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Surgical shunts for extrahepatic portal vein obstruction in pediatric patients: a systematic review.HPB : the Official Journal of the... May 2021Extrahepatic portal vein obstruction (EHPVO) causes portal hypertension in noncirrhotic children. Among surgical treatments, it is unclear whether the meso-Rex shunt... (Review)
Review
BACKGROUND
Extrahepatic portal vein obstruction (EHPVO) causes portal hypertension in noncirrhotic children. Among surgical treatments, it is unclear whether the meso-Rex shunt (MRS) or portosystemic shunt (PSS) offers lower post-operative morbidity and superior patency over time. Our objective was to evaluate long-term outcomes comparing MRS and PSS for pediatric patients with EHPVO.
METHODS
A systematic review was conducted of articles reporting children undergoing surgical shunts for EHPVO from 1/2000-2/2020. Of 87 articles screened, 22 were eligible for inclusion. The primary outcome was shunt thrombosis and secondary outcomes included non-operative complications, stenosis, and re-operation.
RESULTS
Eighteen of 22 studies were of good quality and four had fair quality. Of 461 patients included, 340 underwent MRS and 121 underwent PSS. MRS were associated with a higher rate of post-operative thrombosis when compared to PSS (14.1% vs 5.8%, p = 0.021). There were 40/340 MRS patients (11.8%) that required at least one re-operation for either shunt thrombosis or stenosis, versus 5/121 PSS patients (4.1%), p = 0.019.
CONCLUSION
Both MRS and PSS result in acceptable long-term patency rates, but the more technically demanding MRS is associated with higher post-shunt thrombosis, often requiring further operative intervention. This study suggests that PSS may offer advantages for pediatric patients with EHPVO.
Topics: Child; Humans; Hypertension, Portal; Portal Vein; Portasystemic Shunt, Surgical; Reoperation; Thrombosis
PubMed: 33388243
DOI: 10.1016/j.hpb.2020.11.1149 -
World Journal of Gastroenterology Nov 2019Since its introduction in 2012, associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has significantly expanded the pool of candidates... (Comparative Study)
Comparative Study Review
Since its introduction in 2012, associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) has significantly expanded the pool of candidates for liver resection. It offers patients with insufficient liver function a chance of a cure. ALPPS is most controversial when its high morbidity and mortality is concerned. Operative mortality is usually a result of post-hepatectomy liver failure and can be minimized with careful patient selection. Elderly patients have limited reserve for tolerating the demanding operation. Patients with colorectal liver metastasis have normal liver and are ideal candidates. ALPPS for cholangiocarcinoma is technically challenging and associated with fair outcomes. Patients with hepatocellular carcinoma have chronic liver disease and limited parenchymal hypertrophy. However, in selected patients with limited hepatic fibrosis satisfactory outcomes have been produced. During the inter-stage period, serum bilirubin and creatinine level and presence of surgical complication predict mortality after stage II. Kinetic growth rate and hepatobiliary scintigraphy also guide the decision whether to postpone or omit stage II surgery. The outcomes of ALPPS have been improved by a combination of technical modifications. In patients with challenging anatomy, partial ALPPS potentially reduces morbidity, but remnant hypertrophy may compare unfavorably to a complete split. When compared to conventional two-stage hepatectomy with portal vein embolization or portal vein ligation, ALPPS offers a higher resection rate for colorectal liver metastasis without increased morbidity or mortality. While ALPPS has obvious theoretical oncological advantages over two-stage hepatectomy, the long-term outcomes are yet to be determined.
Topics: Hepatectomy; Humans; Ligation; Portal Vein; Risk Factors
PubMed: 31798275
DOI: 10.3748/wjg.v25.i43.6373 -
Korean Journal of Radiology Jul 2021Owing to improvements in surgical techniques and medical care, living-donor liver transplantation has become an established treatment modality in patients with end-stage... (Review)
Review
Owing to improvements in surgical techniques and medical care, living-donor liver transplantation has become an established treatment modality in patients with end-stage liver disease. However, various vascular or non-vascular complications may occur during or after transplantation. Herein, we review how interventional radiologic techniques can be used to treat these complications.
Topics: Hepatic Artery; Humans; Liver Transplantation; Living Donors; Portal Vein; Postoperative Complications; Radiology, Interventional
PubMed: 33739630
DOI: 10.3348/kjr.2020.0718 -
Updates in Surgery Apr 2022Perihilar cholangiocarcinoma (pCCA) is one of the most complex challenges for hepatobiliary surgeons. Poor results and high incidence of morbidity after Associating...
