Liver Infarction Research Articles

Y90 Radiation Segmentectomy versus Microwave Ablation for Hepatocellular Carcinoma in Locations Suboptimal for Percutaneous Ablation

Abstract Purpose The purpose of our study was to evaluate outcomes following percutaneous microwave ablation (MWA) versus yttrium-90 (Y90) radiation segmentectomy (RS) for tumors in suboptimal locations for ablation. Materials and Methods Retrospective review (January 2014–July 2019) was performed on patients who underwent Y90-RS or MWA (with or without prior transarterial chemoembolization [TACE]) with curative intent for early-stage hepatocellular carcinoma (HCC) lesions in suboptimal locations for percutaneous ablation, defined as locations in which needle placement is within 5 mm of critical structures (liver dome, liver capsule, gallbladder, and hilum). The primary endpoints were treatment response as per the modified Response Evaluation Criteria in Solid Tumors criteria and complications. Statistical Analysis Fischer's exact test was performed for categorical variables, and Student's t-tests for nominal variables. Results Twenty-three lesions in 20 patients (13 male, 67 ± 8.8 years) and 30 lesions in 30 patients (18 male, 62.5 ± 10.6 years) were treated with Y90-RS and MWA (19 with prior TACE), respectively. There were no differences in demographics (p > 0.05). Mean tumor diameter was 2.9 ± 1.0 in those treated with Y90-RS and 2.3 ± 0.9 for MWA (p < 0.05). Lesions were located adjacent to the following structures: dome (n = 22), capsule (n = 16), hilum (n = 9), and gallbladder (n = 6). All patients were Eastern Cooperative Oncology Group performance status 0 to 1. Of the MWA cohort, 19 were Child-Pugh class A, 5 were B, and 6 were C and the mean pretreatment laboratory values were as follows: Model for End-stage Liver Disease sodium (MELD-Na) 12.7 ± 4.6, alpha-fetoprotein (AFP) 848 ± 3168.0, aspartate aminotransferase (AST) 71.9 ± 49.1, alanine aminotransferase (ALT) 48.0 ± 32.4, and total bilirubin 2.4 ± 2.7. Of the Y90-RS cohort, 15 were Child-Pugh class A, 4 were B, and 1 was C and pretreatment laboratory values were as follows: MELD-Na 10.5 ± 3.3 (Y90-RS), AFP 762.2 ± 1793.8 (Y90), AST 50.3 ± 30.5 (Y90), ALT 30.1 ± 16.9 (Y90), and total bilirubin 1.6 ± 1.1 (Y90). Complete response rate following Y90 was 96 versus 76% for MWA, with no disease progression after Y90-RS within the follow-up period. Three (13%) lesions demonstrated progression of disease (time to progression 6.3 months) after MWA. No grade > 2 toxicities or procedure-related complications were noted following Y90-RS. There were 7 major (arterioportal fistula with hemoperitoneum, pneumothorax, liver infarction, and capsular burn) and 3 minor complications following MWA. Conclusion Y90-RS is a valuable alternative to percutaneous MWA as a first-line therapy for early-stage HCC for tumors in suboptimal locations for ablation, offering a favorable treatment response and safety profile.

Endovascular Treatment of Hepatic Artery Pseudoaneurysm after Pancreaticoduodenectomy: A Literature Review.

Pancreaticoduodenectomy (PD) is a complex surgical procedure performed in patients with periampullary tumors located within the pancreatic head, the papilla of Vater, the distal common bile duct, and the duodenum. In advanced tumors, the operative technique involves the need for dissection and divestment of the arteries located within the pancreaticoduodenal field, including the common hepatic artery (CHA) and the proper hepatic artery (PHA) and its branches. The second most important cause of post-PD visceral aneurysms is irritation of the peri-pancreatic arterial wall by pancreatic juice in a postoperative pancreatic fistula (POPF). Hepatic artery pseudoaneurysm (HAP) is a very dangerous condition because it is usually asymptomatic, but it is a rare and potentially lethal pathology because of the high risk of its rupture. Therefore, HAP requires treatment. Currently, selective celiac angiography is the gold-standard diagnostic and therapeutic management for postoperative bleeding and pseudoaneurysm in patients following PD. Open surgery and less invasive endovascular treatment are performed in patients with HAP. Endovascular treatment involves transarterial embolization (TAE) and stent graft implantation. The choice of treatment method depends on the general and local conditions, such as the patient's hemodynamic stability and arterial anatomy. In patients in whom preservation of the flow within the hepatic artery (to prevent hepatic ischemia complications such as liver infarction, abscess, or failure) is needed, stent graft implantation is the treatment of choice. This article focuses on a review of two common methods for endovascular HAP treatment. In addition, risk factors and diagnostic tools have been described.

