A Collateral Venous Pathway in Omental Arch of Barkow After Spleen Preserving Distal Pancreatectomy

For spleen preserving distal pancreatectomy (SPDP), two surgical approaches have gained widespread use: the Kimura (KT) technique with splenic vessels (SV) preservation and the Warshaw (WT) technique with SV resection. WT is deemed a salvage surgical technique to be performed when it is not possible to preserve SV [1]. However, WT has potential risks of splenic infarction or gastric varices [2]. A 55‐year‐old woman, who had undergone open left nephrectomy for cancer 3 years before, was admitted to our institution for open SPDP due to a suspected neuroendocrine tumor measuring 2.5 cm. Division of the gastrocolic ligament outside the gastroepiploic arcade was sufficiently wide to expose the pancreatic body tail. After section of the pancreatic neck, the dissection was carried out to the left through retraction on the distal stump in order to expose SV with branches to the pancreas; it was not possible to spare the splenic vein, which was injured during dissection as it was densely adherent to the pancreas. SPDP was completed with preservation of the splenic artery. The operation time was 180 min. Postoperative course was uneventful. The final pathological diagnosis was pancreatic metastasis of renal carcinoma. During a 5‐year follow‐up, abdominal CT scans revealed collateral venous routes in the gastroepiploic arcade and in the greater omentum, without gastric varices or splenic ischemia (Figure 1). A gastroscopy showed no gastric varices. Iatrogenic splenic vein occlusion and the preservation of the splenic artery have been recognized to be a rare cause of left‐sided portal hypertension with gastric varices; variceal bleeding can develop during the follow‐up, and a subsequent splenectomy will be necessary [3]. Kim et al. [4] newly introduced the modified Warshaw method (MW) which preserves the splenic artery while sacrificing the splenic vein without producing congestive splenomegaly and resulting in a lower incidence of splenic infarction and engorged gastric collaterals compared to the WT [5]. Even after KT, there is a recognized risk of segmental portal hypertension and gastric varices resulting from splenic vein obliteration [6]. Splenic vein occlusion typically establishes two principal collateral pathways: (1) the gastroepiploic route via the left and right gastroepiploic veins along the greater curvature of the stomach, and (2) the short gastric vein route. Gastric varices typically develop when the gastroepiploic pathway is insufficient to handle splenic venous return [7, 8]. We report a less common collateral pathway infrequently described after SPDP: the greater omental venous arch of Barkow—a venous arcade in the anterior greater omentum, connecting omental branches of the left gastroepiploic vein with middle colic and right gastroepiploic tributaries, located inferior to the transverse colon (Figure 2). When it is not possible to preserve the splenic vein according to KT, before moving on to WT, MW can be considered; in all SPDP techniques, surgeons should consider this additional splenic venous drainage via the greater omentum, as preserving it may avert gastric varices and bleeding risks. When accessing the lesser sac, preserve the gastroepiploic arcade, short gastric vessels, and omental branches of the left gastroepiploic vein (Figure 3). If splenic hilar visualization is limited, prefer detaching the greater omentum from the transverse colon rather than dividing the gastrocolic ligament. Protect the dilated greater omental venous arch of Barkow during subsequent abdominal procedures.

FIGURE 1.

Abdominal CT (venous phase): Gastroepiploic arcade (black arrow) and greater omental venous arch of Barkow (white arrow). With splenic vein occlusion, venous flow drains via omental branches of the left gastroepiploic vein and onward to the superior mesenteric vein.

FIGURE 2.

Spatial relationship: Left gastroepiploic vein along the greater curvature (black arrow) and omental vein component of Barkow's arch inferior to the transverse colon (white arrow).

FIGURE 3.

Preoperative abdominal CT: Omental branches of the left gastroepiploic vein (white arrow).

Author Contributions

Carmine Cartanese: conceptualization, investigation, writing – original draft, data curation, writing – review and editing. Matteo Scaramuzzi: visualization. Raffaele De Luca: visualization. Giovanni Mastrandrea: visualization. Mario Sollitto: data curation, visualization.

Funding

The authors declare that financial support was received for the research and/or publication of this article. Preparation of this report was supported by the Italian Ministry of Health (Fondi 5 per mille‐ Deliberazione n.269/2024, In LOVAE for BHyA study) to cover publication costs.

Disclosure

The authors affiliated to the IRCCS Istituto Tumori “Giovanni Paolo II,” Bari are responsible for the views expressed in this article, which do not necessarily represent the Institute.

Consent

Written consent from the patient was obtained for the presentation of her case for educational purposes.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.