Left-sided Portal Hypertension Research Articles

Left-sided portal hypertension caused by peripancreatic lymph node tuberculosis misdiagnosed as pancreatic cancer: a case report and literature review

BackgroundLeft-sided portal hypertension (LSPH) is an extremely rare clinical syndrome, and it is the only form of curable portal hypertension. It is primarily caused by pancreatic disease, and is associated with complications that cause spleen vein compression. Specific symptoms are often lacking, rendering it difficult to diagnose. Splenectomy is the main treatment for cases complicated by variceal bleeding, and the effects of treatment primarily depend on the condition of the primary disease.Case presentationThe patient was a 29-year-old woman who was admitted to the hospital for repeated hematemesis and black stool. She had been misdiagnosed with pancreatic cancer 7 years prior. Combined imaging and endoscopic examination indicated varicose gastric fundus veins, a pancreatic mass, and enlarged peripancreatic lymph nodes. Laboratory investigations revealed reduced erythrocyte, platelet, and leukocyte counts, the interferon gamma release assay was positive, and liver function was normal. Abdominal exploration, splenectomy, varicose vein dissection, and lesion resection were performed via laparotomy. Postoperative biopsy analysis confirmed the diagnosis of lymph node tuberculosis. Based on the above-described factors, LSPH caused by peripancreatic lymph node tuberculosis was a diagnosed.ConclusionsHerein we describe the first reported case of LSPH caused by peripancreatic lymph node tuberculosis. When left portal hypertension occurs simultaneously, peripancreatic lymph node tuberculosis is often misdiagnosed as pancreatic cancer. Further studies are necessary to develop a more favorable diagnostic method for pancreas masses and more advantageous therapy for LSPH, especially in cases caused by mechanical compression.

Left-Sided Portal Hypertension: A Case Series

Left-sided portal hypertension is rarely found, but this condition may cause gastrointestinal tract bleeding and can be life-threatening. The exact incidence of left-sided portal hypertension is unknown as it is rarely found, approximately 1-5%, and most cases were misdiagnosed. We reported 3 cases of left-sided portal hypertension in male patient aged 34 years old, female patient aged 29 years old, and female patient aged 35 years old. Most diagnosis was made based on the clinical findings by excluding the diagnosis of cirrhotic portal hypertension. Splenic vein angiography remains the gold standard in diagnosing left sided portal hypertension. Left-sided portal hypertension is difficult to differentiate from cirrhotic portal hypertension because in these both abnormalities, varices can be present. Left-sided portal hypertension can be considered as a diagnosis in patient with upper gastrointestinal tract bleeding due to oesophageal varices, gastric varices, or portal hypertension gastropathy, accompanied with hypersplenism without the presence of hepatic abnormality or cirrhosis.

Left-sided portal hypertension after pancreatoduodenectomy with resection of the portal/superior mesenteric vein confluence. Results of a systematic review

BackgroundPancreatoduodenectomy with synchronous resection of the portal vein/superior mesenteric vein confluence may result in the development of left-sided portal hypertension. Left-sided portal hypertension presents with splenomegaly and varices and may cause severe gastrointestinal bleeding. The aim of the study is to review the incidence, treatment, and preventive strategies of left-sided portal hypertension. MethodsA systematic literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to identify all studies published up to September 30, 2019 reporting data on patients with left-sided portal hypertension after pancreatoduodenectomy with venous resection. ResultsEight articles including 829 patients were retrieved. Left-sided portal hypertension occurred in 7.7% of patients who had splenic vein preservation and 29.4% of those having splenic vein ligation. Fourteen cases of gastrointestinal bleeding owing to left-sided portal hypertension were reported at a mean interval of 28 months from pancreatoduodenectomy. Related mortality at 1 month was 7.1%. Treatment of left-sided portal hypertension consisted of splenectomy in 3 cases (21%) and colectomy in 1 (7%) case, whereas radiologic, endoscopic procedures or conservative treatments were effective in the other cases (71%). ConclusionLeft-sided portal hypertension represents a potentially severe complication of pancreatoduodenectomy with venous resection occurring at greater incidence when the splenic vein is ligated and not reimplanted. Left-sided portal hypertension-related gastrointestinal bleeding although rare can be managed depending on the situation by endoscopic, radiologic procedures or operative intervention with low related mortality.

