手术中围肝门部血管急症的治疗要点
【摘要】 目的 研究手术中围肝门部血管急症的治疗方法和临床疗效。方法 对10余年来笔者治疗的14例手术中围肝门部血管急症患者的临床资料进行了综合分析。结果 本组中恶性肿瘤7例(50.0%)，良性病变7例(50.0%)。手术中围肝门部血管急症属医源性12例(85.7%)，创伤性2例(14.3%)。发生在围第一肝门部8例(57.1%)，围第二肝门部2例(14.3%)，围第三肝门部4例(28.6%)。发生静脉破裂8例(57.1%)，动脉破裂2例(14.3%)，发生肝动脉急性栓塞、门静脉急性栓塞、肝Ⅶ段和肝右静脉破裂、结扎肝右静脉致肝Ⅶ段血液回流障碍各1例。治疗方法为:行静脉修复7例，行肝动脉修复、肝动脉结扎、肝动脉腔内外药物注射加胆囊切除术、缝合胆总管和门静脉分支、门静脉切开取栓、缝合肝Ⅶ段并缝扎肝右静脉、缝扎肝右静脉保留肝Ⅶ段各1例。本组治愈11例(78.6%)，死亡3例(21.4%)。对11例近期随访疗效良好。结论 围肝门部是上腹部手术、现代外科技术和创伤经常涉及的重要部位，手术中围肝门部血管急症的原因呈多样性，其发生带有突然性和隐匿性，如处理不及时或不得当，短时间内即可严重威胁患者生命。本组手术中围第一肝门部血管急症的发生率最高，是医源性血管急症的高发部位;围第二肝门部是手术中围肝门部创伤性血管急症的高发部位，多合并肝外伤;手术中围第三肝门部血管急症多为医源性，其处理困难，死亡率高，在手术中围肝门部血管急症中属重中之重。提高对手术中围肝门部血管急症的防范意识和处理水平，是改善手术疗效的关键。
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关键词 围肝门部 血管急症 治疗
【文献标识码】 A 【文章编号】 1726-7587(2004)05-0688-07
The therapeutic main points of vascular emergencies in
hepatic perihilar regions during operations
Bai Weiye，Zhao Jianmin，Zhou Kun，et al.
Department of General Surgery，Shanghai Municipal Corps Hospital，
Chinese People’s Armed Police Forces，Shanghai201103.
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【Abstract】 Objective Vascular emergencies(VE)in perihilar regions(PR)of liver is rarely described durˉing operations，but the factors associated with its treatment and the clinical outcomes are poorly characterized.Methods Case logs ofsurgeonsfrom1992to2003were retrospetively reviewed VE in PR during operations.Results Fourˉteen patients of VE in PR during operations were malignant tumor(n=7;50.0%)and benign pathologic change(n=7;50.0%).There were iatrogenicvascular emergencies(IVE)(n=12;85.7%)and traumatic vascular emergencies(TVE)(n=2;14.3%).VE were in the first PR(n=8;57.1%)，the second PR(n=2;14.3%)and the third PR(n=4;28.6%).Phleborrhesis(n=8;57.1%)and arteriorrhesis(n=2;14.3%)and acute embolism of hepatic artery(AEHA)(n=1;7.1%)and acute embolism of portal vein(AEPV)(n=1;7.1%)，ruputure ofⅦsegment of liver and right hepatic vein(n=1;7.1%)，irregularityhepatectomy for right three lobes and hepatectomy for part caudate lobe to be ligated right hepatic vein and retainedⅦsegment of liver complicated hypostasis of HV ofⅦsegˉment(n=1;7.1%).The therapeutic methods of VE were venous repair(7of14)，arteriorrhaphy(1of14)，ligationof hepatic artery(1of14)，portoembolectomy(1of14)，sutured biliary tract and pylic branch and hemostasis by comˉpression(1of14)，cholecystectomy addition intra-outer-injection-arterially of liver(1of14)，suture foⅦsegˉment of liver and right hepatic vein(1of14)，to retain theⅦsegment of liver to be ligated right hepatic vein(1of14).Eleven patients(78.6%)had been cured and three patients(21.4%)died.The curative effect in the postoperaˉtion near future is w
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ell for eleven patients.Conclusion It is the important region that PR is involved operations or therapies and trauma in the epigastrium region.VE in PR during operations had been increasingly reported.The morˉbidity of IVE in the first PR is the highest among PR，the morbidity of TVE complicated hepatic injury in the second PR is the highest，and the treatment of rupture of retrohepatic inferior vena cava(RRIVC)in the third PR is the most difficult problem of VE of the PR among hepatic surgery.This manuscript put forward the views about therapeutic main points to the VE in PR during operations.
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Key words hepatic perihilar region vascular emergency treatment
It is the important region that perihilar regions(PR)of liver is often involved operations or therapies and trauma in the epigastrium region.Blood vessel in the PR is large and complex.Because of anatomic and pathologic characters of the PR，causes of vascular emerˉgencies(VE)are manifold，suddenly，hided，diffcultly treated need to cooperate branches of learning(such as elect anesthesia or use technique of vascular shunt)and patients’safety can be directly threatened.When both VE in the PR need to be treated and the predetermine operation have to complete，a strategic decision is.In the past few years，some operations or malignant tumors that were difficultly resected has been successfully resectedand treatment of trauma in the PR through advances of surgical basic studied and technique，but VE in the PR during operations has been increasingly reported.This problem is being more and more to be followed with inˉterest by surgeons ofhepatobiliary surgery.It is reported that fourteen patients had been treated from1992to2003.
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1 Patients and methods
There were fourteen patients(11men and3wowen;mean age，46.9years;age range，7to68years)with VE in the PR during operations.Ten patients were our hospitaland four patients treated by the authors on operating consultation in outer hospital，which the causes were manifold and the therapies or prognosis were differˉent(see table1).
