Management of gastric cancer in patients with sinistral portal hypertension

Sinistral portal hypertension (SPH) is usually caused by pancreatic pathology and is characterized by splenic vein thrombosis with or without portal vein thrombosis.1 The increased pressure caused by splenic vein occlusion is transmitted via the short gastric and gastroepiploic veins to the portal system.The reversal of blood flow in the left gastric vein results in gastric varices.In patients with SPH,especially those with occlusion of both the splenic and portal veins,the main or even the only pathway of splenic venous return to the portal vein is via the gastric varices,and these patients require special management during gastric surgery.     

Treatment of portal hypertension from portal vein cavernoma with the meso-Rex bypass

Extrahepatic or prehepatic portal vein cavernoma and thrombosis is a more common condition in children than that in adult patients with extrahepatic or prehepatic portal vein obstruction (EHPVO),which involves approximately 30％ of children with portal hypertension and can involve all the portal hypertension complications.Cavernomatous transformation of the portal vein is common after portal thrombosis in non-cirrhotic patients.This challenging situation is relatively more frequent after liver transplantation,particularly in pediatric recipients.Acute bleeding from esophageal and gastric varices is temporarily treated by sclerotherapy or variceal banding.     

STUDIES OF EFFECTS OF PORTASYSTEMIC SHUNT ON THE FUNCTION OF HEPATIC AND PANCREATIC ISLET CELLS

The present study was aimed at dynamic observation of the ef fects of end to side portacaval shunt (PCS) and end to side mesocaval shunt (MCS) in dogs on the functions of the liver and pancreatic islet cells. According to correlation between the changes of plasma insulin level in the portal vein and hepatic flow and liver morphology after PCS and MCS, we conclude that the depletion of hepatic flow is the major factor in the deterioration of liver functions. The levels of insulin and glucagon in both the peripheral vein and the portal vein were decreased after PCS and MCS. There was also depletion of pancreatic islet A and B cells and vacuolar degeneration of the pancreas. These changes were more signifcant in PCS than in MCS, suggesting that portasystemic shunt, especially total portasystemie shunt, might damage pancreatic endocrine functions.     

Intraoperative coronary venography in observing changes of portal blood flow after portal-azygos disconnection.

Intraoperative coronary venography was performed in 24 patients before and after portal-azygos disconnection for portal hypertension. Before the procedure the portal vein was found to be communicated with cardial and esophageal veins by two pathways, i,e., from the esophageal and gastric branches of the coronary vein to the esophageal varices, with the latter branches by way of the gastric intramural venula. The portal blood flow was postulated to be hepatofugal because the portal trunk could not be seen venographically. Coronary venography done after the disconnection revealed no pericardial and esophageal varices and the portal vein with hepatopetal blood flow. We conclude that the operation had the advantage of complete disconnection between the portal vein and the cardio-esophageal varices, thus preventing the bleeding from the varix and increasing hepatopetal blood flow.

     

Direct vision controlled gastric coronary vein embolization for the treatment of portal hypertension.

Complications of gastric mucosal bleeding and ectopic embolism occurred in gastric coronary embolization under direct vision in treating hemorrhage from ruptured esophageal varices though it has been widely used with satisfactory results. 40 patients with portal hypertension were treated by splenectomy and gastric coronary vein embolization under direct vision in this hospital. On the basis of Liu's operative method, 20 of the 40 patients underwent controlled embolization of the gastric coronary vein with satisfactory results. The technic not only occluded the predicted bleeding sites of the veins at the esophageal and gastric fundic regions but also blocked its communication with surrounding veins. Thus serious complications were reduced or prevented. The effectiveness of devascularization derived from the technic in question, the detailed maneuver of the procedure, and prevention of complications are discussed.

     

Transjugular intrahepatic portosystemic stent shunts. Preliminary results in 18 patients.

