Portal Vein Stenting for Portal Vein Stenosis After Pancreatoduodenectomy: A Case Report

Stent placement for main portal vein occlusion to eradicate ectopic varices after pancreatoduodenectomy

Ectopic varices bleeding around the choledochojejunostomy site, potentially caused by portal vein occlusion, is a rare complication following pancreatoduodenectomy. In this report, we present a case of ectopic varices around the choledochojejunostomy site after pancreatoduodenectomy. A 55-year-old man who underwent pancreatoduodenectomy with portal vein reconstruction for pancreatic ductal adenocarcinoma suffered from hematochezia. Contrast-enhanced computed tomography revealed total occlusion of the main portal vein and ectopic varices around the choledochojejunostomy anastomosis site. An attempt at endoscopic hemostasis using clipping was unsuccessful. Consequently, a main portal vein stent was inserted to eliminate the varices. We successfully restored blood flow in the portal vein and eradicated the varices. Additionally, endoscopic changes were directly visualized using double-balloon endoscopy. Therefore, portal vein stent placement may be an effective treatment option for ectopic variceal bleeding around the choledochojejunostomy site following pancreatoduodenectomy.

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.

An Elbow Patch Reconstruction Technique for Narrowed Remnant Portal Veins during Right Lobe Living Donor Hepatectomy: A Rescue Surgery

Background: Treatment of established portal vein narrowing after living donor hepatectomy is challenging. We aimed to present a new approach termed the "elbow patch reconstruction technique" to correct the narrowed remnant portal vein just or late after right lobe living donor hepatectomy. Methods: Demographic and clinical data of 12 living liver donors with narrowed remnant portal veins and treated with the "elbow patch reconstruction technique" were prospectively collected and retrospectively evaluated. Anatomic variation of the portal vein was defined in accordance with the Nakamura classification; six of the living liver donors had type A, three had type B, and the remaining three had type C. In eight of the living liver donors with a narrowed remnant portal vein, diagnosis was detected by intraoperative Doppler ultrasonography and visual inspection by experienced transplant surgeons in the living donor hepatectomy procedure. In the remaining four living liver donors, diagnosis was performed postoperatively when elevation of liver enzymes was noticed during the routine liver function test and Doppler US. The diagnosis was confirmed by multidetector computed tomography. Results: Data from nine males and three females aged 18 to 54 years were analyzed. All of the living liver donors were followed up for a median of 1710 days (min-max: 1178-4447 days; IQR: 1516 days), and none of the living liver donors had any structural or functional complications in the portal vein. Conclusions: Narrowing remnant portal veins are rare, but they are a life-threatening complication in living liver donors, and this condition requires urgent management. Image guided interventions and narrowed segment resection with end-to-end anastomosis using a vascular graft carried a potential risk for thrombosis and restenosis. To avoid these complications, we shared a technique named "elbow patch reconstruction technique". This technique can be very effective in relieving the narrowing of the remnant portal vein after right lobe living donor hepatectomy.

Interventional Management of Portal Hypertension in Cancer Patients

PURPOSE OF REVIEW

To provide an overview of the classifications and clinical hallmarks of common cancer-related conditions that contribute to the high incidence of portal hypertension in this population and provide an update on currently available interventional radiology therapeutic approaches.

RECENT FINDINGS

In the last few decades, there have been significant advancements in understanding the pathophysiology of portal hypertension. This knowledge has led to the development of safer and more effective minimally invasive approaches. The main objective is to provide alternatives to prevent life-threatening complications from clinically significant portal hypertension and to allow the continuation of cancer treatment interventions that would otherwise be stopped. Clinicians involved in cancer care should be aware of risk factors, associated complications, and management of portal hypertension in cancer patients. Interventional radiology offers minimally invasive alternatives that play a central role in improving clinical outcomes and survival of these patients, allowing the continuation of cancer treatments.

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.