1. Urgent intraoperative endovascular stent placement to resolve acute hepatic or portal venous obstruction during liver surgery: a case series
- Author
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Ryoichi Kato, Hiroyuki Nagata, Tatsuya Suzuki, Atsushi Sugioka, Akira Yasuda, Toshihiro Yasui, Yutaro Kato, Gozo Kiguchi, Junichi Yoshikawa, Masayuki Kojima, Ryota Hanaoka, Hokuto Akamatsu, Yoshinao Tanahashi, Ichiro Uyama, Yuichiro Uchida, and Sanae Nakajima
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,lcsh:Surgery ,Case Report ,Liver transplantation ,Anastomosis ,Endovascular stenting ,Hepatic vein ,03 medical and health sciences ,0302 clinical medicine ,Self-expandable metallic stent ,Biliary atresia ,Vascular reconstruction ,medicine ,Vein ,Interventional radiology ,medicine.diagnostic_test ,Liver resection ,business.industry ,lcsh:RD1-811 ,medicine.disease ,Venous Obstruction ,Surgery ,medicine.anatomical_structure ,030220 oncology & carcinogenesis ,Portal vein ,030211 gastroenterology & hepatology ,SEMS ,business ,Perfusion - Abstract
Background Acute obstruction of the hepatic vein (HV) or the portal vein (PV), particularly when it occurs during liver surgery, is potentially fatal unless repaired swiftly. As surgical interventions for this problem are technically demanding and potentially unsuccessful, other treatment options are needed. Case presentation We report two cases of acute, surgically uncorrectable HV or PV obstruction during liver resection or living donor liver transplantation (LDLT), which was successfully treated with urgent intraoperative placement of endovascular stents using interventional radiology (IVR). In Case 1, a patient with colonic liver metastases underwent a non-anatomic partial hepatectomy of the segments 4 and 8 with middle hepatic vein (MHV) resection. Additionally, the patient underwent an extended right posterior sectionectomy with right hepatic vein (RHV) resection for tumors involving RHV. Reconstruction of the MHV was needed to avoid HV congestion of the anterior section of the liver. The MHV was firstly reconstructed by an end-to-end anastomosis between the MHV and RHV resected stumps. However, the reconstruction failed to retain the HV outflow and the anterior section became congested. Serial trials of surgical revisions including re-anastomosis, vein graft interposition and vein graft patch-plasty on the anastomotic wall failed to recover the HV outflow. In Case 2, a pediatric patient with biliary atresia underwent an LDLT and developed an intractable PV obstruction during surgery. Re-anastomosis with vein graft interposition failed to restore the PV flow and elongated warm ischemic time became critical. In both cases, the misalignment in HV or PV reconstruction was likely to have caused flow obstruction, and various types of surgical interventions failed to recover the venous flow. In both cases, an urgent IVR-directed placement of self-expandable metallic stents (SEMS) restored the HV or PV perfusion quickly and effectively, and saved the patients from developing critical conditions. Furthermore, in Cases 1 and 2, the SEMS placed were patent for a sufficient period of time (32 and 44 months, respectively). Conclusions The IVR-directed, urgent, intraoperative endovascular stenting is a safe and efficient treatment tool that serves to resolve the potentially fatal acute HV or PV obstruction that occurs in the middle of liver surgery.
- Published
- 2021