2 Results
The group were malignant tumor(n=7;50.0%) and benign pathologic change(n=7;50.0%)，There were iatrogenic vascular emergencies(IVE)(n=12;85.7%)and traumatic vascular emergencies(TVE)(n=2;14.3%).VE were in the first PR(n=8;57.1%)，the second TP(n=2;14.3%)and the third PR(n=4，28.6%).There were phleborrhesis were(n=8;57.1%)，arteriorrhesis(n=2;14.3%)，acute emˉbolism of hepatic artery(AEHA)(n=1;7.1%)，acute embolism of portal vein(AEPV)(n=1;7.1%)，rupture ofⅦsegment of liver and right hepatic vein(n=1;7.1%)，irregularity hepatectomy for right three lobes and hepatectomy for part of caudate lobe tobe ligated right hepatic vein andretainedⅦsegment of liver complicatˉed hypostasis of HV ofⅦsegment(n=1;7.1%).
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The therapeutic methods of VE were venous repair(7or14)and arteriorrhaphy(1of14)，ligation of hepˉatic artery(1of14)，pylic embolectomy(1of14)，suˉtured biliary tract and pylic branch and hemostasis by compression(1of14)，cholecystectomy addition intra-outer-injection-arterially of liver(1of14)，sutureofⅦsegment of liver and right hepatic vein(1of14)，to be retain theⅦsegmentof liver to be ligated right hepˉatic vein(1of14).
Eleven patients(78.6%)who were in the first PR(n=8)and in the second PR(n=2)and in the third PR(n=1)had been cured and three patients(21.4%)that were rupture of retrohepatic inferior vena cave(RRIVC)in the third PR died(see table1).The curaˉtive effect in the postoperation near future is well for eleven patients.
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Table1 Conditions table of fourteen patients with VE in PR during operations略
3 Comments
3.1 VE of the first PR The first PR is the combinaˉtion site of liver，biliary tract and pancreas.It is the imˉportant channel that is modern surgical technics or new therapies in clinic，which morbidity of IVE in the first PR is the highest among the PR.Operations or reoperaˉtions and trauma of the first PR can certainly be associˉated with injury either hepatic artery(HA)or portal vein(PV).Eight patients who were VE in the first PR and causes manifold had been cured.
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3.1.1 VE of HA
3.1.1.1 Rupture of hepatic artery Two patients complicated that one was rupture of hepatic artery(RHA)to be cured by arteriorrhaphy and another one was rupture of right branch of proper hepatic artery to be cured ligation of hepatic artery.Although the method of hepatic dearterialization has been widely used in clinic for treated malignant tumor of liver and remarkably reached curative effect，RHA can be repaired as far as possible during operation when condition is allowed.Afˉter arterial blood flow of liver is blocked and the operaˉtive region exposed，repair of HA can be taken.The blockage time of HA can be appropriately delayed for complexly RHA of uncirrhosis.Huguet et al [1] had put forward blockage that the time of HA can be1h for heat ischemia of uncirrhosis.Selective extrahepatic artery ligˉation to control arterial hemorrhage of liver can be used.Before HA was ligated，HA and PV shall be carefully explored except anatomic variation or pathologic change.Morbidity of anatomic variation of HA is33%～45%.An extensive injury to either right or left HA can be ligˉated，as long as ipsilate
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ral branch of PV is intact.Signifˉicant injury to both HA and PV is a rare，buttechnicallydifficult，management problem，which one of them that PV is as far as possible retained has to been repaired.Failure to repair one of these two structures o
bviously leads to hepatic ischemia，necrosis，hepatic failure.
3.1.1.2 Acute embolism of hepatic artery One paˉtient had been taken transcatheter arterial emblization(TAE)for cavernous hemangioma of liver in outer hosˉpital，which hepatic arteriography found variation of HA that left hepatic artery sent out from HA and right hepatˉic artery from superior mesenteric artery.The patient when was taken cholecystectomy for acute cholecystitis after TAE was found AEHA and left half hepatonecrosis during operation，which the case had been cured through cholecystectomy addition intra-outer-injection-arteˉrially ofliver and combined treatment that was symptom-group of hepatic failure to be absorpted a large numˉber necrosic tissue at the postoperation.When TAE is taken to be treated benign tumor of liver(such as cavˉernous hemangioma)，damage or necrosis of biliary tract can be caused by AEHA.AEHA has been interested by the surgeons in clinic.Huang Xiaoqiang et al [2] had reˉported that9patients had the complications of TAE and put forward that TAE shall be again evaluated，forbade indeterminately to be used TAE and cirrhosic agent for cavernous hemangioma of liver.It had been reported that patients were died of variant HA to be ligatedor emˉbolism agent mistakenly injected [3] .The therapies of AEHA include c
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ombined nonoperative treatment that is symptom-group of hepatic failure to be absorpted a large number necrosic tissue and operative treatments that are cholecystectomy and choledochotomy-drainge or incision and drainage of liver abscess and take comˉbined treatment at the postoperation.If liver function is continuingdeterioration，portal vein-arterizated can be taken to increasingly provid blood oxygen content proˉceed to improve liver function [4] .