Optimizing the Management Strategies of Delayed Post-Pancreaticoduodenectomy Hemorrhage

Objective: To optimize the management strategies of delayed post-pancreaticoduodenectomy hemorrhage (PPH) by evaluating data from a high-volume pancreatic center. Summary Background Data: Delayed PPH is a potentially lethal complication. The management of delayed PPH remains controversial. Methods: Patients who underwent pancreaticoduodenectomy between July 2018 and June 2023 were identified from an institutional database. The clinical scenarios, management, and outcomes of patients with delayed PPH (>5 d postoperatively) were analyzed. Results: Out of the 2013 patients who underwent elective pancreaticoduodenectomy, 130 (6.5%) with delayed PPH were identified. The overall mortality was 15.4%. The success rates of endoscopy, angiographic intervention, and relaparotomy in treating delayed PPH were 54.5%, 56.5%, and 68.8%, respectively. For PPH from the hepatic arteries or their branches, complete blockade of the common or proper hepatic artery (C/PHA) was performed in 17 patients, either by coil embolization (n=7) or surgical ligation (n=10). Coil embolization of the C/PHA resulted in significant infarction of the left liver in 2 patients. No postoperative liver infarction occurred in patients who underwent ligation of the C/PHA during relaparotomy. Ten patients underwent suture repair of the C/PHA 13 times during relaparotomy. Arterial ligation achieved a significantly higher success rate of hemostasis than suture repair of the C/PHA during relaparotomy (100% vs. 30.8%, P<0.001). Conclusions: Angiography should be attempted first in managing hemodynamically stable delayed PPH. Arterial ligation was preferred for bleeding from the hepatic arteries during relaparotomy with minor consequences for the liver.

Emergency Treatment of Ruptured Abdominal Aneurysm

Introduction: Abdominal aneurysm is considered a formidable pathological condition that requires prompt treatment. Its progressive increase leads to rupture and massive internal bleeding, which requires the most effective medical care. However, despite the improvement in medical equipment and postoperative care, mortality due to ruptured abdominal aneurysms is still close to 50%, which is primarily related to the severity of the pathology and open surgical intervention.
 Materials and Methods: 46 patients diagnosed with rupture of the abdominal aorta took part in the study. Selection criteria were a history of abdominal aortic rupture, conservative/operative treatment for the disease, and absence of other complications (acute renal failure, liver infarction) that could affect the results of the study.
 Results: Since January 2018, 46 cases of ruptured AAAs have been diagnosed. In all forty-six cases, surgical intervention was used: open surgery or endovascular technique. All 100% of patients had a previous history of diagnosed abdominal aortic aneurysm, for which they underwent periodic ultrasound examinations.
 As a result of the study, it was found that endovascular aortic aneurysm correction is the optimal method for both planned and emergency treatment of aortic aneurysm and its rupture. According to the Cochrane Specialized Register, it was established that endovascular repair is associated with a reduction in early morbidity and mortality after abdominal aneurysm, compared with other methods of surgical treatment. Furthermore, the study found that, unlike open surgery methods, endovascular techniques are associated with a lower risk of complications in the form of intestinal ischemia.
 Conclusions: Inferior quality studies and lack of information limit the conclusions of this review. From the statistical data shown in this paper, it can be concluded that there is a difference between endovascular and open methods of treatment of abdominal aortic aneurysm rupture. Mortality within the first 30 days after treatment and short-term complications are significantly lower in patients using EVAR. Systemic complications are also more prevalent in patients who were prescribed open surgical treatment.

Invasive Fungal Infection Mimicking Infarctions in a Child with Acute Lymphoblastic Leukemia

Invasive fungal infection is a major cause of morbidity and mortality after intensive chemotherapy in patients with leukemia who present with febrile neutropenia. The most common sites of involvement are the lungs, sinonasal region, and disseminated blood stream infection. Visceral organ involvement is usually seen in the form of fungal abscesses, with parenchymal infarcts being less common. We report an unusual case of invasive fungal infection presenting with extensive liver infarction, global renal infarction, and multiple brain lesions in a 4-year-old boy with acute lymphoblastic leukemia on induction chemotherapy.

