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Liu J, Wang P, Wang LM, Guo J, Zhong N. Outcomes of endoscopic sclerotherapy for jejunal varices at the site of choledochojejunostomy (with video): Three case reports. World J Gastroenterol 2024; 30:2059-2067. [PMID: 38681128 PMCID: PMC11045488 DOI: 10.3748/wjg.v30.i14.2059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/09/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Hemorrhage associated with varices at the site of choledochojejunostomy is an unusual, difficult to treat, and often fatal manifestation of portal hypertension. So far, no treatment guidelines have been established. CASE SUMMARY We reported three patients with jejunal varices at the site of choledochojejunostomy managed by endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoacrylate injection at our institution between June 2021 and August 2023. We reviewed all patient records, clinical presentation, endoscopic findings and treatment, outcomes and follow-up. Three patients who underwent pancreaticoduodenectomy with a Whipple anastomosis were examined using conventional upper gastrointestinal endoscopy for suspected hemorrhage from the afferent jejunal loop. Varices with stigmata of recent hemorrhage or active hemorrhage were observed around the choledochojejunostomy site in all three patients. Endoscopic injection of lauromacrogol/α-butyl cyanoacrylate was carried out at jejunal varices for all three patients. The bleeding ceased and patency was observed for 26 and 2 months in two patients. In one patient with multiorgan failure and internal environment disturbance, rebleeding occurred 1 month after endoscopic sclerotherapy, and despite a second endoscopic sclerotherapy, repeated episodes of bleeding and multiorgan failure resulted in eventual death. CONCLUSION We conclude that endoscopic sclerotherapy with lauromacrogol/α-butyl cyanoacrylate injection can be an easy, effective, safe and low-cost treatment option for jejunal varicose bleeding at the site of choledochojejunostomy.
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Affiliation(s)
- Jun Liu
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Peng Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Li-Mei Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Jing Guo
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Ning Zhong
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
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2
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Tange Y, Hasegawa N, Sugiyama Y, Endo M, Terasaki M, Yamamoto Y, Ishige K, Fukuda K, Suzuki H, Mizokami Y. Usefulness of argon plasma coagulation for bleeding around hepaticojejunal anastomosis. DEN OPEN 2022; 2:e69. [PMID: 35310759 PMCID: PMC8828236 DOI: 10.1002/deo2.69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/13/2021] [Accepted: 09/26/2021] [Indexed: 06/14/2023]
Abstract
Ectopic varices due to extrahepatic portal vein obstruction (EHO) after hepaticojejunostomy have been previously reported. However, few case reports have described angiodysplasia-like lesions due to EHO around the hepaticojejunal anastomosis because they comprise small vessels in the mucosal surface and cannot be detected by contrast-enhanced computed tomography. Physicians need to insert the endoscope into the long afferent limb to diagnose angiodysplasia-like lesions around the hepaticojejunal anastomosis. Some reports have described that endoscopy stops bleeding from angiodysplasia-like lesions around the hepaticojejunal anastomosis; however, a standard methodology remains to be established. We present three cases of bleeding from an angiodysplasia-like lesion around the hepaticojejunal anastomosis that were successfully treated using argon plasma coagulation (APC) with balloon-assisted enteroscopy. Although one patient died owing to cancer progression 3 months after APC hemostasis, the hemostatic effect persisted for >2 years in the remaining two patients. These results suggest that APC is a good treatment option to stop bleeding from angiodysplasia-like lesions at hepaticojejunal anastomosis.
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Affiliation(s)
- Yoshitaka Tange
- Department of GastroenterologyFaculty of MedicineUniversity of TsukubaIbarakiJapan
| | - Naoyuki Hasegawa
- Department of GastroenterologyFaculty of MedicineUniversity of TsukubaIbarakiJapan
| | - Yutaro Sugiyama
- Department of GastroenterologyFaculty of MedicineUniversity of TsukubaIbarakiJapan
| | - Masato Endo
- Department of GastroenterologyFaculty of MedicineUniversity of TsukubaIbarakiJapan
| | - Masahiko Terasaki
- Department of GastroenterologyFaculty of MedicineUniversity of TsukubaIbarakiJapan
| | - Yoshiyuki Yamamoto
- Department of GastroenterologyFaculty of MedicineUniversity of TsukubaIbarakiJapan
| | - Kazunori Ishige
- Department of GastroenterologyNational Hospital Organization Kasumigaura Medical CenterIbarakiJapan
| | - Kuniaki Fukuda
- Department of GastroenterologyFaculty of MedicineUniversity of TsukubaIbarakiJapan
- Department of GastroenterologyNational Hospital Organization Kasumigaura Medical CenterIbarakiJapan
| | - Hideo Suzuki
- Department of GastroenterologyFaculty of MedicineUniversity of TsukubaIbarakiJapan
| | - Yuji Mizokami
- Department of GastroenterologyFaculty of MedicineUniversity of TsukubaIbarakiJapan
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3
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Tanikawa T, Ishii K, Katsumata R, Urata N, Nishino K, Suehiro M, Kawanaka M, Haruma K, Kawamoto H. Treatment of ectopic variceal bleeding at choledochojejunostomy by endoscopic glue injection therapy with cyanoacrylate: Report of three cases including long‐term outcomes. DEN OPEN 2022; 2:e110. [PMID: 35898592 PMCID: PMC9302350 DOI: 10.1002/deo2.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/26/2022] [Accepted: 03/03/2022] [Indexed: 12/01/2022]
Abstract
Ectopic varices around the choledochojejunostomy site after pancreatoduodenectomy are rare. Diagnosing ectopic varices is difficult but, if untreated or misdiagnosed, the resulting mortality is high. This report describes three cases of ectopic variceal bleeding at the choledochojejunostomy site that were improved by endoscopic glue injection therapy (EGIT) with cyanoacrylate (CA). Case 1 was a 68‐year‐old man admitted to the hospital with hematemesis and melena. Six years prior, the patient underwent a total pancreatectomy for intraductal papillary mucinous adenocarcinoma. We diagnosed ectopic variceal rupture at the choledochojejunostomy site and controlled bleeding by EGIT with alpha‐CA (αCA). Two recurrences of bleeding were improved by EGIT. Case 2 was a 71‐year‐old man admitted to the hospital with melena. Two and a half years prior, the patient underwent pancreatoduodenectomy for pancreatic head adenocarcinoma. We found the red plug on the ectopic varices at the choledochojejunostomy site through endoscopic observation and performed EGIT with αCA. He had no recurrence. Case 3 was a 77‐year‐old woman admitted to the hospital with melena. Eleven years prior, the patient underwent pancreatoduodenectomy for chronic pancreatitis at the pancreatic head. We controlled ectopic variceal bleeding at the choledochojejunostomy site by EGIT with αCA. Seven years after EGIT, ectopic varices could not be identified with an endoscope and there was no recurrence of ectopic bleeding.
