Branch Of Hepatic Artery Research Articles

Hemobilia: an unusual and life threatening complication of laparoscopic cholecystectomy

Hemobilia though rare, occurs due to abnormal vascular and biliary communication established as a result of trauma, gallstones, neoplasms, inflammatory process and vascular disorders. It can rarely complicate a laparoscopic cholecystectomy as a result of hepatic artery injury, clip migration, clip erosion, diathermy and subsequent arteriobiliary fistula, or pseudoaneurysm eroding into the extra hepatic bile ducts. A 34 years female underwent laparoscopic cholecystectomy for cholelithiasis, suffered bile leak that settled on by 13th postoperative day, met with sudden right upper abdominal pain and hypovolemic shock on 15th postoperative day due to massive hemobilia arising out of rupture of pseudoaneurysm of the right hepatic artery into the biliary system. Urgent CT Angiography showed a large pseudoaneurysm of right hepatic artery branch with adjacent small collection, IHBR and CBD dilatation suggestive of hemobilia. Emergency CT guided trans-arterial hepatic artery embolization done to control hemobilia and save the patient. An immediate CT angiography for early diagnosis, in all postoperative laparoscopic cholecystectomy cases with suspicion of hemobilia due to an underlying hepatic artery pseudoaneurysm, followed by CT guided trans-arterial hepatic artery embolization forms the gold standard management in such patients.

Quantitative 4D-Digital Subtraction Angiography to Assess Changes in Hepatic Arterial Flow during Transarterial Embolization: A Feasibility Study in a Swine Model

PurposeTo determine the feasibility of using time-resolved 3D-digital subtraction angiography (4D-DSA) for quantifying changes in hepatic arterial blood flow and velocity during transarterial embolization. Materials and MethodsHepatic arteriography and selective transarterial embolization were performed in 4 female domestic swine (mean weight, 54 kg) using 100–300-μm microspheres. Conventional 2D and 4D-DSA were performed before, during, and after each embolization. From the 4D-DSA reconstructions, blood flow and velocity values were calculated for hepatic arterial branches using a pulsatility-based algorithm. 4D-DSA velocity values were compared to those measured using an intravascular Doppler wire with a linear regression analysis. Paired t-tests were used to compare data before and after embolization. ResultsThere was a weak-to-moderate but statistically significant correlation of flow velocities measured with 4D-DSA and the Doppler wire (r = 0.35, n = 39, P = .012). For vessels with high pulsatility, the correlation was higher (r = 0.64, n = 11, P = .034), and the relationship between 4D-DSA and the Doppler wire fit a linear model with a positive bias toward the Doppler wire (failed to reject at 95% confidence level, P = .208). 4D-DSA performed after partial embolization showed a reduction in velocity in the embolized hepatic arteries compared to pre-embolization (mean, 3.96 ± 0.74 vs 11.8 2± 2.15 cm/s, P = .006). ConclusionQuantitative 4D-DSA can depict changes in hepatic arterial blood velocity during transarterial embolization in a swine model. Further work is needed to optimize 4D-DSA acquisitions and to investigate its applicability in humans.

“Liver or Let Die”: Percutaneous PFO Closure Through Hepatic Vein Access

A 73-year-old farmer presented with platypnoea-orthodeoxia syndrome (POS). A transoesophageal echocardiogram (TOE) disclosed a patent foramen ovale (PFO) with significant right-to-left shunt on assuming upright posture. An initial attempt at PFO closure through the femoral vein was abandoned due to a completely occluded inferior vena cava. A second attempt through the internal jugular vein was also unsuccessful due to the steep angulation between superior vena cava and septum primum flap. Because of disabling symptoms, an attempt through a hepatic vein (HV) was scheduled and performed under general anaesthesia with TOE guidance. Ultrasound-guided access through an intercostal window to a peripheral HV was performed and the position confirmed with contrast injections. The PFO was easily crossed with a glide wire which was exchanged to a stiffer guide wire. A 25mm closure device was successfully deployed across the PFO. After retrieval of the delivery system, haemostasis of the HV was attained with a contrast-guided Gelfoam (Pfizer, New York, NY, USA) injection. Unfortunately, the patient had to undergo subsequent emergency coiling to an iatrogenically injured hepatic artery branch leading to full recovery and significant clinical improvement. Subsequent echocardiography demonstrated a well-positioned device with no residual shunt. This case illustrates that percutaneous PFO closure through a HV is a feasible procedure and should be considered in anatomy that is otherwise prohibitive for conventional approach. Extra care should be taken with initial vascular access into the HV and final haemostasis of the access site.