Total Marrow Irradiation Reduces Organ Damage in a Bone Marrow Transplant Model of Sickle Cell Disease

Sickle cell disease (SCD) is associated with significant organ pathology. Currently, the only curative option is bone marrow transplantation (BMT) after myeloablative conditioning. However, significant organ damage from myeloablative total body irradiation (TBI) remains one of the major side effects of BMT. To reduce exposure to vital organs, but efficient enough to maintain engraftment, we developed 3D image guided-total marrow irradiation (TMI) for targeted delivery to the bone marrow (BM) and spleen of humanized BERK sickle mice while sparing the vital organs. We hypothesized that TMI will prevent organ damage compared to that induced by TBI during BMT. Sickle mice were treated with: [i] TBI (4:4), 4 Gy to the BM & 4 Gy to the whole body; [ii] TMI (4:0), 4 Gy to BM, 0 Gy to the body, and [iii] TMI (8:2), 8 Gy to BM & 2 Gy to the whole body. After 24h of irradiation, SS mice were transplanted with 5 million donor BM cells from HbAA BERK mice expressing normal human hemoglobin A (n=3/group). Thirty days after BMT mice were euthanized, and organs were necropsied for histopathology. Formalin-fixed paraffin-embedded sections of the lung, liver, kidney, spleen, and bone marrow (femur & tibia) were stained with H&E and Prussian blue (iron deposits). Morphologic findings of vascular congestion, inflammatory infiltrate, and iron deposits were scored from '0' for no lesion up to '6' for severe lesions occupying 90-100% of the field (Manci et al., Blood 2006). Tubular brush border thickness was assessed on periodic acid Schiff's (PAS)-hematoxylin-stained kidney sections using a 0-4 grading scale: no changes ='0'; lesion area <25%=1; 25%-50% = 2; >50% = 3 and 100% = 4 (Kasztan et al. J Am Soc Nephrol. 2017). We observed significantly increased vascular congestion in the liver (p=0.003), and spleen (p=0.013), and inflammatory infiltrates in the lungs (p=0.031) of TBI-treated mice compared to TMI (8:2). Total body irradiation has been shown to induce inflammation with granulocyte infiltration into tissues in association with endothelial damage, vascular dilatation, and congestion. Moreover, increase iron content in BM and serum and disrupted iron metabolism is another known sequala of total body irradiation, which contributes to hemosiderin formation in tissues. We found significant increase in iron deposits in TBI (4:4) vs TMI (8:2) in liver (p=0.001), spleen (p=0.014), and kidney (p=0.043). TBI (4:4) led to more renal tubular lesions (p=0.003) marked by a significant loss in the tubular brush border on PAS-stained kidney sections compared to TMI (8:2). Thus, TMI shows lesser damaging effect on vital organs compared to TBI, while TMI (8:2) showed donor chimerism similar to TBI on days 7 and 14 but higher than TMI (4:0) treated mice. However, the engraftment failed (less than 10% chimerism) in all groups by day 30. To improve engraftment, we transplanted 10- and 25-million donor HbAA BERK BM cells into TMI (4:0) and TMI (8:2) treated sickle mice. TMI (8:2) showed sustained donor chimerism but TMI (4:0) did not. Histopathological analysis 90 days post-BMT showed that TMI (8:2) treatment (n=3) results in significantly lesser organ pathology Vs untreated sickle mice (n=2), as evinced by reduction in: vascular congestion (lung, p=0.014; liver, p=0.014; spleen p= 0.014), inflammatory infiltrate (lung, p= 0.031; liver p= 0.005), liver infarctions (p=0.003) and liver and kidney iron deposits (p=0.041 & 0.021, respectively). Untreated mice showed a significant loss in the tubular brush border compared to TMI (8:2) treatment (p=0.008). BM in TMI (8:2) (cellularity~70%) showed improvement in cellular differentiation and topography in comparison to the untreated (cellularity ~90% ) that were packed with minimal fat spaces, thin trabeculae, and marked erythroid hyperplasia. These data suggest recovery from sickle cell phenotype with TMI-8:2 without significant organ pathology. Additionally, toluidine blue stained skin sections showed that the number (~45 Vs ~15) and % degranulating mast cells (~85 % Vs 50 %) were significantly lower in TMI (8:2) Vs untreated sickle mice (p<0.05), suggesting that TMI (8:2) treatment and successful engraftment of healthy donor cells may reduce inflammation and pain phenotype. We show that dose escalated TMI (8:2) is well tolerated with reduced organ pathology. Therefore, TMI has the potential to improve BMT-related outcomes without an adverse effect on organ damage.

