Left-sided portal hypertension: successful management by laparoscopic splenectomy following splenic artery embolization.

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International

Journal

of

Surgery

Case

Reports

jo u r n al ho me p a g e :w w w . c a s e r e p o r t s . c o m

Left-sided

portal

hypertension:

Successful

management

by

laparoscopic

splenectomy

following

splenic

artery

embolization

Damiano

Patrono

_,

_Rosa

_Benvenga

_,

_Francesco

_Moro

_,

_Denis

_Rossato

_,

Renato

Romagnoli

_,

_Mauro

_Salizzoni

a_{GeneralSurgery2UandLiverTransplantationCenter,UniversityofTurin,A.O.U.CittàdellaSaluteedellaScienzadiTorino,CorsoBramante88-90,}

10126Turin,Italy

b_{RadiologyDepartment,UniversityofTurin,A.O.U.CittàdellaSaluteedellaScienzadiTorino,CorsoBramante88-90,10126Turin,Italy}

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Articlehistory:

Received10February2014 Accepted10March2014 Availableonline15August2014

Keywords:

Laparoscopicsplenectomy Splenicarteryembolization Portalhypertension Left-sidedportalhypertension Spleniccavernoma

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INTRODUCTION:Left-sidedportalhypertensionisarareclinicalconditionmostoftenassociatedwith apancreaticdisease.In caseofhemorrhagefrom gastricfundusvarices,splenectomyis indicated. Commonly,theoperationiscarriedoutbylaparotomy,asportalhypertensionisconsideredarelative contraindicationtolaparoscopicsplenectomy(LS).Althoughsomestudieshavereportedthefeasibilityof thelaparoscopicapproachinthesettingofcirrhosis-relatedportalhypertension,experienceconcerning LSinleft-sidedportalhypertensionislacking.

PRESENTATIONOFCASE:A39-year-oldmanwasadmittedtotheEmergencyDepartmentfor haemor-rhagicshockduetoacutehemorrhagefromgastricfundusvarices.Diagnosticworkuprevealedachronic pancreatitis-relatedsplenicveinthrombosiscausingleft-sidedportalhypertensionwithgastricfundus varicesandspleniccavernoma.Followingsplenicarteryembolization(SAE),thecasewassuccessfully managedbyLS.

DISCUSSION:Theadvantagesoflaparoscopicoveropensplenectomyincludelowercomplicationrate, quickerrecoveryandshorterhospitalstay.SplenicarteryembolizationpriortoLShasbeenusedto reduceintraoperativebloodlossesandconversionrate,especiallyincomplexcasesofsplenomegalyor cirrhosis-relatedportalhypertension.Wereportacaseofcomplicatedleft-sidedportalhypertension managedbyLSfollowingSAE.Inspiteofthepresenceoflargevaricesatthesplenichilum,theoperation wasperformedbylaparoscopywithoutanymajorintraoperativecomplication,thankstothereduced venouspressureachievedbySAE.

CONCLUSION:Splenicarteryembolizationmaybeavaluableadjunctincaseofleft-sidedportal hyper-tensionrequiringsplenectomy,allowingasafedissectionofthesplenicvesselsevenbylaparoscopy. ©2014TheAuthors.PublishedbyElsevierLtd.onbehalfofSurgicalAssociatesLtd.Thisisanopen accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/3.0/).

1. Introduction

Theadvantagesoflaparoscopicoveropensplenectomyare well-known and include reduced intraoperative blood losses, faster postoperativerecovery,lowercomplicationrateandshorter hos-pitalstay.1_{Sinceitsfirstdescriptionin1991,}2_{theindicationsfor} laparoscopicsplenectomy(LS)havebeenwideningandnowadays includemostbenignandmalignanthematologicdiseasesaswell ascasesofmassivesplenomegaly(i.e.diameter>20cm).

