• antithrombosis
• meta-analysis
• pancreatic surgery
• portal vein stenosis
• stents
• systematic review

• Humans
• Fibrinolytic Agents/administration & dosage
• Fibrinolytic Agents/adverse effects
• Pancreas/surgery
• Portal Vein
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Stents/adverse effects
• Vascular Patency/drug effects

• jejunal varix
• portal vein resection
• portal vein stenosis
• portal vein stent
• survival

• patency
• portal vein
• stent
• varix
• venous stenosis

• Aged
• Constriction, Pathologic/surgery
• Female
• Humans
• Male
• Middle Aged
• Pancreaticoduodenectomy
• Portal Vein/surgery
• Postoperative Complications/surgery
• Retrospective Studies
• Risk Factors
• Stents/adverse effects
• Time Factors
• Treatment Outcome
• Vascular Diseases/surgery

Margin-free resection is one of the most important factors for favorable prognosis in patients undergoing resection for hepatobiliary malignancies. Herein, we present two cases of hepatobiliary malignancies in patients who underwent bile duct resection combined with hilar portal vein (PV) resection and vein allograft patch plasty. The first case was a 51-year-old female patient with gallbladder cancer, in whom we performed extended cholecystectomy, bile duct resection and extensive lymph node dissection. The tumor-invaded PV wall was meticulously excised and the defect was repaired with a cryopreserved iliac vein allograft patch. The extent of the tumor was pT4N2M0 (stage IVB), thus concurrent chemoradiation therapy and adjuvant chemotherapy were performed. This patient is currently alive for 7 years after surgery without any evidence of tumor recurrence. The second case was a 79-year-old male patient with perihilar cholangiocarcinoma of type I and gallbladder cancer, in whom extended bile duct resection and extensive lymph node dissection were performed. The extent of the bile duct tumor was pT4N1M0 (stage IVA) and that of gallbladder tumor was pT2N0M0 (stage II). No additional treatment was provided because of old age and poor general condition. This patient passed away 11 months after surgery due to rapid progression of tumor recurrence. In conclusion, hilar PV wedge resection and roofing patch venoplasty is a useful option to facilitate complete tumor resection in patients undergoing bile duct resection for hepatobiliary malignancy.

• Bile duct resection
• Gallbladder cancer
• Perihilar cholangiocarcinoma
• Portal vein
• Vascular reconstruction

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.

Deprivation of portal blood flow decreases the hepatic function, thus hepatobiliary cancer patients with total occlusion of the main portal vein (PV) are usually not indicated for major hepatectomy. We herein present a 37-year-old male patient with advanced intrahepatic cholangiocarcinoma, in whom right trisectionectomy was indicated. However, the main PV was nearly completely occluded by tumor invasion, thus resolution of jaundice was markedly slow. To restore the liver function through PV recanalization, a wall stent was inserted percutaneously. Jaundice resolved progressively after PV stenting. Right trisectionectomy, caudate lobectomy, bile duct resection, and en bloc PV segmental resection with iliac vein homograft interposition were performed. However, PV thrombosis developed at the site of PV stent removal, thus a new wall stent was inserted during the operation. The pathology report presented that the tumor was a 5.2 cm-sized well-differentiated adenocarcinoma of periductal infiltrating type with lymph node metastasis. During the follow-up, the interposed PV segment with a wall stent was gradually occluded with development of portal collaterals. At 5 years after surgery, the PV stent was completely occluded and collaterals developed. The patient experienced repetition of febrile episodes of unknown causes. He is currently alive for 8 years with no evidence of tumor recurrence. The detailed surgical procedures were presented with a supplementary video clip of 5 minutes.

• Intahepatic cholangiocarcinoma
• Interposition
• Portal vein
• Right trisectionectomy
• Stent

• Embolization
• interventional radiology (IR)
• pancreatic resection
• postpancreatectomy hemorrhage
• stent-graft

The study aimed to describe portal stenting for postoperative portal occlusion with delayed (≥ 3 months) variceal bleeding in the afferent jejunal loop.

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.

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.

Interventional portal stenting is an effective treatment for delayed jejunal variceal bleeding due to portal occlusion after hepatobiliary-pancreatic surgery.

• Jejunal varix
• Portal vein obstruction
• Stent placement

• Gastrointestinal hemorrhage
• duodenum/surgery
• hypertension
• portal
• portal vein
• stents
• therapeutic embolization

Portal vein stenosis develops due to different causes including postoperative inflammation and oncological processes. However, limited effective therapy is available for portal vein stenosis. The objectives of this study were to evaluate the efficacy of a portal vein stent for portal vein stenosis after hepatobiliary pancreatic surgery and to determine the factors associated with stent patency.

From December 2003 to December 2015, portal vein stents were implanted in 29 patients who had portal vein stenosis after hepatobiliary pancreatic surgery. We conducted a retrospective analysis to evaluate the efficacy and safety of portal vein stent placement. Twelve clinical variables were analyzed for their role in stent patency.

