Liver abscess after central bisegmentectomy with reconstruction of the right posterior segment artery: A case report

A 68-year-old female was admitted with obstructive jaundice caused by gallbladder cancer invading the liver bed and hepatic hilum. The patient underwent a central bisegmentectomy, followed by bilateral hepaticojejunostomy with a transhepatic biliary stent and reconstruction of the right posterior segment artery. The color of the right posterior segment improved after arterial reconstruction, although good pulsation was not obtained in the right posterior segment artery. The patient had a febrile postoperative course. On the 22nd postoperative day,Bacteroides sp. was recovered from the arterial blood. On the 27th postoperative day, a CT examination revealed 2 liver abscesses in the right posterior segment, which was less enhanced than the left lateral segment. The right biliary stent penetrated the center of both abscesses, but the left lateral segment was intact. Percutaneous drainage of the liver abscesses was performed with intensive chemotherapy. The aspirated pus grewPseudomonas aeruginosa, Enterococcus faecalis, Enterobacter cloacae and unidentified gram-positive rods, but was free of fungus. The liver abscesses gradually resolved, and the pateint was discharged on the 78th postoperative day. Since the right posterior segment differed from the left lateral segment only by arterial reconstruction, it is suggested that arterial insufficiency may be of primary importance in the pathogenesis of the liver abscesses observed in this patient.     

Development of intrahepatic arterial shunts in a transplanted liver: a potential pitfall for Doppler sonography

We describe the hemodynamic features and anatomic basis of false-negative Doppler sonographic findings compared with angiographic findings in a 42-year-old woman after orthotopic liver transplantation complicated by hepatic artery thrombosis. Complete common hepatic artery thrombosis was demonstrated by Doppler sonography and digital subtraction angiography (DSA) on the first postoperative day. A thrombectomy was performed. DSA on the third day after transplantation again showed occlusion of the left hepatic artery. No perfusion was observed in the left hepatic lobe. Liver function remained normal. Doppler sonography on days 8, 10, and 16 after transplantation demonstrated arterial blood flow in both the right and left lobes of the liver, suggesting patent left and right hepatic arteries. Repeat DSA revealed that the arterial flow in the left lobe depended on large, intrahepatic shunts originating from the right hepatic artery. Apparently, shunts can develop within a few days in a transplanted liver from radiologically undetectable structures into vessel-like channels capable of supplying the entire left hepatic lobe.     

超声造影诊断肝移植术后早期肝动脉血栓1例

早期肝动脉血栓形成是肝移植术后严重的血管并发症,是导致患者肝功能衰竭既而死亡的重要原因。肝动脉血管造影（以下简称DSA）是诊断肝动脉血栓的金标准,但条件限制其广泛开展。超声造影无创、便捷、无肝肾毒性,重复性佳等特点,其在诊断早期肝动脉血栓形成中有重要意义。本文报道一例肝移植术后早期肝动脉血栓形成患者,通过早期肝脏超声造影提示肝动脉血栓形成,进一步通过DSA明确诊断,继而动脉溶栓得到及时救治,为临床医生及时进行对症治疗争取了关键时间并改善患者预后。本文目的旨在探讨超声造影在诊断肝移植术后早期动脉血栓形成中的应用价值。     

Right hepatic arterial supply to the posterior aspect of segment IV of the liver: analysis by CT during hepatic arteriography

OBJECTIVE: To examine the frequency of the right hepatic arterial supply to the posterior aspect of segment IV (PASIV) of the liver shown on computed tomography (CT) during hepatic arteriography (CTHA). MATERIALS AND METHODS: Seventy-four patients who underwent CTHA from the right and/or left hepatic artery were studied. The right arterial supply to the PASIV was determined when the PASIV was stained on CT during right hepatic arteriography without any opacified arteries originating from the right hepatic artery and distributing to segment IV through the left hepatic hilum or when no staining was seen in the PASIV on CT during left hepatic arteriography. The frequency of the right hepatic arterial supply to the PASIV demonstrated on CTHA was analyzed. RESULTS: In six of 74 patients (8%), the PASIV was supplied from the right hepatic artery. CONCLUSION: This PASIV was supplied by the right hepatic artery in a significant proportion of cases.     

