Weinberg Laurence, Hanus Georgina, Banting Jonathan, Abu-Ssaydeh Diana, Spanger Manfred, Goh Su Kah, Muralidharan Vijayaragavan
Department of Anaesthesia, Austin Hospital, Heidelberg, 3084, Victoria, Australia; Department of Surgery, Austin Health, University of Melbourne, 8002, Victoria, Australia.
Department of Anaesthesia, Austin Hospital, Heidelberg, 3084, Victoria, Australia.
Int J Surg Case Rep. 2017;36:69-73. doi: 10.1016/j.ijscr.2017.05.005. Epub 2017 May 15.
Major liver resection in a Jehovah's Witness presents unique clinical challenges requiring multimodal blood minimization strategies to reduce perioperative complications. We report a case where complete left hepatic lobe devascularisation was undertaken to minimize bleeding in a Jehovah's Witness undergoing left hepatectomy.
A 65-year-old male Jehovah's Witness presented for open left hepatectomy for a large left-sided hepatocellular carcinoma involving segment IV of the liver. Three weeks prior to surgery, the patient underwent left portal vein embolization. To isolate and devascularise the left lobe, the gastroduodenal artery and left hepatic artery were then occluded with coils. The bed of the left hepatic artery was then embolised to stasis with particles. Finally, the anastomosis back to the right hepatic artery was also occluded by coils. The patient underwent uneventful surgery with an estimated blood loss of 450mls.
Left hepatectomy in a Jehovah's Witness patient is feasible but requires careful planning and a multidisciplinary approach. Major liver resection represents a well defined but complex haemostatic challenge from tissue and vascular injury, further complicated by hepatic dysfunction, and activation of inflammatory, haemostatic and fibrinolytic pathways. In addition to the haemoglobin optimization strategies utilized preoperatively, the use of interventional radiology techniques to further reduce perioperative bleeding should be considered in all complex cases.
Combination of portal vein embolization and hepatic lobe devascularisation to produce total vascular occlusion of inflow to the left lobe radiologically allowed a near bloodless surgical field during major liver resection in a Jehovah's Witness patient.
耶和华见证人的肝大部切除术面临独特的临床挑战，需要采取多模式血液量最小化策略以减少围手术期并发症。我们报告一例为尽量减少一名接受左肝切除术的耶和华见证人术中出血而进行完全左肝叶去血管化的病例。
一名65岁男性耶和华见证人因左侧巨大肝细胞癌累及肝IV段而接受开放性左肝切除术。术前三周，患者接受了左门静脉栓塞。为分离左叶并使其去血管化，随后用弹簧圈闭塞胃十二指肠动脉和左肝动脉。然后用微粒栓塞左肝动脉床直至血流停滞。最后，与右肝动脉的吻合处也用弹簧圈闭塞。患者手术过程顺利，估计失血量为450毫升。
耶和华见证人患者的左肝切除术是可行的，但需要仔细规划和多学科方法。肝大部切除术因组织和血管损伤而面临明确但复杂的止血挑战，肝功能障碍以及炎症、止血和纤溶途径的激活使情况更加复杂。除了术前采用的血红蛋白优化策略外，对于所有复杂病例，应考虑使用介入放射学技术进一步减少围手术期出血。
门静脉栓塞和肝叶去血管化相结合，通过放射学方法使左叶流入血管完全闭塞，从而在耶和华见证人患者的肝大部切除术中实现了近乎无血的手术视野。
