Branch Of Portal Vein Research Articles

Study of ramification pattern of right branch of portal vein

Clinically unsuspected pulmonary embolism (UPE) is frequently diagnosed in cancer patients undergoing routine computed tomography scans for staging purposes or treatment response evaluation. The reported incidence of UPE ranges from 1% to 5% which probably represents an underestimation. A significant proportion of cancer patients with UPE actually do have pulmonary embolism (PE) related symptoms. However, these can erroneously be attributed to the cancer itself or to cancer therapy leading to a delayed or missed diagnosis. The incidence of UPE is likely to increase further with the improvements of imaging techniques. Radiologic features of UPE appear similar to symptomatic PE with nearly half of the UPE located in central pulmonary arteries and one third involving both lungs. UPE in cancer patients is not a benign condition with rates of recurrent venous thromboembolic events, bleeding and a mortality rate comparable to cancer patients with symptomatic PE. Current guidelines suggest that UPE should receive similar initial and long-term anticoagulant treatment as for symptomatic PE. However, direct evidence regarding the treatment of UPE is scarce and treatment indications are largely derived from studies performed in cancer patients with symptomatic venous thromboembolism. Selected subgroups of cancer patients with UPE such as those with sub-segmental UPE may be treated conservatively by withholding anticoagulation and avoiding the associated bleeding risk, although this requires further evaluation.© 2014 Elsevier Ltd. All rights reserved.

Terminal branches portal vein embolization for planed hepatectomy

To explore the application of the technique of terminal branches portal vein embolization(TBPVE)for planed hepatectomy. From February 2016 to June 2016, 4 patients with hepatocellular carcinoma underwent TBPVE and liver resection in Yuebei People's Hospital (n=3) and Jiangxi Ji'an Central People's Hospital (n=1). All of them were male and were 50, 64, 39 and 47 years old respectively. All the tumors located in the right lobe. All patients had the liver function of Child-Pugh A classification and liver cirrhosis level of G2S4. The standard liver volume (SLV) were 1 291, 1 109, 1 177 and 1 242 ml and estimated future liver remnant(FLR) were 315, 347, 306 and 323 ml respectively. The puncture site of TBPVE was determined by the three-dimensional reconstruction of portal vein. Three patients were punctured in the segment Ⅵ and the other one punctured in the segment Ⅲ. CT scan was repeated 2 weeks after TBPVE and FLR and FLR/SLV were calculated. All patients underwent right hepatectomy 2 weeks after TBPVE. On the 14(th) day after TBPVE, the FLR of 4 patients were 529, 462, 469 and 498 ml which increased 67.9%, 33.1%, 53.3% and 54.2% compared with that before TBPVE, and FLR/SLV were 41.0%, 41.7%, 39.8% and 40.1% respectively. No severe complication occurred. Right hepatectomy were performed 2 weeks after TBPVE. No inflow blood control applied during the liver resection. The mean blood loss was 950 ml and the mean operating time was 3.3 hours (ranging from 3 to 4 hours). One patient had respiratory infection and two had slight jaundice and ascites for a short period. No other complication occurred. The TBPVE could induce a rapid and large FLR volume that give chances to patients with small FLR to have liver resection for hepatocellular carcinoma.

Distribution of Extra Hepatic Branches of Portal Vein to Caudate Lobe

The caudate lobe of the liver is anatomically distinct from left and right hepatic lobes. Kumon first divided it into three parts: Spiegel lobe, paracaval portion and caudate process. The present study was conducted to note the extra hepatic branching pattern of PV and its distribution to various parts of caudate lobe and to note its variations. Eighty six cadaveric livers were studied. Number of branches from extra hepatic part of portal vein supplying different parts of caudate lobe, their origin from right branch (RPV) or left branch of portal vein (LPV) or from hilar bifurcation (HB) was noted. Their distribution to the parts of caudate lobe and diameter at origin was noted. At least one separate branch to caudate lobe from extra hepatic part of PV was present in 93.02% livers. 62.11% branches were originating from LPV, 26.09% from hilar bifurcation and 11.8% were from the RPV. Spiegel lobe received 98.64% from LPV and 1.35% from HB. Paracaval portion was supplied by 43.54% branches from LPV, 48.39% from HB and 8.06% from RPV. The caudate process received 56% branches from RPV and 44% from HB. Knowledge of vascular anatomy of caudate lobe is important for hepatic surgeons and for anatomists.

