Left Hepatic Vein Research Articles

Robotic Left Hepatectomy Using the Glissonean Approach and Saline-Linked Bipolar Clamp-Crush Technique.

We have previously reported a saline-linked bipolar clamp-crush technique as a novel robotic liver resection method. Herein, we present the surgical techniques and outcomes of robotic left hepatectomy using the Glissonean approach and our liver transection technique. The key procedures included the following: (1) encircling the left Glissonean pedicle using the Tip-Up fenestrated grasper, (2) dissecting the liver parenchyma using the saline-linked bipolar clamp-crush technique, (3) moving the endoscope one trocar to the right to facilitate visualisation of the liver transection plane, and (4) stapling the left pedicle and left hepatic vein. Seven robotic left hepatectomies were performed. The median operative time and estimated blood loss were 395min and 50mL, respectively. The median length of postoperative hospital stay was 9days. Pneumothorax was the only severe postoperative complication. Robotics left hepatectomy using the Glissonean approach and the saline-linked bipolar clamp-crush technique appears safe and feasible.

Laparoscopic Left Lateral Sectionectomy: Guided by the Ligamentum Teres Hepatis and the Umbilical Fissure Vein.

Laparoscopic left lateral sectionectomy (LLLS), a mainstream procedure in liver surgery, often utilizes controlled low central venous pressure (CLCVP) to reduce bleeding in the hepatic venous system. However, anesthesiologists may avoid the use of CLCVP in patients with concurrent cardiovascular and cerebrovascular diseases to prioritize the maintenance of vital organ perfusion. In this report, we present an LLLS guided by the ligamentum teres hepatis (LTH) for dissection of the Glissonian pedicles for segments 2/3 outside the liver, followed by hepatic parenchymal dissection along the falciform ligament and umbilical fissure vein (UFV) while approaching the left hepatic vein root. Guided by LTH and UFV, this LLLS procedure effectively controlled intraoperative bleeding, even in the absence of CLCVP. Additionally, hepatectomy guided by extrahepatic and intrahepatic anatomical landmarks prevents loss of direction during liver dissection and ensures precise hepatic resection. These attributes suggest that the potential benefits extend beyond patients with cardiovascular or cerebrovascular conditions, making it applicable in a wide range of LLLS cases.

A Monograph on Anatomy and Variants of Hepatic Resectional Surgery

BACKGROUND: The liver anatomy appears to be very complex due to the enormous number of vascular and biliary branches as well as the fact that the underlying pathology frequently distorts the anatomy. To prevent damage during surgical or invasive procedures, it is advised to be aware of the arteries’ typical structure and variations. Hepatic surgeons, general surgeons, transplant surgeons, interventional radiologists, and other medical specialists who treat liver problems must have this knowledge. MATERIALS AND METHODS: We have retrospectively evaluated the PubMed databases, Embase, and the Cochrane Library by applying various combinations of subject-related terms. The search terms identified with the medical subject heading were “Anatomy, right hepatectomy, resection, variants.” The databases were used to collect the literature published since 1991. RESULTS: Results delineated that 91.6% of patients had a single right hepatic vein, 81% shared a trunk with their middle hepatic vein (MHV) and left hepatic vein (LHV), and 19% had separate MHV and LHV drainage into the inferior vena cava. Overall prevalences of the abnormal hepatic artery, abnormal right hepatic artery (aRHA), abnormal left hepatic artery (aLHA), and combined aRHA/aLHA were found to be 27.41%, 15.63%, 16.32%, and 4.53%, respectively. The most common variation (type 2) is the so-called “portal vein (PV) trifurcation,” in which the main PV divides into the left PV, the right anterior PV, and the right posterior PV. The right posterior sectoral duct joins the left hepatic duct with a supraportal course, the right posterior sectoral duct joins the right anterior sectoral duct with an infraportal course, the trifurcation variation of the biliary tree, retroportal course, and the left lateral segmental ducts caudal to the umbilical portion of the PV are examples of variant biliary anatomy encountered in PV variations. Duplication of the common bile duct is a very uncommon congenital biliary system defect. CONCLUSION: It is very crucial for surgeon to have abreast knowledge of the tributaries, their anatomy, and variations to limit blood loss and operative morbidities.

Association between the paracaval branches of the caudate lobe and the three major hepatic veins in liver casts: Locating the cranial boundary of the caudate lobe.

