Mesenteric arterioportal shunt after hepatic artery interruption

Multidisciplinary treatment of left hepatic artery pseudoaneurysm after hepatobiliary resection for gallbladder cancer: a case report

BACKGROUND

When a postoperative hepatic artery pseudoaneurysm develops after massive hepatectomy, both an intervention for the pseudoaneurysm and patency of hepatic artery should be considered because occlusion of the residual hepatic artery results in critical liver failure. However, the treatment strategy for a pseudoaneurysm of the hepatic artery after hepatobiliary resection is not well established.

CASE PRESENTATION

A 65-year-old woman underwent right hepatectomy, extrahepatic duct resection, and portal vein resection, for gallbladder cancer. Although the patient had an uneventful postoperative course, computed tomography on postoperative day 6 showed a 6-mm pseudoaneurysm of the hepatic artery. Angiography revealed the pseudoaneurysm located on the bifurcation of the left hepatic artery to the segment 2 artery plus the segment 3 artery and 4 artery. Stent placement in the left hepatic artery was not feasible because the artery was too narrow, and coiling of the pseudoaneurysm was associated with a risk of occluding the left hepatic artery and inducing critical liver failure. Therefore, portal vein arterialization constructed by anastomosing the ileocecal artery and vein was performed prior to embolization of the pseudoaneurysm to maintain the oxygen level of the remnant liver, even if the left hepatic artery was accidentally occluded. The pseudoaneurysm was selectively embolized without occlusion of the left hepatic artery, and the postoperative laboratory data were within normal limits. Although uncontrollable ascites due to portal hypertension occurred, embolization of the ileocolic shunt rapidly resolved it. The patient was discharged on postoperative day 45.

CONCLUSION

Portal vein arterialization prior to embolization of the aneurysm may be a feasible therapeutic strategy for a pseudoaneurysm that develops after hepatectomy for hepatobiliary malignancy to guarantee arterial inflow to the remnant liver. Early embolization of arterioportal shunting after confirmation of arterial inflow to the liver should be performed to prevent morbidity induced by portal hypertension.

Pancreaticoduodenectomy assisted by 3-D visualization reconstruction and portal vein arterialization: A case report (a CARE-compliant article)

BACKGROUND

Three-dimensional visualization reconstruction, the 3-D visualization model reconstructed by software using 2-D CT images, has been widely applied in medicine; but it has rarely been applied in pancreaticoduodenectomy. Although the hepatic artery is very important for the liver, it has to be removed when tumor invades it. Therefore, portal vein arterialization has been used in clinic as a remedial measure, but there still is professional debate on portal vein arterialization.

METHODS

Here, we report 1 case that was diagnosed with poorly differentiated adenocarcinoma of the duodenum. The tumor had large size and invaded surrounding organs and vessels.

RESULTS

Preliminary diagnoses were poorly differentiated adenocarcinoma of the duodenum and viral hepatitis B. Pancreaticoduodenectomy assisted by 3-D visualization reconstruction and portal vein arterialization were performed in this case. The tumor was removed. Liver function returned to normal limits 1 week after operation. Digital subtraction arteriography showed compensatory artery branches within the liver 1 month after operation.

CONCLUSION

3-D visualization reconstruction can provide a reliable assistance for the accurate assessment and surgical design before pancreatoduodenectomy, and it is certainly worth adopting portal vein arterialization when retention of hepatic artery is impossible or conventional arterial anastomosis is required during pancreatoduodenectomy.

Portal vein arterialization: a salvage procedure for a totally de-arterialized liver. The Paul Brousse Hospital experience

BACKGROUND

Portal vein arterialization (PVA) has been used as a salvage inflow technique when hepatic artery (HA) reconstruction is deemed impossible in liver transplantation (LT) or hepatopancreatobiliary (HPB) surgery. Outcomes and the management of possible complications have not been well described.

