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Patel RK, Tripathy T, Chandel K, Marri UK, Giri S, Nayak HK, Panigrahi MK, Pattnaik B, Dutta T, Gupta S, Naik S. Left-sided portal hypertension: what an interventional radiologist can offer? Eur Radiol 2025; 35:2530-2542. [PMID: 39562367 DOI: 10.1007/s00330-024-11196-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2024] [Revised: 10/08/2024] [Accepted: 10/28/2024] [Indexed: 11/21/2024]
Abstract
Left-sided portal hypertension (LPH) refers to increased splenic venous pressure caused by splenic vein stenosis or occlusion. Pancreatitis is the leading cause of LPH. Typically, LPH remains asymptomatic, but it can lead to life-threatening hemorrhage from ruptured fundal varices in about 10% of patients. Further, it may be complicated by hypersplenism. Interventional radiology plays an essential role in LPH patients with failed endoscopic treatment. Variceal embolization is an effective salvage measure in bleeding gastric varices, but it carries a risk of recurrence and worsening of hypersplenism. Considering the pathophysiology, splenic vein recanalization (SVR) appears to be the best treatment; nevertheless, its lower technical success rate limits its utility only to a subgroup of LPH patients. Partial splenic embolization (PSE), a non-surgical alternative to splenectomy, reduces the splenic volume and venous outflow, thereby lowering variceal pressure. PSE is technically easier, which may explain its widespread use. Nonetheless, PSE can be complicated by life-threatening sepsis and portal vein thrombosis. Despite all attempts, some LPH patients eventually require a splenectomy. Importantly, the choice of therapy requires multidisciplinary discussion and is often influenced by availability, expertise, and clinical context. This article discusses various interventional strategies for managing LPH with the available evidence. KEY POINTS: Question Pressure within the main portal vein is normal in left-sided portal hypertension; thus, transjugular intrahepatic portosystemic shunt is ineffective. Findings Splenic vein stent placement can restore hepatopetal splenic blood flow and decompress splenic venous pressure. Clinical relevance Partial splenic embolization (PSE) is the most widely used interventional approach to manage left-sided portal hypertension-related complications.
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Affiliation(s)
- Ranjan Kumar Patel
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, 751019, India.
| | - Taraprasad Tripathy
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, 751019, India
| | - Karamvir Chandel
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bilaspur, Himachal Pradesh, India
| | - Uday Kumar Marri
- Department of Interventional Radiology, AIG Hospitals, Hyderabad, India
| | - Suprabhat Giri
- Department of Gastroenterology, Kalinga Institute of Medical sciences, Bhubaneswar, 751019, India
| | - Hemanta Kumar Nayak
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751019, India
| | - Manas Kumar Panigrahi
- Department of Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751019, India
| | - Bramhadatta Pattnaik
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751019, India
| | - Tanmay Dutta
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751019, India
| | - Sunita Gupta
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bhubaneswar, 751019, India
| | - Suprava Naik
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, 751019, India
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Sihnkai T, Masumoto K, Sanmoto Y, Kawami A, Ishikawa M, Fujii S, Saida T, Ishiguro T, Sakamoto N. Left-sided portal hypertension caused by a solid pseudopapillary neoplasm of pancreas tail: a pediatric case report. Surg Case Rep 2024; 10:256. [PMID: 39523235 PMCID: PMC11551083 DOI: 10.1186/s40792-024-02034-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Accepted: 09/29/2024] [Indexed: 11/16/2024] Open
Abstract
BACKGROUND Solid pseudopapillary neoplasm (SPN) is a low-grade malignant tumor that occurs in 60% of all pediatric pancreas tumors. Radical tumor resection is essential; however, spleen preservation is also crucial to prevent overwhelming post-splenectomy infection. In contrast, spleen preservation is not always possible, because left-sided portal hypertension (LSPH) can cause splenic vein stenosis or occlusion induced by pancreatic tumor. We herein report on a pediatric patient of LSPH due to SPN in the pancreatic tail. CASE PRESENTATION A 12-year-old girl was admitted to our hospital with left upper quadrant abdominal pain. A solid mass was palpated in the left costal region. The patient showed slight anemia (Hb: 11.8 g/dL) and elevation of inflammatory reaction (CRP: 5.98 mg/dL) without positive tumor markers. A radiological examination revealed that a 9 cm-sized mass with hemorrhagic necrosis in the pancreatic tail. Splenic venous flow was not detected and collateral draining into the left gastric vein and left renal veins were developed with splenomegaly. LSPH was involved at the time of diagnosis. The tumor was diagnosed with SPN, hence tumor resection with spleen preservation was performed. Six months after surgery, the patient developed a left quadrant abdominal pain that worsened during exercise. There was no improvement of splenic venous flow and splenomegaly. LSPH remained with splenomegaly, which possibly triggered the patient's abdominal pain. The patient underwent splenectomy 9 months after the tumor resection. After the splenectomy, the patient's abdominal pain disappeared without any recurrence 8-year post-surgery. CONCLUSIONS LSPH has not been a major focus in previous SPN pediatric patients, although most symptomatic LSPH patients required splenectomy. Careful post-operative observation for LSPH is important for pediatric SPN patients.
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Affiliation(s)
- Toko Sihnkai
- Department of Pediatric Surgery, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Kouji Masumoto
- Department of Pediatric Surgery, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Yohei Sanmoto
- Department of Pediatric Surgery, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Akio Kawami
- Department of Pediatric Surgery, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Miki Ishikawa
- Department of Pediatric Surgery, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Shunsuke Fujii
- Department of Pediatric Surgery, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Tsukasa Saida
- Department of Radiology, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Toshitaka Ishiguro
- Department of Radiology, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Noriaki Sakamoto
- Department of Diagnostic Pathology, Institute of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
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Zhang Y, Su Q, Li Y, Zhan X, Wang X, Zhang L, Luo H, Kang X, Lv Y, Liang S, Ren G, Pan Y. Development of a nomogram for predicting pancreatic portal hypertension in patients with acute pancreatitis: a retrospective study. BMJ Open Gastroenterol 2024; 11:e001539. [PMID: 39510600 PMCID: PMC11552527 DOI: 10.1136/bmjgast-2024-001539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Accepted: 09/26/2024] [Indexed: 11/15/2024] Open
Abstract
INTRODUCTION Pancreatic portal hypertension (PPH) is a rare complication of acute pancreatitis (AP) that can lead to severe gastrointestinal bleeding. The risk factors associated with PPH, as well as the overall prognosis, warrant further investigation. This study aims to develop and validate a nomogram to predict PPH in patients with AP. METHODS Consecutive patients with AP from 2015 to 2023 were retrospectively included in the study. Demographic data, clinical manifestations within the first week of AP onset, and initial contrast-enhanced CT findings were used to develop the predictive model. Univariate and multivariate Cox regression analyses were performed to identify risk factors for PPH. Based on the results of the multivariate analysis, a nomogram was developed. The patients were randomly divided into training and validation sets at a 7:3 ratio. The accuracy and discriminative power of the predictive model were assessed using the area under the curve (AUC) from the receiver operating characteristic curve and the calibration curve. RESULTS Of the 1473 patients with AP, 107 (7.3%) developed PPH within 6 months (range: 2-22 months) during follow-up. Multivariate regression analysis showed that body mass index (BMI) (HR, 1.10; 95% CI 1.04 to 1.16; p=0.001), moderately severe grade (HR, 9.36; 95% CI 4.58 to 19.13; p<0.001), severe grade (HR, 12.95; 95% CI 6.22 to 26.94; p<0.001), diabetes (HR, 2.26; 95% CI 1.47 to 3.47; p<0.001), acute fluid accumulation (HR, 2.13; 95% CI 1.31 to 3.47; p=0.002), and necrosis (HR, 3.64; 95% CI 2.30 to 5.78; p<0.001) were independent risk factors for PPH. A nomogram for predicting PPH was developed, with the predictive curves showing an AUC of 0.859 at 6 months and 0.846 at 9 months. In the validation set, the AUC at both time points was 0.812. CONCLUSION In summary, we identified BMI, moderately severe or severe AP, diabetes, acute fluid accumulation, and necrosis as risk factors for AP-related PPH. Using the largest cohort of patients with AP to date, we developed a highly accurate nomogram with strong discriminative ability for predicting PPH. Future studies with larger sample sizes are necessary to confirm our findings and conduct external validation.
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Affiliation(s)
- Yingjie Zhang
- Department of Gastroenterology, Xi'an Medical University, Xi'an, Shaanxi, China
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Qiaoyu Su
- Department of Gastroenterology, Xi'an Medical University, Xi'an, Shaanxi, China
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yunling Li
- Department of Gastroenterology, Xi'an Medical University, Xi'an, Shaanxi, China
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xianchen Zhan
- Department of Gastroenterology, Xi'an Medical University, Xi'an, Shaanxi, China
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - XiangPing Wang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
- Fourth Military Medical University, Xi'an, China
| | - Linhui Zhang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Hui Luo
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
- Fourth Military Medical University, Xi'an, China
| | - Xiaoyu Kang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
- Fourth Military Medical University, Xi'an, China
| | - Yong Lv
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
- Fourth Military Medical University, Xi'an, China
| | - Shuhui Liang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
- Fourth Military Medical University, Xi'an, China
| | - Gui Ren
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
- Fourth Military Medical University, Xi'an, China
| | - Yanglin Pan
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
- Fourth Military Medical University, Xi'an, China
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Zhao G, Wen S, Zhang Y, Zhang K, Cui Y. Acute Necrotizing Pancreatitis Complicated With Sinistral Portal Hypertension And Mechanical Obstruction Of The Colon: A Case Report. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1220-1223. [PMID: 38417808 PMCID: PMC11305833 DOI: 10.1055/a-2250-6502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Indexed: 03/01/2024]
Abstract
Acute necrotizing pancreatitis (ANP) is often associated with acute necrotic collection (ANC) or walled-off necrosis (WON). Due to the close anatomical connection between the pancreas, the spleen, and the transverse colon, necrotizing pancreatitis is often combined with spleen or colon involvement. Gastrointestinal dysfunction usually caused by pancreatitis leads to paralytic intestinal obstruction. However, pancreatitis combined with mechanical colonic obstruction is extremely rare. It can easily be misdiagnosed as malignant intestinal obstruction, and diagnosing the cause of intestinal obstruction becomes more critical when accompanied by Sinistral portal hypertension (SPH). Surgical resection is the primary method for the previous occurrence of colonic complications. In this case report, upon admission, a 37-year-old patient was diagnosed with acute necrotizing pancreatitis with sinistral portal hypertension. On the 6th day after admission, the patient developed a sudden colonic obstruction. After identifying the cause, the patient underwent a transanal decompression tube and minimally invasive necrosectomy, avoiding colon resection. In acute necrotizing pancreatitis combined with colonic mechanical obstruction, it is essential to clarify the etiology, and focus treatment on clearing the peripancreatic necrotic tissue, non-surgical treatment to deal with colonic obstruction is feasible, and the principle of individualized treatment should be used throughout the disease.
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Affiliation(s)
- Guijie Zhao
- Department of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Shuaiyong Wen
- Department of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Yu Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Kun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Yunfeng Cui
- Department of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
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Tidwell J, Thakkar B, Wu GY. Etiologies of Splenic Venous Hypertension: A Review. J Clin Transl Hepatol 2024; 12:594-606. [PMID: 38974953 PMCID: PMC11224904 DOI: 10.14218/jcth.2024.00054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/27/2024] [Accepted: 05/04/2024] [Indexed: 07/09/2024] Open
Abstract
Splenic venous hypertension or left-sided portal hypertension is a rare condition caused by an obstruction of the splenic vein. Usually, it presents with upper gastrointestinal bleeding in the absence of liver disease. Etiologies can be classified based on the mechanism of development of splenic vein hypertension: compression, stenosis, inflammation, thrombosis, and surgically decreased splenic venous flow. Diagnosis is established by various imaging modalities and should be suspected in patients with gastric varices in the absence of esophageal varices, splenomegaly, or cirrhosis. The management and prognosis vary depending on the underlying etiology but generally involve reducing splenic venous pressure. The aim of this review was to summarize the etiologies of splenic venous hypertension according to the mechanism of development.
