Branch Of Portal Vein Research Articles

Surgical treatment of hepatic alveococcosis in highly specialized centre of non-endemic region

Objective. To estimate the results of operative treatment of hepatic alveococcosis in conditions of surgical centre of non-endemic region.
 Materials and methods. From 2004 to 2020 yr in Department of Transplantation and Hepatic Surgery of Shalimov National Institute of Surgery and Transplantation NAMS of Ukraine 13 patients, suffering hepatic alveococcosis, were radically operated. General characteristic of patients, methods of preoperative preparation, іntraoperative data, the indices of morbidity and lethality were investigated.
 Results. In 11 (84.6%) patients the disease was diagnosed on late stages: IIIa-IV in accordance to pTNM by WHO classification. Preoperatively in 5 (38.5%) patients transcutaneous transhepatic cholangiostomy and in 8 (615%) patients - roentgenendovascular occlusion of the portal hepatic vein branches - were performed. In 12 (92.3%) patients extended hepatic resections were done, including in 2 (15.3%) - complete vascular hepatic exclusion with hyperthermic perfusion in situ. Postoperative complications rate of IIIa-IV degrees in accordance to Clavien-Dindo classification have constituted 30.7%, while postoperative mortality - 7.7%. Up to the end of follow-up the disease-free period have persisted in all the patients.
 Conclusion. Aggressive surgical tactics in patients, suffering hepatic alveococcosis, permits to obtain good immediate results in highly specialized centres. Today radical operative intervention continues to be the only one method of treatment in the patients, which may guarantee satisfactory late follow-up results.

Role of multidetector computed tomography (MDCT) in evaluation of main and right portal vein branching patterns and its clinical significance

Introduction: Knowledge of the normal portal vein anatomy and its variations is imperative for various hepatic interventional procedures and liver surgeries like during creation of transjugular intrahepatic portosystemic shunt (TIPS), partial hepatectomy and Liver transplantation. Aims and Objective: The aim of our study was to determine and analyse the spectrum of variations in the main and right portal vein anatomy and their prevalence in Indian population using MDCT. Materials and Methods: Triple phase abdomen CT of 688 patients done on a 64 slice MDCT scanner between February 2012 and March 2014, were retrospectively evaluated by two radiologists independently. Out of these, 500 patients met the inclusion criteria. Axial images of portal and venous phase along with the maximum-intensity-projection and volume rendered images were reviewed and branching patterns of main and right portal vein were recorded. Results: Normal portal vein anatomy was present in 67% of the patients. Main portal vein (MPV) variations were seen in 15.2% of the patients. The most common variant was Z-type pattern (7.6%). Next common was trifurcation pattern (6.6%). Right portal vein (RPV) variations were seen in 17.8% of patients and the most common pattern was early segmental branching (6.8%). Other RPV branching variations were RPV trifurcation (3.6%), RPV quadrification (3.6%), and superior-inferior division (1.4%). Miscellaneous branching variations of RPV were seen in 2.4% of all patients. Conclusion: Variations in the main portal vein and right portal vein anatomy are quite common and can be clearly detected with MDCT. Keywords: Portal vein branching, Portal vein MDCT, MPV variation, RPV variation.

Safety and Efficacy of Camrelizumab Combined with Apatinib for Advanced Hepatocellular Carcinoma with Portal Vein Tumor Thrombus: A Multicenter Retrospective Study.

IntroductionPrevious trials demonstrated that anti-angiogenesis or anti-programmed death protein 1 (PD-1) monotherapy showed unsatisfied effect in advanced hepatocellular carcinoma (HCC). No study existed that focus on the effects of camrelizumab and apatinib (“C+A”) combination therapy for HCC patients with the location and extent of portal vein tumor thrombus (PVTT) as the main variable being assessed. This study was to compare the efficacy and tolerability of “C+A” for HCC patients with PVTT.MethodsWe retrospectively analyzed patients with advanced HCC and PVTT who underwent “C+A” therapy in a multicenter retrospective cohort from Jan 2019 to July 2020. Outcomes of patients who underwent “C+A” were analyzed by using the Kaplan–Meier method according to types of PVTT: PVTT in the main portal vein (type A), PVTT in the first-order portal vein branch (type B), and PVTT in second- or lower-order portal vein branches (type C).ResultsSixty-three patients were finally included and the mean duration of follow-up was 12.6 ± 4.5 months. The objective response rate (ORR) and disease control rate (DCR) for the whole cohort were 44.0% and 75.0%, respectively. The median overall survival (OS), progression-free survival (PFS) and time to progression (TTP) were 14.8 months, 11.8 months and not yet reached (NR), respectively. Patients with type B (OS, 15.9 months; PFS, 14.0 months; TTP, NR) or type C (OS, 16.0 months; PFS, 14.9 months; NR) PVTT appear to have better survival benefits compared with type A (OS, 5.8 months; PFS, 5.0 months; TTP, 7.0 months). Along with AFP, the absence of main PVTT was an independent predictive factor for survival at uni- and multivariate analysis.ConclusionCamrelizumab and apatinib yielded a promising outcome in patients with advanced HCC who developed a tumor thrombus in the first lower-order portal vein branches and was generally safe and had manageable side effects.

