Middle Hepatic Vein Research Articles

Endoscopic injection sclerotherapy for pediatric bleeding esophageal varices complicated by gastric vein, main portal vein, splenic mesenteric junction, and splenic vein occlusion: a case report

BackgroundEndoscopic injection sclerotherapy (EIS) is a life-saving procedure for pediatric patients with bleeding gastric varices (GV) associated with advanced liver cirrhosis and severe portal hypertension. Because of the lack of an endoscopic banding ligation device for pediatric patients, EIS is usually performed for bleeding esophageal varices (EV) in infants with congenital biliary atresia.Case presentationWe present a case of a 15-month-old female infant with type I biliary atresia with jaundice (total serum bilirubin, 22.2 mg/dL), hypoalbuminemia (serum albumin level, 2.58 g/dL), coagulopathy (prothrombin time > 20 s compared with that of a normal control), ascites, splenomegaly, portal hypertension (portal vein velocity, 3.9–5.6 cm/sec of hepatopetal flow), and repeated bleeding of the varices after receiving three doses of intravascularly administered Histoacryl 1 ampoule mixed with Lipiodol UF 8 mL in the EV. Prominent GV and EV were occluded by EIS. The sclerosing agent was also present in the main portal vein, splenic mesenteric junction, and splenic vein, causing an engorged inferior mesenteric vein. The patient underwent total hepatectomy and living donor liver transplantation (LDLT) by left lateral segment graft (segments 2, 3, and 4 of the middle hepatic vein trunk) and left portal vein graft to the recipient inferior mesenteric vein anastomosis. Portal vein stent placement via segment 4 of the portal vein stump was performed from the inferior mesenteric vein to the umbilical portion of the left portal vein. The patient is still alive and doing well after the LDLT.ConclusionsEIS is a life-saving procedure in cases involving bleeding EV complicated by gastric, main portal vein, splenic mesenteric junction, and splenic vein occlusions; hence, it should be kept in mind as a treatment for EV complications in pediatric patients.

Comparison of Patients With and Without Anterior Sector Venous Drainage in Right Lobe Liver Transplantation From Live Donors in Terms of Complications, Rejections, and Graft Survival: Single-Center Experience

AimThe issue of performing an anastomosis of the anterior sector veins to the vena cava in living donor liver transplantation is still controversial. We aimed to research whether there was any difference in terms of complications, rejections, and graft survival between patients with and without anterior sector venous drainage to the vena cava. Patients and MethodsPatients were retrospectively investigated for demographic data and ratio of graft needed to available graft weight. Donors had volumetric calculations and middle hepatic vein anterior sector drainage documented in detail. ResultsSeventy-three donors with middle hepatic vein drainage were included. Thirty-five had anterior sector venous drainage performed and 38 patients did not have drainage procedures performed. The incidence of general complications was higher in the group without anterior sector drainage (78.3% and P = .002). Biloma linked to bile leaks were observed in 8 patients without drainage (72.8%) and 3 patients with drainage (27.2%). Late acute rejection occurring during follow up after transplantation was identified in 28 patients (11.6%). Of these, 1 (14.3%) had anterior sector drainage and 6 (85.7%) were in the patient group without drainage (P = .067). ConclusionAs a result of this study, for patients with grafts at the volume limit (graft weight to receiver weight ratio <0.8) and with congestion observed in the anterior sector after liver implantation and for patients with outflow problems identified on Doppler ultrasonography, anterior sector veins >5 mm should definitely be drained into the vena cava. Hence, both complication and rejection rates will reduce, and we can lengthen the graft, and thus patient, survival.

