Stent Placement for Portal Vein Stenosis After Pancreaticoduodenectomy

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.

Rapid deterioration of steatotic liver disease due to portal vein stenosis after pancreaticoduodenectomy

Steatotic liver disease after pancreatoduodenectomy occurs due to various factors, such as exocrine pancreatic insufficiency, impaired intestinal absorption, and malnutrition. The mechanism of steatogenesis differs to that of conventional steatotic liver disease associated with obesity and insulin resistance. We experienced a rare case of rapidly progressive steatotic liver disease accompanied by portal vein stenosis in the early postoperative period after subtotal stomach-preserving pancreaticoduodenectomy for distal cholangiocarcinoma. Although there was a complication due to postoperative drain infection, the patient was discharged from hospital with no nutritional problems. Two months postoperatively, the patient presented to the emergency room with dyspnea. CT showed a markedly steatotic liver, ascites, and portal vein stenosis. A portal vein stent was inserted transhepatically and the steatotic liver disease gradually improved. During the postoperative course, there were no problems indicated by nutritional markers; although the patient had diarrhea associated with postoperative pancreatic exocrine insufficiency, the symptoms were mild and improved after administration of oral pancrelipase. Before the intervention, the patient had intestinal edema, exacerbation of diarrhea, and a low serum zinc concentration, suggesting that impaired absorption caused by intestinal blood stasis and gut barrier dysfunction contributed to the development of steatotic liver disease.

Percutaneous transhepatic stenting for acute superior mesenteric vein stenosis after pancreaticoduodenectomy with portal vein reconstruction: A case report

BACKGROUND

Percutaneous transhepatic stent placement has become a common strategy for the postoperative treatment of portal vein (PV)/superior mesenteric veins (SMV) stenosis/occlusion. It has been widely used after liver transplantation surgery; however, reports on stent placement for acute PV/SMV stenosis after pancreatic surgery within postoperative 3 d are rare.

CASE SUMMARY

Herein, we reported a case of intestinal edema and SMV stenosis 2 d after pancreatic surgery. The patient was successfully treated using stent grafts. Although the stenosis resolved after stent placement, complications, including bleeding, pancreatic fistula, bile leakage, and infection, made the treatment highly challenging. The use of anticoagulants was adjusted multiple times to prevent venous thromboembolism and the risk of bleeding. After careful treatment, the patient stabilized, and stent placement effectively managed postoperative PV/SMV stenosis.

CONCLUSION

Stent placement is effective and feasible for treating acute PV/SMV stenosis after pancreatic surgery even within postoperative 3 d.

Inverted Y-shaped technique for complex superior mesenteric / portal vein reconstruction in pancreatoduodenectomy for locally advanced pancreatic head ductal adenocarcinoma

Most pancreatoduodenectomy (PD) procedures for locally advanced pancreatic head adenocarcinoma (PDAC) require superior mesenteric/portal vein (SMV/PV) axis resection and reconstruction. Here we describe the inverted Y-shaped as a new technique for complex SMV/PV reconstruction and aimed at evaluating its safety and effectiveness. Among 287 patients who underwent PD for locally advanced PDAC from April, 2007 to December, 2020 at our hospital, 11 patients (3.8%) who underwent PV/SMV reconstruction with this technique were enrolled. Briefly, two distal veins were slit-wedged, sutured, resulting in one orifice, then reconstruction was completed with (n = 6) or without (n = 5) interposed autologous right external iliac vein (REIV) grafts, respectively. Operation time and blood loss were 649 (502-822) min and 1782 (475-6680) mL, respectively. The median length of resected SMV/PV was 40 (20-70) mm, 50 (50-70) mm for REIV grafts, and the splenic vein was resected in eight patients. No patient developed pancreatic fistula; mild leg edema was observed in the six graft patients and the median hospital stay was 36.0 d. PV patency rate at 2 mo after PD was 91% (10/11) and no 90-d mortality was recorded. R0 resection rate was 91% (10/11). It is feasible to safely reconstruct the SMV/PV using the inverted Y-shaped technique in appropriately selected PDAC patients.

Long-term efficacy and risk factors for stent occlusion in portal vein stent placement: a multi-institutional retrospective study

Background

Surgical treatment for PV (portal vein) stenosis/occlusion can pose a fatal risk of massive bleeding from severe adhesions and collateral vessel formation. PV stents placement is a minimally invasive and effective procedure for PV stenosis/occlusion, but PV stents sometimes occlude. The relationship between post-stent PV hemodynamics and stent occlusion has not been thoroughly investigated. Certain precautions during PV stent placement may reduce the risk of stent occlusion. This study aimed to evaluate long-term outcomes of PV stent patency and investigate factors including PV hemodynamics associated with stent occlusion.

