-
Surgical Case Reports Nov 2023Left-sided portal hypertension including gastric venous congestion may be caused by ligating the splenic vein during pancreaticoduodenectomy with portal vein resection...
Reconstruction with the right gastroepiploic vein during pancreaticoduodenectomy and total pancreatectomy to prevent left-sided portal hypertension: a report of two cases.
BACKGROUND
Left-sided portal hypertension including gastric venous congestion may be caused by ligating the splenic vein during pancreaticoduodenectomy with portal vein resection or total pancreatectomy. The usefulness of reconstruction with the splenic vein has been reported in such cases. However, depending on the site of the tumor and other factors, it may be impossible to leave sufficient length of the splenic vein, making anastomosis difficult. We report two patterns of reconstruction with the right gastroepiploic vein during pancreaticoduodenectomy and total pancreatectomy to prevent left-sided portal hypertension.
CASE PRESENTATION
The first patient was a 79-year-old man who underwent pancreaticoduodenectomy for pancreatic cancer. The root of the splenic vein was infiltrated by the tumor, and we resected this vein at the confluence of the portal vein. Closure of the portal vein was performed without reconstruction of the splenic vein. To prevent left-sided portal hypertension, we anastomosed the right gastroepiploic vein to the middle colic vein. Postoperatively, there was no suggestion of left-sided portal hypertension, such as splenomegaly, varices, and thrombocytosis. The second case was a 63-year-old woman who underwent total pancreatectomy for pancreatic cancer. The splenic vein-superior mesenteric vein confluence was infiltrated by the tumor, and we resected the portal vein, including the confluence. End-to-end anastomosis was performed without reconstruction of the splenic vein. We also divided the left gastric vein, left gastroepiploic vein, right gastroepiploic vein, and right gastric vein, which resulted in a lack of drainage veins from the stomach and severe gastric vein congestion. We anastomosed the right gastroepiploic vein to the left renal vein, which improved the gastric vein congestion. Postoperatively, imaging confirmed short-term patency of the anastomosis site. Although the patient died because of tumor progression 8 months after the surgery, no findings suggested left-sided portal hypertension, such as varices. Reconstruction with the right gastroepiploic vein during pancreaticoduodenectomy and total pancreatectomy is useful to prevent left-sided portal hypertension.
PubMed: 37982916
DOI: 10.1186/s40792-023-01773-x -
IJU Case Reports Nov 2023Venous hemorrhage from ectopic varices is potentially fatal. This report describes a rare case in which bleeding from mesenteric varices in an ileal conduit was treated...
INTRODUCTION
Venous hemorrhage from ectopic varices is potentially fatal. This report describes a rare case in which bleeding from mesenteric varices in an ileal conduit was treated successfully by embolization therapy.
CASE PRESENTATION
The patient was an 82-year-old man who had previously undergone total pelvic exenteration for colon cancer with creation of an ileal conduit for urinary diversion. He subsequently developed liver cirrhosis and underwent partial hepatectomy for hepatocellular carcinoma. 9 years after his colon surgery, he was admitted with gross hematuria. Computed tomography revealed subcutaneous mesenteric varices in the ileal conduit and hemorrhage as a result of rupture of the varices. The bleeding continued despite repeated manual compression but was eventually stopped by embolization therapy.
CONCLUSION
Embolization therapy may be helpful for hemostasis in the event of intractable bleeding from mesenteric varices in an ileal conduit.
PubMed: 37928295
DOI: 10.1002/iju5.12644 -
Case Reports in Oncology 2023We report an unusual case of extensive deep vein thrombosis (DVT) and pulmonary embolism (PE) in the setting of metastatic uterine leiomyosarcoma. Recognition of the...
