Hepatic Vein Research Articles

Laparoscopic Right Hemi-hepatectomy of the Bile Duct-Obstructed Area Guided by Real-Time Fluorescence Imaging.

The regions of the liver with cholestasis caused by biliary tumors or thrombosis can be distinctly identified using indocyanine green (ICG) fluorescence imaging.1 The authors' team reported the application of bile-duct obstructed area imaging (BOAI) to assist open hepatectomy for intrahepatic cholangiocarcinoma (ICC) combined with intrahepatic bile duct obstruction previously.2 This video is the first report of real-time BOAI-guided three-dimensional (3D) laparoscopic hepatectomy using a 3D-4K fluorescence imaging system. A 65-year-old man was admitted to the authors' institution with clonorchiasis. Preoperative computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) showed an obstruction and diffuse dilation of the right hepatic duct. A 15-min retention of ICG (ICG R15) was performed 5 days before the operation, with a 3.3% result. Preoperative planning involved performing laparoscopic right hemi-hepatectomy with regional lymph node dissection assisted by visualization technology.3 During the procedure, significant fluorescence accumulation in the right liver was shown by fluorescence imaging. With the guidance of real-time BOAI (Fig. 1), the regions of biliary obstruction were precisely resected, and the middle hepatic vein (MHV) was passively and adequately exposed on the cutting plane. Fig. 1 Administration steps for real-time bile duct-obstructed area imaging. A ICG is injected intravenously 3-5 days before operation at a dose of 0.5 mg/kg. B ICG is accumulated in the whole liver within a few minutes after injection. C ICG is selectively absorbed by the liver and excreted into the intestines, whereby it is retained in areas of biliary obstruction RESULTS: The histopathologic diagnosis indicated high-grade intraepithelial neoplasia of the right bile duct tumor without lymph node metastases and clonorchiasis. The duration of the operation was 300 min, with an intraoperative blood loss of 50 ml. No postoperative complications occurred, and the patient was discharged after 7 days. Laparoscopic right hemi-hepatectomy for the bile-duct obstructed area with the guidance of real-time BOAI is feasible and effective.

The potential role of Akkermansia muciniphila in liver health.

Akkermansia muciniphila (A. muciniphila) is a 'star strain' that has attracted much attention in recent years. A. muciniphila can effectively regulate host metabolism, significantly affect host immune function, and play an important role in balancing host health and disease. As one of the organs most closely related to the gut (the two can communicate through the hepatic portal vein and bile duct system), liver is widely affected by intestinal microorganisms. A growing body of evidence suggests that A. muciniphila may alleviate liver-related diseases by improving the intestinal barrier, energy metabolism and regulating inflammation through its protein components and metabolites. This paper systematically reviews the key roles of A. muciniphila and its derivatives in maintaining liver health and improving liver disease.

Study of confluence of hepatic veins application in liver transplantation.

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

Impact of different concentration iodinated contrast media on pain and comfort in abdominal computed tomography

ObjectivesTo investigate whether high concentration iodinated contrast media (CM), compared with low concentration CM, could reduce pain and discomfort levels in patients who had level II and III venous conditions. MethodsThis prospective, single-center study enrolled patients who had level II and III venous conditions and underwent abdominal contrast-enhanced CT scan between July 2021 and February 2022. The venous condition to establish peripheral venous access for CM injection was graded using the Intravenous Access Scoring system, of which level II and III indicated poor venous condition and difficult venous access. Patients received iomeprol 400 in high concentration group and ioversol 320 in low group at an identical iodine delivery rate of 1.12 gI/s. The primary outcomes were pain and comfort levels. The secondary outcomes included adverse events and image quality. Patients rated pain intensity via Numerical Rating Scale and comfort level via Visual Analogue Scale with higher scores indicating higher levels of pain and discomfort. Quantitative and qualitative image assessment were compared between two groups. Continuous variables were compared using Student’s t test or Mann-Whitney U test. Categorical variables were compared using χ2 test, χ2 test for trend or Fisher’s exact test. ResultsA total of 206 patients (mean age, 60.13 ± 12.14 years; 81 males) were included with 99 in the high concentration group and 107 in the low concentration group. The high group had significantly lower pain scores (median 1 [IQR: 0–2] vs 2 (IQR 2–4), p < 0.001) and comfort scores (1 [IQR: 0–3] vs 3 [IQR: 2–5], p < 0.001) than the low group. Incidence of CM extravasation did not significantly differ (1.0 % vs 4.5 %, p = 0.214). No hypersensitivity reaction was observed. Qualitative assessment showed higher clarity scores of intrahepatic hepatic artery and portal vein in the high group. Quantitative assessment results were comparable between two groups. ConclusionHigh concentration iodinated CM could lower pain intensity and improve comfort levels without comprising image quality of CT scan. High concentration CM is a preferable choice in patients with poor venous conditions during contrast-enhanced CT scan.

