We report herein the case of a patient successfully treated by transhepatic portal venous stent placement for malignant portal vein obstruction with associated gastric and small bowel varices and repeated gastrointestinal bleeding. CT angiography and portography showed severe portal vein obstruction from recurrent pancreatic cancer 15 months following pancreaticoduodenectomy with tumor encasement and dilated collateral veins throughout the gastric and proximal small bowel wall as the suspected cause of the GI bleeding. Successful transhepatic endovascular stent placement of the splenic vein at the portal vein confluence followed by balloon dilation was performed with immediate decompression of the gastric and small bowel varices and relief of GI hemorrhage in this patient until his death four months later. The treatment for patients with this dilemma can prove to be difficult, but as we have shown endovascular stenting of the portal system is an effective treatment option.
Pancreatic cancer remains a major oncologic challenge making up 2
A 58-year-old man was referred to our institution for a suspicious mass within the neck of the pancreas with a dilated pancreatic duct and evidence of chronic pancreatitis identified by abdominal computed tomography (CT). An endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) identified adult diagnosed pancreatic divisum with a 2.5 cm mass within the neck of the pancreas and pancreatic duct stricture. A fine needle aspiration (FNA) of this area showed only chronic inflammation and a CA 19-9 level returned within normal limits. Review at our institutional multidisciplinary conference led to recommendations for surgical resection, and ten months after his initial presenting symptoms, the patient underwent a pylorus-preserving pancreaticoduodenectomy. The final pathology revealed a specimen with chronic pancreatitis and one small focus of invasive carcinoma with perineural invasion. No tumor was identified in twenty-one lymph nodes. All surgical margins were negative for tumor. The patient made an uneventful recovery and afterward elected to forego any further adjuvant treatments.
The patient did well while undergoing routine surveillance until approximately 15 months later when he began to experience mild to moderate abdominal discomfort and nausea. A repeat CT scan of the abdomen revealed a mass at the site of the previous surgical resection with narrowing of the PV confluence and extensive lymphadenopathy at the root of the mesentery. An ultrasound-guided biopsy of this area confirmed recurrent well-differentiated adenocarcinoma, and the patient began concurrent chemoradiotherapy with continuous infusion 5-fluorouracil and external beam radiation therapy (EBRT) for a total dose of 54 Gy.
On follow-up the patient developed upper gastrointestinal (GI) bleeding, requiring multiple blood transfusions, and on upper endoscopy was found to be due to varices of the proximal gastric wall, which appeared to extended through the anastamosis into the efferent jejunal limb. At the time of endoscopy there was no evidence of active bleeding, and so we elected to proceed with medical management for the patient to include
During the same hospitalization the patient again developed variceal bleeding. We found that the recurrent pancreatic tumor had caused a high-grade neoplastic obstruction of the SV at the PV confluence and as a consequence resulted in mesenteric hypertension and gastric and small bowel varices that were refractory to our medical management (Figures
CT evidence of the recurrent pancreatic mass in the previous surgical bed (large arrow) and demonstration of obstruction of the splenic vein at the portal vein confluence (small arrow).
CT angiography coronal plane reconstruction showing the portal vein system with obstruction from the recurrent pancreatic tumor at the portal vein confluence (white arrow) and resulting gastric and small bowel varices (black arrows).
Isolated portal system reconstruction defining the obstruction of the splenic vein at the portal vein confluence (block arrow) and clear confirmation of the subsequent gastric and small bowel varices (normal arrows).
Transhepatic portography characterizing the splenic vein obstruction from the recurrent pancreatic tumor (white arrow) with dilated varices proximally (black arrows).
Transhepatic portography after endovascular stent placement and balloon dilation of the splenic vein obstruction (white arrow) with dramatic decompression of the proximal varices (black arrows).
Immediately after the procedure the patient had no additional episodes of melena or hematemesis, and no further blood transfusions were required. Seven days following the procedure the patient was discharged home from the hospital tolerating an advancing diet. He died 4 months later from natural progression of the malignancy. During this time, he did not experience any additional episodes of GI bleeding and remained relatively comfortable.
Pancreatic cancer remains an oncologic challenge where early metastatic relapse after complete resection is frequently encountered. Sperti et al reported local and hepatic recurrence rates of 72
Extrahepatic portal venous obstruction accounts for 5
Prehepatic portal hypertension from portal vein stenosis or occlusion secondary to malignant invasion is a difficult entity to diagnose and treat. This difficulty is exemplified by the fact that occlusion of the portal vein frequently does not produce an acute manifestation. The reasons are twofold why the blocking of portal blood flow, which accounts for two thirds of the total hepatic supply, results in few clinical manifestations. The first is because of the compensatory mechanism of vasodilation of the hepatic arterial system occurs in response to a decrease in portal vein flow [
When symptoms do occur, they can present in a variety of ways [
As exemplified by our patient, these cases can be a diagnostic and treatment dilemma, with treatment options being few due to rapid tumor growth and related diseases resulting in a very poor prognosis. Historically, treatments for such conditions have been radiation therapy or chemotherapy; however, resolution of the signs and symptoms may have a delayed period of effect up to 3 weeks [
We report here the successful SV at the PV confluence stenting of a patient with active variceal bleeding due to recurrent pancreatic cancer. A MEDLINE review of literature yields a total of 64 reported cases of portal vein stent placement, the first of which was by Harville et al. in 1991 [
The largest series reported in literature is by Yamakodo et al. where they were able to place stents into the portal venous system via a percutaneous transhepatic route across 28 stenotic and 12 obstructive lesions [
Extrahepatic portal venous obstruction can be a major cause of portal hypertension and morbidity to these patients. It seems that in a selected patient population portal venous stents can be used affectively to palliate the symptoms caused by portal hypertension due to these types of conditions. Future studies, like the one by Yamakodo et al. showing that portal venous stent patency is prolonged when there is not substantial splanchnic vein involvement, are needed to further clarify and classify which group of patients with malignant portal venous involvement would benefit from such therapy [
The presence of recurrence occurring at the superior mesenteric/portal venous confluence raises the question of initial portal vein resection. Although the indication and contraindication for portal vein resection has not universally defined, there are many reports addressing its benefit [
The treatment for patients with malignant superior mesenteric/portal vein obstruction and associated bleeding esophageal and gastric varies can prove to be difficult, but as we have shown endovascular stenting of the portal system is an effective treatment option.