Portal Venous Branches Research Articles

Hepatisch portaal veneus gas in combinatie met pneumatosis intestinalis op basis van dunnedarmischemie

Hepatic portal venous gas in combination with pneumatosis intestinalis based on small-bowel ischemia: a case-report A 76-year-old man presented with complaints of abdominal pain and vomiting. An urgent CT scan showed pneumatosis intestinalis of the small intestine with air in the portal vein and the portal venules of the left hepatic lobe. Hepatic portal venous gas is a rare radiological finding: gas is found in the portal venous branches. This can be seen in both benign and life-threatening conditions. In most cases, it is accompanied by underlying intestinal ischemia, which was also the case in this patient. The patient underwent urgent surgery with a partial resection of the small intestine. After a brief admission to the intensive care unit, the man recovered well and was able to leave the hospital in good health.

Diagnosis and medical treatment of portal vein thrombosis in a pet rabbit (Oryctolagus cuniculus)

AbstractPortal vein thrombosis is the partial or total obstruction of blood flow due to a thrombus in the hepatic portal system. This case report outlines the diagnosis and treatment of portal vein thrombosis in a rabbit. The animal presented for inappetence and lack of faecal production, and was found to have markedly elevated alanine transaminase on biochemistry. Abdominal ultrasound revealed a focal hyperechoic structure within the right intrahepatic portal venous branches, with no flow on colour Doppler interrogation. The rabbit was subsequently diagnosed with portal vein thrombosis and treated with clopidogrel and rivaroxaban. Thirty‐two days after presentation, the previously noted intrahepatic portal venous thrombus had resolved, with normal flow visualised in the portal venous branches on colour Doppler interrogation. The rabbit has remained stable for 1 year 5 months after cessation of treatment.

Laparoscopic Anatomical Liver Resection of Segment VIII by Using ICG Fluorescence Positive Staining Under the Guidance of Laparoscopic Ultrasonography

BackgroundAnatomical segmentectomy is a surgical procedure that completely removes a territory (or territories) of the third-order portal venous branches of a Couinaud segment (Wakabayashi et al. in J Hepatobil Pancreat Sci 29(1):82–98, 2022. https://doi.org/10.1002/jhbp.899). Laparoscopic segmentectomy of S8 is considered technically challenging because of the Precise dissection of the Glissonean pedicle of S8, and exposure of the middle and right hepatic veins are required (Ome et al. in J Am Coll Surg 230(3):e13–e20, 2020; Wakabayashi et al. in Ann Surg 261(4):619–29, 2015. https://doi.org/10.1097/sla.0000000000001184; Monden et al. in J Hepatobil Pancreat Sci 29(1):66–81, 2022. https://doi.org/10.1002/jhbp.898). This report describes a new approach, which can reduce unwanted damage to normal tissues and complications.MethodsA 53-year-old man who has suffered from hepatitis B for 10 years was admitted for the treatment of two nodular tumors located in segment VIII. The surgical procedure began with the percutaneous injection of 5 mL, 0.025 mg/mL of ICG into the S8 portal branch by using an 18G PTCD needle under the guidance of laparoscopic ultrasound (Xu et al. in Surg Endosc 34(10):4683–4691, 2020. https://doi.org/10.1007/s00464-020-07691-5; Wang et al. in Ann Surg 274(1):97–106, 2021. https://doi.org/10.1097/sla.0000000000004718; Aoki et al. in J Am Coll Surg 230(3):e7–e12, 2020. https://doi.org/10.1016/j.jamcollsurg.2019.11.004), followed by liver transection on the cranial side of the liver, which used the ICG fluorescence images for exposing the roots of the middle and right hepatic veins and dissecting and ligating S8 portal pedicle. The excision specimen was sent for histopathological diagnosis.ResultsIt took 200 min for the operation and 60 min for the total Pringle maneuver. The estimate of blood loss was 110 mL. The final histopathologic results of the two nodules were hepatocellular carcinoma (HCC). The patient was discharged on postoperative Day 6 with no complications.ConclusionsLaparoscopic anatomical liver resection of S8 has been demonstrated to be feasible. Under the guidance of laparoscopic ultrasonography, ICG positive staining was proven to be optimal for Anatomical segmentectomy.

Liver Venous Deprivation Using Amplatzer Vascular Plug-Assisted N-Butyl Cyanoacrylate Embolization of the Portal and Hepatic Veins: How Do I Do it?

