Kanno Hiroki, Yoshida Atsushi, Goto Yuichi, Hisaka Toru, Akagi Yoshito, Okuda Koji
Department of Surgery, Kurume University School of Medicine, Kurume, Japan.
Department of Surgery, Kurume University School of Medicine, Kurume, Japan.
Int J Surg Case Rep. 2020;76:297-300. doi: 10.1016/j.ijscr.2020.09.203. Epub 2020 Oct 6.
Hepatic venous outflow obstruction (HVOO) is a rare complication of hepatectomy. We report a case of HVOO caused by remnant liver migration into the subphrenic space after hepatectomy, which was successfully managed by repositioning of the remnant liver.
A 55-year-old Japanese man was diagnosed with a liver tumor on ultrasound. Contrast-enhanced CT revealed early enhancement in the arterial phase, followed by a washout in the late phase. Preoperative diagnosis was hepatocellular carcinoma, and hand-assisted laparoscopic extended posterior sectionectomy was performed. On postoperative day 1, middle hepatic vein (MHV) flow was not detected on ultrasound, and the portal flow was hepatofugal. CT during arterial portography revealed absence of the portal flow to the medial and anterior sections, and remnant liver migration into the subphrenic space. Therefore, we suspected that HVOO was caused by the remnant liver migration and performed redo laparotomy to reposition the remnant liver with suturing of the falciform ligament to the anterior abdominal wall. Postoperatively, contrast-enhanced CT demonstrated that the remnant liver remained in the anatomical position, and the medial and anterior sections were well enhanced.
HVOO might occur irrespective of whether the left triangular ligament is preserved. We believe that it is necessary to fix the remnant liver to the abdominal wall in cases with poor venous blood flow confirmed by intraoperative ultrasound. If kinking of the hepatic vein persists, stent insertion should be performed.
HVOO after hepatectomy is rare but potentially fatal, and prevention and countermeasures should be discussed.
肝静脉流出道梗阻（HVOO）是肝切除术后一种罕见的并发症。我们报告一例肝切除术后残余肝移入膈下间隙导致的HVOO病例，该病例通过重新定位残余肝成功得到处理。
一名55岁的日本男性经超声检查诊断为肝肿瘤。增强CT显示动脉期早期强化，随后在延迟期出现廓清。术前诊断为肝细胞癌，遂行手辅助腹腔镜扩大右后叶切除术。术后第1天，超声检查未检测到肝中静脉（MHV）血流，门静脉血流呈离肝血流。动脉门静脉造影CT显示内侧和前叶无门静脉血流，残余肝移入膈下间隙。因此，我们怀疑HVOO是由残余肝移位引起的，遂再次开腹重新定位残余肝，并将镰状韧带缝合至前腹壁。术后，增强CT显示残余肝保持在解剖位置，内侧和前叶强化良好。
无论是否保留左三角韧带，都可能发生HVOO。我们认为，对于术中超声证实静脉血流不佳的病例，有必要将残余肝固定于腹壁。如果肝静脉扭结持续存在，应进行支架置入。
肝切除术后HVOO虽罕见但可能致命，应探讨预防措施及应对方法。
