Acute hepatic vein thrombosis after liver transplantation in a child with biliary atresia and absent inferior vena cava

Stenosis of the hepatic venous outflow anastomosis is rare after liver transplantation. Hepatic venous outflow obstruction affects 5.1% to 7% of transplanted patients. Clinical findings among children include massive ascites and abdominal pain and laboratory findings demonstrate altered liver function tests and coagulopathy. In this article, we report a case of hepatic venous thrombosis occurring 22 days after living-related liver transplantation. The patient was treated with hepatic venoplasty and stent implantation.     

下腔静脉与肝静脉的外科应用解剖

在３２例成人尸体上进行腔静脉与肝静脉的应用解剖学的研究，观测了右肾上腺静脉、左膈下静脉、主肝静脉的长度、横径、注入角度和部位及主肝静脉的汇合类型和下腔静脉各段长度。结果表明，术中阻断肝上膈下下腔静脉，有８４．４％的人可经腹部切口完成，另１５．６％者可能需开胸在心包内阻断下腔静脉，下腔静脉下阻断，有８７．５％可在网膜孔后分离阻断，１２．５％需行下腔静脉肝后段分离阻断。在游离肝右叶时，需注意可能出现的     

Right inferior phrenic vein indicating the right hepatic vein confluence into the inferior vena cava

BACKGROUND: Limiting backflow bleeding from the hepatic veins is a priority when performing hepatectomy. However, hepatic vein encirclement is difficult, especially in re-resection. We verified the presence and trajectory of the right inferior phrenic vein (RIPV), which could be a useful anatomic landmark to guide surgeons in targeting the extrahepatic right hepatic vein (RHV) before dissection. METHODS: Between May 2001 and January 2005, 100 consecutive patients with liver tumors were enrolled and underwent hepatectomy: 77 patients underwent surgery for tumors located in the right hemiliver. RESULTS: RIPV was detected in all but 1 patient (99%), and its trajectory was always guided toward the extrahepatic RHV. The only patient in whom RIPV was not detected had undergone prior liver resection and interstitial therapies for colorectal cancer liver metastases. CONCLUSIONS: Apart from exceptional conditions, detection of the RIPV is always feasible and allows safe surgical dissection while approaching the extrahepatic RHV before hepatic resection.     

Impact of graft hepatic vein inferior vena cava reconstruction with graft venoplasty and inferior vena cava cavoplasty in living donor adult liver transplantation using a left lobe graft

BACKGROUND: Hepatic venous reconstruction is critical in living donor adult liver transplantation (LDALT) because outflow obstruction in small for size graft may lead to graft dysfunction or loss. We describe the usefulness of venoplasties of the graft hepatic vein (HV) and graft HV-recipient inferior vena cava (IVC) reconstruction in LDALT using a left lobe graft. METHODS: Sixty patients who underwent LDALT were studied. We divided the patients into following two groups: venoplasty group (n=30) and control group (n=30). For the patients with venoplasty group, venoplasty of the graft and recipient IVC cavoplasty was made to widen the orifice. Comparison examination of a background factors and postoperative bilirubin and the ascites was carried out. RESULTS: The mean graft volume standard liver volume ratio (GV/SLV) did not have the difference at 41.7% of venoplasty group, and 42.1% of control group (p=NS). The diameter of the hepatic vein in control and venoplasty group before and after venoplasty is 26.9+/-5.5, 28.2+/-2.9, and 34.1+/-3.9 mm, respectively. The diameter of the hepatic vein after venoplasty is larger than that of before venoplasty and of control (P<0.05). Mean total bilirubin level on postoperative day (POD) 7 is 13.8+/-9.3 mg/dl in control group and 7.0+/-3.3 mg/dl in venoplasty group (P<0.05). Mean amount of ascites on POD 7 and 14 are 1576+/-1113 and 1397+/-1661 cc in control group, and 736+/-416 and 550+/-385 cc in venoplasty group, respectively (P<0.05). Two-year survival rate is 75.2 % in control group and 86.6 % in venoplasty group (P<0.05). CONCLUSIONS: We conclude that in LDALT using left lobe graft, HV-IVC reconstruction with graft venoplasty and IVC cavoplasty is useful not only to prevent outflow block but also to improve graft function.     

