Biliary Atresia: histopathologic observations and reflections upon its natural history

Operative liver biopsies and specimens of the extrahepatic ducts and porta hepatis have been studied in 12 cases of biliary atresia. In all cases, the liver showed giant cell transformation and inflammation with mononuclear cells and neutrophils. Most had other features of neonatal hepatitis, including necrosis of hepatocytes. In the intrahepatic bile ducts of all cases but one, the hepatic ducts and glands at the porta hepatis, and in the extrahepatic ducts where epithelium remained, there was degeneration of the epithelium and intramural inflammation. In the ducts at the porta hepatis and in 6 of 8 extrahepatic ducts where epithelium remained, there was extensive mural fibrosis compromising the diameter of the duct lumens. Three cases showed the inflammatory changes distal to sites of closure of the extrahepatic ducts. These findings demonstrate that in biliary atresia, hepatitis, intrahepatic cholangitis, and sclerosing cholangitis of the extrahepatic ducts all interact to produce acquired obstruction to bile flow.     

Five- and 10-year survival rates after surgery for biliary atresia: a report from the Japanese Biliary Atresia Registry

Purpose

The aim of this study was to elucidate the epidemiology and short- and long-term results of biliary atresia in Japan analyzing the data of the Japanese Biliary Atresia Registry (JBAR).

Methods

In 1989, the Japanese Biliary Atresia Society started a nationwide registry, JBAR, to investigate all aspects of biliary atresia. A total of 1,381 patients, 863 girls, 507 boys, and 11 unknown, were registered between 1989 and 1999. JBAR includes an initial and follow-up questionnaires. Using these patients’ data, the incidence, sex distribution, associated anomalies, the type of obstruction, the type of operation, and the surgical results were evaluated. The 5- and the 10-year results of 735 patients who were registered initially in or before 1994 also were analyzed.

Results

The incidence of biliary atresia was 1 in 9,640 live births. One hundred sixty-four patients (11.9%) had type I atresia of the common bile duct, 34 (2.5%) had type II atresia of the hepatic ducts, and 1,162 (84.1%) had type III atresia at the porta hepatis. Congenital associated anomalies were found in 19.6% of the patients including 33 cases associated with polysplenia. Impact of the age at operation on bile flow was not clear until 90 days of age, and after 90 days the bile flow rate worsened. The original Roux-en-Y procedure had been used in more than 50% of the patients since 1995. In 1999, 96% of the patients underwent the original Roux-en-Y procedure or the Roux-en-Y with an intestinal valve, and only 3 patients (3.5%) underwent other modifications. There were no significant differences in either the rate of disappearance of jaundice or the incidence of cholangitis among these 3 procedures. Of the 735 patients registered in or before 1994, 19 patients (2.6%) were lost to follow-up. The 5-year survival rates of patients registered in 1989, 1990, 1991, 1992, 1993, and 1994 were 62%, 64.5%, 61.3%, 59.0%, 58.7%, and 52.7% without liver transplantation (LTx), and 69.4%, 74.2%, 75.2%, 79.5%, 78%, and 78.3% with LTx, respectively. Although the overall 5-year survival rate changed from 69.4% to 78.3%, the difference was not statistically significant. According to the 10-year follow-up results of the 108 patients initially registered in 1989, 72 (66.7%) and 57 (52.8%) survived with and without the aid of LTx, respectively.

Conclusions

The overall 5- and 10-year survival rates were 75.3% (553 of 734) and 66.7% (72 of 108), respectively. In spite of the increasing number of survivors after LTx, there was no significant improvement in the 5-year survival rate. It was shown that the JBAR system was functioning well with only 19 patients lost to follow-up among the 743 patients registered from 1989 to 1994.     

Effect of Liver Transplantation in a Twin for Biliary Atresia on Physical Development and Intellectual Performance: Report of a Case

A case of twins, one of whom suffered from biliary atresia, is described herein. Although the patient had been doing well until 11 years of age after previously undergoing a primary hepatic portoenterostomy, she had to then undergo a liver transplantation due to severe refractory cholangitis at 14 years of age. Although the patient's intellectual performance had severely declined due to the progression of her illness for several years, it completely recovered after the liver transplantation. In cases where the physical development in childhood has been well preserved, liver transplantation might therefore offer the chance for a full recovery of deteriorated intellectual performance. Received: November 18, 1999 / Accepted: March 24, 2000     