The symptoms before portal vein stent placements included nine patients with hepatic encephalopathy, six patients with gastrointestinal bleeding, four patients with ascites, and four patients with hyperbilirubinemia. Portal vein thrombosis due to postoperative portal stenosis was found in four patients. Portal vein stent were successfully implanted without any major complications. Of the 21 patients with symptoms, 17 showed improvement, and stent patency was maintained in 22 (76%) patients. The presence of a collateral vein is the only variable related to the development of an occlusion after portal stenting.

Portal vein stent were implanted safely and had good long-term patency. This procedure is useful to relieve portal hypertension-related symptoms and to improve the quality of life. Our data strongly suggest that embolization to block blood flow in a collateral vein during portal vein stent placement will improve the patency of the stent.

• Hepatobiliary pancreatic surgery
• Portal vein stenosis
• Portal vein stent placement

To evaluate portal vein (PV) stenosis and stent patency after hepatobiliary and pancreatic surgery, using abdominal computed tomography (CT).

Percutaneous portal venous stenting was attempted in 22 patients with significant PV stenosis (> 50%) - after hepatobiliary or pancreatic surgery - diagnosed by abdominal CT. Stents were placed in various stenotic lesions after percutaneous transhepatic portography. Pressure gradient across the stenotic segment was measured in 14 patients. Stents were placed when the pressure gradient across the stenotic segment was > 5 mmHg or PV stenosis was > 50%, as observed on transhepatic portography. Patients underwent follow-up abdominal CT and technical and clinical success, complications, and stent patency were evaluated.

Stent placement was successful in 21 patients (technical success rate: 95.5%). Stents were positioned through the main PV and superior mesenteric vein (n = 13), main PV (n = 2), right and main PV (n = 1), left and main PV (n = 4), or main PV and splenic vein (n = 1). Patients showed no complications after stent placement. The time between procedure and final follow-up CT was 41-761 d (mean: 374.5 d). Twenty stents remained patent during the entire follow-up. Stent obstruction - caused by invasion of the PV stent by a recurrent tumor - was observed in 1 patient in a follow-up CT performed after 155 d after the procedure. The cumulative stent patency rate was 95.7%. Small in-stent low-density areas were found in 11 (55%) patients; however, during successive follow-up CT, the extent of these areas had decreased.

Percutaneous transhepatic stent placement can be safe and effective in cases of PV stenosis after hepatobiliary and pancreatic surgery. Stents show excellent patency in follow-up abdominal CT, despite development of small in-stent low-density areas.

• Liver
• Vein
• Stent
• Computed tomography
• Surveillance
• Efficace

• Adult
• Aged
• Angioplasty, Balloon/adverse effects
• Angioplasty, Balloon/instrumentation
• Computed Tomography Angiography
• Constriction, Pathologic
• Digestive System Surgical Procedures/adverse effects
• Female
• Humans
• Kaplan-Meier Estimate
• Male
• Middle Aged
• Phlebography/methods
• Portal Pressure
• Portal Vein/diagnostic imaging
• Portal Vein/physiopathology
• Portography/methods
• Retrospective Studies
• Stents
• Time Factors
• Treatment Outcome
• Vascular Diseases/diagnostic imaging
• Vascular Diseases/etiology
• Vascular Diseases/physiopathology
• Vascular Diseases/therapy
• Vascular Patency

• Biliary cancer
• Portal vein stenosis
• Recurrence
• Stent

We present 2 patients showing afferent jejunal varix bleeding around hepaticojejunostomy caused by extrahepatic portal vein obstruction after pylorus-preserving pancreatoduodenectomy (PPPD). The case 1 was a 58-year-old woman who had recurrent anemia and hematochezia 3 years after undergoing PPPD. On the portography, the main portal vein was obliterated and collaterals around hepaticojejunostomy were developed. After percutaneous transhepatic balloon dilatation and stent placement through the obliterated portal vein, jejunal varices had disappeared and thereafter no bleeding occurred for 32 months. The case 2 was a 71-year-old man who had frequent melena 7 years after PPPD. Portal stent insertion was first tried, but failed due to severe stenosis of the main portal vein. Therefore, meso-caval shunt operation was attempted in order to reduce the variceal flow. Although an episode of a small amount of melena occurred one month after the shunt operation, there was no occurrence of bleeding for the next 8 months. For the treatment of jejunal varices, a less invasive approach, such as the angiographic intervention of stent insertion, balloon dilatation, or embolization is recommended first. Surgical operations, such as a shunt or resection of the jejunal rim, could be considered when noninvasive approaches have failed.

• Hepaticojejunostomy
• Jejunal varices
• Percutaneous transhepatic angioplasty
• Portal vein stenosis
• Portocaval shunt