‘Benign’ hepatic portal venous gas

The presence of portal venous gas within the hepatic parenchyma is usually associated with a guarded prognosis and a mortality rate approaching 75%. However, there are infrequent causes of portal venous gas not associated with dire clinical outcomes. We describe three patients who made uneventful clinical recoveries after presenting with clinical and imaging manifestations of ischaemic bowel and hepatic portal venous gas, two of which had distended but non‐necrotic bowel at laparotomy.     

C.T. Demonstration of Thrombosis of the Portal Venous System

Thrombosis involving all or part of the portal venous system was demonstrated by C.T. in three patients. Predisposing factors were sigmoid colectomy for adenocarcinoma, appen-diceal abscess and splenectomy for splenic arterio-venous malformation, respectively. Fresh thrombus appeared as high density intraluminal content on noncontrast enhanced scans. Older thrombus appeared as low density intraluminal content surrounded by a high density venous wall on contrast enhanced scans. One patient developed a cavernoma of the portal vein demonstrated by C.T. and porto-graphy. In another patient; bowel infarction with bowel wall thickening and intra-mural gas was demonstrated. Although the diagnosis can be made on non-contrast enhanced scans in the acute phase and by using the bolus intravenous technique for contrast enhanced scans for older thrombus, optimal demonstration of the presence of thrombus and clear definition of the extent of thrombosis requires a dynamic scanning technique during rapid intravenous infusion of contrast.     

Sonographic Recognition of Pneumatosis Intestinalis and Portal Gas in an 11-months-old Infant — Case Report

Sonography was performed on an 11-month old infant who presented with intestinal obstruction. Pneumatosis intestinalis and portal venous gas were detected in addition to dilated small bowel loops. Preoperative diagnosis of small bowel gangrene was made which was proven at operation.     

Portal venous gas following chemotherapy for colorectal cancer liver metastasis

The standard of care for patients with colorectal liver metastases is a combination of chemotherapy and surgery. New chemotherapy regimens with biologic agents (cetuximab, bevacizumab) have been shown to increase tumor response rates. Although this might be beneficial and this is an expected endpoint, it should be noted that patients with synchronous colorectal and liver metastases are at risk of septic complications. We recently encountered a case of hepatic portal venous gas after two cycles of chemotherapy in a patient with right colon cancer liver metastases. Complete necrosis of the liver metastasis subsequently turned into a liver abscess, which fistulized in the right portal vein. Infection of the necrotized metastasis was thought to be promoted by the colic tumor. Although this is a dramatic situation, it does not contraindicate a curative surgical resection.     

A reasoned approach to a case of suspected arteriovenous fistula

The case of an 82-year-old female patient with severe tricuspid regurgitation come to the authors' observation for suspected arteriovenous fistula, is reported. Color-Doppler US was performed for re-evaluation. It documented the presence of systemic venous and portal pulsatility associated with severe ectasia and varicosity of infracardiac systemic venous system due to systemic venous hypertension. Color-Doppler study allowed a correct diagnostic approach, excluding the presence of an arteriovenous fistula.     

Immunohistochemical studies on the main entrance-route of CA19-9 into the peripheral venous blood of gastric cancer patients. Correlation with CA19-9 levels in peripheral and portal blood

The correlation between CA19-9 levels of portal and peripheral venous blood, and immunohistochemical variables of cancer lesions was examined in 53 gastric cancer patients and eight patients with benign diseases. Immunohistochemically, CA19-9 was found in 33 (62.5%) of 53 primary lesions. The antigen was found in the cancer cells of invasive lymphatics and node metastases of every CA19-9 localized cancer, although the cancer cells in veins showed little or no CA19-9. There was little or no antigen in the cancer cells in veins, lymphatics, or metastases of 20 CA19-9 nonlocalized primary lesions. Patients with CA19-9 nonlocalized cancer or with benign diseases showed no elevation of the antigen levels in peripheral or portal blood. CA19-9 levels of portal blood (mean, 76.4 U/ml; positive rate, 33.3%) were not different from those of peripheral blood (mean, 91.5 U/ml; positive rate, 33.3%). Additionally, the antigen levels of the blood in patients with lymphatic invasion or node metastases were significantly higher than those in patients without the invasion or the metastases, and every patient without the invasion showed no elevation of the antigen. These results suggest that production of the antigen in cancer cells may be a premise of CA19-9 elevation in peripheral blood and that CA19-9 may be drained by the thoracic duct of the lymphatic system via node metastases or invasive lymphatics, but not by the hematogenous portal system.     

