Portal venous system thrombosis after pancreatic resection

Venous reconstruction thrombosis after pancreaticoduodenectomy with superior mesenteric/portal vein resection due to pancreatic cancer: an 8 years single institution experience

BACKGROUND

Superior mesenteric/portal vein reconstruction (SMPVR) thrombosis remains a challenging complication following pancreaticoduodenectomy concomitant with venous resection. In this context, we aimed to present our SMPVR experiences and identify potential clinicopathological factors that increased SMPVR thrombosis.

METHODS

A total of 33 patients who underwent SMPVR during pancreaticoduodenectomy were analyzed. Of these, 26 patients who experienced pancreatic head ductal adenocarcinoma met our inclusion criteria. Patients' data were compared as classified by SMPVR type and the development of SMPVR thrombosis. All interposition grafts were Dacron in this cohort.

RESULTS

Types of SMPVR included: tangential resection with primary repair (n = 12); segmental resection with splenic vein preservation and either primary anastomosis (n = 8) or 14 mm tubular Dacron grafting (n = 1); segmental resection with splenic vein division either 14 mm tubular Dacron grafting (n = 2) or 14/7 mm 'Y'-shaped Dacron grafting (n = 3). A total of four patients having 14/7 mm 'Y'-shaped (n = 3) and 14 mm tubular Dacron (n = 1) developed SMPVR thrombosis (p = .001). Dacron grafting (p = .001) and splenic vein division (p = .010) were associated with SMPVR thrombosis. The median time to detection of SMPVR thrombosis was 4.3 months (2.5-21.0 months). The median follow-up time was 12.2 months (3.0-45 months).

CONCLUSIONS

During pancreaticoduodenectomy for pancreatic head ductal carcinoma, extended venous resection requiring SMPVR with 'Y'-shaped and use of Dacron interposition grafts appeared to be associated with the development of SMPVR thrombosis. This result warrants further investigations.

Narrowing of the remnant portal vein diameter and decreased portal vein angle are risk factors for portal vein thrombosis after perihilar cholangiocarcinoma surgery

PURPOSE

To evaluate the incidence, risk factors, management options, and outcomes of portal vein thrombosis following major hepatectomy for perihilar cholangiocarcinoma.

METHODS

A total of 177 perihilar cholangiocarcinoma patients who (1) underwent major hepatectomy and (2) underwent investigating the portal vein morphology, which was measured by rotating the reconstructed three-dimensional images after facilitating bone removal using Aquarius iNtuition workstation between 2002 and 2018, were included. Risk factors were evaluated using the Kaplan-Meier method and Cox proportional hazard models.

RESULTS

Six patients developed portal vein thrombosis (3.4%) within a median time of 6.5 (range 0-22) days. Portal vein and hepatic artery resection were performed in 30% and 6% patients, respectively. A significant difference in the probability of the occurrence of portal vein thrombosis (PV) within 30 days was found among patients with portal vein resection, a postoperative portal vein angle < 100°, remnant portal vein diameter < 5.77 mm, main portal vein diameter > 13.4 mm, and blood loss (log-rank test, p = 0.003, p = 0.06, p < 0.0001, p = 0.01, and p = 0.03, respectively). Decreasing the portal vein angle and narrowing of the remnant PV diameter remained significant predictors on multivariate analysis (p = 0.027 and 0.002, respectively). Reoperation with thrombectomy was performed in four patients, and the other two patients were successfully treated with anticoagulants. All six patients subsequently recovered and were discharged between 25 and 70 days postoperatively.

CONCLUSION

Narrowing of the remnant portal vein diameter and a decreased portal vein angle after major hepatectomy for perihilar cholangiocarcinoma are significant independent risk factors for postoperative portal vein thrombosis.

An outcome analysis of predictive factors for portal or splenic vein thrombosis after distal pancreatectomy

PURPOSES

The aim of this study was to explore predictive factors for portal or splenic vein thrombosis (VT) that might cause serious problems after distal pancreatectomy (DP).

METHODS

A total of 230 patients who underwent DP between 2008 and 2017 were retrospectively reviewed to identify predictive factors for portal or splenic VT.

RESULTS

Ultimately, 164 patients were analyzed. Portal or splenic VT was significantly correlated with age < 65 years old, benign tumor, laparoscopic surgery, preservation of the inferior mesenteric vein (IMV) and left gastric vein (LGV), preservation of the IMV only, no drainage vein, length of the residual splenic vein (RSV) ≥ 26 mm, vessel dissection with a linear stapler, and intra-abdominal abscess (all P < 0.05). Furthermore, a multivariate analysis indicated that the length of the RSV (odds ratio [OR]: 9.15, P = 0.03) was an independent predictive factor for portal VT and that the length of the RSV (OR: 37.9, P < 0.01), vessel dissection with a linear stapler (OR: 6.49, P = 0.03), and intra-abdominal abscess (OR: 23.0, P = 0.02) were independent predictive factors for splenic VT.