Laparoscopic donor right hepatectomy with reconstruction of segment V and VIII tributaries of the middle hepatic vein using a cadaveric iliac artery allograft

Laparoscopic donor right hepatectomy with reconstruction of segment V and VIII tributaries of the middle hepatic vein using a cadaveric iliac artery allograft

The Liver Tunnel

This prospective intention-to-treat validation study evaluated the liver tunnel (LT) technique for patients having ≥1 deep centrally located liver tumor, with or without middle hepatic vein (MHV) invasion. Conservative surgery has been proposed for patients with deep liver tumors having complex relationships. LT is one such novel technique. Eligible patients were prospectively enrolled for LT. LT relies on tumor-vessel detachment, and the presence of communicating veins if MHV resection is necessary. Twenty consecutive patients met the inclusion criteria: 17 had colorectal liver metastases, 1 had hepatocellular carcinoma, 1 had mass-forming cholangiocarcinoma, and 1 had mixed hepatocellular carcinoma-mass-forming cholangiocarcinoma. Nineteen patients underwent LT. The MHV was resected in 6 patients, always sparing segments 4i and 5. Overall, 180 lesions were removed (median 7; range 1-37): 79 lesions were included in the LT specimen (median 3; range 1-13). There was no in-hospital 90-day mortality. Overall morbidity occurred in 10 (50%) patients: major in 2 (10%). All complications were managed conservatively. After a median 15-month follow-up (range 6-48), 2 instances of cut-edge local recurrences were observed. This study shows that LT is technically feasible and safe. Further studies are needed for standardizing its use.

Middle hepatic vein reconstruction in adult right lobe living donor liver transplantation improves recipient survival

BackgroundThe efficacy and necessity of middle hepatic vein (MHV) reconstruction in adult-to-adult right lobe living donor liver transplantation (LDLT) remain controversial. The present study aimed to evaluate the survival beneficiary of MHV reconstructions in LDLT. MethodsWe compared the clinical outcomes of liver recipients with MHV reconstruction (n = 101) and without MHV reconstruction (n = 43) who underwent LDLT using right lobe grafts at our institution from January 2006 to May 2017. ResultsThe overall survival (OS) rate of recipients with MHV reconstruction was significantly higher than that of those without MHV reconstruction in liver transplantation (P = 0.022; 5-yr OS: 76.2% vs 58.1%). The survival of two segments (segments 5 and 8) hepatic vein reconstruction was better than that of the only one segment (segment 5 or segment 8) hepatic vein reconstruction (P = 0.034; 5-yr OS: 83.6% vs 67.4%). The survival of using two straight vascular reconstructions was better than that using Y-shaped vascular reconstruction in liver transplantation with two segments hepatic vein reconstruction (P = 0.020; 5-yr OS: 100% vs 75.0%). The multivariate analysis demonstrated that MHV tributary reconstructions were an independent beneficiary prognostic factor for OS (hazard ratio=0.519, 95% CI: 0.282–0.954, P = 0.035). Biliary complications were significantly increased in recipients with MHV reconstruction (28.7% vs 11.6%, P = 0.027). ConclusionsMHV reconstruction ensured excellent outflow drainage and favored recipient outcome. The MHV tributaries (segments 5 and 8) should be reconstructed as much as possible to enlarge the hepatic vein anastomosis and reduce congestion.

Middle Hepatic Vein (MHV)anatomy and its effect on the outcomes in Modified Right Lobe(MRL) grafts in Living donor Liver transplant(LDLT)

Introduction: Right lobe is the usual graft of choice in LDLT. The anatomy of the MHV(V5,V8) is an important determinant of the venous outflow of the anterior segment. Modified Right lobe grafts are commonly used grafts which usually require the reconstruction of the MHV. This Neo MHV is also prone to thrombosis which could be early or late in the post operative period. We reviewed the impact of MHV reconstruction and the effect of late MHV thrombosis on outcome after transplantation. Method: All the 287 patients who underwent MRL -LDLT between February 2017 to November 2018 were enrolled in the study.MHV anatomy was classified according to number of Segment 5 (V5) and Segment 8 (V8) vein present in the graft into, MHV type 1 (V5-1,V8-1,n=133 ), type 2 (V5-2,V8-1, n=47), type 3 (V5-1,V8-2, n=51), type 4 (MH2= V5-2,V8-2, n=25 ), type 5A (V5≥3,V8-any number,n=10 ), type 5B (V5-any number, V8≥3,n= 12), type 6 (X5= V5-0, V8- any number,n=4), type 7 (X8=V5-any number,V8-0,n=4 ). Statistical analysis was done using chi-square test for nominal variables and wilcoxon test for continuous variables. Result: There was no difference in any of the patient demographics or pre-op parameters. Cold ischemic time was significantly prolonged in MHV5A type (136.5 ±11.6) and least in Type 7 (75.7 ±18.4) F (7,278) = 4.2,p= 0.0002). All other intraoperative and postoperative parameters were comparable among the groups. MHV thrombosis was seen in 33.1% of all patients and they had a higher morbidity(51.57% vs 19.79%). Postoperatively, the incidence of MHV thrombosis was similar between the groups (p=0.56). Conclusion: None of the MHV types affected the outcome in our cohort. Thus, if proper outflow is given during benching all graft can function well irrespective number of veins. However, late MHV thrombosis has a significant effect on the morbidity and re admission rates.

