Clin J Gastroenterol (2012) 5:287–291 DOI 10.1007/s12328-012-0319-0
CASE REPORT
Portal vein embolization for an intractable bile leakage after hepatectomy Seikan Hai • Hiromu Tanaka • Shigekazu Takemura Katsu Sakabe • Tsuyoshi Ichikawa • Shoji Kubo
•
Received: 4 March 2012 / Accepted: 8 June 2012 / Published online: 6 July 2012 Ó Springer 2012
Abstract Bile leakages due to interruption of the intrahepatic bile duct after hepatectomy are often intractable. We herein report a case where portal vein embolization (PVE) decreased the bile production from the embolized part of the liver, which lead to healing of this type of bile leakage. A 77-year old man who had undergone an anterior segmentectomy of the liver for hepatocellular carcinoma 3 years prior was admitted to our hospital for an abscess in the right subphrenic space, and underwent percutaneous drainage. Fluoroscopy using a contrast medium from the drainage tube revealed that the root of the posterior branch of the bile duct was completely interrupted. The hilar side of the interrupted bile duct was closed, and all the bile from the posterior segment continued to be discharged at a rate of 100–150 ml/day for 2 months. The posterior branch of the portal vein was then embolized with fibrin glue by percutaneous transhepatic approach. After the PVE, the volume of discharge gradually decreased, and the drainage tube was removed 2 weeks after the PVE. Three months later, the patient was afebrile and doing well. PVE might be a useful method for treating interrupted type postoperative bile leakages. Keywords Portal vein embolization Bile leakage Hepatectomy
S. Hai H. Tanaka S. Takemura K. Sakabe T. Ichikawa S. Kubo Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan S. Hai (&) Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan e-mail: [email protected]
Introduction Recently, advances in surgical techniques and perioperative management have allowed hepatic resection to be performed more frequently and safely, which has reduced the mortality rate to 1.4–2.6 % [1–3]. However, the postoperative morbidity rate is still high; the incidence of bile leakage is estimated to be 0.5–6.4 % in recent reports [1, 3–5]. Bile leakage due to an interruption of the intrahepatic bile duct after hepatic resection is often intractable and requires interventional procedures or surgical treatment. This report describes a patient with intractable bile leakage that developed after hepatic resection which was successfully treated by portal vein embolization (PVE).
Case report A 77-year old male with right hypochondralgia and a fever was examined with computed tomography (CT) at another hospital and diagnosed as having an abscess in the right subphrenic space. The patient was referred to our hospital for treatment. He had undergone distal gastrectomy and Billroth II reconstruction for a bleeding gastric ulcer at 49 years of age, and 3 years previous to this had been treated with an anterior segmentectomy of the liver for hepatocellular carcinoma detected through findings of liver functional tests (Child-Pugh A, indocyanine green retention at 15 min 9.5 %; normal range,\10 %) during followup for C type hepatitis. Although an abscess in the right subphrenic space occurred 3 days after the hepatectomy, it was thought to have been resolved by percutaneous drainage and the administration of antibiotics. Thereafter, although fluid which had collected in the space of the cut surface led to a suspicion of biloma, a wait-and-see
123
288
Clin J Gastroenterol (2012) 5:287–291
Fig. 1 An abdominal echogram shows a mixture of high and low echoic lesions in subphrenic space
approach was taken because no fever or abdominal pain were present and he was thus treated on an outpatient basis. On admission, the patient was febrile, and laboratory examinations revealed leukocytosis (14400/ll; normal range 4300–8000/ll) and an increased serum concentration of C-reactive protein (12.33 mg/dl; normal range 0–0.4 mg/dl), aspartate transaminase (105 IU/l; normal range 12–40 IU/l) and alanine transaminase (63 IU/l; normal range 10–45 IU/l). Abdominal ultrasonography demonstrated a mixture of high and low echoic lesions in the subphrenic space (Fig. 1), and percutaneous drainage was performed. At that time, pus was drained, and methicillin-resistant Staphylococcus aureus was detected in the discharge. However, the contents of the discharge changed from pus to bile 3 days later. Fluoroscopy using a contrast medium from the drainage tube revealed the root of the posterior branch of the bile duct to be completely interrupted (Fig. 2a). The tube could not be inserted into the bile duct to form an internal fistula and perform endoscopic biliary drainage because of the nature of the post-gastrectomy anatomy and also due to the previous Billroth II reconstruction. After drainage, the hilar side of the interrupted bile duct was closed (Fig. 2b) and all of the bile from the posterior segment continued to be discharged at a rate of 100–150 ml per day for 2 months. A drainage tube could not be inserted into the posterior branch for ethanol injection or fibrin glue sealing. Therefore, PVE was applied for this intractable bile leakage to reduce the production of bile. The umbilical portion of the portal vein was punctured via the percutaneous approach, and a catheter was inserted into the portal vein. Portography was performed (Fig. 3a) and a 5-Fr. balloon catheter was inserted into the posterior branch. The portal flow into the posterior segment was arrested by inflating the balloon, and a mixture of fibrin
