Portal Reconstruction Research Articles

Romanesque portal from Olbin - 3D digital recomposition

The aim of the study was to define the original shape of the 12th-century portal built into the wall of the Church of St. Mary Magdalene in Wrocław. The portal is a remnant of a priceless monument of Romanesque architecture in the region - the Benedictine Abbey in Olbin, which was demolished by order of the city council in 1529. The portal was subjected to very extensive alterations and conservation treatments, which strongly affected its form. Previous studies have linked two other stonework pieces to it - the tympanum and the archivolt, which were probably separated from the portal in 1529. An attempt at reconstruction was made using digital photogrammetric 3D models of the portal, tympanum and archivolt. The juxtaposition of these in 3D software, cutting the model into separate stonework elements, changing its layout and modelling of non-preserved parts allowed the development of three proposals for 3D the reconstruction of the 12th-century portal.

Blood flow reconstruction in portal vein anatomical variations in right lobe living donor liver transplantation

Background. Adequate restoration of blood flow through the portal vein in the graft is only possible with a clear understanding of its anatomy in the donor.The aim was to describe new and extend current data on the portal vein anatomy in a donor of the right liver lobe, to describe variants and formulate principles of portal reconstruction in right lobe living donor liver transplantation.Material and methods. 306 living donor liver transplantations were performed from 2009 to 2021 in the State Research Center – Burnasyan Federal Medical Biophysical Center of Federal Medical Biological Agency. The vascular anatomy of 518 potential donors was analyzed. Portal vein variants of the anatomy of right lobe graft were assessed.Results. Nine types and 3 subtypes of portal vein branching were evaluated. A, B, C, D, E types match the types described earlier in Nakamura classification. Subtypes B1, B2 и D1 are specifications of types B and D. Types F, G, H, I have been described additionally. The incidence of types and subtypes where reconstruction was made: type A (82%), B (4.6%), B1 (3.9%), B2 (1.3%), C (3.9%), D (3.9%). The incidence of E, G, H, I types among 518 potential donors was 0.4%, 0.6%, 0.2%, 0.4%, respectively. The recipient portal vein complications were detected in 12 cases (3.9%), where 3(25%) were Class 3b according to Clavien-Dindo and 9(75%) of Clavien-Dindo Class 2. There were no correlations between portal vein complications and the method of portal vein reconstruction. (p<0.05). No complications occurred with portal vein in donors.Conclusion. The existing classification of right liver graft portal vein has been updated and detailed. A certain way of reconstruction has been proposed for each portal vein type. Anatomical types in which donation and transplantation are contraindicated have been specified.

Insights into varicella-zoster virus assembly from the B- and C-capsid at near-atomic resolution structures

Varicella-zoster is a highly communicable virus that can be transmitted through the airborne route. About one quarter of people are infected with this virus. Previous studies have described the structure of A-capsid and a blurred reconstruction of the C-capsid with icosahedral symmetry. In this study, we have determined the more precise detailed structures of the varicella-zoster virus (VZV) B- and C-capsid in icosahedral symmetry using a combination of block-based reconstruction and symmetry relaxation strategies. In addition, we are reporting structural details of the portal vertex reconstructions in five-fold symmetry and portal reconstructions in twelve-fold symmetry. The structures unveil the basis for the high thermal stability of the VZV capsid. The conformational flexibility of structural elements of the capsid plays a role in the assembly of the capsid and drives processes critical for the viral life cycle. The results of the study open up new avenues for the development of drugs against a highly prevalent and contagious pathogen.

