SV division causes variceal formation, bleeding, and thrombocytopenia.

Sinistral Portal Hypertension Prediction During Pancreatoduodenectomy With Splenic Vein Resection.

BACKGROUND: Pancreaticoduodenectomy with porto-mesenterico-splenic confluence resection can cause sinistral portal hypertension (SPH), which may lead to gastrointestinal bleeding. Nevertheless, it remains difficult to predict SPH development during surgery. The aim of this study is to assess the feasibility of measuring splenic vein (SV) pressure to predict SPH. METHODS: The patients who underwent pancreaticoduodenectomy with porto-mesenterico-splenic confluence resection between January 2016 and December 2017 were included in this study. SV pressure was measured before SV clamping (SVP1) and after SV clamping (SVP2). SPH was defined as varicose vein formation detected by follow-up computed tomography. Incidence of SPH was assessed in patients who had no SV drainage after surgery. RESULTS: SV pressure was measured in 41 patients. Among them, 24 had no SV drainage (13 patients had occluded SV reconstruction, and 11 had SV ligation without an attempt at reconstruction) and were included for the analysis. SPH was observed in 16 of 24 patients (67%). The median ΔSVP (SPV2-SVP1) in patients with SPH was higher than that in patients without SPH (13.5 mmHg versus 7.5 mmHg, P = 0.0237). Most patients with SVP2 >20 mmHg (12/14 [86%]) or ΔSVP >10 mmHg (10/11 [91%]) developed SPH. CONCLUSIONS: For the patients with SV resection, high SV pressure after clamping (≥20 mmHg) and a large SV pressure difference (≥10 mmHg) before and after clamping are feasible indication criteria for SV reconstruction to prevent SPH.

Retrospective Comparison of Clinical Outcomes Following Splenic Vein Stenting and Splenic Arterial Embolization in Sinistral Portal Hypertension-Related Gastrointestinal Bleeding.

BACKGROUND. Sinistral portal hypertension (SPH) is caused by an obstruction of the splenic vein and is a potential cause of upper gastrointestinal bleeding. Although splenic arterial embolization (SAE) and splenic vein stenting are accepted treatment options for SPH, their outcomes have not been compared directly. OBJECTIVE. This retrospective study compared the outcomes of splenic vein stenting and SAE for SPH-related gastrointestinal bleeding. METHODS. Data of patients with SPH treated by interventional radiology between January 1, 2013, and June 1, 2019, who had at least 6 months of clinical follow-up were retrospectively identified from the electronic database at our hospital. Patients were divided into the SAE group (SAE alone), splenic vein stenting-SAE group (SAE immediately after splenic vein stenting failure using the same procedure as the SAE group), and splenic vein stenting group (successful treatment with SVS). Patients' baseline characteristics and follow-up data were retrieved, and their clinical outcomes were compared. RESULTS. Thirty-seven patients with SPH were included. We assigned 11, 12, and 14 patients to the SAE, splenic vein stenting-SAE, and splenic vein stenting groups, respectively. Rebleeding (e.g., hematemesis, melena, or both) was significantly less common (p = .01) in the splenic vein stenting group (7.1% [1/14]) than in the SAE and splenic vein stenting-SAE groups combined (47.8% [11/23]). Splenectomy to resolve rebleeding was not significantly different (p = .63) in the splenic vein stenting group (7.1% [1/14]) compared with the SAE and splenic vein stenting-SAE groups combined (17.4% [4/23]). No interventional procedure-related deaths were observed during follow-up in any group. CONCLUSION. When feasible, splenic vein stenting is a safe and effective treatment of SPH-related gastrointestinal bleeding that appears to better prevent rebleeding than SAE. CLINICAL IMPACT. Splenic vein stenting should be recommended over SAE for the treatment of SPH-related upper gastrointestinal bleeding when possible.

Retrograde artery first approach for "shoulder" pancreatic cancers in minimally invasive distal pancreatectomy.