选择性断流术后门静脉压力梯度变化与上消化道再出血的关系

目的 分析选择性断流术后门静脉压力梯度(portal pressure gradient,PPG)的改变与门静脉高压症患者术后并发症及远期疗效的关系,探讨PPG在评价患者再出血中的作用.方法 收集135例行选择性断流术门静脉高压症患者的临床资料,测量切脾前与断流术后PPG的变化,并与其术后并发症及远期疗效作统计学分析.结果 本组135例门静脉高压症患者均接受断流手术治疗,术后死亡2例(1.5%).依据断流术后PPG＜12 mm Hg、PPG 12 mm Hg但与切脾前比较至少下降20%、PPG≥12 mm Hg但与切脾前比较下降＜20%将患者分为3组,分别为62例、41例和32例.3组术后并发症发生率之间相比差异无统计学意义(P＞0.05).3组1、2、3年累计未出血率分别为100%:100%:95%、100%:97%:90%、100%:93%:87%,3组之间相比差异均有统计学意义(x2=6.859,P=0.032).COX风险回归亦显示PPG是影响门静脉高压症患者术后上消化道出血复发的独立因素(P=0.002).3组1、2、3年累计生存率分别为100%:100%:94%、98%:95%:92%、97%:93%:88%,3组之间相比差异均无统计学意义(x2=2.917,P=0.233).结论 选择性断流术后PPG变化是门静脉高压症患者上消化道出血复发的一项预测指标,但不是生存率的一项预后指标.

Abstract：

Objective To investigate the relationship between the changes of portal pressure gradient after selective devascularization with postoperative complications and recurrent bleeding of gastroesophageal varix in patients of portal hypertension. Methods The clinical data of 135 cases of portal hypertension undergoing selective devascularization was collected. Portal pressure gradient was measured before splenectomy and after selective devascularization, and was analyzed against postoperative complications and recurrent bleeding. Results In this study, 135 patients of portal hypertension underwent selective devascularization, two cases died during perioperative period ( 1.5% ). Postoperatively patients were divided into three groups based on PPG ＜ 12 mm Hg after selective devascularization (62 cases), HVPG ≥ 12 mm Hg but a more than 20% of decrease off the pre-splenectomy baseline (41 cases) and HVPG ≥12 mm Hg with less than 20% of decrease from the baseline (32 cases). The postoperative complications between the three groups were of no significant difference ( P ＞ 0. 05 ). The 1,2,3 year cumulative rate of no variceal rebleeding of the three groups were 100% vs. 100% vs. 95%; 100%vs. 97% vs. 90%; and 100% vs. 93% vs. 87% (x2 =6. 859, P = 0. 032). COX regression analysis indicated portal vein pressure gradient was an independent prognostic factor of variceal bleeding recurrence (P=0.002). 1,2,3 year cumulative survival rates of the three groups were 100% vs. 100% vs. 94%; 98% vs. 95% vs. 92%; 97% vs. 93% vs. 88%, there were no significant difference among the three groups ( x2 = 2. 917, P = 0. 233 ). Conclusions The decrease in the PPG after selective devascularization is a predictor for the risk of rebleeding but not for survival after selective devascularization.     

Portal Vein Resection in Surgery for Cancer of Biliary Tract and Pancreas: Special Reference to the Relationship Between the Surgical Outcome and Site of Primary Tumor

Background Early and late outcomes after superior mesenteric-portal vein resection (VR) combined with pancreaticoduodenectomy, major hepatectomy, or both for pancreaticobiliary carcinoma were retrospectively evaluated. VR is the most frequently used vascular procedure in this field, but an exact role of VR has not been compared according to the primary site of tumor. Materials and Methods Postoperative outcomes were compared between surgery with and without VR in each of the three disease-based groups: hilar cholangiocarcinoma and intrahepatic cholangiocarcinoma with hilar extension (HIC, 56), middle and distal cholangiocarcinoma and gallbladder carcinoma (DGC, 118), and pancreatic head adenocarcinoma (PHC, 77). Results VR was performed in 19.6% of HIC, 8.5% of DGC, and 45.5% of PHC. In-hospital death was 7.1% (4 of 56) patients with VR (3 of DGC and 1 of PHC). Operations with VR in DGC showed a larger amount of blood loss and more increased ratio of R1operation than those with no VR. In HIC, DGC, and PHC, median survival time of patients with VR was 37, 6.8, and 20 months and that of patients without VR was 42.9, 28.6, and 20.3 months, respectively. VR did not affect survival either in HIC or in PHC; however, in DGC, VR was accompanied with dismal outcome compared with no VR (p = 0.001). Conclusions Aggressive surgery with VR can be justified both in HIC and in PHC but should not be recommended for DGC. Surgical outcomes of VR differed considerably, depending on the sites of the primary tumor.     

