Successful treatment of postoperative acute hepatic artery obstruction with mesenteric arterioportal shunt

Fatal biliary complications and liver abscesses are likely in cases of acute hepatic arterial occlusion after hepatobiliary surgery with bilioenteric anastomosis. A 60-year-old man with hilar hepatic metastasis of gastric cancer underwent curative surgery. While the recurrent nodule was removed with the involved bile duct, vascular structures were preserved. Massive bleeding from the hepatic artery occurred suddenly on postoperative day 3, and the hepatic artery was ligated to stop bleeding. As Doppler ultrasonography indicated no arterial flow in the liver, a side-to-side mesenteric arterioportal shunt was created to prevent ischemic complications. Postoperative angiography showed fine patency of the shunt, and ischemic complications were avoided. However, the patient suddenly experienced massive hematemesis and fell into shock four months after the shunt operation. Upper gastrointestinal fiberoscopy showed serious varices throughout the whole esophagus. Angiographic examination indicated excessive shunt flow and markedly expanded mesenteric veins. The shunt was then occluded by coil embolization, but the patient did not recover from shock and eventually died. In the present case, the mesenteric arterioportal shunt appeared to be effective in relieving postoperative acute hepatic arterial occlusion. However, the shunt should be closed as soon as collateral blood flow is completed.