According to Couinaud's definition, the cranial boundary of the caudate lobe is delineated by the three major hepatic veins. However, many branches of the caudate lobe go through the ceiling that is composed of these hepatic veins. The cranial boundary of the caudate lobe should be determined by employing the portal segmentation. We conducted a study based on the dissection of 37 colored resin liver casts to reveal the caudate branches of the liver. The paracaval portal vein branches (PCPvs) were defined as cranial portal branches from the main trunk or first-order branch of the portal vein distributed in front of the inferior vena cava, according to Kumon's classification. The PCVs were traced to reveal the cranial boundary of the caudate lobe. Results showed that in 18 cases (49%), the PCPvs reached the liver surface through the gap between the right and middle hepatic veins (type RM, n = 11), between the tiny branches of the middle hepatic vein (type M, n = 4), and between the middle and left hepatic veins (type ML, n = 3). The PCPvs did not reach the liver surface in 19 cases (type 0). No PCPvs reached the hepatic surface behind the right hepatic vein. Half of the PCPvs in the liver reached the hepatic surface beyond the boundary composed of the three major hepatic veins. Recognition of the PCPvs in the liver is indispensable to perform anatomically precise liver resections involving the major hepatic veins.

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.

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.

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.

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.

Feasibility and long-term outcomes of hepatic vein recanalization in Budd-Chiari syndrome through intrahepatic collateral pathways.

To investigate the feasibility and long-term outcomes of hepatic vein (HV) recanalization using intrahepatic collateral pathways in patients with Budd-Chiari syndrome (BCS) with HV obstruction. Clinical data of 29 BCS patients with HV obstruction and intrahepatic collateral pathways were reviewed. All patients underwent HV recanalization through the intrahepatic collaterals. Follow-up was performed at 1, 3, 6, and 12 months after treatment and annually thereafter. Cumulative patency and survival rates were assessed using Kaplan-Meier curves. The independent predictors of patency were determined using a Cox regression model. HV recanalization was successful in 28 of the 29 patients (96.6%), with no complications. Of the 28 cases, simultaneous recanalization of the accessory HV and right HV was achieved in 11 patients, accessory HV and middle HV in six, accessory HV and left HV in three, right HV and middle HV in five, and left HV and middle HV in three. Twenty-eight patients were followed from 4 to 87 (mean, 53.6 ± 26.7) months after treatment, and six patients developed reocclusion. The overall cumulative 1-, 3-, 5-, and 7-year primary HV patency rates were 96.3, 82.9, 74.6, and 59.7%, respectively. The cumulative 1-, 3-, 5-, and 7-year survival rates were 100, 95.8, 95.8, and 86.3%, respectively. Interventional treatment of HV obstruction in BCS patients through intrahepatic collateral approaches is well tolerated and feasible and can result in excellent long-term patency and survival rates.

Rescue of outflow block of the remnant left liver after extended right hemihepatectomy for resection of a tumor in the caudate lobe.

Outflow block of the liver is a life-threatening event after living donor liver transplantation. Herein, we rescued a patient suffering from the outflow block of the remnant left hemiliver caused by bending of the left hepatic vein (LHV) after right hemihepatectomy plus caudate lobectomy combined with resection of the middle hepatic vein (MHV). A metastatic tumor sized 6 cm in the caudate lobe of the liver involving the root of the MHV was found in a 50's year old patient after resection of a right breast cancer eight years ago. Right hemihepatectomy and caudate lobectomy combined with resection of the MHV was performed using a two-stage hepatectomy (partial TIPE ALPPS). On day 1, the total bilirubin value increased to 4.5 mg/dL, and a dynamic computed tomography (CT) scan showed the bent LHV. On the diagnosis of outflow block of the left liver, a self-expandable metallic stent was placed in the LHV using an interventional approach, and the pressure in the LHV decreased from 27 cmH2O to 12 cmH2O. The bilirubin value decreased to 1.2 mg/dL on day 3. Outflow block of the LHV can happen after extended right hemihepatectomy with resection of the MHV. Early diagnosis and interventional stenting treatment can rescue the patient from congestive liver failure.

Feasibility of Arantius duct maneuver for tunneling between middle and left hepatic veins and their isolation for liver resection: A cadaveric study

Feasibility of Arantius duct maneuver for tunneling between middle and left hepatic veins and their isolation for liver resection: A cadaveric study

Liver Resection Under Total Hepatic Vascular Exclusion with In Situ Hypothermic Isolated Hepatic Perfusion for Advanced Liver Tumors.

