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PubMed2002

Autopsy findings following gastric bypass surgery for morbid obesity.

BACKGROUND: Roux-en-Y gastric bypass, currently the most frequently performed surgical procedure for morbid obesity, has a low but significant mortality rate. There are limited data documenting the findings at necropsy in patients who have died following this procedure. OBJECTIVE: To determine cause of death and pathologic processes present in obese subjects dying after gastric bypass surgery. PATIENTS: We studied 10 patients who underwent autopsy following gastric bypass surgery for morbid obesity between the years 1994 and 2000. RESULTS: There were 6 men and 4 women. The mean age of the patients was 48 years (range, 28-62 years). The mean preoperative weight was 162 kg (range, 112-245 kg), and the mean body mass index was 54 kg/m(2) (range, 39-76 kg/m(2)), similar to all patients undergoing gastric bypass at our institution during the same period. Five deaths were directly attributable to technical complications. Five deaths were attributed to underlying comorbid conditions. One patient died of cirrhosis and one of pulmonary hemorrhage. Three patients died from pulmonary embolism. However, 8 of 10 patients had microscopic evidence of pulmonary emboli, despite prophylaxis for deep vein thrombosis. Most patients had some degree of steatohepatitis and hepatic fibrosis (80% and 70%, respectively). There were no deaths from primary cardiac events. CONCLUSIONS: In patients who die after Roux-en-Y gastric bypass, half die due to technical complications, whereas the other half die of complications of their obesity. Clinically, only 20% of patients were suspected to have pulmonary emboli, yet at autopsy, 80% of patients had pulmonary emboli. In morbidly obese patients undergoing Roux-en-Y gastric bypass, there is an unexpectedly high rate of clinically silent pulmonary emboli contributing to morbidity and mortality.

Adult↗
PubMed2004

Triplex operation for portal hypertension with esophageal variceal bleeding: report of 140 cases.

BACKGROUND: Portal hypertension is a common disease. The surgical therapy of this disease focuses on the resultant upper digestive tract bleeding, which can imperil patients' life directly. This study was to evaluate the effect of triplex operation (mesocaval C shunt with artificial graft, ligation of the coronary vein and splenic artery) on portal hypertension and its associated upper digestive tract bleeding. METHODS: A retrospective study was made on clinical data of 140 patients undergoing triplex operation, who had suffered from portal hypertension and upper digestive tract bleeding. RESULTS: Postoperative portal pressure was 25-43 cmH2O(preoperative portal pressure 27-45 cmH2O) with the average reduction of 10 cmH2O. One patient (0.7%) died of cerebrovascular disease. Five patients (3.5%) suffered from mild hepatic encephalopathy, which was ameliorated through conservative treatment. Lymphatic fistula occurred in 3 patients (2.1%) who recovered without treatment 5, 10 days and 3 months after operation respectively. One hundred patients were followed up for 1 month to 6 years without recurrent hemorrhage or hepatic encephalopathy. Hypersplenism and ascites disappeared in 70 patients (70%) and 80 patients (80%) respectively. A significant reduction of ascites was seen in 12 patients(12%). The artificial vessels remained unblocking detected by B type ultrasonography and Doppler sonography in 95 patients(95%). CONCLUSION: Triplex operation is suitable for patients with the following portal hypertensions: portal hypertension caused by simple occlusion of the hepatic vein (a pathological type of Budd-Chiari syndrome); thrombosis of the portal vein or prehepatic portal hypertension because of cavernous transformation; intrahepatic portal hypertension with rebleeding after splenectomy or non-operation, and those patients with liver function in grade A or B according to the Child-Pugh classification.

Adolescent↗
PubMed2000

Transcatheter closure of fenestrations and excluded hepatic veins after fontan: versatility of the Amplatzer device.