Left-sidedportalhypertensioncomplicatedbygastrointestinal hemorrhagerepresentsanindicationforsplenectomy.3,4_Duetothe increasedriskofintraoperativehemorrhage,portalhypertension

∗ Correspondingauthor.Tel.:+390116334374;fax:+390116336770. E-mailaddress:mauro.salizzoni@unito.it(M.Salizzoni).

hasbeenconsideredasacontraindicationtoLS.1_Althoughsome studieshaveshownthefeasibilityoflaparoscopicsplenectomyin patientssufferingfromcirrhosis-related portalhypertension,5–7 thesettingofleft-sidedportalhypertensionpresentspeculiar diag-nosticandmanagement issuesandpossiblyconstitutesaneven morechallenginganatomicsituationtotheoperatingsurgeon.

Herewereportacase ofleft-sidedportalhypertension com-plicatedbygastricbleedingwhichwassuccessfullymanagedby preoperativesplenicarteryembolization(SAE)followedbyLS.

2. Casereport

A 39-year-oldman wasadmitted tothe Emergency Depart-ment of our hospital for hematemesis and hemorrhagic shock. Hispreviousmedical history wassignificant forarterial hyper-tension, autoimmune thyroiditis and type 2 diabetes mellitus http://dx.doi.org/10.1016/j.ijscr.2014.03.010

2210-2612/© 2014TheAuthors.Published byElsevier Ltd.onbehalf of SurgicalAssociatesLtd. Thisis an openaccessarticle underthe CCBY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).

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Fig.1.Computedtomographyshowingthedilatedstomachoccupiedbyahugebloodclot,theseverelyatrophicpancreasandthesplenomegaly.(A)Thrombosisofthe

splenicvein(thinarrow)andspleniccavernoma(thickarrow).(B)Dilatedgastroepiploicveinfunctioningasashuntfromthesplenichilumtothesuperiormesentericvein.

complicatedbydiabeticneuropathy,retinopathyandnephropathy

leadingtoastage3chronicrenalfailure.Hereportednohistory

of liverdisease, alcohol abuse or exposuretohepatotoxic

sub-stances.Noteworthy,duringtheweekbeforeadmittance,hehad

assumedlargedosesofnon-steroidalanti-inflammatorydrugsfor

hisneuropathic lower limbs pain.After initialresuscitation,an

emergencyesophagogastroduodenoscopy(EGDS)showedahuge

clotinthestomachwithsignsofactivebleeding,butthesource

ofhemorrhagecouldnotbeidentified.Duringtheprocedurehe

presenteda cardiacarrest requiringcardiopulmonary

resuscita-tion for 10min. Once hemodynamic stability achieved,he was

transferredtotheintensivecare unitwhere theadministration

of high-doses of proton pumpinhibitors was started.

Abdomi-nalDopplerultrasonographyshowednosignofliverdiseaseand

anormalflow intothevenaporta,butthepancreasandspleen

regionwerepoorlyassessedbecauseoftheimportantabdominal

meteorism.AfurtherEGDSagainfailedinidentifyingthesource

of bleeding, so a celio-mesenteric arteriography was obtained,

showingnoarterialblush.Duringthefollowingdays,thepatient

presentedtwofurtherepisodesofgastrointestinalhemorrhageand

wasrepeatedlytransfusedwithpackedredbloodcellsandplasma.

Anabdominalcontrast-enhancedcomputedtomography(CT)was

thenobtained,revealingasevereatrophyofthewholepancreas

withsignsofchronicpancreatitis,athrombosisofthesplenicvein,

asplenomegalyandacavernomatoustransformationofthesplenic

hilum(Fig.1).AthirdEGDSperformedaftertheremissionof

bleed-ingshowedthepresenceoflarge,isolatedvaricesofthegastric fundus,withsignsofrecentbleeding.Asawhole,thesefindings wereconsistentwithadiagnosisofleft-sidedportalhypertension complicatedbygastrointestinalhemorrhagefromisolatedgastric fundusvarices.Thus,thepatientwasscheduledforasplenectomy that, given the limited entity of the splenomegaly (longitudi-naldiameter=17cm), wasdeemedfeasible bythelaparoscopic approach.Inordertoreducetheintraoperativebleeding,asplenic arteryembolization wascarriedout24hprior totheoperation, bymeansoftwovascularplugs(Amplatzer®VascularPlug,St.Jude MedicalInc.,MN,USA)andacoil(Cirrus.015,BaltExtrusion, Mont-morency,France),whichwerereleasedproximallytothesplenic hilumregion.Atoperation,thespleenwascompletelyischemic and,althoughareticulumofvariceswasobservedatthesplenic hilum(Fig.2),thedissectioncouldbeachievedbylaparoscopy.The splenicartery,thegastroepiploicandsplenicveinsandtheshort gastricvesselsweredividedbythemeanofanendoscopicvascular