Abdominal Imaging Findings in Patients with COVID-19 Part 2: Solid Organs.

Since severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first appeared in China in December 2019, the globe has been dealing with an ever-increasing incidence of coronavirus disease 2019 (COVID-19). In addition to respiratory disorders, 40% of patients present with gastrointestinal (GI) involvement. Abdominal pain is the most common indication for computed tomography (CT) and ultrasonography. After GI tract involvement, solid visceral organ infarction is the most prevalent abdominal abnormality in COVID-19. This review aims to gather the available data in the literature about imaging features of solid abdominal organs in patients with COVID-19. Gallbladder wall thickening and distension, cholelithiasis, hyperdense biliary sludge, acalculous cholecystitis, periportal edema, heterogeneous liver enhancement, and liver hypodensity and infarction are among hepatobiliary imaging findings in CT, particularly in patients admitted to ICU. Pancreatic involvement can develop as a result of direct SARS-CoV2 invasion with signs of acute pancreatitis in abdominal CT, such as edema and inflammation of the pancreas. Infarction was the most prevalent renal and splenic involvement in patients with COVID-19 who underwent abdominal CT presenting with areas of parenchymal hypodensity. In conclusion, although solid abdominal organs are rarely affected by COVID-19, clinicians must be familiar with the manifestations since they are associated with the disease severity and poor outcome.

A Rare Case of Post-Partum Hemorrhage with Refractory Thrombotic Microangiopathy, and Hepatic Infarction: A Diagnostic Dilemma with High Mortality

We are presenting a very rare and unique case of postpartum hemorrhage with excessive blood loss requiring 6 units of packed red cells, 2 units of single donor platelet transfusions, 4 fresh frozen plasmas, and 4 cryoprecipitates. The patient developed a life-threatening spectrum of thrombotic microangiopathy which is known to result in pregnancy from eclampsia, pre-eclampsia, thrombotic thrombocytopenic purpura, typical and atypical hemolytic uremic syndrome, and hemolysis, elevated liver enzymes, low platelets syndrome and in non-pregnant patients with a wide differential diagnosis. The patient required 7 sessions of plasma exchange along with systemic steroids. During her illness, she developed rising liver enzymes and bilirubin, diffuse intravascular coagulation, renal failure, alveolar hemorrhage, and acute fulminant hepatic failure. A contrast-enhanced computed tomography scan revealed multiple areas of liver infarction with patent hepato-portal vessels. The patient required continuous renal replacement therapy and high supportive care. She stayed in the intensive care unit for 9 days, developed multi-organ failure, and finally expired. It is highly imperative to be aware of the complications of postpartum hemorrhage, as it should be treated promptly to minimize the possible cascade of multi-organ failure with high maternal and fetal mortality. Liver transplantation is the only possible radical therapy in cases with fulminant hepatic failure, worth considering, if clinically possible and applicable.

Is it a liver abscess or liver infarction? Diagnostic dilemma in a patient with systemic lupus erythematosus and antiphospholipid syndrome: a case-based mini review

Is it a liver abscess or liver infarction? Diagnostic dilemma in a patient with systemic lupus erythematosus and antiphospholipid syndrome: a case-based mini review

Preoperative embolization strategy for the combined resection of replaced right hepatic artery in pancreaticoduodenectomy: a small case series

BackgroundReplaced right hepatic artery (rRHA) is a common vascular variation, and combined resection of this vessel is sometimes needed for the curative resection of pancreatic head malignancy. Safe surgical management has not been established, and there is a small number of reported cases. Here, we reported five cases, wherein preoperative embolization of rRHA was performed for combined resection.Case presentationAll patients had pancreatic head malignancies that were in contact with rRHA. We performed a preoperative embolization of the rRHA before the scheduled pancreaticoduodenectomy for the combined resection. Arterial embolization was safely accomplished, and the communicating arcade from the left hepatic artery via the hilar plate was clearly revealed in all cases. Four patients underwent the operative procedure, except for one patient who had liver metastasis at laparotomy. No patient suffered from a severe abnormal liver function during the management; however, one patient had multiple liver infarctions during the postoperative course.ConclusionsPreoperative embolization for the combined resection of rRHA in pancreaticoduodenectomy can be a management option for the precise evaluation of hemodynamics after sacrificing rRHA. In our cases, arterial flow to the right liver lobe was supplied by the left hepatic artery via the bypass route, including the communicating arcade of the hilar plate.

