Relevance of Portalvenous Involvement in Patients Undergoing Surgery for Chronic Pancreatitis
Abstracts
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Background: Involvement of the portal venous system may change the surgical approach in patients with chronic pancreatitis (CP). Data on the incidence and the consequences of these changes are rare. We analyzed our recent experience of portalvenous pathology in 219 patients operated for CP. Methods: From 1994 until 2/2001 219 patients underwent surgery for CP (Whipple 24, pylorus-preserving pancreatoduodenectomy 86, duodenum-preserving pancreatic head resection 65, distal resection 21 and others 24). Most perioperative data were documented prospectively, further data were obtained retrospectively. Preoperative (vascular) diagnostic work-up consisted in visceral angiography (Angio, 90%), MR-angio (MRA, 11%), contrast-enhanced CT-scan (CT, 96%) and endoscopic ultrasound (EUS, 61%). Results: Pathological portalvenous changes were documented intraoperatively in 79 (36%) of the patients. Five percent had portal vein occlusion, 21% splenic vein thrombosis and 1% thrombosis of the superior mesenteric vein (SMV). A venous compression without occlusion was found in 16%. The portalvenous changes led to generalized portal hypertension in 7% of the patients, to sinistral portal hypertension in 15% and to regional portal hypertension of the SMV in 2%. Angio preoperatively diagnozed the different portalvenous changes with an accuracy of > 90% whereas accuracy was lower for CT (39-67%) and for EUS (50-71%). Portalvenous involvement led in 6/79 (8%) patients to a change of the initially planned type of resection (all those patients had generalized portal hypertension). Splenectomy was performed in 35/79 (44%) patients. Relevant bleeding was documented intraoperatively in 26/79 (33%) cases. Portalvenous involvement (n=79) was associated with longer duration of surgery (median 420 mins vs. 390 mins; p< 0.05) and higher amount of blood loss (1500 ml vs. 900 ml; p< 0.001) as compared with patients without portalvenous involvement (n=140). Although postoperative complications were higher in patients with portalvenous involvement (45% vs. 33%) this difference did not reach statistical significance (p=0.07). Median postoperative length of stay was 14 days in both groups. Conclusions: Pathological involvement of the portalvenous system is frequent in patients undergoing surgery for chronic pancreatitis and influences the surgical strategy in about half of these cases. If portalvenous involvement is suspected adequate vascular imaging should be considered before surgery. |