Abstract Mo041: Bile Acid Dysregulation in Response to Right Heart Failure and Hepatic Congestion

Introduction: Right heart failure (RHF), the result of impaired RV contractility and/or severe right-sided valvulopathies, is a clinical syndrome that commonly results in chronically elevated central venous pressures and hepatic congestion. Hepatic dysfunction in patients with heart failure portends a poor prognosis. In part, this may be due to the liver’s pivotal role in bile acid synthesis and processing. In addition to the classic role of a digestive surfactant, bile acids serve as important and dynamic signaling molecule. The present study characterizes a unique bile acid profile found in patients with RHF. Research Question: We hypothesize that RHF and hepatic congestion results in a dysregulation of bile acids. These untoward changes in bile acids concentrations may provide both important prognostic value and novel mechanistic pathways in congestive liver disease. Aims: 1) To characterize systemic and hepatic vein bile acid concentrations in patients with right heart failure. 2) To phenotype a mouse model of hepatic congestion and understand the mechanistic effects of specific bile acids on liver biology Methods: We enrolled a total of 60 patients who were referred for right heart catheterization (RHC). Patient demographics, echocardiograms, and routine laboratory tests were captured at enrollment. Blood was sampled from the IVC and hepatic vein during RHC. Bile acids were quantified from serum using liquid chromatography-tandem mass spectrometry. To model hepatic congestion, mice underwent ligation of the IVC. Blood and tissue samples were harvested and underwent mass spectrometry evaluation for the bile acid composition and immunohistochemistry was performed to characterize the immune landscape, respectively. Results: We captured a total of 12 control samples from patients with normal filling pressures, 25 patients with left heart failure (LHF), and 23 patients with RF. Patients with RHF had poorer survival outcomes compared to control or LHF. Patients with RHF had significant increases in specific conjugated bile acids when compared to control or LHF (Figure 1). Conclusions: In this study, we identified several conjugated bile acids that are uniquely elevated in patients with RHF compared to LHF and control. Additionally, patients with RHF had poorer survival. Collectively, these data suggest bile acids may serve as important biomarkers and signaling molecules in the pathogenesis of cardiogenic liver disease.

Wedged hepatic vein portovenography for assessment of Rex vein patency in children with extrahepatic portal venous obstruction.

Meso-Rex bypass is the surgical intervention of choice for children with extrahepatic portal vein obstruction (EHPVO). Patency of Rex vein, umbilical recessus of the portal vein, is a prerequisite for this surgery. Conventional diagnostic modalities poorly detect patency, while transjugular wedged hepatic vein portography (WHVP) accurately detects patency in 90%. We aimed to assess Rex vein patency and portal vein branching pattern in children with EHPVO using transjugular WHVP and to identify factors associated with Rex vein patency. Transjugular WHVP was performed in 31 children with EHPVO by selective cannulation of left and right hepatic veins. Rex vein patency, type of intrahepatic portal venous anatomy (Types A-E), and factors associated with patency of Rex vein were studied. The patency of Rex recess on transjugular WHVP was 29%. Complete obliteration of intrahepatic portal venous radicles was the commonest pattern (Type E, 38.7%) while Type A, the favorable anatomy for meso-Rex bypass, was seen in only 12.9%. Patency of the Rex vein, but not the anatomical pattern, was associated with younger age at evaluation (patent Rex: 6.6 ± 4.9 years vs. nonpatent Rex: 12.7 ± 3.9 years, p = 0.001). Under-5-year children had a 12 times greater chance of having a patent Rex vein (odds ratio: 12.22, 95% confidence interval: 1.65-90.40, p = 0.004). Patency or pattern was unrelated to local factors like umbilical vein catheterization, systemic thrombophilia, or disease severity. Less than one-third of our pediatric EHPVO patients have a patent Rex vein. Younger age at evaluation is significantly associated with Rex vein patency.

