Portal Vein Flow Research Articles

Agitation thrombolysis combined with catheter-directed thrombolysis for the treatment of non-cirrhotic acute portal vein thrombosis.

AIMTo evaluate the safety and efficacy of agitation thrombolysis (AT) combined with catheter-directed thrombolysis (CDT) for the treatment of non-cirrhotic acute portal vein thrombosis (PVT).METHODSNine patients with non-cirrhotic acute PVT who underwent AT combined with CDT were analyzed retrospectively. Portography was carried out via the transjugular intrahepatic portosystemic (commonly known as TIP) or percutaneous transhepatic (commonly known as PT) route, followed by AT combined with CDT. Complications of the procedure, and the changes in clinical symptoms, hemodynamics of the portal vein and liver function were recorded. Follow-up was scheduled at 1, 3 and 6 mo after treatment, and every 6 mo thereafter, or when the patients developed clinical symptoms related to PVT. Color Doppler ultrasound and contrast-enhanced computed tomography/magnetic resonance imaging were performed during the follow-up period to determine the condition of the portal vein.RESULTSAT combined with CDT was successfully performed. The portal vein was reached via the TIP route in 6 patients, and via the PT route in 3 patients. All clinical symptoms were relieved or disappeared, with the exception of 1 patient who died of intestinal necrosis 9 d after treatment. Significant differences in the changes in portal vein hemodynamics were observed, including the maximum lumen occupancy of PVT, portal vein pressure and flow velocity between pre- and post-treatment (P < 0.05). During the follow-up period, recurrence was observed in 1 patient at 19 mo after the procedure, and the portal vein was patent in the remaining patients.CONCLUSIONAT combined with CDT is a safe and effective method for the treatment of non-cirrhotic acute PVT.

Hemodynamic changes in ALPPS influence liver regeneration and function: results from a prospective study

BackgroundExcessive increase of portal flow and pressure following extended hepatectomy have been associated to insufficient growth or function of the future liver remnant (FLR), with the risk of post-hepatectomy liver failure (PHLF). We prospectively assess the influence of liver hemodynamics on FLR regeneration and function in Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS). MethodsTwenty-three patients underwent ALPPS; liver hemodynamics were assessed throughout the procedures. Volume and function of the FLR were evaluated by angio-CT and 99mTc-Mebrofenin-scintigraphy. ResultsThe portal vein flow at the end of stage-1 correlated with the increase of the FLR volume (p = 0.002). Patients with portal vein pressure (PVP) < 20 mmHg and hepatic to portal vein gradients (HVPG) < 15 mmHg at the end of ALPPS-1 showed higher FLR regeneration (76.7% vs. 30.6%, p = 0.04) and function (26.7% vs. −0.13%, p = 0.02). FLR regeneration was inversely correlated with baseline FLR/Total Liver Volume (p = 0.002) and FLR/Body Weight (p = 0.02). No correlation was found between volumes and function (p = 0.13). ConclusionLiver hemodynamic stress at the end of ALPPS-1 influences the increase of the FLR volume and function, which is higher with PVP < 20 and HVPG < 15 mmHg. Liver volume overestimates liver function and could be imprecise to set stage-2 timing.

Establishment of Highly Intrahepatic Metastatic Cell Line of HCC by In vivo Selection and Investigation of Mechanism by Integrated Microarray Analysis