Early portal vein thrombosis after hepatectomy for perihilar cholangiocarcinoma: Incidence, risk factors, and management

To study the incidence, risk factors and management of portal vein thrombosis (PVT) after hepatectomy for perihilar cholangiocarcinoma (PHCC). Single-center retrospective analysis of 86 consecutive patients who underwent major hepatectomy for PHCC, between 2012 and 2019, with comparison of the characteristics of the groups with (PVT+) and without (PVT-) postoperative portal vein thrombosis. Seven patients (8%) presented with PVT diagnosed during the first postoperative week. Preoperative portal embolization had been performed in 71% of patients in the PVT+ group versus 34% in the PVT- group (P=0.1). Portal reconstruction was performed in 100% and 38% of PVT+ and PVT- patients, respectively (P=0.002). In view of the gravity of the clinical and/or biochemical picture, five (71%) patients underwent urgent re-operation with portal thrombectomy, one of whom died early (hemorrhagic shock after surgical treatment of PVT). Two patients had exclusively medical treatment. Complete recanalization of the portal vein was achieved in the short and medium term in the six survivors. After a mean follow-up of 21 months, there was no statistically significant difference in overall survival between the two groups. Post-hepatectomy PVT for PHCC is a not-infrequent and potentially lethal event. Rapid management, adapted to the extension of the thrombus and the severity of the thrombosis (hepatic function, signs of portal hypertension) makes it possible to limit the impact on postoperative mortality. We did not identify any modifiable risk factor. However, when it is oncologically and anatomically feasible, left±extended hepatectomy (without portal embolization) may be less risky than extended right hepatectomy, and portal vein resection should only be performed if there is strong suspicion of tumor invasion.

Reconstructing the portal vein through a posterior pancreatic tunnel: New choice for portal vein thrombosis during liver transplantation.

Thrombectomy and anatomical anastomosis (TAA) has long been considered the optimal approach to portal vein thrombosis (PVT) in liver transplantation (LT). However, TAA and the current approach for non-physiological portal reconstructions are associated with a higher rate of complications and mortality in some cases. To describe a new choice for reconstructing the portal vein through a posterior pancreatic tunnel (RPVPPT) to address cases of unresectable PVT. Between August 2019 and August 2021, 245 adult LTs were performed. Forty-five (18.4%) patients were confirmed to have PVT before surgery, among which seven underwent PV reconstruction via the RPVPPT approach. We retrospectively analyzed the surgical procedure and postoperative complications of these seven recipients that underwent PV reconstruction due to PVT. During the procedure, PVT was found in all the seven cases with significant adhesion to the vascular wall and could not be dissected. The portal vein proximal to the superior mesenteric vein was damaged in one case when attempting thrombolectomy, resulting in massive bleeding. LT was successfully performed in all patients with a mean duration of 585 min (range 491-756 min) and mean intraoperative blood loss of 800 mL (range 500-3000 mL). Postoperative complications consisted of chylous leakage (n = 3), insufficient portal venous flow to the graft (n = 1), intra-abdominal hemorrhage (n = 1), pulmonary infection (n = 1), and perioperative death (n = 1). The remaining six patients survived at 12-17 mo follow-up. The RPVPPT technique might be a safe and effective surgical procedure during LT for complex PVT. However, follow-up studies with large samples are still warranted due to the relatively small number of cases.

Nonsplenorenal Spontaneous Portosystemic Shunts in Liver Transplant Attitude and Outcomes: A Single-Center Series

Management of nonsplenorenal spontaneous portosystemic shunts (NSRSPSS) in liver transplant (LT) is controversial. Reports on the influence of its ligation suggest improvements in morbidity and survival. Retrospective study of a single-center series. The objective was to analyze the outcomes and post-LT survival after the closure of NSRSPSS. Between January 2005 and April 2021 a total of 23 patients with NSRSPSS underwent LT. The shunt was superior mesenteric vein-vena cava in 12 (52.2%), inferior mesenteric vein-vena cava in 6 (26.1%), through the left gastric vein in 4 (17.4%), and portocava in 1 (4.3%). Seven patients presented portal vein thrombosis, with thrombectomy being performed in 5. Moreover, 21 patients had portoportal anastomosis, 1 patient required portal reconstruction at the splenomesenteric confluence, and 1 had a coronary-portal anastomosis. The NSRSPSS was closed in 22 cases (95.7%). The mean (SD) portal flow before and after the closure of NSRSPSS was 1395 (572) mL/min and 1773 (583) mL/min (104.4 [47.9] mL/min/100 g and 127.9 [4.9] mL/min/100 g, respectively). Six patients (26.1%) presented primary graft dysfunction, 13 (56.5%) acute kidney injury, and 9 (39%) ascites. Three arterial stenoses (13%), 2 biliary stenoses (8.6%), and 1 intrahepatic portal thrombosis (4.3%) occurred. Median intensive care unit and hospital stay was 5 days (range, 3-8 days) and 15 days (range, 13-21 days). After a mean follow-up of 5.18 (3.2) years, all patients except 1 are alive. The closure of the NSRSPSS during LT can optimize portal flow, with potential influence in morbidity and survival rates.