Predictors of Need for Liver Transplantation in Children Undergoing Hepatoportoenterostomy for Biliary Atresia

PurposeThe purpose of this study was to determine perioperative risk factors for need of liver transplantation following hepatoportoenterostomy.MethodsA retrospective review of patients undergoing hepatoportoenterostomy for biliary atresia at our institution from 1990 to 2016 was completed.ResultsA total of 81 patients were identified with a median age of 51 days (IQR: 33-68) at hepatoportoenterostomy and a median follow-up time of 5.7 years (IQR: 1-11.6). Ten-year overall survival was 93% (95% CI: 84-97). Thirty-six patients (44%) ultimately required transplantation at a median time from hepatoportoenterostomy of 8.9 months (IQR: 5.2-19). The 10-year transplant-free survival was 36% (95%CI: 24-49). Steroid use (N = 42) was not associated with improved 10-yr transplant-free survival (33% vs. 38%, p = 0.690). Age at hepatoportoenterostomy was not significantly associated with the need for transplantation. Multivariable logistic regression analysis demonstrated that total bilirubin > 2mg/dL (OR: 97, p < 0.001) and albumin < 3.5g/dL (OR: 24, p = 0.027) at 3 months after surgery were independent predictors of the need for transplantation, while adjusting for age, sex, prematurity, and steroid use.ConclusionOverall survival for children with biliary atresia is excellent, although most patients will ultimately require liver transplantation. Total bilirubin and albumin level at 3 months following hepatoportoenterostomy are predictive of the need for transplantation. Steroid use is not associated with improved outcomes.     

Percutaneous Transhepatic Cholangiodrainage as Rescue Therapy for Symptomatic Biliary Leakage Without Biliary Tract Dilation After Major Surgery

Symptomatic biliary leakage following major upper abdominal surgery is a severe complication resulting in increased morbidity and mortality. Treatment options usually include either endoscopic intervention or surgical revision. These options may be burdened by a high perioperative risk for the patient (e.g., patients with severe disease) or simply may not be possible (e.g., nonpreserved gastroduodenal passage). In the past, percutaneous transhepatic cholangiodrainage did only seem to be a viable option for patients with dilated bile ducts. Here, we present our experience in a consecutive series of patients with symptomatic biliary leakage following major upper abdominal surgery and without dilation of the biliary system that underwent percutaneous transhepatic cholangiodrainage. Percutaneous transhepatic cholangiodrainage was feasible in 15 of 18 patients (83.3%). The procedure was technically not possible in three patients (16.7%). In 10 of the 15 patients (66.6%) with feasible percutaneous transhepatic cholangiodrainage, biliary leakage was definitely controlled without the need for surgical revision. Depending on the experience with the interventional procedure, percutaneous transhepatic cholangiodrainage should be considered as an alternative for treatment of symptomatic biliary leakage instead of immediate reoperation. Presented at the Digestive Disease Week 2005 (DDW), Chicago, IL, May 14–19, 2005 (poster presentation).     

Effectiveness of Roux-en-Y Reconstruction After Distal Gastrectomy Based on an Assessment of Biliary Kinetics

Purpose: To evaluate the efficiency of Roux-en-Y reconstruction (RY) after distal gastrectomy we compared postoperative physiological functions and disorders among patients who underwent RY, conventional Billroth I reconstruction (BI), or Billroth II reconstruction (BII). Methods: The subjects were 91 patients who had undergone distal gastrectomy for gastric cancer more than 1 month earlier. To examine the severity of gastroesophageal reflux, acid reflux and alkali reflux were assessed, and to examine the severity of duodenal reflux into the remnant stomach, biliary scintigraphy was performed. The degree of inflammation in the esophagus and remnant stomach was examined by endoscopy. Questionnaires on postoperative complaints were sent out to the patients to determine how serious their reflux symptoms were. Results: Both acid and alkali reflux were mild in the RY group. Biliary reflux into the remnant stomach, as assessed by biliary scintigraphy, was significantly less severe in the RY group than in the BI and BII groups. Endoscopy showed that inflammation of the lower esophagus and remnant stomach was much less severe in the RY group than in the BI and BII groups. According to the questionnaire survey, none of the patients in the RY group reported any reflux symptoms. Conclusions: In this series, RY was found to be a superior reconstruction method after distal gastrectomy since it was rarely accompanied by the reflux of duodenal juice into the remnant stomach or gastric reflux into the lower esophagus. Received: May 9, 2001 / Accepted: January 8, 2002 Reprint requests to: K. Shinoto     