METHODS

The present study analysed outcomes in 16 patients who underwent PVA during the period from February 2005 to January 2011 for HA thrombosis post-LT (n = 7) or after liver resection (n = 1), during curative resection for locally advanced HPB cancers (requiring HA interruption) (n = 7) and for HA resection without reconstruction (n = 1). In addition, a literature review was conducted.

RESULTS

Nine patients were women. The median age of the patients was 58 years (range: 30-72 years). Recovery of intrahepatic arterial signals and PVA shunt patency were documented using Doppler ultrasound until the last follow-up (or until shunt thrombosis in some cases). Of five postoperative deaths, two occurred as a result of haemorrhagic shock, one as a result of liver ischaemia and one as a result of sepsis. The fifth patient died at home of unknown cause. Three patients (19%) had major bleeding related to portal hypertension (PHT). Of these, two underwent re-exploration and one underwent successful shunt embolization to control the bleeding. Four patients (25%) had early shunt thrombosis, two of whom underwent a second PVA. After a median follow-up of 13 months (range: 1-60 months), 10 patients (63%) remained alive with normal liver function and one submitted to retransplantation.

CONCLUSIONS

Portal vein arterialization results in acceptable rates of survival in relation to spontaneous outcomes in patients with completely de-arterialized livers. The management of complications (especially PHT) after the procedure is challenging. Portal vein arterialization may represent a salvage option or a bridge to liver retransplantation and thus may make curative resection in locally advanced HPB cancers with vascular involvement feasible.

Portal Vein Arterialization as a Bridge Procedure Against Acute Liver Failure After Extended Hepatectomy for Hilar Cholangiocarcinoma

Background. Acute liver failure (ALF) is a severe and highly fatal complication arising after extended hepatobiliary surgery. The aim of this study was to investigate the primary management experience of portal vein arterialization (PVA) as a bridge procedure to reduce the risk of ALF for hilar cholangiocarcinoma (HCCA) after extended hepatectomy. Method. Between January 2010 and January 2012, 4 patients with HCCA with possible involvement of the right and/or left hepatic artery underwent resectional surgery with reconstruction of the right or left artery blood flow by arterializations of portal vein. Results. The arteries used for this surgical procedure included gastroduodenal artery (n = 2), common hepatic artery (n = 1), and right gastroepiploic artery (n = 1). PVA was verified as a key point during the course of the disorder between surgery and postoperative recovery. During follow-up, 1 patient suffered secondary portal hypertension and was subsequently cured by interventional artery coil embolization. Conclusion. PVA can be indicated where there is arterial involvement in HCCA patients who have undergone extended hepatectomy or trisectionectomy.

Partial portal arterialization for hepatic arterial thrombosis after living-donor liver transplant

OBJECTIVES

The most serious, life-threatening complication after living-donor liver transplant is a hepatic arterial thrombosis. Although possible therapies for acute hepatic arterial thrombosis include revascularization to salvage the graft, or retransplant, these may be difficult to perform owing to technical aspects and donor shortages. Previously, we reported the usefulness of partial portal arterialization in such cases.

MATERIALS AND METHODS

Four cases of partial portal arterialization for hepatic arterial occlusion after living-donor liver transplant were reviewed. The surgical procedure of partial portal arterializations involves making an arteriovenous shunt via a side-to-side anastomosis, using mesenteric vessels approximately 2 mm in diameter.

RESULTS

After partial portal arterialization, hepatic arterial flow was not detected, but graft injury owing to hypoxia gradually improved in all cases. In 1 case, occlusion of the arteriovenous shunt itself and the collateral artery to the graft were identified by angiography 45 days after partial portal arterialization. In another case, massive ascites, pleural effusion, and variceal changes of the mesenteric veins owing to portal hypertension were identified, and surgical closure of the shunt was performed 152 days after partial portal arterialization. In the other 2 cases, there were no definite problems related to partial portal arterialization, but the patients died owing to other complications.

