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Harimoto N, Araki K, Muranushi R, Hoshino K, Hagiwara K, Ishii N, Tsukagoshi M, Igarashi T, Watanabe A, Kubo N, Shibuya K, Miyazaki M, Kawanaka H, Shirabe K. Multimodal approach to portal hypertension and gastric varices before hepatic resection for hepatocellular carcinoma: a case report. Surg Case Rep 2020; 6:190. [PMID: 32737609 PMCID: PMC7394985 DOI: 10.1186/s40792-020-00952-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022] Open
Abstract
Background Liver cirrhosis occurs in approximately 80–90% of patients with hepatocellular carcinoma (HCC), and hepatic resection may be dangerous because of well-documented liver cirrhosis, which may be accompanied by portal hypertension (PH). Here we report a patient with advanced HCC with gastric varices and PH who experienced a good clinical course after undergoing balloon-occluded retrograde transvenous obliteration (BRTO), percutaneous transhepatic portal vein embolization (PTPE), hand-assisted laparoscopic (HALS) splenectomy, and right lobectomy of the liver. Case presentation A 72-year-old man had two HCCs with gastric varices. CT revealed one tumor (4.5 cm) located in segment 7, involving the right hepatic vein, adjacent to the middle hepatic vein. Another tumor (2.7 cm) was located in segment 6. He first underwent BRTO for gastric varices and PTPE for planned right lobectomy of the liver. To reduce PH, HALS splenectomy was performed, and uncomplicated right lobectomy of the liver was performed 10 weeks after the first visit. He has remained free of recurrence for at least 1 year. Conclusions Our patient underwent uncomplicated BRTO, PTPE, HALS splenectomy, and right lobectomy of the liver for advanced HCC with PH. Controlling portal pressure is important when hepatic resection is required to treat HCC with PH.
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Affiliation(s)
- Norifumi Harimoto
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Gunma University, 3-39-22, Showamachi, Maebashi, 371-8511, Japan.
| | - Kenichiro Araki
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Gunma University, 3-39-22, Showamachi, Maebashi, 371-8511, Japan
| | - Ryo Muranushi
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Gunma University, 3-39-22, Showamachi, Maebashi, 371-8511, Japan
| | - Kouki Hoshino
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Gunma University, 3-39-22, Showamachi, Maebashi, 371-8511, Japan
| | - Kei Hagiwara
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Gunma University, 3-39-22, Showamachi, Maebashi, 371-8511, Japan
| | - Norihiro Ishii
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Gunma University, 3-39-22, Showamachi, Maebashi, 371-8511, Japan
| | - Mariko Tsukagoshi
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Gunma University, 3-39-22, Showamachi, Maebashi, 371-8511, Japan.,Department of Innovative Cancer Immunotherapy, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Takamichi Igarashi
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Gunma University, 3-39-22, Showamachi, Maebashi, 371-8511, Japan
| | - Akira Watanabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Gunma University, 3-39-22, Showamachi, Maebashi, 371-8511, Japan
| | - Norio Kubo
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Gunma University, 3-39-22, Showamachi, Maebashi, 371-8511, Japan
| | - Kei Shibuya
- Department of Radiation Oncology, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Masaya Miyazaki
- Department of Applied Medical Imaging, Graduate School of Medicine, Gunma University, Maebashi, Japan
| | - Hirofumi Kawanaka
- Clinical Research Institute and Department of Surgery, National Hospital Organization, Beppu Medical Center, Beppu, Japan
| | - Ken Shirabe
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Gunma University, 3-39-22, Showamachi, Maebashi, 371-8511, Japan
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Kawanaka H, Akahoshi T, Nagao Y, Kinjo N, Yoshida D, Matsumoto Y, Harimoto N, Itoh S, Yoshizumi T, Maehara Y. Customization of laparoscopic gastric devascularization and splenectomy for gastric varices based on CT vascular anatomy. Surg Endosc 2017. [PMID: 28639036 DOI: 10.1007/s00464-017-5646-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic gastric devascularization(Lap GDS) and splenectomy (SPL) for gastric varices is technically challenging because of highly developed collateral vessels and bleeding tendency. We investigated the feasibility of customization of Lap GDS and SPL based on CT vascular anatomy. METHODS We analyzed 61 cirrhotic patients with gastric varices who underwent Lap GDS and SPL between 2006 and 2014. Lap GDS was customized according to the afferent feeding veins (left gastric vein (LGV) and/or posterior gastric vein (PGV)/short gastric vein (SGV)) and efferent drainage veins (gastrorenal shunt and/or gastrophrenic shunt, or numerous retroperitoneal veins) based on CT imaging. RESULTS Thirty-four patients with efferent drainage veins suitable for balloon-occluded retrograde transvenous obliteration (B-RTO) underwent B-RTO instead of surgical GDS, with subsequent Lap SPL. Among 27 patients with gastric varices unsuitable for B-RTO, 15 patients with PGV/SGV underwent Lap GDS of the greater curvature and SPL, and 12 patients with LGV or LGV/PGV/SGV underwent Lap GDS of the greater and lesser curvature and SPL. The mean operation time was 294 min and mean blood loss was 198 g. There was no mortality or severe morbidity. Gastric varices were eradicated in all 61 patients, with no bleeding or recurrence during a mean follow-up of 55.9 months. The cumulative 3-, 5-, and 7-year survival rates were 92, 82, and 64%, respectively. CONCLUSIONS Lap GDS and SPL customized based on CT vascular anatomy is a safe and effective procedure for treating gastric varices.
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Affiliation(s)
- Hirofumi Kawanaka
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. .,Clinical Research Institute and Department of Surgery, National Beppu Medical Center, 1473 Uchikamado, Beppu, 874-0011, Japan.
| | - Tomohiko Akahoshi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoshihiro Nagao
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Nao Kinjo
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Daisuke Yoshida
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoshihiro Matsumoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Norifumi Harimoto
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Shinji Itoh
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoshihiko Maehara
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Abstract
Variceal bleeding remains a life-threatening condition with a 6-week mortality rate of ∼20%. Prevention of variceal bleeding can be achieved using nonselective β-blockers (NSBBs) or endoscopic band ligation (EBL), with NSBBs as the first-line treatment. EBL should be reserved for cases of intolerance or contraindications to NSBBs. Although NSBBs cannot be used to prevent varices, if the hepatic venous pressure gradient (HVPG) is ≤10 mmHg, prognosis is excellent. Survival after acute variceal bleeding has improved over the past three decades, but patients with Child-Pugh grade C cirrhosis remain at greatest risk. Vasoactive drugs combined with endoscopic therapy and antibiotics are the best therapeutic strategy for these patients. Transjugular intrahepatic portosystemic shunts (TIPS) should be used in patients with uncontrolled bleeding or those who are likely to have difficult-to-control bleeding. Rebleeding from varices occurs in ∼60% of patients 1-2 years after the initial bleeding episode, with a mortality rate of 30%. Secondary prophylaxis should start at day 6 after initial bleeding using a combination of NSBBs and EBL. TIPS with polytetrafluoroethylene-covered stents are the preferred option in patients who fail combined treatment with NSBBs and EBL. Despite the improvement in patient survival, further studies are needed to direct the management of patients with gastro-oesophageal varices and variceal bleeding.
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