Use of the Rex Shunt in Adults for Left Portal Vein Reconstruction

Introduction: To report an expanded use of Rex shunt (RS) for portal vein (PV) reconstruction in adults. The RS was developed to treat children with extrahepatic portal vein thrombosis (EHPVT) following liver transplantation or with a healthy liver. Method: An RS was used to achieve portal reperfusion during various liver surgeries when a standard porto-left portal anastomosis was deemed technically unsatisfactory or incompatible with right-sided R0 onco-surgical resection. Results: This study involved 5 male and 6 female patients (median age, 59 years). The RS was feasible in all 11 consecutive attempts, including hepatectomy for malignancy combined with PV resection in 9 (82%) patients where the left lobe or liver was left in place.A reinforced Gore-Tex graft was used in 10 patients and an allogenic iliac vein was used in 1 patient.Within 90 days, 1 patient with a patent shunt had died of pulmonary embolism, and 1 patient had died of diffuse PVT with multiple organ failure.In 4 patients, postoperative complications included ascites, biliary fistula, and shunt thrombosis.At a median 13.5-month follow-up, 7 patients with a patent shunt remained alive. A systematic review of RS in adults identified 11 cases in 8 reports performed mainly for EHPVT (9 patients). In 2 patients, postoperative complications involved transient ascites and abdominal bleeding requiring surgical revision.Postoperative mortality was nil. The median long-term patency rate was 24 months. Conclusion: Use of the RS in adults is straightforward, offering a supplementary technical option for left portal reconstruction in patients with malignancy or EHPVT,provided the downstream portal system is normal.

Therapeutic anticoagulation after liver transplantation is not useful among patients with pre‐transplant Yerdel‐grade I/II portal vein thrombosis: A two‐center retrospective study

BackgroundPortal vein thrombosis (PVT) is no longer a contraindication for liver transplantation (LT). While therapeutic anticoagulation (tAC) is recommended during the waiting period, there is no evidence for its usefulness in the prevention of PVT recurrence after LT. ObjectivesThe aim of our study was to evaluate the role of tAC post‐LT in the prevention of PVT recurrence. Patients/methodsAll adult LTs performed in two high‐volume centers between 2003 and 2018 were retrospectively analysed. Only patients with PVT classified as Yerdel grade I or II and with standard portal reconstruction were included. PVT recurrence and tAC‐associated morbidity within 1 year were compared between patients receiving tAC or not. ResultsDuring the study period, of 2612 LTs performed, 235 (9%) patients with PVT were included; 113 patients (48.1%) received post‐LT tAC (tAC group) while 122 (51.9%) did not (non‐tAC group). The incidence of bleeding events was significantly higher in the tAC group (26 [23%] vs. 5 [4.1%], P < .01) and the initial hospitalization duration was longer (21 vs. 17.5 days, P < .01). Within the first year, PVT recurrence was observed for 9 (3.8%) patients without any difference between the tAC and non‐tAC groups (6 [5.1%] vs. 3 [2.5%], P = .39). The only identified risk factor for PVT recurrence was the recipients’ age (odds ratio= 0.94, P = .03). Graft (P = .11) and patient (P = .44) survival were similar between the two groups. ConclusionTherapeutic anticoagulation is not necessary in the prevention of grade I/II PVT recurrence and is associated with higher morbidity and longer hospital stay.

