Portal Vein Occlusion Research Articles

TIPS for Adults Without Cirrhosis With Chronic Mesenteric Venous Thrombosis and EHPVO Refractory to Standard-of-Care Therapy.

Extrahepatic portal vein occlusion (EHPVO) from portal vein thrombosis is a rare condition associated with substantial morbidity and mortality. The purpose of this study is to investigate the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) for the treatment of chronic EHPVO, cavernomatosis, and mesenteric venous thrombosis in adults without cirrhosis who are refractory to standard-of-care therapy. Thirty-nine patients with chronic EHPVO received TIPS. Laboratory parameters and follow-up were assessed at 1, 3, 6, 12, and 24months, and every 6months thereafter. Two hepatologists adjudicated symptom improvement attributable to mesenteric thrombosis and EHPVO before/after TIPS. Kaplan-Meier was used to assess primary and overall TIPS patency, assessing procedural success. Adverse events, radiation exposure, hospital length-of-stay and patency were recorded. Cavernoma was present in 100%, with TIPS being successful in all cases using splenic, mesenteric, and transhepatic approaches. Symptom improvement was noted in 26 of 30 (87%) at 6-month follow-up. Twelve patients (31%) experienced TIPS thrombosis. There were no significant long-term laboratory adverse events or deaths. At 36months, freedom from primary TIPS thrombosis was 63%; following secondary interventions, overall patency was increased to 81%. TIPS in chronic, noncirrhotic EHPVO with cavernomas and mesenteric venous thrombosis is technically feasible and does not adversely affect liver function. Most patients demonstrate subjective and objective benefit from TIPS. Improvement in patency rates are needed with proper timing of adjuvant anticoagulation.

Effect of Portal Vein and Hepatic Artery Occlusion on Radiofrequency Ablation: Animal Experiment Comparing MR and Histology Measurements of the Ablation Zones.

This animal experimental study evaluated how hepatic artery and portal vein transient occlusion affects the ablation zone of hepatic radiofrequency ablation (RFA). Twenty-one rabbits were divided into three groups of seven each: (1) control, (2) hepatic artery occlusion, and (3) portal vein occlusion by a balloon catheter. For each rabbit, two or three RFA sessions were performed using an electrode needle. Ablation time, temperature around the tip of RFA needle at the end of RFA, ablation volume on fat-suppressed T1-weighted image in the hepatobiliary phase, and coagulative necrosis area on histopathology were measured and compared between the three groups using the Kruskal-Wallis paired Mann-Whitney U tests. In 43 RFA sessions (group 1, 15; group 2, 14; group 3, 14), mean tissue temperature in group 3 (77.0°C ± 7.7°C) was significantly higher compared to groups 1 (59.2°C ± 18.8°C; P = 0.010) and 2 (67.5°C ± 9.9°C; P = 0.010). In addition, mean ablation volume and coagulative necrosis in group 3 (2.10 ± 1.37 mm3 and 0.86 ± 0.28 mm2, respectively) were larger compared to groups 1 (0.84 ± 0.30 mm3; P < 0.001 and 0.55 ± 0.26 mm2; P = 0.020, respectively) and 2 (0.89 ± 0.59 mm3; P = 0.002 and 0.60 ± 0.22 mm2; P = 0.024, respectively). Portal vein occlusion potentially boosts tissue temperature, ablation volume, and area of histopathologically proven coagulative necrosis during hepatic RFA in the non-cirrhotic liver.

Sevoflurane alleviates hepatic ischaemia/reperfusion injury by up-regulating miR-96 and down-regulating FOXO4.