, http://www.100md.com 3.1.2 VE of PV
3.1.2.1 Rupture of portal vein Four patients comˉplicated rupture of portalvein(RPV)that two were RPV and one was rupture of pylic branch(RPB)and anˉother one was suicidal canalization wound of PV and splenic vein(SV)，Which two were repair of PV and one was suture wall of common bile duct and pylic branchand hemostasis by compression and another one had been cured by repair anteriorand posterior wall of PV and SV to be used continuous intensification vein suˉture [5] (see table2).When one patient with hepatocirˉrhosis complicated protal hypertention occurred hemorˉrhagic shock during transjugular intrahepaticportosys-temic stent shunt(TIPSS)，the region of RPVwas found1cm on right anterior wall that was at diatance from the first PR3cm during exploratory laparotomy and repair of PV.Two patients with acute pyogenic obstructive cholanˉgitis complicated RPV and RPB during chledochotomy with reexploration，which one had been cured by repair of PV and another one with hepatocirrhosis and portal hyperte
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ntion complicated RPB that wall of common bile duct and pylic branch were simultaneously incised durˉing chledochotomy with exploration，occurred hematorˉrheato be difficultly controlled and the patient had been cured to be accurately taken drainage of“T”vessel and sture wall of common bile duct and pylic branch and hemostasis by compression.If hematorrhea difficultly is controlled，patients’safety can be directly threatened and losed to savable opportunity.Because exposure of injured region of PV is difficult，the treatment is more difficult than HA.When progressive stage of hepatocirˉrhosis，PV can occur pathologic change that diameter is thick，wall meagre，pressure higher and is formed variantpylic branches in the first PR to be named spongioid change of PV [12，13]，which abnormal outflowtract of liver blood is made of vascular net of pachyn
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tic hepatic capˉsule，gallbladder bed and hepatic bed.When the metal conductingwire get out liver during TIPSS and incise wall of common bile duct and pylic branch during chleˉdochotomy with exploration，RPV or RPB can occur and hematorrhea shall be difficultly controlled.Generally speaking，therapeutic methods of RPV include pylic reˉpair in situ，end-to-end anastomosis，venous graft，arˉtificial vascular graft，portacaval shunt，bridge shunt suˉperior mesenteric vein(SMV)to inferior vena cava.It is the more difficult when RPV in posterior pancreas is treated.Only by fully to be exposured PV or as with proximal injury to SMV，the neck of pancreas can be even amputated when circumstance is critical.A signifiˉcant RPV，ligation of PV is the preferred therapy that is as far as possible near the first PR and vast majority paˉtients can be tolerated to the condition.If patient has the symptoms of enteric stasis of blood at the postoperation，exploratory laparotomy shall be performed in24h，which pylic end-to-end anastomosis or portacaval shunt and partial resection of small intestine shall be performed when ischemic change or necrosis intestine occurred [7] .Patient with hepatocirrhosis to complicate acute cholanˉgitis shall be takenpapillosphincterotomy through fiberˉduodenoscope in early stage，againcholedochostomy with“T”tube drainage.If RPB occurred during choledochosˉtomy with“T”tube drainage，sutured biliary tract and pylic branch with hemostasis by compression shall be accurately taken.Hematorrhea can not controlled，local angiopressure hemostasis to be used long gauze tamponˉade out drainge body or temporary closed abdomen cavity can be taken，of when it can be carefully got out from abdomen cavity at the postoperation [14] .
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Table2 Survival condition to be treated of RPV略
3.1.2.2 Acute embolism of portal vein One patient complicated AEPV to be involved SMV during pancreato-duodenectomy and secondary portal enteric congestionand shock was occurred，which portoembolectomy had been performed that embolus was3cm×0.5cm and pancreato-duodenectomy had been successfully taken and quantityof blood transfusion was5000ml on operatˉing.AEPV that can be occurred during pancreato-duoˉdenectomy or exfoliation of portal vein tumor embolus(PVTE)is seldom seen in clinic.It is the cause that veˉnous tunica is injured to lead phlebostenosis，to be slow rate of venous return flow or exfoliation of PVTE when venous branches in head region of pancreatic is managed during operation.Simultaneously to be supplied blood volume and corrected shock，portoembolectomy shall besimultaneously perfomed，which embolus were explored and phleboembolism bipolarity blocked.Before portoemˉbolectomy，phleboembolism shall be acted of avoidingto be crushed and prevented partly scaling.When suture of PV is taken，structure of PV or causes of AEPV shall be removed at the same time.After portal circula
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tion has recovered，entric sanguimotor variation is carefully obˉserved.If the patient should not have hemorrhagic tenˉdency，the patient who portoembolectomy had been perˉformed at2d or3d the postoperation should be used the drugs that have the function of redution of blood viscosiˉty，angiectasis，prevention angiospasm and anticoagulaˉtion as hemostat drugs.
3.2 VE of the second PR Two patients complicated VE of the second PR.One patient who was hepatorrhexis ofⅦsegment and rupture of right hepatic vein due to blunt trauma had been cured by hepatorrhaphy ofⅦsegment and ligation of right hepatic vein to be conˉtrolled interflow and outflow of liver through thoracic cavity.One patient who was taken irregularity hepatectoˉmy for right three lobes and hepatectomy for part of cauˉdate lobe to be retainedⅦsegment of liver complicated hypostasis of hepatic vein(HV)ofⅦsegment，which the patient had been cured and was taken chemotherapy to be embedded of drug delivery system in HA at the postoperation.The second PR is situated in the thoraco-abdominal combination site that HV is large vein near heart，which common emergencies of HV is rupture hematorrhes or aeremia(air embolism).The morbidity of TVE complicated hepatic injury in the second PR is the highest among PR，the area is difficult to surgically exˉpose and repair for HV.Hemostasis-therapies include repair or ligation of HV.Liu AZ，et al [15] had reported that fifteen among twenty patients who were hepatic inˉjuries with rupture of HV in the second PR had been cured.If repair or ligation of HV can not be taken during operation，local angiopression hemostasis or t
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emporary closed abdomen cavity shall be taken，which secondary operation shall be performed in the near future.If hemaˉtorrhea can not be actively controlled，patients′life shall be hazarded in a short time.Only by simultaneously obˉstructing interflow and outflow of hepatic blood can be controlled hematorrhea.Outflow of hepatic blood can need to be obstructed through thoracic cavity at the same time.It is the important problem that the hepatic segˉment draining blood of HV can be involved after branch of HV is ligated.General speaking，normal hepatictissue can not be tolerated obostructed for blood of HV and corresponding segmentectomy of liver shall be perˉformed.Experiment evidenced in recent years，venous collateral circulation of liver can be constructed at the space of hepatic lobes and PV shall have been done blood vessel of shunt that is increased irregularly after branch of HV is ligated on the condition，which blood of HA gets intohepatic sinus and blood circulation of liver can be executed to pass from branc
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hes of PV to hepatic lobes that the organism of patient can be tolerated to thischange and recovered in a short time [16～18] .