We report an unusual case of extensive deep vein thrombosis (DVT) and pulmonary embolism (PE) in the setting of metastatic uterine leiomyosarcoma. Recognition of the associated sequelae of this condition may improve short- and long-term outcomes. A 56-year-old black female with a history of uterine leiomyosarcoma diagnosed incidentally after total abdominal hysterectomy for fibroid uterus without initiation of chemoradiation treatment presented to the emergency department complaining of generalized weakness and progressively worsening stridor for 2 weeks. The patient was experiencing shortness of breath, dysphagia, and hoarseness. Physical exam was remarkable for rhonchi but was otherwise normal. Diagnostic imaging via CT of the abdomen, pelvis, and chest revealed DVTs of the left common and external iliac veins, the superior mesenteric artery, multiple pulmonary emboli of the right pulmonary artery, several nodular lesions within the lungs, and scattered peritoneal necrotic lesions, which were suspicious for metastatic disease. Additionally, CT of the neck showed an exophytic mass protruding into the airway from the subglottic region and thyromegaly with bilateral thyroid lobe nodules. The patient was subsequently started on Eliquis and chemotherapy. The rarity of this case is rooted in the extent of the patient's DVTs and PEs secondary to hypercoagulability in metastatic cancer. This presentation should be further evaluated to exclude thrombophilias or underlying malignancies. Drawing from the lessons of this case will help guide future clinical management regarding the care of metastatic uterine leiomyosarcoma.
PubMed: 37900811
DOI: 10.1159/000531761 -
Radiology Case Reports Dec 2023Duplication of the portal vein is a rare variation, and reports of this condition are quite limited. The present report describes a woman of advanced age who was...
Duplication of the portal vein is a rare variation, and reports of this condition are quite limited. The present report describes a woman of advanced age who was incidentally diagnosed with duplicated portal veins. The portal vein from the splenic vein distributed to the left lobe of the liver, and that from the superior mesenteric vein ran between the pancreas and duodenum to distribute to the right lobe. The former portal vein connected with the round ligament, and its presumptive origin was the left vitelline vein. The latter was presumably from the right vitelline vein. Between the 2 portal veins, 2 anastomotic veins were identified; one anastomosis was posterior to the pancreatic head, and the other was intrahepatic. The common bile duct was located posterolateral to the portal veins. The relationships of these veins to the round ligament and common bile duct support the reverse rotation hypothesis of the duodenum in the development of portal vein variations.
PubMed: 37840894
DOI: 10.1016/j.radcr.2023.09.027 -
Chinese Journal of Traumatology =... Sep 2023Portal vein thrombosis (PVT) secondary to blunt abdominal trauma associated with liver injury is extremely rare in healthy individuals as well as in minor liver injury,...
Portal vein thrombosis (PVT) secondary to blunt abdominal trauma associated with liver injury is extremely rare in healthy individuals as well as in minor liver injury, and it carries a high rate of morbidity and mortality. Moreover, acute asymptomatic PVT is difficult to diagnose. We present a young trauma patient with isolated minor liver injury associated with acute PVT. A 27-year-old man presented to the emergency department after a motor vehicle collision. His primary survey findings were unremarkable. His secondary survey showed a large contusion (7 cm × 7 cm) at the epigastrium with marked tenderness and localized guarding. The CT angiography of the whole abdomen revealed liver injury grade 3 in hepatic segments 2/3 and 4b (according to the American Association for the Surgery of Trauma classification) extending near the porta hepatis with patent hepatic and portal veins and without other solid organ injury. The follow-up CT of the whole abdomen on post-injury day 7 showed a 1.8-cm thrombus in the left portal vein with patent right portal and hepatic veins, and a decreased size of the hepatic lacerations. A liver function test was repeated on post-injury day 4, and it revealed improved transaminitis. The patient received intravenous anticoagulant therapy with low-molecular-weight heparin according to weight-based dosing for treatment. The CT of the whole abdomen performed 2 weeks after anticoagulant therapy showed small residual thrombosis in the left portal vein. The patient received intravenous anticoagulant therapy for a total 3 months. On the follow-up visits at 1 month, 2 months, 6 months, and 1 year after the injury, the patients did not have any detectable abnormal symptoms. PVT post-blunt minor liver injury is an extremely rare complication. If the thrombosis is left untreated, serious morbidity and mortality can ensue. However, its diagnosis in asymptomatic patients is still challenging. Periodic imaging is necessary for highly suspected PVT, especially in liver injury with lacerations close to the porta hepatis, even in cases of a minor injury.