Liver resection can be curative in a select group of patients with primary and secondary hepatobiliary malignancies.[1] For these patients, the size and function of the future liver remnant (FLR) must be carefully considered to limit the potential for posthepatectomy liver failure (PHLF), a predominant cause of mortality.[1] [2] [3] [4] Preoperative portal vein embolization (PVE) has been shown to increase the volume of the FLR, allowing more patients to become surgical candidates and improving postoperative outcomes.[1] [2] [5] [6] [7] PVE occludes the portal venous branches supplying the lobe of the liver to be resected and redirects blood flow toward the FLR, leading to compensatory hypertrophy.[2] [8]

Primary percutaneous stenting above the ampulla for palliative biliary drainage of malignant hilar biliary obstruction.

527 Background: Most patients with malignant hilar biliary obstruction (MHBO) are ineligible for surgical resection due to distant metastasis, locally advanced disease, or poor performance status. These patients mostly undergo biliary drainage with endoscopic stents or percutaneous drains that cross the ampulla. This approach causes bacterial colonization of the bile ducts, recurrent cholangitis, and biliary reinterventions. Few patients become eligible for palliative systemic chemotherapy, because of inadequate drainage and drainage-related complications. The solution is primary percutaneous stenting (PPS) with one or more fenestrated self-expandable metal stent (SEMS) across the biliary obstruction, without crossing the ampulla. After PPS, the percutaneous transhepatic puncture tract is sealed with glue without leaving an external biliary drain. The aim of this study was to assess the safety, feasibility, and effectiveness of PPS in patients with unresectable MHBO. Methods: A single center prospective study was performed from October 2020 till September 2022 including 35 patients with MHBO who underwent PPS. We made a comparison with a historical cohort of 90 consecutive patients treated with primary endoscopic biliary drainage at our center from 2011 till 2020. Results: All 35 patients had technical successful percutaneous SEMS placement. Perihilar cholangiocarcinoma was present in 15 patients (43%), intrahepatic cholangiocarcinoma in 14 patients (40%), and gallbladder cancer in 6 patients (17%). Two patients required two attempts because the stricture could not be passed at the first attempt. Two patients developed cholecystitis and one patient had melaena due to intrahepatic bleeding of a portal venous branch requiring blood transfusion. One patient (3%) developed cholangitis after the first biliary drainage procedure because the tumor extended up to the ampulla, requiring additional stenting. No cholangitis was seen in the other 34 patients. We made a comparison with a historical cohort of 90 consecutive patients treated with primary endoscopic biliary drainage at our center from 2011 till 2020. Only 3 patients (9%) required a readmission and 3 patients (9%) a reintervention. Palliative systemic chemotherapy was administered in 26 patients (75%) versus 18 patients (20%) after primary endoscopic biliary drainage. The median overall survival was 10.6 months (95% CI 8.1 – not reached) versus 4.3 months (95% CI 3.1 – 6.4) after primary endoscopic biliary drainage. After PPS, no patients died because of cholangitis or drainage-related complications. Conclusions: Primary percutaneous stenting with fenestrated SEMS without crossing the ampulla is safe, feasible, and effective for palliative treatment of patients with MHBO. These promising results need to be confirmed in a randomized controlled trial. Clinical trial information: NL9624 .

Evaluation of Morphological Changes in Hepatic Parenchyma, Bile Ducts, and Hepatic Vasculature in Patients with Oriental Cholangiohepatitis using Ultrasonography

Objective: The objective of this study is to study the morphological changes in hepatic parenchyma, to characterize the intra and extrahepatic ductal changes and to study the morphological changes in vasculature of the liver in patients with oriental cholangiohepatitits (OCH). Materials and Methods: All documented or newly diagnosed cases of OCH, referred to the department of radiodiagnosis and imaging from Departments of Surgical Gastroenterology and Medical Gastroenterology were evaluated by ultrasonography (USG) and color Doppler study. The dilatation of the intrahepatic as well as extra-hepatic ducts was noted. The morphological changes in the liver parenchyma as well as hepatic vasculature were studied. Results: USG showed calculi in 53 (98.1%) cases, ductal dilatation in 52 (96.3%), and worms within biliary ducts in 10 cases (18.5%). Among parenchymal changes, atrophy was seen in 9 cases (16.6%), space-occupying lesion was seen in seven cases (12.9%), and peri-portal echogenicity in 10 cases (18.5%). Significant association was found between atrophic segments and reduced/absent blood flow in the affected segmental portal venous branches. Conclusion: USG is the preferred primary examination. Further imaging depends on the USG findings, the patient's symptomatology, the clinical problems, and the intended mode of treatment. Advances in Knowledge: USG plays a pivotal role in the evaluation of oriental cholangiohepatitis in the low resource settings where higher modalities like MRI are not available, especially in the remote areas of developing countries, as it has high degree of accuracy in the diagnosis of OCH.

