Branch Of Portal Vein Research Articles

Abstract No. 412 - CT spectrum of findings in liver parenchyma after transarterial chemoembolization with DC-beads

Purpose To describe MDCT findings and parenchymal changes after transarterial chemoembolization (TACE) with DC-beads in the treatment of primary and metastasic liver tumors. Materials and Methods Baseline and follow-up CT scans obtained in 93 patients with TACE DC-bead treatment between September 2009 and March 2012 were reviewed retrospectively to evaluate changes in biliary ducts, adjacent portal vein branches and hepatic parenchyma. Clinical data including etiology and correlation with CT findings were analyzed using the Fischer test. A p Results 93 patients, 55 men and 38 women (21-78 years) were evaluated. Etiologies included 44 hepatocellular carcinomas (38 with cirrhosis), 17 neuroendocrine metastases, 10 colorectal metastases and 22 others. The average time between TACE and follow-up CT was 50 days (r6-172). The most frequent findings at follow-up were bile duct dilatation (41.9%, n 39), obliteration of adjacent intrahepatic portal vein branches (31.1%, n 29), bilomas (26.8%, n 25), parenchymal hypodense ill-defined areas (44%, n 41), parenchymal infarcts (6.4%, n 6), periportal edema (35.4%, n 33) and perilesional parenchymal enhancement (23.6%, n 22). One patient (1.07%) had an abscess. The first 4 findings showed significant negative association with cirrhosis. In spite of these findings, there were no clinical relevant manifestations in these patients. There were no mayor complications reported. Only one patient required a percutaneous drainage catheter to drain an abscess. Conclusion The spectrum of MDCT findings we report after transarterial chemoembolization with DC-beads were not related with clinical manifestations of mayor complications in most cases. It is important for the radiologist to be familiar with these changes in order to distinguish collateral findings from complications and residual or recurrent tumor.

Abstract No. 385 - Clinical correlation between hepatic vein opacification and hepatopulmonary shunt fraction for 90Y evaluation

Purpose Hepatopulmonary shunt (HPS) fraction ≥20% is one of the occasional criteria preventing 90Y therapy. This study aimed to identify if there is clinical correlation between hepatic vein (HV) opacification and HPS during initial evaluation for 90Y therapy. Materials and Methods We collected 90Y candidates from 2004 to 2011. Patient’s underlying disease, imaging, arteriograms, and HPS calculations were retrospectively reviewed. If the HV was opacified during visceral arteriogram, the time between contrast injection and HV visualization was recorded. Statistical analysis with unpaired t-test compared the time of HV visualization in patients with and without an elevated HPS fraction. Results Total of 151 initial 90Y work up studies in 149 patients were included. The diagnoses included 75 HCC, 53 neuroendocrine tumor metastases, 14 colorectal metastases, 3 cholangiocarcinoma and 4 other metastases. Imaging revealed multifocal disease(n=117, 77%), bilobar disease(102, 68%) and macrovascular invasion (41, 27%). Macrovascular invasions included 4 HV and IVC, 2 HV and portal vein (PV), 1 IVC, 11 main PV, 1 right main PV, 16 right PV branch, 2 left main PV and 4 left PV branch. Mean maximum tumor diameter was 6.9±3.6 cm. Twenty-nine patients (19%) did not complete Y90 therapy; due to (18) high HPS, (5) unfavorable vascular anatomy, (2) declining liver function, (1) gastric uptake, (1) extrahepatic tumor, (1) poor tumor localization and (1) misdiagnosis. HV opacification was noted in 15 studies. Nine out of 15 studies showed HPS fraction ≥20%. PPV and NPV of HV opacification as a predictor of high HPS fraction were 60% and 94%. Average time until visualized HV in patients whom HPS fraction ≥20% and Conclusion The results demonstrated that visualization of the HV during initial arteriogram alone may not be sufficient to predict high HPS. We found that HV opacifications were seen on arteriograms earlier in the patients with high HPS (≥20%) than the patients with shunt

8:32 AM Abstract No. 132 - Transarterial chemoembolization combined with sorafenib for advanced hepatocellular carcinoma with portal vein tumor thrombus: A prospective control study