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Affiliation(s)
- Jasmine Tidwell
- Department of Medicine, University of Connecticut Health Center, Farmington, CT, USA
| | - Bianca Thakkar
- Department of Medicine, University of Connecticut Health Center, Farmington, CT, USA
| | - George Y. Wu
- Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
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Maehira H, Tani M, Mori H, Ichikawa D, Kawashima M, Tajima H, Nagakawa Y, Makino I, Yagi S. Long-term outcomes after spleen-preserving distal pancreatectomy with splenic vessels preservation or resection: A nationwide survey of the Japanese Society of Pancreatic Surgery. Surgery 2024; 175:1570-1579. [PMID: 38519409 DOI: 10.1016/j.surg.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 01/14/2024] [Accepted: 01/21/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND Spleen preserving distal pancreatectomy is achieved by either splenic vessel resection or splenic vessel preservation. However, the long-term outcomes of spleen-preserving distal pancreatectomy with splenic vessel resection and spleen-preserving distal pancreatectomy with splenic vessel preservation are not well known. This study aimed to evaluate the long-term outcomes of spleen-preserving distal pancreatectomy with splenic vessel resection and spleen-preserving distal pancreatectomy with splenic vessel preservation. METHODS The study included a total of 335 patients who underwent spleen-preserving distal pancreatectomy during the study period and underwent computed tomography or magnetic resonance imaging 3 and 5 years after surgery in the Japan Society of Pancreatic Surgery member institutions. We evaluated the diameter of the perigastric and gastric submucosal veins, patency of the splenic vessels, and splenic infarction. Preoperative backgrounds and short- and long-term outcomes were compared between the 2 groups. RESULTS Forty-four (13.1%) and 291 (86.9%) patients underwent spleen-preserving distal pancreatectomy with splenic vessel resection and spleen-preserving distal pancreatectomy with splenic vessel preservation, respectively. There were no significant differences in short-term outcomes between the 2 groups. Regarding long-term outcomes, the prevalence of perigastric varices was higher (P = .006), and platelet count was lower (P = .037) in the spleen-preserving distal pancreatectomy with splenic vessel resection group. However, other complications, such as gastric submucosal varices, postoperative splenic infarction, gastrointestinal bleeding, reoperation, postoperative splenectomy, and other hematologic parameters, were not significantly different between the 2 groups 5 years after surgery. In terms of the patency of splenic vessels in spleen preserving distal pancreatectomy with splenic vessel preservation cases, partial or complete occlusion of the splenic artery and vein was observed 5 years after surgery in 19 (6.5%) and 55 (18.9%) patients, respectively. CONCLUSION Perigastric varices and thrombocytopenia were observed more in spleen-preserving distal pancreatectomy with splenic vessel resection, yet late clinical events such as gastrointestinal bleeding and splenic infarction are acceptable for spleen-preserving distal pancreatectomy with splenic vessel preservation.
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Affiliation(s)
- Hiromitsu Maehira
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Masaji Tani
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan.
| | - Haruki Mori
- Department of Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Daisuke Ichikawa
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Mampei Kawashima
- Department of GI and HBP Surgery, Nippon Medical School, Tokyo, Japan
| | - Hiroshi Tajima
- Department of General-Pediatric-Hepatobiliary Pancreatic Surgery, Kitasato University School of Medicine, Kanagawa, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Isamu Makino
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation/Pediatric Surgery, Kanazawa University, Ishikawa, Japan
| | - Shintaro Yagi
- Department of Hepato-Biliary-Pancreatic Surgery and Transplantation/Pediatric Surgery, Kanazawa University, Ishikawa, Japan
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Liu M, Wei N, Song Y. Splenectomy versus non-splenectomy for gastrointestinal bleeding from left-sided portal hypertension: a systematic review and meta-analysis. Therap Adv Gastroenterol 2024; 17:17562848241234501. [PMID: 38450104 PMCID: PMC10916482 DOI: 10.1177/17562848241234501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 02/06/2024] [Indexed: 03/08/2024] Open
Abstract
OBJECTIVES Left-sided portal hypertension (LSPH) leads to life-threatening gastrointestinal (GI) bleeding. There are no recommendations or consensus about the management of GI bleeding caused by LSPH. This systematic review and meta-analysis were conducted to evaluate the incidence of GI bleeding and the mortality of patients with LSPH receiving different therapeutic strategies. DESIGN A systematic review and meta-analysis were performed to determine the efficacy of different therapeutic strategies for GI bleeding caused by LSPH. DATA SOURCES AND METHODS All relevant studies were searched from PubMed, Embase, Web of Science, Cochrane Library, Scopus, ScienceDirect, MEDLINE, Google Scholar, CNKI, and Wanfang Data without language restriction through 15 November 2023. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated through RevMan5.3 software. (The Cochrane Collaboration, Copenhagen, Denmark). RESULTS Seventeen retrospective studies and one prospective study involving 624 patients were included. This systematic review and meta-analysis found that: (1) splenectomy was more effective than non-splenectomy therapeutic strategies in reducing the incidence of GI bleeding caused by LSPH (OR: 0.12; 95% CI: 0.06-0.27); (2) splenectomy was superior to partial splenic artery embolism (PSAE) (OR: 0.06; 95% CI: 0.01-0.62) or endoscopic interventions (OR: 0.04; 95% CI: 0.01-0.19) in the prevention of GI bleeding, respectively; (3) no significant difference in the mortality was observed between splenectomy and non-splenectomy therapeutic strategies (OR: 0.46; 95% CI: 0.20-1.08); and (4) patients receiving preoperative PSAE followed by splenectomy had less intraoperative bleeding and shorter operative time than those receiving splenectomy. CONCLUSION This meta-analysis demonstrated that splenectomy is superior to non-splenectomy therapeutic strategies in reducing the incidence of GI bleeding from LSPH, which revealed that splenectomy should be recommended in the management of these patients. TRIAL REGISTRATION This study has been registered on the PROSPERO database with the registration number CRD42023483764.
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Affiliation(s)
- Minghui Liu
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ning Wei
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuhu Song
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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Yamamoto M, Hitomi S, Hara T, Kondo H, Oba H. Percutaneous Covered Stenting in Splenic Vein for Left-sided Portal Hypertension Caused by Chronic Splenic Vein Obstruction. INTERVENTIONAL RADIOLOGY (HIGASHIMATSUYAMA-SHI (JAPAN) 2024; 9:31-35. [PMID: 38525002 PMCID: PMC10955463 DOI: 10.22575/interventionalradiology.2023-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 08/16/2023] [Indexed: 03/26/2024]
Abstract
Left-sided portal hypertension (LSPH), an uncommon manifestation of portal hypertension, is characterized by conditions such as isolated gastric varices and splenomegaly, which result from impeded splenic venous drainage in the presence of pancreatic disease. We employed a percutaneous transhepatic technique to achieve regression of isolated gastric varices by implanting a covered stent within a blocked splenic vein and by embolizing the posterior gastric vein and varices using N-butyl-2-cyanoacrylate. We report the successful treatment of stenting for LSPH by the covered stent placement.
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Affiliation(s)
| | - Suguru Hitomi
- Department of Emergency & Critical Care, Saitama Red Cross Hospital, Japan
| | - Takuya Hara
- Department of Radiology, Faculty of Medicine, University of Miyazaki, Japan
| | - Hiroshi Kondo
- Department of Radiology, Teikyo University School of Medicine, Japan
| | - Hiroshi Oba
- Department of Radiology, Teikyo University School of Medicine, Japan
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9
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Liang J, Feng X, Peng M, Duan JT, Chen YY, Zhu J. Combined transhepatic and transsplenic recanalization of chronic splenic vein occlusion to treat left-sided portal hypertension: A cases report. Medicine (Baltimore) 2024; 103:e37109. [PMID: 38306530 PMCID: PMC10843399 DOI: 10.1097/md.0000000000037109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/09/2024] [Indexed: 02/04/2024] Open
Abstract
RATIONALE This report describes a unique case of a combination transhepatic and transsplenic recanalization of chronic splenic vein occlusion to treat left-sided portal hypertension (LSPH). PATIENT CONCERNS In this case report, we report a 49-year-old male who was admitted due to LSPH causing black stools for 2 days and vomiting blood for 1 hour. DIAGNOSES The patient has a history of multiple episodes of pancreatitis in the past. After admission, abdominal contrast-enhanced CT scan showed the appearance of pancreatitis, with extensive splenic vein occlusion and accompanied by gastric varicose veins, indicating the formation of LSPH. INTERVENTION The patient received treatment with a combination of splenic and hepatic splenic venoplasty. OUTCOMES Follow up for 1 year, CT and gastroscopy showed disappearance of gastric varices. LESSONS Splenic venoplasty is an effective method for treating LSPH. When it is difficult to pass through the occluded segment of the splenic vein through a single approach, percutaneous double approach splenic venoplasty can be attempted for treatment.
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Affiliation(s)
- Jie Liang
- School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan Province, China
| | - Xu Feng
- Department of Interventional, The Second People’s Hospital of Yibin, Yibin, Sichuan Province, China
| | - Min Peng
- School of Clinical Medicine, Chengdu Medical College, Chengdu, Sichuan Province, China
| | - Jin-Tao Duan
- Department of Interventional, The Second People’s Hospital of Yibin, Yibin, Sichuan Province, China
| | - Yao-Yong Chen
- Department of Interventional, The Second People’s Hospital of Yibin, Yibin, Sichuan Province, China
| | - Jun Zhu
- Department of Interventional, The Second People’s Hospital of Yibin, Yibin, Sichuan Province, China
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Zhuang Z, Ma J, Zhang Z, Ju S, Gu G, Yang M, Yu J, Yan Z, Zhang W, Luo J. Endovascular management of sinistral portal hypertension-related variceal hemorrhage: a multicenter retrospective study. Abdom Radiol (NY) 2024; 49:597-603. [PMID: 37996543 DOI: 10.1007/s00261-023-04101-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE This study aimed to assess the safety and efficacy of endovascular managements, including splenic vein recanalization (SVR), partial splenic embolization (PSE), and percutaneous transsplenic gastric varices embolization combined with PSE (PSE+GVE), for management of SPH-related variceal hemorrhage (VH). METHODS A total of 61 patients with SPH-related VH from three hospitals were enrolled and classified into three groups: the SVR group (Group 1, n=24), the PSE+GVE group (Group 2, n=17), and the PSE group (Group 3, n=20). Baseline characteristics and clinical outcomes were compared among the groups. RESULTS The technical success rates for transhepatic and transsplenic SVR were 27.8% and 34.6%, respectively. No major complications were observed during any of the procedures. The median follow-up period was 53.2 months. The 2-year GI rebleeding rates for Group 1, 2, and 3 were 0%, 5.9%, and 35%, respectively. Groups 1 and 2 have a lower GI rebleeding rate (p = 0.002, p = 0.048, respectively) and better results of the degree of GV (p = 0.003, p = 0.044, respectively) compared to Group 3. No significant differences were found in 2-year GI rebleeding rates and the degree of GV between Group 1 and 2 (p = 0.415, p = 0.352, respectively). CONCLUSION SVR, PSE+GVE, and PSE seem safe and effective for management of SPH-related VH. SVR appears to be the superior treatment option. Transsplenic access may further increase the SVR success rate. PSE+GVE seems to have comparable outcomes in GV control and GI rebleeding rates compared to SVR, while superior to PSE.
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Affiliation(s)
- Zhiquan Zhuang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Fenglin Road, Xuhui District, Shanghai, 200032, No, China
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University (Xiamen Branch), Xiamen, 361015, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Jingqin Ma
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Fenglin Road, Xuhui District, Shanghai, 200032, No, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
- Shanghai Institute of Medical Imaging, Shanghai, 200032, China
| | - Zihan Zhang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Fenglin Road, Xuhui District, Shanghai, 200032, No, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
- Shanghai Institute of Medical Imaging, Shanghai, 200032, China
| | - Shuai Ju
- Department of Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, 200540, China
| | - Guoqiang Gu
- Department of Radiology, Minhang Hospital, Fudan University, Shanghai, 201100, China
| | - Minjie Yang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Fenglin Road, Xuhui District, Shanghai, 200032, No, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
- Shanghai Institute of Medical Imaging, Shanghai, 200032, China
| | - Jiaze Yu
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Fenglin Road, Xuhui District, Shanghai, 200032, No, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
- Shanghai Institute of Medical Imaging, Shanghai, 200032, China
| | - Zhiping Yan
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Fenglin Road, Xuhui District, Shanghai, 200032, No, China
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
- Shanghai Institute of Medical Imaging, Shanghai, 200032, China
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, 200032, China
| | - Wen Zhang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Fenglin Road, Xuhui District, Shanghai, 200032, No, China.
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
- Shanghai Institute of Medical Imaging, Shanghai, 200032, China.
| | - Jianjun Luo
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Fenglin Road, Xuhui District, Shanghai, 200032, No, China.
- National Clinical Research Center for Interventional Medicine, Zhongshan Hospital, Fudan University, Shanghai, 200032, China.
- Shanghai Institute of Medical Imaging, Shanghai, 200032, China.
- Center for Tumor Diagnosis and Therapy, Jinshan Hospital, Fudan University, Shanghai, 200032, China.
