The portal venous system in cirrhotic patients: Value of the computed tomography

Abstract

We read with great interest the article of Sabbagh et al. about non-hepatic gastrointestinal surgery in patients with cirrhosis, where attention is paid to the patients with portal hypertension [1]. The great impact of this clinical condition on the surgical strategies and risks is well known. Today an important diagnostic role must be recognized to the contrast-enhanced computed tomography (CT), which permits a precise study of the entire portal venous system [2]. The surgeon must know the value of this imaging tool. According to our experience, we underline some aspects of this diagnostic procedure. At first, a severe intra-hepatic obstruction to the portal blood flow, with an impending danger of its marked reduction or even hepatofugal inversion, can be suggested by a group of signs, among which a delayed or attenuated contrast enhancement of the liver, a reduction and distortion of the intrahepatic branches of the portal vein, a decreased diameter of the hepatic veins, and of the portal trunk at the hepatic hilus [3]. This condition predisposes to a postoperative deterioration of the liver function. Similarly, a severe portal hypertension can be supposed in case of evident peri-esophageal venous network or of enlarged left gastric vein, especially if surrounded by multiple collaterals [4]. In this case, an upper digestive endoscopy is indicated to evaluate pre-operatively, and possibly to treat gastro-esophageal varices. The porto-mesenteric trunk can be carefully evaluated, in order to discover its pathology, as thrombosis, cavernous transformation, enlarged collaterals, ectopic varices, etc. which can cause difficulties in the surgical dissection. All the morphological abnormalities discovered in the portal system must be evaluated along with the other clinical scoring systems for staging cirrhosis. We recognize that a great variability in hemodynamic conditions is possible in patients with portal hypertension; nevertheless surgeon must consider essential, before any abdominal operation, an accurate imaging study of the entire portal venous system.