Liver transplantation in patients with non‐neoplastic portal vein thrombosis: 20 years of experience in a single center

The Yerdel classification is widely used for describing the severity of portal vein thrombosis (PVT) in liver transplant (LT) candidates, but might not accurately predict transplant outcome. We retrospectively analyzed data regarding 97 adult patients with PVT who underwent LT, investigating whether the complexity of portal reconstruction could better correlate with transplant outcome than the site and extent of the thrombosis. 79/97 (80%) patients underwent thrombectomy and anatomical anastomosis (TAA), 18/97 (20%) patients underwent non-anatomical physiological reconstructions (non-TAA). PVT Yerdel grade was 1-2 in 72/97 (74%) patients, and 3-4 in 25/97 (26%) patients. Univariate analysis revealed higher 30-day mortality, 90-day mortality, 1-year mortality, and a higher rate of severe early complications in the non-TAA group than in the TAA group (p = .018, .001, .014, .009, respectively). In the model adjusted for PVT Yerdel grade, non-TAA remained independently associated with higher 30-day, 90-day, and 1-year mortality (p = .021, .007, and .015, respectively). The portal vein re-thrombosis and overall patient and graft survival rates were similar. In our experience, the complexity of portal reconstruction better correlated with transplant outcome than the Yerdel classification, which did not even appear to be a reliable predictor of the surgical complexity and technique.

A case from the future of HPB surgical oncology: resection of biliary tract cancer after immunotherapy.

Biliary tract cancers (BTCs) have limited response to systemic therapy and poor prognosis. Immunotherapy in BTCs has been investigated in recent years. Here, we report a case of locally advanced, unresectable gallbladder adenocarcinoma that progressed on chemotherapy. The patient was then treated with ipilimumab and nivolumab, which resulted in tumor shrinkage and autoimmune hepatitis, but established technical resectability. He underwent complete resection through extended right hepatectomy with en bloc cholecystectomy bile duct resection, hepatic and portal lymphadenectomy and Roux-Y hepaticojejunostomy reconstruction. The final pathology revealed a pathologic complete response. The scope of operative intervention after immunotherapy is still evolving for BTCs. Establishing resectability in tumors not susceptible to cytotoxic agents but responding to immunotherapy not only facilitates curative intent resection but also enhances the importance of infection prevention through operative stent-free long-term biliary decompression. Immunotherapy may also carry a unique risk profile for post-operative morbidity potential as in this case with autoimmune hepatitis.

Antiplatelet therapy after pancreaticoduodenectomy with portal vein resection as the optimal preventative strategy for maintaining primary vein patency

Aim: Anticoagulation after pancreaticoduodenectomy with portal vein resection is relevant to maintaining vein patency; however, no uniformly accepted algorithm exists for anticoagulant selection. We evaluated patients undergoing pancreaticoduodenectomy with various degrees of portal venous resection and reconstruction to determine the optimal regimen for anticoagulation therapy. Methods: A retrospective review of 51 patients with pancreatic adenocarcinoma who underwent pancreaticoduodenectomy with venous resection was performed (2006 through 2016). Venous resections were categorized as tangential, segmental with primary anastomosis, or segmental with vein graft. Type of anticoagulation selected by the surgeon was noted. The primary outcome was vein patency measured through the first year postoperatively. Results: Of 33 patients eligible for study, 7 underwent tangential resection, 16 underwent segmental resection, and 10 underwent vein graft. Vein patency rates at 2, 4, 6, and 11 months were 96.9%, 93.1%, 89.3%, and 62.5%, respectively. All patients with tangential resection showed patency at six months, regardless of the use of anticoagulation or not. For segmental resection, patency was higher with antiplatelet/warfarin (62.5%) compared with no treatment (25%). For segmental resection with vein graft, patency at 10 months was higher with antiplatelet therapy (80%) compared with warfarin (33%). Conclusion: For patients undergoing pancreaticoduodenectomy with portal vein resection, anticoagulation therapy may be guided by the degree of resection and reconstruction required. Although anticoagulation therapy may be unnecessary with tangential vein resection, anticoagulation in the form of antiplatelet therapy may be preferable in patients who have segmental vein resections with primary anastomoses and vein grafts.

