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PubMed1996

Donor vascular grafts for arterial reconstruction in pediatric liver transplantation.

The authors compared the results of 48 orthotopic liver transplantations (OLT) in which revascularization was achieved with a conduit interposed between the receptor aorta and the graft (vascular graft [VG] group) with those obtained for 56 OLT performed during the same period (1991 to 1994) in which end-to-end anastomosis (EEA) of the hepatic arteries or celiac trunk was used (EEA group). In the VG group, the interposed conduits were the cadaveric iliac artery (37) the living-donor saphenous vein (3), or nonthrombosed conduits from previous transplants (8) (7 iliac arteries, 1 saphenous vein). There were significant differences between the two groups with respect to recipient age, recipient weight, the retransplant:first transplant ratio, the number of emergency transplantations, the use of reduced-size grafts, and intraoperative transfusion requirements. Twenty-nine grafts in the VG group (60.4%) and 43 in the EEA group (76.7%) currently are functioning. The actuarial 3-year graft survival rates are 60% and 71.5% for the VG and EEA groups (P < .05), respectively. The rate of arterial thrombosis did not differ between the two groups. The authors conclude that, although EEA of the hepatic artery is still the preferred revascularization technique for OLT, revascularization of the liver graft by conduit interposition is safe when EEA is not possible. Reutilization of the interposed conduit during retransplantation proved to be safe in the absence of hepatic artery thrombosis.

Anastomosis, Surgical↗
PubMed2001

Relationship between pre-TIPS liver perfusion by the portal vein and the incidence of post-TIPS chronic hepatic encephalopathy.

OBJECTIVE: In the present study we evaluated the predictive value of pretransjugular intrahepatic portosystemic shunt (TIPS) portal perfusion as assessed by Doppler ultrasonography for the onset of chronic encephalopathy after TIPS. METHODS: A total of 231 cirrhotic patients were followed-up prospectively after TIPS placement. The pattern of intrahepatic portal flow was assessed before TIPS. Patients were divided into two groups according to Doppler findings. Group 1 comprised patients with prograde portal flow (n = 200), whereas group 2 comprised those with loss of portal perfusion (hepatofugal or back-and-forth flow or portal vein thrombosis; n = 31). The presence of chronic encephalopathy during a median follow-up of 32 months was prospectively recorded. The prognostic value of the following parameters for the onset of chronic recurrent encephalopathy after TIPS was evaluated: age, presence of encephalopathy before TIPS, alcoholism, Pugh score, and loss of portal perfusion before TIPS. The independent prognostic value of each variable was tested with a multiple logistic regression analysis. RESULTS: The two groups were comparable in terms of age, incidence of prior episodes of hepatic encephalopathy, and portacaval gradient before and after the procedure; however, liver failure was more severe in patients in group 2 (Pugh score: 9.2 +/- 1.9 vs 10.3 +/- 1.7). The 3-yr survival was identical for both groups; 25% of the 200 patients in group 1 developed chronic encephalopathy as compared to 6% of the 31 patients in group 2 (p = 0.03). Multiple logistic regression analysis demonstrated that loss of portal perfusion and age >65 yr were the only independent predictors of the onset of post-TIPS chronic encephalopathy (odds ratios 0.24 and 1.98, respectively). CONCLUSIONS: Cirrhotic patients with loss of portal perfusion before TIPS were protected against post-TIPS chronic hepatic encephalopathy despite a more severe liver dysfunction at baseline. The only other independent predictive factor for the onset of this complication was age.

Adult↗
PubMed2000

Laparoscopic ultrasound of the liver.