Venous Excess Ultrasound for Fluid Assessment in Complex Cardiac Patients With Acute Kidney Injury.

The introduction of point-of-care ultrasound (POCUS) into clinical practice has revolutionized bedside hemodynamic assessment in recent years. POCUS has expanded its utility to include evaluating and grading venous congestion through Doppler analysis of venous blood flow. This innovative technique, VExUS (venous excess ultrasound), comprehensively evaluates venous congestion across multiple sites, including the inferior vena cava (IVC), hepatic vein, portal vein, and intrarenal vasculature. The aim of the current study was to determine whether venous excess ultrasound can help guide fluid therapy in complex patients with acute kidney injury (AKI) in addition to the standard physical examination and imaging. Our current study shows instructive 18 clinical adult cases (enrolled between January 2024 and May 2024) to determine whether venous excess ultrasound can help guide fluid therapy in complex cardiac patients with acute kidney injury, in addition to the standard physical examination and imaging. VExUS was pivotal in guiding fluid therapy in all complex patients with AKI and suspected right ventricular dysfunction. By integrating VExUS findings with clinical data and cardiac ultrasound results, clinicians were able to make patient-favouring decisions regarding fluid management, diuresis, and vasopressor therapy, addressing critical aspects of conditions such as septic shock, heart failure, and acute kidney injury. In our study of VExUSin sick patients with AKI, we concluded that VExUS proved to be a valuable tool for fluid assessment and management. By providing real-time visualization of venous congestion, VExUS allowed for more precise and individualized fluid management strategies. This led to improved decision-making regarding fluid administration and removal, helping to prevent both fluid overload and hypovolemia. Consequently, the use of VExUS contributed to better clinical outcomes in patients with AKI, demonstrating its potential as a critical component in the management of fluid balance in this vulnerable patient population.

Irreversible Electroporation in Treating Colorectal Liver Metastases in Proximity to Critical Structures

PurposeTo evaluate the safety, efficacy, and oncological outcomes of irreversible electroporation (IRE) of unresectable colorectal liver metastases (CRLMs) close to critical structures. Materials and MethodsThis is a single-center, institutional review board (IRB)–approved, retrospective analysis of patients who underwent percutaneous computed tomography (CT)–guided IRE of CRLM. Between August 2018 and October 2023, 26 patients had 46 tumors treated with percutaneous IRE in 30 ablation sessions. Primary end points were tumor response and local progression-free survival analyzed using Kaplan-Meier survival curves. Secondary end points were overall survival (OS), distant progression-free survival (DPFS) analyzed using Kaplan-Meier survival curves, adverse events rated according to the Common Terminology Criteria for Adverse Events (CTCAE), and length of hospital stay. ResultsAll tumors were close to critical structures, including the portal and hepatic veins, inferior vena cava, bile ducts, and gallbladder. All patients received preprocedural systemic therapy (median 10 cycles). Median length of hospital stay was 1 night. Adverse events occurred in 7 (23%) of 30 procedures, with four Grade 1 and two Grade 2 adverse events, including pleural effusions (n = 2), ileus (n = 1), small hematoma (n = 1), and pneumothorax (n = 2) requiring chest tube placements. Following IRE, the 1- and 2-year local tumor progression-free survival rates were 55.0% and 51.3%. The median DPFS was 3.5 months, with 1- and 2-year DPFS rates of 23.3% and 9.7%. Six patients (23.1%) died during follow-up, with a median OS of 40.4 months. The 1- and 2-year OS rates were 90.9% and 83.9%. ConclusionsIRE is a safe and viable option in the treatment of unresectable CRLMs in locations close to critical structures, but carries a risk of local recurrence.

Radiotherapy with Targeted Therapy or Immune Checkpoint Inhibitors for Hepatocellular Carcinoma with Hepatic Vein and/or Inferior Vena Cava Tumor Thrombi.

