Portal vein thrombosis associated with right hepatic artery injury during cholecystectomy: an uncommon indication for urgent liver transplantation.

In acute liver failure secondary to iatrogenic lesions caused during cholecystectomy, emergency liver transplantation is a last-resort therapeutic option due to the transcendence of the procedure. We present the case report of a patient with damage to the hepatic artery and portal thrombosis that occurred during open cholecystectomy. The patient is a 61-year-old woman with a medical history of fibromyalgia, dyslipidemia, hypothyroidism, obesity and chronic lumbago due to a herniated disc. In another hospital, she had been diagnosed with acute cholecystitis, based on clinical, analytical and ultrasound criteria. Urgent cholecystectomy was performed by a right subcostal laparotomy, with no intraoperative incident. The patient’s postoperative recovery was slow, with malaise, progressive oliguria, metabolic acidosis and atrial fibrillation that required administration of vasoactive drugs. High transaminase levels (17 800 U/l) and a 37% drop in prothrombin time were also observed. CT angiography showed an ischemic lesion in the right liver lobe (RLL) with thrombosis of the right portal branch but did not identify the filiform right hepatic artery (RHA) and left portal branch. With the diagnosis of severe post-cholecystectomy ischemic hepatitis and multiple organ failure, the decision was made to transfer the patient to our hospital for further treatment. Lab work-up upon admission showed: aspartate aminotransferase 6570 IU/l; alanine aminotransferase 5470 IU/l; gamma-glutamyl transpeptidase 540 IU/l; total bilirubin 3.90 mg/dl; alkaline phosphatase 866 IU/l; platelets 51 10/l; and prothrombin time 42.2%. Doppler ultrasound showed evidence of a heterogeneous liver in the RLL region, complete thrombosis of the left portal branch, partial thrombosis of the right portal branch, and permeable RHA that was small in caliber and had a low pulsating flow. Given these findings, we carried out transparietal-hepatic portography and hepatic arteriography with mechanical thrombectomy of the right and left portal vein and balloon angioplasty on the left portal vein. Arteriography demonstrated occlusion of the RHA adjacent to surgical clips with absence of right hepatogram (Fig. 1a and b). Follow-up ultrasound 6 h after the procedure once again detected thrombosis of the 2 intrahepatic branches of the portal vein and part of the extrahepatic portal vein. Given the situation of hepatic ischemia, transplantation was considered a therapeutic option and code 0 was activated, after having previously ruled out other potential causes of portal thrombosis. Within 48 h of being placed on the list, a compatible donor was offered for liver replacement. During surgery, we confirmed the presence of surgical clips in the RHA, the ischemic appearance of the RLL (Fig. 2a) and presence of a thrombus in the main portal vein (Fig. 2b). The pathology study of the surgical specimen reported the presence of complete bilateral portal thrombosis with extension to smaller intrahepatic branches, thrombosis of the hepatic artery, hepatic ischemic infarction and no evidence of underlying liver disease. During hospitalization, the patient did not present any surgery-related complications and had adequate liver function when discharged.