stapler.Bloodlosseswereminimalandnointraoperative compli-cationsoccurred.Thespleenwasextractedthroughoneoftheport sitesaftermorcellation.The postoperativecoursewas unevent-fulandhewasdischargedfromourdepartmentonpostoperative day4;atone-yearfollow-upheisaliveandpresentednofurther episodeofgastricbleedingfromgastricvarices.

3. Discussion

Thisreportdescribesthesuccessfulmanagementofacaseof left-sidedportalhypertensioncomplicatedwithgastricbleeding bytheassociationofpre-operativesplenicarteryembolizationand laparoscopicsplenectomy.

Fig.2. Anintraoperativesnapshotshowingthedensereticulumofvaricesatthe splenichilumandtheischemicspleenaftersplenicarteryembolization.

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Fig.3.Aschemeofthevenousflowredistributionfromthesplenichilumtothe

coronaryveinsthroughtheshortgastricandposteriorveins,andtothesuperior

mesentericveinthroughthegastroepiploicvein.Abbreviations:PV,portalvein;

CV,coronaryveins;SGV,shortgastricveins;SV,splenicvein;GEV,gastroepiploic

vein;HGCT,Henle’sgastrocolictrunk;IMV,inferiormesentericvein;SMV,superior

mesentericvein.

Ourpatientpresentedwithsevereuppergastrointestinal

hem-orrhage which led to the diagnosis of gastric fundus varices,

pancreasatrophy,splenic veinthrombosis andleft-sided portal

hypertension.Inspiteofthenegativeanamnesis,wecanarguethat

boththetype2diabetesandthesplenicveinthrombosiswerethe

issueofaclinically-silentchronicpancreatitisofunknownetiology.

Inpatientssufferingfromchronicpancreatitis,indeed,the

inci-denceofsplenicveinthrombosisisestimatedtobearound12%.8

Splenicveinthrombosis(SVT)maybeassociatedwitha segmen-tal,orleft-sided,formofportalhypertension.Inthisconditionthe venousdrainageofthespleenisredirectedthroughtheshortand posteriorgastricvesselstothecoronaryveins(drainingintothe venaporta)andthroughthegastroepiploicveinstothesuperior mesentericvein,respectively.Thesubmucosalvenousreticulum ofthegastricfundusrepresentstheanatomicbridgebetweenthe shortandposteriorgastricveinsandthecoronaryveinsand,asa consequenceoftheincreasedpressure,maydilateintovaricesand originatebleeding(Fig.3).3

If the indication for splenectomy remains controversial in patientswithuncomplicated left-sidedportalhypertension,3,9,10 bleedingfromgastricvaricesrepresentsawidelyrecognized indi-cation for splenectomy.4 _{The rationale for splenectomy in this} setting is tointerrupt thearterial supply feedingthe collateral drainingveinsandthegastricfundusvarices,thusreducingthe pressureofthesystemand,consequently,theriskofre-bleeding.3 Concerning the choice of the surgical approach, the advan-tages of laparoscopic over open splenectomy are well-known andincludereducedpostoperativepain,lowercomplicationrate, quickerrecoveryandshorterhospitalstay.Nonetheless,according tothe2008EAESguidelinesonlaparoscopicsplenectomy,1_portal hypertensionrepresentsacontraindicationtolaparoscopy,given thehigherriskofintra-operativehemorrhage.Sincethepublication oftheseguidelines,afewarticleshaveshownthefeasibilityofthe laparoscopictechniqueinpatientswithportalhypertension associ-atedwithlivercirrhosis.5–7_{Nopatientintheseseries,however,has} beenreportedtohaveleft-sidedportalhypertension,whichclearly representsaverydifferentanatomicsettingfromcirrhosis-related portalhypertension.Inleft-sidedportalhypertension,indeed,the