肝脏巨大血管瘤行肝静脉与下腔静脉阻断的临床效果分析

目的探讨肝静脉肝外阻断在近第二肝门肝脏巨大血管瘤治疗中的应用。方法回顾性分析2012年2月至2014年5月收治的32例肝门肝脏巨大血管瘤患者的临床资料,根据治疗方法分为肝静脉阻断(HVE组14例)与下腔静脉阻断(IVE组18例)。记录两组患者术中情况、术后情况及并发症情况差异。在SPSS 10.0中进行统计分析,术中指标;术后第1、3、7天的生化指标以(x珋±s)表示,采用两样本独立t检验,两组间并发症率比较采用卡方检验,检验水准取α=0.05。结果 HVE组的手术时间、术中出血量、输血量、术后引流量均显著的低于IVE组(t=3.005、t=8.187、t=17.411、t=6.958,P0.05)。IVE组的总胆红素(TBIL)在术后3 d显著高于HVE组(t=3.024,P=0.012);IVE组的ALT、AST在术后第1天显著高于HVE组(t=2.673、t=2.801、P0.05)差异均有统计学意义。术后并发症HVE组为2例(14.29%)显著低于IVE组的9例(50.00%)(χ2=4.453,P=0.035)。结论相对于IVE技术,HVE技术的术中创伤更小,术后肝功能恢复更快,并发症发生率更低。     

下腔静脉重建联合肝叶切除治疗肝癌的初步研究

目的 探讨在全肝血流控制下不采用静脉转流技术行下腔静脉重建的肝叶切除治疗侵犯下腔静脉的肝癌的临床经验和疗效。方法 自2004年8月至2005年7月，对3例胆管细胞性肝癌和2例肝细胞性肝癌合并下腔静脉直接侵犯而无癌栓患者，在全肝血流控制而无静脉转流技术下行解剖性肝叶切除联合下腔静脉重建术（局部切除修复2例、局部切除补片2例、人工血管移植1例）。结果 5例患者手术均成功。平均手术时间345（300～450）min，平均手术失血量1375（1200～1800）ml。累计平均肝门阻断时间、全肝血流阻断时间和下腔静脉阻断时间分别为19min、21．2min、56min。术后发生胸腔积液1例，胆漏1例，腹水1例，均治愈。患者平均住院时间15．5（11～19）d。随访4～15个月，1例术后9个月死于肿瘤复发，4例已存活4、8、10、15个月。结论 在全肝血流控制而无静脉转流技术下行下腔静脉重建联合解剖性肝叶切除治疗直接侵犯下腔静脉的肝癌不仅可安全施行，而且可延长患者生存时间。     

儿童劈离式肝移植的胆管分型与重建

目的  探讨儿童劈离式肝移植左肝内胆管（LHD）的解剖分型、胆道重建方式及其与术后胆道并发症的关系。方法  回顾性分析75例儿童劈离式肝移植受者的临床资料。供肝劈离前采用碘普罗胺注射液经胆总管逆行造影,根据二、三、四段肝内胆管走向确定供肝LHD的解剖分型,总结不同LHD分型的胆道重建方案,分析儿童劈离式肝移植术后胆道并发症的发生及治疗情况。结果  75个供肝中,LHD解剖分型为Ⅰ型57例（76%）、Ⅱ型9例（12%）、Ⅲ型4例（5%）、Ⅳ型5例（7%）。75例儿童受者的胆道重建方案包括左肝管-空肠Roux-en-Y吻合69例（Ⅰ型53例、Ⅱ型8例、Ⅲ型4例、Ⅳ型4例）,胆总管-空肠Roux-en-Y吻合1例（Ⅳ型）,左肝管-胆总管端端吻合5例（Ⅰ型4例、Ⅱ型1例）。术后6例发生胆道并发症,发生率为8%,其中胆道吻合口狭窄3例,胆道吻合口胆漏2例,肝断面胆漏1例。发生在Ⅰ型4例,发生在Ⅲ型2例,LHD经典型与解剖变异型的胆道并发症发生率差异无统计学意义（均为P > 0.05）。3例胆道吻合口狭窄受者中,2例行经皮经肝胆道引流术（PTCD）,1例行再次胆肠吻合术;2例胆道吻合口胆漏受者均行PTCD;1例断面胆漏受者予局部引流。6例患儿治疗后均存活。结论  供肝中24%存在LHD的解剖变异,其中Ⅱ型最多,为12%。供肝劈离前常规胆道造影和精细的胆道吻合技术可以有效降低胆道并发症的发生率。术后胆道并发症的发生与LHD解剖分型无明显相关性。     

Extended right hepatic lobectomy with resection of inferior vena cava and portal vein for intrahepatic cholangiocarcinoma