Long-Term Outcome of Adult-to-Adult Living Donor Liver Transplantation for Post-Kasai Biliary Atresia

Our objective was to analyze problems in the perioperative management and long-term outcome of living donor liver transplantation (LDLT) for biliary atresia (BA). Many reports have described the effectiveness of liver transplantation (LT) for BA, particularly in pediatric cases, but little information is available regarding LT in adults (> or =16 years old). Between June 1990 and December 2004, 464 patients with BA underwent LDLT at Kyoto University Hospital, of whom 47 (10.1%) were older than 16 years. In this study, we compared the outcomes between adult (> or =16 years old) and pediatric (<16 years old) patients. The incidence of post-transplant intestinal perforation, intra-abdominal bleeding necessitating repeat laparotomy and biliary leakage was significantly higher (p < 0.0001, <0.001 and <0.001, respectively) in adults. Overall cumulative 1-, 5- and 10-year survival rates in pediatric patients were significantly higher (p < 0.005) than in adults. Two independent prognostic determinants of survival were identified: a MELD score over 20 and post-transplant complications requiring repeat laparotomy. Outcome of LDLT in adult BA patients was poorer than in pediatric patients. It seems likely that LT will be the radical treatment of choice for BA and that LDLT should be considered proactively at the earliest possible stage.     

腹腔镜与开腹手术治疗新生儿肠闭锁的比较

目的探讨腹腔镜手术治疗新生儿肠闭锁的疗效。方法采用前瞻性研究,对2002年2月～2006年11月连续61例进行手术治疗的肠闭锁患儿进行编号,奇数编入腹腔镜组,偶数编入开腹组,比较2组术中术后情况。结果2组患儿术后存活率（29/31 vs 28/30,x^2=0.001,P=0.973）、术后并发症构成比统计学上无显著差异（x^2=1.298,P=0.862）。腹腔镜组20例经脐孔拖出行肠切除、肠吻合手术患儿术后脐正常,瘢痕无或很小。61例随访6～18个月,平均11个月,术后复发小肠结肠炎3例（腹腔组2例,开腹组1例）,经保守治疗治愈;粘连性肠梗阻3例（腹腔组1例,开腹组2例）,经保守治疗治愈。结论腹腔镜下治疗新生儿肠闭锁技术简单、安全、几乎无瘢痕。     

Appendiceal Mass in a Neonate After Surgery for Esophageal Atresia and Tracheoesophageal Fistula: Report of a Case

A 23-day-old girl presented with abdominal distension and vomiting. She had been previously operated on for esophageal atresia and tracheoesophageal fistula (EA/TEF) when she was 2 days old. An immediate laparotomy revealed an appendiceal mass caused by perforated appendicitis. The occurrence of appendicitis and an appendiceal mass is extremely rare in neonates and this may be the first such report in the world literature.     

The Effect of Recipient-Specific Surgical Issues on Outcome of Liver Transplantation in Biliary Atresia

Biliary atresia (BA), the most common reason for orthotopic liver transplantation (OLT) in children, is often accompanied by unique and challenging anatomical variations. This study examines the effect of surgical-specific issues related to the presence of complex vascular anatomic variants on the outcome of OLT for BA. The study group comprised 944 patients who were enrolled in the Studies of Pediatric Liver Transplantation (SPLIT) registry and underwent OLT for BA over an 11-year period. 63 (6.7%) patients met the study definition of complex vascular anomalies (CVA). Patient survival, but not graft survival, was significantly lower in the CVA group, (83 vs. 93 % at 1-year post-OLT). The CVA group had a significantly higher incidence of all reoperations, total biliary tract complications, biliary leaks and bowel perforation. The most frequent cause of death was infection, and death from bacterial infection was more common in the CVA group. Pretransplant portal vein thrombosis and a preduodenal portal vein were significant predictors of patient survival but not graft survival. This study demonstrates that surgical and technical factors have an effect on the outcome of BA patients undergoing OLT. However, OLT in these complex patients is technically achievable with an acceptable patient and graft survival.     