Liver infarctions as the first manifestation of antiphospholipid antibody syndrome in pregnancy: a case report

BackgroundThe differential diagnosis of abdominal pain in pregnant women is broad. Liver diseases as the origin of abdominal pain in pregnancy are rare, and severe forms occur in less than 0.1% of pregnancies. Some disorders, such as hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome and preeclampsia, are unique to pregnancy, while others, such as antiphospholipid antibody syndrome, may manifest in pregnancy but have consequences beyond the current pregnancy. All of them require prompt identification and treatment.Case presentationA 27-year-old Caucasian woman who was 15+1 weeks pregnant reported to the emergency department twice due to stabbing right-upper-quadrant abdominal pain. Initial laboratory testing revealed mild leukocytosis and slightly elevated liver enzymes. On second presentation, the patient was febrile and had an increased C-reactive protein concentration. Over the course of the next days, nonhemolytic anemia and thrombocytopenia emerged with elevated liver enzymes. Coagulation studies also revealed a prolongation of activated partial thromboplastin time. Magnetic resonance imaging showed nonspecific alterations in the right liver lobe, possibly corresponding to infection or infarction. A hepatic viral infection was ruled out. At that time, the most likely diagnosis was cholangitis with liver abscess formation, and antibiotic therapy was started. Further worsening of the anemia and thrombocytopenia, development of proteinuria, together with a miscarriage on the fourth day of hospitalization resulted in the tentative diagnosis of (triple-positive) antiphospholipid antibody syndrome, which was confirmed 12 weeks after the initial investigation. Treatment consisted of prompt anticoagulation with heparin and later on with a vitamin K antagonist as well as high-dose glucocorticoid therapy. There was no need for intravenous immunoglobulin therapy or plasma exchange, although we suspected a catastrophic form of antiphospholipid antibody syndrome due to infarctions of the liver, placenta, and possibly kidneys (proteinuria). The outcome was favorable.ConclusionWe report a 27-year-old pregnant woman whose abdominal pain was caused by liver infarctions as the first manifestation of catastrophic antiphospholipid antibody syndrome. The antiphospholipid antibody syndrome was possibly secondary to hitherto clinically silent systemic lupus erythematosus since the antinuclear antibodies were increased later on. Hydroxychloroquine therapy was initiated to prevent antiphospholipid antibody syndrome recurrence in a future pregnancy.

Utilization of an Occlusion Balloon Catheter during Stent-Graft Placement to Treat Postsurgical Visceral Arterial Hemorrhage

The utility of occluding the bleeding artery using an occlusion balloon catheter during stent-graft placement for visceral artery bleeding was evaluated. Stent-graft placement for visceral artery bleeding was performed using a balloon catheter in 6 patients. All bleeding occurred after biliary or pancreatic surgery. Since 1 patient underwent the procedure twice, 7 procedures were assessed in total. Technical success, procedure-related adverse events, and 30-day mortality rates were evaluated. Technical success was defined as the placement of the stent-graft at the target site and the resolution of extravasation or pseudoaneurysm. In all procedures, stent-graft placement was successfully performed (technical success rate, 100%). Focal liver infarction occurred in 2 of 7 patients (29%), but did not require further treatment and was considered a minor adverse event. The 30-day mortality rate was 0%. In conclusion, the use of an occlusion balloon in the feeding artery facilitated successful stent-graft repair of hemorrhage from visceral arteries.

Hepatic impairment as a risk factor of adverse drug reactions

There are a lot of clinical variants of hepatic impairment ranging from asymptomatic increase in transaminases to acute liver failure and fulminant hepatitis. Hepatic impairment is a polietiologic syndrome. According to the epidemiological study conducted in the United States (19982008), the main causes of hepatic impairment were paracetamol overdose (46%), idiopathic liver dysfunction (14%), other drugs (excluding paracetamol, 11%), viral hepatitis B (7%), other infectious and non-infectious diseases with liver damage (except for viral hepatitis) 7%, autoimmune hepatitis (5%), ischemic hepatitis (syn. hypoxic hepatitis, liver infarction) 4%, viral hepatitis A (3%) and Wilson's disease (2%). Hepatic impairment have a direct impact on the pharmacokinetics and pharmacodynamics of drugs decreasing clearance, elimination and excretion of drugs. Also Transjugular intrahepatic porto-systemic shunts, which are often used to treat portal hypertension in patients with liver cirrhosis, can significantly reduce the presystemic elimination of drugs, thereby increasing their absorption. Moreover, in patients with liver cirrhosis, concomitant renal dysfunction also requires an adjustment of the dose of drugs. Correction of pharmacotherapy in accordance to pharmacokinetic and pharmacodynamic changes of drugs ingested by patients with impaired liver function will improve the quality of medical care and reduce the risks of adverse drug reactions.

