Incidence,Management, and Implications of Visceral Thrombosis in Pancreatic Ductal Adenocarcinoma

Background

Visceral or splanchnic thrombosis is defined as thrombi within the hepatoportal venous system, including portal (PV), mesenteric (MV), and splenic vein (SV), as well as thrombi in renal or gonadal veins. There are limited data to evaluate the prognostic significance, incidence, and clinical management of visceral thromboses in patients with pancreatic ductal adenocarcinoma (PDAC).

Visceral Thromboses in Pancreas Adenocarcinoma: Systematic Review

Within gastrointestinal malignancies, primary hepatocellular carcinoma and pancreatic ductal adenocarcinoma (PDAC) are frequently associated with visceral thromboses (VT). Thrombus formation in the portal (PVT), mesenteric (MVT), or splenic vein (SVT) system leads to portal hypertension and intestinal ischemia. VT in PDAC may convey a risk of increased distal thrombosis and poses therapeutic uncertainty regarding the role of anticoagulation. An increasing number of reports describe VT associated with PDAC. It is possible that early diagnosis of these events may help reduce morbidity and speculatively improve oncologic outcomes. To perform a systematic review to study PVT, MVT, and SVT associated with PDAC, and to provide a comprehensive review. Medline/PubMed, Embase, Web of Science, Scopus, and the Cochrane Library. Data Extraction and Assessment: Two blinded independent observers extracted and assessed the studies for diagnosis of PVT, MVT, and SVT in PDAC. Studies were restricted to English-language literature published between 2007 and 2016. Eleven articles were identified. Five case reports and 7 retrospective studies were found, with a total of 127 patients meeting the inclusion criteria. The mean age at diagnosis was 64 years. PVT was found in 35% (n = 46), SVT in 52% (n = 65), and MVT in 13% (n = 15). Mean follow-up time was 26 months. Only 3 of the selected articles studied the impact of anticoagulation in VT. All patients with nonvisceral thrombosis (eg, deep-vein thrombosis, pulmonary emboli) were therapeutically treated; in contrast, patients with VT only rarely received treatment. VT in PDAC is a frequent finding at diagnosis or during disease progression. Evidence to guide treatment choices is limited, and current management is based on inferred experience from nononcologic settings. Anticoagulation appears to be safe in VT, with most of the large studies recommending a careful assessment for patients at a high risk of bleeding.     

Ultrasound-assisted percutaneous catheterization of the axillary vein for totally implantable venous access device

Background

Placing a totally implantable venous access device (TIVAD) using the classical subclavian vein puncture method carries the risk of certain complications including hemothorax, pneumothorax and pinch-off syndrome. We set out to determine whether percutaneous axillary vein catheterization can decrease the incidence of these complications.

Method

This is a prospective, observational, uni-institutional study. We analyzed the outcome of 113 TIVADs performed by ultrasound-assisted percutaneous axillary vein catheterization from Jun. 2008 to Dec. 2008. Junior residents novice to subclavian and axillary vein catheterization performed the procedures. Insertion and indwelling catheter complications were recorded.

Result

In our study population, 100% of TIVAD placements were successful. 27 patients (23.9%) required 3 or more repeated punctures; only one patient (0.9%) had clinically insignificant pneumothorax. Neither arterial puncture nor brachial plexus injury was recorded in our study.

Conclusion

Ultrasound-assisted percutaneous axillary vein catheterization for TIVAD is a safe and relatively simple method for inexperienced operators.     

Portal vein embolization failure: Current strategies and future perspectives to improve liver hypertrophy before major oncological liver resection

Portal vein embolization (PVE) is currently considered the standard of care to improve the volume of an inadequate future remnant liver (FRL) and decrease the risk of post-hepatectomy liver failure (PHLF). PHLF remains a significant limitation in performing major liver surgery and is the main cause of mortality after resection. The degree of hypertrophy obtained after PVE is variable and depends on multiple factors. Up to 20% of patients fail to undergo the planned surgery because of either an inadequate FRL growth or tumor progression after the PVE procedure (usually 6-8 wk are needed before surgery). The management of PVE failure is still debated, with a lack of consensus regarding the best clinical strategy. Different additional techniques have been proposed, such as sequential transarterial chemoembolization followed by PVE, segment 4 PVE, intra-portal administration of stem cells, dietary supplementation, and hepatic vein embolization. The aim of this review is to summarize the up-to-date strategies to overcome such difficult situations and discuss future perspectives on improving FRL hypertrophy.     