Introduction: Intrahepatic metastasis is a frequent pattern of tumor recurrence in hepatocellular carcinoma (HCC). The mechanism of intrahepatic metastasis was speculated as following; cancer cells invaded portal vein and spread via portal vein flow. However, the molecular mechanism of intrahepatic metastasis remains unclear. Here, we investigated the molecular mechanism of intrahepatic metastasis in HCC by establishing a novel highly metastatic cell line and analyzing the integrated microarray analysis. Methods: Highly intrahepatic metastatic HCC cell line (HuH7-M) was established by in vivo selection using trans-portal vein metastatic model. Briefly, parentalHuH-7-Luc cells (HuH7-P) were injected into the spleen of SCID Beige male mouse. After six weeks from the injection, liver metastatic tumors were dissociated and expanded in culture medium. The cell populations were subjected to the next cycle. This cycle was repeated in four cycles and the novel highly metastatic cell line (HuH7-M) was established. The characteristics of HuH7-P and HuH7-M were compared by MTS assay, transendothelial migration assay, sphere formation assay, and Annexin V analysis. Tumorigenesis was compared by simultaneously administering each cell to spleen followed by splenectomy. Subsequently, integrated microarray analysis was performed by combination with mRNA expression and miRNA expression analysis. Results: After four cycles, the metastatic tumor size and the tumorigenesis rate were gradually increased in HuH7-M (33% vs 88%, p=0.036). The microscopic finding revealed that the differentiation of tumor was not changed. Proliferative potential was increased in HuH7-M. But, invasive potential, migration potential, cancer stemness, and morphological change were not observed. The cell of HuH7-M showed the lower rate of apoptosis (3.4% vs 13.4%). Tumorigenesis assay showed that intrahepatic metastatic tumor was formed only in HuH7-M (67% vs 0%). Integrated microarray analysis demonstrated a specific combination of mRNA and miRNA related to apoptosis as a potential target. Conclusion: Highly intrahepatic metastatic HCC model was established by in vivo selection, and the result of integrated microarray analysis indicated a molecular mechanism of intrahepatic metastasis in HCC mediated by apoptosis.834_A Figure 1. The tumorigenesis rate were gradually increased by in vivo selection834_B Figure 2. HuH7-M showed the lower rate of apoptosis than HuH7-P

A Rare Cause of Elevated Liver Tests in a Pregnant Patient

Case: 26-year-old female at 22 weeks gestation with history of anemia presented with nausea, vomiting and sharp, epigastric, non-radiating abdominal pain for 4 days. She denied any bleeding. Surgical and medication history were notable for a previous dilation and curettage and a daily vitamin. Vital signs were normal, physical exam revealed pallor, gravid abdomen with epigastric tenderness to palpation. Hemoglobin was 6.8 g/dL and platelets 84 K/mcL. Liver panel showed AST 87 U/L, ALT 42 U/L and total bilirubin 3.2 mg/dL (direct 0.50 mg/dL). Reticulocytes were 8%, LDH 1142 U/L, haptoglobin undetectable with negative direct antiglobulin test. Peripheral smear showed macrocytosis, thrombocytopenia, anisopoikilocytosis, and no schistocytes. Acute viral hepatitis panel and parvovirus serologies were negative. Doppler ultrasound showed splenomegaly, normal fetus and liver with near occlusive thrombus of the middle hepatic vein with reversal of flow in the right portal vein. CT abdomen/pelvis revealed heterogeneous enhancement of liver with filling defects in multiple hepatic veins suggestive of thrombi. ADAMST13 level, protein C and S, antithrombin, glucose-6-phosphate dehydrogenase levels, factor V Leiden, Beta-2 glycoprotein, ANA, ASMA, SPEP and AMA were all negative. Endoscopy was negative for portal hypertensive gastropathy or varices. Duodenal biopsies were normal. Flow cytometry showed PNH clone percent of 84% in granulocytes, 68% in monocytes, and type III RBC (complete CD59 deficiency) of 8% confirming diagnosis of PNH. The patient was transfused, started on anticoagulation and eculizumab. Her anemia improved and she delivered a healthy, full-term baby. Discussion: PNH is characterized by a triad of intravascular hemolysis, thrombosis and bone marrow failure. Thrombosis occurring in atypical locations should prompt consideration of PNH. The hepatic vein is the most frequently involved vessel. PNH is associated with increased fetomaternal morbidity and mortality and thrombosis is the leading cause of death. Unexplained hemolytic anemia in a pregnant patient with concomitant abnormal liver tests may initially evoke diagnosis of HELLP (hemolysis, elevated liver enzymes, and low platelets), however, management of the two condition differs vastly. Anticoagulation is recommended for pregnant women with PNH thrombosis unless contradicted.Eculizumab reduces the risk of thrombosis. BMT is the only curative therapy for PNH with success rates of up to 100%.