BACKGROUND: The aim of this study was to evaluate the Amplatzer septal occluder (ASO) for transcatheter closure of fenestrations and excluded hepatic veins in patients after modified Fontan operations. Residual right-to-left shunts have improved surgical results of the Fontan operation. Shunt closure may eventually be desirable to eliminate hypoxemia and reduce risk of embolic complications. METHODS AND RESULTS: Ten patients with hypoxemia caused by residual shunts after Fontan procedures were evaluated for closure. After favorable results of test occlusion, all shunts were closed with the use of the ASO. Eight ASOs were used to close fenestrations in 7 patients with 6F transvenous sheaths. Three ASOs were used to close excluded hepatic veins in 3 patients with 6F venous sheaths and transbaffle punctures. Fluoroscopy and transesophageal echocardiography were used to guide device placement. Device placement in all patients was successful. All shunts were closed by angiography after device placement. While breathing room air, systemic oxygen saturation rose from 87.9% +/- 3.0% to 96.3% +/- 0. 9% (P <.001) in the patients. There were no complications of the implant procedures and none noted in outpatient follow-up. CONCLUSIONS: This experience suggests that the ASO is safe and effective for closing surgical shunts after Fontan procedures. The ASO design allows closure of excluded hepatic veins and has advantages over other devices in closure of fenestrations.

Adolescent↗
PubMed2006

Assessment of platelet activation in coupled schistosomiasis and viral hepatitis infection: contribution to complexity of course and development of complications.

This study assessed platelet activation and its possible contribution to the pathogenesis of liver cirrhosis (LC), hepatocellular carcinoma (HCC) and portal vein thrombosis (PVT). Forty-five patients with LC caused by dual schistosomiasis and viral hepatitis infections were enrolled in the study, 15 had LC only, 15 were complicated with HCC, and 15 were complicated with PVT, in addition to 15 healthy controls. Platelet morphological parameters including platelet count, platelet crit, mean platelet volume (MPV) and platelet distribution width (PDW), as well as platelet activation as evidenced by measuring soluble platelet selectin (sP-selectin) level and the release of beta-thromboglobulin (beta-TG), transforming growth factor beta-1 (TGF-beta1) and platelet derived growth factor-AA (PDGF-AA) were evaluated. The results obtained revealed significant reduction in platelet count, platelet crit and MPV while PDW was significantly increased in all LC patients in comparison to controls. sP-selectin, beta-TG, TGF-beta1 & PDGF-AA revealed significant increase in all diseased groups when compared to control group. Patients complicated with HCC or PVT demonstrated significant increase in the aforementioned parameters in comparison to patients with LC only. Patients with PVT showed significant increase versus HCC patients. These findings indicate that platelet activation is a prominent feature in LC and its serious complications HCC & PVT. This activation can play an important role in the pathogenesis of LC, HCC & PVT in patients with mixed schistosomiasis and viral hepatitis infections. Such patients need careful medical attention and effective treatment. Stabilization of the activated platelets and the dual suppression of PDGF & TGF-beta1 could be new therapeutic strategies against LC and its sequels.

Adult↗
PubMed2006

[Idiopathic intrahepatic portosytemic shunts in 4 children].

Intrahepatic portosystemic anastomoses are macroscopic communications between the venous portal system and the systemic circulation and located partly in the liver. We report 4 new cases of type II shunts, which illustrate the circumstances of the diagnosis of these exceptional anomalies. For 2 children, the diagnosis was done antenataly by US and spontaneous involution in a few months was observed. In the third case the malformation was evidenced fortuitously at 3 weeks of life, and this 6-year-old child remains completely asymptomatic so far. Then, in the fourth case, a cerebral venous thrombosis was fortuitously and antenatally evidenced in an otherwise uneventful pregnancy and portosystemic shunt was demonstrated postnataly in the extensive work up of the neonate.

Follow-Up Studies↗
PubMedDate not supplied

Hepatocellular carcinoma presenting as portal thrombosis with intrabiliary growth: US and MR findings.

We present an unusual case of hepatocellular carcinoma presenting as massive portal vein thrombosis with progression to the intrahepatic bile ducts without demonstrable primary hepatic tumor. Ultrasound, magnetic resonance, and percutaneous transhepatic cholangiography findings are described. The histologic diagnosis was achieved by means of percutaneous forceps biopsy of the endobiliary mass.

Biopsy, Needle↗
PubMed1996

Imaging of complications in liver transplantation.

