Transient hepatofugal portal blood flow after hepatectomy in a patient with cirrhosis: Report of a case

We report herein the case of a 60-year-old man who developed hepatic failure with simultaneous transient hepatofugal portal blood flow after undergoing hepatectomy for hepatocellular carcinoma accompanied by cirrhosis with a splenorenal shunt. The transient hepatofugal portal blood flow was detected by color Doppler ultrasonography. Following this case report, the possibility of a relationship between hepatofugal portal blood flow, portal-systemic shunts, and postoperative hepatic failure is discussed.     

肝切除术后门静脉压力变化的变态观察

观察肝切除术后自由门静脉压力动态变化的规律,方法６３例肝癌病人,术中经胃网膜右静脉插管至门静脉主干,并将埋植式给药装置（ＩＤＤＳ）植于腹壁皮下,经ＩＤＤＳ分别测量肝切除前、切除手及术后１,３,５,７,１４,２１,２８ｄ之自由门静脉压（ＦＰＰ）。结果全组病例肝切除术后ＦＰＰ均出现一过性升高,以术后３－７ｄ升高最为显著,之后逐渐缓慢下降。ＦＰＰ的升高幅度及回落状态与肝切除范围,肝门阻断时间长短,肝硬化     

Acute portal hypertension reflecting shear stress as a trigger of liver regeneration following partial hepatectomy

The concept of injury in liver regeneration after partial hepatectomy (PHx), and the reason hepatocytes that have not been directly injured regenerate, remain unclear. It is known that shear stress resulting from blood flow plays an important role in the mechanism of remodeling blood vessels, and portal pressure reflects shear stress. This study was conducted to determine whether acute portal hypertension (APH) can become a trigger of liver regeneration as shear stress following PHx in a rat model. Portal pressures became elevated immediately after 70% and 90% PHx, peaking on postoperative day (POD) 3, and thereafter decreasing in proportion to the diminution of liver regeneration. The portal pressures after 90% PHx were significantly higher than those after 70% PHx even on POD 7, while those of the portocaval (PC) shunt groups decreased following PC shunting both with and without 70% PHx. The liver/body weight (LW/BW) ratio also decreased in the PC shunt both with and even without 70% PHx. The gradient expressions of class I antigen on sinusoidal endothelial cells (SEC) were found only in the periportal area, which has the highest portal pressure in the healthy rat liver. However, after hepatectomy these expressions were detected from the periportal area to the central venous area. These results suggest that APH as shear stress following PHx may not only become a trigger of hepatocyte regeneration, but also of SEC regeneration, and that surplus APH induces liver dysfunction.     

生长抑素对门脉高压病人脾切除手术前后门脉压力的影响

目的 :探讨思他宁对肝硬化门脉高压病人行脾切除手术前后门脉压力的影响。方法 :肝硬化门脉高压脾肿大、脾功能亢进病人 2 5例 ,随机分治疗组 (思他宁组 ) 15例 ,对照组 10例 ,术前 1d及术后第 2天用彩色多普勒测定门脉主干内径、血流速度及血流量。手术中开腹后和术毕关腹前分别经胃网膜右静脉分支测得门静脉压力。治疗组在使用思他宁 5min后测门脉压力一次 (思他宁静脉维持 4 8h) ,记录术中出血量、术后第 1天脾窝引流管引出量。结果 :治疗组 :①使用思他宁前后门脉压力差异有极显著性 (P <0 .0 1)。在思他宁维持过程中 ,行脾切除前后门脉压力差异有显著性 (P <0 .0 5 )。②使用思他宁前后和脾切除术前后门脉内径差异无显著性 ,最大流速及血流量差异有极显著性 (P <0 .0 1)。对照组 :①脾切除前后门脉压力、最大血流量及血液流速差异有显著性 (P <0 .0 5 )。②门脉内径差异无显著性。两组术中出血量 ,术后第 1天腹腔引流管引出量差异有极显著性 (P <0 .0 1)。结论 :周围静脉持续生长抑素维持能降低门脉高压病人脾切除术后的门脉压力 ,降低门脉压力的机制可能是通过降低门脉血流速率从而降低门静脉血流量。术中及术后使用思他宁能明显减少术中及术后创面渗血     