Feasibility of aorta after endarterectomy as middle hepatic vein reconstruction in living donor liver transplantation

Introduction: Cryopreserved iliac vein, Polytetrafluoroethylene (PTFE) grafts, and cryopreserved aorta without endarterectomy have been used as middle hepatic vein (MHV) conduits for right liver graft in living donor liver transplantation, but each has advantages and disadvantages. In this study, we started to use aorta after endarterectomy (AoE) without any additional patches and checked patency after engraftment. Method: From January 2015 to June 2018, 111 cases of adult LDLT with modified right lobe grafts using aorta after endarterectomy were performed at Asan Medical Center. Retrospective analysis of patency in these recipients were carried out and compared with control group who received iliac vein (n=436) during the same study period. All vessels were stored and prepared as cryopreservation. Patency of reconstructed MHV was assessed by computed tomography (CT) which was routinely followed at every week during in-hospital stay and at 1, 3, 6, and 12 months after LDLT. Result: Clinically significant stenosis of MHV requiring interventional stenting was occurred in three patients (2.7%) in AoE group, not significantly different from seventeen patients (3.9%) in iliac vein group (p=0.778). Aorta after endarterectomy showed 3-month patency rate of 91.6% and 1-year patency rate of 63.5%. Mean patency time of MHV with AoE 21.4±1.9 months. When compared to iliac vein group, which demonstrated 3-month and 1-year patency rate as 90.0% and 37.3%, respectively, AoE proved superior patency outcome (p=0.001). Mean patency time of iliac vein was 19.6±2.2 months. Conclusion: In this study, AoE showed an acceptable outcome and even better patency compared to iliac vein. Clinically significant complication of stenosis or obstruction of MHV was fairly low. Larger diameter with well-matched thickness to MHV branches, not requiring iliac artery patch, is of great advantage in AoE as interposition graft.

Strategy for selective middle hepatic vein reconstruction in living donor liver transplantation using right lobe graft

Introduction: In living donor liver transplantation (LDLT) using right lobe(RL) graft, the standardized technique for procuring the graft does not include middle hepatic vein (MHV) trunk and is left to the donor side. This procedure may increase the congestion area in the graft after reperfusion. To overcome such difficulties, MHV reconstruction is widely being performed at the bench procedure. However in the basis of sufficient right hepatic vein territory(RHV) this procedure can be extravagant. The aim of this study is to verify the safety and feasibility of our policy for MHV reconstruction in LDLT using RL graft. Method: 153 LDLTs, using right hemiliver grafts were performed in a tertiary hospital from 2006 to 2016. Among them, 52 selected cases where MHV reconstruction was not performed were compared with 101 recipients who underwent LDLT using right lobe graft with MHV reconstruction. Both groups were compared regarding indications for reconstruction, short-term and long-term complications and operative details and outcomes Result: Two groups differed only in cold ischemic time (108.19 49.81 versus 146.37 58.74 minutes), preoperatively. Also, no statistical difference was seen, regarding short-term post-transplant outcomes and long-term overall and disease-free survival rates. After propensity score matching in both groups with and without MHV reconstruction to annihilate selection bias, two groups were comparable. Conclusion: We found that our selection criteria, whether to reconstruct MHV in LDLT, using right hemiliver graft is feasible and safe.

