Doppler ultrasonic evaluation of hepatic functional reserve]

Ultrasonic Doppler measurement of the blood flow in the portal vein and hepatic artery was conducted to evaluate the function and functional reserve of the liver in 146 patients with various forms of cholangitis combined with biliary cirrhosis and hepatic insufficiency. The functional reserve of the liver was judged by comparison of the basic blood flow on a fasting stomach with the blood flow after a functional histamine load. Five types of responses of the portal vein blood flow to the functional load according to the degree of disturbed hepatic function were revealed. Comparison of the flow of blood along the portal vein in healthy individuals with that in patients with diabetes mellitus and a formed splenorenal shunt showed that disconnection of the blood flow from the splenic vein has no effect on the flow of blood in the portal vein. The latter is regulated at the level of microcirculation in the liver, which is confirmed by the correlation between the blood flow in the portal vein and in the hepatic artery.     

Changes in hemodynamics and angioarchitecture of the hepatolienal basin after embolization of the splenic artery in liver cirrhosis

Complex investigations of regional hemodynamic changes in the spleno-hepatic basin in 72 patients with cirrhosis of the liver after the embolization of the splenic artery have shown that in most patients the embolization of the splenic artery is followed by pronounced alterations in the portal system, decreased portal pressure, inversed blood flow in the main trunk of the splenic vein. The ESA used in the complex surgical treatment of patients facilitates the compensation of the portal blood circulation.     

门静脉高压症手术前后血流动力学改变及临床意义

采用彩色多普勒血流显像（ＣＤＦＩ）．对门静脉高压症手术前后门静脉血流动力学进行观测和对比分析。结果表明：（１）肝硬变门静脉高压症的门、脾静脉内径和血流量显著扩张和增加，和正常人比较差异有显著性（Ｐ＜０．０１）．门静脉血流量增加与脾静脉血流量增加呈正相关；（２）断流术后．门静脉内径变窄和血流量明显减少，与对照组比较差异有显著性（Ｐ＜０．０１）；（３）断流加脾肾分流联合术后，门静脉内径变窄明显大于断流术，但两术式后门静脉血流量减少差异无显著性、结果认为．断流术和断流加脾肾分流联合术均为治疗肝硬变门静脉高压症较合理的术式。     

Indicators of hepatic and intracardiac hemodynamics in the surgical treatment of liver cirrhosis

Under analysis are results of operative treatment of 54 patients with cirrhosis of the liver. Most satisfactory hemodynamic results were obtained after endovascular embolisation of the splenic artery as the increased general hepatic blood flow and simultaneously decreased splenic blood flow, better indices of intracardiac hemodynamics. The method of peritoneoatrial shunting is most perspective in patients with cirrhosis of the liver at the stage of decompensation of portal hypertension. But possible overloading of the heart must be borne in mind.     

Radiofrequency ablation for hypersplenism in patients with liver cirrhosis: A pilot study

Radiofrequency ablation is a relatively new technique used for local ablation of unresectable tumors. We investigated the feasibility and eficacy of radiofrequency ablation for hypersplenism and its effect on liver function in patients with liver cirrhosis and portal hypertension. Nine consecutive patients with hypersplenism due to cirrhotic portal hypertension underwent radiofrequency ablation in enlarged spleens. The ablation was performed either intraoperatively or percutaneously. Patients are followed up for over 12 months. After treatment, between 20% and 43% of spleen volume was ablated, and spleen volume increased by 4%–10.2%. White blood cell count, platelet count, liver function, and hepatic artery blood flow showed significant improvement after 1-year follow-up. Splenic vein and portal vein blood flow were significantly reduced. Only minor complications including hydrothorax (three of nine patients) and mild abdominal pain (four of nine patients) were observed. No mortality or other morbidity occurred. Radiofrequency ablation is a safe, effective, and minimally invasive approach for the management of splenomegaly and hypersplenism in patients with liver cirrhosis and portal hypertension. Increased hepatic artery blood flow may be responsible for sustained improvement of liver condition. Radiofrequency ablation may be used as a bridging therapy for cirrhotic patients waiting for liver transplantation.     

