Left trisegmentectomy and combined resection of the inferior vena cava, without reconstruction, for giant cystadenocarcinoma of the liver

A 54-year-old woman with giant liver cystadenocarcinoma underwent left trisegmentectomy with combined resection of the inferior vena cava (IVC) and the right hepatic vein. As a result, only the right inferior hepatic vein was preserved as a drainage vein. Because the perivertebral plexus and the azygos vein were both well developed, neither veno-venous bypass nor IVC reconstruction was performed. The developed collateral veins acted as the venous drainage pathway to maintain a stable systemic circulation. On the seventh postoperative day, portal vein flow dramatically decreased and the patient tended to liver failure. Prostaglandin E₁ (PGE₁) was administrated via the superior mesenteric artery. The portal flow then gradually increased and liver failure was avoided. Six months after the operation, she was re-admitted due to obstructive jaundice and presented with complete stenosis of the common bile duct (CBD). The jaundice persisted and liver dysfunction progressed. The patient died seven months after the operation. The confluence of the right inferior vein and the IVC could have been deformed, causing outflow blockade. The intrinsic shunt was not good enough to act as the drainage pathway, and IVC reconstruction may have been needed.     

Liver cirrhosis and hepatocellular carcinoma in hepatic vena cava disease, a liver disease caused by obstruction of inferior vena cava

Purpose  Hepatic vena cava disease (HVD), a form of Budd-Chiari syndrome, is caused by the obstruction of hepatic portion of the inferior vena cava. It is a chronic disease characterized by the development of liver cirrhosis (LC) and hepatocellular carcinoma (HCC). As HVD occurred in areas with high incidence of hepatitis B virus (HBV) infection and some patients tested HBsAg positive, it was thought to be the cause of LC and HCC. To assess the pathogenesis of LC or HCC in HVD, a long-term follow-up study was done. Method  Fifty-six patients with HVD diagnosed by ultrasound (US) and confirmed by cavography in 31 and liver biopsy in 34 were followed up for an average of 14.8 ± 9 years. The occurrence of LC was diagnosed by US and/or liver biopsy and that of HCC by US, elevated level of α-fetoprotein, and liver biopsy or fine-needle aspiration cytology, or computed tomographic scan. Other risk factors for LC/HCC such as alcohol use and HBV and hepatitis C virus (HCV) infections were assayed. Results  Forty-four (78.5%) and 6 (10.7%) patients developed cirrhosis and HCC, respectively. LC/HCC occurred more frequently among those who had severe or frequent acute exacerbations (P = 0.017), but it was not related to alcohol use or HBV and HCV infections. Conclusion  HVD is independent risk factors for LC and HCC. Severe and/or recurrent loss of hepatocytes caused by hepatic venous outflow obstruction and/or thrombotic obstruction of small radicals of hepatic and portal veins that occurred during acute exacerbations was considered important in the pathogenesis of LC and HCC in HVD.     

The use of retrievable inferior vena cava filters in the trauma population

OBJECTIVE:

To determine if the use of retrievable filters resulted in an increase in the placement of inferior vena cava (IVC) filters in trauma patients.

DESIGN:

All patients who underwent IVC filter placement at Yale-New Haven Hospital, New Haven, Connecticut, USA between the years 1999 and 2004.

SETTING:

Academic, level 1 trauma centre.

PATIENTS:

Included in the present study were 202 trauma patients and 676 nontrauma patients.

INTERVENTION:

IVC filter placement.

MAIN OUTCOME MEASURE:

Demographics, indications, complication rates and type of IVC filters placed in trauma patients versus nontrauma patients were evaluated.

RESULTS:

The present study determined 45.4% (n=92) of trauma patients undergoing IVC filter placement were younger than 40 years of age, compared with 7.8% (n=53) of nontrauma patients. The most common indication for IVC filter placement in trauma patients was prophylaxis (n=162, 80.2%), while in the nontrauma patients only 11.4% (n=77) of patients underwent prophylactic filter placement. The number of retrievable filters used in trauma patients increased from 46.7% in 2001, the year they became available, to 78.9% in 2004. The use of retrievable filters similarly increased in the nontrauma population from 35.9% in 2001 to 78.3% in 2004. Approximately 24% of the patients that underwent IVC filter placement at Yale-New Haven Hospital were categorized as trauma patients. The complication rate for this time period was 0.5% (n=1) in the trauma population versus 3.7% (n=26) in the nontrauma population.

CONCLUSION:

The overall number of IVC filters placed in trauma patients did not dramatically increase with the introduction of retrievable filters, suggesting that the indications for the use of IVC filters have not changed.     

