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How to manage splenic rupture during major liver resection?
© 2006. Elsevier Masson SAS. Tous droits réservés
CASE REPORT
Gastroenterol Clin Biol 2006;30:1311-1312
How to manage splenic rupture during major liver resection?
Mehdi OUAÏSSI (1), Stéphane BENOIST (1, 2), Christophe PENNA (1, 2), Bernard NORDLINGER (1, 2) (1) Assistance-Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Department of Surgery Boulogne ; (2) Université Versailles Saint Quentin en Yvelines, Versailles.
SUMMARY
RÉSUMÉ
Spontaneous splenic rupture is a rare but life threatening complication of major liver resection with only five reported cases during major liver resection under hepatic vascular occlusion. We report two cases of splenic rupture during liver resection including the first case during portal triad clamping. In both patients, the hemorrhage was stopped by removing the vascular clamp. A splenectomy was performed in both patients and liver resection was completed under vascular clamping without complications. Although very rare, physicians should be aware of the possibility of splenic rupture during liver resection because instead of increasing vascular occlusion, clamp removal usually stops the hemorrhage.
Comment faut-il traiter une rupture spontanée de la rate au cours d’une hépatectomie majeure ? Mehdi OUAÏSSI, Stéphane BENOIST, Christophe PENNA, Bernard NORDLINGER (Gastroenterol Clin Biol 2006;30:1311-1312)
Une rupture spontanée de la rate au cours d’une hépatectomie majeure est une complication rare pouvant mettre en jeu le pronostic vital. Actuellement, seulement cinq cas ont été rapportés, tous au cours d’une hépatectomie majeure réalisée sous exclusion vasculaire du foie. Nous rapportons deux cas de rupture splénique spontanée au cours d’une hépatectomie dont l’un constitue le premier cas de rupture de rate au cours d’une hépatectomie réalisée sous un simple clampage du pédicule hépatique. Dans les deux cas l’hémorragie per-opératoire massive a été arrêtée par le retrait des clamps vasculaires. Dans les deux cas, il a été réalisé une splénectomie et l’hépatectomie a pu ensuite être réalisé sous clampage vasculaire comme prévue initialement. La rupture de la rate au cours d’une hépatectomie majeure réalisée sous clampage vasculaire est une complication grave qui doit être connue car sa prise en charge peroperatoire repose non pas sur la mise en place de clamps vasculaires mais plutôt sur le retrait de ceux utilisés pour la réalisation de l’hépatectomie.
2000 ml and the central venous pressure was 8 mm Hg just before the intra-abdominal hemorrhage. The first hypothesis was injury to the vena cava or hepatic veins by the vascular clamps but no vascular injury was found. There was no injury to the right adrenal vein, which had been ligatured and divided before the vascular clamps were applied. There was no hemorrhage from the cut surface of the liver. Exploration of the peritoneal cavity revealed several lacerations of the splenic capsule with intense bleeding. Hemorrhage was stopped by removing the vascular clamps resulting in a rapid decrease in splenic vein pressure. A splenectomy was performed and the liver resection was performed under hepatic vascular exclusion with no further hemodynamic difficulties. Overall, six units of pack red cells were administered intraoperatively. The postoperative course was uneventful. Pathological examination of the spleen revealed congestion but no another abnormalities and the non malignant liver parenchyma was normal.
Introduction Splenic rupture is a rare but life threatening complication of major liver resection that must be recognized and managed properly to avoid massive hemorrhage. Only five cases of splenic rupture during liver resection have been reported [1-3]. In all theses cases, splenic rupture occurred during liver resection under hepatic vascular exclusion. There are no reported cases with only portal triad clamping [1-3]. We report two cases of splenic rupture during major liver resection including the first case of splenic rupture during portal triad clamping.