Left-sided portal hypertension caused by idiopathic splenic vein stenosis improved by splenectomy: a case report

BackgroundSplenic vein stenosis and occlusion, which are known causes of left-sided portal hypertension, often occur secondary to trauma, pancreatitis, or invasion or compression by pancreatic tumors. However, few reports have described idiopathic splenic vein stenosis.Case presentationA 70-year-old man was referred to our hospital for examination of isolated gastric varices. He had no history of liver disease, pancreatitis, or abdominal trauma. Computed tomography revealed stenosis of almost the entire length of the splenic vein, and development of gastric fundal and short gastric varices. No inflammatory changes or neoplastic lesions of the pancreas were observed in any imaging study. The patient was diagnosed with left-sided portal hypertension caused by idiopathic splenic vein stenosis, and splenectomy was performed. The postoperative course was smooth, and improvement of the gastric varices was shown by upper gastrointestinal endoscopy at 3 months after the operation.ConclusionsIdiopathic splenic vein stenosis is an extremely rare cause of left-sided portal hypertension. Splenectomy is one of the most effective treatments for left-sided portal hypertension caused by idiopathic splenic vein stenosis.

Colonic varices treated with embolization after pancreatoduodenectomy with portal vein resection: a case report

BackgroundPancreatoduodenectomy with resection of the portal vein or superior mesenteric vein confluence has been safely performed in patients with pancreatic head cancer associated with infiltration of the portal vein or superior mesenteric vein. In recent years, left-sided portal hypertension, a late postoperative complication, has received focus owing to increased long-term survival with advances in chemotherapy. Left-sided hypertension may sometimes cause fatal gastrointestinal bleeding because of the rupture of gastrointestinal varices. Here, we present a case of colonic varices caused by left-sided portal hypertension after pancreatoduodenectomy with portal vein resection.Case presentationA 69-year-old man diagnosed with pancreatic head cancer was referred to our department for surgery after undergoing chemotherapy with nine courses of gemcitabine and nab-paclitaxel. Computed tomography showed a mass 25 mm in diameter and in contact with the portal vein. He had undergone subtotal stomach-preserving pancreatoduodenectomy with portal vein resection. Four centimeters of the portal vein had been resected, and end-to-end anastomosis was performed without splenic vein reconstruction. We had to completely resect the right colic vein, accessary right colic vein, and middle colic vein due to tumor invasion. The pathological diagnosis was ypT3, ypN1a, ypM0, and ypStageIIB, and he was administered TS-1 as postoperative adjuvant chemotherapy. Seven months after therapeutic radical surgery, he presented with melena with progressive anemia. Computed tomography revealed transverse colonic varices. He was offered interventional radiology. Trans-splenic arterial splenic venography showed that transverse colonic varices had developed as collateral circulation of the splenic vein and inferior mesenteric vein system. An embolic substance was injected into the transverse colonic varices, which halted the progression of the anemia caused by melena. Fifteen months after therapeutic radical surgery, local recurrence of the tumor occurred; he died 28 months after the surgery.ConclusionsWhen subtotal stomach-preserving pancreatoduodenectomy with portal vein resection is performed without splenic vein reconstruction, colonic varices may result from left-sided portal hypertension. Interventional radiology is an effective treatment for gastrointestinal bleeding due to colonic varices, but it is important to be observant for colonic necrosis and new varices.

Gastrointestinal Bleeding due to Pancreatic Disease-Related Portal Hypertension.