Sclerosing epithelioid fibrosarcoma of the liver infiltrating the inferior vena cava

Sclerosing epithelioid fibrosarcoma （SEF） is a rare and distinct variant of fibrosarcoma, composed of epithelioid tumor cells arranged in strands, nests, cords, or sheets embedded within a sclerotic collagenous matrix. We report a 39-year-old man with SEF of the liver, which infiltrated the inferior vena cava （IVC）. The SEF of the liver was successfully resected, and the infiltrated IVC was also removed together with the liver tumor. Histopathological examination of the tumor showed typical histopathology of SEE Immunohistochemically, the tumor was positive for vimentin. Recurrence was noted 7 mo after surgery. After chemotherapy, the recurrent tumor was resected surgically, and histopathological examination showed similar findings to those of the primary tumor. To our knowledge, this is the first report of SEF of the liver with tumor invasion of the IVC.     

Membranous obstruction of the inferior vena cava and invasion of the inferior vena cava by tumour in hepatocellular carcinoma

A 28 yr old Zulu presented with a painful swelling in the right hypochondrium and severe swelling of the legs of short duration. The serum alpha-fetoprotein concentration was over 2 X 10(5) ng/ml and imaging showed a large hepatic mass-lesion. Radionuclide venography revealed no flow through the inferior vena cava but flow through a large collateral vessel. Contrast venography showed the upper portion of the inferior vena cava to be occluded: large collateral vessels arose from the lower vena cava and the iliac veins. The histological features were those of longstanding hepatic venous outflow obstruction with irregular centrizonal and portal fibrosis: severe acute centrizonal congestion was not seen. This combination of findings indicates the presence of both membranous obstruction of the inferior vena cava, a rare developmental abnormality which predisposes to hepatocellular carcinoma formation, and invasion by the tumour of the inferior vena cava via the hepatic veins, an uncommon complication of hepatocellular carcinoma.     

Feasibility of hanging maneuvers in orthotopic liver transplantation with inferior vena cava preservation and in liver surgery

Background/Purpose

The aim of this work was to study the feasibility and complication rates of liver hanging maneuvers: the Belghiti liver hanging maneuver (BLHM) in liver resection and the modified liver hanging maneuver (MLHM) in orthotopic liver transplantation (OLT) with inferior vena cava (IVC) preservation.

Methods

From January 2001 to August 2003, BLHM was planned in 26 consecutive right hepatectomies and MLHM in 28 consecutive OLTs with IVC preservation.

Results

BLHM was performed in 24/26 patients (92%). In the 2 remaining patients, chronic biliary infection (n = 1) and intraparenchymal hemorrhagic hepatocellular carcinoma (n = 1) did not allow BLHM to be achieved. Bleeding during the BLHM procedure occurred in 1 patient (4%), with no need for interruption. MLHM was performed in all 28 patients, and in none of them was bleeding observed during the maneuver.

Conclusions

BLHM and MLHM are important technical refinements with several advantages. Feasibility rates were 92% and 100%, respectively. Bleeding risk remained low (4%) for BLHM and was 0% for MLHM. The rate of BLHM failure suggests that the feasibility rate may be higher in normal liver parenchyma.

     

原发性肝癌合并下腔静脉和右心房瘤栓致肺栓塞1例

正我们诊治1例原发性肝癌合并下腔静脉和右心房瘤栓致肺栓塞患者,现报道如下。1病例摘要患者男性,54岁,农民。既往体健。因"活动后胸闷、气促5天"于2014年3月1日入院。查体:体温:36.9℃,脉搏:106次/分,呼吸25次/分,血压90/50 mmHg。神志不清,两肺呼吸音粗,未闻及干湿性罗音,心音有力,心脏各瓣膜区未闻及病理性杂音。外院腹部彩超示:肝左叶占位,     

Close relation between the inferior vena cava ligament and the caudate lobe in the human liver

Background/Purpose

This study was conducted to clarify the real relation between the inferior vena cava (IVC) ligament and the caudate lobe in the human liver and also to elucidate their surgical importance in liver surgery.

Methods

Specimens obtained from 20 adult cadaveric livers were submitted for the study. Histological structures of the IVC ligament and its relationship to the caudate lobe and the IVC were microscopically investigated.

Results

The IVC ligament was a broad membranous connective tissue bridging the left and right side edges of the caval groove in which the IVC was embedded. At both edges of the caval groove, the IVC ligament was continuously transformed from the Glisson's capsules of the caudate and right lobes. The component of the portal triad, which originated from that of caudate lobe, and lymphatics were distributed in the IVC ligament without exception and ectopic hepatocytes existed in it in 4 of the 20 cases.

