Ileal conduit stomal variceal bleeding managed by endovascular embolization

Percutaneous Transhepatic Obliteration for Treating Stomal Variceal Bleeding Using a Microballoon Catheter with Systemic Drainage Vein Compression

We report a case of successful treatment of stomal variceal bleeding with percutaneous transhepatic obliteration using a microballoon catheter concomitantly with drainage vein compression. A 72-year-old man with alcoholic cirrhosis was admitted to our hospital due to repeated hemorrhage of stomal varices. Percutaneous transhepatic obliteration was then selected for treatment because computed tomography revealed the stomal varices being fed by only two branches of the superior and inferior mesenteric veins. During microballoon inflation, 5% ethanolamine oleate with iopamidol was injected into each branch, and the systemic drainage veins were compressed by the gauze from the body surface near the stoma. No rebleeding from the stomal varices has been observed 14 months after the procedure.

Trans-hepatic trans-portal selective angioembolization; a management option for severe acute variceal bleeding of ileal conduit stoma

We present a case of severe acute variceal bleeding in an ileal conduit stoma successfully managed with trans-hepatic trans-portal selective angioembolization as a lifesaving measure. Despite repeated transfusions, the patient's hemoglobin continued to be unstable. The patient underwent transhepatic embolization of ileal stoma varicose veins. Angioembolization was followed up with excision of ileal conduit stoma and creation of cutaneous ureterostomy for definitive treatment management of hemorrhage. In conclusion, trans-hepatic trans-portal embolization is an effective option for management of severe acute variceal bleeding in an ileal conduit stoma as a lifesaving measure and can be followed by excision of the conduit.

Bleeding Stomal Varices and Their Interventional Management- A Series of Three Cases

Although stomal and parastomal varices are uncommon causes of variceal bleeding, the mortality rate might be as high as 40%. Timely intervention is essential for the management of these ectopic bleeding varices. Due to the rarity of such varices, no standard treatment guideline is available. We present three cases of bleeding stomal varices managed with an endovascular approach, one through percutaneous transhepatic and the other two through transjugular intrahepatic portosystemic shunt approach.

Muscle-Invasive Bladder Cancer in Patients with Liver Cirrhosis: A Review of Pertinent Considerations

The incidence of liver cirrhosis is increasing worldwide. Patients with cirrhosis are generally at a higher risk of harbouring hepatic and non-hepatic malignancies, including bladder cancer, likely due to the presence of related risk factors such as smoking. Cirrhosis can complicate both the operative and non-surgical management of bladder cancer. For example, cirrhotic patients undergoing abdominal surgery generally demonstrate worse postoperative outcomes, and chemotherapy in patients with cirrhosis often requires dose reduction due to its direct hepatotoxic effects and reduced hepatic clearance. Multiple other considerations in the peri-operative management for cirrhosis patients with muscle-invasive bladder cancer must be taken into account to optimize outcomes in these patients. Unfortunately, the current literature specifically related to the treatment of cirrhotic bladder cancer patients remains sparse. We aim to review the literature on treatment considerations for this patient population with respect to perioperative, surgical, and adjuvant management.

Successful hybrid surgery for ileal conduit stomal varices following oxaliplatin-based chemotherapy in a patient with advanced colorectal cancer

BACKGROUND

Ectopic variceal bleeding is a rare but life-threatening complication of portal hypertension (PH). Oxaliplatin-based chemotherapy for colorectal cancer (CRC) is associated with sinusoidal obstruction syndrome of the liver, which can lead to PH.

CASE PRESENTATION

Here, we report a successful hybrid surgery that included intraoperative obliteration of ileal conduit stomal varices (ICSVs) for a 66-year-old woman with CRC and liver metastasis that had been treated multimodally during the previous 4 years, including 17 courses of oxaliplatin-based chemotherapy. She was admitted to our hospital for massive hemorrhage from an ileal conduct stoma. Image findings showed ICSVs as a part of portosystemic shunt, which were afferently supplied from the superior mesenteric vein (SMV) and drained by the numerous cutaneous veins connected to the left femoral vein. Obliteration of the stomal varices by interventional radiologic techniques alone was inappropriate because of difficulties of cannulating the efferent cutaneous veins. We, therefore, performed hybrid surgery for the ICSV, which included cannulation into the SMV branch and antegrade obliteration of the varices with a 5% solution of ethanolamine oleate with iopamidol under blocking the SMV flow, using a vascular clip and ligation. Hemorrhage in her ileal conduit stoma disappeared completely.

CONCLUSION

Customized treatment of ectopic varices should be based on their precise vascular anatomy; hybrid surgery with intraoperative angiography is an alternative treatment for ectopic varices such as ICSV.

