Arterio-venous fistula as a late complication after distal pancreatectomy with EN BLOC splenic vessels ligation: myth or reality?

Abstract

Background: Distal pancreatectomy (DP) procedure with splenectomy includes ligation of splenic artery and vein. According to the literature, en bloc ligation of the splenic vessels may result in development of arterio-venous (AV) fistula with subsequent portal hypertension and related complications. This study reviews our experience with en bloc splenic vessel ligation along with pancreatic division during DP. Methods: A retrospective review of medical records of patients undergoing DP and splenectomy from 08/2008 to 09/2017 was performed to identify patients with en bloc ligation of splenic vessels and pancreas performed by the gradual stepwise compression technique. Results: Of 291 patients undergoing DP, 139 (47.8%) met inclusion criteria. Previous upper abdominal surgeries were noted in 25.9% of patients. Laparoscopic approach was utilized in majority of patients (90.6%) and splenic vessels with pancreas were transected en bloc with a linear stapler in all cases. Conversion to open surgery was necessitated in five patients due to technical difficulties. Mean operative time was 161.5 min and no reoperation was required. Mean length of hospital stay was noted to be 4.1 days. 90-day overall major morbidity was noted in 10 patients (7.2%). One patient developed delayed gastric empting and pancreatic fistulas were identified in five patients. All six cases were managed conservatively. Two mortalities were seen in patients with advance age and multiple medical comorbidities. No AV fistula was seen in long term follow up. Conclusion: DP and splenectomy with en bloc splenic vessels ligation is safe and does not result in AV fistula formation.Table 2Patient characteritics and outcomes after Distal pancrealectomy with En Bloc ligation of splenic vesselsCharacteristicPt (n = 139)Age, y62.7 (14.5)BMI, kg/m227.9 (5.8)Male74 (53.2)History of pancreatitis18 (12.9)Previous upper abd. surgeries36 (25.9)ASA class I1 (0.7) II39 (28.1) III92 (66.2) IV7 (5.0)Resection type Laparoscopic126 (90.6) Hand-assisted6 (4.4) Open7 (5.0)Conversion5 (3.6)Operative time, min161.5 (77.3)EBL, ml187.4 (356.1)Reoperation0 (0.0)LOS, d4.1 (5.1)90-day morbidity Minor (Cl grade I-II)31 (22.3) Major (Cl grade III-V)10 (7.2) CR-DGE1 (0.8) CR-POPF5 (3.6)PPH3 (2.2) A2 (1.4) B1 (0.8)Death2 (1.4)AV fistula of splenic vessels0 (0.0)Abbreviations: ASA, American Society of Anesthesiologists; BML, body mass index; CI, Clavien-Dindo classification; CORP, chronic obstructive respiratory pathology; EBL, estimated blood loss: LOS, length of stay; CS DGE, clinically significant delayed gastric empty; CS PF, clinically significant pancreatic fistula; PPH, post pancreatectomy hemorrhage; AV, arterio-venous.Values are mean (SD) or No. of patients (%). Open table in a new tab Abbreviations: ASA, American Society of Anesthesiologists; BML, body mass index; CI, Clavien-Dindo classification; CORP, chronic obstructive respiratory pathology; EBL, estimated blood loss: LOS, length of stay; CS DGE, clinically significant delayed gastric empty; CS PF, clinically significant pancreatic fistula; PPH, post pancreatectomy hemorrhage; AV, arterio-venous. Values are mean (SD) or No. of patients (%).