Inferior Hepatic Vein Research Articles

Liver volume regeneration after living donor liver transplantation (LD/LDLTx) depends on segmental perfusion

Background: The ability for liver volume regeneration after LD/LDLTx depends on liver morphology, function, perfusion and ischemia reperfusion injury. Methods: Donor and recipient, each n=42. Preoperative CT-volumetry in donors. Preoperative liverfunction test (LiMAx) for donor and recipient. LD: right hemihepatectomy (right-lobe graft, RLG). During LDLTx 3 liver biopsies were taken: 0-biopsy, from RL while ischemia and after reperfusion and stained with HMGB1. After LD and LDLTx on 2.POD LiMAx, on 10.POD and after 6 month (6M) CT-Volumetry and LiMAx were performed. Results: HMGB1-translocation, ischemia time and liver morphology were nearly same in all donors. Liver function in donors is restored on 10. POD (n=14), in recipients on 2. POD (n=14) and increased with 6M (n=10). Donor remnant liver gained after 6M to approx. 85% of total liver volume (n=12) an the RLG in recipients (adjusted to standard liver volume, SLV) gained to approx. 100% of SLV. Segmental volume regeneration (SVR) in RLG is mainly related to portal vein segments P7 and P8 and less P5. Regarding venous segments only perfusion region of right hepatic vein is gaining in contrast to more outflow obstructed perfusion areas of middle hepatic and inferior hepatic vein. In donors portal SVR takes place in P2 and P3, venous SVR occurs only via left hepatic vein. Conclusion: Liver volume regeneration maybe optimized by reduction of outflow obstruction respectively necessary hepatic vein reconstruction.

Clinical outcomes of Laparoscopic living donor right hepatectomy without Pringle’s and Hanging maneuver

Introduction: Careful preparation and blood-saving surgery will significantly lower the postoperative morbidity in laparoscopic liver resection (LLR). To reduce bleeding during hepatectomy, it is significant to decrease central venous pressure (CVP) and apply Pringle’s & hanging maneuver (P&H). However, P&H are cumbersome and has the potential for further injury by excessive mobilization and dissection of inferior vena cava and right lobe of liver, especially in living liver donors. We would like to present the experience and outcomes of laparoscopic living donor right hepatectomy (LDRH) performed without P&H. Method: Between December 2014 and October 2018, among 97 cases of living donor right hepatectomy, 50 donors underwent LDRH. During LDRH, mean pneumoperitoneal pressure was 12 mmHg and CVP was less than 5 mmHg. The right liver was mobilized to the inferior half portion of retrohepatic IVC and large right inferior hepatic veins were preserved. The caudal approach without P&H was applied for liver parenchymal transection. The V5 and V8 for reconstruction were also preserved until just before the right hepatic duct transection. Result: Mean total operation time was 367 minutes and the warm ischemic time was 9.2 minutes. No donors required blood transfusion, conversion to open surgery, and re-operation. The postoperative course was uneventful except one donor with bile leakage from the cutting edge of the right hepatic duct stump. All donors’ liver function was recovered to normal range within 2 weeks and mean postoperative hospital stay was 8 days. Conclusion: Conclusively, although P&H is not used in LDRH, LLR under low CVP and constant pneumoperitoneal pressure without P&H can help reduce blood loss and prevent further liver graft injury by excessive mobilization of liver. However, because of the donor safety which is the most important issue in living donor hepatectomy, LDRH should be performed by donor surgeon with sufficient experience in laparoscopic hepatectomy.

Biliary intraepithelial neoplasia in liver parenchyma of the caudate lobe: honeycomb appearance

Biliary intraepithelial neoplasia (BilIN) was newly defined by the WHO in 2010 and is characterized by biliary cell atypia with an intraductal papillary lesion. It is always found in the major bile duct, but not in liver parenchyma. A 50-mm irregular tumor was detected in the paracaval portion of the hepatic caudate lobe of a 61-year-old man. He had undergone total gastrectomy for advanced gastric cancer 2 years earlier. The tumor had increased from 20 to 50 mm in the last 6 months. Abdominal CT showed an irregular hypo-enhanced tumor, with a honeycomb appearance inside the tumor. Diffusion-weighted MRI and PET showed that the tumor had malignant features, though no tumor markers were elevated. The tumor seemed to invade into the inferior vena cava (IVC) and hepatic veins. At operation, under side clamping of the IVC, a total of 10 cm of ventral side IVC was resected with the left liver. Pathologically, the tumor was an inflammatory pseudo-tumor that contained intermediate-grade BilIN of persistent liver parenchyma in the tumor. The honeycomb appearance within the tumor showed a causal relationship between the pathological and etiological representations of BilIN. Considering BilIN avoids an unnecessary operation when we encounter atypical imaging findings of liver tumors.

