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PubMed2004

Transjugular intrahepatic portosystemic shunt creation with the Viatorr expanded polytetrafluoroethylene-covered stent-graft.

PURPOSE: To evaluate the midterm clinical results and patency of transjugular portosystemic shunts (TIPS) created with a commercially available expanded polytetrafluoroethylene (ePTFE)-covered stent-graft based on angiographic and ultrasonographic (US) criteria in a series of 71 patients. MATERIALS AND METHODS: Seventy-one patients (61 men, 10 women; mean age, 58.6 years, range, 25-78 years) were included in this series, which was performed in two centers. Indications for TIPS creation were refractory ascites (n = 44) and recurrent esophageal bleeding (n = 27). Ten patients had Child-Pugh class A liver cirrhosis, 43 had class B disease, and 18 had class C disease. Underlying liver diseases were alcoholic cirrhosis (n = 58), cirrhosis resulting from hepatitis (n = 9), cryptogenic cirrhosis (n = 3), and Budd-Chiari syndrome (n = 1). TIPS were created with commercially available ePTFE-covered stent-grafts in all patients. The diameters of the stent-grafts were 10 mm in 58 patients and 8 mm in the remaining 13 patients. Follow-up included clinical examination and color-coded US after 5 days, 1, 3, and 6 months, and every 6 months thereafter. Shunt angiograms were obtained every 6 months. Median follow-up was 16.3 months (range, 3.8-26.6 months). RESULTS: TIPS creation was successful in all patients without complications, and effective portal decompression was observed with a reduction of the mean portal gradient from 19 mm Hg to 6 mm Hg before and after TIPS creation. Four shunt occlusions were observed after 5 days, 2 months, 3 months, and 6 months. Shunt stenosis was observed in three patients at the hepatic vein, which was not fully covered by the stent-graft, after 6 months (n = 2) and 12 months, and at the portal side after 1 month in a patient who initially had portal vein thrombosis. The repeat intervention rate was 11.3%. The primary patency rates were 87.4% (95% CI, 77.7%-97.1%) after 6 months and 80.8% (95% CI, 68.2%-93.4%) after 12 months. The rate of de novo or deteriorated hepatic encephalopathy was 31%. The recurrent bleeding rate was 3.7% (one of 27), and ascites improved or resolved in 64% of patients after 1 month. CONCLUSION: TIPS patency can be significantly increased if the ePTFE-covered stent-graft is used for shunt creation. The increased shunt patency contributes to low repeat intervention and recurrent bleeding rates. The rate of hepatic encephalopathy is within the range of previously reported rates.

Adult↗
PubMed2002

Minimally invasive techniques in the treatment of liver tumors.

BACKGROUND: Despite advances in cancer therapy the treatment of liver tumors remains a challenge. Most patients are poor candidates for surgical resection; both chemotherapy and irradiation have a low success rate and neither is without complications. New minimally invasive techniques for ablation of unresectable tumors have gained attention as effective treatment alternatives. Among these are percutaneous ethanol injection and radiofrequency ablation; both are effective for primary liver tumors and RFA is also effective for hepatic metastases. OBJECTIVE: To report our experience with PEI and RFA in the treatment of hepatic lesions. METHODS: The study included 49 lesions in 27 patients: 23 primary lesions in 13 patents treated with PEI and 26 lesions (22 secondary and 4 primary) in 14 patients treated with RFA. PEI was performed on an outpatient basis in the ultrasound suite; RFA was done in hospitalized patents (9 in the ultrasound suite and 4 in the operating room). Patients were followed with triphasic spiral computerized tomography 1 month after treatment and every 3-6 months thereafter. RESULTS: Complete necrosis was achieved with PEI on the first attempt in 11 of 23 primary lesions (91.3%). In 8.7% (2/23) a second series of treatments was required. Using RFA, complete necrosis was achieved in 85% of lesions (22/26) and partial necrosis in 15% (4/26). Complications included low fever (3 patients), high fever and abscess formation (1 patient), peri-tumoral necrosis (1 patient) and portal vein thrombosis (1 patient). CONCLUSIONS: Our preliminary results confirm that PEI and RFA are an effective and safe option for treating hepatic tumors in patients unfit for surgery.