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11
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Mayer P, Venkatasamy A, Baumert TF, Habersetzer F, Pessaux P, Saviano A, Felli E. Left-sided portal hypertension: Update and proposition of management algorithm. J Visc Surg 2024; 161:21-32. [PMID: 38142180 DOI: 10.1016/j.jviscsurg.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2023]
Abstract
Left-sided or segmental portal hypertension (SPHT) is a rare entity, most often associated with pancreatic disease or antecedent pancreatic surgery. The starting point is splenic vein obstruction secondary to local inflammation or, less often, extrinsic compression. SPHT leads to splenomegaly and development of collateral porto-systemic venous circulation. SPHT should be suspected in patients with pancreatic history who present with episodic upper gastrointestinal bleeding and splenomegaly with normal liver function tests. The most common clinical presentation is major upper gastrointestinal bleeding secondary to rupture of esophageal and/or gastric varices. At the present time, there are no management recommendations for SPHT, particularly when the patient is asymptomatic. In patients with upper gastro-intestinal bleeding, hemostasis can be obtained either by medical or interventional means according to patient status and available resources. For symptomatic patients, splenectomy is the reference treatment. Recently, less invasive, radiologic procedures, such as splenic artery embolization, have been developed as an alternative to surgery. Additionally, sonography-guided endoscopic hemostasis can also be envisioned, leading to the diagnosis and treatment of the lesion by elastic band ligation or by glue injection into the varices during the same procedure. The goal of this article is to describe the pathophysiological mechanisms behind SPHT and its clinical manifestations and treatment, based on a review of the literature. Because of the absence of recommendations for the management of SPHT, we propose a decisional algorithm for the management of SPHT based on the literature.
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Affiliation(s)
- Pierre Mayer
- Hepato-gastroenterology Department, Hepato-digestive Unit, New Civil Hospital, University Hospitals of Strasbourg (HUS), Strasbourg, France; IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, France.
| | - Aïna Venkatasamy
- IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, France; Streinth Lab (Stress Response and Innovative Therapies), Inserm UMR_S 1113 IRFAC, Interface Recherche Fondamentale et Appliquée à la Cancérologie, 3 avenue Molière, Strasbourg, France
| | - Thomas F Baumert
- Hepato-gastroenterology Department, Hepato-digestive Unit, New Civil Hospital, University Hospitals of Strasbourg (HUS), Strasbourg, France; IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, France; Inserm U1110, Institute of Viral and Liver Diseases, LabEx HepSYS, University of Strasbourg, Medical School, Strasbourg, France
| | - François Habersetzer
- Hepato-gastroenterology Department, Hepato-digestive Unit, New Civil Hospital, University Hospitals of Strasbourg (HUS), Strasbourg, France; IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, France; Inserm U1110, Institute of Viral and Liver Diseases, LabEx HepSYS, University of Strasbourg, Medical School, Strasbourg, France
| | - Patrick Pessaux
- IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, France; Inserm U1110, Institute of Viral and Liver Diseases, LabEx HepSYS, University of Strasbourg, Medical School, Strasbourg, France; Hepato-biliary surgery unit, Department of Digestive and Endocrine Surgery, New Civil Hospital, Strasbourg University Hospital, Strasbourg, France
| | - Antonio Saviano
- Hepato-gastroenterology Department, Hepato-digestive Unit, New Civil Hospital, University Hospitals of Strasbourg (HUS), Strasbourg, France; IHU-Strasbourg (Institut Hospitalo-Universitaire), Strasbourg, France; Inserm U1110, Institute of Viral and Liver Diseases, LabEx HepSYS, University of Strasbourg, Medical School, Strasbourg, France
| | - Emanuele Felli
- Inserm U1110, Institute of Viral and Liver Diseases, LabEx HepSYS, University of Strasbourg, Medical School, Strasbourg, France; Department of Digestive Surgery and Liver Transplantation, Trousseau Hospital, Tours, France
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12
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Zeng Y, Yang J, Zhang JW. Safety and efficacy of modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension. World J Gastrointest Endosc 2024; 16:29-36. [PMID: 38313456 PMCID: PMC10835474 DOI: 10.4253/wjge.v16.i1.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/07/2023] [Accepted: 12/27/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Gastric variceal hemorrhage is one of the primary manifestations of left-sided portal hypertension (LSPH). The hemorrhage is fatal and requires safe and effective interventions. AIM To evaluate the clinical safety and efficacy of modified endoscopic ultrasound (EUS)-guided selective N-butyl-2-cyanoacrylate (NBC) injections for gastric variceal hemorrhage in LSPH. METHODS A retrospective observational study of patients with LSPH-induced gastric variceal hemorrhage was conducted. Preoperative EUS evaluations were performed. Enrolled patients were divided into modified and conventional groups according to the NBC injection technique. The final selection of NBC injection technique depended on the patients' preferences and clinical status. The technical and clinical success rates, operation time, NBC doses, perioperative complications, postoperative hospital stay, and recurrent bleeding rates were analyzed, respectively. RESULTS A total of 27 patients were enrolled. No statistically significant differences were observed between the two groups regarding baseline characteristics. In comparison to patients in the conventional group, patients in the modified group demonstrated significantly reduced NBC doses (2.0 ± 0.6 mL vs 3.1 ± 1.0 mL; P = 0.004) and increased endoscopic operation time (71.9 ± 11.9 min vs 22.5 ± 6.7 min; P < 0.001). Meanwhile, the two groups had no significant difference in the technical and clinical success rates, perioperative complications, postoperative hospital stay, and recurrent bleeding rates. CONCLUSION Modified EUS-guided selective NBC injections demonstrated safety and efficacy for LSPH-induced gastric variceal hemorrhage, with advantages of reduced injection dose and no radiation risk. Drawbacks were time consumption and technical challenge.
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Affiliation(s)
- Yan Zeng
- Department of Psychology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jian Yang
- Department of Gastroenterology, Changdu People's Hospital of Xizang, Changdu 854000, Tibet Autonomous Region, China
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Jun-Wen Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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13
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Zhao X, Mao TY, Jiang KY, Xie QY, Yang J, Du B, Wang ZX, Fu JQ, Gao FW, Lei ZH. Analysis of risk factors for acute pancreatitis complicated with pancreatic sinistral portal hypertension and construction of predictive model. Front Physiol 2024; 14:1256615. [PMID: 38260093 PMCID: PMC10801064 DOI: 10.3389/fphys.2023.1256615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024] Open
Abstract
Objective: Pancreatic sinistral portal hypertension (PSPH) is a common complication of acute pancreatitis (AP) and can cause massive gastrointestinal bleeding, which is one of the causes of AP-related mortality. However, there is currently no predictive model for AP concurrent with PSPH. This study aimed to identify the risk factors for AP concurrent with PSPH and use these factors to build a related predictive model. Materials and methods: We collected clinical data from 282 patients with AP. 192 patients were used as a training group and 90 patients as a validation group. Univariate and multivariate analyses were used to identify independent risk factors for AP complicated with PSPH, and then a nomogram was established. The models are cross verification and Internal verification. The predictive ability and accuracy of the model were evaluated based on the working curve of the subjects and the calibration curve, respectively. The clinical value of the model was evaluated using decision curve analysis (DCA). Results: The univariate analysis revealed significant differences in the occurrence of PSPH with respect to sex, recurrent AP, history of hypertension, smoking history, patency of the splenic vein, pancreatic necrosis or pancreatic pseudocyst formation, the most significant site of pancreatic swelling, presence of a Dmure D polymer, MCTSI, and involvement of lipase and amylase. The logistic multivariate regression analysis showed that male sex, splenic-vein stenosis or occlusion and swelling were located in the body-tail, and MCTSI was an independent risk factor for PSPH. The nomogram and ROC curve were constructed. The area under the working curve of the subjects was 0.91, and the sensitivity and specificity were 82.5% and 89.1%, respectively. In the validation group, the C-index is 0.826. The nomogram was internally validated using 1,000 bootstrap samples, and the c-index was 0.898. The calibration curve demonstrated that the predicted probability was concordant with the observed probability, and the DCA confirmed that the model had robust clinical utility. Conclusion: Male sex, splenic-vein stenosis or occlusion, recurrent AP, and swelling are located in the body-tail, and MCTSI is an independent risk factor for the occurrence of PSPH. The predictive model developed for AP complicated with PSPH may serve toward developing preventive and therapeutic approaches for PSPH.
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Affiliation(s)
- Xin Zhao
- Department of Hepatopancreatobiliary Surgery, The People’s Hospital of Leshan, Leshan, Sichuan, China
- Diagnosis and Treatment Center for Liver, Gallbladder, Pancreas and Spleen System Diseases of Leshan, Leshan, Sichuan, China
| | - Tian-Yang Mao
- Department of Hepatopancreatobiliary Surgery, The People’s Hospital of Leshan, Leshan, Sichuan, China
- Diagnosis and Treatment Center for Liver, Gallbladder, Pancreas and Spleen System Diseases of Leshan, Leshan, Sichuan, China
| | - Kang-Yi Jiang
- Department of Hepatopancreatobiliary Surgery, The People’s Hospital of Leshan, Leshan, Sichuan, China
- Diagnosis and Treatment Center for Liver, Gallbladder, Pancreas and Spleen System Diseases of Leshan, Leshan, Sichuan, China
| | - Qing-Yun Xie
- Department of Hepatopancreatobiliary Surgery, The People’s Hospital of Leshan, Leshan, Sichuan, China
- Diagnosis and Treatment Center for Liver, Gallbladder, Pancreas and Spleen System Diseases of Leshan, Leshan, Sichuan, China
| | - Jie Yang
- Department of Hepatopancreatobiliary Surgery, The People’s Hospital of Leshan, Leshan, Sichuan, China
- Diagnosis and Treatment Center for Liver, Gallbladder, Pancreas and Spleen System Diseases of Leshan, Leshan, Sichuan, China
| | - Bo Du
- Department of Hepatopancreatobiliary Surgery, The People’s Hospital of Leshan, Leshan, Sichuan, China
- Diagnosis and Treatment Center for Liver, Gallbladder, Pancreas and Spleen System Diseases of Leshan, Leshan, Sichuan, China
| | - Zhi-Xu Wang
- Department of Hepatopancreatobiliary Surgery, The People’s Hospital of Leshan, Leshan, Sichuan, China
- Diagnosis and Treatment Center for Liver, Gallbladder, Pancreas and Spleen System Diseases of Leshan, Leshan, Sichuan, China
| | - Jin-Qiang Fu
- Department of Hepatopancreatobiliary Surgery, The People’s Hospital of Leshan, Leshan, Sichuan, China
- Diagnosis and Treatment Center for Liver, Gallbladder, Pancreas and Spleen System Diseases of Leshan, Leshan, Sichuan, China
| | - Feng-Wei Gao
- Liver Transplantation Center, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, Sichuan, China
| | - Ze-Hua Lei
- Department of Hepatopancreatobiliary Surgery, The People’s Hospital of Leshan, Leshan, Sichuan, China
- Diagnosis and Treatment Center for Liver, Gallbladder, Pancreas and Spleen System Diseases of Leshan, Leshan, Sichuan, China
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14
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Mansour N, Sirtl S, Angele MK, Wildgruber M. Management of Sinistral Portal Hypertension after Pancreaticoduodenectomy. Dig Dis 2024; 42:178-185. [PMID: 38185113 PMCID: PMC10997249 DOI: 10.1159/000535774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 12/08/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Sinistral, or left-sided, portal hypertension (SPH) is a rare cause of upper gastrointestinal (GI) hemorrhage resulting from obstruction of the splenic vein. Venous drainage from the spleen via collaterals can result in venous hemorrhage into both the retroperitoneal and intra-abdominal spaces due to increased venous blood pressure in peripancreatic and gastroduodenal vasculature. SPH can occur secondary to pancreatitis with thrombosis of the splenic vein. Another possible cause is the surgical ligation of the splenic vein as part of pancreaticoduodenectomy (PD). Although splenectomy has been traditionally considered as the treatment of choice to relieve venous hypertension, individual concepts for each patient have to be developed. Considering the venous collateral drainage pathways, a comprehensive approach involving surgical, endoscopic, and interventional radiology interventions may be necessary to address the underlying cause of variceal bleeding. Among these approaches, splenic artery embolization (SAE) has demonstrated efficacy in mitigating the adverse effects associated with elevated venous outflow pressure. SUMMARY This review summarizes key imaging findings in SPH patients after PD and highlights the potential of minimally invasive embolization for curative treatment of variceal hemorrhage. KEY MESSAGES (i) SPH is a potential consequence after major pancreas surgery. (ii) Collateral flow can lead to life-threatening abdominal bleeding. (iii) Depending on the origin and localization of the bleeding, a dedicated management is required, frequently involving interventional radiology techniques.