原发性肝癌经肝动脉插管化疗栓塞（TACE）治疗25例疗效分析

目的：探讨原发性肝癌经血管介入治疗的临床疗效。方法：对2006年1月至2007年6月我院诊治的25例原发性肝癌行血管介入肝动脉化疗栓塞（TACE）治疗后进行随访和回顾性分析,其中男性10例,女性15例。年龄（48±1.8）岁。所有患者术前均行AFP,CT及彩超检查。术中经股动脉穿刺插管至肝动脉造影,经肿块供血动脉注入化疗药物,用碘化油栓塞。术后3个月,6个月再次行AFP,CT及彩超检查并再次行肝动脉化疗栓塞。结果：TA-CE均获成功,术后经3次以上复查再行肝动脉化疗栓塞,肝脏肿块明显缩小,1例患者复查彩超,CT,AFP等均正常。结论：肝动脉化疗栓塞治疗不能手术切除的原发性肝癌是首选的治疗方法,术后应随访AFP,彩超或CT,及时发现复发,并再行介入栓塞。     

Comparison of the SonoSite and Acuson 128/XP10 ultrasound machines in the 'bed-side' assessment of the post liver transplant patient.

Hepatic artery thrombosis after liver transplant is associated with biliary sepsis and irretrievable loss of the graft. Early identification of hepatic artery thrombosis, using a 'high-specification' ultrasound machine incorporating spectral Doppler, is crucial to patient management in the postoperative period with portable ultrasound as the first line of investigation for evaluation of the hepatic artery. We evaluated the efficacy of the SonoSite portable ultrasound machine, which uses power Doppler only, in the evaluation of the post transplant hepatic artery. An Acuson 128/XP10 ultrasound machine was used as the comparison 'reference-standard' with identification of the hepatic artery by both colour and spectral Doppler trace. The SonoSite accurately identified the hepatic artery in 88.4% of patients with power Doppler. The SonoSite was easier to transport and manage at the bedside leading to considerable time saving. In 11.6% of patients a repeat ultrasound using the 'reference-standard' machine would be necessary.     

Revolution CT轴位全肝灌注“一站式”成像的可行性

目的 探讨Revolution CT轴位扫描全肝灌注"一站式"成像的可行性。方法 选取19例患者行Revolution CT上腹部增强检查,获得全肝CT灌注（CTP）图像、静脉期及平衡期图像。于CTP图像上由2名观察者分别确定腹主动脉与门静脉主干时间-密度曲线（TDC）峰值对应的rank值及CT值,定量测量肝左、右叶灌注参数血流量（BF）、血容量（BV）、平均通过时间（MTT）、达峰时间（TP）、肝动脉分数（HAF）。采用腹主动脉和门静脉TDC峰值所对应的图像重组肝动脉CTA、门静脉CTV,并提取动脉期图像。记录CT灌注和"一站式"检查的辐射剂量。比较肝左、右叶灌注参数的差异,并对2名观察者的结果进行一致性分析。结果 肝左叶、右叶的BF和MTT值差异有统计学意义（P均<0.05）;2名观察者对肝动脉CTA、门静脉CTV及动脉期图像的主观评分均 ≥2分,一致性良好（Kappa值均>0.6）。灌注期和"一站式"检查有效辐射剂量分别为14.47 mSv、21.29 mSv。结论 Revolution CT轴位全肝灌注"一站式"成像,在保证较低辐射剂量的前提下,可获得肝脏CTP的多个定量参数,又可提供清晰的肝动脉CTA、门静脉CTV和3期增强扫描图像,具有广阔的临床应用前景。     

Recurrent pyogenic liver abscess after pancreatoduodenectomy caused by common hepatic artery injury: A case report

BACKGROUNDPancreaticoduodenectomy (PD) has been increasingly performed as a safe treatment option for periampullary malignant and benign disorders. However, the operation may result in significant postoperative complications. Here, we present a case that recurrent pyogenic liver abscess after PD is caused by common hepatic artery injury in atypical celiac axis anatomy.CASE SUMMARYA 56-year-old man with a 1-d history of fever and shivering was diagnosed with hepatic abscess. One year and five months ago, he underwent PD at a local hospital to treat chronic pancreatitis. After the operation, the patient had recurrent intrahepatic abscesses for 4 times, and the symptoms were relieved after percutaneous transhepatic cholangial drainage combining with anti-inflammatory therapy in the local hospital. Further examination showed that the recurrent liver abscess after PD was caused by common hepatic artery injury due to abnormal abdominal vascular anatomy. The patient underwent percutaneous drainage but continued to have recurrent episodes. His condition was eventually cured by right hepatectomy. In this case, preoperative examination of the patient’s anatomical variations with computed tomography would have played a pivotal role in avoiding arterial injuries.CONCLUSIONA careful computed tomography analysis should be considered mandatory not only to define the operability (with radical intent) of PD candidates but also to identify atypical arterial patterns and plan the optimal surgical strategy.     

