Korean J Hepatobiliary Pancreat Surg.  2016 Feb;20(1):44-47. 10.14701/kjhbps.2016.20.1.44.

Postoperative portal vein thrombosis and gastric hemorrhage associated with late-onset hemorrhage from the common hepatic artery after pancreaticoduodenectomy

• Watanobe I
• Ito Y
• Akimoto E
• Sekine Y
• Haruyama Y
• Amemiya K
• Miyano S
• Kosaka T
• Machida M
• Kitabatake T
• Kojima K

• KMID: 2243031
• DOI: http://doi.org/10.14701/kjhbps.2016.20.1.44

Abstract

Portal vein thrombosis (PVT) is a rare but serious postoperative complication of pancreaticoduodenectomy (PD). We reported a case of late-onset postoperative PVT with hemorrhage from the common hepatic artery (CHA) in a 73-year-old man who underwent pylorus-preserving pancreaticoduodenectomy (PPPD) for duodenum papilla cancer, followed by reconstruction using the modified Child's technique. The pancreaticojejunostomy was achieved by end-to-side, 2-layer invagination anastomosis without pancreatic duct stenting. Drain removal and hospital discharge were scheduled on postoperative day (POD) 18, but blood-stained fluid in the drain and sudden hematemesis were noted. Emergency surgery was performed because PVT and imaging findings were suggestive of necrosis of the lifted jejunum. Although no jejunal necrosis was identified during surgery, bleeding from the side of the CHA was detected and the bleeding point was suture-closed to achieve hemostasis. We suspected late-onset postoperative arterial hemorrhage and subsequent hematoma formation, which caused portal vein compression and PVT formation. We chose a conservative treatment strategy for PVT, taking into account the operation time, intraoperative vital signs and blood flow in the portal vein. Despite the complicated postoperative course, he was discharged home in a fully ambulatory state on POD 167.

Keyword

Portal vein thrombosis; Pancreaticoduodenectomy; Late-onset hemorrhage; Postoperative hemorrhage; Postoperative pancreatic fistula

MeSH Terms

Aged
Duodenum
Emergencies
Hematemesis
Hematoma
Hemorrhage*
Hemostasis
Hepatic Artery*
Humans
Jejunum
Necrosis
Pancreatic Ducts
Pancreaticoduodenectomy*
Pancreaticojejunostomy
Portal Vein*
Postoperative Complications
Postoperative Hemorrhage
Stents
Venous Thrombosis*
Vital Signs

Figure

• 

  Fig. 1 Abdominal computed tomography (CT) scans at postoperative day 18 showed edematous wall thickening and portal vein gas associated with bowel ischemia and necrosis. (A) Gas in the superior mesenteric vein (arrows); (B) Gas in the area corresponding to the wall of the lifted jejunum, with a series of bubbles suggestive of intramural emphysema (arrows).

• 

  Fig. 2 Contrast-enhanced CT scans after hemostatic treatment at postoperative day 18. (A) Thrombi were found from the superior mesenteric vein to the portal vein (arrow); (B) The right and left intra-hepatic portal branches were contrast-enhanced, indicating preserved blood flow (arrows).

• 

  Fig. 3 Ultrasonographic examination of blood flow at 149 days after the second surgery. (A) Examination of the left hepatic artery was performed, as it was easily identified. The results confirm preserved blood flow; (B) Portal blood flow was easily measured at the umbilical point. The results confirm preserved blood flow.

Reference

1. Monge JJ, Judd ES, Gage RP. Radical pancreatoduodenectomy: a 22-year experience with the complications, mortality rate, and survival rate. Ann Surg. 1964; 160:711–722. PMID: 14210370.

2. Mergenthaler FW, Harris MN. Superior mesenteric vein thrombosis complicating pancreatoduodenectomy: successful treatment by thrombectomy. Ann Surg. 1968; 167:106–111. PMID: 5635177.

3. Thomas RM, Ahmad SA. Management of acute post-operative portal venous thrombosis. J Gastrointest Surg. 2010; 14:570–577. PMID: 19582513.

4. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. International Study Group on Pancreatic Fistula Definition. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005; 138:8–13. PMID: 16003309.

5. Whipple AO, Parsons WB, Mullins CR. Treatment of carcinoma of the ampulla of vater. Ann Surg. 1935; 102:763–779. PMID: 17856666.

6. Cameron JL, Riall TS, Coleman J, Belcher KA. One thousand consecutive pancreaticoduodenectomies. Ann Surg. 2006; 244:10–15. PMID: 16794383.

7. Gouillat C, Chipponi J, Baulieux J, Partensky C, Saric J, Gayet B. Randomized controlled multicentre trial of somatostatin infusion after pancreaticoduodenectomy. Br J Surg. 2001; 88:1456–1462. PMID: 11683740.

8. Büchler MW, Wagner M, Schmied BM, Uhl W, Friess H, Z'graggen K. Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg. 2003; 138:1310–1314. PMID: 14662530.

9. Balcom JH 4th, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg. 2001; 136:391–398. PMID: 11296108.

10. Büchler MW, Friess H, Wagner M, Kulli C, Wagener V, Z'Graggen K. Pancreatic fistula after pancreatic head resection. Br J Surg. 2000; 87:883–889. PMID: 10931023.

11. Choi SH, Moon HJ, Heo JS, Joh JW, Kim YI. Delayed hemorrhage after pancreaticoduodenectomy. J Am Coll Surg. 2004; 199:186–191. PMID: 15275871.

12. Suc B, Msika S, Fingerhut A, Fourtanier G, Hay JM, Holmières F, et al. French Associations for Surgical Research. Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective randomized trial. Ann Surg. 2003; 237:57–65. PMID: 12496531.

13. Virchow RR. Cellular pathology. London: Churchill;1860.