Perihilar cholangiocarcinoma (pCCA) is one of the most complex challenges for hepatobiliary surgeons. Poor results and high incidence of morbidity after Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) for pCCA discouraged this indication. It has been proposed that minimally invasive approach for ALPPS first stage, as well as combination of surgical liver partition and radiologic portal vein embolization (PVE), may improve outcomes reducing interstage morbidity. We report a case of right trisectionectomy with enbloc caudatectomy ALPPS scheduled for pCCA with robotic approach at stage-1, the full video is provided as supplementary material. Due to intraoperative presence of portal vein tumor infiltration during hilar dissection (no evidence in the pre-operative work-up), a radiologic right PVE was performed after stage-1 instead of portal vein ligation, followed by portal vein resection and biductal hepatico-jejunostomy at stage-2 with open approach. The patient was a 74-year-old female diagnosed with 3-cm mass-forming pCCA. The total clean liver volume was 1231 cc, with future liver remnant (FLR) volume of 25.1% (segments II and III). She was discharged in the interstage interval on postoperative day (POD) 4; CT scan on POD 12 showed that FLR increased up to 33% (369 cc) (Fig. 1). ALPPS was completed on POD 17, the postoperative course was uneventful, and the patient was discharged in good general condition on POD 19 after stage-2. Besides the already demonstrated advantages in terms of reduced interstage morbidity, robotic ALPPS represents a promising strategy to expand surgical indication in patients with pCCA. The combination of liver partition and PVE may increase the opportunities to perform radical resections in selected patients with pCCA and portal vein infiltration.
Topics: Aged; Bile Duct Neoplasms; Female; Hepatectomy; Humans; Klatskin Tumor; Ligation; Liver; Liver Neoplasms; Portal Vein; Robotic Surgical Procedures; Treatment Outcome
PubMed: 34846695
DOI: 10.1007/s13304-021-01209-x -
Technology in Cancer Research &... 2022This retrospective study aimed to evaluate the technical feasibility and safety of the delayed catheter removal technique in trans-hepatic portal vein embolization...
This retrospective study aimed to evaluate the technical feasibility and safety of the delayed catheter removal technique in trans-hepatic portal vein embolization (PVE) and to explore a suitable technique. This was a retrospective study. In 278 consecutive patients, the puncture tract of the trans-hepatic PVE was treated using the delayed catheter removal technique after PVE. The existence of peripheral hepatic hematoma formation was assessed using ultrasound (US). Follow-up examinations such as magnetic resonance imaging (MRI), computed tomography (CT), and/or US were performed to evaluate perihepatic hematoma formation, hemoperitoneum, and other major complications. Instant hemostasis was achieved in all patients after the procedure. PVE-associated complications were observed in 9 patients (3.24%). No perihepatic hematoma or hemoperitoneum was found in any of the patients. With the appropriate technique, the delayed catheter removal technique can be reliably utilized as a substitute for hemostasis as it is simple and free. This technique should be further evaluated and compared with other methods. This study is the first to investigate the safety and feasibility of the delayed catheter removal technique for embolizing the puncture tract of the trans-hepatic PVE.
Topics: Catheters; Feasibility Studies; Hepatectomy; Humans; Liver Neoplasms; Portal Vein; Retrospective Studies; Treatment Outcome
PubMed: 35119340
DOI: 10.1177/15330338221075154 -
Experimental Animals Feb 2022The current ischemic models of liver failure are difficult and usually time-consuming to produce. The aim of this study was to develop a simplified and reproducible...
The current ischemic models of liver failure are difficult and usually time-consuming to produce. The aim of this study was to develop a simplified and reproducible porcine model of acute liver failure for use in preclinical research. Eighteen Bama miniature pigs were randomly divided into Groups A, B, and C. The hepatic artery and common bile duct were ligated in all groups. While the portal vein was completely preserved in Group A, it was narrowed by 1/3 and 1/2 in Groups B and C, respectively. Results of biochemical analyses, encephalopathy scores, and survival times were compared among the groups. Results of hematoxylin-eosin staining, terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling, Masson staining, and Ki-67 analyses were recorded. Survival times in Groups B and C were 11.67 ± 1.86 and 2.16 ± 0.75 days, respectively, shorter than that in Group A (>15 days). Following surgery, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, alkaline phosphatase, total bilirubin, and direct bilirubin levels significantly increased relative to baseline values in all groups (P<0.05). Groups B and C exhibited a significant decrease in encephalopathy scores and a significant increase in ammonia levels, which were negatively correlated with one another. Pathological analysis revealed obvious necrosis of liver cells, which correlated closely with the degree of portal vein constriction. Our simple, highly reproducible model effectively mimics the clinical characteristics of acute liver failure in humans and provides a foundation for further research on artificial liver support system development.