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Affiliation(s)
- Tomohiro Tanikawa
- Department of General Internal Medicine 2 Kawasaki Medical School Okayama Japan
| | - Katsunori Ishii
- Department of General Internal Medicine 2 Kawasaki Medical School Okayama Japan
| | - Ryo Katsumata
- Department of General Internal Medicine 2 Kawasaki Medical School Okayama Japan
| | - Noriyo Urata
- Department of General Internal Medicine 2 Kawasaki Medical School Okayama Japan
| | - Ken Nishino
- Department of General Internal Medicine 2 Kawasaki Medical School Okayama Japan
| | - Mitsuhiko Suehiro
- Department of General Internal Medicine 2 Kawasaki Medical School Okayama Japan
| | - Miwa Kawanaka
- Department of General Internal Medicine 2 Kawasaki Medical School Okayama Japan
| | - Ken Haruma
- Department of General Internal Medicine 2 Kawasaki Medical School Okayama Japan
| | - Hirofumi Kawamoto
- Department of General Internal Medicine 2 Kawasaki Medical School Okayama Japan
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4
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You Y, Heo JS, Han IW, Shin SH, Shin SW, Park KB, Cho SK, Hyun D. Long term clinical outcomes of portal vein stenting for symptomatic portal vein stenosis after pancreaticoduodenectomy. Medicine (Baltimore) 2021; 100:e27264. [PMID: 34596122 PMCID: PMC8483817 DOI: 10.1097/md.0000000000027264] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/30/2021] [Indexed: 01/05/2023] Open
Abstract
Gastrointestinal bleeding caused by portal vein (PV) stenosis is serious complication after pancreaticoduodenectomy (PD) The purpose of this study is to reveal the long-term clinical outcomes of PV stenting for symptomatic PV stenosis and risk factors of stent related complication.Fifteen patients who underwent portal vein stenting for symptomatic PV stenosis after PD between 2000 and 2018 were retrospectively reviewed. The whole cohort was divided into 9 patients with benign stenosis group (Group-B) and 6 patients with recurrence group (Group-R).The median follow up period was 17.0 (interquartile range 12.0-38.0) months. The technical success rate and clinical success rate was revealed at 93.3% and 86.7%. The primary patency rate of stents was 79.4% and mean patency period was 14.0 (4.0-28.0) months. There was significant difference in time to stenosis and proportion of anticoagulation treatment between 2 groups [2.0 (1.0-4.0) months vs 18.5 (2.5-50.3) months, P = .035 and 100% vs 50%, P = .044. In univariable analysis, stent diameter was found to have a significant correlation with stent occlusion (P = .036).PV stenting was found to be feasible and safe in the treatment of symptomatic PV stenosis from a long term point of view.
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Affiliation(s)
- Yunghun You
- Department of Surgery, Eulji University School of Medicine, 95, Dunsanseo-ro, Seo-gu, Daejeon, South Korea
| | - Jin Seok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, South Korea
| | - In Woong Han
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, South Korea
| | - Sang Hyun Shin
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, South Korea
| | - Sung Wook Shin
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, South Korea
| | - Kwang Bo Park
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, South Korea
| | - Sung Ki Cho
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, South Korea
| | - Dongho Hyun
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, South Korea
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5
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Solanki S, Jena SS, Das SAP, Yadav A, Mehta NN, Nundy S. Isolated ectopic jejunal varices in a patient with extrahepatic portal vein obstruction - A case report. Int J Surg Case Rep 2021; 86:106299. [PMID: 34419724 PMCID: PMC8379621 DOI: 10.1016/j.ijscr.2021.106299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 01/17/2023] Open
Abstract
Introduction and importance Among the various causes for lower gastrointestinal bleeding, ectopic varices constitute a small chunk. Though rare, these can pose a diagnostic challenge with recurrent bleed leading to multiple admission and blood transfusions. Case presentation A 41-year-old male presented to our department with multiple episodes of melena. On further evaluation with CT angiography, a diagnosis of extrahepatic portal vein obstruction with moderate splenomegaly and ectopic jejunal varix was made. He underwent splenectomy with resection of involved jejunal segment with side to side anastomosis. Clinical discussion The diagnosis of ectopic varices remains elusive in a large number of cases in view of the varied etiology. Various newer endoscopic and imaging modalities can play a diagnostic as well as therapeutic role but this also further complicates the management as there is a lack of substantial guidelines directing the treatment protocol. As a result, we have to resort to a case by case approach for the optimal management in these cases. Conclusion The main modality of management for bleeding ectopic varices is percutaneous or endoscopic. Surgery is reserved for refractory cases, with decompressive shunts combined with segmental resection of involved intestine being at the forefront of surgical options. Ectopic varices are an unusual cause of lower GI bleeding caused by porto-systemic collaterals. Ectopic varices most commonly occur at jejuno-ileum, but duodenal varices are more prone to bleed. The optimal management varies with each case due to paucity of treatment guidelines. Decompressive shunt with splenectomy and segmental resection of intestine effectively prevents rebleeding.
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Affiliation(s)
- Sanket Solanki
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India.
| | - Suvendu Sekhar Jena
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| | - Sri Aurobindo Prasad Das
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| | - Amitabh Yadav
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| | - Naimish N Mehta
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, New Delhi, Delhi 110060, India
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6
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Naidoo SF, Obuch JC. Late Manifestation of Massive Jejunal and Cecal Varices Post Liver and Small Bowel Transplantation in a Patient With Microvillus Inclusion Disease. Cureus 2021; 13:e15884. [PMID: 34327104 PMCID: PMC8304195 DOI: 10.7759/cureus.15884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 11/16/2022] Open
Abstract
We report the case of an 18-year-old male with a medical history of microvillous inclusion disease (MID) and notable surgical history of small bowel, liver, and pancreas transplant who presented with massive jejunal and cecal varices. Endoscopy findings demonstrated a large grape-like cluster, with subsequent CT angiography (CTA) showing other variceal lesions in the cecum. The patient was transferred to the original transplant center for recommended open surgical evaluation and combined interventional radiology (IR) embolization of varices. MID is a rare genetic disorder caused by mutations in the Myosin VB (MYO5B) gene leading to a lack of myosin Vb. Patients subsequently develop liver damage at birth, which necessitates a small bowel/liver transplant in childhood.
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Affiliation(s)
- Shiva F Naidoo
- Internal Medicine, Geisinger Health System, Wilkes-Barre, USA
| | - Joshua C Obuch
- Gastroenterology, Geisinger Health System, Wilkes-Barre, USA
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7
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Takao S, Hirakawa M, Takeishi K, Motomura Y, Sakamoto K, Otsu H, Yonemura Y, Mimori K, Ishigami K. Portal Vein Stenting for Jejunal Variceal Bleeding after Recurrence of Pancreatic Adenocarcinoma: A Case Report and Review of the Literature. INTERVENTIONAL RADIOLOGY 2021; 6:44-50. [PMID: 35909910 PMCID: PMC9327411 DOI: 10.22575/interventionalradiology.2020-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 03/07/2021] [Indexed: 02/07/2023]
Abstract
A 73-year-old woman with portal vein stenosis caused by tumor recurrence after pancreatoduodenectomy was treated with stent placement without embolization of the jejunal varix. Anticoagulation therapy using heparin followed by rivaroxaban was administered after the procedure. She continued to receive systemic chemotherapy as an outpatient. Neither restenosis nor stent thrombosis was observed after 7 months. Based on the presented case and literature review, portal vein stenting is an effective treatment option for jejunal variceal bleeding caused by malignant portal venous stricture after pancreaticoduodenectomy. Antithrombotic therapy following portal venous stenting is required to prevent stent thrombosis in the majority of cases, although it has a risk of inducing recurrent variceal bleeding. Adjunctive jejunal variceal embolization can possibly be omitted in selected cases to obtain sufficient portal-SMV flow reconstruction.
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Affiliation(s)
| | | | | | - Yushi Motomura
- Department of Radiology, Kyushu University Beppu Hospital
| | | | - Hajime Otsu
- Department of Surgery, Kyushu University Beppu Hospital
| | | | - Koshi Mimori
- Department of Surgery, Kyushu University Beppu Hospital
| | - Kousei Ishigami
- Department of Clinical Radiology, Graduate School of Medical Science, Kyushu University
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8
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Wakasugi M, Tsujie M, Goda S, Ohnishi K, Koga C, Tei M, Kawabata R, Hasegawa J. Laparotomy-assisted transcatheter variceal embolization for bleeding jejunal varices formed at the site of choledochojejunostomy: Report of a case and review of the literature. Int J Surg Case Rep 2020; 77:554-559. [PMID: 33395844 PMCID: PMC7701888 DOI: 10.1016/j.ijscr.2020.11.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 11/29/2022] Open
Abstract
Jejunal varices should be included in the differential diagnosis of melena in patients with a bilioenteric anastomosis and portal vein hypertension. Laparotomy-assisted transcatheter variceal embolization is one of the options for the treatment of jejunal varices. A multidisciplinary approach is critical for timely management of the unstable patient with bleeding from jejunal varices.