Abstract No. 469 Improved intra-arterial tumor targeting using an omniphobic oil in a pig model

Intra-arterial lipiodol is specifically retained in HCC and other tumors, due to leaky tumor vasculature, and poor clearance from the tumor. Suboptimal lipiodol retention and early lipiodol washout after chemoembolization are associated with residual or recurrent tumor. We hypothesize that tumor targeting could be improved using a low viscosity omniphobic oil. The low viscosity could improve tumor uptake via leaky tumor vasculature. The omniphobic oil interacts poorly with both water and hydrocarbon oils, and should thus be difficult for the body to remove from the tumor. Liver tumors (n=3) were induced in an Oncopig (a transgenic pig with Cre-inducible p53 and Kras mutations) using an adenoviral vector carrying the Cre recombinase gene. We injected lipiodol versus FC-70 (a radiopaque omniphobic fluorocarbon oil) selectively into hepatic artery branches supplying tumor. 3 days after injection, we quantified oil retention in the tumors or background liver (v/v%), by measuring the Hounsfield units on non-contrast CT, compared to the Hounsfield units of pure oil. Lipiodol was retained in tumor at a concentration of 1.9%, and in background liver at a concentration of 0.6% (3.5x specificity for tumor). FC-70 was retained in tumor at a concentration of 6.8%, and in background liver at a concentration of 1.4% (4.9x specificity for tumor). Intra-arterial FC-70 is an alternative to lipiodol, which can result in improved tumor uptake and specificity. FC-70 is a fluorocarbon oil that has no functional groups in common with lipiodol, indicating a non-specific tumor-targeting mechanism, and suggesting that tumor targeting can be modulated by changing the physical properties of the oil.

A cadaveric study on variations of the cystic artery in the department of pathology, at the University Teaching Hospitals, Lusaka, Zambia

The main source of blood supply to the gall bladder is the cystic artery which is a branch of the right hepatic artery. Anatomical variations of the cystic artery are frequent. Thus, careful dissection of the Calot`s triangle is necessary for conventional and laparoscopic cholecystectomy. The knowledge of variations of the origin, course, and length of the cystic artery is important for the surgeon as bleeding from the cystic artery during cholecystectomy can lead to death. Thirty-two post-mortem human cadavers at the University Teaching Hospitals, Pathology Department, Lusaka were dissected and examined over a period of five weeks, to establish the origin, length and course of the cystic artery. And to establish the relationship of the cystic artery to the cystic duct. Out of the 32 human cadavers, the cystic artery was found to be originating from the right hepatic artery in twenty-eight (87.5%), from hepatic artery proper in three (9.4%) and from the left hepatic artery in one (3.1%). In the twenty-nine (90.6%) cadavers dissected, only one cystic artery was identified and in three (9.4%)others there were two arteries detected. The cystic artery length ranged from 2 – 6 cm (mean 3.56± 1.0285 cm). The cystic artery was found to be inside Calot`s triangle in twenty-seven (84.3%) while in three (9.4%) cadavers it was outside the Calot`s triangle. The cystic artery was found to be passing supero-medial to the cystic duct in thirty (93.7%) cadavers while in two (6.3%) the cystic artery was passing anterior to the cystic duct. Demographic characteristic (gender and age) had no statistically significant association to variations of cystic artery (p>0.005). Five (18.5%) of males had variants of cystic artery and no females had variants of the cystic artery. Variations of the cystic artery origin, length, its course through the Calot`s triangle and its relation to the cystic duct are common. Knowledge of these variations is important and helpful in preventing and controlling haemorrhage or avoiding other complications during conventional and laparoscopic cholecystectomy. Key words: Cystic artery, Variations, Cholecystectomy, Calot`s triangle

Trans biliary proximal and distal coil embolization of an arteriobiliary fistula: report of a case and review of literature

