Preservation of right gastroepiploic vein to lessen left-sided portal hypertension after pancreaticoduodenectomy with combined portal vein resection

Abstract

Background: In pancreaticoduodenectomy (PD) resection of portal vein (PV) and superior mesenteric vein (SMV) confluence, splenic vein (SV) and inferior mesenteric vein (IMV) division may cause left sided portal hypertension (LPH). Preservation of right gastroepiploic vein (RGEPV) may reduce congestion of the stomach and spleen after PD with concomitant vascular resection. Methods: The 42 of 133 pancreatic ductal adenocarcinoma patients who underwent PD with concomitant vascular resection between January 2008 and September 2018 were included in this retrospective study. These patients were classifed into 4 groups: SV and IMV were preserved Group A (n = 22), SV and IMV were divided in GroupB (n = 5) , SV was divided in Group C (n = 10), SV and IMV were divided and RGEPV was preserved in GroupD (n = 5) The venous flow pattern from the spleen and splenic hypertrophy were examined after surgery. Results: The spleen volume ratio at 6months after operation comparing to preoperative value was 1.00, 1.4, 1.00, 1.03 in Group A, B, C and D, respectively (Group B vs. A, C and D: p < 0.01, p < 0.01 and p < 0.03). The incidence of postoperative varices and congestion in Group A, B, C and D was 0, 75, 0 and 0%, respectively (p < 0.001). Gastric remnant venous congestion and bleeding ocured only in Group B (n = 4), and esophageal varices without hemorrhagic potential occured only in Group B (n = 4). LPH associated findings were less frequently observed when left gastric vein -portal vein and IMV-SV confluences were preserved, even if SV was divided. Preservasion of EGEPV may be effective against the LPH when SV , LGV and IMV were divided. Conclusion: In PD with resection of PV-SMV confluence, SV and IMV division causes LPH, but concomitant preservation of RGEPV may attenuate LPH.