Background and Aims Left-sided portal hypertension (LSPH) is a rare type of portal hypertension, which occurs due to obstruction, stenosis, or thrombosis within the splenic vein. Pancreatic diseases are the most common etiology of LSPH. This study is aimed at reporting our experiences and discussing the presentation, management, and prognosis of LSPH secondary to pancreatic diseases. Patients and Methods. We retrospectively reviewed five patients who were diagnosed with LSPH secondary to pancreatic diseases at our department. We collected the demographic information, history, comorbidities, clinical presentations, laboratory tests, esophagogastroduodenoscopy (EGD), images, and outcome data. Results Three elderly patients (>60 years old) were diagnosed with pancreatic cancer, of whom one underwent laparoscopic radical distal pancreatectomy and splenectomy, one received chemotherapy, and another one chose conservative management due to multiple systemic metastases. Two younger patients (<40 years old) were diagnosed with acute recurrent pancreatitis and chronic pancreatitis. Four of these five included patients presented with hematemesis and/or melena at our admission. All patients had gastric varices, and one of them also had esophageal varices. One elderly patient with metastatic pancreatic cancer underwent endoscopic variceal treatment as a rescue therapy but finally died of refractory gastrointestinal (GI) bleeding; another younger patient with chronic pancreatitis died of massive GI bleeding; and the remaining three patients survived at their last follow-up. Conclusions LSPH should be seriously taken into consideration in patients with pancreatic diseases who develop upper GI bleeding. Clinicians should individualize the treatment strategy of LSPH according to the patients' clinical conditions and nature of pancreatic diseases.

A73 PHARYNGEAL VARICES AS A COMPLICATION OF PORTAL HYPERTENSION: A CASE SERIES

Abstract Background One of the complications of portal hypertension, with or without the presence of cirrhosis, is the development of varices along the length of the gastrointestinal tract. The commonest sites are along the esophagus or in the stomach. Ectopic varices in the small and large bowels can also be observed, but ectopic varices in the pharynx are extremely uncommon. Aims To present a case series and review the literature regarding pharyngeal varcies. Methods - Results Three elderly female patients presented for esophagogastric varices surveillance gastroscopy were diagnosed with pharyngeal varices. One patient has hepatitis C cirrhosis, while the other two non-cirrhotic patients have myeloproliferative neoplasm (MPN). None of the patients had thromboses of the portal vein or its tributaries. All three patient have concomitant esophageal varices, but only one required band ligation of her esophageal varices. All patients are asymptotic except for mild dysphagia. No patient has bled from their pharyngeal varices to date. Two patients have had prophylactic treatment of their portal hypertension with non-selective beta blocker (NSBB), while the third one has not received NSBB prophylaxis because of her age. Conclusions Pharyngeal varices are extremely rare. To date, there are three case reports in the literature, however, we have been able to identify three cases in our practice. The previous two cases reported possible left-sided portal hypertension with splenic vein thrombosis, leading to the development of collateral vessels including a gastrocaval shunt, which by some contiguous route connects to the brachiocephalic vein; and a third case was a complication of neck dissection surgery. In our case series, none of our patients had splenic vein thrombosis. However, none of them has had a careful CT angiogram to delineate the portal vein tributaries and the collateral vessels, which may further help to define their pathogenesis. It is unclear whether NSBB would be effective as primary prophylaxis against their bleeding, The plan is to continue to monitor these patients to learn about the natural history of these pharyngeal varices. Funding Agencies None

Vascular Complications of Splenectomy in a Patient with Gastric Dieulafoy-like Lesions in Left-sided Portal Hypertension Secondary to Splenic Vein and Artery Thrombosis

Due to lower clinical significance, the management of Dieulafoy and Dieulafoy-like lesions is less commonly reported than the management of their impending venous equivalent, variceal bleeding. Though Dieulafoy and Dieulafoy-like lesions are often benign, they can become life-threatening in certain clinical scenarios, especially with substantial changes in hemodynamic blood flow, which results in hemorrhage. Post-procedural hemodynamic blood flow should be carefully monitored in patients who receive procedures that drastically alter hemodynamic flow pressures. Factoring in the presence of Dieulafoy and Dieulafoy-like lesions might deepen the complexity of an intuitive surgical or interventional procedure for an experienced operator, and should, therefore, involve the cooperative effort between surgical, interventional, and diagnostic services to appropriately manage the patients. The case we present demonstrates the dire consequences of a routine splenectomy when a considerable change in hemodynamic pressure across benign Dieulafoy-like lesions occurs in a patient with both splenic artery and venous thrombosis.