Purpose To assess the efficacy and safety of transarterial chemoembolization (TACE) combined with sorafenib for advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). Materials and Methods 106 patients with advanced HCC were enrolled in this study. Among them, 45 were treated with TACE and sorafenib (T+S group), 61 were treated with TACE alone (T group). In T+S group, sorafenib was orally administered 3-5 days after first TACE (400 mg twice daily). Sorafenib was not interrupted during follow-up TACE treatments. PVTT was classified as follows: tumor involving the main portal vein (type A), right/left portal vein (type B), segmental branches of portal vein (type C) and without portal vein invasion (type D). Baseline characteristics, disease control rate (DCR), time to tumor progression (TTP), overall survival (OS) and adverse events (AEs) were compared for the two groups. Results The baseline characteristics between T+S group and T group were similar (P>0.05). DCR in T+S group was significantly higher than in T group (P=0.001). With the exception of patients with type A, the median TTP and OS of patients with type B, type C and type D were significantly improved in T+S group than in T group (P 0.05); however in patients with type A, liver function at 1 month after treatment deteriorated significantly. 37 patients (82.2%) experienced AEs related to sorafenib. Among them, 9 required sorafenib dose reductions for grade 3 hand-foot skin reactions in 5 patients and grade 3/4 diarrhea in 4 patients; 4 required sorafenib interruption for gastrointestinal hemorrhage. Conclusion TACE combined with sorafenib in patients with advanced HCC was safe. Patients without main portal vein invasion can obtain benefit from the combined treatment, which have a longer TTP and OS than TACE alone. However, in patients with main portal vein invasion, although sorafenib is recommended according to Barcelona Clinic Liver Cancer therapy guide, our results do not support the combination therapy in these patients.

Percutaneous Transsplenic Portal Vein Catheterization: Technical Procedures, Safety, and Clinical Applications

PurposeTo evaluate the safety and feasibility of percutaneous transsplenic portal vein catheterization (PTSPC) by retrospective review of its use in patients with portal vein (PV) occlusion. Materials and MethodsFrom July 2004 to December 2010, 46 patients with a history of uncontrolled gastroesophageal variceal bleeding secondary to portal hypertension underwent endovascular PV interventions via a percutaneous transsplenic approach. All patients had occlusion of the main PV or central intrahepatic PV branches, which prevented the performance of a transhepatic approach. A vein within the splenic parenchyma was punctured under fluoroscopic guidance by referencing preoperative computed tomography images. PTSPC-related complications and clinical applications were analyzed. ResultsPTSPC was successfully performed in 44 of 46 patients (96%); two failures were caused by inaccessible small intrasplenic veins. PTSPC-related major bleeding complications occurred in three patients (6.5%), including large intraperitoneal hemorrhage in one patient and large splenic subcapsular hemorrhage in two patients. Two of the three patients developed hypotension, and one developed severe anemia. All three of the patients required blood transfusions. PTSPC-related minor bleeding complications occurred in six patients (13%) as a result of a small splenic subcapsular hemorrhage. In addition, three patients exhibited mild left pleural effusion, which subsided spontaneously 1 week later. All 44 patients successfully treated via PTSPC received gastroesophageal variceal embolization. Eight patients received PV stents, five for treatment of PV occlusion and three during transjugular intrahepatic portosystemic shunt placement. ConclusionsPTSPC is a safe and effective access for endovascular PV interventions in patients without a transhepatic window.

Clinical observation of transcatheter arterial chemoembolization plus sorafenib in the treatment of advanced hepatocellular carcinoma with different types of portal vein tumor thrombosis

