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Inferior vena caval thrombosis complicating pyogenic liver abscess after pancreatoduodenectomy: a case report.

Kubo H, Taniguchi F, Shimomura K, Nanishi K, Ueshima Y, Takahashi A, Shioaki Y, Otsuji E - Surg Case Rep (2015)

Bottom Line: PLA and septic shock were diagnosed, and conservative therapy with antibiotics was initiated.The patient was discharged 10 weeks after surgery.Our experience suggests that physicians should consider the existence of a middle hepatic vein and IVC thrombi when examining PLA patients and that surgical intervention can be applied successfully in such cases.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, 15-749, Hommachi, Higashiyama-ku, Kyoto-shi, Kyoto, Japan ; Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachihirokoji, Kamigyo-ku, Kyoto-shi, Kyoto, Japan.

ABSTRACT

Pyogenic liver abscess (PLA) complicated by inferior vena caval (IVC) thrombosis is rare but life-threatening. We experienced a case of PLA complicated by an IVC thrombus close to the right atrium after pancreatoduodenectomy. A 75-year-old man had undergone pancreatoduodenectomy with modified-Child reconstruction for pancreatic cancer 3 years prior, and no recurrence was noted on follow-up. He was admitted to our hospital owing to fever and general fatigue. PLA and septic shock were diagnosed, and conservative therapy with antibiotics was initiated. His general condition gradually improved, but a thrombus in the middle hepatic vein and IVC was noted on follow-up computed tomography on hospital day 8. Although anticoagulant therapy using heparin was started, the thrombus size increase and extended to the right atrium. Considering the risk of pulmonary embolism, we planned a surgical intervention with a cardiovascular surgeon to remove the thrombus. During surgery, we made an incision in the right atrium and removed the thrombus using extracorporeal circulation. After removal, we dissected the middle hepatic vein using an automated suturing device to prevent the thrombus from extending into the IVC. The patient was discharged 10 weeks after surgery. Eighteen months post-intervention, there was no recurrence of either PLA or thrombi. Our experience suggests that physicians should consider the existence of a middle hepatic vein and IVC thrombi when examining PLA patients and that surgical intervention can be applied successfully in such cases.

No MeSH data available.


Related in: MedlinePlus

a The thrombus removed from the inferior vena cava was yellow. b We dissected the middle hepatic vein using an automated suturing device to prevent the thrombus from extending into the inferior vena cava (arrows)
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Fig4: a The thrombus removed from the inferior vena cava was yellow. b We dissected the middle hepatic vein using an automated suturing device to prevent the thrombus from extending into the inferior vena cava (arrows)

Mentions: The patient underwent a thrombectomy using extracorporeal circulation. We made an incision in the right atrium and removed the thrombus through the orifice of the middle hepatic vein. The thrombus was yellow (Fig. 4a), and pathological observation showed that it consisted of fibrous material including many neutrophils and macrophages. Accordingly, we made a diagnosis of septic thrombosis. Intraoperative trans-esophageal echocardiography showed a thrombus in the right pulmonary artery. A preoperative CT scan showed no thrombus in the right pulmonary artery; therefore, we believed that the embolism might have occurred since the preoperative CT scan was performed. We made an incision in the artery and attempted to remove it using a Fogarty catheter. We then noted extensive bleeding from the right bronchus. We diagnosed a fistula of the right pulmonary artery and bronchus caused by catheter handling. To control the bleeding, the patient underwent a right lower lobectomy. We did not identify the pulmonary thrombus. Subsequently, we transferred the operating field to the abdomen. We dissected the middle hepatic vein using an automated suturing device to prevent the thrombus from extending into the IVC (Fig. 4b). The operation took 14 h and 5 min, while the total blood loss was 11,920 g.Fig. 4


Inferior vena caval thrombosis complicating pyogenic liver abscess after pancreatoduodenectomy: a case report.

Kubo H, Taniguchi F, Shimomura K, Nanishi K, Ueshima Y, Takahashi A, Shioaki Y, Otsuji E - Surg Case Rep (2015)

a The thrombus removed from the inferior vena cava was yellow. b We dissected the middle hepatic vein using an automated suturing device to prevent the thrombus from extending into the inferior vena cava (arrows)
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4562987&req=5

Fig4: a The thrombus removed from the inferior vena cava was yellow. b We dissected the middle hepatic vein using an automated suturing device to prevent the thrombus from extending into the inferior vena cava (arrows)
Mentions: The patient underwent a thrombectomy using extracorporeal circulation. We made an incision in the right atrium and removed the thrombus through the orifice of the middle hepatic vein. The thrombus was yellow (Fig. 4a), and pathological observation showed that it consisted of fibrous material including many neutrophils and macrophages. Accordingly, we made a diagnosis of septic thrombosis. Intraoperative trans-esophageal echocardiography showed a thrombus in the right pulmonary artery. A preoperative CT scan showed no thrombus in the right pulmonary artery; therefore, we believed that the embolism might have occurred since the preoperative CT scan was performed. We made an incision in the artery and attempted to remove it using a Fogarty catheter. We then noted extensive bleeding from the right bronchus. We diagnosed a fistula of the right pulmonary artery and bronchus caused by catheter handling. To control the bleeding, the patient underwent a right lower lobectomy. We did not identify the pulmonary thrombus. Subsequently, we transferred the operating field to the abdomen. We dissected the middle hepatic vein using an automated suturing device to prevent the thrombus from extending into the IVC (Fig. 4b). The operation took 14 h and 5 min, while the total blood loss was 11,920 g.Fig. 4

Bottom Line: PLA and septic shock were diagnosed, and conservative therapy with antibiotics was initiated.The patient was discharged 10 weeks after surgery.Our experience suggests that physicians should consider the existence of a middle hepatic vein and IVC thrombi when examining PLA patients and that surgical intervention can be applied successfully in such cases.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Japanese Red Cross Kyoto Daiichi Hospital, 15-749, Hommachi, Higashiyama-ku, Kyoto-shi, Kyoto, Japan ; Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachihirokoji, Kamigyo-ku, Kyoto-shi, Kyoto, Japan.

ABSTRACT

Pyogenic liver abscess (PLA) complicated by inferior vena caval (IVC) thrombosis is rare but life-threatening. We experienced a case of PLA complicated by an IVC thrombus close to the right atrium after pancreatoduodenectomy. A 75-year-old man had undergone pancreatoduodenectomy with modified-Child reconstruction for pancreatic cancer 3 years prior, and no recurrence was noted on follow-up. He was admitted to our hospital owing to fever and general fatigue. PLA and septic shock were diagnosed, and conservative therapy with antibiotics was initiated. His general condition gradually improved, but a thrombus in the middle hepatic vein and IVC was noted on follow-up computed tomography on hospital day 8. Although anticoagulant therapy using heparin was started, the thrombus size increase and extended to the right atrium. Considering the risk of pulmonary embolism, we planned a surgical intervention with a cardiovascular surgeon to remove the thrombus. During surgery, we made an incision in the right atrium and removed the thrombus using extracorporeal circulation. After removal, we dissected the middle hepatic vein using an automated suturing device to prevent the thrombus from extending into the IVC. The patient was discharged 10 weeks after surgery. Eighteen months post-intervention, there was no recurrence of either PLA or thrombi. Our experience suggests that physicians should consider the existence of a middle hepatic vein and IVC thrombi when examining PLA patients and that surgical intervention can be applied successfully in such cases.

No MeSH data available.


Related in: MedlinePlus