Laparoscopic right hepatectomy for fibrolamellar HCC

Background: We present the case of a 27-yo female presenting with asymptomatic 8 cm tumor in liver segment 7. Liver function and AFP were normal, no viral infection was detected. Percutaneous biopsy showed hepatocellular carcinoma. Methods: The patient was placed in a partial left lateral decubitus. We used three 12mm and two 5 mm trocars. The optical trocar was placed on the mid-axillary line. Abdominal cavity exploration confirmed a normal liver with no signs of cirrhosis. The tumor was only visible at laparoscopic ultrasound. Results: Right portal vein and right hepatic artery were selectively divided extra-parenchymally. The hepatectomy was performed without prior liver mobilization. The parenchymal transection was pursued along the middle hepatic vein with CUSA and Thunderbeat. Hemostasis and biliostasis were achieved with Hem-o-loks. Right hepatic duct was divided intraparenchymally. Once hepatic transection was completed and inferior vena cava exposed, accessory right hepatic veins were selectively controlled with Hem-o-loks. Right hepatic vein was isolated and divided using a linear stapler. The surgical specimen was extracted through a Pfannenstiel incision. Intermittent hepatic pedicle clamping was used for 27 minutes. Blood loss was 350 mL, no intra or post-operative blood transfusion was needed. Conclusion: Pathological report showed a well differentiated fibrolamellar HCC with a R0 resection developed on a normal liver. Post-operative course was uneventful. Patient was discharged on 6th postoperative day.

Anatomical segment 1, 4 resection with hanging tape and selective hepatic pedicle control

Summary Background: The caudate lobe of the liver is divided into three portions – The Spiegel lobe, the paracaval portion and caudate process. Caudate lobe resection is a difficult and challenging operation even with hepatobiliary surgeons. Caudate lobe resection may be performed in isolation or in combination with other portions of the liver. We reported in detail of the technique to resect segment 1 and 4 enbloc with liver hanging maneuver and selective hepatic pedicle control. Patient and result: female patient 31 year-old with HCC tumor located in paracaval portion of segment 1, invaded into middle hepatic vein. Liver function test is normal, HBsAg (+), AFP 224 ng/ml. We performed anatomical segment 1, 4 resection using two tapes for hanging to transect two margins and intermittently clamp the left and right hepatic pedicle respectively for bleeding control. Time operation 370 minutes, blood loss: 200 ml, no peri and postoperative complications and blood transfusion, hospital stay 11 days. For long outcome, the patient is now without recurrence for more than 3 years Conclusion: Using liver hanging tape and selective hepatic pedicle control make segment 1, 4 resection become more safe and easier. We should consider to change from isolation segment 1 resection to segment 1 and 4 resection for large size tumour or suspicious for invading middle hepatic vein.

Laparoscopic anatomical resection of segment 7 and segment 8 when right hepatic vein reconstruction was not necessary

Introduction: For a huge liver cancer in segment 7 and 8 with right hepatic vein (RHV) involvement, some patients with large inferior right hepatic veins (IRHV) can avoid complex vascular reconstruction after en bloc resection of segment 7 and 8 and RHV. In such a situation, safe laparoscopic surgery becomes possible. Method: This is a case report about a 9.7cm HCC in segment 7 and 8 with RHV involvement inside liver parenchyma. This patient had at least two large IRHV in computed tomography. In this operation, I transected the parenchyma along the middle hepatic vein first to create a midline plane. Then the right major Glisson's pedicle and S8 pedicle next to it were exposed in parenchyma from the opened liver midline. After S8 pedicle was transected, I advanced the dissection between segment 5 and 8 ( the transverse plane) and cut the tributaries and the dominant tract of RHV in this plane. The surface of a large IRHV was exposed in this transverse plane too. In another direction, I deepened the midline plane to expose IVC superior to the liver hilum. The root of RHV was ligated and cut from IVC. The root of the large IRHV on IVC was exposed in this midline plane between RHV and liver hilum. So, the large IRHV was preserved in both midline and transverse plane. I further advanced the parenchyma dissection to cross the surface of IRHV, and then deepened the dissection dorsally to separate the segment 7 & 6. Triangular and coronary ligaments were cut at last. Result: Hepatopetal portal flows were all preserved. Conclusion: In summary, this laparoscopic operation was performed using caudal to cranial (midline), medial to lateral ( between S5-S8), and ventral to dorsal (between S6-S7) approach. There was not any dissection between IVC and segment 1 right portion behind liver hilum.