Clinical Outcomes of Totally Laparoscopic Living Donor Right Hepatectomy

Initial concerns regarding healthy donor’s safety and graft integrity, need for acquiring surgical expertise in both laparoscopic liver surgery and living donor transplantation (LDLT) have delayed the development of laparoscopic donor hepatectomy in adult-to-adult LDLT. However, decreased blood loss, less postoperative pain, shorter length of stay in hospital, and excellent cosmetic outcome have well been validated as the advantage of laparoscopic hepatectomy. Hence, the safety and feasibility for laparoscopic donor should be further investigated. We report initial experiences and adequate inclusion criteria for totally laparoscopic living donor right hepatectomy. Totally laparoscopic living donor right hepatectomy in 13 cases were performed from May 2016 up to April 2017. For this procedure, the donors’ right portal vein with long segment of more than 5 mm were preferentially included. However, the bile duct anomaly was preoperatively evaluated with magnetic resonance cholangiopancreatography (MRCP) and was not excluded for totally laparoscopic approach. The 1st case used 2D conventional rigid 30° rigid laparoscopic system and the next 12 cases used 3D flexible laparoscopic system. In 8 cases, hepatic duct anomalies (Type 2, 3a, 3b) were identified. Mean operation time was about 463 min and the warm ischemic time was within 15 minutes. During operation, there was no transfusion and the inflow control like Pringle maneuver was not used at all. V5 or V8 were reconstructed in 12 cases and large right inferior hepatic vein was prepared for anastomosis in 6 cases. All grafts were removed through the supra-pubic transverse incision. The donors were discharged at mean 7 days after hepatectomy. Bile leakage was identified in only 1 case and resolved after the biliary stent insertion by ERCP. During the short-term follow-up period in the donors except this case, complications were not confirmed. Conclusively, totally laparoscopic right donor hepatectomy in adult-to-adult LDLT can be initially attempted after enough experiences of laparoscopic hepatectomy and LDLT. However, the true benefits of totally laparoscopic living donor right hepatectomy should be fully assessed through various experiences from multi-institutes.

Extended left hepatectomy for intrahepatic cholangiocarcinoma: hepatic vein reconstruction with in-situ hypothermic perfusion and extracorporeal membrane oxygenation

BackgroundLiver resection for intrahepatic cholangiocarcinoma (ICC) with invasion of the inferior vena cava (IVC) and hepatic veins (HV) is a challenging procedure.Case presentationWe report a case of a 63-year-old woman with a 6-cm, centrally located liver mass. Her biochemistry results were normal except for a Ca19–9 level of 1199 U/ml. The liver biopsy was consistent with ICC and 60% macrosteatosis. Abdominal CT scans revealed a large central mass invading the left HV, middle HV and right HV, infringing on their junction with the vena cava. An operation was planned using a 3-dimensional (3D) computer simulation model using dedicated software. We also describe a novel veno-portal-venous extracorporeal membrane oxygenation (VPV-ECMO) support with in-situ hypothermic perfusion (IHP) during this procedure. We aimed to perform an extended left hepatectomy and reconstruct 3 right HV orifices with an interposition jump graft to the IVC with total vascular exclusion (TVE) and IHP A supplemental video describing the preoperative planning, the operative procedure with the postoperative follow-up in detail is presented. After the patient was discharged, she developed a hepatic venous outflow obstruction 3 months postoperatively, which was effectively managed with hepatic venous stenting by interventional radiology. She is currently symptom free and without tumour recurrence at the 1-year follow-up.ConclusionsThis report demonstrates that extended left hepatectomy for IHC with IHP and VPV-ECMO is safe and feasible under the supervision of a highly experienced team.

Reconstruction of Inferior Right Hepatic Veins in Living Donor Liver Transplantation

A proper knowledge of the anatomy of the liver (including its vascular particularities) is mandatory in cases which are going to be submitted to major hepatic resection, including living donor liver transplantation. We present the case of a living donor liver transplantation in which a particularity of the anatomy of the hepatic veins was reported for the donor: two inferior hepatic veins for segments 5 and 6. This particularity imposed the need for creation of a supplemental anastomosis in the recipient: a phleboplasty of the two inferior veins followed by direct re-implantation into the inferior cava vein. However, the postoperative course was uneventful for both the donor and the recipient. In certain cases presenting vascular particularities such as two inferior hepatic veins, phleboplasty followed by reimplantation into the inferior cava vein might be needed in order to provide a good vascular outflow of the liver graft.