Case reports
Patient 2 A 67-year-old man without any underlying liver disease was operated for a 10 cm diameter hepatocellular carcinoma located in the right lobe of the liver. A right hepatectomy (segments V, VI, VII, VIII) was planned. At surgery, the non malignant liver was normal and there was no evidence of portal hypertension. Ten minutes after liver transsection began under portal triad clamping, a sudden and massive intra-abdominal hemorrhage occurred. The overall intraoperative fluid balance was 1500 ml, the central venous pressure was 6 mm Hg and the mean arterial pressure was 102 mmHg just before the intra-abdominal hemorrhage. The absence of portal vein injury by vascular clamp was checked. There was no hemorrhage from the cut surface of the liver and no injury of the retrohepatic vena cava was found. Finally, exploration of the peritoneal cavity revealed a ruptured spleen with several lacerations of the splenic capsule. The hemorrhage was stopped by removal of the vascular clamp. A splenectomy was performed and the liver resection was completed under portal triad clamping with no complications. Four units of
Patient 1 A 72-year-old man was operated on for metachronous colorectal liver metastasis. Intraoperative ultrasonography showed three liver lesions in the right lobe with one lesion close to the cavo-hepatic junction. A right hepatectomy under hepatic vascular exclusion was planned. Five minutes after liver transsection, there was a rapid drop in mean arterial pressure from 93 to 45 mm Hg and a sudden and severe intra-abdominal hemorrhage occurred. The overall intraoperative fluid balance was Reprints: B. NORDLINGER, Service de Chirurgie Générale et Digestive, Hôpital Ambroise Paré, 9, Avenue Charles de Gaulle, 92104 Boulogne Cedex. E-mail : [email protected]
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M. Ouaïssi et al.
finishing the major liver resection and exposes the patient to a high risk of further postoperative bleeding. To our knowledge, this is the first case of splenic rupture during portal triad clamping. After portal triad clamping, there is a moderate increase in portal venous pressure and most of the portal blood flow is redirected to the left gastric vein and the short gastric vein via the splenic vein and the spleen [4]. In our second non-cirrhotic patient, these portosystemic collateral channels were probably insufficiently developed and after portal triad clamping, the retrograde blood flow in the splenic vein may have caused severe congestion of the spleen elevating intrasplenic pressure and causing rupture of the splenic capsule. This hemodynamic hypothesis is supported by the fact that acute hemorrhage was stopped by removing thel of vascular clamps.
pack red cells were administered intraoperatively. The patient experienced postoperative left pleural effusion requiring drainage. Pathological examination confirmed a complete resection of the hepatocellular carcinoma on a non cirrhotic liver. The spleen was congested with no other abnormalities.
Discussion Massive bleeding during liver transsection can be life threatening if the cause is not rapidly recognized and treated. The most common etiology of massive bleeding is injury to the hepatic vessels in the cut surface of the liver. Massive bleeding can also be related to injury to the major hepatic vessels injury such as the portal vein, the hepatic veins or the inferior vena cava. In these situations, the control of acute hemorrhage is achieved by applying or replacing the vascular clamp to control and stitch the injured vessel. In contrast, in case of splenic rupture, the vascular clamps must be removed, resulting in a rapid decrease of intrasplenic pressure to control massive bleeding. This is simpler and more effective than supra-celiac aortic and splenic artery clamping. For these reasons, although it is very rare, the possibility of splenic rupture should be known because instead of increasing vascular occlusion, removing the clamps usually stops the hemorrhage. As previously reported [1-3], we performed a splenectomy after stopping the hemorrhage by removing the vascular clamp. Conservative management such as splenopexy is not recommended because it prevents the use of vascular occlusion while
REFERENCES
1. Baniel J, Bihrle R, Wahle GR, Foster RS. Splenic rupture during occlusion of the porta hepatis in resection of tumors with vena caval extension. J Urol 1994;151:992-4.
2. Douzdjian V, Broughan A. Spontaneous splenic rupture during total vascular occlusion of the liver. Br J Surg 1995;82:406-7.
3. Belghiti J, Noun R, Zante E, Ballet T, Sauvanet A. Portal triad clamping or hepatic vascular exclusion for major liver resection. A controlled study. Ann Surg 1996;224:155-61.
4. De Cosmo AG, Adducci E, Gualtieri E. Haemodynamic and metabolic changes during major liver resection with use of hepatic total vascular exclusion. Int Surg 2000;85:243-7.