Comparison of tumor response following conventional versus drug-eluting bead transarterial chemoembolization in early- and very early-stage hepatocellular carcinoma

ObjectiveTo compare the safety of conventional transarterial chemoembolization (cTACE) vs drug-eluting bead TACE (DEB-TACE) in very early- and early-stage hepatocellular carcinoma (HCC). MethodsData of patients with early- and very early-stage HCC treated with cTACE or DEB-TACE were evaluated retrospectively in this study. A total of 40 patients were included, 20 treated with cTACE and 20 with DEB-TACE. The cTACE and DEB-TACE groups were comprised of 80% and 75% males, while there were 20% females in cTACE group and 25% in Deb-TACE group respectively. The mean age of patients in cTACE group was 57.43 ​+ ​5.6 years, while it was 56.4 ​+ ​5.5 years in DEB-TACE group. All patients had liver status of Child–Pugh Class A and a score ≤ 7 in Child-Pugh class type B in very early- (stage 0) or early-phase (stage A) stages according to the Barcelona Clinic Liver Cancer (BCLC) system. ResultsThe Child-Pugh class degradation in the cTACE group was slightly higher than that in the DEB-TACE group. Serious complications like peritumoral parenchymal ischemia were observed in 4 patients in the cTACE group and 5 in the DEB-TACE group. Localized bile duct dilation was seen in 2 patients in the cTACE group and 6 in the DEB-TACE group.No significant variation in serious complications between the two groups was established in localized bile duct dilatation. Other minor complications noted were liver failure, liver abscess, liver infarction, acute cholecystitis, biliary tree necrosis, and mortality. Further, no substantial variation in tumor response between the groups was reported immediately and 1-year post-procedural assessment. Conversion rate to other treatment modalities such as surgical resection, radiofrequency ablation (RFA), or swap between cTACE and DEB-TACE was substantially higher in the DEB-TACE group (40%) than in the cTACE group (10%) at the 1-year completion period of the study. ConclusionIn terms of tumor response, the DEB-TACE group showed a better response, to some extent, as an initial therapy for HCC in the early stages as compared to the cTACE group, and DEB-TACE also exhibited better clinical efficacy in patients with HCC.

Splanchnic vein thrombosis-related mortality in the Veneto region (Italy), 2008–2019: Retrospective analysis of epidemiological data

BackgroundSplanchnic vein thrombosis (SVT) is an uncommon manifestation of venous thromboembolism. Epidemiological data on SVT-related mortality rate is not available to date. MethodsWe investigated time trends in SVT-related mortality rate, 2008–2019, in Veneto, an Italian high-income region of approximatively 5,000,000 inhabitants. SVT-related deaths were identified by the following ICD-10 codes: I81 (portal vein thrombosis), K75.1 (phlebitis of portal vein), K76.3 (liver infarction), K76.5 (hepatic veno-occlusive disease) or I82.0 (Budd-Chiari syndrome). ResultsDuring the study period, a total of 557,932 deaths were recorded. SVT was reported in 823 cases; 776 (94%) consisted of portal vein thrombosis. The age-standardized SVT-related mortality rate varied from 1.47 (year 2008) to 1.52 (year 2019) per 100,000 person-years. An increase in the cause-specific annual mortality rate was observed in women (0.56 in 2008 to 1.04 per 100,000 person-years in 2019; average annual percent change +5.7%, 95%CI +3.1; +8.3%). In men, the cause-specific mortality rate moved from 2.53 in 2008 to 2.03 per 100,000 person-years in 2019 (average annual percent change −1.2%, 95%CI -4.0; +1.6%). After conditioning for age and sex, the odds of having a concomitant liver disease were higher for SVT-related deaths (OR 31.6; 95%CI 17.1–37.0) compared with non-SVT-related deaths. This also applies to gastrointestinal cancers (OR 1.28; 95%CI 1.07–1.55), although to a lesser extent. ConclusionsWe report first epidemiological estimates of SVT-related mortality in a Western country. These values will serve as a reference to weight novel potential factors associated with SVT-related death and interpret them from an epidemiological perspective.