This study evaluated the clinical outcomes of patients with hepatocellular carcinoma (HCC) with hepatic vein tumor thrombus (HVTT) and/or inferior vena cava tumor thrombus (IVCTT) receiving radiotherapy (RT) combined with systemic therapies. Patients with HCC with HVTT and/or IVCTT who received RT were identified at our institution. The prescription doses were 30-65 Gy for planning target volume and 40-65 Gy for the gross tumor volume. Targeted therapy and immune checkpoint inhibitors were used concurrently if patients were at a high risk of or already had distant metastasis. After RT completion, follow-up was performed at 1, 3, 6, and 12 months, and 3 to 6 months thereafter. The objective response rate (ORR), overall survival (OS), progression-free survival (PFS) and toxicity were recorded. Thirty-four patients were retrospectively enrolled between January 2016 and September 2021. Most patients received concurrent targeted therapy (70.6%) and/or post-RT (79.4%). The in-field ORR and disease control rates were 79.4% and 97.1%, respectively. The OS rates were 77.6% at 1 year and 36.3% at 2 years (median OS, 15.8 months). The median PFS and median in-field PFS were 4.2 months and not reached, respectively. The PFS and in-field PFS rates were 24.6% and 79.2% at 1 year, 19.7% and 72.0% at 2 years, respectively. An alpha-fetoprotein level >1000 ng/mL was a significant prognostic factor for worse OS (HR, 5.674; 95% CI, 1.588-20.276; p=0.008); in-field complete/partial response was a significant prognostic factor for better OS (HR, 0.116; 95% CI, 0.027-0.499; p=0.004). The most common site of first failure was the lungs (13/34 patients, 38.2%), followed by the liver (7/34 patients, 20.6%). No patients developed radiation-induced liver disease or pulmonary embolism during follow-up. Combining RT and systemic therapy was safe and effective in treating patients with HCC with HVTT and IVCTT.

Enhancing the therapeutic potential of P29 protein-targeted monoclonal antibodies in the management of alveolar echinococcosis through CDC-mediated mechanisms.

Alveolar echinococcosis (AE) is a highly lethal helminth infection. Current chemotherapeutic strategies for AE primarily involve the use of benzimidazoles (BZs) such as mebendazole (MDZ) and albendazole (ABZ), which exhibit limited efficacy. In a previous study, the vaccine of recombinant Echinococcus granulosus P29 (rEgP29) showed significant immunoprotection against E. granulosus in both mice and sheep. In the current study, we utilized hybridoma technology to generate five monoclonal antibodies (mAbs) against P29, among which 4G10F4 mAb exhibited the highest antigen-specific binding capacity. This mAb was selected for further investigation of anti-AE therapy, both in vivo and in vitro. In vitro, 4G10F4 inhibited a noteworthy inhibition of E. multilocularis protoscoleces and primary cells viability through complement-dependent cytotoxicity (CDC) mechanism. In vivo, two experiments were conducted. In the first experiment, mice were intraperitoneally injected with Em protoscoleces, and subsequently treated with 4G10F4 mAb (2.5/5/10 mg/kg) at 12 weeks postinfection once per week for 8 times via tail vein injection. Mice that were treated with 4G10F4 mAb only in dosage of 5mg/kg exhibited a significant lower mean parasite burden (0.89±0.97 g) compared to isotype mAb treated control mice (2.21±1.30 g). In the second experiment, mice were infected through hepatic portal vein and treated with 4G10F4 mAb (5mg/kg) at one week after surgery once per week for 8 times. The numbers of hepatic metacestode lesions of the 4G10F4 treatment group were significantly lower in comparison to the isotype control group. Pathological analysis revealed severe disruption of the inner structure of the metacestode in both experiments, particularly affecting the germinal and laminated layers, resulting in the transformation into infertile vesicles after treatment with 4G10F4. In addition, the safety of 4G10F4 for AE treatment was confirmed through assessment of mouse weight and evaluation of liver and kidney function. This study presents antigen-specific monoclonal antibody immunotherapy as a promising therapeutic approach against E. multilocularis induced AE.

Minimally Invasive Left Hepatectomy: Choosing the Suitable Surgical Strategy.