Continuous dissection or simultaneous reconstruction of the hepatic vein (HV) and inferior vena cava (IVC) was achieved under total hepatic vascular exclusion (THVE) with in situ hypothermic isolated hepatic perfusion (HIHP) in two cases. CASE 1: The patient previously underwent liver resections with the right HV for colorectal liver metastasis (CRLM). This time, the CRLM had invaded the left HV and IVC, and five courses of FOLFILI plus ramucirumab were given, resulting in stable disease. Due to expected high HV pressure, liver parenchymal transection was started under THVE. Sub-segmentectomy with patch graft plasty of the IVC and reconstruction of the left HV using a jugular vein graft were performed under THVE and HIHP. This patient died at home 3 months after surgery; the cause of death was unknown. CASE 2: Hepatocellular carcinoma in the caudate lobe was in extensive contact with the roots of three main HVs and the IVC, and pressed the hepatocaval confluence, with high HV pressure expected. In addition, tumor thrombosis extended to both the main portal vein and the common bile duct, resulting in the inability to introduce chemotherapy. After tumor thrombectomy, liver parenchymal transection was started under THVE. Extended left hepatectomy with wedge resection, and primary suture of the right HV and IVC was performed under THVE and HIHP. Recurrence-free and overall survivals were 8 months (lung metastasis) and 31 months, respectively. In liver resection for liver tumors located in the hepatocaval confluence, THVE with HIHP is useful for ensuring the safety.

Robotic Right Hepatectomy with En Bloc Caudatectomy for Bismuth IIIa Hilar Cholangiocarcinoma: A Video Demonstration of Left-Liver-First Anterior Radical Modular Orthotopic Right Hemihepatectomy.

Minimally invasive resection for perihilar cholangiocarcinoma is a complicated and technically demanding surgical procedure. Radical surgical resection is regarded as the best treatment for hepatic hilar cholangiocarcinoma.1,2 Right hepatectomy with caudate lobe resection is necessary as the treatment for bismuth IIIa hilar cholangiocarcinoma.3 The left-liver-first anterior radical modular orthotopic right hemihepatectomy (LARMORH), which can simplify surgical steps and decrease procedural difficulty, may be a better choice for Bismuth IIIa hilar cholangiocarcinoma.4 However, there are no reports of this approach using robotic technique for this operation. We will provide a detailed introduction to this method through this video. A 45-year-old female patient was diagnosed with a hilar cholangiocarcinoma. Following a 7-day percutaneous biliary drainage of the left intrahepatic bile duct and obtaining informed consent, we performed a robotic radical resection of the HCCA using the LARMORH approach. The patient was positioned supine with the entire bed elevated 20° and tilted 15° to the left. Trocars were placed in position (Fig. 1). After entering the abdominal cavity, it was explored for tumor metastasis. The surgery adopted a left approach, initially exploring the left hepatic artery and vein to further assess resectability. After confirming resectability, the right hepatic artery and gastroduodenal artery (GDA) were dissected. The common bile duct was dissected and transected at its distal end, ensuring R0 surgical margins. Lymph nodes were cleared from the foot side to the head side, confirming the metastasis to the lymph node group 13a, so we further cleared the group 16 and 9 lymph nodes.5 Subsequently, we approached the resection of the right half and the entire caudate lobe with the reverse thinking of left hepatic resection mode, preserving only the left branch of the portal vein and left hepatic artery, and dissecting the liver tissue along the resection plane of the left liver. After transection of the left hepatic duct, the activity space of the left liver was larger and the caudate lobe could be better exposed. The Spiegel lobe was lifted to the right in a "turn the page" fashion for in situ resection of the entire caudate lobe and the right half of the liver. Finally, a bilioenteric anastomosis was performed using the Roux-en-Y method. Robotic right hepatectomy with caudate lobectomy was successfully performed in 450 min, with an estimated blood loss of 200ml. The histological grading was determined as T1aN1M0 (stage IIIB) on the basis of postoperative pathological biopsy results. The patient achieved a satisfactory postoperative recovery and was discharged on the 14th postoperative day without any major complications. Following the operation, the patient received capecitabine chemotherapy according to the Chinese Society of Clinical Oncology (CSCO) criteria. Since September 2022, our team has completed three radical resections for Bismuth IIIa HCCA using this technique. All patients achieved a satisfactory postoperative recovery without any further complications. Robotic left-liver-first anterior radical modular orthotopic right hemihepatectomy for Bismuth IIIa HCCA is both safe and feasible. This method may provide a new surgical approach for patients with type IIIA HCCA or liver diseases requiring right hemihepatectomy combined with total caudate lobectomy.

Dorsal approach in laparoscopic extended left hemi-hepatectomy: A case series.