Magnetic Resonance Venography Findings of Obstructed Hepatic Veins and the Inferior Vena Cava in Patients with Budd-Chiari Syndrome

ObjectiveThis study aimed to illustrate the magnetic resonance venography (MRV) manifestations of obstructed hepatic veins (HVs), the inferior vena cava (IVC), and accessory hepatic veins (AHVs) in patients with Budd-Chiari syndrome (BCS) and to evaluate the visualization capacity of MRV in the diagnosis of BCS.Materials and MethodsFifty-two patients with chronic BCS were included in this study. All patients were examined via MRV performed with a 3T system following injections of gadolinium-diethylene triamine pentaacetic acid (Gd-DTPA) or Gd-ethoxibenzyl-DTPA. HV and IVC lesions were classified, and their characteristics were described. HV cord-like occlusions detected via MRV were compared using ultrasonography (US). Digital subtraction angiography (DSA) was performed as a contrast in the MRV detection of IVC lesions. The HVs draining collaterals, mainly AHVs, were carefully observed. HV lesions were classified as segmental stenosis, segmental occlusion, membranous stenosis, membranous occlusion, cord-like occlusion, or non-visualized. Except for patent IVCs, IVC lesions were classified as segmental occlusion, segmental stenosis, membranous occlusion, membranous stenosis, and hepatomegaly-induced stenosis.ResultsAll patients (52/52, 100%) showed HV lesions of different degrees. MRV was inferior to US in detecting cord-like occlusions (6 vs. 19, χ2 = 11.077, p < 0.001). Dilated AHVs, including 50 (50/52, 96.2%) caudate lobe veins and 37 (37/52, 71.2%) inferior HV and AHV lesions, were well-detected. There were no significant differences in detecting segmental lesions and thrombosis between MRV and DSA (χ2 = 0.000, p1 = 1.000, p2 = 1.000). The capacity of MRV to detect membranous lesions was inferior to that of DSA (7 vs. 15, χ2 = 6.125, p = 0.013).ConclusionIn patients with BCS, MRV can clearly display the lesions in HVs and the IVC, as well as in AHVs, and it has diagnostic and therapeutic value.

Role of Accessory Right Inferior Hepatic Veins in evaluation of Liver Transplantation

Purpose: The purpose of the study is to access the prevalence of accessory right inferior hepatic veins and their relevant signifi cance in liver transplantation. Materials and Methods: A retrospective study was done in which the CT of 82 potential liver transplant candidates between January 2012 and March 2013 were reviewed. The presence of the accessory right inferior hepatic vein was examined; the diameters of the accessory inferior hepatic veins and the distance between the point where they open into the inferior vena cava on the coronal plane and to the right hepatic vein-inferior vena cava junction was measured. Results: Out of 82 patients, 42 (51%) had accessory right inferior hepatic veins. Right accessory inferior hepatic veins larger than 3 mm were detected in 23 (28%) patients. The distance of these veins to the right hepatic vein-inferior vena cava junction was more than 4 cm in 13 (15%) patients. Conclusion: The precise preoperative knowledge of accessory right inferior hepatic veins is essential in living donor liver transplantation.

Disappearance of a spontaneous intrahepatic portosystemic shunt managed by hepatic vein closure: Why?