Renoportal Anastomosis during Liver Transplantation in Patients with Portal Vein Thrombosis: First long-term Results from a Multicenter Study

Purpose: To evaluate the short- and long-term outcomes of renoportal anastomosis (RPA) in a large multicentric series. Summary Background: The current knowledge on RPA for portal reconstruction during liver transplantation (LT) in patients with diffuse portal vein thrombosis (PVT) and a large splenorenal shunt (SRS) is poor and limited to case reports and small case series. Method: All consecutive LTs with RPA performed in 5 centers between 1998 and 2020 were included. RPA was physiological provided it drained the splanchnic venous return through a large SRS (≥1 cm diameter). Complications of portal hypertension (PHT), long-term RPA patency, and patient and graft survival were assessed. RPA success was achieved provided the 3 following criteria were all fulfilled: patients were alive with patent RPA and without clinical PHT. Results: RPA was attempted and feasible in 57 consecutive patients and was physiological in 51 patients (89.5%). Ninety-day mortality occurred in 5 (8.5%) patients, and PHT-related complications occurred in 42.9% of patients. With a median follow-up of 63 months, the 1-, 3- and 5-year patient and graft survival rates were 87%, 83%, and 76% and 82%, 80%, and 73%, respectively. The primary and primary-assisted patency rates at 5 years were 84.5% and 94.3%, respectively. Success was achieved in 90% (27/30) of patients with a follow-up ≥ 5 years. Conclusions: Despite a high rate of PHT-related complications, excellent long-term patient and graft survival could be achieved. RPA could be considered successful in the vast majority of patients. The expanded use of RPA is warranted.

Living donor liver transplantation for idiopathic portal hypertension with extrahepatic portal vein stenosis and splenic artery aneurysms: a case report and review of the literature

BackgroundIdiopathic portal hypertension (IPH) generally has a good prognosis and rarely results in liver transplantation. Furthermore, there are few reports of living donor liver transplantation (LDLT) for IPH with extrahepatic portal vein stenosis.Case presentationWe report the case of a 51-year-old female patient diagnosed with IPH more than 20 years ago. She suffered severe jaundice, massive ascites, and encephalopathy at the time of her visit to our hospital. The patient’s extrahepatic portal vein showed a scar-like stenosis, and the portal flow was completely hepatofugal. Collateral circulation such as the splenorenal shunt was well developed, and multiple splenic artery aneurysms up to 2 cm were observed in the splenic hilum. Her Model for End-Stage Liver Disease score increased to over 40 because of renal dysfunction, requiring temporary dialysis. We performed LDLT using her husband’s right lobe graft and splenectomy. The extrahepatic stenotic portal vein was completely resected, and the superficial femoral vein (SFV) graft collected from the recipient’s right leg was used for portal reconstruction as an interposition graft. Although the clinical course after LDLT had many complications, the patient was discharged on postoperative day 113 and has been fine for 2 years after LDLT. Histopathologically, the explanted liver had obliterative portal venopathy, nodular regenerative hyperplasia, and incomplete septal cirrhosis.ConclusionThis case showed that severe IPH is occasionally associated with extrahepatic portal vein stenosis and can be treated with LDLT with portal vein reconstruction using an interposition graft. It was also suggested that the SFV is a useful choice for the interposition graft.

Living donor liver transplantation for congenital absence of portal vein in portal venous reconstruction with a great saphenous vein graft

BackgroundCongenital absence of portal vein (CAPV) is a rare structural anomaly in which the portal vein (PV) blood that normally flow into the liver directly drains into the systemic venous system through other collateral circulation. Congenital portal vein shunts (CPSs) is classified into types I and II according to the absence or presence of the intrahepatic portal vein, respectively. The CPS type I is also known as CAPV. The liver transplantation may be the only treatment option for CAPV. The key point of liver transplantation for CAPV is the reconstruction of the PV.Case presentationA 29-year-old man was diagnosed with CAPV with splenomegaly and gastroesophageal varix when being treated for pancytopenia and liver dysfunction. A living donor liver transplantation was performed for him using the right lobe which had been donated by his mother. The PV was reconstructed using his own great saphenous vein (GSV) as a graft vein. The end of the GSV graft was anastomosed to the inferior mesenteric vein while the other end was anastomosed to the vein graft of the right hepatic vein from the explanted liver.ConclusionUsing the patient’s own GSV for PV reconstruction during living donor transplantation in the patient with CAPV seems to be an effective method.

