Role of portal vein embolization in hepatobiliary malignancy

BACKGROUND/AIMS: Inadequate remnant liver volume is the major cause of postoperative liver failure. Preoperative portal vein embolization (PVE) is the well accepted procedure to increase future liver remnant (FLR) volume and decrease the incidence of this complication. This study described the author's experience of preoperative PVE at King Chulalongkorn Memorial Hospital since 2002. METHODOLOGY: The clinical data of 29 patients who underwent PVE were reviewed. The FLR volumes before and after the procedure were calculated by CT volumetry. PVE was performed when estimated FLR volume was < 25% in normal liver or < 40% in damaged liver and also when major liver resection combined with major intraabdominal surgery was planned. The complications after PVE and hepatectomy were recorded. RESULTS: There were no deaths or complications after PVE. The mean growth of FLR was 11%. Power of liver regeneration was suboptimal in old age patients. Sixteen patients underwent liver resection (resectability rate 55.17%). There were 2 cases of postoperative hyperbilirubinemia (12.5%). The hospital mortality rate was 1/16 (6.25%). CONCLUSIONS: PVE is a useful and safe optional procedure to increase FLR. It not only reduces the postoperative liver failure but also increases the chance of curative resection.     

Hepatic venous outflow reconstruction using an external iliac vein graft for hepatic malignancies (with video)

Background

Hepatic venous outflow reconstruction after major hepatectomy for advanced hepatic malignancies is often difficult even for experienced surgeons because of difficulties in application of anastomotic techniques and selection of the appropriate graft. We present our approach to hepatic venous reconstruction using an external iliac vein (EIV) graft for patients with hepatic malignancies.

Methods

The EIV graft was preoperatively assessed using three-dimensional abdominal multidetector computed tomography (MDCT). The EIV graft (3.5?C4.5?cm) was harvested extraperitoneally through an upper groin incision. First, the inferior vena cava and the EIV graft were sutured at two separate sites by using 6/0 propolypropylene as a traction suture with an operating loupe (×2.5) under hemi-hepatic portal inflow occlusion. The distal end of the right hepatic vein (HV) was then reconstructed using the same technique. Graft patency was confirmed by intraoperative color Doppler ultrasonography (Aloca SSD2000, Japan).

Results

The mean reconstruction time was 34?±?6?min. There were no complications related to the HV reconstruction and no mortality. Follow-up MDCT showed patency of the graft in all cases without noticeable caliber change.

Conclusions

The EIV graft for hepatic venous outflow reconstruction during hepatic resection is a simple technique with long-term graft patency for major HV reconstruction.     

Hepatic venous outflow reconstruction in right lobe graft without middle hepatic vein

Background: We explored the pattern of hepatic venous outflow reconstruction in adult right lobe (segments V5-8) living donor liver transplantation (LDLT) without the middle hepatic vein (MHV). The difficulty and challenge of LDLT without MHV is the outflow reconstruction of hepatic vein. We have modified the surgical procedure and here report the results. Methods: Retrospective analysis was made of the clinical data of 50 recipients who underwent LDLT using right lobe without MHV. Results: Forty-five recipients (90.0%, 45/50) are alive at median follow up of 10 months. The graft-to-recipient bodyweight ratio (GRWR) was 1.21% +/- 0.49% (range, 0.72% to 1.98%). The recipients of GRWR <0.8% (extra-small graft), 0.8% < GRWR < 1.2% (small graft) and GRWR > 1.2% (ideal graft) were 14, 27 and 9, respectively. Total ratio venous outflowreconstruction of V5, V8 and inferior right hepatic vein was 66.0% (33/50). The overall incidence of small-for-size syndrome was 10.0% (n = 5), the overall graft survival rate was 92.0% (46/50). Conclusions: Graft function and survival rates are not only influenced by graft size, but also by hepatic venous outflow reconstruction; the 'multiple-opening vertical anastomosis' for reconstruction of hepatic vein outflow was used when the GRWR was smaller than 1.2%. This technique alleviates surgical risk in living donors, ensures excellent venous drainage, and reduces the incidence of small-for-size syndrome.     

Right hepatectomy combined with retrohepatic caval resection,using a left renal vein patch graft for advanced cholangiocarcinoma

Combined resection of the inferior vena cava for hepatobiliary malignancies remains a technical challenge. We successfully resected an intrahepatic cholangiocarcinoma involving the retrohepatic vena cava, and reconstructed the caval defect using a left renal vein patch graft. The patient was a 79-year-old man. Preoperative ultrasonography and computed tomography revealed that the tumor was located in the right lobe of the liver and was about 6?cm in diameter. Arteriogram revealed encasement of the right arterial and portal branches. Magnetic resonance imaging scan revealed that the tumor involved the retrohepatic vena cava. The patient underwent a right hepatectomy combined with resection of the retrohepatic vena cava. The resected portion of the caval wall was 3.6?cm long and 2.7?cm wide. The caval defect was reconstructed using a left renal vein patch graft of a rhomboid shape, which was made by oblique incision of the vein graft. The postoperative course was uneventful. Postoperative cavogram showed adequate patency of the reconstructed retrohepatic vena cava. The patient was disease-free 22 months after surgery. In conclusion, major liver resection combined with caval resection and reconstruction can be performed safely. Furthermore, a left renal vein graft can provide a flexible patch according to the form and size of the caval defect.     