Laparoscopic right hepatectomy for fibrolamellar HCC

Background: We present the case of a 27-yo female presenting with asymptomatic 8 cm tumor in liver segment 7. Liver function and AFP were normal, no viral infection was detected. Percutaneous biopsy showed hepatocellular carcinoma. Methods: The patient was placed in a partial left lateral decubitus. We used three 12mm and two 5 mm trocars. The optical trocar was placed on the mid-axillary line. Abdominal cavity exploration confirmed a normal liver with no signs of cirrhosis. The tumor was only visible at laparoscopic ultrasound. Results: Right portal vein and right hepatic artery were selectively divided extra-parenchymally. The hepatectomy was performed without prior liver mobilization. The parenchymal transection was pursued along the middle hepatic vein with CUSA and Thunderbeat. Hemostasis and biliostasis were achieved with Hem-o-loks. Right hepatic duct was divided intraparenchymally. Once hepatic transection was completed and inferior vena cava exposed, accessory right hepatic veins were selectively controlled with Hem-o-loks. Right hepatic vein was isolated and divided using a linear stapler. The surgical specimen was extracted through a Pfannenstiel incision. Intermittent hepatic pedicle clamping was used for 27 minutes. Blood loss was 350 mL, no intra or post-operative blood transfusion was needed. Conclusion: Pathological report showed a well differentiated fibrolamellar HCC with a R0 resection developed on a normal liver. Post-operative course was uneventful. Patient was discharged on 6th postoperative day.

Multimodal threedimensional resection planning for extended liver resection in a severe case of Echinococcus multilocularis

Background: Liver infections of Echinococcus multilocularis (EM) are rare in Germany. The optimal therapy of EM is surgical liver resection similar to malignant tumors. Methods: We describe the case of a 22-year-old patient who was diagnosed with increased liver enzymes during a routine checkup. Further radiologic diagnostics revealed an extended, cystic tumor of the liver with infiltration of left and middle hepatic vein and close contact to the right hepatic vein (RHV) and the inferior vena cava (VCI). Serologic tests confirmed the infection with EM. The patient was referred with the question of resectability after primary azole treatment. For a better preoperative evaluation, we performed a 3D reconstruction and resection planning. We combined this with 3D printing of the liver and the virtual display of the reconstruction in a virtual reality head mounted display (VR-HMD). For a curative and functional operation, resection of the VCI and reconstruction of the RHV seemed the only possibility. Results: We performed extended left hepatectomy with resection of segment 1, the extrahepatic bile duct, partial resection of the VCI and reconstruction with pericardial patch and end-to-end anastomosis of the segmentally resected RHV. The tumor was completely resected and histopathological analysis confirmed EM. Conclusion: In extended cases, the use of 3D reconstruction in combination with latest display methods such as VR-HMD or 3D printed models can improve surgical liver resection planning.

Multimodal threedimensional resection planning for extended liver resection in a severe case of Echinococcus multilocularis

Background: Liver infections of Echinococcus multilocularis (EM) are rare in Germany. The optimal therapy of EM is surgical liver resection similar to malignant tumors. Methods: We describe the case of a 22-year-old patient who was diagnosed with increased liver enzymes during a routine checkup. Further radiologic diagnostics revealed an extended, cystic tumor of the liver with infiltration of left and middle hepatic vein and close contact to the right hepatic vein (RHV) and the inferior vena cava (VCI). Serologic tests confirmed the infection with EM. The patient was referred with the question of resectability after primary azole treatment. For a better preoperative evaluation, we performed a 3D reconstruction and resection planning. We combined this with 3D printing of the liver and the virtual display of the reconstruction in a virtual reality head mounted display (VR-HMD). For a curative and functional operation, resection of the VCI and reconstruction of the RHV seemed the only possibility. Results: We performed extended left hepatectomy with resection of segment 1, the extrahepatic bile duct, partial resection of the VCI and reconstruction with pericardial patch and end-to-end anastomosis of the segmentally resected RHV. The tumor was completely resected and histopathological analysis confirmed EM. Conclusion: In extended cases, the use of 3D reconstruction in combination with latest display methods such as VR-HMD or 3D printed models can improve surgical liver resection planning.