BACKGROUND: "Shoulder" pancreatic cancer, defined as tumor located at the confluence where the splenic vein meets the portal vein, has specific adjacent anatomies. It's difficult to resect this type of tumor with adequate regional lymphadenectomy. METHODS: We described a new concept of "shoulder" pancreatic cancer, and retrospectively analyzed eleven consecutive cases from September 2019 to April 2020, to assess the safety and efficacy of the retrograde artery first approach in minimally invasive distal pancreatectomy. The primary outcome was set as radical (R0) resection rate. RESULTS: All of the 11 cases achieved R0 resection, with a median of 8 (range 5-32) lymph nodes harvested, given the ratio of embraced splenic vein in 72.7% of the cases, splenic artery embracement in 45.5%, and SMV-PV wall invasion in 27.3%. The maximum tumor size on pathology was 35 (range 20-65) mm. The median operative time was 260 (range 155-470) min, and the median estimated blood loss was 200 (range 50-1000) ml. One case needed intraoperative transfusion. One grade B postoperative pancreatic fistula occurred accompanied with abdominal infection, while the rest of cases recovered uneventful. The median postoperative length of stay was 9 (range 6-20) days. CONCLUSIONS: "Shoulder" pancreatic cancers are clinically significant. Retrograde artery first approach is a potentially safe and effective alternative to achieve a radical resection margin for shoulder pancreatic cancers in minimally invasive era. More evidences are needed in the future.

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

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.

Direct splenic vein reconstruction combined with resection of the portal vein/superior mesenteric vein confluence during pancreaticoduodenectomy.

PURPOSE: Splenic vein (SV) ligation combined with portal vein (PV)/superior mesenteric vein (SMV) confluence resection during pancreaticoduodenectomy (PD) is reported to cause left-side portal hypertension (LPH). The purpose of this study was to present our technique of the SV reconstruction and to evaluate the surgical outcomes with/without SV ligation during PD. METHODS: Twenty-four patients undergoing PD with PV and/or SMV resection and being followed over 4 months after surgery between March 2013 and December 2019 in our hospital were evaluated. Resection of the PV/SMV confluence were performed in 14, and SV reconstruction was successfully performed in 3. Presence of LPH was assessed by examining changes in splenic volume, newly venous collateral formation, and platelet counts before and 4-8 months after PD. Surgical technique is the direct anastomosis between SV and PV. RESULTS: Splenic volume ratio was significantly higher in the SV ligation group (n = 11) than in the SV preservation group (n = 13) (median (range) 1.11 (0.57-1.62) vs. 1.68 (1.05-2.22), p < 0.01), but no significant differences were found in the incidence of newly formed venous collaterals or platelet counts between groups. CONCLUSION: SV ligation may represent the cause of LPH after PD combined with resection of PV/SMV confluence. Our simple procedure may help decrease the incidence of LPH.

Percutaneous treatment of a splenorenal shunt with an atrial septal closure device.

We present the case of a 70-year-old female who underwent liver transplantation in 2011 due to enolic cirrhosis with a normofunction graft and no portal hypertension. During the last months, recurrent hospitalization was needed due to hepatic encephalopathy, in spite of treatment with lactulose and rifaximin. An abdominal computed tomography (CT) showed a large varicose dilatation of the splenic vein up to 14-16 mm, descending by the left abdominal side, communicating with the renal vein with direct drainage into inferior cava vein (ICV).

Retrospective evaluation of risk factors of postoperative varices after pancreaticoduodenectomy with combined portal vein resection.

BACKGROUND: Combined portal vein (PV) resection is performed for pancreatic head cancer to achieve clear resection margins. This can be complicated by the formation of varices due to sinistral portal hypertension after pancreaticoduodenectomy (PD) with combined PV resection. However, clinical strategies to prevent varices formation due to sinistral portal hypertension remain controversial. Moreover, the critical vein among splenic vein (SPV), inferior mesenteric vein, left gastric vein, or middle colonic vein requiring preservation to prevent the development of varices remains unclear. METHODS: We retrospectively analyzed patients with pancreatic cancer who underwent PD with combined PV resection over 18 years at our institution. Varices were evaluated using enhanced computed tomography (CT) and endoscopy. Preoperative types of porto-mesenterico-splenic confluence, venous drainage, and venous resection types were determined by operative records and CT findings. RESULTS: Of the 108 subjects, the incidence of postoperative varices was observed in 24.1% of cases over 5.6 months. These varices were classified into five types based on location, as pancreaticojejunostomy anastomotic (11.5%), gastrojejunostomy anastomotic (11.5%), esophageal (11.5%), splenic hilar-gastric (23.1%), and right colonic (65.4%) varices. No case of variceal bleeding occurred. Multivariate analysis showed SPV ligation as the greatest risk factor of varices (P < 0.001), with a higher incidence of left-sided varices in patients with all the SPV venous drainage sacrificed (60%) than in the others (16.7%). Therefore, sacrificing all the SPV venous drainage was the only independent risk factor of varices (P = 0.049). CONCLUSIONS: Preservation of SPV venous drainage should be considered during SPV ligation to prevent post-PD varices.

