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Portal Vein Thrombosis Associated With Right Hepatic Artery Injury During Cholecystectomy: An Uncommon Indication for Urgent Liver Transplantation
Trombosis portal asociada a lesión de la arteria hepática derecha durante una colecistectomía: indicación infrecuente de trasplante hepático urgente
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array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Portal Vein Thrombosis Associated With Right Hepatic Artery Injury During Cholecystectomy: An Uncommon Indication for Urgent Liver Transplantation" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "45" "paginaFinal" => "46" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Joana Ferrer-Fábrega, Marta Barrufet, Verónica Prado, Jose Fuster, Juan Carlos García-Valdecasas" "autores" => array:5 [ 0 => array:3 [ "nombre" => "Joana" "apellidos" => "Ferrer-Fábrega" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Marta" "apellidos" => "Barrufet" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Verónica" "apellidos" => "Prado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:4 [ "nombre" => "Jose" "apellidos" => "Fuster" "email" => array:1 [ 0 => "jfuster@clinic.ub.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 4 => array:3 [ "nombre" => "Juan Carlos" "apellidos" => "García-Valdecasas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Cirugía Hepatobiliopancreática y Trasplante, ICMDiM, Hospital Clínic, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Angiorradiología, Centro de Diagnóstico por Imagen, Hospital Clínic, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Hepatología, ICMDiM, Hospital Clínic, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Trombosis portal asociada a lesión de la arteria hepática derecha durante una colecistectomía: indicación infrecuente de trasplante hepático urgente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1796 "Ancho" => 1624 "Tamanyo" => 212011 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Hepatic arteriography; (b) Transhepatic portography with absence of left portal branch. CHA, common hepatic artery; RHA, right hepatic artery; LHA, left hepatic artery; CT, celiac trunk; PV, portal vein; RPV, right portal vein.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In acute liver failure secondary to iatrogenic lesions caused during cholecystectomy, emergency liver transplantation is a last-resort therapeutic option due to the transcendence of the procedure.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case report of a patient with damage to the hepatic artery and portal thrombosis that occurred during open cholecystectomy. The patient is a 61-year-old woman with a medical history of fibromyalgia, dyslipidemia, hypothyroidism, obesity and chronic lumbago due to a herniated disc. In another hospital, she had been diagnosed with acute cholecystitis, based on clinical, analytical and ultrasound criteria. Urgent cholecystectomy was performed by a right subcostal laparotomy, with no intraoperative incident. The patient's postoperative recovery was slow, with malaise, progressive oliguria, metabolic acidosis and atrial fibrillation that required administration of vasoactive drugs. High transaminase levels (17<span class="elsevierStyleHsp" style=""></span>800<span class="elsevierStyleHsp" style=""></span>U/l) and a 37% drop in prothrombin time were also observed. CT angiography showed an ischemic lesion in the right liver lobe (RLL) with thrombosis of the right portal branch but did not identify the filiform right hepatic artery (RHA) and left portal branch. With the diagnosis of severe post-cholecystectomy ischemic hepatitis and multiple organ failure, the decision was made to transfer the patient to our hospital for further treatment.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Lab work-up upon admission showed: aspartate aminotransferase 6570<span class="elsevierStyleHsp" style=""></span>IU/l; alanine aminotransferase 5470<span class="elsevierStyleHsp" style=""></span>IU/l; gamma-glutamyl transpeptidase 540<span class="elsevierStyleHsp" style=""></span>IU/l; total bilirubin 3.90<span class="elsevierStyleHsp" style=""></span>mg/dl; alkaline phosphatase 866<span class="elsevierStyleHsp" style=""></span>IU/l; platelets 51<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>/l; and prothrombin time 42.2%. Doppler ultrasound showed evidence of a heterogeneous liver in the RLL region, complete