Introduction Bleeding from jejunal varices formed at the site of a bilioenteric anastomosis due to portal vein hypertension is relatively rare and difficult to treat. Presentation of case An 80-year-old man with melena, slight fever, and abdominal pain was referred to our hospital. He had undergone subtotal stomach-preserving pancreaticoduodenectomy for cancer of the ampulla of Vater six years earlier. Follow-up computed tomography (CT) three years earlier showed occlusion of the extrahepatic portal vein and the growth of collateral flow into the lateral segment of the liver, but there were no signs of recurrence of the cancer of the ampulla of Vater. The patient underwent prophylactic endoscopic variceal ligation for esophageal varices one year earlier. On admission, blood tests showed anemia and elevated liver enzyme and bilirubin levels. Esophagogastroduodenoscopy and colonoscopy failed to identify the site of bleeding. Double-balloon endoscopy showed the dilated blood vessels around the stenotic anastomosis of the choledochojejunostomy. A CT scan was consistent with total occlusion of the portal vein and varices around the choledochojejunostomy site. With a diagnosis of jejunal varices, laparotomy-assisted transcatheter variceal embolization was performed. Double-balloon endoscopy performed one month after laparotomy-assisted transcatheter variceal embolization showed no varices, and dilation of the stenotic anastomosis of the choledochojejunostomy was performed safely. Conclusion Jejunal varices should be included in the differential diagnosis of melena in patients with a previous history of surgery with a bilioenteric anastomosis and portal vein hypertension. Laparotomy-assisted transcatheter variceal embolization is one of the options for the treatment of jejunal varices.
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Affiliation(s)
| | | | - Seiichi Goda
- Department of Diagnostic and Interventional Radiology, Osaka Rosai Hospital, Japan
| | - Kohsaku Ohnishi
- Department of Gastroenterology, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, Osaka, 591-8025, Japan
| | - Chikato Koga
- Department of Surgery, Osaka Rosai Hospital, Japan
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9
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Khan A, Kleive D, Aandahl EM, Fosby B, Line PD, Dorenberg E, Guvåg S, Labori KJ. Portal vein stent placement after hepatobiliary and pancreatic surgery. Langenbecks Arch Surg 2020; 405:657-664. [PMID: 32621087 PMCID: PMC7449988 DOI: 10.1007/s00423-020-01917-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/23/2020] [Indexed: 12/11/2022]
Abstract
Purpose To evaluate the long-term outcomes of percutaneous transhepatic stent placement for portal vein (PV) stenosis after liver transplantation (LT) and hepato-pancreato-biliary (HPB) surgery. Methods Retrospective study of 455 patients who underwent LT and 522 patients who underwent resection of the pancreatic head between June 2011 and February 2016. Technical success, clinical success, patency, and complications were evaluated for both groups. Results A total of 23 patients were confirmed to have postoperative PV stenosis and were treated with percutaneous transhepatic PV stent placement. The technical success rate was 100%, the clinical success rate was 80%, and the long-term stent patency was 91.3% for the entire study population. Two procedure-related hemorrhages and two early stent thromboses occurred in the HPB group while no complications occurred in the LT group. A literature review of selected studies reporting PV stent placement for the treatment of PV stenosis after HPB surgery and LT showed a technical success rate of 78–100%, a clinical success rate of 72–100%, and a long-term patency of 57–100%, whereas the procedure-related complication rate varied from 0–33.3%. Conclusions Percutaneous transhepatic PV stent is a safe and effective treatment for postoperative PV stenosis/occlusion in patients undergoing LT regardless of symptoms. Due to increased risk of complications, the indication for percutaneous PV stent placement after HPB surgery should be limited to patients with clinical symptoms after an individual assessment.
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Affiliation(s)
- Ammar Khan
- Department of Transplantation Medicine, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway. .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Dyre Kleive
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Einar Martin Aandahl
- Department of Transplantation Medicine, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Bjarte Fosby
- Department of Transplantation Medicine, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Pål-Dag Line
- Department of Transplantation Medicine, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Eric Dorenberg
- Department of Radiology, Oslo University Hospital, Oslo, Norway
| | - Steinar Guvåg
- Department of Transplantation Medicine, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway
| | - Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
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Abdalla AO, Abdallah MA, Calvo LA. Successful Treatment of a Case of Ectopic Jejunal Varices with Portal Venous Stenting. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:948-952. [PMID: 31266933 PMCID: PMC6621934 DOI: 10.12659/ajcr.916003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patient: Female, 77 Final Diagnosis: Ectopic variceal bleeding of the jejunum Symptoms: Abdominal pain • hematemesis • melena Medication: — Clinical Procedure: Portal vein stenting Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Abubaker O Abdalla
- Department to Internal Medicine, University of Nevada, School of Medicine, Reno, NV, USA
| | - Mohamed A Abdallah
- Department to Internal Medicine, University of South Dakota, Sioux Falls, SD, USA
| | - Lisa A Calvo
- Department to Internal Medicine, University of Nevada, School of Medicine, Reno, NV, USA
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11
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Kasper P, Schramm C, Jaspers N, Goeser T. Jejunal varices as a rare cause of recurrent gastrointestinal bleeding in a 74-year-old man with extrahepatic portal hypertension after pancreato-biliary surgery. BMJ Case Rep 2019; 12:12/3/e228527. [PMID: 30872345 DOI: 10.1136/bcr-2018-228527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 74-year-old man presented to our hospital with recurrent lower gastrointestinal bleeding. His past medical history was remarkable for a duodenal papilla carcinoma and he underwent a pylorus-preserving pancreaticoduodenectomy 4 years before. During diagnostic work-up a severe portal vein stenosis after surgery and multiple dilated intramural jejunal varices, which formed as collateral pathways could be detected. Based on these findings, the recurrent haemorrhages were considered to be due to repeated rupturing and bleeding of jejunal varices. Therapeutically, the portal vein stenosis was treated with endovascular stent placement leading to a reduction in prestenotic portal pressure. During follow-up no further episodes of gastrointestinal bleeding were observed. Bleeding from jejunal varices is a very rare cause of gastrointestinal haemorrhages and represents a diagnostic and therapeutic challenge. However, it should be considered in differential diagnosis of obscure recurrent gastrointestinal haemorrhages in patients with a history of hepato-pancreato-biliary surgery.
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Affiliation(s)
- Philipp Kasper
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, North Rhine-Westphalia, Germany
| | - Christoph Schramm
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, North Rhine-Westphalia, Germany
| | - Natalie Jaspers
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, North Rhine-Westphalia, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, North Rhine-Westphalia, Germany
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12
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Li M, Li Q, Lei Q, Hu J, Wang F, Chen H, Zhen Z. Unusual bleeding from hepaticojejunostomy controlled by side-to-side splenorenal shunt: A case report. Medicine (Baltimore) 2018; 97:e11784. [PMID: 30095636 PMCID: PMC6133541 DOI: 10.1097/md.0000000000011784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
RATIONALE Ectopic variceal bleeding due to hepaticojejunostomy (HJ) is unusual and difficult to manage. Reports on the use of side-to-side splenorenal shunt for severe bleeding from varices at HJ anastomosis are lacking. PATIENT CONCERNS A 43-year-old man was admitted to our hospital with repeated episodes of hematemesis. He has a history of right hemihepatectomy with HJ reconstruction to the left hepatic duct for hilar cholangiocarcinoma. Two years after surgery, he presented with repeated episodes of hematemesis and underwent blood transfusion. DIAGNOSES Imaging tests and endoscopic investigation failed to identify the bleeding source. When conservative management failed to control his bleeding, he underwent emergency laparotomy, which revealed hemorrhage from ectopic varices at the HJ anastomosis. INTERVENTIONS To arrest the bleeding, a side-to-side venovenal anastomosis was created between the splenic and left renal veins to form a shunt for decompression of the varices at the HJ anastomosis. OUTCOMES After the surgery, the patient's symptoms ceased, and a no bleeding in the digestive tract was noted at 2-year follow-up. LESSONS The present patient is the first reported case of unusual bleeding from HJ controlled by a side-to-side splenorenal shunt. We believe this approach is a useful and effective surgical treatment for severe bleeding from varices at the HJ anastomosis.