Materials and methods

Thirty-four consecutive patients with PV stenosis/occlusion who underwent PV stent placement in four institutions between December 2006 and February 2021 were retrospectively examined. The primary study endpoints were technical success, clinical success, and cumulative stent patency rate. The secondary endpoints were risk factors of stent occlusion. A univariable Cox proportional hazards model with sixteen variables was used to determine predictors of stent occlusion. Factors with p-value ≤ 0.1 in univariable analysis were included in the multivariable analysis. Alpha was set at 0.05.

Results

Technical and clinical success rates were 88.2% and 79.4%, respectively. Six patients (17.7%) experienced stent occlusion. The cumulative stent patency rate at six months, one year, and three years was 79.1%, 79.1%, and 65.9%, respectively. In the univariate analysis, the variables with p-value ≤ 0.1 were lesion length > 4 cm, hepatofugal collateral vein visualization after stent placement, and residual stenosis > 30% after stent placement. In the multivariate analysis, residual stenosis > 30% after stent placement was significantly associated with stent occlusion (hazard ratio, 10.80; 95% confidence interval, 1.08–108.44; p = 0.04).

Conclusion

PV stent placement was technically feasible and effective in improving portal hypertension. However, stent occlusion was not uncommon. Residual stenosis > 30% after stent placement was significantly associated with stent occlusion. We should pay attention to correctly assess the range of stenosis and release the stenosis as much as possible.

The short-term outcomes of distal pancreatectomy with portal vein/superior mesenteric vein resection

BACKGROUND

Portal vein/superior mesenteric vein (PV/SMV) resection during distal pancreatectomy (DP) is often associated with technical difficulties due to the close anatomic relationship between pancreatic head and PV/SMV. In this paper, we present our operative technique and short-term outcomes of DP combined with venous resection (DP-VR) for left-sided pancreatic cancer (PC).

METHODS

We reviewed 368 consecutive cases of DP for PC from January 2013 to December 2018 in our institution, and identified 41 patients (11.1%) who had undergone DP-VR. The remaining 327 DP patients (88.9%) were matched to DP-VR using propensity scores in the proportion of 1:2. Demographics, intraoperative details, postoperative complications and the pathological results were compared between the two groups.

RESULTS

Out of the 41 DP-VR cases, in 14 (34.1%) venous resection with primary closure was performed, while the remaining 27 (65.9%) underwent end-to-end anastomosis without graft. A propensity-score-matched analysis revealed that DP-VR caused an increased risk of postoperative bleeding (17.1% vs. 3.7%, P = 0.016) and delayed gastric emptying (9.8% vs. 1.2%, P = 0.042) compared to standard DP. Overall morbidity (46.3% vs. 36.6%, P = 0.332), postoperative pancreatic fistula (31.7% vs. 26.8%, P = 0.672), R0 resection (58.5% vs. 67.1%, P = 0.223), 30-day reoperation (2.4% vs. 3.7%, P = 0.719), and 90-day mortality (0% vs. 2.5%, P = 0.550) were comparable between the two groups. In postoperative computed tomographic scans of 34 patients (82.9%) at a 90-day follow-up, PV/SMV stenosis was suggested in two patients (5.9%).

CONCLUSION

Despite the higher rates of postoperative bleeding, DP-VR was found to be a feasible and safe surgery with acceptable postoperative morbidity and mortality compared to standard DP for left-sided pancreatic cancer.

Usefulness of argon plasma coagulation for bleeding around hepaticojejunal anastomosis

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.

Long term clinical outcomes of portal vein stenting for symptomatic portal vein stenosis after pancreaticoduodenectomy

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.

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.

Portal vein stent placement after hepatobiliary and pancreatic surgery

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.

Benign Portal Vein Stenosis After Pancreaticoduodenectomy

BACKGROUND

The long-term patency of the portal vein (PV) in patients who survive after pancreaticoduodenectomy (PD) remains unclear. The aim of the present study was to investigate the clinical features and risk factors for benign PV stenosis after PD.

METHODS

We retrospectively analyzed the patients who underwent PD from September 2002 and December 2015 at our institution without intraoperative radiation therapy or concomitant PV resection. The postoperative computed tomography of each patient was evaluated, and PV stenosis was defined as the shortest diameter of the PV being <3 mm. The patients with PV stenosis due to local recurrence were excluded.

RESULTS

Of the 458 patients, PV stenosis occurred in 57 (12.4%), including benign PV stenosis in 28 (6.1%) and PV stenosis due to local recurrence in 29 (6.3%). Of the 28 patients with benign PV stenosis, 7 (25%) developed symptoms related to portal hypertension, namely recurrent gastrointestinal bleeding in 5 and refractory ascites in 2. Six patients were treated with percutaneous transhepatic PV stent placement, and all of their symptoms improved. A multivariate analysis found that a postoperative pancreatic fistula was an independent risk factor for benign PV stenosis after PD (odds ratio, 4.36; p = 0.005).

CONCLUSIONS

Postoperative pancreatic fistula was a significant risk factor for benign PV stenosis after PD. Stent placement for benign PV stenosis was effective for the patients with symptoms due to portal hypertension.