Successful treatment using balloon-assisted enteroscopy for jejunal loop variceal bleeding after pancreaticoduodenectomy

Management of jejunal variceal bleeding after pancreaticoduodenectomy can be difficult. Previously, these cases were treated by portal vein stenting or shunt operations, resulting in a high likelihood of rebleeding. Endoscopic management could provide an alternative to invasive surgery; however, few reports have demonstrated endoscopic treatment ^{1 2 3 4} . We report a successful case of balloon-assisted enteroscopy for jejunal loop variceal bleeding.

A 66-year-old man had undergone pancreaticoduodenectomy with portal vein resection for pancreatic cancer. He had a history of jejunal loop variceal bleeding ( Fig. 1 ), and transvenous vein obliteration via laparotomy ( Fig. 2 ). Enhanced computed tomography revealed the presence of cavernous vessels in the hepatic hilus ( Fig. 3 ). Surgery and additional interventional radiology via laparotomy would be difficult due to adhesions and a high likelihood of rebleeding. Therefore, endoscopic treatment was attempted ( Video 1 ).

Fig. 1.

 Enhanced computed tomography revealed cavernous vessels at the hepatic hilus caused by portal hypertension.

Fig. 2.

 Transvenous vein obliteration via laparotomy was performed in the previous hospital.

Fig. 3.

 Enhanced computed tomography revealed recurrence of varicose veins.

Video 1  Successful sclerotherapy using balloon-assisted enteroscopy for jejunal loop variceal bleeding after pancreaticoduodenectomy combined with resection of the portal vein.

Download video file ^{(19.1MB, mp4)}

Endoscopic findings revealed F2 varices ( Fig. 4 ) and a white plug near the jejunojejunostomy of the jejunal loop. We observed bleeding while the patient was coughing, which made us suspect that the hemorrhage resulted from a rupture of the varices. We punctured the varicose vein using a 25-gauge needle (TOP Co., Tokyo, Japan) and injected 64 % N-butyl-2-cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany). We confirmed stagnation of the sclerosing agent in the varicose vein and no obvious leak into the intrahepatic portal vein ( Fig. 5 ). He was discharged 5 days postoperatively without rebleeding.

Fig. 4.

 F2 varices were observed near the cholangiojejunostomy of the jejunum loop.

Fig. 5.

 Stagnation of sclerosing agent in the varicose vein was observed on enhanced computed tomography after 3 days of treatment.

The endoscopic approach for patients with surgically altered gastrointestinal anatomy is technically challenging but less invasive. It enables multiple treatment interventions compared with interventional radiology via laparotomy. Moreover, the endoscopic approach may be ideal for direct diagnosis and immediate treatment compared with invasive surgery and interventional radiology. There are few reports of sclerotherapy using Histoacryl for balloon-assisted enteroscopy, owing to the technical difficulty, but it may be an effective treatment option with less recurrence of bleeding.

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