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PubMed1993

Isolated pancreatectomy for pancreatic head carcinoma using catheter bypass of the portal vein.

We investigated perioperative complications and survival rate in 114 patients with pancreatic cancer who underwent surgical resection between July, 1981 and March, 1992 with an antithrombogenic bypass catheter of the portal vein which we have developed. With this catheter, mesenteric venous blood can be bypassed to the systemic circulation or intrahepatic portal vein to prevent portal congestion or hepatic ischemia during portal obstruction or simultaneous obstruction of the hepatic artery. All the arteries supplying, and veins draining, the pancreas are dissected prior to its manipulation, following which isolated pancreatectomy accompanied by portal vein resection can be performed. Eighty patients (70%) also underwent isolated pancreatectomy. The perioperative death rate was 9.6%, and the main factor contributing to mortality with the bypass method was not portal vein resection, but various postoperative complications, such as insufficiency of the pancreatojejunostomy and thrombosis of the hepatic artery or superior mesenteric artery after resection and reconstruction. We conclude that aggressive surgery with the bypass method increases the operability of pancreatic cancer, although auxiliary therapies combined with radical surgery are necessary to improve the therapeutic outcome for this cancer.

Catheterization↗
PubMed2006

Chemoembolization in patients at high risk: results and complications.

PURPOSE: Transarterial chemoembolization (TACE) has become a standard treatment option for unresectable hepatocellular carcinoma (HCC) and is often used to palliate hepatic metastases. Many patients who are candidates for TACE present with poor hepatic reserve, advanced tumor stage with major portal vein (PV) invasion or thrombosis, and/or biliary dilation. These factors have been associated with a poor prognosis and increased complications after chemoembolization. Accordingly, these patients are classified as being at high risk and may not be considered for therapy. The aim of this study is to evaluate the results of TACE in these patients. MATERIALS AND METHODS: Over a period of 5 years, 141 patients underwent 355 TACE procedures. Thirty-six patients (26%) were in the high-risk group as a result of major PV thrombosis, increased serum bilirubin level (>2 mg/dL), and/or intrahepatic biliary dilation. HCC was the underlying tumor in 60% of patients. Thirty-seven percent of patients had Child-Pugh class B/C disease. Patients in the high-risk group received more selective embolization with fewer particles and fewer procedures (2.0 vs 2.7; P < .04). RESULTS: Patients in the high-risk group were more likely to have HCC (83% vs 51%; P < .01) and were also more likely to have advanced disease according to Child-Pugh classification versus patients in the low-risk group (49% vs 20%; P < .01). The overall complication rate was 4.3%, with no significant difference in complication rate between groups (3.2% vs 8.2%; P = .12). The overall 30-day mortality rate was 2.3%, and no significant difference in 30-day mortality rate was observed between the high- and low-risk groups (5.5% vs 1.4%; P = .11). A trend toward increased survival in the low-risk group did not reach statistical significance. CONCLUSIONS: These data suggest that patients with advanced disease and decreased hepatic reserve who are treated with TACE exhibit no significant increase in morbidity or mortality and no significant decrease in survival. With variations in technique, TACE can be performed safely in patients with the relative risk factors that may classify them in high-risk groups.

Adult↗
PubMed2002

[Doppler imaging of hepatic vessels - review].

Hepatic blood flow has been investigated using color Doppler ultrasonography in patients with liver disease, especially in patients with portal hypertension (e. g. liver cirrhosis, portal vein thrombosis, Budd-Chiari-syndrome). Duplex examination protocols, however, differ considerably because no standard technique has been established so far. Whereas there is an agreement about the angle of the ultrasound application (< 60 degrees ), neither the exact location nor the relevant examination parameters have been standardized. Based on a search of the relevant literature, published examination techniques and results were analyzed. These findings are to serve as a basis for a prospective multicenter study for the determination of standard values.

Blood Flow Velocity↗
PubMed1988

Sonographic demonstration of hepatic venous gas in mesenteric arterial thrombosis.

Hepatic portal venous gas is an ominous prognostic sign in bowel necrosis from mesenteric arterial occlusion. Ultrasonic examination is a sensitive and accurate method of demonstrating portal venous gas. We describe a case where the ultrasonic diagnosis of portal venous gas led to the rapid diagnosis of bowel infarction. Ultrasound is an appropriate emergency examination in all patients with suspected mesenteric artery occlusion.