BackgroundHepatic arterial injury is an uncommon complication of percutaneous transhepatic biliary drainage interventions that commonly presents with hemobilia and peri catheter hemorrhage. It is classically managed with antegrade trans arterial embolization. However, this approach may not be possible due to altered anatomy and alternative techniques need to be considered. We report a case of an arteriobiliary fistula which was successfully coil embolized both distal and proximal to the lesion using a trans biliary approach. This is the first report of such method and interventionalists should be aware of this option. The literature is reviewed.Case presentationWe report a case of a 49-year-old male with advanced colorectal cancer presented with cholangitis. His duodenal anatomy precludes endoscopic intervention, so he underwent percutaneous biliary drainage complicated by intractable hemobilia and pericatheter bleeding. Hepatic arterial anatomy evaluated by two catheter angiographies was shown to be isolated at multiple levels by tumors and prohibited antegrade access of bleeding artery for embolization. Sheath cholangiography revealed an arteriobiliary fistula involving left hepatic arterial branches. The arterial injury was successfully treated by coil embolization distal and proximal to the lesion via a retrograde trans biliary approach, with complete resolution of hemobilia.ConclusionTrans biliary proximal and distal coil embolization is a newly reported approach for treating biliary hemorrhage when traditional antegrade arterial embolization is not feasible due to preclusive anatomic factors. Interventionalists should be familiar with this management option.

Trans-T-tube Biliary Drainage; an Alternative Treatment Option for Intractable Postoperative Biliary Fistula after Choledochotomy

Introduction: Persistent biliary fistula after biliary operation is not common, but sometimes it is very difficult problem, especially in case of friable common bile duct (CBD). Herein, we report a case of intractable postoperative biliary leakage treated with trans-T-tube biliary drainage (TTBD). Method: A 65-years-old man visited because of CBD stone and multiple left intrahepatic bile duct (IHBD) stones. After the left hemihepatectomy and choledocholithotomy, primary closure of CBD was performed because there was endoscopic retrograde biliary drainage (ERBD) catheter inserted already. On postoperative day 7, covered stent insertion in right hepatic artery was performed due to bleeding from hepatic artery branch. On the 5th day after the intervention, bile leakage was observed from drain and re-operation was performed. There was necrosis of CBD wall around choledochotomy site and debridement and T-tube insertion was performed. Persistent bile leakage was observed with average amount of 500ml/day even though well-functioning T-tube until 30 days after re-operation. And two times of ERBD tries were failed. T-tube cholangiography revealed bile leakage from CBD more proximal portion to T-tube insertion site. A drainage catheter through T-tube was inserted with positioning the catheter tip in right IHBD. Result: Two days after the procedure of TTBD, the amount of bile from drain was dramatically decreased and the drain was removed after 6 days after TTBD. Four weeks after the TTBD, T-tube and TTBD catheter were removed without any problem. Conclusion: For intractable persistent biliary fistula after choledochotomy, TTBD could be considered for useful alternative treatment option.

Spontaneous Rupture of Fibrolamellar Variant Hepatocellular Carcinoma

Fibrolamellar hepatocellular carcinoma (FL-HCC) is a unique variant of hepatocellular carcinoma. The majority of cases present with nonspecific symptoms like vague abdominal pain, weight loss and fatigue. Ruptured FL-HCC occurs rarely and mortality in the acute phase is very high. We report a rare case of a ruptured FL-HCC successfully managed with transarterial embolization for hemostasis. A 37-year-old male previously in good health presented with a severe, sharp epigastric pain that started 1 h prior to the presentation. He denied trauma, fever, nausea, vomiting, or diarrhea. Tenderness in the epigastrium was noted, with no palpable masses, guarding or rigidity. His blood pressure and pulse were 159/105 mm Hg and 105 beats/min. Platelets and coagulation parameters were within normal limits; transaminases were elevated. Abdominal computed tomography (CT) scan with contrast revealed an 8 cm lobulated mass with central hypodensity in the left hepatic lobe with perilesional blood and free pelvic fluid, indicating tumor rupture. CT angiography showed tumor neovascularization from a branch of the left hepatic artery which was embolized using transarterial gelfoam. Liver magnetic resonance imaging (MRI) and biopsy were consistent with fibrolamellar variant hepatocellular carcinoma. After 4 days, as the symptoms resolved, and the lab results were stable, patient was discharged and underwent a left hepatectomy 3 weeks later. FL-HCC occurs commonly in the left lobe of a young and non-cirrhotic liver. Typically, cross sectional imaging reveals a lobulated mass with well-defined margins, areas of hypervascularity and a central calcified scar. Histologic appearance is characterized by eosinophilic polygonal shaped cells separated by lamellar fibrosis. Surgical resection is the treatment of choice with better outcome when compared to conventional HCC. Disease recurrence after complete surgical resection is however high in the first 5 years. Tumors > 5 cm in size are at high risk for rupture with high mortality and recurrence rates secondary to significant spillage of tumor. While an emergency hepatectomy is preferred in unstable patients, those that are hemodynamically stable can undergo radiologic transarterial embolization for hemostasis followed by staged hepatectomy.

