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Ogawa S, Yamamoto A, Jogo A, Kageyama K, Sohgawa E, Ohira G, Kimura K, Tanaka S, Amano R, Takemura S, Ishizawa T, Miki Y. Embolization with or without portal vein stenting for bleeding ectopic jejunal varices in hepatopetal portal collaterals due to extrahepatic portal vein occlusion or stenosis after hepatobiliary and pancreatic surgery. Jpn J Radiol 2024:10.1007/s11604-024-01616-1. [PMID: 38935221 DOI: 10.1007/s11604-024-01616-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE To evaluate the efficacy and safety of embolization with or without portal vein stenting for bleeding ectopic jejunal varices in the hepatopetal portal collateral due to extrahepatic portal vein occlusion or stenosis after hepatobiliary and pancreatic surgery. MATERIALS AND METHODS This study included consecutive patients who underwent embolization for bleeding ectopic jejunal varices in the hepatopetal collateral due to extrahepatic portal vein occlusion or stenosis after hepatobiliary and pancreatic surgery between September 2012 and December 2020. The safety, technical and clinical success rates (no re-bleeding within 1 month) and re-bleeding-free survival after the first therapy and overall survival were assessed. RESULTS Fourteen sessions in 11 patients were included. Four patients (7 sessions) underwent variceal embolization only, and the remaining seven patients (7 sessions) underwent portal vein stenting and variceal embolization. Technical success was achieved in all 14 sessions (100%). Clinical success was achieved in 13 of 14 sessions (92.9%). No treatment-related serious complications including liver failure were observed. One-year and 2-year re-bleeding-free survival rate after the first endovascular therapy in all 11 patients was 90.9 and 60.6%, respectively. Two patients who experienced re-bleeding had repeat embolization treatment. There was no significant difference in re-bleeding-free survival after endovascular therapy between the combination with stenting and embolization group and the embolization-only group (p = 0.13). CONCLUSION Embolization with or without portal vein stenting of bleeding ectopic jejunal varices in the hepatopetal portal collateral due to extrahepatic portal vein occlusion or stenosis after hepatobiliary and pancreatic surgery can be considered a safe, effective, and repeatable therapy for long-term hemostasis of uncontrollable bleeding.
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Affiliation(s)
- Satoyuki Ogawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
- Department of Diagnostic Radiology, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-Ku, Osaka, 530-0012, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan.
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Etsuji Sohgawa
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
| | - Go Ohira
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Kenjiro Kimura
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Shogo Tanaka
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Ryosuke Amano
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Shigekazu Takemura
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Takeaki Ishizawa
- Department of Hepato-Biliary-Pancreatic Surgery Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, 1-4-3 Asahi-Machi, Abeno-Ku, Osaka, 545-8585, Japan
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Liu J, Wang P, Wang LM, Guo J, Zhong N. Outcomes of endoscopic sclerotherapy for jejunal varices at the site of choledochojejunostomy (with video): Three case reports. World J Gastroenterol 2024; 30:2059-2067. [PMID: 38681128 PMCID: PMC11045488 DOI: 10.3748/wjg.v30.i14.2059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/09/2024] [Accepted: 03/26/2024] [Indexed: 04/12/2024] Open
Abstract
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.
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Affiliation(s)
- Jun Liu
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Peng Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Li-Mei Wang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Jing Guo
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Ning Zhong
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
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Miyamura S, Ishimaru H, Oka T, Otsuka T, Yoshimi S, Hidaka M, Miyazoe Y, Uetani M. Combined Transhepatic and Transsplenic Recanalization of Chronic Portal Vein Occlusion to Treat Jejunal Varices: A Report of Two Cases. INTERVENTIONAL RADIOLOGY 2022; 7:63-68. [PMID: 36196385 PMCID: PMC9527106 DOI: 10.22575/interventionalradiology.2021-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 02/02/2022] [Indexed: 11/17/2022]
Abstract
We report two cases of chronic portal vein occlusion with jejunal varices successfully treated using percutaneous intervention with a combined transhepatic and transsplenic approach. Case 1 was a 60-year-old man with uncontrolled jejunal variceal bleeding, and case 2 was a 79-year-old man with anastomotic jejunal variceal bleeding and cholangitis. Single access via the transhepatic or transsplenic route failed to allow catheter advancement through the occlusion. After introducing pull-through access via the transhepatic and transsplenic routes, a metallic stent was could be used to dilate the occluded portal vein. Anastomotic jejunal varices functioning as hepatopetal collaterals were embolized after the establishment of antegrade portal flow. No symptom relapse was observed during the follow-up period (31 months for case 1 and 34 months for case 2).