CONCLUSIONS

When hepatic arterial thrombosis occurs after living-donor liver transplant, revascularization should be performed first. However, this sometimes may be difficult, as when the arterial dissection reaches into the graft. Partial portal arterialization is an easy and effective surgical procedure. Therefore, partial portal arterialization appears to be a useful option to gain time until collateral arterial vessels develop or retransplant, even if revascularization cannot be performed.

Portal vein arterialization in hilar cholangiocarcinoma: one case report and literature review

Advanced hilar cholangiocarcinoma (HCCA) often involves the stump or branch of the hepatic artery (HA) and portal vein (PV). Violated PV resection and reconstruction is currently considered a safe procedure without risks. However, HA resection and reconstruction is less common, because the reconstruction and anastomosis is more complicated and may be impossible when the artery is deeply encased by tumor. Radical resection of HCCA remains a major challenge for surgeons aiming to prolong the long-term survival of patients who have undergone such a surgical procedure. Here, we report our clinical experience with PV arterialization (PVA) in an advanced HCCA patient; PVA was achieved by anastomosing the gastroduodenal artery and the PV with an end-to-side running suture. PVA, at least in this patient, was verified as a key point during the course of the disorder between surgery and postoperative recovery. According to literature review, we can believe that this novel approach might be a useful technique to allow surgeons to guarantee a better oncological result and a better chance for long-term survival in HCCA patients.

Hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma: an audit of 50 consecutive cases

OBJECTIVE

To outline our experience with hepatectomy with simultaneous resection of the portal vein and hepatic artery for advanced perihilar cholangiocarcinoma, and to discuss the clinical significance of this challenging hepatectomy.

SUMMARY BACKGROUND DATA

Only a few authors reported negative results for this surgery in a very limited number of patients.

METHODS

We retrospectively reviewed medical records of 50 patients with advanced cholangiocarcinoma who underwent hepatectomy (left trisectionectomy in 26, left hepatectomy in 23, and right hepatectomy in 1) with simultaneous resection and reconstruction of the portal vein and hepatic artery, focusing on surgical outcome and survival.

RESULTS

The operative time was 776 +/- 191 minutes, and blood loss was 2593 +/- 1890 mL. Time of vessel resection and reconstruction was 25 +/- 19 minutes for the portal vein and 119 +/- 56 minutes for the hepatic artery. A total of 27 (54.0%) patients developed several kinds of complications, including intra-abdominal abscess (n = 13), wound infection (n = 9), bile leakage from liver stump (n = 9), and liver failure (n = 7). Relaparotomy was necessary in 5 (10.0%) patients. One (2.0%) patient died of a postoperative complication. Microscopic cancer invasion of the resected portal vein was found in 44 (88.0%) patients, while that of the resected hepatic artery was found in 27 (54.0%). The distal bile duct margin, proximal bile duct margin, and radial margin were positive for cancer in 2 (4.0%), 4 (8.0%), and 17 (34.0%) patients, respectively. Consequently, R0 resection was achieved in 33 (66.0%) patients. The 1-, 3-, and 5-year survival rates were 78.9%, 36.3%, and 30.3%, respectively. Survival for 30 patients with pM0 disease who underwent R0 resection was better, being 40.7% at the 3- and 5-year time points.

CONCLUSION

Major hepatectomy with simultaneous resection and reconstruction of the portal vein and hepatic artery is technically demanding. However, this surgery can be performed with acceptable mortality by an experienced surgeon and offers a better chance of long-term survival in selected patients.

Eleven cases of postoperative hepatic infarction following pancreato-biliary surgery

BACKGROUND

Postoperative hepatic infarction is rare; therefore, clinical characteristics and outcomes of postoperative hepatic infarction after pancreatobiliary surgery have not been obvious.

METHODS

Eleven patients encountered hepatic infarction after pancreato-biliary surgery. Management, clinical course, and outcome of these 11 patients were retrospectively analyzed.

