Accessory Hepatic Veins Research Articles

Liver Ischemia After Transarterial Embolization for Hepatic Trauma Injury.

Transarterial embolization (TAE) is a routine procedure performed by interventional radiologists to manage traumatic hepatic injuries. Hepatic super-selective TAE rarely results in ischemia within the embolized area. In this case, the initial CT scan revealed significant contrast extravasation, leading to an urgent TAE. Due to continued concerns about bleeding, a second TAE was performed two days later. Subsequent CT scans revealed localized ischemia and necrosis following increased abdominal pain and elevated liver functions. Further analysis identified a common hepatic artery variation in this case. Thus, the ischemia in segments 6 and 7 was determined to be unrelated to the embolization procedure. A detailed review of the CT images suggests that injury to the accessory right inferior hepatic veins (IHVs) likely caused ischemia and eventual necrosis in segments 6 and 7. While hepatic vein variations are not uncommon, this case highlights the importance of evaluating the condition of hepatic veins, in addition to the hepatic artery and portal vein, during preoperative planning. If no arterial extravasation is identified, conservative treatment may be an option for the patient. Further research on this topic is warranted.

Study of confluence of hepatic veins application in liver transplantation.

Liver has exceptional regeneration capacity which makes live donor liver transplantation a good surgical option for patients waiting for donors. Hepatic veins play major role in transplantation surgeries. Variations of hepatic veins can have great impact on surgical approach and outcome of the surgery. In the present study, total number of hepatic veins, presence and absence of accessory veins and confluence with its varied patterns were studied. We found maximum cases with 2 and 3 major hepatic veins which indicate presence of confluence. Confluence between left and middle hepatic veins was highest with 38% of total 54% of cases with confluence. We also found confluence between middle and accessory hepatic vein which is not mentioned in any present classifications. In addition, we have measured confluence length and diameter which holds significance in hepatic resection and anastomosis. The mean confluence length was 0.88±0.39 cm while mean confluence diameter was 0.57±0.20 cm. We found accessory hepatic veins in 15% of cases. The knowledge of this surgical anatomy and associated variations is of paramount importance in liver transplantation, radiological interventional procedures of liver and hepatic tumor resection procedures.

Feasibility and long-term outcomes of hepatic vein recanalization in Budd-Chiari syndrome through intrahepatic collateral pathways.

To investigate the feasibility and long-term outcomes of hepatic vein (HV) recanalization using intrahepatic collateral pathways in patients with Budd-Chiari syndrome (BCS) with HV obstruction. Clinical data of 29 BCS patients with HV obstruction and intrahepatic collateral pathways were reviewed. All patients underwent HV recanalization through the intrahepatic collaterals. Follow-up was performed at 1, 3, 6, and 12 months after treatment and annually thereafter. Cumulative patency and survival rates were assessed using Kaplan-Meier curves. The independent predictors of patency were determined using a Cox regression model. HV recanalization was successful in 28 of the 29 patients (96.6%), with no complications. Of the 28 cases, simultaneous recanalization of the accessory HV and right HV was achieved in 11 patients, accessory HV and middle HV in six, accessory HV and left HV in three, right HV and middle HV in five, and left HV and middle HV in three. Twenty-eight patients were followed from 4 to 87 (mean, 53.6 ± 26.7) months after treatment, and six patients developed reocclusion. The overall cumulative 1-, 3-, 5-, and 7-year primary HV patency rates were 96.3, 82.9, 74.6, and 59.7%, respectively. The cumulative 1-, 3-, 5-, and 7-year survival rates were 100, 95.8, 95.8, and 86.3%, respectively. Interventional treatment of HV obstruction in BCS patients through intrahepatic collateral approaches is well tolerated and feasible and can result in excellent long-term patency and survival rates.

Adrenal Vein Sampling: Tips and Tricks.