Portal flow diversion based on portography is superior than puncture site in the prediction of overt hepatic encephalopathy after TIPS creation

BackgroundTargeted puncture of an appropriate portal venous branch during transjugular intrahepatic portosystemic shunt (TIPS) procedure may reduce the risk of postprocedural overt hepatic encephalopathy (HE). This study aimed to describe blood distribution under portography and combined it with puncture site to determine portal flow diversion, and to evaluate its prognostic value in predicting post-TIPS overt HE.MethodsIn this retrospective analysis of patients with cirrhosis undergoing TIPS, we included 252 patients to describe blood distribution under portography and 243 patients to assess the association between portal flow diversion and post-TIPS overt HE.ResultsAt the first stage, 51 (20.2%) patients were identified as type A (unilateral type with the right portal branch receives blood from splenic vein [SV]), 16 (6.4%) as type B (unilateral type with the right branch receives blood from superior mesenteric vein [SMV]) and 185 (73.4%) as type C (fully mixed type). At the second stage, 40 patients were divided into the SV group, 25 into the SMV group and 178 into the mixed group. Compared with the mixed group, the risk of post-TIPS overt HE was significantly higher in the SMV group (adjusted HR 3.70 [95% CI 2.01–6.80]; p < 0.001), whereas the SV group showed a non-significantly decreased risk (adjusted HR 0.57 [95% CI 0.22–1.48]; p = 0.25). Additionally, the SMV group showed a substantial increase in ammonia level at 3 days and 1 month after procedure.ConclusionsOur results support the clinical use of portal flow diversion for risk stratification and decision-making in the management of post-TIPS overt HE.

Effects of contrast enhancement boost postprocessing technique in combination with different reconstruction algorithms on the image quality of abdominal CT angiography

ObjectivesTo investigate whether contrast-enhancement-boost (CE-boost) in combination with hybrid iterative reconstruction (Hybrid IR, also named HIR [AIDR 3D, adaptive iterative dose reduction three dimensional]) and model-based iterative reconstruction (MBIR [FIRST, forward projected model-based IR solution]) algorithms can improve the image quality of abdominal CT angiography (CTA). MethodsThis retrospective study included 50 patients who underwent abdominal CTA. Both arterial and portal phases were reconstructed using three different algorithms [filtered-back projection (FBP), AIDR 3D, and FIRST] separately. CE-boost was performed additionally to generate AIDR 3D-boost and FIRST-boost images. Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of the arteries and portal system were compared among the five datasets (FBP, AIDR 3D, FIRST, AIDR 3D-boost, FIRST-boost). In subjective analyses, two radiologists independently ordered images (5, best; 1, worst) based on the visual image quality of distal arterial or portal venous branches. The Friedman and the Dunn-Bonferroni post-hoc tests were used for statistical analysis. ResultsFIRST-boost arterial and portal images had the lowest noise compared with FBP, AIDR 3D, FIRST, and AIDR 3D-boost images (all P < 0.05), and significantly higher SNR and CNR than FBP, AIDR 3D, and FIRST images (all P < 0.05). AIDR 3D-boost images showed lower noise, and higher SNR and CNR than FBP and AIDR 3D images (all P < 0.05). FIRST-boost images had higher subjective grading scores than FBP, AIDR 3D, and AIDR 3D-boost images (all P < 0.05). ConclusionThe postprocessing technique CE-boost can improve the image quality of abdominal CTA images. MBIR in combination with CE-boost (FIRST-boost) images had the best image quality compared with the other four image datasets.

Quantitative analysis of contrast-enhanced ultrasound estimates intrahepatic portal vascularity in dogs with single extrahepatic portosystemic shunt.