Histomorphological Studies of Liver in Buffalo (Bubalus bubalis)

The histomorphological studies of the 24 buffalo livers (12 male and 12 female) were carried out. The liver was covered by dense white fibrous connective tissue formed the interlobular septa which was extended from the capsule. The cords of hepatocytes of one lobule were appeared to be blend into the adjacent lobules without a clear line of demarcation. In each hepatic lobule, the plates of hepatocytes and sinusoids were appeared to be radiated outward from the central vein to the periphery of the liver lobule. Hepatocytes were polyhedral shaped cells, characterized by a centrally located spherical nucleus with chromatin granules and distinct cell membrane. The cytoplasm showed the dirty stained mitochondria. Hepatic sinusoids were observed between the rows of hepatocytes. The lumen of sinusoids was lined by Von-Kupffer cells and endothelial cells. Bile canaliculi were observed in between two adjacent hepatocytes. As the bile duct enlarges from bile canaliculi to the hepatic duct, the epithelium was gradually increased in height as a simple columnar epithelium. The portal triad consisted of interlobular branches of hepatic artery, portal veins, interlobular bile duct, small lymphatic vessels and nerves. Collagen fibers were observed in the capsule, interlobular connective tissue and blood vessels, elastic fibers were observed in the capsule, interlobular connective tissue and blood vessels and the reticular fibers were observed in the capsule, interlobular septa and sinusoids of the liver in both male and female buffaloes.

A vascular variant allows to resect "en bloc" cholangiocarcinoma Bismuth IV

Background: Curative hepatectomy with bile duct resection is the treatment for perihilar cholangiocarcinoma. When vessel involvement in imaging preoperative studies is found, the use of more aggressive aproach with bloc resection is the recommendation. Methods: A video of the surgical approach used in a case of Bismuth type IV Klatskin tumor resected with extended left hepatectomy. Results: A 67-year-old man who presented with epigastric pain and abnormal liver function was referred to our clinic for further examination. Serial examination resulted in diagnosis of Bismuth IV hilar cholangiocarcinoma, atrophying mainly the left hepatic lobe, and infiltrating right and left hepatic artery branches. Fortunately, the patient presented a SVI-VII artery arising from gastroduodenal artery no invaded, anatomical variant that allows tumor resection, keeping the arterial supply of the liver. The variant anatomical of the vessel was identified preoperatively. He underwent left hepatectomy with the main right hepatic artery, caudate lobectomy and extrahepatic bile duct resection without any complications. Pathological study of specimen showed a 4.9x1.2cms cholangiocarcinoma with free margins. No recurrence 1 year late. Conclusion: Aggressive approach with "en bloc" and extended liver resections in the treatment of Bismuth IV hilar cholangiocarcinoma could be feasible. It’s important a meticulous preoperative evaluation with images in this cases, because we can identify anatomical variations make surgery possible.

Development of Repeatable Microcatheter Access Port for Intra-arterial Therapy of Liver Cancer.

To develop an implantable port in which a microcatheter can be inserted for a combination therapy of repeated transarterial chemoembolization (TACE) and hepatic arterial infusion chemotherapy (HAIC) for advanced liver cancer. The design of a currently used implantable port was modified. A funnel part was constructed in the port. The septum was punctured by a 20-gauge indwelling needle, and 2.0-Fr non-tapered microcatheter was inserted into the port. In the in vitro studies, the advance of a microcatheter out of the funnel part was evaluated via seven different septum puncture sites. A 5-Fr indwelling catheter connected to the port was placed in a vascular model, and a microcatheter catheterization was evaluated. In an in vivo study, the port-catheter system was implanted in the hepatic artery in a pig. A microcatheter was percutaneously inserted through the port into the hepatic arterial branches, and embolization was performed. In the in vitro studies, the microcatheter was smoothly advanced out of the port and catheterizations into the hepatic arteries were successful via all septum puncture sites. In the in vivo study, repeated selective embolization through the port was successfully conducted on 7, 14 and 21days after the implantation. The developed implantable port can be used for repeated catheter insertion into the hepatic artery. The combination of repeated TACE and HAIC could be possible using this device.

