Surgery Today Jpn. J. Surg. (1992) 22:568-571
~
SURGERYTODAY
© Springer-Verlag 1992
Short Communication Partial Portal Arterialization for the Prevention of Massive Liver Necrosis following Extended Pancreatobiliary Surgery: Experience of Two Cases JouJI ISEKI, KAZUSHIGE TOUYAMA, TAMAKI NOIE, KAZUHIKO NAKAGAMI, MASAKAZU TAKAGI, KOUJI HAKAMADA, ATSUSHI TANAKA1, ATSUSHI YAMADA2, JYUNYA HANAKITA, and HIDEYUKI SUWA3 Departments of ~Surgery, ~Plastic Surgery, and 3 Neurological Surgery, Shizuoka General Hospital, 4-27-1 Kita-Andou, Shizuoka, 420 Japan
Abstract: Massive liver necrosis, which is a severe and highly fatal complication after extended pancreatobiliary surgery, may occur due to an interruption of the hepatic arterial flow caused by such events as an excision of the hepatic artery invaded by cancer, a ligation of the postoperatively ruptured hepatic artery, or a thrombotic obstruction of the reconstructed hepatic artery. In order to improve this ischemic state of the liver, we have performed a partial arterialization of the portal vein by making an arteriovenous shunt at the mesenteric vascular branches in two cases. Although a sufficient pathophysiological investigation could not be fully conducted, partial portal arterialization was considered to be effective in one patient, while no clinically noticeable adverse effects were revealed in the other patient. Words: partial portal arterialization, mesenteric arterioportal shunt, hepatic arterial interruption Key
result in massive liver necrosis due to a rapid fall in the oxygen supply to the liver. Accordingly, it would appear essential to raise the portal venous oxygen gas tension without delay. Portal arteriovenous fistula is one of the well known clinical states in which a portal vein is accidentally arterialized by either trauma or rupture of an aneurysm. 8-1° Portal arterialization either with or without a portacaval shunt in cirrhotic patients or animals is another well known state that can increase portal venous flow and oxygen gas tension. 11-13 As excessive arterial flow into the portal circulation is often accompanied by severe portal hypertension, various types of flow and pressure regulated portal arterialization have been devised. 14-15 Here we report on two cases in which a partial portal arterialization was performed by anastomosing the mesenteric arterial branch to the venous branch.
Introduction
In recent years, extended operations with an excision and reconstruction of either the hepatic artery or portal vein have been adopted for pancreatobiliary malignant neoplasms. 1'2 As a result, massive liver necrosis following an interruption of the hepatic artery such as a clamping or excision of the hepatic artery during operation, a ligation of the hepatic artery proximal to the hepatic arterial aneurysm formed postoperatively, or a thrombotic obstruction of the reconstructive artery is being closely followed with interest as a potential fatal complication) Hepatic arterial interruption has been regarded as a safe procedure because of the existence of many collateral arterial pathways. 4-7 However, under extended pancreatobiliary surgery, many collateral arteries are also widely dissected, which may Reprint requests to: J. Iseki (Received for publication on Mar. 2, 199l; accepted on Jan. 10, 1992)
Case Reports
Case 1
A 52-year-old male diagnosed as having pancreatic cancer underwent a total pancreatectomy, an excision of the replaced right hepatic artery involved by the cancer, as well as an excision of the pancreatic segment of the portal vein with an interposition of an iliac vein graft connecting the superior mesenteric vein to the portal vein on January 6, 1989. On Jan 12, an emergency laparotomy was done due to a rupture of the left hepatic artery. The wrapping and clipping of the common hepatic artery and the ligation of it at a more distal portion was then performed. On the next day, laboratory studies showed a rapid rise of liver enzymes as follows: glutamic o~aloacetic transaminase (GOT) 6010IU/L, glutamic-pyruvic transaminase (GPT) 3170IU/L, and lactate dehydrogenase (LDH) 14760IU/L. The total
J. Iseki et al.: Arterialization Following Pancreatobiliary Surgery
569
Fig. 1. Arterioportal shunt using the branches of the jejunal artery and vein (arrow)
bilirubin level was 2.9 mg/dl. On January 19, when his total bilirubin level rose to 17.5 mg/dl, an end-to-end anastomosis between the branches of the jejunal artery and vein was performed under microscopic observation with good venous pulsation just before closure of the wound (Fig. 1). The caliber of the arterial branch and venous one at the anastomotic portion was 2ram and 3mm, respectively. Although the patient's systemic state was stable, the bilirubin level continued to rise afterwards, and he later died of liver failure on February 16. A postoperative radiologic examination was not performed, and thus the patency of the arterioportal shunt remained unconfirmed.