Adrenal vein sampling (AVS) is the standard method for distinguishing unilateral from bilateral sources of autonomous aldosterone production in patients with primary aldosteronism. This procedure has been performed at limited specialized centers due to its technical complexity. With recent advances in imaging technology and knowledge of adrenal vein anatomy in parallel with the development of adjunctive techniques, AVS has become easier to perform, even at nonspecialized centers. Although rare, anatomic variants of the adrenal veins can cause sampling failure or misinterpretation of the sampling results. The inferior accessory hepatic vein and the inferior emissary vein are useful anatomic landmarks for right adrenal vein cannulation, which is the most difficult and crucial step in AVS. Meticulous assessment of adrenal vein anatomy on multidetector CT images and the use of a catheter suitable for the anatomy are crucial for adrenal vein cannulation. Adjunctive techniques such as intraprocedural cortisol assay, cone-beam CT, and coaxial guidewire-catheter techniques are useful tools to confirm right adrenal vein cannulation or to troubleshoot difficult blood sampling. Interventional radiologists should be involved in interpreting the sampling results because technical factors may affect the results. In rare instances, bilateral adrenal suppression, in which aldosterone-to-cortisol ratios of both adrenal glands are lower than that of the inferior vena cava, can be encountered. Repeat sampling may be necessary in this situation. Collaboration with endocrinology and laboratory medicine services is of great importance to optimize the quality of the samples and for smooth and successful operation. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Accessory hepatic vein recanalization for Budd-Chiari syndrome: a systematic review and meta-analysis

BackgroundBudd-Chiari syndrome (BCS) results when the outflow of the hepatic vein (HV) is obstructed. BCS patients exhibiting an accessory HV (AHV) that is dilated but obstructed can achieve significant alleviation of liver congestion after undergoing AHV recanalization. This meta-analysis was developed to explore the clinical efficacy of AHV recanalization in patients with BCS.Materials and methodsPubMed, Embase, and Wanfang databases were searched for relevant studies published as of November 2022, and RevMan 5.3 and Stata 12.0 were used for pooled endpoint analyses.ResultsTwelve total studies were identified for analysis. Pooled primary clinical success, re-stenosis, 1- and 5-year primary patency, 1- and 5-year secondary patency, 1-year overall survival (OS), and 5-year OS rates of patients in these studies following AHV recanalization were 96%, 17%, 91%, 75%, 98%, 91%, 97%, and 96%, respectively. Patients also exhibited a significant reduction in AHV pressure after recanalization relative to preoperative levels (P < 0.00001). Endpoints exhibiting significant heterogeneity among these studies included, AHV pressure (I2 = 95%), 1-year primary patency (I2 = 51.2%), and 5-year primary patency (I2 = 62.4%). Relative to HV recanalization, AHV recanalization was related to a lower rate of re-stenosis (P = 0.002) and longer primary patency (P < 0.00001), but was not associated with any improvements in clinical success (P = 0.88) or OS (P = 0.29) relative to HV recanalization.ConclusionsThe present meta-analysis highlights AHV recanalization as an effective means of achieving positive long-term outcomes in patients affected by BCS, potentially achieving better long-term results than those associated with HV recanalization.

Non-Contrast Enhanced Magnetic Resonance Venography Using the Fast Imaging Employing Steady-State Acquisition (FIESTA) Pulse Sequence in Preoperative Evaluation of Liver Donors: Can it Replace CT Venography?

Background: Liver transplantation has now become the preferred treatment for patients with liver failure. Pre-operative assessment of hepatic/portal vein anatomy of donors is necessary for which CT venography is most commonly used but it exposes the donors to huge radiation burden. To avoid this, non-contrast MR venography is the most preferred alternative for evaluation of veins. Objective: To determine diagnostic yield of magnetic resonance venography using Fast Imaging Employing Steady-State Acquisition (FIESTA) pulse sequence in comparison to computed tomography venography for the determination of portal/hepatic venous anatomy of potential liver donors. Methods: Retrospective study was conducted in which the venous phase CT scan and FIESTA (b-SSFP) sequence of 50 potential liver donors between 01-07-2021 and 30-11-2021 were reviewed. The hepatic and portal venous anatomy was reviewed. The assessment comprised the type of portal venous anatomy, the number of prominent tributaries from segment VIII and V of liver having diameter of 4mm or more emptying into the middle hepatic vein and the total number of accessory inferior right hepatic veins from segment VI and VII emptying into inferior vena cava (IVC). Results: With 100% sensitivity and specificity, the FIESTA sequence precisely identified the portal vein anatomy, total number of accessory inferior right hepatic veins, and the total number of 4 mm thick tributaries from segment V and VIII draining into middle hepatic vein Conclusion: We propose that magnetic resonance venography using FIESTA sequence can be used instead of CT venography to determine hepatic and portal vein anatomy of liver donors.

