Ligation Of Splenic Vessels Research Articles

S1906 A Rare Cause of Delayed Life-Threatening Hemorrhage in a Patient With Pancreas Transplant

Introduction: Complications of vascular anastomosis usually occur early after pancreas transplant (PTx) and carry a substantial risk of graft loss and mortality. Hemorrhage may result from arterial anastomosis failure, but more commonly from superior mesenteric or splenic vessel ligation. We present a challenging case of GI hemorrhage from a pseudoaneurysm (PA) in the implanted vascular Y graft 7 years after PTx. Case Description/Methods: A 45-year-old male 7 years post simultaneous pancreas-kidney transplant presented with painless rectal bleeding. EGD and Colonoscopy showed blood throughout the duodenum and colon, but the source could not be localized. Push enteroscopy showed blood extending into the proximal jejunum, and no active bleeding source could be identified. CT angiogram showed active extravasation into a small bowel loop near the PTx. Mesenteric angiography with IR revealed active extravasation into jejunum from a PA which had developed off the SMA Y graft anastomosis, eroding into the adjacent duodenal stump. Successful coil embolization was performed. 2 days later, he developed rectal bleeding requiring massive transfusion. Tagged RBC scan and CT angiography could not localize the bleeding source. Emergent mesenteric angiography showed contrast leakage into the anastomotic stump beyond the previously placed coil (Figure A). A covered stent was placed into the right external iliac artery arresting the bleeding into the SMA anastomotic stump (Figure B). Bleeding and shock resolved, and he was discharged with transplant surgery follow-up. Discussion: Pseudoaneurysms, AV fistulae, arterial dissection and stenosis represent rare vascular complications of PTx. PAs, if early, may be the result of surgical technique, infection, severe pancreatitis, or allograft biopsy. Arterial anastomotic PAs can be asymptomatic or present with symptoms signaling impending rupture such as abdominal pain, pulsatile mass, or endocrine failure. Endoscopic localization and management of bleeding from Y graft PAs are challenging due to altered anatomy and brisk bleeding. Multidisciplinary management is essential and often involves endovascular hemostasis with IR, possibly with surgical exploration. Stent placement is usually preferred over embolization due to the ability to deploy with precision while maintaining end-organ perfusion. Although guidelines are lacking, it would be reasonable to consider periodic Doppler US to screen for post-operative PAs for early detection and preventative endovascular treatment.Figure 1.: A. Pre-stent mesenteric angiogram with contrast leaking through coil into SMA anastomotic stump; B. Post stent mesenteric angiogram with no contrast leaking into the SMA anastomotic stump.

Laparoscopic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein (Kimura's procedure)

Authors present the case of a laparoscopic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein (Kimura's procedure). A 26-year old female patient was admitted with a neoplasm of the tail of the pancreas detected by abdominal ultrasound. Pancreatic protocol CT-scan revealed a 7 cm round-shaped tumor in the tail of the pancreas. The CT features of the lesion were suggestive for mucinous cystadenoma. Spleen-preserving laparoscopic distal pancreatectomy is considered as the first choice procedure for benign lesions located at the body or tail of the pancreas and is performed very frequently worldwide. The advantages of preservation of the spleen are related to the preserved immune function of the organ. The two main surgical techniques that have been proposed and widely adopted for spleen preserving laparoscopic distal pancreatectomy are the Warshaw (splenic vessel ligation) and Kimura (splenic vessel preservation) techniques. The procedure was complicated due to the large size of the lesion and firm adhesions between the vessels and the tumor. Nevertheless the splenic vessels were successfully preserved after clipping all the branches of the splenic vein and artery. No significant bleeding occurred. The estimated blood loss was 50 ml. The operation time was 210 minutes. The postoperative course was complicated by a postoperative pancreatic fistula (POPF) grade B (according to the ISGPF classification), which was managed successfully using interventional percutaneous drainage. Final histopathological examination confirmed mucinous cystadenoma of the tail of the pancreas. The patient was discharged on postoperative day 14 with external drainage tube, which was removed in three weeks after amylase level control in an outpatient clinic. The purpose of the video is to demonstrate our experience in performing Kimura's procedure.

