Portal Venous Drainage Research Articles

SP6.9 - Assessing European Pancreas Transplant Practices to Optimize Patient Outcomes

Abstract Purpose Practise variability exists in pancreas transplantation, but the extent across the EU is unknown. We surveyed pancreas transplant surgeons to assess current practices. Methods A 40-question survey was sent to 84 surgeons at 17 centres in 8 EU countries. Validity and reliability were analysed. Variability was evaluated using descriptive statistics and random effects modelling. Results The response rate was 92% (78/84). The survey demonstrated good validity and reliability (Cronbach’s alpha 0.82). Substantial variability existed in donor selection criteria such as acceptable BMI (range <10 to 35) and age (<30 to >60 years). Back-bench preparation also varied, including arterial reconstruction (52% continuous vs. 48% interrupted sutures) and duodenal closure (66% always buried staple line, 34% not). Systemic portal venous drainage was most common (70%), but 22% used portal drainage. Post-operative anticoagulation varied from 1 week to 3 months in duration. Random effects modelling found significant variability attributable to individual surgeons, centres, and case factors. Conclusions This rigorous survey identified modifiable targets to improve the quality and consistency of pancreas transplantation across the EU. Standardised best practise guidelines should focus on reducing variability in donor selection, back-bench preparation, surgical techniques, and post-operative management. Volume of Pancreas Transplants Performed Annually per CenterNumber of Transplants PerformedRespondents, n (%)<1036 (46%)11-2016 (21%)21-4013 (17%)41-608 (10%)605 (6%) Surgical Experience of RespondentsNumber of PancreasTransplants Performed AnnuallyRespondents, n (%)<24 (5%)2-528 (36%)6-817 (22%)8-129 (12%)1520 (26%)

Abstract PR012: A novel, immune-competent, Myc-dependent murine model of rapid metastatic recurrence of pancreatic cancer after resection

Abstract Pancreatic ductal adenocarcinoma (PDAc) remains a resistant malignancy with dismal outcomes. Early diagnosis, systemic treatment, and complete resection are interdependently essential in improving survival. But even with these interventions, 20-30% of patients will experience a metastatic recurrence within six months of surgery. This “rapid recurrence” (rrPDAc) is devastating and poorly understood, contributing to the nihilism surrounding pancreatic cancer. Overlapping etiologies of these metastatic lesions are possible. They include occult synchronous metastases, as well as disseminated metachronous lesions, both of which we hypothesize may be affected by systemic and microenvironmental changes that occur due to surgical intervention. In human rrPDAc primary tumors, we have identified increased expression of Myc-targets and differences in elements of the tumor immune microenvironment when compared to long-term non-recurrers, in the absence of substantial clinical differences. We describe a novel mouse model of immune competent, surgically resected human PDAc that models rapid recurrence compared to control mice. Our lab has developed an inducible, p48-Cre-recombinase driven LSL-KrasG12D/+ LSL-ROSA-MYC+/+ mouse model that reproducibly develops ADM to PanIN to PDAc lesions that highly recapitulate human carcinogenesis. Lesions lose Smad4 expression progressively, a feature associated with metastatic phenotypes of human PDAc, and also metastasize to the liver. Considering the role MYC plays in regulation of the immune microenvironment, we hypothesized that lines derived from this model would perform well in a model of rapid recurrence. We derived several cell lines from these tumors and implanted them orthotopically in syngeneic mice, monitoring tumor development over fourteen days with ultrasound. Mice were then subjected to takedown (‘pre-op’, n = 5), anesthesia-only controls (n = 17), sham surgical incision (n = 11), and distal pancreatectomy (n = 14). No micro-metastases were identified in livers of the ‘preop’ controls. Mice were tracked via twice-weekly trans-abdominal ultrasound. Surgically resected and sham surgery mice developed metastases a median of 10 days earlier than controls (p = 0.008), suggesting that surgical intervention perturbs the development of metastatic lesions. Furthermore, we have demonstrated that circulating tumor cells may be isolated from the portal venous drainage of these mice, allowing for a novel resource in studying pre-, intra-, and metastatic-compartments of tumor. This model will allow for investigation into rrPDAc and the role surgery may play in exacerbation of metastasis. Citation Format: Patrick J. Worth, Isabel A. English, Jackie M. Phipps, Jason M. Link, Ellen M. Langer, Motoyuki Tsuda, Colin Daniel, Carl Pelz, Jonathan Brody, Brett C. Sheppard, Rosalie C. Sears. A novel, immune-competent, Myc-dependent murine model of rapid metastatic recurrence of pancreatic cancer after resection [abstract]. In: Proceedings of the AACR Special Conference: Cancer Metastasis; 2022 Nov 14-17; Portland, OR. Philadelphia (PA): AACR; Cancer Res 2022;83(2 Suppl_2):Abstract nr PR012.

