A case of esophagojejunal varices rupture after proximal gastrectomy with double-tract reconstruction

Naoki Shinno,Chikato Koga,Shingo Noura,Atsuya Okada,Ryohei Kawabata,Junzo Shimizu,Junichi Hasegawa,Tae Matsumura,Haruna Furukawa,Toshinori Sueda,Seiichi Goda

doi:10.1186/s40792-020-0775-6

Naoki Shinno, Chikato Koga + Show 9 more

Open Access

https://doi.org/10.1186/s40792-020-0775-6

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Abstract

BackgroundThe varices after proximal or total gastrectomy are uncommon because the supplying vessels are all divided. Emergent upper gastrointestinal endoscopy is the cornerstone of first-line management for the diagnosis and treatment of esophageal varices. However, there is no widely accepted standard strategy for esophagojejunal varices. We report a patient with esophagojejunal varices rupture 3 months after proximal gastrectomy treated with percutaneous transhepatic obliteration.Case presentationA 50-year-old man who had undergone proximal gastrectomy with double-tract reconstruction for esophagogastric junctional cancer 3 months before was admitted to the hospital due to gastrointestinal perforation. We performed emergency surgery and abdominal symptoms and inflammatory response improved postoperative. However, on POD3, he had eruptive bleeding at the just anal side of esophagojejunal anastomosis. Endoscopic clipping was unsuccessful because the mucosa was fragile and easily lacerated. Contrast-enhanced CT scan revealed the dilatation of the jejunal vein flowing into the ascending jejunal limb. Therefore, he was diagnosed as esophagojejunal varices rupture and percutaneous transhepatic obliteration (PTO) was tried for hemostasis. The portal and superior mesenteric veins were catheterized with the percutaneous transhepatic approach. Contrast agent injection into the jejunal branch demonstrated retrograde flow to the azygos vein through esophagojejunal varices. The microcatheter was inserted into the variceal blood supply branch and 10 mL of 5% ethanolamine oleate with iopamidol was injected. After obliteration therapy, the superior mesenteric venogram showed complete occlusion of the variceal supply branch. The patient was discharged from the hospital without any complications after 14 days.ConclusionPTO can be effective for gastroesophageal varices rupture with a dilated jejunal vein of the ascending limb, few supplying vessels, and little ascites.

Highlights

Esophageal varices are one of the major complications of portal hypertension, and upper gastrointestinal endoscopy is the golden standard for the detection and treatment
percutaneous transhepatic obliteration (PTO) can be effective for gastroesophageal varices rupture with a dilated jejunal vein of the ascending limb, few supplying vessels, and little ascites
We report a patient with esophagojejunal varices rupture 3 months after proximal gastrectomy treated with percutaneous transhepatic obliteration (PTO)

Summary

Introduction

Esophageal varices are one of the major complications of portal hypertension, and upper gastrointestinal endoscopy is the golden standard for the detection and treatment. We report a patient with esophagojejunal varices rupture 3 months after proximal gastrectomy treated with percutaneous transhepatic obliteration (PTO). Emergency upper gastrointestinal endoscopy revealed an exposed blood vessel with eruptive bleeding at the just anal side of esophago-jejunum anastomosis (Fig. 1a). The results revealed the dilatation of the jejunal vein flowing into the ascending jejunal limb (Fig. 2). Based on this finding, the patient was diagnosed with esophagojejunal varices rupture, and we tried PTO for hemostasis. Contrast agent injection into the jejunal branch demonstrated retrograde flow to the azygos vein through esophagojejunal varices (Fig. 3a, b).

Discussion

Conclusion