The management of splanchnic vein thrombosis in acute pancreatitis: a global DELPHI consensus study

Background: Splanchnic vein thrombosis (SpVT) occurs in 17%-23 % of acute pancreatitis cases. Serious sequelae include hepatic and bowel ischaemia. However, management with therapeutic anticoagulation remains controversial due to potential bleeding risk. We aim to determine the level of consensus on prognosis, diagnosis, management, and outcomes of SpVT through a DELPHI process. Methods: Using purposive, non-probability sampling and DELPHI methodology, 173 clinicians with experience of SpVT in acute pancreatitis were approached. From April 2022 to April 2023, a three-round DELPHI process was implemented to completion. A total of 88 statements were posed for ranking via a four-point Likert scale. Results: The mean acute pancreatitis caseload per respondent per year was 68.0, 72.6 and 73.0 for DELPHI rounds 1,2 and 3 respectively. For SpVT anatomical location, there was strong consensus favouring anticoagulation for portal vein (89.1 %) and SMV thrombosis (90.9 %), and no consensus to treat splenic vein thrombosis (47.3 %). 74.1 % rejected radiological resolution as a definitive anticoagulation endpoint. Majority consensus favoured death, bleeding risk, bowel or liver ischaemia, hospital admission length and ITU admission as significant outcomes for experimental research design. Conclusion: There was significant consensus for anticoagulation treatment of SpVT of the portal and superior mesenteric veins, especially with complete occlusion by thrombosis. Randomised controlled trials are required to grade management recommendations.