PubMed: 37838579
DOI: 10.1016/j.cjtee.2023.09.003 -
International Journal of Surgery Case... Oct 2023Idiopathic myointimal hyperplasia of mesenteric veins (IMHMV) is a rare type of chronic colonic ischemia. Patients commonly present with progressive abdominal pain,...
INTRODUCTION
Idiopathic myointimal hyperplasia of mesenteric veins (IMHMV) is a rare type of chronic colonic ischemia. Patients commonly present with progressive abdominal pain, bloody diarrhea, and weight loss. IMHMV is a common mimicker of inflammatory bowel disease. However, medical management does not have a primary role and curative treatment is surgical resection.
PRESENTATION OF CASE
We report two cases of IMHMV with atypical presentation. The first is an 82-year-old male who had refractory, painless, explosive, and non-bloody diarrhea initially treated with antidiarrheal medications and dietary changes to no effect. Colonoscopy was not clarifying. However, CT scan had characteristic findings of IMHMV. He underwent partial colectomy and recovered well. The second case is a 59-year-old male who had recurrent episodes of sudden, massive diarrhea. He was initially treated for diverticulitis based on colonoscopy findings but did not experience relief. Eventually, MRI of the abdomen was suggestive of IMHMV. He underwent surgical resection, which confirmed the diagnosis of IMHMV. He was treated for Clostridioides difficile diarrhea five months after surgery and pulmonary embolism seven months after surgery. With over a year of follow up, neither has had disease recurrence.
DISCUSSION
Diagnosis and treatment of rare disorders like IMHMV is challenging, especially when they mimic common entities or present in atypical ways.
CONCLUSION
We present two cases to highlight IMHMV as part of the differential for colitis-like symptoms. These cases demonstrate the importance of diagnostic imaging in diagnosis. Diagnostic uncertainty can lead to exposure to ineffective medical treatments and delay in curative surgery.
PubMed: 37769411
DOI: 10.1016/j.ijscr.2023.108839 -
Cureus Aug 2023Nutcracker syndrome (NCS) is an uncommon condition that predominantly affects the left renal vein (LRV) because of its entrapment between the aorta and superior...
Nutcracker syndrome (NCS) is an uncommon condition that predominantly affects the left renal vein (LRV) because of its entrapment between the aorta and superior mesenteric vein. It can result in pain in the left flank or back, hematuria, and proteinuria. May-Thurner syndrome (MTS) is described as a condition in which the left common iliac vein is compressed by the right common iliac artery, causing swelling, fullness, venous ulcers, or varicose veins in the leg. We present a case of a 77-year-old female who had these symptoms for over a decade, until she was diagnosed in 2017. Initially, she experienced swelling and pain in her left leg, which began in 2005; however, treatment did not begin until she had her left ovarian vein embolized in 2017. Her symptoms returned the following year, leading to the diagnosis of bilateral MTS. Owing to recurring symptoms in 2022, a repeat venogram revealed bilateral external iliac vein constriction, requiring intervention. She presented to our clinic in 2023 after being referred by her cardiologist because of persistent back pain and venous congestion. This led to the findings and diagnosis of NCS with bilateral MTS.
PubMed: 37746485
DOI: 10.7759/cureus.43996 -
Radiology Case Reports Nov 2023Portal hypertension is a frequent syndrome characterized by an increased portal pressure gradient. The relevance of portal hypertension derives from the frequency and...
Portal hypertension is a frequent syndrome characterized by an increased portal pressure gradient. The relevance of portal hypertension derives from the frequency and severity of its complications. Rectal varicose is relatively common in portal hypertension patients with meager bleeding rates; However, rectal variceal bleeding is a complicated and sometimes life-threatening condition. The management of rectal variceal bleeding has yet to be adequately established. Endoscopy, surgery, or transjugular intrahepatic portosystemic shunt placement (TIPS) can be performed in patients with gastrointestinal bleeding secondary to portal hypertension due to different etiologies. We present a successful case of direct abdominal percutaneous embolization of multiple and tortuous superior rectal varicose via the inferior mesenteric vein in a 7-year-old female patient with refractory rectal variceal bleeding, not susceptible to endoscopic, surgical, or TIPS management.