Introduction Spontaneous intrahepatic portosystemic shunt (PSS) is uncommon. A few cases have been reported with its disappearance after outflow occlusion. It is unclear why it had disappeared, and the mechanism is closely related to the pathophysiology of PSS. The portal circulation is a ‘flow’ and governed by Ohm’s law (Flow=Pressure/Resistance). This can be explained through simulation using an electric circuit, which is also a flow system. Case description A 62-year old woman visited with hepatic encephalopathy. She had no history of chronic liver disease or liver trauma. Imaging studies revealed an intrahepatic aneurysmal PSS in Couinaud’s segment 6, formed between the posterior branch of right portal vein and the right inferior hepatic vein. She was managed by laparoscopic right inferior hepatic vein closure using an autostapling device. Her encephalopathic symptoms improved immediately after the operation, and she was discharged uneventfully. At her 8 month follow-up, she was symptom-free and her PSS disappeared entirely. Results and Conclusions The basic configuration of splanchnic circulation is essentially two resistors connected in series; the mesenteric vascular resistance and the portal vascular resistance. It is a pressure divider between the aortic pressure and systemic venous pressure. In turn, the portal vascular resistance can be seen as two resistors connected in parallel; the hepatic vascular resistance and the PSS resistance. A PSS means the shunt flow above zero, and according to Ohm’s law, there are two ways for the PSS to be formed. In one condition, the portal pressure increases sufficiently high and a PSS begins to form at a fixed shunt resistance. Once the shunt channel is established, portal pressure will decrease until equilibrium is reached between the portal pressure and the shunt flow. A clinical example is liver cirrhosis. In this condition, PSS will persist even if the outflow is occluded. In the other condition, the shunt resistance can decrease at a fixed portal pressure, such as an aneurysmal dilatation of PSS. In this case, PSS will disappear after outflow occlusion, because the shunt flow becomes zero. The puzzling phenomenon of the disappearance of PSS in our case can be easily explained by simulation using an electric circuit theory. Take home message Blood flow is similar to an electric current and is governed by Ohm’s law. By simulating splanchnic blood flow with an electric circuit, we can easily understand the underlying pathophysiology of many seemingly curious phenomena.

Adult-to-adult living donor liver transplantation preoperative survey using MDCT, a single medical center experience in Taiwan

This study evaluated multi-detector computed tomography (MDCT) scans performed on potential living donors for adult-to-adult liver transplantation (LDLT), with the aim of identifying significant findings that could be used to exclude potential transplantation donors. We retrospectively reviewed the medical records of 151 consecutive potential adult donors for LDLT from May 2007 to January 2015. Liver parenchyma steatosis, focal hepatic mass or intraabdominal malignancy, vascular variations, and donor liver volume were evaluated via MDCT. Grounds for excluding potential donors were also recorded and analyzed. Of the 151 potential donors, nine (6.0%) had moderate to severe fatty liver, 37 (24.5%) had hepatic arterial variants, 22 (14.6%) had significant portal venous variants, and more than half were found to have right accessory inferior hepatic vein. No intraabdominal malignancies were found. Eighty-eight potential donors were rejected, with the most common cause being insufficient recipient volume or remnant donor volume (47.7%), moderate to severe parenchymal steatosis (10.2%), and recipient expiration prior to transplantation (8.0%). An additional 16 potential donors were excluded by the surgical team due to the complexity of their portal venous variations. The rate of exclusion by pre-transplant imaging evaluation with MDCT was 33.8%. MDCT can provide accurate quantification of donor liver volume and steatosis severity along with precise demonstration of vascular variants, which are crucial for the preoperative evaluation of LDLT. However, MDCT may be ineffective for evaluating the biliary system without hepatobiliary-excreted contrast agent and has the disadvantage of ionizing radiation.

Expanding the limits of resectability: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) using monosegment 6, facilitated by an inferior right hepatic vein

We describe our technique using the combination of a recent surgical technique (ALPPS) and an anomalous vascular anatomy to push the current limits of liver resectability. The approach allowed the resection of the three hepatic veins and preserved a peripheral segment 6 as the only future liver remnant, having an inferior hepatic vein as its outflow.

Potential of lysophosphatidylinositol as a prognostic indicator of cardiac arrest using a rat model

Aims: The potential of a lysophosphatidylinositol species, LPI(18:0), as a biomarker of ischaemia was tested using a rat model of cardiac arrest (CA).Methods: Male Sprague-Dawley rats were subjected to asphyxia-induced CA or CA followed by cardiopulmonary bypass (CPB) resuscitation. The brain, heart, kidney and liver tissues were harvested from rats after 0, 5, 10, 20, 30 and 60 min CA and 30 min CA followed by 60 min CPB resuscitation. Blood samples were collected from inferior vena cava and hepatic veins following 30 min CA. Phospholipids were extracted from the four tissues and blood and analysed by HPLC-MS.Results: The relative content of LPI(18:0) compared to a phosphatidylinositol species, PI(18:0,22:4), was significantly increased in the brain, heart, liver and kidney following 30 min CA and decreased following CPB resuscitation. In addition, the increase of the LPI(18:0)/PI(18:0,22:4) ratio in the four tissues was proportional to the duration of ischaemia for CA lasting up to 60 min. The ratio was also found to be increased in plasma from the hepatic vein following 30 min CA.Conclusion: LPI(18:0) is a good indicator of CA downtime and has a potential to be used for early prognostication of outcome in CA.