Topics: Animals; Hepatocytes; Ischemia; Liver; Liver Failure; Liver Failure, Acute; Portal Vein; Swine
PubMed: 34497163
DOI: 10.1538/expanim.21-0076 -
Experimental and Clinical... Sep 2022This study aimed to assess portal and hepatic venous volumes as related to the planning of complex liver resections and segmental liver transplant.
OBJECTIVES
This study aimed to assess portal and hepatic venous volumes as related to the planning of complex liver resections and segmental liver transplant.
MATERIALS AND METHODS
We analyzed 3-dimensional computed tomography of portal and hepatic vein territorial maps of 140 potential living related liver donors. Portal and hepatic vein maps were simulated both separately and in overlap (cross-mapping) to calculate inflow and outflow volumes.
RESULTS
In total liver volume, the right hemiliver was always dominant (mean 64.7 ± 4.8%) and the right medial sector (mean 36.4 ± 6.8%) and segment 8 (mean 19.1 ± 4.3%) accounted for the largest volumes, whereas the left medial sector(mean 13.5 ± 3.1%) and segment 4A (mean 5.8 ± 1.8%) accounted for the smallest volumes (with exclusion of caudate lobe). The right hepatic vein was dominant for both right hemiliver and right lateral sector and had the largest drainage volume in total liver volume (mean 40.0 ± 11.2%). The left hepatic vein was dominant for both left hemiliver and left lateral sector but had the smallest drainage volume fortotal liver volume (mean 21.3 ± 5.0%). The middle hepatic vein drained 50.2 ± 12.5% of the right medial sector and 75.8 ± 15.4% of the left medial sector. In 67 cases, an accessory vein (inferior hepatic vein) drained 16.5 ± 13.2% ofthe right hemiliver, 31.4 ± 25.1% ofthe right lateral sector, 26.6 ± 23.2% of segment 7, and 37.4 ± 31.3% of segment 6.
CONCLUSIONS
The portal and hepatic vein territorial anatomy was characterized by extensive individual variability. An extremely smallremnant volume (<25% of total liver volume) precluded a minority of virtual extended left and a majority of extended right hepatectomies. Left trisectionectomy was associated with risky drainage from the middle hepatic vein, extensive segment 6 remnant congestion volume in 8% of cases, and right lateral sector-favorable inferior hepatic vein large drainage pattern in 13% of livers.
Topics: Hepatectomy; Hepatic Veins; Humans; Liver; Living Donors; Portal Vein; Tomography, X-Ray Computed; Treatment Outcome
PubMed: 36169105
DOI: 10.6002/ect.2022.0053 -
Radiology Jan 2021Background The current standard for assessing the severity of portal hypertension is the invasive acquisition of hepatic venous pressure gradient (HVPG). A noninvasive...
Background The current standard for assessing the severity of portal hypertension is the invasive acquisition of hepatic venous pressure gradient (HVPG). A noninvasive US-based technique called subharmonic-aided pressure estimation (SHAPE) could reduce risk and enable routine acquisition of these pressure estimates. Purpose To compare quantitative SHAPE to HVPG measurements to diagnose portal hypertension in participants undergoing a transjugular liver biopsy. Materials and Methods This was a prospective cross-sectional trial conducted at two hospitals between April 2015 and March 2019 (ClinicalTrials.gov identifier, NCT02489045). This trial enrolled participants who were scheduled for transjugular liver biopsy. After standard-of-care transjugular liver biopsy and HVPG pressure measurements, participants received an infusion of a US contrast agent and saline. During infusion, SHAPE data were collected from a portal vein and a hepatic vein, and the difference was compared with HVPG measurements. Correlations between data sets were determined by using the Pearson correlation coefficient, and statistical significance between groups was determined by using the Student test. Receiver operating characteristic analysis was performed to determine the sensitivity and specificity of SHAPE. Results A total of 125 participants (mean age ± standard deviation, 59 years ± 12; 80 men) with complete data were included. Participants at increased risk for variceal hemorrhage (HVPG ≥12 mm Hg) had a higher mean SHAPE gradient compared with participants with lower HVPGs (0.79 dB ± 2.53 vs -4.95 dB ± 3.44; < .001), which is equivalent to a sensitivity of 90% (13 of 14; 95% CI: 88, 94) and a specificity of 80% (79 of 99; 95% CI: 76, 84). The SHAPE gradient between the portal and hepatic veins was in good overall agreement with the HVPG measurements ( = 0.68). Conclusion Subharmonic-aided pressure estimation is an accurate noninvasive technique for detecting clinically significant portal hypertension. © RSNA, 2020 See also the editorial by Kiessling in this issue.