To evaluate the clinical impact on quantitative analysis of contrast-enhanced ultrasound (CEUS) on single extrahepatic portosystemic shunt (PSS) in dogs. 21 client-owned dogs with single extrahepatic PSS and 5 healthy Beagles. In all dogs, CEUS was performed to calculate the rising time (RT), rising rate (RR), and portal vein-to-hepatic parenchyma transit time (ΔHP-PV) from the time-intensity curve obtained in the hepatic parenchyma and portal vein. All dogs in the PSS group underwent preoperative CT angiography (CTA) and surgery. The CEUS variables in the PSS group were compared with those in the healthy dogs (control group) and were analyzed for shunt types and grades of intrahepatic portal venous branches based on CTA findings, intraoperative portal pressure, and surgical procedures. All 3 CEUS variables showed no significant differences between the PSS and control groups. The RT and ΔHP-PV in the left gastrophrenic shunt group were significantly longer than in the other shunt types. In the intrahepatic portal vascularity, the RT in grade 1 was significantly shorter than in grades 3 and 4, and the RR in grade 1 was significantly higher than in grade 4. The RT and ΔHP-PV were significantly correlated with portal pressure variables. The RT in dogs with partial ligation was significantly shorter than in dogs with complete ligation and percutaneous transvenous coil embolization. Quantitative assessments of CEUS may be useful for estimating intrahepatic portal vascularity in dogs with single extrahepatic PSS.

PECULIARITIES OF THE PORTA-CAVAL FIBROUS UNION EXISTENCE IN A SEPARATE SEGMENT OF HUMAN LIVER

undamental work relies on studying 40 normal human livers. Macro-microscopic morphologic methods have been used to reveal presence of porta-caval fibrotic connections and its characteristics in single hepatic segment. In hepatic segments major branches of portal complexes and hepatic veins in the area of intersection touch each other and give rise to porta-caval fibrotic connections. It has been demonstrated in all livers. In a single organ, number of porta-caval fibrotic connections ranged from 1 to 9, which depended on a density of portal and caval venous branching. Left lobular segments are remarkable for the constant presence of porta-caval fibrotic connections, where there is an abundance of fan-shaped (I segment) and overlying (II and III segments) connection types. In terms of porta-caval fibrotic connections, bile ducts are in contact with wall of hepatic veins and inferior vena cava, which determines high likelihood of extension of inflammatory process of biliary pathways to the caval veins.

Management of Bleed from Percutaneous Portal Puncture Site (post-BRTO) by Trans-jugular-Trans-Hepatic Embolization

AbstractWe report the case of an elderly male, who was a known case of chronic liver parenchymal disease. He presented with a history of melena for 2 weeks and upper-GI endoscopy revealed fundal varices. He was planned for BRTO. Along with BRTO, a percutaneous trans-hepatic puncture of a branch of the right portal vein was also performed for proper embolization of the varices. The trans-hepatic puncture-tract was embolized after the procedure. However, after 24 hours of the procedure, the patient developed hypotension and abdominal distension due to hemorrhage from the portal puncture site. Portal-venography was performed via the trans-jugular-trans-hepatic route to confirm the source of hemorrhage and embolization of the culprit portal venous branch was performed via the same route. The patient was stable after the procedure.Various interventional procedures via the trans-jugular route have been routinely described in the literature, including trans-jugular liver biopsies, placement of TIPSS shunts and endovascular interventions for haemodialysis. However, the literature on trans-jugular embolization of portal vein is scarce. This case describes the unexpected clinical situation, in the form of bleeding from the portal puncture site, despite embolization of the trans-hepatic tract after BRTO. Finally, a creative solution was thought of and trans-jugular embolization of the portal vein was performed, which succeeded in terminating the ongoing bleeding from the portal vein.

Virtual Monoenergetic Spectral Detector CT for Preoperative CT Angiography in Liver Donors