Hepatic transplantations are being performed with increasing frequency, leading to greater demand for accurate evaluation of related complications. Ultrasonography (US) is the primary screening technique for detection of vascular complications of hepatic transplantation: angiography is used to confirm the US findings or when the US study is suboptimal. Hepatic artery thrombosis, the most common (as high as 42% of pediatric cases; 4%-12% of adult cases) and important vascular complication, may be associated with bilomas, infarcts, or abscesses at gray-scale US and absence of proper hepatic and intrahepatic arterial flow at Doppler analysis. Hepatic artery stenosis (seen in 11% of cases) is suspected if a focal accelerated velocity of greater than 2-3 m/sec with turbulence is seen at or distal to the stenosis or if a tardus parvus pattern of intrahepatic arterial flow is seen. In cases of inferior vena cava thrombosis and stenosis, US may show echogenic thrombus or obvious narrowing, with a substantially increased flow velocity through the stenosis or reversal of flow in the hepatic veins. Biliary complications occur relatively often (13%-25% of cases) after liver transplantation; bile leakage and biliary stricture, the most common biliary complications, are seen as a fluid collection and a stricture, respectively. Although acute rejection is one of the most serious complications affecting graft survival, it cannot be reliably detected with available diagnostic tests or radiologic methods.

Anastomosis, Surgical↗
PubMed2004

Use of Yttrium-90 glass microspheres (TheraSphere) for the treatment of unresectable hepatocellular carcinoma in patients with portal vein thrombosis.

PURPOSE: Intra-arterial injection of Yttrium-90 glass microspheres ((90)Y- microS; TheraSphere, MDS Nordion, Ottawa, Canada) is indicated for treatment of unresectable hepatocellular carcinoma (HCC) in the presence of acceptable liver function. This study presents hepatic toxicity results after unilobar and bilobar intra-arterial administration of (90)Y- microS in patients with unresectable HCC who had known portal vein thrombosis (PVT) without evidence of cavernous transformation. MATERIALS AND METHODS: Fifteen patients with unresectable HCC and PVT of one or both first order and related segmental portal venous branches received a total of 29 infusions of (90)Y- microS for treatment of HCC. All patients had pretreatment evaluation including: computed tomography (CT) imaging, alpha-fetoprotein (AFP) levels, liver function tests, technetium-99m macroaggregated albumin ((99)Tc-MAA) scan for evaluation of lung and visceral shunting, and angiography with visualization into the portal venous phase. (90)Y- micro S dose was based on lobar hepatic volume with adjustment for lung shunt activity. Liver toxicity was assessed by serum total bilirubin graded for severity according to the NIH NCI Clinical Toxicity Criteria (CTC version 2.0). Other adverse events were reported according to the standards established by the Society of Interventional Radiology. RESULTS: There were no procedural complications with delivery of (90)Y- microS, and treatment was well tolerated by all patients. Increased post-treatment bilirubin levels were observed across all treatments in five patients, four of whom had CT or AFP evidence of intrahepatic disease progression. After initial treatment, two patients developed bilirubin toxicity (grades 1 and 2); one patient demonstrated an increment in bilirubin toxicity grade (grade 1 to grade 3) and one patient had an improvement in grade after initial treatment. There were no new treatment-related toxicities in nine patients after a second treatment. CONCLUSIONS: (90)Y- microS treatment was well tolerated and appears to be safe to use in patients with compromised portal venous flow in one or both first order and related segmental portal venous branches and no evidence of cavernous transformation. In patients who did not exhibit disease progression, there appeared to be no clinically significant change in bilirubin.

Adult↗
PubMed2003

A single-center experience with retrograde reperfusion in liver transplantation.