Cerebellar hemorrhage in patients treated with edoxaban for portal vein thrombosis after hepatobiliary surgery: a report of two cases

BackgroundThe standard therapeutic agent administered for portal vein thrombosis (PVT) in patients with or without cirrhosis is warfarin or low-molecular weight heparin. However, therapy with edoxaban appears to be one of the most promising treatments for patients who require anticoagulation therapy. We encountered two cases of cerebellar hemorrhage in patients treated with edoxaban for PVT after hepatobiliary surgery during the past 2 years.Case presentationCase 1 A 67-year-old male underwent cholecystectomy and choledocholithotomy with choledochoduodenostomy to treat choledocholithiasis after cholangitis. Enhanced computed tomography (CT) on the 1st postoperative day (POD) revealed thrombosis in the left and anterior segment of the portal vein branches. We administered antithrombin III concentrate with heparin for 5 days; thereafter, we switched to 60 mg edoxaban. A sudden decrease in the patient’s level of consciousness was observed due to cerebellar hemorrhage on POD 27. Cerebellar hemorrhage was successfully treated with craniotomy hematoma evacuation and ventricular drainage; however, the patient died from aggravation of hepatic failure due to PVT and intra-abdominal infection. Case 2 A 67-year-old male received laparoscopic microwave coagulation therapy for two hepatic nodules suggestive of hepatocellular carcinoma in the left lobe of the liver due to alcoholic hepatitis. Enhanced CT on POD 5 revealed a thrombosis in the 4th segment branch of the portal vein, and the patient was treated with 60 mg edoxaban. Cerebellar hemorrhage with ventricular perforation occurred on POD 15. Cerebellar hemorrhage was successfully treated by craniotomy hematoma evacuation with ventricular drainage. Prolonged consciousness disorder persisted, and the patient was transferred to another medical facility for rehabilitation 49 days after brain surgery.ConclusionsAlthough edoxaban is recently described to be one of the options for patients with PVT who require anticoagulation therapy instead of heparin or warfarin, it should be used with caution, given its propensity to induce severe hemorrhagic adverse events in cases such as those described above. The monitoring of hepatic dysfunction and decision for continuation of drug may be required during edoxaban use for PVT, especially after hepatobiliary surgery.

Role of CT Imaging With Three-Dimensional Maximum Intensity Projection Reconstruction in the Evaluation of Portal Vein Variants at a Tertiary Care Hospital

Introduction: Portal vein (PV) is the principal blood vessel transporting blood from the alimentary tract and spleen to the liver. The aim of this study is to determine the prevalence of PV anatomical variations in our population using multidetector CT with maximum intensity projection (MIP) technique at a tertiary care hospital.Methods: This cross-sectional study was prospectively conducted from November 2018 to June 2019 in the Department of Radiology at a tertiary care hospital in Karachi. After informed consent, all the patients with no known hepatic pathology undergoing routine abdomen CT were included in this study. Patients with previous hepatic resection surgeries, undiagnosed large hepatic tumors/metastasis, and those with PV thrombosis were excluded.Results: A total of 500 patients (256 males and 244 females) were included in the study; the mean age of female patients was relatively higher as compared to the male patients (53.80 ± 18.44 vs. 44.15 ± 19.94 years; p = 0.000). Standard PV anatomy (type 1) was found in 438 patients (87.6%). Trifurcation (type 2) occurred in 18 patients (3.6%). Right posterior portal vein as the first branch of main PV (type 3) was found in 22 patients (4.4%). A separate branch of the right portal vein (RPV) to segment VII (type 4) and separate branch of the RPV to segment VI (type 5) were found in 6 (1.2%) and 16 (3.2%) patients, respectively.Conclusion: Our study displayed a relatively higher frequency of standard PV anatomy (type 1) compared to previous studies. We highlight the role of MIP in the analysis of hepatic venous anatomy with its utility demonstrating improved detection of variations.