OBJECTIVE: Despite recent advances in medical imaging, pre-operative evaluation of liver tumors, whether benign or malignant, is often lacking in accuracy and precision. With the development of surgical laparoscopy, the benefits of diagnostic laparoscopy have been combined with those of operative ultrasound. This article aims to describe the technique of laparoscopic ultrasound of the liver, and to define its applications and the role of its association with diagnostic laparoscopy in the localization and assessment for resectability of liver tumors. METHODS: After an initial visual inspection with the laparoscope, laparoscopic ultrasound is utilized to further examine the liver. This relies largely on recognition of branches of the portal vein and tributaries of the hepatic veins. During this procedure, the hepatic parenchyma is also examined. Minimal displacement of the transducer, using clockwise and anti-clockwise rotatory movements, allows a full exploration of the liver. RESULTS: The combination of visual with sonographic laparoscopy allows accurate localization of benign and malignant hepatic tumors, as well as ultrasound-guided biopsies of these. Laparoscopic ultrasound can detect small lesions previously unseen by pre-operative imaging techniques. The relationship of tumors to adjacent blood vessels can be defined. Portal vein thrombosis can be diagnosed. CONCLUSION: Curability and liver tumor resectability can be determined and the appropriate surgical treatment thus planned.

Biopsy↗
PubMed2003

Association of adenoma and focal nodular hyperplasia: experience of a single French academic center.

BACKGROUND: We report our experience of the simultaneous occurrence of adenoma and focal nodular hyperplasia (FNH). Liver cell adenoma together with FNH was found in five out of 30 cases of "multiple benign hepatocytic nodules" collected in our files of the Department of Pathology of the University Hospital of Bordeaux, during the last 12 years. All five cases were women on oral contraceptives. In all cases, the reason for surgery was the discovery, by imaging techniques, of an adenoma (4 cases) or of an unidentified benign tumor, possibly an adenoma. RESULTS: Four cases of FNH were discovered by imaging techniques, prior to surgery. Additional small nodules were diagnosed either during surgery or during the slicing of the specimen in 3 cases. Adenoma and the FNH cases identified by imaging techniques were confirmed as such by light microscopy. Some small nodules could not be categorized with certainty because they contained biliary structures without ductular reaction. In one case, the non-nodular liver was abnormal around the area in which there were multiple nodules: there was approximation of portal tracts with portal and hepatic venous thromboses, and portal tract remnants with arteries surrounded with a rim of fibrosis. In two cases, some large hepatic veins had thickened walls. CONCLUSIONS: The association of FNH and adenoma could be coincidental or secondary to shared causal mechanisms: a) systemic and local angiogenic abnormalities induced by oral contraceptives; b) tumor-induced growth factors; c) thrombosis and local arterio-venous shunting. A better recognition of the association of adenoma and FNH, particularly in the context of multiple nodules, could be useful in clinical practice.

Journal Article↗
PubMed1995

Protein C, protein S, and antithrombin III in acute ocular occlusive diseases.

Hereditary and acquired deficiencies of protein C, protein S, and antithrombin III are important risk factors of thrombosis, especially in peripheral veins. In a prospective study, concentrations of these factors were measured to determine the prevalence of deficiencies of these proteins in ocular vascular occlusive disease. A total of 167 patients with acute retinal arterial (28%) or venous occlusion (55%) or ischemic optic neuropathy (17%) were included. Exclusion criteria were anticoagulant therapy, renal insufficiency, and hepatic disease. The mean values obtained for all patients were in normal range (protein C, 102 +/- 25%; protein S, 109 +/- 22%; antithrombin III, 23.6 +/- 3.1 IU/ml). Antithrombin III was pathologically reduced in one patient with branch venous occlusion. Proteins C and S were severely altered in two patients with central venous occlusion, in one individual with ischemic optic neuropathy, and in one patient with branch arterial occlusion. Subnormal values were found in 21 patients for antithrombin III (16.1-19.9 IU/ml), in 7 patients for protein C (55-65%). Two of these five patients with pathologic findings showed severe vascular manifestations in the form of current deep-vein thrombosis and multiple retinal occlusions. Their age was 30 and 53 years, respectively, and differed considerably from the mean age of the entire group (65 +/- 12 years). This study suggests that these proteins were important factors for the development of ocular vascular occlusive diseases in single patients. Although the prevalence is low, measurement of these parameters in young patients may be useful in preventing other vascular complications.