3.3 VE of the third PR Four patients complicated VE of the third PR.One patient that was performed hepˉatectomy for caudate lobe complicated RRIVC that therupture region was1.0cm had been cured by repair of retrohepatic inferior vena cava(RIVC)，which repair method of RRIVC was continuous intensification vein suˉture to be preventively taken a Satinsky’s clamp on anˉterior wall of RIVC.Three patients were died of RRIVC.VE of the third PR is RRIVC or rupture of hepatic short vein(RHSV)，which RRIVC can be occurred when RHSV was unappropriatelymanaged by hemostasis durˉing right hepatectomy or caudate lobectomy of liver [19] .The treatment of RRIVC is the most difficult problem of hepatic surgery among VE of PR [20] and the case-fatalˉity rate is33.3%～75.0% [21] (see table3).Before right hepatectomy or caudate lobectomy of liver is perˉformed，operative difficulty and occurrence possibility of RRIVC or RHSV shall be evaluated and relative prepaˉration taken by us.To be managed hepatic short vein(HSV)during operations，HSV and hepatic tissue shall be together holded and ligated.ASatinsky’s clamp shall be preventively taken on anterior wall of inferior vena
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cava，which the method can prevent both RRIVC and diˉrectly repair it injured.
When RRIVC or RHSV had ocˉcurred，therapeutic methods include intra-abdominal technique of vascular isolation of liver that is total hepˉatic vascular exclusion or selective hepatic vascular exˉclusion [24] .Liver can be completely isolated from circuˉlation by cross-damping the first PR and below liver，which the injurious region andclassification shall be deˉtermined to be taken [25] .The region of RRIVC or RHSV can be repaired to be used Satinsky’s clamp or forcep of varscular tissue.If hemostasis or repair can not be takˉen，vein-vein shunt or atriocaval shunt that is introˉ duced through atriumabove with occluding tourniquets being applied around inferior vena cava above and bolow liver，which is probably still the most commonly emˉployed technique f
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or diversion of blood away from RRIVC.If hemostasis has not yet done，local angiopresˉsion hemostasis or temporary closed abdomen cavity can be taken，of when p
ositive antishock and secondary manˉagement shall be taken in the near future of postoperaˉtion.
Table3 Treatment results of RRIVC略
4 Conclusions
Because of anatomic and pathologic characters of the PR，blood vessel in PRis large and complex and the region is involved operations or therapies and trauma in the epigastrium region.The morbidity of IVE in the first PR is the highest among PR，the morbidity of TVE comˉplicated hepatic injury in the second PR is the highest and the treatment of RRIVC in the third PR is the most difficult problem of VE of PR among hepatic surgery.This manuscript put forward the views about thetheraˉpeutic main points to the VE in PR during operations:
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The repair method of phleborrhesis is continuous intensification vein suture.
The patient when was taken cholecystectomy for aˉcute cholecystitis after TAE wasfound AEHA and left half hepatonecrosis during operation，which the case had been cured through cholecystectomyadditionintra-outˉer-injection-arterially of liver and combined treatment that was symptom-group of hepatic failure to be abˉsorpted a large number necrosic tissue of liver at the postoperation.We suggest thatTAE shall be again evaluˉated and forbade indiscriminately to use TAEand cirrhoˉsis agent for cavernous hemangioma of liver.
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The patient with suicidal canalization wound of PV and SV had been cured by repair anterior and posterior wall of PV and SV to be used continuous intensification vein suture.
When patient with hepatocirrhosis and portal hyˉpertention complicated severe cholangitis was taken reˉ operation of exploration biliary tract and occurred RPB that wall of common bile duct and pylic branch were siˉmultaneously incised during chledochotomy with exploˉration，we shall be accurately taken drainage of“T”vesˉsel and sutre wall of common bile duct and pylic branch and hemostasis by compression.
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Significant injury to both HA and PV is a rare，but technically difficult，management problem，which one of them that PV is as far as possible retained has to been repaired.
Patient complicated AEPV to be involved SMV during pancreato-duodenectomy and secondary portal enteric congestion and shock was occurred，Which porˉtoembolectomy had been performed that embolus was3cm×0.5cm and pancreato-duodenectomy had been successfully taken and quantity of blood transfusion was5000ml on operating.If the patient should not have hemorrhagic tendency，the patient who portoembolectomy had been performed at2d or3d the postoperation should be used the drugs that have the function of reduction of blood viscosity，angiectasis，prevention angiospasm and anticoagulation as hemostat drugs.
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Patient who had been taken irregularity hepatectoˉmy for right three lobes and hepatectomy for part of cauˉdate lobe to be retainedⅦsegment of liver complicated hypostasis of HV ofⅦsegment，which the patient had been cured and was taken chemotherapy to be embedded of drug delivery system in HA at the postoperation.
Patient that was performed hepatectomy for caudate lobe complicated RRIVC that the rupture region was1.0cm had been cured by repair of RIVC，which repair method of RRIVC was continuous intensification vein suˉture to be preventively taken a Satinsky’sclamp on anˉterior wall of RIVC.
