Liver Parenchyma Perforation following Endoscopic Retrograde Cholangiopancreatography

Although endoscopic retrograde cholangiopancreatography (ERCP) is an effective modality for the diagnosis and treatment of biliary and pancreatic diseases, it is still related with several severe complications. We report on the case of a female patient who developed liver parenchyma perforation following ERCP. She underwent ERCP with sphincterotomy and extraction of a common bile duct stone. Shortly after ERCP, abdominal distension was identified. Abdominal computed tomography revealed intraabdominal air leakage and leakage of contrast dye penetrating the liver parenchyma into the space around the spleen. Since periampullary perforation related to sphincterotomy could not be denied, she was referred for immediate surgery. Obvious perforation could not be found at surgery. Cholecystectomy, insertion of a T tube into the common bile duct, placement of a duodenostomy tube and drainage of the retroperitoneum were performed. She did well postoperatively and was discharged home on postoperative day 28. In conclusion, as it is well recognized that perforation is one of the most serious complication related to ERCP, liver parenchyma perforation should be suspected as a cause

A Case of Successful Multi-Venous Reconstruction Using Recipient\u27s Jugular Vein in Right Lobe-Living Donor Liver Transplantation

生体肝移植において,十分なグラフト容積を確保し,かつドナーのリスクを低減するため,右葉グラフトを用いることは一般的である.右葉グラフトでは右肝静脈に加え中肝静脈分枝を切離するため,右内側区に高度の鬱血を来たす可能性がある.右内側区・右外側区の還流域には個人差があり,これら静脈は可能な限り再建することが望ましい.再建には,大伏在静脈やシャント血管など様々なグラフトが用いられてきたが,レシピエントへの侵襲増大やグラフト感染,グラフト入手困難などといった問題があり,安定した有効なグラフト確保は困難であった.グラフトとして現在一般的には,摘出肝門脈が使用されている.摘出肝門脈は適切な径および長さのグラフトが得られることが多く,元来3穴を有することから,多孔静脈の再建に適している.今回4静脈孔の再建を要する右葉生体肝移植症例で あったが,レシピエントは門脈血栓・狭小化症例であり,これをグラフト静脈再建に用いることは不可能であった.このため,内頸静脈・外頸静脈を再建に使用し,さらに体外での多孔静脈一括形成を行うことで,短時間で再建し,かつ良好に経過した症例を経験したので報告する.In right lobe-living donor liver transplantation (RT-LDLT), hepatic venous reconstruction of the graft is essential to prevent posttansplant graft congestion and have a good outcome. The patient was a 56-year-old man who had decompensated liver cirrhosis secondary hepatitis C with massive ascites, jaundice and hepatic encephalopathy. He underwent LDLT using his son\u27s right lobe graft. Preoperative simulation by 3D-CT volumetry revealed that the right lobe graft needed multi-venous reconstruction for right inferior hepatic vein (RIHV) and middle hepatic venous tributaries. Preoperative CT scan revealed that the recipient had portal venous thrombus and stenosis, which meant that the recipient\u27s explanted portal vein (EPV) was not suitable for the venous reconstruction of the right lobe graft. Therefore, the recipient\u27s internal and external jugular veins (IJV and EJV) were procured for venous reconstruction. The multiple veins of the right lobe graft were reconstructed to have single co-orifice at the backtable, and the co-orifice was anastomosed to inferior vena cava in short time. The recipient discharged on postoperative day 22 with good venous patency. In RT-LDLT unavailable for recipient\u27s EPV, recipient\u27s IJV and EJV grafts are very useful for multi-venous reconstruction