Acute Disease↗
PubMed2006

Splenectomy for thrombocytopenia in patients with hepatitis C cirrhosis.

BACKGROUND: Many patients with hepatitis C cirrhosis and low Model for End-Stage Liver Disease scores are too early for transplant but too thrombocytopenic to treat with interferon. GOAL: To report a case series of splenectomy to raise platelet counts so that pegylated interferon and ribavirin can be given in patients with hepatitis C cirrhosis. METHODS: Retrospective chart and computer record review. RESULTS: Seven patients with hepatitis C cirrhosis (mean age=45.4+/-11.1 y, 4 men) had elective splenectomy for thrombocytopenia before pegylated interferon-alpha 2b therapy. All had thrombocytopenia contraindicating antiviral therapy. Five were Child's-Pugh Class A; 2 were B. All 7 had increases in platelet count (mean 32,400 to 222,140 /mL, P<0.01) at 221+/-151 days postsurgery. Median hospital stay and blood loss were 9 days (4 to 25) and 750 mL (100 to 2500 mL). Median platelet packs, units of packed red blood cells and fresh frozen plasma given were 1 (0 to 7), 0 (0 to 14) and 0 (0 to 2), respectively. There were no deaths or portal vein thrombosis. One patient who was status-post liver transplantation had significant morbidity. Five completed pegylated interferon-alpha 2b and ribavirin therapy; 1 is on therapy and 1 awaits initiation. Of the 5 who completed therapy, there were 2 with sustained virologic response, 1 nonresponse, 1 breakthrough, and 1 relapse. CONCLUSIONS: Splenectomy in patients with hepatitis C cirrhosis can be done safely to allow application of antiviral treatment and potentially avoid transplantation. It may be considered in patients with Child's-Pugh A cirrhosis, no prior abdominal surgeries and with non-1 HCV viral genotype.

Adult↗
PubMed1995

[Acute Budd-Chiari syndrome of traumatic origin].

The diagnosis of Budd-Chiari syndrome is based on clinical signs including liver enlargement and ascitis and findings of complementary examinations: echography, echo-Doppler, CT-scan, magnetic resonance imaging, angiography, pressure readings, laparoscopy and biopsy. Trauma is rarely reported as a cause of acute Budd-Chiari syndrome. In some cases, the trauma is so violent the supra-hepatic veins are ruptured and the dramatic outcome leaves no time for the syndrome to develop. In others, the resulting haematomas form a compression block of the suprahepatic vessels. The mechanism of the trauma in our case appears to have been unreported to date. Four days after a violent motorcycle accident, a 33-year-old man developed an acute Budd-Chiari syndrome probably due to partial and temporary thrombosis of the left and middle suprahepatic veins. A side-to-side porto-cava anastomosis with a calibrated venous graft was performed in an emergency procedure. Outcome was quite favourable and after a 4 year follow-up, the patient is in good health.

Accidents, Traffic↗
PubMed1981

Long-term loss of Warren's shunt selectivity. Angiographic demonstration.

Fifteen patients with a patent shunt after distal splenorenal shunt with gastrosplenic disconnection were prospectively studied by angiography three to 36 months after operation. In all patients a collateral circulation from the portomesenteric to the gastrosplenic system was developed through enlarged venous channels. In all patients the portal flow decreased, as suggested by the angiographically assessed degradation of the portal perfusion of the liver and/or the diminution of the diameter of the portal vein. In two patients the portal vein was thrombotic. We conclude that three months after operation distal splenorenal shunt with gastrosplenic disconnection is not hemodynamically different than portacaval laterolateral shunt.

Celiac Artery↗
PubMed1987

Sinusoidal circulatory disturbance by microthrombosis as a cause of endotoxin-induced hepatic injury.