Imaging features and clinical relevance of portal venous systems shown by extrahepatic portal angiography in children with extrahepatic portal venous obstruction

ObjectiveThis study investigated the morphologic changes of portal cavernoma in children with extrahepatic portal venous obstruction and explored the relationship with prognosis. MethodsFrom February 2008 to October 2017, there were 107 patients with cavernous transformation of the portal vein admitted to our hospital. Rex shunts were performed in 99 cases, Warren shunts in 7 cases, and laparoscopic splenic vessel ligation in 1 case. Intraoperative superior mesenteric venography was used to determine the structure of the portal venous system. According to the morphologic features of the portal vein shown by portal venography, groups were assigned as follows: patients with the cotton form of portal cavernoma; patients with visible collateral veins of portal cavernoma; patients with and without a visible left gastric vein; and patients with and without a clearly visible intrahepatic portal vein. The preoperative and postoperative portal pressure, preoperative incidence of esophageal varices, time at onset, incidence of postoperative rebleeding, preoperative and postoperative size of the spleen, and age at time of operation were compared between these groups. ResultsThe preoperative incidence of esophageal varices, time at onset, postoperative size of spleen, and age at time of operation were significantly lower in the group with the cotton form than in those with visible collateral veins (P < .05). There was a significant correlation between the visible left gastric vein and esophageal varices (P = .002). The time at onset, preoperative and postoperative size of the spleen, and age at time of operation were markedly lower in the group with a good visible intrahepatic portal vein than in those without a clearly visible intrahepatic portal vein (P < .05). The visible left gastric vein was notably associated with the performance of a gastroportal shunt (P = .000), and the group with a visible left gastric vein had a higher ratio of children undergoing a gastroportal shunt. ConclusionsThe cotton form, an early-stage manifestation of cavernous transformation of the portal vein, typically occurs in younger children with a shorter time to onset. Children with the cotton form of portal cavernoma typically have a better prognosis after Rex shunt.

Laparoscopic ligation of splenic vessels for the treatment of hereditary spherocytosis in children.

Total splenectomy is the most effective surgical treatment for hereditary spherocytosis (HS). Nevertheless, post-splenectomy sepsis and hypoimmunity can pose a great risk to children. Some alternative treatments have been proposed to avoid the post-splenectomy complications. In this study, we propose such a procedure (laparoscopic ligation of splenic vessels, L-LSV) for the treatment of HS in children and investigate its effectiveness and feasibility. A total of 17 children with HS who underwent the L-LSV at our hospital between May 2015 and Apr 2018 were enrolled in the current study. All patients were followed-up for 3-38months (mean 19.8months). The volume of spleen was preoperatively and postoperatively measured using the AW VolumeShare5. The size of functional spleen and the condition of splenic infarction were evaluated using ultrasound and computed tomography (CT) after surgery. The routine blood, biochemistry and coagulation tests were carried out after surgery. The L-LSV was successfully performed in all patients. The average operative time was 115min (range 60-180min). No patients underwent blood transfusion during surgery, and the length of hospital stay varied 5-9days after surgery (mean 7days). Postoperatively, the red blood cells, platelet and hemoglobin were significantly increased (P < 0.05). The postoperative volume of functional spleen was significantly smaller than preoperative volume of spleen (307.393 ± 177.634cm3 vs. 581.242 ± 270.260cm3, P = 0.000). The recent volume of functional spleen was significantly bigger than the postoperative 1month volume of functional spleen in ten children who were followed-up for more than 1 year (P = 0.004). The index of splenic infarction (the proportion of the postoperative 1-month volume of splenic infarction in the preoperative volume of spleen) was 0.31-0.99 (mean 0.53). There were no patients undergoing the blood transfusion after surgery. The L-LSV is an effective treatment for HS in children; however, future studies should re-evaluate the long-term prognosis.