Aged↗
PubMed1975

End-to-side splenorenal shunt for treatment of portal hypertension.

Twenty-eight patients with portal hypertension were treated with splenectomy and end-to-side splenorenal shunt. Nineteen had cirrhosis and nine had portal vein thrombosis. Among the patients with cirrhosis, there was one hospital death due to recurrent bleeding in a patient in whom shunt could not be constructed and only splenectomy was done. During the follow-up period, one patient developed encephalopathy and later died of liver failure. There were three additional deaths, one due to an unrelated causes and two due to liver failure. All the remaining patients are well and none has had recurrent bleeding. All the patients with portal vein thrombosis survived the operation and are well. None has had recurrent bleeding. Encouraged by these results, we continue to use end-to-side splenorenal shunt in all patients except small children.

Adolescent↗
PubMed1996

[Disorders of hepatic circulation and imaging with color doppler ultrasonography].

The authors analyse disturbances of hepatic circulation and the possibilities of their imaging by colour Doppler ultrasonography (CDU) in combination with standard B two-dimensional imaging. The predominance of arterial perfusion in liver cirrhosis, portal vein thrombosis, malign diseases of the liver, or extraluminal obstruction of portal vein are changes which can be imaged by means of high-quality colour Doppler imaging. CDU is a non-invasive method of evaluation of portal hypertension, namely of prehepatic, hepatic and posthepatic type. It is a method of investigation of the viability of the hepatic artery after transplantation of the liver, including that of surgical portocaval anastomoses and transjugular intrahepatic portosystemic shunts. (Fig. 6, Ref. 33.).

Humans↗
PubMed1998

The clinical complexity of splenic vein thrombosis.

Upper gastrointestinal hemorrhage secondary to splenic vein thrombosis is a curable form of localized portal hypertension when treated with splenectomy. A high index of suspicion is necessary in order to promptly diagnose and treat this underrecognized condition that is most commonly caused by inflammation or neoplasm of the pancreas. The triad of isolated gastric varices, splenomegaly, and normal hepatic function is classic; it is not uncommon, however, for patients to have only some or even none of these conditions. Mesenteric angiography with venous phase imaging is the gold standard of diagnosis. Ultrasound and CT may identify splenic vein thrombosis, but are most helpful in delineating concomitant upper abdominal pathology. Early recognition and intervention allow associated underlying conditions to be treated under the same anesthetic with minimal morbidity and mortality.

Adenocarcinoma↗
PubMed1989

Distal splenorenal shunt with splenopancreatic disconnection. A 4-year assessment.

The aims of distal splenorenal shunt with splenopancreatic disconnection (DSRS-SPD) were to improve maintenance of portal flow and prevent siphoning of hepatotrophic factors from the pancreas, as occurs after standard DSRS. The main patient population targeted for improvement were alcoholic cirrhotics, who have poorer survival than nonalcoholic cirrhotics and greater loss of portal flow (60%) after standard DSRS. Seventy-eight patients had DSRS-SPD during the study period 1983 to 1987: thirty-two patients were Child's A, 25 were Child's B, and 21 were Child's C. The 35 patients with alcoholic cirrhosis were a significantly poorer risk group by Child's class and galactose elimination capacity (GEC) than the 39 patients with nonalcoholic cirrhosis. Four patients had portal vein thrombosis. At 4-year follow-up, portal perfusion is maintained in 84% alcoholic and 90% nonalcoholic patients, with hepatic and systemic hemodynamics showing identical patterns for both groups. Hepatic function measured by GEC was maintained in alcoholic patients (290 +/- 68 mg/min to 303 +/- 74 mg/min) and nonalcoholics patients (342 +/- 92 to 320 +/- 118 mg/min). Gastric variceal rebleeding occurred in 10 patients--4 early (less than 2 months) and 6 late (18 to 54 months), leading to operation in 4 and transhepatic embolization in 4 patients: 2 of these patients died from this complication. Survival data show an operative mortality rate of 6.4% and overall mortality rate of 30%, with no significant difference between alcoholic and nonalcoholic cirrhotics. DSRS-SPD has significantly improved maintenance of portal perfusion and survival in patients with alcoholic cirrhosis requiring selective shunt for variceal bleeding when compared to standard DSRS. In this population DSRS-SPD is the operation of choice. In patients with nonalcoholic cirrhosis, the current data have not shown DSRS-SPD to have advantage over standard DSRS.

