Portocaval Shunt Research Articles

Irreversible Graft Failure Requiring 3 Repeated Liver Transplantations Combined With a 2-Stage Liver Transplantation: A Case Report

IntroductionAlthough repeated liver transplantation (RLT) for irreversible graft failure is relatively rare, RLT is the only life-saving option available for a patient with failure of a previous liver transplant (LT). In cases in which failure of a previous LT is combined with TLS and exsanguination, waiting for organ allocation is not feasible and 2-stage liver transplantation (TSLT) is required. The aim of our case report was to describe the clinical management, including the criteria informing clinical decisions, for a patient who required 3 RLTs combined with TSLT. CaseA 55-year-old man was admitted with liver cirrhosis associated with hepatitis B and multiple hepatocellular carcinomas. LT was performed using an emergent deceased donor graft of marginal quality. The graft was unsuccessful, with the patient showing hemodynamic deterioration and primary nonfunction of the graft. A total hepatectomy, with temporary portocaval shunt, was performed, with a second transplantation performed 3 days later. The second graft was from a 71-year-old, non–heart-beating donor, which resulted in a second episode of primary nonfunction. A third transplantation was performed 4 days later. The patient progressively recovered with extensive rehabilitation. ConclusionWe report the successful outcome for a patient requiring 3 RLTs, with TSLT used as a bridge between transplants to reduce the duration of the anhepatic state. In selected cases, the combination of RLT and TSLT can provide a chance of survival from life-threatening liver failure.

Assessment of splanchnic hemodynamics in patients with cirrhosis after splenectomy in comparison with non-operated patients at the decompensated stage

Splenectomy in patients with cirrhosis presupposes an increase of blood inflow into portal system to decrease the portal pressure. At the same time there are different opinions about splenectomy. So it is actual to study the character of changes of blood flow in vessels of abdominal cavity in pre- and postsurgical periods and assessment of an influence of these changes on the clinical course of cirrhosis.Aim of research: To assess an influence of splenectomy on the character of changes of splanchnic hemodynamics in patients with cirrhosis comparing to non-operated patients with compensated and decompensated clinical course.Materials and methods: There were examined 190 patients with cirrhosis: gastrointestinal bleeding from oesophagus varicose veins took place in 133 patients, diuretic resistant ascites – in 57 ones. 19 patients underwent splenectomy: 7 – in association with sewing of the left gastric vein and artery, 6 – with “skeletonization” of the lesser curvature of stomach with Nessen’s operation, 2 – with Patsiora’s operation, 2 – with application of selective porto-caval shunt between the low mesenteric vein and the left vein of an ovary. 84 patients died during observation. The duration of observation was from 0.5 to 3.5 years. All patients underwent fibrogastroscopy every 3–4 month. Hemodynamics was assessed on the base of repeated ultrasound of abdominal cavity. There were assessed diameter of hepatic and splenic vessels; qualitative and quantitative characteristics of blood flow in hepatic and splenic arteries, portal and splenic veins.Results of research: Changes of hemodynamics in patients after splenectomy as opposed to non-operative patients are characterized with the decrease of diameter of portal vein at almost stable speed of the linear blood flow in it. The result is some decrease of the volume of portal blood and index of portal blood congestion that indirectly indicates the decrease of portal pressure after splenectomy. At the same time arterial hepatic blood flow stays without essential changes.At fibrogastroscopy there was noticed a decrease of esophageal varicose veins dilatation, its tension, elimination of «red signs” that is a prognostic marker of the menace of bleeding. There were noticed no one relapse of bleeding and the sign of refractory ascites during the period of observation.Conclusio: The changes of splanchnic hemodynamics after splenectomy are characterized with decrease of the volume of splanchnic blood. The result is a decrease of portal pressure that is proved with decrease of congestion index in portal vein, decrease of tension of varicose veins, elimination of “red signs” and consequently elimination of the menace of relapse of bleeding and development of resistant ascites. At the same time splectomy can be done in patients with decompensated clinical course of cirrhosis that is proved with an absence of lethality in postsurgical period

