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PubMed1993

[Transjugular intrahepatic portacaval shunt. Preliminary results].

Transjugular implantation of a metallic prosthesis between main portal branch and a hepatic vein is a new intrahepatic portosystemic shunt method to treat portal hypertension. Forty-nine cirrhotic patients with portal hypertension were treated using this technique. The success rate of implantation was 94%. Mortality due to the procedure was 2%. Early complications decreased with the operator's learning curve consisting of bleeding (20%): digestive hemorrhage (n = 5; 12%), hemobilia (n = 4; 8%), which ceased after withdrawal of post-operative heparin. Early thrombosis following shunt implantation occurred in 13% of the patients. Shunt implantation resulted in a 53 +/- 16% decrease in the portocaval pressure gradient (21 +/- 5 to 10 +/- 4 mmHg). Shunts were performed in 45 patients to prevent a recurrence of variceal bleeding. Follow-up of 41 patients showed 12.2% with variceal rebleeding and 16 patients (39%) with a stenosis requiring a redilation. Ascites improved in 95% of the patients and hepatic encephalopathy occurred in 17%. One year survival was 85%. Controlled studies are needed to determine the indications of this new treatment for ascites and bleeding.

Actuarial Analysis↗
PubMed2001

[Expression rates of three angiogenic factors in hepatocellular carcinoma and their relation with microvessel density and portal vein tumor thrombosis].

OBJECTIVE: To investigate the expression rates of the three angiogenic factors-basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF), and platelet-derived endothelial cell growth factor (PD-ECGF) in hepatocellular carcinoma (HCC) and to investigate the relation of their expression rates to the microvessel density (MVD) of the tumor and to the formation of portal vein tumor thrombus (PVTT). METHODS: Immunohistochemical staining was conducted on 61specimens of hepatic cell carcinoma removed in operation. RESULTS: The expression rates of dFGF, VEGF, and PD-ECGF in HCC tissue were 45.9%, 75.4% and 70.5% respectively. The incidence rates of PVTT while all of the 3 angiogenic factor were negatively expressed, one of them was positively expressed, two of them were positively expressed, and all of them were positively expressed were 16.7%, 25.0%, 54.2% and 63.2% respectively (P < 0.05, test for trend). The MVD counts in HCC tissue in the above-mentioned four conditions were 99 +/- 56, 113 +/- 27, 140 +/- 347 and 194 +/- 52 respectively (P < 0.001, ANOVA test). CONCLUSION: As the number of positively expressed angiogenic factors in HCC tissue increases, the angiogenic capability of the tumor enhances greatly, and the incidence rate of PVTT increases too.

Adult↗
PubMed2001

[Pre-hepatic portal hypertension as a late complication of liver transplantation in children].

UNLABELLED: In the long-term after liver transplantation (LT), some children develop prehepatic portal hypertension (PPH) and raise problems not very well known yet; many of the lessons learned with the management of these patients may be useful outside the LT. AIM: 1. To analyze the incidence and risk factors of PPH after LT. 2. To evaluate the results with the different treatments used. METHODS: Retrospective study over 164 children surviving more than 1 year after LT. Univariant analysis of possible risk factors associated and multivariant (logistic regression), for those that had significance in the univariant analysis. Other factors associated are analyzed as well as the indications and results of two types of treatment: percutaneous pneumatic dilatation and surgical shunt (splenorenal and Rex shunt). RESULTS: 9 children developed symptomatic PPH (hemorrhage in 8, ascites in 1), associated to lymphoproliferative post-LT disease in 2, and to anastomotic biliary stricture in 1. The age at first LT (children under 1 year old), weight (below 10 kg), and need of retransplantation (reLT) were in the univariant analysis the associated variables with increased risk of PPH. The diagnosis (biliary atresia) and the emergency status of the LT were almost significative. In the multivariant analysis, the need of reLT is the only independent variable that increases the risk (relative risk: 4.5, confidence interval 95%: 1.29-18.87). At diagnosis 3 cases showed portal estenosis, and 5 showed absence of permeability with cavernomatous transformation. The PPH was caused in one case because of the esplenic vein disconnection (treatment not required at the moment); the three cases of portal estenosis were dilated percutaneously with success, and 2 of the 5 cases with portal thrombosis have been surgically shunted: one by an splenorenal shunt and the other by a Rex shunt (first case done in Spain); the other 3 cases are stable waiting for a surgical solution. The hepatic function is normal in the 9 cases. CONCLUSIONS: The PPH can complicate the prognostic of the pediatric LT in the long term. The treatment depends on the permeability of the portal trunk. Whenever possible, percutaneous dilatation should be attempted; should surgery be required, the Rex shunt is the best option.

