title: A novel surgical technique for bleeding duodenal varices after failure of balloon-occluded retrograde transvenous obliteration: a case report.
abstract: BACKGROUND
  Duodenal varices are a low-frequency cause of gastrointestinal bleeding; however, greater than 40 % mortality has been reported after the initial bleeding episode.
  
  
  METHODS
  This report describes a 72-year-old woman with bleeding duodenal varices treated by surgery after failure of balloon-occluded retrograde transvenous obliteration (B-RTO). The patient presented with profuse melena. Emergent upper endoscopy was immediately performed, and bleeding duodenal varices in the second portion of the duodenum were seen. Endoscopic band ligation was attempted first followed by B-RTO; however, the combined procedures failed. Laparotomy under general anesthesia was then performed, and the venous collaterals were cannulated using an 18-gauge needle. Following intraoperative angiography, the venous collateral was ligated on the peripheral side of the needle entry point, and ethanolamine oleate was injected into the afferent collateral vessel. Endoscopic examination on postoperative day 4 showed embolization of the duodenal varices. The patient was discharged on postoperative day 11.
  
  
  CONCLUSIONS
  This technique is simple and effective, and we believe it is a potential alternative surgical treatment for duodenal varices with portal hypertension.
authors.affiliation: Department of Surgery, Saga-Ken Medical Centre Koseikan, 400 Kase-machi Nakabaru, Saga, 840-8571, Japan. gottingottin2000@yahoo.co.jp.
authors.forename: Go
authors.initials: G
authors.lastname: Anegawa
authors.affiliation: Department of Surgery, Saga-Ken Medical Centre Koseikan, 400 Kase-machi Nakabaru, Saga, 840-8571, Japan.
authors.forename: Kenji
authors.initials: K
authors.lastname: Sumi
authors.affiliation: Department of Surgery, Saga-Ken Medical Centre Koseikan, 400 Kase-machi Nakabaru, Saga, 840-8571, Japan.
authors.forename: Atsushi
authors.initials: A
authors.lastname: Miyoshi
authors.affiliation: Department of Surgery, Saga-Ken Medical Centre Koseikan, 400 Kase-machi Nakabaru, Saga, 840-8571, Japan.
authors.forename: Kenji
authors.initials: K
authors.lastname: Kitahara
authors.affiliation: Department of Surgery, Saga-Ken Medical Centre Koseikan, 400 Kase-machi Nakabaru, Saga, 840-8571, Japan.
authors.forename: Seiji
authors.initials: S
authors.lastname: Satou
keywords: Balloon-occluded retrograde transvenous obliteration; Cirrhosis; Duodenal varices; Embolization; Endoscopic band ligation