ObjectiveThe purpose of this study was to evaluate the use of virtual monoenergetic images (VMI) in pre-operative CT angiography of potential donors for living donor adult liver transplantation (LDALT), and to determine the optimal energy level to maximize vascular signal-to-noise and contrast-to-noise ratios (SNR and CNR, respectively). Materials and methodsWe retrospectively evaluated 29 CT angiography studies performed preoperatively in potential liver donors on a spectral detector CT scanner. All studies included arterial, early venous, and delayed venous phase imaging. Conventional polyenergetic images were generated for each patient, as well as virtual monoenergetic images in 10 keV increments from 40 –100 keV. Arteries (aorta and celiac, superior mesenteric, common hepatic, right and left hepatic arteries) were assessed on arterial phase images; portal venous system branches (splenic, superior mesenteric, main, right, and left portal veins) on early venous phase images; and hepatic veins on late venous phase images. Vascular attenuation, background parenchymal attenuation, and noise were measured on each set of virtual monoenergetic and conventional images. ResultsBackground hepatic and vascular noise decreased with increasing keV, with the lowest noise at 100 keV. Vascular SNR and CNR increased with decreasing keV and were highest at 40 keV, with statistical significance compared with conventional ( P < 0.05). ConclusionsIn preoperative CT angiography for potential liver donors, the optimal keV for assessing the vasculature to improve SNR and CNR is 40 keV. Use of low keV VMI in LDALT CT protocols may facilitate detection of vascular anatomical variants that can impact surgical planning.

Study of the human liver by ultrasound examination to search for variations of venous anatomy.

Knowledge about venous patterns (especially portal and hepatic venous) and their variations are extremely crucial for liver transplantation and other surgical procedures on liver. Studies have been done at national or international level on variations of hepatic venous patterns by CT or MRI or by dissection on cadaveric liver. No definitive or authentic study on this topic could be noted in electronic and print media, as well as in standard textbook. Considering low cost and noninvasive nature, we utilized ultrasonography to bridge this lacuna. To estimate prevalence and types of anatomical variations of hepatic venous system and to determine association of among variations. It is an observational cross-sectional study where ultrasonographic evaluation of hepatic venous pattern on adult population of either sex (consecutive sampling) without any major liver disorders was done in RG Kar Medical College and data were analyzed with appropriate statistical procedures. Normal hepatic venous pattern along with normal portal venous pattern is much higher in our study, which is a unique finding. The proportion of normal portal venous pattern is more in extra hepatic bifurcation group. Variations of portal vein and normal hepatic venous pattern are more in case of intrahepatic bifurcation of portal venous branching group. Overall presence of intrahepatic bifurcation of portal vein is significantly higher than extrahepatic bifurcation. This study provides an updated database for the prevalence and distribution of anatomic variations of the hepatic venous and portal venous system.

S2610 Perihepatic Biloma: A Rare Complication After Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Introduction: Transjugular intrahepatic portosystemic shunt (TIPS) is a minimally invasive procedure and an effective therapeutic option for managing portal hypertension complications. Biliary complications after TIPS are uncommon. Here we present a case of recurrent perihepatic biloma in a woman who underwent TIPS. Case Description/Methods: A 40-year-old woman was admitted for epigastric abdominal pain for five days. She reported taking oral contraceptive pills (OCPs) for one month before presentation. She had epigastric tenderness on examination and normocytic anemia (Hgb 10 g/L) on admission labs. CT scan of the abdomen showed a large thrombus in the main portal vein extending into the right and left portal venous branches. The patient was started on heparin drip and underwent TIPS with thrombectomy. Hypercoagulability workup was unremarkable. The post-procedure course was complicated by elevation of alkaline phosphatase (552 U/L), AST (293 U/L), and ALT (324 U/L). Abdomen MRI showed patent TIPS and persistent complete thrombosis of all intrahepatic portal venous branches. She underwent repeat thrombolysis. However, liver enzymes continued to rise, and a repeat MRI showed intrahepatic biloma at the mid aspect of TIPS (Figure 1A, B). IR-guided drainage of the biloma was performed. The hospital course was complicated by fever and leukocytosis. A follow-up CT scan showed a 13 cm complex fluid collection at the dome of the liver (Figure 2A). She underwent drainage of the new collection and received IV Cefoxotin with an interval decrease in the collection size (Figure 2B). Fever resolved, and liver enzymes normalized. Discussion: Bilomas are either intra- or extrahepatic collections of bile that can occur spontaneously, or as a result of trauma to the biliary tree, including iatrogenic injury. Bilomas are usually asymptomatic but may present with abdominal pain due to symptomatic bile peritonitis or secondary bacterial infection leading to abscess formation and sepsis. A biloma may wall off or may continue to have active bile leakage. CT intravenous cholangiography, MRI with gadolinium, and Tc99 scintigraphy can identify bile leak. Differential diagnoses include hepatic cyst and hematoma, liver abscess, loculated ascites, and postoperative fluid collections, including seroma and lymphocele. Treatment options include endoscopic drainage, IR guided, or surgical drainage with bile leak repair.Figure 1.: 1A, and 1B: MRI coronal T2W, MRI axial T2W and MRI coronal post contrast, respectively, showing intrahepatic biloma (white arrow) abutting a portion of the TIPS (yellow arrow) with upstream intrahepatic biliary ductal dilatation (blue arrow). 2A and 2B: CT coronal image demonstrates a new peri-hepatic collection surrounding the hepatic dome (black arrow) and interval placement of a percutaneous drainage catheter and decrease in size of the peri-hepatic collection (black arrow).

