Ann Hepatobiliary Pancreat Surg.  2020 Aug;24(3):345-351. 10.14701/ahbps.2020.24.3.345.

Necrosectomy of hepatic left lateral section after blunt abdominal trauma in a patient who underwent central hepatectomy and bile duct resection for perihilar cholangiocarcinoma

• Oh SG
• Hwang S
• Ha S
• Kim H
• Ryu LN

• KMID: 2505349
• DOI: http://doi.org/10.14701/ahbps.2020.24.3.345

Abstract

When the liver is divided into the right and left halves after central hepatectomy, a serious injury to the one half of the liver can destroy the ipsilateral half. We report a case showing total necrosis of the hepatic left lateral section (LLS) caused by blunt abdominal trauma in a patient who had undergone central hepatectomy and bile duct resection for perihilar cholangiocarcinoma. A 47-year-old female patient was transferred because of postoperative status following blunt abdominal trauma. Five years before, she had been diagnosed with perihilar cholangiocarcinoma. Since the tumor extent was compatible with Bismuth-Corlette type IV, she underwent central hepatectomy and bile duct resection. After five years, she experienced an industrial safety accident, in which a heavy refrigerator fell over her body. She underwent emergency duodenal diversion surgery with distal gastrectomy and Roux-en-Y gastrojejunostomy. During this surgery,serious ischemic injury of the LLS with occlusion of the left portal vein and hepatic artery was identified, but not treated. After three weeks, LLS necrosectomy with repair of the jejunal limb was done. Postoperative bile leak developed and required supportive care for two months for its healing. She is currently doing well without any physical discomfort four months after the necrosectomy. Our experience with this case suggests that an injury to the afferent jejunal limb requires an individualized treatment strategy including long-standing waiting with effective drainage for spontaneous healing. The experience of this case appears to be theoretically matched with late-stage resection of LLS following central hepatectomy and bile duct resection.

Keyword

Central hepatectomy; Abdominal trauma; Bile leak; Cholangiocarcinoma; Necrosis

Figure

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  Fig. 1 Initial preoperative radiologic findings. The computed tomography scan showed perihilar cholangiocarcinoma (A). Magnetic resonance cholangiopancreatography showed an intraluminal mass involving the right and left hepatic ducts (B).

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  Fig. 2 Postoperative radiologic findings taken at one week after central hepatectomy and bile duct resection. The computed tomography scan showed that the medial portion of the right anterior section was resected (A). Biliary reconstruction and intervening jejunal limb is visible (B).

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  Fig. 3 Gross photographs of the resected specimen showing well-differentiated cholangiocarcinoma of papillary type.

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  Fig. 4 Postoperative radiologic findings taken at two years after the central hepatectomy and bile duct resection. The computed tomography scan showed no bile duct dilatation at the right (A) and left (B) liver parts.

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  Fig. 5 Radiologic finding showing complete ischemic necrosis of the left lateral section soon after blunt abdominal trauma.

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  Fig. 6 Magnetic resonance cholangiopancreatography showed massive bile leak at the afferent jejunal limb.

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  Fig. 7 Gross photographs of the surgical procedure for necrosectomy. Necrotic materials filling the left lateral section space were gently removed (A and B). Intrahepatic vascular structures were ligated (C). Dye solution was injected into the afferent jejunal limb after temporary clamping of the jejunojejunostomy (D).

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  Fig. 8 Gross photographs of the resected liver specimen showing complete necrosis of the hepatic parenchyma.

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  Fig. 9 Postoperative hepatobiliary scintigraphy taken ten days after necrosectomy showed major bile leak.

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  Fig. 10 Radiologic finding showing resolution process of bile leak. Computed tomography scans were taken at one week (A), two weeks (B), six weeks (C) and nine weeks (D) after the necrosectomy.

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  Fig. 11 Postoperative hepatobiliary scintigraphy taken two months after necrosectomy showed no bile leak.

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