Pre-hepatectomy portal vein embolization: Single center experience

Aim

To evaluate the feasibility and the effectiveness of portal vein embolization (PVE) as preoperative treatment in patients scheduled to undergo right hepatectomy, when the volume of the future remnant liver (FRL) appears to be insufficient to prevent the risk of post-surgical hepatic failure.

Materials and Methods

Thirty-one consecutive patients (19 men, 12 women; age range: 54–77 years; mean age: 66.2 years) with liver malignancy (7 hepatocellular carcinoma, 13 metastases, 9 cholangiocarcinoma, and 2 gallbladder carcinoma) were selected after clinical–radiological evaluation for PVE. After the embolization changes in volume of FRL, portal pressure, liver enzymes, and complications before and after hepatectomy were assessed.

Results

PVE was successful in all patients without major complications. The mean volume of FRL, calculated before and 4 weeks after PVE, increased from 319.2 ± 45.1 to 460.2 ± 27.7 cm³ (+44.2%) in the non-cirrhotic group and from 458.4 ± 38.3 to 605.2 ± 27 cm³ (+32.1%) in the cirrhotic group. The FRL/TELV ratio increased by 9%.

Conclusion

In our experience, PVE resulted feasible, safe, with a very low rate of complications, and effective to induce liver regeneration before right hepatectomy in patients with liver malignancy.     

C.T. Demonstration of Thrombosis of the Portal Venous System

Thrombosis involving all or part of the portal venous system was demonstrated by C.T. in three patients. Predisposing factors were sigmoid colectomy for adenocarcinoma, appen-diceal abscess and splenectomy for splenic arterio-venous malformation, respectively. Fresh thrombus appeared as high density intraluminal content on noncontrast enhanced scans. Older thrombus appeared as low density intraluminal content surrounded by a high density venous wall on contrast enhanced scans. One patient developed a cavernoma of the portal vein demonstrated by C.T. and porto-graphy. In another patient; bowel infarction with bowel wall thickening and intra-mural gas was demonstrated. Although the diagnosis can be made on non-contrast enhanced scans in the acute phase and by using the bolus intravenous technique for contrast enhanced scans for older thrombus, optimal demonstration of the presence of thrombus and clear definition of the extent of thrombosis requires a dynamic scanning technique during rapid intravenous infusion of contrast.     

长春瑞宾颈外静脉与前臂静脉给药静脉炎发生率比较

目的:对比通过颈外静脉留置针与前臂静脉穿刺在长春瑞宾应用中静脉炎发生情况。方法:对108例滴注长春瑞宾的乳腺癌、肺癌患者随机分为两组,68例为颈外静脉留置组(A组),40例前臂静脉组(B组)。观察静脉炎发生情况。结果:A组发生率为3%,B组发生率为57.5%,两组患者静脉炎发生有明显差异。结论:颈外静脉留置滴注长春瑞宾能减少静脉炎的发生。     

Technical modifications and outcomes after Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) for primary liver malignancies: A systematic review

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) represents a novel surgical technique which provides rapid and effective liver regeneration allowing for the resection of lesions initially deemed unresectable. The objective of this systematic review is to summarize all technical modifications of the original ALPPS approach (mALPPS) for primary liver malignancies and evaluate short- and long-term outcomes. A systematic search of the literature was conducted using PubMed, Scopus, Cochrane Library Central, Google Scholar, and clinicaltrials.gov databases until July, 31 2019. The following keywords were utilized: “Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy”, “ALPPS”, “Portal Vein Embolization (PVE) And In Situ Split”, “Portal Vein Ligation (PVL) And In Situ Split”. A total of 24 studies were identified incorporating data on 83 patients who underwent a mALPPS for a primary liver malignancy. Median FLR hypertrophy after ALPPS-1 was 54% (range, 6.7–133%) and median EBL during the ALPPS 1 and ALPPS 2 stages was 200 mL (range 0–1000) and 700 ml (range 100–4000), respectively. R0 resections were achieved in all patients (100%). Most complications occurred post ALPPS- 2 (n = 33/72, 45.8%), while overall 30-day mortality was 13.3%. After a median follow up of 7 months (range 3–60), recurrence rate was 18.9%. Disease-free survival ranged from 3 to 60 months with a median of 10 months and overall survival ranged from 3 to 60 months with a median of 11 months. ALPPS with the various technical modifications offers a reasonable chance of complete tumor resection among patients with initially unresectable primary liver tumors. Further advances in patient selection, surgical techniques and perioperative management are required to minimize complications rates. Large scale prospective trials are needed to validate the role of the technical modifications of ALPPS in the treatment of patients with primary liver malignancies in an individualized setting.     

