Rajvilas Anil Narkhede1* and Snehal Ashok Naphade2
1Department of Surgical Gastroenterology, Global hospital, Lakdi Ka Pul, Hyderabad, India 2M V P Medical College, Nasik, Maharashtra, India
Received: 20 June, 2016; Accepted: 02 July, 2016; Published: 04 July, 2016
Dr. Rajvilas Anil Narkhede, Pushpanjali, Shemba, Nandura, Buldana, Maharashtra, 440103, India, Tel: +918897389898; E-mail:
Narkhede RA, Naphade SA (2016) Pancreatic Siphon: A Major Determinant of Selective Shunts. Is it a Historical Entity now?. J Surg Surgical Res 2(1): 039-042.10.17352/2455-2968.000029
© 2016 Narkhede RA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Pancreatic siphon; Distal spleno-renal shunt; Intra-pancreatic collaterals; Spleno-pancreatic disconnection; Selective shunt
Surgical management of portal hypertension has changed according to time, evolving from just complete shunts to selective shunts and to liver transplantation. The outcomes also greatly improved owing to better understanding of portal hemodynamics and disease nature. Introduction of selective shunts showed promising results just to be challenged by poor outcome with development of “pancreatic siphon” which then studies in detail. This intra-pancreatic and peri-pancreatic collateral veins which connected portal and splenic veins formed basis of systemic loss of portal flow and thus ending up in failure of selectivity. Pancreatic siphon was found to be associated with increased rates of hepatic encephalopathy post selective shunting along with increased rates of hepatic failure. In addition to this pancreatic siphon led to metabolic sequel like new onset of diabetes, ischemic or compressive pancreatic ductopathy and intrapancreaic cholangiopathy. Although the shunting procedures are not that commonly done, pancreatic siphon has moved out of the limelight. It was just an attempt of recapping the existence of an unfamiliar entity forming delicate balance in the portal circulation.
Treatment of portal hypertension has evolved greatly over last few decades. Of these Distal splenorenal shunt (DSRS) was found to provide long lasting solution to the problem. DSRS was based on the idea that esophageal and gastric varices will be decompressed into renal vein via short gastric vessels and spleen after disconnecting coronary vein at the same time maintaining hepatopetal flow in mesentericoportal circulation and supply of hepatotropic factors to liver . But over time the shunt showed loss of this selectivity and showed increased rates of hepatic failure secondary to loss of portal flow from portal circulation to systemic circulation through peri-pancreatic and intra-pancreatic surgery. The ‘pancreatic siphon’ term gained its existence only after the popularisation of distal splenorenal shunt. It was found to be the communication between mesenerico-portal and the disconnected gastrosplenic compartments. This pancreatic and peripancreatic venous collaterals decompressing portal circulation into splenic vein after DSRS is said to be “pancreatic siphon”.
What is exactly “Pancreatic siphon”?
Large collaterals leave the portal vein into the head of the pancreas, drain through the body and tail of the pancreas via intrapancreatic branches that communicate directly with the shunt distal splenic vein . In 65.79 % anatomical pieces studied by Piras C et al., showed that the veins of the pancreatic tail flowed in segmentary branches of the splenic vein. These branches could be responsible for the loss of distal splenorenal shunt selectivity . Since the portal system is valve less; retrograde flow through this siphon is possible; away from portal system to the shunt (Figure 1).
- Piras C, Paulo DNS, Paulo ICAL, Rodrigues H, Silva AL da (2010) Venous drainage from the tail of the pancreas to the lienal vein and its relationship with the distal splenorenal shunt selectivity. Acta Cir Bras 25: 105-110 .
- Warren WD, Millikan Jr. WJ, Henderson JM, Rasheed ME, Salam AA (1984) Selective variceal decompression after splenectomy or splenic vein thrombosis. With a note on splenopancreatic disconnection. Ann Surg 199: 694-702.
- Hongo N, Mori H, Matsumoto S, Okino Y, Ueda S, et al. (2010) Anatomical variations of peripancreatic veins and their intrapancreatic tributaries: Multidetector-row CT scanning. Abdom Imaging 35: 143–153 .
- Durualp E, Bekta G, Ergin D, Karaca E, Topçu E (2011) Annelerin Sigara Kullanımı ile Yenidoğanın Doğum Kilosu, Boyu ve Baș Çevresi Arasındaki İlișkinin İncelenmesi 64: 119–126 .
- Wright AS, Rikkers LF (2005) Current management of portal hypertension. J Gastrointest Surg 9: 992-1005 .
