Sakamoto Sodai, Goto Ryoichi, Kawamura Norio, Koshizuka Yasuyuki, Watanabe Masaaki, Ota Minoru, Suzuki Tomomi, Abo Daisuke, Yamashita Kenichiro, Kamiyama Toshiya, Taketomi Akinobu, Shimamura Tsuyoshi
Department of Gastroenterological Surgery I, Hokkaido University, Sapporo, Japan.
Division of Organ Transplantation, Hokkaido University Hospital, Sapporo, Japan.
Surg Case Rep. 2017 Aug 23;3(1):89. doi: 10.1186/s40792-017-0364-5.
Hepaticojejunostomy may be used for biliary reconstruction in certain cases of liver transplantation. In this occasion, Roux-en-Y biliary reconstruction is predominantly performed. Petersen's hernia is an internal hernia that can occur after Roux-en-Y reconstruction, and it may lead to extensive ischemic changes affecting incarcerated portions of the small bowel or Roux limb resulting in severe complications with a poor prognosis.
The present case was a 44-year-old male who underwent living donor liver transplantation (LDLT) for familial amyloid polyneuropathy and in whom biliary reconstruction was performed with Roux-en-Y hepaticojejunostomy. Two years after liver transplantation, symptomatic bowel strangulation was diagnosed by CT examination and emergent surgery was performed accordingly. On exploration, an ischemic limb associated with Petersen's hernia was observed. Although repositioning of the incarcerated bowel loop gradually improved the color of the limb, the limb failed to completely recover to a normal color. To allow accurate evaluation for the viability of the limb, we decided to perform a second-look operation after 48 h. On re-exploration, the surface of the limb remained a dark color; however, intraoperative endoscopic findings revealed only partial necrosis of the mucosa. Next, we resected the portion of ischemic damaged limb only following side-to-side jejunojejunostomy. Consequently, redoing of biliary reconstruction could be avoided and the original hepaticojejunostomy site was preserved. Although the stricture of the remnant Roux limb occurred 1 month thereafter, it was successfully managed by balloon dilation via percutaneous transhepatic biliary drainage route.
The occurrence of Petersen's hernia should always be considered in cases of liver transplantation with Roux-en-Y biliary reconstruction. On the basis of an accurate assessment of the extent of jejunal limb injury, reanastomosis of the hepaticojejunostomy, a potentially high-risk surgical procedure, can be avoided in emergent situations.
肝空肠吻合术可用于某些肝移植病例的胆道重建。在这种情况下，主要进行Roux-en-Y胆道重建。彼得森疝是一种可在Roux-en-Y重建术后发生的内疝，它可能导致广泛的缺血性改变，影响小肠或Roux袢的嵌顿部分，从而导致严重并发症，预后不良。
本病例为一名44岁男性，因家族性淀粉样多神经病接受活体肝移植（LDLT），并采用Roux-en-Y肝空肠吻合术进行胆道重建。肝移植术后两年，CT检查诊断为有症状的肠绞窄，并据此进行了急诊手术。术中发现与彼得森疝相关的缺血性肠袢。尽管将嵌顿的肠袢复位后肠袢颜色逐渐改善，但仍未完全恢复正常颜色。为准确评估肠袢的活力，我们决定在48小时后进行二次探查手术。再次探查时，肠袢表面仍呈深色；然而，术中内镜检查结果显示仅黏膜部分坏死。接下来，我们仅切除缺血受损的肠袢部分，随后进行端端空肠吻合术。因此，避免了再次进行胆道重建，并保留了原肝空肠吻合部位。尽管此后1个月残余Roux袢出现狭窄，但通过经皮经肝胆道引流途径进行球囊扩张成功解决。
在采用Roux-en-Y胆道重建的肝移植病例中，应始终考虑彼得森疝的发生。在准确评估空肠袢损伤程度的基础上，在紧急情况下可避免进行肝空肠吻合术这种潜在高风险的手术再次吻合。