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18 高之阳，高瞰非.严重肝损伤的若干手术对策.腹部外科，2001，14(4):239-240.
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19 邢雪，李洪，刘卫国，等.主肝静脉切除后保留引流肝段的临床应用.中华肝胆外科杂志，2003，9(11):694-696.
20 黄志强.单独肝尾状叶全切除术.消化外科，2002，1(1):62-65.
21 黄洁夫.腹部外科学.北京:人民卫生出版社，2001，1074-1084.
22 张培华.临床血管外科学.北京:科学出版社，2003，393-396.23 曹杰，谭卫民，区庆嘉.肝癌术中肝后段下腔静脉损伤的处理.中华肝胆外科杂志，2002，8(6):352-353.
24 白伟业，赵建民，周坤.手术中门静脉急症的处理.罕少疾病杂志，2003，10(3):9-11.
25 Vassiios ES，Georgia GK，Evangelos LG，et al.Total versus selective hepatic vascular exclusion in major liver resections.Am J Surg，2002，183(2):173-178.
作者单位:1201103上海武警上海总队医院普通外科
2046000山西长治解放军51272部队医院外科
(收稿日期:2004-02-13)
(编辑 李阳), 百拇医药
, http://www.100md.com
关键词 围肝门部 血管急症 治疗
【文献标识码】 A 【文章编号】 1726-7587(2004)05-0688-07
The therapeutic main points of vascular emergencies in
hepatic perihilar regions during operations
Bai Weiye，Zhao Jianmin，Zhou Kun，et al.
Department of General Surgery，Shanghai Municipal Corps Hospital，
Chinese People’s Armed Police Forces，Shanghai201103.
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【Abstract】 Objective Vascular emergencies(VE)in perihilar regions(PR)of liver is rarely described durˉing operations，but the factors associated with its treatment and the clinical outcomes are poorly characterized.Methods Case logs ofsurgeonsfrom1992to2003were retrospetively reviewed VE in PR during operations.Results Fourˉteen patients of VE in PR during operations were malignant tumor(n=7;50.0%)and benign pathologic change(n=7;50.0%).There were iatrogenicvascular emergencies(IVE)(n=12;85.7%)and traumatic vascular emergencies(TVE)(n=2;14.3%).VE were in the first PR(n=8;57.1%)，the second PR(n=2;14.3%)and the third PR(n=4;28.6%).Phleborrhesis(n=8;57.1%)and arteriorrhesis(n=2;14.3%)and acute embolism of hepatic artery(AEHA)(n=1;7.1%)and acute embolism of portal vein(AEPV)(n=1;7.1%)，ruputure ofⅦsegment of liver and right hepatic vein(n=1;7.1%)，irregularityhepatectomy for right three lobes and hepatectomy for part caudate lobe to be ligated right hepatic vein and retainedⅦsegment of liver complicated hypostasis of HV ofⅦsegˉment(n=1;7.1%).The therapeutic methods of VE were venous repair(7of14)，arteriorrhaphy(1of14)，ligationof hepatic artery(1of14)，portoembolectomy(1of14)，sutured biliary tract and pylic branch and hemostasis by comˉpression(1of14)，cholecystectomy addition intra-outer-injection-arterially of liver(1of14)，suture foⅦsegˉment of liver and right hepatic vein(1of14)，to retain theⅦsegment of liver to be ligated right hepatic vein(1of14).Eleven patients(78.6%)had been cured and three patients(21.4%)died.The curative effect in the postoperaˉtion near future is w
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ell for eleven patients.Conclusion It is the important region that PR is involved operations or therapies and trauma in the epigastrium region.VE in PR during operations had been increasingly reported.The morˉbidity of IVE in the first PR is the highest among PR，the morbidity of TVE complicated hepatic injury in the second PR is the highest，and the treatment of rupture of retrohepatic inferior vena cava(RRIVC)in the third PR is the most difficult problem of VE of the PR among hepatic surgery.This manuscript put forward the views about therapeutic main points to the VE in PR during operations.
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Key words hepatic perihilar region vascular emergency treatment
It is the important region that perihilar regions(PR)of liver is often involved operations or therapies and trauma in the epigastrium region.Blood vessel in the PR is large and complex.Because of anatomic and pathologic characters of the PR，causes of vascular emerˉgencies(VE)are manifold，suddenly，hided，diffcultly treated need to cooperate branches of learning(such as elect anesthesia or use technique of vascular shunt)and patients’safety can be directly threatened.When both VE in the PR need to be treated and the predetermine operation have to complete，a strategic decision is.In the past few years，some operations or malignant tumors that were difficultly resected has been successfully resectedand treatment of trauma in the PR through advances of surgical basic studied and technique，but VE in the PR during operations has been increasingly reported.This problem is being more and more to be followed with inˉterest by surgeons ofhepatobiliary surgery.It is reported that fourteen patients had been treated from1992to2003.
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1 Patients and methods
There were fourteen patients(11men and3wowen;mean age，46.9years;age range，7to68years)with VE in the PR during operations.Ten patients were our hospitaland four patients treated by the authors on operating consultation in outer hospital，which the causes were manifold and the therapies or prognosis were differˉent(see table1).