The utility of the dorsal approach has been reported for laparoscopic left hemi-hepatectomy. The aim of the present study is to show the usefulness of the dorsal approach for laparoscopic extended left-hemi-hepatectomy while ensuring safe identification of hepatic veins and dissection of the dorsal tumor margin. Tumors requiring extended left hemi-hepatectomy. After mobilization of the lateral sector and division of the Arantius plate, parenchyma above the Arantius plate is removed to expose the root of the middle hepatic vein and left hepatic vein. Each of these veins can be isolated separately either intra- or extra-hepatically. After removing the parenchyma on the cranial side of the left Glissonean pedicle continuous with the exposed hepatic veins, the left Glissonean pedicle is isolated using the Glissonean pedicle transection method. After division of the left hepatic vein and Glissonean pedicle, segment 4 (in which the main part of the tumor is commonly located) is dissected from the anterior plane of the paracaval portion of the caudate lobe by the dorsal approach, along with the hepatic hilum. Following dissection of the dorsal side of the tumor, and division of parenchyma from the anterior edge of the liver, the anterior Glissonean branches and middle hepatic vein are divided safely and the specimen is resected. Three patients underwent laparoscopic extended left hemi-hepatectomy, with no open conversions. Operative time and blood loss were 331 (concomitant with another partial hepatectomy), 277, and 315 minutes; and 200, 100, and 100 g, respectively. The postoperative courses were uneventful. The dorsal approach maximizes the advantages of laparoscopic extended left hemi-hepatectomy and can be performed safely.

Laparoscopic left hemihepatectomy guided by indocyanine green fluorescence: A cranial-dorsal approach.

Advancements in laparoscopic technology and a deeper understanding of intrahepatic anatomy have led to the establishment of more precise laparoscopic hepatectomy (LH) techniques. The indocyanine green (ICG) fluorescence navigation technique has emerged as the most effective method for identifying hepatic regions, potentially overcoming the limitations of LH. While laparoscopic left hemihepatectomy (LLH) is a standardized procedure, there is a need for innovative strategies to enhance its outcomes. To investigate a standardized cranial-dorsal strategy for LLH, focusing on important anatomical markers, surgical skills, and ICG staining methods. Thirty-seven patients who underwent ICG fluorescence-guided LLH at Qujing Second People's Hospital between January 2019 and February 2022 were retrospectively analyzed. The cranial-dorsal approach was performed which involves dissecting the left hepatic vein cephalad, isolating the Arantius ligament , exposing the middle hepatic vein, and dissecting the parenchyma from the dorsal to the foot in order to complete the anatomical LLH. The surgical methods, as well as intra- and post-surgical data, were recorded and analyzed. Our hospital's Medical Ethics Committee approved this study (Ethical review: 2022-019-01). Intraoperative blood loss during LLH was 335.68 ± 99.869 mL and the rates of transfusion and conversion to laparotomy were 13.5% and 0%, respectively. The overall incidence of complications throughout the follow-up (median of 18 months; range 1-36 months) was 21.6%. No mortality or severe complications (level IV) were reported. LLH has the potential to become a novel, standardized approach that can effectively, safely, and simply expose the middle hepatic vein and meet the requirements of precision surgery.

Case Report: Budd-Chiari Syndrome (BCS) on Hepatocellular Carcinoma (HCC): Primary or Secondary Cause?

This is the case of a 63-year-old female patient admitted for management of a liver mass discovered incidentally on imaging. The patient presented with weight loss and prutitus, and on clinical examination had collateral venous circulation and scraping lesions. Abdominal ultrasound coupled with Doppler showed a hepatic tissue mass with left-sided portal thrombosis. Hepatic MRI confirmed the diagnosis and also revealed SBC with infiltration of the left and median hepatic veins. Liver biopsy confirmed diagnosis of hepatocellular carcinoma (HCC)in cirrhotic liver. Etiological work-up for prothrombotic factors and cirrhosis was negative. The patient was a candidate for palliative treatment. But our dilemma: is this a case of primary or secondary BCS? Scholars Middle East Publishers

Gut microbiota regulates hepatic ischemia-reperfusion injury-induced cognitive dysfunction via the HDAC2-ACSS2 axis in mice.