Numerous surgical techniques are currently available for minimally invasive left hepatic resection, each offering its own advantages and disadvantages. This multimedia manuscript delves into the primary approaches for minimally invasive left hepatectomy, with a focus on particular topics such as left hepatic vein approach, transection and middle hepatic vein exposure, and Glissonean approach. We examine key factors that surgeons should consider when choosing among these methods and provide practical recommendations. To enhance understanding, our article includes video footage from multiple centres, showcasing expertly executed surgeries for each approach along with their main considerations. This multimedia resource will serve as a valuable guide for surgeons, aiding in the selection of the most suitable strategy for minimally invasive left hepatectomies, tailored to the specific needs of the patient and the characteristics of the lesion.

Dependent contrast layering sign on CT in patients irrespective of cardiac dysfunction and its clinical implications: A preliminary retrospective study

Purpose: CT findings of contrast layering in dependent areas of the central venous system and solid organs have been reported in the literature to be associated with imminent cardiac arrest. However, no systematic research has explored the association of this distinctive CT finding with cardiac arrest and mortality. Therefore, we investigated the radiological manifestations of dependent layering of contrast in various vascular structures and organs and its clinical implications. Methods: A computerized search of radiological database was conducted using keywords “layering contrast” between January 2008 and January 2022. After reviewing CT scans of 226 patients that met the keyword criteria, 21 patients who exhibited the dependent contrast layering sign (DCLS) in vascular structures and organs were included in the final study population. Clinical data such as cardiac arrest within 2 hours, in-hospital mortality, and shock index ≥ 0.9 were collected. Number of involved structures in each patient is also investigated. Statistical significance and frequency regarding the association between radiologic findings and clinical data were analyzed. Results: The distribution of DCLS across anatomical structures reveals IVC is involved in 90.5% of patients and followed by hepatic vein (80.9%), liver parenchyma and right atrium. Cardiac arrest within 2 hours is significantly more common in patients with DCLS in right atrium (p=0.02, odds ratio = 21.6) and liver parenchyma (p=0.01, odds ratio = 24.8). DCLS in liver parenchyma is associated with the highest rate of in-hospital mortality (4 of 7, 57.1%). The total number of involved structures (p=0.01) and the number of common structures (p=0.001) are significantly higher in patients with cardiac arrest within 2 hours. Conclusions: The presence of DCLS in the right atrium and liver, as well as the larger number of involved structures, are significantly associated with impending cardiac arrest. Thus, it may offer additional insights for both radiologists and clinicians and aid in prompt initiation of resuscitative interventions before the onset of cardiac arrest. Nevertheless, larger prospective studies are warranted to validate the clinical relevance of DCLS across various vascular structures and organs.

Influence of tumor thrombus morphology on the surgical complexity in renal cell carcinoma with inferior vena cava tumor thrombus: a single-center, large-sample study from China

BackgroundThe morphology of tumor thrombus varies from person to person and it may affect surgical methods and tumor prognosis. However, studies on the morphology of tumor thrombus are limited. The purpose of our study was to evaluate the impact of tumor thrombus morphology on surgical complexity.MethodsWe retrospectively reviewed the clinical data of 229 patients with renal cell carcinoma combined with inferior vena cava (IVC) tumor thrombus who underwent surgical treatment at Peking University Third Hospital between January 2014 and December 2021. The patients were divided into floating morphology (107 patients) and filled morphology (122 patients) tumor thrombi groups. Chi-square and Mann–Whitney U tests were used for categorical and continuous variables, respectively. Postoperative complications were evaluated using the Clavien–Dindo surgical complication classification method.ResultsPatients with filled morphology tumor thrombus required more surgical techniques than those with floating morphology tumor thrombus, which was reflected in more open surgeries (P < 0.001), more IVC interruptions (P <0.001), lesser use of the delayed occlusion of the proximal inferior vena cava (DOPI) technique (P < 0.001), and a greater need for cut-off of the short hepatic vein (P < 0.001) and liver dissociation (P = 0.001). Filled morphology significantly increased the difficulty of surgery in patients with renal cell carcinoma with tumor thrombus, reflected in longer operation time (P < 0.001), more surgical blood loss (P <0.001), more intra-operative blood transfusion (P < 0.001), and longer postoperative hospital stay (P < 0.001). Filled morphology tumor thrombus also led to more postoperative complications (53% vs. 20%; P < 0.001).ConclusionCompared with floating morphology thrombus, filled morphology thrombus significantly increased the difficulty of surgery in patients with renal cell carcinoma with IVC tumor thrombus.

