Portal vein stenting to treat portal vein stenosis in a patient with malignant tumor and gastrointestinal bleeding

Portal vein stenting blocked the inflow tract and completely resolved bile duct varices, formed by cavernous transformation of the portal vein

There is no established treatment for bleeding bile duct varices (BDVs). We report the first case of portal vein (PV) stenting completely eradicating bleeding BDVs. A 70-year-old male with malignant lymphoma developed BDVs due to PV obstruction, which had caused compression and stricture of the distal bile duct. Endoscopic retrograde cholangiography was performed to evaluate the stricture and bleeding from the ruptured BDV was observed. Endoscopic hemostasis was difficult, requiring reopening of the extra-hepatic PV and reducing the blood flow to the BDVs for hemostasis. Therefore, PV stenting was performed. During the procedure, portal angiography confirmed an inflow tract to the BDVs. Therefore, covered stents were placed in the PV and adjusted to block the inflow tract to the BDVs at the distal end. After stenting, the BDVs were successfully blocked and all PV blood flowed through the stent placed in the extra-hepatic PV. Two weeks after stenting, the BDVs had disappeared completely and the bleeding has not recurred for months. We experienced a case in which PV stenting not only reopened an obstructed PV but also successfully occluded the inflow tract. This case demonstrates the potential of PV stenting for the treatment of hemorrhagic BDVs.

Comparison of patency rates and complications with or without antithrombotic therapy following portal vein stent placement after pancreatic surgery: a systematic review and meta-analysis

BACKGROUND

Portal vein stent placement is used for portal vein stenosis. However, reports on postpancreatic surgery cases are rare. Whether antithrombotic therapy should be administered remains controversial. In this paper, the authors reviewed current data to evaluate the influence of antithrombosis on stent patency after pancreatic surgery.

MATERIALS AND METHODS

This systematic review and meta-analysis compared studies in which patients did or did not receive antithrombotic therapy after portal vein stent placement. The authors compared patency after stent placement and complication rate.

RESULTS

There were 22 ( n =207) studies in which patients received antithrombotic therapy and 8 ( n =61) in which patients did not receive therapy. Antithrombotic agents, such as aspirin, clopidogrel, heparin, and warfarin, were used. The overall patency rates were similar between the groups (79.2% in the antithrombosis group vs. 88.0% in the nonantithrombosis group). Subgroup analyses included those for the etiology of stenosis, types of antithrombotic agents, acute or chronic stenosis, and causes of stent stenosis. None revealed a significant difference between the patency rates in the antithrombosis and nonantithrombosis groups. However, bleeding complications only occurred in patients who received antithrombotic therapy.

CONCLUSION

There is no significant benefit of antithrombotic therapy after portal vein stent placement following pancreatic surgery. Antithrombotic therapy should be performed with caution because it may cause complications, such as bleeding.

Outcomes of endoscopic sclerotherapy for jejunal varices at the site of choledochojejunostomy (with video): Three case reports

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.

Disseminated tuberculosis following invasive procedures for peripancreatic lymph node tuberculosis with portal vein obstruction: a case report

Peripancreatic tuberculous lymphadenopathy can mimic pancreatic cancer on imaging. There have only a few reports on varices from portal vein obstruction due to abdominal tuberculous lymphadenopathy. Iatrogenic disseminated tuberculosis is also rare. Herein, we present a rare case of peripancreatic tuberculous lymphadenopathy with ruptured duodenal varices due to portal vein obstruction. The patient presented to our hospital with hematemesis. Computed tomography revealed a peripancreatic mass. Duodenal varices rupture from portal vein obstruction due to pancreatic cancer were initially suspected. The patient underwent portal vein stenting for portal vein obstruction and endoscopic ultrasound-guided fine-needle aspiration for diagnosis, which revealed granulomas indicative of tuberculosis. The patient was discharged once because fine-needle aspiration did not lead to a definitive diagnosis of tuberculosis. Subsequently, he developed disseminated tuberculosis. Peripancreatic tuberculous lymphadenopathy can cause ectopic varices with portal vein obstruction. Tuberculosis should also be included in the differential diagnosis in the case of portal vein obstruction, to facilitate early treatment and avoid unnecessary surgery. Furthermore, fine-needle aspiration or portal vein stenting for tuberculous lesions can cause disseminated tuberculosis. Since a diagnosis might not be made until after several fine-needle aspirations have been conducted, careful follow-up is necessary after the procedure for such lesions.