超声造影监测活体肝移植术后血流灌注变化的研究

目的探讨超声造影在不含肝中静脉的成人间活体右半肝移植（A—ALDLT）中的作用。方法对7例不含肝中静脉的成人间活体右半肝移植患者进行超声造影检查。结果7例中1例移植肝肝动脉栓塞，门静脉栓塞，移植物失功能；4例移植肝V5、V8段回声增高，微循环血流灌注与V6、V7段明显不同步，呈现早灌注早消退的图像特征，于移植后28d恢复正常；1例术后出现肝梗塞灶于第7天移植肝失功能；1例肝移植术后超声造影检查正常。结论超声造影有助于观察A—ALDLT的血流灌注，早期发现肝移植术后并发症。     

肝脏三维超声立体断层图的解剖学基础

目的探讨肝脏立体断层面的标志性结构.方法应用经甲醛固定的离体肝脏标本,以各肝裂的体表投影线为标志切割,获得各肝段的立体断层.对走行在断层线及各断层面上的血管作为标志性结构,进行观察、记录并照相.结果肝脏的正中裂立体断层、右叶间裂立体断层、右前叶立体断层、右后叶立体断层和左半肝立体断层等各有不同的标志性结构,而且可以在三维超声立体图像上显示.结论肝脏立体断层解剖可以为肝脏的三维超声立体断层图提供形态学基础.     

Proximal bifurcation of hepatic artery: Novel findings on hepatic arteries demonstrated by ultrasound Doppler imaging, B-flow, and US angiography

Purpose It has generally been held that each portal branch is always accompanied by a single arterial branch in the liver. During Doppler ultrasound examination, however, we sometimes encounter a portal branch that appears to be associated with two arterial branches, a phenomenon referred to below asthis finding orthis phenomenon. Here we attempt to confirm that this finding is based on a correct interpretation of the image and to disclose its basic mechanism. Material and Methods Five cases of chronic liver disease in which this phenomenon appeared were analyzed with B-flow imaging. Videotapes obtained from 30 patients who had chronic liver disease and had undergone ultrasound angiography (USAG) with arterial infusion of CO₂ micro bubbles were reviewed in order to look for similar findings. Sixty-nine healthy controls were also examined with Doppler sonography for this purpose. Histopathologic specimens from 7 patients who had undergone hepatectomy (3 with hepatocellular carcinoma, 3 with metastatic tumor, and 1 with focal nodular hyperplasia) were examined to study the basic structure of the hepatic vessels. Results and Discussion Three parallel color signals (two pulsatile and one of a constant waveform) observed on Doppler examination were confirmed by the B-flow method to be three independent vessels in all five cases in which both Doppler sonography and B-flow imaging were used. In 13 (43%) of the 30 cases of USAG, two vessels along a portal branch were visualized by the inflow of micro bubbles, indicating that the two vessels were arteries. The trio of one portal and two arterial branches was also detected with Doppler sonography in 12 (17%) of the 69 healthy controls. In 10 (59%) of the 17 cases (5 of liver disease and 12 normal) that showed this finding on Doppler examination, bifurcations of the hepatic artery and portal vein were both visualized. Hepatic arterial branches were found to bifurcate slightly more proximal to the hepatic hilus than the accompanying portal branch. Histopathologic study revealed Glisson’s areas that contained one portal branch and two arterial vessels in nontumorous parts of specimens from all 7 patients with hepatectomy. Conclusion Two arterial branches can be demonstrated along a portal branch as a result of a more-proximal bifurcation of the hepatic artery than of the portal vein.     

