Colonic varices treated with embolization after pancreatoduodenectomy with portal vein resection: a case report

Abstract

Background: Pancreatoduodenectomy with resection of the portal vein or superior mesenteric vein confluence has been safely performed in patients with pancreatic head cancer associated with infiltration of the portal vein or superior mesenteric vein. In recent years, left-sided portal hypertension, a late postoperative complication, has received focus owing to increased long-term survival with advances in chemotherapy. Left-sided hypertension may sometimes cause fatal gastrointestinal bleeding because of the rupture of gastrointestinal varices. Here, we present a case of colonic varices caused by left-sided portal hypertension after pancreatoduodenectomy with portal vein resection. Case presentation: A 69-year-old man diagnosed with pancreatic head cancer was referred to our department for surgery after undergoing chemotherapy with nine courses of gemcitabine and nab-paclitaxel. Computed tomography showed a mass 25 mm in diameter and in contact with the portal vein. He had undergone subtotal stomachpreserving pancreatoduodenectomy with portal vein resection. Four centimeters of the portal vein had been resected, and end-to-end anastomosis was performed without splenic vein reconstruction. We had to completely resect the right colic vein, accessary right colic vein, and middle colic vein due to tumor invasion. The pathological diagnosis was ypT3, ypN1a, ypM0, and ypStageIIB, and he was administered TS-1 as postoperative adjuvant chemotherapy. Seven months after therapeutic radical surgery, he presented with melena with progressive anemia. Computed tomography revealed transverse colonic varices. He was offered interventional radiology. Trans-splenic arterial splenic venography showed that transverse colonic varices had developed as collateral circulation of the splenic vein and inferior mesenteric vein system. An embolic substance was injected into the transverse colonic varices, which halted the progression of the anemia caused by melena. Fifteen months after therapeutic radical surgery, local recurrence of the tumor occurred; he died 28 months after the surgery. Conclusions: When subtotal stomach-preserving pancreatoduodenectomy with portal vein resection is performed without splenic vein reconstruction, colonic varices may result from left-sided portal hypertension. Interventional radiology is an effective treatment for gastrointestinal bleeding due to colonic varices, but it is important to be observant for colonic necrosis and new varices.

Isolated Colonic Varices in Pancreatic Adenocarcinoma

“…However, it is important to note that colonic varices can also be seen with other diseases that cause portal vein occlusion, such as pancreatic cancer. [6][7][8][9] The gold standard for diagnosis is CT or selective mesenteric angiography, which can also be therapeutic with embolization in some cases. Often, these varices are diagnosed during colonoscopy for evaluation of lower gastrointestinal bleeding.…”

Sinistral Portal Hypertension after Pancreaticoduodenectomy with Splenic Vein Resection: Pathogenesis and Its Prevention

“…Splenectomy or splenic arterial embolization has been conventionally employed for gastric varices after SV occlusion [ 45 , 46 , 47 , 48 ], and recently, SV stenting has also been introduced as a safe and effective treatment for SPH-related gastrointestinal bleeding [ 49 ]. Similarly, several treatments combatting gastrointestinal bleeding for SPH after PD with PMSC resection have been reported [ 11 , 13 , 16 , 17 , 18 , 19 , 29 , 30 , 32 , 33 , 37 ]. At the point of determining the appropriate treatment, it is important to recognize the number of developed varicose veins and the location of the bleeding.…”

“…Some studies indicated no gastrointestinal bleeding even after the incidence of varicose formation [ 10 , 14 , 18 , 21 , 26 , 27 , 28 ], but others reported the incidence of severe variceal bleeding [ 4 , 5 , 6 , 7 , 8 , 9 , 11 , 13 , 17 , 19 , 24 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ]. This difference may be due to the dedicated adjustment of SV pressure by collateral routes from the spleen.…”

“…Either endoscopic variceal ligation or endoscopic hemostasis were applied for esophageal [ 13 , 16 , 17 , 18 ], pancreatojejunostomy [ 16 ], gastrojejunostomy [ 37 ] or colonic varices [ 16 , 31 ]. Interventional radiology, such as the obliteration of the varices via a transhepatic portal venous approach, is also utilized for localized varices and bleeding [ 29 , 30 , 32 , 33 , 37 ]. Some patients experienced repeat bleeding even after treatment.…”

Percutaneous transhepatic sclerotherapy for ascending colonic varices due to left-sided portal hypertension

“…Left-sided portal hypertension (LSPH) is thought to cause gastrointestinal varices and splenomegaly due to stenosis or obstruction of the splenic vein by various factors despite normal liver function and portal blood flow [ 1 , 2 ]. Colonic varices are rare and their treatment has not been standardized [3] , although cases of rupture and fatal hemorrhage have been reported [ 4 , 5 ].…”