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

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 13 mg/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