经IDDS定期肝动脉造影监测早期肝复发癌的临床研究

目的：探讨经ｉｍｐｌａｎｔａｂｌｅｄｒｕｇｄｅｌｉｖｅｒｙｓｙｓｔｅｍ（ＩＤＤＳ）定期肝动脉造影对早期肝复发癌的诊断价值。材料和方法：２８例肝癌患者，肝切除术中插管至肝固有动脉，术后定期经植入皮下的ＩＤＤＳ进行肝动脉造影检查并拍摄点片。结果：造影可以定期重复开展，肝动脉及其分支显影良好，发现ＣＴ漏诊的肝内微小复发病灶４例，另发现肝动脉炎１２例。结论：经ＩＤＤＳ定期肝动脉造影是监测早期肝复发癌的较好方法。     

原发性肝癌自发破裂出血的数字减影血管造影特征及急诊动脉栓塞治疗效果

目的探讨原发性肝癌(简称肝癌)自发破裂出血的数字减影血管造影(DSA)表现特征及急诊动脉栓塞的治疗方法和临床疗效。方法收集我院13例经CT检查、B超检查及腹腔穿刺等方法证实为肝癌自发破裂并行急诊肝动脉造影栓塞的病例,分析肝癌破裂出血的DSA造影表现特征,根据DSA显示情况,经肝外寄生动脉或肝动脉急诊介入栓塞治疗,观察临床疗效。结果 13例肝癌破裂出血患者中,10例为真性出血、3例为隐性出血。隐性出血DSA表现为肿瘤周边血管缺损,没有明显造影剂外渗现象。所有患者均成功止血,短期临床效果满意。结论肝癌自发破裂出血有特殊的DSA特征,同时也存在假阴性病例,在临床上应重视。急诊动脉栓塞是治疗肝癌自发破裂出血的有效方法。     

超声对引起原位肝移植术后黄疸相关因素的分析

目的探讨超声对于提示引起原位肝移植术后黄疸相关因素的价值。方法28例实施肝移植术后临床拟诊黄疸的患者，以二维超声检查移植肝内外胆管及肝周情况，以彩色多普勒超声（CDI）评估移植肝动、静脉血流情况，并结合临床资料、肝穿刺活检病理诊断结果和内镜逆行胰胆管造影（ERCP）综合分析。结果22例患者术后出现胆道并发症，其中5例CDI提示有肝动脉并发症，超声检出胆漏者4例，胆道梗阻者18例；其余6例肝穿刺活检证实有排斥反应。结论多普勒超声显像可以较好地提示引起原位肝移植术后黄疸的相关因素，有利于临床医师作出正确的病情判断及确定相应的治疗方案。     

动态增强MRA诊断活体肝移植术后血管并发症

目的 评估钆贝葡胺动态增强磁共振血管成像(DCE MRA)对活体肝移植术后肝动脉、门静脉、肝静脉血管并发症的诊断价值. 方法 34例活体肝移植受体,术后均接受MR扫描.经静脉注入1 ml钆贝葡胺注射液后同时启动testbolus测出循环至腹主动脉时间.后行冠状位三维T1加权快速扰相小角度梯度回波(3D-FLASH)序列扫描,自动脉期开始连续扫描4期,每期相隔10 s,获得肝动脉、门静脉、肝静脉期图像.两名放射科医师观察原始及最大密度重建(MIP)图像.并把MRA图像质量定为5级.观测肝动脉、门静脉、肝静脉及下腔静脉吻合口与邻近血管的相对大小、血管的显示程度,并将结果与同期进行的数字减影血管造影(DSA)、超声和临床综合资料的结果对照. 结果 MRA对于肝动脉、门静脉、肝静脉系统的显示均较好.肝动脉狭窄4例,门静脉狭窄6例,门静脉栓塞2例,肝中静脉重度狭窄1例.其中DSA证实10例,手术证实4例,其余均经超声、随访等证实. 结论 钆贝葡胺动态增强MRA安全无创,对肝动脉、门静脉、肝静脉显示清楚,对于血管并发症的诊断准确率较高,有可能成为活体肝移植术后诊断血管并发症首选的影像学检查手段.     

超声检测肾段动脉阻力对门静脉高压的预测价值

目的探讨肝硬化患者肾段动脉阻力与门静脉压力之间的关系。方法12例肝硬化患者应用超声检测双肾肾段动脉的阻力指数（RI）和搏动指数（PI）;同时放置肝静脉导管检测肝静脉压力梯度（HVPG）。结果左肾肾段动脉的平均RI、P1分别为0．66±0．07和1．23±0．25;右肾肾段动脉的平均RI、P1分别为0．65±0．06和1．20±0．26。HVPG为（18．7±4．6）mmHg;肾段动脉阻力和HVPG值之间呈显著线性正相关（r=0．41,P〈0．05）。结论肾段动脉高阻力能有效预测门静脉高压的发生。     