Hepatic ischemia-reperfusion injury (HIRI) resulting from hepatic inflow occlusion, which is a common procedure in liver surgery is inevitable. Previous research has confirmed that the cognitive dysfunction induced by HIRI is closely related to dysbiosis of the gut microbiota. This research aims to investigate the mechanisms underlying this complication. C57BL/6 mice underwent hepatic ischemia experimentally through the occlusion of the left hepatic artery and portal vein. To assess the HDAC2-ACSS2 axis, gut microbiota transplantation. Enzyme-linked immunosorbent assay and LC/MS short-chain fatty acid detection were utilized. The findings indicated a notable decline in ACSS2 expression in the hippocampus of mice experiencing hepatic ischemia-reperfusion injury, emphasizing the compromised acetate metabolism in this particular area. Furthermore, the cognitive impairment phenotype and the dysregulation of the HDAC2-ACSS2 axis could also be transmitted to germ-free mice via fecal microbial transplantation. Enzyme-linked immunosorbent assay revealed reduced Acetyl-coenzyme A (acetyl-CoA) and Acetylated lysine levels in the hippocampus. These findings suggest that acetate metabolism is impaired in the hippocampus of HIRI-induced cognitive impairment mice and related to dysbiosis, leading to compromised histone acetylation.

Exploring the utility of EUS in Budd-Chiari syndrome: a multicenter multiobserver prospective cohort study

Background and aimsThe diagnosis of Budd-Chiari syndrome (BCS) is essentially radiological and is needed to plan appropriate therapy. We therefore conducted this proof of concept study to assess the utility of EUS in assessing anatomy of BCS. MethodsA prospective multi-centre observational study including 50 consecutive patients with a diagnosis of BCS were enrolled. All patients underwent a detailed EUS examination by three independent endosonographers, blinded to the anatomical details of BCS and others’ findings. This was compared to each other and to conventional angiography (where available) or Magnetic resonance venography (MRV). Outcomes assessed include inter observer agreement, sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy in diagnosing pathological lesions of BCS. ResultsFifty BCS patients (Mean age 34 years ; range 13-65 years) underwent EUS. Results showed good agreement among endosonographers for diagnosing right hepatic vein (RHV) (kappa=0.716) and left hepatic vein (LHV) lesions (kappa=0.722), moderate agreement for middle hepatic vein (MHV) lesions (kappa=0.660) and very good agreement for inferior vena cava (IVC) lesions (kappa=0.823). EUS demonstrated high sensitivity, positive predictive value, low inter-observer variability, and overall diagnostic accuracy for BCS lesions. ConclusionsIn conclusion, EUS is a safe and accurate diagnostic tool for BCS. It can provide accurate mapping of hepatic veins, intrahepatic collaterals, and the IVC.

Total hepatectomy during living donor liver transplantation at 108 Military Central Hospital

Objective: To evaluate the results and summarizing the experiences of total hepatectomy in living donor liver transplantation. Subject and method: A cross-sectional, descriptive study, over 165 cases of living donor liver transplantation at 108 Military Central Hospital from January 2019 to April 2023. Result: The average age of patients was 51.57 ± 13.19 years old, HBV infection rate was 70.9%. Indications for liver transplantation include acute liver failure (2.4%), acute on chronic liver failure (34%), decompensated cirrhosis (24.8%), hepatocellular carcinoma (37%), intrahepatic cholangiocarcinoma (1.2%), liver metastases from colon cancer (0.6%). High hilum dissection of the hepatic artery in continuity with the bile duct rate was 95.2%, individual dissection in 3% and total occlusion in 1.8% of cases. The left and middle hepatic veins trunk was divided before segment 1 dissection in 95.8% of patients. Average time of total hepatectomy was 148.12 ± 38.9 minutes, average blood loss during total hepatectomy was 867 ± 442ml. Conclusion: High hilum dissection of the hepatic artery in continuity with the bile duct combined with left and middle hepatic veins trunk divided before dissecting of the segment 1 is safe and feasible for total hepatectomy during living donor liver transplantation.

Extensive systemic thrombo-embolism including intra-cardiac thrombosis mimicking an atrial myxoma in a patient with beta thalassaemia major – a case report

BackgroundSepsis and thrombo-embolic disease are well known complications of thalassemia major. Intracardiac thrombi are however rare and can lead to diagnostic dilemmas.Case presentationWe report the case of a 20-year-old female splenectomised thalassaemia major patient with severe iron overload, who presented with life threatening sepsis associated with a liver abscess. Discovery of a large oscillating intra cardiac lesion on 2D echocardiogram confirmed by Contrast Enhanced Computed Tomography (CECT) chest in the right atrium extending from the left hepatic vein through the inferior vena cava complicated the clinical course. After a prolonged Intensive Care Unit (ICU) stay supported with antibiotics and anticoagulation, she recovered with evidence of resolution of the intra cardiac thrombus.ConclusionsEarly recognition and prompt aggressive treatment of sepsis in patients with thalassemia is essential to prevent complications. Intracardiac thrombosis is a potentially treatable cause for an intra cardiac mass in patients with thalassemia major, which should not be missed.