CONCLUSION

As the length of the RSV was significantly associated with portal or splenic VT, a follow-up imaging diagnosis might be recommended for such cases.

Incidence of Splanchnic Vein Thrombosis After Abdominal Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Abdominal surgery may increase the risk of splanchnic vein thrombosis (SVT). We determined the incidence of SVT after abdominal surgery and identified groups at highest risk.

MATERIALS AND METHODS

MEDLINE and Embase were searched for clinical studies evaluating the incidence of postoperative SVT after abdominopelvic surgery. Study selection, data abstraction, and risk of bias assessment were carried out independently by two reviewers. Clinical heterogeneity was explored by subgroup analyses (i.e., type of intra-abdominal procedure and organ group).

RESULTS

Of 5549 abstracts screened, 48 were analyzed. Pooled incidence of SVT (n = 50,267) was 2.68% [95% confidence interval (CI), 2.24 to 3.11] (1347 events), I² = 96%. Pooled incidence of SVT in high-risk procedures were splenectomy with devascularization (24%), hepatectomy in patients with cirrhosis (9%), and pancreatectomy with venous resection (5%). Pooled incidence of symptomatic and asymptomatic SVT was 1.02% (95% CI: 0.97% to 1.07%) and 0.98% (95% CI 0.88% to 1.07%), respectively. Most common causes of SVT-related mortality were irreversible thrombosis, bowel ischemia, liver failure, and gastrointestinal bleed. Most studies included were at a high risk of bias due to lack of prospective data collection and lack of SVT screening for all participants.

CONCLUSIONS

Incidence of SVT after abdominal surgery is low but remains a relevant complication. Patients undergoing procedures involving surgical manipulation of the venous system and splenectomy are at the highest risk. Given the life-threatening risks associated with SVT, there is a need for larger prospective studies on the incidence and impact of SVT after abdominal surgery.

A Diagnostic Prediction Model of Acute Symptomatic Portal Vein Thrombosis

BACKGROUND

The aim of this study was to develop a diagnostic prediction model to improve identification of acute symptomatic portal vein thrombosis (PVT).

METHODS

We examined 47 patients with PVT and 94 controls without PVT in the Second Affiliated Hospital of Soochow University and Suqian People's Hospital of Nanjing, Gulou Hospital Group. We constructed a prediction model by using a support vector machine (SVM) classifier coupled with a least absolute shrinkage and selection operator (LASSO). We applied a 10-fold cross-validation to estimate the error rate for each model.

RESULTS

The present study indicated that acute symptomatic PVT was associated with 11 indicators, including liver cirrhosis, D-Dimer, splenomegaly, splenectomy, inherited thrombophilia, ascetic fluid, history of abdominal surgery, bloating, C-reactive protein (CRP), albumin, and abdominal tenderness. The LASSO-SVM model achieved a sensitivity of 91.5% and a specificity of 100.0%.

CONCLUSIONS

We developed a LASSO-SVM model to diagnose PVT. We demonstrated that the model achieved a sensitivity of 91.5% and a specificity of 100.0%.

Analysis of risk factors for portal vein thrombosis after liver resection

Purpose

We evaluated the risk factors for posthepatectomy thrombosis including portal vein thrombosis (PVT) and clinical outcomes.

Methods

We retrospectively analyzed 563 patients who had undergone hepatectomy from February 2009 to December 2014. Twenty-nine patients with preoperatively confirmed thrombosis and tumor recurrence-related thrombosis were excluded. We identified the location of the thrombosis as main portal vein (MPV), peripheral portal vein (PPV) and other site such as hepatic vein or inferior vena cava. Patients with MPV thrombosis and PPV thrombosis with main portal flow disturbance were treated with anticoagulation therapy. We performed operative thrombectomy before anticoagulation therapy who did combined portal vein (PV) segmental resection.

Results

Of the 534 patients, 22 (4.1%) developed posthepatectomy thrombosis after hepatectomy. Among them, 19 (86.4%) had PVT. The mean duration of Pringle's maneuver was significant longer in the PVT group than the no-thrombosis group (P = 0.020). Patients who underwent combined PV segmental resection during hepatectomy were more likely to develop posthepatectomy PVT (P = 0.001). Thirteen patients who had MPV thrombosis and PPV thrombosis with main portal flow disturbance received anticoagulation therapy immediately after diagnosis and all of them were improved. Among them, 2 patients who developed PVT at the PV anastomosis site after PV segmental resection, underwent operative thrombectomy before anticoagulation therapy and both were improved. There were no patients who developed complications related to anticoagulation therapy.