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Sakamoto T, Arai Y, Morimoto M, Amisaki M, Tokuyasu N, Honjo S, Ashida K, Saito H, Yata S, Ohuchi Y, Fujiwara Y. Portal Vein Stenting for Portal Vein Stenosis After Pancreatoduodenectomy: A Case Report. Yonago Acta Med 2018. [DOI: 10.33160/yam.2018.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Teruhisa Sakamoto
- *Division of Surgical Oncology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
| | - Yosuke Arai
- *Division of Surgical Oncology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
| | - Masaki Morimoto
- *Division of Surgical Oncology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
| | - Masataka Amisaki
- *Division of Surgical Oncology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
| | - Naruo Tokuyasu
- *Division of Surgical Oncology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
| | - Soichiro Honjo
- *Division of Surgical Oncology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
| | - Keigo Ashida
- *Division of Surgical Oncology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
| | - Hiroaki Saito
- *Division of Surgical Oncology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
| | - Shinsaku Yata
- †Division of Radiology, Department of Pathophysiological and Therapeutic Science, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
| | - Yasufumi Ohuchi
- †Division of Radiology, Department of Pathophysiological and Therapeutic Science, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
| | - Yoshiyuki Fujiwara
- *Division of Surgical Oncology, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago 683-8504, Japan
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Hyun D, Park KB, Cho SK, Park HS, Shin SW, Choo SW, Do YS, Choo IW, Choi DW. Portal Vein Stenting for Delayed Jejunal Varix Bleeding Associated with Portal Venous Occlusion after Hepatobiliary and Pancreatic Surgery. Korean J Radiol 2017; 18:828-834. [PMID: 28860900 PMCID: PMC5552466 DOI: 10.3348/kjr.2017.18.5.828] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 01/08/2017] [Indexed: 12/14/2022] Open
Abstract
Objective The study aimed to describe portal stenting for postoperative portal occlusion with delayed (≥ 3 months) variceal bleeding in the afferent jejunal loop. Materials and Methods Eleven consecutive patients (age range, 2–79 years; eight men and three women) who underwent portal stenting between April 2009 and December 2015 were included in the study. Preoperative medical history and the postoperative clinical course were reviewed. Characteristics of portal occlusion and details of procedures were also investigated. Technical success, treatment efficacy (defined as disappearance of jejunal varix on follow-up CT), and clinical success were analyzed. Primary stent patency rate was plotted using the Kaplan-Meier method. Results All patients underwent hepatobiliary-pancreatic cancer surgery except two children with liver transplantation for biliary atresia. Portal occlusion was caused by benign postoperative change (n = 6) and local tumor recurrence (n = 5). Variceal bleeding occurred at 27 months (4 to 72 months) and portal stenting was performed at 37 months (4 to 121 months), on average, postoperatively. Technical success, treatment efficacy, and clinical success rates were 90.9, 100, and 81.8%, respectively. The primary patency rate of portal stent was 88.9% during the mean follow-up period of 9 months. Neither procedure-related complication nor mortality occurred. Conclusion Interventional portal stenting is an effective treatment for delayed jejunal variceal bleeding due to portal occlusion after hepatobiliary-pancreatic surgery.
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Affiliation(s)
- Dongho Hyun
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Kwang Bo Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Sung Ki Cho
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Hong Suk Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Sung Wook Shin
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Sung Wook Choo
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Young Soo Do
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - In Wook Choo
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Dong Wook Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
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15
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Shim DJ, Shin JH, Ko GY, Kim Y, Han K, Gwon DI, Ko HK. Portal vein stent placement with or without varix embolization of jejunal variceal bleeding after hepatopancreatobiliary surgery. Acta Radiol 2017; 58:423-429. [PMID: 27307028 DOI: 10.1177/0284185116654329] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Extrahepatic portal hypertension after surgery involving the duodenum or jejunum might result in massive ectopic variceal bleeding. Purpose To report the results of portal vein stent placement with the addition of variceal embolization. Material and Methods Between January 2000 and June 2015, portal vein stent placement was attempted in 477 patients. Of these, 22 patients (age, 63 ± 10 years) with jejunal variceal bleeding caused by portal vein obstruction after surgery were included in this study. Computed tomography (CT) findings before and after treatment and the rates of technical and clinical success, complications, and clinical outcomes were retrospectively evaluated. Results Stent placement was successful in 19 of 22 patients. Additional variceal embolization was performed in five cases. Clinical success, defined as the cessation of bleeding without recurrence within 1 month, was achieved in 18 of 19 patients with technical success. One patient developed recurrent bleeding 4 days after stent placement and was successfully treated with additional variceal embolization. There were no procedure-related complications. A regression of the jejunal varices was noted in 14 of 19 patients on follow-up CT scans. During the follow-up period (258 days; range, 7-1196 days), stent occlusion and recurrent bleeding occurred in six and four patients, respectively, of the 19 patients who achieved technical success. Statistical analyses revealed no significant differences regarding stent patency between benign and malignant strictures. Conclusion Percutaneous, transhepatic, portal vein stent placement with or without jejunal variceal embolization appears to be a safe and effective treatment for jejunal variceal bleeding after surgery.
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Affiliation(s)
- Dong Jae Shim
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Gi-Young Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Yook Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Kichang Han
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Dong-Il Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Heung-Kyu Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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16
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Shim DJ, Shin JH. Management of jejunal bleeding by jejunal variceal embolization and portal venous recanalization after pylorus-preserving pancreaticoduodenectomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2015. [DOI: 10.18528/gii1150002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Dong Jae Shim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Yoshimatsu R, Yamagami T, Ishikawa M, Kajiwara K, Kakizawa H, Hiyama E, Tashiro H, Murakami Y, Ohge H, Awai K. Embolization therapy for bleeding from jejunal loop varices due to extrahepatic portal vein obstruction. MINIM INVASIV THER 2015; 25:57-61. [PMID: 26330264 DOI: 10.3109/13645706.2015.1075557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Four patients underwent embolization therapy for hemorrhage from varices in the jejunal loop after choledochojejunostomy existing in hepatopetal collateral veins due to chronic extrahepatic portal vein obstruction through the afferent veins using microcoils and/or n-butyl cyanoacrylate. In all four patients, all afferent veins were successfully embolized and successful hemostasis was achieved without liver dysfunction. However, recurrence of the varices and rebleeding occurred within a year in two patients. Embolization for hemorrhage from varices in the jejunal loop after choledochojejunostomy through afferent veins is acceptable in terms of safety and is useful to achieve hemostasis in emergency circumstances.
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Affiliation(s)
- Rika Yoshimatsu
- a 1 Department of Diagnostic Radiology, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan.,b 2 Department of Radiology, Kochi University , Kochi, Japan
| | - Takuji Yamagami
- a 1 Department of Diagnostic Radiology, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan.,b 2 Department of Radiology, Kochi University , Kochi, Japan
| | - Masaki Ishikawa
- a 1 Department of Diagnostic Radiology, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan
| | - Kenji Kajiwara
- a 1 Department of Diagnostic Radiology, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan
| | - Hideaki Kakizawa
- c 3 Department of Radiology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital , Hiroshima, Japan
| | - Eiso Hiyama
- d 4 Department of Pediatric Surgery, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan
| | - Hirotaka Tashiro
- e 5 Department of Surgery, Division of Frontier Medical Science, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan
| | - Yoshiaki Murakami
- f 6 Department of Surgery, Division of Clinical Medical Science, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan
| | - Hiroki Ohge
- g 7 Department of Surgery, Division of Colon and Rectal Surgery, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan
| | - Kazuo Awai
- a 1 Department of Diagnostic Radiology, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan
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Sato T. Treatment of ectopic varices with portal hypertension. World J Hepatol 2015; 7:1601-1605. [PMID: 26140080 PMCID: PMC4483542 DOI: 10.4254/wjh.v7.i12.1601] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 02/21/2015] [Accepted: 04/14/2015] [Indexed: 02/06/2023] Open
Abstract
Ectopic varices are unusual with portal hypertension and can involve any site along the digestive tract outside the gastroesophageal region. Hemorrhage from ectopic varices generally are massive and life threatening. Diagnosis of ectopic varices is difficult and subsequent treatment is also difficult; the optimal treatment has not been established. Recently, interventional radiology and endoscopic treatments have been carried out successfully for hemorrhage from ectopic varices.