Child↗
PubMed2000

Chemotherapy for hepatocellular carcinoma with portal hypertension due to tumor thrombus.

A case of hepatocellular carcinoma (HCC) complicated by tumor thrombosis of the main trunk is presented. Four courses of hepatic arterial infusion therapy, via a subcutaneously implanted injection port, were performed using cisplatin (10 mg for 1 hour on days 1-5) and 5-fluorouracil (250 mg for 5 hours on days 1-5). After four courses of the chemotherapy, marked reduction in size of HCC and the tumor markers were noted. The esophageal varices and ascites were improved after the chemotherapy with a recanalization of the left branch of the portal vein. The patient was doing well with a survival period of 28 months after the chemotherapy. These encouraging results suggested that the present therapy, based on the biochemical modulation, was a useful option for advanced HCC with portal hypertension due to tumor thrombosis of the main portal vein.

Aged↗
PubMed1996

Radionuclide venography as a clue to the diagnosis of Budd-Chiari syndrome.

A patient was examined with radionuclide venography (RVG) to investigate unilateral leg oedema which might be due to deep vein thrombosis. RVG with Tc-99m MAA demonstrated no findings to suggest deep vein thrombosis of the right leg. However, collateral flow derived from the left common iliac vein and truncated inferior vena cava (IVC) were revealed. Contrast venography confirmed the obstruction of IVC and collateral flow from the left common iliac vein to the left ascending lumbar vein. It also showed the obstruction of hepatic veins and the patient was finally diagnosed as Budd-Chiari syndrome. Although unilateral leg oedema is an atypical symptom in Budd-Chiari syndrome, the findings on RVG led us to conduct further imaging studies to reach the diagnosis.

Budd-Chiari Syndrome↗
PubMed2006

Combined hepatocellular and cholangiocarcinoma: clinical features and prognostic study in a Thai population.

BACKGROUND/PURPOSE: Combined hepatocellular and cholangiocarcinoma (HCC-CC) is an uncommon subtype of primary liver cancer, the clinicopathological features of which have rarely been reported in detail. Some authors believe that HCC-CC behaves like HCC, but biliary differentiation may be associated with poorer prognosis. Moreover, CC has more frequent lymph node metastases. In this study, we aimed to determine the clinical course and survival outcome of HCC-CC patients in a Thai population by comparing them with patients with ordinary HCC. METHODS: The clinicopathological features of patients who were diagnosed with HCC-CC at Ramathibodi Hospital during 2000-2004 were retrospectively studied by comparing them with the features of patients suffering from ordinary HCC. Twenty-five patients who were diagnosed with HCC-CC were included in this study, and subsequently 50 patients with HCC who had tissues taken during the same period were selected randomly from among 148 HCC patients. Statistical analysis was done by using SPSS version 10.0. The Kaplan-Meier method was used to assess the survival rate. Multiple logistic regression analysis was performed to assess correlations. A value of P < 0.05 was considered statistically significant. RESULTS: There were no significant differences in etiologic risk factors between HCC-CC and HCC patients: cirrhosis (50% vs 44%), chronic alcohol abuse (36% vs 43%), presence of hepatitis B surface antigen (HBsAg; 66% vs 78%) and presence of hepatitis C virus (HCV) antibody (13% vs 3%). The serum alpha-fetoprotein (AFP) value in the HCC-CC group was lower than that in the HCC group (5.87 vs 41.46 ng/ml). No differences in tumor characteristics or liver status (tumor size, presence of multinodular lesions, portal vein thrombosis, intrahepatic bile duct dilatation, intraabdominal lymphadenopathy, extrahepatic metastasis, liver cirrhosis, portal hypertension, and ascites) between these two groups were found. The overall median survival of HCC-CC patients was 38 weeks while that of HCC patients was 54 weeks. Multivariate analysis showed that elevated carbohydrate antigen (CA)19-9 (>/=80 U/ml) and the presence of intrahepatic bile duct dilatation were independent risk factors for worse survival. CONCLUSIONS: The demographic and clinical features of patients with combined HCC-CC were similar to those of patients with HCC. The presence of cholangiocellular differentiation appeared to worsen the prognosis when compared with pure HCC, although this difference did not reach statistical significance. An increased CA19-9 level and intrahepatic bile duct dilatation in patients with HCC-CC were considered to be independent factors that suggested poor prognosis.