Locoregional Therapy With Transarterial Chemoembolization (TACE) for Stage 1A Intrahepatic Cholangiocarcinoma (ICC) Before Surgical Resection: A Case Report

Intrahepatic cholangiocarcinoma is usually treated by hepatic resection to achieve negative resection margins but only minority of patients present with early stage disease. Hepatic artery based therapies such as radioembolization (TACE) is used for locally advanced unresectable disease. We present a case of stage 1A localized ICC treated with TACE followed by radiotherapy with possible liver resection in the future. A 42 year old male with history of alcohol use disorder, diabetes mellitus and hypertension came in with right upper quadrant abdominal pain. Abdominal examination was significant for distended abdomen with epigastric tenderness. Labs revealed alanine transaminase (ALT) 72 U/L, aspartate transaminase (AST) 79 U/L, platelet count 132 k/uL, and INR of 1.0. He had a sonogram of the liver which revealed a complex left hepatic lobe lesion with peripheral vascularity, so magnetic resonance imaging (MRI) of abdomen was done which showed cirrhosis with portal hypertension and 2.6 x 2.3 cm lesion involving segment II and III (Figure 1). His viral hepatitis panel was negative, and CA 19-9 was 36.8 U/ml. He underwent EGD and colonoscopy which revealed no mass. Interventional radiology (IR) guided liver biopsy of mass ICC. Patient underwent IR guided TACE with 75 mg of Doxorubicin beads administered into segmental branch of right hepatic artery the tumor (Figure 2) followed by split beam radiation therapy (SBRT). Repeat CT scan of abdomen done 7 months post TACE has not shown recurrent disease (Figure 3).2328_A Figure 1. MRI abdomen showing 2.6 x 2.3 cm lesion involving segment II and III of liver (red arrow) before TACE procedure2328_B Figure 2. Cone beam CT imaging (right) during TACE procedure showing chemotherapy beads being administered near tumor site by catheter (red arrow) & contrast enhancement of tumor site (left) on digital subtraction angiography (DSA) imaging.2328_C Figure 3. CT abdomen showing post treatment tumor with surrounding peripheral region of hyper density representing post TACE changes (red arrow).Intrahepatic tumors derive blood supply from hepatic artery rather than portal vein. This has led to development of TACE which involves elimination of tumor's blood supply by particle embolization and/or cytotoxic chemotherapy infusion into the branch of hepatic artery that feeds the tumor. Such therapies, particularly radioembolization, appear promising for patients with locally advanced unresectable ICC. Partial hepatectomy is the treatment of choice for small peripheral ICC. In our case due to patient's current heavy alcohol use and compensated cirrhosis, partial hepatectomy was thought to confer a very high risk for hepatic decompensation postoperatively. So, he was successfully treated with TACE followed by radiotherapy, with plan of left hepatic resection once he is abstinent from alcohol. Our case demonstrates the effectiveness of TACE for ICC which cannot undergo partial liver resection due to his alcoholic cirrhosis.

Subcapsular Hematoma: An Unusual Complication of ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) developed in 1968 is a minimally invasive procedure for diagnosis and treatment of biliary and pancreatic disease. Complications include cholangitis, perforation, bleeding and pancreatitis. They occur in 2.5-8% of cases with mortality rates ranging 0.5-1.0%. Hepatic hematoma post ERCP is an exceedingly rare complication with only a limited number of cases described in the literature. Presented is a case of a subcapsular hematoma following ERCP. A 39-year-old female presented with acute, diffuse abdominal pain associated with non-bloody, non-bilious vomiting one day after ERCP for elevated liver tests. ERCP showed a 3cm stricture in the mid common bile duct (CBD) with proximal dilation of the biliary tree and CBD to 14mm. A 7 Fr x 7mm CBD stent was placed. Sphincterotomy was not performed. On admission, vital signs were within normal limits. Labs were significant for total bilirubin 2.4 mg/dL, alkaline phosphatase 215 U/L, AST 208 U/L, ALT 496 U/L, lipase 2730 U/L, Hgb 12.9 g/dL. CT abdomen showed a 5.8 x 5.6 x 18cm collection in relation to the right lobe of the liver concerning for subcapsular hematoma. Due to persistent abdominal pain, repeat CT was performed showing expansion now measuring 12 x 6.8 x 21cm. A right hepatic arteriogram was performed by IR revealing a pseudoaneurysm arising from a peripheral branch of the right hepatic artery that was embolized. She had ultrasound-guided drainage of the subcapsular hematoma with 500cc of blood drained. She completed 5 days of ceftriaxone and metronidazole for prophylaxis and was discharged on hospital day 8. Subcapsular hematoma is a rare complication that requires early identification and intervention. Presentation with severe abdominal pain and/or hypotension with associated nausea and/or vomiting should raise concern for a subcapsular hematoma. Symptoms often occur within the first 24 hours but can present as late as 2 weeks post-ERCP. A decreasing hemoglobin or hematocrit is the only laboratory finding that may raise suspicion in certain cases. Hematomas can occur as a result of incidental rupture of small caliber intrahepatic vessels due to advancement of the ERCP guide wire. Post ERCP diagnostic imaging consists of abdominal ultrasound, CT or MRI. In our case, due to an active bleeding vessel, embolization was warranted, but in a majority of cases conservative measures were the treatment of choice.1947_A Figure 1. CT Abdomen performed on admission showing a 5.8 x 5.6 x 18cm collection.1947_B Figure 2. CT Abdomen performed 12 hours after admission showing a 12 x 6.8 x 21cm collection.