Peristomal variceal hemorrhage at the ileal conduit site due to extrahepatic portosystemic shunt

Peristomal variceal bleeding is a rare but known complication with portal hypertension. In patients with recurrent peristomal hemorrhage, atypical varices should be considered, and liver cirrhosis should be excluded even with normal liver function tests. We report a case of a 76-year-old male who presented with recurrent ileal conduit site peristomal hemorrhage without known chronic liver disease. His liver function tests were normal, but computed tomography of the abdomen and pelvis showed liver nodularity and peristomal varices. He was diagnosed to have cirrhosis with portal hypertension and further tested positive for active hepatitis C infection. The patient's extrahepatic portosystemic ileal conduit site shunt was successfully treated with transjugular intrahepatic portosystemic shunt and endovascular variceal coiling. This case identifies a situation where it is imperative to identify occult liver cirrhosis with portosystemic shunt as a cause of ileal conduit site recurrent stomal bleeding.

Successful embolization of ileal conduit stomal varices with N-butyl cyanoacrylate via a recanalized paraumbilical vein

A 77-year-old woman with liver cirrhosis was admitted to our hospital for marked hemorrhage in her ileal conduit stoma. She had a history of cystectomy and urinary diversion for bladder carcinoma 2 years ago. Contrast-enhanced CT demonstrated varices in the ileal conduit stoma. We accessed the varices via a recanalized paraumbilical vein to avoid pain from the transhepatic approach, and selectively embolized the varices with N-butyl cyanoacrylate (NBCA). We consider antegrade embolization of ileal conduit stomal varices with NBCA to be effective and feasible. Access via a paraumbilical vein is a useful alternative to the transhepatic approach.

Direct Percutaneous Embolization of Peristomal Ileostomy Varices in an Emergency Setting

Patients with liver disease and portal hypertension who have had surgical formation of an abdominal stoma are at risk of developing peristomal varices. These varices have a predilection for bleeding. Ideally, portal decompression via TIPS procedure is performed, with or without direct embolization of the bleeding varix. When TIPS is not an appropriate option due to significant liver disease and hepatic encephalopathy there are other approaches to treat peristomal variceal hemorrhage. We report the embolization of such a varix via direct percutaneous puncture under ultrasound guidance when portal decompression was not an appropriate option.

Bleeding stomal varices in portal hypertension

We report a case of a 50-year-old man with a history of liver cirrhosis and colon cancer post end colostomy presenting to the emergency department with stomal bleeding and passage of clots into the colostomy bag. The patient was treated with transjugular intrahepatic portosystemic shunt (TIPS) and concomitant embolization of the stomal varices via the TIPS shunt using N-butyl cyanoacrylate mixed with ethiodol. Although stomal variceal bleeding is uncommon, this entity can have up to 40% mortality upon initial presentation, given the challenges in diagnosis and management. Currently, there are no established standard treatments for stomal variceal bleeding. In addition, to the best of our knowledge, there are no cases in the current literature in which treatment of this entity is performed with a combination of TIPS shunt placement and N-butyl cyanoacrylate variceal embolization.

Peristomal variceal bleeding treated by coil embolization using a percutaneous transhepatic approach

Peristomal variceal bleeding due to portal hypertension is an entity that has rarely been reported with 3%-4% risk of death. A 68-year-old woman who had undergone a palliative colostomy (colorectal carcinoma) presented with a massive hemorrhage from the colostomy conduit. Considering her oncological status with medial and right hepatic veins thrombosis due to liver metastasis invasion, an emergency transhepatic coil embolization was successfully performed. Standard treatment modality for these cases has not been established. Percutaneous transhepatic coil embolization of varices is a safe and effective choice in patients who present with life threatening bleeding and exhibit contraindications to transjugular intrahepatic portosystemic shunt.

Ectopic variceal bleeding from colonic stoma: two case reports

Parastomal variceal bleeding is a rare complication of portal hypertension, which often occurs in a recurrent manner and might be life-threatening in extreme situations. Treatment options vary, and no standard therapy has been established. Herein, we report 2 such cases. The first patient suffered from parastomal variceal bleeding after Hartmann procedure for rectal cancer. Stomal revision was performed, but bleeding recurred 1 month later. The second patient developed the disease after Miles procedure for rectal cancer. Embolization via the percutaneous transhepatic approach was performed using the Onyx liquid embolic system (LES) (Micro Therapeutics Inc, dba ev3 Neurovascular) in combination with coils, and satisfactory results were obtained after a 4-month follow-up. Our cases illustrate that surgical revision should be used with caution as a temporary solution due to the high risk of rebleeding, whereas transhepatic embolization via the Onyx LES and coils could be considered a safe and effective choice for skillful managers.