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CASE REPORT
Gastroenterol Clin Biol 2006;30:1311-1312
How to manage splenic rupture during major liver resection?
Mehdi OUAÏSSI (1), Stéphane BENOIST (1, 2), Christophe PENNA (1, 2), Bernard NORDLINGER (1, 2) (1) Assistance-Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Department of Surgery Boulogne ; (2) Université Versailles Saint Quentin en Yvelines, Versailles.
SUMMARY
RÉSUMÉ
Spontaneous splenic rupture is a rare but life threatening complication of major liver resection with only five reported cases during major liver resection under hepatic vascular occlusion. We report two cases of splenic rupture during liver resection including the first case during portal triad clamping. In both patients, the hemorrhage was stopped by removing the vascular clamp. A splenectomy was performed in both patients and liver resection was completed under vascular clamping without complications. Although very rare, physicians should be aware of the possibility of splenic rupture during liver resection because instead of increasing vascular occlusion, clamp removal usually stops the hemorrhage.
Comment faut-il traiter une rupture spontanée de la rate au cours d’une hépatectomie majeure ? Mehdi OUAÏSSI, Stéphane BENOIST, Christophe PENNA, Bernard NORDLINGER (Gastroenterol Clin Biol 2006;30:1311-1312)
Une rupture spontanée de la rate au cours d’une hépatectomie majeure est une complication rare pouvant mettre en jeu le pronostic vital. Actuellement, seulement cinq cas ont été rapportés, tous au cours d’une hépatectomie majeure réalisée sous exclusion vasculaire du foie. Nous rapportons deux cas de rupture splénique spontanée au cours d’une hépatectomie dont l’un constitue le premier cas de rupture de rate au cours d’une hépatectomie réalisée sous un simple clampage du pédicule hépatique. Dans les deux cas l’hémorragie per-opératoire massive a été arrêtée par le retrait des clamps vasculaires. Dans les deux cas, il a été réalisé une splénectomie et l’hépatectomie a pu ensuite être réalisé sous clampage vasculaire comme prévue initialement. La rupture de la rate au cours d’une hépatectomie majeure réalisée sous clampage vasculaire est une complication grave qui doit être connue car sa prise en charge peroperatoire repose non pas sur la mise en place de clamps vasculaires mais plutôt sur le retrait de ceux utilisés pour la réalisation de l’hépatectomie.
2000 ml and the central venous pressure was 8 mm Hg just before the intra-abdominal hemorrhage. The first hypothesis was injury to the vena cava or hepatic veins by the vascular clamps but no vascular injury was found. There was no injury to the right adrenal vein, which had been ligatured and divided before the vascular clamps were applied. There was no hemorrhage from the cut surface of the liver. Exploration of the peritoneal cavity revealed several lacerations of the splenic capsule with intense bleeding. Hemorrhage was stopped by removing the vascular clamps resulting in a rapid decrease in splenic vein pressure. A splenectomy was performed and the liver resection was performed under hepatic vascular exclusion with no further hemodynamic difficulties. Overall, six units of pack red cells were administered intraoperatively. The postoperative course was uneventful. Pathological examination of the spleen revealed congestion but no another abnormalities and the non malignant liver parenchyma was normal.
Introduction Splenic rupture is a rare but life threatening complication of major liver resection that must be recognized and managed properly to avoid massive hemorrhage. Only five cases of splenic rupture during liver resection have been reported [1-3]. In all theses cases, splenic rupture occurred during liver resection under hepatic vascular exclusion. There are no reported cases with only portal triad clamping [1-3]. We report two cases of splenic rupture during major liver resection including the first case of splenic rupture during portal triad clamping.