Case 2 A 64-year-old male diagnosed as having hepatic hilar cancer underwent a pancreatoduodenectomy and extended left hepatic lobectomy with an excision of the right hepatic artery involved by the cancer on May 19, 1989. The right hepatic artery was repaired by direct anastomosis connecting the proximal portion of the right hepatic artery to the anterior segmental artery of the liver. Just before closure of the wound, the pulsation of the reconstructed hepatic artery was noticed to be weak. On the next day, laboratory studies revealed a rapid rise in liver enzymes as follows: G O T 1989IU/L, GPT 939IU/L, L D H 4521IU/L, and total bilirubin 4.1 mg/dl. Immediately, an arterioportal shunt at the branches of the ileal artery and vein was made under microscopic observation. The caliber of the arterial branch and venous branch at the anastomotic portion was 3 m m and 4 m m , respectively. On the next day, his liver enzyme levels decreased as follows: GOT 636IU/L, GPT 696IU/L, and L D H 1197IU/L. There-
after, they gradually returned to the normal values. Three weeks later, selective arteriography revealed an obstruction in the reconstructed hepatic artery, a development of the collateral hepatic artery via the right phrenic artery. The patency of the arterioportal shunt was confirmed by an early appearance of the portal vein during the arterial phase (Fig. 2). A gastrofiberscopic examination did not reveal any esophageal varices. He maintained a good postoperative state for 3 months, but thereafter he followed a rapid downhill course. On September 1, he died of recurrence of the carcinoma. Autopsy revealed massive peritoneal dissemination but without any metastatic or necrotic changes of the liver. The site of the arterioportal shunt could not be confirmed because of a disappearance of the pulsation.
Discussion Ligation or embolization of the hepatic artery following the hepatic arterial rupture has been thought to be not so dangerous because of the existence of many collateral arterial pathways into the liver. 6'7 However, in the event of extended pancreatobiliary surgery, many collateral arteries to the liver are eradicated almost completely. Accordingly, if the hepatic artery is interrupted following extended pancreatobiliary surgery, massive liver necrosis leading to fatal liver failure may occur. Under these circumstances, it would seem of essential importance to raise the portal venous oxygen gas tension without delay, until the remaining collateral arteries develop sufficiently to supply enough oxygen to the liver. In the first case, we feared an occurrence of fatal liver necrosis following a ligation
570
J. Iseki et al.: Arterialization Following Pancreatobiliary Surgery esophageal varices and hypersplenism usually appeared after a 3-year quiescent period. This fact supports that our method using an appropriate size of the mesenteric artery ranging from 2 to 3 mm in external diameter would not be followed by any clinically apparent portal hypertension during the short postoperative term. Adamson et al. reported the anastomosis between the right gastroepiploic artery and umbilical portal vein to avoid excessive arterial flow into the portal circulation. t4 Our operative maneuver can be safely performed in the lower abdominal cavity which is quite different from the first operative field, and even if portal hypertension should appear as a late complication, the mesenteric arterioportal shunt can still be easily closed. In the first case, which underwent a total pancreatectomy, the time when the arterioportal shunt was devised and performed was too late to obtain a satisfactory result, and so this method should be performed without delay after the recognition of hepatic parenchymal ischemia due to an interruption of the hepatic artery. Although we were not able to measure the portal blood flow, pressure, and gas tensions during the mesenteric shunt operation because of severe adhesion of the upper abdomen, a thorough pathophysiological study on this method is thought to be urgently needed in the near future.