Hepatic ischaemia/reperfusion (I/R) injury represents an event characterized by anoxic cell death and an inflammatory response, that can limit the treatment efficacy of liver surgery. Ischaemic preconditioning agents such as sevoflurane (Sevo) have been highlighted to play protective roles in hepatic I/R injury. The current study aimed to investigate the molecular mechanism underlying the effects associated with Sevo in hepatic I/R injury. Initially, mouse hepatic I/R injury models were established via occlusion of the hepatic portal vein and subsequent reperfusion. The expression of forkhead box protein O4 (FOXO4) was detected using reverse transcription quantitative polymerase chain reaction and Western blot analysis from clinical liver tissue samples obtained from patients who had previously undergone liver transplantation, mouse I/R models and oxygen‐deprived hepatocytes. The morphology of the liver tissues was analysed using haematoxylin‐eosin (HE) staining, with apoptosis detected via TUNEL staining. Immunohistochemistry methods were employed to identify the FOXO4‐positive cells. Mice with knocked out FOXO4 (FOXO4‐KO mice) were subjected to I/R. In this study, we found FOXO4 was highly expressed following hepatic I/R injury. After treatment with Sevo, I/R modelled mice exhibited an alleviated degree of liver injury, fewer apoptotic cells and FOXO4‐positive cells. FOXO4 was a target gene of miR‐96. Knockdown of FOXO4 could alleviate hepatic I/R injury and decrease cell apoptosis. Taken together, the key observations of our study suggest that Sevo alleviates hepatic I/R injury by means of promoting the expression of miR‐96 while inhibiting FOXO4 expression. This study highlights the molecular mechanism mediated by Sevo in hepatic I/R injury.

N-acetylcysteine therapy for ischaemic hepatic failure: a successful antidote

Acute liver failure (ALF) is characterised by severe liver injury with the onset of coagulopathy (INR ≥1.5) and encephalopathy in the absence of pre-existing liver disease. It is associated with a high mortality rate of 10-57%, which is largely driven by multi-organ failure, sepsis and cardiac arrhythmia. Current management focuses on identifying and treating the aetiology, providing supportive care and monitoring liver function. The use of N-acetylcysteine (NAC) therapy is well-studied in the treatment of paracetamol toxicity but is controversial in other causes of ALF. We reported the first case of ischaemic hepatic failure secondary to prolonged portal vein occlusion treated with 72 hours of NAC therapy. Although ischaemic hepatopathy is a relatively uncommon cause of ALF, it is associated with a high mortality rate. The case highlights how early use of NAC therapy may improve hepatic serology biomarkers and should warrant consideration in ALF secondary to ischaemic hepatopathy.

The prognostic role of tumor-associated unilateral portal vein occlusion in perihilar cholangiocarcinoma

BackgroundWhile a certain degree of tumor infiltration of the portal vein is common in patients with perihilar cholangiocarcinoma (pCCA) scheduled for surgery, complete tumor-associated portal vein occlusion (PVO) is less frequently observed. Here, we analyzed the impact of PVO on perioperative and oncological outcomes in pCCA patients. MethodsBetween 2010 and 2019, 127 patients with pCCA underwent surgery in curative intent at our department of which 17.3% (22/127) presented with PVO. Extensive group comparisons were conducted and the association of cancer-specific (CSS) and disease-free survival (DFS) with PVO and other clinico-pathological characteristics were assessed using Cox regression models. ResultsPatients without PVO showed a median CSS of 65 months (3-year-CSS = 64%, 5-year-CSS = 53%) compared to 31 months (3-year-CSS = 43%, 5-year-CSS = 17%) in patients with PVO (p = 0.025 log rank). Patients with PVO did also display significant perioperative mortality (22.7%, 5/22) compared to patients without PVO (14.3%, 15/105, p = 0.323). Further, PVO (CSS: HR = 5.25, p = 0.001; DFS: HR = 5.53, p = 0.001) was identified as independent predictors of oncological outcome. ConclusionsPVO has been identified as an important prognostic marker playing a role in inferior oncological outcome in patients with pCCA. As PVO is also associated with notable perioperative mortality, surgical therapy should be considered carefully in pCCA patients.

Application of percutaneous transluminal sharp recanalization in transjugular intrahepatic portosystemic shunt for patients with chronic portal vein occlusion.

We aimed to evaluate the feasibility and safety of a modified technique for portal vein recanalization, percutaneous transluminal sharp recanalization (PTSR), when performing transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of chronic portal vein occlusion (CPVO) and portal hypertension. Nine consecutive patients with CPVO and portal hypertension had undergone TIPS and PTSR procedure after failing in conventional percutaneous catheterization from March 2017 to July 2019. Technical success rates, effectiveness, and complications were evaluated. Follow-up of patients' clinical outcomes and shunt patency were performed periodically. Primary and secondary shunt patency were analyzed by Kaplan-Meier method. The occluded portal veins were successfully recanalized after failing in conventional percutaneous catheterization, and TIPS procedures were completed in all 9 patients. Two patients suffered from procedure-related complications. A portosystemic pressure gradient <12 mmHg, or a percent reduction of 25% to 50% of baseline, was achieved in all 9 patients after TIPS. During the median follow-up period of 28 months (range, 9-36 months), 1 patient experienced recurrent ascites and the other 8 patients remained asymptomatic. The cumulative rates of primary and secondary shunt patency were 66.67% and 100%, respectively, at 2 years. As a supplementary method, PTSR is a feasible and safe method for portal vein recanalization when performing TIPS for patients with CPVO and portal hypertension.