Adult↗
PubMed1999

Liver transplantation in infants.

PURPOSE: In view of the earlier reports that children below 1 year of age constitute a high-risk group for liver transplantation, the authors reviewed their experience in performing orthotopic liver transplantation in this age group. METHODS: The records of 9 children aged less than 1 year who underwent 6 living-related liver transplants and 3 reduced-size liver transplants between December 1993 and June 1997 were reviewed. RESULTS: Five reexplorations were required for 3 children who had 1 or more of the following early complications: bleeding from hepatic vein to inferior vena cava anastomosis (n = 1), right hepatic vein stump bleeding (n = 1), intraabdominal hematoma (n = 2), jejuno-jejunostomy leakage (n = 1), and colonic perforation (n = 1). Late complications include stricture at the biliary-enteric anastomosis requiring percutaneous balloon dilatation (n = 3) and hepatitis of undetermined etiology requiring retransplantation (n = 1). There was no hepatic artery thrombosis despite the small arteries available for anastomosis. Follow-up ranged from 19 to 61 months (mean, 40 months). Patient survival rate was 100%, and graft survival with good liver function was 89%. All living donors, 2 fathers and 4 mothers, are well. CONCLUSIONS: Liver transplantation in infants less than 1 year of age is technically demanding but feasible and still can be performed with a good outcome. Age alone (under 1 year) should not be considered as a contraindication for liver transplantation.

Age Factors↗
PubMed1976

Portal diversion for portal hypertension in early childhood.

Twenty-three children under 6 years of age with portal hypertention were treated by portal diversion. Fourteen had cavernomatous transformation of the portal vein and 9 had an intrahepatic block due to cirrhosis (8) or congenital hepatic fibrosis (1). Portal-systemic shunts were central splenorenal in 20 patients, side-to-side portacaval in 2 and mesocaval in one. In 20 of the 21 peripheral shunts, the veins used for the anastomosis were less than 10 mm in diameter. There was no operative mortality. Thrombosis of the shunt occurred in 3 children (13%) and was responsible for recurrent bleeding in one who was treated later with success by a mesocaval shunt. The two other children with a thrombosed shunt are waiting, at the present time, for a mesocaval anastomosis. The volume of blood flowing through the shunt was small initially and the fall in pressure gradient was slight: therefore intraoperative angiography appeared to be a better way to assess the patency of shunts done at an early age than pressure or flow measurements. The figures recently reported by Clatworthy, with a mortality rate of 12% directly or indirectly related to repeated hemorrhage, are for us a forceful argument for early adequate management of portal hypertension in children. Until now, portal-systemic shunts have been complicated by a high frequency of thrombosis and have given discouraging results. Our results suggest that it is possible to perform portal diversion successfully on diminutive veins (down to 4 mm). From this experience early portal diversion appears to represent the treatment of choice for portal hypertension in childhood.

Child, Preschool↗
PubMed1980

Congenital hepatic fibrosis combined with protein-losing enteropathy and recurrent thrombosis.

Two siblings, suffering from recurrent thrombosis and protein-losing enteropathy are presented. Histopathological examination of the liver in one of the patients, who died of multiple thrombosis, showed changes characteristic of Congenital Hepatic Fibrosis. Coagulation studies in the second child revealed decreased antithrombin-III in plasma, which might have had pathogenetic implications for the thrombosis tendency seen in both patients.

Adolescent↗
PubMedDate not supplied

Antineoplaston treatment for advanced hepatocellular carcinoma.