Living Donor Liver Transplantation for Biliary Atresia: A Single-Center Experience with First 100 Cases

The aim of this study is to present our institutional experience in living donor liver transplantation (LDLT) as a treatment for end-stage liver disease in children with biliary atresia (BA). A retrospective review of transplant records was performed. One hundred BA patients (52 males and 48 females) underwent LDLT. The mean follow-up period was 85.5 months. The mean age was 2.4 years. The mean preoperative weight, height, and computed GFR were 12.2 kg, 82.5 cm, and 116.4 ml/min/1.73 m2, respectively. Twenty-seven patients were below 1 year of age, and 49 patients were below 10 kg at the time of transplantation. Ninety-six had had previous Kasai operation prior to transplant. The mean recipient operative time was 628 min. The mean recipient intraoperative blood loss was 176 ml. Thirty-five did not require blood or blood component transfusion. The left lateral segment (64) was the most common type of graft used. There were 27 operative complications which included 3 reoperations for postoperative bleeding, 9 portal vein, 4 hepatic vein, 4 hepatic artery, and 7 biliary complications. There was one in-hospital mortality and one retransplantation. The overall rejection rate was 20%. The overall mortality rate was 3%. The 6-month, 1-year and 5-year actual recipient survival rates were 99%, 98% and 98%, respectively.     

Portal Vein Stenting for Portal Hypertension Caused by Local Recurrence After Pancreatoduodenectomy for Periampullary Cancer

Portal hypertension after extensive abdominal surgery is an unusual cause of repetitive gastrointestinal bleeding. We report on a 68-year-old male patient with intermittent gastrointestinal bleeding secondary to portal vein stenosis caused by local recurrence of the distal bile duct cancer after pancreatoduodenectomy. Severe portal vein stenosis without sufficient development of portal venous collaterals was detected 25 months after pancreatoduodenectomy. Direct portography using a percutaneous transhepatic approach showed that there was a pressure gradient of 18 mmHg across the portal vein stenosis. Portal vein stenting successfully relieved portal hypertension and bowel congestion. Gastrointestinal bleeding episodes ceased after stenting. The patient died from liver metastasis 14 months after stent insertion and 39 months after pancreatoduodenectomy. Based on this case and literature reports, the possibility of portal vein stenosis should be considered for patients who have undergone pancreatoduodenectomy and then showed unexplained gastrointestinal bleeding. Percutaneous transhepatic stent insertion appears to be the treatment of choice for focal portal vein stenosis.     

Laparoscopic Cholecystocholangiography as an Effective Alternative Exploratory Laparotomy for the Differentiation of Biliary Atresia

Purpose Exploratory laparotomy with cholecystocholangiography is often performed for the definitive diagnosis of biliary atresia (BA) when radiological and biochemical studies are inconclusive. Laparoscopic cholecystocholangiography (LCC) has recently been introduced as an alternative procedure to avoid unnecessary laparotomy. We discuss the advantages and indications of LCC based on our experience of performing this diagnostic procedure in four infants with prolonged direct hyperbilirubinemia. Methods We performed LCC in four infants by direct percutaneous puncture of the gallbladder by inserting a cholangiocatheter into the gallbladder or cystic duct. The decision to perform LCC was based on ultrasonography and computed tomography findings of an atrophic gallbladder with a patent lumen, although analysis of duodenal juice and hepatobiliary scintigraphy showed no sign of the excretion of bile into the small intestine. Results In three infants, LCC did not show the entire biliary system, and laparotomy was necessary to confirm the diagnosis of BA. However, in the other patient LCC showed a normal biliary system and BA was excluded. Conclusion Laparoscopic cholecystocholangiography may be useful for the differential diagnosis of BA in patients with a patent gallbladder when imaging and biochemical findings are inconclusive. Furthermore, unnecessary exploratory laparotomy may be avoided in patients without BA.     

联合门静脉切除重建的肝脏左三区切除治疗进展期肝门部胆管癌

The clinical value of applying portal vein resection and reconstruction in left trisectionectomy for treating advanced hilar cholangiocarcinoma is approved, while it is still a big challenge for clinicians. One female patient suffering from abdominal pain and jaundice received treatment in the General Hospital of PLA in July, 2009. She was prelimiarily diagnosed with Bismuth type Ⅲ a hilar cholangiocarcinoma. A tube was inserted in the left lateral inferior bile duct to carry out percutaneous transhepatic biliary drainage (PTBD). After the anatomic variation of the left bile duct was found, the diagnosis was revised as Bismuth type Ⅳ. A left trisectionectomy was proposed, and another PTBD tube was inserted in the right posterior bile duct.Combined portal vein resection and reconstruction and left trisectionectomy was successfully performed. The postoperation course was uneventful, except for the transient liver dysfunction and biliary-enteric anastomotic leakage.     