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Affiliation(s)
- Nabeel Mansour
- Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Simon Sirtl
- Department of Medicine II, LMU University Hospital, LMU Munich, Munich, Germany
| | - Martin K. Angele
- Department for General, Visceral and Transplantation Surgery, LMU University Hospital, LMU Munich, Munich, Germany
| | - Moritz Wildgruber
- Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany
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15
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Gao H, Sun B, Li X, Bai T, Du L, Song Y, Zheng C, Kan X, Liu F. Risk factors for portal vein system thrombosis after partial splenic embolisation in cirrhotic patients with hypersplenism. Clin Radiol 2023; 78:919-927. [PMID: 37634989 DOI: 10.1016/j.crad.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/18/2023] [Accepted: 07/26/2023] [Indexed: 08/29/2023]
Abstract
AIM To determine risk factors for portal venous system thrombosis (PVST) after partial splenic artery embolisation (PSAE) in cirrhotic patients with hypersplenism. MATERIALS AND METHODS Between March 2014 and February 2022, 428 cirrhotic patients with hypersplenism underwent partial splenic artery embolisation and from these patients 208 were enrolled and 220 were excluded. Medical records of enrolled patients were collected. Computed tomography (CT) images were reviewed by two blinded, independent radiologists. Statistical analyses were performed by using SPSS. RESULTS Progressive PVST was observed in 18.75% (39/208) of cirrhotic patients after PSAE. No significant differences in peripheral blood counts, liver function biomarkers, and renal function were observed between the patients with progressive PVST and the patients without progressive PVST. The imaging data showed significant differences in PVST, the diameters of the portal, splenic, and superior mesenteric veins between the progressive PVST group and non-progressive PVST group. Univariate and multivariate analysis demonstrated portal vein thrombosis, spleen infarction percentage, and the diameter of the splenic vein were independent risk factors for progressive PVST. Seventeen of 173 (9.83%) patients showed new PVST; the growth of PVST was observed in 62.86% (22/35) of the patients with pre-existing PVST. Spleen infarction percentage and the diameter of the splenic vein were independent risk factors for new PVST after PSAE. CONCLUSION The present study demonstrated portal vein thrombosis, spleen infarction percentage, and the diameter of the splenic vein were independent risk factors for PVST after PSAE in cirrhotic patients with hypersplenism.
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Affiliation(s)
- H Gao
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - B Sun
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - X Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - T Bai
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - L Du
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Y Song
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - C Zheng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - X Kan
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - F Liu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
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16
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Watanabe Y, Osaki A, Yamazaki S, Yokoyama H, Takaku K, Sato M, Sato D, Yokoyama N, Waguri N, Terai S. Two Cases of Gastric Varices with Left-sided Portal Hypertension Due to Essential Thrombocythemia Treated with Gastric Devascularization or Partial Splenic Embolization. Intern Med 2023; 62:2839-2846. [PMID: 36823082 PMCID: PMC10602822 DOI: 10.2169/internalmedicine.1273-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 01/10/2023] [Indexed: 02/25/2023] Open
Abstract
Left-sided portal hypertension (LSPH) is a condition of extrahepatic portal hypertension that often results in bleeding from isolated gastric varices (GVs). LSPH is sometimes caused by myeloproliferative diseases, such as essential thrombocythemia (ET). We herein report two cases of GVs with LSPH due to ET that were successfully controlled by gastric devascularization (GDS) or partial splenic embolization (PSE). Since each patient with LSPH due to ET has a different pathology, optimal treatment should be performed depending on the patient's condition, such as platelet counts, hemodynamics, or the prognosis. We believe that these cases will serve as a reference for future cases.
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Affiliation(s)
- Yusuke Watanabe
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Japan
- Division of Preemptive Medicine for Digestive Disease and Healthy Active Life, School of Medicine, Niigata University, Japan
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Japan
| | - Akihiko Osaki
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Japan
| | - Shun Yamazaki
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Japan
| | - Hanako Yokoyama
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Japan
| | - Kenichi Takaku
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Japan
| | - Munehiro Sato
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Japan
| | - Daisuke Sato
- Department of Surgery, Niigata City General Hospital, Japan
| | | | - Nobuo Waguri
- Department of Gastroenterology and Hepatology, Niigata City General Hospital, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Japan
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17
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Zheng J, Han M, Chen J, Deng MM, Luo G. Predictive value of D-dimer and fibrinogen degradation product for splanchnic vein thrombosis in patients with severe acute pancreatitis: a single-center retrospective study. Scand J Gastroenterol 2023; 58:1166-1172. [PMID: 37221650 DOI: 10.1080/00365521.2023.2215367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 05/14/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND AND AIM Early diagnosis of splanchnic vein thrombosis (SVT) after severe acute pancreatitis (SAP) remains difficult because of its insidious onset. Common serum markers for thrombosis such as D-dimer (D-D) have lost their diagnostic value due to their elevation in non-thrombotic patients with SAP. The aim of this study is to predict SVT after SAP using common serum indicators of thrombosis by establishing a new cut-off value. METHODS 177 SAP patients were included in a retrospective cohort study from September 2019 to September 2021. Patient demographics, dynamic changes of coagulation and fibrinolysis indicators were collected. Univariate analyses and binary logistic regression analyses were applied to assess potential risk factors for the development of SVT in SAP patients. A receiver operating characteristic (ROC) curve was generated to assess the predictive value of independent risk factors. Moreover, clinical complications and outcomes were compared between two groups. RESULTS Among 177 SAP patients, 32 (18.1%) developed SVT. The most common cause of SAP was biliary (49.8%), followed by hypertriglyceridemia (21.5%). Multivariate logistic regression analyses showed that D-D (OR, 1.135; 95%CI, 1.043-1.236; p = 0.003) and fibrinogen degradation product (FDP) (OR, 1.037; 95%CI, 1.015-1.060; p = 0.001) were independent risk factors for SVT development in patients with SAP. The area under ROC curve for D-D was 0.891 (p = 0.003, sensitivity= 95.3%, specificity = 74.1%) at a cut-off value of 6.475, and the area under ROC curve for FDP was 0.858 (p = 0.001, sensitivity = 89.4%, specificity = 72.4%) at a cut-off value of 23.155. CONCLUSION D-D and FDP are significant independent risk factors with high predictive value for SVT in patients with SAP.
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Affiliation(s)
- Jie Zheng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Ming Han
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Jie Chen
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Ming Ming Deng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Gang Luo
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
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Füssel LM, Müller-Wille R, Dinkhauser P, Schauer W, Hofer H. Treatment of colonic varices and gastrointestinal bleeding by recanalization and stenting of splenic-vein-thrombosis: A case report and literature review. World J Gastroenterol 2023; 29:3922-3931. [PMID: 37426315 PMCID: PMC10324528 DOI: 10.3748/wjg.v29.i24.3922] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/27/2023] [Accepted: 05/30/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Splenic vein thrombosis is a known complication of pancreatitis. It can lead to increased blood flow through mesenteric collaterals. This segmental hypertension may result in the development of colonic varices (CV) with a high risk of severe gastrointestinal bleeding. While clear guidelines for treatment are lacking, splenectomy or splenic artery embolization are often used to treat bleeding. Splenic vein stenting has been shown to be a safe option.
CASE SUMMARY A 45-year-old female patient was admitted due to recurrent gastrointestinal bleeding. She was anemic with a hemoglobin of 8.0 g/dL. As a source of bleeding, CV were identified. Computed tomography scans revealed thrombotic occlusion of the splenic vein, presumably as a result of a severe acute pancreatitis 8 years prior. In a selective angiography, a dilated mesenterial collateral leading from the spleen to enlarged vessels in the right colonic flexure and draining into the superior mesenteric vein could be confirmed. The hepatic venous pressure gradient was within normal range. In an interdisciplinary board, transhepatic recanalization of the splenic vein via balloon dilatation and consecutive stenting, as well as coiling of the aberrant veins was discussed and successfully performed. Consecutive evaluation revealed complete regression of CV and splenomegaly as well as normalization of the red blood cell count during follow-up.
CONCLUSION Recanalization and stenting of splenic vein thrombosis might be considered in patients with gastrointestinal bleeding due to CV. However, a multidisciplinary approach with a thorough workup and discussion of individualized therapeutic strategies is crucial in these difficult to treat patients.
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Affiliation(s)
- Lisa-Michaela Füssel
- Department of Internal Medicine I, Gastroenterology and Hepatology, Klinikum Wels-Grieskirchen, Wels 4600, Austria
| | - Rene Müller-Wille
- Department of Radiology, Klinikum Wels-Grieskirchen, Wels 4600, Austria
| | - Patrick Dinkhauser
- Department of Internal Medicine I, Gastroenterology and Hepatology, Klinikum Wels-Grieskirchen, Wels 4600, Austria
| | - Walter Schauer
- Department of Abdominal Surgery, Klinikum Wels-Grieskirchen, Wels 4600, Austria
| | - Harald Hofer
- Department of Internal Medicine I, Gastroenterology and Hepatology, Klinikum Wels-Grieskirchen, Wels 4600, Austria
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19
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Angiographic patterns of portal venous system in children with extrahepatic portal hypertension and its etiological and clinical relevance. Pediatr Surg Int 2023; 39:97. [PMID: 36723662 DOI: 10.1007/s00383-023-05384-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 02/02/2023]
Abstract
PURPOSE To study the relationship between the angiographic pattern of extrahepatic portal vein obstruction (EHPVO) and its etiology and clinical manifestations. METHODS Clinical, etiological, and angiographic findings in 155 children with EHPVO were reviewed. Anatomy of extrahepatic portal venous system (EPVS) was categorized into five imaging patterns. Assessment of the severity of esophageal and gastric varices (EV and GV) was performed by upper gastrointestinal endoscopy. RESULTS Based on multislice CT angiography, most commonly observed pattern of EHPVO was type I (48.4%) and type II (29%). According to anamnesis, 68 (43.8%) children had pathological conditions in neonatal period. Of these, 35 (22.6%) had an umbilical vein catheterization, 11 (7.1%) had a history of omphalitis, and 9 (5.8%) had prolonged jaundice. Thirteen (8.4%) patients had various septic conditions in neonatal period and it was more common associated with widespread thrombosis throughout the EPVS (type 5)-28% of observations. Significantly lower risk of bleeding from EV (p = 0.01) was noted in children with type IV pattern, whereas children with type III and V patterns had higher grades of EV. CONCLUSION Angiographic pattern of portomesenteric occlusion may provide a clue to its etiology, and clinical manifestation, especially in children with widespread thrombosis throughout the EPVS.
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20
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Mayer P, Felli E, Enescu I, Habersetzer F, Tripon S. Upper gastrointestinal bleeding due to left side portal hypertension after pancreatic surgery. Hepatobiliary Pancreat Dis Int 2023; 22:81-84. [PMID: 35000846 DOI: 10.1016/j.hbpd.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/16/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Pierre Mayer
- Department of Hepatology and Gastroenterology, Pôle Hépato-digestif, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg (HUS), Strasbourg, France; Institut Hospitalo-universitaire (IHU) de Strasbourg, Pôle Hépato-digestif, Strasbourg, France.
| | - Emanuele Felli
- Institut Hospitalo-universitaire (IHU) de Strasbourg, Pôle Hépato-digestif, Strasbourg, France; Department of Hepato-biliary and Pancreatic surgery, Pôle Hépato-digestif, Nouvel Hôpital Civil, HUS, Strasbourg, France; Institut des Maladies Virales et Hépatiques, Inserm U1110, Université de Strasbourg, Faculté de Médecine, Strasbourg, France
| | - Iulian Enescu
- Department of Interventional Radiology, Pôle d'imagerie, Nouvel Hôpital Civil, HUS, Strasbourg, France
| | - François Habersetzer
- Department of Hepatology and Gastroenterology, Pôle Hépato-digestif, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg (HUS), Strasbourg, France; Institut Hospitalo-universitaire (IHU) de Strasbourg, Pôle Hépato-digestif, Strasbourg, France; Institut des Maladies Virales et Hépatiques, Inserm U1110, Université de Strasbourg, Faculté de Médecine, Strasbourg, France
| | - Simona Tripon
- Department of Hepatology and Gastroenterology, Pôle Hépato-digestif, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg (HUS), Strasbourg, France; Institut Hospitalo-universitaire (IHU) de Strasbourg, Pôle Hépato-digestif, Strasbourg, France; Institut des Maladies Virales et Hépatiques, Inserm U1110, Université de Strasbourg, Faculté de Médecine, Strasbourg, France
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21
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Xu Q, Li P, Zhang H, Wang M, Liu Q, Liu W, Dai M. Identifying the preoperative factors predicting the surgical difficulty of robotic distal pancreatectomy. Surg Endosc 2023; 37:3823-3831. [PMID: 36690891 DOI: 10.1007/s00464-023-09865-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/04/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Few studies have evaluated the preoperative factors predicting the surgical difficulty of robotic distal pancreatectomy (RDP). This study aims to explore such factors and provide guidance on the selection of suitable patients to aid surgeons lacking extensive experience in RDP. METHODS A retrospective study was conducted on consecutive patients who underwent RDP to identify preoperative factors predicting surgical difficulty. High surgical difficulty was defined by both operation time and intraoperative estimated blood loss exceeding their median, or by conversion to laparotomy. RESULTS A total of 161 patients were ultimately enrolled, including 51 patients with high levels of surgical difficulty. Multivariate analysis revealed that male sex [OR (95% CI): 4.07 (1.77,9.40), p = 0.001], body mass index (BMI) ≥ 25 kg/m2 OR (95% CI): 2.27 (1.03,5.00), p = 0.042], tumors located at the neck of the pancreas [OR (95% CI): 4.15 (1.49,11.56), p = 0.006] and splenic artery type B [OR (95% CI): 3.28 (1.09,9.91), p = 0.035] were independent risk factors for surgical difficulty. Regarding postoperative complications, high surgical difficulty was associated with the risk of overall complications and pancreatic fistula (grade B/C) (49.0% vs. 22.7%, p < 0.001; 39.2% vs. 19.1%, p = 0.006). CONCLUSION Male sex, body mass index ≥ 25 kg/m2, tumor located at the neck of the pancreas and splenic artery type B are associated with a high RDP difficulty level. These factors can be used preoperatively to assess the difficulty level of surgery, to help surgeons choose patients suitable for them and ensure surgical safety.