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Mizuno T, Ebata T, Yokoyama Y, Igami T, Sugawara G, Mori Y, Suzuki K, Nagino M. Percutaneous transhepatic portal vein stenting for malignant portal vein stenosis secondary to recurrent perihilar biliary cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:740-5. [PMID: 26084448 DOI: 10.1002/jhbp.265] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 05/07/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND Transhepatic portal vein (PV) stenting has been shown to be one of the most important treatments for patients with PV stenosis caused by hepatopancreatobiliary malignancy. METHODS Ten consecutive patients with PV stenosis caused by the recurrence of a perihilar biliary malignancy underwent transhepatic PV stenting. A self-expandable metallic stent was deployed at the stenosis site. The patients were retrospectively analyzed with regard to the procedure, complications, and survival after the stent placement. RESULTS The median interval between the primary resection and the PV stenting was 22 months. The initial hepatic resection was a left trisectionectomy with caudate lobectomy in seven patients, a left hepatectomy with caudate lobectomy in one patient, a right anterior sectionectomy with caudate lobectomy following a left hepatectomy in one patient and a partial liver resection in one patient. The angle of the PV around the stenosis was greater in the patients with PV stenosis located in the right posterior PV. Eight patients with successful PV stent placement were able to receive anticancer treatment, with a median survival of 14 months. The remaining two patients without successful PV stent placement survived less than 6 months. CONCLUSIONS Portal vein stenting might offer relief from the symptoms associated with PV hypertension and the opportunity for sustainable anticancer therapy in patients with recurrent perihilar biliary malignancy.
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Affiliation(s)
- Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Gen Sugawara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yoshine Mori
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kojiro Suzuki
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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20
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Abstract
BACKGROUND Portal vein (PV) stenosis is a worrisome late complication following pancreaticoduodenectomy (PD) that causes intestinal bleeding from varices, which must be diagnosed correctly and treated promptly. Recent reports advocate the usefulness of stent placement to improve PV stenosis. METHODS We evaluated the cause, diagnosis, and treatment method of PV stenosis after PD and the duration of stent patency in our institution. RESULTS Intestinal bleeding caused by PV stenosis occurred in 5 (2.4%) of 205 patients. A computed tomography scan was useful to diagnose this complication. Four of 5 patients with PV stenosis underwent percutaneous transhepatic PV stent placement. The duration of stent patency was 21-41 months, and no rebleeding occurred. CONCLUSIONS Percutaneous stent placement is viable, less invasive option than laparotomy for the management of PV stenosis after PD.
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21
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Portal vein stenting to treat portal vein stenosis in a patient with malignant tumor and gastrointestinal bleeding. Int Surg 2015; 99:91-5. [PMID: 24444277 DOI: 10.9738/intsurg-d-13-00128.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
This report describes the successful use of portal venous stent placement for a patient with recurrent melena secondary to jejunal varices that developed after subtotal stomach preserved pancreatoduodenectomy (SSPPD). A 67-year-old man was admitted to our hospital with tarry stool and severe anemia at 2 years after SSPPD for carcinoma of the head of the pancreas. Abdominal computed tomography examination showed severe stenosis of the extrahepatic portal vein caused by local recurrence and showed an intensely enhanced jejunal wall at the choledochojejunostomy. Gastrointestinal bleeding scintigraphy also revealed active bleeding near the choledochojejunostomy. Based on these findings, jejunal varices resulting from portal vein stenosis were suspected as the cause of the melena. Portal vein stenting and balloon dilation was performed via the ileocecal vein after laparotomy. Coiling of the jejunal varices and sclerotherapy of the dilate postgastric vein with 5% ethanolamine oleate with iopamidol was performed. After portal stent placement, the patient was able to lead a normal life without gastrointestinal hemorrhage. However, he died 7 months later due to liver metastasis.
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22
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Unusual bleeding from hepaticojejunostomy controlled by adult variable stiffness colonoscopy: report of a case and literature review. Int Surg 2014; 99:584-9. [PMID: 25216425 DOI: 10.9738/intsurg-d-13-00126.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
We herein present a case of a 59-year-old man who had undergone pylorus preserving pancreaticoduodenectomy with regional lymph node dissection prior to episodes of melena. Series of conventional endoscopic investigations failed to identify the bleeding source. Enhanced computed tomography scan revealed complete obstruction of the main portal vein with numerous collateral veins running towards the hepatic hilus. Comprehensively, hemorrhage from the jejunal varices caused by postoperative portal hypertension was highly suspected. As the jejunal loop was out of reach, adult variable-stiffness colonoscope (AVSC) was utilized to solve the Roux-en-Y anatomy. Numerous telangiectasis and small varices at hepaticojejunostomy were observed and in the mean time, bleeding was noticed and endoclips were placed without any delay. Ectopic variceal bleeding in jejunal loop after pancreaticoduodenectomy is difficult to manage. We believe that AVSC is an alternative device when specialized jejunal endoscopy is not available.
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23
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Haq TU, Alqamari N, Sayani R, Hilal K. Successful percutaneous angioembolisation of bleeding jejunal varix by acrylate glue and coils. BMJ Case Rep 2013; 2013:bcr-2013-201874. [PMID: 24158303 DOI: 10.1136/bcr-2013-201874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Portal hypertension is a common disease worldwide. One of its rare complications is bleeding jejunal varices which is usually asymptomatic and may present with gastrointestinal bleeding. We present a case of a jejunal bleeding that was successfully embolised with acrylate glue and embolisation coils. A middle-aged woman with a history of multiple abdominal surgeries for adenocarcinoma of right ovary, presented to us with multiple episodes of haematochezia. On a CT scan of the abdomen, she was diagnosed with chronic liver disease with portal hypertension, multiple varices at porto-systemic anastomosis and ectopic jejunal varix. She was treated by interventional radiologists by percutaneous embolisation of bleeding varix using glue and embolisation coils through a portal venous approach.
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Affiliation(s)
- Tanveer Ul Haq
- Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan
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24
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Zhou ZQ, Lee JH, Song KB, Hwang JW, Kim SC, Lee YJ, Park KM. Clinical usefulness of portal venous stent in hepatobiliary pancreatic cancers. ANZ J Surg 2013; 84:346-52. [PMID: 23421858 DOI: 10.1111/ans.12046] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2012] [Indexed: 01/26/2023]
Abstract
BACKGROUND Treatment options for patients with portal vein (PV) stenosis or occlusion after surgery are limited. The purpose of this study was to investigate the efficacy and safety of PV stent placement in patients with portal vein occlusion or stenosis after radical operation for hepatobiliary pancreatic malignant tumour. METHODS We retrospectively reviewed the records of 59 patients who underwent portal venous stent placement at the Asan Medical Center, Seoul, Korea, for PV stenosis or occlusion between February 2008 and February 2012. RESULTS Stents were placed in the portal venous system across stenotic (n = 47) and occlusive (n = 12) lesions after percutaneous transhepatic portography. Reasons for stent placement were tumour recurrence (n = 30), portal vein resection and anastomosis (n = 18) and post-operative inflammatory changes (n = 11). Pressure gradients (superior mesenteric vein, main PV) decreased immediately after stent placement, from 10.5 mm Hg ± 4.4 (standard deviation) to 2.5 mm Hg ± 2.6 (P < 0.0001). Liver function was improved post-stenting (P < 0.05). The median time between the original surgery and stent placement was 16 (1-137) days in the vascular-orientated group and 306 (13-3703) days in the tumour recurrence group (P < 0.0001). Transient fever developed in 11 patients, but resolved in 2-5 days. Stents were occluded in 15 of the 59 patients (25.4%). CONCLUSION PV stent placement is a safe choice, has an acceptable success rate and provides marked relief from portal hypertension due to portal vein occlusion or stenosis after hepatobiliary pancreatic surgery. Liver function data are also improved after portal venous stent placement.