Laparoscopic cholecystectomy for left-sided gallbladder.

Left-sided gallbladder (LSGB) is a rare congenital anomaly in the gallbladder, which is defined as a gallbladder located on the left side of the falciform ligament without situs inversus. We retrospectively analyzed 13 patients diagnosed with LSGB in a single center to confirm the safety of laparoscopic cholecystectomy (LC) and reviewed the anatomical implications in those patients. Of the 4910 patients who underwent LC for the treatment of gallbladder disease between August 2007 and December 2019, 13 (0.26%) were diagnosed as having LSGB. We retrospectively analyzed these 13 patients for general characteristics, perioperative outcomes, and other variations through the perioperative imaging workups. All patients underwent LC for gallbladder disease. In all cases, the gallbladder was located on the left side of the falciform ligament. The operation was successfully performed with standard four-trocar technique, confirming "critical view of safety (CVS)" as usual without two cases (15.4%). In one case, which had an intraoperative complication and needed choledochojejunostomy because of common bile duct injury, there was an associated variation with early common bile duct bifurcation. The other patient underwent an open conversion technique because of severe fibrosis in the Calot's triangle. Furthermore, on postoperative computed tomography, abnormal intrahepatic portal venous branching was found in all cases. Although LSGB is usually encountered by chance during surgery, it can be successfully managed through LC with CVS. However, surgeons who find LSGB have to make efforts to be aware of the high risk of bile duct injury and possibility of associated anomalies.

Challenging the Treatment Paradigm: Selecting Patients for Surgical Management of Hepatocellular Carcinoma with Portal Vein Tumor Thrombus.

Portal vein tumor thrombus (PVTT) remains a common presentation in patients with hepatocellular carcinoma (HCC). Approximately 30–50% of patients newly diagnosed with HCC will present with a concomitant PVTT. Current guidelines recommend systemic therapy for treatment of HCC with PVTT. Real-world application of partial hepatectomy in HCC patients with PVTT has increased over the past two decades, as perioperative complications have declined. However, it is unclear if there is an association between the extent of PVTT and overall survival and rates of recurrence and whether the perioperative morbidity outweighs these potential benefits. Partial hepatectomy with en bloc resection of PVTT in second-order branches and distal can offer significant benefits in carefully selected patients; however, once the HCC-associated PVTT extends into first-order portal venous branches or more proximal into the superior mesenteric vein, the risks of surgical resection outweigh the benefits. The aim of this review is to determine which patients with HCC presenting with PVTT benefit from surgical resection. We will discuss the classification systems of PVTT and review both outcome and perioperative measures in patients undergoing partial hepatectomy with extirpation of HCC-related PVT.

Laparoscopic portal branch ligation of the right caudate lobe concomitant with portal vein embolization for planned right hemihepatectomy in advanced hepatobiliary cancers.

The role of ligation of the portal venous branches to the caudate lobe (cPVL) as preparation for planned major hepatectomy is unclear. The aim of this study was to evaluate the efficacy of laparoscopic cPVL (Lap-cPVL) concomitant with transileocolic portal vein embolization of the right portal venous system (rTIPE), namely, Lap-cPVL/rTIPE, for planned right hemihepatectomy (rHx) in advanced hepatobiliary cancer patients. Thirty-one patients who underwent rHx after rTIPE with/without Lap-cPVL between March 2013 and March 2020 were enrolled in this study. The Lap-cPVL was performed for the portal branches of the right caudate lobe. Eight of the 31 patients underwent Lap-cPVL/rTIPE. The degree of hypertrophy was significantly increased in Lap-cPVL/rTIPE (19.3%, range 6.5-25.6%) as compared to rTIPE (7.2%, range - 1.1 to 21.2%) (p=0.027). The functional kinetic growth rate was also significantly increased in Lap-cPVL/rTIPE (5.40%, range 2.17-5.97) than that in rTIPE (1.85%, range - 0.22 to 6.45%) (p=0.046). Postoperative liver failure ≧ grade B occurred in 21.7% of patients in rTIPE, while there was no postoperative liver failure ≧ grade B in Lap-cPVL/rTIPE. Mortality rates were zero after rHx in this study. Lap-cPVL/rTIPE is safe and provides an additional effect on liver hypertrophy in advanced hepatobiliary cancers.