Biliary atresia and pregnancy: puberty may be an important point for predicting the outcome

Purpose

The aim of this study was to study the late clinical features of biliary atresia in relation to pregnancy.

Materials and Methods

Of the 175 patients with biliary atresia operated on at our department, the data for 49 patients (18 males, 31 females) older than 15 years were reviewed and analyzed.

Results

Six patients delivered 7 newborns (5 with their native liver and 1 with a transplanted liver). Although one of the patients delivered twice after transplantation, another underwent transplantation after delivery. None of the 7 newborns showed any congenital anomalies; however, 6 were small-for-date newborns. Their birth weight tended to be inversely related to the mothers' age at delivery. An additional 13 patients required liver transplantation, of whom 1 died after transplantation and 1 died before transplantation. The remaining 30 patients showed uneventful courses without transplantation. The age at Kasai operation was significantly higher in the 5 patients who delivered babies with their native liver compared with that in these 30 patients (88.0 vs 68.6 days). A significant difference between these 5 patients and those who died or required transplantation before pregnancy was recognized even at the age of puberty in the alanine aminotransferase (36.5 ± 26.5 vs 126.4 ± 56.1 IU/L), aspartate aminotransferase (36.2 ± 26.5 vs 114.2 ± 48.9 IU/L), and choline esterase (249.7 ± 64.8 vs 163.5 ± 40.2 IU/L).

Conclusions

The age at Kasai operation may not necessarily impact the late clinical course; however, liver function at puberty may predict the subsequent clinical course, including the safety of pregnancy. The management strategies should be revised after puberty.     

Risk Factors for and Clinical Course of Non-Anastomotic Biliary Strictures After Liver Transplantation

Non-anastomotic biliary stricture (NAS) formation is a major complication of liver transplantation. We prospectively determined the time to development of responsiveness to treatment, and clinical outcomes following NAS formation. In addition, an extensive analysis of the association of recipient, donor, and clinical variables with NAS formation was performed. A total of 749 consecutive patients was studied in a prospective, protocol-based fashion. Seventy-two patients (9.6%) developed NAS at a mean of 23.6 +/- 34.2 weeks post-transplantation. Non-anastomotic biliary stricture formation resolved in only 6% of affected patients. Although patient survival was not affected, retransplantation and graft loss rates were significantly greater in recipients who developed NAS. In contrast to previous reports, a pretransplant diagnosis of HCV was associated with a low frequency of NAS formation. The incidence of NAS was independently associated with pretransplant diagnoses of PSC and autoimmune hepatitis. Hepatic artery thrombosis, and prolonged warm and cold ischemia times were also independent risk factors for NAS formation. We conclude that NAS developed in approximately 10% of primary liver transplant recipients. A pretransplant diagnosis of autoimmune hepatitis has been identified as a novel independent risk factor for NAS formation. Development of NAS significantly attenuates graft but not patient survival.     

Portal Venous Dilatation and Stenting for Bleeding Jejunal Varices: Report of Two Cases

We present two patients who underwent a portal stent placement for bleeding jejunal varices of the afferent loop caused by extrahepatic portal venous stenosis. Case 1 involved a 66-year-old woman who developed bleeding jejunal varices due to extrahepatic portal venous stenosis 1 year after a pancreaticoduodenectomy with intraoperative radiation therapy. Percutaneous transhepatic balloon dilatation and stent placement were performed. Since undergoing the procedure, no bleeding has occurred. Case 2 concerned a 44-year-old woman who had a rupture and bleeding of jejunal varices 16 years after a choledocojejunostomy. Stenosis was observed from the right and left branches of the portal vein to its intrahepatic branches. Both balloon dilatation and stent placement were attempted. However, the stent could not be fully inserted into the intrahepatic portal vein. Portal stent placement is less invasive and radical, and therefore should be attempted for the treatment of extrahepatic portal venous stenosis. However, there are limits to its application if the stenosis extends to the intrahepatic branches of the portal vein. Received: February 8, 2001 / Accepted: July 17, 2001