Application value of split-bolus spectral computed tomography in the portal venography

Objective To investigate the effect of split-bolus spectral computed tomography(CT) on the portal venography and radiation dose. Methods The prospective study was adopted. The clinical data of 119 patients who underwent spectral CT at China-Japan Union Hopital from September 2014 to March 2015 were collected. Patients were randomly divided into the portal venography with split-bolus spectral CT single-phase enhanced scan group and portal vein multi-phase scan group by random sequence method. In the portal venography with split-bolus spectral CT single-phase enhanced scan group, the spectral CT was used with the method of split-bolus single phase imaging, and in the portal vein multi-phase scan group, standard spiral CT was used to perform three-phase scan. Two observers evaluated CT portal venography subjectively and objectively, measured CT values, contrast to noise ratio (CNR), signal noise ratio (SNR), and calculated radiation dose. Observed indices included (1) choice of optimal monochromatic images. (2) CT values of portal veins, measurement of CNR and SNR. (3) Subjective scoring of portal venography quality. (4) Comparison of radiation dose. Measurement data with normal distribution were presented as±s, comparison between groups was analyzed by independent sample t test. Comparison of count data was analyzed by chi-square test. Results The 113 patients were screened for eligibility, including 59 in the portal venography with split-bolus spectral CT single-phase enhanced scan group and 54 in the portal vein multi-phase scan group. (1) Choice of optimal monochromatic images: optimal monochromatic images were abstracted at 60 keV from spectral CT portal venography. (2) CT values of portal veins and measurement of CNR and SNR: the CT values of intrahepatic portal vein, extrahepatic portal vein and branches of portal vein were (319±44)HU, (328±53)HU, (294±45)HU in the reconstructed images at the energy level of 60 keV in the portal venography with split-bolus spectral CT single-phase enhanced scan group and (213±41)HU, (228±49)HU, (210±41)HU in the portal vein multi-phase scan group, with significant differences between the 2 groups(t=8.04, 6.34, 6.82, P 0.05). The SNR of intrahepatic portal vein, extrahepatic portal vein and branches of portal vein were 31±6, 29±6, 27±6 in the portal venography with split-bolus spectral CT single-phase enhanced scan group and 29±7, 28±9, 26±6 in the portal vein multi-phase scan group, respectively, with no significant differences (t=-0.688, 0.615, 0.600, P>0.05). (3) Subjective scoring of portal venography quality: the subjective score of image quality of portal venography was 14.3±1.0 in the portal venography with split-bolus spectral CT single-phase enhanced scan group and 12.5±1.8 in the portal vein multi-phase scan group, with a significant difference (t=12.43, P<0.05). (4) Comparison of radiation dose: the radiation dose was (8.1±1.1)mSv of patients in the portal venography with split-bolus spectral CT single-phase enhanced scan group and (17.4±7.5)mSv in the portal vein multi-phase scan group, with a significant difference (t=24.14, P<0.05). Conclusion Spectral CT portal vein imaging combined with split-bolus protocol can achieve better manifestations of portal vein and its branches, and reduce radiation dose in the scanning process. Key words: Liver diseases; Portal vein; Spilt-bolus; Tomography, X-ray computed; Spectral imaging; Radiation dose

Limits of and Complications after Embolization of the Hepatic Artery and Portal Vein to Induce Segmental Hypertrophy of the Liver: A Large Mini-Pig Study