Early Percutaneous Intervention in Pediatric Chronic Extrahepatic Portal Vein Occlusion Is Feasible And Safe

Early Percutaneous Intervention in Pediatric Chronic Extrahepatic Portal Vein Occlusion Is Feasible And Safe

A case of jejunal loop varices caused by portal vein occlusion after pancreatoduodenectomy for duodenal cancer successfully treated with interventional radiology via laparotomy

症例は76歳女性．2年前に他院で十二指腸癌に対して亜全胃温存膵頭十二指腸切除術を施行された．術後に急性膵炎を発症し，それに伴う門脈閉塞により側副血行路が発達した．その後，胆管空腸吻合部の挙上空腸静脈瘤からの出血を繰り返したため静脈瘤治療目的で当院紹介．小腸ダブルバルーン内視鏡検査では，肝管空腸吻合部に静脈瘤を認めたが，細い新生血管の拡張を主体としており内視鏡的治療は困難と判断した．また門脈閉塞のため経門脈的治療も困難と考え，全身麻酔下・開腹下に経回結腸静脈的静脈瘤塞栓術を施行した．術後のCTで挙上空腸静脈瘤の造影効果は消失し，塞栓物質の良好な停滞を認めた．本症例では術後再出血なく経過しているが，新たな側副血行路発達や再出血のリスクがあるため慎重な経過観察が必要である．

Influence of portal vein occlusion on portal flow and liver elasticity in an animal model.

Hepatic fibrosis causes an increase in liver stiffness, a parameter measured by elastography and widely used as a diagnosis method. The concomitant presence of portal vein thrombosis (PVT) implies a change in hepatic portal inflow that could also affect liver elasticity. The main objective of this study is to determine the extent to which the presence of portal occlusion can affect the mechanical properties of the liver and potentially lead to misdiagnosis of fibrosis and hepatic cirrhosis by elastography. Portal vein occlusion was generated by insertion and inflation of a balloon catheter in the portal vein of four swines. The portal flow parameters peak flow (PF) and peak velocity magnitude (PVM) and liver mechanical properties (shear modulus) were then investigated using 4D-flow MRI and MR elastography, respectively, for progressive obstructions of the portal vein. Experimental results indicate that the reduction of the intrahepatic venous blood flow (PF/PVM decreases of 29.3%/8.5%, 51.0%/32.3% and 83.3%/53.6%, respectively) measured with 50%, 80% and 100% obstruction of the portal vein section results in a decrease of liver stiffness by 0.8% ± 0.1%, 7.7% ± 0.4% and 12.3% ± 0.9%, respectively. While this vascular mechanism does not have sufficient influence on the elasticity of the liver to modify the diagnosis of severe fibrosis or cirrhosis (F4 METAVIR grade), it may be sufficient to attenuate the increase in stiffness due to moderate fibrosis (F2-F3 METAVIR grades) and consequently lead to false-negative diagnoses with elastography in the presence of PVT.

First two-stage robotic ALPPS in HCC patients with hepatic vein invasion: a step-by-step procedure from a clinical case