Exchanging dual‐lumen central venous catheters: How I do it

The management of a blocked long‐term central venous catheter has traditionally been removal and re‐siting, even when device failure is not associated with venous thrombosis or sepsis. It is not possible to ‘railroad’ a split dual‐lumen central venous catheter down a long tortuous s.c. tunnel. Our exchange technique was designed to salvage the tunnel and venous access site in a long‐term catheter that has had uncomplicated primary device failure. In this technique we divide the dual‐lumen catheter and secure the venous access site and the s.c. tunnel with separate peel‐away sheaths. The new catheter is then introduced in the conventional manner through the two peel‐away sheaths, which are then removed. The key advantage of the technique is that it preserves one of the few central venous access sites available. This article describes exchange of an internal jugular catheter, but the same technique is applicable to subclavian catheters.     

A case report of hepatocellular carcinoma with hepatic and portal venous tumor thrombus and multiple intrahepatic metastasis who survived over 1 year after the operation with combined locoregional chemotherapy

Hepatocellular carcinoma (HCC) with vascular invasion and/or intrahepatic metastasis (IM) has a poor prognosis, so advanced HCC may be considered as a contraindication for hepatectomy. We experienced a case of HCC with hepatic venous and portal venous tumor thrombus and multiple IM who survived over 1 year after the operation with combined locoregional chemotherapy. (Case): A 67-year-old male patient was diagnosed with HCC with extracapsular invasion after transarterial embolization (TAE). CT scan revealed the HCC had a right portal venous tumor thrombus and multiple IM. Posterior lobectomy and thrombectomy of hepatic venous and portal venous tumor thrombus and placement of portal venous catheter ware performed. From the first day after operation the patient received continuous intravenous and intraportal 5-FU for 3 weeks. At the first month after operation, TAE and PEIT were given against residual IM. After discharge the patient received hepatic arterial infusion chemotherapy (MTX/CDDP/5-FU/Leucovorin). Fourteen months after operation, the patient is surviving in good physical condition.     

Modern Methods for Reliable Preoperative Localization of Insulinoma

A case of insulinoma is reported in which the correct localization of tumor was made with PTP and immunoreactive insulin values from the portal venous system and in which pancreas angiography indicated a false positive tumor localization. PTP should be done to every patient to confirm the preoperative location of the insulinoma(s).     

A case of advanced gastric cancer found to be remaining by gastrectomy after a clinically complete response to chemotherapy

The patient was a 72-year-old woman diagnosed with advanced gastric cancer, hepatic portal lymph node and para-aortic lymph node metastases. After five courses of S-1/CDDP combination therapy, both the primary tumor and lymph node metastases disappeared clinically. She wished to continue chemotherapy instead of having a resection. After three more courses of S-1/CDDP therapy, gastric cancer and lymph node metastases were still completely regressed, but complications of carcinoma of the gallbladder were suspected. Gastrectomy was performed with cholecystectomy, and a histopathological examination revealed cancer cells remaining in the gastric submucosa and xanthogranulomatous cholecystitis. We consider surgical therapy for clinically completely disappearing advanced gastric cancer by chemotherapy, in addition to case report.     

Multiresistant Stenotrophomonas maltophilia tunneled CVC-related sepsis, treated with systemic and lock therapy

In the last decade, a remarkable increase in the incidence of nosocomial Gram-negative infections has been observed. These pathogens represent a substantial problem in clinical practice, due to the high resistance profile of most commonly used antibiotics. This phenomenon is surely a co-factor that exposes these susceptible patients to infections caused by selected pathogens like multiresistant Gram-negative rods. A typical example is represented by VAP (ventilator-associated pneumonia) sustained by Acinetobacter spp., Pseudomonas aeruginosa, Bulkolderia cepacia. The Authors describe a case of a central venous cather (CVC)-related Stenotrophomonas maltophilia sepsis in a patient affected by solid tumor, successfully treated with systemic antibiotic therapy associated with "lock therapy". This combination was able to cure the infection, allowing the patient to continue chemotherapy and saving the in situ CVC. The surveillance of CVCs, good adherence to the protocols and guidelines and "good practice" are the cornerstones for the prevention of nosocomial infections.     

Colocutaneous fistula complicating Tenckhoff catheter placement for intraperitoneal chemotherapy

In view of the characteristic intra-abdominal spread of carcinoma of the colon and rectum [1-3], the use of intraperitoneal chemotherapy may offer an alternative to intravenous or oral drug therapy and even radiation therapy for recurrent disease [4,5]. Several investigators have demonstrated that intraperitoneal drug administration may result in portal vein levels ten to 20 times higher than those observed in peripheral venous blood samples [6]. Traditionally, intraperitoneal chemotherapy has been administered through the Tenckhoff catheter system which was originally developed for peritoneal dialysis in patients with acute or chronic renal failure [7,8]. We report a case of Tenckhoff catheter erosion into the colon with subsequent fistulization developing 20 days after intra-operative placement for intraperitoneal or "belly bath" chemotherapy; this complication occurred in a patient with locally recurrent colorectal adenocarcinoma in whom pelvic peritoneal implants without hepatic metastases were identified at reoperation. This complication of the Tenckhoff catheter system has not previously been reported in the surgical literature.     