Angiography↗
PubMed2004

Early postoperative complications in recipients of living donor liver transplantation.

PURPOSE: Complications are common in the early postoperative period after living donor liver transplantation (LDLT). The aims of this analysis were to describe and identify risk factors for early postoperative complications. METHODS: Between June 1994 and June 2003, 140 consecutive LDLT patients were divided into 3 groups: group I was small infants <9 kg (n = 30); group II, pediatric patients (n = 63); and group III, adult patients (n = 47). The complications within 3 months after operation were analyzed. RESULTS: The mortality rate was 1.4%. Surgical complications requiring relaparotomy occurred in 7.9% of patients. Intraoperative portal vein thrombosis requiring immediate thrombectomy, which occurred in 10 patients, was significantly more frequent in the small infant group (23.1% vs 3.2% vs 2.1%; P < .01). Acute hepatic artery thrombosis that occurred in 2 patients was remedied successfully using operative rearterilization. Hepatic outflow obstruction requiring radiological interventions developed in 5 subjects. Medical complications included the following: pulmonary (14.3%), renal (19.3%), bacteremia (10.7%), cytomegalovirus infection (9.3%), and drain-related infections (20.7%). The incidence of hospital-acquired renal insufficiency was significantly higher in adult patients (3.3% vs 14.3% vs 36.2%; P < .01). There was no significant difference in the incidence of acute cellular rejection between members of the 3 groups (10.0% vs 17.5% vs 17%; P = .63). CONCLUSIONS: Sophisticated postoperative care with multiple disciplinary involvements may achieve a low early mortality rate in LDLT. Small infants weighing <9 kg may carry a greater risk of intraoperative portal vein thrombosis. Pulmonary complications and renal function impairments were the most troublesome in pediatric and adult recipients, respectively.

Child, Preschool↗
PubMed1998

[Budd-Chiari syndrome: retrospective study of 8 cases assessed with computerized tomography].

PURPOSE: Budd-Chiari syndrome is a rare disease due to the obstruction of hepatic veins and, sometimes, of the inferior vena cava. The disease, whose etiopathogenesis is often unproven, may show acute or chronic clinical course with different features at pathology. We carried out a retrospective study of 8 consecutive patients with the Budd-Chiari syndrome to assess the diagnostic role of CT and to define the main patterns of the disease. MATERIAL AND METHODS: Our patient population consisted of 8 women with clinical and instrumental suspicion of Budd-Chiari syndrome. Three patients had acute and 5 chronic clinical presentation: the former had had acute symptoms right after delivery, while one of the latter was referred to oral contraceptive abuse, another was diagnosed 18 months after delivery and finally the cause was not known in the other 3 cases. CT was performed with contiguous slices (8 mm) of the upper abdomen, before and after i.v. contrast agent infusion. Liver images were always acquired 15-20 minutes after contrast agent administration. RESULTS: In the acute patients, CT showed increased liver volume, diffuse parenchymal hypodensity in unenhanced scans, except for some skip areas (segments I and IV, paracaval parenchyma) and strong postcontrast enhancement. Thrombosis of the suprahepatic veins was found in all patients and partial thrombosis of the inferior vena cava in one. Abundant peritoneal effusion was always found. In the chronic patients, CT showed caudate lobe and left lobe hypertrophy, mostly associated with right lobe hypo-atrophy. Moreover the hypertrophic areas showed bright and inhomogeneous contrast enhancement, with a reversed pattern at 15-20 minutes postcontrast. Thrombosis of the suprahepatic veins was found in 3 patients and partial thrombosis of the inferior vena cava in one. Peritoneal effusion was seen in 2 cases. CONCLUSIONS: The Budd-Chiari syndrome causes anatomical, morphological and volumetric changes in the hepatic parenchyma which are referrable to difficult venous flow and differ in acute vs chronic forms. CT permits to grade liver involvement by the organ's morphodensitometric changes, which are once again different in the acute vs the chronic disease. Moreover, thrombosis of suprahepatic veins and of the inferior vena cava and portal vein is often demonstrated. Therefore CT can be considered a valid diagnostic tool for use in the patients with suspected Budd-Chiari syndrome together with B-mode and color Doppler US.

