A case of hilar cholangiocarcinoma repeated portal vein thrombosis following portal reconstruction associated with protein C deficiency

A 64-year-old man with hilar cholangiocarcinoma for whom right hepatectomy and caudate lobectomy and resection of the extrahepatic bile duct we were planned was found, during surgery, to have portal vein invasion necessitating portal resection and reconstruction with an end-to-end anastomosis. Bleeding developed due to portal hypertension. Palpation and ultrasonography showed thrombotic obstruction at the anastomotic site. Despite thrombectomy and reanastomosis, a similar reobstruction occurred although neither twisting nor stricture occurred at the anastomosis. Suspecting hypercoagulation, we conducted continuous heparin injection via a catheter placed in the gastroepiploic vein after rereanastomosis. No more thrombus was formed and the postoperative course was uneventful. Postoperative examination of coagulation showed a low level of Protein C on postoperative day (POD) 19, while liver function improved. Warfarin administration replaced heparin injection for Protein C deficiency. The man was discharged on POD 49 and has been well without thrombosis for one year.