65 year old man with a history of chronic pancreatitis. 15 years ago he had gallstone induced pancreatitis, originally treated with cholecystectomy. Had a prolonged course, eventually developing infected pancreatic necrosis. This was treated with multiple debridements during an 8 month hospital stay. Since that time has had chronic abdominal pain and an enlarged head of pancreas. +/- malabsorptive diarrhea. No baseline liver dysfunction.
Laboratory and diagnostic studies
Now is admitted with pneumonia, when he experiences severe upper GI bleeding. Taken to ICU, resuscitated. Upper endoscopy eventually demonstrated isolated duodenal varices, actively bleeding. No gastric or esophageal varices. Unable to control this endoscopically.
Patient taken to angiography. This demonstrated patent portal vein and splenic vein with completely occluded SMV. Large paraduodenal varices noted. Hepatic vein wedge pressure 6. The angiographer (who is normally quite aggressive) feels he has nothing to offer.
The patient continues to bleed.
Treatment of Duodenal Varices
Being treated with Octreotide (somatostatin) drip at high dose.
What operative strategies to you all have in this man with a very hostile abdomen/retroperitoneum? Then I’ll let you know what we did and how it is working.