Pancreatic tumor removal cured intractable gastric antral vascular ectasia due to the left-sided portal hypertension caused by the tumor

Pancreatic tumor removal cured intractable gastric antral vascular ectasia due to the left-sided portal hypertension caused by the tumor

3139 Variceal Bleeding, Beyond the Liver Disease: Case Report

INTRODUCTION: Varices are dilated blood vessels in the esophagus or stomach caused by portal hypertension. They cause no symptoms unless they rupture and bleed, which can be life-threatening (1). We report unusual cause of variceal bleeding which is polycythemia rubra Vera causing splenic vein thrombosis. Splenic vein thrombosis (SVT) is known as one of the rare causes of upper gastrointestinal bleeding and is mostly seen in the fifth decade of life and male sex (2). CASE DESCRIPTION/METHODS: 39 years old Lady presented to the emergency room with history of hematemesis and melena for 2 days. She had chronic headache for that she is advised to take paracetamol but did not work, so she took ibuprofen. She had more epigastric pain for which she took continuous ibuprofen too. She never had symptoms of dizziness, black out/syncope or palpitations with/without standing. Although she had active hematemesis and melena but her hemoglobin never dropped below 10 g/dl. She had no history of any chronic illness or surgical intervention. She was not smoker and denied alcohol intake. Gastroscopy revealed: Esophagus: normal, no varices Stomach: full of blood and there is large clot in the fundus. Large fundal varices (tortuous and complex). Isolated gastric varices IGV1: 2 large FIII ulcer seen in the fundus with one visible blood vessel seen on one gastric fold just near to gastroesophageal junction (Dieulafoy's lesion) which is typical for location. One rubber band was applied on the visible vessel. 1 mg histoacryl was injected in varices and hemostasis is maintained. Duodenum: normal. DISCUSSION: isolated obstruction (mainly due to thrombosis) of the splenic vein usually results in left-sided portal hypertension and isolated fundal varices formation. This syndrome is a rare cause of gastrointestinal bleeding. Pancreatic diseases are among the most common etiologies of splenic vein obstruction. Renal disorders are rarely reported as a cause of splenic vein thrombosis 3. We screen for most thrombophilia causes (Table 1). So, we deal with patient with Non cirrhotic liver. Isolated splenic vein thrombosis. Massive splenomegaly Negative hemophilia screen. No evidence of pancreatitis or pancreatic mass on cross sectional imaging. When we review her lab we noted that she had persistently high WBC, platelet and Hematocrit despite GI bleeding, so we screened for myeloproliferative Disorders, and we found mutation for JAK 2 exon 12 is positive. And this patient met the WHO criteria for polycythemia Vera. thrombophilia screen negative.

2159 Endoscopic Management of Isolated Gastric Varices: Hematemesis in Pancreatitis-Induced Splenic Vein Thrombosis

INTRODUCTION: Brisk upper GI bleeding with acute blood loss anemia requires emergent endoscopic evaluation. Often, lesions are due to peptic ulcer disease or variceal hemorrhage. Here, we present a case of isolated bleeding gastric varices in a patient with splenic vein thrombosis likely due to recurrent episodes of acute pancreatitis. CASE DESCRIPTION/METHODS: A 48-year-old man with alcohol abuse, thrombocytopenia, and chronic LUQ abdominal pain presented with four days of hematemesis and melena. He intermittently takes PPI, but reported no NSAID use or history of H. pylori. Previously, two similar episodes associated with severe epigastric pain radiating to his back occurred with heavy drinking. On exam, he is hemodynamically stable with an unremarkable abdominal exam. His admission hemoglobin is 4.9 g/dl and BUN is 26 mg/dl. He is resuscitated with blood products and EGD reveals type 1 isolated gastric varices (IGV) in the fundus with stigmata of recent bleed (Figure 1). Subsequent EUS confirms presence of fundal varices. Hemostasis is achieved with coiling and cyanoacrylate (CYA) glue (Figures 2 and 3). CT A/P shows splenomegaly with chronic splenic vein thrombosis with collateral gastric varices. On discharge, he is counseled on alcohol cessation, as his bleeding gastric varices were attributable to pancreatitis-induced splenic vein thrombosis (PISVT). DISCUSSION: PISVT is a sequalae of acute and chronic pancreatitis. The pathophysiology is centered on left-sided portal hypertension with collateral blood flow developing in the splenoportal or gastroepiploic systems. Most patients with subsequent IGV are asymptomatic, but in high-risk symptomatic groups, EUS guided CYA glue injection and intravascular coil embolization is an emerging therapy that has the potential to achieve higher rates of hemostasis and lower rebleeding rates compared to sclerotherapy or balloon-occluded retrograde transvenous obliteration. A recent study demonstrated that out of 100 patients who underwent EUS-guided coil and CYA glue injection, 93 had complete obliteration (on Doppler study) of gastric fundal varices on follow-up EUS examination (Bhat, GIE 2016). Patients who do not achieve hemostasis after CYA injection and coil should be considered for splenic artery embolization or splenectomy, which is currently the gold standard for management of splenic vein thrombosis complicated by variceal hemorrhage. A large comparison trial would be most beneficial to validate this treatment modality compared to existing conventional therapies.