Assessment of splanchnic hemodynamics in patients with cirrhosis after portocaval shunting in comparison with no-operated patients with the compensated and decompensated course of disease

Portocaval shunting is recommended for decrease of the portal pressure and regression of the varicose veins in patients with cirrhosis. But the shunting surgery at cirrhosis is limited by the high risk of development of hepatic encephalopathy and the hepatocellular insufficiency in post-surgical period. And the disorder of the hepatic and splanchnic hemodynamics that inevitably appears at different dates after surgery is considered as the main cause of these states.Aim of research. To assess an influence of the shunting surgical interventions on the character of changes of splanchnic hemodynamics in patients with cirrhosis in comparison with no-operated patients with compensated and decompensated course of disease.Material and methods. 190 patients with cirrhosis were examined: 133 had gastrointestinal bleeding, 57 – diuretic-resistant ascites. 18 patients underwent surgery – portocaval shunting. 84 patients died during observation (10 after surgery). The duration of observation was from 2-3 weeks to 2,5-3 years.All patients underwent the repeated ultrasound examination of abdominal cavity. There were defined the diameter of hepatic and splenic vessels; quantitative and qualitative characteristics of the blood flow in hepatic and splenic arteries, in portal and splenic veins. Results of research. At assessment of splanchnic hemodynamics we noticed the differences of parameters depending on time that passed after surgery. The changes of portal blood flow in first 3-6 month were characterized by the moderate widening of portal and splenic veins at little decrease of its mean linear and volume speed so an inflow of the portal blood still stable. Arterial blood flow in hepatic artery was forced at the expense of both widening of diameter and increase of the mean speed of blood flow. The splenic arterial blood flow practically was not changed. The reliable decrease of the volume blood flow in portal vein at the expense of decrease of its linear speed was observed in all patients at later dates. An unfavorable sign was an increase of an index of haemostasia in portal vein and of splenic and hepatic portal index in dynamics that took place in all operated patients and in no-operated ones at the stage of decompensation.Conclusions. The character of changes of splanchnic hemodynamics after portocaval shunting is analogous to the one in no-operated patients at transition from the compensated course of cirrhosis to decompensated one. The compensatory mechanism that preserves the volume of the portal inflow to liver is the widening of the portal vein and preservation of the splenic blood flow. The quality of life in post-surgical period is determined by the duration of compensation of hemodynamic disorders

Focal nodular hyperplasia in an individual with Abernethy malformation type 1b

An asymptomatic 16-year-old man presented for evaluation of ultiple focal liver lesions, the largest measuring 5 cm. Clinical xamination and laboratory values were normal. Magnetic resonance (MR) imaging (axial T2-weighted images) howed isointense to the liver parenchyma lesions with hyperinense central scar (Fig. 1A). Dynamic study showed intense early rterial phase contrast enhancement with non-enhancing scar Fig. 1B). On T1 late phase, the lesions were isointense but the scar nhanced frankly (Fig. 1C). The findings were compatible with focal odular hyperplasia (FNH). Surprisingly, MR venography revealed portocaval shunt. The portal vein (arrow) drained into the infeior vena cava (double arrowhead), thus constituting Abernethy alformation type 1b [1] (Fig. 1D).

Anesthesia for liver transplantation.

