Management of the splenic vein during a pancreaticoduodenectomy with venous resection for malignancy

Nowadays, pancreaticoduodenectomies (PD) with an "en-bloc" resection of the spleno-mesenterico-portal (SMP) venous axis are safely performed at tertiary centers for patients presenting venous invasion. However, for tumors infiltrating the SMP confluence optimal management of the splenic vein (SV) remains a matter of debate. Simple SV ligation has been associated with the development of sinistral portal hypertension, gastrointestinal bleeding and hypersplenism over the long term. To avoid these complications, reconstructive methods such as the direct implantation of the SV into a SMP "neoconfluence", the inferior mesenteric vein-SV anastomosis and the distal spleno-renal shunt have been reported. This article summarizes the different technical solutions available and the current evidence supporting the optimal management of the SV stump during a "safe" radical PD for pancreatic cancer. Technical issues, advantages as well as drawbacks of the different techniques, are discussed.