thrombosis of the left portal branch, partial thrombosis of the right portal branch, and permeable RHA that was small in caliber and had a low pulsating flow. Given these findings, we carried out transparietal-hepatic portography and hepatic arteriography with mechanical thrombectomy of the right and left portal vein and balloon angioplasty on the left portal vein. Arteriography demonstrated occlusion of the RHA adjacent to surgical clips with absence of right hepatogram (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a and b). Follow-up ultrasound 6<span class="elsevierStyleHsp" style=""></span>h after the procedure once again detected thrombosis of the 2 intrahepatic branches of the portal vein and part of the extrahepatic portal vein. Given the situation of hepatic ischemia, transplantation was considered a therapeutic option and code 0 was activated, after having previously ruled out other potential causes of portal thrombosis. Within 48<span class="elsevierStyleHsp" style=""></span>h of being placed on the list, a compatible donor was offered for liver replacement. During surgery, we confirmed the presence of surgical clips in the RHA, the ischemic appearance of the RLL (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a) and presence of a thrombus in the main portal vein (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>b).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The pathology study of the surgical specimen reported the presence of complete bilateral portal thrombosis with extension to smaller intrahepatic branches, thrombosis of the hepatic artery, hepatic ischemic infarction and no evidence of underlying liver disease.</p><p id="par0025" class="elsevierStylePara elsevierViewall">During hospitalization, the patient did not present any surgery-related complications and had adequate liver function when discharged.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In recent years, the progressive use of laparoscopy for gallbladder surgery and the necessary learning curve have increased the number of cases with iatrogenic injuries to the hepatic hilum. Although there are a growing number of cases in laparoscopic cholecystectomy, these incidences may also occur in open surgery. As described by some authors,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> vascular lesions are normally associated with biliary duct lesions. A single lesion of the RHA rarely has any clinical significance,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and the need for liver transplantation for single lesions is rare.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Less information is available about portal vein injury as it is a structure that is less vulnerable to iatrogenesis.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The present case report involves injury to the RHA together with bilateral portal thrombosis resulting in severe ischemic hepatitis and multiple organ failure. Intraoperative bleeding during cholecystectomy occasionally involves performing imprecise hemostatic surgical maneuvers that lead to iatrogenic vascular lesions (especially of the portal vein). In general, the therapeutic options for different vascular/biliary injuries depend on their nature and on the associated clinical repercussions. Treatment of surgical lesions to the portal triad should be multidisciplinary and done in hospitals that have experience in liver surgery and transplantation.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Acute liver failure secondary to this type of lesions during cholecystectomy is a very serious complication. The indication for urgent liver transplantation is the context of liver failure with acute coagulopathy and secondary multiple organ failure, with transplantation as the only valid therapeutic option. Although the number of case reports is limited, this affirmation is supported by other authors,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–9</span></a> and the recently published series by Parrilla et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> on biliary duct lesions is especially interesting. Nonetheless, due to the severe nature of these indications, these situations should be carefully assessed after continuous clinical follow-up in order to choose the right time for transplantation.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ferrer-Fábrega J, Barrufet M, Prado V, Fuster J, García-Valdecasas JC. Trombosis portal asociada a lesión de la arteria hepática derecha durante una colecistectomía: indicación infrecuente de trasplante hepático urgente. Cir Esp. 2015;93:45–46.