Tangential gunshot injury of the right portal vein branch resulting in subacute main portal vein thrombosis: Successful treatment without hepatectomy

This report describes the successful treatment (without hepatectomy) of a patient who underwent laparotomy and bullet removal for a gunshot injury to the liver at another institution. The patient was later referred for hemobilia and was found to have an un-recognized tangential injury to the right portal vein branch, resulting in portal vein thrombosis, diagnosed on the twelfth day after injury. The patient subsequently developed severe cholangitis. Hepatic arteriography did not identify the source of hemobilia. Fol-lowing thrombectomy of the main portal vein and its left branch, along with portal vein repair, bilateral external biliary drainage from the common hepatic duct was performed. Hemobilia ceased after portal revascularization. A low-volume biliary fistula developed in the early postoperative period but resolved within 17 days with gradual removal of abdominal drains. The patient experienced no further complications during six months of follow-up. Standard biochemical blood tests remained within normal limits, except for slightly elevated alkaline phosphatase (167 U/L: 40-129) and gamma-glutamyl transpeptidase (100 U/L: 8-61) levels. Follow-up contrast-enhanced computed tomography scans on postoperative day 10 and at six months confirmed patency of the main portal vein and its left branch. Additionally, right lobe atrophy and left lobe hypertrophy were observed. In conclusion, applying principles from elective hepatopancreatobiliary surgery to trauma care, and avoiding major hepatectomy in the setting of severe cholangitis, played a crucial role in achieving a successful outcome.