Mapping Of Retroperitoneal Lymph Nodal Metastases After Surgery For Lower Thoracic Esophageal Cancer: A Recommendation For Clinical Target Volume

Our previous study showed that retroperitoneal lymph node (RetroLN) metastasis was common in patients with lower thoracic esophageal squamous cell cancer (LTESCC) treated after surgery, indicating a possible benefit of adjuvant radiotherapy in retroperitoneal region. However, little is known about the pattern of RetroLNs failure in LTESCC, which hinders further study. We herein document the site of RetroLNs failure in LTESCC treated after surgery, and propose a delineation for CTV boundaries. LTESCC patients having RetroLNs metastasis after R0 radical esophagectomy in our institution were reviewed. The epicenter of each RetroLN was represented by a circle of 5 mm diameter, and was registered onto corresponding axial CT images of a standard patient, with reference to the surrounding vascular and bony structures. After analyzing the node distribution features, a CTV boundary was proposed, based on which a post-operative RT plan was applied in three simulated cases for safety analysis. A number of 257 RetroLNs from 69 patients were recorded. Twelve patients had solitary RetroLNs metastasis, and 31 patients had RetroLNs failure with distant metastasis. The three most frequent metastasis sites were lateral aortic (48.3%), pre-aortic (22.0%) and intermediate lumber (20.5%). Longitudinally, one LN was higher than the middle level of vertebral T12, and 75.7% of the LNs were seen above the border of 2 cm inferior to the left renal artery, which often near the bottom of vertebral L2. Horizontally, 80% of LNs in celiac level were located within the region confined by the anterior surface of aorta, inferior vena cava (IVC), portal vein, splenic vein and celiac branches. In the superior mesenteric artery (SMA) level, all the LNs except 1 post-aortic LNs were behind the anterior edge of the SMA and anterior to the posterior edge of aorta, 85% were left to the left edge of IVC, and 95% were within 1.5 cm of the left side of the SMA. In the region beneath SMA, 92.7% of LNs appeared right to the lateral edge of the left psoas major (LPM), and all the LNs lied behind the anterior surface of the left renal vein or adjacent to the anterior surface of the aorta, left to the right border of the IVC, and anteriorly to the vertebral and the anterior edge of the LPM. The proposed CTV from the middle level of vertebral T12 to the 2cm below the left renal artery or the bottom of vertebral L2 (depending on which one is lower) with aforementioned boundaries can cover 74.52% of the LNs in the studied group. The post-operative RT treatment plan which included the commonly used T-shield field and the proposed CTV for RetroLNs in three simulated cases all met with satisfactory in the dosimetric analysis. The proposed CTV is the first that focus on the high-risk area of RetroLNs failure in LTESCC patients treated after surgery, and is also feasible in terms of dosimetric performance. The result can serve as a reference for future study to better improve the disease control in LTESCC.

Transjugular intrahepatic portosystemic shunt through left branch versus right branch of portal vein: a meta-analysis.

To compare the clinical outcomes between patients that underwent transjugular intrahepatic portosystemic shunt (TIPS) via the left and right portal veins (PVs). All relevant studies in the Pubmed, Embase, and Cochrane Library databases published as of June 2020 were identified by searching, after which RevMan v5.3 was used to conduct the present meta-analysis. Relevant endpoint data were extracted from each study, related to postoperative hepatic encephalopathy (HE) rates, TIPS dysfunction, re-bleeding, and mortality. A total of eight studies were identified as being relevant for inclusion in this meta-analysis. These studies included 2592 total patients suffering from liver cirrhosis that underwent TIPS treatment via the left (n = 1500) or right (n = 1092) PVs. Rates of postoperative HE were significantly lower in the left PV group relative to the right PV group (5.7% vs. 18.1%, OR 0.19; P < 0.00001), as were rates of TIPS dysfunction (8.1% vs. 16.5%, OR 0.41; P < 0.00001). In contrast, the rates of re-bleeding did not differ significantly between these groups (12.0% vs. 14.9%, OR 0.76; P = 0.11), nor did mortality rates (30.9% vs. 31.0%, OR 0.85, P = 0.22). We did not detect any significant heterogeneity among included studies for any analyzed endpoints, nor was any risk of publication bias pertaining to these studies detected through the use of funnel plots. TIPS conducted via the left PV was associated with decreased rates of postoperative HE and TIPS dysfunction relative to TIPS conducted via the right PV.