Background: The aim of this study was to compare arterial embolization (AE) with portal vein embolization (PVE) for the induction of segmental hypertrophy regarding procedural efficacy, safety and outcome. Methods: A total of 29 mini pigs were subjected to PVE, AE or assigned to the sham (SO) group. Correspondingly, 75% of the hepatic artery or portal vein branches were embolized. Growth and atrophy of the liver lobes, calculating the liver-to-body weight index (LBWI), laboratory data, arteriography, portography, Doppler ultrasound (US) and histopathology were analyzed. Results: After PVE, 2 animals had to be excluded due to technical problems. After AE, 4 animals had to be excluded because of technical problems and early sacrifice. Postprocedural US demonstrated effective AE and PVE of the respective lobes. Four weeks after PVE, portography showed a slow refilling of the embolized lobe by collateral portal venous vessels. Four weeks after AE, arteriography revealed a slight revascularization of the embolized lobes by arterial neovascularization. Segmental AE led to extensive necrotic and inflammatory alterations in the liver and bile duct parenchyma. Significant hypertrophy of the non-embolized lobe was only noted in the PVE group (LBWI: 0.91 ± 0.28%; p = 0.001). There was no increase in the non-embolized lobe in the AE (LBWI: 0.45 ± 0.087%) and SO group (LBWI: 0.45 ± 0.13%). Conclusion: PVE is safe and effective to induce segmental hypertrophy. Portal reperfusion by collateral vessels may limit hypertrophy. AE did not increase the segmental hepatic volume but carries the risk of extensive necrotic inflammatory damage.

Combined Multidimensional Microscopy as a Histopathology Imaging Tool.

Herein, we present a highly versatile bioimaging workflow for the multidimensional imaging of biological structures across vastly different length scales. Such an approach allows for the optimised preparation of samples in one go for consecutive X-ray micro-computed tomography, bright-field light microscopy and backscattered scanning electron microscopy, thus, facilitating the disclosure of combined structural information ranging from the gross tissue or cellular level, down to the nanometre scale. In this current study, we characterize various aspects of the hepatic vasculature, ranging from such large vessels as branches of the hepatic portal vein and hepatic artery, down to the smallest sinusoidal capillaries. By employing high-resolution backscattered scanning electron microscopy, we were able to further characterize the subcellular features of a range of hepatic sinusoidal cells including, liver sinusoidal endothelial cells, pit cells and Kupffer cells. Above all, we demonstrate the capabilities of a specimen manipulation workflow that can be applied and adapted to a plethora of functional and structural investigations and experimental models. Such an approach harnesses the fundamental advantages inherent to the various imaging modalities presented herein, and when combined, offers information not currently available by any single imaging platform. J. Cell. Physiol. 232: 249-256, 2017. © 2016 Wiley Periodicals, Inc.

Left Hemiliver Medial Sector-Portal Venous Anatomy

Background: The aim of this study was to classify the left hemiliver medial sector portal branches on the basis of their site of origin and area that supply. The leading motive for this investigation was to contribute to the modern liver practice, especially to the respective and transplantation ones. Methods: The examined material consisted of 27 portobiliary casts performed by injection-corrosive method using adult cadaveric human liver specimens. During observation under magnifying lens were determined the site and kind of origin of medial sector portal branches, numerical frequency of segmental portobiliary elements and their relation. Results: According to the supplied area two distinct segmentssuperior IVa and inferior IVb were distinguished. At the level of each segment portal branches appeared as main, additional and newly ramified. As to their origin at the level of segment IVa the mixed origin (separate and common) was prevalent versus separate or only common origin - 17/7/2 cases and portal branches were not observed in only one case in this segment. Also, at the level of segment IVb the mixed origin of portal branches was prevalent versus separate ones - 19/8 cases. The incidence of newly ramified branches to segment IVa was 22.22% and to segment IVb 37.037%. At the level of segment IVa there were additional or newly ramified branches on the superior surface of umbilical portion of the left portal vein branch (37.037%) and only additional branches for segment IVb on the superior, as well as inferior surface of this portion (7.41%). Conclusion: In the left hemiliver medial sector portal branches supply two distinct segments-superior SgIVa and inferior SgIVb. At the level of each segment multiple branches with varied number appear as main, additional and newly ramified. According to their origin the branches may be either separate for each segment or additionally to the branches with separate origin common branches for both segments and only with common origin branches to the SgIVa.

