Transjugular Retrograde Obliteration prior to Liver Resection for Hepatocellular Carcinoma Associated with Hyperammonemia due to Spontaneous Portosystemic Shunt
A 67-year-old woman had hepatocellular carcinoma (HCC) measuring 3.7？cm at S8 of the liver with hyperammonemia due to a spontaneous giant mesocaval shunt. Admission laboratory data revealed albumin, 2.9？g/dL; total bilirubin, 1.3？mg/dL; plasma ammonia level (NH3), 152？g/dL; total bile acid (TBA) 108.5？μmoL/L; indocyanine green retention rate at 15？min (ICG15), 63%. Superior mesenteric arterial portography revealed a hepatofugal giant mesocaval shunt, and the portal vein was not visualized. Before surgery, transjugular retrograde obliteration (TJO) for the mesocaval shunt was attempted to normalize the portal blood flow. Via the right internal jugular vein, a 6 F occlusive balloon catheter was inserted superselectively into the mesocaval shunt. The mesocaval shunt was successfully embolized using absolute ethanol and a 50% glucose solution. Eleven days after TJO, NH3, TBA, and ICG15 decreased to 56, 44, and 33, respectively. Superior mesenteric arterial portography after TJO revealed a hepatopetal portal flow. Partial hepatectomy of S8 was performed 25 days after TJO. The subsequent clinical course showed no complications, and the woman was discharged on postoperative day 14. We conclude that the combined therapy of surgery and TJO is an effective means of treating HCC with hyperammonemia due to a spontaneous portosystemic shunt. 1. Introduction Hepatocellular carcinoma (HCC) with hyperammonemia due to a spontaneous portosystemic shunt (PSS) is not common, and the guidelines for such a condition have not been established yet [1]. Liver function is an important factor to determine the treatment strategy for HCC. To lower morbidity after hepatic resection, the Makuuchi criteria, including the presence or absence of ascites, serum total bilirubin level, and the plasma indocyanine green retention rate at 15？min (ICG15), are widely used [2, 3]. However, the existence of PSS often increases the level of ICG15 and the plasma ammonia level (NH3) and reduces the hepatopetal portal blood flow. We previously reported that transjugular retrograde obliteration (TJO) for PSS reduced ICG15 and NH3 [4]. A mesocaval shunt is one of the PSSs. Here, we describe a case of HCC associated with hyperammonemia due to a spontaneous mesocaval shunt treated by the combined therapy of surgery and TJO. 2. Case Report A 67-year-old woman suffered from HCC with hyperammonemia due to a spontaneous giant mesocaval shunt. Six months before that, she had undergone interferon therapy for hepatitis C. However, follow-up CT examination revealed HCC, so she was referred to our department for
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