S2662 An Unexpected Cause of Refractory Liver Abscesses

INTRODUCTION: We report a case of multifocal liver abscesses with recurrent fevers refractory to prolonged antibiotic therapy and catheter drainage due to penetration of a toothpick into the portal vein. CASE DESCRIPTION/METHODS: A 72-year-old male with type II diabetes presented with fever, confusion, and right upper quadrant pain associated with malaise and unintentional weight loss. Objective findings were consistent with septic shock and acute liver injury. Computed tomography (CT) and Magnetic Resonance Imaging (MRI) showed a 6.9 × 8.0 × 5. hepatic abscess and several scattered fluid collections (Figure 1). Immediate broad-spectrum antibiotics and percutaneous catheter drainage resulted in clinical improvement. Abscess fluid and blood cultures grew actinomyces odontolyticus and streptococcus viridans, respectively. Amebic serology was negative. Transition to appropriate outpatient antibiotics resulted in two readmissions for recurrent fevers with persistent drainage output for weeks. A repeat CT showed a shrunken abscess and a 4.6 cm radio-opaque linear foreign body penetrating through the gastric antrum into a branch of the left portal vein (Figure 2). Review of previous imaging confirmed the foreign body was present since first admission. Upper endoscopy showed a patch of erythematous mucosa in the antrum encircling a pinpoint opening to a fistulous tract and exuding purulent fluid (Figure 3). Exploratory laparotomy revealed a 4.5 cm wooden toothpick in the portal vein surrounded by a dense fibrotic scar. Foreign body removal and porto-enteric fistula repair were performed. Follow up CT showed complete resolution of the abscess. DISCUSSION: Penetrating foreign body is a rare cause of liver abscess. To our knowledge, penetration of a foreign body into the portal vein resulting in liver abscesses has never been reported. Discovery of foreign body requires a high index of suspicion as patients rarely remember ingesting the object, and it can be easily missed on CT. When suspected, a non-contrast CT is recommended with attention to coronal/sagittal views with signs such as thickened antral wall and fistulous tract. Non-specific clinical features such as hematemesis, subacute/chronic abdominal pain, and failure of antibiotic therapy can be suggestive. In the setting of any of these findings, foreign body should be considered in patients with unexplained liver abscess.Figure 1.: A large dominant hepatic abscess measuring 6.9 × 8.0 × 5.3cm, involving segments 4A and 4B of the liver, extending to and involving the anterior wall of the gallbladder, as well as several scattered small fluid collections (MRI of liver without contrast).Figure 2.: A 4.6cm radio-opaque linear foreign body penetrating through the gastric antrum into a branch of the left portal vein (CT of abdomen and pelvis without contrast).Figure 3.: A patch of erythematous mucosa in the pre-pyloric antrum encircling a pinpoint opening to a fistulous tract and scant purulent liquid; the foreign body was not visible (upper endoscopy).

Efficacy of puncturing different portal vein branch during transjugular intrahepatic portosystemic shunt with 8 mm covered stent: a propensity-score analysis.

Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS) remains an unsolved problem; therefore, this study aimed to compare the efficacy of shunting different portal vein branch during TIPS with 8 mm covered stent for preventing gastroesophageal variceal rebleeding in cirrhotic patients. Between November 2015 and December 2018, the medical records of consecutive cirrhotic patients who received TIPS with an 8 mm covered stent for preventing gastroesophageal variceal rebleeding were analyzed retrospectively. Shunting the left and right branches of the portal vein was performed in 58 (group A) and 104 patients (group B), respectively. Afterwards, 54 patients in each group were produced by the PSM method. The incidence of overt hepatic encephalopathy (OHE), shunt patency, variceal rebleeding and survival were compared between two groups by using Kaplan-Meier analysis and log-rank test. The median follow-up time was 37 months (range 0.3-50 months). The 6-,12- and 24-months cumulative OHE free rates in groups A and B were 92.5, 86.2, 83.6% and 74.1, 70.2, 67.6%, respectively (P = 0.042; hazard ratio = 0.469; 95% CI, 0.223-0.988). Two (3.7%) and eight (14.8%) patients experienced severe OHE in groups A and B, respectively (P = 0.042). There were no significant differences between the two groups in terms of shunt patency, variceal rebleeding and survival. Shunting the left portal vein branch during TIPS with an 8 mm covered stent for preventing gastroesophageal variceal rebleeding in cirrhotic patients might decrease the occurrence of OHE significantly. The prospective trial is needed to further provide evidence of this results in future.