Fig. 2. Superior mesenteric arteriography shows an early appearance of the superior mesenteric vein and portal vein (arrow) during the arterial phase
of the hepatic artery, but no effective method was postulated on that occasion. One week later, however, we devised a method of partial portal arterialization by making an arterioportal shunt at the branches of the jejunal artery and vein under severe liver failure, but it was too late for the arterioportal shunt to be effective. In the second case, liver enzymes such as G O T , GPT, and L D H showed a rapid rise on the day following extended pancreatobiliary surgery. As a thrombotic obstruction of the reconstructed right hepatic artery was suspected, we immediately made an arterioportal shunt between the branches of ileal artery and vein for the purpose of preventing massive liver necrosis. In this case, the patency of the mesenteric arterioportal shunt was confirmed by postoperative angiography, which showed an early appearance of the portal vein during the arterial phase, and a postoperative endoscopic examination did not reveal the existence of esophageal varices. It has been pointed out that one of the unique features of portal arteriovenous fistula is their tendency to produce portal hypertension. 8 In cases of portal arteriovenous fistula, Stone et al. 9 stated that bleeding
References 1. Lygidakis NJ, Heyde MN, Dongen RJAM, Kromhout JG, Tytgat GNJ, Huibregtse K (1988) Surgical approaches for unresectable primary carcinoma of the hepatic hilus. Surg Gynecol Obstet 166:107-114 2. Nakamura S, Sakaguchi S, Suzuki S, Muro H (1989) Aggressive surgery for carcinoma of the gallbladder. Surgery 106:467-473 3. Takada T, Hanyu F, Nakamura M, Yasuhiko F, Imaizumi T, Yoshikawa T, Yasuda H, Kanayama S, Ohashi M, Uchiyama K0 Suzuki M (1982) Extended surgery for carcinoma of the pancreas (in Japanese with English abstract). Nippon Geka Gakkai Zasshi (J Jpn Surg Soc) 83:122-131 4. Brittain RS, Marchiolo TL, Hermann G (1964) Accidental hepatic artery ligation in humans. Am J Surg 107:822-832 5. Kim DK, Kinne DW, Fortner JG (1973) Occlusion of the hepatic artery in man. Surg Gynecol Obstet 136:966-968 6. Michels NA (1953) Collateral arterial pathways to the liver after ligation of the hepatic artery and removal of the celiac axis. Cancer 6:708-724 7. Iseki J, Tada Y, Wada T, Nobori M (1983) Hepatic artery aneurysm: Report of a case and review of the literature. Gastroenterol Jpn 18:84-92 8. VanWay CW, Crane JM, Riddell DH, Foster JH (1971) Arteriovenous fistula in the portal circulation. Surgery 70: 876 - 890 9. Stone HH, Jordan WD, Acker J J, Martin JD (1965) Portal arteriovenous fistulas: Review and case report. Am J Surg 109:191-196 10. Iseki J, Hashimoto D, Tada Y, Wada T (1980) A case of congenital mesenteric arteriovenous fistula and review of the literature (in Japanese) Gekashinryou (Surgical Treatment) 22:247-252
J. Iseki et al.: Arterialization Following Pancreatobiliary Surgery 11. Shilling JA, McKee FW, Wilt W (1950) Experimental hepatic portal arteriovenous anastomoses. Surg Gynecol Obstet 90:473-480 12. Zuidema GD, Gaisford WD, Abell MR, Brody TM, Neill SA, Child CG (1963) Segmental portal arterialization of canine liver. Surgery 53:689-698 13. Fisher B, Russ C, Updegraff H, Fisher ER (1954) Effect of
571 increased hepatic blood flow upon liver regeneration. Arch Surg 69:263-272 14. Adamsons RJ, Kinkhabwala M, Moskowitz H, Himmelfarb E, Minkowitz S, Lerner B (1972) Portacaval shunt with arterialization of the hepatic portion of the portal vein. Surg Gynecol Obstet 135:529-535 15. Asakawa H, Kasai S, Mito M (1985) Flow and pressure adapted portal arterialization in dogs. Jap J Surg 15:291-298
~
SURGERYTODAY
© Springer-Verlag 1992
Short Communication Partial Portal Arterialization for the Prevention of Massive Liver Necrosis following Extended Pancreatobiliary Surgery: Experience of Two Cases JouJI ISEKI, KAZUSHIGE TOUYAMA, TAMAKI NOIE, KAZUHIKO NAKAGAMI, MASAKAZU TAKAGI, KOUJI HAKAMADA, ATSUSHI TANAKA1, ATSUSHI YAMADA2, JYUNYA HANAKITA, and HIDEYUKI SUWA3 Departments of ~Surgery, ~Plastic Surgery, and 3 Neurological Surgery, Shizuoka General Hospital, 4-27-1 Kita-Andou, Shizuoka, 420 Japan