123
Fig. 2 a A fistulogram shows an interruption of the root of the posterior bile duct communicating with the common bile duct . b After drainage, the hilar side of the interrupted bile duct (arrow) is closed
glue and iodized oil (Lipiodol; Kodama Pharmaceutical, Tokyo, Japan) was injected. The balloon was deflated and the complete occlusion of the posterior branch was confirmed by portography (Fig. 3b). The discharge immediately thinned after the PVE without any worsening of the liver functional tests, and the volume also gradually decreased. The drainage tube was removed 2 weeks after the PVE, when the discharge was 10 ml per day and aseptic. CT demonstrated atrophy of the posterior segment and compensatory hypertrophy of the left liver without a bile leakage (Fig. 4). The patient was afebrile and doing well 3 months after the above procedures.
Discussion Bile leakage is one of the most common complications after hepatic resection. Although around 70 % of bile leakages are thought to heal spontaneously [6, 7], further management is required upon confirmation of the leakage
Clin J Gastroenterol (2012) 5:287–291
Fig. 3 a A catheter is inserted into the portal vein from the umbilical portion and portography is performed. b Complete occlusion of the posterior branch is confirmed by portography after percutaneous transhepatic portal vein embolization
site by a fistulogram or biliary scintigram, because such leakage may lead to sepsis or hepatic failure when bile leakage is intractable. Nagano et al. [5] classified patients with postoperative bile leakage into four groups according to the fistulogram or biliary scintigram: type A, minor leakage with only a small amount of bile leakage; type B, major leakage due to insufficient closure of the bile duct stump; type C, major leakage due to injury of the bile duct; type D, major leakage due to division of the bile duct. Slight bile leakage from the raw cut surface, as in type A, is thought to be effectively treated by the placement of a drainage tube. Biliary decompression, endoscopic biliary drainage, sphincterotomy, and biliary stenting are nonsurgical procedures that are effective for treating bile leakage associated with the common bile duct [4, 8, 9], as in type B and C. In the present case, fluoroscopy using a contrast medium from the drainage tube showed an interruption of the root of the posterior bile duct communicating with the
289
common bile duct, thus indicating that biloma had developed after the resolution of the bile leakage that had occurred 3 days after the hepatectomy. The biloma was thought to have become infected in a retrograde fashion about 3 years after the hepatectomy. After drainage, a complete interruption of the posterior branch was demonstrated by a fistulogram, and endoscopic biliary drainage could not be performed because of the post-gastrectomy and Billroth II reconstruction anatomical features. Internal fistula formation also could not be performed because the drainage tube could not be inserted into the hilar side of the interrupted bile duct, which was closed by continuous drainage. Therefore, this case lapsed into a state of steady type D bile leakage, which was intractable. Ethanol injection [10, 11] or fibrin glue sealing [9] of the interrupted bile duct is an effective treatment for this type of bile leakage. However, such treatments were abandoned due to the incomplete external fistula formation and an excessive amount of bile discharge from the drainage tube. Although nonsurgical procedures were thought to be limited and surgery was considered, it is often difficult to identify and repair the leakage site because of the presence of dense adhesions. Therefore, resection of the parenchyma of the liver, including the leaking ducts, is recommended when bile leakage cannot be resolved by nonsurgical procedures. Portal vein embolization was administered in an attempt to decrease the bile production from the embolized part of the liver, which would lead to healing of this type of bile leakage, and the posterior branch of the portal vein was embolized with fibrin glue. PVE was initially developed by Kinoshita et al. [12] as a presurgical treatment to increase the safety of hepatic resection and extend the surgical indications for hepatocellular carcinoma while minimizing postoperative liver dysfunction. PVE is now widely used in extended hepatectomy for hepatobiliary malignancies. PVE induces atrophy and compensatory hypertrophy in the embolized and nonembolized parts of the liver, respectively [12–14]. These morphological changes are thought to be associated with the liver function. Although total liver function tests after PVE have been evaluated in many reports, the partial liver function has not yet been adequately examined. Kubo et al. [15] indicated that PVE induces a shift of liver function from the embolized to the nonembolized part of the liver by using 99mTc-galactosyl human serum albumin scintigraphy, which causes specific binding to viable hepatocytes and serves as an index of liver function. It is therefore possible that PVE may induce a decrease of bile secretion in the embolized lobe by decreasing the hepatic function. PVE was performed based on the possibility that the intractable bile leakage in the present case could be closed without surgery. As a result, the bile discharge from the drainage tube gradually
