SELECTIVE DEVASCULARIZATION OF THE GASTRIC FUNDUS IN PATIENTS WITH CHRONIC PANCREATITIS AND HEPATIC PORTAL HYPERTENSION. Case Series Preliminary Report
Abstract
Background. Making treatment / prevention decisions in bleeding from gastroesophageal varices in patients with subhepatic portal hypertension remains challenging and thus requires further research. Objective. To perform a preliminary analysis of the outcomes of selective devascularization of the gastric fundus in patients with chronic pancreatitis and subhepatic portal hypertension. Material and methods. Selective devascularization of the gastric fundus was performed in five patients (3 men and 2 women) aged 23 to 54 with chronic recurrent pancreatitis and subhepatic portal hypertension. In 2 patients, Roux-en-Y cystojejunostomy for pancreatic pseudocyst was performed as the main treatment, and in 3 patients - Frey's surgery. Selective devascularization of the gastric fundus was adjuvant to a draining surgery or a resection-draining one. Results. All patients underwent surgery successfully. The duration of the operation (Me [min; max]) was 205 [190; 255] min. The time spent in the Department of anesthesiology, resuscitation and intensive care comprised 1 [1; 2] days. Postoperative follow-up of these patients over the period of 17 - 58 months detected no recurrence of bleeding from gastric varices. Endoscopy performed a year after revealed a decrease in the size of esophageal varices in all patients. Conclusions. The proposed technique of selective devascularization of the gastric fundus is substantiated by numerous studies of the variant anatomy of venous outflow from the spleen in extrahepatic portal hypertension. This technique is regarded as adjuvant to a draining surgery or a resection-draining one in patients with chronic pancreatitis and subhepatic portal hypertension performed to prevent bleeding from gastric fundus varices. There should be noted the reproducibility of this surgical intervention, its effectiveness and safety. Further research on the efficiency of the technique using randomized controlled trials is required.References
Garcia-Pagán JC, Hernández-Guerra M, Bosch J. Extrahepatic portal vein thrombosis. Semin Liver Dis. 2008;28(3):282-92. https://doi.org/10.1055/s-0028-1085096.
Latorre Fragua RA, Manuel Vazquez A, Lopez Marcano AJ, Gijón de la Santa L, de la Plaza Llamas R, Ramia Ángel JM. Pancreatic Surgery in Chronic Pancreatitis Complicated by Extrahepatic Portal Hypertension or Cavernous Transformation of the Portal Vein: A Systematic Review. Scand J Surg. 2019;109(6):1-10. https://doi.org/10.1177/1457496919857260.
Zheng K, Guo X, Feng J, Bai Z, Shao X, Yi F, Zhang Y, Zhang R, Liu H, Romeiro FG, Qi X. Gastrointestinal Bleeding due to Pancreatic Disease-Related Portal Hypertension. Gastroenterol Res Pract. 2020;2020(2):3825186. https://doi.org/10.1155/2020/3825186.
Pal S, Mangla V, Radhakrishna P, Sahni P, Pande GK, Acharya SK, Chattopadhyay TK, Nundy S. Surgery as primary prophylaxis from variceal bleeding in patients with extrahepatic portal venous obstruction. J Gastroenterol Hepatol. 2013;28(6):1010-4. https://doi.org/10.1111/jgh.12123.
Zhang Z, Chen X, Li C, Feng H, Yu H, Zhu R, Wang T. Safety and Efficacy of a Novel Shunt Surgery Combined with Foam Sclerotherapy of Varices for Prehepatic Portal Hypertension: A Pilot Study. Clinics (Sao Paulo). 2019;74:e704. https://doi.org/10.6061/clinics/2019/e704.
Ławniczak M, Raszeja-Wyszomirska J, Marlicz W, Białek A, Wiechowska-Kozłowska A, Lubikowski J, Wójcicki M, Starzyńska T. Nawracajace krwawienia z zylaków przełyku u chorej z zakrzepica zyły wrotnej i sledzionowej w przebiegu złozonej trombofilii [Recurrent variceal bleeding in a patient with portal and splenic vein thrombosis secondary to complex thrombophilia]. Pol Merkur Lekarski. 2008;25(146):150-2. (Polish).
Mahiliavets EV, Batvinkov NI, inventors; Mahiliavets EV, Batvinkov NI, assignee. Sposob profilaktiki krovotechenij iz varikozno rasshirennyh ven pishhevoda i zheludka pri podpechenochnoj portalnoj gipertenzii na fone hronicheskogo pankretita : BY patent 21339. 2017 Nov 30. (Russian).
Butler JR, Eckert GJ, Zyromski NJ, Leonardi MJ, Lillemoe KD, Howard TJ. Natural history of pancreatitis-induced splenic vein thrombosis: a systematic review and meta-analysis of its incidence and rate of gastrointestinal bleeding. HPB (Oxford). 2011;13(12):839-45. https://doi.org/10.1111/j.1477-2574.2011.00375.x.