The effect and clinical significance of using nathanson liver retractor on liver function tests in laparoscopic gastric cancer surgery.

There are very few studies in the literature investigating the changes caused by the Nathanson retractors in liver function tests (LFT) after LG and its clinical significance. The present study investigated the changes made by the Nathanson retractor used during LG on LFT and its clinical significance. The data of 236 patients, who underwent radical gastrectomy for primary gastric cancer at Surgical Oncology Unit in the period between January 2015 and January 2020 were retrospective studied. The patients were divided into two groups: laparoscopic gastrectomy (LG; 136 cases) and open gastrectomy (OG; 106 cases). Patients who have undergone cholecystectomy, with primary or secondary liver tumors, with chronic hepatic disease, who have preoperative high ALT, AST and bilirubin values were excluded from the study. LFT were measured preoperatively and postoperative day 1 (LFT1), LFT3, LFT5 and LFT7. LFT: ALT, AST and Total bilirubin (BIL). ALT1, ALT3, ALT5, ALT7 ALT values and AST1, AST3, AST5 AST values of the patients in the LG group were found to be significantly higher (P &lt;0.001). Mean total bilirubin values of the groups were similar (P &gt;0.05). In order to evaluate how the increase in LFT due to the use of the Nathanson retractors reflected on the patients&apos; clinic, we divided the patients who underwent LG into two groups based on ALT increase in ALT1: Normal and Elevated. The in-hospital mortality rates (P = 0.080) and oral nutrition time (P = 0.913) of the groups were similar. No liver infarction developed in any of the groups. The duration of stay in the ICU was significantly longer in individuals with elevated LFT (P = 0.019). Although the use of the Nathanson retractor during LG causes an increase in liver function tests, this does not cause major clinical problems in patients. Key Words: Gastrectomy; gastric cancer; laparoscopy; liver enzymes; liver dysfunciton.

S2651 Acute Liver Infarct with a Superimposed Liver Abscess as a Consequence of Hypercoagulable State in a Patient with COVID-19 Without Respiratory Manifestations

Introduction: COVID-19 infection have been associated to a hypercoagulable state. We present a case of a 66-year-old man with SARS-CoV-2 infection without respiratory symptoms that debuted with thrombosis of the portal vein and branches of the hepatic artery, liver infarction and superimposed hepatic abscess as the only clinical manifestation. Hepatocellular carcinoma, liver cirrhosis, intra-abdominal and pelvic inflammation or infection were absent. No history of coagulopathies reported. We postulate that the hypercoagulable state associated to COVID-19 led to thrombosis of the portal vein and branches of the hepatic artery leading to patient's clinical presentation and ultimate complications. Case Description/Methods: A 66-year-old man presented to the ED complaining of fever, night sweats, generalized malaise, unintentional weight loss, and epigastric pain. Ten days prior, a COVID- 19 PCR test was done with positive results. Physical examination demonstrated bilateral clear lungs and a benign abdomen. Labs showed neutrophilic leukocytosis, reactive thrombocytosis, normocytic normochromic anemia, elevation of liver enzymes and inflammatory markers. Abdominal US revealed acute PVT. He was admitted and started on vancomycin, piperacillin/tazobactam and full anticoagulation with enoxaparin. Chest CT scan excluded pulmonary consolidations and ground glass opacities. Abdominopelvic contrast CT scan confirmed the PVT involving the main, right and left portal veins without collateral vessels. No other infectious foci was identified. Contrast MRI findings were consistent with a multiseptated liver abscess within the left liver lobe lateral segment and PVT associated with a large infarction involving the right liver lobe anterior segment and the left liver lobe medial and lateral segments. Blood and urine cultures, stool ova and parasite, E. histolytica IgG ELISA and viral hepatitis panel were negative. After 12 days, the patient was discharged to complete 4 weeks of antibiotics and 6 months of full anticoagulation. Follow-up contrast CT scan showed new cavernous transformation of the porta hepatis and resolution of the liver abscess. Discussion: Physicians should be aware that patients with COVID-19 infection can debut with thromboembolic phenomenon and potential involvement of hepatic circulation as the only clinical manifestation of COVID-19. Prompt recognition can help physicians to direct appropriate therapy earlier for these complications, which can have a significant impact in patient's outcomes and prognosis. (Table Presented).