Stent patency and outcome of TIPS through the left versus the right portal branches

BackgroundOur purpose is to compare the stent patency and clinical outcome of trans-jugular intra-hepatic porto-systemic shunt (TIPS) through the left branch portal vein (TIPS-LPV) to the standard TIPS through the right branch (TIPS-RPV). We retrospectively reviewed all patients (n = 54) with refractory portal hypertension who were subjected to TIPS-LPV at our institute (TIPS-LPV) between 2016 and 2018. These patients were matched with 56 control patients treated with the standard TIPS-RPV (TIPS-RPV). The 2 groups were compared regarding the stent patency rate, encephalopathy, and re-interventions for 1 year after the procedure.ResultsTIPS-LPV group showed 12 months higher patency rate (90.7% compared to 73.2%) (P < 0.005). The number of the encephalopathy attacks in the TIPS-LPV group was significantly lower than that of the TIPS-RPV group at 6 and 12 months of follow-up [P = 0.012 and 0.036, respectively]. Re-bleeding and improvement of ascites were the same in the two groups [P > 0.05]. Patients underwent TIPS-LPV needed less re-interventions and required less hospitalizations than those with TIPS-RPV [P = 0.039 and P = 0.03, respectively].ConclusionThe new TIPS approach is to extend the stent to LPV. This new TIPS-LPV approach showed the same clinical efficiency as the standard TIPS-RPV in treating variceal bleeding and ascites. However, it proved a better stent patency with lower rates of re-interventions, encephalopathy, and hospital admissions than TIPS through the right branch.

Characteristics of approaches that increase the effectiveness of surgical treatment of focal liver diseases

The aim of the study was to clarify the causes that reduce the effectiveness of surgical treatment of focal liver diseases of various origins. The presented review of the literature data showed an urgent need tothe need to remove large volumes of liver parenchyma. To reduce the number of complications (liver failure, bleeding), a combination of approaches is proposed. Use of chemotherapy andembolization of the arteries of the resection area reduces the size of the formation. Obstruction of portal vein branches by embolization or ligation increases the amount of repair and prevents the development of hepaticfailures. The rate of remnant hypertrophy increases the separation of the liver parenchyma along the resection border. Combined use of tactical approaches, modern equipment and surgical techniquesincreases the effectiveness of treatment of focal liver formations.

Liver histopathology in severe COVID 19 respiratory failure is suggestive of vascular alterations.

SARS2‐CoV‐2 breakout in Italy caused a huge number of severely ill patients with a serious increase in mortality. Although lungs seem to be the main target of the infection, very few information are available about liver involvement, possibly evocating a systemic disease. Post‐mortem wedge liver biopsies from 48 patients died from severe pulmonary COVID‐19 disease with respiratory failure were collected from two main hospitals in northern Italy. No patient had clinical symptoms of liver disease or signs of liver failure before and during hospitalization; for each of them liver function tests were available. All liver samples showed minimal inflammation features. Histological pictures compatible with vascular alterations were observed, characterized by increase in number of portal vein branches associated with lumen massive dilatation, partial or complete luminal thrombosis of portal and sinusoidal vessels, fibrosis of portal tract, focally markedly enlarged and fibrotic. SARS‐CoV‐2 was found in 15 of 22 samples tested by in situ hybridization method. Our preliminary results confirm the clinical impression that liver failure is not a main concern and this organ is not the target of significant inflammatory damage. Histopathological findings are highly suggestive for marked derangement of intrahepatic blood vessel network secondary to systemic changes induced by virus that could target not only lung parenchyma but also cardiovascular system, coagulation cascade and endothelial layer of blood vessels. It still remains unclear if the mentioned changes are directly related to virus infection or if SARS‐CoV‐2 triggers a series of reactions leading to striking vascular alterations.

