Background: The varices after proximal or total gastrectomy are uncommon because the supplying vessels are all divided. Emergent upper gastrointestinal endoscopy is the cornerstone of first-line management for the diagnosis and treatment of esophageal varices. However, there is no widely accepted standard strategy for esophagojejunal varices. We report a patient with esophagojejunal varices rupture 3 months after proximal gastrectomy treated with percutaneous transhepatic obliteration. Case presentation: A 50-year-old man who had undergone proximal gastrectomy with double-tract reconstruction for esophagogastric junctional cancer 3 months before was admitted to the hospital due to gastrointestinal perforation. We performed emergency surgery and abdominal symptoms and inflammatory response improved postoperative. However, on POD3, he had eruptive bleeding at the just anal side of esophagojejunal anastomosis. Endoscopic clipping was unsuccessful because the mucosa was fragile and easily lacerated. Contrast-enhanced CT scan revealed the dilatation of the jejunal vein flowing into the ascending jejunal limb. Therefore, he was diagnosed as esophagojejunal varices rupture and percutaneous transhepatic obliteration (PTO) was tried for hemostasis. The portal and superior mesenteric veins were catheterized with the percutaneous transhepatic approach. Contrast agent injection into the jejunal branch demonstrated retrograde flow to the azygos vein through esophagojejunal varices. The microcatheter was inserted into the variceal blood supply branch and 10 mL of 5% ethanolamine oleate with iopamidol was injected. After obliteration therapy, the superior mesenteric venogram showed complete occlusion of the variceal supply branch. The patient was discharged from the hospital without any complications after 14 days. Conclusion: PTO can be effective for gastroesophageal varices rupture with a dilated jejunal vein of the ascending limb, few supplying vessels, and little ascites.

Highlights Jejunal varices should be included in the differential diagnosis of melena in patients with a bilioenteric anastomosis and portal vein hypertension. Laparotomy-assisted transcatheter variceal embolization is one of the options for the treatment of jejunal varices. A multidisciplinary approach is critical for timely management of the unstable patient with bleeding from jejunal varices.

Background Varicose veins in the esophagogastric junction rarely occur after surgery of esophagogastric junctional carcinoma, because the collateral pathway of the left gastric vein and short gastric vein was sacrificed. We presented a case of jejunal variceal bleeding successfully treated with percutaneous transhepatic obliteration after surgery of esophagogastric junctional carcinoma. Methods Case report. Results A 50-year-old man with alcoholic liver cirrhosis (Child-B) was admitted for abdominal pain, three months after proximal gastrectomy for esophagogastric junctional carcinoma. After diagnosed with peritonitis due to jejunal perforation, emergency surgery was performed. The next day after surgery, he had developed a lot of black stool. Gastroduodenoscopy revealed the variceal bleeding at the anal side of the esophagojejunal anastomois. Although endoscopic clipping was performed, intermittent bleeding was observed for several days. Since the contrast-enhanced computed tomography scanning revealed jejunal vein dilation at the anal side of the esophagojejunal anastomois, we planned to perform percutaneous transhepatic obliteration. Percutaneous transhepatic portography revealed jejunal varices and drained to the inferior vena cava, and continuously obliterated by 5% EOI (Ethanolamine oleate iopamidol). He was discharged without re-bleeding on the 14th day after the obliteration. Conclusion Percutaneous transhepatic obliteration might be a useful treatment option for jejunal variceal bleeding after surgery of esophagogastric junctional carcinoma. Disclosure All authors have declared no conflicts of interest.