123
290
Clin J Gastroenterol (2012) 5:287–291
Fig. 4 Computed tomography shows atrophy of the posterior segment that has been embolized and compensatory hypertrophy of the nonembolized part of the liver
Table 1 Reported cases of undergoing portal vein embolization (PVE) for an intractable bile leakage Author
Age
Sex
Diagnosis
Hepatectomy
Leaking duct
Type of bile leakage Interrupted
1. Yamakado
66
F
Hila bile duct cancer
S4a ? S5 resection
B8
2. Sadakari
58
M
Liver metastasis
Central bisegmentectomy
B7
Interrupted
3. Honore
63
M
HCC
Posterior segmentectomy
Anterior branch
Interrupted
4. Present case
77
M
HCC
Anterior segmentectomy
Posterior branch
Interrupted
Duration of bile leakage
Antecedent treatment
Discharge (ml)
Approach of PVE
Obstructing materials
1. 5 months
Ethanol injection
\150
Via the ideal vein under general anesthesia
Ethanol
2. 116 days 3. 12 months
Ethanol injection Surgical drainage
50 200
Percutaneous transhepatic –
Gelatin sponge –
4. 2 months
None
200
Percutaneous transhepatic
Fibrin glue
Embolized area
Clinical course after PVE
Removal of the drainage tube
Outcome
1. Anterior–superior branch
Uneventful
12 days
Resolution
2. Posterior branch
Uneventful
6 days
Resolution
3. Anterior branch
–
–
Failure ) hepatectomy
4. Posterior branch
Uneventful
14 days
Resolution
decreased and the intractable bile leakage healed after PVE, although the change in the embolized liver function was obscure due to the fact that no method to examine the split liver function, such as scintigraphy, was performed either pre- or post-PVE. Portal vein embolization has been reported for the treatment of intractable bile leakage without serious complications in three cases (Table 1). Yamakado et al. [16] and Sadakari et al. [17] reported that an intractable bile leakage was successfully treated by selective PVE following the use of ethanol injection therapy, which reduced the discharge but did not completely resolve the bile
123
leakage problem. On the other hand, Honore et al. [18] reported that liver resection was performed as the definitive treatment because PVE failed to stop the bile leakage although it contributed to the difficulties associated with liver resection, including adhesions, infection or abscess formation, and anatomical distortions brought about by the regeneration of the remaining liver. In the latter case, neither ethanol injection therapy nor fibrin glue sealing was performed before PVE. Therefore, combination therapy with bile duct ablation by ethanol injection and PVE might lead to the successful resolution of intractable bile leakage in the former two cases. In conclusion, the interrupted type
Clin J Gastroenterol (2012) 5:287–291
of postoperative bile leakage was effectively resolved by PVE alone in the present case. PVE might therefore be a useful method for treating this type of bile leakage when other types of nonsurgical management prove to be ineffective, and PVE should also be considered before surgery is performed even though the methods or indications of PVE for the treatment of intractable bile leakage have not yet been clearly established. Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Taketomi A, Kitagawa D, Itoh S, Harimoto N, Yamashita Y, Gion T, et al. Trends in morbidity and mortality after hepatic resection for hepatocellular carcinoma: an institute’s experience with 625 patients. J Am Coll Surg. 2007;204:580–7. 2. Yan LN, Chen XL, Li ZH, Li B, Lu SC, Wen TF, et al. Perioperative management of primary liver cancer. World J Gastroenterol. 2007;13:1970–4. 3. Yang T, Zhang J, Lu JH, Yang GS, Wu MC, Yu WF. Risk factors influencing postoperative outcomes of major hepatic resection of hepatocellular carcinoma for patients with underlying liver diseases. World J Surg. 2011;35:2073–82. 4. Terajima H, Ikai I, Hatano E, Uesugi T, Yamamoto Y, Shimahara Y, et al. Effectiveness of endoscopic nasobiliary drainage for postoperative bile leakage after hepatic resection. World J Surg. 2004;28:782–6. 5. Nagano Y, Togo S, Tanaka K, Masui H, Endo I, Sekido H, et al. Risk factors and management of bile leakage after hepatic resection. World J Surg. 2003;27:695–8. 6. Capussotti L, Ferrero A, Vigano L, Sgotto E, Muratore A, Polastri R. Bile leakage and liver resection: where is the risk? Arch Surg. 2006;141:690–4. 7. Vigano L, Ferrero A, Sgotto E, Tesoriere RL, Calgaro M, Capussotti L. Bile leak after hepatectomy: predictive factors of spontaneous healing. Am J Surg. 2008;196:195–200.