Portal vein reconstruction using a left renal vein graft for a patient with hilar cholangiocarcinoma

We report a patient with hilar cholangiocarcinoma who underwent combined portal vein reconstruction using a left renal vein graft. A 68-year-old man was referred to the hospital with a one-week history of dark urine and jaundice. Cholangiography through the percutaneous transhepatic biliary drainage catheter and magnetic resonance cholangiopancreatography demonstrated complete obstruction of the hepatic primary confluence extended to the left secondary confluence. The patient underwent left hepatic lobectomy combined with total caudate lobectomy and extrahepatic bile duct resection. At operation, carcinoma invasion was observed from the portal trunk to the right portal branch. So, combined portal vein resection and graft interpose using left renal vein was performed. The caliber of left renal vein was wider than the right portal branch. No remarkable renal and hepatic dysfunction occurred postoperatively. In conclusion, left renal vein seems appropriate as an autograft when reconstructing the portal vein, especially main portal trunk, in patients with advanced hepatobiliary malignancies. It may be necessary to adjust the caliber when anastomosing the left renal vein to the right or left portal branch because the diameter of the left renal vein is usually wide.     

Gonadal vein graft for hepatic artery reconstruction.

BACKGROUND/AIMS: Resection of hepatic arteries is often obligatory on resecting pancreatic, gastric and hepatobiliary malignancies. Hepatic artery reconstruction is required to preserve liver function and blood flow to the bile duct. We applied the gonadal vein to hepatic artery reconstruction. METHODOLOGY: Hepatic artery reconstruction using a gonadal vein graft was performed in two patients: one with gallbladder cancer and the other with recurrent gastric cancer. RESULTS: The right ovarian vein, 2 mm in diameter and 4 cm in length, was grafted for reconstruction between the proper hepatic and the posterior hepatic artery in one patient who underwent modified central hepatic bisegmetectomy and common bile duct resection. The left spermatic vein, 3 mm in diameter and 6 cm in length, was grafted for reconstruction between the celiac artery and the right hepatic artery in the other, who underwent upper abdominal exenteration. The former graft was occluded due to tumor invasion at 4 months after surgery, the latter one was patent at 8 weeks after surgery. CONCLUSIONS: The gonadal vein had an ideal diameter and sufficient length to accomplish hepatic arterial reconstruction. The gonadal vein graft will be a new and preferable addition to the selection of an optimal graft for hepatic arterial reconstruction.     

Off-pump resection of aorto-saphenous vein graft pseudoaneurysm

Pseudoaneurysms of saphenous vein grafts are rare. We present the case of a 58-year-old man who presented with recurrent angina nine years following quadruple coronary artery bypass graft surgery in 1983. He was found to have an aneurysm arising from the ascending aorta. The patient underwent off-pump aorto-saphenous vein pseudoaneurysm resection and redo coronary artery bypass grafts.     

Total reconstruction of a diseased saphenous vein graft by means of conventional and autologous tissue-coated stents

This is the first report of a total reconstruction of a diseased saphenous vein graft, with thrombus-containing lesion and multiple stenoses, by the implantation of arterial graft- and venous graft-coated stents, and of conventional stents. The procedure was successful without any complications, and follow-up angiography after 6 months revealed patency of the vessel. Cathet. Cardiovasc. Diagn. 43:318–321, 1998. © 1998 Wiley-Liss, Inc.     

Patency for autologous vein is superior to cadaveric vein in portal-mesenteric venous reconstruction

BackgroundPortal venous reconstruction (PVR) is often needed during resection of hepatopancreato-biliary (HPB) malignancies. Primary repair (PR), autologous vein (AV), or cryopreserved cadaveric vein (CCV) are frequently utilized, however relative patency is not well studied.MethodsAll patients undergoing PVR between 2007-2019 at our center were identified. 3-year primary patency (PP), overall survival (OS), and survival-adjusted patency (SAP) were evaluated with Kaplan-Meier and Cox proportional hazards modeling.ResultsOne-hundred-twenty patients were identified with a median follow-up of 11 months. PR, AV, and CCV reconstruction were used in 28 (23%), 35 (29%), and 57 (48%) patients, respectively, with two (7%), four (11%), and 29 (51%) thromboses, respectively. 3-year PP was greater for both primary repair (90%) and AV (83%) compared to CCV (33%, both p<0.001). On multivariable analysis, CCV had worse 3-year PP (HR 7.89, p=0.005) and SAP (HR 2.09, p=0.02) compared to PR; AV reconstruction had equivalent oncologic and patency-related outcomes to PR (p>0.4 for both comparisons).ConclusionsPrimary patency for PR and AV reconstruction is superior to CCV for PVR during resection of HPB malignancies. AV conduit should be the preferred choice of reconstruction when PR is not achievable. Surgeons should only use CCV when factors preclude PR/AV reconstruction.     