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

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 (%).

Exploration of the safety and feasibility of the preservation of spleen with ligation of splenic vessels

As an important immune organ, spleen also plays a crucial role in stabilizing hematologic system. Previous reports support that splenectomy must be performed after the ligation of spleen vessels. At recent time, with the deep knowledge of the anatomy and function of spleen, the surgeons have tried to preserve this organ after the ligation of the vessels. From March 2012 to April 2016, five patients in our hospital have undergone the distal pancreatectomy with spleen preservation after the ligation of splenic vessels, and all the patients' outcomes were satisfactory in the follow-up. This essay aims to discuss the safety and feasibility of preserving spleen after the ligation of the vessels by reporting our own experience and reviewing related literatures on this topic. Key words: Ligation of spleen vessels; Preservation of spleen; Distal pancreatectomy

Laparoscopic splenic vessels ligation as a treatment of hypersplenism and thrombocytopenia in children

Splenectomy and partial splenic embolization as the surgical approach in the treatment of hypersplenism and thrombocytopenia have been reported. However, there are still some disadvantages in the application of these techniques. In this article, we propose a new technique for the treatment of hypersplenism and thrombocytopenia in children and report our preliminary experience. From Aug 2014 to Dec 2014, four children with hypersplenism and three children with idiopathic thrombocytopenic purpura were treated in our hospital. Laparoscopic splenic vessels ligation was performed in all patients. The gastric wall was suspended to expose the pancreatic tail and spleen, and the splenic artery was ligated at the superior border of the pancreas. The splenic venous branches were dissected and ligated at the splenic hilum using the Hem-o-lok. The laparoscopic splenic vessels ligation was successfully performed in all patients. The average operative time was 126min (range 120-150min). No patient required transfusion, and the length of hospital stay varied from 4 to 11days (mean 6.6days). The patients were followed up for 6-10months (mean 8.5months). The complete blood counts were within normal range. The size of spleen decreased postoperatively. The partial splenic infarction and the reduction in splenic blood flow were confirmed in all patients by postoperative ultrasound and CT. The laparoscopic splenic vessels ligation is a feasible option for treating hypersplenism and thrombocytopenia in children.

Stump closure reinforcement with absorbable fibrin collagen sealant sponge (TachoSil) does not prevent pancreatic fistula after distal pancreatectomy: the FIABLE multicenter controlled randomized study

BackgroundThe aim of this study is to evaluate the effectiveness of TachoSil sponge on distal pancreatectomy remnant stump in reducing the rate and severity of postoperative pancreatic fistula (POPF). MethodsAll consecutive patients requiring distal pancreatectomy were randomized in 45 centers. The principal end point was onset of “clinically relevant” POPF. Univariate and multivariate analyses were searched for predictive factors. ResultsOf the 270 patients randomized (134 with TachoSil; 136 without), 150 (55.6%) patients sustained a POPF [74 clinically relevant and 76 clinically silent (27.4% and 28.1%), respectively]: no statistically significant difference was found between patients sustaining clinically relevant POPF [41 (30.6%) with vs 33 (24.3%) without TachoSil (P = .276)], or overall POPF [73 (54.5%) with vs 77 (56.6%) without TachoSil, (P = .807)], but there were more clinically relevant POPF after hand-sewn (32.3%) versus mechanical closure (19.8%) (P = .025) and, in case of splenic preservation, after splenic vessel ligation (15/32, 46.9%) versus vascular preservation (17/72, 23.6%) (P = .024). Hand-sewn pancreatic remnant closure (P = .023) and splenic vessel ligation in splenic preservation (P = .035) were independent predictive factors for the onset of clinically relevant POPF. ConclusionTachoSil sponge reinforcement of the proximal remnant after distal pancreatectomy reduced neither the rate nor the severity of POPF.

