Abstract
Purpose
Pancreaticoduodenectomy (PD) concomitant with portal vein resection (PVR) often develops into digestive varices with an occurrence rate of 30–50%, and the variceal bleeding is sometimes untreatable and results in fatality. Against this issue, splenic artery (SpA) ligation during PD-PVR is emerging as an easy and effective prophylactic surgical option. The aim of this study was to investigate the significance of SpA ligation in the development of digestive varices in patients undergoing PD-PVR.
Method
We retrospectively investigated 97 patients with PDAC who received PD-PVR in two hospitals. Vascular reconstruction of the splenic vein (SpV) was not performed in either hospital. We assessed the occurrence rate of digestive varices in these patients in association with the performance of SpA ligation.
Results
The occurrence rate of digestive varices was 23%. SpA ligation was the only significant decreasing factor for the development of digestive varices (odds ratio 0.3, p = 0.035). Although SpV resection was not a significant risk factor for the development of digestive varices in all patients, SpV resection was a significant risk factor for the development of digestive varices in patients without SpA ligation, as demonstrated in previous reports. SpA ligation did not increase surgical complications or impair pancreatic function.
Conclusion
PD-PVR surgery was accompanied by a 23% incidence of digestive varices, and SpA ligation significantly decreased the development of digestive varices without causing clinically significant complications.
Trial registration
No.18196 (Osaka International Cancer Institute) and no. 19006 (National Hospital Organization Osaka National Hospital)
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Data availability
The datasets in the current study are available from the corresponding author on reasonable request.
References
Fuhrman GM, Leach SD, Staley CA, Cusack JC, Charnsangavej C, Cleary KR, el-Naggar AK, Fenoglio CJ, Lee JE, Evans DB (1996) Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group. Ann Surg 223:154–162
Toomey P, Hernandez J, Morton C, Duce L, Farrior T, Villadolid D, Ross S, Rosemurgy A (2009) Resection of portovenous structures to obtain microscopically negative margins during pancreaticoduodenectomy for pancreatic adenocarcinoma is worthwhile. Am Surg 75:804–809 discussion 809-810
Tanaka H, Nakao A, Oshima K, Iede K, Oshima Y, Kobayashi H, Kimura Y (2017) Splenic vein reconstruction is unnecessary in pancreatoduodenectomy combined with resection of the superior mesenteric vein-portal vein confluence according to short-term outcomes. HPB (Oxford) 19:785–792
Ono Y, Matsueda K, Koga R, Takahashi Y, Arita J, Takahashi M, Inoue Y, Unno T, Saiura A (2015) Sinistral portal hypertension after pancreaticoduodenectomy with splenic vein ligation. Br J Surg 102:219–228
Gyoten K, Mizuno S, Nagata M, Ogura T, Usui M, Isaji S (2017) Significance of simultaneous splenic artery resection in left-sided portal hypertension after pancreaticoduodenectomy with combined portal vein resection. World J Surg 41:2111–2120
Mizuno S, Kato H, Yamaue H, Fujii T, Satoi S, Saiura A, Murakami Y, Sho M, Yamamoto M, Isaji S (2019) 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 Publish Ahead of Print
Kobayashi M, Mizuno S, Murata Y, Kishiwada M, Usui M, Sakurai H, Tabata M, Ii N, Yamakado K, Inoue H, Shiraishi T, Yamada T, Isaji S (2014) Gemcitabine-based chemoradiotherapy followed by surgery for borderline resectable and locally unresectable pancreatic ductal adenocarcinoma: significance of the CA19-9 reduction rate and intratumoral human equilibrative nucleoside transporter 1 expression. Pancreas 43:350–360
Misuta K, Shimada H, Miura Y et al (2005) The role of splenomesenteric vein anastomosis after division of the splenic vein in pancreatoduodenectomy. J Gastrointest Surg 9:245–253
Yamada D, Takahashi H, Asukai K, Hasegawa S, Tomokuni A, Wada H, Akita H, Yasui M, Miyata H, Ishikawa O (2019) Pathological complete response (pCR) with or without the residual intraductal carcinoma component following preoperative treatment for pancreatic cancer: revisiting the definition of “pCR” from the prognostic standpoint. Ann Gastroenterol Surg 3:676–685
Asaoka T, Miyamoto A, Maeda S, Hama N, Tsujie M, Ikeda M, Sekimoto M, Nakamori S (2018) CA19-9 level determines therapeutic modality in pancreatic cancer patients with para-aortic lymph node metastasis. Hepatobiliary Pancreat Dis Int 17:75–80
Takahashi H, Akita H, Ioka T, Wada H, Tomokoni A, Asukai K, Ohue M, Yano M, Ishikawa O (2018) Phase I trial evaluating the safety of preoperative gemcitabine/nab-paclitaxel with concurrent radiation therapy for borderline resectable pancreatic cancer. Pancreas 47:1135–1141
Eguchi H, Nagano H, Kobayashi S, Kawamoto K, Wada H, Hama N, Tomimaru Y, Akita H, Sakai D, Satoh T, Kudo T, Isohashi F, Mori M, Doki Y (2014) A phase I trial of combination therapy using gemcitabine and S-1 concurrent with full-dose radiation for resectable pancreatic cancer. Cancer Chemother Pharmacol 73:309–315
Takahashi H, Ohigashi H, Gotoh K, Marubashi S, Yamada T, Murata M, Ioka T, Uehara H, Yano M, Ishikawa O (2013) Preoperative gemcitabine-based chemoradiation therapy for resectable and borderline resectable pancreatic cancer. Ann Surg 258:1040–1050