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Affiliation(s)
| | | | - Taiga Oka
- Department of Radiology, Nagasaki University Hospital
| | | | | | | | - Yuri Miyazoe
- Department of Gastroenterology and Hepatology, Koseikai Hospital
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Wakasugi M, Tsujie M, Goda S, Ohnishi K, Koga C, Tei M, Kawabata R, Hasegawa J. Laparotomy-assisted transcatheter variceal embolization for bleeding jejunal varices formed at the site of choledochojejunostomy: Report of a case and review of the literature. Int J Surg Case Rep 2020; 77:554-559. [PMID: 33395844 PMCID: PMC7701888 DOI: 10.1016/j.ijscr.2020.11.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 11/29/2022] Open
Abstract
Jejunal varices should be included in the differential diagnosis of melena in patients 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 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.
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Affiliation(s)
| | | | - Seiichi Goda
- Department of Diagnostic and Interventional Radiology, Osaka Rosai Hospital, Japan
| | - Kohsaku Ohnishi
- Department of Gastroenterology, Osaka Rosai Hospital, 1179-3 Nagasone-cho, Kita-ku, Sakai, Osaka, 591-8025, Japan
| | - Chikato Koga
- Department of Surgery, Osaka Rosai Hospital, Japan
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Abdalla AO, Abdallah MA, Calvo LA. Successful Treatment of a Case of Ectopic Jejunal Varices with Portal Venous Stenting. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:948-952. [PMID: 31266933 PMCID: PMC6621934 DOI: 10.12659/ajcr.916003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patient: Female, 77 Final Diagnosis: Ectopic variceal bleeding of the jejunum Symptoms: Abdominal pain • hematemesis • melena Medication: — Clinical Procedure: Portal vein stenting Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Abubaker O Abdalla
- Department to Internal Medicine, University of Nevada, School of Medicine, Reno, NV, USA
| | - Mohamed A Abdallah
- Department to Internal Medicine, University of South Dakota, Sioux Falls, SD, USA
| | - Lisa A Calvo
- Department to Internal Medicine, University of Nevada, School of Medicine, Reno, NV, USA
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Biondetti P, Fumarola EM, Ierardi AM, Carrafiello G. Bleeding complications after pancreatic surgery: interventional radiology management. Gland Surg 2019; 8:150-163. [PMID: 31183325 DOI: 10.21037/gs.2019.01.06] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Pierpaolo Biondetti
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo and Carlo, University of Milan, Milan, Italy
| | - Enrico Maria Fumarola
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo and Carlo, University of Milan, Milan, Italy
| | - Anna Maria Ierardi
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo and Carlo, University of Milan, Milan, Italy
| | - Gianpaolo Carrafiello
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo and Carlo, University of Milan, Milan, Italy
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Li M, Li Q, Lei Q, Hu J, Wang F, Chen H, Zhen Z. Unusual bleeding from hepaticojejunostomy controlled by side-to-side splenorenal shunt: A case report. Medicine (Baltimore) 2018; 97:e11784. [PMID: 30095636 PMCID: PMC6133541 DOI: 10.1097/md.0000000000011784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
RATIONALE Ectopic variceal bleeding due to hepaticojejunostomy (HJ) is unusual and difficult to manage. Reports on the use of side-to-side splenorenal shunt for severe bleeding from varices at HJ anastomosis are lacking. PATIENT CONCERNS A 43-year-old man was admitted to our hospital with repeated episodes of hematemesis. He has a history of right hemihepatectomy with HJ reconstruction to the left hepatic duct for hilar cholangiocarcinoma. Two years after surgery, he presented with repeated episodes of hematemesis and underwent blood transfusion. DIAGNOSES Imaging tests and endoscopic investigation failed to identify the bleeding source. When conservative management failed to control his bleeding, he underwent emergency laparotomy, which revealed hemorrhage from ectopic varices at the HJ anastomosis. INTERVENTIONS To arrest the bleeding, a side-to-side venovenal anastomosis was created between the splenic and left renal veins to form a shunt for decompression of the varices at the HJ anastomosis. OUTCOMES After the surgery, the patient's symptoms ceased, and a no bleeding in the digestive tract was noted at 2-year follow-up. LESSONS The present patient is the first reported case of unusual bleeding from HJ controlled by a side-to-side splenorenal shunt. We believe this approach is a useful and effective surgical treatment for severe bleeding from varices at the HJ anastomosis.
