One-lung ventilation to treat hepatic dome lesion – a furthe
In August 2017, a 58-year-old white man was referred to our center of Hepatobiliary Surgery and Liver Transplantation at the Policlinic Hospital of Padua for paracaval, subdiaphragmatic recurrent HCC in the absence of underlying liver disease. He had a history of multiple abdominal surgeries: in August 2015, a laparotomic right hepatectomy for HCC (with negative oncological margins, R0); in April 2016, excision of cutaneous HCC metastases; and in January 2017, a local intrahepatic recurrence of HCC occurred, treated with liver and diaphragm en bloc resection with right diaphragmatic patch located near the resection margin. Both resections were performed in another hospital via a J-shaped incision.

During the follow-up, a thoracoabdominal triple-phase computed tomography (CT) scan showed a HCC nodule of 18 × 14 mm located immediately upstream of the confluence of the middle hepatic vein with the inferior vena cava (Fig. 1a, b). Abdominal US evaluation did not clearly detect the hepatic lesion due to lung and bowel interposition. He was asymptomatic, had a normal level of alpha-fetoprotein (AFP), negative hepatitis viral markers, and normal liver function: Child–Pugh A5 and Model for End-Stage Liver Disease (MELD) 6. His body mass index (BMI) was 24.

In select patients, percutaneous ultrasound-guided thermal ablation is a valid non-surgical alternative due to its safety, efficacy, and good tolerability. Hepatic lesions located in the posterosuperior segments, however, can be difficult to reach via a percutaneous approach.

For this case, one-lung left-sided ventilation may be particularly helpful in blocking the right hemidiaphragm and improving the acoustic window to the liver.

Source: Journal of Medical Case Reports 2019 13:83

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