Case Report: Preoperative treatment of portal hypertension by splenic artery embolization for safe major hepatectomy: experience in three patients

Post-resection portal pressure is one of the most important determinants of post-hepatectomy liver failure. Therefore, preexisting portal hypertension is a significant risk factor for PHLF. Preoperative splenic artery embolization (SAE) was used to alleviate portal hypertension before right-sided hepatectomy in three non-cirrhotic female patients with colorectal liver metastases (45), perihilar cholangiocarcinoma (55), and intrahepatic cholangiocarcinoma (69). Two had received chemotherapy and one had undergone radiotherapy, transarterial radioembolization as well. All had thrombocytopenia (79 × 10 3 /µL, 51 × 10 3 /µL, 58 × 10 3 /µL respectively), two patients had splenomegaly and one had esophageal varices. Partial SAE was performed in two cases (upper pole preserved) and total SAE in one with coils and plug. This resulted in normalization of platelet counts within two weeks (419 × 10 3 /µL, 340 × 10 3 /µL, 159 × 10 3 /µL respectively) and regression of varices. The calculated future remnant liver volumes were 47%, 63% and 62% respectively. All subsequently underwent surgery: extended right hepatectomy including the middle hepatic vein (H5678-MHV), right hepatectomy-total caudate lobectomy-Roux-Y cholangiojejunostomy (H15678-B) and right hepatectomy (H5678). The perihilar cholangiocarcinoma patient developed grade B post-hepatectomy liver failure and recovered with supportive treatment. All patients were discharged. One patient died of recurrent disease at 17 months, whereas the remaining two are disease-free at 21 and 36 months. SAE should be considered for portal flow modulation in major hepatectomy candidates with portal hypertension.