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Hyun D, Park KB, Cho SK, Park HS, Shin SW, Choo SW, Do YS, Choo IW, Choi DW. Portal Vein Stenting for Delayed Jejunal Varix Bleeding Associated with Portal Venous Occlusion after Hepatobiliary and Pancreatic Surgery. Korean J Radiol 2017; 18:828-834. [PMID: 28860900 PMCID: PMC5552466 DOI: 10.3348/kjr.2017.18.5.828] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 01/08/2017] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Dongho Hyun
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Kwang Bo Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Sung Ki Cho
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Hong Suk Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Sung Wook Shin
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Sung Wook Choo
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Young Soo Do
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - In Wook Choo
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Dong Wook Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
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Belsha D, Thomson M. Challenges of banding jejunal varices in an 8-year-old child. World J Gastrointest Endosc 2015; 7:1350-1354. [PMID: 26722617 PMCID: PMC4689798 DOI: 10.4253/wjge.v7.i19.1350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/02/2015] [Accepted: 07/17/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscoic variceal ligation (EVL) by the application of bands on small bowel varices is a relatively rare procedure in gastroenterology and hepatology. There are no previously reported paediatric cases of EVL for jejunal varices. We report a case of an eight-year-old male patient with a complex surgical background leading to jejunal varices and short bowel syndrome, presenting with obscure but profound acute gastrointestinal bleeding. Wireless capsule endoscopy and double balloon enteroscopy (DBE) confirmed jejunal varices as the source of bleeding. The commercially available variceal banding devices are not long enough to be used either with DBE or with push enteroscopes. With the use of an operating gastroscope, four bands were placed successfully on the afferent and efferent ends of the leads of the 2 of the varices. Initial hemostasis was achieved with obliteration of the varices after three separate applications. This case illustrates the feasibility of achieving initial hemostasis in the pediatric population.
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Abe S, Akamatsu N, Hoshikawa M, Shirata C, Sakamoto Y, Hasegawa K, Kokudo N. Ectopic Jejunal Variceal Rupture in a Liver Transplant Recipient Successfully Treated With Percutaneous Transhepatic Coil Embolization: A Case Report. Medicine (Baltimore) 2015; 94:e2151. [PMID: 26632745 PMCID: PMC5059014 DOI: 10.1097/md.0000000000002151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Here we present the rupture of ectopic jejunal varices developing in a liver transplant recipient without portal hypertension, which was successfully treated with percutaneous transhepatic coil embolization.A 48-year-old man with massive melena was admitted to our department. He had undergone liver transplantation for hepatitis B virus-related liver cirrhosis 8 months before, and his postoperative course was satisfactory except for an acute cellular rejection. No evidence of bleeding was detected by upper endoscopy or colonoscopy, but dynamic multidetector computed tomography of the whole abdomen revealed an intestinal varix protruding into the lumen of the jejunum with suspected extravasation. There was no evidence of portal venous stenosis or thrombosis. Immediately upon diagnosis of the ruptured ectopic jejunal varix, percutaneous transhepatic coil embolization was performed, achieving complete hemostasis. The portal venous pressure measured during the procedure was within normal limits. He was discharged from the hospital 11 days after embolization and remained in stable condition without re-bleeding 6 months after discharge.This is the first report of an ectopic intestinal variceal rupture in an uneventful liver transplant recipient that was successfully treated with interventional percutaneous transhepatic coil embolization. Clinicians encountering liver transplant recipients with melena should be aware of the possibility of late-onset rupture of ectopic varices, even in those having an uneventful post-transplant course without portal hypertension.