Adult↗
PubMedDate not supplied

Radiofrequency ablation of rabbit liver in vivo: effect of the pringle maneuver on pathologic changes in liver surrounding the ablation zone.

OBJECTIVE: We wished to evaluate the effect of the Pringle maneuver (occlusion of both the hepatic artery and portal vein) on the pathologic changes in the hepatic vessels, bile ducts and liver parenchyma surrounding the ablation zone in rabbit livers. MATERIALS AND METHODS: Radiofrequency (RF) ablation zones were created in the livers of 24 rabbits in vivo by using a 50-W, 480-kHz monopolar RF generator and a 15-gauge expandable electrode with four sharp prongs for 7 mins. The tips of the electrodes were placed in the liver parenchyma near the porta hepatis with the distal 1 cm of their prongs deployed. Radiofrequency ablation was performed in the groups with (n=12 rabbits) and without (n=12 rabbits) the Pringle maneuver. Three animals of each group were sacrificed immediately, three days (the acute phase), seven days (the early subacute phase) and two weeks (the late subacute phase) after RF ablation. The ablation zones were excised and serial pathologic changes in the hepatic vessels, bile ducts and liver parenchyma surrounding the ablation zone were evaluated. RESULTS: With the Pringle maneuver, portal vein thrombosis was found in three cases (in the immediate [n=2] and acute phase [n=1]), bile duct dilatation adjacent to the ablation zone was found in one case (in the late subacute phase [n=1]), infarction adjacent to the ablation zone was found in three cases (in the early subacute [n=2] and late subacute [n=1] phases). None of the above changes was found in the livers ablated without the Pringle maneuver. On the microscopic findings, centrilobular congestion, sinusoidal congestion, sinusoidal platelet and neutrophilic adhesion, and hepatocyte vacuolar and ballooning changes in liver ablated with Pringle maneuver showed more significant changes than in those livers ablated without the Pringle maneuver (p < 0.05) CONCLUSION: Radiofrequency ablation with the Pringle maneuver created more severe pathologic changes in the portal vein, bile ducts and liver parenchyma surrounding the ablation zone compared with RF ablation without the Pringle maneuver. Therefore, we suggest that RF ablation with the Pringle maneuver should be performed with great caution in order to avoid unwanted thermal injury.

Animals↗
PubMed1996

Major extended hepatic resections in diseased livers using hypothermic protection: preliminary results from the first 12 patients treated with this new technique.

BACKGROUND: Hepatic vascular exclusion allows the performance of major hepatic resections with minimal intraoperative blood loss. We have previously shown that normothermic ischemia can be tolerated by a healthy liver for up to 90 minutes, and this period is increased to 4 hours if the liver is cooled to 4 degrees C using University of Wisconsin solution. STUDY DESIGN: This study assessed whether these techniques could be successfully applied for patients requiring resection of a diseased liver, which is more sensitive to ischemic damage. Between July 1990 and May 1994, 12 patients (6 men, 6 women; mean age, 57.8 years) in whom the planned hepatic resection was believed to require hepatic vascular exclusion for more than 1 hour were treated with perfusion with the University of Wisconsin solution. The surgical procedures were right hepatectomy (one patient), extended right hepatectomy (seven patients), and extended left hepatectomy (four patients). The underlying hepatic disease was cirrhosis or severe fibrosis with hepatocellular carcinoma (four patients), cholestasis (due to cholangiocarcinoma and biliary stricture, one patient each), and more than 30 percent steatosis after treatment of hepatic metastases with chemotherapy (six patients). The University of Wisconsin solution that had been cooled to 4 degrees C was perfused through a cannula placed in the portal vein or the hepatic arterial branch of the segment to be resected, but with flow directed toward the liver that should be retained and effluent fluid drained through a cavotomy. Before reperfusion, the liver was rinsed with Ringer's lactate solution, which was also 4 degrees C. RESULTS: The mean duration of hepatic ischemia was 121 minutes (range, 65 to 250 minutes), and venovenous bypass was used in three cases. The mean amount of blood transfused intraoperatively was 4.3 +/- 4 U; four cases required no transfusion. One patient died on postoperative day seven of portal vein thrombosis. The median hospital stay was 21 days (range, 12 to 56 days). Postoperative complications consisted of pneumonia (one patient), liver insufficiency (one patient, who recovered spontaneously), and subphrenic abscess (one patient). The postoperative tests of hepatic function were altered to the same degree as that seen after hepatic vascular exclusion of less than 1-hour duration in healthy livers. All patients who left the hospital were alive at 1 year. CONCLUSIONS: Cooling of the hepatic parenchyma allowed us to perform major hepatic resection in patients with diseased livers using hepatic vascular exclusion for longer than 1 hour without increased morbidity or mortality. However, because of particular difficulties due to the size or location of the lesions, the application of these new techniques should only be considered for the largest and most complex hepatic resections for which hepatic vascular exclusions longer than 1 hour are foreseen.