Conclusion

Long duration of Pringle's maneuver and PV segmental resection were risk factors. Anticoagulation therapy or operative thrombectomy should be considered for PVT without contraindications.

Pancreatic cancer and thromboembolic disease, 150 years after Trousseau

The connection between pancreatic cancer and venous thrombosis has been discussed for almost 150 years. The exact pathophysiological mechanisms are still partly understood, but it is known that pancreatic cancer induces a prothrombotic and hypercoagulable state and genetic events involved in neoplastic transformation (e.g., KRAS, c-MET, p53), procoagulant factors [e.g., tissue factor (TF), platelet factor 4 (PF4), plasminogen activator inhibitor type 1 (PAI-1)], mucin production (e.g., through activation of P- and L-selectin) and pro-inflammatory factors [e.g., cytokines, cyclooxygenase-2 (COX-2)] may be implicated. Also pancreatitis, both acute and chronic, is associated with increased risk of venous thrombosis, but in this circumstance a direct inflammatory process may be more important. This article discusses the incidence, treatment and outcome of venous thromboembolism (VTE) complicating pancreatic disease, with special emphasis on new knowledge obtained during the last fifteen years.

Incidence, risk factors, and management options for portal vein thrombosis after hepatectomy: a 14-year, single-center experience

BACKGROUND

Portal vein thrombosis (PVT) after hepatectomy is rare; however, it increases mortality and morbidity. Few studies have been conducted that focused on PVT following major hepatectomy.

METHODS

Patients who underwent hepatectomy at a single institution were retrospectively reviewed, and risk factors and management options were evaluated.

RESULTS

Of the 1,193 patients undergoing hepatectomy, 25 patients developed PVT. Right-sided hepatectomy, caudate lobectomy, splenectomy, and postoperative bile leakage were independent risk factors for PVT following hepatectomy. PVT occurred more frequently after major hepatectomy compared with minor hepatectomy. Increased instability and reduced portal venous flow caused by kinking was the reason for increasing the risk of PVT after right-sided hepatectomy with caudate lobectomy. The new operative procedure, suturing the posterior wall of the portal vein with the anterior wall of the inferior vena cava, was effective for reducing the risk of PVT following right-sided hepatectomy. Operative thrombectomy showed significant benefits for PVT detected within 5 days after hepatectomy.

CONCLUSIONS

PVT frequently occurs following major hepatectomy. Urgent operative thrombectomy is strongly recommended for PVT with early detection.

Prosthetic graft for superior mesenteric-portal vein reconstruction in pancreaticoduodenectomy: a retrospective, multicenter study

BACKGROUND

The use of prosthetic grafts for superior mesenteric-portal vein reconstruction (SMPVR) after pancreaticoduodenectomy (PD) with venous resection remains controversial. We evaluated the effectiveness and safety of using polytetrafluoroethylene (PTFE) interposition grafts for SMPVR after PD.

METHODS

We identified 76 patients who underwent PD with segmental vein resection for pancreatic head and periampullary neoplasms at three centers between January 2007 and June 2012. The venous reconstruction technique depended on the length of venous involvement. Forty-two and 34 patients underwent SMPVR with primary anastomosis and SMPVR with PTFE interposition grafts, respectively. The postoperative morbidity, mortality, and patency were compared. For the patients with pancreatic ductal adenocarcinoma (n = 65), survival was compared between the SMPVR with primary anastomosis (n = 36) and SMPVR with PTFE interposition graft groups (n = 29).

RESULTS

Patients undergoing SMPVR with PTFE grafts had larger tumor sizes (3.4 ± 0.9 cm, 2.9 ± 0.9 cm, P = 0.016), longer operative durations (492.9 ± 107.5 min, 408.8 ± 78.8 min, P < 0.001), and greater blood loss (986.8 ± 884.5 ml, 616.7 ± 485.5 ml, P = 0.040) compared to those undergoing SMPVR with primary anastomosis. However, 30-day postoperative morbidity and mortality did not differ (29.4 and 2.9 %, respectively, for PTFE grafts and 33.3 and 7.1 %, respectively, for primary anastomosis). There were no cases of graft infection. The estimated cumulative patency of SMPVR 6 and 12 months after surgery did not differ (87.9 and 83.5 % after PTFE grafts, respectively, and 94.4 and 86.4 % after primary anastomosis, respectively). For patients who underwent surgery for pancreatic ductal adenocarcinoma, there were no significant differences in the median survival time (11 vs. 12 months) or the 1-, 2-, and 3-year survival rates (35.7, 12.5, and 4.2 vs. 36.4, 17.3, and 8.7 %, respectively) for the PTFE and primary anastomosis groups.

CONCLUSIONS

PTFE grafts could provide a safe and effective option for venous reconstruction after PD in patients with segmental vein resection.