LAUSR

ALTHOUGH ANASTOMOTIC VARICES are caused by neovascularization of the small intestine due to postoperative adhesions occurring between the small intestine and the abdominal wall and increased portal pressure, bleeding from anastomotic varices is quite rare. Herein, we present a case of successful endoscopic injection sclerotherapy (EIS) for recurrent anastomotic variceal bleeding after pancreaticoduodenectomy (PD). The patient was a 58-year-old woman who had undergone PD for massforming pancreatitis in the pancreatic head 13 years prior. Subsequently, the portal vein was gradually occluded due to the development of pancreatic cancer, and perianastomotic varices around the choledochojejunostomy deteriorated (Fig. 1). Although the patient had recurrent bleeding, it was difficult to identify the hemorrhagic site as the varices around the anastomosis were flattened. Finally, therapeutic intervention proceeded, as bleeding from the veins was confirmed by contact stimulation with a balloon catheter. Multiple afferent collateral vessels had developed, and blood flow to the liver was confirmed via contrast computed tomography. Using a colonoscope (PCF-H290I; Olympus, Tokyo, Japan), EIS was performed by administering a mixture including 2.0 mL n-butyl-2-cyanoacrylate and 0.5 mL Lipiodol (Guerbet, Villepinte, France) with a 21G, 1600 mm long endoscopic puncture needle (Top Corporation, Tokyo, Japan) (Fig. 2a–c). The sclerosing agent was injected from the bleeding site under fluoroscopic guidance to ensure that it did not flow from the varices to the liver without additional glucose solution injection (Fig. 2d); the second injection was performed from the varix with a red color sign (Video S1). After treatment, no adverse events or rebleeding were observed until the patient’s death. There is no standard treatment for anastomotic varices; however, to date, endovascular treatment, portal vein stenting, and