Topics: Adult; Aged; Aged, 80 and over; Contrast Media; Cross-Sectional Studies; Female; Humans; Hypertension, Portal; Image Enhancement; Male; Middle Aged; Portal Vein; Prospective Studies; Sensitivity and Specificity; Ultrasonography
PubMed: 33201789
DOI: 10.1148/radiol.2020202677 -
United European Gastroenterology Journal Jun 2020Type-C hepatic encephalopathy is a complex neurological syndrome, characteristic of patients with liver disease, causing a wide and complex spectrum of nonspecific... (Review)
Review
Type-C hepatic encephalopathy is a complex neurological syndrome, characteristic of patients with liver disease, causing a wide and complex spectrum of nonspecific neurological and psychiatric manifestations, ranging from a subclinical entity, minimal hepatic encephalopathy, to a deep form in which a complete alteration of consciousness can be observed: overt hepatic encephalopathy. Overt hepatic encephalopathy occurs in 30-40% of patients. According to the time course, hepatic encephalopathy is subdivided into episodic, recurrent and persistent. Diagnostic strategies range from simple clinical scales to more complex psychometric and neurophysiological tools. Therapeutic options may vary between episodic hepatic encephalopathy, in which it is important to define and treat the precipitating factor and hepatic encephalopathy and secondary prophylaxis, where the standard of care is non-absorbable disaccharides and rifaximin. Grey areas and future needs remain the therapeutic approach to minimal hepatic encephalopathy and issues in the design of therapeutic studies for hepatic encephalopathy.
Topics: Administration, Oral; Anti-Bacterial Agents; Drug Therapy, Combination; Endovascular Procedures; Enema; Hepatic Encephalopathy; Hepatic Veins; Humans; Imaging, Three-Dimensional; Lactulose; Liver Cirrhosis; Male; Middle Aged; Non-alcoholic Fatty Liver Disease; Portal Vein; Prevalence; Psychometrics; Rifaximin; Severity of Illness Index; Stents; Tomography, X-Ray Computed; Urinary Tract Infections
PubMed: 32213035
DOI: 10.1177/2050640620909675 -
HPB : the Official Journal of the... Dec 2022Jejunal varix is a concerning late complication after pancreatoduodenectomy (PD) due to the risk of recurrent and intractable bleeding. Our aim was to investigate the...
BACKGROUND
Jejunal varix is a concerning late complication after pancreatoduodenectomy (PD) due to the risk of recurrent and intractable bleeding. Our aim was to investigate the incidence, risk factors, and outcomes of jejunal varix after PD.
METHODS
A total of 709 patients who underwent PD between 2007 and 2017 were included. Preoperative and postoperative CT images were reviewed to evaluate the development of portal vein (PV) stenosis (≥50%) and jejunal varices.
RESULTS
Jejunal varix developed in 83 (11.7%) patients at a median of 12 months after PD. Eighteen (21.7%) patients experienced variceal bleeding. PV stenosis (P < 0.001; odds ratio [OR] 33.2, 95% confidence interval [CI] 15.6-66.7) and PV/superior mesenteric vein resection (P = 0.028; OR 2.3, 95% CI 1.1-4.7) were independent risk factors for jejunal varix. Of the nine patients who underwent stent placement for PV stenosis before the formation of jejunal varices, none experienced variceal bleeding. By contrast, 18 (27.3%) of the 135 patients without PV stent placement experienced at least one episode of variceal bleeding.
CONCLUSIONS
The incidence of jejunal varix was substantial after PD. PV stenosis was a strong risk factor for jejunal varix. Early PV stent placement and maintaining stent patency could reduce the risk of variceal bleeding in patients with PV stenosis.
Topics: Humans; Esophageal and Gastric Varices; Constriction, Pathologic; Gastrointestinal Hemorrhage; Stents; Portal Vein; Varicose Veins; Risk Factors
PubMed: 36150971
DOI: 10.1016/j.hpb.2022.08.011