Laparoscopic anatomical right hepatectomy using a four-incision anterior approach: Technical details and surgical outcomes (with Video)

With the continuous advancements of laparoscopic techniques, many surgeons have enhanced the feasibility and safety of this approach for carefully selected patients. This study aims to offer a comprehensive account of the technical aspects and surgical outcomes associated with laparoscopic anatomical right hepatectomy, explicitly utilizing a four-incision anterior approach. The surgical procedure involved several maneuvers, including blocking the Glissonean pedicle, ligation of the right hepatic artery, right branch of the portal vein, and the right hepatic duct, removal of the liver parenchyma along the ischemic line, and determination of the liver section based on four anatomical landmarks: the right anterior Glissonian pedicle, middle hepatic vein, root of the right hepatic vein, and retrohepatic inferior vena cava. The article provides clear visualization of these anatomical landmarks following right hepatectomy. Proper patient positioning and precise incision placement are crucial factors for ensuring the success of the laparoscopic right anterior hepatectomy procedure. The separation of the extrahepatic Glissonean pedicle at the liver hilum to determine the hepatic resection ischemia line, as well as the identification of liver sections using four anatomical landmarks are essential steps in the liver resection process. The laparoscopic anatomical right hepatectomy using a four-incision anterior approach was performed smoothly, with standard intraoperative techniques completed. Measures are in place to address any complications that may arise during the surgery.

Role of liver augmentation prior to hepatic resection – a survey on standards, procedures, and indications in Germany, Switzerland, and Austria

PurposeFor primary and secondary liver tumors oncological resection remains a chance of cure. Augmentation of functional liver tissue may be necessary to preserve sufficient future liver remnant (FLR). Clinical decision-making on liver augmentation techniques and indications may differ internationally. Thus, this study aims to identify standards of liver augmentation in hepato-pancreatico-biliary (HPB) centers in Germany, Switzerland, and Austria.MethodsUsing a web-based survey, 48 hospitals in Germany, Switzerland, and Austria were invited to report their surgical indication, standard procedures, and results of liver augmentation.ResultsForty (83.3%) of the hospitals invited participated. Most of the hospitals were certified liver centers (55%), performing complex surgeries such as liver transplantation (57.5%) and ALPPS (80%). The standard liver augmentation technique in all countries was portal vein embolization (PVE; 56%), followed by ALPPS (32.1%) in Germany or PVE with hepatic vein embolization (33.3%) in Switzerland and Austria. Standard procedure for liver augmentation did not correlate with certification as liver center, performance of liver transplantation or ALPPS. Surgical indication for PVE varied depending on tumor entity. Most hospitals rated the importance of PVE before resection of cholangiocarcinoma or colorectal metastases as high, while PVE for hepatocellular carcinoma was rated as low.ConclusionThe survey gives an overview of the clinical routine in HPB centers in Germany, Austria, and Switzerland. PVE seems to dominate as standard technique to increase the FLR. However, there is a variety in the main indication for liver augmentation. Further studies are necessary evaluating the differing PVE techniques for liver augmentation.

Wilms Tumor with Vena Caval Intravascular Extension: A Surgical Perspective.

Wilms tumor (WT) is the most common kidney tumor in pediatric patients. Intravascular extension of WT above the level of the renal veins is a rare manifestation that complicates surgical management. Patients with intravascular extension are frequently asymptomatic at diagnosis, and tumor thrombus extension is usually diagnosed by imaging. Neoadjuvant chemotherapy is indicated for thrombus extension above the level of the hepatic veins and often leads to thrombus regression, obviating the need for cardiopulmonary bypass in cases of cardiac thrombus at diagnosis. In cases of tumor extension to the retrohepatic cava, neoadjuvant therapy is not strictly indicated, but it may facilitate the regression of tumor thrombi, making resection safer. Hepatic vascular isolation and cardiopulmonary bypass increase the risk of bleeding and other complications when utilized for tumor thrombectomy. Fortunately, WT patients with vena caval with or with intracardiac extension have similar overall and event-free survival when compared to patients with WT without intravascular extension when thrombectomy is successfully performed. Still, patients with metastatic disease at presentation or unfavorable histology suffer relatively poor outcomes. Dedicated pediatric surgical oncology and pediatric cardiothoracic surgery teams, in conjunction with multimodal therapy directed by a multidisciplinary team, are preferred for optimized outcomes in this patient population.

