Iida Hiroya, Miyake Toru, Tani Masaji, Tanaka Takuya, Kawakami Kayo, Ikuno Yoshihiro, Mandai Ryoichi, Shimizu Tomoharu
Department of Surgery, Shiga University of Medical Science, Otsu, Shiga, 520-2192, Japan.
Medical Safety Section, Shiga University of Medical Science Hospital, Otsu, Shiga, 520-2192, Japan.
Surg Case Rep. 2020 Dec 10;6(1):319. doi: 10.1186/s40792-020-01086-3.
The standard therapeutic agent administered for portal vein thrombosis (PVT) in patients with or without cirrhosis is warfarin or low-molecular weight heparin. However, therapy with edoxaban appears to be one of the most promising treatments for patients who require anticoagulation therapy. We encountered two cases of cerebellar hemorrhage in patients treated with edoxaban for PVT after hepatobiliary surgery during the past 2 years.
Case 1 A 67-year-old male underwent cholecystectomy and choledocholithotomy with choledochoduodenostomy to treat choledocholithiasis after cholangitis. Enhanced computed tomography (CT) on the 1st postoperative day (POD) revealed thrombosis in the left and anterior segment of the portal vein branches. We administered antithrombin III concentrate with heparin for 5 days; thereafter, we switched to 60 mg edoxaban. A sudden decrease in the patient's level of consciousness was observed due to cerebellar hemorrhage on POD 27. Cerebellar hemorrhage was successfully treated with craniotomy hematoma evacuation and ventricular drainage; however, the patient died from aggravation of hepatic failure due to PVT and intra-abdominal infection. Case 2 A 67-year-old male received laparoscopic microwave coagulation therapy for two hepatic nodules suggestive of hepatocellular carcinoma in the left lobe of the liver due to alcoholic hepatitis. Enhanced CT on POD 5 revealed a thrombosis in the 4th segment branch of the portal vein, and the patient was treated with 60 mg edoxaban. Cerebellar hemorrhage with ventricular perforation occurred on POD 15. Cerebellar hemorrhage was successfully treated by craniotomy hematoma evacuation with ventricular drainage. Prolonged consciousness disorder persisted, and the patient was transferred to another medical facility for rehabilitation 49 days after brain surgery.
Although edoxaban is recently described to be one of the options for patients with PVT who require anticoagulation therapy instead of heparin or warfarin, it should be used with caution, given its propensity to induce severe hemorrhagic adverse events in cases such as those described above. The monitoring of hepatic dysfunction and decision for continuation of drug may be required during edoxaban use for PVT, especially after hepatobiliary surgery.
对于伴有或不伴有肝硬化的门静脉血栓形成（PVT）患者，标准的治疗药物是华法林或低分子肝素。然而，对于需要抗凝治疗的患者，依度沙班治疗似乎是最有前景的治疗方法之一。在过去2年中，我们遇到了2例在肝胆手术后接受依度沙班治疗PVT的患者发生小脑出血的病例。
病例1 一名67岁男性因胆管炎后胆总管结石接受了胆囊切除术、胆总管切开取石术及胆总管十二指肠吻合术。术后第1天（POD）的增强计算机断层扫描（CT）显示门静脉分支左前节段血栓形成。我们给予抗凝血酶III浓缩物联合肝素治疗5天；此后，改为使用60mg依度沙班。在POD 27时，患者因小脑出血出现意识水平突然下降。小脑出血通过开颅血肿清除术和脑室引流成功治疗；然而，患者因PVT和腹腔内感染导致肝功能衰竭加重而死亡。病例2 一名67岁男性因酒精性肝炎对肝脏左叶两个提示肝细胞癌的肝结节接受了腹腔镜微波凝固治疗。POD 5的增强CT显示门静脉第4段分支血栓形成，患者接受60mg依度沙班治疗。在POD 15时发生小脑出血并伴有脑室穿孔。小脑出血通过开颅血肿清除术及脑室引流成功治疗。患者持续存在意识障碍延长，脑手术后49天被转至另一家医疗机构进行康复治疗。
尽管依度沙班最近被描述为需要抗凝治疗而非肝素或华法林的PVT患者的选择之一，但鉴于其在上述病例中易引发严重出血不良事件的倾向，应谨慎使用。在使用依度沙班治疗PVT期间，尤其是在肝胆手术后，可能需要监测肝功能障碍并决定是否继续用药。