To explore the efficacy and safety of transcatheter arterial chemoembolization (TACE) plus sorafenib in the treatment of advanced hepatocellular carcinoma with different types of portal vein tumor thrombosis. A total of 32 patients of advanced hepatocellular carcinoma with tumor thrombosis in portal vein were retrospectively analyzed. All of them took oral sorafenib after TACE. They were divided into 3 groups according to imaging examinations of tumor thrombosis in portal vein. Tumor thrombosis in main portal vein was group A, tumor thrombosis in right/left portal branch group B and tumor thrombosis in the second branch of portal vein group C. Tumor response rate, disease control rate (DCR), overall survival (OS) and time to tumor progression (TTP) was followed up. Liver functions were compared with the pre-treatment level. The occurrences of adverse events were recorded. DCR was 20.0% (Group A), 70.0% (Group B) and 91.7 % (Group C) at 2 months post-treatment. DCR in groups B and C had significant differences with group A (P < 0.05). The median OS was 3 (Group A), 9 (Group B) and 14 months (Group C) and the median TTP 0 (Group A), 3 (Group B) and 6 months (Group C) respectively. The median OS and median TTP were significantly longer in Groups B and C than those in Group A (P < 0.05). Liver function at 2 months post-treatment had no statistical difference with the baseline. The most common adverse effects included hand foot skin reaction (n = 23, 3 cases of grade 3), hypertension (n = 3), diarrhea (n = 25, 3 cases of grade 3), hair loss (n = 12), oral ulcers (n = 1) and gastrointestinal bleeding (n = 2). The combined use of TACE and sorafenib is both safe and efficacious in the treatment of advanced hepatocellular carcinoma with tumor thrombosis in portal vein. And it may prolong OS and TTP in hepatocellular carcinoma with tumor thrombosis in right/left portal vein and second branch of portal vein.

Thrombolysis of portal vein thrombosis after splenectomy following liver transplantation

Thrombolysis of portal vein thrombosis after splenectomy following liver transplantation

Haemoperitoneum with hereditary haemorrhagic telangiectasia

In August, 2011, an 83-year-old woman presented to our emergency department with several days of diff use persistent abdominal pain. She also reported an episode of lower gastrointestinal bleeding with symptoms of orthostasis. She had a history of cardiac failure, pulmonary hypertension, and epistaxis of un known cause. On initial physical examination she was haemodynamically stable without signs of acute ab dom inal disease. She had oral mucocutaneous telangiectases. Gastric lavage was done, and no evidence of upper gastrointestinal bleeding was seen. Blood tests showed a haematocrit concentration reduction from 25% to 20%, and a haemoglobin of 69 g/L. She was admitted for blood transfusion and assessment. After 5 days, she developed acute abdominal pain, tachycardia (135 beats per min), and hypotension (80/40 mm Hg). Sonography of the abdomen showed a large amount of free abdominal fl uid. Multi-detector computed tomography (MDCT) of the abdomen and pelvis confi rmed intra-abdominal fl uid and also showed liver arteriovenous malformations. CT-guided paracentesis confi rmed a diagnosis of haemo peritoneum. An emergency surgical exploration of the abdominal cavity was done because of her poor clinical condition. Explor ation showed haemo peritoneum and a portal vein branch with active bleeding due to the vascular malformations (fi gure). Haemostatic suturing was done to stop bleeding, and the abdominal cavity was drained. She had an uneventful postoperative course and was discharged at postoperative day 10. At last follow-up in Lancet 2013; 381: 962

Image quality and diagnostic value of portal vein angiography in cirrhotic patients with non-contrast enhanced and contrast enhanced MR angiography

Objective To evaluate the imaging quality of the non-contrast enhanced MR angiography of sampling perfection with application optimized contrasts using different flip angle evolutions (SPACE) in showing portal system and compared it with that of the contrast enhanced MR angiography of volumetric interpolated breath-hold examination (VIBE),and study its diagnostic ability in the detection of portosystemic and portohepatic collaterals. Methods Thirty consecutively cirrhotic patients with suspected of portosystemic and portohepatic collaterals were enrolled,and underwent SPACE followed by VIBE at 1.5 T MR scanner.The diagnostic accuracy of SPACE for the portal vein disease was evaluated by two doctors and compared it with that of VIBE.The contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) of two MRA techniques were compared by using the Wilcoxon signed rank test.The quality assessment including scores of the portal vein segments and overall image quality were used the paired t test. Results Twenty-one patients were diagnosed as portal hypertension,including five types of portosystemic collaterals: esophageal varices (n=5),gastric fundic varices (n=11),splenic varices (n=5),paraumbilical varices (n=5) and cavemous transformation (n=2),and one patient was diagnosed as portal vein tumor thrombus.The diagnostic efficiency of SPACE was equivalent to that of VIBE.In SPACE,the SNR were 291±57,301±74,344±76 and the CNR were 231±59,242±73,286±76 at main portal vein,the left branch of portal vein and the right branch of portal vein,respectively.However in VIBE,the SNR were 185±56,176±52,182±52 and the CNR were 57±23,50±21,57±19 at,respectively.Both SNR and CNR of portal vein segments in the former were better than those in the latter (t values were 7.691,7.418,7.946,15.746,13.508 and 13.880,respectively,P 0.05).The scores of displaying the distal branches of left and right portal vein were 2.08±0.78,2.08±0.78 in SPACE,and 1.75±0.53,1.71±0.55 in VIBE,respectively.It was better (Z=-2.138,-2.324,P<0.05) in SPACE than that in VIBE. Conclusion The SPACE has better visualization of portal vein distal branches than VIBE,and it can be applied for the diagnosis of the portal vein disease. Key words: Portal vein; Magnetic resonance imaging; Liver cirrhosis