彩色多普勒及超声造影在肝移植术后肝动脉血栓形成的应用研究

目的探讨彩色多普勒血流成像（CDFI）及超声造影在肝移植术后肝动脉血栓形成（HAT）诊断中的应用价值。方法对106例肝移植术后患者进行CDFI检查，并对其中9例肝动脉异常不能排除HAT的患者行超声造影检查。采用对比脉冲序列（CPS）成像技术，造影剂为SonoVue。结果106例肝移植术后患者中，98例肝动脉多普勒血流信号清晰显示，8例术后早期多切面扫查未显示肝门区及肝内门静脉周围肝动脉彩色血流信号，CDFI不能排除HAT。行超声造影后，6例肝动脉主干及分支清晰显示，走行正常，除外HAT，经随访证实；2例超声造影后肝动脉仍未显示者诊断为HAT，经数字减影血管造影（DSA）或对比CT血管成像（CTA）证实。1例患者于术后10个月CDFI检查发现肝动脉血流信号显示但频谱异常，收缩期峰值流速降低，阻力指数〈0．50，收缩期加速时间延长，超过0．08S，呈Tardus，Parvus改变；超声造影后见肝动脉密集细小且走行迂曲，诊断为HAT侧支循环形成，经CTA证实。结论CDFI结合超声造影检查可提高肝移植术后HAT的诊断准确性。     

肝动脉栓塞化疗微创治疗中晚期肝癌的护理体会

目的探讨肝动脉栓塞化疗微创治疗中晚期肝癌的的整体护理方案,促进患者顺利渡过术,达到预期治疗目的。方法对42例患者实施改良Seldinger法经皮肝动脉栓塞化疗术。实施中晚期原发性肝癌动脉栓塞化疗术前、术中和术后的整体护理和配合工作,确保经皮肝动脉灌注栓塞术的顺利进行。选择肝动脉灌注化疗药物和栓塞剂。并严防并发症的出现及有效处理。结果由于措施得当,处理及时,本组未发生不能恢复的并发症,患者满意,效果好。结论TACE围手术期护理可消除患者心理紧张,使治疗顺利进行,术后恢复快,是综合治疗不可缺的重要环节。     

超声检查进餐前后肝脏血供改变及其意义

目的探寻进餐前后肝脏血流的超声扫查指标及其意义。方法超声对比检测正常肝与弥漫性肝病进餐前后门静脉和右肝动脉血流改变。结果进餐前后门脉内径、流速和流量，肝动脉阻力指数等正常组与异常组存在明显差异。结论餐后异常组的门静脉内径、流量，肝动脉阻力指数等指标与正常组的差异，可能对理解肝血供异常有参考意义。     

Laparoscopic common hepatic artery ligation and staging followed by distal pancreatectomy with en bloc resection of celiac artery for advanced pancreatic cancer

INTRODUCTION: Adeno-carcinomas of pancreatic body are usually asymptomatic and progress to advanced stage with involvement of major arteries. Resection of advanced cancer along with en bloc resection of a common hepatic artery and celiac trunk enables a "curative" resections and only possible treatment. However, the celiac axis resection always has a risk of compromising blood supply to liver, resulting in the hepatic insufficiency. We evaluated practicability of a two-stage procedure for the advanced pancreases body cancer, laparoscopic clamping of a common hepatic artery followed by open distal pancreatectomy with en bloc celiac arterial resection to prevent the hepatic insufficiency. MATERIALS AND SURGICAL TECHNIQUE: Seventy-five-year-old woman diagnosed with a 50-mm pancreatic body mass, invading splenic artery, common hepatic artery, splenic vein, and portal vein at the confluence. STAGE-1: At laparoscopy, after confirming absence of the peritoneal, superficial liver metastases and negative peritoneal cytology; we approached the common hepatic artery through the lesser sac and ligated. STAGE-2: Her liver function tests were normal after 2 weeks, and CT angiography showed complete blockage of the common hepatic artery with sufficient collateral circulation to the liver through inferior pancreatico-duodenal artery and gastro-duodenal artery. We performed an open distal pancreatectomy with en bloc resection of celiac artery. Histopathology examination confirmed R0 resection. DISCUSSION: The celiac axis resection with distal pancreatectomy improves the chance of R0 resection and potentially, survival of the patient. Preoperative laparoscopic ligation of the common hepatic artery is a safe, effective, and in-expensive technique to prevent postoperative hepatic insufficiency and improves the safety of en bloc celiac artery resection with a distal pancreatectomy. Also these patients have high risk of peritoneal dissemination. Diagnostic laparoscopy is useful to detect occult metastasis, which are missed by per-operative CT scan.