Right and Ventral Margins of Caudate Lobe: 3D Reconstruction Analysis Using Synapse 3D

Introduction: As the hilar cholangiocarcinoma holds the possibility of metastasis via minute bile duct branches to the caudate lobe, total caudate lobectomy along with hepatic resection is necessary This study was undertaken whether we can figure out preoperatively the right and ventral margins of caudate lobe using Synapse 3D (Fujifilm), or not. Method: : 18 cadaveric liver specimens were dissected and by calculating the distance from the right side of inferior vena cava (IVC) and height from the hilar plate of a rightmost branch, we figured out the right margin and ventral margin of paracaval portion, respectively. 39 preoperative liver computed tomography images were obtained from donors and reconstructed by Synapse Vincent software. Result: In the respect of right margin, the mean length in Synapse Vincent group was 1.7cm, greater than 1.2cm of cadaveric dissection group meaningfully (P<0.05). Synapse Vincent showed 4 types of ventral margin. Type 1: the ventral margin of paracaval portion is restricted to the dome-like area between the middle hepatic vein (MHV) and right hepatic vein (RHV) insertion to the IVC (30 cases, 76.9%); Type 2: ventral margin extends beyond this dome-like area (7 cases, 17.9%); Type 3: ventral margin extends beyond the RHV (1 case, 2.6%); Type 4: ventral margin extends beyond both RHV and MHV-RHV dome-like area (1 case, 2.6%). Conclusion: Evaluating the anatomy of caudate lobe using Synapse 3D preoperatively would helpful for us to perform the anatomical resection of caudate lobe more precisely.

Radiofrequency-assisted liver partition for staged hepatectomy (R-ALPPS). A preliminary experience with a fully laparoscopic first stage approach

Background: ALLPS is still a matter of debate among HPB surgeons. The main criticism concerns its worrisome complication rate. To reduce morbidity, few technical variations have been described. We present 2 cases of modified ALLPS, being the liver parenchyma laparoscopically ablated with radiofrequency (R-ALLPS). Methods: Recently, we carried out 2 R-ALLPS. Stage I was performed laparoscopically, right portal vein was secured by locking clips and liver partition was obtained by radiofrequency. Stage II required open right trisectionectomy (ORT). Results: Case 1: 67 year-old male with a metachronous colorectal liver metastasis involving S-IV/V/VII/VIII and middle hepatic vein. FLR/ETLV and FLR/BW were 15% and 0.33. CT volumetry was performed on day 8 and 15 after stage I. FLR/ETLV increased to 24%, FLR/BW to 0.52. An ORT was carried out. The patient developed transient grade A liver failure. Case 2: 70 year-old HBV-cirrhotic male with a huge HCC involving S-IV/VIII/VII with a right anterior portal pedicle thrombosis. FLR/ETLV and FLR/BW were 27% and 0.44. CT volumetry after 10 days showed FLR/ETLV and FLR/BW of 39% and 0.63. He was discharged 9 days after ORT without complications. Both patients were discharged 3 days after stage I R-ALLPS without complications. Conclusion: We believe that R-ALLPS will play a major role in patients in need of a two-staged hepatectomy due to its safety and feasibility. Trials are needed to compare the difference with ALLPS in inducing FLR hypertrophy both in normal and cirrhotic livers.