Hypofractionated radiotheapy using helical tomotherapy for advanced hepatocellular carcinoma with portal vein tumor thrombosis

BackgroundWe want to evaluate the efficacy of helical tomotherapy (HT) for treating advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT).MethodsWe treated 35 patients for unresectable HCC combined with PVTT in whom other treatment modalities were not indicated. The tumor thrombi involved the main trunk of the portal vein in 18 patients (51.4%) and the first or second order branches in 17 patients (48.6%). A median dose of 50 Gy (range: 45–60 Gy) was delivered in 10 fractions. Capecitabine was given concomitantly at a dose of 600 mg/m2 twice daily during radiotherapy.ResultsThe responses were evaluated via computed tomography. There was a complete response (CR) in 5 patients (14.3%), partial response (PR) in 10 patients (28.6%), stable disease (SD) in 18 patients (51.4%) and progressive disease (PD) in 2 patients (5.7%). The Child-Pugh classification (A vs B) and the Japan integrated staging (JIS) score (2 vs 3) were statistically significant parameters that predicted the response of PVTT (p = 0.010 and p = 0.026, respectively). The median survival, one and two year survival rate of all patients was 12.9 months, 51.4% and 22.2%, respectively. The patients with tumor thrombi in the main portal trunk showed statistically inferior overall survival than patients with tumor thrombi in the portal vein branches (9.8 versus 16.6 months, respectively, p = 0.036). The responders’ median survival was 13.9 months, double 6.9 months as the median survival of the non-responders. No radiation induced liver disease or treatment related mortality was not appeared.ConclusionsHypofractionated radiotherapy with HT was effective not only for tumor response but also for survival in the advanced HCC patients with PVTT. And stricter patient selection by Child-Pugh classification and JIS score may maximize the potential benefits of this treatment.

Study of vascular segments of liver on computerised tomography in subjects with normal liver

Liver, the largest gland in the body receives total perfusion of 1500ml per min even in inactive state. The introduction of Computerised Tomography has made imaging of liver more detailed and safe. The liver is divided into eight vascular segments. Each of them receives a portal pedicle. The ramifications of hepatic veins define intersegmental planes. Aims: Pattern of ramification of both portal and hepatic veins, internal diameter of these vessels and their angulation is measured. Methods and Material: CT scans of 50 adult patients both male and female for indications other than liver pathology and clinically normal liver were included in the study. Results: Portal vein divides into three branches, namely Left branch of portal vein, anterior and posterior segmental vein; branches of right portal vein in 12% of cases. Patterns of drainage of hepatic veins indicate variable internal architecture. Internal diameter of vessels and ramification within 1 cm from IVC determine surgical plan. Conclusions: Pattern of internal architecture is unique for each individual. Preoperative CT scan will help to plan resection along the intersegmental plane with minimal loss of liver tissue. The liver transplantation is done using cadaver donor or partial transplantation using live donor. In trauma and malignancy, the affected lobe and segments of liver can be resected preserving the rest, which can hypertrophy to compensate for the loss.