Abstract B026: Surgery accelerates metastatic recurrence in a novel, immune-competent mouse model of resectable pancreatic cancer

Abstract Pancreatic ductal adenocarcinoma (PDAc) remains a resistant malignancy with dismal outcomes. Early diagnosis, systemic treatment, and complete resection are interdependently essential in improving survival. But even with these, 20-30% of patients will experience a metastatic recurrence within six months of surgery. This “rapid recurrence” (rrPDAc) is devastating and poorly understood and contributes to the nihilism surrounding pancreatic cancer. Overlapping etiologies of these metastatic lesions are possible. They include occult synchronous metastases, as well as disseminated metachronous lesions, both of which we hypothesize may be affected by systemic and microenvironmental changes that occur due to surgical intervention. In human rrPDAc primary tumors, we have identified increased expression of Myc-targets and differences in tumor immune microenvironment when compared to long-term non-recurrers, in the absence of substantial clinical differences in the cohorts, supporting the hypothesis that cell-intrinsic, biological differences exist in patients who undergo rapid recurrence. Furthermore, we have demonstrated in a clinical cohort that this effect persists in spite of neoadjuvant or adjuvant therapy, and is promoted by postoperative surgical site infections. Here, we describe a novel mouse model of immune competent, surgically resected PDAc that models rapid recurrence compared to control mice. Utilizing novel cell lines derived from our lab’s inducible, p48-Cre-recombinase driven LSL-KrasG12D/+ LSL-ROSA-MYC+/+ mouse model, we orthotopically implanted 25,000 cells into the tail of F1-generation BL/6-129J mice and monitored growth and identifiable liver metastases via trans-abdominal ultrasound weekly for two weeks. Mice taken down at day 14 (‘pre-op’ cohort) did not demonstrate micrometastases on serial liver sectioning, however circulating tumor cells (EpCAM+ CD45-) cells were present in venous blood. Experimental mice were then randomized into control (anesthesia only, n = 17), distal pancreatectomy (n = 14), and sham laparotomy cohorts (n = 11). Metastases were tracked via twice-weekly trans-abdominal ultrasound. Surgically resected and sham surgery mice developed metastases a median 12 days earlier than controls (p = 0.003), suggesting that surgical intervention promotes and accelerates the development of metastatic lesions. Furthermore, we have demonstrated that circulating tumor cells may be isolated from the portal venous drainage of these mice, allowing for a novel resource in studying pre-, intra-, and metastatic-compartments of tumor. Through this model we are able to access early metastatic lesions not obtainable in human subjects. Furthermore we can utilize this model to probe the effects of surgical intervention and the immune system on metastasis. This model will allow for investigation into rrPDAc and the role surgery may play in exacerbation of metastasis in humans with an eye towards developing targeted translational investigations. Citation Format: Jackie L. Phipps, Isabel A. English, Jennifer M. Chu, Motoyuki Tsuda, Carl Pelz, Colin Daniel, Dove Keith, Brett C. Sheppard, Jonathan Brody, Rosalie C Sears, Patrick J. Worth. Surgery accelerates metastatic recurrence in a novel, immune-competent mouse model of resectable pancreatic cancer [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr B026.

