Ann Hepatobiliary Pancreat Surg.  2021 May;25(2):270-275. 10.14701/ahbps.2021.25.2.270.

Therapeutic plasma exchange as an effective salvage measure for post-hepatectomy hepatic failure: A case report

• Ryu LN
• Hwang S
• Ha S

• KMID: 2516251
• DOI: http://doi.org/10.14701/ahbps.2021.25.2.270

Abstract

Major hepatectomy can result in post-hepatectomy hepatic failure (PHHF) and therapeutic plasma exchange (TPE) can be used as a salvage procedure for liver support. We herein present a case of 69-year-old male patient with perihilar cholangiocarcinoma who was successfully managed with salvage TPE. Preoperative portal embolization was performed to reduce the parenchymal resection rate. The extent of surgery was right hepatectomy with partial excision of the ventral portion of the segment IV, caudate lobectomy, bile duct resection and extensive lymph node dissection. No noticeable surgical complications occurred after the operation, but serum total bilirubin level increased gradually and reached 10 mg/dl at 1 month after the operation. At postoperative day 38, total bilirubin level raised to 19.8 mg/dl and prothrombin time deteriorated significantly, thus salvage TPE was started. TPE was performed three times per week for 2 weeks; consequently, the total bilirubin level was maintained below 10 mg/dl. A few days later, a rebound of total bilirubin occurred; accordingly, 2 sessions of TPE were performed additionally. Overall, a total of 8 sessions of TPE were performed. The patient was discharged at 84 days after operation. The total bilirubin level returned to normal at 5 months after operation. This patient is doing well for past 9 months. In Korea, TPE for liver support has been approved by the social health insurance since August 2020. In conclusion, salvage TPE is an effective liver support measure for PHHF, thus we suggest starting TPE if serum total bilirubin level reaches 10 mg/dl after hepatectomy.

Keyword

Major hepatectomy; Hepatic failure; Hyperbilirubinemia; Liver support; Hepatic decompensation

Figure

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  Fig. 1 Initial preoperative radiologic findings. Bismuth type IV perihilar cholangiocarcinoma is visible at the dynamic abdomen computed tomography images (A, B) and magnetic resonance cholangiopancreatography (C, D).

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  Fig. 2 Preoperative percutaneous biliary drainage (PTBD). (A) A PTBD catheter was inserted into the left hepatic duct. (B) The color of bile from the left hepatic duct appears watery clear, indicating loss of excretory hepatocyte function.

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  Fig. 3 Imaging study findings before and after percutaneous transhepatic portal embolization (PTPE). (A) The pre-PTPE volume of the future remnant left liver is 39% of the whole liver volume. (B, C) Right PTPE is performed through an ipsilateral approach. (D) The future remnant left liver is increased to 50% of the whole liver volume at 20 days after PTPE.

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  Fig. 4 Gross photograph of the resected specimen showing a perihilar cholangiocarcinoma of flat infiltrative type, 4.2 cm-sized moderately differentiated adenocarcinoma, with extension beyond the bile duct and involvement of the liver.

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  Fig. 5 Postoperative computed tomography (CT) follow-up images. No abnormal findings can be seen in the 1-week CT scan (A). One-month CT scan shows ascites and splenomegaly (B). No abnormal findings except splenomegaly are visible in the 3-month (C) and 8-month (D) CT scans.

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  Fig. 6 Changes in the serum total bilirubin level before and after surgery. A total of 8 sessions of therapeutic plasma exchange (TPE) were performed. PTPE denotes percutaneous transhepatic portal embolization.

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