291 8. Bhattacharjya S, Puleston J, Davidson BR, Dooley JS. Outcome of early endoscopic biliary drainage in the management of bile leaks after hepatic resection. Gastrointest Endosc. 2003;57: 526–30. 9. Tanaka S, Hirohashi K, Tanaka H, Shuto T, Lee SH, Kubo S, et al. Incidence and management of bile leakage after hepatic resection for malignant hepatic tumors. J Am Coll Surg. 2002; 195:484–9. 10. Kyokane T, Nagino M, Sano T, Nimura Y. Ethanol ablation for segmental bile duct leakage after hepatobiliary resection. Surgery. 2002;131:111–3. 11. Shimizu T, Yoshida H, Mamada Y, Taniai N, Matsumoto S, Mizuguchi Y, et al. Postoperative bile leakage managed successfully by intrahepatic biliary ablation with ethanol. World J Gastroenterol. 2006;12:3450–2. 12. Kinoshita H, Sakai K, Hirohashi K, Igawa S, Yamasaki O, Kubo S. Preoperative portal vein embolization for hepatocellular carcinoma. World J Surg. 1986;10:803–8. 13. Hemming AW, Reed AI, Howard RJ, Fujita S, Hochwald SN, Caridi JG, et al. Preoperative portal vein embolization for extended hepatectomy. Ann Surg. 2003;237:686–91. 14. Nagino M, Kamiya J, Nishio H, Ebata T, Arai T, Nimura Y. Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: surgical outcome and long-term follow-up. Ann Surg. 2006;243:364–72. 15. Kubo S, Shiomi S, Tanaka H, Shuto T, Takemura S, Mikami S, et al. Evaluation of the effect of portal vein embolization on liver function by (99m)tc-galactosyl human serum albumin scintigraphy. J Surg Res. 2002;107:113–8. 16. Yamakado K, Nakatsuka A, Iwata M, Kondo A, Isaji S, Uemoto S, et al. Refractory biliary leak from intrahepatic biliary-enteric anastomosis treated by selective portal vein embolization. J Vasc Interv Radiol. 2002;13:1279–81. 17. Sadakari Y, Miyoshi A, Ohtsuka T, Kohya N, Takahashi T, Matsumoto K, et al. Percutaneous transhepatic portal embolization for persistent bile leakage after hepatic resection: report of a case. Surg Today. 2008;38:668–71. 18. Honore C, Vibert E, Hoti E, Azoulay D, Adam R, Castaing D. Management of excluded segmental bile duct leakage following liver resection. HPB (Oxford). 2009;11:364–9.