Transjugular Intrahepatic Portosystemic Shunt

Chronic liver disease is the 11th leading cause of mortality in the United States.1 Portal hypertension is a common endpoint for progressive liver disease, and can clinically manifest as refractory ascites, splenomegaly, and life-threatening esophageal and gastric variceal bleeding. Transjugular intrahepatic portosystemic shunt (TIPS) is an endovascular procedure that treats portal hypertension by making a connection between the portal and systemic venous systems. By creating a low-resistance outflow tract for portal venous drainage, TIPS decreases portal hypertension and its dangerous sequelae in patients not responding to medical therapy.

Portal vein thrombosis and pylephlebitis following laparoscopic appendectomy in a patient with esophageal varices

Pylephlebitis is defined as infectious suppurative thrombosis of the portal vein. The etiologies of pylephlebitis are variable, however, nearly all cases represent a rare albeit serious complication of an intraabdominal infectious process due to the regional portal venous system drainage. Appendicitis is a well-documented cause of pylephlebitis. A 1995 review of 19 cases of reported pylephlebitis demonstrated appendicitis as the second most common pre-disposing etiology in the development of pylephlebitis, with Bacteroides and E. coli being the most commonly cultured organisms. The utility of therapeutic anticoagulation following diagnosis is presently undetermined. We describe a case of pylephlebitis presenting 5 days status post laparoscopic appendectomy for uncomplicated acute appendicitis in a 62-year-old adult male with a history of cirrhosis and esophageal varices. Considering the patient’s history of cirrhosis and resultant esophageal varices, this uncertainty regarding the use of anticoagulation was particularly problematic. Given the lack evidence-based guidelines, a multidisciplinary approach weighing the risks and benefits of systemic anticoagulation was employed. Ultimately, the decision was made to proceed with therapeutic anticoagulation under close supervision with serial imaging to identify thrombus propagation and/or recanalization. While the patient did not demonstrate evidence of recanalization after 58 days of therapy, the throm-bus did indeed fail to propagate further. Clarification regarding the utility of anticoagulation in the setting of pylephlebitis in conjunction with risk stratification based on individual patient factors is certainly warranted to optimize future clinical outcomes.

European Neuroendocrine Tumor Society (ENETS) 2022 Guidance Paper for Carcinoid Syndrome and Carcinoid Heart Disease

European Neuroendocrine Tumor Society (<scp>ENETS</scp>) 2022 Guidance Paper for Carcinoid Syndrome and Carcinoid Heart Disease

P.133: Systemic Venous Versus Portal Venous Drainage in Simultaneous Pancreas-Kidney Transplantation: A Matched-pair Analysis

Purpose: Portal venous drainage of pancreatic transplant appears more physiologic compared to systemic venous drainage. However, present data does not support the superiority of one technique over the other. The study purpose was to evaluate outcomes in vascularized pancreas transplantation (PTx) with enteric exocrine drainage based on technique of venous delivery. Methods: We retrospectively analyzed 231 simultaneous pancreas-kidney transplants (SPKTs) performed at our center between 7/2003 – 7/2019 and identified 27 that were performed with systemic venous (iliac vein) and enteric exocrine (systemic-enteric [S-E]) drainage. These 27 patients were compared to 27 case controls with portal venous and enteric exocrine drainage matched for recipient age, gender, race, and date of transplant. Results: The 2 groups were well-matched.Indications for S-E drainage were central obesity/thickened mesentery (10), unfavorable vascular anatomy (11), or surgeon preference (6). The S-E drainage group was characterized byslightly more patients ≥ 80 kg (44% S-E versus 26% P-E), with C-peptide positive diabetes (30% S-E versus 18% P-E), and with diabetes onset at >20 years of age (41% S-E versus 26% P-E, all p=NS), suggesting a Type 2 diabetes phenotype. Although the incidence of early pancreas thrombosis (3.7% S-E versus 0% P-E), early relaparotomy (30% S-E versus 22% P-E), and mean initial length of hospital stay (11 days S-E versus 8 days P-E) were numerically higher in S-E versus P-E SPKTs, none of these differences were significant. With a mean follow-up of 5 years in both groups, respective one and 3-year patient survival (100% and 96% S-E vs 100% and 100% P-E), kidney graft survival (100% and 96% S-E vs 100% and 89% P-E), and pancreas graft survival (96% and 96% S-E vs 100% and 100% P-E) rates were comparable. Conclusions: The method of venous delivery of insulin following PTx does not appear to influence medium-term outcomes in SPKT with enteric exocrine drainage. K. Gurung2, R. Stratta2, A. Farney2, G. Orlando2, C. Jay2, A. Reeves-Daniel3, A. Mena-Gutierrez3, N. Sakhovskaya3, W. Doares4, S. Kaczmorski4, M. Magid4, J. Rogers2 .