Method and safety analysis of interventional treatment of Budd-Chiari syndrome in 1 246 patients

Objective To analysis the method and safety of interventional treatment of Budd-Chiari syndrome (BCS). Methods The retrospective cross-sectional study was adopted. The clinicopathological data of 1 246 patients with BCS who underwent interventional treatment at the Beijing Shijitan Hospital of Capital Medical University between October 1993 and February 2015 were collected. According to the classification and level of BCS and clinical symptoms of patients, percutaneous vena cava and hepatic vein balloon angioplasty, inferior vena cava or hepatic vein or collateral vessels stent angioplasty, vena cava and hepatic vein combined with stent angioplasty, hepatic vein angioplasty combined with percutaneous transhepatic embolization of coronary vein of stomach, transjugular intrahepatic portosystemic shunt (TIPS) combined with inferior vena cava (hepatic vein) stent angioplasty and TIPS were conducted. Observation indicators included (1) results of surgical treatment, (2) surgery-related complications, (3) changes of pre- and post-operative vascular pressures. Measurement data with normal distribution were presented as ±s, and repeated measures data were analyzed by the repeated measures ANOVA. Results (1) Results of surgical treatment: 1 241 of 1 246 patients with BCS received successful interventional treatment, including 163 undergoing percutaneous inferior vena cava or hepatic vein balloon angioplasty, 61 undergoing double balloon angioplasty, 611 undergoing inferior vena cava or hepatic vein or collateral vessels stent angioplasty, 85 undergoing inferior vena cava and hepatic vein combined with stent angioplasty, 13 undergoing hepatic vein angioplasty combined with percutaneous transhepatic embolization of coronary vein of stomach, 58 undergoing TIPS combined with inferior vena cava stent angioplasty, 7 undergoing TIPS combined with hepatic vein stent angioplasty and 243 undergoing TIPS. Five patients didn't receive successful interventional treatment, including that occlusion in the length of inferior vena cava cannot be opened in 2 patients, partial occlusion of hepatic vein cannot be opened in 2 patients, and unsuccessful TIPS due to total occlusion of hepatic vein was in 1 patient. (2) Surgery-related complications: 1 patient died of liver puncture pleural bleeding and respiratory circulatory failure. Four patients had severe complications, including 1 with abdominal bleeding, 1 with pericardial effusion due to partial stents of inferior vena cava migrated to right atrium, 1 with acute occlusion of hepatic vein stent and 1 with pericardial effusion due to punch through the right atrium and pericardium, and they were cured by symptomatic treatment. (3) Changes of pre- and post-operative vascular pressures: pressures of portal vein, inferior vena cava and hepatic vein from pre-operation to post-operation were (3.8±0.7)kPa to (2.3±0.6) kPa, (2.9±0.4)kPa to (1.7±0.5)kPa, (2.6±0.4)kPa to (1.4±0.3)kPa, respectively, showing statistically significant differences between the pre-operation and post-operation (F= 3.26, 2.58, 2.79, P<0.05). Conclusion According to the classification, degree and clinical symptoms of BCS, it is safe and effective to choose different interventional treatment of BCS, with a satisfactory efficacy. Key words: Budd-Chiari syndrome; Interventionnal Radiology

Genetic Traits in the Liver Anatomy Between Parents and Children: An Analysis of Liver Transplant Recipients and Living Donors.

To date, no significant similarities in the anatomy of the hepatic vasculature have been observed between blood-related individuals. However, we have frequently encountered anatomic similarities between parents and their children; thus, we performed an analysis of the genetic traits in the anatomy of the liver. The study cohort was 330 adult cases of living-donor liver transplantation (LDLT), in which the donor-recipient relationship was child to parent. The subjects underwent LDLT from January 2013 to December 2014. Preoperative dynamic computerized tomographic scans were used to classify the anatomy of the hepatic vasculature. Portal vein (PV) anatomy was classified as typical and 2 variant types. PV anatomy combinations in donor and recipient were typical in 232 subjects, variant in 16, and typical-variant in 82. The PV concordance rate was 75.2%, and the contingency coefficient was 0.130 (P= .017). Hepatic artery (HA) anatomy was classified as typical and 4 variant types. HA anatomy combinations in donor and recipient were typical in 167 subjects, variant in 33, and typical-variant in 130. The HA concordance rate was 60.6%, and the contingency coefficient was 0.058 (P= .294). The sizable inferior right hepatic vein in donor and recipient was present in 44 subjects, absent in 160, and discordant in 126; its concordance rate was 61.8% and contingency coefficient 0.133 (P= .014). There may be a shared but weak genetic trait between parents and children regarding the anatomy of the PV and inferior hepatic vein. This information may be helpful when LDLT is performed between 1st-degree relatives.