In 18 consecutive patients receiving the transjugular intrahepatic portosystemic stent shunts (TIPSS), 15 were male and 3 female. The patients aged from 34 to 66 years had liver cirrhosis with portal hypertension and esophageal varices. Twelve had recurrent bleedings from raptured gastroesophageal varices. Shunts were established in 16 of the 18 patients and no operative death was noted. Portal vein pressure was reduced from 3.98± 0.24 kPa before shunting to 2.40±0.16 kPa after shunting. Doppler ultrasound examination revealed that the maximum blood flow velocity in the main portal vein increased from 14.0±4.5 cm / sec to 48.0±16.5 cm / sec. The mean follow-up time in the successful cases was 4.5 months (range 2-8 months). The shunt patency was determined with color Doppler ultrasound in 15 patients: occlusion in one and no accites in 4. Varices disappeared in 8 patients and became less evident in 7. No patients had recurrence of varices bleeding or encephalopathy during follow-up. The results sugges     

Esophagogastric variceal bleeding in cirrhotic portal hypertension： onsensus on prevention and management （2008）

Portal hypertension is a clinical syndrome which is a consequence of a pathological increase in portal vein pressure due to various causes, liver cirrhosis being the most common. The basic pathophysiological characteristic of portal hypertension is resistance to portal vein flow or an increase in portal vein flow, which results in elevation of pressure in the portal vein and its tributaries and the formation of collateral circulation.     

Liver function

930536 Applied anatomy for interhepatic porto-caval shunt.DU Xiangke(杠湘珂),et al.DeptRadiol,Beijing People's Hosp,Beijing Med U-niv,Beijing,100044.Chin J Radiol 1993;27(3):148—151.The results of measurement of the anatormicalrelationship of hepatic and portal vein in 70 hu-man liver specimens were reported including theirdistance and overlapping areas.The resultsdemonstrated that,when the catheter enteredthe posterior segment of IVC in the liver andthen passed into the left,middle or right branch-es of hepatic vein for an average of 4—5cm,thesegmental branches of portal vein would be over-lapped.The authors suggested that the catheter     

Liver

<正>209461 Intraoperative ligation of recipient’s portasystemic shunt in liver transplantation/Chen Litian(,Organ Transplant Center,Tianjin 1st Centr Hosp Tianjin 300192)…∥Chin J Gen Surg.-2009,25(4).-489～491Objective To investigate the clinical significance of ligating the portasystemic shunt confirmed by preoperative CT evaluation during orthotopic liver transplantation.Methods From January 2007 to August 2008,35 patients in Tianjin First Central Hospital underwent preoperative three-dimensional CT scan,among them 23 patients had spontaneous major portasystemic shunts,the other 12 patients did not have portasystemic shunts.16 out of the 23 cases with significant shunts underwent shunt ligation based on portal blood flow volume measured by intraoperative portal vein flowmetry.The shunt of the other 7 patients were left untreated.Results The portal blood flow in the 12 patients without portasystemic shunt judged by preoperative CT scanning were(1 101±70)ml/min.The shunts in 7 patients with portal blood flow greater than 1 000 ml/min were not ligated,that of the 16 patients with portal blood flow volume lower than 1 000 ml/min were ligated.The portal blood flow volume in those 16 patients before and after ligating the shunt were(657±112)ml/min and(1 136±161)ml/min,respectively(P<0.05).Postoperatively 2 patients suffered from portal vein thrombosis,among them 1 patients suffered from intermittent disturbance of consciousness,2 patients died within 3 months,with one died of respiratory failure from pulmonary aspergillus infection,one died of hepatic failure in 2 months after operation because of graft dysfunction.The other 19 patients with normal blood flow and well-functioning graft were alive.Conclusion The ligation of portasytemic shunt is mandatory in patients when pretransplant CT evaluation showing a major porto-systemic shunts and portal blood flow volume was less than 1 000 ml/min.5 refs,2 figs.     

Applicability of prostaglandin E1 indirect portal vein angiography in patients with portal hypertension.

The imaging quality of the portal vein was obviously improved with prostaglandin E1 (PGE1) indirect portal vein digital subtraction angiography (DSA) in 23 cases. The time-density curve showed that the occurrence rate of opposite hepatic blood flow of splenic vein (SV) was the highest (17.4%). The total visualization rate of the left gastric vein (LGV) was 78.3%, and the visualization rate of the short gastric vein (SGV) was 36.4%. 38.9% of the LGV and all the SGV were visualized with indirect portal vein DSA through SA. Indirect portal vein angiography through superior mesenteric artery and that through splenic artery were of equal importance. In portal hypertension patients with hemorrhage of the digestive tract, when LGV and SGV could not be visualized in PGE1 indirect portal vein DSA, the possibility of non-varices vein bleeding should be considered. When opposite hepatic blood flow with obvious dilation appeared in LGV and SGV, devascularization of the pericardial blood vessels would be justifiable.