Patients with end stage liver disease (ESLD) have complex problems such as cirrhotic cardiomyopathy, coronary artery disease, hepatopulmonary syndrome (HPS), portopulmonary hypertension (POPH), hepatic encephalopathy, intracranial hypertension, (ICP), left ventricular outflow tract obstruction (LVOTO), high Model of end liver disease (MELD) scores, hyponatremia, and coagulopathies. The anesthesia management for liver transplantation can be very complex, dynamic and challenging. Anesthesia agents affect hepatic blood flow and anesthetic drug distribution, metabolism and elimination maybe altered in end stage liver disease. Other non-anesthetic agents such as nitric oxide, epoprosterenol, THAM, hypertonic saline, fibrinogen concentrates, fresh frozen plasma, platelets, packed red blood cells, recombinant plasminogen activator, calcium chloride, epinephrine etc. may play a vital role in the perioperative management of these patients. Intraoperative hemostasis and coagulation management can be very arduous as these patients may bleed or be at risk for thrombosis. Monitoring modalities such as Thromboelastography (TEG), Transcranial Doppler (TCD), Transesophageal Echocardiography (TEE), Bispectral Index (BIS) and Optic Nerve Sheath Diameter (ONSD) ultrasound play a significant role in various circumstances. Surgical techniques include complete or partial occlusion of the inferior vena cava (IVC) with or without use of venovenous bypass (VVBP) or portocaval shunts. Post reperfusion syndrome (PRS) is a crucial event in this procedure, where patients may experience arrhythmia and/or cardiac arrest. Anesthetic handling of this phase has been recapitulated in detail. Provision of anesthesia services to the living liver transplant donor and pain management has been outlined.

Emergent Salvage Direct Intrahepatic Portocaval Shunt Procedure for Acute Variceal Hemorrhage

PurposeTo review the safety and effectiveness of direct intrahepatic portocaval shunt (DIPS) creation with variceal embolization for acute variceal hemorrhage after a failed transjugular intrahepatic portosystemic shunt (TIPS) creation attempt or in patients with prohibitive anatomy. Materials and MethodsTransjugular intrahepatic portosystemic shunt and DIPS procedures performed for variceal hemorrhage between January 2008 and July 2014 were reviewed. The default procedure was TIPS creation, with DIPS creation reserved for patients with unfavorable anatomy or who had technically unsuccessful TIPS creation. Thirteen patients underwent DIPS creation (mean age, 60 y ± 12; Child–Pugh class A/B/C, 8%/62%/30%; Model for End-stage Liver Disease score, 15 ± 5; range, 8–26) and 117 underwent TIPS creation. Four patients underwent a TIPS attempt and were converted to DIPS creation upon technical failure; 9 were treated primarily with DIPS creation because of preprocedural imaging revealing unfavorable anatomy (intrahepatic portal thrombosis, n = 2; venous distortion from prior hepatic resections, n = 2; severely angulated hepatic veins, n = 5). ResultsDirect intrahepatic portocaval shunt creation with variceal embolization (six gastric or esophageal; seven stomal, duodenal, or rectal) was successful in all patients; 11 also had concomitant variceal sclerotherapy. Mean DIPS procedure time was less than 2 hours. There was 1 major procedural complication. During a mean follow-up of 13.0 months ± 15.5, 1 patient developed DIPS thrombosis and recurrent hemorrhage; 1 patient underwent successful transplantation. Two deaths were observed within 30 days, neither associated with recurrent hemorrhage. ConclusionsDirect intrahepatic portocaval shunt creation appears to be a safe, expedient, and effective treatment for patients with acute variceal hemorrhage who are poor anatomic candidates for TIPS creation or who have undergone unsuccessful TIPS creation attempts.

Beneficial Impact of Temporary Portocaval Shunt in Living-Donor Liver Transplantation With a Difficult Total Hepatectomy

BackgroundAlthough a temporary portocaval shunt (TPCS) improves hemodynamic stability during liver transplantation, the role of TPCS is controversial. We assessed the effects of TPCS in patients undergoing living-donor liver transplantation (LDLT) with a difficult total hepatectomy. MethodsWe analyzed outcomes by means of retrospective review of 116 LDLTs performed in our institution from May 2011 to October 2013; among these, 33 recipients received TPCS (group I) and 83 did not (group II). We performed TPCS in a high-risk group, such as those with severe perihepatic adhesions, severe retrohepatic adhesions to the vena cava, or massive bleeding during total hepatectomy. Patient demographics and intraoperative and postoperative variables were reviewed. ResultsNo significant differences were observed in the perioperative variables except intraoperative blood loss. The transfusion requirement and operative time in group I were similar to those in group II despite the higher blood loss and more complicated cases. Hemodynamic status and the vasopressor requirement during the operation were similar between the 2 groups. We also compared 2 subgroups to evaluate the effects of TPCS more precisely in the high-risk patients: subgroup A (Model for End-Stage Liver Disease score [MELD], >20) and subgroup B (MELD, ≤20). The intraoperative requirements for platelet concentrate and epinephrine during the early reperfusion phase in subgroup A were significantly lower than those in subgroup A without TPCS. ConclusionsTPCS was a safe and useful procedure to improve hemodynamic status and postoperative LDLT outcomes in high-risk and select patients.