Remedial radiofrequency ablation or portal vein embolization combined with radiofrequency ablation-assistant associating liver partition and portal vein ligation for staged hepatectomy in the treatment of patients with hepatocellular carcinoma with cirrhosis

Objective To explore the clinical effect of remedial radiofrequency ablation (RFA) or portal vein embolization (PVE) combined with radiofrequency ablation-assistant associating liver partition and portal vein ligation for staged hepatectomy (RALPPS) in the treatment of patients with insufficient future liver remnant (FLR) after the first staged operation and hepatocellular carcinoma (HCC) with cirrhosis. Methods The retrospective and descriptive cross-sectional study was adopted. The clinical data of 5 patients with insufficient FLR after the first staged of RALPPS and HCC with cirrhosis who underwent remedial RFA or PVE at the Southwest Hospital of the Third Military Medical University between September 2014 and February 2016 were collected. Standard liver volume (SLV)=613.0×body surface area (BSA)+ 162.8, BSA=0.007 1×height+ 0.013 3×body mass. Patients with FLR<40% received RALPPS. In the first staged operation, RFA was used to cauterize a coagulated avascular area between the FLR and contralateral lobe, and then right branch of portal vein was ligated. After the operation, remedial RFA or PVE was performed in patients with insufficient FLR. Once the FLR achieved the target value, the second staged RALPPS was performed. Observation indicators included (1) perioperative complications and death, complications in stage IIIa and above of Clavien-Dindo as main complications, (2) changes of FLR and tumor progression, (3) intraoperative situation, (4) follow-up. The follow-up using outpatient examination was performed up to February 2016, including laboratory examination, tumor markers and imaging examinations (enhanced scan of computed tomography in the epigastric region or ultrasound). Measure-ment data with normal distribution were represented as ±s. Results (1) Perioperative complications and death: of 5 patients, 2 didn′t receive second staged RALPPS and 3 completed both stages. Five patients had no postoperative main complications and 1 died of renal failure and pulmonary infection after second staged RALPPS. (2) Changes of FLR and tumor progression: the average FLR and percentage of FLR to SLV were (329±80)cm3 , 25%±5% in 5 patients before first staged operation and (533±45)cm3, 43%±3% in 3 patients before second staged operation, with an average growth rate of 44%-113%. The average interval time of 5 patients was (29.0±2.2)days. For the 3 patients which completed both stages, the 1-week increased percentage of FLR was 33.5%-68.9% after first staged operation, 1.2%-14.3% and 9.7%-29.8% before and after remedial RFA or PVE. Two patients didn′t undergo the second staged operation, 1 patient was due to not reach standard of safe resection after 4 times remedial PVE, and 1 patient was due to tumor metastasis during intermittent stage after remedial RFA with average FLR after 2 weeks and average 1-week increased percentage of 762.0 cm3 and 10.6%. (3) Intraoperative situations: 1 patient underwent laparoscopic-assisted first staged RALPPS and 1 underwent RFA in the left lobe of liver. The first staged operation time, RFA time and volume of intraoperative blood loss were (240±43)minutes, (15±8)minutes and (190±136)mL, and no patient had blood transfusion. After first staged operation, 5 patients received 5 times remedial PVE and 7 times RFA. Two patients underwent right hemihepatectomy and 1 patient underwent hepatic trisegmentectomy in the second staged operation. The second staged operation time and volume of intraoperative blood loss of 3 patients were (257±33)minutes and (303±73)mL, and 3 patients received R0 resection and no intraoperative blood transfusion. (4) Follow-up: 1 patient was dead during hospitalization and 4 patients were followed up for 1-12 months with a median time of 6 months. Of 2 patients without second staged operation, 1 continued to undergo interventional treatment and then was dead after half year, and 1 continued to undergo transcatheter arterial chemoembolization (TACE) and had good survival up to the end of follow-up. Of the other 2 patients, 1 with tumor recurrence at postoperative month 2 received interventional treatment and traditional Chinese medicine and then was dead after 6 months, and 1 had no tumor recurrence and metastasis during the follow-up. Conclusion For the patients with HCC with cirrhosis who had insufficient FLR after the first staged RALPPS, remedial RFA or PVE could promote further regeneration of FLR and thus improve the completion rate of both stages. Key words: Liver neoplasms; Cirrhosis; Associating liver partition and portal vein ligation for staged hepatectomy; Radiofrequency ablation; Portal vein embolization; Future liver remnant

Percutaneous electrochemotherapy of malignant main portal veins thrombosis: a prospective case series.

e15586Background: We report our experience in thrombosis of portal vein and/or 1st order branches (Vp3-4PVTT) from Hepatocellular carcinoma (HCC) treated with Percutaneous Electrochemotherapy (ECT)...

