Modified interventional obliteration for variceal hemorrhage from elevated jejunum after pylorus-preserving pancreatoduodenectomy

Abstract

Ectopic variceal hemorrhage caused by sinistral portal hypertension after splenic vein ligation during a pyloric-preserving pancreatoduodenectomy is a rare entity. We report the case of a 58-year-old man with symptoms of refractory melena. The varices could not be treated endoscopically and surgery was considered unsuitable due to severe adhesions and altered anatomy. Following clinical failure of partial splenic embolization, an alternative obliteration method by a retrograde trans-portal-venous approach was successfully performed and resolved the problem. It seems to be an effective method for ectopic variceal bleeding, especially when other interventions are unavailable or highly risky.

Percutaneous transsplenic obliteration of ectopic varices following pancreaticoduodenectomy with portal vein resection and splenic vein ligation

“…Therefore, variceal obliteration via the transhepatic portal vein approach was performed in the first IR procedure. Sakamoto et al 9 reported successful endovascular treatment for varices located in the afferent jejunal loop, which was the bleeding site involved like this case. They achieved complete variceal embolization using balloon-occluded retrograde transhepatic obliteration, and no re-bleeding was observed over the one-year follow-up period.…”

“…Although ectopic variceal bleeding due to LSPH is very rare, it can be life-threatening, and no standard treatment has been established yet. 4,9,10 According to previous studies, it can be managed by surgical, endoscopic, IR, and conservative treatments. 4,5 We chose IR treatment as the first therapeutic option because surgical treatment such as splenectomy was considered too invasive, and endoscopic sclerotherapy appeared impossible to perform due to the altered anatomy and severe adhesions.…”

“…Several studies have indicated the usefulness of PSE and transvenous obliteration in the management of ectopic varices induced by LSPH. 9,10 In this case, because active bleeding was observed, transvenous obliteration was preferred over PSE in the interest of direct variceal occlusion rather than indirect flow reduction to achieve an immediate cessation of hemorrhage. The systemic venous approach appeared unsuitable because of the absence of a portosystemic shunt.…”

“…4 LSPH is a potentially severe complication, because it can cause ectopic varices, resulting in massive gastrointestinal bleeding. 4,5,[7][8][9] Here, we report a case of variceal hemorrhage induced by LSPH following PD, which recurred after percutaneous transhe-patic obliteration, and which was managed by a transsplenic antegrade approach.…”

Treatment of bleeding from a portion of pancreatojejunostomy after pancreaticoduodenectomy with division of the splenic vein: two case reports

“…In our second case, we selected obliteration of the varices at the PJ via a trans-portal-venous approach because CT scans showed a route from the PV to the varices at a portion of the PJ. This procedure was previously reported by Sakamoto et al [18] in 2014. This procedure had several benefits that could maintain the splenic arterial flow and approach the varices directly.…”