Poor graft function secondary to injury by ischemia and reperfusion remains a major problem with regard to morbidity and mortality in clinical liver transplantation (LTX). Up to one fifth of patients suffer from poor initial liver function due to severe damage to hepatocytes. This situation leads either to primary nonfunction described in approximately 6% of LTX or to slow recovery. We present a new method of reperfusion during LTX. From July 1998 to July 2002, 42 LTX in 39 recipients, (10 female, 52 years old (26-70) were performed. LTX was carried out in piggy-back technique. After completing the piggy-back anastomosis, the caval vein was declamped immediately, and retrograde low pressure reperfusion of the graft with low oxygenated venous blood was established. Portal anastomosis was performed using a running suture. In order to provide optimal retrograde liver perfusion, no clamping of the donor portal vein was done. After completing portal anastomosis, the recipient portal vein was declamped immediately. During arterial anastomosis, the transplanted liver was antegradely perfused via the portal vein. After completing hepatic artery anastomosis, declamping of the hepatic artery was done and arterial perfusion started. No backtable or in-situ-flushing except the described reperfusion technique was performed. Forty-two LTX in 39 recipients using piggy-back technique and retrograde reperfusion via the caval vein followed by antegrade reperfusion via the portal vein were performed; 38 out of 39 patients (97.44%) were alive and well at day 8 after LTX. One patient (2.56%) died of a pre-existing portal vein thrombosis on day 2 after LTX. Three patients had to undergo retransplantation for hepatic artery thrombosis (7.14%). Liver enzymes, bilirubine, prothrombine time and AT III on day 1, 3, 5 and 8 after LTX showed favourable values. Median aspartate aminotransferase (ASAT) was 219 U/l on day 1 after LTX. One-month survival rate was 95.23%, and 1-year survival rate 87.88%. Two patients died of liver-associated causes (5.12%). One patient died of a late hepatic artery thrombosis, and one more of rejection. No other severe case of rejection appeared. We can conclude that retrograde reperfusion might be highly sufficient method of removing perfusion fluid from the transplanted liver. Low pressure perfusion with low oxygenated blood might reduce the production of free oxygen radicals. Retrograde reperfusion via the caval vein and antegrade reperfusion via the portal vein seemed to lower postoperative liver enzyme values and to improve initial liver function after LTX.

Adult↗
PubMed1975

Unusual problems of venous thrombosis.

Although venous thrombosis (thrombophlebitis) is well known, there are uncommon manifestations which are seen infrequently, discussed rarely, and documented poorly. Experiences with 38 patients in seven categories are discussed in terms of our results and the pertinent reports of others. Pulmonary necrosis after embolic pulmonary infarction (six patients) may require tube thoracotomy and/or lung resection and contraindicate further heparin therapy. Iliac and/or femoral vein thrombosis occasionally fails to recanalize. Long-standing occlusion (18 patients) may be benefited by a cross-over saphenous vein graft. Left iliac venous occlusion secondary to pressure from the crossing right iliac artery (four patients) may indicate repair or bypass. Budd-Chiari syndrome (thrombosis of the hepatic venous outflow) was, in a single patient, carried past a critical period by a long Dacron tube shunt graft from the umbilical vein to the azygos vein. Subclavian and axillary venous thrombosis due to thoracic outlet pressure syndrome (three patients) often responds to heparin but may require thrombectomy; later resection of the first rib is indicated. Phlegmasia cerulea dolens (blue phlebitis) with tissue gangrene (three patients) requires immediate venous thrombectomy and subsequent heparinization. The occluded inferior vena cava (three patients) remains a challenging unsolved problem.

Adult↗
PubMed1990

The value of Doppler sonography in the detection of major vessel thrombosis in the neonatal abdomen.

Duplex spectral or color Doppler sonography demonstrated major abdominal vessel blocks affecting 18 vessels in 16 infants aged between 23 and 56 weeks postconceptional age. The portal vein was affected in 8 infants, the renal vein in 3, the renal vein and inferior vena cava in 1, the renal artery in 1, the inferior vena cava and hepatic vein in 1, and the aorta in 2 infants. Doppler sonography confirmed the grey-scale findings and often demonstrated the extent of vascular flow, providing functional information not available from the grey-scale scan. It facilitated the follow-up of thrombosis during therapy. Most important of all, in many instances it enabled a rapid and reliable specific diagnosis often not possible on the grey-scale study alone and hence altered patient management.

Abdomen↗
PubMed2006

Radiation-induced liver disease in three-dimensional conformal radiation therapy for primary liver carcinoma: the risk factors and hepatic radiation tolerance.