Aged↗
PubMed1995

[A case of liver metastasis of gastric cancer with portal vein tumor thrombosis responding to chemotherapy with 5-FU and epirubicin].

A 67-year-old male patient having liver metastasis from gastric cancer with portal vein tumor thrombosis was treated by chemotherapy with 5-FU and EPI. A dose of 500 mg/body/day of 5-FU was continuously administered via the central venous catheter. Anorexia and hepatic dysfunction were reduced. In addition, 20 mg/body/week of low-dose EPI was added to the chemotherapy. This treatment produced marked regression of portal vein tumor thrombosis on CT. The side effect observed was slight nausea, but no bone marrow suppression was found. Thus, chemotherapy with 5-FU and EPI appears to be a useful and safe treatment for liver metastasis with portal vein tumor thrombosis.

Adenocarcinoma↗
PubMed1999

Septic thrombosis of the portal vein due to peripancreatic ligamental abscess.

Septic thrombus formation of both the main portal vein and its intrahepatic branches were observed on CT in a patient with peripancreatic abscess. The septic thrombosis of portal vein (STPV) extended from the level of porta hepatis into the intrahepatic branches, but the portal vein and superior mesenteric vein at the level of pancreatic head were preserved with no evidence of thrombosis angiographically. The gas-containing abscess near the head of the pancreas extended toward the hepatic hilum and surrounded the portal vein and its branches on CT. It was concluded that these thrombi of portal vein branches at porta hepatis and intrahepatic branches were caused by extensions of peripancreatic abscess via the hepatoduodenal ligament and ligamentum teres. Computed tomography was useful in depicting the ligamentous spread of peripancreatic abscess resulting in STPV.

Abscess↗
PubMed1982

[Secondary neoplastic involvement of the hepatic pedicle (author's transl)].

Neighboring tumors can extend to the hepatic pedicle, usually through lymphatic involvement. Four such cases are reported. Thrombosis of the portal vein may develop. Cholestatic jaundice is the main clinical feature. Prehepatic portal hypertension may be present. Hepatojejunostomy is often the only possible surgical procedure.

Aged↗
PubMed1992

CT of portal venous occlusion.

Thrombosis of a portion of the portal venous system can be directly imaged by contrast-enhanced CT as a low-attenuation lesion within the involved portal venous segment with or without expansion of the vessel or enhancement at the margin of the thrombus. Collateral venous pathways are often evident, which provide supporting evidence of the occlusion. Alterations in portal venous blood flow lead to metabolic disturbances in the liver and to abnormalities in parenchymal enhancement during dynamic CT scanning, and these changes are manifested as abnormalities in hepatic parenchymal density. The detection of portal venous thrombosis or occlusion, collateral veins, or abnormal liver enhancement should initiate a search for the diseases that cause these abnormalities.

Budd-Chiari Syndrome↗
PubMed1993

The role of the radiologist in liver transplantation.

The radiologist is an important member of the liver transplant team. His main pre-operative role is to detect abnormalities which may preclude transplantation or alter the standard surgical approach in patients. Colour Doppler ultrasound and computerised tomography (CT) are the primary imaging methods utilised pre-operatively. Knowledge of the surgical procedure employed is essential and comprises four basic vascular anastomoses, namely: supra- and infra- inferior vena cava, portal vein and hepatic artery. In the immediate post-transplant period, hepatic artery thrombosis is the most common vascular complication. The radiologist plays a major role in the diagnosis and management of vascular and biliary complications, as well as the assessment and treatment of fluid collections. The current status of imaging graft rejection remains uncertain. Doppler ultrasound and direct cholangiography are the most frequent post-operative investigations. Emphasis is placed on early radiological evaluation of complications leading to graft failure, patient morbidity and mortality, so as to enable institution of the appropriate surgical or radiological interventional procedure.

Bile Duct Diseases↗
PubMed1997

Hepatic venous outflow block caused by short-length hepatic vein stenoses.