Shah SR, Deshmukh HL, Mathur SK. Extensive portal and splenic vein thrombosis: differences in hemodynamics and management. Hepatogastroenterology. 2003;50(52):1085-9.
Sharma M, Rameshbabu CR. Collateral pathways in portal hypertension. J Clin Exp Hepatol. 2012;2(4):338-52. https://doi.org/10.1016/j.jceh.2012.08.001.
Menon KV, Kamath PS. Regional and systemic hemodynamic disturbances in cirrhosis. Clin Liver Dis. 2001;5(3):617-27. https://doi.org/10.1016/s1089-3261(05)70184-7.
Cichoz-Lach H, Celiński K, Słomka M, Kasztelan- Szczerbińska B. Pathophysiology of portal hypertension. J Physiol Pharmacol. 2008;59(Suppl 2):231-238.
Moubarak E, Bouvier A, Boursier J, Lebigot J, Ridereau-Zins C, Thouveny F, Willoteaux S, Aubé C. Portosystemic collateral vessels in liver cirrhosis: a three-dimensional MDCT pictorial review. Abdom Imaging. 2012;37(5):746-66. https://doi.org/10.1007/s00261-011-9811-0.
Koito K, Namieno T, Nagakawa T, Morita K. Balloon-occluded retrograde transvenous obliteration for gastric varices with gastrorenal or gastrocaval collaterals. AJR Am J Roentgenol. 1996;167(5):1317-1320. https://doi.org/10.2214/ajr.167.5.8911204.
Wind P, Alves A, Chevallier JM, Gillot C, Sales JP, Sauvanet A, Cuénod CA, Vilgrain V, Cugnenc PH, Delmas V. Anatomy of spontaneous splenorenal and gastrorenal venous anastomoses. Review of the literature. Surg Radiol Anat. 1998;20(2):129-34. https://doi.org/10.1007/s00276-998-0129-8.
Sarin SK, Agarwal SR. Extrahepatic portal vein obstruction. Semin Liver Dis. 2002;22(1):43-58. https://doi.org/10.1055/s-2002-23206.
Shin SM, Kim S, Lee JW, Kim CW, Lee TH, Lee SH, Kim GH. Biliary abnormalities associated with portal biliopathy: evaluation on MR cholangiography. AJR Am J Roentgenol. 2007;188(4):341-347. https://doi.org/10.2214/AJR.05.1649.
Sharma M. Bleeding after endoscopic biliary sphincterotomy. J Clin Exp Hepatol. 2011;1(1):45-47. https://doi.org/10.1016/S0973-6883(11)60117-5.
Widrich WC, Srinivasan M, Semine MC, Robbins AH. Collateral pathways of the left gastric vein in portal hypertension. AJR Am J Roentgenol. 1984;142(2):375-382. https://doi.org/10.2214/ajr.142.2.375.
Kamel IR, Lawler LP, Corl FM, Fishman EK. Patterns of collateral pathways in extrahepatic portal hypertension as demonstrated by multidetector row computed tomography and advanced image processing. J Comput Assist Tomogr. 2004;28(4):469-77. https://doi.org/10.1097/00004728-200407000-00006.
Ishigami K, Sun S, Berst MJ, Heery SD, Fajardo LL. Portal vein occlusion with aberrant left gastric vein functioning as a hepatopetal collateral pathway. J Vasc Interv Radiol. 2004;15(5):501-504. https://doi.org/10.1097/01.rvi.0000126810.67111.ca.
Jung SC, Lee W, Chung JW, Jae HJ, Park EA, Jin KN, Shin CI, Park JH. Unusual causes of varicose veins in the lower extremities: CT venographic and Doppler US findings. Radiographics. 2009;29(2):525-536. https://doi.org/10.1148/rg.292085154.
Hashimoto M, Heianna J, Yasuda K, Tate E, Watarai J, Shibata S, Sato T, Yamamoto Y. Portal flow into the liver through veins at the site of biliary-enteric anastomosis. Eur Radiol. 2005;15(7):1421-1425. https://doi.org/10.1007/s00330-005-2667-3.
Seeger M, Günther R, Hinrichsen H, Both M, Helwig U, Arlt A, Stelck B, Bräsen JH, Sipos B, Schafmayer C, Braun F, Bröring DC, Schreiber S, Hampe J. Chronic portal vein thrombosis: transcapsular hepatic collateral vessels and communicating ectopic varices. Radiology. 2010;257(2):568-578. https://doi.org/10.1148/radiol.10100157.
Ibukuro K, Ishii R, Fukuda H, Abe S, Tsukiyama T. Collateral venous pathways in the transverse mesocolon and greater omentum in patients with pancreatic disease. AJR Am J Roentgenol. 2004;182(5):1187-1193. https://doi.org/10.2214/ajr.182.5.1821187.