A pharmacological analysis of prostaglandin E1 on portal blood flow after partial hepatectomy in rats

Portal venous flow (PVF) and portal venous pressure (PVP) were examined after the jugular or portal injection of Prostaglandin E₁ (PGE) in rats partially hepatectomized by either 40% or 66%. In the 66% hepatectomized animals, the jugular injection of PGE at 5.0 g/kg/min produced an increase in PVF concomitant with a fall in systemic arterial pressure (SAP), while PVP remained unchanged. The portal injection of PGE at 0.5 g/kg/min increased PVF to a level equivalent to that evoked by the jugular injection of 5.0 g/kg/min PGE, without any change in SAP. PVP was reduced synchronistically with an increase in PVF. The PVF response to a portal injection of PGE at 0.5 g/kg/min was not reproduced in liver intact rats. These results suggest that PGE is potent in increasing PVF in the partially resected condition of the liver and that the portal vascular bed is involved in this response.     

Increased intraabdominal pressure impairs liver regeneration after partial hepatectomy in rats

BACKGROUND: There are many experimental studies showing that increased intraabdominal pressure (IAP) reduces liver blood flow, leading to ischemia and portal venous congestion. But, there is no study evaluating the effect of increased IAP on liver regeneration. It is well known that acute liver ischemia and portal venous congestion impair liver regeneration. We, therefore, aimed to determine the effect of increased IAP on liver regeneration in this study. METHODS: Sprague-Dawley rats underwent partial hepatectomy with or without IAP of 12-14 mm Hg for 24 h or sham operation. Rats were randomly divided into six groups: two sham-operated groups, two hepatectomy groups, and two hepatectomy with increased IAP groups. Mitotic index, proliferating cell nuclear antigen (PCNA)-labeling index, and liver regeneration rate as liver regeneration parameters were studied on day 1 or on day 4 after operation. Additionally, serum aspartate transaminase (AST) level and histopathological changes in intestinal mucosa were studied. RESULTS: Hepatectomy with/without increased IAP groups had significantly higher serum AST levels than the sham-operated group on day 1. Serum AST level was found to be significantly higher in the hepatectomy with increased IAP group than in the other groups on day 4. Intestinal mucosal injury was found in the hepatectomy with increased IAP groups on days 1 and 4. Mitotic index and PCNA-labeling index were markedly higher in all hepatectomy with/without increased IAP groups than in the sham-operated groups. However, together with liver regeneration rate, both indices were significantly less in the hepatectomy with increased IAP groups than in the hepatectomy groups both on day 1 and on day 4. CONCLUSION: Maintenance of IAP between 12 and 14 mm Hg for 24 h impaired liver regeneration after partial hepatectomy in rats.     

术前选择性门静脉栓塞在肝癌二期切除中的应用

目的 探讨术前选择性门静脉栓塞(POSPVE)后不能手术切除的原发性肝癌(HCC)二期切除的可能性。方法 采用B超引导下经皮经肝细针门静脉分支穿刺栓塞法对26例不能手术切除的HCC病人行POSPVE，栓塞剂由无水乙醇、碘油按1：2比例配制，以0．4ml/kg为标准，平均用量26．5ml。观察手术成功率及术后不良反应、肝功能改变、各肝叶体积及肝切除率的动态变化、二期手术切除率等指标。结果 POSPVE成功24例(92．3％)，右侧门静脉支栓塞的21例栓塞后，右肝体积逐步减小，栓塞前、栓塞后1，2，3周体积分别为683．7，657．4，621．3，604．1cm^3，左肝体积逐步增大，栓塞前、栓塞后1，2，3周体积分别为332．2，343．7，375．1，392．8cm^3。肝切除率逐步下降，栓塞前、栓塞后1，2，3周分别为66．3％、65．4％、62．7％、59．2％。POSPVE后出现不同程度的肝区隐痛、恶心呕吐、低热和以肝酶、胆红素升高为主的肝功能减退。POSPVE后2—3周，12例(46．2％)完成了肝切除术。结论 POSPVE扩大肝癌肝切除手术的适应证，提高手术的安全性，具有确定的临床实用价值。     