Case Report of Extensive Isolated Spontaneous Celiac Trunk Dissection After Liver Transplantation

Arterial dissection is a rare complication after liver transplantation (LT). We report a case of extensive isolated spontaneous celiac trunk dissection (ISCTD) up to the proper hepatic artery, left gastric artery, and splenic artery after living donor liver transplantation. A 48-year-old woman with cryptogenic liver cirrhosis underwent living donor liver transplantation. Intraoperative and postoperative Doppler ultrasound revealed sufficient flow in the hepatic artery, portal vein, and hepatic vein. On postoperative day (POD) 10, Doppler ultrasound showed reduction of hepatic arterial flow. On POD 16, a contrast-enhanced computed tomography scan showed that the ISCTD extended to the proper hepatic artery, left gastric artery, and splenic artery with an entry tear on the proximal side of the celiac trunk. Although the computed tomography scan showed ischemia of a small part of the liver, blood flow to the liver was kept to some extent. Because all false lumens were occluded by thrombi and the liver enzyme levels normalized, we chose conservative therapy with antiplatelet agents. The patient was discharged on POD 53. She remains well without any liver dysfunction after 18 months with reduction in all false lumens and a patent hepatic artery. Several cases of ISCTD have been reported apart from LT, most of which were treated with conservative therapy. We conclude that conservative therapy could be the first choice in ISCTD even after LT.     

超声引导下门静脉穿刺导引TIPS联合曲张静脉栓塞治疗肝硬化上消化道出血

目的探讨超声引导下经皮经肝穿刺门静脉导引TIPS联合食管胃底曲张静脉栓塞术(PTVE)治疗肝硬化上消化道出血的临床价值。方法收集82例肝硬化伴反复上消化道出血患者,对其中47例(病例组)采用超声引导下经皮经肝门静脉穿刺并导引TIPS联合PTVE,对35例(对照组)采用传统TIPS路径联合PTVE。比较2组分流道穿刺次数及时长、PTVE完成时长及手术总时长等指标,分别比较2组手术前后肝脏血管情况。记录2组并发症。结果病例组分流道穿刺次数和时长、手术总时长及术中出血率均低于对照组,而分流道穿刺成功率高于对照组(P均0.05);2组PTVE手术时长差异无统计学意义(P=0.15)。与术前相比,2组术后门静脉及脾静脉内径均缩小;门静脉、脾静脉、肠系膜上静脉及下腔静脉流速均加快,肝动脉流速均减低、RI均增高(P均0.05)。病例组无复发消化道出血病例,对照组3例(3/35,8.57%)复发消化道出血(t=3.15,P0.001)。结论超声引导下门静脉穿刺导引TIPS及PTVE可缩短手术时间、提高手术成功率及降低术后复发消化道出血的风险。     

Embolization of the splenic artery in liver cirrhosis with portal hypertension and splenomegaly

Results of subacute embolization of the splenic artery with a metallic spiral obtained in 22 patients with cirrhosis of the liver with splenomegaly were studied at the stage of sub- and decompensation of the portal blood circulation. Results of the study and their clinical evaluation suggest that the subacute embolization of the splenic artery is a relatively safe, atraumatic and effective method of surgical treatment of splenomegaly, hypersplenism resulting from liver cirrhosis with portal hypertension. The method allows to decrease hypersplenism, splenomegaly, portal hypertension, to eliminate the pain syndrome due to splenomegaly.     