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Affiliation(s)
- Qiang Xu
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Pengyu Li
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Hanyu Zhang
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Mengyi Wang
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Qiaofei Liu
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Wenjing Liu
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China
| | - Menghua Dai
- Department of General Surgery, Peking Union Medical College Hospital (PUMCH), Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1, Shuai Fu Yuan, Dongcheng, Beijing, 100730, China.
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22
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Povzun SA. [Varicose veins of the esophagus as a manifestation of left-sided portal hypertension]. Arkh Patol 2023; 85:45-47. [PMID: 37814849 DOI: 10.17116/patol20238505145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
An autopsy of pancreatic cancer in a woman who died from acute posthemorrhagic anemia due to repeated bleeding from esophageal varices is presented. The mechanism of development of esophageal varices associated with the so-called left-sided portal hypertension, caused by compression of the splenic vein by the tumor and the opening of porto-caval anastomoses, is considered. A brief review discusses other possible causes of left-sided portal hypertension syndrome and its consequences.
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Affiliation(s)
- S A Povzun
- I.I. Dzanelidze Saint-Petersburg Scientific Research Institute of Emergency Aid, St. Petersburg, Russia
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23
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Pak J, Lee S, Lee HN, Hyun D, Park SJ, Cho Y. Isolated Gastric Varix Bleeding Caused by Splenic Vein Obstruction: Two Case Reports. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:291-297. [PMID: 36818695 PMCID: PMC9935947 DOI: 10.3348/jksr.2022.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/16/2022] [Accepted: 07/28/2022] [Indexed: 02/09/2023]
Abstract
Isolated left-sided portal hypertension is a rare clinical syndrome caused by splenic veno-occlusive disease. Splenic vein thrombosis and extrinsic compression causes proximal splenic vein hypertension, and the splenic blood flows into the superior mesenteric or portal vein through the upper stomach's collateral vessels, such as the short gastric, coronary, and gastroepiploic veins. Open splenectomy is recommended to treat gastrointestinal bleeding caused by isolated left-sided portal hypertension. Interventional management could be a clinically useful option for selected patients who want to avoid surgical corrections. The report presents two cases of left-sided portal hypertension with gastric variceal bleeding.
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Affiliation(s)
- Juyoung Pak
- Department of Radiology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Sangjoon Lee
- Vascular Center, The Eutteum Orthopedic Surgery Hospital, Paju, Korea
| | - Hyoung Nam Lee
- Department of Radiology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Dongho Hyun
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung-Joon Park
- Department of Radiology, Korea University College of Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Youngjong Cho
- Department of Radiology, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung, Korea
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24
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Higashino N, Kawai N, Sonomura T, Fukuda K, Sato H, Ikoma A, Kawai M, Minamiguchi H. Percutaneous transsplenic venous embolization of elevated jejunal varices after pancreaticoduodenectomy: A case report. Radiol Case Rep 2022; 18:737-740. [PMID: 36582761 PMCID: PMC9792728 DOI: 10.1016/j.radcr.2022.11.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/20/2022] [Indexed: 12/23/2022] Open
Abstract
Recent advances in chemotherapy and radiotherapy have led to an increase in the number of long-term survivors of pancreatic cancer. However, this has also increased the number of patients suffering from ectopic varices and bleeding owing to left-sided portal hypertension and thrombocytopenia caused by splenomegaly after pancreaticoduodenectomy combined with resection of the splenic vein. A 65-year-old woman with varices of the elevated jejunum due to left sided portal hypertension after pancreaticoduodenectomy had repeated melena, which started about 1 year before admission. We describe the first reported case of percutaneous transsplenic venous embolization using metallic coils, which successfully achieved hemostasis of refractory bleeding from the elevated jejunal varices after pancreaticoduodenectomy.
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Key Words
- CT, computed tomography
- CTV, computed tomography during venography
- EO, ethanolamine oleate
- Elevated jejunal varices
- LSPH, left-sided portal hypertension
- Left-sided portal hypertension
- PD, pancreaticoduodenectomy
- PSE, partial splenic artery embolization
- PV, portal vein
- Pancreaticoduodenectomy
- Percutaneous transsplenic venous embolization
- SMV, superior mesenteric vein
- STS, sodium tetradecyl sulfate
- SV, splenic vein
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Affiliation(s)
- Nobuyuki Higashino
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayamashi, Wakayama 641-8509, Japan
- Corresponding author.
| | - Nobuyuki Kawai
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayamashi, Wakayama 641-8509, Japan
| | - Tetsuo Sonomura
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayamashi, Wakayama 641-8509, Japan
| | - Kodai Fukuda
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayamashi, Wakayama 641-8509, Japan
| | - Hirotatsu Sato
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayamashi, Wakayama 641-8509, Japan
| | - Akira Ikoma
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayamashi, Wakayama 641-8509, Japan
| | - Manabu Kawai
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - Hiroki Minamiguchi
- Department of Radiology, Wakayama Medical University, 811-1 Kimiidera, Wakayamashi, Wakayama 641-8509, Japan
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25
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Yang J, Zeng Y, Zhang JW. Endoscopic ultrasound-guided diagnosis and treatment of gastric varices. World J Gastrointest Endosc 2022; 14:748-758. [PMID: 36567822 PMCID: PMC9782569 DOI: 10.4253/wjge.v14.i12.748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/25/2022] [Accepted: 11/21/2022] [Indexed: 12/14/2022] Open
Abstract
Gastric varices (GV) represent a common and severe complication in patients with portal hypertension, commonly seen in patients with cirrhosis and severe pancreatic disease. Endoscopic ultrasonography is a safe and efficacious approach that can perform real-time ultrasonic scanning and intervention for the gastrointestinal submucosa, portal vein and its tributaries, and collateral circulations during direct endoscopic observation. Recently, various studies have been published about endoscopic ultrasound (EUS)-guided management of GV, mainly including diagnosis, treatment, and prognostic analysis. This article reviews published articles and guidelines to present the development process and current management of EUS-guided GV procedures.
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Affiliation(s)
- Jian Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yan Zeng
- Department of Psychology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jun-Wen Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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26
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Martino A, Di Serafino M, Zito FP, Maglione F, Bennato R, Orsini L, Iacobelli A, Niola R, Romano L, Lombardi G. Massive bleeding from gastric submucosal arterial collaterals secondary to splenic artery thrombosis: A case report. World J Gastroenterol 2022; 28:5506-5514. [PMID: 36312836 PMCID: PMC9611706 DOI: 10.3748/wjg.v28.i37.5506] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 07/17/2022] [Accepted: 09/07/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gastric submucosal arterial collaterals (GSAC) secondary to splenic artery occlusion is an extraordinary rare and potentially life-threatening cause of acute upper gastrointestinal bleeding. Here, we report a case of massive bleeding from GSAC successfully treated by means of a multidisciplinary minimally invasive approach.
CASE SUMMARY A 60-year-old non-cirrhotic gentleman with a history of arterial hypertension was admitted due to hematemesis. Emergent esophagogastroduodenoscopy revealed pulsating and tortuous varicose shaped submucosal vessels in the gastric fundus along with a small erosion overlying one of the vessels. In order to characterize the fundic lesion, pre-operative emergent computed tomography-angiography was performed showing splenic artery thrombosis (SAT) and tortuous arterial structures arising from the left gastric artery and the left gastroepiploic artery in the gastric fundus. GSAC was successfully treated by means of a minimally invasive step-up approach consisting in endoscopic clipping followed by transcatheter arterial embolization (TAE).
CONCLUSION This was a previously unreported case of bleeding GSAC secondary to SAT successfully managed by means of a multidisciplinary minimally invasive approach consisting in endoscopic clipping for the luminal bleeding control followed by elective TAE for the definitive treatment.
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Affiliation(s)
- Alberto Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Marco Di Serafino
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Francesco Paolo Zito
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Franco Maglione
- Department of Radiology, Sanatrix Clinic, Napoli 80127, Italy
| | - Raffaele Bennato
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Luigi Orsini
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | | | - Raffaella Niola
- Department of Interventional Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Luigia Romano
- Department of General and Emergency Radiology, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Giovanni Lombardi
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
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27
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Sikana AM, Thamrin H. Splenic vein thrombosis in cirrhosis of the liver: A rare case. Ann Med Surg (Lond) 2022; 81:104439. [PMID: 36147171 PMCID: PMC9486553 DOI: 10.1016/j.amsu.2022.104439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/03/2022] [Accepted: 08/12/2022] [Indexed: 11/16/2022] Open
Abstract
Splenic Vein Thrombosis (SpVT) in a young patient with non-hepatitis B and C liver cirrhosis is an infrequent case generating hemorrhagic manifestations. Herein we report a 28-year-old man presenting with hematemesis, melena, and features of liver cirrhosis. Hematemesis, melena, and ascites resolve following a conservative treatment. Abdominal ultrasound confirmed portal hypertension. Serial endoscopy on day 14, 17 and 1-month evaluation showed grade II-III esophageal varices and severe hypertensive portal gastropathy. Abdominal CT scan with contrast within 1 week after discharge revealed thrombus along ± 5.8 cm, splenomegaly with dilated splenic vein, dilatation and tourtosity of the left gastric vein and visualized distal esophageal vein. Liver biopsy 2 months after hospitalization showed hepatocytes with extensive hydropic degeneration with fibrosis (F3).
Splenic Vein Thrombosis (SpVT) occurring in a young patient is a rare case SpVT might occur without relating to hepatitis-B or hepatitis-C infection. In this situation, even mostly asymptomatic, gastrointestinal bleeding secondary to esophageal or gastric varices commonly arises. Heparinization should be done to increase survival and prevent recurrent thrombosis. Immediate splenectomy is strongly recommended in patients with bleeding esophageal varices to prevent massive bleeding.
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28
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Tanaka Y, Kariya S, Nakatani M, Ueno Y, Ono Y, Maruyama T, Komemushi A, Tanigawa N. Percutaneous Transsplenic Embolization of Gastric Varices in Left-sided Portal Hypertension. INTERVENTIONAL RADIOLOGY 2022; 7:58-62. [PMID: 36196384 PMCID: PMC9527103 DOI: 10.22575/interventionalradiology.2021-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 01/26/2022] [Indexed: 11/15/2022]
Abstract
An 81-year-old man with previously diagnosed cancer of the pancreatic body presented with melena and anemia. Upper gastrointestinal endoscopy showed gastric varices with bleeding in the entire stomach. Contrast-enhanced computed tomography identified a splenic vein occlusion resulting from invasion by the pancreatic body cancer and dilated collateral pathways from the splenic hilum to the gastric fundus. The patient was diagnosed with gastric varices associated with left-sided portal hypertension caused by obstruction of the splenic vein and underwent percutaneous transsplenic embolization with n-butyl-2-cyanoacrylate mixed with lipiodol. Splenic subcapsular hematoma occurred and was treated conservatively. The patient died of advanced cancer 5 months after the procedure, without experiencing rebleeding. Percutaneous transsplenic embolization was effective in treating gastric variceal bleeding caused by left-sided portal hypertension.