BackgroundThe associating liver partitioning and portal vein occlusion for staged hepatectomy (ALPPS) procedure is gaining interest because it brings hope to patients who cannot undergo radical surgical resection due to insufficient remnant liver volume. However, the indications and technical aspects of this procedure are still under debate. This report demonstrates the technical aspects of the first two-stage robotic ALPPS for HCC.Case presentationA 55-year-old man with type II portal vein variation was diagnosed with hepatocellular carcinoma. Preoperative 3D reconstruction of the liver based on CT showed a future liver remnant/standard liver volume (FLR/SLV) of 24.45%. The ALPPS procedure was performed using the da Vinci Si system. At the first stage of the operation, we removed the gallbladder and ligated the right anterior branch of the portal vein and the right posterior branch. Following blocking of the hepatic hilum, the liver parenchyma was removed 1 cm away from the right side of the falciform ligament in an incision manner from the top to the bottom and from shallow to deep. The second-stage operation was performed on the 12th postoperative day with a FLR/SLV of 45.13%. During this step, the right hemiliver plus left medial section was separated and removed. Postoperative pathology showed a negative margin. The operative times were 195 and 217 min, respectively. Estimated blood loss was 250 and 500 ml, respectively. There was no need for transfusion or hospitalization in intensive care. The patient was discharged on the 6th postoperative day. Recovery was uneventful after both stages, and the patient did not present any sign of liver failure. Elevation of liver enzymes was minimal. The patient had no evidence of the disease 14 months after the procedure.ConclusionsThe two-stage robotic ALPPS procedure is a safe and feasible technique for select patients with HCC.

Portal Vein Complications After Adult Living Donor Liver Transplantation: Time of Onset and Deformity Patterns Affect Long-Term Outcomes.

Portal vein complications (PVCs) after adult living donor liver transplantation (LDLT) are potentially lethal. We categorized PVCs by the time of onset (early versus late, <1month versus ≥1month, respectively) and deformity patterns (portal vein stenosis [PVS], portal vein thrombosis [PVT], and portal vein occlusion [PVO]) to establish optimal treatment strategies. Overall, 35/322 (10.9%) recipients developed PVCs between 2000 and 2019. Pretransplant PVT (odds ratio [OR], 15.20; 95% confidence interval [CI], 3.70-62.40; P<0.001) was the only independent risk factor for PVS. In contrast, male sex (OR, 5.57; 95% CI, 1.71-18.20; P=0.004), pretransplant PVT (OR, 4.79; 95% CI, 1.64-14.00; P=0.004), and splenectomy (OR, 3.24; 95% CI, 1.23-8.57; P=0.018) were independent risk factors for PVT. PVS was successfully treated with interventional radiology regardless of its time of onset. On the other hand, late PVT and PVO had significantly lower treatment success rates (2/15, 13%) compared with those that occurred in the early period (10/11, 91%) despite aggressive intervention (P<0.001). Deformity patterns had a significant impact on the 5-year cumulative incidence of graft loss as a result of PVC (PVO+Yerdel grades 2-4 PVT group [n=16], 41% versus PVS+Yerdel grade 1 PVT group [n=19], 0%; P=0.02). In conclusion, late grades 2 to 4 PVT and PVO are refractory to treatment and associated with poor prognoses, whereas PVS has a good prognosis regardless of time of onset. A tailored approach according to the time of onset and deformity patterns of PVC is essential.

Multimodal treatment strategies for colorectal liver metastases.

Colorectal cancer is the third most common cancer worldwide. Half of CRC patients develop liver metastases during the course of the disease, with a 5-year survival rate close to zero in the absence of therapy. Surgical resection remains the only possible curative option, and current guidelines recommend adjuvant chemotherapy, resulting in a 5-year survival rate exceeding 50%. Neoadjuvant systemic therapy is not indicated in cases with simple resection but should be offered to all patients with extensive bilobar disease. Personalised systemic treatment is essential to convert upfront non-resectable lesions to resectable ones. Anatomical resections, non-anatomical resections and two-stage hepatectomies can be performed though open or minimally invasive (laparoscopic or robotic) surgery. The extent of a hepatic resection is limited by the risk of postoperative liver failure due to a too small liver remnant, inflow or outflow obstruction or insufficient biliary drainage. About 75% of patients are diagnosed with non-resectable liver metastases not amenable to a standard upfront resection. In recent years, effective therapeutic approaches have revolutionised liver surgery and new strategies have enabled the conversion of primarily non-resectable metastatic disease for resection. These strategies include oncological and surgical therapies, as well as combinations of the two. From an oncological perspective, colorectal liver metastases&nbsp; may be treated by systemic chemotherapy or immunotherapy, or selective intra-hepatic arterial infusion chemotherapy, depending on the extent of the disease and the mutational status. In surgery, we often apply two-stage strategies using portal vein occlusion, such as portal vein embolisation or ligation, or complex two-stage hepatectomy such as associating liver partition and portal vein ligation for staged hepatectomy. Other additive tools to reach curative resection are tumour ablations (electroporation, microwave or radiofrequency). The role of stereotactic radiation of liver metastases is not yet well defined. Modern radiation techniques, including image guidance, breath hold and gating, were only introduced for a larger patient population in recent years. Therefore, prospective studies with larger patient cohorts are still pending. Over the last decade, liver transplantation has gained increasing attention in selective cases of non-resectable colorectal liver metastases, with promising cohort studies, but definitive recommendations must await the results of ongoing randomised controlled trials. The optimal treatment of patients with colorectal liver metastases requires the timely association of various strategies, and all cases must be discussed at multidisciplinary team conferences. While colorectal liver metastases was a uniformly lethal condition a few decades ago, it has become amenable to curative therapies, with excellent quality of life in many scenarios. This review reports on up-to-date treatment modalities and their combinations in the treatment algorithm of colorectal liver metastases. &nbsp; &nbsp.