Adenosine↗
PubMed1988

Massive hepatic infarction associated with polyarteritis nodosa.

A massive hepatic infarction was found in a 44-year-old man who had suffered from polyarteritis nodosa for two years. The polyarteritis had been well controlled by administration of corticosteroids, but he died due to an opportunistic fungal infection. At autopsy, a massive hepatic infarct and a fresh thrombus occluding the right portal vein trunk were found. In addition, occlusion of the heptic arterial branch with fibrosis and dissociation of elastic fibers due to polyarteritis was noted. Massive hepatic infarction is uncommon. The clinicopathologic features of this case are described, and the pathogenesis of hepatic infarcts is discussed.

Adult↗
PubMed1997

Surgical approach to tumor thrombus of renal cell carcinoma at the level between hepatic vein and diaphragm.

BACKGROUND: The curative resection of tumor thrombus of renal cell carcinoma often provides a good prognosis, but the best surgical method for resection at the level between hepatic vein and diaphragm is still a matter of controversy. METHODS: We performed transabdominal surgery without cardio-pulmonary bypass on 4 patients with tumor thrombus at the level between hepatic vein and diaphragm. The surgical procedures were as follows: The right lobe of the liver was separated and detached from the retroperitoneum, and then the vena cava was clamped just below the diaphragm simultaneous with clamping the porta hepatis. After complete circulatory isolation of the vena cava, the tumor thrombus was resected. RESULTS: There were no severe complications postoperatively. Two patients died of cancer 18 and 38 months after surgery, and the other 2 are alive without evidence of disease after 62 and 66 months. CONCLUSION: This anatomically rational approach is thought to be a good alternative to the pull-through method or cardio-pulmonary bypass for removing a tumor thrombus at this level.

Carcinoma, Renal Cell↗
PubMed1985

Hepatic lipogranulomatosis simulating veno-occlusive disease of the liver.

Two cases of unsuspected veno-occlusive disease of the liver were discovered at autopsy. Nearly all central veins and sublobular venules were occluded by lipogranulomas consisting of lipid-laden macrophages, epithelioid histiocytes, giant cells, fibroblasts, lymphocytes, and deposits of collagen. The process extended into the sublobular hepatic venules. Large hepatic veins were uninvolved. Known causes of veno-occlusive disease were ruled out, and the cause of the present cases is unknown.

Aged↗
PubMed1996

Portal vein thrombosis mimicking tumour and causing obstructive jaundice. A case report.

The case of a 28-year-old female patient with portal vein thrombosis mimicking tumour and causing obstructive jaundice is presented. The cavernous-transformed enlarged portal vein, explaining the mass-like lesion in the hepatic hilum on ultrasonography, compressed the extrahepatic bile ducts and caused obstructive jaundice. Endoscopic retrograde cholangiography demonstrated multiple nodular extrinsic indentations of the extrahepatic bile ducts with moderately dilated intrahepatic bile ducts.

Adult↗