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Affiliation(s)
- Satoru Abe
- From the Department of Surgery, Artificial Organ and Transplantation Division, Graduate School of Medicine, The University of Tokyo, Hongo, Bunkyo-ku, Tokyo, Japan
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Yoshimatsu R, Yamagami T, Ishikawa M, Kajiwara K, Kakizawa H, Hiyama E, Tashiro H, Murakami Y, Ohge H, Awai K. Embolization therapy for bleeding from jejunal loop varices due to extrahepatic portal vein obstruction. MINIM INVASIV THER 2015; 25:57-61. [PMID: 26330264 DOI: 10.3109/13645706.2015.1075557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Four patients underwent embolization therapy for hemorrhage from varices in the jejunal loop after choledochojejunostomy existing in hepatopetal collateral veins due to chronic extrahepatic portal vein obstruction through the afferent veins using microcoils and/or n-butyl cyanoacrylate. In all four patients, all afferent veins were successfully embolized and successful hemostasis was achieved without liver dysfunction. However, recurrence of the varices and rebleeding occurred within a year in two patients. Embolization for hemorrhage from varices in the jejunal loop after choledochojejunostomy through afferent veins is acceptable in terms of safety and is useful to achieve hemostasis in emergency circumstances.
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Affiliation(s)
- Rika Yoshimatsu
- a 1 Department of Diagnostic Radiology, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan.,b 2 Department of Radiology, Kochi University , Kochi, Japan
| | - Takuji Yamagami
- a 1 Department of Diagnostic Radiology, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan.,b 2 Department of Radiology, Kochi University , Kochi, Japan
| | - Masaki Ishikawa
- a 1 Department of Diagnostic Radiology, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan
| | - Kenji Kajiwara
- a 1 Department of Diagnostic Radiology, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan
| | - Hideaki Kakizawa
- c 3 Department of Radiology, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital , Hiroshima, Japan
| | - Eiso Hiyama
- d 4 Department of Pediatric Surgery, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan
| | - Hirotaka Tashiro
- e 5 Department of Surgery, Division of Frontier Medical Science, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan
| | - Yoshiaki Murakami
- f 6 Department of Surgery, Division of Clinical Medical Science, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan
| | - Hiroki Ohge
- g 7 Department of Surgery, Division of Colon and Rectal Surgery, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan
| | - Kazuo Awai
- a 1 Department of Diagnostic Radiology, Institute and Graduate School of Biomedical Sciences, Hiroshima University , Hiroshima, Japan
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Unusual bleeding from hepaticojejunostomy controlled by adult variable stiffness colonoscopy: report of a case and literature review. Int Surg 2014; 99:584-9. [PMID: 25216425 DOI: 10.9738/intsurg-d-13-00126.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
We herein present a case of a 59-year-old man who had undergone pylorus preserving pancreaticoduodenectomy with regional lymph node dissection prior to episodes of melena. Series of conventional endoscopic investigations failed to identify the bleeding source. Enhanced computed tomography scan revealed complete obstruction of the main portal vein with numerous collateral veins running towards the hepatic hilus. Comprehensively, hemorrhage from the jejunal varices caused by postoperative portal hypertension was highly suspected. As the jejunal loop was out of reach, adult variable-stiffness colonoscope (AVSC) was utilized to solve the Roux-en-Y anatomy. Numerous telangiectasis and small varices at hepaticojejunostomy were observed and in the mean time, bleeding was noticed and endoclips were placed without any delay. Ectopic variceal bleeding in jejunal loop after pancreaticoduodenectomy is difficult to manage. We believe that AVSC is an alternative device when specialized jejunal endoscopy is not available.