Cell death induction (extrinsic versus intrinsic apoptotic pathway) by intestinal ischemia-reperfusion injury in rats is time-depended.

We investigate the mechanism of intestinal cell apoptosis and its relation to the time of reperfusion in a rat model of intestinal ischemia-reperfusion (IR). Rats were divided into 4 groups: Sham-24 and Sham-48 rats underwent laparotomy without an intentional ischemic intervention and were sacrificed 24 or 48h hours later; IR-24 and IR-48 rats underwent occlusion of SMA and portal vein for 20min followed by 24 or 48h of reperfusion, respectively. Park's injury score, cell proliferation and apoptosis were determined at sacrifice. Proliferation and apoptosis-related gene and protein expression were determined using Real-Time PCR, Western Blot and Immunohistochemistry. IR-24 rats demonstrated a strong increase in cell apoptosis along with an elevated Bax and decreased Bcl-2 expression and a decrease in cell proliferation (vs Sham-24). IR-48 group showed an increase in cell proliferation and a decrease in cell apoptosis compared to IR-24 animals. IR-48 rats demonstrated an increase in apoptotic rate that was accompanied by greater TNF-α mRNA, Fas mRNA and FasL mRNA compared to Sham-48 animals. While cell apoptosis in IR-24 rats is regulated mainly by intrinsic apoptotic pathway, 48h followed ischemia extrinsic apoptotic pathway is responsible for pro-apoptotic effects of IR injury.

Early venous intervention during resection of pancreatic neoplasms with SMV/PV occlusions

Introduction: Pancreatic neoplasms with superior mesenteric and/or portal vein (SMV/PV) occlusions present the significant (substantial) surgical challenge of mesenteric hypertension. We present a series of patients who underwent pancreas resection with complete SMV/PV occlusion. Methods: A retrospective review of patients diagnosed with pancreas tumors with concomitant SMV/PV occlusions, and underwent pancreas resection with vascular intervention in the form of portosystemic shunting, resection and thrombectomy was performed. Demographics, perioperative characteristics and outcomes were reviewed. Results: Eleven patients, with a median age of 56, underwent pancreas resection with vascular intervention for pancreas neoplasms with SMV/PV occlusion. The median follow-up was 26 months. Six patients were treated for pancreatic neuroendocrine tumor, two for pancreatic adenocarcinoma, two for solid pseudopapillary tumor and one for a cystic lesion believed to be a large cystic tumor (final pathology revealed sclerosing pancreatitis). Two underwent pancreaticoduodenectomy, 6 left sub- or near total pancreatectomy, and 3 total pancreatectomy. Six underwent early mesocaval shunting, with SMV/PV reconstruction following pancreas resection. Four underwent in-line SMV/PV reconstruction with conduit prior to the bulk pancreatic dissection/reconstruction, and one underwent early tumor thrombectomy. The internal jugular vein was graft of choice in nine patients. Median hospital length of stay was 11 days. Five patients developed complications with Clavien-Dindo grade >III. Six patients required readmission. There were no 90-day mortalities. Conclusion: Despite the technical challenges that arise from the sequelae of SMV/PV occlusion, early mesenteric decompression via mesocaval shunting or immediate in-line SMV/PV reconstruction with graft allows pancreatectomy in the face of SMV/PV occlusion to be performed safely.