肝切除术前实时组织弹性成像评估肝纤维化程度及门静脉压力

目的探讨实时组织弹性成像(real-timetissue elastography,RTE)在术前评估肝纤维化程度及门静脉压力的可行性。方法 2010年6月至2010年8月广西医科大学第一附属医院对34例肝切除病人术前实时超声检测肝组织弹性,术中测量门静脉压力(portalvein pressure,PVP),并结合临床及术后病理进行分析。结果术前实时组织弹性成像定量参数(AREA%)中位数为32.2%(6.8%～77.9%)。术中门静脉压力中位数为19(13～28)cmH2O(1cmH2O=0.098kPa)。肝纤维化分期F04例,F18例,F29例,F31例,F412例。PVP值与肝纤维化分级显著相关(spearman相关系数为0.548,P<0.001)。AREA%随肝纤维分级的升高而显著增加(P<0.01),与肝纤维化分级显著相关(spearman相关系数为0.642,P<0.001)。AREA%与PVP有着显著的线性相关(R=0.753,P<0.001)。AREA%判断重度纤维化的ROC曲线下的面积为0.81。结论实时组织弹性成像可在术前提供一个方便、无创的新方法来评估肝纤维化的程度及门静脉压力。     

生长抑素对兔大部分肝切除术后门静脉压力的影响

目的探讨生长抑素对肝切除术后门静脉压力的影响。方法32只家兔随机分成正常对照组、生理盐水组、生长抑素组，并建立门静脉置管及肝切除动物模型。术中及术后持续给药，比较各组间门静脉压力的差值。结果与生理盐水组比较，生长抑素组肝切除术前与术后门静脉压力的差值显著减少（P=0．003）。结论生长抑素可明显降低肝切除术后升高的门静脉压力，而且其降压作用是持续而稳定的。     

Changes in liver blood flow after hepatectomy in conscious dogs

Hepatic circulation after hepatectomy was investigated in conscious dogs under fasting and feeding conditions. After a 40% hepatectomy, both the hepatic arterial and portal blood flow were measured simultaneously using ultrasonic transit time flowmeters. During fasting, the total hepatic blood flow (i.e., the sum of arterial and portal blood flow) changed in a biphasic pattern after hepatectomy. The first peak (517.9±42.7 ml/min; 130.1% of preoperative flow) was seen on the 1st postoperative day (POD) and the second peak (444.8±25.6 ml/min; 112.7% of preoperative flow) occurred on the 7th POD. The portal flow demonstrated the same biphasic changes as the total hepatic flow, although the hepatic arterial flow showed only the first peak. A heart rate analysis suggested that the first peak was probably due to hyperdynamic circulatory conditions, as has been previously reported. In addition, the existence of the second peak was established by the present study. The postprandial hepatic blood flow decreased during the first 2 weeks postoperatively, but exceeded the presurgical levels on PODs 21 and 28.     

Efficacy of preoperative portal vein embolization prior to major hepatectomy for patients with impaired liver function: A retrospective study

Hepatocellular carcinoma (HCC) is often associated with chronic liver disease, such as hepatitis or cirrhosis, and this association may limit the use of surgery as a therapy, and if surgery is pursued, may give rise to postoperative hepatic failure. We evaluated the outcome in patients with HCC given preoperative portal vein embolization (PVE) before they underwent major hepatectomy. After PVE, portal pressure increased significantly. Two weeks after PVE, both the volume of the non-embolized lobe and the 15-min indocyamine green retention rate (ICG R15) were significantly increased. The prognostic score, calculated on the basis of age, ICG R15, and the resection rate, was significantly decreased. The operative mortality rate was significantly lower in patients who underwent PVE before surgery than in patients who did not receive PVE. The cumulative survival rate of the PVE patients, even those with cirrhosis of the liver, was significantly higher. Prior PVE appears to allow more extensive major hepatectomy and to lessen the risk of this invasive surgery. However, patients in whom the portal pressure immediately after PVE was more than 30cm H₂O and/or whose prognostic score exceeded 50 points developed postoperative hepatic failure. These features should be kept in mind when it is decided whether surgery is indicated. Nevertheless, preoperative PVE appears to be a beneficial procedure for patients undergoing major hepatectomy, particularly those with chronic liver disease.     