Optimal Contrast of Computed Tomography Portal Venography Using Dual-Energy Computed Tomography

The objective of this study was to evaluate image quality of computed tomography (CT) portal venography using nonlinear blending technique of dual-energy CT (DECT) in portal phase. Fifty patients underwent contrast-enhanced abdominal scan with DECT at portal venous phase. The images of 2 energy levels were mixed by a nonlinear blending filter defined by blending center (BC) and blending width (BW) and compared with linear mixing images with a ratio of 0.5. Image quality was evaluated by the images' contrast-to-noise ratios (CNRs) and the grade of visible branches of portal vein (grades 1-6). The BC and BW were optimized for the best CNRs. The portal-to-hepatic contrast was significantly higher when the average of the liver and portal vein CT values was chosen as the BC, and 0 to 20 Hounsfield units were chosen as the BW than when using the default mixing values (80.04 [SD, 28.09] vs 38.55 [SD, 14.49] Hounsfield units, P < 0.001). In the optimized images using the nonlinear mixing technique, the mean CT values for the portal venous system and the CNRs were significantly greater than those of the linear mixing images (P < 0.001). A visible branch grade 5 or greater was assigned to 76% of the patients in the optimized group and 36% of the patients in the default linear mixing group. This difference was significant (P < 0.01). The nonlinear blending technique of DECT can improve the image quality of portal venography and show more branches of portal vein without changing the conventional scan protocol.

Variation or newly identified glissonian pedicles between the lateral and medial sections of the liver, using cadaver dissection

PurposeStudies of liver anatomy have developed alongside clinical achievements, as these types of research complement each other. The aim of this study is to determine whether or not the portal vein branches (P4d) in 'Nagino's trisectionectomy' exist, and to examine their characteristics using cadaver dissection.MethodsFrom April 2012 to July 2012, 31 adult cadavers were delicately dissected. We defined a 'NewGP' as an extra glissonian pedicle (GP) other than the traditional GPs that supply segments II, III, IVa, and IVb in the ordinary direction, and anatomically located superior to the umbilical fissure (UF).ResultsWe identified 'NewGPs' based on the UF and UF vein. The incidence of 'NewGPs' was 30/31 (96.8%). The diameter of the 'NewGPs' ranged from 3.5 to 5.6 mm, which was not significantly different from that of traditional GPs (II-, III-, or IV-GP), which have diameters ranging from 3.7 to 9.7 mm.ConclusionWe think that the P4d in 'Nagino's trisectionectomy' correspond to the 'IVa NewGP' and the additional pedicle. We believe the clinical significance of the 'NewGP' is to complement the traditional II, III, IVa, and IVb pedicles in supplying the liver.

A Mini Accessory Liver Lobe in the Fissure for Ligamentum Teres and Its Clinical Significance: A Case Report

The liver can present a number of congenital anomalies. More common among them are the irregularities of the shape and the number of lobules. The less common variations include the presence of accessory lobes or accessory livers. The accessory lobes may be attached to the liver through a mesentery or a bridge of the hepatic tissue and they are usually asymptomatic. An accessory liver lobe is a very rare occurrence and when it exists, it becomes clinically important because of its rarity. We are reporting here the presence of a very small accessory liver lobe and have discussed its clinical relevance. We observed a mini liver lobe which was situated in the posterior part of the fissure for ligamentum teres. It was triangular in shape and about one inch in width. It was attached to the left anatomical lobe of the liver through a vascular pedicle which contained the branches of hepatic artery and portal vein and hepatic duct. Histological sectioning revealed the normal liver architecture in the accessory lobe. The knowledge of this accessory lobe could be of use to surgeons and radiologists.

Idiopathic portal hypertension and related ultrasound findings

Objective: to characterize idiopathic portal hypertension clinically and by ultrasound (US). Patients and methods: 60 patients with clinical diagnosis of chronic liver disease and portal hypertension were retrospectively assessed by color Doppler US, from January 1996 to January 2006, in a privately owned clinic. Two cases of idiopathic portal hypertension were found. Comments: in young patients with splenomegaly, recurring hematemesis, anemia, ascites, normal liver function and portal hypertension without evidence of cirrhosis, US revealed livers of usual size, heterogeneous texture and flat surface, without deformities in the branches of the intra-hepatic portal veins. The portal vein walls were also thickened starting at 3 mm and marked by an abrupt narrowing of the secondary intra-hepatic portal veins, accompanied by splenomegaly.