Superior mesenteric vein to the right testicular vein shunt operation for jejunal varices bleeding associated with extrahepatic portal vein obstruction after pancreaticoduodenectomy: a case report

Background

Causes of extrahepatic portal vein obstruction include abdominal surgeries such as pancreaticoduodenectomy. We improved jejunal variceal bleeding due to extrahepatic portal vein occlusion after pancreaticoduodenectomy, by shunting of the testicular vein.

Case presentation

A 72-year-old man was diagnosed with extrahepatic bile duct cancer and underwent subtotal stomach-preserving pancreaticoduodenectomy 5 years ago. No postoperative complications occurred, adjuvant chemotherapy using gemcitabine hydrochloride was performed, and the patient remained recurrence-free. One year and 6 months post-operation, extrahepatic portal vein stenosis appeared, but no recurrence was noted. However, 4 years and 6 months later, recurrent gastrointestinal bleeding occurred, and the patient was diagnosed with an extrahepatic portal vein obstruction. Double-balloon enteroscopy showed capillary dilatation and varicose veins in the hepaticojejunostomy region, and venous bleeding from collateral blood vessels was diagnosed. A superior mesenteric vein to the right testicular vein shunt operation was performed, following which the gastrointestinal bleeding disappeared, and the anemia improved. Although transient hepatic encephalopathy occurred, conservative treatment relieved it. Double-balloon enteroscopy confirmed the disappearance of abnormal blood vessels.

Conclusions

A portosystemic shunt operation using the right testicular vein effectively relieved refractory variceal bleeding around the hepaticojejunostomy site in the jejunum due to an extrahepatic portal vein obstruction after pancreaticoduodenectomy.

Effect of Stent Placement on Survival in Patients with Malignant Portal Vein Stenosis: A Propensity Score-Matched Study

Objective

Percutaneous portal vein (PV) stent placement can be an effective treatment for symptoms associated with portal hypertension. This study aimed to evaluate the effect of PV stenting on the overall survival (OS) in patients with malignant PV stenosis.

Materials and Methods

Two groups of patients with malignant PV stenosis were compared in this retrospective study involving two institutions. A total of 197 patients who underwent PV stenting between November 2016 and August 2019 were established as the stent group, whereas 29 patients with PV stenosis who were treated conservatively between July 2013 and October 2016 constituted the no-stent group. OS was compared between the two groups before and after propensity score matching (PSM). Risk factors associated with OS were evaluated using the Cox proportional hazards model. Procedure-associated adverse events were also evaluated.

Results

The stent group finally included 100 patients (median age, 65 [interquartile range, 58–71] years; 64 male). The no-stent group included 22 patients (69 [61–75] years, 13 male). Stent placement was successful in 95% of attempted cases, and the 1- and 2-year stent occlusion–free survival rate was 56% (95% confidence interval, 45%–69%) and 44% (32%–60%), respectively. The median stent occlusion–free survival time was 176 (interquartile range, 70–440) days. OS was significantly longer in the stent group than in the no-stent group (median 294 vs. 87 days, p < 0.001 before PSM, p = 0.011 after PSM). The 1- and 3-year OS rates before PSM were 40% and 11%, respectively, in the stent group. The 1-year OS rate after PSM was 32% and 5% in the stent and no-stent groups, respectively. Anemia requiring transfusion (n = 2) and acute thrombosis necessitating re-stenting (n = 1) occurred in three patients in the stent group within 1 week.

Conclusion

Percutaneous placement of a PV stent may be effective in improving OS in patients with malignant PV stenosis.

Portal Vein Stenting for Jejunal Variceal Bleeding after Recurrence of Pancreatic Adenocarcinoma: A Case Report and Review of the Literature

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.

Laparotomy-assisted transcatheter variceal embolization for bleeding jejunal varices formed at the site of choledochojejunostomy: Report of a case and review of the literature

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Jejunal varices should be included in the differential diagnosis of melena in patients with a bilioenteric anastomosis and portal vein hypertension.

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Laparotomy-assisted transcatheter variceal embolization is one of the options for the treatment of jejunal varices.

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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.

A Case of Portal Venous Stenting for Metastatic Hilar Stricture After the Radical Resection of Colon Cancer

Like standard stenting in an unresectable malignant stricture of the biliary or digestive tract, minimally invasive modality for portal stenosis is indispensable for palliation. We describe here a safe and practical procedure of portal stenting in a case of metastatic hilar strictures developed nine years after the radical resection of sigmoid colon cancer. After urgent delivery of the biliary tract stenting for the relief of jaundice, the patient received palliative stenting for the stricture of the portal trunk. Transhepatic approach, via the anterior branch, of the portal vein intervention may fit into the standard aspects for portal stenting.