Clinical features and prognosis of primary myelofibrosis with hepatic vascular disease and/or portal hypertension

Objective To investigate the clinical features, liver histopathological features, treatment, and prognosis of primary myelofibrosis (PMF)-associated hepatic vascular disease and portal hypertension. Methods A retrospective analysis was performed for the clinical and pathological features of 68 patients who were diagnosed with PMF in 960 Hospital of the PLA Joint Logistics Support Force and Xijing Hospital of Digestive Diseases, Air Force Medical University, from July 2010 to December 2020, among whom 22 patients had hepatic vascular disease/portal hypertension as the main manifestation. The patients were divided into two groups according to the presence or absence of thrombosis, and treatment and prognosis were summarized. The Kaplan-Meier method was used to plot survival curves, and the log-rank test was used to compare long-term survival rate between the two groups. Results Among the 68 patients with PMF, 22 had hepatic vascular disease and/or portal hypertension, resulting in a prevalence rate of 32.35%, and among these 22 patients, 13 (59.1%) had extrahepatic portal vein occlusion, 1 (4.5%) had Budd-Chiari syndrome, and 8 (36.4%) had portal hypertension. Biopsy was performed for 7 patients, and pathological results showed extramedullary hematopoiesis in the liver and varying degrees of infiltration of lymphocytes, plasma cells, and eosinophils at the lobular and portal areas, but the lobular structure was normal. A total of 7 patients died during follow-up, among whom 5 died of complications associated with thrombosis or portal hypertension. The overall median survival time was 57.99 months for all patients; the median survival time was 45.33 months in patients with thrombosis and 64.00 months in patients without thrombosis, and although there was no significant difference between the two groups (χ2=3.035, P=0.081), the non-thrombosis group tended to have better survival and prognosis than the thrombosis group. Conclusion The possibility of PMF as the primary disease should be considered for patients with hepatic vascular disease and portal hypertension. Patients with PMF should be screened for hepatic vascular disease, and early intervention should be given. The patients without thrombosis tend to have better survival and prognosis than those with thrombosis.

Portal vein reconstruction using side-to-side unification technique for infant-to-infant deceased donor whole liver transplantation.

Backgrounds/AimsInfant-to-infant whole liver transplantation (I2I-WLT) has been rarely performed in Korea. We analyze clinical sequences of our 7 cases of I2I-WLT and present evolution of surgical techniques to prevent PV stenosis.MethodsA total of 7 cases of I2I-WLT were performed at our institution during last 13 years, which represented 0.1% of our LT volume. Patient perioperative profiles and clinical sequences were analyzed with focusing on portal vein (PV) complications.ResultsDonor ages were 6-17 months and graft weights were 140-525 g. Recipient ages were 7-16 months and body weights were 6-10.1 kg and Primary diagnoses were biliary atresia in 6 and progressive familial intrahepatic cholestasis in 1. The first case underwent PV stenting 2 months after I2I-WLT, and underwent retransplantation 6 years later. The second case underwent intraoperative PV stenting, but died 32 days later. The third case underwent repeated PV dilatation. The fourth, fifth and seventh cases experienced no surgical complications, and PV reconstruction was performed using a side-to-side unification venoplasty technique. The sixth case had poor development of the PV system, so customized PV venoplasty was performed, but PV occlusion requiring PV stenting occurred. Early retransplantation was performed, but scanty PV flow was detected despite no obvious PV stenosis, resulting in graft failure. Serious PV complications developed in 4, but none experienced after adoption of side-to-side unification venoplasty.ConclusionsAs PV size in infant donors and recipients is very small, PV reconstruction in I2I-WLT requires specialized surgical techniques of side-to-side unification venoplasty.