Risk factors for urolithiasis in dogs with congenital extrahepatic portosystemic shunts: 95 cases (1999-2013).

To identify risk factors for urolithiasis in dogs with congenital extrahepatic portosystemic shunts (EHPSSs) and to determine whether portoazygos shunts were associated with increased risk of urolithiasis at the initial evaluation for EHPSS. Retrospective case series. Dogs (n = 95) with EHPSSs confirmed via CT angiography or surgery. Medical records from 1999 to 2013 were reviewed. Variables of interest included signalment, previous medical management, and results of urinalysis, urolith analyses, and diagnostic imaging. Univariable and multivariable logistic regression analyses for assessment of risk factors for urolithiasis at the time of initial EHPSS evaluation were performed. The dogs' median age was 0.9 years (range, 0.2 to 12.6 years). Among the 95 dogs, 27 (28.4%) and 68 (71.6%) had portoazygos and portocaval shunts, respectively. Urinalysis was performed for 79 (83.2%) dogs, 29 (36.7%) of which had crystalluria (mainly ammonium urate and struvite crystals). Uroliths were present in 34 of 95 (35.8%) dogs; 16 of 17 uroliths analyzed were composed of ammonium urate. Portoazygos shunts were not associated with significantly increased odds of urolithiasis at the time of the initial evaluation for EHPSS. However, the odds of urolithiasis was significantly increased for male dogs, older dogs, and dogs that received previous medical treatment. In dogs with EHPSS, shunt morphology was not associated with increased odds of urolithiasis at the initial evaluation. Male dogs, older dogs, and dogs having received medical management for EHPSS prior to initial evaluation should be considered at increased risk for development of urolithiasis.

Management of rectal varices in portal hypertension.

Rectal varices are portosystemic collaterals that form as a complication of portal hypertension, their prevalence has been reported as high as 94% in patients with extrahepatic portal vein obstruction. The diagnosis is typically based on lower endoscopy (colonoscopy or sigmoidoscopy). However, endoscopic ultrasonography has been shown to be superior to endoscopy in diagnosing rectal varices. Color Doppler ultrasonography is a better method because it allows the calculation of the velocity of blood flow in the varices and can be used to predict the bleeding risk in the varices. Although rare, bleeding from rectal varices can be life threatening. The management of patients with rectal variceal bleeding is not well established. It is important to ensure hemodynamic stability with blood transfusion and to correct any coagulopathy prior to treating the bleeding varices. Endoscopic injection sclerotherapy has been reported to be more effective in the management of active bleeding from rectal varices with less rebleeding rate as compared to endoscopic band ligation. Transjugular intrahepatic portsystemic shunt alone or in combination with embolization is another method used successfully in control of bleeding. Balloon-occluded retrograde transvenous obliteration is an emerging procedure for management of gastric varices that has also been successfully used to treat bleeding rectal varices. Surgical procedures including suture ligation and porto-caval shunts are considered when other methods have failed.

Bipartite portosystemic shunt with single insertion: a rare congenital vascular anomaly in a dog

A case of a bipartite extra hepatic portosystemic shunt is described in a one-year-old, male entire Maltese Terrier breed dog. On CT angiography, one vessel was visibly a portocaval shunt...