Aberrant Right Hepatic Artery Leading to Duodenal Obstruction

A 60-year-old male presented with 1 day of epigastric abdominal pain and vomiting. His medical history included type II diabetes and hypertension. He underwent a weight loss of approximately 45 pounds in five months to better control his diabetes. General physical examination revealed diffuse tenderness and distention of the abdomen without peritoneal signs. Complete blood count and basic metabolic panel results were normal. An abdominal radiograph showed marked gastric distention with air-fluid levels in the stomach and proximal duodenum (Fig. 1). Computed tomography angiogram of the abdomen showed an aberrant right hepatic artery (ARHA) causing proximal duodenal obstruction (Fig. 2). The patient's clinical condition improved with nasogastric drainage and he was subsequently discharged the day after admission. He consulted with a vascular surgeon one week after discharge. The vascular supply to the liver consists of the hepatic portal vein and hepatic artery. Within 77% of the population the hepatic artery branches from the celiac artery to supply the liver; however, aberrant hepatic arterial anatomy is quite common. Studies have shown greater than 41% of the population posses anomalies of which 13-26% have anomalies in the origin of their right hepatic artery. Despite its frequency ARHAs are generally encountered during pancreaticoduodenectomy and have not been associated with intestinal obstruction. The condition is also encountered in liver transplant (15% of donor livers). ARHA can arise from the superior mesenteric artery in 11.6% of patients. This case presents an ARHA originating from the superior mesenteric artery that encircled the second portion of the duodenum and led to compression after a rapid weight loss by the patient. The main importance is recognition by the radiologist and surgical consultation to prevent ligation of the aberrant artery or biliary duct which can lead to ischemia. The patient opted for conservative management as an outpatient but was offered vascular input versus a surgical Biliroth II procedure.2584_A Figure 1. Moderate gastric distention with multiple air-fluid levels seen in the stomach and proximal duodenum on abdominal radiograph.2584_B Figure 2. An aberrant right hepatic artery causing obstruction of the proximal duodenum on computed tomography angiogram of the abdomen.

Retracted: Cadaveric study on variations of the cystic artery in a Zambian population

This article has been retracted by the authors. An incorrect dataset was used, therefore the resullts are misleading.The main source of blood supply to the gall bladder is the cystic artery which is a branch of the right hepatic artery. Anatomical variations of the cystic artery are frequent. Thus, careful dissection of the Calot`s triangle is necessary for conventional and laparoscopic cholecystectomy. The knowledge of variations of the origin, course, and length of the cystic artery is important for the surgeon as bleeding from the cystic artery during cholecystectomy can lead to death. Forty-three post-mortem human cadavers at the University Teaching Hospitals, Pathology Department, Lusaka were dissected and examined over a period of five weeks, to establish the origin, length and course of the cystic artery. And to establish the relationship of the cystic artery to the cystic duct. Out of the 43 human cadavers, the cystic artery was found to be originating from the right hepatic artery in 37 cases (86%), from hepatic artery proper in four cases (9.3%), from the left hepatic artery in one case (2.3%) and liver parenchyma in one case (2.3%). In the forty (93%) cadavers dissected, only one cystic artery was identified and in three (7%) others there were two arteries detected. The cystic artery length ranged from 2 – 6 cm (mean 3.53± 0.962 cm). The cystic artery was found to be inside Calot`s triangle in 37 cases (86%) while in four cases (9.3%) it was outside the Calot`s triangle. The cystic artery was found to be passing supero-medial to the cystic duct in 40 cases (93%) while in two cases (4.7%) the cystic artery was passing anterior to the cystic duct and one (2.3%) was unrelated (from the gall bladder bed) to the cystic duct. Demographic characteristic (gender and age) had no statistically significant association to variations of cystic artery (p>0.005). Six (16.2%) of males had variants of cystic artery and no females had variants of the cystic artery. Variations of the cystic artery origin, length, its course through the Calot`s triangle and its relation to the cystic duct are common. Knowledge of these variations is important and helpful in preventing and controlling haemorrhage or avoiding other complications during conventional and laparoscopic cholecystectomy.Keywords: Cystic artery, Cholecystectomy, Calot`s triangle