肝炎后肝硬化患者手术前后血氧分压变化的临床研究

为了解肝炎后肝硬化患者手术前后动脉血氧分压变化以及氧疗法对其动脉、门静脉和周围静因氧分压的影响，作者对３２例肝炎后肝硬化患者和８例非肝病患者吸氧前后桡动脉、门 周围静脉血氧分压进行检测。结果：（１）肝炎后肝经组术后动脉氧分压低于术前；（２）肝硬化组门静脉氧分压高于对照组，且与桡动脉血氧分压呈正相关；（３）肝硬化组肝功能分级和门静脉压力与桡动脉、门静脉氧分压无明显关系；（４）肝硬化组吸氧后门静脉、桡     

Partial splenic embolization in patients with liver cirrhosis and hepatocellular carcinoma: Effects on portal hemodynamics

Partial splenic embolization (PSE) was performed on patients with liver cirrhosis to control hypersplenism and gastroesophageal varices. In this study, we evaluated the effects of PSE on the portal hemodynamics and hepatic function of 17 cirrhotic patients with hepatocellular carcinoma. The mean splenic volume and the peak platelet count increased significantly and the splenic vein pressure decreased significantly after PSE. However, the portal blood flow did not change. Changes in the 15-min retention rate of indocyanine green and the arterial ketone body ratio were not significant, but the redox tolerance index increased from 0.24 ± 0.28 × 10^–2 to 0.59 ± 0.35 × 10^–2. These results suggest that PSE may reduce perioperative risks in cirrhotic patients with hepatocellular carcinoma who are candidates for hepatic resection.     

肝硬化脾切除术后门静脉系统血栓形成的原因分析

目的 探讨肝硬化门静脉高压患者行脾脏切除+贲门周围血管离断术后门静脉系统血栓(portal vein thrombosis,PVT)形成的原因.方法 回顾性分析我院2004年1月至2010年1月204例肝炎后肝硬化门静脉高压症行手术治疗患者的临床资料.结果 其中150例行脾切除+贲门周围血管离断术,54例行脾脏部分切除术+贲门周围血管离断术.术后发生PVT30例,未发生PVT174例;发生PVT患者的门静脉和脾静脉直径、术后门静脉血液流速及术后并发症与未发生PVT患者有显著性差异(P<0.05),脾脏部分切除术后患者PVT的发生率明显比脾脏切除患者低,有显著性差异(P<0.05).结论 门静脉和脾静脉直径、门静脉血液流速及术后并发症是肝硬化门脉高压症脾切+贲门周围血管离断术后PVT形成的危险因素,脾脏部分切除术可有效减少断流术后PVT的发生.     

Portosystemic encephalopathy and splanchnic hemodynamics in liver cirrhosis]

In 166 patients with liver cirrhosis (LC) and the portal hypertension syndrome the complex hemodynamical investigations were performed. It was established that portosystemic encephalopathy (PSE) is caused by the portosystemic shunts occurrence resulting in lowering of the volumetric blood flow in portal vein and hepatic artery, the diameter and intraluminal pressure in portal vein are diminished. It was observed in patients with encephalopathy, comparing with healthy persons, the hyperdynamical state of splenic blood circulation with the volumetric blood flow enhancement in a. et v. lienalis, and in patients with LC, suffering PSE, the volumetric blood flow in a. et v. lienalis is less than in patients without encephalopathy. While encephalopathy there was observed the enhancement of volumetric component of arterial blood and the lowering of the blood component from v. portae in common hepatic blood flow, including the liver inflow level and the sinusoid vessels level.     

Splenic artery ligation in distal splenorenal shunts

Splenic artery ligation, a simple surgical procedure expected to decrease splenic flow and portal pressure in patients with cirrhosis of the liver, was performed concomitantly with a distal splenorenal shunt procedure in six patients and as the main surgical procedure in two patients. Immediate cessation of bleeding was achieved in the four patients in whom the splenic artery was ligated to reduce intraoperative bleeding. However, three of the seven patients with previous gastroesophageal hemorrhage rebled from various postoperatively. Symptoms of splenic infarction were observed in six patients, resulting in thrombosis of the splenic vein and/or of the distal splenorenal shunt in four patients and necessitating splenectomy in one. This incidence of thrombosis of the distal splenorenal shunt is much higher than the overall incidence of 5 per cent observed at our institution. It is thus concluded that the splenic artery should not be ligated in cirrhotic patients with patent distal splenorenal shunts, since splenic arterial collateral vessels have already been reduced by the gastric devascularization, an integral component of the distal splenorenal shunt.     