2 Results
The group were malignant tumor(n=7;50.0%) and benign pathologic change(n=7;50.0%)，There were iatrogenic vascular emergencies(IVE)(n=12;85.7%)and traumatic vascular emergencies(TVE)(n=2;14.3%).VE were in the first PR(n=8;57.1%)，the second TP(n=2;14.3%)and the third PR(n=4，28.6%).There were phleborrhesis were(n=8;57.1%)，arteriorrhesis(n=2;14.3%)，acute emˉbolism of hepatic artery(AEHA)(n=1;7.1%)，acute embolism of portal vein(AEPV)(n=1;7.1%)，rupture ofⅦsegment of liver and right hepatic vein(n=1;7.1%)，irregularity hepatectomy for right three lobes and hepatectomy for part of caudate lobe tobe ligated right hepatic vein andretainedⅦsegment of liver complicatˉed hypostasis of HV ofⅦsegment(n=1;7.1%).
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The therapeutic methods of VE were venous repair(7or14)and arteriorrhaphy(1of14)，ligation of hepˉatic artery(1of14)，pylic embolectomy(1of14)，suˉtured biliary tract and pylic branch and hemostasis by compression(1of14)，cholecystectomy addition intra-outer-injection-arterially of liver(1of14)，sutureofⅦsegment of liver and right hepatic vein(1of14)，to be retain theⅦsegmentof liver to be ligated right hepˉatic vein(1of14).
Eleven patients(78.6%)who were in the first PR(n=8)and in the second PR(n=2)and in the third PR(n=1)had been cured and three patients(21.4%)that were rupture of retrohepatic inferior vena cave(RRIVC)in the third PR died(see table1).The curaˉtive effect in the postoperation near future is well for eleven patients.
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Table1 Conditions table of fourteen patients with VE in PR during operations略
3 Comments
3.1 VE of the first PR The first PR is the combinaˉtion site of liver，biliary tract and pancreas.It is the imˉportant channel that is modern surgical technics or new therapies in clinic，which morbidity of IVE in the first PR is the highest among the PR.Operations or reoperaˉtions and trauma of the first PR can certainly be associˉated with injury either hepatic artery(HA)or portal vein(PV).Eight patients who were VE in the first PR and causes manifold had been cured.
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3.1.1 VE of HA
3.1.1.1 Rupture of hepatic artery Two patients complicated that one was rupture of hepatic artery(RHA)to be cured by arteriorrhaphy and another one was rupture of right branch of proper hepatic artery to be cured ligation of hepatic artery.Although the method of hepatic dearterialization has been widely used in clinic for treated malignant tumor of liver and remarkably reached curative effect，RHA can be repaired as far as possible during operation when condition is allowed.Afˉter arterial blood flow of liver is blocked and the operaˉtive region exposed，repair of HA can be taken.The blockage time of HA can be appropriately delayed for complexly RHA of uncirrhosis.Huguet et al [1] had put forward blockage that the time of HA can be1h for heat ischemia of uncirrhosis.Selective extrahepatic artery ligˉation to control arterial hemorrhage of liver can be used.Before HA was ligated，HA and PV shall be carefully explored except anatomic variation or pathologic change.Morbidity of anatomic variation of HA is33%～45%.An extensive injury to either right or left HA can be ligˉated，as long as ipsilate
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ral branch of PV is intact.Signifˉicant injury to both HA and PV is a rare，buttechnicallydifficult，management problem，which one of them that PV is as far as possible retained has to been repaired.Failure to repair one of these two structures o
bviously leads to hepatic ischemia，necrosis，hepatic failure.
3.1.1.2 Acute embolism of hepatic artery One paˉtient had been taken transcatheter arterial emblization(TAE)for cavernous hemangioma of liver in outer hosˉpital，which hepatic arteriography found variation of HA that left hepatic artery sent out from HA and right hepatˉic artery from superior mesenteric artery.The patient when was taken cholecystectomy for acute cholecystitis after TAE was found AEHA and left half hepatonecrosis during operation，which the case had been cured through cholecystectomy addition intra-outer-injection-arteˉrially ofliver and combined treatment that was symptom-group of hepatic failure to be absorpted a large numˉber necrosic tissue at the postoperation.When TAE is taken to be treated benign tumor of liver(such as cavˉernous hemangioma)，damage or necrosis of biliary tract can be caused by AEHA.AEHA has been interested by the surgeons in clinic.Huang Xiaoqiang et al [2] had reˉported that9patients had the complications of TAE and put forward that TAE shall be again evaluated，forbade indeterminately to be used TAE and cirrhosic agent for cavernous hemangioma of liver.It had been reported that patients were died of variant HA to be ligatedor emˉbolism agent mistakenly injected [3] .The therapies of AEHA include c
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ombined nonoperative treatment that is symptom-group of hepatic failure to be absorpted a large number necrosic tissue and operative treatments that are cholecystectomy and choledochotomy-drainge or incision and drainage of liver abscess and take comˉbined treatment at the postoperation.If liver function is continuingdeterioration，portal vein-arterizated can be taken to increasingly provid blood oxygen content proˉceed to improve liver function [4] .