Non-cirrhotic Extra-Hepatic Porto-Systemic Shunt Causing Adult-Onset Encephalopathy Treated with Endovascular Closure.

INTRODUCTION: Encephalopathy secondary to hyperammonemia due to Congenital Extra-hepatic Porto-systemic shunt (CEPS) in the absence of liver cirrhosis is an exceptionally unusual condition. We describe the case of a 54-year-old woman admitted to the Emergency Department complaining of recurrent episodes of confusion and worsening cognitive impairment. At admission, the patient displayed slowing cognitive-motor skills with marked static ataxia and impaired gait. Hyperammonemia was detected in the serum. An abdominal computed tomography (CT) excluded portal hypertension and liver cirrhosis, detecting a congenital extra-hepatic porto-systemic shunt which is a highly unusual vascular malformation. The patient was treated by interventional radiologists with a successful endovascular closure. AREAS COVERED: We have performed a review of the last three decades of the literature, starting from the introduction of CT scanning in common clinical practice. Eighteen studies (case reports) described 29 patients with encephalopathy secondary to hyperammonemia due to CEPS in the absence of liver cirrhosis: They underwent treatment similar to our case report of CEPS. EXPERT COMMENTARY: Encephalopathy secondary to hyperammonemia in the absence of hepatic dysfunction is an important diagnostic dilemma to many clinicians. An interventional radiologic approach is currently preferred.

Paneled Saphenous Vein Grafts Compared to Internal Jugular Vein Grafts in Venous Reconstruction after Pancreaticoduodenectomy.

BACKGROUND: Venous resection during pancreaticoduodenectomy for the excision of pancreatic cancer allows for a more complete resection with negative margins, which increases survival. When the resected vein is greater than 3 cm, reconstruction with an interposition graft is recommended. However, consensus regarding the optimal venous conduit has not been reached. The objective of this study is to compare outcomes between the paneled saphenous vein graft (SVG) and internal jugular vein graft (IJVG) in portomesenteric venous reconstructions after pancreaticoduodenectomy. METHOD: A retrospective review was performed of patients undergoing pancreaticoduodenectomy requiring an interposition graft for venous reconstruction between 2011 and 2019. Patients were stratified based on the type of conduit used (paneled SVG or IJVG). Preoperative patient characteristics, reconstruction details, and postoperative outcomes including graft patency were recorded. RESULTS: During the study period, 18 patients met inclusion criteria (10 female, mean age: 63 years, age range: 41-82 years). Thirteen patients underwent reconstruction with paneled SVG and five with IJVG. Comparing SVG and IJVG groups, there were no significant differences in venous resection length, venous diameters at the resection margins, or splenic vein ligation rate. For the paneled SVG, the average length of harvested vein was 168 mm which rendered 3-paneled grafts with an average diameter of 12 mm. The time to complete the venous reconstructions did not differ between the two groups (SVG: 263+/-204 min, IJVG: 216+/-77 min, P = 0.63). There were five graft thrombosis, three in the SVG group (mean follow-up time of 17 months) and two in the IJVG group (mean follow-up time of 8 months). All but one of the graft thromboses occurred during the index hospitalization. There was one donor site seroma and wound dehiscence in the SVG group and none in the IJVG group. Hospital length of stay was longer for the IJVG group (IJVG: 15.2 days, SVG: 10.2 days, P = 0.03). However, in-hospital and late mortality did not differ between the groups. CONCLUSIONS: Paneled SVG and IJVG are both versatile and durable conduits for venous reconstruction after pancreaticoduodenectomy, able to accommodate a wide range of venous defects. In this small series, SVG has comparable outcomes to IJVG. Paneled SVG is a suitable alternative to IJVG for portomesenteric reconstruction.

Surgical treatment of gastric venous congestion in association with extended resection of pancreas: a case report.