Preserving inferior right hepatic vein enabled bisegmentectomy 7 and 8 without venous congestion: a case report

BackgroundIn hepatectomy, the preservation of portal perfusion and venous drainage in the remnant liver is important for securing postoperative hepatic function. Right hepatectomy is generally indicated when a hepatic tumor involves the right hepatic vein (RHV). However, if a sizable inferior RHV (IRHV) exists, hepatectomy with preservation of the IRHV territory may be another option. In this case, we verified the clinical feasibility of anatomical bisegmentectomy 7 and 8 with RHV ligation, averting the right hepatic parenchyma from venous congestion, utilizing the presence of the IRHV.Case presentationA 70-year-old man was presented with a large hepatic tumor infiltrating the RHV on computed tomography during a medical checkup. The patient was diagnosed with hepatocellular carcinoma (HCC), T2N0M0, stage III. Right hepatectomy was first considered, but multi-detector computed tomography (MDCT) also revealed a large IRHV draining almost all of segments 5 and 6, suggesting that IRHV-preserving liver resection may be another option. The calculated future remnant liver volumes were 382 mL (26.1% of the total volume) after right hepatectomy and 755 mL (51.7% of the total volume) after anatomical bisegmentectomy 7 and 8; therefore, we scheduled IRHV-preserving anatomical bisegmentectomy 7 and 8 considering the prevention of postoperative liver failure and increased chance of performing repeat resections in cases of recurrence. Preoperative three-dimensional simulation using MDCT clearly revealed the portal perfusion area and venous drainage territories by the RHV and IRHV. There was an issue with invisibility of the anatomical resection line of segments 7 and 8, which was completely dissolved by intraoperative ultrasonography using Sonazoid and the portal dye injection technique with counter staining. The postoperative course in the patient was uneventful, without recurrence of HCC, for 30 months after hepatectomy.ConclusionsIRHV-preserving anatomical bisegmentectomy 7 and 8 is a safe and feasible procedure utilizing the three-dimensional simulation of the portal perfusion area and venous drainage territories and the portal dye injection technique.

Early partial portal venous contrast enhancement in canine CT‐Angiography

Early partial portal vein contrast enhancement (EPoVE) during the late arterial phase is seen in CT angiography of dogs. Previously, it has been a finding attributed to arterioportal vascular anomalies. However, EPoVE may be a normal feature of venous return from abdominal organs. This prospective, descriptive study investigated the origin of EPoVE using four-dimensional CT (4D-CT). Sixteen dogs undergoing 4D-CT for disease of the cranial abdomen were prospectively collected. Regions of interest were placed in the hepatic artery (HA), gastroduodenal vein (GV), extrahepatic portal vein (EHPV) cranial and caudal to the GV, and splenic vein (SV) caudal to its EHPV entry. Times to earliest, partial, full, and maximal vascular enhancement were recorded. A mixed model analysis of variance was used to compare time-to-contrast enhancement between vessels. The number, origin, and time of EPoVE were recorded if visible. A total of 24 EPoVE areas were observed in all dogs. Most dogs had either one (10/16) or two (5/16) areas of EPoVE. The origin of EPoVE was identified in 14 of 24 areas: the GV in five areas, cranial mesenteric vein in four areas, pancreatic branch of SV in three areas, and SV in two areas. The time-to-contrast-enhancement was significantly different for the individual veins compared to the HA. EPoVE during the late arterial phase is a common phenomenon of early portal venous drainage of abdominal organs; it should not be interpreted as pathognomonic for arterioportal vascular anomalies, which should be diagnosed based on additional criteria.

