Gastric venous congestion after pancreatic surgery: A systematic review, metanalysis and suggested protocol for assessment and management

BACKGROUND: Gastric venous congestion (GVC) is an under-recognised complication of pancreatic surgery, particularly in the context of venous resection and splenectomy. This systematic review aimed to evaluate the incidence, clinical impact, and current strategies for diagnosis, prevention, and management of GVC. METHODS: A PRISMA-compliant systematic review was conducted across MEDLINE, Embase, Cochrane Library, and additional sources (2005-2024). Studies reporting on GVC in pancreatic surgery were included. Data on surgical characteristics, incidence of intraoperative and postoperative GVC, and clinical outcomes were extracted. A single-arm meta-analysis of proportions was performed for outcomes reported in ≥5 studies using a random-effects model. RESULTS: Sixteen studies including 1,133 patients were analysed. Intraoperative GVC was reported in 5.0-27.9% of cases, while postoperative GVC occurred in up to 24.1%. Meta-analysis demonstrated a pooled intraoperative GVC incidence of 16.3% (95% CI 9.8-25.9; I²=81.0%) and postoperative GVC incidence of 4.7% (95% CI 1.3-15.4; I²=83.3%). GVC was associated with increased morbidity, including delayed gastric emptying (pooled 17.3%, 95% CI 13.2-22.4), major complications (13.5%, 95% CI 8.1-21.6), and postpancreatectomy haemorrhage (4.5%, 95% CI 2.7-7.5). Ninety-day mortality was 4.3% (95% CI 2.9-6.5). Preservation or reconstruction of gastric venous drainage pathways was consistently associated with reduced postoperative GVC in reported series, although evidence was limited to non-comparative studies. CONCLUSION: GVC is a relatively common intraoperative finding and is associated with clinically significant postoperative morbidity. Pooled incidence estimates highlight substantial heterogeneity, reflecting variation in definitions and diagnostic approaches. Current evidence is predominantly retrospective and non-comparative; we therefore propose a potential standardised diagnosis and management pathway, of which prospective evaluation is required.