Antineoplaston A10 injection (antineoplaston A10 I) exhibited cystostatic growth inhibition of human hepatocellular carcinoma (HCC) cells in vitro and showed minimum adverse effects in a phase I clinical trial. Advanced HCC is hard to control because the potent anticancer drugs or embolizations easily induce hepatic failure. We review herein 2 cases of advanced HCC treated with antineoplaston A10 I. Both cases showed interesting responses to antineoplaston A10 I. One showed massive coagulation necrosis of tumors after intra-arterial infusion of antineoplaston A10 I and the other showed resolution of portal vein tumor thrombosis with systemic infusion of antineoplaston A10 I. The usefulness of anti-neoplaston A10 I in terminal staged HCC is discussed.

Aged↗
PubMedDate not supplied

[Computerized tomography of pancreatic tumors].

Few pancreatic carcinomas (5-22%) are resectable at the time of diagnosis because this lesion is seldom diagnosed in an early stage. A considerable improvement in the rate of survival is described only for resectable tumors: it is extremely necessary to find an imaging technique for early diagnosis and for accurate staging of pancreatic carcinoma to discern operable from inoperable cancer. The sensitivity of CT in predicting that pancreatic carcinoma is unresectable has been described as approaching 100%. However the reverse is not true. More than one third of the tumors revealed with CT and interpreted as resectable cannot be excised. The major reason for errors with CT are failure to detected liver metastases, peritoneal implants, lymph node involvement and encasement of the great vessels by tumor. Significant progress has recently been made to improve the detection of these details with the recent introduction of helical CT with infusion of a bolus of contrast material and thin section collimation. Traditionally, when a single sequence of images was acquired during abdominal CT, the time of the acquisition was dominated by the requirement to scan during maximal hepatic enhancement, which unfortunately may not be optimal for evaluation of the pancreas. With the advent of helical CT, the acquisition of two sets of images after infusion of contrast material is now possible; the first one takes place during the arterial enhancement; it is useful to detect tumor vascular encasement and the maximum difference of tissue attenuation between normal greater pancreatic enhancement and hypodense pancreatic mass, less vascularizated. It appears that the peak parenchymal enhancement achieved with helical CT may improve the sensitivity of CT scanning in detecting pancreatic carcinoma, especially small tumors confined within the organ. The second phase takes place during the venous or portal enhancement and provides useful information about venous encasement and hepatic metastasis. Extraglandular extension with invasion of adjacent major arterial (celiac axis or its branches, superior mesenteric artery) and venous (portal, splenic, superior mesenteric) appear as soft-tissue attenuation thickening obscuring the perivascular fat, with deformity, thrombosis or occlusion of the vessels. In cases of venous occlusion, collateral vein can be identified. Dilatation of the small veins that surround the head of the pancreas might be used as an additional criterion of extrapancreatic extension of neoplasia. With the features of spiral CT (contrast material optimization and continuous scanning), the detection of small lesions in the liver and peritoneal implants has been increased. Helical CT seems not to detect anything else about lymph node involvement than conventional CT, limited by the same morphologic criteria. The only CT means of detection of node involvement by pancreatic carcinoma is the pathologic enlargement of lymph nodes without specificity for neoplastic or not neoplastic ones. In many cases 2D, 3D and MIP imaging are helpful to evaluate vasculature encasement, especially for visualization of vessels which lie in oblique, coronal or sagittal plane. Consequently helical CT has the potential to become an alternative angiographic technique. Many studies have been done to evaluate spiral CT potential impact and to compare the value of this technique with other ones in the initial diagnosis and staging of pancreatic carcinoma. One of these studies compares dual-phase helical CT and endoscopic endo-sonography. The Authors observe that the two techniques do not differ significant statistically in detecting pancreatic carcinoma, except endoscopic sonography is more sensitive than helical CT for tumors smaller than 15-20 mm. They found the accuracy to predict unresectable carcinoma is 100% for dual-phase helical CT and less for endoscopic endosonography (86%). (ABSTRACT TRUNCATED)

Humans↗
PubMed1979

[Primary liver cell carcinoma, aetiology and clinical picture (author's transl)].