123
CASE REPORT
Portal vein embolization for an intractable bile leakage after hepatectomy Seikan Hai • Hiromu Tanaka • Shigekazu Takemura Katsu Sakabe • Tsuyoshi Ichikawa • Shoji Kubo
•
Received: 4 March 2012 / Accepted: 8 June 2012 / Published online: 6 July 2012 Ó Springer 2012
Abstract Bile leakages due to interruption of the intrahepatic bile duct after hepatectomy are often intractable. We herein report a case where portal vein embolization (PVE) decreased the bile production from the embolized part of the liver, which lead to healing of this type of bile leakage. A 77-year old man who had undergone an anterior segmentectomy of the liver for hepatocellular carcinoma 3 years prior was admitted to our hospital for an abscess in the right subphrenic space, and underwent percutaneous drainage. Fluoroscopy using a contrast medium from the drainage tube revealed that the root of the posterior branch of the bile duct was completely interrupted. The hilar side of the interrupted bile duct was closed, and all the bile from the posterior segment continued to be discharged at a rate of 100–150 ml/day for 2 months. The posterior branch of the portal vein was then embolized with fibrin glue by percutaneous transhepatic approach. After the PVE, the volume of discharge gradually decreased, and the drainage tube was removed 2 weeks after the PVE. Three months later, the patient was afebrile and doing well. PVE might be a useful method for treating interrupted type postoperative bile leakages. Keywords Portal vein embolization Bile leakage Hepatectomy
S. Hai H. Tanaka S. Takemura K. Sakabe T. Ichikawa S. Kubo Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka 545-8585, Japan S. Hai (&) Department of Surgery, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nishinomiya, Hyogo 663-8501, Japan e-mail: [email protected]
Introduction Recently, advances in surgical techniques and perioperative management have allowed hepatic resection to be performed more frequently and safely, which has reduced the mortality rate to 1.4–2.6 % [1–3]. However, the postoperative morbidity rate is still high; the incidence of bile leakage is estimated to be 0.5–6.4 % in recent reports [1, 3–5]. Bile leakage due to an interruption of the intrahepatic bile duct after hepatic resection is often intractable and requires interventional procedures or surgical treatment. This report describes a patient with intractable bile leakage that developed after hepatic resection which was successfully treated by portal vein embolization (PVE).
Case report A 77-year old male with right hypochondralgia and a fever was examined with computed tomography (CT) at another hospital and diagnosed as having an abscess in the right subphrenic space. The patient was referred to our hospital for treatment. He had undergone distal gastrectomy and Billroth II reconstruction for a bleeding gastric ulcer at 49 years of age, and 3 years previous to this had been treated with an anterior segmentectomy of the liver for hepatocellular carcinoma detected through findings of liver functional tests (Child-Pugh A, indocyanine green retention at 15 min 9.5 %; normal range,\10 %) during followup for C type hepatitis. Although an abscess in the right subphrenic space occurred 3 days after the hepatectomy, it was thought to have been resolved by percutaneous drainage and the administration of antibiotics. Thereafter, although fluid which had collected in the space of the cut surface led to a suspicion of biloma, a wait-and-see
123
288
Clin J Gastroenterol (2012) 5:287–291
Fig. 1 An abdominal echogram shows a mixture of high and low echoic lesions in subphrenic space
approach was taken because no fever or abdominal pain were present and he was thus treated on an outpatient basis. On admission, the patient was febrile, and laboratory examinations revealed leukocytosis (14400/ll; normal range 4300–8000/ll) and an increased serum concentration of C-reactive protein (12.33 mg/dl; normal range 0–0.4 mg/dl), aspartate transaminase (105 IU/l; normal range 12–40 IU/l) and alanine transaminase (63 IU/l; normal range 10–45 IU/l). Abdominal ultrasonography demonstrated a mixture of high and low echoic lesions in the subphrenic space (Fig. 1), and percutaneous drainage was performed. At that time, pus was drained, and methicillin-resistant Staphylococcus aureus was detected in the discharge. However, the contents of the discharge changed from pus to bile 3 days later. Fluoroscopy using a contrast medium from the drainage tube revealed the root of the posterior branch of the bile duct to be completely interrupted (Fig. 2a). The tube could not be inserted into the bile duct to form an internal fistula and perform endoscopic biliary drainage because of the nature of the post-gastrectomy anatomy and also due to the previous Billroth II reconstruction. After drainage, the hilar side of the interrupted bile duct was closed (Fig. 2b) and all of the bile from the posterior segment continued to be discharged at a rate of 100–150 ml per day for 2 months. A drainage tube could not be inserted into the posterior branch for ethanol injection or fibrin glue sealing. Therefore, PVE was applied for this intractable bile leakage to reduce the production of bile. The umbilical portion of the portal vein was punctured via the percutaneous approach, and a catheter was inserted into the portal vein. Portography was performed (Fig. 3a) and a 5-Fr. balloon catheter was inserted into the posterior branch. The portal flow into the posterior segment was arrested by inflating the balloon, and a mixture of fibrin
123
Fig. 2 a A fistulogram shows an interruption of the root of the posterior bile duct communicating with the common bile duct . b After drainage, the hilar side of the interrupted bile duct (arrow) is closed
glue and iodized oil (Lipiodol; Kodama Pharmaceutical, Tokyo, Japan) was injected. The balloon was deflated and the complete occlusion of the posterior branch was confirmed by portography (Fig. 3b). The discharge immediately thinned after the PVE without any worsening of the liver functional tests, and the volume also gradually decreased. The drainage tube was removed 2 weeks after the PVE, when the discharge was 10 ml per day and aseptic. CT demonstrated atrophy of the posterior segment and compensatory hypertrophy of the left liver without a bile leakage (Fig. 4). The patient was afebrile and doing well 3 months after the above procedures.