Laparoscopic approach of hepatic hydatid double cyst in pediatric patient: difficulties, indications and limitations

Purpose: Laparoscopic management analysis of a rare condition having potentially severe evolution, seen in pediatric surgical pathology. Aims: Outlining the optimal surgical approach method of hepatic hydatid double cyst and the laparoscopic method’s limitations. Materials and Methods: The patient is a 6 years old girl that presented with two simultaneous giant hepatic hydatid cysts (segments VII-VIII), having close vicinity to the right branch of portal vein and to hepatic veins; she benefited from a single stage partial pericystectomy Lagrot performed by laparoscopy. Results: The procedure had no intraoperative accidents or incidents. Had good postoperative evolution without immediate or late complications. Trocars positioning had been adapted to the patient’s size and cysts topography. Conclusions: The laparoscopic treatment is feasible and safe, but is not yet the gold standard for a hepatic hydatid disease due to certain inconveniences.

Three-dimensional C-arm CT-guided transjugular intrahepatic portosystemic shunt placement: Feasibility, technical success and procedural time.

Establishment of transjugular intrahepatic portosystemic shunts (TIPS) constitutes a standard procedure in patients suffering from portal hypertension. The most difficult step in TIPS placement is blind puncture of the portal vein. This study aimed to evaluate three-dimensional mapping of portal vein branches and targeted puncture of the portal vein. Twelve consecutive patients suffering from refractory ascites by liver cirrhosis were included in this retrospective study to evaluate feasibility, technical success and procedural time of C-arm CT-targeted puncture of the portal vein. As a control, 22 patients receiving TIPS placement with fluoroscopy-guided blind puncture were included to compare procedural time. Technical success could be obtained in 100% of the study group (targeted puncture) and in 95.5% of the control group (blind puncture). Appropriate, three-dimensional C-arm CT-guided mapping of the portal vein branches could be achieved in all patients. The median number of punctures in the C-arm CT-guided study group was 2 ± 1.3 punctures. Procedural time was significantly lower in the study group (14.8 ± 8.2min) compared to the control group (32.6 ± 22.7min) (p = 0.02). C-arm CT-guided portal vein mapping is technically feasible and a promising tool for TIPS placement resulting in a significant reduction of procedural time. • C-arm CT-mapping of the portal vein for 3D TIPS guidance is feasible. • Targeted punctures of the portal vein by C-arm CT reduce procedural time. • A decreased number of punctures could improve patient safety.

Incertitudini în managementul postoperator al unei paciente gravide, cu chist hidatic hepatic

There are 3 therapeutic modalities to treat cystic echinococcosis: chemotherapy, surgery (classic or laparoscopic), PAIR technique (puncture, aspiration, injection, and re-aspiration), with the latter two being performed with or without chemotherapy. We present the case of of a 17-year-old female, with a 6-month-old caesarean section in her medical history, diagnosed, by another medical facility, with a hepatic hydatid cyst, who presents with pain in the right hypochondrium, nausea and vomiting. The ultrasound examination revealed a cystic mass in the fifth hepatic segment, on the visceral surface, which compresses the right branch of portal vein and the gall bladder. It was decided to perform a Lagrot cystectomy under general anesthesia with orotracheal intubation. The pacient received albendazole postoperatively, knowing that the patient will continue breastfeeding, because this treatment can be safely administered due to the reduced concentration of the active metabolite in breast milk.

Portal Vein Embolization as an Oncosurgical Strategy Prior to Major Hepatic Resection: Anatomic, Surgical, and Technical Considerations.