PubMed: 37745766
DOI: 10.1016/j.radcr.2023.08.094 -
Frontiers in Pharmacology 2023Patients with venous thrombosis of splanchnic circulation represent a group of high risk with significant morbidity and mortality, if treatment is delayed. We present a...
Patients with venous thrombosis of splanchnic circulation represent a group of high risk with significant morbidity and mortality, if treatment is delayed. We present a patient with thrombosis of portal vein and its tributaries combined with deep venous thrombosis (DVT) of the lower extremities who was successfully treated with conservative management. This patient case highlights the importance of early empiric anti-inflammatory therapy along with systemic anticoagulation to reduce the intestinal inflammation and enteritis and break the vicious circuit resulting in secondary progressive thrombosis of the splanchnic veins, fluid shifts, and functional ileus. : A previously healthy 61-years-old female patient with no significant medical history was admitted with progressive upper abdominal pain, nausea and vomiting, low-grade fever, mild signs of ileus, and malaise. Imaging studies revealed portal venous dilation reaching ∼20 mm with near-total obliteration of the lumen by a thrombus. In addition, thrombosis of superior mesenteric and splenic veins with thrombophlebitis was found. Imaging studies also confirmed the presence of DVT of lower extremities including thrombus propagation into the iliac veins. An immediate therapy was started with parenteral antibiotics, anti-inflammatory medications, systemic anticoagulants, and intravenous fluid infusions to restore the circulating volume deficit and treat electrolyte disbalance. With such therapy, the patient's symptoms resolved within a month, and she was discharged from the hospital with full recovery. Heparin infusion was started to reach systemic anticoagulation. With resolution of symptoms, anticoagulation was continued with warfarin. We used non-steroidal anti-inflammatory drugs (NSAIDs) as a component in management of intestinal and systemic inflammation and multifocal thrombosis when the antiphospholipid syndrome was also on the list of differential diagnoses. : We present a previously asymptomatic patient with progressive portal venous thrombosis and ascending DVT. Early establishment of diagnosis and initiation of therapy with systemic anticoagulants, anti-inflammatory and antibacterial drugs helped to stop thrombus progression, prevent irreversible intestinal ischemia, and allow for re-canalization of the occluded veins. This case highlights the importance of early interventions to improve the treatment outcome.
PubMed: 37745074
DOI: 10.3389/fphar.2023.1246914 -
World Journal of Gastroenterology Sep 2023Splanchnic vein thrombosis (SVT) is a manifestation of venous thromboembolism in an unusual site. Portal, mesenteric, and splenic veins are the most common vessels... (Review)
Review
Splanchnic vein thrombosis (SVT) is a manifestation of venous thromboembolism in an unusual site. Portal, mesenteric, and splenic veins are the most common vessels involved in SVT which occurs mainly in patients with liver cirrhosis, although non-cirrhotic patients could be affected as well. Thrombosis of hepatic veins, also known as Budd-Chiari syndrome, is another manifestation of SVT. Prompt diagnosis and intervention are mandatory in order to increase the recalization rate and reduce the risk of thrombus progression and hypertensive complications. Traditional anticoagulation with heparin and vitamin-K antagonists is the treatment of choice in these cases. However, recent studies have shown promising results on the efficacy and safety of direct oral anticoagulants (DOACs) in this setting. Available results are mainly based on retrospective studies with small sample size, but first clinical trials have been published in the last years. This manuscript aims to provide an updated overview of the current evidence regarding the role of DOACs for SVT in both cirrhotic and non-cirrhotic patients.
Topics: Humans; Retrospective Studies; Anticoagulants; Heparin; Budd-Chiari Syndrome; Venous Thromboembolism
PubMed: 37731994
DOI: 10.3748/wjg.v29.i33.4962