Post-Operative Hepatic Necrosis due to Reduction in Hepatic Arterial Blood Flow during Surgery for Chronic Biliary Obstruction

Three patients with malignant biliary obstruction, who developed postoperative hepatic necrosis due to compromise of the hepatic arterial blood flow, are reported. Two patients had major hepatic necrosis following ligation of the common hepatic or right hepatic artery during resection of a hilar cholangiocarcinoma. The 3rd patient suffered temporary ischemia of the liver during total pancreatectomy and developed a necrotic abscess on the left lobe with subsequent atrophy of the left liver. One patient died on the 12th postoperative day. Of the 2 survivors, 1 required extensive right hepatectomy on the 4th postoperative day, while the other had percutaneous drainage of a liver abscess 30 days after surgery. The presenting features of this dangerous complication are described, and the pathogenic mechanisms which render the cholestatic liver particularly prone to ischemic necrosis are discussed. Caution is recommended when hepatic artery ligation is being considered during the course of a difficult operation for biliary obstruction.