Anti-diabetic activity of aqueous extract of Trichilia prieureana A. Juss leaves in fructose-fed streptozotocin-induced diabetic male Wistar rats

Background and aimEthanolic extract of Trichilia prieureana leaves have been reported to exhibit anti-hyperglycemic activities without detailed information on the anti-diabetic activities. This study investigated the anti-diabetic activity of aqueous extract of T. prieureana leaves (AETPL) in type 2 diabetic (T2DM) male rats. Experimental procedureT2DM rats (induced with 10 % fructose solution ad libitum for 2 weeks and streptozotocin [STZ]; 40 mg/kg body weight {BW}) in groups B, C, D, E, and F were also administered distilled water (DW), metformin (100 mg/kg BW), 11.2, 22.3, and 44.6 mg/kg BW of AETPL, respectively, whilst non-diabetic rats in Group A received DW only (Sham Control, SC) for 14 days. The T2DM-related parameters were then evaluated. ResultsThe fructose-fed streptozotocin-(FSTZ) treatment related significant (p < 0.05) increases in FBS, HbA1c, fructosamine, HOMA-IR, G6P, GP, TC, TG, LDL-C, urea, bilirubin, hepatic and pancreatic MDA levels; decreases in BW, serum insulin, creatinine, albumin, HOMA-β, glycogen, G6PD, HK, HDL-C, hepatic and pancreatic SOD, GPX, RG, catalase, Hb, PCV, MCH, MCHC, MCV, RBC, WBC, differentials and the destruction of the pancreatic β-cells, hepatocyte degeneration, and central hepatic vein congestion were reversed by AETPL, to values that compared well with SC in most cases. In the IpGGT model, the intraperitoneally administered AETPL reduced the blood glucose and elevated the plasma insulin levels. The AETPL at 44.6 mg/kg BW exhibited the most pronounced effects. ConclusionAETPL (44.6 mg/kg BW) restored T2DM-glycemic control and associated biochemical changes via up-regulation of insulin, carbohydrate metabolizing enzymes and restoration of pancreatic and hepatic histoarchitecture.

Outcomes of Patients Undergoing the Kawashima Procedure at an Early Age: A Single Center Experience.

Previous reports have demonstrated the safety and efficacy of performing early Kawashima procedure (KP). Despite this, more recent studies have shown that the average age at the time of operation remains greater than one year of age. We report our experience with performing KP at an earlier age than previously reported. A retrospective review was completed of patients undergoing KP at a single center (January 2000 to June 2020). Clinical outcomes were examined. Initial palliation was performed in 11 out of 12 patients. Age and weight at time of KP were 8.25 months (6.4-9.7) and 7.7 kg (6.5-8.6). Intensive care unit stay was 3.16 days (1-12), overall length of stay was 9.5 days (3-22). There was one unplanned reoperation, and no mortality in the cohort. Discharge oxygen saturation was 88% (80%-98%). Seven patients developed pulmonary arteriovenous malformations (PAVMs) with six proceeding to hepatic vein incorporation (HVI). Interval time to development of PAVMs was 42.3 months (16-121). Four of the 12 patients were left with antegrade pulmonary blood flow (PBF) and three (75%) remain without PAVMs. Median follow-up was 10 years (1.5-22) with 11 of 12 (91.67%) survival for the cohort. The KP can be done at a younger age than previously reported with adequate early and late results. Most patients will go on to develop PAVMs and require HVI but leaving patients with some antegrade PBF is likely protective but will need further investigation to show definitive benefit.

Ante Situm Liver Resection for Tumors Invading the Inferior Vena Cava Hepatic Vein Confluence.