In contrast with the well-recognized membranous obstruction of the inferior vena cava, short-length hepatic vein stenoses are not well-recognized causes of hepatic venous outflow block. The aim of this study was to ascertain the prevalence, causes, manifestations, and outcome of short-length hepatic vein stenoses. We performed a retrospective study of patients with short-length hepatic vein stenosis among 86 patients with hepatic venous outflow block who were seen between 1970 and 1992. There were 25 patients with short-length hepatic vein stenosis. A thrombogenic condition was identified in 14 patients (56%). The lesions of the accompanying hepatic veins in these patients were variable (short-length stenoses, thromboses, or nonspecific changes) and similar to that seen in patients without short-length hepatic vein stenosis. In 3 necropsied cases, the venous lesions were suggestive of fibrous sequela of prior thromboses. In patients with short-length hepatic vein stenosis, splenomegaly (28% vs. 55%, P < .05) and hypersplenism were significantly less common; serum transaminase (P < .001) and creatinine levels (P < .02) were lower, prothrombin was higher (P < .001), and 5-year survival was significantly better (Kaplan-Meier estimates: 80% vs. 50%, P < .05). In patients with hepatic venous outflow block, short-length hepatic vein stenosis is a common lesion that appears to be the sequela of localized thrombosis. Long-term anticoagulation and percutaneous angioplasty (with or without stenting) are potentially applicable in these lesions. The long-term results of these treatments merit further evaluation.

Adult↗
PubMed2003

Three-dimensional contrast-enhanced MR angiography in diagnosis of portal vein involvement by hepatic tumors.

AIM: To assess the accuracy of three-dimensional contrast-enhanced magnetic resonance angiography (3D CE MRA) in evaluation of the portal vein involvement in patients with hepatic tumors. METHODS: 3D CE MRA was performed in 62 patients with hepatic tumors to assess the patency of the main, right and left portal veins before hepatic surgery. A total of 186 veins were examined for encasement, occlusion and tumor thrombosis. The results of 3D CE MRA diagnosis were then correlated with the surgical-pathological and intra-operative sonographic findings. RESULTS: 3D CE MRA correctly detected 48 of 49 involved and 135 of 137 noninvolved portal veins with the sensitivity of 98 %, specificity of 99 %, positive predictive value of 96 % and negative predictive value of 99 %. CONCLUSION: 3D CE MRA is accurate in evaluation of the portal vein involvement in patients with hepatic tumors.

Adult↗
PubMed2000

Local radiotherapy with or without transcatheter arterial chemoembolization for patients with unresectable hepatocellular carcinoma.

PURPOSE: To evaluate the treatment outcome, patterns of failure, and prognostic factors for patients with unresectable hepatocellular carcinoma (HCC) treated with local radiotherapy alone or as an adjunct to transcatheter arterial chemoembolization (TACE). METHODS AND MATERIALS: From March 1994 to December 1997, 25 patients with unresectable HCC underwent local radiotherapy to a portion of the liver. Twenty-three patients were classified as having cirrhosis in Child-Pugh class A and 2 in class B. Mean diameter of the treated hepatic tumor was 10.3 cm. Mean dose of radiation was 46.9 +/- 5.9 Gy in a daily fraction of 1.8-2 Gy. Sixteen patients were also treated with Lipiodol and chemotherapeutic agents mixed with Ivalon or Gelfoam particles for chemoembolization, either before and/or after radiotherapy. Percutaneous ethanol injection therapy (PEIT) was given to one patient. All patients were monitored for treatment-related toxicity and for survival and patterns of failure. RESULTS: In a median follow-up period of 23 months, 11 patients were alive and 14 dead. The median survival duration from treatment was 19.2 months with a 2-year survival of 41%. Only 3 of 25 patients had local progression of the treated hepatic tumor. The recurrences were seen within the liver or extrahepatic. The 2-year local, regional, and extrahepatic progression-free survival rates were 78%, 46%, and 39%, respectively. The local control ranked the highest. Patients with Okuda Stage I disease had significantly longer survival than those with Stage II and III (p = 0.02). Patients with T4 disease (p = 0.02) or treated with radiotherapy alone (p = 0.003) had significantly shorter survival. T4 disease (p = 0.03) and pretreatment alpha-fetoprotein level of more than 200 ng/ml (p = 0. 03) were associated with significantly worse regional progression-free survival. A significant difference was observed in both regional progression-free survival (p = 0.0001) and extrahepatic progression-free survival (p = 0.005) between patients with and without portal vein thrombosis before treatment. The presence of satellite nodules had a significantly worse impact on regional progression-free survival (p = 0.04) and extrahepatic progression-free survival (p = 0.03). Patients with hepatic tumor more than 6 cm in diameter or portal vein thrombosis tended to have shorter survival. Radiation-induced liver disease (RILD) and gastrointestinal bleeding were the most common treatment-related toxicities. CONCLUSION: Radiotherapy is effective in the treatment of patients with unresectable HCC. Its effect appeared to be more prominent within the site to which radiation was given. The combination of TACE and radiation was associated with better control of HCC than radiation given alone, probably due to the selection of patients with favorable prognosis for the combined treatment. A dose-volume model should be established in the next phase of research in the treatment of unresectable HCC.

