A novel surgical technique for bleeding duodenal varices after failure of balloon-occluded retrograde transvenous obliteration: a case report
© The Author(s). 2016
Received: 24 March 2016
Accepted: 21 June 2016
Published: 27 June 2016
Duodenal varices are a low-frequency cause of gastrointestinal bleeding; however, greater than 40 % mortality has been reported after the initial bleeding episode.
This report describes a 72-year-old woman with bleeding duodenal varices treated by surgery after failure of balloon-occluded retrograde transvenous obliteration (B-RTO). The patient presented with profuse melena. Emergent upper endoscopy was immediately performed, and bleeding duodenal varices in the second portion of the duodenum were seen. Endoscopic band ligation was attempted first followed by B-RTO; however, the combined procedures failed. Laparotomy under general anesthesia was then performed, and the venous collaterals were cannulated using an 18-gauge needle. Following intraoperative angiography, the venous collateral was ligated on the peripheral side of the needle entry point, and ethanolamine oleate was injected into the afferent collateral vessel. Endoscopic examination on postoperative day 4 showed embolization of the duodenal varices. The patient was discharged on postoperative day 11.
This technique is simple and effective, and we believe it is a potential alternative surgical treatment for duodenal varices with portal hypertension.
Duodenal varices are a low-frequency cause of gastrointestinal bleeding; however, greater than 40 % mortality has been reported after the initial bleeding episode [1, 2]. Several treatments exist to control bleeding including interventional radiology, endoscopic therapy, and surgical modalities (e.g., variceal ligation, duodenal resection, and extrahepatic portosystemic shunts) . Endoscopic therapy is often the first choice for bleeding duodenal varices and can include endoscopic injection sclerotherapy and the use of N-butyl-2-cyanoacrylate [4, 5]. However, these procedures are specialized and performed in few institutions in Japan. Endoscopic band ligation is easy and useful for temporary hemostasis; however, the frequency of variceal re-bleeding is high and additional therapy including interventional radiology and/or surgical treatment is necessary [5, 6]. We present a novel surgical technique for bleeding duodenal varices after failure of balloon-occluded retrograde transvenous obliteration (B-RTO).
From our experience, we believe that direct injection of ethanolamine oleate into the afferent collateral vessel under laparotomy could be an alternative surgical hematemesis for rupture of duodenal varicose vein when EVL and B-RTO were failed.
B-RTO, balloon-occluded retrograde transvenous obliteration
Ethics approval and consent to participate
All procedures were in accordance with the ethical standards of the responsible committees on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions. The patient gave informed consent for the procedures.
Consent for publication
Informed consent was obtained from the patient to publish the details of her case.
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- D’Imperio N, Piemontese A, Baroncini D, Billi P, Borioni D, Dal Monte PP, et al. Evaluation of undiluted N-butyl-2-cyanoacrylate in the endoscopic treatment of upper gastrointestinal tract varices. Endoscopy. 1996;28:239–43.View ArticlePubMedGoogle Scholar
- Khouqeer F, Morrow C, Jordan P. Duodenal varices as a cause of massive upper gastrointestinal bleeding. Surgery. 1987;102:548–52.PubMedGoogle Scholar
- Kakizaki S, Toyoda M, Ichikawa T, Sato K, Takagi H, Arai H, et al. Clinical characteristics and treatment for patients presenting with bleeding duodenal varices. Dig Endosc. 2010;22:275–81.View ArticlePubMedGoogle Scholar
- Barbish AW, Ehrinpreis MN. Successful endoscopic injection sclerotherapy of a bleeding duodenal varix. Am J Gastroenterol. 1993;88:90–2.PubMedGoogle Scholar
- Ota K, Shirai Z, Masuzaki T, Tanaka K, Higashihara H, Okazaki M, et al. Endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate for ruptured duodenal varices. J Gastroenterol. 1998;33:550–5.View ArticlePubMedGoogle Scholar
- Ohta M, Yasumori K, Saku M, Saitsu H, Muranaka T, Yoshida K. Successful treatment of bleeding duodenal varices by balloon-occluded retrograde transvenous obliteration: a transjugular venous approach. Surgery. 1999;126:581–3.View ArticlePubMedGoogle Scholar