A Tailored Strategy for Recipient Hepatectomy: Left Portal Flow Preserving High Hilar Dissection

BackgroundLee et al. (Liver Transpl 10(9):1158–1162, 2004) reported high hilar dissection (HHD) technique as a novel method for recipient hepatectomy to overcome limitations of conventional hilar dissection (CHD). HHD allowed performing multiple tension-free biliary anastomoses and easy reconstruction of double portal vein orifices. However, longer anhepatic phase is its main drawback. We describe a new modification of original HHD, called left portal vein flow preserving HHD (LFP-HHD). The new technique aims to gain the balance between CHD and original HHD. MethodsThe detailed technique of recipient hepatectomy by LFP-HHD is shown in the electronic video file. It involves high intrahepatic division of hilar structures while maintaining portal drainage through maintained left portal vein (LPV). Control of right hemi-liver inflow allows for division of right hepatic vein, and safe dissection of inferior vena cava (IVC) and hilar structures. According to coordination with donor surgery, the liver could be easily explanted. DiscussionLFP-HHD has the same principle of original HHD allowing for multiple tension-free well-vascularized biliary anastomoses. LFP-HHD allows for shortening of anhepatic phase duration as portal venous drainage is continued through maintained LPV avoiding prolonged total portal clamping with bowel edema or the need for temporary porto-caval shunt. On the other hand, the number and the length of the hilar structures can be decreased compared with the original HHD technique. However, the level of division of the hilar structures is acceptable in most of the cases. ConclusionLFP-HHD is a novel simple technique for recipient hepatectomy that can be tailored for certain clinical conditions.

A Tailored Strategy for Recipient Hepatectomy: Left Portal Flow Preserving High Hilar Dissection

Summary: High hilar dissection (HHD) technique was reported as a novel technique for recipient hepatectomy. It allowed performing multiple tension-free duct to duct biliary anastomoses, hence reducing biliary complications. However, longer anhepatic phase is its main drawback. We describe a new modification of HHD technique, called left portal vein flow preserving HHD (LFP-HHD). It involves high intrahepatic division of hilar structures while maintaining the portal venous drainage through the left portal vein. Control of right hemi-liver inflow allows for division of the right hepatic vein, and further dissection of the retro-hepatic inferior vena cava easily and safely. Dissection of the anterior hilar structures can be accomplished. According to the co-ordination with the donor and bench surgery, the liver could be easily explanted. LFP-HHD technique is a novel simple technique for recipient hepatectomy that can be tailored for certain clinical conditions. It overcomes limitations of original HHD technique without compromising its merits.

Where’s Waldo? Extrahepatic Site Options for Islet Transplantation

The current predominant location for allo- and auto-transplantation of islet cells is into the liver via the portal venous system. Despite the relative success of this site over the last several decades, further study has revealed multiple disadvantages. Portal hypertension, portal vein thrombosis, bleeding, low oxygen tension, instant blood mediated inflammatory reaction, inadequate alpha cell function, and delays in neovascularization are factors that continue to drive researchers to explore alternative extrahepatic sites for islet transplantation. The spleen, kidney, intestinal wall, bone marrow, omentum, peritoneum and other sites have been evaluated for islet transplant. Factors to include in choosing an optimal site includes: capacity, transplant efficacy, portal venous drainage, high oxygen tension, easy retrivability and access. Some sites have been explored only in a experimental capacity with preclinical work, while other sites, such as the omentum, are currently undergoing clinical trials. The various benefits and limitations of these sites are reviewed in this article.