We report a case of intrahepatic cholangiocarcinoma treated by extended right lobectomy and resection of the inferior vena cava (IVC) and portal vein. A 53-year-old man was referred with elevated serum alkaline phosphatase (ALP) and γ-glutamyl transpeptidase (γ-GTP) levels on April 23, 1999. He was not jaundiced and did not have any symptoms. Endoscopic retrograde cholangiopancreatography (ERCP) revealed irregular strictures in both the anterior and posterior segmental ducts. Contrast-enhanced computed tomography (CT) scan demonstrated a low-density tumor with an unclear margin in the right lobe of the liver. The patient underwent extended right hepatic lobectomy and total caudate lobectomy. Partial resection of the IVC (6 cm) was performed under total hepatic vascular exclusion. The main portal trunk and left portal vein were resected and reconstructed with an end-to-end anastomosis. Macroscopically, a 5.0 × 5.0 × 4.5-cm periductal infiltrating-type tumor occupied the right hepatic parenchyma along the posterior and anterior segmental ducts. Histological examination revealed moderately differentiated tubular adenocarcinoma with marked perineural invasion. Lymph node metastasis was observed in the hepatoduodenal ligament and posterior surface of the pancreatic head. The resected margins of the common bile duct and left hepatic duct were free of tumor. The patient's postoperative course was uneventful, and he was discharged from hospital on the 28th postoperative day. Nine months after the operation, he suddenly developed obstructive jaundice, and died with recurrent disease. This is the first reported case of intrahepatic cholangiocarcinoma treated with major hepatectomy and resection of the IVC and portal vein except ex situ procedure. This aggressive surgical approach may offer hope for patients with intrahepatic cholangiocarcinoma involving the IVC. Received: March 27, 2000 / Accepted: August 8, 2000     

Tissue-engineered patch for the reconstruction of inferior vena cava during living-donor liver transplantation

In living-donor liver transplantation, only a portion of the donor's liver is grafted into the recipient; therefore, if the hepatic vein and inferior vena cava (IVC) in the recipient fail to be transformed or dilated properly, it could cause inadequate blood flow from the liver graft to the IVC. We have developed an easy-to-use tissue engineered patch that can be used for the reconstruction of the hepatic vein and IVC. Five hybrid pigs (weighing 15-30 kg) served as the recipients of the patch. A bioabsorbable polymer sheet was used to produce the patch, with no cells seeded. The pigs were laparotomized, followed by the removal of a 3 x 2-cm portion of the infrahepatic IVC, which was then patched with the polymer sheet. Three months after the operation, the graft site was removed and subjected to gross and histologic examinations. All five pigs survived until they were killed 3 months after the operation. On gross examination, the polymer sheet grafted onto the IVC was completely absorbed, and the graft site was morphologically similar to the native IVC. In all five pigs, the patched IVC was free of stenosis or deformation. Immunohistochemical examination revealed that the patch site was lined with endothelial cells and that smooth muscle was present under the epithelium. Like the native IVC, the patch site tested positive for factor VIII. These findings suggest that this polymer sheet may be useful for the reconstruction of the IVC and hepatic vein during living-donor liver transplantation in humans.     

肝静脉和下腔静脉血流控制在高难度肝肿瘤切除中的应用

目的评估肝静脉主干和(或)下腔静脉血流控制在高难度肝切除术中的作用和意义。方法对33例位于Ⅳ、Ⅶ、Ⅷ段和左半肝、右半肝、右三叶的肝肿瘤进行了游离下腔静脉和肝静脉主干并加以控制的肝切除术。其中肝细胞性肝癌26例;胆管细胞性肝癌2例;转移性肝癌2例;肝血管瘤3例。32例患者在术中成功预置了下腔静脉和肝静脉的阻断带,必要时控制肝静脉和下腔静脉血流。1例患者预置肝静脉阻断带失败。结果33例全部成功切除肿瘤,术中输血0-1600ml,其中7例没有输血。全组无术中死亡病例。结论熟练掌握和合理控制肝静脉主干和下腔静脉血流,可以提高复杂肝肿瘤切除的安全性和减少输血,有助于完成高难度肝肿瘤的切除。     

A new technique for bilateral iliac vein and inferior vena cava reconstruction using reinforced polytetrafluoroethylene

We report on the management of a patient with intractable venous claudication and ulceration due to bilateral iliac vein and inferior vena cava occlusion. An inverted V graft was constructed from two 8 mm diameter reinforced PTFE grafts. The upper end was anastomosed to the inferior infrarenal vena cava and the lower ends anastomosed to the common femoral veins. Bilateral arteriovenous fistulas were fashioned. Nine months later the graft is patent and the patient's only symptom is mild ankle edema. The theoretical advantage of this type of graft is that occlusion of one limb will not compromise the other, thus leaving a number of secondary options open if this should happen.     