PURPOSE: To identify risk factors relevant to radiation-induced liver disease (RILD) and to determine the hepatic tolerance to radiation. METHODS AND MATERIALS: The data of 109 primary liver carcinomas (PLC) treated with hypofractionated three-dimensional conformal radiation therapy (3D-CRT) were analyzed. Seventeen patients were diagnosed with RILD and 13 of 17 died of it. RESULTS: The risk factors for RILD were late T stage, large gross tumor volume, presence of portal vein thrombosis, association with Child-Pugh Grade B cirrhosis, and acute hepatic toxicity. Multivariate analyses demonstrated that the severity of hepatic cirrhosis was a unique independent predictor. For Child-Pugh Grade A patients, the hepatic radiation tolerance was as follows: (1) Mean dose to normal liver (MDTNL) of 23 Gy was tolerable. (2) For cumulative dose-volume histogram, the tolerable volume percentages would be less than: V5 of 86%, V10 of 68%, V15 of 59%, V20 of 49%, V25 of 35%, V30 of 28%, V35 of 25%, and V40 of 20%. (3) Tolerable MDTNL could be estimated by MDTNL (Gy) = -1.686 + 0.023 * normal liver volume (cm3). CONCLUSION: The predominant risk factor for RILD was the severity of hepatic cirrhosis. The hepatic tolerance to radiation could be estimated by dosimetric parameters.

Adult↗
PubMed2004

Percutaneous management of a hepatic artery aneurysm: bleeding after liver transplantation.

In this article we present an unusual case of hepatic artery aneurysm bleeding due to a hepatic artery thrombosis after liver transplantation. The patient developed a recurrent hepatic artery thrombosis leading to severe graft failure in four consecutive liver transplantations. While being evaluated for a fifth transplant, stabilization of the clinical situation was attempted by interventional therapy. The first intervention was to place a stent into the hepatic artery to prevent further ischemic damage. This failed to improve graft function, but unfortunately led to the development of a pseudoaneurysm at the distal end with a subsequent rupture into the biliary tree. Bleeding was treated successfully by direct puncture and coil embolization of the aneurysm. In addition, the patient demonstrated a hemodynamically relevant portal vein stenosis on the CT scan. Stenting of the portal vein markedly improved graft function. After extensive investigations, a paroxysmal nocturnal hemoglobinuria was found to be the underlying cause of the recurrent hepatic artery thrombosis. Here we suggest that hepatic artery aneurysm bleeding is a rare but potentially fatal complication that can be successfully treated by percutaneous coil embolization. Additionally, we propose that stenting of the portal vein can lead to a significant improvement of the graft perfusion even though the hepatic artery remained occluded.

Adult↗
PubMed2003

Emergencies after liver transplantation.

Liver transplantation has become the procedure of choice for a wide variety of patients with end-stage liver disease. Perioperative morbidity and mortality have decreased dramatically over the past two decades, and superior graft and patient survival rates are now routine. Despite these advances, however, there remain several potentially lethal possibilities that may complicate the immediate postoperative period. Failure of the graft to regain any useful metabolic activity is known as primary nonfunction, and almost uniformly requires retransplantation for any hope of survival. Lesser degrees of immediate dysfunction require experienced clinical judgment as to the probability of sustaining long-term patient viability. Another potentially catastrophic development is thrombosis of the grafted hepatic artery. This is sometimes successfully managed by surgical reconstruction. It may develop immediately, or present insidiously much later. Thrombosis of the portal vein, while not usually fatal, can significantly complicate the immediate course, carrying with it a significant risk of sepsis. Close monitoring of patients in the period following liver transplantation is crucial, as prompt diagnosis and early intervention directly affects the patient's chances of survival.

Adult↗
PubMedDate not supplied

Surgical complications in human orthotopic liver transplantation.