Congenital Giant Left Atrium with Severe Mitral Valve Regurgitation.

A three-month-old male infant presented to the Royal Hospital, Muscat, Oman in April 2014 following two episodes of pneumonia. On presentation, the patient was not dysmorphic; however, he was tachycardic and tachypnoeic with severe respiratory distress. A pansystolic murmur was heard in his apex, radiating to the axilla. A chest examination showed bilateral wheezing and scattered crepitations. An abdominal examination revealed a soft abdomen with hepatomegaly (liver span of 12 cm), situated 4 cm below the right costal margin. Echocardiography and an angiographic volume-rendered reconstructed computed tomograph showed a giant left atrium measuring 7.4 × 4.7 cm [Figure 1]. The atrium had severe mitral valve regurgitation from poor coaptation of the mitral valve leaflets due to annulus dilation of 22 mm. The mitral valve apparatus and left atrial appendage were normal, excluding the associated left atrial appendage aneurysm. There was mild tricuspid valve regurgitation with a peak gradient of 90 mmHg (systemic blood pressure: 80/55 mmHg), indicating severe pulmonary hypertension. The left ventricle was moderately dilated—the left ventricular posterior wall dimension in diastole was 4 mm; the interventricular septum dimension in diastole was 4 mm; the left ventricular end diastolic dimension was 40 mm; and the left ventricular end systolic dimension was 18 mm. Normal ventricular systolic function was noted (ejection fraction: 62%). The right ventricle was compressed by the dilated left ventricle, with severe compression of the right atrium secondary to the dilated left atrium. The inferior vena cava and hepatic veins were dilated; however, the superior vena cava was compressed by the dilated left atrium with a mean gradient of 8 mmHg at its midportion. The dilated pulmonary veins drained normally to the left atrium. No intracardiac vegetation or thrombi were seen. These findings were confirmed by cardiac computed tomography (CT) angiography; severe compression of the left main bronchus was also observed [Figure 2]. The CT angiography also revealed a left atrial volume of 84 mL compared to a left ventricular volume of 10 mL. A chest radiograph of the infant revealed a persistent left-sided lung opacity [Figure 3]. Further abdominal ultrasonography and CT findings indicated eventration of the left hemidiaphragm with a raised spleen position corresponding to the opaque shadow seen on the chest radiograph. A diagnosis of a congenital giant left atrium (CGLA) was made. Figure 1A & B: A: Four chamber echocardiograph showing a giant congenital left atrium (white arrow) severely compressing the right atrium (red arrow) in a three-month-old male infant. B: Volume-rendered reconstructed computed tomography angiograph showing the giant ... Figure 2A & B: A: Axial computed tomography (CT) angiograph showing a giant congenital left atrium (black arrow) with left upper lobe and segmental right lower lobe atelectasis (red arrows) in a three-month-old male infant. B: Maximum-intensity CT angiograph projection ... Figure 3: Frontal chest radiograph of a three-month-old male infant with congenital giant left atrium showing a persistent left-sided lung opacity (arrow). This was determined by ultrasonography and computed tomography to be a raised spleen caused by eventration ... Despite cardiac anti-failure medications and inotropic support, a high-risk operation was performed to repair the mitral valve due to the cardiac findings and prolonged intubation. A posterior annuloplasty and a posterior left atrial wall excision were also carried out concurrently. The diagnosis of CGLA was confirmed during the course of the surgery. Following the operation, the left atrial dilation improved and the right ventricular systolic pressure decreased to 30 mmHg (estimated from the tricuspid valve regurgitation jet). Unfortunately, the moderate mitral valve regurgitation continued postoperatively and the infant died two weeks later due to severe cardiorespiratory compromise.

Gastrointestinal Congestion Dilates the Hepatic Artery Through the P38 MAPK Signal Transduction Pathway During Liver Transplantation.