Leiomyosarcoma of the inferior vena cava. Resection and reconstruction of the renal vein using the gonadal vein

(Received for publication on Jan. 10, 1997; accepted on July 8, 1997)     

切除累及下腔静脉肝癌的体会

目的探讨累及下腔静脉肝癌切除的可能性。方法复习近三年中我科切除的累及下腔静脉的原发性肝癌２６例。结果手术经过顺利，术后无严重并发症，无手术死亡。结论良好的麻醉、熟练的切肝技术和控制大出血的能力，切除累及下腔静脉的肝癌是可行的     

Thrombophlebitis of the ovarian vein with free-floating thrombus in the inferior vena cava

Two cases of thrombophlebitis of the right ovarian vein, one occurring after cesarean section and the other after natural childbirth, are reported. The clinical diagnosis was based on the symptoms of postpartum fever in association with right flank pain and confirmed by abdominal CT scans. In both cases the thrombosis extended into the inferior vena cava and was associated with a free-floating thrombus extending up to the renal veins. Thrombectomy of the inferior vena cava and ligation of the right ovarian vein were performed with good results in both cases, as shown by late follow-up CT scans. This and alternative therapeutic strategies are discussed.     

Hepatic vein-to-azygos vein connection in a patient with interrupted inferior vena cava.

Massive systemic-to-hepatic venous collaterals developed in a 8-year-old boy with left isomerism and azygos connection of the inferior vena cava who had undergone total cavopulmonary shunt leaving the hepatic vein connected to the common atrium 5 years previously. A hepatic vein-to-azygos vein connection via an autologous pericardial roll successfully ameliorated cyanosis and physical activity. Hepatic vein-to-azygos vein connection is technically easy and is favorable in providing balanced distribution of hepatic venous blood to both lungs. We recommend this technique as an effective alternative to hepatic vein-to-pulmonary artery connection in patients developing collateral vessels after total cavopulmonary shunt.     

The effect of hepatic portal dissection on the portal vein structure in biliary atresia

Superior mesenteric portograms were performed on 30 patients with biliary atresia (BA) at the time of initial portoenterostomy in 20, and at the stoma closure operation in 10. A withered-branch-shaped irregularity of the intrahepatic portal vein (PV) and collateral vessels were seen in 2 of 11 patients with portal pressures (PP) of 200 to 300 mmH₂O; in 1 of 2 patients with PPs of over 300 mmH₂O at the initial operation; and in 3 jaundice-free patients with PPs of 285, 320, and 305 mmH₂O, respectively, at the stoma closure operation. Collaterals were the only abnormalities seen in two additional jaundice-free patients with PPs of 370 and 183 mmH₂O, respectively. No anatomic changes in the extrahepatic PV at the porta hepatis were found on the portograms of either group of patients. Thus, we conclude that portal dissection itself does not affect the PV structure anatomically, a finding which has important implications in determining whether or not portoenterostomy adversely affects potential liver transplantation.     

Treatment for hepatocellular carcinoma with tumor thrombosis in the hepatic vein or inferior vena cava: A comprehensive review

Hepatocellular carcinoma (HCC) is the most common type of liver cancer with a high mortality rate worldwide. The percentage of HCC patients with vascular invasion is high. However, tumor thrombus in the hepatic vein (HVTT) has a lower incidence than tumor thrombus in the portal vein (PVTT). Conventionally, HCC patients with HVTT are treated the same as HCC patients with PVTT and offered sorafenib or other systemic agents. However, according to recent studies, it is evident that HCC with HVTT shows different outcomes when classified into different subgroups. In this review, we discuss the recent progress and changes in treatment of HCC with HVTT.     

Management and outcome in patients with Klatskin-mimicking lesions of the biliary tree

The preoperative and even intraoperative differentiation between benign and malignant strictures at the hepatic hilum remains difficult. The aim of this study was to assess clinical, radiologic, intraoperative, and histopathologic findings; surgical treatment; and outcome of patients with Klatskin mimicking benign lesions. Of 49 consecutive patients who were operated on the initial preoperative radiologic diagnosis of hilar adenocarcinoma (Klatskin tumor), 7 (14%) had benign conditions after final histopathologic diagnosis. Pretreatment work-up, therapy, and outcome of these patients were analyzed. Based on preoperative clinical symptoms, imaging assessment, and CA19-9 values, all seven patients were classified as having malignant neoplasms. At laparotomy, the tumors of six patients were judged to be malignant. Five patients underwent hilar resection and concomitant liver resection, and two patients underwent hilar resection alone. There were no operative deaths. The definitive histopathologic examination showed severe cholangitis with extensive periductal fibrosis in all patients. After a median follow-up of 32 months, all patients are well. Clinical presentation and imaging assessment were similar for Klatskin tumors and benign fibrosing disease; therefore, an aggressive resectional approach is justified in any patient with suspicious obstruction of the liver hilum.