Congenital Portosystemic Shunts

The purpose of this study was to evaluate prenatal sonographic findings that could be helpful for diagnosis of congenital intrahepatic portosystemic venous shunts and the follow-up results. Six neonates with congenital shunts between the portal vein and hepatic vein were enrolled in this study. Prenatal sonography was performed in 5 cases. We categorized the cases according to a previously published classification of intrahepatic portosystemic venous shunts and retrospectively reviewed the prenatal and postnatal sonographic examinations to identify findings that might be helpful for diagnosing shunts prenatally. Follow-up sonographic examinations were done until closure of the shunts. Clinical features were also determined. According to the original reports, intrahepatic portosystemic venous shunts were diagnosed by prenatal sonography in 2 of 5 cases. In the remaining 3 cases, there were suggestive abnormal findings on retrospective review, including an abnormal intrahepatic tubular structure, a prominent hepatic vein, and congestive heart failure. Postnatal sonography showed type 2 shunts in all 6 cases. In 1 case, there were 2 type 2 lesions between two branches of the left portal vein and the middle and left hepatic veins. On follow-up sonography, 5 of the 6 congenital shunts had spontaneously closed by 11 months of age. One case was treated with coil embolization during the neonatal period. Intrauterine growth restriction was the most commonly clinical feature prenatally. Findings such as an abnormal tubular structure, a prominent hepatic vein, and congestive heart failure can be important clues for identifying congenital intrahepatic portosystemic venous shunts on prenatal sonography. The use of prenatal and postnatal sonography is feasible for detection and evaluation of these shunts.

Neuroendocrine carcinoma of the extrahepatic bile duct: Case report and literature review

Neuroendocrine carcinoma (NEC) of the extrahepatic bile duct is rare, and only 22 cases have been reported. Only two of these were large-cell NEC (LCNEC); the vast majority were small-cell NEC. Here, we report a third case of LCNEC of the extrahepatic bile duct. A 76-year-old male presented to a local hospital with painless jaundice. Imaging studies revealed a tumor at the hepatic hilum. The patient underwent right hepatic lobectomy, bile duct resection, and cholecystectomy. The resection specimen showed a 5.0-cm invasive neoplasm involving the hilar bile ducts and surrounding soft tissue. Histologically, the tumor consisted of nests of medium to large cells with little intervening stroma. The tumor invaded a large portal vein branch. All four excised lymph nodes were positive for metastasis, and metastatic deposits were also present in the gallbladder wall. The tumor was diffusely positive for synaptophysin and focally positive for chromogranin A. Approximately 70%-80% of the tumor cells were positive for Ki-67, indicating strong proliferative activity. A diagnosis of LCNEC was made. A few bile ducts within and adjacent to the invasive tumor showed dysplasia of the intestinal phenotype and were focally positive for synaptophysin and chromogranin A, suggesting that the dysplastic intestinal-type epithelium played a precursor role in this case. A postoperative computer tomography scan revealed rapid enlargement of the abdominal and retroperitoneal lymph nodes. The patient died 21 d after the operation. NEC of the bile duct is an aggressive neoplasm, and its biological characteristics remain to be better defined.

Application of Hepatic Segmental Staining in Anatomic S8 Segmentectomy Under Intra-Operative Ultrasonography

Objective The purpose of this study was to investigate the clinical value of hepatic segmental staining under intra-operative ultrasonography guidance in anatomic segment 8 (S8) segmentectomy. Method This was a retrospective study of 31 patients with hepatocellular carcinoma (HCC) whose lesions were located in S8. Under intra-operative ultrasonography guidance, the hepatic portal vein branch of S8 was dyed and then the resection line was marked with an electric knife on the stained area of the liver surface, in preparation for the anatomic S8 segmentectomy. The liver section exposed the right hepatic vein, the middle hepatic vein trunk side wall and the hepatic pedicle of S8. Results The average operation time of 31 cases of anatomic S8 segmentectomy was (230±76) min, the average surgical blood loss was (305±235) ml, the incidence of post-operative complications was 26% (8/31), average post-operative hospitalization time was (13±3) d, with a 1-year recurrence rate of 19% (6/31) and a 1-year survival rate of 94% (29/31). Conclusion Under the guidance of intra-operative ultrasonography, hepatic segmental staining can improve the precision of an anatomic S8 segmentectomy, maximally reducing the post-operative complications and improving the safety of liver resection.