Survival and clinical success of endovascular intervention in patients with Budd-Chiari syndrome: A systematic review.

Budd-Chiari syndrome is a complex clinical disorder of hepatic venous outflow obstruction, originating from the accessory hepatic vein (HV), large HV, and suprahepatic inferior vena cava (IVC). This disorder includes both HV and IVC obstructions and hepatopathy. This study aimed to conduct a systematic review of the survival rate and clinical success of different types of endovascular treatments for Budd-Chiari syndrome (BCS). All participant studies were retrieved from four databases and selected according to the eligibility criteria for systematic review of patients with BCS. The survival rate, clinical success of endovascular treatments in BCS, and survival rates at 1 and 5 years of publication year were calculated accordingly. A total of 3398 patients underwent an endovascular operation; among them, 93.6% showed clinical improvement after initial endovascular treatment. The median clinical success rates for recanalization, transjugular intrahepatic portosystemic shunt (TIPS), and combined procedures were 51%, 17.50%, and 52.50%, respectively. The median survival rates at 1 and 5 years were 51% and 51% for recanalization, 17.50% and 16% for TIPS, and 52.50% and 49.50% for combined treatment, respectively. Based on the year of publication, the median survival rates at 1 and 5 years were 23.50% and 22.50% before 2000, 41% and 41% in 2000‒2005, 35% and 35% in 2006‒2010, 51% and 48.50% in 2010‒2015, and 56% and 55.50% after 2015, respectively. Our findings indicate that the median survival rate at 1 and 5 years of recanalization treatment is higher than that of TIPS treatment, and recanalization provides better clinical improvement. The publication year findings strongly suggest progressive improvements in interventional endovascular therapy for BCS. Thus, interventional therapy restoring the physiologic hepatic venous outflow of the liver can be considered as the treatment of choice for patients with BCS which is a physiological modification procedure.

Intraorgan architectonics of hepatic veins in piglets

The liver of animals and humans is characterized by polyfunctionality. All the variety of liver functions and the intensity of their course is determined by the peculiarities of its hemodynamics. According to the morphological anatomy of the pig liver, I distinguish six lobes: the right lateral and medial, the left lateral and medial, square and caudate. The functional anatomy of the liver is based on the division of the liver into segments. In this case, the division is based on the fact that each segment has its own double blood supply, bile and lymph outflow routes. The aim of the study is to study the architectonics of the hepatic veins of newborn piglets, to give a morphometric characteristic of the branches of the intraorgan venous bed, as well as the segmental structure of the liver of piglets. The corpses of newborn piglets of the Landrace breed served as the material for the study. Vasorentgenography, fine anatomical dissection, and morphometry were chosen as research methods. The study included 15 piglets of the newborn period. During the study, it was found that four hepatic veins (right accessory, right, left and middle) flow into the caudal genital vein. Hepatic veins have complex intra-organ architectonics and take branches of the first and second order along their course. The maximum diameter is the left hepatic vein, which carries out the outflow of blood from the left lateral and medial lobes of the liver. The right hepatic vein drains blood from the right lateral and medial lobes, the middle hepatic vein drains from the square lobe, gallbladder and part of the left medial lobe. The smallest diameter is characteristic of the right accessory hepatic vein, which drains the caudate lobe.Having studied the intra–organ architectonics of the branches of the hepatic veins, it can be concluded that the liver of piglets has eight segments - one segment each in the caudate, left medial, right medial and square lobes, two segments each in the left and right lateral lobes.

Mixed reality navigation training system for liver surgery based on a high-definition human cross-sectional anatomy data set.