Identification Of Liver Fluke Eggs In Bile Duct Brush Cytology In An 82 Year Old Man With A Hepatic Mass: Report Of A Case

Abstract Introduction/Objective Clonorchis sinensis infects the liver, gallbladder, and bile ducts in humans. It is acquired via consumption of raw/undercooked fish, crabs, or crayfish in endemic areas. Though majority are asymptomatic, long lasting infections may cause severe disease. Without treatment, human infections may persist for the parasite lifespan (25–30 years). Diagnosis in cytology is challenging with a potentially acellular sample with miniscule eggs that can be overlooked as an artifact. Here we reported a rare case of liver fluke eggs diagnosed in bile duct brush cytology. Methods An 82 year old man who emigrated from China 20 years prior presented to the hospital with worsening jaundice for 2 weeks. Abdominal CT revealed a 4.8 x 2.9 cm central right hepatic lobe mass extending to the hilum, obstructing the bile ducts, resulting in severe intrahepatic ductal dilatation and stricture and focal occlusion of the right anterior portal vein. His CBC revealed eosinophilia. Bile duct brushing was submitted for cytology. Results ThinPrep and cell block showed oval-shaped parasite eggs measuring 10-24 µm. There was no other cellular matter. Eggs had a convex operculum resting on “shoulders” at the smaller end of the egg. At the opposite (abopercular) end, a small knob or hook-like protrusion was often visible. Wet mounts revealed visible miracidium inside the eggs. These findings were compatible with liver fluke eggs. Conclusion Cytologic microbiologic features of fluke eggs confirmed the findings. The most important features are the shape and size of the eggs; The seated operculum with its prominent “shoulders”, a small knob at the abopercular end, which can distinguish them from acellular artifact or a human cell. The cytologic and microbiologic features combined with the travel history and clinical presentation can aid in achieving the diagnosis.

S2607 A Unique Case of Thrombopoietin Receptor Agonists-Induced Portal Vein Thrombosis

INTRODUCTION: It is well known that patients with cirrhosis develop thrombocytopenia secondary to their portal hypertension. Many patients with chronic liver disease induced thrombocytopenia (CLD-T) experience significant acute blood loss due to esophageal variceal bleeding, epistaxis, gingival bleeding, and other adverse bleeding events. Recently, thrombopoietin receptor agonists (TPORA), such as avatrombopag, have come into favor to use periprocedurally for patients with CLD-T. Here, we present a unique case of TPORA induced portal vein thrombosis (PVT). CASE DESCRIPTION/METHODS: A 64-year-old female with a history of decompensated alcohol liver cirrhosis, whose last drink was in December of 2016, presented to the hepatology clinic for routine follow up. One month prior, she was given avatrombopag prior to dental extractions with partial dentures for her thrombocytopenia since during her last dental procedures she had major bleeding requiring hospitalization with blood transfusions. Prior to her procedure her platelets were 81, INR 1.2 and comprehensive metabolic panel normal besides a bilirubin of 1.5. The patient was given avatrombopag 40 mg daily for five days prior to her dental procedure. There was no major bleeding or adverse events. As part of her routine follow up she had an abdominal ultrasound for hepatocellular carcinoma surveillance where she was found to have a new main PVT, compared to her prior abdominal ultrasound done nine months prior. An MRI performed to confirm this showed occlusion of the left portal vein and diminutive main and right portal veins without thrombus. She was started on direct oral anticoagulation with resolution of her left portal vein thrombus on repeat imaging six months later. DISCUSSION: Consideration of thrombosis after use of TPORA such as avatrombopag, especially with platelet counts above 50, is important as this can cause new onset ascites and preclude individuals from liver transplantation. Several peer reviewed articles suggest that there is no increase rate in PVT in patients with CLD-T who use these agents periprocedurally.1,2,3,4,5 Yet, there is a prescribing warning for these medications that PVT can occur in 2% of patients with CLD-T receiving these drugs.6 A high suspicion after utilization of these medications with symptoms such as abdominal pain, new ascites, or other clinical manifestations should warrant clinicians to rule out PVT after use of these medications and start appropriate anticoagulation as able.

