Korean J Radiol.  2017 Oct;18(5):828-834. 10.3348/kjr.2017.18.5.828.

Portal Vein Stenting for Delayed Jejunal Varix Bleeding Associated with Portal Venous Occlusion after Hepatobiliary and Pancreatic Surgery

• Hyun D
• Park KB
• Cho SK
• Park HS
• Shin SW
• Choo SW
• Do YS
• Choo IW
• Choi DW

• KMID: 2427219
• DOI: http://doi.org/10.3348/kjr.2017.18.5.828

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.

Keyword

Portal vein obstruction; Jejunal varix; Stent placement

MeSH Terms

Adolescent
Adult
Aged
Biliary Atresia/pathology/*surgery/therapy
Child
Child, Preschool
Female
Hemorrhage/*etiology
Humans
Jejunum/blood supply
Liver Transplantation
Male
Middle Aged
Neoplasm Recurrence, Local
Pancreatic Neoplasms/pathology/*surgery/therapy
Pancreaticoduodenectomy
Portal Vein/pathology
Postoperative Complications
Stents/*adverse effects
Tomography, X-Ray Computed
Treatment Outcome
Varicose Veins/pathology
Young Adult

Figure

• 

  Fig. 1 53-year-old man with hematochezia.Patient underwent pylorus-preserving pancreaticoduodenectomy due to pancreatic cancer 737 days ago.A. Axial image shows varix in afferent jejunal loop (arrow). B, C. Direct portogram (B) via transhepatic approach shows occlusion of main portal vein (arrowhead). Superior mesenteric venogram (C) demonstrates extensive collateral channels along afferent jejunal loop (arrow) and segmental occlusion of portal vein (smaller arrows). D. Direct venogram after deployment of stent (12 mm in diameter and 80 mm in length) shows disappearance of collateral channels and opacification of both portal veins. E. Follow-up CT performed 60 days after portal stenting shows patent stent and disappearance of varix in afferent jejunal loop (arrow).

• 

  Fig. 2 Primary patency rate of portal stent.

Reference

1. Choi JW, Kim HC, Jae HJ, Jung HS, Hur S, Lee M, et al. Transcatheter embolotherapy with N-butyl cyanoacrylate for ectopic varices. Cardiovasc Intervent Radiol. 2015; 38:344–351. PMID: 25011645.

2. Hiraoka K, Kondo S, Ambo Y, Hirano S, Omi M, Okushiba S, et al. Portal venous dilatation and stenting for bleeding jejunal varices: report of two cases. Surg Today. 2001; 31:1008–1011. PMID: 11766071.

3. Mathias K, Bolder U, Löhlein D, Jäger H. Percutaneous transhepatic angioplasty and stent implantation for prehepatic portal vein obstruction. Cardiovasc Intervent Radiol. 1993; 16:313–315. PMID: 8269429.

4. Ota S, Suzuki S, Mitsuoka H, Unno N, Inagawa S, Takehara Y, et al. Effect of a portal venous stent for gastrointestinal hemorrhage from jejunal varices caused by portal hypertension after pancreatoduodenectomy. J Hepatobiliary Pancreat Surg. 2005; 12:88–92. PMID: 15754107.

5. 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. 2013; 43:550–555. PMID: 22777133.

6. Sakai M, Nakao A, Kaneko T, Takeda S, Inoue S, Yagi Y, et al. Transhepatic portal venous angioplasty with stenting for bleeding jejunal varices. Hepatogastroenterology. 2005; 52:749–752. PMID: 15966197.

7. Sato T, Yasui O, Kurokawa T, Hashimoto M, Asanuma Y, Koyama K. Jejunal varix with extrahepatic portal obstruction treated by embolization using interventional radiology: report of a case. Surg Today. 2003; 33:131–134. PMID: 12616377.

8. Kang MJ, Jang JY, Chang YR, Jung W, Kim SW. Portal vein patency after pancreatoduodenectomy for periampullary cancer. Br J Surg. 2015; 102:77–84. PMID: 25393075.

9. Wang J, Yang W, Huang Q, Gao K, Wei B, Zhai R, et al. Interventional treatment for portal venous occlusion after liver transplantation: long-term follow-up results. Medicine (Baltimore). 2015; 94:e356. PMID: 25634164.

