Severe Intestinal Bleeding Due To Left-Sided Portal Hypertension after Pancreatoduodenectomy with Portal Resection and Splenic Vein Ligation

In patients with pancreatic head cancer, tumor invasion of the portal vein (PV) or superior mesenteric vein (SMV) is common because of the close anatomical relationship of the pancreatic head and uncinate process to the venous portal system. Pancreatoduodenectomy (PD) with portal vein or superior mesenteric vein resection is well accepted for pancreatic head cancer because of the improvement in margin-negative resection and survival rates, without increasing postoperative morbidity and mortality in high volume centers ⦋1-4⦌. When tumor infiltration involves PV-SMV confluence the splenic vein (SV) is ligated to achieve a margin negative resection. However, SV ligation may result in sinistral (left-sided) portal hypertension and gastrointestinal bleeding. Usually, compression of the splenic vein causes backpressure in the left portal venous system and subsequent gastric varices but, in the postoperative state, the pathophysiologic condition is altered and makes it difficult to diagnose ⦋5-10⦌. We report a case of severe intestinal bleeding due to left-sided portal hypertension in patient who underwent a PD with PV-SMV confluence segmental resection and splenic ligation, for pancreatic adenocarcinoma, seven months previously that have required a massive haemostatic resuscitation and surgical procedure (Figure 1). Case Presentation