Reliability and Variability of Hepatic Venous Pressure Gradient as a Surrogate of Portal Pressure Gradient: Insights from a Computational Model-Based Study

Hepatic venous pressure gradient (HVPG) measurement has been increasingly accepted as a useful means for indirectly measuring portal venous pressure in patients with portal hypertension (PHT) caused by chronic liver diseases. Despite the existence of numerous studies addressing the clinical utility of HVPG measurement, it is as yet unclear how the accuracy of measured HVPG as a surrogate of portal pressure gradient (PPG) is influenced by the pathological status of the hepatic circulation that not only changes with the progression of liver disease but also differs considerably among patients. In addition, it remains unclear whether HVPGs measured in different hepatic veins (HVs) are exchangeable, and if not, what factors determine inter-HV HVPG differences? In this context, we developed a stochastic computational model of the hepatic circulation, and performed a series of model-based numerical experiments to quantitatively investigate the respective/combined effects of various hepatic vascular properties on the accuracy of HVPG measurement. Major findings were: 1) a variation in presinusoidal portal vascular resistance significantly altered the difference between HVPG and PPG, whereas, an enhancement in portosystemic collateral flow (caused by growth of portosystemic collateral vessels or shunt intervention) tended to improve the accuracy of HVPG measurement; and 2) misdiagnosis of clinically significant PHT with HVPG was more likely to occur in the presence of high splanchnic vascular resistance combined with low presinusoidal and postsinusoidal portal vascular resistances. Stochastic numerical simulations of HVPG measurement in multiple HVs revealed that HVPGs measured in the right and middle HVs were basically exchangeable, whereas HVPGs measured in the left HV were relatively lower. The difference in measured HVPG between the middle/left and right HVs correlated positively with the proportion of blood flow rate through the middle/left HV, implying that the lower reading of left-HV HVPG measurement is due primarily to the lower blood flow rate through the HV. These findings may contribute as useful theoretical references for guiding data interpretation or choosing a proper HV for implementing catheterization in the clinical application of HVPG measurement.

Can we delineate preoperatively the right and ventral margins of caudate lobe of the liver?

PurposeComplete removal of the caudate lobe, which is sometimes necessary, is accomplished via isolated caudate lobectomy or hepatectomy that includes the caudate lobe. It is impossible, however, to confirm the right and ventral margins of the caudate lobe by preoperative imaging. This study was undertaken to determine whether we could identify the right and ventral margins of the caudate lobe preoperatively using Synapse 3D visualization software.MethodsNinety-four preoperative 3-dimensional (3D) computed tomographic images (1-mm slices) of the liver from candidate donors were examined. The images of the caudate lobe were subjected to a counter-staining method according to Synapse 3D to delineate their dimensions. We first examined whether the right margin of the caudate lobe exceeded the plane formed by the root of the right hepatic vein (RHV) and the right side of the inferior vena cava (IVC). Second, we determined whether the ventral margin of the caudate lobe exceeded the plane formed by the root of the middle hepatic vein (MHV) and the root of the RHV.ResultsFor the right margin, 17 cases (18%) exceeded the RHV-IVC plane by a mean of 10.2 mm (range, 2.4–27.2 mm). For the ventral margin, 28 cases (30%) exceeded the MHV-RHV plane by a mean of 17.4 mm (range, 1.2–49.1 mm).ConclusionEvaluating the anatomy of caudate lobe using Synapse 3D preoperatively could be helpful for more precise anatomical resection of the caudate lobe.

Extended right hepatectomy with anterior approach for infant hepatoblastoma

Summary Background: Hepatoblastoma is the most common liver malignancy in children with the incidence about one per million children. Radical resection plays a key role in the successful treatment of children with hepatoblastoma. However, the feasibility of radical resection is relatively difficult when the tumor is huge and invades hilar structure. This video showed early extended right hepatectomy for infant huge right lobe hepatoblastoma. Methods: Preoperative CT suggested the huge mass was found in right lobe of a 28-month-old female infant. The laboratory examination showed AFP was >1210ng/ml. Three-dimensional (3D) reconstruction showed the middle hepatic vein (MHV) was obviously compressed and pushed to the left lobe. The remaining liver volume after 3D simulated surgical excision was 39.7%. According to the accurate preoperative evaluation, this patient was successfully performed with extended right hepatectomy using anterior approach. Results: Operative time was 4 hours. Blood loss was 100ml. The tumor size was 12cm*10cm*7.5cm. The pathology suggested mixed epithelial mesenchymal hepatoblastoma. The patient obtained rapid recovery and was discharged 15 days after surgery. Conclusion: According to the accurate preoperative evaluation, radical resection instead of chemotherapy was technically safe and offers potential cure for hepatoblastoma.

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.