The present study was undertaken in rats to examine the significance of sinusoidal circulatory disturbance by microthrombosis in the pathogenesis of hepatic damage and dysfunction due to endotoxin. Administration of endotoxin induced fibrin deposits and infiltration of polymorphonuclear leukocytes in the sinusoids, focal random coagulative hepatocellular necrosis and elevation of serum transaminase activities. When heparin was given simultaneously with endotoxin, the formation of fibrin thrombus in the sinusoids was prevented, and the endotoxin-induced morphological and functional changes in the liver were markedly inhibited. Infusion of thrombin into the portal vein induced a large amount of fibrin thrombi in the sinusoids, focal random necrotic foci resembling the lesions produced by endotoxin and elevation of levels of serum transaminases. These experimental data suggest that disturbance of hepatic microcirculation by sinusoidal thrombosis is the necessary and sufficient condition for the development of endotoxin-induced hepatic injury.

Alanine Transaminase↗
PubMed1975

Histological-venographic correlates in portal hypertension.

Magnification hepatic wedge venography and manometry were evaluated in 40 patients with portal hypertension and in 6 normal individuals. Venography (alone or in combination with manometry) generally facilitated prediction of histology in cirrhosis, hepato-venular occlusive disease, periportal fibrosis, congenital hepatic fibrosis, and portal vein obstruction. The magnification wedge venograms demonstrated a number of histological features of cirrhosis that have not previously been described in vivo, including porto-hepatic vein shunts, micro- and macronodular regeneration, and obstructive changes which were more severe in hepatic than in portal veins.

Alcoholism↗
PubMed1995

Drug injection in jugular veins: a new risk factor for vascular diseases in HIV-infected patients? A case report.

The authors describe a rare case of diffused thrombosis of the superficial veins in the whole body and periphlebitis with perivascular abscesses in an human immunodeficiency virus (HIV)-infected drug abuser who was using neck veins to inject cocaine and heroin. In addition the patient presented oral candidiasis, hepatitis C virus infection, bronchopneumonitis, and endocarditis of the tricuspid valve with valvular failure. The conditions of the patient needed repeated vascular catheterizations for therapy administration. Similar pathologies, in HIV-infected patients, highly increase the risk of opportunistic infections, especially in the encephalic territory; in addition the need for vascular catheterizations represents a further risk factor for bacterial infections.

Abscess↗
PubMed1987

The correlation between MR and angiography in portal hypertension.

Forty-two MR examinations and hepatic panangiograms in 38 patients with portal hypertension were correlated with MR images to determine the ability of MR to detect portal vein hemodynamics. These studies were prospectively analyzed for degree of portal perfusion and direction of flow, portal vein thrombosis, and presence and type of shunt surgery. Thirty-three MR examinations were determined to have grade I (good) or II (fair) portal blood flow. Twenty-nine of these were grade I or II by angiography; the other four were grade IV. Of the eight cases documented as grade IV (hepatofugal portal blood flow) by angiography, none were considered grade IV by MR, suggesting that MR was unable to detect retrograde flow. The other case was not graded because of cavernous transformation of the portal vein. MR correlated well with angiography for the detection or absence of portal vein thrombus, agreeing with angiography in 41 of 42 cases. Two angiographically proven cases of portal vein thrombosis were correctly identified on MR. MR correctly identified the absence of portal vein clot in 39 of 40 angiographically negative cases. MR and angiography also agreed in 41 of 42 cases that a shunt was either present/absent or patent/occluded. The single error was due to inadequate MR scanning in the region of interest. The results show that MR cannot be used to grade blood flow in the portal vein. However, MR accurately detects portal vein thrombosis and the patency of surgical shunts.

Angiography↗
PubMed2000

Detection of vascular complications after liver transplantation: early experience in multislice CT angiography with volume rendering.

OBJECTIVE: Our objective was to investigate the usefulness of three-dimensional multislice CT angiography for the evaluation of liver transplant recipients presenting with clinical or sonographic findings suggestive of hepatic vascular complications. CONCLUSION: Our early results indicate that three-dimensional multislice CT angiography with volume rendering can reveal common and potentially lethal vascular complications in patients who have undergone liver transplantation.