‘Benign’ hepatic portal venous gas

The presence of portal venous gas within the hepatic parenchyma is usually associated with a guarded prognosis and a mortality rate approaching 75%. However, there are infrequent causes of portal venous gas not associated with dire clinical outcomes. We describe three patients who made uneventful clinical recoveries after presenting with clinical and imaging manifestations of ischaemic bowel and hepatic portal venous gas, two of which had distended but non‐necrotic bowel at laparotomy.     

Histologic tumor involvement of superior mesenteric vein/portal vein predicts poor prognosis in patients with stage II pancreatic adenocarcinoma treated with neoadjuvant chemoradiation

BACKGROUND:

Studies have shown that superior mesenteric vein (SMV)/portal vein (PV) resection with pancreaticoduodenectomy (PD) is safe and feasible for patient with pancreatic adenocarcinoma (PAC). However, the prognostic significance of tumor involvement of the resected vein in patients who received neoadjuvant therapy is unclear.

METHODS:

The authors evaluated 225 consecutive patients with stage II PAC who received neoadjuvant therapy and PD with or without SMV/PV resection. The resected SMV/PV was entirely submitted for histologic assessment and reviewed in all cases. Tumor involvement of the SMV/PV was correlated with clinicopathologic features and survival.

RESULTS:

Among the 225 patients, SMV/PV resection was performed in 85 patients. Histologic tumor involvement of the resected SMV/PV was identified in 57 patients. Histologic tumor involvement of the SMV/PV was associated with larger tumor size, higher rates of positive margin, and local/distant recurrence. By multivariate analysis, tumor involvement of the SMV/PV was an independent predictor of both disease‐free survival (DFS) and overall survival (OS). However, addition of venous resection to PD itself had no impact on either DFS or OS compared with those with PD alone.

CONCLUSIONS:

Histologic tumor involvement of the SMV/PV is an independent predictor of both DFS and OS in patients with stage II PAC treated with neoadjuvant therapy and PD. Complete histologic evaluation of the resected SMV/PV is important for the prognosis in patients with PAC who received neoadjuvant therapy and PD. Cancer 2012. © 2011 American Cancer Society.     

TACE联合门静脉支架治疗伴门静脉癌栓原发性肝癌的效果分析

目的 研究肝动脉化疗栓筛(TACE)联合门静脉支架植入术治疗伴门静脉癌栓原发性肝癌的效果.方法 在遵循随机对照原则和入选标准的基础上,选取2012年7月至2015年1月确诊为原发性肝癌伴门静脉癌栓15例患者为观察组,选取2010年1月至2012年6月于我科确诊为原发性肝癌伴门静脉癌栓但仅接受TACE治疗的15例患者为对照组,而观察组则接受肝动脉化疗栓筛(TACE)联合门静脉支架植入术治疗.对比两组患者治疗前后肝功能主要指标和并发症情况,并随访两组患者的生存时间.结果 与治疗前比较,两组患者治疗后肝功能主要指标水平差异明显,均具有统计学意义(P<0.05),且观察组肝功能主要指标改善情况显著优于对照组,差异均具有统计学意义(P<0.05).与对照组比较,观察组出现肝性腹腔积液、肝性脑病、严重感染及肺转移患者例数明显减少,且差异均具有统计学意义(P<0.05).与对照组比较,观察组总生存时间明显延长,且差异均具有统计学意义(P<0.05).结论 肝动脉化疗栓筛(TACE)联合门静脉支架植入术不仅可降低患者并发症的发生率,同时还可有效改善中晚期患者的肝功能,其在延长患者生存时间上也有显著的效果,值得临床推广运用.     

胰十二指肠切除联合肠系膜上静脉／门静脉切除治疗胰头癌11例报告

目的 :提高胰头癌侵犯门静脉和 (或 )肠系膜上静脉 (PV/SMV)的根治性切除率。方法 :对包括受侵的 PV/SMV在内的扩大的胰头十二指肠切除术 11例进行回顾分析。结果 :11例中有8例行血管壁部分切除 ,3例行血管节段切除 ,全组患者均未发生血管栓塞、肠坏死、肝衰竭等并发症 ,近期随访无 1例死亡和复发。结论 :对单纯侵犯 PV/SMV的胰头癌施行包括 PV/SMV在内的胰头十二指肠扩大根治术是可行的     

中心静脉置管在肿瘤内科的用途及价值探讨

目的探讨中心静脉置管在肿瘤内科的用途及其价值,以满足肿瘤内科给药的多种特殊需求.方法以一次性中心静脉导管经锁骨下穿刺置管于上腔静脉末端.结果中心静脉置管用于治疗20种中晚期癌症患者482例,13种特殊用药所需399例(82.8%);肺癌和肺部转移癌为增加肺部药物持续浓度130例(27.0%);外周静脉条件差难以顺利给药127例(26.3%);需长期输液24例(5.0%);为避免外周静脉化疗的痛苦、不便和静脉炎或曾发生静脉炎,患者要求13例(2.7%);外周静脉留置针失败后1例(0.2%).结论经锁骨下中心静脉置管在肿瘤内科用途甚广,可满足多种病种给药的多种特殊需求,既有助于提高疗效减轻副作用,又可避免外周静脉给药的痛苦和不便及其局部并发症,有助于改善患者生活质量,值得推广.     