This study aims to use the three-dimensional (3D) mixed-reality model of liver, entailing complex intrahepatic systems and to deeply study the anatomical structures and to promote the training, diagnosis and treatment of liver diseases. Vascular perfusion human specimens were used for thin-layer frozen milling to obtain liver cross-sections. The 104-megapixel-high-definition cross sectional data set was established and registered to achieve structure identification and manual segmentation. The digital model was reconstructed and data was used to print a 3D hepatic model. The model was combined with HoloLens mixed reality technology to reflect the complex relationships of intrahepatic systems. We simulated 3D patient specific anatomy for identification and preoperative planning, conducted a questionnaire survey, and evaluated the results. The 3D digital model and 1:1 transparent and colored model of liver established truly reflected intrahepatic vessels and their complex relationships. The reconstructed model imported into HoloLens could be accurately matched with the 3D model. Only 7.7% participants could identify accessory hepatic veins. The depth and spatial-relationship of intrahepatic structures were better understandable for 92%. The 100%, 84.6%, 69% and 84% believed the 3D models were useful in planning, safer surgical paths, reducing intraoperative complications and training of young surgeons respectively. A detailed 3D model can be reconstructed using the higher quality cross-sectional anatomical data set. When combined with 3D printing and HoloLens technology, a novel hybrid-reality navigation-training system for liver surgery is created. Mixed Reality training is a worthy alternative to provide 3D information to clinicians and its possible application in surgery. This conclusion was obtained based on a questionnaire and evaluation. Surgeons with extensive experience in surgical operations perceived in the questionnaire that this technology might be useful in liver surgery, would help in precise preoperative planning, accurate intraoperative identification, and reduction of hepatic injury.

Accessory Hepatic Vein Stenting in the Management of Budd-Chiari Syndrome: A Case Report

The Budd-Chiari Syndrome (BCS) is associated with hepatic venous outflow obstruction. A 22-year-old female patient presented with abdominal pain and backache for 12 days, along with generalised weakness. Physical examination revealed pitting pedal oedema and abdominal distension. An abdominal ultrasound with Doppler Ultrasonography (USG) was performed, revealing liver parenchymal disease with gross ascites and occlusion of all three Hepatic Veins (HV), suggestive of BCS. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) of the liver, as well as a right hepatic venogram using Digital Subtraction Angiography (DSA), showed chronic total occlusion at the ostium. An Accessory Hepatic Vein (AHV) was identified, joining the Right Hepatic Vein (RHV) to the Inferior Vena Cava (IVC). The accessory RHV exhibited high-grade stenosis (approximately 90-95%) at its junction with the IVC. Recanalisation of the AHV (balloon dilatation/stent insertion) was performed. Post-procedure accessory hepatic venogram showed a patent stented segment with a significant reduction in adjacent venous collaterals. No procedure-related complications were observed. The present case highlights the importance of AHV stenting in BCS patients, as it helps maintain normal physiology, in contrast to Direct Intrahepatic Porto-systemic Shunt (DIPS), which alters normal physiology by allowing portal venous blood to mix directly into the systemic circulation, bypassing the liver parenchyma.

Percutaneous recanalization in hepatic vein-type Budd-Chiari syndrome: hepatic or accessory hepatic vein

Purpose This study was designed to assess the clinical efficiency and long-term outcomes of hepatic vein (HV) and accessory hepatic vein (AHV) recanalization in patients with HV-type Budd-Chiari syndrome (BCS). Material and methods A total of 27 patients with HV-type BCS underwent AHV recanalization and 94 patients had HV recanalization at our center from January 2012 to December 2019. The treatment effectiveness and long-term outcomes were compared. Results Technical success was accomplished in all patients, without any procedure-related complications. The clinical success rates were 96.3% (26/27) and 95.7% (90/94) (p = 1.000). In the AHV and HV groups, re-obstruction was observed in 5 and 36 patients, respectively (p = 0.056). The median primary durations of AHV and HV patency were 64 and 49 months, respectively (p = 0.036), while the median secondary durations of AHV and HV patency were 70 and 64 months, respectively (p = 0.134). The median overall survival after AHV and HV recanalization was 73 and 78 months, respectively (p = 0.263). Conclusions Our findings suggest that AHV could be employed as a replacement for HV, as a hepatic drainage vein, in HV-type BCS patients.