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Chu HH, Kim HC, Hur S, Jae HJ, Chung JW. Percutaneous transhepatic portal vein stent-graft placement and jejunal varices embolization after hepaticojejunostomy. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2013.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ahn DW, Jeong JB. Jejunal varices causing recurrent obscure gastrointestinal hemorrhage. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2014; 63:191-193. [PMID: 24783319 DOI: 10.4166/kjg.2014.63.3.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Lee JY, Song SY, Kim J, Koh BH, Kim Y, Jeong WK, Kim MY. Percutaneous transsplenic embolization of jejunal varices in a patient with liver cirrhosis: a case report. ACTA ACUST UNITED AC 2013; 38:52-5. [PMID: 22527157 DOI: 10.1007/s00261-012-9894-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Bleeding jejunal varices are rare and could be life threatening. They are usually found in the presence of portal hypertension and prior history of gastrointestinal surgery. They can be effectively managed by radiological interventions such as transjugular intrahepatic portosystemic shunt or transhepatic embolization of varices. However, in patients with portal vein obstruction, an alternative access is necessary. We report a case of bleeding jejunal varices associated with postoperative adhesion in a patient with portal vein thrombosis which was successfully managed by percutaneous transsplenic embolization.
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Affiliation(s)
- Ji Young Lee
- Department of Radiology, Hanyang University Hospital, 17 Haengdang-dong, Sungdong-gu, Seoul, 133-792, Korea
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Saeki Y, Ide K, Kakizawa H, Ishikawa M, Tashiro H, Ohdan H. Controlling the bleeding of jejunal varices formed at the site of choledochojejunostomy: report of 2 cases and a review of the literature. Surg Today 2012; 43:550-5. [PMID: 22777133 DOI: 10.1007/s00595-012-0243-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2011] [Accepted: 01/15/2012] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Hemorrhage from jejunal varices formed at the site of Roux-en-Y choledochojejunostomy is rather rare, and no guidelines have so far been established for its treatment. This report presents the cases of 2 patients with jejunal varices formed at the site of choledochojejunostomy that were treated using different methods. An obstruction of the extrahepatic portal vein resulted in massive gastrointestinal bleeding in both cases CASE 1: A 59-year-old male developed jejunal varices at the site of choledochojejunostomy. Multidetector computed tomography showed that the source of bleeding was located in the small intestine near portojejunal varices. The jejunal vein supplying the afferent loop was embolized using interventional radiology. There was no evidence of liver dysfunction or rebleeding after the embolization CASE 2: A 79-year-old female developed jejunal varices at the site of choledochojejunostomy. Abdominal angiography could not detect the source of bleeding, and hence, a mesocaval shunt operation was performed.
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Affiliation(s)
- Yoshihiro Saeki
- Department of Surgery, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi Minami-ku, Hiroshima 734-8551, Japan
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17
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Koo SM, Jeong SW, Jang JY, Lee TH, Jeon SR, Kim HG, Kim JO, Kim YJ. Jejunal variceal bleeding successfully treated with percutaneous coil embolization. J Korean Med Sci 2012; 27:321-4. [PMID: 22379346 PMCID: PMC3286782 DOI: 10.3346/jkms.2012.27.3.321] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 11/04/2011] [Indexed: 12/17/2022] Open
Abstract
A 52-yr-old male with alcoholic liver cirrhosis was hospitalized for hematochezia. He had undergone small-bowel resection due to trauma 15 yr previously. Esophagogastroduodenoscopy showed grade 1 esophageal varices without bleeding. No bleeding lesion was seen on colonoscopy, but capsule endoscopy showed suspicious bleeding from angiodysplasia in the small bowel. After 2 weeks of conservative treatment, the hematochezia stopped. However, 1 week later, the patient was re-admitted with hematochezia and a hemoglobin level of 5.5 g/dL. Capsule endoscopy was performed again and showed active bleeding in the mid-jejunum. Abdominal computed tomography revealed a varix in the jejunal branch of the superior mesenteric vein. A direct portogram performed via the transhepatic route showed portosystemic collaterals at the distal jejunum. The patient underwent coil embolization of the superior mesenteric vein just above the portosystemic collaterals and was subsequently discharged without re-bleeding. At 8 months after discharge, his condition has remained stable, without further bleeding episodes.
