Budd-Chiari Syndrome – The Forgotten Danger of Repeat Liver Surgery

Abstract

Introduction: Budd-Chiari syndrome (BCS) is defined as obstruction of the hepatic outflow anywhere along the hepatic venous course. With certain liver resections, a risk exists for inadvertent disruption to the main venous outflow tracts predisposing to iatrogenic BCS in return resections. Specified pre-operative imaging of the hepatic outflow is generally not undertaken prior to repeat hepatic resections, meaning the hepatic venous outflow can remain unclassified in operative planning. We present the death of a man whose main venous outflow was inadvertently divided during a right hepatectomy following a previous segment 4 metastectomy. Discussion: Our case report describes an iatrogenic cause of BCS after routine stapling of the right hepatic vein eliminated all hepatic outflow due to the patient’s abnormal venous vasculature following previous resection. The patient’s previous hepatic surgery had inadvertently disrupted the hepatic outflow at the confluence of the left and middle hepatic veins, making the right hepatic vein the main outflow route. This was not identified pre-operatively despite the patient undergoing innumerable imaging procedures including portal vein embolization. He subsequently died immediately following surgery from a combination of blood loss and acute liver failure. Conclusion: In the setting of previous hepatic surgery, it is imperative to assess in detail the pre-operative hepatic venous vasculature. Furthermore, when unusual intraoperative hepatic congestion and bleeding occurs, operators need to strongly consider the possibility of obstruction to the venous outflow tracts and thus make every effort to return venous outflow to the remnant liver.