PMC7082604_01
Delayed uptake of contrast medium in the hepatic parenchyma and massive ascites.
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Fig. 1 shows significant delay in uptake of contrast in the hepatic parenchyma with severe congestion, indicating significant venous outflow obstruction of the liver.
a and b The stenoses of the left hepatic vein was confirmed by transjugular phlebography and retrohepatic segment of inferior vena cava were completely occluded.
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Stenoses of left hepatic vein was subsequently confirmed by transjugular phlebography of hepatic veins and verified by measurement of the prestenotic to poststenotic venous pressure with a difference of 54.3 cmH2o (Fig. 2a). The middle and right hepatic veins and retrohepatic segment of inferior vena cava were completely occluded (Fig. 2b).
a and b The transjugular placement of self expanding metal mesh stents and congestion of liver was disappeared.
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Instead, with angiographic evidence of left hepatic vein stenosis with a high pressure gradient, transjugular placement of a self-expanding metal mesh stent (William Cook Europe Aps, Sandet 6,DK-4632 8/60 mm) in the left hepatic vein (Fig. 3A) was decided. China formula was 1018 mL. CT indicated that congestion of liver disappeared and the volume of the future remnant liver was 1180 mL and the predictive graft-to-recipient weight ratio (GRWR) was 1.97% (Fig. 3b).
a Ex vivo liver resection was performed for the liver AE lesion.. 1: left hepatic biliary duct opening. 2: PV opening of segment II. 3: PV opening of segment III. 4: HV opening of segment II. 5: HV opening of segment III. b The left PV and outflow of the left HV to the IVC was reconstructed using artificial blood vessel for a wide mouth anastomosis.. 1: left PV. 2: left HV.
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Parenchymal liver transection was performed with a minimum of 1.0-cm lesion-free margin (Fig. 4a). The left PV and outflow of the left HV to the IVC waswere reconstructed using artificial blood vessels (Fig. 4b).
a The left HV was reconstructed to IVC using end-to-side anastomosis. The left-PV and left-HA were reconstructed using end-to-end anastomosis. The left-HB was reconstructed using bilioenterostomy. 1: left HV, 2: left-PV, 3: IVC. b The resected specimen.
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The left hepatic duct was reconstructed using bilioenterostomy (Fig. 5a). The resected specimen was sent for histopathological examination (Fig. 5b).
The CT scan indicated no recurrence, thrombus, liver congestion and cholangiectasis.
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There was no liver congestion, cholangiectasis and stenosis of the duct-jejunum anastomosis (Fig. 6).