RESULTS

Possible causes of the hepatic infarction were inadvertent injury of the hepatic artery during lymph node dissection in five patients, right hepatic artery ligation in two patients, long-term clamp of the hepatic artery during hepatic arterial reconstruction in two patients, suturing for bleeding from the right hepatic artery in one patient, and celiac axis compression syndrome in one patient. Five of the 17 infarcts extended for one whole section of the liver, and distribution of the other 12 was less than one section. Ten patients discharged from hospital; however, one patient died of sepsis of unknown origin.

CONCLUSIONS

Attention should be paid to inadvertent injury of hepatic artery to prevent hepatic infarction. Hepatic infarctions after pancreato-biliary surgery seldom extend to the entire liver and most of them are able to be treated without intervention.

Clostridium perfringens liver abscess after pancreatic resection

BACKGROUND

Liver abscess is a rare complication after pancreatectomy. Clostridium perfingens is a rare cause of intrahepatic infections.

CASE REPORT

A 65-year-old woman with pancreatic cancer underwent explorative laparotomy, during which encasement of the hepatic artery by the tumor was found. Neoadjuvant radiochemotherapy with capecitabine was started, which caused tumor regression, and duodenopancreatectomy was performed. The portal vein was occluded and infiltrated by cancer and therefore was resected and not reconstructed. After a slow recovery, the patient developed hemorrhage at the gastrojejunal anastomosis, which was controlled by fibrin injection. Within a few days, she presented with signs of sepsis, and blood cultures yielded Clostridium perfringens, Streptococcus oralis, Staphylococcus aureus, and Candida albicans. The source of the sepsis proved to be a 9-cm liver abscess, which was drained; cultures grew C. perfringens, Hafnia alvei, and Enterobacter cloacae. Despite antibiotic treatment, the patient died from sepsis and multiorgan failure 27 days after pancreatic surgery.

CONCLUSION

Such rare infections can follow pancreatic resection with neoadjuvant radiochemotherapy. Clostridium perfringens-associated liver abscess maintains a high mortality rate.

Ischemic complications after pancreaticoduodenectomy: incidence, prevention, and management

OBJECTIVE

To assess prevalence, prevention, and management strategy of visceral ischemic complications after pancreaticoduodenectomy (PD).

BACKGROUND

Ischemic complications after PD resulting from preexisting celiac axis (CA), superior mesenteric artery (SMA), stenosis, or intraoperative arterial trauma appear as an underestimated cause of death. Their prevention and adequate management are challenging.

METHODS

From 1995 to 2006, 545 PD were performed in our institution. All patients were evaluated by thin section multidetector computed tomography (CT) with arterial reconstruction to detect and class SMA or CA stenosis. Hemodynamical significance of stenosis was assessed preoperatively by arteriography for atherosclerotic stenosis and intraoperatively by gastroduodenal artery clamping test for CA compression by median arcuate ligament. Significant atherosclerotic stenosis was stented or bypassed, whereas CA compression was treated by median arcuate ligament division during PD. Multidetector-CT accuracy to detect arterial stenosis, results of revascularization procedures, and both prevalence and prognosis of ischemic complications after PD were analyzed.

RESULTS

Among 62 (11%) stenoses detected by multidetector-CT, 27 (5%) were hemodynamically significant, including 23 CA compressions by median arcuate ligament, 2 CA, and 2 SMA atherosclerotic stenoses, respectively. All atherosclerotic stenoses were successfully treated by preoperative stenting (n = 3) or bypass (n = 1). Among the 23 cases who underwent median arcuate ligament division, 3 (13%) failed due to 1 CA injury and 2 misdiagnosed intrinsic CA stenoses. Overall, 6 patients developed ischemic complications, due to intraoperative hepatic artery injury (n = 4), unrecognized SMA atherosclerotic stenosis (n = 1), or CA fibromuscular dysplasia (n = 1). Five (83%) of them died, representing 36% of the 14 deaths of the whole series (overall mortality = 2.6%). Overall, CT detected significant arterial stenosis with a 96% sensitivity and determined etiology of CA stenosis with a 92% accuracy.