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Affiliation(s)
- Yuki Tanaka
- Department of Radiology, Kansai Medical University
| | - Shuji Kariya
- Department of Radiology, Kansai Medical University
| | | | - Yutaka Ueno
- Department of Radiology, Kansai Medical University
| | - Yasuyuki Ono
- Department of Radiology, Kansai Medical University
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29
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Yang J, Zeng Y, Zhang JW. Modified endoscopic ultrasound-guided selective N-butyl-2-cyanoacrylate injections for gastric variceal hemorrhage in left-sided portal hypertension: A case report. World J Clin Cases 2022; 10:6254-6260. [PMID: 35949826 PMCID: PMC9254179 DOI: 10.12998/wjcc.v10.i18.6254] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/09/2022] [Accepted: 04/22/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Left-sided portal hypertension (LSPH), also known as sinistral portal hypertension or regional portal hypertension, refers to extrahepatic portal hypertension caused by splenic vein obstruction or stenosis. N-butyl-2-cyanoacrylate (NBC) has been widely used in the endoscopic hemostasis of portal hypertension, but adverse events including renal or pulmonary thromboembolism, mucosal necrosis and gastrointestinal (GI) bleeding may occur after treatment. Herein, we report successfully managing gastric variceal (GV) hemorrhage secondary to LSPH using modified endoscopic ultrasound (EUS)-guided selective NBC injections. CASE SUMMARY A 35-year-old man was referred to our hospital due to an upper GI hemorrhage. Gastroscopy revealed GV hemorrhage and computed tomography venography (CTV) confirmed LSPH. The patient requested endoscopic procedures and rejected surgical therapies including splenectomy. EUS-guided selective NBC injections were performed and confluences of gastric varices were selected as the injection sites to reduce the injection dose. The "sandwich" method using undiluted NBC and hypertonic glucose was applied. No complications occurred. The patient was followed up regularly after discharge. Three months later, the follow-up gastroscopy revealed firm gastric submucosa with no sign of NBC expulsion and the follow-up CTV showed improvements in LSPH. No recurrent GI hemorrhage was reported during this follow-up period. CONCLUSION EUS-guided selective NBC injection may represent an effective and economical treatment for GV hemorrhage in patients with LSPH.
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Affiliation(s)
- Jian Yang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yan Zeng
- Department of Psychology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Jun-Wen Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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30
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Yu C, Ding L, Jiang M, Liao Q, Huang X, Lei Y, Ke H, Xiong H, He W, Xia L, Zeng X, Lu N, Zhu Y. Dynamic Changes and Nomogram Prediction for Sinistral Portal Hypertension in Moderate and Severe Acute Pancreatitis. Front Med (Lausanne) 2022; 9:875263. [PMID: 35721067 PMCID: PMC9198833 DOI: 10.3389/fmed.2022.875263] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives To investigate the dynamic changes in gastric varices in patients with acute pancreatitis (AP) and to develop a novel nomogram for the early prediction of sinistral portal hypertension (SPH). Methods This was a retrospective, case-control study with an analysis of the quantitative, dynamic computed tomography imaging results of SPH in patients with moderate and severe AP with a long-term follow-up. Multivariate logistic regression analysis and nomogram were employed. Results The SPH group (n = 94) and non-SPH group (n = 94) were matched. The dynamic changes showed an increasing trend in the diameter of gastric fundus, short gastric, gastric coronary, and gastroepiploic veins, which did not recover during the one-year follow-up. Multivariate analysis showed that male (adjusted odds ratio (adjOR), 8.71; 95% confidence interval (CI), 2.86–26.53; P < 0.001), body mass index ≥27.5 kg/m2 (adjOR, 5.49; 95% CI, 1.85–16.29; P = 0.002), prothrombin time ≥12.6 s (adjOR, 2.82; 95% CI, 1.11–7.17; P = 0.03), and the patency of splenic vein [stenosis (adjOR, 8.48; 95% CI, 2.13–33.71; P = 0.002), and occlusion (adjOR, 34.57; 95% CI, 10.87–110.00; P < 0.001)] were independently associated with the development of SPH. The nomogram incorporating these factors demonstrated good discrimination, calibration and clinical utility. The area under the curve was as high as 0.92 (95% CI, 0.87–0.95). Conclusion The dynamic changes in varices in SPH are long-term and slowly progressing. Males and obese patients with abnormal splenic veins and coagulopathies are at high risk for developing SPH. A simple nomogram tool helps in the early, accurate prediction of SPH.
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Affiliation(s)
- Chen Yu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China.,Jiangxi Province Medical Imaging Research Institute, Nanchang, China
| | - Ling Ding
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Meilan Jiang
- Gaoxin Hospital of the First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Qian Liao
- Jiangxi Province Medical Imaging Research Institute, Nanchang, China.,Department of Radiology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xin Huang
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yupeng Lei
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huajing Ke
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Huifang Xiong
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wenhua He
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Liang Xia
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xianjun Zeng
- Jiangxi Province Medical Imaging Research Institute, Nanchang, China.,Department of Radiology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Nonghua Lu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yin Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Song YH, Xiang HY, Si KK, Wang ZH, Zhang Y, Liu C, Xu KS, Li X. Difference between type 2 gastroesophageal varices and isolated fundic varices in clinical profiles and portosystemic collaterals. World J Clin Cases 2022; 10:5620-5633. [PMID: 35979133 PMCID: PMC9258365 DOI: 10.12998/wjcc.v10.i17.5620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/17/2022] [Accepted: 04/09/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There is significant heterogeneity between gastroesophageal varices (GOV2) and isolated gastric varices (IGV1). The data on the difference between GOV2 and IGV1 are limited. AIM To determine the etiology, clinical profiles, endoscopic findings, imaging signs, portosystemic collaterals in patients with GOV2 and IGV1. METHODS Medical records of 252 patients with gastric fundal varices were retrospectively collected, and computed tomography images were analyzed. RESULTS Significant differences in routine blood examination, Child-Pugh classification and MELD scores were found between GOV2 and IGV1. The incidence of peptic ulcers in patients with IGV1 (26.55%) was higher than that of GOV2 (11.01%), while portal hypertensive gastropathy was more commonly found in patients with GOV2 (22.02%) than in those with IGV1 (3.54%). Typical radiological signs of cirrhotic liver were more commonly observed in patients with GOV2 than in those with IGV1. In patients with GOV2, the main afferent vessels were via the left gastric vein (LGV) (97.94%) and short gastric vein (SGV) (39.18%). In patients with IGV1, the main afferent vessels were via the LGV (75.61%), SGV (63.41%) and posterior gastric vein (PGV) (43.90%). In IGV1 patients with pancreatic diseases, spleno-gastromental-superior mesenteric shunt (48.15%) was a major collateral vessel. In patients with fundic varices, the sizes of gastric/esophageal varices were positively correlated with afferent vessels (LGVs and PGVs) and efferent vessels (gastrorenal shunts). The size of the esophageal varices was negatively correlated with gastrorenal shunts in GOV2 patients. CONCLUSION Significant heterogeneity in the etiology and vascular changes between GOV2 and IGV1 is useful in making therapeutic decisions.
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Affiliation(s)
- Yu-Hu Song
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Hong-Yu Xiang
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Ke-Ke Si
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
- Hubei Province Key Laboratory of Molecular Imaging, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Ze-Hui Wang
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Yu Zhang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
- Hubei Province Key Laboratory of Molecular Imaging, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Chang Liu
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Ke-Shu Xu
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Xin Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
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Zafar M, Heslop-Harrison W, Loterh L, Ofuafor K. Splenic Vein Thrombosis: A Case Series of Consequential Chronic Pancreatitis and Sequential Myeloproliferative Disorder. Cureus 2022; 14:e25924. [PMID: 35720785 PMCID: PMC9199563 DOI: 10.7759/cureus.25924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2022] [Indexed: 11/21/2022] Open
Abstract
We present a case series of two patients with splenic vein thrombosis (SVT), a relatively uncommon condition supposed to occur in the context of pancreatitis or pancreatic malignancies. Splenic vein thrombosis may also be seen in cases of chronic pancreatitis, as in one of our patients. At times, splenic vein thrombosis may present with an incidental, isolated finding of gastric varices on computed tomography pulmonary angiogram (CTPA) while investigating for pulmonary embolus; such a result should prompt further investigation to rule out associated splenic vein thrombosis in a sequence. We attempt to highlight the importance of performing a blood count and hematocrit, supplementary to a liver screen, in another patient where the cause was not related to liver disease, but to myeloproliferative disorder, which resulted in a hyper-thrombotic state and splenic vein thrombosis as a consequence.
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Usefulness of partial splenic embolization for left-sided portal hypertension in a patient with a pancreatic neuroendocrine neoplasm: a case report and review of the literature. Clin J Gastroenterol 2022; 15:796-802. [PMID: 35430638 PMCID: PMC9334412 DOI: 10.1007/s12328-022-01631-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/30/2022] [Indexed: 11/01/2022]
Abstract
AbstractLeft-side portal hypertension (LSPH) is caused by isolated obstruction of the splenic vein and is associated with esophagogastric varices that extend from the lower esophagus to the greater curvature of the gastric body. Here, we report on a 74-year-old man with a pancreatic neuroendocrine neoplasm (NEN) in the pancreatic tail with multiple liver metastases. We decided that partial splenic embolization (PSE) was the best course of treatment to prevent rupture of the gastric varices, which were classified as markedly enlarged, nodular, or tumor-shaped and showed erosion of the mucosa. After PSE, the patient had no major complications and was discharged. At 3 and 6 months after the procedure, esophagogastroduodenoscopy and enhanced computerized tomography showed that the gastric varices had improved. This case demonstrates the usefulness of PSE for LSPH in patients with unresected pancreatic NEN.
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Gyoten K, Mizuno S, Nagata M, Ito T, Hayasaki A, Murata Y, Tanemura A, Kuriyama N, Kishiwada M, Sakurai H. Concomitant splenic artery ligation has no preventive effect on left‐sided portal hypertension following pancreaticoduodenectomy with the resection of the portal and superior mesenteric vein confluence for pancreatic ductal adenocarcinoma. Ann Gastroenterol Surg 2022; 6:420-429. [PMID: 35634189 PMCID: PMC9130910 DOI: 10.1002/ags3.12545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/30/2021] [Accepted: 12/27/2021] [Indexed: 11/13/2022] Open
Abstract
Background Left‐sided portal hypertension (LSPH) caused by splenic vein (SV) division in pancreaticoduodenectomy (PD) with portal vein (PV) resection remains challenging. The current study aimed to investigate the efficacy of splenic artery (SA) ligation in preventing LSPH. Methods One‐hundred thirty patients who underwent PD with PV resection for pancreatic ductal adenocarcinoma were classified into SV and SA preservation (SVP, n = 30), SV resection and SA preservation (SVR, n = 59), and SV resection and SA ligation (SAL, n = 41). The postoperative incidence of LSPH was assessed. Results The incidence of variceal formation in SVP, SVR, and SAL were 4.8%, 53.2%, and 46.4% at 3 mo, 13.0%, 71.2%, and 62.5% at 6 mo, and 25.0%, 87.5%, and 87.1% at 12 mo, respectively. The rate was significantly higher in SVR at 3 and 6 mo (P = .001 and P < .001, respectively) and in SVR and SAL (P < .001) at 12 mo. Variceal hemorrhage occurred only in SVR (n = 4). The platelet count ratio at 3, 6, and 12 mo began to significantly decrease from 3 mo in SVR (0.77, 0.67, and 0.60, respectively; P < .001) and 6 mo in SAL (0.91, 0.73, and 0.69, respectively; P < .001). The spleen volume ratio also showed significant increase from 3 mo in SVR (1.24, 1.34, and 1.42, respectively; P < .001) and 6 mo in SAL (1.31, 1.32, and 1.34, respectively; P < .001). SVR and SAL were significant risk factors for variceal formation at 12 mo (odds ratio, 21.0 and 20.3, respectively). Conclusion In PD with PV resection, SAL delayed LSPH but could not prevent its occurrence.
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Affiliation(s)
- Kazuyuki Gyoten
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
| | - Motonori Nagata
- Department of Radiology Mie University School of MedicineMie University School of Medicine Tsu Japan
| | - Takahiro Ito
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
| | - Aoi Hayasaki
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
| | - Yasuhiro Murata
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
| | - Akihiro Tanemura
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
| | - Naohisa Kuriyama
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
| | - Masashi Kishiwada
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
| | - Hiroyuki Sakurai
- Department of Hepatobiliary Pancreatic and Transplant Surgery Mie University School of Medicine Tsu Japan
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Liu J, Meng J, Yang M, Zhou C, Yang C, Huang S, Shi Q, Wang Y, Li T, Chen Y, Xiong B. Two-step complete splenic artery embolization for the management of symptomatic sinistral portal hypertension. Scand J Gastroenterol 2022; 57:78-84. [PMID: 34581650 DOI: 10.1080/00365521.2021.1983641] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Sinistral portal hypertension (SPH) is a rare clinical syndrome. The purpose of this study was to assess the clinical outcomes and safety of splenic artery embolization (SAE) in the treatment of SPH. METHODS This retrospective study included 39 SPH patients who underwent SAE treatment between August 2009 and May 2021. The cases had esophageal, gastric, or ectopic varices detected by endoscopy or enhanced CT, with symptoms or signs of upper gastrointestinal (GI) bleeding and/or postprandial fullness. Clinical symptom improvement rate, complications, and symptomatic recurrence rate were observed and analyzed after treatment. RESULTS All the procedures were performed successfully. Of all patients, 17 received the 2-step complete SAE procedure, 19 received only the first step of the 2-step protocol (i.e., partial splenic embolization [PSE] procedure), and the remaining three received the 1-step complete SAE procedure. After the procedures, the symptoms completely disappeared in all patients, and the main complications were post-embolization syndromes, with 27 patients (69.2%) developing a low-grade fever, 24 (61.5%) developing abdominal pain and 4 (10.3%) developing nausea or mild vomiting. During the prolonged follow-up, varicose veins were gradually reduced as detected by enhanced CT; liver function parameters and platelet count remained in the normal range. Only one patient who underwent PSE treatment developed upper GI rebleeding 7 months after the procedure. CONCLUSION Two-step complete SAE is a safe and feasible procedure for the treatment of symptomatic SPH.