During the neohepatic stage of liver transplantation, hemodynamics change markedly. The current study aimed to investigate whether gastrointestinal congestion caused by inferior vena cava and hepatic portal vein clamping can dilate the hepatic artery and to determine the associated mechanisms. Ring segments of the hepatic artery were treated with the plasma from gastrointestinal congestion or the superior vena cava. The fractions in gastrointestinal congestion and the superior vena cava plasma were tested, and the effect of these fractions on the tone of the hepatic artery ring was examined. Different signal transduction blockers and different inhibitors were then used to determine the exact signal transduction pathway involved. In addition, endothelial cell structure was observed by transmission electron microscopy after treatment with the gastrointestinal congestion plasma or the superior vena cava plasma. Gastrointestinal congestion plasma contained more inflammatory cytokines than superior vena cava plasma, and these cytokines could cause hepatic artery ring dilatation. A P38 mitogen-activated protein kinase (P38 MAPK) signal transduction pathway blocker and nitric oxide (NO), prostaglandin (PGI2), nuclear factor-κB (NF-κB), and adenosine triphosphate (ATP)-sensitive K (KATP) channel inhibitors were able to significantly reverse the ring tension caused by gastrointestinal congestion plasma. The normal endothelium was also injured by treatment with gastrointestinal congestion plasma. The inflammatory cytokines in gastrointestinal congestion can cause hepatic artery ring dilatation through the P38 MAPK signal transduction pathway, and this phenomenon is also associated with NO, PGI2, NF-κB, and the KATP channel. These inflammatory cytokines can injure endothelial cells in the hepatic artery.

Anatomical and surgical consequences of tumour compression of the hepatic veins confluence

Aims: Venous drainage pathways that develop in the liver due to the tumor compression of the hepatic veins have been rarely described. The aim of this study was to describe these pathways in patients with tumor obstruction of hepatic veins confluence, according to the extent of obstruction and the presence of accessory veins, and the relevance in the setting of liver resection. Methods: Between 2009 and 2013, 32 patients with compression of at least one main hepatic vein undergoing liver resection were retrospectively selected from a prospective database. Preoperative CT-scans were re-assessed for the extent of hepatic vein compression, presence of accessory veins and collateral veins (both intra hepatic end subcapsular). A 2:1 matched control group was used for comparison of intra operative outcomes. Results: The right hepatic vein was involved in 23 (77%) patients. Two hepatic veins were obstructed in 12 (38%) patients, and all three in 4 (12%). Intra hepatic collaterals were observed in 66% of the patients, mostly between segments 3/4b and 5/4b. Sub-capsular collaterals were observed in 31% of the patients. A right inferior hepatic vein was present in 25% of the patients. Patients with right hepatic vein compression and with an accessory right hepatic vein developed less collateral pathways than patients without (3/7 (43%) vs. 15/16 (94%), p = 0.017). Caudate veins were never observed. There was a significant increase in blood losses (700 mL vs 500 mL, p = 0.0096) and transfusion requirements (transfusion rate 56% versus 13%, p < 0.0001), whereas there was no difference regarding pedicular clamping and operative time. Inferior vena cava clamping was necessary in 11 patients (34%). Conclusions: The development of collateral pathways depends on the type and number of hepatic veins involved and of pre-existing accessory veins. The presence of collateral veins increases blood losses and transfusion rate during liver resection.

Scimitar Syndrome with Dilated Azygos Vein and Interrupted Inferior Vena Cava

A 3 year-old girl with recurrent chest infections had chest radiograph showing the typical “Turkish sword” sign which could be found in 70% in the childhood-adult group of Scimitar syndrome, a rare form of partial anormalous pulmonary venous drainage (PAPVD) associated with hypoplastic lung. The anomalous pulmonary veins drain into the systemic venous system such as inferior vena cava (IVC), right atrium, hepatic or portal vein.

Evaluation of contrast enhancement and image quality:a comparison between different tube voltages and iodine concentrations in abdominal dynamic CT scans in minipigs