CONCLUSIONS

Ischemic complications are an underestimated cause of death after PD and are due to preexisting stenoses of CA and SMA, or intraoperative hepatic artery injury. Preexisting arterial stenoses are detected by routine multidetector CT. Preoperative endovascular stenting for intrinsic stenosis, division of median arcuate ligament for extrinsic compression, and meticulous dissection of the hepatic artery can contribute to minimize ischemic complications.

Management of postoperative arterial hemorrhage after pancreato-biliary surgery according to the site of bleeding: re-laparotomy or interventional radiology

BACKGROUND/PURPOSE

Intra-abdominal arterial hemorrhage is still one of the most serious complications after pancreato-biliary surgery. We retrospectively analyzed our experiences with 15 patients in order to establish a therapeutic strategy for postoperative arterial hemorrhage following pancreato-biliary surgery.

METHODS

Between August 1981 and November 2007, 15 patients developed massive intra-abdominal arterial bleeding after pancreato-biliary surgery. The initial surgery of these 15 patients were pylorus-preserving pancreatoduodenectomy (PPPD) (7 patients), hemihepatectomy and caudate lobectomy with extrahepatic bile duct resection or PPPD (4 patients), Whipple's pancreatoduodenectomy (PD) (3 patients), and total pancreatectomy (1 patient). Twelve patients were managed by transcatheter arterial embolization and three patients underwent re-laparotomy.

RESULTS

Patients were divided into two groups according to the site of bleeding: SMA group, superior mesenteric artery (4 patients); HA group, stump of gastroduodenal artery, right hepatic artery, common hepatic artery, or proper hepatic artery (11 patients). In the SMA group, re-laparotomy and coil embolization for pseudoaneurysm were performed in three and one patients, respectively, but none of the patients survived. In the HA group, all 11 patients were managed by transcatheter arterial embolization. None of four patients who had major hepatectomy with extrahepatic bile duct resection survived. Six of seven patients (85.7%) who had pancreatectomy survived, although hepatic infarction occurred in four.

CONCLUSIONS

Management of postoperative arterial hemorrhage after pancreato-biliary surgery should be done according to the site of bleeding and the initial operative procedure. Careful consideration is required for indication of interventional radiology for bleeding from SMA after pancreatectomy and hepatic artery after major hepatectomy with bilioenteric anastomosis.

Resection of a locally advanced hilar tumor and the hepatic artery after stepwise hepatic arterial embolization: A case report

We herein report a case of a hilar tumor with extensive invasion to the proper hepatic artery, which was successfully treated with a radical resection in a 57-year-old female patient after a stepwise hepatic arterial embolization. She underwent right colectomy and partial hepatectomy for advanced colon cancer two years ago and radiofrequency ablation therapy for a liver metastasis one year ago, respectively. A recurrent tumor was noted around the proper hepatic artery with invasion to the left hepatic duct and right hepatic artery 7 mo previously. We planned a radical resection for the patient 5 mo after the absence of tumor progression was confirmed while he was undergoing chemotherapy. To avoid surgery-related liver failure, we tried to promote the formation of collateral hepatic arteries after stepwise arterial embolization of the posterior and anterior hepatic arteries two weeks apart. Finally, the proper hepatic artery was occluded after formation of collateral flow from the inferior phrenic and superior mesenteric arteries was confirmed. One month later, a left hepatectomy with hepatic arterial resection was successfully performed without any major complications.