Geographic area, age and sex influence the epidemiology of hepatoma. Aetiological factors are aflatoxins, sex hormones, thorotrast, alpha 1-antitrypsin deficiency, immunosuppression, vinylchloride, parasites, cirrhosis of the liver, and the hepatitis-B virus. Early diagnosis of the tumour is possible using alpha 1-fetoprotein estimations and modern morphological methods, particularly scintiscanning. Tumour resection is therapeutically desirable, while selective chemotherapy remains palliative and liver transplantation failed to prolong survival.

Adrenal Gland Neoplasms↗
PubMed2005

Liver transplantation in children weighting less than 6 kg: the Bergamo experience.

Liver transplantation (OLT) remains a major medical and surgical challenge in small patients. From October 1997 through July 2004, 17 babies less than 6 kg underwent 18 OLTs. Median age and weight were 3 months (range = 1 to 9) and 4.7 kg (range = 2.2 to 5.8). Two whole, one reduced, and 15 split-liver grafts (left lateral segments) were obtained from donors of median age and weight of 11.6 years (range = 0.5 to 62) and 50 kg (range = 7 to 63). Donor-to-recipient median weight ratio (D/R) was 9.1 kg (range = 1.3 to 17.6) and median graft-to-recipient weight ratio (GRWR) was 5% (range = 3.1 to 10). The incidence of biliary complications was 23%. The only vascular complication was a portal vein thrombosis (6%). Fourteen patients (79%) are alive with good graft function at a median follow-up of 39 months (range = 0.5 to 74). Three patients (all status 1) died on postoperative day 285 (brain death), 17 (multiorgan failure), and 229 (cardiovascular failure during retransplantation). Actuarial patient survivals at 6 months and 6 years are 94% and 78% while graft survivals are 89% and 74%, respectively. Currently all the patients listed as UNOS status 2 and 3 (73%) at the time of transplant are alive. During the same period one premature neonate (1.8 kg) who presented with fulminant hepatic failure died on the waiting list after 12 days. Our data confirm that the extensive use of a split-liver technique from small adult or pediatric cadaveric donors can offer the benefits of liver transplantation to small pediatric candidates with excellent results.

Adolescent↗
PubMed1996

Doppler ultrasound of the hepatic artery and vein performed daily in the first two weeks after orthotopic liver transplantation. Useful for the diagnosis of acute rejection?

RATIONALE AND OBJECTIVES: To analyze changes in Doppler ultrasound variables in relation to liver biopsy findings for the diagnosis of acute rejection after orthotopic liver transplantation (OLT), the authors performed in a prospective study 316 Doppler ultrasound examinations in the first 2 weeks after OLT on 23 patients. METHODS: Recordings were obtained daily from the hepatic artery (resistive index [RI]) and hepatic vein (damping index [DI]). Correlations were explored between the Doppler ultrasound findings and histologic data. The chi-square test was used to analyze differences in Doppler ultrasound variables in patients with and without acute rejection. RESULTS: Serial Doppler ultrasound examinations showed a significant increase in the RI in 11 of 22 patients (50%); the 23rd patient was excluded because of hepatic artery thrombosis. Despite an agreement in 15 of 22 patients (68%) no statistically significant correlation could be found (positive predictive value 6/11 = 55%; negative predictive value 9/11 = 82%; chi-square = 3.14; P > 0.05). A significant increase in the DI was observed in 14 of 23 patients (61%). However, no statistically significant correlation could be found as well with this parameter (positive predictive value 6/14 = 43%; negative predictive value 6/9 = 67%; chi-square = 0.00; P > 0.05). CONCLUSION: Serial Doppler ultrasound examinations were not helpful in predicting acute rejection.

Acute Disease↗
PubMedDate not supplied

Pulmonary embolism from a parasitic cardiac clot secondary to hepatic alveolar echinococcosis.

An exceptional form of hepatic alveolar echinococcosis with metastasis of the right atrium is reported. This cardiac location of the parasitosis was revealed by attacks of pulmonary embolism which produced secondary pulmonary lesions. This case suggests that pulmonary metastases of alveolar echinococcosis of the liver might be due to the migration of parasitic clots from the hepatic veins.

Antigens, Helminth↗