title: Pattern of Venous Collateral Development after Splenic Vein Occlusion in an Extended Whipple Procedure (Whipple at the Splenic Artery) and Long-Term Results.
abstract: Extended Whipple procedures may require division of the splenic vein (SV). Controversy exists regarding the risk of sequelae of sinistral portal hypertension when the SV is ligated without reimplantation. The aim of this study was to identify postoperative venous collateral patterns and sequelae of SV ligation, as well as long-term results in an extended Whipple procedure.
  
  
  
  Patients who had an extended Whipple procedure (Whipple at the Splenic Artery or WATSA) were entered in an institutional database. Evaluation of the venous collaterals was performed at least 5 months postoperatively by imaging. Spleen size and platelet counts were measured before and after operation.
  
  
  
  Fifteen patients were entered from 2009 to 2014. SV was not reconstructed and the IMV-SV junction was always resected. Two collateral routes developed. An inferior route was present 14/15 patients. It connected the residual SV to the SMV via intermediate collateral veins in the omentum and along the colon. A superior route, present in 10/15 patients connected the residual SV to the portal vein via gastric, perigastric, and coronary veins. Gastrointestinal bleeding did not occur. Mean platelet count and spleen size were not affected significantly. Procedures were long, but few severe complications developed. In 12 patients with adenocarcinoma, the median survival has not been reached.
  
  
  
  Patients who have SV ligation in an extended Whipple are protected against sequelae of sinestral portal hypertension by inferior collateral routes. The omentum and marginal veins of the colon are key links in this pathway.
authors.affiliation: Section of Hepato-Pancreato-Biliary Surgery, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 4990 Children's Place, Suite 1160, (Campus Box 8109), St Louis, MO, 63110, USA.|Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Vasco de Quiroga 15 Col, Tlalpan, 14000, Mexico City, Mexico.
authors.forename: Ismael Dominguez
authors.initials: ID
authors.lastname: Rosado
authors.affiliation: Mallinckrodt Institute of Radiology, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 660 S Euclid Ave Campus Box 8131, St Louis, MO, 63110, USA.
authors.forename: Sanjeev
authors.initials: S
authors.lastname: Bhalla
authors.affiliation: Section of Vascular Surgery, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 660 S Euclid Ave Campus Box 8109, St Louis, MO, 63110, USA.
authors.forename: Luis A
authors.initials: LA
authors.lastname: Sanchez
authors.affiliation: Section of Hepato-Pancreato-Biliary Surgery, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 4990 Children's Place, Suite 1160, (Campus Box 8109), St Louis, MO, 63110, USA.
authors.forename: Ryan C
authors.initials: RC
authors.lastname: Fields
authors.affiliation: Section of Hepato-Pancreato-Biliary Surgery, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 4990 Children's Place, Suite 1160, (Campus Box 8109), St Louis, MO, 63110, USA.
authors.forename: William G
authors.initials: WG
authors.lastname: Hawkins
authors.affiliation: Section of Hepato-Pancreato-Biliary Surgery, Washington University in Saint Louis School of Medicine, Siteman Cancer Center, and Barnes-Jewish Hospital, 4990 Children's Place, Suite 1160, (Campus Box 8109), St Louis, MO, 63110, USA. strasbergs@wustl.edu.
authors.forename: Steven M
authors.initials: SM
authors.lastname: Strasberg
mesh_terms: D000368:Aged; D003097:Collateral Circulation / Q000502:physiology*; D005260:Female; D006801:Humans; D006975:Hypertension, Portal / Q000209:etiology / Q000503:physiopathology; D008026:Ligation; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000473:pathology / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects* / Q000379:methods; D013157:Splenic Artery / Q000601:surgery; D013162:Splenic Vein / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects*
keywords: Colonic varices; Gastric varices; Hypersplenism; Pancreas cancer; Pancreatoduodenectomy; Portal hypertension; Sinestral portal hypertension; Splenic vein; WATSA; Whipple at the splenic artery