Reinsertion of the gastric coronary vein to avoid venous gastric congestion in pancreatic surgery

Background

Both partial and total pancreatoduodenectomy (PD) are standard surgical procedures and can be combined with resection of the mesenteric–portal venous axis.¹ During such procedures, the gastric coronary vein (CV) may be sacrificed as a result of direct tumour involvement, may be iatrogenically injured or may require ligation because its drainage is resected. The CV drains both the anterior and posterior stomach walls, and thus is extremely important to the venous drainage of the stomach.² The coronary vein may terminate into the portal vein (PV) either distal to or at the confluence of the splenic and portal veins (type 1 anatomy), or alternatively the CV may terminate into the splenic vein alone (type 2 anatomy) (Fig. 1).³ Combining pancreatic resection with resection of the portosplenic venous axis such that the splenic vein is either resected or disconnected from the PV can severely compromise gastric venous drainage, leading to venous congestion and subsequent ischaemia. The aim of this report is to describe the indications for and the technical approach to the preservation of venous gastric drainage by reconstructing the CV into the portal venous system.

Figure 1.

Portal vein resection and resection of the splenic vein with preservation of the coronary vein (anatomical situation type 2). White arrow: portal vein anastomosis; dotted white arrow: coronary vein; broken white arrow: splenic vein; black arrow: additional superior mesenteric artery anastomosis

Indications

In partial PD, there is no need for CV reconstruction if splenic venous drainage is maintained. If PV resection is performed in patients with type 1 anatomy, the PV resection may be performed below the level of the CV–PV junction to give sufficient gastric venous drainage, irrespective of the resulting splenic venous drainage. In type 2 anatomy, the CV can be preserved by reinserting the splenic vein after PV resection. However, if this is not possible, it may be prudent to reconstruct CV drainage to the portal system depending on the degree of collateral venous drainage from the splenic vein.

Following total PD with splenectomy, if the CV drainage is type 1 and the CV is preserved, gastric venous drainage will be satisfactory. However, if the procedure is combined with a resection of the PV that includes the CV or if the CV is located within type 2 anatomy, gastric venous ischaemia may result. In this situation, the CV should be reinserted to avoid immediate gastric resection and postoperative gastric ischaemia.

Technique

The reinsertion of the CV into the PV is performed in an end-to-side fashion. When possible, a patch of the splenic vein (in type 2 anatomy) should be preserved to enable a larger anastomosis and lower the potential risk for thrombosis (Figs 4). After resection of the specimen and, if it is performed, PV reconstruction, the PV is completely or partially clamped and incised on its craniolateral aspect on the left side. This incision is located above the PV anastomosis when present. The CV is reinserted using atraumatic non-absorbable running sutures. Prior to the completion of the sutures, the CV is flushed and the sutures are tied under perfusion to avoid any purse-string effect. In the authors' experience, local or systemic heparin instillation is not necessary because the rate of flow through the CV is high unless the anastomosis is of a small diameter (≤ 3 mm). It is crucial to avoid the twisting of the CV anastomosis. The mobility of the stomach makes it easy to avoid tension.

Figure 4.

Completed anastomosis of the coronary vein. The vein is reinserted above the portal vein anastomosis created previously. Restoration of the stomach drainage can be seen by release of the venous congestion (right upper corner)

Figure 2.

Mobilisation and preparation of the coronary vein. A patch of the splenic vein is preserved for the anastomosis (between the forceps). Intraoperative venous congestion of the stomach is visible (right upper corner)

Figure 3.

Anastomosis of the coronary vein in an end-to-side fashion using the patch of the splenic vein

Gastric venous drainage should be evaluated before the gastrointestinal reconstruction is completed (Fig. 4). Postoperatively, if thrombosis of the CV is suspected, endoscopy should be performed.

Discussion

The technique described focuses on the gastric CV as a potentially underestimated vessel during pancreatic surgery. The CV is physiologically important not only to gastric venous drainage, but also in the pathophysiology of left-sided portal hypertension.^3,4 In patients undergoing pancreatic resection associated with disconnection of the splenic vein from the portomesenteric venous axis, the CV becomes the main route of gastric and splenic venous drainage. Failure to recognize this and to restore adequate drainage to the portal system intraoperatively can lead either to acute gastric venous ischaemia requiring subtotal and perhaps even total gastrectomy, or to chronic gastric venous ischaemia that will either necessitate a delayed gastric resection or, if it is less pronounced, will cause longlasting delayed gastric emptying. In total PD with splenectomy, adequate drainage of the CV is essential because total gastrectomy in this scenario is associated with increased perioperative morbidity and impairment of the patient's quality of life.⁵ When the splenic vein is disconnected from the portomesenteric axis, reconstruction of the CV drainage may help to reduce the complications associated with left-sided portal hypertension. As the CV is of large diameter, it has the capacity to drain both the spleen and the stomach, which lowers the risk for left-sided portal hypertension.

In conclusion, the technique described draws attention to the CV as an important vessel in the respective surgical settings and offers strategies that will help to avoid unnecessary gastric resection and the occurrence of severe complications arising from gastric venous congestion or ischaemia.

Conflicts of interest

None declared.