MRI assessment of altered dynamic changes in liver haemodynamics following a meal challenge in compensated cirrhosis

BackgroundThe aim was to use magnetic resonance imaging (MRI) to dynamically assess postprandial changes in hepatic and collateral blood flow, liver perfusion and oxygenation in healthy participants and patients with liver disease with compensated cirrhosis (CC).MethodsWe evaluated blood flow in the portal vein, hepatic artery and azygos vein (using phase-contrast MRI), liver perfusion (using arterial spin labelling) and blood oxygenation (using transverse relaxation time [T2*] mapping). Measures were collected at baseline and at 6–7-min intervals from 20 to 65 min following a test meal (440 mL, 660 kcal) in 10 healthy participants and 10 patients with CC.ResultsIn healthy participants, we observed a significant postprandial increase in portal vein flow from baseline (+ 137 ± 26% (mean ± standard deviation), p < 0.001) coupled with a reduction in hepatic artery flow from baseline (− 30 ± 18%, p = 0.008), reflecting the hepatic artery buffer response. In patients with CC, a lower but still significant increase in portal vein flow (67 ± 50%, p = 0.014) was observed, without a clear hepatic artery buffer response. Healthy participants showed a significant increase in postprandial liver perfusion (138 ± 75%, p < 0.001), not observed in patients with CC. There was no change in liver T2* for either group.ConclusionsPostprandial changes in liver perfusion, oxygenation and hepatic and collateral circulation can be measured noninvasively using MRI. Differences between healthy participants and patients with CC were shown, which may help stratify liver cirrhosis in patients.

Stereotactic body radiotherapy based treatment for hepatocellular carcinoma with extensive portal vein tumor thrombosis

BackgroundThere is currently no worldwide consensus for the management of hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). We evaluated the efficacy of stereotactic body radiotherapy (SBRT) as the initial treatment for HCC with extensive PVTT based on a relatively large number of patients.MethodsIn our multidisciplinary approach for patients with hepatobiliary tumors, SBRT is recommended for unresectable HCC with PVTT or those with contraindication for transarterial chemoembolization (TACE). The aim is to shrink the tumor thrombus and preserve adequate portal venous flow, thus facilitating subsequent treatments such as TACE and tumor resection. In the present study, 70 continuous cases of HCC patients with extensive PVTT initially treated with SBRT were studied. The median follow-up period was 9.5 months (range, 1.0–21.0 months). The dynamic changes of tumor thrombosis with time after SBRT were also analyzed.ResultsThe median survival time for the whole group was 10.0 months (95% CI, 7.7–12.3 months), with a 6- and 12-month overall survival (OS) rate of 67.3%, and 40.0% respectively. Patients who received combined SBRT and TACE showed significantly longer OS than those without indication for TACE after SBRT (12.0 ± 1.6 vs. 3.0 ± 1.0 months). Patients with good response to radiation usually had better survival. SBRT was well tolerated in our patient series.ConclusionsIn conclusion, SBRT used as the initial treatment for HCC patients with extensive PVTT originally unsuitable for resection or TACE can achieve adequate thrombus shrinkage and portal vein flow restoration in the majority of cases. It could thus offer the patients an opportunity to undergo further treatment such as resection or TACE procedure. Such therapeutic strategy may result in survival advantage, especially for those who do receive combined modality with SBRT.

Alterations in Portal Vein Flow and Intrarenal Venous Flow Are Associated With Acute Kidney Injury After Cardiac Surgery: A Prospective Observational Cohort Study.

