Portomesenteric Venous Complications after Pancreatic Surgery with Venous Reconstruction: Imaging and Intervention

Abstract

Pancreatic surgery with en bloc venous resection and reconstruction is becoming increasingly common in the current era of expanding neoadjuvant oncologic therapies and advanced surgical techniques for patients with more anatomically complex tumors. However, patients who have alterations in their venous outflow are at increased risk for postoperative portomesenteric venous stenosis and/or thrombosis. Cross-sectional imaging for postoperative surveillance, including multiphase CT or MRI, is critical for recognizing portomesenteric venous complications and thus implementing early intervention and preventing complications related to portomesenteric venous hypertension. Hypertension-related complications include ascites, variceal or gastrointestinal bleeding, postprandial abdominal pain, intestinal edema, protein-losing enteropathy, malabsorptive diarrhea, and splenomegaly. Percutaneous transhepatic, transsplenic, and transjugular portomesenteric interventions, including venoplasty, stent placement, and thrombectomy or thrombolysis, are safe and effective options for restoring patency to the portomesenteric venous system. Preintervention CT or MRI and diagnostic catheter venography are important for procedural planning, while postintervention CT or MRI surveillance is critical for detecting recurrent stenosis or thrombosis, or de novo portomesenteric venous disease.

Endovascular management of portal vein obstruction in hepatobiliary cancer patients

“…Patient selection is essential to identify suitable candidates to undergo these procedures. The technical success rate, clinical improvement and stent patency in our group of patients concurs with the rates described in other reports (2,6,14). Stent placement was successful in all patients and clinical improvement was seen in 80% of our patients, similar to what has been reported elsewhere (2).…”

“…The technical success rate, clinical improvement and stent patency in our group of patients concurs with the rates described in other reports (2,6,14). Stent placement was successful in all patients and clinical improvement was seen in 80% of our patients, similar to what has been reported elsewhere (2). Primary stent patency at 1, 3 and 6 months was 95%, 84% and 68 % respectively.…”

“…Six patients had stent occlusion and all were secondary to tumor progression. Stent selection is a challenge and there is no evidence that any type of stent works better for this indication (2,8). Bare stents were used in most of the cases in the current series; and the indications for stent-graft insertion were: persistent thrombus in the main portal vein that could not be eliminated during the recanalization procedure, portal vein perforation with acute bleeding and erosion of the portal vein by an infected uid collection (15).…”

“…Obstruction of the splenoportal or mesoportal venous system occurs in approximately 15%–25% of patients with hepatobiliary malignancies 1,2 . These patients are prone to develop obstruction of the portal and mesenteric veins both because of local factors such as tumor compression or stenosis after pancreato‐biliary surgery and systemic factors such as cancer‐related hypercoagulability 3 .…”

“…These patients are prone to develop obstruction of the portal and mesenteric veins both because of local factors such as tumor compression or stenosis after pancreato‐biliary surgery and systemic factors such as cancer‐related hypercoagulability 3 . Obstruction may be acute or chronic 3 ; acute obstruction presents with thrombus formation, abdominal pain, ascites, and abnormal liver function tests, and it is usually secondary to surgical complications after liver resection or pancreaticoduodenectomy with venous reconstruction 2 . Chronic obstruction usually presents with signs of portomesenteric venous hypertension including diffuse, nonspecific abdominal pain, abdominal distention, ascites, variceal bleeding, or lower gastrointestinal bleed.…”