Jejunal Variceal Bleeding in an Undiagnosed Cirrhotic: Detected on Capsule Endoscopy and Treated With Embolization

Case Report: A 62-year-old woman presented with hematochezia for 2 days with acute blood loss anemia (drop in Hb from 12 to 7 gm/dL). The patient denied nausea, vomiting, abdominal pain, fever, or change in appetite or weight. She had no prior history of melena, hematemesis, or GI bleeding. Her past medical history was significant for HTN, DM, CHF, and dual renal-pancreas transplant complicated by failed renal graft now on chronic hemodialysis. Physical exam revealed orthostasis and tachycardia. After initial resuscitation, she underwent EGD and colonoscopy, which were unremarkable. Tagged-RBC nuclear scan localized bleeding in LLQ; however, subsequent angiography was unable to localize the bleed. Video capsule endoscopy (VCE) showed large ectopic varices in the jejunum without active bleeding. She underwent transjugular liver biopsy and HVPG measurement, confirming cirrhosis and portal HTN. Extensive work-up for etiology of cirrhosis was negative, and she was diagnosed with cryptogenic cirrhosis. A month later, she again presented with hematochezia. Transjugular intrahepatic porto-systemic shunt (TIPS) was not an option, given her history of ESRD on HD and CHF. She underwent percutaneous coil embolization of superior mesenteric artery branches with complete occlusion of the varices. Since then, she has not had further bleeding. Discussion: While esophagogastric varices are common manifestations of portal hypertension, jejunal variceal bleeding is a rare complication of liver cirrhosis. Jejunal varices account for 5% of all variceal bleeding and are found mostly in patients with prior history of abdominal surgery like our patient. The incidence of bleeding is low, but it can result in severe, life-threatening hemorrhage with in-hospital mortality rates approaching 40%. Endoscopic diagnosis and management is often limited by poor visualization of varices due to their distal location and relatively small size. VCE might show ectopic varices, mostly in the small intestine, along with other changes of portal hypertension such as portal enteropathy. Therapeutic options include endoscopic sclerotherapy, vasoactive drugs, surgery, and TIPS with or without focal variceal embolization. Unless the underlying portal hypertension is treated, suture ligation of varices and sclerotherapy have high rebleeding rates. Surgical portocaval shunts are effective with low rebleeding rates, but only recommended in patients who can tolerate a major surgical procedure. TIPS can effectively reduce portocaval gradient and consequently decrease the risk of rebleeding. Embolization should be considered for patients who are not good candidates for endotherapy, TIPS, or surgery.

Schistosomiasis and the pulmonary vasculature (2013 Grover Conference series).

Inflammation is associated with multiple forms of pulmonary arterial hypertension (PAH), including autoimmune (scleroderma) and infectious (HIV, schistosomiasis) etiologies. More than 200 million people worldwide are infected with Schistosoma, predominantly in Brazil, Africa, the Middle East, and South Asia. Schistosomiasis causes PAH in about 6.1% of those chronically infected and is particularly associated with the species Schistosoma mansoni. Treatment for schistosomiasis-associated PAH includes antihelminthic treatment, if active infection is present (although associated with little immediate benefit to the pulmonary hypertension), and then pharmacologic treatment with targeted pulmonary vascular therapies, including phosphodiesterase type 5 inhibitors and endothelin receptor antagonists. The pathophysiological mechanism by which this parasitic infection causes pulmonary hypertension is unknown but is unlikely to be simple mechanical obstruction of the pulmonary vasculature by parasite eggs. Preexisting hepatosplenic disease due to Schistosoma infection is likely important because of portopulmonary hypertension and/or because it allows egg embolization to the lung by portocaval shunts. Potential immune signaling originating in the periegg granulomas causing the pulmonary vascular disease includes the cytokines interleukin (IL)-4, IL-6, IL-13, and transforming growth factor β. Modulating these pathways may be possible targets for future therapy of schistosomiasis-associated PAH specifically, and study of this disease may provide novel insights into other inflammatory causes of PAH.