Techniques for splenic vein reconstruction after pancreaticoduodenectomy with portal vein resection for pancreatic cancer

BackgroundPancreaticoduodenectomy (PD) with splenic vein (SV) ligation may result in sinistral portal hypertension (SPH). The aim of this study was to compare the outcomes of various types of SV reconstruction to prevent SPH and to define the optimal reconstruction method.MethodsThis study included patients who underwent PD with SV resection and reconstruction for pancreatic cancer between December 2013 and June 2017. The patency of various types of SV anastomosis and SPH was evaluated by follow up computed tomography.ResultsThe type of SV reconstruction was divided into two groups: (i) end-to-side anastomosis (n = 10), in which the SV was anastomosed with either the left renal vein (LRV; n = 8) or portal vein (n = 2); and (ii) end-to-end anastomosis (n = 20), in which the SV was anastomosed with another smaller vein or graft. The patency rate for Group 1 was 90% (9/10), compared with 45% (9/20) for Group 2 (P = 0.024). Half the patients in whom the SV anastomosis was occluded (6/12) developed gastrointestinal varices, whereas only 11% of patients with a patent SV anastomosis (2/9) had varices (P = 0.034).ConclusionSV-LRV reconstruction is widely applicable, effectively reduces the risk of SPH, and should be considered for the case of extended PD.     

兔自体颈动脉移植于静脉后形态学及分子改变

目的以往的研究已证实动脉移植到静脉后，即使在高血脂状态下，也不发生粥样硬化，而是发生萎缩样改变，提示了血流动力学特别是切应力在动脉粥样斑块形成和血管重构中的作用。为探讨移植后动脉重构的机理，该文对移植动脉段进行了细胞分子生物学研究。方法建立动脉移植到静脉的新西兰白兔模型，6个时间点后取材，HE染色光镜下观察血管内、中膜厚度与面积；扫描电镜观察内皮变化，透射电镜观察超微结构改变；TUNEL方法观察细胞凋亡状况，RT－PCR检测基因表达水平。结果HE染色发现移植动脉在极低切应力状态下，随时间推移，除管壁发生“类静脉化”的萎缩样改变外，管腔面积先减小后增加；TUNEL结果显示移植动脉发生了细胞凋亡，而且凋亡先发于血管内膜细胞，进而过度到中层，最后累及外膜；通过弹力纤维和胶原纤维双染色证实，弹力纤维在整个过程中并未有显著数量改变，而胶原纤维却发生崩解，最终导致管壁萎缩；术后一周移植动脉的MMP2和MMP9表达明显增高，以后渐下降。结论低切应力作用于血管内膜层细胞致使其凋亡继而由内而外信号转递的过程，这构成了移植动脉发生萎缩样变的基础；胶原纤维的崩解在移植动脉萎缩样变过程中也发挥了重要作用，伴随着MMP表达的上凋。     

Asymptomatic portal vein obstruction after hepatobiliary resection: early detection by Doppler ultrasonography

We report two different types of portal vein obstruction after liver resection: portal vein thrombosis due to steal phenomenon via a splenorenal shunt, and kinking of the skeletonized left portal vein after right hepatic lobectomy with caudate lobectomy. The two cases of portal vein obstruction were asymptomatic without any suggestive laboratory findings. Only routine Doppler ultrasonography detected portal vein obstruction which was successfully treated by emergency operation.     

Middle hepatic vein reconstruction of graft for a patient with intrahepatic portosystemic shunt

Middle hepatic vein reconstructions for modified right liver grafts in living donor liver transplantation provide satisfactory results. We report a patient who had undergone transjugular intrahepatic portosystemic shunt before living donor liver transplantation, in which the middle hepatic vein was reconstructed using a preserved great saphenous vein. A 41-year-old Japanese man with a 5-year history of alcoholic liver cirrhosis and esophageal varices was admitted to our hospital for living donor liver transplantation. He had undergone endoscopic variceal ligations and transjugular intrahepatic portosystemic shunt for esophageal variceal bleeding, and ascites. He had living donor liver transplantation, which was performed using his sister's right lobe without the middle hepatic vein. The recipient's estimated standard liver volume calculated by abdominal computer-assisted tomography was 1166 mL. The exact weight of the donor's right lobe was 507 g, which was equivalent to 44% of the recipient's standard liver volume. At bench surgery, the middle hepatic vein was reconstructed using a preserved great saphenous vein, which was cut in 2 strips to make a thicker tube graft by suturing, and subsequently, the newly made tube graft end was anastomosed to V5 and V8 branches of the graft. The metallic stent for transjugular intrahepatic portosystemic shunt buried in the recipient's right hepatic vein was removed with the right hepatic vein. The other end of the saphenous tube graft was anastomosed to the right anterior aspect of the vena cava. Stumps of the middle and left hepatic veins were oversewn. Postoperative blood flow in the graft and the reconstructed hepatic veins has been satisfactory with normal liver functions.