BACKGROUND: Total pancreatectomy is performed for chronic pancreatitis, tumors involving the entire pancreas or remnant pancreas after pancreatectomy. Gastric venous congestion and bleeding may be associated with total pancreatectomy. We report the case of a patient who underwent left gastric vein to splenic vein bypass to relieve gastric venous congestion during total pancreatectomy for remnant pancreatic cancer. CASE PRESENTATION: A 60-year-old woman underwent subtotal stomach-preserving pancreaticoduodenectomy for cancer of the pancreatic head. A follow-up computed tomography revealed a low-density tumor of the remnant pancreas. The pathological diagnosis was adenocarcinoma on endoscopic ultrasound-fine needle aspiration. Total resection of the remnant pancreas was performed for the tumor 3 years after the initial surgery. We ligated the splenic vein at the point of distal side of the left gastric vein confluent. Immediately, the vein congestion around the stomach was confirmed. We found the stenosis of the confluent between the left gastric vein and splenic vein. We subsequently anastomosed the left gastric vein and splenic vein, following which the gastric venous congestion was relieved. CONCLUSION: In cases wherein all the drainage veins from the stomach are removed, an anastomosis between the left gastric vein and splenic vein can be effectively used to prevent gastric venous congestion and bleeding after total pancreatectomy.

Coronary Renal Shunt with Splenectomy (CRSS) for Selective Variceal Decompression.

BACKGROUND: Distal splenorenal shunt and coronary caval shunt are commonly used for selective decompression of esophagogastric varices, but they may not solve severe hypersplenism and their application may be hampered by the presence of splenic venous thrombosis or a left gastric vein (LGV) situated deeply behind the pancreas. On the other hand, some patients have an LGV entering the splenic vein (SV). We tried to work out a new selective shunt for this group of patients. METHODS: Sixteen patients with severe hypersplenism and esophagogastric varices received coronary renal shunt using the SV following splenectomy. After splenectomy, the proximal portion of the SV and the LGV was isolated from the pancreas. The isolated SV was divided at a point 3-5 cm left to its junction with the LGV. The proximal orifice was anastomosed to the left renal vein, and the distal orifice was ligated. A clip was applied to the SV for occlusion between the portal vein and LGV. The right gastric and gastroepiploic vessels were divided to block backflow from the portal vein and to reduce the arterial inflow of the varices. RESULTS: No operative mortality or procedure-related complications occurred. Postoperative computed tomography and endoscopy showed that all the shunts were patent and that the varices had been obliterated or markedly alleviated. In the 6-36 months' follow-up period, no recurrent variceal hemorrhage or encephalopathy occurred. CONCLUSION: Coronary renal shunt combined with splenectomy can achieve the goal of selective decompression of esophagogastric varices. It would become an alternative means of selective variceal decompression for patients whose LGV enters the SV.

Risk Factors for Late-Onset Gastrointestinal Hemorrhage After Pancreatoduodenectomy for Pancreatic Cancer.

BACKGROUND: Late-onset gastrointestinal hemorrhage after pancreatoduodenectomy (PD) occasionally occurs repeatedly or leads to a serious condition. This retrospective study aimed to clarify its frequency and pathogenesis. METHODS: A total of 147 consecutive patients who underwent PD for pancreatic cancer between 2006 and 2014 were evaluated. Patients were divided into two groups according to the occurrence of late-onset gastrointestinal hemorrhage on postoperative day 100 or later. Furthermore, recurrence and portal vein (PV) hemodynamics were thoroughly reevaluated by computed tomography. RESULTS: Eleven patients experienced late-onset gastrointestinal hemorrhage. The bleeding sites were gastrojejunostomy in four patients, choledochojejunostomy in two, transverse colic marginal vein in one, and unknown in four. The median occurrence time of late-onset gastrointestinal hemorrhage was 13.3 months after PD. PV occlusion (63.6 vs. 8.9%; p < 0.001), no patency of PV-splenic vein (SPV) confluence (54.5 vs. 12.7%; p = 0.002), and SPV ligation (36.4 vs. 9.6%; p = 0.025) were found to be significant risk factors for late-onset gastrointestinal hemorrhage. Among 11 patients who experienced late-onset gastrointestinal hemorrhage, 7 had PV occlusion and 6 had local recurrence. CONCLUSIONS: Our data suggested for the first time that both oncologic and non-oncologic factors might contribute to late-onset gastrointestinal hemorrhage after PD for pancreatic cancer. Furthermore, PV occlusion, no PV-SPV patency, and SPV ligation were found to be significant risk factors for late-onset gastrointestinal hemorrhage. Therefore, to prevent late-onset gastrointestinal hemorrhage, we must consider various approaches to maintain the patency of the PV and SPV.