A rare intrahepatic portacaval tubular shunt in a patient with spastic paraparesis

Although there are numerous communications between the portal and systemic venous systems, intrahepatic portosystemic venous shunts are not frequently encountered in clinical practice. Here we report a patient who presented with spastic paraparesis, who was found to have chronic liver disease with tubular intrahepatic portacaval shunting.     

Mouse models of subcutaneous spleen reservoir for multiple portal venous injections to treat liver malignancies

Dog and rat animal models have been developed for repeated intravascular administrations to the liver. However, mice have generally been considered too small to use for these models. This study describes the development of mouse models that permit the establishment of liver metastases that can be subsequently treated by repeated injections into the portal venous system. A mini-laparotomy is done to mobilize the spleen and transpose it to a s.c. pocket with its vascular pedicle intact. A suspension of single tumor cells is then inoculated into the portal vein to establish diffuse liver metastases. These tumors may be treated by simple percutaneous injections directly into the s.c. whole spleen reservoir. The ease of injection into the s.c. spleen permits repeated injections into the portal venous system. The usefulness of this model was shown in experiments revealing that multiple portal venous administrations of a replication-conditional, oncolytic herpes simplex virus mutant are more effective than a single portal venous administration. In a modification of this model, the spleen is first split into two, leaving intact the vascular pedicle for each half of the spleen. Tumor cells are inoculated into one hemi-spleen, which is then resected 10 minutes later. The other hemi-spleen is transposed to the s.c. position, thereby permitting subsequent repetitive portal venous injections via percutaneous injections into the s.c. hemi-spleen. These mouse models are useful for a wide range of studies.     

Systemic mycoses during prophylactical use of liposomal amphotericin B (Ambisome®) after liver transplantation

We investigated the prophylactical administration of liposomal amphotericin B (Ambisome) in the early phase after liver transplantation (LTx). Fifty-eight patients received Ambisome prophylactically after LTx. Ambisome (1 mg kg-1 day-1) was given intravenously for 7 days after LTx. Immunosuppressive prophylaxis was cyclosporin A (CsA) based in 11 patients. Forty-seven patients had a tacrolimus-based immunosuppressive regimen. CsA and tacrolimus dosages were adjusted to trough levels of 150-250 ng ml-1 (EMIT) and 5-15 ng ml-1 (MEIA II) respectively. Three patients died from sepsis due to Aspergillus fumigatus infection. Reasons for a fatal outcome were foudroyant Aspergillus pneumonia in a patient transplanted for fulminant hepatic failure on post-operative day (pod) 8; Aspergillus sepsis with severe endocardidtis in a patient with two retransplantations for graft non/dysfunction on pod 24; and disseminated aspergillosis due to Aspergillus fumigatus in a patient retransplanted for primary non-function (pod 19). All three patients underwent haemofiltration for renal failure. One patient with Candida albicans sepsis (pod 4) recovered under increased dosage of Ambisome (3 mg kg-1 per day). Ambisome (1 mg kg-1 per day) seems to be beneficial against systemic Candida infections. However, the onset of systemic Aspergillus infections could not be prevented. Obviously, higher Ambisome doses appear to be necessary against Aspergillus. We recommend the use of Ambisome (3 mg kg-1 per day) for patients with risk factors such as graft dys-/non-function, retransplantation, haemofiltration and complicated acute liver failure to prevent invasive aspergillosis.     

Protocol for the implantation of a venous access device (Port-A-Cath System). The complications and solutions found in 560 cases

Introduction The cannulation of suitable peripheral veins may be a very painful experience. Implantable venous access systems have to some degree relieved this problem and help to provide an improvement in terms of quality of life. Material and methods We have evaluated 560 patients during a follow up period of two years. A low overall complication percentage of 7.32% was seen when using the venous access device. Results Complications and treatments were: pneumothorax; portal rotation or infection; catheter infection; embolism and migration; extravasation; partial or total obstruction of the device; rupture of the catheter or the membrane. Conclusions There is no other system that allows repeated venous access on such a long term basis. Placing the devices completely under the skin allows the patient to conduct a normal life style, and its maintenance does not need any special care, with the exception of the monthly heparinised serum infusion. The preferred option is to insert the catheter through the cephalic vein in the delto pectoral groove.     