Comprehensive approach to oncological liver surgery with 3D Personalized models in preoperative planning

Introduction: Increase in indications of primary hepatic to metastatic cancer operations require more detailed knowledge of the vascular, tumoral and organal anatomy. 3D printing liver models are used in new surgical approaches, innovative operative strategies and preoperative planning. Our purpose to create life-like individual 3D patient models is to aid hepatectomy process of the surgeon, to assess tumor extent, spread and liver arterial supply as well as biliary structures, portal and hepatic venous drainage. Methods: 20 patients' computed tomography scans were imported into DICOM imaging software to obtain 3D surface renderings of liver tumoral tissue and its vascular structures. 3D models of liver, tumoral tissue, portal veins, hepatic veins, hepatic arteries and biliary system were created using 3D modelling software. Results: 3D anatomosurgical models assist us to comprehend the spatial anatomy configuration of like-like models. 3D personalized liver models help to examine the location of the liver tumor in details with reference as well as its extension and neighboring relationship of vascular structures in patients suffering from hepatic carcinoma. Not only the geometrical changes caused by the tumor and the changes in liver tissues but also the relationship of neighboring vascular structures could easily be manipulated from different angles with the models. Conclusion: Patient-specific models could provide an increased understanding of the complex vascular hepatic anatomy of the tumor and allow surgeons to orient tumoral structure operation more effectively. These models also help them gain valuable experience in surgical techniques without exposing patients to risks of harm.

A comparison of portal venous versus systemic venous drainage in pancreas transplantation

BackgroundThe decision to utilize portal or systemic venous drainage in pancreas transplantation is surgeon- and center-dependent. Information regarding the superior method is based on single-center reports and animal models. MethodsUNOS data on adults receiving pancreas and kidney-pancreas transplants from 1987 to 2016 were analyzed (n = 29 078). The groups analyzed were: systemic venous pancreas graft drainage (SVD, n = 24 512) or portal venous pancreas graft drainage (PVD, n = 4566). A Cox proportional hazard model compared patient and allograft survival between groups. ResultsNo statistically significant differences were observed for patient and allograft survival at 1, 3, 5, 10, or 15 years post-transplant at each time interval and cumulatively (patient – HR:1.041; 95% CI:0.989–1.095; allograft – HR:0.951; 95% CI:0.881–1.027). PVD reduced the risk of death by 22.0% (P = 0.017) compared to SVD for patients undergoing pancreas after kidney transplant (PAK); no statistically significant difference was found for patients undergoing other types of transplants. ConclusionThere is no significant clinical difference in patient or allograft survival between PVD and SVD in pancreas transplantation for the majority of patients. For the subgroup of PAK, PVD was associated with decreased mortality. For individual surgeons, center and patient scenarios should dictate which technique is performed.

Portal Supply and Venous Drainage of the Caudate Lobe in the Healthy Human Liver: Virtual Three-Dimensional Computed Tomography Volume Study.

The venous vascular anatomy of the caudate lobe is exceptional. The purpose of this study was to assess portal inflow and venous outflow volumes of the caudate lobe. Extrahepatic (provided by the first-order branches) versus intrahepatic (provided by the second- to third-order branches) portal inflow, as well as direct (via Spieghel veins) versus indirect (via hepatic veins) venous drainage patterns were analyzed in virtual 3-D liver maps in 140 potential live liver donors. The caudate lobe has a greater intrahepatic than extrahepatic portal inflow volume (mean 55±26 vs. 45±26%: p=0.0763), and a greater extrahepatic than intrahepatic venous drainage (mean 54-61 vs. 39-46%). Intrahepatic drainage based on mean estimated values showed the following distribution: middle > inferior (accessory) > right > left hepatic vein. Sacrifice of extrahepatic caudate portal branches can be compensated by the intrahepatic portal supply. The dominant outflow via Spieghel veins and the negligible role of left hepatic vein in caudate venous drainage may suggest reconstruction of caudate outflow via Spieghel veins in instances of extended left hemiliver live donation not inclusive of the middle hepatic vein. The anatomical data and the real implication for living donors must be further verified by clinical studies.

Catheter interventional treatment of congenital portosystemic venous shunts in childhood.