Rosado ID, Bhalla S, Sanchez LA, Fields RC, Hawkins WG, Strasberg SM. Pattern of Venous Collateral Development after Splenic Vein Occlusion in an Extended Whipple Procedure (Whipple at the Splenic Artery) and Long-Term Results. J Gastrointest Surg. 2017;21(3):516-526. https://doi.org/10.1007/s11605-016-3325-6.
Hattori M, Fujii T, Yamada S, Inokawa Y, Suenaga M, Takami H, Kanda M, Sugimoto H, Nomoto S, Murotani K, Nakao A, Kodera Y. Significance of the Splenic Vein and Its Branches in Pancreatoduodenectomy with Resection of the Portal Vein System. Dig Surg. 2015;32(5):382-8. https://doi.org/10.1159/000438797.
Tanaka H, Nakao A, Oshima K, Iede K, Oshima Y, Kobayashi H, Kimura Y. Splenic vein reconstruction is unnecessary in pancreatoduodenectomy combined with resection of the superior mesenteric vein-portal vein confluence according to short-term outcomes. HPB (Oxford). 2017;19(9):785-792. https://doi.org/10.1016/j.hpb.2017.02.438.
Tanaka M, Ito H, Ono Y, Matsueda K, Mise Y, Ishizawa T, Inoue Y, Takahashi Y, Hiratsuka M, Unno T, Saiura A. Impact of Portal Vein Resection with Splenic Vein Reconstruction after Pancreatoduodenectomy on Sinistral Portal Hypertension: Who Needs Reconstruction? Surgery. 2019;165(2):291-297. https://doi.org/10.1016/j.surg.2018.08.025.
Yu X, Bai X, Li Q, Gao S, Lou J, Que R, Yadav DK, Zhang Y, Li H, Liang T. Role of Collateral Venous Circulation in Prevention of Sinistral Portal Hypertension after Superior Mesenteric-Portal Vein Confluence Resection During Pancreaticoduodenectomy: A Single-Center Experience. J Gastrointest Surg. 2019;24(9):2054-2061. https://doi.org/10.1007/s11605-019-04365-z.
Kamimura H, Ishikawa T, Ishihara N, Terai S. Specific Gastric Blood Vessels in Sinistral Portal Hypertension. Intern Med. 2018;57(7):1053-1054. https://doi.org/10.2169/internalmedicine.9699-17.
Tsukamoto T, Ikuta T, Uenishi T, Shuto T, Tanaka H, Kubo S, Hirohashi K, Kinoshita H. Laparoscopic Splenectomy for Variceal Bleeding with Non-Cirrhotic Portal Vein Thrombosis: A Case Report. Hepatogastroenterology. 2003;50(50):574-576.
Hayashi H, Shimizu A, Motoyama H, Kubota K, Notake T, Ikehara T, Yasukawa K, Kobayashi A, Soejima Y. Left- sided Portal Hypertension Caused by Idiopathic Splenic Vein Stenosis Improved by Splenectomy: A Case Report. Surg Case Rep. 2020;6(1):148. https://doi.org/10.1186/s40792-020-00912-y.
Tsamalaidze L, Stauffer JA, Brigham T, Asbun HJ. Postsplenectomy Thrombosis of Splenic, Mesenteric, and Portal Vein (PST-SMPv): A Single Institutional Series, Comprehensive Systematic Review of a Literature and Suggested Classification. Am J Surg. 2018;216(6):1192- 1204. https://doi.org/10.1016/j.amjsurg.2018.01.073.
Mada PK, Castano G, Joel Chandranesan AS. Invasive Group B Streptococcal Infection with Toxic Shock-Like Syndrome in a Postsplenectomy Patient. Case Rep Infect Dis. 2020:4048610. https://doi.org/10.1155/2020/4048610.
Lee J-H, Han H-S, Kim H-A, Koo M-Y. Long-term Results of Fundectomy and Periesophagogastric Devascularization in Patients with Gastric Fundal Variceal Bleeding. World J Surg. 2009;33(10):2144-2149. https://doi.org/10.1007/s00268-009-0153-9.
Zuiki T, Hosoya Y, Sakuma Y, Hyodo M, Lefor AT, Sata N, Nagamine N, Isoda N, Sugano K, Yasuda Y. Laparoscopic Gastric Devascularization without Splenectomy is Effective for the Treatment of Gastric Varices. Int J Surg Case Rep. 2016;19:119-123. https://doi.org/10.1016/j.ijscr.2015.12.036.
Overhaus M, Park LG, Fimmers R, Glowka TR, van Beekum C, Manekeller S, Kalff JC, Schaefer N, Vilz T. The Devascularisation Procedure for the Treatment of Fundic and Oesophageal Varices in Portal Hypertension - A Retrospective Analysis of 55 Cases. Zentralbl Chir. 2018;143(5):480-487. https://doi.org/10.1055/a-0710-5095.