Discussion Bile leakage is one of the most common complications after hepatic resection. Although around 70 % of bile leakages are thought to heal spontaneously [6, 7], further management is required upon confirmation of the leakage
Clin J Gastroenterol (2012) 5:287–291
Fig. 3 a A catheter is inserted into the portal vein from the umbilical portion and portography is performed. b Complete occlusion of the posterior branch is confirmed by portography after percutaneous transhepatic portal vein embolization
site by a fistulogram or biliary scintigram, because such leakage may lead to sepsis or hepatic failure when bile leakage is intractable. Nagano et al. [5] classified patients with postoperative bile leakage into four groups according to the fistulogram or biliary scintigram: type A, minor leakage with only a small amount of bile leakage; type B, major leakage due to insufficient closure of the bile duct stump; type C, major leakage due to injury of the bile duct; type D, major leakage due to division of the bile duct. Slight bile leakage from the raw cut surface, as in type A, is thought to be effectively treated by the placement of a drainage tube. Biliary decompression, endoscopic biliary drainage, sphincterotomy, and biliary stenting are nonsurgical procedures that are effective for treating bile leakage associated with the common bile duct [4, 8, 9], as in type B and C. In the present case, fluoroscopy using a contrast medium from the drainage tube showed an interruption of the root of the posterior bile duct communicating with the
289
common bile duct, thus indicating that biloma had developed after the resolution of the bile leakage that had occurred 3 days after the hepatectomy. The biloma was thought to have become infected in a retrograde fashion about 3 years after the hepatectomy. After drainage, a complete interruption of the posterior branch was demonstrated by a fistulogram, and endoscopic biliary drainage could not be performed because of the post-gastrectomy and Billroth II reconstruction anatomical features. Internal fistula formation also could not be performed because the drainage tube could not be inserted into the hilar side of the interrupted bile duct, which was closed by continuous drainage. Therefore, this case lapsed into a state of steady type D bile leakage, which was intractable. Ethanol injection [10, 11] or fibrin glue sealing [9] of the interrupted bile duct is an effective treatment for this type of bile leakage. However, such treatments were abandoned due to the incomplete external fistula formation and an excessive amount of bile discharge from the drainage tube. Although nonsurgical procedures were thought to be limited and surgery was considered, it is often difficult to identify and repair the leakage site because of the presence of dense adhesions. Therefore, resection of the parenchyma of the liver, including the leaking ducts, is recommended when bile leakage cannot be resolved by nonsurgical procedures. Portal vein embolization was administered in an attempt to decrease the bile production from the embolized part of the liver, which would lead to healing of this type of bile leakage, and the posterior branch of the portal vein was embolized with fibrin glue. PVE was initially developed by Kinoshita et al. [12] as a presurgical treatment to increase the safety of hepatic resection and extend the surgical indications for hepatocellular carcinoma while minimizing postoperative liver dysfunction. PVE is now widely used in extended hepatectomy for hepatobiliary malignancies. PVE induces atrophy and compensatory hypertrophy in the embolized and nonembolized parts of the liver, respectively [12–14]. These morphological changes are thought to be associated with the liver function. Although total liver function tests after PVE have been evaluated in many reports, the partial liver function has not yet been adequately examined. Kubo et al. [15] indicated that PVE induces a shift of liver function from the embolized to the nonembolized part of the liver by using 99mTc-galactosyl human serum albumin scintigraphy, which causes specific binding to viable hepatocytes and serves as an index of liver function. It is therefore possible that PVE may induce a decrease of bile secretion in the embolized lobe by decreasing the hepatic function. PVE was performed based on the possibility that the intractable bile leakage in the present case could be closed without surgery. As a result, the bile discharge from the drainage tube gradually
123
290