Abstract: Massive liver necrosis, which is a severe and highly fatal complication after extended pancreatobiliary surgery, may occur due to an interruption of the hepatic arterial flow caused by such events as an excision of the hepatic artery invaded by cancer, a ligation of the postoperatively ruptured hepatic artery, or a thrombotic obstruction of the reconstructed hepatic artery. In order to improve this ischemic state of the liver, we have performed a partial arterialization of the portal vein by making an arteriovenous shunt at the mesenteric vascular branches in two cases. Although a sufficient pathophysiological investigation could not be fully conducted, partial portal arterialization was considered to be effective in one patient, while no clinically noticeable adverse effects were revealed in the other patient. Words: partial portal arterialization, mesenteric arterioportal shunt, hepatic arterial interruption Key
result in massive liver necrosis due to a rapid fall in the oxygen supply to the liver. Accordingly, it would appear essential to raise the portal venous oxygen gas tension without delay. Portal arteriovenous fistula is one of the well known clinical states in which a portal vein is accidentally arterialized by either trauma or rupture of an aneurysm. 8-1° Portal arterialization either with or without a portacaval shunt in cirrhotic patients or animals is another well known state that can increase portal venous flow and oxygen gas tension. 11-13 As excessive arterial flow into the portal circulation is often accompanied by severe portal hypertension, various types of flow and pressure regulated portal arterialization have been devised. 14-15 Here we report on two cases in which a partial portal arterialization was performed by anastomosing the mesenteric arterial branch to the venous branch.
Introduction
In recent years, extended operations with an excision and reconstruction of either the hepatic artery or portal vein have been adopted for pancreatobiliary malignant neoplasms. 1'2 As a result, massive liver necrosis following an interruption of the hepatic artery such as a clamping or excision of the hepatic artery during operation, a ligation of the hepatic artery proximal to the hepatic arterial aneurysm formed postoperatively, or a thrombotic obstruction of the reconstructive artery is being closely followed with interest as a potential fatal complication) Hepatic arterial interruption has been regarded as a safe procedure because of the existence of many collateral arterial pathways. 4-7 However, under extended pancreatobiliary surgery, many collateral arteries are also widely dissected, which may Reprint requests to: J. Iseki (Received for publication on Mar. 2, 199l; accepted on Jan. 10, 1992)
Case Reports
Case 1
A 52-year-old male diagnosed as having pancreatic cancer underwent a total pancreatectomy, an excision of the replaced right hepatic artery involved by the cancer, as well as an excision of the pancreatic segment of the portal vein with an interposition of an iliac vein graft connecting the superior mesenteric vein to the portal vein on January 6, 1989. On Jan 12, an emergency laparotomy was done due to a rupture of the left hepatic artery. The wrapping and clipping of the common hepatic artery and the ligation of it at a more distal portion was then performed. On the next day, laboratory studies showed a rapid rise of liver enzymes as follows: glutamic o~aloacetic transaminase (GOT) 6010IU/L, glutamic-pyruvic transaminase (GPT) 3170IU/L, and lactate dehydrogenase (LDH) 14760IU/L. The total
J. Iseki et al.: Arterialization Following Pancreatobiliary Surgery
569
Fig. 1. Arterioportal shunt using the branches of the jejunal artery and vein (arrow)
bilirubin level was 2.9 mg/dl. On January 19, when his total bilirubin level rose to 17.5 mg/dl, an end-to-end anastomosis between the branches of the jejunal artery and vein was performed under microscopic observation with good venous pulsation just before closure of the wound (Fig. 1). The caliber of the arterial branch and venous one at the anastomotic portion was 2ram and 3mm, respectively. Although the patient's systemic state was stable, the bilirubin level continued to rise afterwards, and he later died of liver failure on February 16. A postoperative radiologic examination was not performed, and thus the patency of the arterioportal shunt remained unconfirmed.