Tailored classification of portal vein thrombosis for liver transplantation: Focus on strategies for portal vein inflow reconstruction.

Portal vein thrombosis (PVT) is currently not considered a contraindication for liver transplantation (LT), but diffuse or complicated PVT remains a major surgical challenge. Here, we review the prevalence, natural course and current grading systems of PVT and propose a tailored classification of PVT in the setting of LT. PVT in liver transplant recipients is classified into three types, corresponding to three portal reconstruction strategies: Anatomical, physiological and non-physiological. Type I PVT can be removed via low dissection of the portal vein (PV) or thrombectomy; porto-portal anastomosis is then performed with or without an interposed vascular graft. Physiological reconstruction used for type II PVT includes vascular interposition between mesenteric veins and PV, collateral-PV and splenic vein-PV anastomosis. Non-physiological reconstruction used for type III PVT includes cavoportal hemitransposition, renoportal anastomosis, portal vein arterialization and multivisceral transplantation. All portal reconstruction techniques were reviewed. This tailored classification system stratifies PVT patients by surgical complexity, risk of postoperative complications and long-term survival. We advocate using the tailored classification for PVT grading before LT, which will urge transplant surgeons to make a better preoperative planning and pay more attention to all potential strategies for portal reconstruction. Further verification in a large-sample cohort study is needed.

Clinical value of portal venous pressure based on three dimensional reconstruction model of portal vein combined with finite element analysis in patients with portal hypertension

Objective To study the clinical value of three-dimensional CT reconstruction model of portal venous system combined with finite element analysis to measure portal venous pressure in patients with portal hypertension. Methods A retrospective study was conducted on 27 patients who were diagnosed to have portal hypertension at the Second Affiliated Hospital of Kunming Medical University from May 2016 to May 2018. There were 17 males and 10 females, with ages ranging from 34 to 77 years (mean 56 years). All these patients underwent transjugular intrahepatic portal venous shunt (TIPS) during which the portal venous pressure was measured. The imaging data was imported into the three-dimensional software of medical imaging to reconstruct the three dimensional model of portal vein, and the finite element analysis software of ANSYS was used to calculate the portal venous pressure by calculation with given boundary conditions. Pearson correlation was used to analyze the correlation between the actual measurement of portal venous pressure and the predicted value. Results The actual measured value of portal vein pressure before TIPS in 27 patients with portal hypertension was (3 783±930) Pa, and the predicted value was (4 238±1 218) Pa. There was no significant difference (P>0.05). The predicted value of portal venous pressure was positively correlated with the actual measured value (r=0.402, 95%CI: 0.026-0.678, P<0.05). Conclusion Non-invasive measurement of portal venous pressure based on three-dimensional portal venous reconstruction combined with finite element analysis correlated with actual portal venous pressure in patients with portal hypertension. Key words: Hypertension, portal; Imaging, three-dimensional; Multislice spiral computerized tomography; Correlation

The Role of Interventional Radiology in the Pretransplant Management of Hepatocellular Carcinoma and Portal Vein Thrombosis

AbstractHepatocellular carcinoma (HCC) is the most common primary liver tumor and is currently the leading indication for liver transplantation in the United States. Liver transplantation may provide a curative option for patients with HCC, but some present outside of the transplant criteria. Additionally, as the criteria for liver transplant eligibility in HCC are expanded and the incidence of disease increases, waitlist times are becoming progressively longer, which increases the chance of a patient suffering from disease progression while awaiting an organ becoming ineligible for transplant. Multiple studies have demonstrated the successful use of locoregional therapies, including trans-arterial chemoembolization and trans-arterial radioembolization, in downstaging HCC to within transplant criteria, as well as in preventing progression of disease in patients already listed for transplant. Cirrhotic patients also commonly develop portal vein thrombosis (PVT), which is a contraindication to transplantation at many centers. PVT can lead to worsened outcomes after transplant depending on the type of portal venous reconstruction that is performed. The purpose of this article is to discuss the integral role of interventional radiology in the care of these patients, including the role of transarterial therapies in the pretransplant treatment of HCC and the use of endovascular techniques to recanalize thrombosed portal veins in order to establish or maintain transplant eligibility.