, http://www.100md.com 3.1.2 VE of PV
3.1.2.1 Rupture of portal vein Four patients comˉplicated rupture of portalvein(RPV)that two were RPV and one was rupture of pylic branch(RPB)and anˉother one was suicidal canalization wound of PV and splenic vein(SV)，Which two were repair of PV and one was suture wall of common bile duct and pylic branchand hemostasis by compression and another one had been cured by repair anteriorand posterior wall of PV and SV to be used continuous intensification vein suˉture [5] (see table2).When one patient with hepatocirˉrhosis complicated protal hypertention occurred hemorˉrhagic shock during transjugular intrahepaticportosys-temic stent shunt(TIPSS)，the region of RPVwas found1cm on right anterior wall that was at diatance from the first PR3cm during exploratory laparotomy and repair of PV.Two patients with acute pyogenic obstructive cholanˉgitis complicated RPV and RPB during chledochotomy with reexploration，which one had been cured by repair of PV and another one with hepatocirrhosis and portal hyperte
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ntion complicated RPB that wall of common bile duct and pylic branch were simultaneously incised durˉing chledochotomy with exploration，occurred hematorˉrheato be difficultly controlled and the patient had been cured to be accurately taken drainage of“T”vessel and sture wall of common bile duct and pylic branch and hemostasis by compression.If hematorrhea difficultly is controlled，patients’safety can be directly threatened and losed to savable opportunity.Because exposure of injured region of PV is difficult，the treatment is more difficult than HA.When progressive stage of hepatocirˉrhosis，PV can occur pathologic change that diameter is thick，wall meagre，pressure higher and is formed variantpylic branches in the first PR to be named spongioid change of PV [12，13]，which abnormal outflowtract of liver blood is made of vascular net of pachyn
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tic hepatic capˉsule，gallbladder bed and hepatic bed.When the metal conductingwire get out liver during TIPSS and incise wall of common bile duct and pylic branch during chleˉdochotomy with exploration，RPV or RPB can occur and hematorrhea shall be difficultly controlled.Generally speaking，therapeutic methods of RPV include pylic reˉpair in situ，end-to-end anastomosis，venous graft，arˉtificial vascular graft，portacaval shunt，bridge shunt suˉperior mesenteric vein(SMV)to inferior vena cava.It is the more difficult when RPV in posterior pancreas is treated.Only by fully to be exposured PV or as with proximal injury to SMV，the neck of pancreas can be even amputated when circumstance is critical.A signifiˉcant RPV，ligation of PV is the preferred therapy that is as far as possible near the first PR and vast majority paˉtients can be tolerated to the condition.If patient has the symptoms of enteric stasis of blood at the postoperation，exploratory laparotomy shall be performed in24h，which pylic end-to-end anastomosis or portacaval shunt and partial resection of small intestine shall be performed when ischemic change or necrosis intestine occurred [7] .Patient with hepatocirrhosis to complicate acute cholanˉgitis shall be takenpapillosphincterotomy through fiberˉduodenoscope in early stage，againcholedochostomy with“T”tube drainage.If RPB occurred during choledochosˉtomy with“T”tube drainage，sutured biliary tract and pylic branch with hemostasis by compression shall be accurately taken.Hematorrhea can not controlled，local angiopressure hemostasis to be used long gauze tamponˉade out drainge body or temporary closed abdomen cavity can be taken，of when it can be carefully got out from abdomen cavity at the postoperation [14] .
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Table2 Survival condition to be treated of RPV略
3.1.2.2 Acute embolism of portal vein One patient complicated AEPV to be involved SMV during pancreato-duodenectomy and secondary portal enteric congestionand shock was occurred，which portoembolectomy had been performed that embolus was3cm×0.5cm and pancreato-duodenectomy had been successfully taken and quantityof blood transfusion was5000ml on operatˉing.AEPV that can be occurred during pancreato-duoˉdenectomy or exfoliation of portal vein tumor embolus(PVTE)is seldom seen in clinic.It is the cause that veˉnous tunica is injured to lead phlebostenosis，to be slow rate of venous return flow or exfoliation of PVTE when venous branches in head region of pancreatic is managed during operation.Simultaneously to be supplied blood volume and corrected shock，portoembolectomy shall besimultaneously perfomed，which embolus were explored and phleboembolism bipolarity blocked.Before portoemˉbolectomy，phleboembolism shall be acted of avoidingto be crushed and prevented partly scaling.When suture of PV is taken，structure of PV or causes of AEPV shall be removed at the same time.After portal circula
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tion has recovered，entric sanguimotor variation is carefully obˉserved.If the patient should not have hemorrhagic tenˉdency，the patient who portoembolectomy had been perˉformed at2d or3d the postoperation should be used the drugs that have the function of redution of blood viscosiˉty，angiectasis，prevention angiospasm and anticoagulaˉtion as hemostat drugs.
3.2 VE of the second PR Two patients complicated VE of the second PR.One patient who was hepatorrhexis ofⅦsegment and rupture of right hepatic vein due to blunt trauma had been cured by hepatorrhaphy ofⅦsegment and ligation of right hepatic vein to be conˉtrolled interflow and outflow of liver through thoracic cavity.One patient who was taken irregularity hepatectoˉmy for right three lobes and hepatectomy for part of cauˉdate lobe to be retainedⅦsegment of liver complicated hypostasis of hepatic vein(HV)ofⅦsegment，which the patient had been cured and was taken chemotherapy to be embedded of drug delivery system in HA at the postoperation.The second PR is situated in the thoraco-abdominal combination site that HV is large vein near heart，which common emergencies of HV is rupture hematorrhes or aeremia(air embolism).The morbidity of TVE complicated hepatic injury in the second PR is the highest among PR，the area is difficult to surgically exˉpose and repair for HV.Hemostasis-therapies include repair or ligation of HV.Liu AZ，et al [15] had reported that fifteen among twenty patients who were hepatic inˉjuries with rupture of HV in the second PR had been cured.If repair or ligation of HV can not be taken during operation，local angiopression hemostasis or t
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emporary closed abdomen cavity shall be taken，which secondary operation shall be performed in the near future.If hemaˉtorrhea can not be actively controlled，patients′life shall be hazarded in a short time.Only by simultaneously obˉstructing interflow and outflow of hepatic blood can be controlled hematorrhea.Outflow of hepatic blood can need to be obstructed through thoracic cavity at the same time.It is the important problem that the hepatic segˉment draining blood of HV can be involved after branch of HV is ligated.General speaking，normal hepatictissue can not be tolerated obostructed for blood of HV and corresponding segmentectomy of liver shall be perˉformed.Experiment evidenced in recent years，venous collateral circulation of liver can be constructed at the space of hepatic lobes and PV shall have been done blood vessel of shunt that is increased irregularly after branch of HV is ligated on the condition，which blood of HA gets intohepatic sinus and blood circulation of liver can be executed to pass from branc
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hes of PV to hepatic lobes that the organism of patient can be tolerated to thischange and recovered in a short time [16～18] .