Preoperative portal vein embolization (PVE) is used to extend the indications for major hepatic resection, and it has become the standard of care for selected patients with hepatic malignancies treated at major hepatobiliary centers. To date, various techniques with different embolic materials have been used with similar results in the degree of liver hypertrophy. Regardless of the specific strategy used, both surgeons and interventional radiologists must be familiar with each other’s techniques to be able to create the optimal plan for each individual patient. Knowledge of the segmental anatomy of the liver is paramount to fully understand the liver segments that need to be embolized and resected. Understanding the portal vein anatomy and the branching variations, along with the techniques used to transect the portal vein during hepatic resection, is important because these variables can affect the PVE procedure and the eventual surgical resection. Comprehension of the advantages and disadvantages of approaches to the portal venous system and the various embolic materials used for PVE is essential to best tailor the procedures for each patient and to avoid complications. Before PVE, meticulous assessment of the portal vein branching anatomy is performed with cross-sectional imaging, and embolization strategies are developed based on the patient’s anatomy. The PVE procedure consists of several technical steps, and knowledge of these technical tips, potential complications, and how to avoid the complications in each step is of great importance for safe and successful PVE and ultimately successful hepatectomy. Because PVE is used as an adjunct to planned hepatic resection, priority must always be placed on safety, without compromising the integrity of the future liver remnant, and close collaboration between interventional radiologists and hepatobiliary surgeons is essential to achieve successful outcomes.

Rex shunt in pediatric prehepatic portal hypertension: a clinical analysis of 5 cases

Objective To study the therapeutic efficacy of Rex shunt in treating pediatric patients with prehepatic portal hypertension (PHPH). Methods Five children with PHPH who were admitted from October 2014 to May 2015 were reviewed. There were three boys and two girls, with age ranging from 50 to 95.5 months [(75.8±1.9) months]. They all suffered from recurrent upper gastrointestinal (GI) blee-ding. Their red blood cell (RBC), white blood cell (WBC) and platelet (PLT) counts were decreased, but laboratory findings revealed no liver dysfunction. Ultrasound and CT scan diagnosed cavernous transformation of portal vein (CTPV) and splenomegaly. The mean splenic length was (42.8±8.2) cm. Indirect portal venography revealed patent left portal vein. All patients underwent Rex shunt and were followed up for 3~7 months. Results The mean duration of operation was (566.0±39.7) min. Intraoperative bleeding varied from 10 to 50 ml. The portal pressure significantly decreased after surgery from [(25.6±1.5) mmHg, 1 mmHg=0.133 kPa] preoperatively to (19.2±3.3) mmHg postoperatively (P<0.05). Portal venography indicated patent left portal vein after the Rex shunt. The postoperative course was uneventful in the five patients with a mean hospital stay of (26±9.3) days. There was no further GI bleeding. The RBC, WBC and PLT counts increased. Ultrasound indicated patent anastomotic stomas and decreased splenic size. Conclusion A Rex shunt in treating patients with PHPH is safe, feasible and efficacious. Key words: Rex shunt; Prehepatic portal hypertension; Cavernous transformation of portal vein; Children; Superior mesenteric vein; Left branch of portal vein

Delayed Severe Hemobilia Due to Bilio-venous Fistula After Percutaneous Transhepatic Biliary Drainage: Treatment With Covered Stent Placement

Biliovenous fistula occurs due to development of a communication between hepatic duct and portal vein branches and is a rare complication of percutaneous transhepatic biliary drainage (PTBD). Most of them are self-limiting and only occasionally they need interventional management. Placement of biliary stent graft is a viable option. We present here a case of a 56-year-old male with carcinoma of gall bladder presenting with hemodynamic shock due to severe hemobilia after PTBD and treated successfully by biliary covered stent placement.

Incidence and clinical sequelae of portal and hepatic venous thrombosis following percutaneous cryoablation of liver tumors

To assess the incidence and sequelae of portal and hepatic venous thrombosis after percutaneous cryoablation of hepatic tumors. From November 1998 through December 2010, 223 hepatic tumors were cryoablated during 170 ablation procedures in 135 patients. 24-h post-procedure MR images were reviewed retrospectively by two abdominal radiologists in consensus to identify tumor ablations that developed one or more new portal or hepatic venous thromboses in or outside the ablation zone. On follow-up MRI and CT examinations the outcomes of thromboses were classified as resolved, partially recanalized, persistent, or propagated. Venous thrombosis developed in association with 54 (24%) of 223 tumor ablations treated during 53 (31%) ablation procedures in 39 (28.8%) patients (15 women, 24 men; age range 40-82years, mean 59years). Of these 54 thromboses, 49 (91%) were located in portal vein branches, four (7%) in both portal and hepatic vein branches, and one (2%) in a hepatic vein branch. Thrombosed veins were outside but abutted the ablation zone in 36 (66.7%), and within it in 18 (33.3%). On follow-up imaging (n=49), thrombi resolved in 29 (59%), partially recanalized in two (4%), persisted in 18 (37%) and propagated from sub-segmental or segmental branches to the left or right portal branches in five (10%). No thrombus propagated to the main portal vein or inferior vena cava. Portal and hepatic vein branch thromboses are common in small branches following percutaneous cryoablation of hepatic tumors and most resolve spontaneously without sequelae.