The study aimed on the catheter interventional treatment of congenital portosystemic venous shunt (CPSVS) in childhood and the impact on vascular growth of hypoplastic portal veins. Clinical course and follow up of partial or complete closure of CPSVS are described. CPSVS is a very rare vascular malformation of the portal venous drainage resulting in potentially life threatening abdominal, pulmonary, cerebral, and cardiac complications. The anatomic type, clinical course, and diagnosis must be determined for optimal management. Single centre case series. Eight (6 female) children with extrahepatic (n = 5) and intrahepatic (n = 3) CPSVS were diagnosed invasively by catheterization, including test balloon occlusion of the shunt and simultaneous retrograde angiography, and treated by catheter interventions (n = 5) with partial (n = 2) and complete (n = 3) occlusion of CPSVS at a median age of 3.9 years (range 0.7-21). Congenital heart disease (CHD) was the most frequent associated organ manifestation (n = 5) followed by mild to severe pulmonary arterial hypertension (n = 4), hepatopulmonary syndrome (n = 2), and portosystemic encephalopathy (n = 1). CHD was simple (n = 3) or complex type (n = 2). Three patients were untreated so far, because they were in excellent clinical condition at an age <1 year, refused treatment, or planned for later treatment. Accurate invasive diagnosis of CPSVS with test balloon occlusion of the shunt is mandatory to depict the anatomic situation. Catheter interventional treatment of CPSVS offers a feasible and safe approach with complete or partial closure of the vascular malformation inducing potentially significant vascular growth of a former hypoplastic portal venous system. © 2015 Wiley Periodicals, Inc.

Systematic examination of the fetal abdominal precordial veins: a cohort study.

Examination of the fetal venous system is a necessary part of complete fetal organ scanning to confirm landmark anatomy, such as the ductus venosus and course of the umbilical veins, and, whenever cardiovascular anomalies are identified, to exclude associated anomalous development of the fetal veins. We aimed to develop a protocol for systematic examination of the fetal venous system during midtrimester targeted organ scanning. We included low-risk women with a singleton fetus presenting between January 2011 and June 2013 to our center for routine midtrimester (20-24 weeks) targeted organ scanning. Imaging of the venous system was added to the booked scan and comprised two-dimensional color Doppler scanning of the fetal abdomen in three discrete planes, two transverse and one longitudinal. The more caudal plane was obtained in a ventral or lateral transverse abdominal plane to image the umbilical vein, left portal vein, portal sinus, anterior right portal vein, posterior right portal vein, main portal vein and splenic vein and artery. Moving cephalad, a ventral or lateral transverse plane was obtained to image the right, middle and left hepatic veins and inferior vena cava (IVC). Finally, a longitudinal anteroposterior plane showed the umbilical vein, ductus venosus, IVC and left hepatic vein. In some cases the pulsed Doppler waveform of a given target vessel was also examined. Three-dimensional/4D ultrasound was applied as necessary, when anomalous cases were encountered. We examined 1810 women. Their body mass index ranged from 19 to 40 (mean, 24.7). In 38 (2.1%) women, the target anatomy was not visualized satisfactorily owing to maternal body habitus. A T-shaped configuration of the portal system vessels was observed in 63% of cases, an X-shaped configuration in 25% and an H-shaped configuration in 12%. During the study period, 24 congenital anomalies of the precordial venous system were diagnosed: nine cases of persistent right umbilical vein, seven of agenesis of the ductus venosus, five of anomalous portal venous drainage and three of interrupted IVC with azygos continuation. Examination of the fetal venous system is feasible with the application of three abdominal planes. While a venous system scan is not practicable as part of a screening-level examination, mastery of the normal anatomy is an essential part of the professional knowledge base, in order to provide ready and complete scanning of the system in cases of suspected anomalies or disordered cardiac function.

Vascular anatomy of canine hepatic venous system: a basis for liver surgery.

Detailed knowledge of the vascular anatomy is important for improving surgical approaches to the liver. Twelve canine livers were skeletonized to describe the anatomy of their portal and hepatic veins in details. Our data suggest that the liver can be divided into two sections, three divisions, seven lobes and two to four sub-lobes. This differs from the classic division into four lobes, four sub-lobes and two processes. The right section was perfused by the right portal branch and drained by independent hepatic veins, while most of the left section, perfused by the left portal branch, was drained by the main hepatic vein deriving from the middle and the left hepatic vein confluence. Part of the right medial lobe, and in some cases the papillary process of the caudate lobe, drained directly into the caudal vena cava. A proper right hepatic vein draining blood from more than one lobe was never observed. Portal connections between the quadrate and the left medial lobe were frequently recorded. Two sub-lobes with different portal blood supply and venous drainage could be identified in the right lateral (33.3% of cases) and the left lateral (100% of cases) lobes. From our results, the classic nomenclature of the liver lobes does not reflect their vascularization. Based on similarities between canine lobes and human segments, a new nomenclature is possible and may be less confounding in surgical settings.

