Marginal Ulcer Following Completion Pancreatectomy Complicated by Portal Vein Erosion

Abstract

Marginal ulcers are a known complication of pancreaticoduodenectomy (PD) and total pancreatectomy (TP) with mean incidence of 2.5%. When severe bleeding is encountered, mortality rate has been reported above 20%. 57-year-old female with remote history of pancreatic tail intraductal papillary mucinous neoplasm (IPMN) status post distal pancreatectomy/splenectomy and subsequent completion pancreatectomy for pancreatic head IPMN presented three years later with acute gastrointestinal bleed. Abdominal computed tomography revealed air between superior mesenteric vein (SMV) and duodenum concerning for SMV erosion. Esophagogastroduodenoscopy demonstrated large actively bleeding gastrojejunal (GJ) anastomosis ulcer; controlled with over-the-scope clips. (Figure-1) Five days later, patient developed significant hematochezia with acutely decreased hemoglobin. Taken emergently to operating room (OR), GJ opened for exploration revealing 10 x 5 cm ulcer with brisk venous bleeding from 1 cm portal vein (PV) defect. This was repaired with 3-0 Prolene and overlying mucosa imbricated with 3-0 Vicryl. Hemostasis confirmed, patient left open and returned to OR within 48 hours. All intestine was viable and abdomen closed. Postoperative course complicated by development of acute on chronic deep vein thrombosis prompting inferior vena cava filter placement. Discharged to long term acute care facility and eventually returned home. Marginal ulcers from PD and TP causing portal vein erosion are extremely rare and carry high morbidity and mortality. Massive hemorrhage from these ulcers is an emergency and difficult to treat due to acute decompensation. Multimodal approach to treatment of these patients is warranted due to their complexity, but may require urgent operative intervention if other modalities fail.