Aneurysm↗
PubMed2003

[Long-term outcome of advanced hepatocellular carcinoma that received transarterial hepatic chemotherapy].

Nineteen patients with far advanced hepatocellular carcinoma received transarterial hepatic chemotherapy. Twelve patients were Child-Pugh A, 2 were B, and 2 were C. Seventeen patients had portal vein thrombus, and 2 patients had extra-hepatic metastasis. Among the 19 patients, 13 received low-dose CDDP and 5-FU, and 5-FU with interferon was performed in 2. Lipiodol chemotherapy with epirubicin and MMC was performed after first-line chemotherapy, following the evaluation of the progressive disease. The 1- and 3-year survival rates in all cases were 42.5% and 18.2%, respectively. Of the 18 patients evaluated for response, 1 showed complete response, 2 showed partial responses, 8 had stable disease, and 7 progressed. Median survival time of CR, PR and SD patients was 14.2 months. A multivariate analysis identified CLIP score and therapeutic effect as independent predictors for mortality. It is concluded that transarterial hepatic chemotherapy was very useful for far advanced hepatocellular carcinoma.

Aged↗
PubMed1984

[Regional liver circulation and scintigraphic imaging of portal circulation with 133Xe].

Regional hepatic blood flow has been determined by 4 methods with the aid of the 133Xe washout technique: scintisplenoportography (direct application of 133Xe into the spleen by means of a thin needle); arterial method (133Xe is injected into the A. hepatica by means of a catheter); retrograde-venous method (133Xe administered by an occluding hepatic vein catheter); percutaneous intrahepatic method (133Xe administered directly into the parenchyma by means of a Chiba needle). Ad 1.: Scintisplenoportography (SSP) was executed with 97 patients: 8 patients with a healthy liver presented a hepatic blood flow of 103.37 +/- 11.5 ml/100 g/min. 4 patients with a chronic hepatitis showed a hepatic blood flow of 105.67 +/- 10.2 ml/100 g/min. In 38 patients with compensated cirrhosis, hepatic blood flow was determined with 58.15 +/- 11.5 ml/100 g/min and 19 patients with decompensated cirrhosis showed a blood flow of 34.54 +/- 7.2 ml/100 g/min. Of the 19 patients, who did not present any liver image, 2 patients suffered from a prehepatic block, 1 patient (female) from a posthepatic block, the rest were decompensated cirrhoses. In 5 patients suffering from steatosis only collateral circulation was determined and in 4 patients the spleen could not be punctured. In the patients with compensated and decompensated cirrhosis of the liver, hepatic blood flow differentiated significantly (p less than 0.001) from patients with healthy livers and chronic hepatitis. In the patients with bioptically assured steatosis only the washout constant was determined. Reproducibility of this method was tested in 4 patients and no statistical difference of hepatic blood flow values could be found and the correlation coefficient amounted to 0.9856. The advantage of SSP lies in the possibility of recording the portal vein circulation: cranial collaterals were found in 33 patients, 2 patients had caudal collaterals exclusively and 29 patients cranial and caudal collaterals. 33 cirrhosis patients presented evidence of hepatic shunts. In nearly all patients hepatic blood flow was higher in the right lobe than in the left. Ad 2.: Arterial method was executed in 26 patients: 2 patients with healthy livers had a hepatic blood flow of 89.85 +/- 2.9 ml/100 g/min, 19 compensated cirrhoses with 49.28 +/- 11 ml/100 g/min and 3 decompensated cirrhoses with 36.43 +/- 3.4 ml/100 g/min. Patients suffering from cirrhosis demonstrated significantly lower hepatic blood flow than patients with healthy livers (p less than 0.001). In arterial application also, with the exception of a single patient, the values for hepatic blood flow were higher for the right than the left lobe of the liver.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