Preoperative Portal Vein Embolization in the Combined Treatment of Malignant Liver Tumor

Aim. To improve the efficiency of preoperative portal vein mbolization as a method of prevention of postoperative liver failure after extensive resections. Material and Methods. The study included 30 patients with isolated liver tumors in whom advanced liver resection was planned. 33 embolizations were performed. In 23 observations mechanical embolization and scleroobliteration of the right branch of portal vein were made, oily chemoembolization and mechanical embolization of the right branch of the portal vein – in 10 cases. In 8 cases preoperative portal vein embolization was performed after oily chemoembolization of hepatic artery. 3 patients underwent repeated portal vein embolization due to insufficient hypertrophy of the remaining liver parenchyma. Results. Volume of remnant liver parenchyma increased by 41% after preoperative portal vein embolization on the average. In 5 cases insufficient volume of remnant liver was marked. The reasons of insufficient liver volume were partial recanalization of the embolized branches of the portal vein, the development of multiple intrahepatic portal collaterals (hemostatic spongeas as a embolic material in 3 cases), liver cirrhosis and 2 lines of previous chemotherapy in history (2 cases). In 3 patients repeated portal vein embolization using PVA particles and scleroobliteration with etoxisclerol foam was performed to achieve necessary hypertrophy. Extensive liver resection was performed in 24 patients. Postoperative mortality was noted in 2 cases. There was similar frequency of postoperative complications in patients with and without preoperative portal vein embolization. Conclusion. Preoperative portal vein embolization is a minimally invasive technique for increase of remnant liver volume prior to advanced liver resection without augmentation of postoperative complications rate. The results and technique may be improved (segment IV branch embolization, the use of foam scleroobliteration, mechanical occlusion combined with chemoembolization, combination of portal vein embolization and hepatic artery chemoembolization). Repeated embolization procedures can provide necessary liver hypertrophy in some cases

SAT-082 - Percutaneous Electrochemotherapy of Malignant Main Portal Veins Thrombosis: A Prospective Case Series

e15586Background: We report our experience in thrombosis of portal vein and/or 1st order branches (Vp3-4PVTT) from Hepatocellular carcinoma (HCC) treated with Percutaneous Electrochemotherapy (ECT)...

Intraoperative air embolism during hepatectomy.