Visualization of segmental arterialization with arrival time parametric imaging using Sonazoid-enhanced ultrasonography in portal vein thrombosis: A case report

A 55-year-old male was admitted in mid-April 2011 with a fever of >39°C and pain in the lower right abdomen. A medical examination revealed sepsis originating from colonic diverticulitis. Abdominal B-mode ultrasonography (US) performed on admission detected thrombi in the superior mesenteric vein and in the right branch of the hepatic portal vein. Arrival time parametric imaging (At-PI) using Sonazoid-enhanced US showed arterialization of the entire right lobe of the liver. The treatment for the sepsis and portal thrombi that had been started upon admission dissolved the thrombi by day 22, with the exception of one thrombus in the P8 branch of the portal vein. At-PI performed on the same day confirmed arterialization in segment 8, but portal vein dominance was restored elsewhere. When the blood inflow from the hepatic portal vein was reduced, the hepatic arterial blood flow was increased to compensate for the reduction in the total blood supply. The At-PI functions used in the Sonazoid-enhanced US were simple yet effective in visualizing the changes in the hepatic hemodynamics caused by the portal thrombus.

Ligadura da veia porta associada à transecção para hepatectomia em dois estágios (ALPPS): uma nova abordagem nas ressecções hepáticas

Postoperative liver failure consequent to insufficiency of remnant liver is a feared complication in patients who underwent extensive liver resections. The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a new approach for patient which tumor is previously considered unresectable. To present ALPPS as an innovative surgical technique of two-staged hepatectomy for the treatment of patients with marginally resectable or initially nonresectable primary and metastatic liver tumors. The procedure is performed in two steps. The first consists on ligation of the right portal vein branch. Subsequently, total or nearly total parenchyma dissection along the falciform ligament is performed, including the middle hepatic vein. A plastic bag is used to cover the right extended lobe, and the abdomen is drained and closed. The second one is performed after a computer tomography, six to 12 days interval. After laparotomy, the plastic bag is removed. The right artery, right bile duct and the right hepatic vein are divided. The extended right lobe is removed. Drain is placed at the resection surface, and the abdomen is closed. The associating of liver partition and portal vein ligation can enable curative resection of liver metastasis in patients with lesions previously considered unresectable.

Enhanced tumor growth after portal vein embolization in a rabbit tumor model

BackgroundPreoperative portal vein embolization (PVE) is used to increase future remnant liver volume through induction of hepatocellular regeneration. This event, however, potentially enhances tumor growth. The aim of our study was to assess tumor growth and liver regeneration after PVE in a rabbit hepatic tumor model. The VX2 carcinoma is derived from a virus-induced papilloma tumor in rabbits. The tumor grows rapidly, and its blood supply is similar to that of human hepatocellular carcinoma. Materials and methodsTwo weeks after subcapsular implantation of a VX2 carcinoma in the cranial liver lobe, New Zealand White rabbits were allocated to a control or PVE group (n = 5 per group). In the PVE group, the portal vein branch to the cranial liver lobes (80%) was embolized using particles and coils, leaving the caudal liver lobe (20%) free. In the tumor control group, the liver was mobilized. Computed tomography volumetry was performed on days 3, 7, 10, and 14. Tumor growth rate (TGR), hepatocellular proliferation rate, and liver damage parameters were assessed before PVE and on days 1, 3, 7, 10, and 14. ResultsPortography confirmed complete occlusion of the portal vein branch to the cranial liver lobes in all PVE rabbits. The hypertrophy response and proliferation rate in the nonembolized liver lobes were significantly higher in the PVE group, which was confirmed by liver-to-body weight index assessment. TGR was increased in both groups, with a significantly larger increase in the PVE group over time (day 14: mean, 34.4 ± 4.3 mL/d versus control: mean, 24.1 ± 7.2 mL/d; P < 0.05). ConclusionsTGR was significantly increased after PVE in the rabbit tumor model. This finding supports the notion that PVE potentially enhances tumor growth, along with the regeneration of the nonembolized liver lobe.