Laparoscopic Spleen-Preserving Distal Pancreatectomy: The Technique Must Suit the Lesion

Splenic preservation is currently recommended during minimally invasive surgery for benign tumors of the distal pancreas. The aim of this study was to evaluate the outcomes of patients undergoing laparoscopic spleen-preserving distal pancreatectomy, with particular attention paid to the technique used for spleen preservation (splenic vessel ligation vs preservation). A review of consecutive patients who underwent laparoscopic distal pancreatectomy with the intention of splenic preservation was conducted. Patient demographics, operative data, and outcomes were collected and analyzed. Fifty-five consecutive patients underwent laparoscopic distal pancreatectomy with the intention of splenic preservation; 5 required splenectomy (9 %). Of the remaining 50 patients, 31 (62 %) had splenic vessel ligation, and 19 (38 %) had vessel preservation. Patient demographics and tumor size were similar. The vessel ligation group had significantly more pancreas removed (95 vs 52 mm, P < 0.001) and longer operative times (256 vs 201 min, P = 0.008). Postoperative outcomes, complication rates, and splenic viability were similar between groups. Laparoscopic spleen-preserving distal pancreatectomy is a safe operation with a high rate of success (91 %). Vessel ligation was the chosen technical strategy for lesions that required resection of a greater length of pancreas. We found no advantage to either technique with respect to outcomes and splenic preservation. Operative approach should reflect technical considerations including location in the pancreas.

Pancréatectomie gauche avec dissection « centrifuge » des vaisseaux spléniques

We describe a technique of distal pancreatectomy begining with division of pancreatic neck before control of splenic vessels. Early neck division allows safer vascular control. For distal pancreatectomy, primary section of the neck and splenic vessels ligation, combined with division of left gastro-epiploic and short gastric vessels, precedes mobilization of a devascularized specimen, decreases operative bleeding and seems more logical from a carcinologic point of view. Furthermore, this technique could be the first step of left pancreatectomy with splenic preservation.

Techniques, indications et résultats précoces de la conservation splénique dans les exérèses pancréatiques gauches

Study aim. Splenic preservation is rarely performed during left pancreatectomy. We compared retrospectively the early results of left pancreatectomy with and without splenic preservation to define the place of this procedure. Patients and methods. From 1979 to 1997, among 54 left pancreatectomies for another indication than adenocarcinoma, 13 were performed with and 41 without splenic preservation. The technique used for splenic preservation was prograde dissection of the left pancreas with ( n = 4) and without ( n = 9) preservation of both splenic artery and vein. The preoperative caracteristics of the patients, peroperative data, postoperative morbidity and length of stay were compared. Results. Mean operative time was longer with splenic preservation (262 ± 67 min versus 215.6 ± 59 min, p < 0.05), particularly in case of splenic vessels preservation (295 ± 38 min, p < 0.02) whereas no difference was noted with splenic vessels ligation (240 ± 76 min, p > 0.05). No mortality occurred. Prevalence of peroperative or postoperative haemorrhage, morbidity, or length of stay (intensive care unit and whole hospitalisation) did not differ with or without splenic preservation. Five patients developed pancreatic fistula without influence of splenic preservation: 1/13 (7.7%) versus 4/41 (9.7%) ; conversely, surgery following acute pancreatitis was associated with an higher risk of pancreatic fistula : 3/5 versus 2/49 ( p < 0.005). No splenic necrosis occurred after splenic preservation. Conclusion. During left pancreatectomy, splenic preservation increases the operative duration (only in case of preservation of splenic vessels) but does not increase morbidity. This technique should be used whenever possible to allow long term immunological benefits of splenic preservation.

Rapid technique for splenectomy

The spleen is the most commonly injured organ in blunt trauma of the abdomen. In the haemodynamically unstable patient bleeding from a splenic injury, rapid control of the splenic hilum can be a technically demanding operation. We describe a technique which allows for rapid control of the splenic hilum and unhurried ligation of splenic vessels. This technique has been used on 30 patients without any complications related to splenectomy. It is most helpful when one is working with an inexperienced assistant.