Case 2 A 64-year-old male diagnosed as having hepatic hilar cancer underwent a pancreatoduodenectomy and extended left hepatic lobectomy with an excision of the right hepatic artery involved by the cancer on May 19, 1989. The right hepatic artery was repaired by direct anastomosis connecting the proximal portion of the right hepatic artery to the anterior segmental artery of the liver. Just before closure of the wound, the pulsation of the reconstructed hepatic artery was noticed to be weak. On the next day, laboratory studies revealed a rapid rise in liver enzymes as follows: G O T 1989IU/L, GPT 939IU/L, L D H 4521IU/L, and total bilirubin 4.1 mg/dl. Immediately, an arterioportal shunt at the branches of the ileal artery and vein was made under microscopic observation. The caliber of the arterial branch and venous branch at the anastomotic portion was 3 m m and 4 m m , respectively. On the next day, his liver enzyme levels decreased as follows: GOT 636IU/L, GPT 696IU/L, and L D H 1197IU/L. There-
after, they gradually returned to the normal values. Three weeks later, selective arteriography revealed an obstruction in the reconstructed hepatic artery, a development of the collateral hepatic artery via the right phrenic artery. The patency of the arterioportal shunt was confirmed by an early appearance of the portal vein during the arterial phase (Fig. 2). A gastrofiberscopic examination did not reveal any esophageal varices. He maintained a good postoperative state for 3 months, but thereafter he followed a rapid downhill course. On September 1, he died of recurrence of the carcinoma. Autopsy revealed massive peritoneal dissemination but without any metastatic or necrotic changes of the liver. The site of the arterioportal shunt could not be confirmed because of a disappearance of the pulsation.
Discussion Ligation or embolization of the hepatic artery following the hepatic arterial rupture has been thought to be not so dangerous because of the existence of many collateral arterial pathways into the liver. 6'7 However, in the event of extended pancreatobiliary surgery, many collateral arteries to the liver are eradicated almost completely. Accordingly, if the hepatic artery is interrupted following extended pancreatobiliary surgery, massive liver necrosis leading to fatal liver failure may occur. Under these circumstances, it would seem of essential importance to raise the portal venous oxygen gas tension without delay, until the remaining collateral arteries develop sufficiently to supply enough oxygen to the liver. In the first case, we feared an occurrence of fatal liver necrosis following a ligation
570
J. Iseki et al.: Arterialization Following Pancreatobiliary Surgery esophageal varices and hypersplenism usually appeared after a 3-year quiescent period. This fact supports that our method using an appropriate size of the mesenteric artery ranging from 2 to 3 mm in external diameter would not be followed by any clinically apparent portal hypertension during the short postoperative term. Adamson et al. reported the anastomosis between the right gastroepiploic artery and umbilical portal vein to avoid excessive arterial flow into the portal circulation. t4 Our operative maneuver can be safely performed in the lower abdominal cavity which is quite different from the first operative field, and even if portal hypertension should appear as a late complication, the mesenteric arterioportal shunt can still be easily closed. In the first case, which underwent a total pancreatectomy, the time when the arterioportal shunt was devised and performed was too late to obtain a satisfactory result, and so this method should be performed without delay after the recognition of hepatic parenchymal ischemia due to an interruption of the hepatic artery. Although we were not able to measure the portal blood flow, pressure, and gas tensions during the mesenteric shunt operation because of severe adhesion of the upper abdomen, a thorough pathophysiological study on this method is thought to be urgently needed in the near future.