Adult↗
PubMed2005

[Effect of transjugular intrahepatic portosystemic shunt for variceal bleeding in hepatocellular carcinoma patients with portal vein thrombosis].

BACKGROUND/AIMS: Transjugular Intrahepatic Portosystemic Shunt (TIPS) is commonly used in patients with variceal bleeding. However, this procedure is contraindicated in hepatocellular carcinoma patients with portal vein thrombosis. This study was done to evaluate the effect of TIPS in those patients with variceal bleeding. METHODS: Between 1997 and 2004, six hepatocellular carcinoma (HCC) patients with portal vein thrombosis were enrolled in this study due to their variceal bleeding. All the patients underwent TIPS placement to treat the variceal bleeding that had not responded to endoscopic treatment. Effective shunt creation was assessed by the decrease of the portal pressure gradient (less than 12 mmHg) or if good patency and flow were seen on a doppler examination. RESULTS: Shunts were successfully created in all the patients and the bleeding was immediately controlled in the active bleeding cases. The bleeding was caused by esophageal varices in one patient and, by gastric varices in five patients. The HCC types were diffuse or massive in five patients, and a single nodule was present in one patient. All the patients had portal vein thrombosis. Rebleeding was noted in two patients at 10 days and 3 months, respectively, due to the shunt occlusion. Hepatic encephalopathy was noted in two patients. The causes of death were hepatorenal syndrome after 2 weeks in one patient, bleeding due to portal hypertensive gastropathy after 3 weeks in another, and cancer progression after 4 months in third patient. CONCLUSIONS: For HCC patients with portal vein thrombosis, TIPS can be an effective treatment modality if uncontrolled variceal bleeding presents when using endoscopic hemostasis or pharmacologic therapy. However, further studies are needed.

Adult↗
PubMed1991

[Treatment of different variants of the mixed form of portal hypertension].

Among 425 patients who were under observation for portal hypertension 72 (16.9%) had its mixed form. Thrombosis of the portal vein in liver cirrhosis occurred in 6 patients. Marked hepatic fibrosis caused by obstruction of the portal vein was encountered in 14 patients. Compression of the hepatic segment of the inferior vena cava was found in 44 patients with cirrhosis of the liver. Nutmeg cirrhosis developed in 8 patients in prolonged disorder of venous flow from the liver. Coexistence of pre- and intrahepatic forms of portal hypertension occurred in the first two situations and coexistence of intra- and suprahepatic forms in the second two. The variety of mixed forms of portal hypertension should be borne in mind in choosing the method of operative treatment and defining its prognosis.

Constriction, Pathologic↗
PubMed2001

Elevation of hepatic transaminases after enoxaparin use: case report and review of unfractionated and low-molecular-weight heparin-induced hepatotoxicity.

Enoxaparin, a low-molecular-weight heparin (LMWH), is widely used for the treatment and prophylaxis of thromboembolic disorders, such as deep vein thrombosis. Low-molecular-weight heparin products have smaller and more uniform molecular weights than unfractionated heparin, allowing them to exhibit a much greater affinity for factor Xa than factor IIa. Compared with traditional unfractionated heparin, LMWHs have proved to be equally efficacious and may be safer. The distinctive characteristics of LMWHs have resulted in decreased rates of bleeding and equivalent rates of thrombocytopenia compared with unfractionated heparin. This favorable safety profile has been identified in several studies and may have led clinicians to believe that LMWHs have lower frequencies of all common side effects. A 66-year-old woman developed increased hepatic transaminases during treatment with enoxaparin for a deep vein thrombosis; they returned to normal after enoxaparin discontinuation. A causal relationship between unfractionated heparin and asymptomatic, transient increases in hepatic transaminase levels has been documented; these increased levels also appear to be an underrecognized, adverse effect of LMWH therapy.

Aged↗