Doppler characteristics of hepatic venous hemodynamics in adult healthy camels (Camelus dromedarius)

Abstract The present study was designed to describe the Doppler measurements of hepatic venous blood flow in camels (Camelus dromedarius). A total number of 9 adult healthy camels underwent hepatic Doppler examinations on the right side between the 11th and 9th intercostal spaces. The splenic and cranial mesenteric veins showed turbulent blood flows at their fusion to form the main portal trunk. At porta hepatis, the main portal vein exhibited turbulent blood flows and the mean velocities ranged from 21 to 28 cm/sec. In contrast, the intrahepatic branches of portal veins revealed smooth laminar spectral patterns with low blood velocities ranged from 12 to 22 cm/sec. In addition, hepatic veins and caudal vena cava have laminar blood flows. In conclusion, as a non-invasive clinical tool, Doppler ultrasonography is a simple and easy applicable method for assessment of hepatic hemodynamics in camels (Camelus dromedaries). The present findings have the potential to serve as references for evaluating the health status of the liver from camels. Therefore; a further research study, including comparative evaluation of Doppler findings in camels with various hepatic diseases, may be required.

Liver Histopathology in COVID-19 Infection Is Suggestive of Vascular Alteration

Background: COVID-19 breakout in Italy caused a huge number of severely ill patients with a serious increase in mortality. Although lungs seem to be the main target of the infection very few information are available about liver involvement, possibly evocating a systemic disease. Methods: Post-mortem wedge liver biopsies from 48 patients died for COVID-19 infection were collected from two main hospitals in the north of Italy: all samples were obtained during autopsies. No patient had clinical symptoms of liver disease or signs of liver failure before and during hospitalization; for each of them liver function tests were available. Findings: All liver samples showed minimal inflammation features. Histological pictures compatible with vascular alterations were observed, characterized by increase of number of portal vein branches associated with lumen massive dilatation, partial or complete luminal thrombosis of portal and sinusoidal vessels, fibrosis of portal tract, focally markedly enlarged and fibrotic. Interpretation: Our preliminary results confirm the clinical impression that liver failure is not a main concern and this organ is not the target of significant inflammatory damage. Histopathological findings are highly suggestive for marked derangement of intrahepatic blood vessel network secondary to systemic changes induced by virus that could target not only lung parenchyma but also cardiovascular system, coagulation cascade and endothelial layer of blood vessels. Funding Statement: This work has no financial support. Declaration of Interests: None of the authors declare a conflict of interest Ethics Approval Statement: This work is based exclusively on routine file autoptic material and is ethical approval exempt to use anonymous data. The study followed the Italian general rules used for research related to scientific purposes (official regulations n.72-26 /03/2012).

Variations of the right branch of hepatic portal vein in children based on three-dimensional simulation technology.

To study the variations of the right branch of the hepatic portal vein in children. A total of 810 children's abdominal CT images were reconstructed with three-dimensional (3D) simulation software, Variations of the right branch of the hepatic portal vein were analyzed and classified. The most common anatomy (type A) was seen in 355 patients (43.83%). Trifurcation in the right anterior portal vein (type B) variation was seen in 250 cases (30.86%). The right posterior portal vein arched without obvious branching (type C) was seen in 71 cases (8.77%). There were 134 special variants (16.54%) named type D, including 14 cases (1.73%) with the right anterior branch in four sub-branches, 13 cases (1.60%) in one trunk and multiple sub-branches, 92 cases (11.36%) originating from the left trunk of the portal vein, and 15 cases (1.85%) with the VI segment of the portal vein originating from the right anterior branch of the portal vein. Variations in the right branch of the hepatic portal vein seems to be very frequent. Recognition of such variations is important in the preoperative evaluation of children with surgery planned, because these variations may have implications for anatomy-guided liver resection and for planning the operative approach.

SAT-660 Rare Case of Portal Vein Thrombosis Secondary to Acute Pyelonephritis in Type 1 Diabetic Patient

