Postoperative portal vein thrombosis and gastric hemorrhage associated with late-onset hemorrhage from the common hepatic artery after pancreaticoduodenectomy

Stent placement for benign portal vein stenosis following pancreaticoduodenectomy in a hybrid operating room

Benign portal vein stenosis is a rare complication following pancreaticoduodenectomy. Because a direct surgical approach to the portal vein is difficult due to severe adhesions following pancreaticoduodenectomy, portal vein stent placement is considered a good treatment option. Herein, we report 3 cases of severe portal vein stenosis following pancreaticoduodenectomy that were treated with portal venous stent placement in a hybrid operating room, combining a conventional operating room with an angiography suite. High-resolution images on digital subtraction angiography provide better contrast and support accurate stent placement compared to using a mobile C-arm.

Intrahepatic portal vein thrombosis due to postoperative biliary obstruction successfully treated by a partial thrombectomy combined with thrombolytic drug therapy

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Portal vein thrombosis due to constriction of hepaticojejunostomy is rarely occured, in which increased biliary pressure by obstructive jaundice decreased portal flow.

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Re-anastomosis and postoperative thromolytic therapy recovered occluded portal flow.

Introduction

This case report aims to inform pancreatic surgeons about our perioperative management of intrahepatic portal vein thrombosis caused by an obstruction of hepaticojejunostomy (HJ) after pancreaticoduodenectomy (PD).

Case presentation

A 65-year-old woman was diagnosed with pancreas head carcinoma involving the superior mesenteric vein (SMV). Pancreaticoduodenectomy combined with SMV resection was followed by HJ. Twisting or narrowing was not evident during anastomosis. Total bilirubin values progressively increased to 13 mg/dL on day 5. At that time, we suspected anastomotic occlusion and found complete portal thrombosis of the left liver. Therefore, emergency re-anastomosis of the HJ was followed by thrombectomy, which was not completely successful and did not completely recover initial portal flow. Thrombolytic drugs improved obstructive jaundice, eradicated the organized thrombosis and recovered the portal flow by day 30. The post-operative course was uneventful.

Discussion

A thrombosis immediately formed in the portal vein due to biliary obstruction of an anastomotic site. We speculated that biliary dilation and related inflammation caused a relative increase in arterial flow and decreased portal flow at the localized part of the umbilical portion. Although early surgical thrombectomy was attempted soon after the primary operation, the organized thrombosis persisted. However, thrombolytic therapy eradicated the thrombosis.

Conclusion

Careful anastomosis of HJ during PD was necessary to avoid postoperative biliary stricture. This type of complication affects intrahepatic blood flow, particularly via the portal vein. Although immediate re-anastomosis or thrombectomy is applied, organized thrombosis cannot always be surgically removed.