Portal vein arterialization for liver transplantation with extensive portomesenteric vein thrombosis: a case report

We report herein a case of extensive thrombosis of portal venous system including mesenteric vein in a 70-year-old man who suffered from end-stage post-hepatitis C cirrhosis and who underwent orthotopic liver transplantation. There was no way to divert portal blood flow to the new liver because such an extensive thrombosis of portomesenteric venous system. There are some case reports of portocaval hemitransposition with some success but high mortality. We decided to arterialize the portal vein of the liver allograft with the recipient hepatic artery and the donor hepatic artery was anastomosed to the supraceliac aorta. He recovered slowly from the operation. At 1 year after the transplantation, he is doing well with perfect liver function tests. This case challenges our belief that portal blood flow is essential for the liver because of hepatotrophic factors.     

In vivo evaluation of an implantable portal pump system for augmenting liver perfusion

BACKGROUND: Increasing portal inflow in cirrhosis using a mechanical pump reduces portal venous pressure and improves liver function. A pump has been developed for portal vein implantation in human cirrhosis. This study describes the initial in vivo evaluation in a porcine model. METHODS: Five Large White pigs underwent laparotomy and exposure of the liver. Flow in the hepatic artery, portal vein and hepatic microcirculation was monitored continuously. Hepatic tissue oxygenation was measured by near-infrared spectroscopy. After baseline measurements the pump was inserted into the portal vein. Pump flow rate was then increased stepwise to 50 per cent over the baseline value for a period of 2 h. The pump was then stopped for 20 min and left in situ while continuing to collect systemic and hepatic haemodynamic data. The animal was killed and biopsies for histological examination were taken from the liver, small intestine and spleen. RESULTS: The baseline total hepatic blood flow was 626(39) ml/min; the hepatic artery supplied 18.4(2.1) per cent and the portal vein 81.6(2.1) per cent. The pump was inserted successfully in all animals without surgical complications. During surgical insertion of the pump, the temporary portal vein occlusion resulted in a significant rise in hepatic artery blood flow (22(3) per cent; P < 0.01 versus baseline). Portal vein flow was augmented by pumping; there was a significant correlation between the pump motor speed and portal vein flow (P < 0.0001). This inflow correlated directly with flow in the hepatic microcirculation and hepatic tissue oxygenation (P < 0.001). The pump ran satisfactorily throughout the study. Histological examination revealed no evidence of structural damage to the liver or ischaemic changes in the small intestine or spleen. CONCLUSION: It is technically possible and safe to insert an implantable pump in the portal vein. Portal venous blood flow can be increased up to 50 per cent with a resultant increase in flow in the hepatic microcirculation and hepatic oxygenation and without adverse effects on either hepatic or systemic haemodynamics.     

部分脾动脉栓塞术治疗肝硬化门静脉高压症的临床疗效分析

目的探讨部分脾动脉栓塞术（PSE）治疗肝硬化门静脉高压症的临床疗效。方法选取我院62例肝硬化食管胃底静脉曲张破裂出血和脾功能亢进患者。全组均行PSE,观察手术前后外周血象变化,门静脉、脾静脉管径变化及术后并发症发生情况。结果PSE术后白细胞、血小板计数高于术前（P〈0．05）;门静脉、脾静脉管径较术前缩小（P〈0．05）,全组病例无严重并发症发生。结论PSE治疗肝硬化并脾功能亢进操作简便、创伤较小、疗效稳固,可以抢救和预防再出血,尤适用于高危病重、老年不适于手术治疗者,是值得临床推广和应用的手术方法。     