10. Hwang S, Sung KB, Park YH, Jung DH, Lee SG. Portal vein stenting for portal hypertension caused by local recurrence after pancreatoduodenectomy for periampullary cancer. J Gastrointest Surg. 2007; 11:333–337. PMID: 17458607.

11. Ko GY, Sung KB, Lee S, Yoon HK, Kim KR, Kim KM, et al. Stent placement for the treatment of portal vein stenosis or occlusion in pediatric liver transplant recipients. J Vasc Interv Radiol. 2007; 18:1215–1221. PMID: 17911510.

12. Park KB, Choo SW, Do YS, Shin SW, Cho SG, Choo IW. Percutaneous angioplasty of portal vein stenosis that complicates liver transplantation: the mid-term therapeutic results. Korean J Radiol. 2005; 6:161–166. PMID: 16145291.

13. Tannuri U, Velhote MC, Santos MM, Gibelli NE, Ayoub AA, Maksoud-Filho JG, et al. Pediatric liver transplantation: fourteen years of experience at the children institute in SãoPaulo, Brazil. Transplant Proc. 2004; 36:941–942. PMID: 15194325.

14. Carnevale FC, de Tarso Machado A, Moreira AM, Dos Santos AC, da Motta-Leal-Filho JM, Suzuki L, et al. Long-term results of the percutaneous transhepatic venoplasty of portal vein stenoses after pediatric liver transplantation. Pediatr Transplant. 2011; 15:476–481. PMID: 21585632.

15. Saad WE, Saad NE, Koizumi J. Stomal varices: management with decompression tips and transvenous obliteration or sclerosis. Tech Vasc Interv Radiol. 2013; 16:176–184. PMID: 23830674.

16. Eriguchi N, Aoyagi S, Hara M, Miyazaki T, Tanaka M, Toyonaga A. Jejunal varices as a cause of massive gastrointestinal bleeding--a case report. Kurume Med J. 1998; 45:227–230. PMID: 9715053.

17. Yuki N, Kubo M, Noro Y, Kasahara A, Hayashi N, Fusamoto H, et al. Jejunal varices as a cause of massive gastrointestinal bleeding. Am J Gastroenterol. 1992; 87:514–517. PMID: 1553940.

18. Sasamoto A, Kamiya J, Nimura Y, Nagino M. Successful embolization therapy for bleeding from jejunal varices after choledochojejunostomy: report of a case. Surg Today. 2010; 40:788–791. PMID: 20676866.

19. Sakurai K, Amano R, Yamamoto A, Nishida N, Matsutani S, Hirata K, et al. Portal vein stenting to treat portal vein stenosis in a patient with malignant tumor and gastrointestinal bleeding. Int Surg. 2014; 99:91–95. PMID: 24444277.

20. Sacks D, McClenny TE, Cardella JF, Lewis CA. Society of Interventional Radiology clinical practice guidelines. J Vasc Interv Radiol. 2003; 14(9 Pt 2):S199–S202. PMID: 14514818.

21. Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology. 1998; 28:1154–1158. PMID: 9755256.

22. Moncure AC, Waltman AC, Vandersalm TJ, Linton RR, Levine FH, Abbott WM. Gastrointestinal hemorrhage from adhesion-related mesenteric varices. Ann Surg. 1976; 183:24–29. PMID: 1082310.

23. Lein BC, McCombs PR. Bleeding varices of the small bowel as a complication of pancreatitis: case report and review of the literature. World J Surg. 1992; 16:1147–1149. discussion 1150. PMID: 1455887.

24. Bambini DA, Superina R, Almond PS, Whitington PF, Alonso E. Experience with the Rex shunt (mesenterico-left portal bypass) in children with extrahepatic portal hypertension. J Pediatr Surg. 2000; 35:13–18. discussion 18-19. PMID: 10646766.

25. Chen VT, Wei J, Liu YC. A new procedure for management of extrahepatic portal obstruction. Proximal splenic-left intrahepatic portal shunt. Arch Surg. 1992; 127:1358–1360. PMID: 1444799.

26. Saad WE, Kitanosono T, Koizumi J, Hirota S. The conventional balloon-occluded retrograde transvenous obliteration procedure: indications, contraindications, and technical applications. Tech Vasc Interv Radiol. 2013; 16:101–151. PMID: 23830671.