splenichilumisthefulcrumofthehypertensivevenoussystem, fromwhichallthevenouscollaterals,i.e.thedilatedshortgastric, posteriorgastricandgastroepiploicveins,branchoff.Inthissetting, asafedissectionofthe“spleniccavernoma”bylaparoscopymaybe evenmorehazardousthaninpatientswithlivercirrhosis.

Forthisreasonweconsideredpre-operativeSAEasameanto reducethevenouspressureatthesplenichilumandtoallowasafer andeasierdissectionofthesplenicvessels,whichwassuccessfully accomplishedbylaparoscopy.Splenicarteryembolizationisnot devoidofpotentialcomplications,includingsplenicrupture,acute pancreatitis,gastric ulcer,pleural effusion,lungatelectasis, sep-sisandtheso-called“post-infarctionsyndrome”,representedby abdominalpain,leukocytosisandfever.However,theincidenceof thesecomplicationcanbereducedbypropertechnique,antibiotic coverageandeffectiveanalgesia.11_{Oneofthefirststudiesabout} thecombinationofSAEwithLSwasthatofPoulinetal.12_reporting aninitialdecreaseintheconversionrateassociatedwith preoper-ativeSAE,whichwassuccessivelyovertakenbytheacquisitionofa moreeffectivesurgicaltechnique.Resoetal.13_{usedSAEbeforeLS} inpatientswithsplenomegalysufferingmostlyfromhematologic malignanciesandfounditassociatedwithreducedbloodlosses, a shorter operative time and a reduced conversion rate.Hama etal.6 _{usedpreoperativesplenicarteryocclusionwithaballoon} in patientsundergoingLSfor cirrhosis-relatedportal hyperten-sionandsplenomegaly,obtainingresultscomparabletothoseof LSinpatientswithnormal-sizespleensandnoportal hyperten-sion.Finally,Wuetal.14_{comparedSAEplusLSversusLSaloneand} opensplenectomyinthesettingofsplenomegaly.Noteworthy,the mostfrequentindicationforsplenectomyintheirstudywasliver cirrhosis.TheyfoundthatthepatientstreatedwithSAEplusLShad lessintraoperativebloodloss,lowercomplicationrateandshorter hospitalstay,concludingthatSAEisavaluableadjunctinpatients withsplenomegaly.Inourcase,inconsiderationoftheexpected technicaldifficulties,SAEclearlyseemedtohaveanadvantageous risk/benefitratio,whichwasconfirmedduringtheoperation:in spiteofthepresenceoflargeandnumerousvarices,thesplenic hilumcouldbedissectedeasilyandthesplenicvesselssafely con-trolled.

4. Conclusion

Splenicarteryembolizationrepresentsapreciousadjunctinthe managementof complexcasesrequiring LS,as inpatientswith anenlargedspleeninthesettingofcomplicatedleft-sidedportal hypertension.

Conflictofintereststatement

None.

Funding

None.

Ethicalapproval

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Authorcontributions

DamianoPatronowrotethepaper,obtainedtheinformed con-sent,processed thedigital imagesand performedtheliterature

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search;RosaBenvengawastheresidentinchargeofpatientcare,

performedtheliteraturesearchandhelpedinwritingthepaper;

FrancescoMoroperformedthelaparoscopicsplenectomyand

crit-icallyrevisedthemanuscript;DenisRossatoperformedthesplenic

arteryembolizationandcriticallyrevisedthemanuscript;Renato

Romagnolicriticallyrevisedthemanuscript;MauroSalizzoniwas

theoverallresponsibleforthecareofthepatient,supervisedand

criticallyrevisedthemanuscript.

Keylearningpoint

• Splenicarteryembolizationallowedasafedissectionofsplenicvesselsduringlaparoscopicsplenectomyfor

compli-catedleft-sidedportalhypertension.

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