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Affiliation(s)
- Zun Qiang Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Saeki Y, Ide K, Kakizawa H, Ishikawa M, Tashiro H, Ohdan H. Controlling the bleeding of jejunal varices formed at the site of choledochojejunostomy: report of 2 cases and a review of the literature. Surg Today 2012; 43:550-5. [PMID: 22777133 DOI: 10.1007/s00595-012-0243-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2011] [Accepted: 01/15/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Hemorrhage from jejunal varices formed at the site of Roux-en-Y choledochojejunostomy is rather rare, and no guidelines have so far been established for its treatment. This report presents the cases of 2 patients with jejunal varices formed at the site of choledochojejunostomy that were treated using different methods. An obstruction of the extrahepatic portal vein resulted in massive gastrointestinal bleeding in both cases CASE 1: A 59-year-old male developed jejunal varices at the site of choledochojejunostomy. Multidetector computed tomography showed that the source of bleeding was located in the small intestine near portojejunal varices. The jejunal vein supplying the afferent loop was embolized using interventional radiology. There was no evidence of liver dysfunction or rebleeding after the embolization CASE 2: A 79-year-old female developed jejunal varices at the site of choledochojejunostomy. Abdominal angiography could not detect the source of bleeding, and hence, a mesocaval shunt operation was performed.
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Affiliation(s)
- Yoshihiro Saeki
- Department of Surgery, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi Minami-ku, Hiroshima 734-8551, Japan
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Koo SM, Jeong SW, Jang JY, Lee TH, Jeon SR, Kim HG, Kim JO, Kim YJ. Jejunal variceal bleeding successfully treated with percutaneous coil embolization. J Korean Med Sci 2012; 27:321-4. [PMID: 22379346 PMCID: PMC3286782 DOI: 10.3346/jkms.2012.27.3.321] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 11/04/2011] [Indexed: 12/17/2022] Open
Abstract
A 52-yr-old male with alcoholic liver cirrhosis was hospitalized for hematochezia. He had undergone small-bowel resection due to trauma 15 yr previously. Esophagogastroduodenoscopy showed grade 1 esophageal varices without bleeding. No bleeding lesion was seen on colonoscopy, but capsule endoscopy showed suspicious bleeding from angiodysplasia in the small bowel. After 2 weeks of conservative treatment, the hematochezia stopped. However, 1 week later, the patient was re-admitted with hematochezia and a hemoglobin level of 5.5 g/dL. Capsule endoscopy was performed again and showed active bleeding in the mid-jejunum. Abdominal computed tomography revealed a varix in the jejunal branch of the superior mesenteric vein. A direct portogram performed via the transhepatic route showed portosystemic collaterals at the distal jejunum. The patient underwent coil embolization of the superior mesenteric vein just above the portosystemic collaterals and was subsequently discharged without re-bleeding. At 8 months after discharge, his condition has remained stable, without further bleeding episodes.
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Affiliation(s)
- So My Koo
- Institute for Digestive Research and Digestive Disease Center, Department of Gastroenterology, Soonchunhyang University Hospital, Seoul, Korea
| | - Soung Won Jeong
- Institute for Digestive Research and Digestive Disease Center, Department of Gastroenterology, Soonchunhyang University Hospital, Seoul, Korea
| | - Jae Young Jang
- Institute for Digestive Research and Digestive Disease Center, Department of Gastroenterology, Soonchunhyang University Hospital, Seoul, Korea
| | - Tae Hee Lee
- Institute for Digestive Research and Digestive Disease Center, Department of Gastroenterology, Soonchunhyang University Hospital, Seoul, Korea
| | - Seong Ran Jeon
- Institute for Digestive Research and Digestive Disease Center, Department of Gastroenterology, Soonchunhyang University Hospital, Seoul, Korea
| | - Hyun Gun Kim
- Institute for Digestive Research and Digestive Disease Center, Department of Gastroenterology, Soonchunhyang University Hospital, Seoul, Korea
| | - Jin Oh Kim
- Institute for Digestive Research and Digestive Disease Center, Department of Gastroenterology, Soonchunhyang University Hospital, Seoul, Korea
| | - Yong Jae Kim
- Institute for Digestive Research and Digestive Disease Center, Department of Radiology, Soonchunhyang University Hospital, Seoul, Korea
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27
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Lee SD, Park SJ, Kim HB, Han SS, Kim SH, You TS, Kim YK, Cho SY, Lee SA, Ko YH, Hong EK. Jejunal varix bleeding with extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy: report of two cases. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2012; 16:37-42. [PMID: 26388904 PMCID: PMC4575013 DOI: 10.14701/kjhbps.2012.16.1.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Revised: 09/28/2011] [Accepted: 09/30/2011] [Indexed: 11/17/2022]
Abstract
We present 2 patients showing afferent jejunal varix bleeding around hepaticojejunostomy caused by extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy (PPPD). The case 1 was a 58-year-old woman who had recurrent anemia and hematochezia 3 years after undergoing PPPD. On the portography, the main portal vein was obliterated and collaterals around hepaticojejunostomy were developed. After percutaneous transhepatic balloon dilatation and stent placement through the obliterated portal vein, jejunal varices had disappeared and thereafter no bleeding occurred for 32 months. The case 2 was a 71-year-old man who had frequent melena 7 years after PPPD. Portal stent insertion was first tried, but failed due to severe stenosis of the main portal vein. Therefore, meso-caval shunt operation was attempted in order to reduce the variceal flow. Although an episode of a small amount of melena occurred one month after the shunt operation, there was no occurrence of bleeding for the next 8 months. For the treatment of jejunal varices, a less invasive approach, such as the angiographic intervention of stent insertion, balloon dilatation, or embolization is recommended first. Surgical operations, such as a shunt or resection of the jejunal rim, could be considered when noninvasive approaches have failed.
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Affiliation(s)
- Seung Duk Lee
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Sang-Jae Park
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Hyun Boem Kim
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Sung-Sik Han
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Seong Hoon Kim
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Tae Suk You
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Young-Kyu Kim
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Seong Yeon Cho
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Soon-Ae Lee
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Young Hwan Ko
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Eun Kyung Hong
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
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Kyriazanos ID, Tsoukalos GG, Papageorgiou G, Verigos KE, Miliadis L, Stoidis CN. Local recurrence of pancreatic cancer after primary surgical intervention: how to deal with this devastating scenario? Surg Oncol 2011; 20:e133-42. [PMID: 21576013 DOI: 10.1016/j.suronc.2011.04.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 04/13/2011] [Accepted: 04/18/2011] [Indexed: 02/08/2023]
Abstract
The dismal prognosis of pancreatic cancer reflects into the increased recurrence rate, even after R0 pancreaticoduodenectomy. Although, conventional radiation-, chemo- or surgical therapy in much selected cases, seem to work out favorably long term, less invasive and non-toxic methods with more immediate results are always preferred, concerning the already aggravated status of this group of patients. We present hereby a comprehensive review of the literature concerning the treatment of recurrent pancreatic cancer based on the case of a patient who 20 months after a pancreaticoduodenectomy developed portal hypertension and symptomatic first degree esophageal, gastric and mesenteric varices, caused by the nearly complete splenic vein obstruction at the portal vein confluence. The varices were revascularized by a percutaneous transhepatic placement of an endovascular stent into the splenic vein, along with a sequent stereotactic body radiation therapy for the local tumor control. Thanks to the accuracy and safety of the present combined treatment, the patient one year later presents control of the disease and its complications. Our paper is the first in the international literature that tries to review all the treatment modalities available (surgical, adjuvant, neoadjuvant and palliative therapy) and their efficacy, concerning the locally recurrent pancreatic cancer; furthermore, we tried to analyze the application of the above mentioned combined therapeutic approach in similar cases, elucidating simultaneously all the questions that arise. The limited existing data in the international literature and the lack of randomized controlled trials make this effort difficult, but the physician should be aware after all of all the available and innovative treatment modalities, before he chooses one. Finally, we would like to emphasize the fact that not only the local control but also the management of the complications are important for a prolonged median survival and a better quality of life after all.
