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Rao K, Aswani Y, Bindner H, Patel A, Averill S, Davis T, Amarneh M. Intra-abdominal Venous Thromboses and Their Management. Acad Radiol 2024; 31:3212-3222. [PMID: 38184416 DOI: 10.1016/j.acra.2023.12.018] [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: 09/30/2023] [Revised: 12/09/2023] [Accepted: 12/12/2023] [Indexed: 01/08/2024]
Abstract
While a plethora of articles discuss management of deep venous thromboses in extremities, there is a relative scarcity of literature comprehensively describing intra-abdominal venous thromboses, and their management. Intra-abdominal venous thromboses include iliocaval venous obstruction (ICVO), hepatic venous thrombosis (HVT), portal venous thrombosis (PVT), renal vein thrombosis (RVT), splenic vein thrombosis (SVT), and gonadal vein thrombosis (GVT); each of which provides unique microenvironmental challenges to management. Doppler ultrasound is the first line imaging modality for diagnosis, and computed tomography and magnetic resonance imaging can help define the extent of thrombus burden and aid with interventional planning. Systemic anticoagulation remains the common medical treatment for intra-abdominal venous thrombosis, however, catheter directed thrombolysis and thrombectomy show positive outcomes in ICVO, HVT, PVT, and RVT, with transjugular intrahepatic portosystemic shunt (TIPS) creation especially beneficial in HVT and PVT. In this review article, we describe pathophysiology, clinical features, imaging findings, and current management options for intra-abdominal venous thromboses.
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Affiliation(s)
- Karan Rao
- Department of Vascular and Interventional Radiology, University of Iowa, lowa city, lowa, USA (K.R., Y.A., H.B., A.P.)
| | - Yashant Aswani
- Department of Vascular and Interventional Radiology, University of Iowa, lowa city, lowa, USA (K.R., Y.A., H.B., A.P.)
| | - Hans Bindner
- Department of Vascular and Interventional Radiology, University of Iowa, lowa city, lowa, USA (K.R., Y.A., H.B., A.P.)
| | - Aditi Patel
- Department of Vascular and Interventional Radiology, University of Iowa, lowa city, lowa, USA (K.R., Y.A., H.B., A.P.)
| | - Sarah Averill
- Roswell Park Comprehensive Cancer Institute, Buffalo, New York, USA (S.A.)
| | - Trent Davis
- Dignity Health St. Joseph's Radiology, Phoenix, Arizona, USA (T.D.)
| | - Mohammad Amarneh
- Department of Pediatric Interventional Radiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, Massachusetts 02115, USA (M.A.).
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Șandra-Petrescu F, Tzatzarakis E, Mansour Basha M, Rückert F, Reissfelder C, Birgin E, Rahbari NN. Impact of spleen preservation on the incidence of postoperative pancreatic fistula after distal pancreatectomy: Is less more? Pancreatology 2022; 22:1013-1019. [PMID: 35945100 DOI: 10.1016/j.pan.2022.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/11/2022] [Accepted: 07/24/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a major complication after distal pancreatectomy (DP) with a significant impact on patients' quality of life. There is limited evidence that preservation of the spleen reduces the risk of POPF. Therefore, we aimed to investigate the impact of splenectomy on perioperative outcome. METHODS Data from patients who underwent DP for malignant and benign disease at our institution between 2004 and 2021 were reviewed. Patients were grouped according to spleen preservation (SP-DP) and splenectomy (DPS). Intraoperative parameters and postoperative outcomes were compared between groups. Univariable and multivariable analyses were used to investigate factors that influence the occurrence of clinically relevant (cr)POPF. RESULTS A total of 199 patients were included, of whom 61 (30.7%) patients underwent SP-DP. Patients who underwent SP-DP had a significantly lower rate of crPOPF (p = 0.022), shorter hospital stay (p = 0.003), and less readmissions (p = 0.012). On multivariate analysis, obesity (OR 2.88, p = 0.021), benign lesions (OR 2.35, p = 0.018), postoperative acute pancreatitis (OR 2.53, p = 0.028), and splenectomy (OR 2.83, p = 0.011) were independent risk factors associated with the onset of crPOPF. DISCUSSION Preservation of the spleen reduces the risk of crPOPF in patients undergoing distal pancreatectomy for benign and malignant disease.