3.3 VE of the third PR Four patients complicated VE of the third PR.One patient that was performed hepˉatectomy for caudate lobe complicated RRIVC that therupture region was1.0cm had been cured by repair of retrohepatic inferior vena cava(RIVC)，which repair method of RRIVC was continuous intensification vein suˉture to be preventively taken a Satinsky’s clamp on anˉterior wall of RIVC.Three patients were died of RRIVC.VE of the third PR is RRIVC or rupture of hepatic short vein(RHSV)，which RRIVC can be occurred when RHSV was unappropriatelymanaged by hemostasis durˉing right hepatectomy or caudate lobectomy of liver [19] .The treatment of RRIVC is the most difficult problem of hepatic surgery among VE of PR [20] and the case-fatalˉity rate is33.3%～75.0% [21] (see table3).Before right hepatectomy or caudate lobectomy of liver is perˉformed，operative difficulty and occurrence possibility of RRIVC or RHSV shall be evaluated and relative prepaˉration taken by us.To be managed hepatic short vein(HSV)during operations，HSV and hepatic tissue shall be together holded and ligated.ASatinsky’s clamp shall be preventively taken on anterior wall of inferior vena
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cava，which the method can prevent both RRIVC and diˉrectly repair it injured.
When RRIVC or RHSV had ocˉcurred，therapeutic methods include intra-abdominal technique of vascular isolation of liver that is total hepˉatic vascular exclusion or selective hepatic vascular exˉclusion [24] .Liver can be completely isolated from circuˉlation by cross-damping the first PR and below liver，which the injurious region andclassification shall be deˉtermined to be taken [25] .The region of RRIVC or RHSV can be repaired to be used Satinsky’s clamp or forcep of varscular tissue.If hemostasis or repair can not be takˉen，vein-vein shunt or atriocaval shunt that is introˉ duced through atriumabove with occluding tourniquets being applied around inferior vena cava above and bolow liver，which is probably still the most commonly emˉployed technique f
, 百拇医药
or diversion of blood away from RRIVC.If hemostasis has not yet done，local angiopresˉsion hemostasis or temporary closed abdomen cavity can be taken，of when p
ositive antishock and secondary manˉagement shall be taken in the near future of postoperaˉtion.
Table3 Treatment results of RRIVC略
4 Conclusions
Because of anatomic and pathologic characters of the PR，blood vessel in PRis large and complex and the region is involved operations or therapies and trauma in the epigastrium region.The morbidity of IVE in the first PR is the highest among PR，the morbidity of TVE comˉplicated hepatic injury in the second PR is the highest and the treatment of RRIVC in the third PR is the most difficult problem of VE of PR among hepatic surgery.This manuscript put forward the views about thetheraˉpeutic main points to the VE in PR during operations:
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The repair method of phleborrhesis is continuous intensification vein suture.
The patient when was taken cholecystectomy for aˉcute cholecystitis after TAE wasfound AEHA and left half hepatonecrosis during operation，which the case had been cured through cholecystectomyadditionintra-outˉer-injection-arterially of liver and combined treatment that was symptom-group of hepatic failure to be abˉsorpted a large number necrosic tissue of liver at the postoperation.We suggest thatTAE shall be again evaluˉated and forbade indiscriminately to use TAEand cirrhoˉsis agent for cavernous hemangioma of liver.
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The patient with suicidal canalization wound of PV and SV had been cured by repair anterior and posterior wall of PV and SV to be used continuous intensification vein suture.
When patient with hepatocirrhosis and portal hyˉpertention complicated severe cholangitis was taken reˉ operation of exploration biliary tract and occurred RPB that wall of common bile duct and pylic branch were siˉmultaneously incised during chledochotomy with exploˉration，we shall be accurately taken drainage of“T”vesˉsel and sutre wall of common bile duct and pylic branch and hemostasis by compression.
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Significant injury to both HA and PV is a rare，but technically difficult，management problem，which one of them that PV is as far as possible retained has to been repaired.
Patient complicated AEPV to be involved SMV during pancreato-duodenectomy and secondary portal enteric congestion and shock was occurred，Which porˉtoembolectomy had been performed that embolus was3cm×0.5cm and pancreato-duodenectomy had been successfully taken and quantity of blood transfusion was5000ml on operating.If the patient should not have hemorrhagic tendency，the patient who portoembolectomy had been performed at2d or3d the postoperation should be used the drugs that have the function of reduction of blood viscosity，angiectasis，prevention angiospasm and anticoagulation as hemostat drugs.
, 百拇医药
Patient who had been taken irregularity hepatectoˉmy for right three lobes and hepatectomy for part of cauˉdate lobe to be retainedⅦsegment of liver complicated hypostasis of HV ofⅦsegment，which the patient had been cured and was taken chemotherapy to be embedded of drug delivery system in HA at the postoperation.
Patient that was performed hepatectomy for caudate lobe complicated RRIVC that the rupture region was1.0cm had been cured by repair of RIVC，which repair method of RRIVC was continuous intensification vein suˉture to be preventively taken a Satinsky’sclamp on anˉterior wall of RIVC.
, 百拇医药
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, 百拇医药
19 邢雪，李洪，刘卫国，等.主肝静脉切除后保留引流肝段的临床应用.中华肝胆外科杂志，2003，9(11):694-696.
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作者单位:1201103上海武警上海总队医院普通外科
2046000山西长治解放军51272部队医院外科
(收稿日期:2004-02-13)
(编辑 李阳), 百拇医药