Infant with bilateral pulmonary sequestrations with portal venous drainage excised by video-assisted thoracic surgery

IntroductionBilateral pulmonary sequestrations are rare congenital anomalies. Despite its benign nature, the potential complications of pulmonary sequestration (PS) are significant, including recurrent pulmonary infections, hemoptysis, congestive heart failure, and malignant potential. Therefore, the main treatment is surgical excision, even for patients with asymptomatic PS. CaseWe present an infant in whom an intralobar PS of the right lung and an extralobar PS of the left lung were diagnosed on prenatal screening ultrasonography. Both were found to have venous drainage into the portal vein. Surgical excision was performed via video-assisted thoracic surgery (VATS) at 14months of age. ConclusionPS may present with unique vascular connections, including venous drainage into the portal vein. VATS resection for pulmonary sequestration is feasible and effective as an alternative to bilateral thoracotomies, in the setting of extensive preoperative planning and performance by an experienced thoracoscopic surgeon.

Pancreas transplantation: The Wake Forest experience in the new millennium.

To investigate the Wake Forest experience with pancreas transplantation in the new millennium with attention to surgical techniques and immunosuppression. A monocentric, retrospective review of outcomes in simultaneous kidney-pancreas transplant (SKPT) and solitary pancreas transplant (SPT) recipients was performed. All patients underwent pancreas transplantation as intent-to-treat with portal venous and enteric exocrine drainage and received depleting antibody induction; maintenance therapy included tapered steroids or early steroid elimination with mycophenolate and tacrolimus. Recipient selection was based on clinical judgment whether or not the patient exhibited measureable levels of C-peptide. Over an 11.25 year period, 202 pancreas transplants were performed in 192 patients including 162 SKPTs and 40 SPTs. A total of 186 (92%) were primary and 16 (8%) pancreas retransplants; portal-enteric drainage was performed in 179 cases. A total of 39 pancreas transplants were performed in African American (AA) patients; of the 162 SKPTs, 30 were performed in patients with pretransplant C-peptide levels > 2.0 ng/mL. In addition, from 2005-2008, 46 SKPT patients were enrolled in a prospective study of single dose alemtuzumab vs 3-5 doses of rabbit anti-thymocyte globulin induction therapy. With a mean follow-up of 5.7 in SKPT vs 7.7 years in SPT recipients, overall patient (86% SKPT vs 87% SPT) and kidney (74% SKPT vs 80% SPT) graft survival rates as well as insulin-free rates (both 65%) were similar (P = NS). Although mortality rates were nearly identical in SKPT compared to SPT recipients, patterns and timing of death were different as no early mortality occurred in SPT recipients whereas the rates of mortality following SKPT were 4%, 9% and 12%, at 1-, 3- and 5-years follow-up, respectively (P < 0.05). The primary cause of graft loss in SKPT recipients was death with a functioning graft whereas the major cause of graft loss following SPT was acute and chronic rejection. The overall incidence of acute rejection was 29% in SKPT and 27.5% in SPT recipients (P = NS). Lower rates of acute rejection and major infection were evidenced in SKPT patients receiving alemtuzumab induction therapy. Comparable kidney and pancreas graft survival rates were observed in AA and non-AA recipients despite a higher prevalence of a "type 2 diabetes" phenotype in AA. Results comparable to those achieved in insulinopenic diabetics were found in the transplantation of type 2 diabetics with detectable C-peptide levels. In the new millennium, acceptable medium-term outcomes can be achieved in SKPT and SPTs as nearly 2/3rds of patients are insulin independent following pancreas transplantation.