A Successful Case of Liver Transplantation in an Adult With Congenital Hepatic Arteriovenous Fistulae Associated Cardiac Dilatation and Heart Failure

Congenital hepatic arteriovenous fistulae (CHAVF) are direct communications between the hepatic artery and portal vein or hepatic vein. Clinical symptoms of CHAVF depend mainly on the location, duration, and blood flow volume of the fistulae, which are manifested by portal hypertension, hepatic fibrosis, cardiac enlargement, and eventually heart failure.Here we report a female patient aged 54 who was first admitted to our hospital due to recurrent chest tightness and palpitations in March 2014. Metoprolol tartrate and diltiazem hydrochloride were prescribed to control the symptom since nothing unusual was found in coronary angiography and abdominal ultrasound. Until April 2015, the patient's syndrome relapsed and abdominal computed tomography angiography and digital subtraction angiography revealed diffuse arteriovenous fistulae between the branches of hepatic artery and vein. Subsequently, 3 attempts at hepatic arterial embolization were performed; however, her abdominal pain aggravated and her heart discomfort could not be relieved eventually.Therefore, orthotopic liver transplantation as the salvage treatment was performed using a hepatic graft from a 19-year-old cardiac-death donor performed on January 1, 2017. Upon operation, the enlarged right hepatic artery whose diameter was approximately 1.5 cm in this recipient. And we also demonstrated a novel manner that the graft's celiac artery patch was anastomosed to the recipient's proper hepatic artery and gastroduodenal artery patch, which could reduce the blood flow successfully. The patient recovered uneventfully and was discharged home on the postoperatively 15th day. Since her liver transplantation, she has not complained of cardiac discomfort and abdominal pain, and her heart size has returned to normal on echocardiography. The hepatic artery peak velocity reduced to normal and the heart shadow also recovered.Nevertheless, for complex and diffuse intrahepatic vascular fistulae after failed hepatic artery embolization, liver transplantation should be strongly considered as the definitive treatment of choice.

Trans-T-tube biliary drainage; an alternative treatment option for intractable postoperative biliary fistula after choledochotomy

Introduction: Persistent biliary fistula after biliary operation is not common, but sometimes it is very difficult problem, especially in case of friable common bile duct (CBD). Herein, we report a case of intractable postoperative biliary leakage treated with trans-T-tube biliary drainage (TTBD). Methods: A 65-years-old man visited because of CBD stone and multiple left intrahepatic bile duct (IHBD) stones. After the left hemihepatectomy and choledocholithotomy, primary closure of CBD was performed because there was endoscopic retrograde biliary drainage (ERBD) catheter inserted already. On postoperative day 7, covered stent insertion in right hepatic artery was performed due to bleeding from hepatic artery branch. On the 5th day after the intervention, bile leakage was observed from drain and re-operation was performed. There was necrosis of CBD wall around choledochotomy site and debridement and T-tube insertion was performed. Persistent bile leakage was observed with average amount of 500ml/day even though well-functioning T-tube until 30 days after re-operation. And two times of ERBD tries were failed. T-tube cholangiography revealed bile leakage from CBD more proximal portion to T-tube insertion site. A drainage catheter through T-tube was inserted with positioning the catheter tip in right IHBD. Results: Two days after the procedure of TTBD, the amount of bile from drain was dramatically decreased and the drain was removed after 6 days after TTBD. Four weeks after the TTBD, T-tube and TTBD catheter were removed without any problem. Conclusion: For intractable persistent biliary fistula after choledochotomy, TTBD could be considered for useful alternative treatment option.