BackgroundAcute kidney injury (AKI) after cardiac surgery is associated with adverse outcomes. Venous congestion can impair kidney function, but few tools are available to assess its impact at the bedside. The objective of this study was to determine whether portal flow pulsatility and alterations in intrarenal venous flow assessed by Point‐Of‐Care ultrasound are associated with AKI after cardiac surgery.Methods and ResultsThis single‐center prospective cohort study recruited patients undergoing cardiac surgery with cardiopulmonary bypass. Hepatic and renal Doppler ultrasound assessments were performed before surgery, at the intensive care unit admission, and daily for 3 days after surgery. The primary statistical analysis was performed using proportional hazards model for time‐dependent variables. Among the 145 patients included, 49 patients (33.8%) developed AKI after cardiac surgery. The detection of portal flow pulsatility was associated with an increased risk of AKI (hazard ratio: 2.09, confidence interval, 1.11–3.94, P=0.02), as were severe alterations of intrarenal venous flow (hazard ratio: 2.81, confidence interval, 1.42–5.56, P=0.003). These associations remained significant in multivariable models. The addition of these markers to preoperative risk factors and central venous pressure measurement at intensive care unit admission improved the prediction of AKI. (Continuous net reclassification improvement: 0.364, confidence interval, 0.081–0.652 for portal Doppler and net reclassification improvement: 0.343, confidence interval, 0.081–0.628 for intrarenal Doppler)ConclusionsPortal flow pulsatility and intrarenal flow alterations are markers of venous congestion and are independently associated with AKI after cardiac surgery. These tools might offer valuable information to develop strategies aimed at treating or preventing congestive cardiorenal syndrome after cardiac surgery.Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02831907.

Hemodynamic and clinical effects of shunt diameter in portacaval shunt: a systematic review

Introduction: Portacaval shunts (PCS) were used to decrease the portal vein flow (PVF) and pressure (PVP). However, the proper shunt diameter to optimize PVF and PVP is still controversial. Our aim was to systematically review the effects of different PCS diameters reported, to determine the efficient shunt with lower complication rates. Methods: A systematic literature search was performed to find studies reporting diameter of H-Graft PCS in patients with cirrhosis, portal hypertension and gastrointestinal varices. Articles reporting hepatic hemodynamic changes and outcomes with specified PCS diameters were included and reviewed. Results: Our search results identified 360 articles. After screening, 12 studies with 440 patients were included in the study. Mean postoperative PVP was 19.3±5.5 in 8mm diameter and 16.7±3.8 in 10mm (p=0.0022). PVP decreased 33.9% after 8mm PCS and 44.3% after 10mm (p=0.1242). PVF was prograde in 92.0% of patients with 8mm and 74.9% with 10mm PCS (p=0.0002). Variceal rebleeding occurred in 3.1% of 8mm and 4.5% of 10mm PCS (p=0.5759). Shunt thrombosis occurred in 6.5% of 8mm group and 6.3% of 10mm (p=0.9502). Chronic encephalopathy was diagnosed in 3.6% of 8mm PCS and 13.4% of 10mm PCS (p=0.0060). Conclusion: Diameter of a shunt plays an important role on its efficacy. In patients with cirrhosis, portal hypertension and variceal bleeding, 8mm PCS comparing to 10mm PCS was associated with higher prograde PVF, more efficient decrease in PVP, lower variceal rehemorrhage, and chronic encephalopathy. Further studies are necessary to compare the role of shunt diameter on its efficacy.

Minimally invasive ALPPS-is it the future?

Introduction: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) represents a new technique to achieve resection in patients with predicted small volumes of future liver remnant (FLR). ALPPS leads to rapid hypertrophy of FLR but also high postoperative mortality and morbidity. The feasibility and benefits of minimally invasive liver surgery have been well documented, and such approaches might represent the solution to this complex issue. Method: Review of published literature. Results: The ALPPS procedure has been performed laparoscopically by stage or its entirety. Its great benefit seems to come in facilitating the second part of the operation. This stage is often complicated by fibrous adhesions, which could be minimised with less invasive technique in the first stage. Laparoscopy reduces surgical stress and systemic inflammatory reaction and both intra-operative blood loss and bile leakage are less common. The portal vein flow reduces by 50% with pneumoperitoneum, and there is improved visibility of dissection planes. Multiple techniques such as round-the-liver ligation, microwave ablation and selective hepatic artery clamping have all been implemented successfully laparoscopically. In all published series results were comparable to those of the open approach, and patients often benefited from lower complication rate and shorter hospital stay. Recently, ALPPS was completed robotically, opening further possibilities for development. Conclusions: Minimally invasive ALPPS is feasible and safe. Post-operative results compare to those of open procedures, and early data suggest decreased complication rate. However ALPPS technique is still nascent, and further studies need to establish appropriate indications, approach and guidelines.