Percutaneous Portosystemic Shunts: TIPS and Beyond.

Percutaneous interventions for portal hypertension have been available since the 1990s. Over time, improved technology-including covered stent grafts-and clinical understanding has expanded the available procedures for percutaneous portal decompression. While transjugular intrahepatic portosystemic shunt creation is the most commonly cited percutaneous intervention, direct intrahepatic portocaval shunt and percutaneous mesocaval shunt creation are important alternatives with specific advantages and applications. This article reviews contemporary, minimally invasive interventional approaches to percutaneous portosystemic shunt creation in terms of procedure rationale, patient selection, interventional technique, and technical outcomes.

Diversity of disorders causing neonatal cholestasis - the experience of a tertiary pediatric center in Germany.

Background and Objective: Rapidly establishing the cause of neonatal cholestasis is an urgent matter. The aim of this study was to report on the prevalence and mortality of the diverse disorders causing neonatal cholestasis in an academic center in Germany.Methods: Clinical chemistry and cause of disease were retrospectively analyzed in 82 infants (male n = 42, 51%) that had presented with neonatal cholestasis to a tertiary medical center from January 2009 to April 2013.Results: Altogether, 19 disorders causing neonatal cholestasis were identified. Biliary atresia was the most common diagnosis (41%), followed by idiopathic cases (13%), progressive familial intrahepatic cholestasis (PFIC, 10%), cholestasis in preterm infants (10%), α1AT deficiency, Alagille syndrome, portocaval shunts, mitochondriopathy, biliary sludge (all 2%), and others. Infants with biliary atresia were diagnosed with a mean age of 62 days, they underwent Kasai portoenterostomy ~66 days after birth. The majority of these children (~70%) received surgery within 10 weeks of age and 27% before 60 days. The 2-year survival with their native liver after Kasai procedure was 12%. The time span between Kasai surgery and liver transplantation was 176 ± 73 days. Six children (7%), of whom three patients had a syndromic and one a non-syndromic biliary atresia, died prior to liver transplantation. The pre- and post-transplant mortality rate for children with biliary atresia was ~12 and ~17%, respectively.Conclusion: Neonatal cholestasis is a severe threat associated with a high risk of complications in infancy and it therefore requires urgent investigation in order to initiate life saving therapy. Although in the last 20 years new causes such as the PFICs have been identified and newer diagnostic tools have been introduced into the clinical routine biliary atresia still represents the major cause.

SS9. Vascular Reconstruction plays an Important Role in the Treatment of Pancreatic Adenocarcinoma

Previous studies have proven the feasibility of performing a pancreaticoduodenectomy (Whipple) in patients with portal veinn/superior mesenteric vein (PV/SMV) or arterial invasion. We report our institutional experience with the use of a variety of vascular reconstructive methods during pancreatic resections for adenocarcinoma. A retrospective review was performed identifying all Whipple and total pancreatectomy patients from January 2003 through February 2013. All venous (PV/SMV) and arterial (SMA/hepatic) reconstructions were extracted and reviewed to determine survival and perioperative complications. During the 10-year study period, 270 Whipple and total pancreatectomy procedures were performed, of which 183 were for adenocarcinoma of the pancreas. A total of 60 of 183 (32.8%) vascular reconstructions were found, 49 venous and 11 arterial. Venous reconstruction included 37 (61.7%) primary repairs, 4 (6.7%) reconstructions with cryovein, 3 (5.0%) repairs with autologous vein patch, 3 (5.0%) autologous saphenous reconstructions, and 2 (3.33%) portocaval shunts. Additionally, there were 11 (18.3%) arterial reconstructions (seven hepatic artery and four superior mesenteric artery). There was one perioperative death (1.7%). One-year survival for all reconstructions was 70.3%, which is equivalent to T3 lesions that did not receive vascular reconstruction (72.6%), with a median survival time of 515 days and 12 patients still alive. Survival time was comparable with each type of venous reconstruction, averaging 528 days (11 of 49 patients still alive). Of the venous reconstructions, four of 49 (8.2%) resulted in PV thrombosis, three within the primary repair group and one delayed thrombosis within the cryovein group. There was no thrombosis in any patients after arterial reconstruction. An aggressive approach for stage II pancreatic cancers with venous or arterial invasion can be performed with comparable results when executed by an experienced institution with skilled oncologic and vascular surgeons.

