Jejunal varices around the hepaticojejunostomy (HJ) site are rare complications of pancreaticoduodenectomy and may cause massive and life-threatening gastrointestinal bleeding.1 The complex postoperative anatomy makes endoscopic access technically demanding, and optimal management remains to be established.
A 48-year-old man underwent pylorus-preserving pancreaticoduodenectomy with pediatric reconstruction for pancreatic cancer. During chemotherapy for tumor recurrence, he developed recurrent hematochezia, and bleeding from the jejunal varices at the HJ site was suspected (Fig. 1). Despite blood transfusions, the patient developed severe anemia due to recurrent bleeding.
Fig. 1.
Endoscopic and radiological findings for jejunal varices at the hepaticojejunostomy site. (A) Coronal view of non-contrast-enhanced computed tomography showing dilated varices along the afferent jejunal limb. (B) Coronal view of contrast-enhanced computed tomography during the portal venous phase, highlighting the jejunal varices (circle). (C, D) Endoscopic images showing prominent varices around the hepaticojejunostomy anastomosis.
Conventional oblique-viewing echoendoscopes have limited flexibility, making deep insertion difficult in patients with surgically altered anatomy. A forward-viewing convex echoendoscope (TGF-UC260J; Olympus Medical) allows for deep access and stable visualization. Endoscopic ultrasound (EUS) revealed prominent varices at the anastomotic site. A varix measuring approximately 7 mm was punctured under real-time EUS guidance using a 19-gauge needle (EZ Shot 3 Plus; Olympus Medical) after removing the stylet and priming it with contrast medium (Video 1). Aspiration of the dark venous blood confirmed the intravariceal placement, followed by contrast injection under fluoroscopic guidance to delineate the inflow and outflow. The needle was flushed with 50% glucose solution before and after the glue injection. During the first session, 2.5 mL of 83% N-butyl-2-cyanoacrylate was injected, followed by an additional 4.5 mL one week later. Doppler sonography confirmed immediate disappearance of the flow, and post-treatment imaging verified obliteration of the varices. No adverse events occurred, and two months after the second session, the patient remained without rebleeding.
Forward-viewing EUS-guided vascular intervention for jejunal varices at the HJ site has been described in only one report previously.2 Our case represents the second reported instance treated using this approach, demonstrating its feasibility and potential generalizability.3 Although coil-assisted embolization could have reduced the glue volume, coil use was not feasible because it is not reimbursed by the Japanese health insurance system.
Footnotes
Conflicts of Interest
The authors have no potential conflicts of interest.
Funding
None.
Acknowledgments
Informed consent was obtained from the patient for the publication of this case report and the accompanying images and video.
Author Contributions
Conceptualization: KO, MW; Procedure: KO, MW, SI, AT; Writing–original draft: KO, NN, CK; Writing–review & editing: all authors.
Video
Endoscopic ultrasound-guided cyanoacrylate injection for jejunal varices at the hepaticojejunostomy site using a forward-viewing echoendoscope.
A video related to this article can be found online at https://doi.org/ce.2025.333.
REFERENCES
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Associated Data
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Supplementary Materials
Endoscopic ultrasound-guided cyanoacrylate injection for jejunal varices at the hepaticojejunostomy site using a forward-viewing echoendoscope.