Liver malignancy invading the retrohepatic inferior vena cava beyond the cavo-hepatic vein venous confluence can be resected by an ante situm technique first described by Hannoun et al.1 In this approach, a major hepatectomy is performed and the hepatic veins are sectioned to allow the inferior vena cava reconstruction while the liver is cold perfused and the liver remains within the abdominal cavity. The hepatic vein is then reimplanted on the reconstructed inferior vena cava in "a liver autotransplantation fashion." The patient was a 66-year-old with a recurrent adrenocortical carcinoma cancer invading the right liver and the retrohepatic inferior vena cava with intraluminal thrombus extending beyond to the hepatic vein confluence. A right hepatectomy extended to segment 1 and the retrohepatic inferior vena cava was planned because of the intracaval tumoral thrombus and the infiltration of the right liver. The future liver remnant (FLR) (646 cc) to total liver volume (1526 cc) ratios was 42% while the FLR to patient weight ratio was 0.9%. The parenchymal liver transection was performed under a total vascular exclusion, venovenous bypass, and hypothermic perfusion of the left liver.2 The common trunk of the left and middle hepatic veins was sectioned, allowing the liver to be rotated toward the left. Vena cava reconstruction was achieved by a ringed Gore-Tex prosthesis, with reimplantation of the left and middle hepatic veins directly over the prosthesis. Surgery lasted 580 min, total duration of venovenous bypass and liver vascular exclusion was 143 min and 140 min, respectively. Blood loss was 2 liters and 8 red blood cell (RBC) units were transfused. The patient spent 5 days in the ICU, liver function tests normalized by postoperative day 8 and patient was discharged home on postoperative day 20; 1 year later, the patient is alive and disease free under mitotane treatment. The ante situm technique represents a safe surgical option for complex liver resection for malignancy involving the cavo-hepatic venous confluence. Compared with the ex situ liver resection, this technique allows liver remnant outflow reconstruction to be performed while the liver is cold perfused within the abdominal cavity with an intact hepatic pedicle.

Can central venous pressure help identify acute right ventricular dysfunction in mechanically ventilated critically ill patients?

ObjectiveTo investigate the relationship between central venous pressure (CVP) and acute right ventricular (RV) dysfunction in critically ill patients on mechanical ventilation.MethodsThis retrospective study enrolled mechanically ventilated critically ill who underwent transthoracic echocardiographic examination and CVP monitoring. Echocardiographic indices including tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tricuspid lateral annular systolic velocity wave (S’) were collected to assess RV function. Patients were then classified into three groups based on their RV function and presence of systemic venous congestion as assessed by inferior vena cava diameter (IVCD) and hepatic vein (HV) Doppler: normal RV function (TAPSE ≥ 17 mm, FAC ≥ 35% and S’ ≥9.5 cm/sec), isolated RV dysfunction (TAPSE < 17 mm or FAC < 35% or S’ <9.5 cm/sec with IVCD ≤ 20 mm or HV S ≥ D), and RV dysfunction with congestion (TAPSE < 17 mm or FAC < 35% or S’ <9.5 cm/sec with IVCD > 20 mm and HV S < D).ResultsA total of 518 patients were enrolled in the study, of whom 301 were categorized in normal RV function group, 164 in isolated RV dysfunction group and 53 in RV dysfunction with congestion group. Receiver operating characteristic analysis revealed a good discriminative ability of CVP for identifying patients with RV dysfunction and congestion(AUC 0.839; 95% CI: 0.795–0.883; p < 0.001). The optimal CVP cutoff was 10 mm Hg, with sensitivity of 79.2%, specificity of 69.4%, negative predictive value of 96.7%, and positive predictive value of 22.8%. A large gray zone existed between 9 mm Hg and 12 mm Hg, encompassing 95 patients (18.3%). For identifying all patients with RV dysfunction, CVP demonstrated a lower discriminative ability (AUC 0.616; 95% CI: 0.567–0.665; p < 0.001). Additionally, the gray zone was even larger, ranging from 5 mm Hg to 12 mm Hg, and included 349 patients (67.4%).ConclusionsCVP may be a helpful indicator of acute RV dysfunction patients with systemic venous congestion in mechanically ventilated critically ill, but its accuracy is limited. A CVP less than10 mm Hg can almost rule out RV dysfunction with congestion. In contrast, CVP should not be used to identify general RV dysfunction.