Clin J Gastroenterol (2012) 5:287–291
Fig. 4 Computed tomography shows atrophy of the posterior segment that has been embolized and compensatory hypertrophy of the nonembolized part of the liver
Table 1 Reported cases of undergoing portal vein embolization (PVE) for an intractable bile leakage Author
Age
Sex
Diagnosis
Hepatectomy
Leaking duct
Type of bile leakage Interrupted
1. Yamakado
66
F
Hila bile duct cancer
S4a ? S5 resection
B8
2. Sadakari
58
M
Liver metastasis
Central bisegmentectomy
B7
Interrupted
3. Honore
63
M
HCC
Posterior segmentectomy
Anterior branch
Interrupted
4. Present case
77
M
HCC
Anterior segmentectomy
Posterior branch
Interrupted
Duration of bile leakage
Antecedent treatment
Discharge (ml)
Approach of PVE
Obstructing materials
1. 5 months
Ethanol injection
\150
Via the ideal vein under general anesthesia
Ethanol
2. 116 days 3. 12 months
Ethanol injection Surgical drainage
50 200
Percutaneous transhepatic –
Gelatin sponge –
4. 2 months
None
200
Percutaneous transhepatic
Fibrin glue
Embolized area
Clinical course after PVE
Removal of the drainage tube
Outcome
1. Anterior–superior branch
Uneventful
12 days
Resolution
2. Posterior branch
Uneventful
6 days
Resolution
3. Anterior branch
–
–
Failure ) hepatectomy
4. Posterior branch
Uneventful
14 days
Resolution
decreased and the intractable bile leakage healed after PVE, although the change in the embolized liver function was obscure due to the fact that no method to examine the split liver function, such as scintigraphy, was performed either pre- or post-PVE. Portal vein embolization has been reported for the treatment of intractable bile leakage without serious complications in three cases (Table 1). Yamakado et al. [16] and Sadakari et al. [17] reported that an intractable bile leakage was successfully treated by selective PVE following the use of ethanol injection therapy, which reduced the discharge but did not completely resolve the bile
123
leakage problem. On the other hand, Honore et al. [18] reported that liver resection was performed as the definitive treatment because PVE failed to stop the bile leakage although it contributed to the difficulties associated with liver resection, including adhesions, infection or abscess formation, and anatomical distortions brought about by the regeneration of the remaining liver. In the latter case, neither ethanol injection therapy nor fibrin glue sealing was performed before PVE. Therefore, combination therapy with bile duct ablation by ethanol injection and PVE might lead to the successful resolution of intractable bile leakage in the former two cases. In conclusion, the interrupted type
Clin J Gastroenterol (2012) 5:287–291
of postoperative bile leakage was effectively resolved by PVE alone in the present case. PVE might therefore be a useful method for treating this type of bile leakage when other types of nonsurgical management prove to be ineffective, and PVE should also be considered before surgery is performed even though the methods or indications of PVE for the treatment of intractable bile leakage have not yet been clearly established. Conflict of interest of interest.
The authors declare that they have no conflict
References 1. Taketomi A, Kitagawa D, Itoh S, Harimoto N, Yamashita Y, Gion T, et al. Trends in morbidity and mortality after hepatic resection for hepatocellular carcinoma: an institute’s experience with 625 patients. J Am Coll Surg. 2007;204:580–7. 2. Yan LN, Chen XL, Li ZH, Li B, Lu SC, Wen TF, et al. Perioperative management of primary liver cancer. World J Gastroenterol. 2007;13:1970–4. 3. Yang T, Zhang J, Lu JH, Yang GS, Wu MC, Yu WF. Risk factors influencing postoperative outcomes of major hepatic resection of hepatocellular carcinoma for patients with underlying liver diseases. World J Surg. 2011;35:2073–82. 4. Terajima H, Ikai I, Hatano E, Uesugi T, Yamamoto Y, Shimahara Y, et al. Effectiveness of endoscopic nasobiliary drainage for postoperative bile leakage after hepatic resection. World J Surg. 2004;28:782–6. 5. Nagano Y, Togo S, Tanaka K, Masui H, Endo I, Sekido H, et al. Risk factors and management of bile leakage after hepatic resection. World J Surg. 2003;27:695–8. 6. Capussotti L, Ferrero A, Vigano L, Sgotto E, Muratore A, Polastri R. Bile leakage and liver resection: where is the risk? Arch Surg. 2006;141:690–4. 7. Vigano L, Ferrero A, Sgotto E, Tesoriere RL, Calgaro M, Capussotti L. Bile leak after hepatectomy: predictive factors of spontaneous healing. Am J Surg. 2008;196:195–200.
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