肝硬化患者HA、LN及IV-C变化与门脉血流变化对胃运动影响的相关性研究

目的 探讨肝硬化患者血浆中肝纤维化指标HA、LN及IV-C的变化与门脉血流变化对胃运动影响的相关性研究,为肝硬化的治疗提供理论依据。方法 应用同步对比研究,采用放射免疫分析、多普勒超声及体表胃电检测的方法,同时设立健康对照组,分别检测肝硬化患者及正常人血浆中透明质酸(HA)、层粘连蛋白(LN)以及IV型胶原(IV-C)的水平;门静脉的平均宽度(PVD),门静脉血管内最大血流速(PVmax)和血流参数(PVF);进餐前后胃电活动的变化情况。结果 在肝硬化患者,肝纤维化指标HA、LN及IV-C的水平随着肝功能的减退呈现增加的趋势,而PVmax和PVF呈递减趋势,与正常状况差异显著。而在胃电中,肝硬化患者的胃电幅值随着肝功能的减退呈下降趋势,但其主功率在餐前明显高于正常,餐后却显著降低,且随着肝功能的减退餐后主频率逐渐下降。而门静脉的平均宽度(PVD)的改变与肝功能受损程度无显著相关性。结论 随着肝纤维化指标HA、LN及IV-C水平的增高,肝硬化患者Pvmax和PVF减低,餐后胃排空能力下降。     

Effects of nonshunting operations on portal venous pressure and hepatic blood flow

A comparative analysis has been presented of the effect of the nonshunting operation on portal venous pressure and effective hepatic blood flow in patients with liver cirrhosis and idiopathic portal hypertension. A reduction of portal pressure after splenectomy with esophagogastric devascularization in 17 patients with idiopathic portal hypertension was significantly greater than that in 79 patients with liver cirrhosis (-21 +/- 4.1 percent versus -8.9 +/- 1.6 percent, p less than 0.01). Clearance of galactose from the blood, which approximates effective hepatic blood flow, was decreased after the nonshunting operation by 6.7 percent in five patients with liver cirrhosis (p value not significant). On the other hand, there was a 19.4 percent reduction (statistically significant) in galactose clearance in four patients with idiopathic portal hypertension (p less than 0.05). Based on these data, we suggest that in patients with idiopathic portal hypertension, the splenic circuit largely contributes to the portal hypertension, the effective hepatic blood flow, or both. We recommend a nonshunting operation for the treatment of esophageal varices from the hemodynamic viewpoint in cirrhotic patients.     

Hemihepatectomy and replacement of the afferent hepatic blood supply in the dog. Resection of liver and hepatoduodenal ligament

Hemihepatectomy along with portal vein or hepatic artery replacement in dogs was well tolerated, but combined with replacement of both vessels it was lethal because of outflow block and shock. Total liver blood flow should be kept as high as possible during such procedures in man.     

术中监测及调整门静脉血流预防活体肝移植术后小肝综合征

目的探讨活体肝移植术中门静脉血流量及门静脉压力的监测及调整对小肝综合征的预防作用。方法回顾性分析我院移植一科2007年10月至2008年10月期间行活体肝移植并进行术中门静脉血流监测的44例患者的临床资料,包括实测供肝重量占受者体重比(GRWR)、门静脉血流量及压力、术后是否出现小肝综合征表现等。对于实测GRWR偏小(GRWR1%)的病例,如果术中门静脉压力12 mm Hg(1 mm Hg=0.133 kPa)或者门静脉血流量250 ml/(min.100 g),在术中加行脾切除或脾动脉结扎,分析监测和调整门静脉血流(脾切除和脾动脉结扎)是否可以预防小肝综合征的发生。结果行脾切除6例,切脾后门静脉血流量及压力均较切除前明显降低(P0.05);脾动脉结扎7例,结扎后门静脉压力较结扎前明显降低(P0.05),而门静脉血流量无明显变化(P0.05)。术后44例患者均未出现小肝综合征表现。结论活体肝移植术中通过切脾或行脾动脉结扎降低移植肝门静脉血流量及压力对术后小肝综合征有预防作用