Bleeding complications after pancreatic surgery: interventional radiology management

Surgical intervention in the pancreas region is complex and carries the risk of complications, also of vascular nature. Bleeding after pancreatic surgery is rare but characterized by high mortality. This review reports epidemiology, classification, diagnosis and treatment strategies of hemorrhage occurring after pancreatic surgery, focusing on the techniques, roles and outcomes of interventional radiology (IR) in this setting. We then describe the roles and techniques of IR in the treatment of other less common types of vascular complications after pancreatic surgery, such as portal vein (PV) stenosis, portal hypertension and bleeding of varices.

Jejunal varices: an unconsidered cause of recurrent gastrointestinal haemorrhage

A 78-year-old woman presented with melaenic stool and severe anaemia 4 years after a pancreaticoduodenectomy for adenocarcinoma of the pancreas. Initial workup revealed haemorrhage from the choledochojejunostomy site. Despite multiple endoscopic clips to the region, bleeding reoccurred multiple times over a period of several months. Due to ongoing haemorrhage, her case was urgently presented at the hospital's multidisciplinary hepatobiliary conference. The contrast-enhanced abdominal CT revealed severe stenosis of the extrahepatic portal vein and large afferent jejunal varices at the choledochojejunostomy, suspected as the cause of her persistent bleed. The recommendation was a percutaneous transhepatic approach for stenting of the portal vein stenosis that resulted in rapid decompression of the jejunal varices and control of her haemorrhage.

Portal Vein Stenting for Delayed Jejunal Varix Bleeding Associated with Portal Venous Occlusion after Hepatobiliary and Pancreatic Surgery

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.

Portal vein stent placement for the treatment of postoperative portal vein stenosis: long-term success and factor associated with stent failure

Background

Portal vein stenosis develops due to different causes including postoperative inflammation and oncological processes. However, limited effective therapy is available for portal vein stenosis. The objectives of this study were to evaluate the efficacy of a portal vein stent for portal vein stenosis after hepatobiliary pancreatic surgery and to determine the factors associated with stent patency.

Methods

From December 2003 to December 2015, portal vein stents were implanted in 29 patients who had portal vein stenosis after hepatobiliary pancreatic surgery. We conducted a retrospective analysis to evaluate the efficacy and safety of portal vein stent placement. Twelve clinical variables were analyzed for their role in stent patency.

Results

The symptoms before portal vein stent placements included nine patients with hepatic encephalopathy, six patients with gastrointestinal bleeding, four patients with ascites, and four patients with hyperbilirubinemia. Portal vein thrombosis due to postoperative portal stenosis was found in four patients. Portal vein stent were successfully implanted without any major complications. Of the 21 patients with symptoms, 17 showed improvement, and stent patency was maintained in 22 (76%) patients. The presence of a collateral vein is the only variable related to the development of an occlusion after portal stenting.

Conclusion

Portal vein stent were implanted safely and had good long-term patency. This procedure is useful to relieve portal hypertension-related symptoms and to improve the quality of life. Our data strongly suggest that embolization to block blood flow in a collateral vein during portal vein stent placement will improve the patency of the stent.

Endovascular Reconstruction of Extrahepatic Portal Vein in Noncirrhotic and Nonmalignant Chronic Portal Vein Thrombosis Secondary to an Iatrogenic Stenotic Lesion

Portal vein (PV) thrombosis (PVT) in the absence of liver disease or thrombophilia is rare. We report a 57-year-old male with a history of stage 3 chronic kidney disease who presented at the emergency department 18 months after abdominal surgery with progressive abdominal pain and distention. Computed tomography revealed PVT with multiple collaterals and moderate ascites. He had undergone partial gastrectomy and gastrojejunal anastomosis at an outside facility for gastrointestinal stromal tumors that caused an iatrogenic stenotic lesion in the PV. The patient underwent balloon angioplasty and endovascular deployment of an 8 mm × 100 mm Viabahn covered stent (W. L. Gore and Associates, Flagstaff, Arizona) in the extrahepatic PV via a transhepatic approach; the device allowed complete restoration of prograde portal flow with clinical improvement. At 6 months from the intervention, he remains symptom-free with normal liver function tests and patent endoprosthesis on antiplatelet therapy.

Stent Placement for Portal Vein Stenosis After Pancreaticoduodenectomy

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.