1
|
Uehara H, Kawanaka H, Nakanoko T, Sugiyama M, Ota M, Mano Y, Sugimachi K, Morita M, Toh Y. Successful hybrid surgery for ileal conduit stomal varices following oxaliplatin-based chemotherapy in a patient with advanced colorectal cancer. Surg Case Rep 2020; 6:236. [PMID: 32990797 PMCID: PMC7524906 DOI: 10.1186/s40792-020-01021-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/21/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Ectopic variceal bleeding is a rare but life-threatening complication of portal hypertension (PH). Oxaliplatin-based chemotherapy for colorectal cancer (CRC) is associated with sinusoidal obstruction syndrome of the liver, which can lead to PH. CASE PRESENTATION Here, we report a successful hybrid surgery that included intraoperative obliteration of ileal conduit stomal varices (ICSVs) for a 66-year-old woman with CRC and liver metastasis that had been treated multimodally during the previous 4 years, including 17 courses of oxaliplatin-based chemotherapy. She was admitted to our hospital for massive hemorrhage from an ileal conduct stoma. Image findings showed ICSVs as a part of portosystemic shunt, which were afferently supplied from the superior mesenteric vein (SMV) and drained by the numerous cutaneous veins connected to the left femoral vein. Obliteration of the stomal varices by interventional radiologic techniques alone was inappropriate because of difficulties of cannulating the efferent cutaneous veins. We, therefore, performed hybrid surgery for the ICSV, which included cannulation into the SMV branch and antegrade obliteration of the varices with a 5% solution of ethanolamine oleate with iopamidol under blocking the SMV flow, using a vascular clip and ligation. Hemorrhage in her ileal conduit stoma disappeared completely. CONCLUSION Customized treatment of ectopic varices should be based on their precise vascular anatomy; hybrid surgery with intraoperative angiography is an alternative treatment for ectopic varices such as ICSV.
Collapse
Affiliation(s)
- Hideo Uehara
- Department of Gastroenterological Surgery, National Hospital Organization Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan.
| | - Hirofumi Kawanaka
- Clinical Research Institute and Department of Surgery, National Hospital Organization Beppu Medical Center, 1473 Uchikamado, Beppu, Oita, 874-0011, Japan
| | - Tomonori Nakanoko
- Department of Gastroenterological Surgery, National Hospital Organization Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
| | - Masahiko Sugiyama
- Department of Gastroenterological Surgery, National Hospital Organization Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
| | - Mitsuhiko Ota
- Department of Gastroenterological Surgery, National Hospital Organization Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
| | - Yohei Mano
- Department of Hepatobiliary-Pancreatic Surgery, National Hospital Organization Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
| | - Keishi Sugimachi
- Department of Hepatobiliary-Pancreatic Surgery, National Hospital Organization Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
| | - Masaru Morita
- Department of Gastroenterological Surgery, National Hospital Organization Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
| | - Yasushi Toh
- Department of Gastroenterological Surgery, National Hospital Organization Kyushu Cancer Center, Notame 3-1-1, Minami-ku, Fukuoka, 811-1395, Japan
| |
Collapse
|
2
|
Hashimoto N, Akahoshi T, Yoshida D, Kinjo N, Konishi K, Uehara H, Nagao Y, Kawanaka H, Tomikawa M, Maehara Y. The efficacy of balloon-occluded retrograde transvenous obliteration on small intestinal variceal bleeding. Surgery 2009; 148:145-50. [PMID: 20004438 DOI: 10.1016/j.surg.2009.10.052] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Accepted: 10/12/2009] [Indexed: 01/26/2023]
Abstract
BACKGROUND Small intestinal variceal bleeding is an unusual cause of gastrointestinal hemorrhaging of portal hypertensive patients, but once it occurs it may lead to life-threatening bleeding because this problem is difficult to diagnose and treat. This study investigated the efficacy of balloon occluded retrograde transvenous obliteration (B-RTO) to treat small intestinal variceal bleeding. METHODS From 2003 to 2007, 6 patients with small variceal bleeding were treated by B-RTO. The characteristics of the patients, B-RTO procedures, prognosis, and occurrence of risky esophageal and gastric varices were evaluated according to their medical records. RESULTS Three-dimensional (3-D) angiography by MD-CT was useful for the diagnosis of small intestinal varices and the draining vessels. In all cases, variceal bleeding was controlled by B-RTO treatment, although rebleeding was recognized in one patient after 30 months (16.6%). All patients were alive throughout the follow-up except 1 patient who died of liver failure (6-44 months). Risky esophageal varices and gastric varices occurred in 2 patients (33.3%) after B-RTO. However, no variceal bleeding occurred. CONCLUSION B-RTO was found to be an effective treatment modality which provided good initial hemostasis, thereby eradicating ectopic small intestinal varices.