A simple experimental model of total hepatectomy,hepatic ischemia and extrahepatic portal obstruction in rats using splenic transposition

The objective of this study was to develop an easy and simple experimental rat model of total hepatectomy, hepatic ischemia and extrahepatic portal obstruction. The first operation involved transposing the spleen with its scarified capsule in a subcutaneous pouch to produce portasystemic anastomosis. Total hepatectomy was easily performed in a lobe-by-lobe fashion 2 weeks following the first stage operation. Anhepatic rats receiving a glucose infusion survived for about 10 hours and all died of acute hepatic failure. Hepatic support systems can be accurately evaluated in this anhepatic rat model because of its uniformity. Sixty minutes of hepatic ischemia was able to be performed in rats with a transposed spleen for a portasystemic shunt and no complicated or technically involved procedure was required for the ischemic model. No rats died due to technical difficulties, suggesting the reliability and reproducibility of this ischemic model. An animal model resembling extrahepatic portal vein obstruction was also obtained by ligation of the portal vein; a simple maneuver which was able to produce collateral veins to the liver and cavernous transformation, as similarly seen in clinical patients with extrahepatic portal obstruction. Because these 3 animal models were so easily achieved in the rat, and since the changes in hepatic function and formation of the collaterals to the liver after portal vein occlusion are still poorly understood, this model should prove valuable for future study.     

原发性肝癌切除术后门静脉血栓相关性肝坏死的临床分析

目的 探讨原发性肝癌切除术后门静脉血栓相关性肝坏死的临床表现及诊疗方法 .方法 回顾性分析上海东方肝胆外科医院2018年11月至2019年10月8例原发性肝癌切除术后门静脉血栓相关性肝坏死患者的临床资料,包括患者的人口统计学特征、临床表现、手术方式、实验室检查及影像学检查结果 、临床诊疗及预后等.结果 原发性肝癌切除术...     

联合肝脏离断和门静脉结扎的二步肝切除术

肝癌的完整切除是肝癌患者获得根治性治疗效果的最主要途径,切除术后足够的剩余肝脏体积是避免肝衰竭的必要条件.为了达到上述目的,近年来,一种全新手术方式——联合肝脏离断和门静脉结扎的二步肝切除术(ALPPS)已见报道.本研究回顾性分析2013年4月复旦大学附属中山医院收治的1例传统手术不能切除的巨大肝癌患者行ALPPS的临床资料.第1步手术先结扎门静脉右支,再在镰状韧带的右侧,原位劈离肝左外叶和左内叶.距离第1次手术7d后,剩余肝脏体积由术前291 ml增加至579ml,第8天即行第2步扩大右半肝切除术.ALPPS这一创新技术为不能切除的肝癌患者提供了治愈的希望.     

Clinical significance of right hepatectomy along the main portal fissure on donors in living donor liver transplantation

There might be discordance between inter‐lobar borders of the main portal fissure (MPF) using the middle hepatic vein (MHV) and of the portal segmentation. Forty‐five living donors who underwent right hepatectomy for the adult recipients from 2007 to 2011 in a tertiary hospital were retrospectively analyzed. The donors were classified into conventional right hepatectomy along the MPF (cRL group, n = 26) and modified right hepatectomy along right‐side shifted transection plane from the MPF (mRL group, n = 19). The cRL donors had higher postoperative peak level of INR (1.84 vs. 1.62; P = 0.022), and bilirubin (3.37 mg/dl vs. 2.74 mg/dl; P = 0.065) than the mRL donors. cRL donors experienced greater depression of platelet count (144 per nL vs. 168 per nL; P = 0.042) and enlargement of splenic volume (52% vs. 37%; P = 0.025) than mRL donors for 7 days after hepatectomy. The regeneration of the left lateral sector was more accelerated in the cRL donors than the mRL donors for postoperative 3 months (148% vs. 84%; P = 0.015). There were no differences in the post‐transplant graft function, incidence of complications, and graft survival rates between the two groups of recipients (P > 0.05). This study suggests that the conventional right hepatectomy along the MHV might increase donor risk by reducing parenchymal liver volume of the segment IV.     