2704 Urosepsis Is Difficult to Stomach!

INTRODUCTION: Gastric ischemia is a rare condition associated with poor prognosis typically presenting with abdominal pain, GI bleed and altered mentation and may be caused due to states of shock. We present a rare case of gastric ischemia due to urosepsis. CASE DESCRIPTION/METHODS: A 70 year-old male with past medical history of peripheral vascular disease, chronic Foley catheter and dementia presented with altered mentation, hypotension, tachycardia and decreased urine output. The Foley catheter was replaced revealing purulent urine. Initial labs revealed acute kidney injury, lactic acidosis, and leukocytosis. CT abdomen pelvis without contrast revealed gastric pneumatosis with adjacent left upper quadrant portal venous gas and branching portal venous gas throughout the liver. Esophagogastroduodenoscopy was performed which showed proximal gastric ischemia and necrosis from the midbody to the fundus; biopsies revealed acute hemorrhagic gastritis, and gastroenterology recommended resection. General surgery was consulted who recommended conservative management. Patient improved clinically while receiving antibiotic therapy, intermittent nasogastric tube suction, intravenous proton pump inhibitor therapy and parenteral nutrition. Repeat imaging showed resolution of portal gas and gastric pneumatosis and repeat EGD showed resolution of gastric ischemia. DISCUSSION: Gastric ischemia is a serious condition which is under-recognized clinically. Etiologies include systemic hypotension, vasculitis or disseminated thromboembolism. Gastric pneumatosis or portal venous gas on imaging suggest ischemia; EGD with biopsy is the diagnostic gold standard. Gastric ischemia is either managed surgically or medically with fluid resuscitation, nasogastric tube placement to prevent gastric distension and acid reduction along with antibiotics for patients with gastric pneumatosis.

Precision surgery for primary liver cancer

Liver resection remains the best curative option for primary liver cancer, such as hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma. In particular, in liver resection for HCC, anatomical resection of the tumor-bearing segments is highly recommended to eradicate the intrahepatic metastases spreading through portal venous branches. Anatomical liver resection, including anatomical segmentectomy and subsegmentectomy using the dye-injection method, is technically demanding and requires experience for completion of a precise procedure. The recent development of imaging studies and new computer technologies has allowed for the preoperative design of the operative procedure, intraoperative navigation, and postoperative quality evaluation of the anatomical liver resection. Although these new technologies are related to the progress of artificial intelligence, the actual operative procedure is still performed as human-hand work. A precise anatomical liver resection still requires meticulous exposure of the boundary of hepatic venous tributaries with deep knowledge of liver anatomy and utilization of intraoperative ultrasonography.

Vascular complications following selective portal venous embolisation - Is postinterventional extended liver resection still possible?

Background: Planning strategy for extended liver resection in patients with intrahepatic malignomas is usually based on 2 dimensional(2-D) CT-Scans.In selected cases extension of 2-D scans with virtual 3 dimensional(3-D) liver reconstructions to improve the presentation of the intrahepatic vascular topography,tumor burden and the suspending segmental volumes is necessary to maintain a functional suitable “remnant liver volume"(RLV).If RLV is insufficient portal venous embolization(PVE) is one of the most common procedures to improve liver function reserve. Methods: We report about a 60 y old male patient suffering from colon carcinoma with synchronous bilateral liver metastases.After rectal resection and completing adjuvant chemotherapy restaging CT scan showed downsizing of the remainig right sided liver metastases.During liver resection additional metastases in segment I, II and III were found and resected.As LRV was to small operation was terminated and a PVE of the right portal branch was initiated with accidental spread of embolization fluid into the left portal venous branch as well. Results: Finally 3-D CT-Scans showed progredient volume growth with sufficient LRV to perform extended right hemihepatectomy including segment I.Complete tumor resection was achieved. Conclusion: Eventhoogh a major complication during PVE with an almost complete occlusion of the left sided portal venous branch occured.We recommand extended virtual 3-D reconstruction to evaluate RLV for proper resection planning.