Direct intrahepatic portocaval shunt creation via the inter-strut space of the inferior vena cava stent

Direct intrahepatic portocaval shunt creation via the inter-strut space of the inferior vena cava stent J. Tsauo , Y. Yu , X. Luo , Z. Wang , L. Liu , X. Li a,b,c,* a Institute of Interventional Radiology, West China Hospital, Sichuan University, Chengdu 610041, China Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu 610041, China Department of Radiology, West China Hospital, Sichuan University, Chengdu 610041, China

Successful living donor liver transplantation for giant extensive venous malformation

We report our success in employing LDLT as a course of treatment for extensive hepatic VM. A 14-yr-old pediatric patient presented at our hospital with nosebleed, fatigability, orthopnea, and abdominal distension. He had a history of right hemicolectomy with primary anastomosis due to VM of the transverse colon at age seven. Coagulation abnormalities were apparent, characterized by high international normalized ratio of prothrombin time, decreased fibrinogen level, increased FDPs, and D-dimer. T2-weighted magnetic resonance imaging revealed numerous, variable-sized high signal intensity nodules. Abdominal ultrasonography and CT scan showed hepatomegaly with multiple hypo-echogenic lesions and arteriovenous shunting in the liver. Doppler ultrasound showed hypokinetic flow in the hypo-echogenic lesions of liver. Immediate LDLT was performed to avoid spontaneous rupture and DIC. The right lobe of the liver was implanted with temporary portocaval shunt to prevent intestinal congestion and bleeding. Pathologic examination of the explanted liver confirmed the presence of an extensive hepatic VM. The postoperative course was uneventful, and the patient remained symptom-free with normal liver function throughout the 12-month follow-up period.

Spontaneous intrahepatic portocaval shunt in a patient undergoing liver transplantation

We recently observed a single large intrahepatic portocaval hunt (IPS) in a patient with significant encephalopathy underoing liver transplantation. Pre-transplant computed tomography can showed a large IPS connecting the right portal vein to the etrohepatic vena cava (Fig. 1). Patient was transplanted followng the piggy-back technique with temporary portocaval shunt. epatectomy initially followed a standard right-side approach to he left side resulting in shunt laceration with profuse bleeding. nce haemostasis was obtained the surgical strategy was changed nd the hepatectomy was carried out from left-side to the right llowing lateral clamping of the inferior vena cava thus makng it easier to suture the shunt and minimizing blood loss [1]. PS is a rare venous malformation characterized by diversion of ortal blood flow away from the liver into the systemic circulaion. It may be congenital (Abernethy malformation) or acquired, n adults mostly associated with cirrhosis and portal hypertenion or hepatic trauma. This malformation is extremely rare in on-cirrhotic patients where it has been reported associated with patent ductus venosus. In case of portal hypertension IPS is mall and diffusely located in the cirrhotic liver, but a single nd large IPS that diverges a large amount of portal flow into he systemic circulation is extremely rare. Preoperative recogition of IPS and a left-to-right approach are essential in liver ransplantation.

Fatal massive infectious gas gangrene in a liver transplant recipient

Fatal massive infectious gas gangrene in a liver transplant recipient

8:27 AM; Abstract No. 168 - Initial experience with direct intrahepatic portocaval shunting (DIPS) in patients with anatomy not amenable to transjugular intrahepatic portovenous shunting (TIPS)

To determine the rates of technical success and intermediate-term patency of DIPS (inferior vena cava to portal vein) in patients with hepatic vascular anatomy not amenable to TIPS (hepatic vein to portal vein).