Associating liver partition and portal vein ligation for staged hepatectomy versus sequential transarterial chemoembolization and portal vein embolization in staged hepatectomy for HBV-related hepatocellular carcinoma: a randomized comparative study

BackgroundBoth portal vein embolization (PVE) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) have merits and demerits when used in patients with unresectable liver cancers due to insufficient volumes in future liver remnant (FLR).MethodsThis study was a single-center, prospective randomized comparative study. Patients with the diagnosis of hepatitis B related hepatocellular carcinoma (HCC) were randomly assigned in a 1:1 ratio to the 2 groups. The primary endpoints were tumor resection and three-year overall survival (OS) rates.ResultsBetween November 2014 to June 2016, 76 patients with unresectable HBV-related HCC due to inadequate volume of FLR were randomly assigned to ALPPS groups (n=38) and TACE + PVE groups (n=38). Thirty-seven patients (97.4%) in the ALPPS group compared with 25 patients (65.8%) in the TACE + PVE group were able to undergo staged hepatectomy (risk ratio 1.48, 95% CI: 1.17–1.87, P<0.001). The three-year OS rate of the ALPPS group (65.8%) (95% CI: 50.7–80.9) was significantly better than the TACE + PVE group (42.1%) (95% CI: 26.4–57.8) (HR 0.50, 95% CI: 0.26–0.98, two-sided P=0.036). However, no significant difference in the OS rates between patients who underwent tumor resection in the 2 groups of patients was found (HR 0.80, 95% CI: 0.35–1.83, two-sided P=0.595). Major postoperative complications rates after the stage-2 hepatectomy were 54.1% in the ALPPS group and 20.0% in the TACE + PVE group (risk ratio 2.70, 95% CI: 1.17–6.25, P=0.007).ConclusionsALPPS resulted in significantly better intermediate-term OS outcomes, at the expenses of a significantly higher perioperative morbidity rate compared with TACE + PVE in patients who had initially unresectable HBV-related HCC.     

对“联合肝脏离断和门静脉结扎的二步肝切除术”的述评

联合肝脏离断和门静脉结扎的二步肝切除术(ALPPS)是一个非常新的外科手术.该手术主要针对因未来剩余肝脏体积较小而不能接受大范围肝切除术的T分期较晚的肝癌患者而设计的.ALPPS第1步手术后,患者剩余肝脏对手术的反应非常强烈,使得肝脏体积急剧增生.因而可在第1步手术后1周左右施行第2步手术以切除所有肝内肿瘤(R0切除).本文追溯ALPPS的发展历史,描述该手术的传统步骤和手术的偏离等情况,分析该手术的短期疗效.尽管ALPPS后零死亡已有报道,但初步的研究结果表明:ALPPS的手术死亡率和并发症发生率仍然较高.ALPPS后尚没有明确的长远治疗肿瘤效果的报道.该手术在肝硬化肝癌患者中能否安全施行尚有疑问.     

Flow- and pressure-adapted portal arterialization in dogs

The effects of portal arterialization after portacaval shunt were studied in dogs. Flow- and pressure-adapted portal arterialization was performed by mounting a Teflon cuff on an autogenous vein bypass graft between the hepatic stump of the portal vein and the right renal artery. Immediately following operation, the total hepatic blood flow and intrahepatic portal venous pressure were within normal range. Eight weeks after operation, the intrahepatic portal venous pressure remained within the preoperative range, while total hepatic blood flow had increased double or triple. However, structual change due to increased flow was absent in the liver, even sixteen months after operation. Body weight, liver enzyme chemistry, ICG clearance rate, and amino acid metabolism were well maintained for the entire period of investigation. These findings suggest that sequelae such as hepatic encephalopathy and impaired hepatic metabolism after portacaval shunt can be avoided by portal arterialization, in the presence of an appropriate flow and pressure.