One hundred consecutive hepatobiliary resections for biliary hilar malignancy: preoperative blood donation, blood loss, transfusion, and outcome

BACKGROUND

Many reports on blood loss and transfusion requirements during hepatectomy for metastatic liver cancer or hepatocellular carcinoma have been published; however, there are no reports on these issues in hepatectomy for biliary hilar malignancy. The aim of this study was to review our experience with blood loss and perioperative blood requirements in 100 consecutive hepatectomies for biliary hilar malignancy.

METHODS

One hundred consecutive hepatectomies with en bloc resection of the caudate lobe and extrahepatic bile duct for hilar malignancies were performed, including 81 perihilar cholangiocarcinomas and 19 advanced gallbladder carcinomas involving the hepatic hilus. Fifty-eight hilar resections were combined with other organ and/or vascular resection. Data on preoperative blood donation, intraoperative blood loss, and perioperative transfusion were collected and analyzed.

RESULTS

Preoperative autologous blood donation was possible in 73 patients (3.4 +/- 1.2 U). Intraoperative blood loss was 1850 +/- 1000 mL (range, 677-5900 mL), and it was < 2000 mL in 62 patients. Intraoperatively, only 7 of the 73 patients (10%) who donated blood received transfusion of unheated, homologous blood products (packed red blood cells or fresh frozen plasma), whereas 18 the 23 patients (67%) without donation received homologous transfusions. Only 16 patients received transfusion postoperatively, and overall, 35 patients received unheated homologous blood products. Total serum bilirubin concentrations after hepatectomy in patients receiving autologous blood transfusion only was similar to those in patients who did not receive transfusion. The incidence of postoperative complications was higher in the 35 patients who received perioperative homologous transfusion than in 65 patients who did not (94% vs 52%; P <.0001). The mortality rate (including all deaths) was 3% (myocardial infarction, intra-abdominal bleeding, and liver failure, 1 patient each).

CONCLUSIONS

Despite the technical difficulties arising from hepatectomy for biliary hilar malignancy, approximately two thirds of hepatectomies can be performed in an experienced center without perioperative homologous blood transfusion using preoperative blood donation.

Portal flow into the liver through veins at the site of biliary-enteric anastomosis

The aim of this study was to establish the role played by jejunal veins in hepatopetal flow after biliary-enteric anastomosis and to evaluate the helical CT features of hepatopetal flow through the anastomosis. We retrospectively analyzed helical CT images of the liver in 31 patients with biliary-enteric anastomosis who underwent hepatic angiography with (n=13) or without (n=18) CT arterial portography within 2 weeks of the CT examination during the last 4 years. Arterial portography showed hepatopetal flow through small vessels located (communicating veins) between the elevated jejunal veins and the intrahepatic portal branches in two (9%) of 22 patients with a normal portal system. Helical CT showed focal parenchymal enhancement around the anastomosis in these two patients. All nine patients with extrahepatic portal vein occlusion (100%) had hepatopetal flow through the anastomosis, and four of the nine had decreased portal flow. CT revealed small communicating veins in two of these four patients. In five patients with normal portal perfusion despite extrahepatic portal vein occlusion, CT detected dilated communicating veins and elevated jejunal veins. The presence of communicating veins and/or focal parenchymal enhancement around the anastomosis indicates hepatopetal flow through the elevated jejunal veins.

Arterioportal shunting as an alternative to microvascular reconstruction after hepatic artery resection

Background

Portal vein and hepatic artery resection and reconstruction may be required in radical surgery for biliary cancer. Microvascular reconstruction requires special equipment and training, and may be difficult to accomplish when the arterial stump is small, when there are multiple vessels or when the stump lies deep within the wound. This study examined the feasibility and safety of arterioportal shunting as an alternative to arterial reconstruction.

Methods

Over 30 months, ten patients with biliary cancer (six bile duct and four gallbladder carcinomas) underwent radical surgery with en bloc resection of the hepatic artery and end-to-side arterioportal reconstruction between the common hepatic or gastroduodenal artery and the portal trunk.