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Affiliation(s)
- Flavius Șandra-Petrescu
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Emmanouil Tzatzarakis
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Mamdouh Mansour Basha
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Felix Rückert
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Reissfelder
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Emrullah Birgin
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nuh N Rahbari
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
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Yamada S, Fujii T, Sonohara F, Kawai M, Shibuya K, Matsumoto I, Fukuzawa K, Baba H, Aoki T, Unno M, Satoi S, Kishi Y, Hatano E, Uemura K, Horiguchi A, Sho M, Takeda Y, Shimokawa T, Kodera Y, Yamaue H. Safety of Combined Division vs Separate Division of the Splenic Vein in Patients Undergoing Distal Pancreatectomy: A Noninferiority Randomized Clinical Trial. JAMA Surg 2021; 156:418-428. [PMID: 33656542 PMCID: PMC7931136 DOI: 10.1001/jamasurg.2021.0108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Question In distal pancreatectomy, is combined division of the splenic vein safe compared with separate division of the splenic vein? Findings In this noninferiority randomized clinical trial, the proportion of grade B/C pancreatic fistula in the separate division group was 27.1% vs 28.6% in the combined division group, demonstrating noninferiority of the combined division of the splenic vein against separate division. Meaning The safety of combined division of the splenic vein in distal pancreatectomy was established, such that the approach could be recommended with more confidence. Importance In distal pancreatectomy (DP), the splenic vein is isolated from the pancreatic parenchyma prior to being ligated and divided to prevent intra-abdominal hemorrhage from the splenic vein stump with pancreatic fistula (PF). Conversely, dissecting the splenic vein with the pancreatic parenchyma is easy and time-saving. Objective To establish the safety of combined division of the splenic vein compared with separate division of the splenic vein. Design, Setting, and Participants This study was designed as a multicenter prospective randomized phase 3 trial. All results were analyzed using the modified intent-to-treat set. Patients undergoing DP for pancreatic body and tail tumors were eligible for inclusion. Patients were randomly assigned between August 10, 2016, and July 30, 2019. Interventions Patients were centrally randomized (1:1) to either separate division of the splenic vein or combined division of the splenic vein. Main Outcomes and Measures The primary end point was the incidence of grade B/C PF, and the incidence of intra-abdominal hemorrhage was included as one of the secondary end points. Results A total of 318 patients were randomly assigned, and 2 patients were excluded as ineligible. Of the 316 remaining patients, 150 (50.3%) were male. The modified intent-to-treat population constituted 159 patients (50.3%) in the separate division group and 157 patients (49.7%) in the combined division group. In the modified intent-to-treat set, the proportion of grade B/C PF in the separate division group was 27.1% (42 of 155) vs 28.6% (44 of 154) in the combined division group (adjusted odds ratio, 1.108; 95% CI, 0.847-1.225; P = .047), demonstrating noninferiority of the combined division of the splenic vein against separate division. The incidence of postoperative intra-abdominal hemorrhage in the 2 groups was identical at 1.3%. Conclusions and Relevance This study demonstrated noninferiority of the combined division of the splenic vein compared with separate division of the splenic vein regarding safety. Thus, isolating the splenic vein from the pancreatic parenchyma is deemed unnecessary. Trial Registration ClinicalTrials.gov Identifier: NCT02871804
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Affiliation(s)
- Suguru Yamada
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Tsurumai-cho, Showa-ku, Nagoya, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Sugitani, Toyama, Japan
| | - Fuminori Sonohara
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Tsurumai-cho, Showa-ku, Nagoya, Japan
| | - Manabu Kawai
- Second Department of Surgery, Wakayama Medical University, Kimiidera, Wakayama, Japan
| | - Kazuto Shibuya
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Sugitani, Toyama, Japan
| | - Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Ono-higashi, Osaka-Sayama, Japan
| | - Kengo Fukuzawa
- Department of Surgery, Oita Red Cross Hospital, Chiyo-machi, Oita, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Science, Honjo, Chuo-ku, Kumamoto, Japan
| | - Takeshi Aoki
- Department of Gastroenterological and General Surgery, Showa University School of Medicine, Hatanodai, Shinagawa-ku, Tokyo, Japan
| | - Michiaki Unno
- Division of Hepato-Biliary Pancreatic Surgery, Tohoku University Graduate School of Medicine, Seiryo-cho, Aoba-ku, Sendai, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Shinmachi, Hirakata, Japan
| | - Yoji Kishi
- Department of Surgery, National Defense Medical College, Namiki, Tokorozawa, Saitama, Japan
| | - Etsuro Hatano
- Department of Gastroenterological Surgery, Hyogo College of Medicine, Mukogawa, Nishinomiya, Hyogo, Japan
| | - Kenichiro Uemura
- Department of Surgery, Hiroshima University Graduate School of Biomedical and Health Sciences, Kasumi, Minami-ku, Hiroshima, Japan
| | - Akihiko Horiguchi
- Department of Gastroenterological Surgery, Fujita Health University Bantane Hospital, Otobashi, Nakagawa-ku, Nagoya, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University School of Medicine, Shijo-cho, Kashihara, Nara, Japan
| | - Yutaka Takeda
- Department of Surgery, Japan Organization of Occupational Health and Safety, Kansai Rosai Hospital, Inabaso, Amagasaki, Japan
| | - Toshio Shimokawa
- Clinical Study Support Center, Wakayama Medical University, Kimiidera, Wakayama, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Tsurumai-cho, Showa-ku, Nagoya, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, Kimiidera, Wakayama, Japan
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