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The authors of the following article have received no funding or grants, and the article has not been previously presented at congresses.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1796 "Ancho" => 1624 "Tamanyo" => 212011 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Hepatic arteriography; (b) Transhepatic portography with absence of left portal branch. CHA, common hepatic artery; RHA, right hepatic artery; LHA, left hepatic artery; CT, celiac trunk; PV, portal vein; RPV, right portal vein.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1447 "Ancho" => 1000 "Tamanyo" => 241959 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(a) Explanted liver; (b) Portal thrombus.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 0 | 6 |
| 2024 October | 47 | 7 | 54 |
| 2024 September | 48 | 3 | 51 |
| 2024 August | 39 | 3 | 42 |
| 2024 July | 37 | 6 | 43 |
| 2024 June | 49 | 3 | 52 |
| 2024 May | 65 | 4 | 69 |
| 2024 April | 50 | 3 | 53 |
| 2024 March | 64 | 5 | 69 |
| 2024 February | 63 | 6 | 69 |
| 2024 January | 72 | 1 | 73 |
| 2023 December | 65 | 4 | 69 |
| 2023 November | 70 | 6 | 76 |
| 2023 October | 104 | 3 | 107 |
| 2023 September | 41 | 2 | 43 |
| 2023 August | 42 | 3 | 45 |
| 2023 July | 83 | 4 | 87 |
| 2023 June | 67 | 5 | 72 |
| 2023 May | 81 | 9 | 90 |
| 2023 April | 37 | 2 | 39 |
| 2023 March | 72 | 4 | 76 |
| 2023 February | 48 | 6 | 54 |
| 2023 January | 45 | 4 | 49 |
| 2022 December | 48 | 3 | 51 |
| 2022 November | 54 | 8 | 62 |
| 2022 October | 47 | 8 | 55 |
| 2022 September | 60 | 13 | 73 |
| 2022 August | 44 | 7 | 51 |
| 2022 July | 30 | 9 | 39 |
| 2022 June | 37 | 8 | 45 |
| 2022 May | 55 | 8 | 63 |
| 2022 April | 43 | 9 | 52 |
| 2022 March | 60 | 11 | 71 |
| 2022 February | 39 | 5 | 44 |
| 2022 January | 81 | 9 | 90 |
| 2021 December | 42 | 14 | 56 |
| 2021 November | 55 | 11 | 66 |
| 2021 October | 48 | 10 | 58 |
| 2021 September | 47 | 11 | 58 |
| 2021 August | 58 | 6 | 64 |
| 2021 July | 37 | 12 | 49 |
| 2021 June | 30 | 7 | 37 |
| 2021 May | 48 | 8 | 56 |
| 2021 April | 70 | 14 | 84 |
| 2021 March | 49 | 9 | 58 |
| 2021 February | 31 | 12 | 43 |
| 2021 January | 46 | 11 | 57 |
| 2020 December | 39 | 9 | 48 |
| 2020 November | 40 | 9 | 49 |
| 2020 October | 30 | 8 | 38 |
| 2020 September | 36 | 10 | 46 |
| 2020 August | 29 | 5 | 34 |
| 2020 July | 23 | 8 | 31 |
| 2020 June | 19 | 5 | 24 |
| 2020 May | 21 | 7 | 28 |
| 2020 April | 20 | 3 | 23 |
| 2020 March | 25 | 9 | 34 |
| 2020 February | 36 | 4 | 40 |
| 2020 January | 30 | 10 | 40 |
| 2019 December | 56 | 12 | 68 |
| 2019 November | 25 | 10 | 35 |
| 2019 October | 25 | 11 | 36 |
| 2019 September | 39 | 4 | 43 |
| 2019 August | 20 | 5 | 25 |
| 2019 July | 33 | 20 | 53 |
| 2019 June | 50 | 17 | 67 |
| 2019 May | 137 | 33 | 170 |
| 2019 April | 54 | 28 | 82 |
| 2019 March | 19 | 7 | 26 |
| 2019 February | 22 | 9 | 31 |
| 2019 January | 14 | 11 | 25 |
| 2018 December | 22 | 6 | 28 |
| 2018 November | 31 | 6 | 37 |
| 2018 October | 39 | 7 | 46 |
| 2018 September | 28 | 8 | 36 |
| 2018 August | 3 | 6 | 9 |
| 2018 July | 10 | 4 | 14 |
| 2018 June | 12 | 1 | 13 |
| 2018 May | 12 | 10 | 22 |
| 2018 April | 13 | 1 | 14 |
| 2018 March | 22 | 1 | 23 |
| 2018 February | 9 | 2 | 11 |
| 2018 January | 17 | 2 | 19 |
| 2017 December | 7 | 0 | 7 |
| 2017 November | 12 | 6 | 18 |
| 2017 October | 13 | 4 | 17 |
| 2017 September | 16 | 6 | 22 |
| 2017 August | 18 | 3 | 21 |
| 2017 July | 19 | 2 | 21 |
| 2017 June | 23 | 17 | 40 |
| 2017 May | 29 | 3 | 32 |
| 2017 April | 22 | 7 | 29 |
| 2017 March | 23 | 19 | 42 |
| 2017 February | 32 | 4 | 36 |
| 2017 January | 22 | 8 | 30 |
| 2016 December | 47 | 9 | 56 |
| 2016 November | 32 | 12 | 44 |
| 2016 October | 55 | 8 | 63 |
| 2016 September | 48 | 5 | 53 |
| 2016 August | 57 | 16 | 73 |
| 2016 July | 25 | 6 | 31 |
| 2016 June | 32 | 16 | 48 |
| 2016 May | 35 | 13 | 48 |
| 2016 April | 29 | 42 | 71 |
| 2016 March | 41 | 24 | 65 |
| 2016 February | 28 | 9 | 37 |
| 2016 January | 38 | 9 | 47 |
| 2015 December | 33 | 9 | 42 |
| 2015 November | 27 | 13 | 40 |
| 2015 October | 33 | 8 | 41 |
| 2015 September | 45 | 7 | 52 |
| 2015 August | 27 | 5 | 32 |
| 2015 July | 26 | 10 | 36 |
| 2015 June | 15 | 1 | 16 |
| 2015 May | 33 | 3 | 36 |
| 2015 April | 13 | 6 | 19 |
| 2015 February | 2 | 1 | 3 |
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