Treatment of bleeding from a portion of pancreatojejunostomy after pancreaticoduodenectomy with division of the splenic vein: two case reports

BackgroundThere is no definitive strategy for gastrointestinal bleeding due to left-sided portal hypertension after pancreaticoduodenectomy (PD) for pancreatic cancer (PC) with concomitant portal vein resection (PVR).Case presentationCase 1: A 70-year-old woman underwent a PD for PC with PVR. Seven years after her surgery, she suffered severe anemia with suspected gastrointestinal bleeding. Computed tomography scan (CT) revealed varices at a portion of the pancreaticojejunostomy (PJ). Angiography revealed that splenic venous flow drained into the varices and then into the portal vein. A diagnosis of bleeding varices of the PJ due to left-sided portal hypertension was made. Following a partial splenic artery embolization, her anemia improved.Case 2: An 80-year-old male underwent a PD for pancreatic head cancer combined with resection of the confluence of the portal and splenic veins with a reconstruction between the portal and superior mesenteric veins. Eighteen months after his surgery, he developed melena with negative endoscopy findings in his large and small bowel. CT revealed varices at the site of the PJ that communicated with the jejunal and portal veins. He underwent obliteration of the varices via a trans-portal-venous approach. As a result, he remained without melena until he died of PC 17 months after the embolization.ConclusionsLeft-sided portal hypertension following a PD with bleeding varices can be treated by interventional radiology with minimal invasiveness.

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.

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. Little is known about LPH after PD with resection of the PV/SMV confluence. 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). 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). PD with SV division causes variceal formation, bleeding, and thrombocytopenia.

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

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.

Role of Splenic Artery Embolization in Gastric Variceal Hemorrhage due to Sinistral Portal Hypertension

AbstractSinistral or left-sided portal hypertension is a localized form of portal hypertension usually due to isolated obstruction of splenic vein. Most commonly, it is secondary to pancreatitis. Rarely this can present as life-threatening gastric variceal bleeding. In such patients, splenectomy is traditionally considered as the treatment of choice to relieve venous hypertension. Unfortunately, a surgical operation may not be safe in most of the patients because of the unfavorable operative field. Splenic artery embolization (SAE) is an effective method, theoretically akin to splenectomy, blocking the direct arterial inflow to the spleen and thereby reducing the outflow venous pressure. The authors demonstrate a case of a 58-year-old man who presented with severe gastric variceal hemorrhage due to sinistral portal hypertension (SPH) secondary to an episode of pancreatitis, which he had 1 month back. He was successfully managed by SAE and remains symptom-free. The authors bring to the fore the potential curability of gastric variceal hemorrhage secondary to SPH using SAE, which is a safe and effective interventional radiologic procedure.