Ohigashi H, Ishikawa O, Eguchi H, Takahashi H, Gotoh K, Yamada T, Yano M, Nakaizumi A, Uehara H, Tomita Y, Nishiyama K (2009) Feasibility and efficacy of combination therapy with preoperative full-dose gemcitabine, concurrent three-dimensional conformal radiation, surgery, and postoperative liver perfusion chemotherapy for T3-pancreatic cancer. Ann Surg 250:88–95
Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213
Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M, International Study Group on Pancreatic Fistula Definition (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138:8–13
Yamada D, Eguchi H, Iwagami Y, Asaoka T, Noda T, Kawamoto K, Gotoh K, Kobayashi S, Mori M, Doki Y (2018) The investigation of the survival time after recurrence in patients with pancreatic ductal adenocarcinoma for individualization of adjuvant chemotherapy. Surg Today 48:952–962
Chikamori F, Kuniyoshi N, Shibuya S, Takase Y (2001) Correlation between endoscopic and angiographic findings in patients with esophageal and isolated gastric varices. Dig Surg 18:176–181
Tanaka M, Ito H, Ono Y, Matsueda K, Mise Y, Ishizawa T, Inoue Y, Takahashi Y, Hiratsuka M, Unno T, Saiura A (2019) Impact of portal vein resection with splenic vein reconstruction after pancreatoduodenectomy on sinistral portal hypertension: who needs reconstruction? Surgery 165:291–297
Ishikawa O, Ohigashi H, Eguchi H, Yokoyama S, Yamada T, Takachi K, Miyashiro I, Murata K, Doki Y, Sasaki Y, Imaoka S (2004) Long-term follow-up of glucose tolerance function after pancreaticoduodenectomy: comparison between pancreaticogastrostomy and pancreaticojejunostomy. Surgery 136:617–623
Desaki R, Mizuno S, Tanemura A et al (2014) A new surgical technique of pancreaticoduodenectomy with splenic artery resection for ductal adenocarcinoma of the pancreatic head and/or body invading splenic artery: impact of the balance between surgical radicality and QOL to avoid total pancreatectomy. Biomed Res Int 2014:219038
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Daisaku Yamada made substantial contributions to conception and design, acquisition of data, and analysis and interpretation of data; drafted the manuscript; and gave final approval of the version to be published. Hidenori Takahashi made substantial contributions to conception and design, acquisition of data, and analysis and interpretation of data; revised the manuscript critically for important intellectual content; and gave final approval of the version to be published. Naoki Hama made substantial contributions to conception and design, acquisition of data, and analysis and interpretation of data; revised the manuscript critically for important intellectual content; and gave final approval of the version to be published. Reishi Toshiyama made substantial contributions to conception and design, and analysis and interpretation of data; revised the manuscript critically for important intellectual content; and gave final approval of the version to be published. Kei Asukai made substantial contributions to conception and design, and analysis and interpretation of data; revised the manuscript critically for important intellectual content; and gave final approval of the version to be published. Shinichiro Hasegawa made substantial contributions to conception and design, and acquisition of data; revised the manuscript critically for important intellectual content; and gave final approval of the version to be published. Hiroshi Wada made substantial contributions to conception and design, and acquisition of data and analysis and interpretation of data; revised the manuscript critically for important intellectual content; and gave final approval of the version to be published. Masato Sakon made substantial contributions to conception and design, and acquisition of data; revised the manuscript critically for important intellectual content; and gave final approval of the version to be published. Osamu Ishikawa made substantial contributions to conception and design, and analysis and interpretation of data; revised the manuscript critically for important intellectual content; and gave final approval of the version to be published.
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This study protocol was approved by the ethics committee of each institution (no. 18196 at the Osaka International Cancer Institute and no. 19006 at the National Hospital Organization Osaka National Hospital).
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Supplementary figure 1
Flow chart of the number and percentage of patients with digestive varices and variceal bleeding in comparison between the patients with SpA ligation and those without SpA ligation (PNG 9 kb).
Supplementary figure 2
The alteration of splenic vein (SpV) pressure during surgery. The alteration of SpV pressure of each 3 patients are depicted as solid and dotted lines. SpV pressure was measured during surgery. First, the native SpV pressure was measured (Preclamp). Second, the SpV pressure with clamping of the SpV was measured (SpV clamp); subsequently, the SpV pressure was measured after adding a SpA clamp (SpV clamp + SpA clamp). (PNG 3 kb).
Supplementary Table 1
(DOCX 17 kb).
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Yamada, D., Takahashi, H., Hama, N. et al. The clinical impact of splenic artery ligation on the occurrence of digestive varices after pancreaticoduodenectomy with combined portal vein resection: a retrospective study in two institutes. Langenbecks Arch Surg 406, 1469–1479 (2021). https://doi.org/10.1007/s00423-020-02010-x
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DOI: https://doi.org/10.1007/s00423-020-02010-x