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Affiliation(s)
- Jiacheng Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jie Meng
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Ming Yang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chongtu Yang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Songjiang Huang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Qin Shi
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yingliang Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Tongqiang Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yang Chen
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
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Weerasuriya S, Palmer K, Gregory S, Whitelaw BC, Gonzalez E, Srirajaskanthan R. Mesenteric Variceal Haemorrhage and Ectopic Cushing's Syndrome as Presenting Features of a Pancreatic Neuroendocrine Tumour Recurrence. Case Rep Gastroenterol 2021; 15:919-926. [PMID: 34899150 PMCID: PMC8613585 DOI: 10.1159/000518021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/11/2021] [Indexed: 11/23/2022] Open
Abstract
Pancreatic neuroendocrine tumours can have varied and complex presentations. Whilst hormone hypersecretion often induces characteristic clinical syndromes, non-specific symptoms may arise due to localized tumour effects. Malignant invasion of local vasculature is an increasingly recognized complication of these neoplasms and can be associated with significant morbidity. Herein, we present the case of a 47-year-old male with a recurrence of a pancreatic neuroendocrine tumour who presented with unusual upper gastrointestinal bleeding. The tumour had recurred within the superior mesenteric vein, replacing the vessel and invading its branches. This resulted in porto-mesenteric hypertension and the formation of bleeding mesenteric varices. The patient subsequently developed progressive metabolic disturbances and was diagnosed with ectopic Cushing's syndrome, despite his primary tumour having been non-functional. This case demonstrates not only a rare pattern of tumour recurrence but also the potential for pancreatic neuroendocrine tumours to de-differentiate and change from non-functional to hormone secreting, a phenomenon which may complicate diagnosis and management.
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Affiliation(s)
- Scott Weerasuriya
- King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Kieran Palmer
- King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Stephen Gregory
- King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Benjamin C Whitelaw
- King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Elisa Gonzalez
- King's College Hospital National Health Service Foundation Trust, London, United Kingdom
| | - Rajaventhan Srirajaskanthan
- King's College Hospital National Health Service Foundation Trust, London, United Kingdom.,Department of Gastroenterology, Institute of Liver Studies, ENETS Centres of Excellence NET Unit, Kings College Hospital, London, United Kingdom.,Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
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Ono Y, Inoue Y, Kato T, Matsueda K, Oba A, Sato T, Ito H, Saiura A, Takahashi Y. Sinistral Portal Hypertension after Pancreaticoduodenectomy with Splenic Vein Resection: Pathogenesis and Its Prevention. Cancers (Basel) 2021; 13:cancers13215334. [PMID: 34771498 PMCID: PMC8582504 DOI: 10.3390/cancers13215334] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/21/2021] [Accepted: 10/22/2021] [Indexed: 11/16/2022] Open
Abstract
To achieve curative resection for pancreatic cancer during pancreaticoduodenectomy (PD), extensive portal vein (PV) resection, including porto-mesenterico-splenic confluence (PMSC), may sometimes be necessary if the tumor is close to the portal venous system. Recently, this extended resection has been widely accepted in high-volume centers for pancreatic resection due to its favorable outcomes compared with non-operative treatment. However, in patients with long-term survival, sinistral portal hypertension (SPH) occurs as a late-onset postoperative complication. These patients present gastrointestinal varices due to congested venous flow from the spleen, which may cause critical variceal bleeding. Since the prognosis of patients with pancreatic cancer has improved, owing to the development of chemotherapy and surgical techniques, SPH is no longer a negligible matter in the field of pancreatic cancer surgery. This review clarifies the pathogenesis and frequency of SPH after PD through PMSC resection and discusses its prediction and prevention.
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Affiliation(s)
- Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
- Correspondence: ; Tel.: +81-3-3520-0111
| | - Tomotaka Kato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Kiyoshi Matsueda
- Department of Diagnostic Imaging, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan;
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, School of Medicine, Juntendo University, Tokyo 113-0033, Japan;
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan; (Y.O.); (T.K.); (A.O.); (T.S.); (H.I.); (Y.T.)
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Preoperative splenic artery embolism followed by splenectomy is safe and effective in patients with sinistral portal hypertension. Langenbecks Arch Surg 2021; 407:313-319. [PMID: 34537854 PMCID: PMC8847163 DOI: 10.1007/s00423-021-02329-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/06/2021] [Indexed: 02/05/2023]
Abstract
Background
Although preoperative splenic artery embolism (SAE) has been widely used for splenomegaly, the efficiency and safety of preoperative SAE in patients with sinistral portal hypertension (SPH) is unknown. Methods We designed a retrospective cohort of SPH patients who received preoperative SAE in our hospital (February 2018 to September 2020) and compared to those who received splenectomy only, in terms of intraoperative and postoperative outcomes. Results In all, 59 patients (18 patients received preoperative SAE) were analyzed. The median age was 44.7 years. Preoperative SAE reduced the intraoperative blood loss (637.0 vs. 420.3 ml, P = 0.041) and operation time (174.0 vs. 141.5 min, P = 0.012). The incidence of complications including postoperative pancreatic fistula (POPF), bleeding, and thromboembolism was comparable. Multivariate analysis showed that SAE was a protective factor for intraoperative blood loss and operation time, while prior pancreatic pseudocyst/abscess was a risk factor. Conclusions Preoperative SAE could reduce intraoperative blood loss and operation time in SPH patients without increasing the incidence of complications compared to splenectomy only.
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39
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Bolger JC, Parente DN, Yeung JC. Esophagectomy in the setting of left sided portal hypertension. Ann Thorac Surg 2021; 113:e413-e415. [PMID: 34474025 DOI: 10.1016/j.athoracsur.2021.07.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 11/29/2022]
Abstract
Left-sided portal hypertension is a rare entity with considerable splenogastric collateralization. We report a case of esophagectomy in the setting of left-sided portal hypertension with resulting treatment of both the esophageal cancer and the portal hypertension.
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Affiliation(s)
- Jarlath C Bolger
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
| | - David N Parente
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jonathan C Yeung
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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40
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Helavar RV, Ramappa V, Wali PP. Imaging of Portal Gastroduodenopathy. JOURNAL OF GASTROINTESTINAL AND ABDOMINAL RADIOLOGY 2021. [DOI: 10.1055/s-0041-1728235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractPortal hypertension is characterized by elevated pressure in portal venous system due to portal resistance due to various causes. The etiologies are either pre-hepatic, hepatic, or post-hepatic. Elevated portal pressure results in varices at various sites some of which are difficult to identify on endoscopy alone. Other manifestations of elevated portal pressure include portal gastropathy, enteropathy, colopathy, gastric antral vascular ectasia, and ascites. Imaging plays an essential role in diagnosis and imaging of various manifestations of portal hypertension by determining the locations of varices and plan the management for same. Endoscopy helps in visualizing mucosal varices but newer imaging modalities give a panoramic extent of the disease in the entire gastrointestinal tract with great specificity and sensitivity. Initially, Barium study was used to determine esophageal or gastric varices, computed tomography provides detailed anatomic information which can be used to plan management. Due to advancement in imaging and interventional techniques, treatment for varices has seen advent of multiple minimally invasive interventional radiological techniques. A brief outlook on anatomical aspect of varices and various recent advances in management of the same has been provided. Overall knowledge of the various imaging manifestations of portal hypertension can be helpful to evaluate prognosis and plan proper management.
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Affiliation(s)
- Rajesh V. Helavar
- Department of Diagnostic and Interventional Radiology, Columbia Asia Radiology Group, Bengaluru, Karnataka, India
| | - Vidyasagar Ramappa
- Department of Gastroenterology and Hepatology, Columbia Asia Referral Hospital, Bengaluru, Karnataka, India
| | - Praveen P. Wali
- Department of Diagnostic Radiology, Columbia Asia Radiology Group, Bengaluru, Karnataka, India
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Abraham M, Doshi S, Asfari MM, Yap JEL, Bowers HG. Isolated Gastric Variceal Hemorrhage Secondary to Idiopathic Sinistral Portal Hypertension. Cureus 2021; 13:e16165. [PMID: 34367775 PMCID: PMC8336330 DOI: 10.7759/cureus.16165] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2021] [Indexed: 11/26/2022] Open
Abstract
Sinistral portal hypertension (SPH), also known as left-sided portal hypertension or segmental portal hypertension, is a rare cause of upper gastrointestinal bleeding. Historically, SPH is a result of obstruction of the splenic vein often secondary to pancreatic pathology. To our knowledge, there are no reported cases of idiopathic SPH in which the findings cannot be attributed to any etiology. It is important to do a detailed workup to rule out common pathologies of SPH before making a diagnosis of idiopathic SPH. Treatment of gastric variceal bleed secondary to idiopathic SPH can be challenging and requires a multidisciplinary approach with surgery and interventional radiology. Our patient’s history, examination findings, and imaging revealed no identifiable cause for SPH suggesting idiopathic SPH. We describe a case of isolated gastric variceal hemorrhage due to idiopathic SPH that was successfully treated.
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Affiliation(s)
- Mona Abraham
- Gastroenterology and Hepatology, Augusta University Medical College of Georgia, Augusta, USA
| | - Shreyans Doshi
- Gastroenterology and Hepatology, Augusta University Medical College of Georgia, Augusta, USA
| | - Mohammad Maysara Asfari
- Gastroenterology and Hepatology, Augusta University Medical College of Georgia, Augusta, USA
| | - John Erikson L Yap
- Gastroenterology and Hepatology, Augusta University Medical College of Georgia, Augusta, USA
| | - H Gregory Bowers
- Interventional Radiology, Augusta University Medical College of Georgia, Augusta, USA
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Mizuno S, Kato H, Yamaue H, Fujii T, Satoi S, Saiura A, Murakami Y, Sho M, Yamamoto M, Isaji S. 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. Ann Surg 2021; 274:e36-e44. [PMID: 31356273 DOI: 10.1097/sla.0000000000003487] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE 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. SUMMARY BACKGROUND DATA Little is known about LPH after PD with resection of the PV/SMV confluence. METHODS 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). RESULTS 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). CONCLUSIONS PD with SV division causes variceal formation, bleeding, and thrombocytopenia.
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Affiliation(s)
- Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Hiroyuki Kato
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, Wakayama, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Hirakata, Japan
| | - Akio Saiura
- Department of Gastroenterological Surgery, Cancer Institute Ariake Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yoshiaki Murakami
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shuji Isaji
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
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Grout-Smith H, Dumenci O, Tait NP, Alsafi A. Splenic Artery Embolisation for the Emergency Treatment of Sinistral Portal Hypertension: A Systematic Review. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2021. [DOI: 10.1055/s-0041-1730876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Objectives Sinistral portal hypertension (SPH) is caused by increased pressure on the left portal system secondary to splenic vein stenosis or occlusion and may lead to gastric varices. The definitive management of SPH is splenectomy, but this is associated with significant mortality and morbidity in the acute setting. In this systematic review, we investigated the efficacy and safety of splenic artery embolisation (SAE) in managing refractory variceal bleeding in patients with SPH.
Methods A comprehensive literature search was conducted using MEDLINE and Embase databases. A qualitative analysis was chosen due to heterogeneity of the studies.
Results Our search yielded 339 articles, 278 of which were unique. After initial screening, 16 articles relevant to our search remained for full text review. Of these, 7 were included in the systematic review. All 7 papers were observational, 6 were retrospective. Between them they described 29 SAE procedures to control variceal bleeding. The technical success rate was 100% and there were no cases of rebleeding during follow up. The most common complication was post-embolisation syndrome. Four major complications occurred, two resulting in death. These deaths were the only 30-day mortalities recorded and were in patients with extensive comorbidities.
Conclusions Although there is a distinct lack of randomized controlled studies comparing SAE to other treatment modalities, it appears to be safe and effective in treating hemorrhage secondary to SPH.