Venographic Analysis of Portal Flow After TIPS Predicts Future Shunt Revision.

The purpose of this study was to investigate a new method-the portal vein enhancement curve-for quantifying portal vein blood flow immediately at transjugular intrahepatic portosystemic shunt (TIPS) creation using digital subtraction angiography images and its potential usefulness as a predictor of TIPS revision. The portal vein flow time constant, Qτ, was significantly different (p = 0.002) between patients grouped by 12-month revision (TIPS angioplasty, TIPS reduction, no revision); Qτ was higher in patients who required TIPS reduction.

Clinical Analysis of Impact of Intraoperative Hepatic Blood Inflow on Acute Kidney Injury following Allogeneic Liver Transplantation

Background Acute kidney injury (AKI) is a major and severe complication following allogeneic liver transplantation and is associated with increased postoperative morbidity and mortality. With proposal of RIFLE (Risk, Injury, Failure, Loss, End-stage kidney disease) and AKIN (Acute Kidney Injury Network) standards, the diagnosis of AKI has been significantly improved. However, the risk factors and the prognosis factors of AKI remain uncertain, the relativity of intraoperative hepatic blood flow and acute renal injury following liver transplantation hasn't been discussed yet. Method 140 patients who underwent allogeneic liver transplantation at first hospital of China Medical University from January 2006 to October 2016 was analyzed. AKI was diagnosed and graded by AKIN standard. Incidence rate, risk factors, prognosis factors of AKI were investigated. Results Of the 140 cases of allogeneic liver transplantation, the overall incidence rate of AKI was 34.3%(n=48). Multivariate logistic regression analysis showed that preoperative TBil, cold ischemia time, intraoperative RBC infusion unit, intraoperative mean hepatic artery and portal blood flow were risk factors of AKI following liver transplantation. Anhepatic phase was independent risk factor between AKI stage III and AKI stage I /II. Compared with patients whose renal function was fully recovered in 30 days following allogeneic liver transplantation, postoperative TBil, postoperative MELD score, AKI stage III and postoperative CRRT were significantly higher and intraoperative minimum, mean, maximum portal blood flow were obviously lower in patients whose renal function was partially recovered. Conclusion Incidence rate of AKI following liver transplantation is relatively high, and is closely related to multiple perioperative risk factors such as intraoperative blood flow of hepatic artery and portal vein. Anhepatic phase is the independent risk factor of sever AKI and the early recovery of renal function is worse in patients with lower intraoperative portal blood flow.

Intraoperative Portal Vein Flow > 123 mL/min Per 100 g Predicts a Better Survival of Patients After Liver Transplantation

ObjectiveTo assess the importance of intraoperative portal vein flow measurement during liver transplantation in relation to postoperative complications and graft and patient survival. Materials and methodsRetrospective review including 291 patients who had all the information and covering a period of 10 years (2007–2017). Using a receiver operating characteristic curve, a cut-off point that would have the greatest impact on the probability of being alive at 5 years was established. In relation to this value, 2 groups were formed (low and high flow) and demographic variables, intraoperative variables, postoperative complications, and graft and patient survival were compared. ResultsA portal flow of 123 mL/min per100 g of liver tissue was established (area under the curve = 0.58), obtaining a low-flow (n = 129) and a high-flow group (n = 162). The 2 groups were similar in their preoperative characteristics, except for a higher proportion of preoperative ascites, a higher Model for End-Stage Liver Disease score and a lower weight of donors in the high-flow group. The arterial and portal flows were significantly higher in the high-flow group. In the postoperative period, the high-flow group presented a higher rate of ascites. The 5-year survival rate of patients was significantly higher in the high-flow group (76% vs 84%, P = .03). ConclusionsPatients undergoing liver transplantation with an intraoperative portal vein flow measurement >123 mL/min per 100 g present a greater 5-year survival rate.

