Endoscopic sclerotherapy with a high concentration of n-butyl-2-cyanoacrylate for anastomotic varices after choledochojejunostomy.

Anastomotic varices are an uncommon cause of variceal bleeding. After choledochojejunostomy, the anastomosed afferent jejunal loop may have a propensity to form varices, with hepatopetal flow [1,2]. Endoscopic sclerotherapy has the potential to cause intrahepatic obstruction of the portal vein [3–5]. This report describes endoscopic sclerotherapy with a high concentration of n-butyl-2-cyanoacrylate for anastomotic varices after choledochojejunostomy. An 82-year-oldwoman presentedwith intermittent melena. She had undergone pancreaticoduodenectomy for carcinoma of the papilla of Vater 6 years previously. Computed tomography showed portal vein thrombosis with cavernous transformation, leading to the formation of varices around the choledochojejunostomy site (●" Fig.1). Endoscopy with an upper gastrointestinal endoscope (GIF-H290; Olympus, Tokyo, Japan) was undertaken to assess the varices. A small amount of fresh blood was seen in the afferent jejunal loop, and varices were observed around the choledochojejunostomy site (●" Fig.2). We opted to perform endoscopic sclerotherapy with a high concentration of n-butyl-2-cyanoacrylate. A total of 1.2mL of glue mixture (1.0mL of n-butyl-2-cyanoacrylate and 0.2mL of Lipiodol) was injected with a 23-gauge needle under fluoroscopic guidance (●" Fig.3). The sclerosant filled the varices and did not leak into the liver. A computed tomographic scan showed the deposition of Lipiodol in the anastomotic varices without any deposition in the liver parenchyma (●" Fig.4). The bleeding ceased without any complication, and no further bleeding was observed. Unlike gastric varices, anastomotic varices after choledochojejunostomy drain directly into the intrahepatic portal vein within a short distance. Therefore, the rapid polymerization of the usual concentration of n-butyl-2-cyanoacrylate (ratio Fig.3 Endoscopic sclerotherapy images. a A high concentration of n-butyl-2-cyanoacrylate is injected under fluoroscopic guidance. b The sclerosant fills the varices and polymerizes without leaking into the liver. Fig.2 Endoscopic view of the anastomosed afferent jejunal loop.a Anastomotic varices are revealed around the choledochojejunostomy site. b A small erosion (arrow) implicated in the bleeding is found on the varices. Fig.1 Computed tomography shows anastomotic varices (arrow) in the afferent jejunal loop (arrowheads) in an 82-year-old woman who underwent pancreaticoduodenectomy for carcinoma of the papilla of Vater 6 years previously.