Results of portosystemic shunts during extended pancreatic resections.

PURPOSE: Patients with borderline resectable pancreatic cancer are increasingly explored after neoadjuvant treatment protocols. A complete resection, then, frequently includes the resection of the mesentericoportal axis. Portosystemic shunting for advanced tumours with infiltration of the splenic vein or cavernous transformation of the portal vein can enable complete tumour resection and prevent portovenous congestion of the intestine. The aim of this study was to report the results of this technique for selected patients. METHODS: Patients operated for pancreatic cancer at our department between September 2012 and December 2017 using intraoperative portosystemic shunting were included in this retrospective analysis. RESULTS: Some 11 patients with pancreatectomy and simultaneous portosystemic shunting were included. The median age was 65.1 years. A distal splenorenal shunt and a temporary mesocaval shunt were accomplished in 5 and 4 cases, respectively. Two patients were operated using persistent mesocaval shunts (from the coronary, splenic or inferior mesenteric veins). The median operating time was 9.43 h. All but one patient were resected with tumour-negative resection margins; 5 patients had relevant complicated postoperative courses. There was one case of in-hospital mortality but no further 30- or 90-day mortality or graft-associated complications. Five patients were alive after a median follow-up of 24.6 months. The median postoperative survival was 12 months. CONCLUSION: Portosystemic shunting at the time of extended pancreatectomy is technically challenging but feasible and enables complete tumour resection in cases in which standard vascular reconstruction is limited by cavernous transformation or to prevent sinistral portal hypertension with acceptable morbidity in selected cases. Considering the limited overall survival, the potential individual patient benefit needs to be weighed against the considerable morbidity of advanced tumour resections.

Techniques for splenic vein reconstruction after pancreaticoduodenectomy with portal vein resection for pancreatic cancer.

BACKGROUND: Pancreaticoduodenectomy (PD) with splenic vein (SV) ligation may result in sinistral portal hypertension (SPH). The aim of this study was to compare the outcomes of various types of SV reconstruction to prevent SPH and to define the optimal reconstruction method. METHODS: This study included patients who underwent PD with SV resection and reconstruction for pancreatic cancer between December 2013 and June 2017. The patency of various types of SV anastomosis and SPH was evaluated by follow up computed tomography. RESULTS: The type of SV reconstruction was divided into two groups: (i) end-to-side anastomosis (n = 10), in which the SV was anastomosed with either the left renal vein (LRV; n = 8) or portal vein (n = 2); and (ii) end-to-end anastomosis (n = 20), in which the SV was anastomosed with another smaller vein or graft. The patency rate for Group 1 was 90% (9/10), compared with 45% (9/20) for Group 2 (P = 0.024). Half the patients in whom the SV anastomosis was occluded (6/12) developed gastrointestinal varices, whereas only 11% of patients with a patent SV anastomosis (2/9) had varices (P = 0.034). CONCLUSION: SV-LRV reconstruction is widely applicable, effectively reduces the risk of SPH, and should be considered for the case of extended PD.

[Leiomyosarcoma of the splenic vein]. / Leiomiosarkoma selezenochnoi veny.

Vascular leiomyosarcoma (LMS) is an extremely rare disease. Venous lesion is approximately 5 times more common than arterial. LMS is usually found in retroperitoneal veins and in inferior vena cava. Lesion of the splenic vein is extremely rare. A 52-year-old woman with recurrent abdominal pain is reported in the article. Abdominal contrast-enhanced CT revealed a 6 cm tumor of the pancreatic tail. The patient underwent laparoscopic distal pancreatectomy with splenectomy en bloc. Histological and immunohistochemical studies revealed LMS originating from the smooth muscles of the splenic vein. Surgery was followed by adjuvant chemotherapy. There was no local recurrence in 1 year after surgery. In this article, we analyze the available information on leiomyosarcoma of the splenic vein.