Fig. 2. Superior mesenteric arteriography shows an early appearance of the superior mesenteric vein and portal vein (arrow) during the arterial phase
of the hepatic artery, but no effective method was postulated on that occasion. One week later, however, we devised a method of partial portal arterialization by making an arterioportal shunt at the branches of the jejunal artery and vein under severe liver failure, but it was too late for the arterioportal shunt to be effective. In the second case, liver enzymes such as G O T , GPT, and L D H showed a rapid rise on the day following extended pancreatobiliary surgery. As a thrombotic obstruction of the reconstructed right hepatic artery was suspected, we immediately made an arterioportal shunt between the branches of ileal artery and vein for the purpose of preventing massive liver necrosis. In this case, the patency of the mesenteric arterioportal shunt was confirmed by postoperative angiography, which showed an early appearance of the portal vein during the arterial phase, and a postoperative endoscopic examination did not reveal the existence of esophageal varices. It has been pointed out that one of the unique features of portal arteriovenous fistula is their tendency to produce portal hypertension. 8 In cases of portal arteriovenous fistula, Stone et al. 9 stated that bleeding
References 1. Lygidakis NJ, Heyde MN, Dongen RJAM, Kromhout JG, Tytgat GNJ, Huibregtse K (1988) Surgical approaches for unresectable primary carcinoma of the hepatic hilus. Surg Gynecol Obstet 166:107-114 2. Nakamura S, Sakaguchi S, Suzuki S, Muro H (1989) Aggressive surgery for carcinoma of the gallbladder. Surgery 106:467-473 3. Takada T, Hanyu F, Nakamura M, Yasuhiko F, Imaizumi T, Yoshikawa T, Yasuda H, Kanayama S, Ohashi M, Uchiyama K0 Suzuki M (1982) Extended surgery for carcinoma of the pancreas (in Japanese with English abstract). Nippon Geka Gakkai Zasshi (J Jpn Surg Soc) 83:122-131 4. Brittain RS, Marchiolo TL, Hermann G (1964) Accidental hepatic artery ligation in humans. Am J Surg 107:822-832 5. Kim DK, Kinne DW, Fortner JG (1973) Occlusion of the hepatic artery in man. Surg Gynecol Obstet 136:966-968 6. Michels NA (1953) Collateral arterial pathways to the liver after ligation of the hepatic artery and removal of the celiac axis. Cancer 6:708-724 7. Iseki J, Tada Y, Wada T, Nobori M (1983) Hepatic artery aneurysm: Report of a case and review of the literature. Gastroenterol Jpn 18:84-92 8. VanWay CW, Crane JM, Riddell DH, Foster JH (1971) Arteriovenous fistula in the portal circulation. Surgery 70: 876 - 890 9. Stone HH, Jordan WD, Acker J J, Martin JD (1965) Portal arteriovenous fistulas: Review and case report. Am J Surg 109:191-196 10. Iseki J, Hashimoto D, Tada Y, Wada T (1980) A case of congenital mesenteric arteriovenous fistula and review of the literature (in Japanese) Gekashinryou (Surgical Treatment) 22:247-252
J. Iseki et al.: Arterialization Following Pancreatobiliary Surgery 11. Shilling JA, McKee FW, Wilt W (1950) Experimental hepatic portal arteriovenous anastomoses. Surg Gynecol Obstet 90:473-480 12. Zuidema GD, Gaisford WD, Abell MR, Brody TM, Neill SA, Child CG (1963) Segmental portal arterialization of canine liver. Surgery 53:689-698 13. Fisher B, Russ C, Updegraff H, Fisher ER (1954) Effect of
571 increased hepatic blood flow upon liver regeneration. Arch Surg 69:263-272 14. Adamsons RJ, Kinkhabwala M, Moskowitz H, Himmelfarb E, Minkowitz S, Lerner B (1972) Portacaval shunt with arterialization of the hepatic portion of the portal vein. Surg Gynecol Obstet 135:529-535 15. Asakawa H, Kasai S, Mito M (1985) Flow and pressure adapted portal arterialization in dogs. Jap J Surg 15:291-298
