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Gastrointestinal: Intractable delayed gastrointestinal bleeding after pancreatoduodenectomy

Wereport the case of a 66-year-oldwoman, a 4-year survivor of pancreatic adenocarcinoma, who developed a vascular anastomotic stricture of theportal vein/superiormesenteric vein (SMV)as a result of pancreatoduodenectomy with portal vein resection that was initially treated by stenting. This resulted in in-stent stenosis and recurrent gastrointestinal bleeding. On computed tomography imaging, the portal vein was thrombosed with partial stenosis of the SMV inferior to the stentwith a central thrombusbelow this. Therewas associated bowel wall edema (Fig. 1a). Gastroscopy and colonoscopy revealed moderate grade esophageal varices and grade two hemorrhoids. Enteroscopy demonstrated gastrointestinal varices (Fig. 1b). As the bleeding was a result of increased portal pressures, we performed a transjugular intrahepatic portosystemic shunt (TIPS). A tract was created with the right portal vein and stented with a 10mm×8+2 cmViatorr (Gore) Stent. This allowed access to the occluded portal vein stent where venoplasty was performed with a 4mm×10 cm Rival balloon (Bard) followed by thrombolysis using the Power Pulse function of the Angiojet through the Solent Omni catheter (Boston Scientific). This achieved successful recanalization of the superior mesenteric vein inferiorly. Residual thrombus in the right portal vein was treated with a Cragg-McNamara infusion catheter (ev3) thrombolysis with an infusion of 1mg tPA/h and intravenous heparin (500 units/h) (Fig. 2a). Two months later, the patient represented with recurrent melena. Computed tomography demonstrates stenosis in the TIPS stent and a short segment occlusion of the superior mesenteric/portal vein stent. Venogram now demonstrates marked venous collateralization/cavernous transformation allowing venoplasty at the TIPS stent and SMV that eventually achieved a normal appearing portal venogram (Fig. 2b). Manometry confirmed a reduction in portal pressures from 17 to 10mmHg post-treatment. Following the second TIPS procedure, the patient remains symptom free and has been well 12months after. This expanded application of TIPS allowed the successful treatment of an unusual cause of portal hypertensive gastrointestinal bleeding that occurred as a complication of vascular anastomotic stricture after pancreatoduodenectomy and portal vein resection.