Case reports
Patient 2 A 67-year-old man without any underlying liver disease was operated for a 10 cm diameter hepatocellular carcinoma located in the right lobe of the liver. A right hepatectomy (segments V, VI, VII, VIII) was planned. At surgery, the non malignant liver was normal and there was no evidence of portal hypertension. Ten minutes after liver transsection began under portal triad clamping, a sudden and massive intra-abdominal hemorrhage occurred. The overall intraoperative fluid balance was 1500 ml, the central venous pressure was 6 mm Hg and the mean arterial pressure was 102 mmHg just before the intra-abdominal hemorrhage. The absence of portal vein injury by vascular clamp was checked. There was no hemorrhage from the cut surface of the liver and no injury of the retrohepatic vena cava was found. Finally, exploration of the peritoneal cavity revealed a ruptured spleen with several lacerations of the splenic capsule. The hemorrhage was stopped by removal of the vascular clamp. A splenectomy was performed and the liver resection was completed under portal triad clamping with no complications. Four units of
Patient 1 A 72-year-old man was operated on for metachronous colorectal liver metastasis. Intraoperative ultrasonography showed three liver lesions in the right lobe with one lesion close to the cavo-hepatic junction. A right hepatectomy under hepatic vascular exclusion was planned. Five minutes after liver transsection, there was a rapid drop in mean arterial pressure from 93 to 45 mm Hg and a sudden and severe intra-abdominal hemorrhage occurred. The overall intraoperative fluid balance was Reprints: B. NORDLINGER, Service de Chirurgie Générale et Digestive, Hôpital Ambroise Paré, 9, Avenue Charles de Gaulle, 92104 Boulogne Cedex. E-mail : [email protected]
1311
M. Ouaïssi et al.
finishing the major liver resection and exposes the patient to a high risk of further postoperative bleeding. To our knowledge, this is the first case of splenic rupture during portal triad clamping. After portal triad clamping, there is a moderate increase in portal venous pressure and most of the portal blood flow is redirected to the left gastric vein and the short gastric vein via the splenic vein and the spleen [4]. In our second non-cirrhotic patient, these portosystemic collateral channels were probably insufficiently developed and after portal triad clamping, the retrograde blood flow in the splenic vein may have caused severe congestion of the spleen elevating intrasplenic pressure and causing rupture of the splenic capsule. This hemodynamic hypothesis is supported by the fact that acute hemorrhage was stopped by removing thel of vascular clamps.
pack red cells were administered intraoperatively. The patient experienced postoperative left pleural effusion requiring drainage. Pathological examination confirmed a complete resection of the hepatocellular carcinoma on a non cirrhotic liver. The spleen was congested with no other abnormalities.
Discussion Massive bleeding during liver transsection can be life threatening if the cause is not rapidly recognized and treated. The most common etiology of massive bleeding is injury to the hepatic vessels in the cut surface of the liver. Massive bleeding can also be related to injury to the major hepatic vessels injury such as the portal vein, the hepatic veins or the inferior vena cava. In these situations, the control of acute hemorrhage is achieved by applying or replacing the vascular clamp to control and stitch the injured vessel. In contrast, in case of splenic rupture, the vascular clamps must be removed, resulting in a rapid decrease of intrasplenic pressure to control massive bleeding. This is simpler and more effective than supra-celiac aortic and splenic artery clamping. For these reasons, although it is very rare, the possibility of splenic rupture should be known because instead of increasing vascular occlusion, removing the clamps usually stops the hemorrhage. As previously reported [1-3], we performed a splenectomy after stopping the hemorrhage by removing the vascular clamp. Conservative management such as splenopexy is not recommended because it prevents the use of vascular occlusion while
REFERENCES
1. Baniel J, Bihrle R, Wahle GR, Foster RS. Splenic rupture during occlusion of the porta hepatis in resection of tumors with vena caval extension. J Urol 1994;151:992-4.
2. Douzdjian V, Broughan A. Spontaneous splenic rupture during total vascular occlusion of the liver. Br J Surg 1995;82:406-7.
3. Belghiti J, Noun R, Zante E, Ballet T, Sauvanet A. Portal triad clamping or hepatic vascular exclusion for major liver resection. A controlled study. Ann Surg 1996;224:155-61.
4. De Cosmo AG, Adducci E, Gualtieri E. Haemodynamic and metabolic changes during major liver resection with use of hepatic total vascular exclusion. Int Surg 2000;85:243-7.
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