Morbidity and mortality of hepatic right lobe living donors: systematic review and perspectives.

The main restriction in the development of adult-adult Living Donor Liver Transplantation (LDLT) is the risk of morbidity and mortality for donors, which raises ethical questions. The objectives of this study are to review published studies dealing with morbidity and mortality in LDLT and to identify the proposed management and strategies for preventing donor mortality and morbidity in LDLT. The Medline database was searched from 2000 to 2017 using the MeSH terms "liver transplantation" and "morbidity" or "mortality" in combination with keywords "living donor liver transplantation". Among the 382 articles obtained, 43 articles were relevant for morbidity, 15 for mortality and 6 for both morbidity and mortality. Twenty-three papers reported donor deaths. The major cause of death was sepsis (30%). Morbidity ranged from 10% to 78.3% depending on the studies. The living donors' morbidity and mortality is high, currently representing the main restriction in the development of LDLT. Some promising techniques, such as the donor portal vein flow modulation could lead to the further development of LDLT.

Association Between Changes in Splanchnic Hemodynamics and Risk Factors of Portal Venous System Thrombosis After Splenectomy with Periesophagogastric Devascularization.

BackgroundThe purpose of this study was to investigate splanchnic hemodynamic changes and determine an optimal cutoff value for risk factors of portal venous system thrombosis (PVST) after splenectomy with periesophagogastric devascularization (SPD) in cirrhotic patients with esophageal and gastric variceal bleeding (EGVB) and portal hypertension (PH).Material/MethodsData on patients who underwent SPD were collected retrospectively from January 2013 to December 2017. Color Doppler ultrasound was performed to detect hemodynamic changes of the hepatic artery, splenic artery, splenic vein, and portal vein in included patients (n=60) and healthy volunteers (n=30). Outcomes were compared between preoperative and postoperative biochemical indicators. The cutoff values for hemodynamics were identified using receiver operating characteristic (ROC) curve analysis, and univariate and multivariate analyses of risk factors of PVST were performed.ResultsIn our series, hemodynamic indexes of splenic artery, spleen vein, and portal vein in the study group were significantly higher than that of the control group (P<0.05). Multivariate analysis revealed that the portal vein flow and the internal diameter of the portal vein were significantly correlated with PVST. The ROC analysis revealed that the cutoff points for portal vein flow and internal diameter of the splenic vein and portal vein were ≥1822.32 ml/min, ≥1.37 cm, and ≥1.56 cm, respectively.ConclusionsSPD is an effective treatment in cirrhotic patients with concomitant EGVB and PH by increasing hepatic artery flow and decreasing portal vein flow. High portal vein flow and wider diameters of the portal vein and splenic vein are important markers of PVST.

Liver blood dynamics after bariatric surgery: the effects of mixed-meal test and incretin infusions.

Aims/hypothesisThe mechanisms for improved glycemic control after bariatric surgery in subjects with type 2 diabetes (T2D) are not fully known. We hypothesized that dynamic hepatic blood responses to a mixed-meal are changed after bariatric surgery in parallel with an improvement in glucose tolerance.MethodsA total of ten morbidly obese subjects with T2D were recruited to receive a mixed-meal and a glucose-dependent insulinotropic polypeptide (GIP) infusion before and early after (within a median of less than three months) bariatric surgery, and hepatic blood flow and volume (HBV) were measured repeatedly with combined positron emission tomography/MRI. Ten lean non-diabetic individuals served as controls.ResultsBariatric surgery leads to a significant decrease in weight, accompanied with an improved β-cell function and glucagon-like peptide 1 (GLP-1) secretion, and a reduction in liver volume. Blood flow in portal vein (PV) was increased by 1.65-fold (P = 0.026) in response to a mixed-meal in subjects after surgery, while HBV decreased in all groups (P < 0.001). When the effect of GIP infusion was tested separately, no change in hepatic arterial and PV flow was observed, but HBV decreased as seen during the mixed-meal test.Conclusions/interpretationEarly after bariatric surgery, PV flow response to a mixed-meal is augmented, improving digestion and nutrient absorption. GIP influences the post-prandial reduction in HBV thereby diverting blood to the extrahepatic sites.