Between March 1, 1980 and December 31, 1984, 393 orthotopic liver transplantations (OLT) were performed in 313 consecutive recipients. Technical complications were responsible for a substantial morbidity (41/393 allograft loss--10.4%) and mortality (26/313 patient loss--8.3%). Failure of the biliary tract reconstruction, mainly expressed as leakage and obstruction, is the most frequent complication of OLT (52/393 grafts--13.2%). Biliary tract complication (BTC) was directly responsible for 5 deaths (9.6%). Reliance upon standardized methods of direct duct-to duct repair with T-tube (CC-T) and Roux-Y choledocho-jejunostomy (RYCH-J), appropriate postoperative investigation and treatment will reduce morbidity and mortality of BTC. A complicated CC-T will be conversed to a RYCH-J; a complicated RYCH-J needs surgical correction. Hepatic artery thrombosis (HAT) has become the "Achilles heel" of OLT. HAT is expressed by three different patterns: fulminant hepatic necrosis, delayed bile leakage and relapsing bacteremia. Diagnosed in 27 grafts (6.8%), HAT was responsible for 16 deaths (16/25 pat: 64%). The only chance to rescue patients presenting HAT is an early diagnosis and prompt retransplantation before occurrence of septic complications. Aneurysm of the hepatic arterial supply (4/393 grafts--1%) also needs aggressive surgery because of the high rate of fatal rupture (3/4 pat--75%). The incidence of thrombosis of the reconstructed portal vein (PVT) was only 2.2% (7 pat.), three inferior vena caval thromboses (0.9%) (CVT) were diagnosed after OLT. Four of the 7 patients whose portal veins clotted are alive. Three have their original graft. One patient, presenting both PVT and CVT, was rescued by prompt retransplantation. PVT was responsible for 3 patient (3/7 pat--42.8%) and 4 graft losses (4/7 pat--57%). The rate of graft (3/3) and patient loss (2/3) was even higher after CVT.

Aneurysm↗
PubMedDate not supplied

Alterations in hepatic uptake and distribution of organ-specific superparamagnetic MRI contrast media: clinical findings and classification according to pathogenesis.

PURPOSE: The aim of this study was to classify the alterations in the liver uptake and distribution of superparamagnetic contrast media that could potentially lead to diagnostic errors. These alterations, referred to as SPIO-LUDA for convenience, may be caused by a variety of disorders, such as cirrhosis, vascular thrombosis, hepatitis and liver steatosis, that interfere with the normal uptake of the contrast material. These conditions can give rise to focal or diffuse areas of hyperintensity or hypointensity which may mimic the presence of neoplastic lesions or hinder the detection or characterisation of neoplasms. MATERIALS AND METHODS: We retrospectively reviewed the hepatic MR examinations of 412 patients performed to detect hepatocellular carcinoma in 349 cases and metastases in 63 cases, with the aim of identifying conditions corresponding to the definition of SPIO-LUDA. All the examinations were performed using a 1.5 Tesla MR unit with SE and GE sequences, T1 and T2 weighted images, and SPIO as a contrast agent, in 402 cases ferumoxide (Endorem, Guerbet) and in 10 cases SHU-555-A (Resovist, Schering). The SPIO-LUDA were classed into two groups: due to reduced uptake (cell replacement, reduced vascular flow and cellular inhibition) and due to increased uptake (Kupffer cell hyperactivity or increased vascularity). From a quantitative point of view we evaluated the percentage of signal loss (PSIL) of the SPIO-LUDA relative to the surrounding healthy parenchyma, as an expression of increase or reduced uptake of contrast material. RESULTS: In 54 patients we identified potentially misleading SPIO-LUDA: 41 were due to reduced uptake and 13 to increased uptake. In 16 cases, all of which cases of reduced uptake, the alteration significantly limited the diagnostic effectiveness of the MR examination. The reduced-uptake SPIO-LUDA were caused by fibrosis in 31 cases, by portal vein thrombosis in 3, by suprahepatic vein thrombosis in 2, by peritumoural vascular shunts in 3 and by hepatitis in 2. The increased-uptake SPIO-LUDA were caused by focal steatosis in 2 cases and by dysplastic nodules in cirrhosis in 11. The reduced-uptake SPIO-LUDA exhibited 30% lower PSIL values than the normal liver (range 15-45%); the increased-uptake SPIO-LUDA displayed 19% higher PSIL values than the surrounding liver (range 15-23%). Out of a total of 412 patients, the alteration of SPIO uptake was so severe as to prevent detection or exclusion of focal lesions in 4% of cases. CONCLUSIONS: SPIO-LUDA constitute a diagnostic challenge. The recognition and correct interpretation of these alterations are fundamental for avoiding confusion with other diseases and to obtain further clues for the interpretation of abnormal patterns detected at MRI or other imaging modalities.

Adult↗