Collapse
Affiliation(s)
- Naotaka Hashimoto
- Department of Surgery and Science, Graduate School of Medical Science, Kyushu University, Higashi-ku, Fukuoka, Japan.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Abstract
Ectopic varices (EcV) comprise large portosystemic venous collaterals located anywhere other than the gastro-oesophageal region. No large series or randomized-controlled trials address this subject, and therefore its management is based on available expertise and facilities, and may require a multidisciplinary team approach. EcV are common findings during endoscopy in portal hypertensive patients and their bleeding accounts for only 1–5% of all variceal bleeding. EcV develop secondary to portal hypertension (PHT), surgical procedures, anomalies in venous outflow, or abdominal vascular thrombosis and may be familial in origin. Bleeding EcV may present with anaemia, shock, haematemesis, melaena or haematochezia and should be considered in patients with PHT and gastrointestinal bleeding or anaemia of obscure origin. EcV may be discovered during panendoscopy, enteroscopy, endoscopic ultrasound, wireless capsule endoscopy, diagnostic angiography, multislice helical computed tomography, magnetic resonance angiography, colour Doppler-flow imaging, laparotomy, laparoscopy and occasionally during autopsy. Patients with suspected EcV bleeding need immediate assessment, resuscitation, haemodynamic stabilization and referral to specialist centres. Management of EcV involves medical, endoscopic, interventional radiological and surgical modalities depending on patients’ condition, site of varices, available expertise and patients’ subsequent management plan.
Collapse
|
4
|
Vidal V, Joly L, Perreault P, Bouchard L, Lafortune M, Pomier-Layrargues G. Usefulness of transjugular intrahepatic portosystemic shunt in the management of bleeding ectopic varices in cirrhotic patients. Cardiovasc Intervent Radiol 2006; 29:216-9. [PMID: 16284702 DOI: 10.1007/s00270-004-0346-4] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the control of bleeding from ectopic varices. METHODS From 1995 to 2004, 24 cirrhotic patients, bleeding from ectopic varices, mean age 54.5 years (range 15-76 years), were treated by TIPS. The etiology of cirrhosis was alcoholic in 13 patients and nonalcoholic in 11 patients. The location of the varices was duodenal (n = 5), stomal (n = 8), ileocolic (n = 6), anorectal (n = 3), umbilical (n = 1), and peritoneal (n = 1). RESULTS TIPS controlled the bleeding in all patients and induced a decrease in the portacaval gradient from 19.7 +/- 5.4 to 6.4 +/- 3.1 mmHg. Postoperative complications included self-limited intra-abdominal bleeding (n = 2), self-limited hemobilia (n = 1), acute thrombosis of the shunt (n = 1), and bile leak treated by a covered stent (n = 1). Median follow-up was 592 days (range 28-2482 days). Rebleeding occurred in 6 patients. In 2 cases rebleeding was observed despite a post-TIPS portacaval gradient lower than 12 mmHg and was controlled by variceal embolization; 1 patient underwent surgical portacaval shunt and never rebled; in 3 patients rebleeding was related to TIPS stenosis and treated with shunt dilatation with addition of a new stent. The cumulative rate of rebleeding was 23% and 31% at 1 and 2 years, respectively. One- and 2-year survival rates were 80% and 76%, respectively. CONCLUSION The present series demonstrates that bleeding from ectopic varices, a challenging clinical problem, can be managed safely by TIPS placement with low rebleeding and good survival rates.
Collapse
Affiliation(s)
- V Vidal
- Department of Radiology, CHUM - Saint-Luc Hospital, 1058, Saint-Denis Street, Montréal, QC, H2X 3J4, Canada
| | | | | | | | | | | |
Collapse
|