S2491 Small Duct Primary Sclerosing Cholangitis: An Atypical Presentation

INTRODUCTION: Primary sclerosing cholangitis (PSC) is a chronic progressive disease of the liver and biliary tract causing cholestasis, fibrosis, and strictures in intra and extrahepatic bile ducts. Patients are often asymptomatic, but as the disease progress, complications occur and include: recurrent cholangitis, portal hypertension, cirrhosis of the biliary tract, end-stage liver disease, and hepatobiliary malignancies, namely cholangiocarcinoma. Within the entity of PSC, there are two distinct variants: small duct PSC and large duct PSC. Here we present a case of small duct PSC presenting atypically with chronic portal vein thrombosis and a hilar mass. CASE DESCRIPTION/METHODS: 36- year old Pakistani man presented with right upper quadrant abdominal pain, jaundice, and fever. He reported a history of chronic abdominal pain and recurrent jaundice, as well as chronic portal vein thrombosis (PVT) since childhood. The patient was recently hospitalized in another institute for the same complaint for which he had a Computerized tomography (CT) of the abdomen that revealed marked splenomegaly together with evidence of portal vein occlusion with cavernous transformation as well as Intrahepatic biliary ductal dilation with a transition in the common hepatic duct and a hilar mass. The patient underwent endoscopic retrograde cholangiography (ERC) with biopsies obtained through cholangioscopy that were unremarkable. Liver biopsy showed findings consistent with primary sclerosing cholangitis with acute cholangitis and changes secondary to portal vein thrombosis. DISCUSSION: Primary sclerosing cholangitis is a chronic, incurable disease in which the liver and biliary tract become fibrosed, and strictures form in the intra and extrahepatic biliary ducts causing obstruction, portal hypertension, and eventual liver cirrhosis necessitating a liver transplant. MRC is the most frequently used diagnostic tool due to its high specificity and sensitivity. Although ERC is more sensitive, there are added risks and complications (i.e., pancreatitis and bacterial cholangitis) with this technique. When ERC is performed, findings typically include multifocal short annular strictures, which create a "beaded" pattern. Although most patients are shown to have intra and extrahepatic bile duct involvement, a small subset presents with only intra or extrahepatic bile duct involvement. Only a few small duct PSC cases were reported in the literature, and it rarely presents with an inflammatory mass as well as PVT, as in our case.Figure 1.: Portal fibrosis with mild to focal moderate ductular reaction, accompanied by neutrophils.Figure 2.: A Coronal contrast-enhanced CT image through the abdomen shows intrahepatic beading (red arrow) with intervening sites of alternating strictures, mildly dilated, and normal ducts. There is compensatory hypertrophy of the right lobe and caudate lobe of the liver (green arrows).Figure 3.: A Coronal MRCP Image through the liver shows multiple multifocal diffuse intrahepatic and extrahepatic strictures (red arrows) and severely dilated intrahepatic ducts (blue arrows), with a branching-tree appearance. There is extrahepatic beading with intervening sites of a normal, narrow stricture (long red arrow), and mildly dilated extrahepatic ducts (yellow arrow).

Use of primary surgical drains in synchronous resection for colorectal liver metastases: a NSQIP analysis of current practice paradigm.

There are no studies examining the use of subhepatic drains after simultaneous resection of synchronous colorectal liver metastases (sCRLM). This study aimed to (1) describe the current practices regarding primary drain placement, (2) evaluate drain efficacy in mitigating postoperative complications, and (3) determine impact of drain maintenance duration on patient outcomes. The ACS-NSQIP targeted data from 2014 to 2017 were analyzed. Propensity score of surgical drain versus no drain cohorts was performed. Main study outcomes were mortality, major morbidity, organ/space surgical site infection (SSI), secondary drain/aspiration procedure, and any septic events. Additional univariate/multivariate logistic analyses were performed to identify associations with drain placement and duration. Major hepatectomy was defined as formal right hepatectomy and any trisectionectomy. 584 combined liver and colorectal resection (CRR) cases were identified. Open partial hepatectomy with colectomy was the most common procedure (70%, n = 407). Nearly 40% of patients received surgical drains (n = 226). Major hepatectomy, lower serum albumin, and no intraoperative portal vein occlusion (Pringle maneuver) were significantly associated with drain placement (p < 0.05). In the matched cohort (n = 190 in each arm), patients with surgical drains experienced higher rates of major morbidity (30% vs 12%), organ/space SSI (16% vs 6%), postoperative drain/aspiration procedures (9% vs 3%), and sepsis/septic shock (12% vs 4%) (all p < 0.05). Patients with severely prolonged drain removal, defined as after postoperative day 13 (POD13), had higher risk of postoperative morbidity compared to those with earlier drain removal (p < 0.01). 30-day mortality rate was not significantly different between the two groups. Primary surgical drains were placed in a substantial percentage of patients undergoing combined resection for sCRLM. This case-matched analysis suggested that surgical drains are associated with an increase in postoperative morbidity. Postoperative drain maintenance past 13 days is associated with worse outcomes compared to earlier removal.