The anatomical variations of the hepatic veins in a South African sample

of the hepatic veins and any variation thereof is pivotal for successful hepatic surgeries, as these vessels serve as a hepatic field guideline in living donor liver transplantations (LDLT) and hepatic resections. To date, numerous morphological variations in different populations other than a South African population have been published and thus the following research study was conducted to investigate and document morphological variations in a South African population. The following descriptive study aimed to contribute to a better preoperative understanding of hepatic vein anatomy impacting surgeries conducted in South Africa. This research study was conducted on 40 livers from donated bodies of 20 females and 20 males, used for academic purposes in the Department of Human Biology, at the University of Cape Town. The age range was between 33 to 105 years old with an average age of 75. The livers were removed, and the liver tissue was scraped away to expose the hepatic veins from their origin of the inferior vena cava (IVC) to their terminating branching points within the various hepatic segments. All the livers presented all three major hepatic veins, 90.0% of the livers had a common trunk (n = 36), and the remaining 10.0% had no common trunk (n = 4). The major and minor hepatic veins were observed for all the livers. This study found various morphological variations in a South African population that are of clinical significance with a high prevalence of accessory right hepatic veins.

Haemodynamic changes during radical nephrectomy with inferior vena cava thrombectomy: A pilot study.

Haemodynamic changes during radical nephrectomy with inferior vena cava thrombectomy: A pilot study.

Case report of a Gore-Tex TCPC conduit dissection causing severe stenosis

BackgroundThe patient is a 15-year-old male with situs inversus, dextrocardia, bilateral superior caval veins, atrioventricular discordance with a single outlet, large perimembranous ventricular septal defect, aortic override, pulmonary atresia, and right aortic arch. The complex anatomy with a Ventricular Septal Defect (VSD) distant from the aorta (unsuitable for baffling to the aorta) meant he was unsuitable for biventricular repair and proceeded down a univentricular palliation pathway.Case summaryPost-total cavopulmonary connection his clinical course was uneventful until the age of 5 when he developed fatigability with desaturation. An accessory hepatic vein was surgically banded with improved saturations and exercise tolerance. At the age of 15, cardiovascular magnetic resonance (CMR) was performed to investigate borderline saturations and as workup for transition to adult services. Cardiovascular magnetic resonance and cardiac computed tomography (CT) imaging demonstrated an eccentric thrombus causing stenosis of the extracardiac conduit and a thrombus outside of the lumen contained by the thin outer membrane of the Gore-Tex conduit. Collateralization suggested this was longstanding. Cardiac catheterization demonstrated a 4 mm × 6 mm stenosis at the junction of the conduit with the pulmonary arteries. The region was successfully balloon dilated and stented with a 34 mm-long Cheatham Platinum stent, with no complications.DiscussionTo date, this is the first documented case of a dissecting thrombus of a Gore-Tex graft in the literature. This case emphasizes the need for anticoagulation and serial cross-sectional imaging (CT or CMR) in Fontan patients with prosthetic grafts throughout a patients’ lifetime.

Imaging Analysis During Adrenal Venous Sampling Operations

Abstract Background To investigate the imaging anatomy and variations of bilateral adrenal veins to improve the success rate during adrenal venous sampling (AVS) and reduce the incidence of complications. Methods A total of 120 patients who underwent AVS from June 2017 to January 2019 were collected. RadiAnt Viewer software was used to retrospectively analyze the intraoperative imaging data, intraoperative anatomical variation data, the success rate, and complications of AVS. Results The ostium of the right adrenal vein was located mainly between the lower 1/3 of the 11th thoracic vertebra and the middle 1/3 of the 12th thoracic vertebra, accounting for 75.5% of the cases. Most of the ostium (83.3%) was transversely distributed between 9 o’clock and 12 o’clock. The main morphology of the right adrenal venography was a triangular pattern (48.2%). As the body mass index increased, the ostium was higher, and the distance between the ostium and the spine was greater (P &amp;lt; 0.05). The success rate of the right AVS, the left AVS, and the bilateral AVS was 95.0%, 97.5%, and 92.5%, respectively. The anatomical variation rate of the right adrenal vein was 5.3%. All cases showed that the right adrenal vein entered the accessory right hepatic vein and then into the inferior vena cava. The anatomical variation rate of the left adrenal vein was 4.3%. Conclusions Body mass index can be used to predict the location of the right adrenal vein ostium. Understanding of the anatomy and variation of the adrenal vein and right adrenal venography is essential to a successful AVS.