Portal vein aneurysm associated with arterioportal fistula after hepatic anterior segmentectomy: Thought-provoking complication after hepatectomy

BackgroundFew cases of postoperative arterioportal fistula (APF) have been documented. APF after hepatectomy is a very rare surgery-related complication.Case presentationA 62-year-old man was diagnosed with hepatocellular carcinoma in segments 5 and 8, respectively. Anterior segmentectomy was performed as a curative surgery. Each branch of the hepatic artery, portal vein, and biliary duct for the anterior segment was ligated together as the Glissonean bundle. The patient was discharged on postoperative day 14. Three months later, dynamic magnetic resonance imaging showed an arterioportal fistula and portal vein aneurysm. Surprisingly, the patient did not have subtle symptoms. Although a perfect angiographic evaluation could not be ensured, we performed angiography with subsequent interventional radiology to avoid sudden rupture. Arteriography was immediately performed to create a portogram via the APF from the stump of the anterior hepatic artery, and portography clearly revealed hepatofugal portal vein flow. Portography also showed that the stump of the anterior portal vein had developed a 40-mm-diameter portal vein aneurysm. Selective embolization of the anterior hepatic artery was accomplished in the whole length of the stump of the anterior hepatic artery, and abnormal blood flow through the APF was drastically reduced. The portal vein aneurysm disappeared, and portal flow was normalized. Dynamic computed tomography after embolization clearly demonstrated perfect interruption of the APF. The patient maintained good health thereafter.ConclusionsPost-hepatectomy APFs are very rare, and some appear to be cryptogenic. Our thought-provoking case may help to provide a possible explanation of the causes of post-hepatectomy APF.

Successful recanalization of acute extensive portal vein thrombosis by aspiration thrombectomy and thrombolysis via an operatively placed mesenteric catheter: a case report.

Portal vein thrombosis (PVT) after hepatobiliary surgery is rare but can cause lethal and severe complications. If early diagnosis and recanalization can be achieved, the PVT is expected to be eliminated. A 70-year-old male was diagnosed as having hepatocellular carcinoma occupying the right lobe of the liver. As oligometastatic lung tumors were simultaneously detected on contrast-enhanced CT (CECT), hepatectomy was not indicated. However, the primary tumor was very large, and as large tumor size can be associated with an unfavorable prognosis, and owing to the strong desire of the patient, he underwent right lobe hepatectomy. Jaundice appeared on post-operative Day (POD) 2 and CECT displayed slight intraheptatic bile duct dilation. However, a PVT did not exist at this time. Percutaneous transhepatic biliary drainage was performed and Doppler echo displayed intrahepatic and extrahepatic PVT on post-operative Day 5. Emergent thrombectomy was performed using a Vasplyser PlusTM thrombus aspiration catheter (Johnson & Johnson K.K. Medical Company, Tokyo, Japan) via the ileocolic vein under laparotomy. The mesenteric catheter was placed at the distal point of the residual PVT. Thrombolysis and anticoagulant therapy were performed using heparin and urokinase. In the CECT performed 16 days after the additional operation, the PVT had disappeared and the portal vein was completely recanalized. The mesenteric catheter was removed on the same day and oral anticoagulant therapy was continued. At the time of writing, 14 months have passed with no recurrence of PVT. Early diagnosis of PVT enables treatment with emergent thrombectomy, thrombolysis, and anticoagulant therapy. These treatments result in the improvement of portal vein flow and the complete disappearance of PVT.

Impact of graft thickness reduction of left lateral segment on outcomes following pediatric living donor liver transplantation.

