Takada Satoshi, Nakanuma Shinichi, Kobori Renta, Araki Takahiro, Kato Kazuki, Nasr Abdulrahman, Takei Ryohei, Saito Daisuke, Kato Kaichiro, Okazaki Mitsuyoshi, Makino Isamu, Yagi Shintaro
Department of Hepato-Biliary-Pancreatic Surgery and Transplantation, Kanazawa University, Kanazawa, Ishikawa, Japan.
Department of Thoracic Surgery, Kanazawa University, Kanazawa, Ishikawa, Japan.
Surg Case Rep. 2025;11(1). doi: 10.70352/scrj.cr.25-0341. Epub 2025 Sep 2.
Liver transplantation for polycystic liver disease (PLD) poses significant intraoperative risks due to the presence of a massively enlarged liver. We report a rare case of intraoperative pneumothorax and pneumatocele formation during total hepatectomy, which was successfully managed with a non-operative approach.
A female patient in her 40s with a history of autosomal dominant polycystic kidney disease presented with progressive liver cyst enlargement (Gigot type III, Qian classification Grade 4), which led to decreased activities of daily living and intracystic hemorrhage. The patient underwent a deceased-donor liver transplantation. During mobilization of the liver from the right side of the diaphragm, the patient experienced sudden onset of pneumothorax. Incision of the diaphragm revealed a cystic structure containing a hematoma, suggesting pneumatocele formation. The pneumatocele was not resected during the ongoing operation; instead, thoracic drainage was performed as the primary intervention. Postoperatively, no air leakage was observed, and the thoracic drain was successfully removed on POD 12. The pneumatocele, which measured approximately 10 × 10 × 7 cm, showed no signs of infection, and was monitored without additional surgical intervention. On POD 19, a fever prompted further evaluation, and CT-guided cyst aspiration for culture was performed, which revealed no evidence of infection. Acute T-cell-mediated rejection was observed on POD 27, and a steroid pulse was administered, but even after that, the pneumatocele gradually decreased in size without any signs of infection.
A pneumatocele is an uncommon but important consideration during liver transplantation for PLD, potentially resulting from barotrauma related to abrupt changes in intrathoracic pressure during hepatectomy and mechanical ventilation. Considering the risk of infection in immunosuppressed patients, close monitoring is essential. On the contrary, surgical resection also carries the risk of pulmonary or bronchial fistulae; therefore, careful consideration is required. This case demonstrates that non-operative management with careful observation can be an effective strategy in selected patients.
由于肝脏极度肿大，多囊肝疾病（PLD）患者进行肝移植手术时存在重大术中风险。我们报告了一例在全肝切除术中罕见的术中气胸和气囊肿形成病例，该病例通过非手术方法成功处理。
一名40多岁的女性患者，有常染色体显性多囊肾病病史，出现渐进性肝囊肿增大（吉戈特III型，钱氏分类4级），导致日常生活活动能力下降及囊内出血。患者接受了尸体供肝肝移植。在从右侧膈肌游离肝脏过程中，患者突然发生气胸。切开膈肌发现一个含有血肿的囊性结构，提示气囊肿形成。在正在进行的手术中未切除气囊肿；相反，作为主要干预措施进行了胸腔引流。术后未观察到漏气，胸腔引流管于术后第12天成功拔除。气囊肿大小约为10×10×7cm，无感染迹象，在未进行额外手术干预的情况下进行监测。术后第19天，发热促使进一步评估，进行了CT引导下囊肿穿刺培养，未发现感染证据。术后第27天观察到急性T细胞介导的排斥反应，给予类固醇冲击治疗，但即便如此，气囊肿大小仍逐渐减小，无任何感染迹象。
气囊肿在PLD肝移植过程中虽不常见但却是重要的考虑因素，可能是由于肝切除和机械通气期间胸腔内压力突然变化相关的气压伤所致。考虑到免疫抑制患者存在感染风险，密切监测至关重要。相反，手术切除也有发生肺或支气管瘘的风险；因此，需要仔细权衡。本病例表明，对于部分患者，仔细观察的非手术管理可能是一种有效的策略。
