Management of post-operative portal vein thrombosis after pancreatectomy: A systematic review

Introduction: Post-operative portal vein thrombosis (PPVT) is a potentially fatal complication following pancreatectomy and can occur in 1.2–5 %¹ of patients after resection. Treatment strategies include therapeutic anticoagulation (TAC), portal vein stent (PVS), or thrombectomy. To date, there has been no consensus on the optimal treatment strategy. The objective of this study is to systematically review the incidence and management of PPVT following pancreatectomy and to compare the clinical outcomes of treatment. Methods: We conducted a systematic review and searched Embase, PubMed, Cochrane, Web of Science, and Scopus databases for studies published between December 1990 and July 2022. MeSH terms were used to identify quantitative studies involving pancreatectomies and PPVT. We extracted data on the PPVT incidence, management, and clinical outcomes, which included thrombus resolution rate and 90-day mortality. Two reviewers [YY, AB] independently performed study selection, data abstraction, and quality assessment. Results: Of the 1028 studies initially identified, 12 were eligible for inclusion. Pancreatoduodenectomy, distal pancreatectomy, and total pancreatectomy were the most common surgeries performed. The incidence of PPVT ranged from 1.5 % to 26 %. Five studies reported outcomes of TAC, three reported outcomes of PVS, and five reported outcomes for patients treated with multiple strategies. Of the TAC-only studies, 1 study reported 100 % thrombus resolution (n = 2). 3 studies found no difference in thrombus resolution rate or mortality. In the 3 studies that reported PVS-only, initial technical success rates were 66.7 % (n = 3), 100 % (n = 3), and 100 % (n = 9), respectively. Long-term patency rates were not uniformly reported. Most deaths were reported in studies that performed surgical thrombectomy (4 studies, mortality rate of 40–100 %) compared to TAC-only (1 study, mortality rate of 33 %), and PVS-only (1 study, mortality rate of 66 %). Conclusion: PPVT is often managed with combined strategies and, less commonly with thrombectomy or PVS alone. PVS has high initial technical success rates, though the long-term patency rate is limited to small case series. Mortality was most frequently reported in patients treated with surgical thrombectomy; this might be because of selection bias for high-risk patients. Thrombus resolution after treatment was not consistently reported in the literature. Given the significant heterogeneity between studies, there is no consensus on the optimal strategy. Larger quantitative studies that routinely assess treatment response and report long-term outcomes are needed.