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Affiliation(s)
- Ioannis D Kyriazanos
- Department of Surgery, Athens Navy Hospital, 70 Deinokratous str., 11521 Athens, Greece.
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29
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Sato T, Akaike J, Toyota J, Karino Y, Ohmura T. Clinicopathological features and treatment of ectopic varices with portal hypertension. Int J Hepatol 2011; 2011:960720. [PMID: 21994879 PMCID: PMC3170857 DOI: 10.4061/2011/960720] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Accepted: 05/12/2011] [Indexed: 12/12/2022] Open
Abstract
Bleeding from ectopic varices, which is rare in patients with portal hypertension, is generally massive and life-threatening. Forty-three patients were hospitalized in our ward for gastrointestinal bleeding from ectopic varices. The frequency of ectopic varices was 43/1218 (3.5%) among portal hypertensive patients in our ward. The locations of the ectopic varices were rectal in thirty-two, duodenal in three, intestinal in two, vesical in three, stomal in one, and colonic in two patients. Endoscopic or interventional radiologic treatment was performed successfully for ectopic varices. Hemorrhage from ectopic varices should be kept in mind in patients with portal hypertension presenting with lower gastrointestinal bleeding.
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Affiliation(s)
- Takahiro Sato
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan,*Takahiro Sato:
| | - Jun Akaike
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Jouji Toyota
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Yoshiyasu Karino
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Takumi Ohmura
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
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Sasamoto A, Kamiya J, Nimura Y, Nagino M. Successful embolization therapy for bleeding from jejunal varices after choledochojejunostomy: report of a case. Surg Today 2010. [PMID: 20676866 DOI: 10.1007/s00595-009-4149-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We report a case of successful embolization of jejunal varices that were the cause of massive gastrointestinal bleeding from a choledochojejunostomy site, resulting from obstruction of the extrahepatic portal vein. A 42-year-old man who had undergone choledochojejunostomy for intrahepatic and choledochal stones was readmitted after he started passing massive dark bloody stools. Gastrointestinal endoscopic examination and angiography could not identify the source of bleeding. Percutaneous transhepatic portography showed obstruction of the right branches of the portal vein. The formation of jejunal varices at the site of choledochojejunostomy was revealed by portography and by cholangioscopy, suggesting the varices as the cause of massive bleeding. Bleeding could not be controlled long-term by cholangioscopic sclerosing therapy. We finally stopped the bleeding by embolizing a jejunal vein to the afferent loop.
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Affiliation(s)
- Akitoshi Sasamoto
- Department of Surgery, Shizuoka Kosei Hospital, 23 Kitaban-cho, Aoi-ku, Shizuoka, 420-8623, Japan
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Sasamoto A, Kamiya J, Nimura Y, Nagino M. Successful embolization therapy for bleeding from jejunal varices after choledochojejunostomy: report of a case. Surg Today 2010; 40:788-91. [PMID: 20676866 DOI: 10.1007/s00595-009-4129-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Accepted: 06/16/2009] [Indexed: 02/06/2023]
Abstract
We report a case of successful embolization of jejunal varices that were the cause of massive gastrointestinal bleeding from a choledochojejunostomy site, resulting from obstruction of the extrahepatic portal vein. A 42-year-old man who had undergone choledochojejunostomy for intrahepatic and choledochal stones was readmitted after he started passing massive dark bloody stools. Gastrointestinal endoscopic examination and angiography could not identify the source of bleeding. Percutaneous transhepatic portography showed obstruction of the right branches of the portal vein. The formation of jejunal varices at the site of choledochojejunostomy was revealed by portography and by cholangioscopy, suggesting the varices as the cause of massive bleeding. Bleeding could not be controlled long-term by cholangioscopic sclerosing therapy. We finally stopped the bleeding by embolizing a jejunal vein to the afferent loop.
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Affiliation(s)
- Akitoshi Sasamoto
- Department of Surgery, Shizuoka Kosei Hospital, 23 Kitaban-cho, Aoi-ku, Shizuoka, 420-8623, Japan
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32
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Hsu YC, Yen HH, Chen YY, Soon MS. Successful endoscopic sclerotherapy for cholecystojejunostomy variceal bleeding in a patient with pancreatic head cancer. World J Gastroenterol 2010; 16:123-5. [PMID: 20039459 PMCID: PMC2799908 DOI: 10.3748/wjg.v16.i1.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Variceal bleeding outside the esophagus and stomach is rare but important because of its difficult diagnosis and treatment. Bleeding from cholecystojejunostomy varices has been reported to be a late complication of palliative biliary surgery for chronic pancreatitis. Such ectopic variceal bleeding has never been reported after palliative surgery for pancreatic cancer, probably because of the limited lifespan of these patients. Herein, we report our successful experience using endoscopic cyanoacrylate sclerotherapy to treat bleeding from cholecystojejunostomy varices in a 57-year-old man with pancreatic head cancer. To our knowledge, this is the first case report in the literature of this rare complication.
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Hoffer EK, Krohmer S, Gemery J, Zaki B, Pipas JM. Endovascular recanalization of symptomatic portomesenteric venous obstruction after pancreaticoduodenectomy and radiation. J Vasc Interv Radiol 2009; 20:1633-7. [PMID: 19854066 DOI: 10.1016/j.jvir.2009.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2009] [Revised: 08/24/2009] [Accepted: 09/01/2009] [Indexed: 01/21/2023] Open
Abstract
Intraoperative radiation therapy (RT) may improve outcomes after pancreaticoduodenectomy for periampullary cancer; however, there is a 20% risk of late portomesenteric venous obstruction. This retrospective study evaluated the percutaneous treatment of portomesenteric venous obstruction that occurred a mean of 10 months after pancreaticoduodenectomy and intraoperative RT. Five patients with medically refractory ascites and portomesenteric obstruction on computed tomographic angiography had successful recanalization with elimination of the pressure gradient and no procedural complications. One patient showed no improvement clinically. Recurrent ascites after stent occlusion was successfully treated in two patients. Percutaneous transhepatic recanalization appears to be a safe and effective therapy in this population.
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Affiliation(s)
- Eric K Hoffer
- Section of Vascular and Interventional Radiology, Dartmouth-Hitchcock Medical Center and Norris Cotton Cancer Center, One Medical Center Drive, Lebanon, NH 03756, USA.