Comparative anatomo-radiological study of intrahepatic venous vascularization in the Spain

BackgroundAnatomic variations in the hepatic venous system are the least understood aspect of hepatic anatomy. The variations are diverse, and data are lacking with respect to the population of Spain and methods of detection. The objective was to examine morphological patterns of variations in hepatic venous vascularization using cadaveric dissections vs. radiological imaging, and to analyze the findings with respect to Spain and to published studies. MethodsThirty-one livers were anatomically dissected and analyzed for their hepatic venous anatomy and then compared to the venous anatomy of livers examined in 216 CT scans from 119 men and 97 women, ranging between 27 and 89 years of age. Statistical analysis was done using the Chi squared and Fisher homogeneity tests. ResultsThe hepatic portal vein showed morphological variations in cadavers vs. CT of 67.3% vs. 67.6% (p-I), 29% vs. 12.2% (p-II), 0% vs. 14.6% (p-III), 0% vs. 14.6% (p-IV), 3.2% vs. 0.5% (p-V) and 6.5% vs. 1.9% (p-VI), respectively in cadavers vs. CT. Hepatic vein pattern variation were found in 64.5% vs. 50.7% (h-I), 32.2% vs. 31.5% (h-II), 0% vs. 2.3% (h-III), 0% vs. 4.7% (h-IV), respectively in dissections vs. CT). In Accessory Hepatic Veins the frequency in pattern variation was 64.5% vs. 18.8% (a-2.1), 29.0% vs. 8.0% (a-2.2), 58.1% vs. 11.3% (a-2.3), 9.7% vs. 0.9% (a-2.4), 67.7% vs. 16.9% (a-2.5), 9.7% vs. 4.2% (a-2.6) and 0% vs. 0.5% (a-2.7), respectively, in cadavers vs. CT. CT showed in 27.2% no accessory hepatic veins. Sex was not a factor influencing patterns of variation. ConclusionAnatomical variants of the hepatic portal vein, the hepatic vein and accessory hepatic veins are very diverse and show greater variability in the specimens compared to those detected with radiological images, finding a wider spectrum of variations as it allows the clinician to have a more precise definition of the vasculature. A higher precision in the definition of anatomical variations is warranted for surgical planning in liver resection and transplantation.

Recanalization of accessory hepatic vein for hepatic vein-type Budd-Chiari syndrome.

To evaluate the clinical efficacy and long-term outcomes associated with the treatment of hepatic vein (HV)-type Budd-Chiari syndrome (BCS) via accessory HV (AHV) recanalization. In total, 26 HV-type BCS patients underwent AHV recanalization between July 2014 and December 2019 at our hospital, while 73 HV-type BCS patients without compensatory AHV underwent main HV (MHV) recanalization and served as controls in the present study. Short- and long-term clinical outcomes were compared. AHV and MHV recanalization approaches were both associated with 100% technical success rates, with one recanalization procedure being performed per patient. Respective clinical success rates for the AHV and MHV recanalization approaches were 96.2% and 94.5% (P = 0.744). Re-obstruction rates were comparable between these two approaches at 20% and 34.8%, respectively (P = 0.17). Primary cumulative 1-, 2-, and 5-year patency rates in the AHV group were 96.0%, 91.6%, and 76.3%, respectively, whereas in the MHV group, these three respective rates were 87.0%, 78.6%, and 58.6% (P = 0.048). Secondary cumulative 1-, 2-, and 5-year patency rates in the AHV group were 96.0%, 96.0%, and 96.0%, respectively, whereas in the MHV group, they were 97.1%, 97.1%, and 81.8%, respectively (P = 0.289). Cumulative 1-, 2-, and 5-year survival rates for AHV group patients were 96.0%, 96.0%, and 96.0%, respectively, while for the MHV group, these respective rates were 98.6%, 95.2%, and 89.7% (P = 0.462). HV-type BCS can be safely and effectively treated via AHV recanalization, which may achieve longer patency relative to MHV recanalization.