Sir, Vascular air embolism (VAE) is a rare and lethal complication of partial hepatectomy with a relative risk of <5%.[1] Even in the absence of intracardiac abnormalities, paradoxical embolism can occur in cirrhotic patients undergoing liver resection because of abnormal arteriovenous communications in the pulmonary circulation.[2] Anaesthetic vigilance along with thorough knowledge of surgical interventions and ensuing physiological perturbations is essential for ensuring patient survival. A 56-year-old female diagnosed with hilar cholangiocarcinoma was posted for extensive right hepatectomy. Clinical examination was normal except for the presence of jaundice with elevated bilirubin and liver enzymes. Anaesthetic technique included general anaesthesia with thoracic epidural block. Electrocardiogram (ECG), oxygen saturation, blood pressure and end-tidal carbon dioxide (ETCO2) were monitored. Left radial artery was cannulated for invasive blood pressure (IBP) monitoring and right internal jugular vein for central venous pressure (CVP), with double lumen 7 Fr central venous catheter (CVC). To reduce the blood loss and transfusion requirements, a low CVP (≈5 mmHg) was targeted. Hepatic resection using cavitron ultrasonic surgical aspirator (CUSA) began after clamping the branches of portal vein and hepatic artery to the right lobe. Three hours into the surgery, surgeon informed accidental opening of a branch of hepatic vein which got retracted into liver parenchyma. Simultaneously, a distinct sucking-in sound was heard, following which IBP dropped to 50/40 mmHg and ETCO2 to 22 mmHg from 34 mmHg while oxygen saturation and CVP (8 mmHg) remained stable. VAE was suspected and nitrous oxide was cut off and the patient ventilated with 100% oxygen. Surgical field was immediately covered with saline-soaked gauze, and then flooded with saline. Resuscitative measures were initiated rapidly with fluid resuscitation, dopamine infusion at 10μg/kg/min and adopting a Trendelenburg position. Aspiration of CVC produced 3 ml of frothy blood. As IBP remained low, epidural infusion was discontinued and a bolus of 50μg adrenaline was administered intravenously. Once vitals stabilised, surgery proceeded with 100% oxygen after giving fentanyl and midazolam. Fifteen minutes later, a second episode of VAE occurred and was accompanied by a fall in oxygen saturation, IBP, ETCO2 and a rise in CVP to 18 mmHg. ECG showed frequent atrial ectopic beats. Dopamine infusion rate was increased and CVC aspirated to obtain 3–4 ml of air. Two more episodes of haemodynamic instability occurred which was treated similarly. At the end of the procedure, her vitals were stable with dopamine support. She was shifted to intensive care unit and was weaned from haemodynamic and ventilator support next day. Factors predisposing to VAE during liver resection include surgical technique, size and site of the tumour, blood loss and low CVP.[3] There are reports of increased incidence and severity of VAE during hepatic resection using CUSA.[4,5] Resection of large tumours situated in the right lobe close to inferior vena cava or the cavo-hepatic junction increases the risk of VAE.[3] Low CVP further enhances the negative pressure gradient and increases the possibility of VAE. Hepatic vascular control using selective hepatic vascular exclusion (SHVE) technique reduces both blood loss and risk of VAE.[3] In our case, site of the tumour, resection using CUSA and lack of SHVE technique along with low CVP anaesthesia all contributed to the incident. Although lethal volume of venous air for adults is about 200–300 ml, the proximity of the entraining vessel to the heart makes even smaller volumes fatal in liver resection.[1,3] Management consists of steps to prevent further entrainment of air and haemodynamic support with inotropic agents.[1,2,3,4] To conclude, both surgeons and anaesthesiologists should be aware of the risk for VAE during hepatectomy and employ appropriate surgical techniques and levels of monitoring to ensure patient safety. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Modern Methods of Liver Fragment Vicarious Hypertrophy Stimulation prior to Advanced Resections: Assessment of Efficiency and Ways to Improve the Results

Aim. To assess an efficiency of modern methods of vicarious hypertrophy stimulation of the remnant liver after advanced resection and to reduce the risk of postoperative liver failure. Material and Methods. Programmed stimulation of liver vicarious hypertrophy was applied in 119 patients including ligation and transection of portal vein branches in 76 patients (64.8%), endovascular embolization of portal vein branches in 21 patients (17.6%), endovascular embolization of the portal vein combined with chemoembolization of the hepatic artery in 15 patients (12.7%), and split in situ liver resection in 7 patients (5.9%). Volume of remnant liver was measured using computerized tomography, magnetic resonance imaging and/or ultrasound prior to and in 2–4 weeks after occlusion of portal vein branches. Results. According to CT/MRI data remnant liver volume increased from 28.4% to 48.7% (by 38.9 ± 5.5% on the average). 72 patients (60.5%) were operated: right-sided or extended right-sided hemihepatectomies were performed in 49 cases (68%), atypical liver resection – in 21 cases (29.2%). Postoperative complications were registered in 16 cases (22%). Mortality due to post-resection hepatic failure was 2.8%. Liver resection was not performed in 47 cases (39.5%) due to insufficient increase of liver fragment, newly diagnosed intrahepatic metastases or local recurrence of colorectal cancer. Conclusion. Preoperative programmed stimulation of liver fragment is a perspective method that increases percent of operable patients with liver tumors and reduces the risk of hepatic failure after extensive liver resection. Surgical and endovascular methods of preoperative programmed stimulation of liver vicarious hypertrophy are technically feasible and safe.