Reducing graft thickness is essential to prevent large-for-size graft problems in pediatric living donor liver transplantation (LDLT). However, long-term outcomes of LDLT using reduced-thickness left lateral segment (LLS) grafts are unclear. In 89 patients who underwent LDLT using reduced LLS grafts between 2005 and 2017, short-term and long-term outcomes were compared between a nonanatomically reduced LLS (NAR-LLS) graft group and a reduced-thickness LLS graft group. Estimated blood loss was lower and abdominal skin closure was less needed in the recipient operation in the reduced-thickness LLS graft group. Postoperatively, portal vein (PV) flow was significantly decreased in the NAR-LLS graft group, and there was shorter intensive care unit (ICU) stay and fewer postoperative complications, especially bacteremia, in the reduced-thickness LLS graft group. Graft survival at 1 and 3years after LDLT using reduced-thickness LLS grafts was 95.2% and 92.4%, respectively, which was significantly better than for NAR-LLS grafts. Multivariate analysis revealed that fulminant liver failure, hepatofugal PV flow before LDLT, and NAR-LLS graft were associated with poor graft survival. In conclusion, LDLT using reduced-thickness LLS grafts is a safe and feasible option with better short- and long-term outcomes in comparison with NAR-LLS grafts.

Analysis of the Relationship Between Hemorheologic Parameters, Aluminum, Manganese, and Selenium in Smokers.

Smoking is a significant risk factor in fatal pathologies including cardio-cerebrovascular and respiratory diseases. Aluminum (Al) is a toxic element without known biological function, but with recognized toxic effects. Manganese (Mn) and selenium (Se) are essential trace elements involved in cellular antioxidant defense mechanisms. Al, Mn, and Se carry out their metabolic activities via blood flow and tissue oxygenation. The structure and number of red blood cells (RBC) play important role in tissue oxygenation throughout blood flow. Increased hematocrit (Hct) as a result of probable hypoxia induces disturbed blood flow, RBC aggregation (RBC Agg), RBC deformability index (Tk), and oxygen delivery index (ODI). Therefore, we aimed to investigate the effects of altered Al, Mn, and Se levels on number, structure, and function of RBCs (Hct, blood and plasma viscosity (BV and PV, respectively), RBC Agg, Tk, ODI) in smokers without diagnosis of chronic obstructive pulmonary disease (COPD) in a study group (n = 128) categorized as ex-smokers (ES), smokers (S), and healthy controls (HC). Elements were analyzed in serum using ICP-OES. BV and PV were measured via Brookfield and Harkness viscometers at 37°C, respectively. Smokers had statistically higher serum Al and Mn levels, BV, RBC, Hgb, Hct, PV, fibrinogen, RBC Agg, Tk45, and pulmonary blood flow rate, but lower serum Se levels and ODI45 values versus HC. In conclusion, increased Al, Mn, and hemorheological parameters and decreased Se and ODI45 might result from inflammatory response in defense mechanism in smokers without diagnosis of COPD. Our results point out that serum Al, Mn, and Se with hemorheological parameters may be beneficial markers of tissue oxygenation and defense mechanism before the clinic onset of COPD in smokers.

Intra-operative portal hemodynamics in pediatric LDLT: Doppler ultrasound surveillance.

Doppler ultrasonography is useful in monitoring intra-operative PV flow in LDLT. A retrospective cohort study included 550 pediatric recipients (<18years) who underwent LDLT from October 2006 to August 2016 in our hospital. A total of 33 recipients (incidence 6%) were found to have insufficient intra-operative PV flow after PV reperfusion. The treatments included intra-operative stent placement (n=25), anticoagulation (n=3), thrombectomy and re-anastomosis (n=2), graft repositioning (n=1), collateral ligation (n=1), and replaced PV (n=1). The peak PV velocity, HAPSV, HARI, and HV velocity before and after the interventions were significantly improved 0(0,5.5) cm/s vs. 37.36±15.30cm/s, 38.68±8.92cm/s vs. 62.30±16.97cm/s, 0.55±0.08 vs. 0.76±0.10, and 32.37±10.33cm/s vs. 40.94±15.01cm/s, respectively (P<.01). Insufficient PV flow and decreased HARI are two significant criteria indicating need for intra-operative PV management. Dramatic changes in the hepatic hemodynamics were detected after proper treatment. Immediate resolution of PV flow is feasible in pediatric LDLT.