Reverse ALPPS on Makuuchi Vein after Combined Systemic and Local Chemotherapy: Compound Existing CRLM Management Techniques to Achieve Surgical Resectability

Aims: The main aim of this report to show how incorporation of different techniques in CRLM management has created an opportunity for the resection of locally advanced hepatic tumors formerly considered unresectable. Materials and methods: The current study reports the case of a 38 year-old patient with synchronous CRLM involving all three hepatic veins initially deemed unresectable. The patient developed systemic chemotherapy with molecularly targeted therapy and selective transarterial chemoembolization during 12 months. Subsequent imaging demonstrated a decrease in tumor size with unchanged involvement of the major hepatic veins. However, a right accessory hepatic vein (Makuuchi vein) remained free of disease. Left trisectionectomy by reverse-ALPPS technique with right accessory hepatic vein preservation has been performed. Results: The patient was discharged on POD 14. At the most recent follow-up (23 months), he had presented without evidence of disease. Conclusions: Isolated CRLM where surgical resection is first-line treatment, technical advances and surgical innovations can expand the spectrum of curative interventions. Meantime in patients as was presented only the combination of cross-disciplinary techniques may transform primary irresectability. In this report, the simultaneous utilization of non surgical therapies and advanced surgical skills enabled resection for patients with complex tumors.

Experience in identifying the variant adrenal venous anatomy during modified retroperitoneoscopic adrenalectomy.

Background:Adrenal vein plays an important role in performing laparoscopic adrenalectomy successfully. However, it often presents with a multitude of venous anatomical variants. Hence, having a thorough knowledge on the variant types is crucial to reduce operative complications. This study aims to present our experience in identifying adrenal vein variation in adrenalectomy through modified retroperitoneal approach.Patients and Methods:A total of 187 patients underwent modified retroperitoneoscopic adrenalectomy between July 2017 and February 2019. Perioperative data and adrenal vein variants were recorded and analysed.Results:Variant adrenal veins were encountered in seven patients. On the right side, two cases were drained by two adrenal veins; one case had a common trunk of adrenal vein and an accessory hepatic vein and one case had an adrenal vein joined with the opening of the right renal vein. On the left side, two cases of anatomic variations were described as follows: one vein converged with the left inferior phrenic vein and joined with the left renal vein, whereas the other vein directly joined with the left renal vein. One case had two adrenal veins that joined with the left renal vein.Conclusions:Accurate identification and proper handling of the anatomical variation in the drainage of adrenal vein are crucial to safe LA. It is helpful to anticipate and avoid bleeding, especially in large adrenal tumours.

Ultrasonic Evaluation of Spontaneous Portosystemic Shunts in Patients with Budd-Chiari Syndrome

Background: Spontaneous portosystemic shunts (SPSS) are one of the hallmarks of Budd-Chiari syndrome (BCS). Ultrasound can accurately show the location and type of portosystemic collaterals. Objectives: To study the sonographic feature of SPSS in patients with BCS and to evaluate differences in the main portal vein diameter among multiple types of portosystemic shunts. Patients and Methods: Ultrasonographies of 44 patients with SPSS among 352 BCS patients between June 2000 and November 2015 were reviewed retrospectively. The SPSS in 44 BCS patients were first detected by ultrasound and then confirmed via digital subtraction angiography (DSA), computed tomography angiography (CTA) or magnetic resonance venography (MRV). The location, course, diameter and hemodynamics of the spontaneous portosystemic shunts were observed by ultrasound. In addition, one-way analysis of variance (ANOVA) was performed to evaluate the difference in the main portal vein diameter between the different shunt types. Results: The blood drainage patterns of SPSS in 44 of 352 patients with BCS were classified as the following five types: portal-umbilical shunts (15/44), portal-hepatic shunts (11/44), portal-accessory hepatic shunts (6/44) (the accessory hepatic veins included the inferior right hepatic vein and the caudate lobe vein), splenorenal shunts (8/44) and main portal vein-inferior vena cava shunts (4/44). The corresponding hemodynamics of the five types mentioned above were obtained. Main portal vein-inferior vena cava shunts had a significantly larger mean portal trunk diameter compared with all other types (P &lt; 0.05 for all comparisons). In addition, the mean portal trunk diameters in portal-umbilical shunts and portal-hepatic shunts were obviously larger than that of splenorenal shunts (P &lt; 0.05), while there were no statistically significant differences between the other types. Conclusion: Spontaneous portosystemic shunts are not rare in patients with BCS. Ultrasound is a reliable means for their diagnosis and it offers substantial information for use in clinical treatment.