Background: Portal vein thrombosis (PVT) refers to venous thrombosis that develops within the extrahepatic portal venous system and can extend to the branches of the intrahepatic portal vein or up to splenic veins and superior mesenteric. A few cases have been reported about portal vein thrombosis in non-cirrhotic patient. Asymptomatic or non-specific symptom of portal vein thrombosis may lead to misdiagnosed or delay the diagnosis until the complications develop. We report a case of Portal vein thrombosis in type one diabetes associated with acute pyelonephritis. Case report: 18 years old female with type one diabetes on insulin pump present with epigastric abdominal pain for three days associated with nausea and vomiting of three days duration. On examination; conscious alert oriented young female looks in pain, vital sign were stable temperature 37oC, heart rate 89 beat per minute, blood pressure 103/72 mmHg, respiratory rate 20 per minute, oxygen saturation 100% and random blood sugar (RBS) 179 mg/dl. Abdominal examination revealed soft and lax abdomen with tenderness in the epigastric area and right renal angle. No sign of rigidity or rebound tenderness. Bowel sound was present. No sign of ascites, splenomegaly or hepatomegaly. Investigations showed; WBC: 10.2, neutrophil 65%, urine analysis WBCs 30-50 per high field microscopy, RBC 5-10, PH 7, negative nitrate and culture did not show any growth. ESR was 48 and CRP was 4.2. Thrombophilic screen was done and all within normal. Computed tomography (CT) reveled reduced enhancement of right kidney likely indicating acute pyelonephritis and portal vein edema with complete occlusion of left branch of portal vein. Local factors and prothrombotic disorders were ruled out. The patient was managed with ciprofloxacin, enoxaparin and warfarin. The patient was symptomatic free and discharge home with a therapeutic range INR. Conclusion: Portal vein thrombosis is uncommon condition in absence of liver diseases. Few case report liking between sepsis and portal vein thrombosis. Sepsis can create a predisposed environment for hypercoagulability.

The Role of Spleen and Liver Elastography and Color-Doppler Ultrasound in the Assessment of Transjugular Intrahepatic Portosystemic Shunt Function

The reference standard for assessing transjugular intrahepatic portosystemic shunt (TIPS) function is venography with portosystemic pressure gradient (PPG) measurement. This procedure is invasive and expensive; thus, we assessed the feasibility, reproducibility and diagnostic accuracy of color-Doppler ultrasound (CDUS) and spleen and liver stiffness (LS) measurements for identifying TIPS dysfunction. Twenty-four patients (15 undergoing TIPS placement and nine undergoing TIPS revision) consecutively underwent CDUS examination and LS and spleen stiffness (SS) determination by transient elastography (TE) and point shear-wave elastography (pSWE). All parameters were taken before TIPS placement/revision (1–15 d before) and 24 h after, just before revision by venography. pSWE inter-observer agreement was assessed by intra-class correlation coefficient (ICC). CDUS and elastographic data were correlated (Pearson coefficient) with pressure gradients (hepatic venous pressure gradient [HVPG], PPG). Main determinants of TIPS dysfunction were investigated by linear regression. Forty-nine paired examinations were performed in total: 49 (100%) SS reliable measurements by pSWE and 38 (88%) by TE. The ICC for pSWE values was 0.90 (95% confidence interval [CI] 0.81‒0.94). SS values significantly correlated with HVPG and PPG (R = 0.51, p = 0.01). The area under the Receiver-Operating Characteristic (AUROC) curve of SS for diagnosing TIPS dysfunction was 0.86 (95% CI 0.70‒0.96) using a 25 kPa cutoff. At multivariate analysis, the flow direction of the intrahepatic portal vein branches and SS values were independently associated to TIPS dysfunction. The intrahepatic portal vein branches flow direction and SS value are two simple, highly sensitive parameters accurately excluding TIPS dysfunction. SS measurement by pSWE is feasible, reproducible and both positively and significantly correlates with HVPG and PPG values.

A comparative study on preoperative portal vein embolization using tris-acryl gelatin microspheres versus coils

Objective To compare preoperative portal vein embolization (PVE) using tris-acryl gelatin microspheres (TAGM) versus coils. Methods From March 2016 to June 2018, 21 consecutive patients with a future liver remnant (FLR) ratio of less than 45% before planned major hepatectomy for malignant or benign liver diseases were enrolled from the First Department of Biliary Surgery, Eastern Hepatobiliary Surgery Hospital into this study. The patients were divided to receive portal vein embolization (PVE) using TAGM distally and coils proximally (the TC group) and PVE using multiple coils (the CC group). Post-PVE complications, liver function, routine blood tests; FLR hyperplasia, types of liver resection, operation time, intraoperative blood loss, and postoperative complications were compared between the two groups. Results Eight patients were included in the TC group. There were 4 males and 4 females, with a mean age of (55.3±7.7) years. Of 13 patients included into the CC group, there were 11 males and 2 females, with a mean age of (52.6±11.3) years. There were no significant differences in sex, age, types of hepatic diseases, volume of FLR, ratio of FLR, ratio of standard FLR, types of surgery, operation duration, blood loss, major complications, and liver failure rates between the two groups. All patients in the two groups had successful PVE. The TC group developed effective growth of volume of FLR with one patient who failed to undergo surgery because of tumor progression. In the CC group, four patients failed to undergo liver resection: one patient developed thrombosis of the left branch and main trunk of portal vein; tumor progression occurred in one patient and two patients had insufficient FLR growth. Compared with the CC group, the TC group had a significantly higher volume of FLR hyperplasia [(9.0±2.8) % vs. (5.2±3.8) %, P 0.05], a greater but insignificant increase in percentage of proliferation [(33.6±20.1) % vs. (20.9±15.1) %, P>0.05]. Conclusions This study showed that PVE with TAGM plus coils is safe and effective. It induced a better degree of hypertrophy of FLR compared to PVE using multiple coils. Key words: Liver diseases; Portal vein embolization; Tris-acryl gelatin microsphere; Coils; Major hepatectomy