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Novellas S, Denys A, Bize P, Brunner P, Motamedi JP, Gugenheim J, Caroli FX, Chevallier P. Palliative portal vein stent placement in malignant and symptomatic extrinsic portal vein stenosis or occlusion. Cardiovasc Intervent Radiol 2008; 32:462-70. [PMID: 18956224 DOI: 10.1007/s00270-008-9455-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Revised: 09/10/2008] [Accepted: 09/12/2008] [Indexed: 02/07/2023]
Abstract
This article evaluates the results of portal vein (PV) stent placement in patients with malignant extrinsic lesions stenosing or obstructing the PV and causing symptomatic PV hypertension (PVHT). Fourteen patients with bile duct cancer (n = 7), pancreatic adenocarcinoma (n = 4), or another cancer (n = 3) underwent percutaneous transhepatic portal venous stent placement because of gastroesophageal or jejunal varices (n = 9), ascites (n = 7), and/or thrombocytopenia (n = 2). Concurrent tumoral obstruction of the main bile duct was treated via the transhepatic route in the same session in four patients. Changes in portal venous pressure, complications, stent patency, and survival were evaluated. Mean +/- standard deviation (SD) gradient of portal venous pressure decreased significantly immediately after stent placement from 11.2 mmHg +/- 4.6 to 1.1 mmHg +/- 1.0 (P < 0.00001). Three patients had minor complications, and one developed a liver abscess. During a mean +/- SD follow-up of 134.4 +/- 123.3 days, portal stents remained patent in 11 patients (78.6%); stent occlusion occurred in 3 patients, 2 of whom had undergone previous major hepatectomy. After stent placement, PVHT symptoms were relieved in four (57.1%) of seven patients who died (mean survival, 97 +/- 71.2 days), and relieved in six (85.7%) of seven patients still alive at the end of follow-up (mean follow-up, 171.7 +/- 153.5 days). Stent placement in the PV is feasible and relatively safe. It helped to relieve PVHT symptoms in a single session.
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Affiliation(s)
- Sébastien Novellas
- Department of Radiology and Interventional Radiology, Hôpital Archet, 151 route de Saint Antoine de Ginestière, 06202, Nice, France
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Taniguchi H, Moriguchi M, Amaike H, Fuji N, Murayama Y, Kosuga T. Hemorrhage from varices in hepaticojejunostomy in the fifth and tenth year after surgery for hepatic hilar bile duct cancer: a case report. CASES JOURNAL 2008; 1:59. [PMID: 18652705 PMCID: PMC2515292 DOI: 10.1186/1757-1626-1-59] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Accepted: 07/25/2008] [Indexed: 11/21/2022]
Abstract
We report a case of a 64-year-old female patient who underwent a right lobectomy of the liver (including total resection of the caudate lobe), dissection of the group 2 lymph nodes, left hepaticojejunostomy (Roux-en-Y fashion), and reconstruction of the portal vein (end-to-end anastomosis between the main portal vein and the left portal branch) for treatment of hepatic hilar bile duct cancer in 1996. In 2001, the anastomotic site of the hepaticojejunostomy was dissected and re-anastomosed due to gastrointestinal bleeding caused by variceal rupture in the jejunal loop. In 2006, splenectomy was performed for recurrence of gastrointestinal bleeding due to another variceal rupture in the jejunal loop. Portal venography performed perioperatively showed a decrease in portal blood flow into the liver via the jejunal varices and an increase in portal blood flow into the liver via the left gastric vein. She had two jejunal variceal ruptures at five-year intervals after extrahepatic portal obstruction and underwent successful treatments.
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Affiliation(s)
- Hiroki Taniguchi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokohji, Kamigyo-ku, Kyoto 602-8566, Japan.
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Hwang S, Sung KB, Park YH, Jung DH, Lee SG. Portal vein stenting for portal hypertension caused by local recurrence after pancreatoduodenectomy for periampullary cancer. J Gastrointest Surg 2007; 11:333-7. [PMID: 17458607 DOI: 10.1007/s11605-006-0058-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Portal hypertension after extensive abdominal surgery is an unusual cause of repetitive gastrointestinal bleeding. We report on a 68-year-old male patient with intermittent gastrointestinal bleeding secondary to portal vein stenosis caused by local recurrence of the distal bile duct cancer after pancreatoduodenectomy. Severe portal vein stenosis without sufficient development of portal venous collaterals was detected 25 months after pancreatoduodenectomy. Direct portography using a percutaneous transhepatic approach showed that there was a pressure gradient of 18 mmHg across the portal vein stenosis. Portal vein stenting successfully relieved portal hypertension and bowel congestion. Gastrointestinal bleeding episodes ceased after stenting. The patient died from liver metastasis 14 months after stent insertion and 39 months after pancreatoduodenectomy. Based on this case and literature reports, the possibility of portal vein stenosis should be considered for patients who have undergone pancreatoduodenectomy and then showed unexplained gastrointestinal bleeding. Percutaneous transhepatic stent insertion appears to be the treatment of choice for focal portal vein stenosis.
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Affiliation(s)
- Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 138-736, South Korea.
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Ichihara T, Sato T, Miyazawa H, Shibata S, Hashimoto M, Ishiyama K, Yamamoto Y. Stent placement is effective on both postoperative hepatic arterial pseudoaneurysm and subsequent portal vein stricture: A case report. World J Gastroenterol 2007; 13:970-2. [PMID: 17352034 PMCID: PMC4065940 DOI: 10.3748/wjg.v13.i6.970] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
To treat postoperative bleeding after hepato-pancreato-biliary surgery, interventional radiology has become essential. We report a case of coincidental pseudoaneurysm and jejunal varices that were both successfully treated by stent-grafts. After a pancreaticoduodenectomy, the patient developed a pseudoaneurysm in the hepatic artery and a stenosis in its periphery. After establishing hepatic arterial flow by placing stent-grafts over both the pseudoaneurysm and the stenosis, the pseudoaneurysm was embolized with microcoils. Nine months later, the patient developed jejunal varices caused by a severe stricture in the main trunk of the portal vein. Percutaneous transhepatic portography was performed and stent-grafts were placed over the stenotic segment. A venoplasty using stent-grafts normalized the portal blood flow and the jejunal varices vanished. Although stenosis occurred due to scarred tissues from leakage after pancreaticoduodenectomy, stent-grafts were useful for managing jejunal bleeding post-operatively.
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Affiliation(s)
- Toshiaki Ichihara
- Department of Gastroenterological Surgery, Akita University School of Medicine, 1-1-1 Hondo, Akita 010-8543, Japan.
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Hekmat H, Al-toma A, Mallant MPJH, Mulder CJJ, Jacobs MAJM. Endoscopic N-butyl-2-cyanoacrylate (Histoacryl) obliteration of jejunal varices by using the double balloon enteroscope. Gastrointest Endosc 2007; 65:350-2. [PMID: 17259003 DOI: 10.1016/j.gie.2006.07.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2006] [Accepted: 07/02/2006] [Indexed: 02/08/2023]
Affiliation(s)
- Hakim Hekmat
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
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Shan H, Xiao XS, Huang MS, Ouyang Q, Jiang ZB. Portal venous stent placement for treatment of portal hypertension caused by benign main portal vein stenosis. World J Gastroenterol 2005; 11:3315-8. [PMID: 15929192 PMCID: PMC4316073 DOI: 10.3748/wjg.v11.i21.3315] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the value of endovascular stent in the treatment of portal hypertension caused by benign main portal vein stenosis.
METHODS: Portal vein stents were implanted in six patients with benign main portal vein stenosis (inflammatory stenosis in three cases, postprocedure of liver transplantation in another three cases). Changes in portal vein pressure, portal vein patency, relative clinical symptoms, complications, and survival were evaluated.
RESULTS: Six metallic stents were successfully placed across the portal vein stenotic or obstructive lesions in six patients. Mean portal venous pressure decreased significantly after stent implantation from (37.3±4.7) cm H2O to (18.0±1.9) cm H2O. The portal blood flow restored and the symptoms caused by portal hypertension were eliminated. There were no severe procedure-related complications. The patients were followed up for 1-48 mo. The portal vein remained patent during follow-up. All patients survived except for one patient who died of other complications of liver transplantation.
CONCLUSION: Percutaneous portal vein stent placement for the treatment of portal hypertension caused by benign main portal vein stenosis is safe and effective.
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Affiliation(s)
- Hong Shan
- Department of Radiology, Changzheng Hospital of the Second Military Medical University, Shanghai 200433, China.
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40
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Schwartz RS. Taking the stent in vein: interventions in the other half of the vascular tree. Catheter Cardiovasc Interv 2003; 59:63-5. [PMID: 12720243 DOI: 10.1002/ccd.10518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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