Left-sided portal hypertension due to retroperitoneal fibrosis: a rare case report

Left-sided portal hypertension due to retroperitoneal fibrosis: a rare case report

Abstract No. 611 Left-sided portal hypertension in the presence or absence of splenic vein thrombosis: a single tertiary center experience

Abstract No. 611 Left-sided portal hypertension in the presence or absence of splenic vein thrombosis: a single tertiary center experience

Isolated Gastric Varices: A Rare Presentation of Pancreatic Cancer

Pancreatic cancer remains a disease with high morbidity and mortality. Due to vague symptoms at presentation, the disease is often diagnosed at late stages, with a 5-year survival rate of only 8%. Approximately 75% of all pancreatic carcinomas occur within the head or neck of the pancreas, 15-20% occur in the body of the pancreas, and 5-10% occur in the tail. This case describes a new diagnosis of a pancreatic tail mass presenting as obscure overt gastrointestinal bleeding in the context of portal hypertension. A 60-year-old male presented with recurrent melena associated with fatigue and dyspnea. His symptoms started two months prior to presentation, at which time he underwent upper endoscopy, colonoscopy, tagged-RBC scan, and capsule endoscopy, all of which were negative. Upon hospital presentation, he underwent a repeat upper endoscopy. He was found to have isolated gastric varices that bled during the procedure. Abdominal CT scan with portal venous phase contrast revealed a nodular and heterogenous appearance of the liver parenchyma, splenomegaly, and a recanalized umbilical vein suggestive of portal hypertension. There was a 3.4 cm area of hypo-enhancement of the midpole of the spleen with some mildly enlarged retroperitoneal lymph nodes, suggestive of a mass lesion. He underwent urgent transjugular intrahepatic portosystemic shunt (TIPS) placement, with successful reduction of the hepatic venous pressure gradient from 15 to 2 mmHg, with occlusion of the distal portion of the splenic vein near the splenic hilum. Thereafter, he underwent laparoscopic distal pancreatectomy and splenectomy. The pathology revealed invasive, undifferentiated carcinoma of the pancreas with local lymph node involvement. He subsequently commenced adjuvant chemotherapy. Pancreatic body and tail cancer may cause left sided portal hypertension, with isolated gastric varices, splenomegaly, and hypersplenism. Other patients may have established portal hypertension, but the finding of isolated gastric varices should raise suspicion for left-sided portal hypertension. Endoscopists evaluating obscure gastrointestinal bleeding must maintain a high index of suspicion for less common causes of bleeding. When isolated gastric varices are detected, abdominal cross-sectional imaging should be considered to evaluate for splenic vein thrombosis and/or a pancreatic or splenic mass leading to left-sided portal hypertension.

Left-sided portal hypertension associated with acute pancreatitis treated by splenectomy : Clinical characteristics and outcomes in a cohort of 79 cases

Left-sided portal hypertension associated with acute pancreatitis treated by splenectomy : Clinical characteristics and outcomes in a cohort of 79 cases

Splenic vein reconstruction is unnecessary in pancreatoduodenectomy combined with resection of the superior mesenteric vein–portal vein confluence according to short-term outcomes

BackgroundSuperior mesenteric vein–portal vein confluence resection combined with pancreatoduodenectomy (SMPVrPD) is occasionally required for resection of pancreatic head tumors. It remains unclear whether such situations require splenic vein (SV) reconstruction for decompression of left-sided portal hypertension (LSPH). MethodsThe data from 93 of 104 patients who underwent pancreatoduodenectomy (PD) for pancreatic head malignancies were reviewed. Surgical outcomes in three groups—standard PD (control group), PD combined with vascular resection and SV preservation (SVp group), and SMPVrPD with SV resection (SVr group)—were compared. The influence of division and preservation of the two natural confluences (left gastric vein–portal vein and/or inferior mesenteric vein–SV confluences) on portal hemodynamics were evaluated using three-dimensional computed tomographic portography. ResultsNo mortality occurred. The morbidity rates were not significantly different among the three groups (18/43, 8/21, and 7/29, respectively; p = 0.306). In the SVr group, three patients had gastric remnant venous congestion, and three had esophageal varices without hemorrhagic potential. No patients had splenomegaly, or severe or prolonged thrombocytopenia. These LSPH-associated findings were less frequently observed when the two confluences were preserved. ConclusionsSMPVrPD without SV reconstruction can be safely conducted. Additionally, preservation of these two confluences may reduce the risk of LSPH.