PMC2892662_01
Imaging after sentinel bleeding. (a) CT scan on the 16th day postsurgery shows no abscess or hematoma around the pancreatic anastomosis. (b) The stump of the GDA is 6.0 mm in diameter (arrow), and very close to the drain placed at the anterior aspect of the pancreaticojejunostomy (arrowhead). (c) and (d) an upper endoscopy on the 17th day postsurgery shows ulcerative changes without massive hemorrhage in the gastrojejunostomy (c) and the pancreaticojejunostomy (d).
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fig1
A computed tomography (CT) was performed which demonstrated neither an abscess nor a hematoma around the pancreaticojejunostomy (Figures  1(a) and 1(b)). The stump of the gastroduodenal artery (GDA) showed an outgrowth with a length of 6.0 mm without formation of pseudoaneurysm (Figure 1(b), arrow). The stump of the GDA was immediately adjacent to the tip of the drainage tube placed at the anterior aspect of the pancreaticojejunostomy (Figure 1(b), arrowhead). Upper endoscopy revealed a stomach filled with blood but the bleeding point was unable to be identified around the gastrojejunostomy or pancreaticojejunostomy (Figures  1(c) and 1(d)).
Emergency angiography on the 18th day postsurgery. (a) A 2.7 cm pseudoaneurysm of the GDA stump is observed (arrow). (b) Coil embolization of the hepatic artery, between the proximal and distal side of the pseudoaneurysm was performed. (c) A complete hemostasis was achieved. Obstruction of the portal branches was not observed.
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fig2
A 2.7 cm diameter pseudoaneurysm arising from the stump of the GDA was identified (Figure 2(a), arrow). Therefore, coil embolization, both proximal (common hepatic artery) and distal (right and left hepatic artery) of the pseudoaneurysm was performed with microcoils (MWCE-18S-TORNADO) (Figures 2(b) and 2(c).
(a) Clinical course during the periods between admission and emergency angiography. (b) The change in laboratory values and treatment after embolization. Hb: hemoglobin (g/dl); WBC: white blood count (per mm3); CRP: C-reactive protein; T-Bil: Total bilirubin; GOT: glutamic oxaloacetic transaminase; GPT: glutamic pyrubic transamynase; PT: prothrombin time; FDP: fibrin degradation producrt; BT: body temperature; ABPC: ampicillin; VCM: vancomycin; MAP: packed RBC; FFP: fresh frozen plasma; LVFX: quinolone; PGE2: prostaglandin E2; IPM: imipenem; PVPV: portal vein peak velocity.
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fig3
The clinical course and schematic presentation are shown in Figures  3 and 4.
Schematic presentation of the reconstruction and liver abscess after embolization. Drainage tubes, a decompression tube placed in the hepaticojejunostomy, and pancreatic anastomosis are shown.
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fig4
The clinical course and schematic presentation are shown in Figures  3 and 4.
Representative images of CT performed after embolization. (a) 3 days after embolization. (b) 16th day after embolization. (c) 30th day after embolization. (d) 68th day after embolization. (e) 161 st day after embolization.
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fig5
Coagulation tests on day 5 postcoil embolization revealed a marked elevation of fibrin degradation product (FDP). CT of the abdomen revealed that segments 2/3 of the liver were replaced by a low density area located near the edge of the liver (Figure 5(a)). C on the 16th day after coil embolization. CT demonstrated that segments 2/3 of the liver were replaced by fluid-level components with accumulation of gases (Figure 5(b)). On the 32nd day after coil embolization, a CT scan revealed that segments 2/3 of the liver were replaced by a homogenous low-density area with thick capsule formation (Figure 5(c)). A hepatic abscess was localized by CT in the edge of segments 2/3 penetrating to the lesser sac, which was immediately treated by percutaneous drainage (Figure 5(d)). Two months after discharge a CT scan showed disappearance of segments 2/3 of the liver with no abscess formation present (Figure 5(e)).
Doppler ultrasonography shows gradual decrease of the portal vein peak velocity of the left portal branch and inverse increase of the portal vein peak velocity of the right portal branch.
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fig6
Because the right main branch of the portal vein was clearly visualized with a high value of portal vein peakvelocity (PVPV) on a doppler ultrasonography (Figure 6), we believed that severe hepatic failure would not occur.
Leakage in the pancreaticojejunostomy (a) is successfully treated by effective drainage (b).
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fig7
In addition, anastomotic leakage persisted with a high-output pancreatic fistula from the drain adjacent to the pancreaticojejunostomy (Figure 7(a)). Continuous irrigation from the drain with saline and enteral nutrition from the jejunostomy catheter yielded complete relief of symptoms associated with anastomotic leakage on the 34th day after coil embolization (Figure 7(b)).