Hepatic Necrosis after Trans-Arterial Embolization of Metastatic Neuroendocrine Tumour.

Liver metastases from neuroendocrine tumours (NETs) are usually seen on cross-sectional imaging at presentation. In such cases, curative surgical resection is usually not possible given that most patients have bilobar disease. Various locoregional approaches are now widely available that enable local control of disease and management of systemic symptoms. These include trans-arterial embolization (TAE), trans-arterial chemoembolization (TACE), selective internal radiotherapy and thermal ablation.We describe a rare case of hepatic necrosis after TAE in a 61-year-old woman with a metastatic NET. Cross-sectional imaging showed extensive necrosis affecting segments VII and VIII of the liver. This occurred secondary to thrombosis in the portal vein branches to these segments, confirmed on a Doppler ultrasound scan. The mechanism of portal vein thrombosis after TAE could be due to the presence of occult arterioportal anastomoses. These allow transit of the embolizing agents into the portal vein branches supplying the treated segments and subsequent thrombosis.LEARNING POINTSHepatic necrosis is a very rare but significant complication of TAE. The incidence of this complication after TAE has not yet been reported.Hepatic necrosis may be mimicked by the more commonly encountered post-embolization syndrome (PES). Hepatic necrosis should be suspected when symptoms are prolonged, or if the patient exhibits any form of deterioration. Prompt cross-sectional imaging is crucial in establishing diagnosis.Thorough supportive management is key in the setting of liver injury or failure. Sepsis should be treated aggressively with regular blood cultures and specialist input should be sought for optimization of antibiotic regimes.

Multiple liver metastases originating from synchronous double cancer of neuroendocrine tumor and rectal cancer: a case report

BackgroundNeuroendocrine tumor (NET) is a relatively rare tumor and can develop in almost any organ, but primary mesenteric NETs are extremely rare. In addition, liver metastases from synchronous double cancer of neuroendocrine tumor graded as G1 and second primary malignancies (SPMs) have never been reported before. We herein report a case of multiple liver metastases from synchronous double cancer of NET (G1) at the ileal mesentery and rectal cancer.Case presentationA 66-year-old man was identified as having tumors in the rectum and the ileal mesentery by computed tomography (CT). He underwent laparoscopic low anterior resection for rectal cancer and biopsy of the ileal mesentery lymph node and was diagnosed with rectal cancer as pT3 pN1 cM0 (stage IIIB) and NET (G1) of the ileal mesentery. He received oxaliplatin and capecitabine (XELOX) for 3 months as adjuvant chemotherapy for rectal cancer. The NET (G1) of the ileal mesentery was low grade and had not expanded at follow-up. A CT scan performed 4 years after the surgery indicated multiple liver metastases. All the metastases had the same findings on CT and magnetic resonance imaging (MRI). Thus, the patient underwent the first stage of modified associating liver partition and portal vein ligation for staged hepatectomy (modified ALPPS), comprising partial hepatectomies of segments 3 and 4, ligation of the right branch of portal vein, and hepatic partition on the demarcation line, followed by the second stage of modified ALPPS (right lobectomy). Histopathological findings revealed that the 14 nodules were metastatic liver tumors of rectal cancer and the 2 nodules were liver metastases of the NET (G1).ConclusionsOur findings suggest that synchronous double cancer of NET and gastrointestinal cancer may be indistinguishable in preoperative images. However, curative resection, precise pathological diagnosis, and adequately adjusted treatment may result in a better prognosis.