Central splenorenal shunt for hemorrhagic varices around a choledochojejunostomy site secondary to extrahepatic portal vein obstruction after pancreatoduodenectomy

Abstract

A 58-year-old woman underwent pylorus-preserving pancreatoduodenectomy with an Imanaga reconstruction, including choledochojejunostomy, for minimally invasive intraductal papillary mucinous carcinoma of the pancreatic head in 2001 and presented with severe gastrointestinal bleeding episodes in 2005. After the Imanaga reconstruction, we endoscopically identified bleeding from varices around the choledochojejunostomy site. Endoscopic clipping was successfully performed to stop the bleeding. Angiography showed that the repeat bleeding originated from obstructions of the main portal trunk and collateral veins. These obstructions were believed to have formed varices around the choledochojejunostomy site consequent to portal hypertension and secondary to extrahepatic portal vein obstruction. Through a transmesenteric approach under general anesthesia, metallic stents were placed in a Y-shape between the main trunk and bilateral intrahepatic branches of the portal vein using portography and interventional laparotomy techniques, followed by embolization of the jejunal varices. However, bleeding recurred after 5 months. Despite endoscopic treatments such as sclerotherapy and clipping, intermittent bleeding from the varices continued for more than 4 months. Finally, in 2006, a central splenorenal shunt and an initial splenectomy were performed to divert some of the portal blood to systemic circulation. Subsequently, the patient resumed normal activities and has not experienced complications such as bleeding or hepatic encephalopathy during the 9-year follow-up. In conclusion, this is a special case of portosystemic shunt placement in this patient that was found to be safe and effective for the treatment of variceal bleeding around a choledochojejunostomy site secondary to extrahepatic portal vein obstruction after pancreatoduodenectomy.