Objective To investigate the effect of tube voltage and iodine concentration of contrast medium (CM) on abdominal dynamic enhanced CT image quality. Methods Six miniature pigs underwent repeated upper abdomen dynamic contrast-enhanced CT scans in 4 scanning protocols with different concentration of CM and tube voltage, namely, protocol 1, CM with iodine concentration of 270 milligrams iodine per milliliter (mg/ml) and 80 kV tube voltage; protocol 2, 270 mg/ml and 120 kV; protocol 3, 370 mg/ml and 80 kV and protocol 4, 370 mg/ml and 120 kV. The same iodine dose (600 mg/ml) and iodine delivery rate (IDR) (920 mg/s) were used in all protocols. The CM with iodine concentration of 270 mg/ml were injected at a flow rate of 3.4 ml/s, and 370 mg/ml CM injected at 2.5 ml/s. Image reconstruction was performed with iterative reconstruction (iDose4) in protocol 1 and 3,filtered back projection (FBP) was used in protocol 2 and 4. A subjective scoring system for image quality, image noise and sharpness was conducted by 2 radiologists independently. The measured values (peak of enhanced CT values, image noise of aorta, inferior vena cava, portal vein, hepatic vein and liver parenchyma) as well as the calculated values [their time-to-peak, signal-to-noise (SNR) and contrast-to-noise (CNR) ratios] were compared between among 4 protocols. The CT volume dose index (CDTIvol) and dose length product (DLP) were recorded from the CT console after each scanning. Factorial designed ANOVA was used for comparison of enhanced CT values of vessels and liver parenchyma, noise, SNR and CNR. The Kruskal-Wallis test was used for comparison of values among the 4 protocols, including the time-to-peak enhancement of vessels and liver parenchyma, the subjective scores of image quality indices. Result There was no significant differences in subjective scores of the image quality, image noise and image sharpness (P>0.05). The scored were more than 3, and the images with 4 scanning protocols were all acceptable for diagnosis. There was no significant differences between protocol 1 and 3, protocol 2 and 4 in the peak enhancement CT values of aorta [(729±46) HU vs.(707±59)HU,(515±84)HU vs. (513±53)HU], inferior vena cava [(366±95)HU vs. (368±92)HU, (282±39)HU vs. (262 ± 67)HU], portal vein [(213 ± 18)HU vs.(201 ± 29)HU, (180 ± 21)HU vs. (176 ± 27)HU], hepatic vein[(207±18)HU vs. (193±10)HU, (179±24)HU vs. (170±14)HU] and liver parenchyma [(128±7) HU vs. (127±4) HU,(135±5)HU vs.(135±6)HU] (P>0.05). But the CT values of vessels (aorta, inferior vena cava, portal vein and hepatic vein) in protocol 1 and 3 were significantly higher than those in protocol 2 and 4 (P 0.05). No significant differences were observed on the peak times, SNR and CNR in aorta, inferior vena cava, portal vein, hepatic vein and liver parenchyma among 4 protocols (P>0.05). The CDTIvol and DLP! were 199.67 mGy, 1 597.4 mGy·cm respectively in protocol 1 and 3,585.12 mGy and 4 680.9 mGy·cm in protocol 2 and 4 (scanning with 120 kV). Conclusions CM with different iodinated concentration could achieve the same enhancement in the abdominal vessels and liver parenchyma by using the proper scan protocols, which have the same IDR and iodine dose per kilogram body weight.Higher vessel enhanced peak values were achieved when using the protocols with 80 kV tube voltage than 120 kV. By using a low dose protocol of 80 kV tube voltage with the iterative reconstruction algorithm, the quality of image can be warranted. Key words: Tomography, X-ray computed; Contrast media; Radiation dosage

PD35-07 EVALUATION AND MANAGEMENT OF RENAL FOSSA RECURRENCE FOLLOWING NEPHRECTOMY FOR RENAL CELL CARCINOMA

after surgical resection a flexible cystoscope is inserted into the vena cava for direct visual inspection of the caval lumen with high flow heparinized saline irrigation. Perioperative outcomes including estimated blood loss, transfusion requirements, residual tumor, changes in management due to findings at cavoscopy, and postoperative complications were analyzed. RESULTS: All patients underwent endoscopy of the vena caval lumen without complications. 8 of 32 patients were found to have residual tumor thrombus upon visualization of the lumen. Of these, six patients were noted to have tumor invasion of the intraluminal wall resulting in cavectomy. Residual intraluminal tumor was noted in 2 patients which was bluntly resected with no residual tumor visible on repeat endoscopy. Median estimated blood loss was 3L (0.5-16) with a median intraoperative transfusion requirement of 14 units (0-63 units). Median Pringle Maneuver time was 15 minutes (3-30 minutes). Median length of stay was 10 days (4-73 days). Postoperative lower extremity edema was noted in 5 patients (3 following cavectomy) with resolution in all patients and a median resolution time of 52 days (30-322 days). There were no complications associated with vena cavoscopy. CONCLUSIONS: Vena Cavoscopy using a flexible cystoscope is an expedient and feasible technique that may be utilized intra-operatively in order to ensure clearance of residual thrombus burden within the inferior vena cava or hepatic veins and to assess for caval wall invasion.