Incidence of Silent Thrombosis in Patients Younger Than 60 Years With Myeloproliferative Neoplasms: Single-Center Egyptian Study

BackgroundIdentification of janus kinase 2 (JAK2) mutation even in absence of myeloproliferative disorders (MPNs) was found to be related to venous thromboembolism occurrence. Venous thrombosis screening is not routinely requested in patients with myeloproliferative neoplasms unless the patient is symptomatic. It has been reported that the incidence of thrombosis in elderly patients is much higher than in young patients. The aim of this work was to screen MPN patients for venous thrombosis and study its correlation with JAK2 allele burden and with MPN 10 score.Patients and MethodsWe enrolled 73 patients with JAK2-positive MPN from our Hematology Clinic in the period August 2015 to Feb 2017. All patients had been screened for thrombosis in the venous system in lower limbs (LLs), upper limbs, portal, and mesenteric systems using color Doppler ultrasound imaging.ResultsFifty-three (72.6%) patients were younger than 60 years. Twenty-two (30%) had essential thrombocytosis, 35 (47.9%) had polycythemia rubra vera, and 16 (22%) had idiopathic myelofibrosis. Twenty-seven venous thrombotic attacks were reported in 22 (30.1%) patients. Five (6.8%) had thrombosis in 2 sites. Seventeen (23%) had superior mesenteric and portal vein thrombosis. Six (8%) had iliofemoral (8%) and 4 (5%) had combined LL and portal thrombosis. Eight (10.8%) had active thrombosis at screening. Only 3 patients (4%) were symptomatic with abdominal pain during screening. Pruritis (P = .02) and abdominal pain (P = .039) were significantly different between cases with and without thrombosis. There was no significant difference in MPN 10 score between cases with active or previous thrombosis.ConclusionWe recommend routine screening for venous thrombosis in any case of MPN when diagnosed and screening for MPNs in any patient with venous thrombosis especially of the portal vein or atypical sites. If MPN patients present with increasing pruritus or abdominal pain, they also should be screened for venous thrombosis. Further research on a large scale in MPN age groups younger than 60 years regarding pathogenesis of thrombosis is highly recommended.     

Percutaneous transhepatic portal vein stenting for portal hypertension caused by local recurrence of intrahepatic cholangiocarcinoma

A 62-year-old woman underwent an extended left hepatectomy with a combined resection of portal vein and extrahepatic bile duct for intrahepatic cholangiocarcinoma (ICC). After 7 years, she presented with repeated tarry black stool and severe anemia. The source of bleeding was not identified on upper and lower gastrointestinal endoscopy. Computed tomography (CT) revealed a small hypodence lesion at portal hepatis, by which portal vein (PV) stenosis was induced in the absence of sufficient development of portal venous collateral. Positron emission tomography revealed an accumulation of fluorodeoxy glucose around PV obstruction. Based on these findings, we diagnosed that the local recurrence of ICC, which resulted in mesenteric hypertension and small bowel varices. Therefore, portal stent placement was carried out under percutaneous transhepatic portgraphy to maintain portal blood flow. An uncovered expandable metallic stent was inserted into the stenotic region. Portgraphy after the stent replacement showed a relief of the PV stenosis and disappearance of the collateral pathways. After this procedure, the patient had no additional episode of gastrointestinal hemorrhage. Our experience suggests that stent placement for postoperative PV stenosis is recommended as a useful treatment for gastrointestinal bleeding caused by portal hypertension that is less invasive.     

High-dose cyclophosphamide in the treatment of refractory lymphomas and solid tumor malignancies

Twenty-two patients with refractory solid tumors or lymphoma were treated with a single course of high-dose cyclophosphamide (120 mg/kg intravenously [IV] over 2 days) whereas three patients received two courses each. Marrow infusion was not used. In the 22 courses evaluable for tumor response there were 14 responses (64%) of which 11 were partial responses (PR) (50%) and three complete responses (CR) (14%). In the 12 evaluable courses given in patients with lymphoid malignancies a partial response was obtained in seven (58%) and complete response in two (17%) for an overall response rate of 75%. The median duration of response was short: 2 months (range, 1-12 months). Twenty-seven courses were evaluable for toxicity. All patients had nadir polymorphonuclear leukocytes counts less than 500/mm3 with median time to recovery to a level greater than 500/mm3 of 9 days (range, 6-21 days). The median nadir platelet count was 30,000/mm3. One patient had prolonged thrombocytopenia of 225 days. There were two toxic deaths related to leukopenia, one secondary to Pneumocystis carinii pneumonia, and the second from probable sepsis and cholecystitis. Nineteen patients had previously received cyclophosphamide in standard doses. In the patients with lymphoid malignancies who had previously received cyclophosphamide, 22% achieved a CR with an overall response rate of 78%. High-dose cyclophosphamide may be given with acceptable toxicity in heavily pretreated patients. Given the short response duration in patients with progressive disease, the optimal results of such high-dose cyclophosphamide may be achieved when it is employed earlier in the natural history of the disease in conjunction with other alkylators, or as consolidation therapy.