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Affiliation(s)
| | - Ozbil Dumenci
- Faculty of Medicine, Imperial College London, London, United Kingdom
| | - N. Paul Tait
- Department of Imaging, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ali Alsafi
- Department of Imaging, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
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44
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Agarwal AK, Kalayarasan R, Javed A. Vascular Complications in Chronic Pancreatitis. CLINICAL PANCREATOLOGY FOR PRACTISING GASTROENTEROLOGISTS AND SURGEONS 2021:322-332. [DOI: 10.1002/9781119570097.ch41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Hong JA, Liu CA, Lee RC, Chiu NC, Hwang HE. Unusual case of left-sided portal hypertension induced variceal bleeding after pancreaticoduodenectomy treated with transplenic embolization. Radiol Case Rep 2021; 16:2061-2064. [PMID: 34158895 PMCID: PMC8203571 DOI: 10.1016/j.radcr.2021.04.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 01/08/2023] Open
Abstract
With the advances in surgical technique and the accumulation of experiences, pancreatic cancer with portal-superior mesenteric vein (PV-SMV) invasion is no longer considered as an absolute contraindication for surgical resection. After resection of the PV-SMV confluence, congestion of the splenic vein (SV) may develop, resulting in splenomegaly and variceal formation, also known as left-sided portal hypertension (LPH). Along with improved postoperative prognosis, LPH induced varices are given enough time to develop and eventually bleed, which can be lethal. We present a 59-year-old woman who underwent pancreaticoduodenectomy (PD) for pancreatic cancer with a concomitant PV-SMV resection. Massive upper gastrointestinal bleeding and hypovolemic shock occurred 15 months after the surgery. Various exams, including endoscopy, dynamic computed tomography (CT) imaging, celiac, and superior mesenteric artery (SMA) angiography, were performed. However, the exact location of the bleeding could not be identified. LPH-induced varices bleeding was suspected and diagnosed by venography. The varices were embolized with n-BCA and lipiodol mixture by trans-splenic venous approach with complete cessation of bleeding. It is important to identify potential life-threatening LPH-induced varices bleeding, especially if certain clinical histories or classic imaging findings are presented. As for treatment, interventional radiology methods could be considered as the first choice.
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Wei B, Zhang L, Tong H, Wang Z, Wu H. Retrospective Comparison of Clinical Outcomes Following Splenic Vein Stenting and Splenic Arterial Embolization in Sinistral Portal Hypertension-Related Gastrointestinal Bleeding. AJR Am J Roentgenol 2021; 216:1579-1587. [PMID: 32845712 DOI: 10.2214/ajr.20.23859] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND. Sinistral portal hypertension (SPH) is caused by an obstruction of the splenic vein and is a potential cause of upper gastrointestinal bleeding. Although splenic arterial embolization (SAE) and splenic vein stenting are accepted treatment options for SPH, their outcomes have not been compared directly. OBJECTIVE. This retrospective study compared the outcomes of splenic vein stenting and SAE for SPH-related gastrointestinal bleeding. METHODS. Data of patients with SPH treated by interventional radiology between January 1, 2013, and June 1, 2019, who had at least 6 months of clinical follow-up were retrospectively identified from the electronic database at our hospital. Patients were divided into the SAE group (SAE alone), splenic vein stenting-SAE group (SAE immediately after splenic vein stenting failure using the same procedure as the SAE group), and splenic vein stenting group (successful treatment with SVS). Patients' baseline characteristics and follow-up data were retrieved, and their clinical outcomes were compared. RESULTS. Thirty-seven patients with SPH were included. We assigned 11, 12, and 14 patients to the SAE, splenic vein stenting-SAE, and splenic vein stenting groups, respectively. Rebleeding (e.g., hematemesis, melena, or both) was significantly less common (p = .01) in the splenic vein stenting group (7.1% [1/14]) than in the SAE and splenic vein stenting-SAE groups combined (47.8% [11/23]). Splenectomy to resolve rebleeding was not significantly different (p = .63) in the splenic vein stenting group (7.1% [1/14]) compared with the SAE and splenic vein stenting-SAE groups combined (17.4% [4/23]). No interventional procedure-related deaths were observed during follow-up in any group. CONCLUSION. When feasible, splenic vein stenting is a safe and effective treatment of SPH-related gastrointestinal bleeding that appears to better prevent rebleeding than SAE. CLINICAL IMPACT. Splenic vein stenting should be recommended over SAE for the treatment of SPH-related upper gastrointestinal bleeding when possible.
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Affiliation(s)
- Bo Wei
- Department of Gastroenterology, West China Hospital, Sichuan University, Guo Xue Ln 37, Chengdu 610041, Sichuan, China
| | - Linhao Zhang
- Department of Gastroenterology, West China Hospital, Sichuan University, Guo Xue Ln 37, Chengdu 610041, Sichuan, China
- Laboratory of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Huan Tong
- Department of Gastroenterology, West China Hospital, Sichuan University, Guo Xue Ln 37, Chengdu 610041, Sichuan, China
| | - Zhidong Wang
- Department of Gastroenterology, West China Hospital, Sichuan University, Guo Xue Ln 37, Chengdu 610041, Sichuan, China
| | - Hao Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, Guo Xue Ln 37, Chengdu 610041, Sichuan, China
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Kumar S, Raobiakady R, Watkins D, Terlizzo M, Bhogal RH. Radical resection of large metastatic non-functioning pancreatic neuroendocrine carcinoma complicated by splenic vein thrombosis and sinistral portal hypertension. Int J Surg Case Rep 2021; 81:105724. [PMID: 33820735 PMCID: PMC8073194 DOI: 10.1016/j.ijscr.2021.105724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE There are limited reports in the literature of radical surgical resection for pancreatic neuroendocrine carcinoma (PNEC). In patients with non-functioning PNEC (NF-PNEC) within the tail of the pancreas tumours can cause splenic vein thrombosis (SVT) and subsequent sinitral portal hypertension (SPH). Radical surgical resection in such patients with concomitant liver metastasis has not previously been reported. CASE PRESENTATION We present a 67-year old female patient who presented with a large NF-PNEC within the tail of the pancreas with liver metastasis. We performed a distal pancreatectomy, splenectomy, partial gastrectomy and liver resection to achieve radical resecton. DISCUSSION All patients with NF-PNEC within the tail of the pancreatic should be considered for radical surgical resection. In the presence of multi-visceral involvement and complications such as SVT and/or SPH multi-speciality surgical expertise is likely to be required. CONCLUSION Radical multi-visceral resection for large NF-PNEC can be safely performed in the presence of SVT and SPH.
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Affiliation(s)
- S Kumar
- The Royal Marsden Hospital (NHS Foundation Trust), Department of Surgery, Fulham Road, Chelsea, London, SW3 6JJ, United Kingdom; Division of Radiotherapy & Imaging, The Institute for Cancer Research, 123 Old Brompton Road, London, United Kingdom; Imperial College London, Department of Surgery & Cancer, Exhibition Road, South Kensington, London, SW7 2BU, United Kingdom
| | - R Raobiakady
- The Royal Marsden Hospital (NHS Foundation Trust), Department of Anaesthetics, Fulham Road, Chelsea, London, SW3 6JJ, United Kingdom
| | - D Watkins
- The Royal Marsden Hospital (NHS Foundation Trust), Department of Oncology, Fulham Road, Chelsea, London, SW3 6JJ, United Kingdom
| | - M Terlizzo
- The Royal Marsden Hospital (NHS Foundation Trust), Department of Histopathology, Fulham Road, Chelsea, London, SW3 6JJ, United Kingdom
| | - R H Bhogal
- The Royal Marsden Hospital (NHS Foundation Trust), Department of Surgery, Fulham Road, Chelsea, London, SW3 6JJ, United Kingdom; Division of Radiotherapy & Imaging, The Institute for Cancer Research, 123 Old Brompton Road, London, United Kingdom.
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Gairing SJ, Kloeckner R, Pitton MB, Baumgart J, von Auer-Wegener C, Lang H, Galle PR, Foerster F, Schattenberg JM. Multidisciplinary approach to the complex treatment for non-cirrhotic portal hypertension - case-report-based discussion. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:43-49. [PMID: 33429449 DOI: 10.1055/a-1330-9827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Non-cirrhotic portal vein thrombosis (PVT) in patients with antiphospholipid syndrome (APS) is a rare complication, and the management has to be determined individually based on the extent and severity of the presentation. We report on a 37-year-old male patient with non-cirrhotic chronic PVT related to a severe thrombophilia, comprising APS, antithrombin-, factor V- and factor X-deficiency. Three years after the initial diagnosis of non-cirrhotic PVT, the patient presented with severe hemorrhagic shock related to acute bleeding from esophageal varices, requiring an emergency transjugular intrahepatic portosystemic stent shunt (TIPSS). TIPSS was revised after a recurrent bleeding episode due to insufficient reduction of the portal pressure. Additionally, embolization of the dilated V. coronaria ventriculi led to the regression of esophageal varices but resulted simultaneously in a left-sided portal hypertension (LSPH) with development of stomach wall and perisplenic varices. After a third episode of acute esophageal varices bleeding, a surgical distal splenorenal shunt (Warren shunt) was performed to reduce the LSPH. Despite anticoagulation with low molecular weight heparin and antithrombin substitution, endoluminal thrombosis led to a complete Warren shunt occlusion, aggravating the severe splenomegaly and pancytopenia. Finally, a partial spleen embolization (PSE) was performed. In the postinterventional course, leukocyte and platelet counts increased rapidly and the patient showed no further bleeding episodes. Overall, this complex course demonstrates the need for individual assessment of multimodal treatment options in non-cirrhotic portal hypertension. This young patient required triple modality porto-systemic pressure reduction (TIPSS, Warren shunt, PSE) and involved finely balanced anticoagulation and bleeding control.
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Affiliation(s)
- Simon J Gairing
- I. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Roman Kloeckner
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Michael B Pitton
- Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Janine Baumgart
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Charis von Auer-Wegener
- III. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Hauke Lang
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Peter R Galle
- I. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Friedrich Foerster
- I. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
| | - Jörn M Schattenberg
- I. Medizinische Klinik und Poliklinik, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Germany
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Practice guidance for diagnosis and treatment of pancreatitis-related splanchnic vein thrombosis (Shenyang, 2020). J Dig Dis 2021; 22:2-8. [PMID: 33215862 DOI: 10.1111/1751-2980.12962] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/12/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
Splanchnic vein thrombosis is a severe complication of pancreatitis. To date, no consensus over the management of pancreatitis-related splanchnic vein thrombosis has been established. Based on the consensus of multidisciplinary experts, this practice guidance systematically reviewed the epidemiology, anatomy, pathophysiology, risk assessment and clinical presentations of splanchnic vein thrombosis, and formulated a diagnosis and treatment strategy for providing guidance in clinical practice for this disease.
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50
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Specchi S, Bertolini G. CT angiography identifies collaterals in dogs with splenic vein obstruction and presumed regional splenic vein hypertension. Vet Radiol Ultrasound 2020; 61:636-640. [PMID: 32996204 DOI: 10.1111/vru.12914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/22/2020] [Accepted: 07/22/2020] [Indexed: 01/15/2023] Open
Abstract
Occlusion of the splenic vein, without occlusion of the portal vein, can lead to a localized, regional splenic hypertension, referred as sinistral or left-sided portal hypertension in the human radiology literature. In people, may cause gastrointestinal hemorrhages from the esophageal and gastric varices and the primary pathology usually includes pancreatitis and pancreatic neoplasms. The final diagnosis of localized splenic hypertension necessitates accompanying normal liver functions and a patent extrahepatic portal vein. Following obstruction, the resultant elevated splenic bed venous pressure causes formation of collateral routes, the extent of which depends upon the level and degree of obstruction. In this retrospective descriptive study, authors assessed the collateral pathways in dogs with isolated splenic vein occlusion and possible regional splenic vein hypertension. Out of the 46 patients initially recruited, 25 were excluded due to the presence of concomitant portal thrombosis and direct/indirect CT signs of portal hypertension. The remaining 21 dogs had clinicopathological tests suggesting normal liver function. The causes of obstruction identified included splenic pedicle torsion, tumoral splenic vein invasion, and splenic vein thrombosis. Four of 21 dogs with isolated splenic vein obstruction showed collateral pathways through the left gastroepiploic vein (4/4), left gastric vein (2/4), and splenogonadal vein (1/4). The diagnosis of isolated, regional splenic hypertension should be based on clinical, biochemical, and radiological evaluation. Computed tomography is an excellent tool to assess the collateral patterns and to determine the underlying cause.
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Affiliation(s)
- Swan Specchi
- Ospedale Veterinario i Portoni Rossi, Anicura, Bologna, Italy.,Antech Imaging Service, Fountain Valley, California
| | - Giovanna Bertolini
- San Marco Veterinary Clinic and Laboratory, Diagnostic and Interventional Radiology Division, Veggiano, Padova, Italy
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