中心静脉与外周静脉置管在恶性肿瘤化疗中的应用

目的比较中心静脉与外周静脉置管在恶性肿瘤化疗中的应用。方法共136例恶性肿瘤化疗病人，随机分为两组，每组68例，即中心静脉置管组（Ⅰ组）和外周静脉穿刺术置管组（Ⅱ组）。结果①Ⅰ，Ⅱ组一次穿刺成功率分别为95．58％和98．52％（P〉0．05）；②Ⅰ，Ⅱ组发生药物渗漏和，或脉管炎者分别为0％，22．2％和0％，36．4％（P〈0．05）；③Ⅰ，Ⅱ组留管中位时闻分别为78d和5d（P〈0．001）；④穿刺置管与留管期间，病人有心理恐惧和，或焦虑的Ⅰ，Ⅱ组分别为42．1％和12．5％（P〈0．001）；⑤两组均未发生置管感染和栓塞。结论中心静脉置管术安全、创伤小、留置时间长，静脉炎的发生率低，且能提高护理质量，值得在恶性肿瘤的化疗和长期补液病人中推广应用。     

Experimental study on enhancement of the metastatic potential of portal vein tumor thrombus-originated hepatocellular carcinoma cells using portal vein serum

Objective： Portal vein metastasis of hepatocellular carcinoma（HCC） results in a poor prognosis and seriously affects the survival rate of patients. The mechanism underlying the formation of portal vein tumor thrombus（PVTT） is complex and is not yet fully understood. This study was conducted to investigate the impact of portal vein blood on the proliferation, metastasis, invasion and apoptosis of PVTT cells and to explore its possible mechanisms, which was expected to lay a foundation for ascertaining the mechanism underlying the portal vein metastasis of HCC.
Methods： Peripheral blood and portal vein blood were collected from patients with HCC, and the sera from these two sources were used to culture the PVTT-originated HCC cell line CSQT-2. The cells were collected after 24 h, and flow cytometry was performed to detect cell proliferation, cell cycle stages and apoptosis. Transwell migration and invasion assays were applied to detect the metastasis and invasion of the cells in each group. The changes in the expression of MMP-2 and MMP-9 in cells were detected via Western blotting. The contents of IL-12, IFN-γ, IL-1β, IL-2 and TNF-α in the two groups of sera were quantified using corresponding kits.
Results： Compared with the group of cells cultured with peripheral serum, the cells cultured with portal vein serum showed significantly lower apoptosis（P〈0.01）, significantly enhanced cell metastasis and invasion（P〈0.01）, whereas cell proliferation and the stages of the cell cycle did not differ significantly（P〉0.05）. A significantly increased expression level of MMP-2 has been observed in tumor cells treated portal vein serum. In addition, compared with peripheral serum, the content of IL-12 was significantly decreased in portal vein serum（P〈0.05）, while the contents of IFN-γ, IL-1β, IL-2, and TNF-α did not differ significantly（P〈0.05）.
Conclusions： Portal vein serum from HCC patients could inhibit the apoptosis of PVTT-originated HCC cells and promote cell met     

Infrahepatic caudal/inferior vena cava interruption with azygos/hemiazygos continuation. Vascular anomaly in swine

Background

Swine are commonly used as a model to study congenital cardiovascular defects that occur in humans and these models have been both spontaneous and experimentally induced. Ventricular septal defect, patent ductus arteriosus, and atrial septal defect (ASD) are examples of experimentally induced models. Absence of caudal/inferior vena cava (CVC/IVC) with azygos/hemiazygos continuation is an uncommon vascular anomaly.

Case report

The vascular anomaly presented in this case report was an incidental finding on a pig that was evaluated for experimental percutaneous atrial septal defect creation and its closure using a percutaneous femoral vein approach. Absence of CVC/IVC was confirmed by venography and necropsy.

Conclusions

To the best of the investigators knowledge, this is the first report of absence of CVC/IVC with azygos/hemiazygos continuation in the swine.