Benign Hepatic Lesions Arising in Accessory Hepatic Lobes

Abstract An accessory hepatic lobe is an uncommon hepatic congenital anomaly that can sometimes mimic a mass lesion clinically and radiologically. Because accessory hepatic lobes are only rarely resected, detailed descriptions of their histologic features are sparse. We report the histologic and immunohistochemical features of 3 cases of resected accessory hepatic lobes, all of which contained benign hepatic lesions (2 hepatic adenomas [HAs] and 1 focal nodular hyperplasia). All accessory lobes were connected to the liver by a pedicle. Histologically, all lesions demonstrated no cytologic or architectural atypia. Based on immunohistochemical analysis, 1 HA was classified as inflammatory type (positive for C-reactive protein and serum amyloid A), and 1 was unclassified type (negative for C-reactive protein, serum amyloid A, glutamine synthetase, and β-catenin and positive for liver fatty acid–binding protein); the focal nodular hyperplasia showed the typical map-like staining pattern with glutamine synthetase. Interestingly, multiple foci of myelolipoma were identified within the unclassified-type HA. Of note, in all cases, the nonlesional hepatic parenchyma featured structural vascular abnormalities of the hepatic artery branches, including abnormal thickening of arterial branches and multiple arterial branches per single portal tract. Our findings describe, for the first time, benign hepatic lesions arising in accessory hepatic lobes and suggest that accessory lobes are perhaps prone to such benign lesions because of structural abnormalities in their vasculature.

Patient-specific gamma-index analysis to evaluate 99mTc-MAA as a predictor for 90Y glass microspheres liver radioembolisation dosimetry

ABSTRACTRadioembolisation (RE) is a minimally invasive therapy for primary/metastatic liver tumours. Yttrium-90 (90Y) microspheres (MS) are infused through the hepatic artery. Positron emission tomography (PET) allows visualisation of the 90Y-MS distribution in the liver after the RE procedure. All patients are submitted to a pretherapeutic Technetium-99m (99mTc) macroaggregated albumin (MAA) perfusion scintigraphy and single-photon emission computed tomography (SPECT) liver imaging. This work investigates the value of pre-treatment 99mTc-MAA SPECT to predict intrahepatic 90Y-MS treatment dosimetry, using the gamma-index (γ-index) analytical method. Six treatments with MAA and MS administered in the same hepatic artery branches were retrospectively selected. Multimodal images were used for semi-automatic and manual segmentation of liver and tumour volumes. Absorbed dose was calculated on SPECT and PET maps using the Imalytics Research Workstation (Philips). The γ-index calculation and analysis were performed using ‘in-house’ software with multiple distance to agreement (DTA) and dose difference (DD) tolerance criteria. γ-index passing rate values of 80% and > 90% were achieved for respectively conservative 10 mm/10% and less conservative 15 mm/15% (DTA/DD) tolerance criteria. RE treatments performed in similar conditions to planning give γ-index passing rates (several DTA/DD criteria) indicating potential predictive power of dosimetry planning for post-radioembolisation dosimetry outcome.

Image-guided chemistry altering biology: An in vivo study of thermoembolization.

RationaleAdvances in image-guided drug delivery for liver cancer have shown a significant survival benefit. However, incomplete treatment is common and residual disease is often found in explanted liver specimens. In addition, the need to treat a malignancy from multiple mechanisms at the same time for optimal outcomes is becoming more widely appreciated. To address this, we hypothesized that an exothermic chemical reaction could be performed in situ. Such a strategy could in principle combine several angles of attack, including ischemia, hyperthermia, acidic protein denaturation, and metabolic modulation of the local environment.MethodsThe University of Texas MD Anderson Cancer Center Institutional Animal Care and Use Committee approved this study. Outbred swine (25–35 kg, 5 control and 5 experimental) were treated under general anesthesia. Embolization was performed with coaxial microcatheter technique in a segmental hepatic arterial branch using either ethiodized oil as control or with thermoembolic solutionBlood samples were obtained before, immediately after, and the day following the procedure just before CT scans and euthanasia. Livers were explanted and samples were obtained for histologic analysis.ResultsAll animals survived the procedure and laboratory values of the control and experimental groups remained within normal limits. The control group had a diffuse or cloudy pattern of attenuation on follow-up CT scan the day after, consistent with gradual antegrade sinusoidal transit of the embolic material. The experimental group had clearly defined vascular casts with some degree of peripheral involvement. At histology, the control group samples had the appearance of normal liver, whereas the experimental group had coagulative necrosis in small pale, punctate areas extending several hundred microns away from the treated vessels and a brisk inflammatory response just outside the margins.ConclusionIn situ chemistry via thermoembolization shows early promise as a fundamentally new tactic for image-guided therapy of solid tumors.