Results

No patient died. Complications included bile leakage in two patients and liver abscess in one. Routine angiography performed 1 month after surgery revealed shunt occlusion in three patients. Once the existence of hepatopetal arterial collaterals had been confirmed in the remaining patients, the shunt was occluded by coil embolization.

Conclusion

Arterioportal shunting appears to be a safe alternative to microvascular reconstruction after hepatic artery resection. However, the safety of the procedure and its potential to increase the cure rate require further assessment in a larger series with a longer follow-up.

Efficacy of continuous infusion of prostaglandin E1 through the superior mesenteric artery against ischemic liver cell necrosis after hepatic artery occlusion

BACKGROUND

Hepatic artery occlusion (HAO) can cause severe ischemic liver injury, especially after an interruption of collateral circulation after extensive hepatobiliary surgery. To minimize a decrease in oxygen delivery after HAO, a continuous infusion of prostaglandin (PG)E1 through the superior mesenteric artery (SMA) was studied in comparison with other infusion routes.

METHODS

Twenty-four pigs were assigned to four groups: HAO without PGE1 (control group); HAO with PGE1 (0.02 microg/kg/min, continuously) through the jugular vein (intravenous group); HAO with PGE1 through the portal vein (PV group); and HAO with PGE1 through the SMA (SMA group). PV flow, hepatic oxygen delivery, and serum aspartate aminotransferase were measured after infusion. In addition, 72-hr survival rates were observed, and histologic examination of liver specimens was performed.

RESULTS

PGE1 infusion through the SMA seems to affect PV flow and elevate the oxygen content of portal blood, whereas other routes of administration do not. The reduction of hepatic oxygen delivery after HAO was 51% in the control group, 46% in the intravenous group, and 49% in the PV group, whereas it was limited to 13% in the SMA group. Serum aspartate aminotransferase values 24 hr after HAO were lowest in the SMA group, which was statistically significant, as confirmed by histology. The survival rate of animals was 100% in the SMA group and 33% in the other three groups.

CONCLUSION

These findings indicate that continuous PGE1 infusion through the SMA may prove useful in clinical settings to prevent liver damage after HAO.

Continuous arterial infusion of prostaglandin E(1) via the superior mesenteric artery in the treatment of postoperative liver failure

Impaired hepatic blood flow is one of the causative factors in postoperative liver failure. To restore the hepatic blood flow in case of hepatic artery interruption (HAI), the effect of continuous arterial infusion of prostaglandin E(1) (PGE(1)), which has a strong vasodilatory effect on vascular smooth muscles, was assessed experimentally and clinically. Twelve pigs underwent ligation and division of the hepatic artery and were divided into 2 groups. In the control group, saline was infused in the superior mesenteric artery (SMA), and in the PGE(1) group, 0.02 microg/kg/min of PGE(1) was infused continuously in the SMA. Hepatic oxygen delivery (HDO(2)) in the control group was 87.8 +/- 8.9 ml/min before HAI and decreased to 43.1 +/- 2.6 ml/min at 60 min after HAI, showing 50.9% decrease by HAI. On the contrary, HDO(2) in the PGE(1) group was 86.7 +/- 9.1 ml/min before HAI and was 76.6 +/- 12.2 ml/min at 60 min after HAI, showing only 11.6% decrease by HAI. Clinically, a 65-year-old female suffering from cholangiocellular carcinoma underwent extended left hepatic lobectomy. At operation, the branch of the hepatic artery to the anterior segment of the liver was ligated, and the right branch of the portal vein became stenotic unavoidably. Postoperatively, severe liver dysfunction developed so that continuous PGE1 infusion in the SMA was initiated at a rate of 0.01 microg/kg/min on the eighth postoperative day and continued for 9 days. Plasma exchange was performed twice concomitantly. Portal venous flow increased from 612 ml/min to 1,192 ml/min, and bile flow from external biliary drainage tube doubled by the PGE(1) infusion. The liver function was ameliorated after PGE(1) infusion.