Management and outcomes for portal venous thrombosis after pancreaticoduodenectomy

Postpancreatectomy portal venous thrombosis (PPVT) is an uncommon but significant complication that requires evolving management strategies. Furthermore, the actual effect of PPVT is underreported. This study aimed to summarize our institutional experience in managing patients with PPVT.

This was a single-institution database of patients who developed PPVT after pancreaticoduodenectomy or total pancreatectomy between 2011 and 2023. Patients who had preoperative PVT or underwent distal pancreatectomy were excluded from the study.

Of 53 patients with PPVT, most were female, White, and diagnosed with pancreatic ductal adenocarcinoma. Vascular resections were performed in 20 patients (38%) and were associated with early PPVT (≤30 days postoperatively) vs late PPVT (55% vs 26%, respectively; P = .03). Anticoagulation was frequently used in the early (59%) and late (58%) PPVT groups, followed by anticoagulation with stenting in the late group (16%). Of note, 1-year mortality rates did not differ between the early and late PPVT groups (18% vs 19%, respectively; P = .915), and the 1-year portal vein (PV) patency rates were 55% in the early PPVT group and 35% in the late PPVT group (P = .160). Univariate regression analysis revealed that the combination of anticoagulation and stenting was associated with an increased 1-year PV patency (odds ratio, 14; P = .03). Compared with a propensity-matched control without PPVT, PPVT was associated with higher 90-day Clavien-Dindo grade III to V complications (19% vs 32%, respectively; P = .03) but similar 1-year overall mortality (18% vs 19%, respectively; P = .810).

Although PPVT remains a crucial complication, it does not affect 1-year mortality. The underlying pathogenesis differs between early and late PPVTs, with vascular resection and tumor recurrence being the main risk factors for early and late PPVTs, respectively. Overall, anticoagulation therapy remains the most common treatment. However, the combination of anticoagulation and PV stenting results in better 1-year PV patency in patients with late PPVT.