Significance of Preoperative Portal Vein Emblization of Cirrhotic Liver for Major Hepatectomy

Patients with hepatocellular carcinoma are often combined with liver cirrhosis, which limits the extent of liver resection. We evaluated the effect of preoperative portal vein embolization (PVE) on perioperative course of major hepatectomy of cirrhotic livers. A case-controlled study categorized by PVE and liver cirrhosis was perfomed in 63 cases undergone right lobectomy for hepatocellular carcinoma. The cirrhotic PVE group showed the following changes before and after PVE, respectively; indocyanine green 15 minutes retention rate of 7.5% and 9.1%, left lobe volume of 433.8 ml and 461.5 ml, and portal pressures of 13.0 mmHg and 18.8 mmHg. The non-cirrhotic PVE group showed a smaller increase in the portal pressure after PVE. There were no PVE-related complications. Postoperative changes in the remnant liver volume at 2 weeks and 3 months showed no significant differences between the cirrhotic PVE and the cirrhotic non-PVE groups. Postoperative bleeding and hepatic failure occurred in 5.3% versus 22.7% and additional hepatic decompensation at postoperative 3 months was found in 10.5% versus 18.2% of the cirrhotic PVE and the cirrhotic non-PVE groups, respectively. The mean size of the tumor in mortality cases was 3.8 cm, and there was no mortality in PVE cases with a tumor less than 5 cm. PVE of a functionally preserved cirrhotic liver was a safe procedure and lowered liver function-related complications, which may be at least partially due to atrophy-hypertrophy of the liver parenchyme and to the attenuated portal pressure change following right lobectomy after PVE. Conclusively, preoperative PVE may provide safety after major hepatectomy for the patients with cirrhotic livers or small-sized tumors.

Major Complications after Orthotopic Liver Transplantations

A retrospective study was conducted to determine the incidence of major complications after liver transplantations which had been performed at Asan Medical Center from August 1992 to October 1996. Among the 43 orthotopic liver transplantations(OLTs), 27 were cadaveric donor liver transplantation(CDLT) including one retransplantation, 16 were living donor liver transplantation(LDLT). The over-all incidence of major complication was 52.4%, and there were no statistical difference between CDLT and LDLT. But the one-year cumulative survival was better in LDLT than CDLT(86.2% vs 63.3% : p < 0.1). To reduce the incidence of major complications after OLT, proper management of donors, early transplantation of recipients and shortening of cold ischemic time are mandatory especially in CDLT.

Iatrogenic Pseudoaneurysm of Splanchnic Artery after Hepato-Biliary-Pancreatic Surgery

Extensive hepato-biliary-pancreatic (H-B-P) surgery is still associated with a high postoperative morbidity and mortality than other intraabdominal organ operation. Especially, iatrogenic pseudoaneurysm of splanchnic artery after major H-B-P surgery, although not frequent, can be a devastating and often leads to fatal hemorrhage due to aneurysm rupture. In a series of 300 patients who underwent major hepato-biliary-pancreatic surgery between 1989 and 1995, 6 patients with iatrogenic pseudoaneurysm were reviewed retrospectively. There were 1 hepatic artery pseudoaneurysm after hepatopancreaticoduodenectomy and portal vein resection for Klatskin tumor, 1 proper hepatic artery pseudoaneurysm after extended right hepatectomy and bile duct resection for Klatskin tumor, 1 superior mesenteric artery and common hepatic artery pseudoaneurysm after pancreatoduodenectomy for periampullary cancer, 1 hepatic artery pseudoaneurysm after pancreatoduodenectomy for periampullary cancer,1 pseudoaneurysm of anastomotic site between hepatic artery and splenic artery after type II regional total pancreatectomy for periampullary cancer, and 1 pseudoaneurysm of iliac artery conduit for hepatic artery reconstruction after orthotopic liver transplantation. Five of these 6 pseudoaneurysms were resulted from aggressive radical surgery including skeletonization of hepatoduodenal ligament. Pseudoaneurysm should be highly suspected when continued leukocytosis, fever and gastrointestinal bleeding such as hematemesis or melena are shown. Celiac angiogram should be considered for the early detection of pseudoaneurysm. Angiographic embolization might be considered as a primary treatment, however, if it is not successful, early surgical intervention might be an another life-saving option.