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Affiliation(s)
- So My Koo
- Institute for Digestive Research and Digestive Disease Center, Department of Gastroenterology, Soonchunhyang University Hospital, Seoul, Korea
| | - Soung Won Jeong
- Institute for Digestive Research and Digestive Disease Center, Department of Gastroenterology, Soonchunhyang University Hospital, Seoul, Korea
| | - Jae Young Jang
- Institute for Digestive Research and Digestive Disease Center, Department of Gastroenterology, Soonchunhyang University Hospital, Seoul, Korea
| | - Tae Hee Lee
- Institute for Digestive Research and Digestive Disease Center, Department of Gastroenterology, Soonchunhyang University Hospital, Seoul, Korea
| | - Seong Ran Jeon
- Institute for Digestive Research and Digestive Disease Center, Department of Gastroenterology, Soonchunhyang University Hospital, Seoul, Korea
| | - Hyun Gun Kim
- Institute for Digestive Research and Digestive Disease Center, Department of Gastroenterology, Soonchunhyang University Hospital, Seoul, Korea
| | - Jin Oh Kim
- Institute for Digestive Research and Digestive Disease Center, Department of Gastroenterology, Soonchunhyang University Hospital, Seoul, Korea
| | - Yong Jae Kim
- Institute for Digestive Research and Digestive Disease Center, Department of Radiology, Soonchunhyang University Hospital, Seoul, Korea
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Lee SD, Park SJ, Kim HB, Han SS, Kim SH, You TS, Kim YK, Cho SY, Lee SA, Ko YH, Hong EK. Jejunal varix bleeding with extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy: report of two cases. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2012; 16:37-42. [PMID: 26388904 PMCID: PMC4575013 DOI: 10.14701/kjhbps.2012.16.1.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Revised: 09/28/2011] [Accepted: 09/30/2011] [Indexed: 11/17/2022]
Abstract
We present 2 patients showing afferent jejunal varix bleeding around hepaticojejunostomy caused by extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy (PPPD). The case 1 was a 58-year-old woman who had recurrent anemia and hematochezia 3 years after undergoing PPPD. On the portography, the main portal vein was obliterated and collaterals around hepaticojejunostomy were developed. After percutaneous transhepatic balloon dilatation and stent placement through the obliterated portal vein, jejunal varices had disappeared and thereafter no bleeding occurred for 32 months. The case 2 was a 71-year-old man who had frequent melena 7 years after PPPD. Portal stent insertion was first tried, but failed due to severe stenosis of the main portal vein. Therefore, meso-caval shunt operation was attempted in order to reduce the variceal flow. Although an episode of a small amount of melena occurred one month after the shunt operation, there was no occurrence of bleeding for the next 8 months. For the treatment of jejunal varices, a less invasive approach, such as the angiographic intervention of stent insertion, balloon dilatation, or embolization is recommended first. Surgical operations, such as a shunt or resection of the jejunal rim, could be considered when noninvasive approaches have failed.
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Affiliation(s)
- Seung Duk Lee
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Sang-Jae Park
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Hyun Boem Kim
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Sung-Sik Han
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Seong Hoon Kim
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Tae Suk You
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Young-Kyu Kim
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Seong Yeon Cho
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Soon-Ae Lee
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Young Hwan Ko
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
| | - Eun Kyung Hong
- Center for Liver Cancer, National Cancer Center, Goyang, Korea
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Sato T, Akaike J, Toyota J, Karino Y, Ohmura T. Clinicopathological features and treatment of ectopic varices with portal hypertension. Int J Hepatol 2011; 2011:960720. [PMID: 21994879 PMCID: PMC3170857 DOI: 10.4061/2011/960720] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Accepted: 05/12/2011] [Indexed: 12/12/2022] Open
Abstract
Bleeding from ectopic varices, which is rare in patients with portal hypertension, is generally massive and life-threatening. Forty-three patients were hospitalized in our ward for gastrointestinal bleeding from ectopic varices. The frequency of ectopic varices was 43/1218 (3.5%) among portal hypertensive patients in our ward. The locations of the ectopic varices were rectal in thirty-two, duodenal in three, intestinal in two, vesical in three, stomal in one, and colonic in two patients. Endoscopic or interventional radiologic treatment was performed successfully for ectopic varices. Hemorrhage from ectopic varices should be kept in mind in patients with portal hypertension presenting with lower gastrointestinal bleeding.
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Affiliation(s)
- Takahiro Sato
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan,*Takahiro Sato:
| | - Jun Akaike
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Jouji Toyota
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Yoshiyasu Karino
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Takumi Ohmura
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
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