Abstract
BackgroundFew cases of postoperative arterioportal fistula (APF) have been documented. APF after hepatectomy is a very rare surgery-related complication.Case presentationA 62-year-old man was diagnosed with hepatocellular carcinoma in segments 5 and 8, respectively. Anterior segmentectomy was performed as a curative surgery. Each branch of the hepatic artery, portal vein, and biliary duct for the anterior segment was ligated together as the Glissonean bundle. The patient was discharged on postoperative day 14. Three months later, dynamic magnetic resonance imaging showed an arterioportal fistula and portal vein aneurysm. Surprisingly, the patient did not have subtle symptoms. Although a perfect angiographic evaluation could not be ensured, we performed angiography with subsequent interventional radiology to avoid sudden rupture. Arteriography was immediately performed to create a portogram via the APF from the stump of the anterior hepatic artery, and portography clearly revealed hepatofugal portal vein flow. Portography also showed that the stump of the anterior portal vein had developed a 40-mm-diameter portal vein aneurysm. Selective embolization of the anterior hepatic artery was accomplished in the whole length of the stump of the anterior hepatic artery, and abnormal blood flow through the APF was drastically reduced. The portal vein aneurysm disappeared, and portal flow was normalized. Dynamic computed tomography after embolization clearly demonstrated perfect interruption of the APF. The patient maintained good health thereafter.ConclusionsPost-hepatectomy APFs are very rare, and some appear to be cryptogenic. Our thought-provoking case may help to provide a possible explanation of the causes of post-hepatectomy APF.
Highlights
Few cases of postoperative arterioportal fistula (APF) have been documented
Our thoughtprovoking case may help to provide a possible explanation of the causes of post-hepatectomy APF
Our case may be informative with respect to explaining the possible causes of APF after hepatectomy
Summary
Causes of APF include trauma, iatrogenic causes (e.g., biliary drainage, percutaneous biopsy, and radiofrequency ablation), congenital disease, malignant tumors, and splanchnic artery aneurysm rupture [1,2,3,4, 6,7,8]. The infant had been successfully treated by super-selective embolization using titanium coils His artery, portal vein, and bile duct were ligated, respectively. A definitive diagnosis of APF was made only 3 months after hepatectomy, and we considered that the reason why the patient had no symptoms was the prompt diagnosis of APF followed by adequate IVR. Glissonean pedicle transection (i.e., FSTG) is routinely employed during hepatectomy worldwide We consider this maneuver to be very useful during major hepatectomy. Abbreviations 3D: Three-dimensional; APF: Arterioportal fistula; CT: Computed tomography; FSTG: Fully simultaneous transection of the Glissonean pedicle; IVR: Interventional radiology; MRI: Magnetic resonance imaging; PVA: Portal vein aneurysm. The patient involved in this report provided his written informed consent authorizing the use and disclosure of his protected health information. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations
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