Canción triste de San Vicente de Frías

La portada esculpida de la iglesia de San Vicente de Frías (Burgos)(s. XIII) fue destruida en 1906 al derrumbarse su torre. Los fragmentos rescatados se encuentran hoy en el Museo de los Claustros de Nueva York donde fueron instalados en 1932 siguiendo una reconstrucción hipotética de la portada original. Para recuperar este conjunto olvidado por la historiografía del arte hispana el presente artículo ofrece un análisis histórico-artístico de la iglesia y sus esculturas así como del proceso de traslado y reconstrucción de la portada. En suma se propone retrasar la datación actual de la iglesia hasta mediados del siglo XIII, se describen los talleres que participaron en la obra con sus posibles filiaciones y se identifican los principales temas del programa destacando un ciclo desconocido de la vida de San Millán.

Right extended hepatectomy for alveolar echinococcosis, with portal reconstruction under total vascular exclusion and liver cooling

Background: (VIDEO) We report the case of a 43-years old men suffering of a 10cm alveolar echinococcosis of the right liver, with left portal vein involvement. A right extended hepatectomy with portal reconstruction and hepaticojejunostomy is planned, under Total Vascular Exclusion (TVE) and Liver Cooling (LC). Methods: The first step is preparing for TVE: the liver is fully mobilized to expose and control the infra and suprahepatic inferior vena cava with a tape. The pedicle is prepared dissecting the portal vein independently from the artery and bile duct, in order to obtain a selective portal occlusion. Results: The second step is to prepare for Extra corporeal circulation (ECC): the inferior mesenteric vein is cannulated, the right femoral and left axillary veins are cannulated using a percutaneous echo guided approach. Finally the circuit is purged by saline, and connected to the pump. Conclusion: The third step starts with ECC: the pump flow is progressively increased, and simultaneously TVE is started, while in situ perfusion for the liver with refrigerated liver preservation solution is achieved by direct cannulation of the portal trunk. Moreover topical cooling is achieved either with crushed ice in plastic bags or cold water. The fourth step is the liver transection, followed by portal reconstruction. Liver is rewarmed, ECC is weaned and cannulas are removed. Finally, the hepatocojejunostomy is realized.

Right extended hepatectomy for alveolar echinococcosis, with portal reconstruction under total vascular exclusion and liver cooling

Background: (VIDEO) We report the case of a 43-years old men suffering of a 10cm alveolar echinococcosis of the right liver, with left portal vein involvement. A right extended hepatectomy with portal reconstruction and hepaticojejunostomy is planned, under Total Vascular Exclusion (TVE) and Liver Cooling (LC). Methods: The first step is preparing for TVE: the liver is fully mobilized to expose and control the infra and suprahepatic inferior vena cava with a tape. The pedicle is prepared dissecting the portal vein independently from the artery and bile duct, in order to obtain a selective portal occlusion. Results: The second step is to prepare for Extra corporeal circulation (ECC): the inferior mesenteric vein is cannulated, the right femoral and left axillary veins are cannulated using a percutaneous echo guided approach. Finally the circuit is purged by saline, and connected to the pump. Conclusion: The third step starts with ECC: the pump flow is progressively increased, and simultaneously TVE is started, while in situ perfusion for the liver with refrigerated liver preservation solution is achieved by direct cannulation of the portal trunk. Moreover topical cooling is achieved either with crushed ice in plastic bags or cold water. The fourth step is the liver transection, followed by portal reconstruction. Liver is rewarmed, ECC is weaned and cannulas are removed. Finally, the hepatocojejunostomy is realized.