title: Late complication in patients undergoing pancreatic resection with intraoperative radiation therapy: gastrointestinal bleeding with occlusion of the portal system.
abstract: BACKGROUND
  There are few reports of late complications in patients who have undergone pancreatic resection with intraoperative radiation therapy (IORT), because carcinoma of the pancreas (PCa) and the bile duct (BCa) have a poor prognosis. The purpose of the present paper was to review gastrointestinal (GI) bleeding occurring with occlusion of the portal system (PVs) as a complication of IORT in patients surviving long term without recurrence.
  
  
  METHODS
  From 1990 to 1999, 45 patients underwent surgical resection of the pancreas with IORT. Eleven of these patients survived >3 years without recurrence, and occlusion of PVs was recognized in five patients at follow-up examination. Three of these five patients received repeated blood transfusions for GI bleeding.
  
  
  RESULTS
  One patient had BCa and two had PCa, and pancreatoduodenectomy was carried out. The delivered radiation doses of IORT were 30 Gy (two patients) and 35 Gy (one patient). The postoperative periods to initial GI bleeding were 36, 26 and 9 months, respectively. In all cases, angiography revealed occlusion of PVs and the collateral circulation. The bleeding points were esophageal varix (case 1), remnant stomach varix (case 2) and a jejunal ulcer (case 3), and blood transfusions were carried out totaling 44, 60 and 16 units, respectively. The GI bleeding disappeared spontaneously in case 1, developed sporadically in case 2 and was stopped by metallic stent insertion in PVs in case 3.
  
  
  CONCLUSIONS
  During long-term follow up after pancreatectomy with IORT, it is necessary to monitor patients for GI bleeding. A clinical trial on optimum doses, long-term safety and benefit of IORT is necessary.
authors.affiliation: Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya 464, Japan. yshimizu@aichi-cc.jp
authors.forename: Yasuhiro
authors.initials: Y
authors.lastname: Shimizu
authors.forename: Kenzo
authors.initials: K
authors.lastname: Yasui
authors.forename: Nobukazu
authors.initials: N
authors.lastname: Fuwa
authors.forename: Yasuaki
authors.initials: Y
authors.lastname: Arai
authors.forename: Kenji
authors.initials: K
authors.lastname: Yamao
mesh_terms: D001650:Bile Duct Neoplasms / Q000532:radiotherapy / Q000601:surgery*; D003131:Combined Modality Therapy; D016099:Endoscopy, Gastrointestinal; D005260:Female; D005500:Follow-Up Studies; D006471:Gastrointestinal Hemorrhage / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D041981:Gastrointestinal Tract / Q000473:pathology / Q000528:radiation effects; D006801:Humans; D007432:Intraoperative Period; D008297:Male; D008641:Mesenteric Vascular Occlusion / Q000150:complications / Q000175:diagnosis; D008642:Mesenteric Veins; D008875:Middle Aged; D010180:Pancreatectomy; D010190:Pancreatic Neoplasms / Q000532:radiotherapy / Q000601:surgery*; D011172:Portography; D011183:Postoperative Complications; D011832:Radiation Injuries / Q000209:etiology; D011882:Radiotherapy, High-Energy; D014055:Tomography, Emission-Computed