Intrahepatic portal vein thrombosis due to postoperative biliary obstruction successfully treated by a partial thrombectomy combined with thrombolytic drug therapy

Naoya Imamura; Atsushi Nanashima; Yuki Tsuchimochi; Takeomi Hamada; Koichi Yano; Masahide Hiyoshi; Yoshiro Fujii; Kunihide Nakamura

doi:10.1016/j.ijscr.2017.11.047

Intrahepatic portal vein thrombosis due to postoperative biliary obstruction successfully treated by a partial thrombectomy combined with thrombolytic drug therapy

Int J Surg Case Rep. 2018:42:20-23. doi: 10.1016/j.ijscr.2017.11.047. Epub 2017 Nov 27.

Authors

Naoya Imamura¹, Atsushi Nanashima², Yuki Tsuchimochi¹, Takeomi Hamada¹, Koichi Yano¹, Masahide Hiyoshi¹, Yoshiro Fujii¹, Kunihide Nakamura³

Affiliations

¹ Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan.
² Division of Hepato-Biliary-Pancreas Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan. Electronic address: a_nanashima@med.miyazaki-u.ac.jp.
³ Division of Cardiovascular Surgery, Department of Surgery, University of Miyazaki Faculty of Medicine, 5200 Kihara Kiyotake, Miyazaki, 889-1692, Japan.

Abstract

Introduction: This case report aims to inform pancreatic surgeons about our perioperative management of intrahepatic portal vein thrombosis caused by an obstruction of hepaticojejunostomy (HJ) after pancreaticoduodenectomy (PD).

Case presentation: A 65-year-old woman was diagnosed with pancreas head carcinoma involving the superior mesenteric vein (SMV). Pancreaticoduodenectomy combined with SMV resection was followed by HJ. Twisting or narrowing was not evident during anastomosis. Total bilirubin values progressively increased to 13mg/dL on day 5. At that time, we suspected anastomotic occlusion and found complete portal thrombosis of the left liver. Therefore, emergency re-anastomosis of the HJ was followed by thrombectomy, which was not completely successful and did not completely recover initial portal flow. Thrombolytic drugs improved obstructive jaundice, eradicated the organized thrombosis and recovered the portal flow by day 30. The post-operative course was uneventful.

Discussion: A thrombosis immediately formed in the portal vein due to biliary obstruction of an anastomotic site. We speculated that biliary dilation and related inflammation caused a relative increase in arterial flow and decreased portal flow at the localized part of the umbilical portion. Although early surgical thrombectomy was attempted soon after the primary operation, the organized thrombosis persisted. However, thrombolytic therapy eradicated the thrombosis.

Conclusion: Careful anastomosis of HJ during PD was necessary to avoid postoperative biliary stricture. This type of complication affects intrahepatic blood flow, particularly via the portal vein. Although immediate re-anastomosis or thrombectomy is applied, organized thrombosis cannot always be surgically removed.

Keywords: Case report; Organized portal thrombosis; Pancreatic head cancer; Stricture of biliary anastomosis; Surgery; Thrombolytic therapy.