JAK2V617F positive polycythemia vera with paroxysmal nocturnal hemoglobinuria and visceral thromboses: a case report and review of the literature

BackgroundPolycythemia vera (PV) is characterized by red cell mass expansion in the peripheral blood and can be complicated with thrombosis, bleeding, evolution to acute myeloid leukemia (AML) or a fibrotic phase. Paroxysmal nocturnal hemoglobinuria (PNH) in an acquired clonal haematopoietic stem cell disorder associated with chronic intravascular hemolysis, venous thrombosis, defective hematopoiesis, frequent episodes of infection and, rarely, leukemic transformation. Herein, we report an interesting case of a patient with coexistence of PNH clones and a JAK2V617F positive PV, with unusual thromboses without hemolysis.Case presentationA 51-year-old woman presented with increased levels of hematocrit, multiple liver, spleen, and left kidney infarctions and ascites; further investigation revealed a JAK2V617F-positive polycythemia vera and the presence of a significant PNH population (more than 90% CD55– CD59– cells among both granulocytes and red blood cells). Interestingly, the patient has experienced severe thrombotic events without any signs or symptoms of hemolysis.ConclusionsThis case raises questions over uncharted aspects of the PNH etiopathogenesis and its potential association with myeloproliferative neoplasms (MPN) and highlights the difficulty of diagnosing and managing patients with more than one potentially thrombophilic conditions, especially with established and severe thromboses.

Direct Percutaneous Puncture and Embolization of Visceral Pseudoaneurysm: Safety and Clinical Efficacy

Abstract Purpose The aim of the study is to assess the safety and clinical effectiveness of direct percutaneous embolization of visceral artery pseudoaneurysms. Materials and Methods Retrospective analysis of patients who had undergone direct percutaneous embolization of visceral artery pseudoaneurysms between January 2012 and May 2017 was performed. The study included 26 patients with a mean age of 36 years (range 10–71 years). The indications for direct percutaneous embolization included the inability to catheterize endovascularly (n = 24) or prior embolization (n = 2) of the feeding artery. Patient demographics, details of the procedure, complications, and outcomes were evaluated. Patients were followed for a mean of 15 months to assess for recurrence of the pseudoaneurysms on ultrasound. Results Splenic artery (n = 13), gastroduodenal artery (n = 4), right hepatic artery (n = 3), pancreaticoduodenal arteries (n = 3), left gastric artery (n = 2), and left hepatic artery (n = 1) were the embolized arteries. Etiology for pseudoaneurysm were pancreatitis (n = 20), trauma (n = 2), postoperative (n = 2), and few were incidentally detected (n = 2). N-butyl cyanoacrylate (NBCA) with lipiodol was used in 23 (88.4%) patients, coil in one (3.8%), and both coil and NBCA in two patients (7.7%). Embolization of the pseudoaneurysm was successful in all cases. No procedure-related complication was observed. Follow-up showed no recurrence of the pseudoaneurysm. Self-limiting splenic infarct was seen in six patients. Self-limiting abdominal pain was seen in all the patients with embolization with NBCA. One patient developed liver infarct and subsequent liver abscess requiring percutaneous drainage. Conclusion Direct percutaneous embolization is safe and effective in the treatment of visceral artery pseudoaneurysms and should be considered as an alternative in patients with a failed endovascular approach.

COVID-19 Infection Causing Liver Infarction, Severe Cholangiopathy, and Biliary Cast Syndrome

We present a patient with COVID-19 pneumonia with severe multi-organ failure who developed a liver infarction in the setting of acute illness and following recovery, had persistent cholestatic liver injury. On further evaluation, he was found to have a severe destruction of the intrahepatic bile ducts and biliary cast syndrome and ultimately, was felt to have severe ischemic cholangiopathy in the setting of recent COVID-19 infection. Because of the extent of destruction and persistent cholestasis, he is at risk of secondary biliary cirrhosis and is therefore undergoing a liver transplant evaluation. This case highlights a rare entity of liver infarction and severe cholangiopathy with biliary cast syndrome in the setting of COVID-19 infection. It is the first case of this reported to date, and its recognition in the presence of the COVID-19 pandemic is important. Keywords: Biliary cast, Cirrhosis, Cholangiopathy , COVID-19, Liver infarction.