Kato Yutaro, Sugioka Atsushi, Kojima Masayuki, Yoshikawa Junichi, Tanahashi Yoshinao, Nakajima Sanae, Yasuda Akira, Kiguchi Gozo, Uchida Yuichiro, Yasui Toshihiro, Suzuki Tatsuya, Akamatsu Hokuto, Hanaoka Ryota, Nagata Hiroyuki, Kato Ryoichi, Uyama Ichiro
Department of Surgery, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan.
Department of Pediatric Surgery, Fujita Health University, Toyoake, Japan.
Surg Case Rep. 2021 Jan 6;7(1):2. doi: 10.1186/s40792-020-01093-4.
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.
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).
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.
肝静脉（HV）或门静脉（PV）急性梗阻，尤其是在肝脏手术过程中发生时，若不迅速修复，可能会致命。由于针对该问题的手术干预技术要求高且可能不成功，因此需要其他治疗选择。
我们报告了两例在肝切除或活体肝移植（LDLT）期间发生的急性、手术无法纠正的HV或PV梗阻病例，通过介入放射学（IVR）在术中紧急放置血管内支架成功治疗。病例1中，一名患有结肠肝转移的患者接受了第4和8段非解剖性部分肝切除术并切除了肝中静脉（MHV）。此外，该患者因肿瘤累及右肝静脉（RHV），接受了扩大的右后段切除术并切除了RHV。需要重建MHV以避免肝脏前段HV充血。首先通过将MHV与切除的RHV残端进行端端吻合来重建MHV。然而，重建未能保持HV流出，前段出现充血。包括重新吻合、静脉移植插入和在吻合壁上进行静脉移植补片成形术等一系列手术修复尝试均未能恢复HV流出。病例2中，一名患有胆道闭锁的儿科患者接受了LDLT，并在手术期间出现难治性PV梗阻。带静脉移植插入的重新吻合未能恢复PV血流，延长的热缺血时间变得至关重要。在这两个病例中，HV或PV重建中的错位可能导致了血流梗阻，各种类型的手术干预均未能恢复静脉血流。在这两个病例中，通过IVR引导紧急放置自膨式金属支架（SEMS）迅速有效地恢复了HV或PV灌注，并使患者免于发展为危急状况。此外，在病例1和病例2中，放置的SEMS在足够长的时间内保持通畅（分别为32个月和44个月）。
IVR引导的术中紧急血管内支架置入术是一种安全有效的治疗工具，可用于解决肝脏手术过程中发生的潜在致命性急性HV或PV梗阻。
