Treatment of multiple huge liver cysts in a hybrid operating room: a case report

Abstract

Background: Liver cysts are common, with most cases being asymptomatic. In symptomatic cases, the disease is amenable to treatment. However, huge or multiple liver cysts with vascular narrowing and associated systemic symptoms are extremely rare. Furthermore, the performance of a reliable and effective surgery in such cases remains a major problem. Here, we report a case of multiple giant liver cysts with impaired blood flow surgically treated in a hybrid operating room.

Case presentation: A 73-year-old male presented to a previous doctor with leg edema and dyspnea on exertion; computed tomography revealed that the cause complaint was right lung and heart compression and inferior vena cava (IVC) stenosis due to huge liver cysts in the caudal lobe. The patient was referred to our hospital because of disease recurrence despite percutaneous aspiration of the cyst. Multiple liver cysts were observed in addition to the drained cysts, two of which were located on both sides of the IVC and caused IVC stenosis. We performed open surgery for the liver cysts and used the hybrid operating room for intraoperative IVC angiography and measuring the hepatic vein and portal vein (PV) pressure. We performed unroofing of the hepatic cyst and cauterization of the cyst wall on the hepatic side. Angiography was performed before and after unroofing of the liver cysts, and IVC stenosis release was confirmed. IVC pressure measured at the peripheral side of the stenosis and PV pressures were continuously measured during surgery and were confirmed to have decreased during the opening of the liver cysts. The patient had a good postoperative course and was discharged on the 10th postoperative day. No recurrence was observed 6 months postoperatively.

Conclusions: Cyst unroofing surgery using angiography in a hybrid operating room is a useful treatment for deep hepatic lesions in that vascular stenosis improvement can be intraoperatively confirmed. Moreover, in cases wherein the cyst compresses the vasculature, intraoperative monitoring of IVC and PV pressures can be used to prove that the liver cyst is hemodynamically involved.

Keywords: Angiography; Hepatic cystotomy; Huge liver cysts; Hybrid operating room; Unroofing.

Fig. 1

Computed tomography (CT) image taken at the first visit. The cyst is observed in the eighth segment of the liver and measures 13 cm in diameter; it is the largest of the cysts in this case. The cyst appears to have compressed the right side of the heart and the right thoracic cavity (a). The cysts are observed to be located dorsal to the liver on both sides of the inferior vena cava (IVC); they were thought to have caused the stenosis of the IVC (b). One of the cysts is seen to be in contact with the right and left branches of the portal vein; the right branch appears compressed and stenotic (c)

Fig. 2

Three-dimensional reconstructed image of the liver. The hemodynamically involved cysts are indicated by arrows, respectively. a Shows all cysts, and the arrow indicates the largest lesion in segment eight. b Shows cysts on both sides of the IVC and near the portal bifurcation in green (arrowheads)

Fig. 3

Preoperative angiography. Angiography confirms stenosis of the inferior vena cava (IVC) preoperatively (a). Angiography of the superior mesenteric artery reveals a left gastric vein–left renal vein shunt, although the portal veins enhanced the antegrade flow (b)

Fig. 4

Intraoperative imaging studies. Angiography confirms that the stenosis of the inferior vena cava (IVC) was resolved after cyst fenestration (a). Computed tomography confirms that the cysts decompressed the right heart and that cyst fenestration released the IVC stenosis (b, c). Computed tomography arterial portography confirms that the stenosis of the portal vein had improved (d)

Fig. 5

Computed tomography performed 6 months after the surgery reveals no recurrence of the right heart decompression (a), inferior vena cava stenosis (b), or portal vein stenosis (c). The 3D reconstructed image shows the disappearance of the cyst near the IVC and RHV (d)