Kuwabara Shota, Matsumoto Joe, Tojima Hiroyasu, Wada Hideyuki, Kato Kohei, Tabata Yukiko, Ichinokawa Masaomi, Yoshioka Tatsuya, Murakawa Katsuhiko, Ikeda Atsushi, Ohtake Setsuyuki, Ono Koichi
Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan.
Surg Case Rep. 2020 Jun 3;6(1):126. doi: 10.1186/s40792-020-00888-9.
Pancreatoduodenectomy with resection of the portal vein or superior mesenteric vein confluence has been safely performed in patients with pancreatic head cancer associated with infiltration of the portal vein or superior mesenteric vein. In recent years, left-sided portal hypertension, a late postoperative complication, has received focus owing to increased long-term survival with advances in chemotherapy. Left-sided hypertension may sometimes cause fatal gastrointestinal bleeding because of the rupture of gastrointestinal varices. Here, we present a case of colonic varices caused by left-sided portal hypertension after pancreatoduodenectomy with portal vein resection.
A 69-year-old man diagnosed with pancreatic head cancer was referred to our department for surgery after undergoing chemotherapy with nine courses of gemcitabine and nab-paclitaxel. Computed tomography showed a mass 25 mm in diameter and in contact with the portal vein. He had undergone subtotal stomach-preserving pancreatoduodenectomy with portal vein resection. Four centimeters of the portal vein had been resected, and end-to-end anastomosis was performed without splenic vein reconstruction. We had to completely resect the right colic vein, accessary right colic vein, and middle colic vein due to tumor invasion. The pathological diagnosis was ypT3, ypN1a, ypM0, and ypStageIIB, and he was administered TS-1 as postoperative adjuvant chemotherapy. Seven months after therapeutic radical surgery, he presented with melena with progressive anemia. Computed tomography revealed transverse colonic varices. He was offered interventional radiology. Trans-splenic arterial splenic venography showed that transverse colonic varices had developed as collateral circulation of the splenic vein and inferior mesenteric vein system. An embolic substance was injected into the transverse colonic varices, which halted the progression of the anemia caused by melena. Fifteen months after therapeutic radical surgery, local recurrence of the tumor occurred; he died 28 months after the surgery.
When subtotal stomach-preserving pancreatoduodenectomy with portal vein resection is performed without splenic vein reconstruction, colonic varices may result from left-sided portal hypertension. Interventional radiology is an effective treatment for gastrointestinal bleeding due to colonic varices, but it is important to be observant for colonic necrosis and new varices.
对于伴有门静脉或肠系膜上静脉浸润的胰头癌患者，已安全实施了门静脉或肠系膜上静脉汇合部切除的胰十二指肠切除术。近年来，随着化疗进展使长期生存率提高，作为术后晚期并发症的左侧门静脉高压受到关注。左侧门静脉高压有时可能因胃肠道静脉曲张破裂导致致命的胃肠道出血。在此，我们报告1例门静脉切除术后胰十二指肠切除引起左侧门静脉高压导致结肠静脉曲张的病例。
一名69岁男性被诊断为胰头癌，在接受9个疗程吉西他滨和白蛋白结合型紫杉醇化疗后转诊至我科接受手术。计算机断层扫描显示一个直径25毫米的肿块，与门静脉接触。他接受了保留部分胃的门静脉切除胰十二指肠切除术。切除了4厘米门静脉，未进行脾静脉重建，行端端吻合。由于肿瘤侵犯，不得不完全切除右结肠静脉、副右结肠静脉和中结肠静脉。病理诊断为ypT3、ypN1a、ypM0和ypIIB期，术后给予替吉奥作为辅助化疗。根治性手术后7个月，他出现黑便并伴有进行性贫血。计算机断层扫描显示横结肠静脉曲张。为他提供了介入放射学治疗。经脾动脉脾静脉造影显示，横结肠静脉曲张是作为脾静脉和肠系膜下静脉系统的侧支循环发展而来。向横结肠静脉曲张内注入栓塞物质，止住了黑便引起的贫血进展。根治性手术后15个月，肿瘤局部复发；他在手术后28个月死亡。
在未进行脾静脉重建的情况下实施保留部分胃的门静脉切除胰十二指肠切除术时，左侧门静脉高压可能导致结肠静脉曲张。介入放射学是治疗结肠静脉曲张引起的胃肠道出血的有效方法，但必须密切观察结肠坏死和新的静脉曲张情况。