- Orozco H, Takahashi T, Mercado MA, Gonzalez-Lopez-Lira A, Hernandez-Ortiz J (1992) Intermittent changes in portal venous flow in relation with spleno-pancreatic collaterals--“the pancreatic siphon”--after a selective shunt in a patient with idiopathic portal hypertension: case report. Surgery 111: 105–108 .
- Vilgrain V, Condat B, O’Toole D, Plessier A, Ruszniewski P, et al. (2009) Pancreatic portal cavernoma in patients with cavernous transformation of the portal vein: MR findings. Eur Radiol 19: 2608–2613.
- Warren WD, Millikan Jr. WJ, Henderson JM, Abu-Elmagd KM, Galloway JR, et al. (1986) Splenopancreatic disconnection. Improved selectivity of distal splenorenal shunt. Ann Surg 204: 346-355 .
- Henderson J, Warren W (1986) A method of measuring quantitative hepatic function and hemodynamics in cirrhosis: The changes following distal splenorenal shunt. Surg Today. Springer Japan 16: 157–168 .
- Warren WD, Whitehead JB (1986) Recent advances in the management of variceal bleeding. Surg Today 16: 77–83.
- Ezzat FA, Abu-Elmagd KM, Sultan AA, Aly MA, Fathy OM, et al. (1989) Schistosomal versus nonschistosomal variceal bleeders. Do they respond differently to selective shunt (DSRS)? Ann Surg 209: 489–500 .
- Isomatsu T (1983) Loss of selectivity of warren shunt in long-term observation. Surg Today 13: 202–206 .
- Myburgh JA (1990) Selective shunts: The Johannesburg experience. Am J Surg 160: 67–74 .
- Warren WD, Henderson JM, Millikan WJ, Galambos JT, Brooks WS, et al. (1986) Distal splenorenal shunt versus endoscopic sclerotherapy for long-term management of variceal bleeding. Preliminary report of a prospective, randomized trial. Ann Surg 203: 454–462 .
- Zeppa R, Hensley GT, Levi JOEU, Bergstresser PR, Hutson DG, et al. (1976) The Comparative Survivals of Alcoholics Versus Nonalcoholics After Distal Splenorenal Shunt 510–513 .
- Shapiro RS, Varma C V, Schwartz ME, Miller CM (1997) Splenorenal shunt closure after liver transplantation: intraoperative Doppler assessment of portal hemodynamics. Liver Transpl Surg 3: 641–642 .
- Orozco H, Mercado MA, Granados JG, Hernandez-Ortiz J, Tielve M, et al. (1997) Selective shunts for portal hypertension: Current role of a 21-year experience. Liver Transplant Surg 3: 475–480 .
- Nozaki H, Shimada T, Fukushima Y, Inou T, Takeda Y (1998) Successful surgical treatment for hepatic encephalopathy caused by a pancreatic siphon: Report of a case. Surg Today. Springer Japan 28: 1069–1072 .
- Sharma M, Rameshbabu CS (2014) Portal cavernoma cholangiopathy: An endoscopic ultrasound based imaging approach. J Clin Exp Hepatol. Elsevier Ltd 4: S53–61 .
- Collins JC, Rypins EB, Sarfeh IJ (1994) Narrow-diameter portacaval shunts for management of variceal bleeding. World J Surg. Springer New York 18: 211–215 .
- Abu-Elmagd KM, Ezzat FA, Fathy OM, El-Ghawlby NA, Aly MA, et al. (1991) Should both schistosomal and nonschistosomal variceal bleeders be disconnected? World J Surg. Springer New York 15: 389–397.
- Kato K, Kondo S, Morikawa T, Okushiba S, Katoh H (1999) Selective distal splenorenal shunt without requiring splenopancreatic disconnection with the use of the external iliac vein graft: A preliminary report. Surgery Mosby 126: 577–580 .
- Katoh H, Shimozawa E, Kojima T, Tanabe T (1989) Modified splenorenal shunt with splenopancreatic disconnection. Surgery 106: 920–924 .
- Warren WD, Millikan WJ, Henderson JM, Wright L, Kutner M, et al. (1982) Ten years portal hypertensive surgery at Emory. Results and new perspectives. Ann Surg 195: 530–542.
- Paquet K, Mercado M, Klingele H, Klingele R (1991) Investigation of the portal perfusion index after low diameter mesocaval interposition and distal splenorenal shunt — a prospective study. Surg Endosc 5: 204–208 .
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