Conclusions

A close relation between the IVC ligament and the caudate lobe was confirmed. The findings suggested that the IVC ligament is a kind of degenerated hepatic tissue. When dissecting it, surgeons should manipulate it carefully to prevent unexpected bleeding and bile leakage.

     

Ins and outs of inferior vena cava filters in patients with venous thromboembolism: the experience at Monash Medical Centre and review of the published reports

Background: Inferior vena cava (IVC) filters are an alternative management strategy to anticoagulation in patients with venous thromboembolism (VTE). However, an IVC filter has its own inherent risks and complications and may not be the best management strategy. The aims of this study were to evaluate our institution’s practice of permanent Vena Tech (B. Braun Medical S.A., Boulogne, France) and retrievable Gunther Tulip (William Cook Europe, Bjaeverskov) IVC filters and to review the available published reports. Methods: Retrospective single centre audit from the medical record. Results: Eighty‐three and 42 patients had a VT and GT filter inserted, respectively. Median age was 57 years for VT and 63 years for GT. The majority (75% for VT and 83% for GT) was inserted for acute VTE and contraindication to anticoagulation. Both filters were efficacious at preventing pulmonary embolism (PE) and there was a low rate of recurrent deep venous thrombosis in both groups. Insertion‐related complications were low in both groups. Of the GT filters (n = 42), 16 were deemed an ongoing requirement, and thus, removal was not planned. In a further six patients, there was insufficient documentation as to why removal was not planned. Removal was attempted in 19 patients and was successful in 11. Failure of removal was as a result of clot in the filter (n = 7) or inability to snare it (n = 1). Conclusions: Both the permanent and retrievable filters are efficacious at preventing PE and are associated with a low complication rate. Planned removal of the GT filter may not be possible in a significant proportion of cases.     

Compressive stenosis of the inferior vena cava due to localized ascites after living-donor liver transplantation

A 54-year-old woman was admitted to our hospital following the diagnosis of decompensated liver cirrhosis with hepatitis C. She underwent living-donor liver transplantation, performed using the left hepatic lobe with the middle hepatic vein donated by her husband. After the transplantation, the patient suffered from massive ascites with liver dysfunction. Computed tomography demonstrated stenosis of the suprahepatic inferior vena cava (IVC) with focal collection of fluid. A second laparotomy was performed 19 days after the transplantation. When the encapsulated localized ascites on both sides of the IVC was opened, the ascites was flushed away. Subsequently, the grafted liver was easily mobilized and it was placed in the natural position without any tension, and the pressure gradient of the IVC was improved. Herein, we report a very rare case of compression stenosis of the IVC resulting in Budd-Chiari syndrome caused by localized encapsulated ascites.     

Suprarenal stricture of the inferior vena cava with massive iliocaval and distal thromboses successfully treated with catheter-directed thrombectomy, thrombolysis and angioplasty

Long-term complications from deep vein thrombosis, such as post-thrombotic syndrome and chronic venous insufficiency, can result in significant morbidity for the affected patient. Although anticoagulation has been the conventional method of treatment, the benefit of thrombus burden removal cannot be underestimated. The present case report describes the successful treatment of extensive iliocaval and distal thrombosis with suprarenal inferior vena cava stricture using catheter-directed thrombolysis, thrombectomy and angioplasty.     

Approaches to reconstruction of inferior vena cava by ex vivo liver resection and autotransplantation in 114 patients with hepatic alveolar echinococcosis

BACKGROUNDHepatic alveolar echinococcosis (AE) is most commonly found in retrohepatic inferior vena cava (RHIVC). Ex vivo liver resection and autotransplantation (ELRA) can better realize the radical resection of end-stage hepatic AE with severely compromised hepatocaval confluences, and reconstruction of the affected vessels. Currently, there is a scarcity of information regarding RHIVC reconstruction in ELRA.AIMTo propose reasonable RHICV reconstruction strategies for ex vivo liver resection and autotransplantation.METHODSWe retrospectively summarized the clinical data of 114 patients diagnosed with hepatic AE who treated by ELRA in our department. A total of 114 patients were divided into three groups according to the different reconstruction methods of RHIVC: Group A with original RHIVC being repaired and reconstructed (n = 64), group B with RHIVC being replaced (n = 43), and group C with RHIVC being resected without reconstruction (n = 7). The clinical data of patients, including the operation time, anhepatic phase, intraoperative blood loss, complications and postoperative hospital stay, were analyzed and the patients were routinely followed up. The normally distributed continuous variables were expressed as means ± SD, whereas the abnormally distributed ones were expressed as median and analyzed by analysis of variance. Survival curve was plotted by the Kaplan-Meier method.RESULTSAll patients were routinely followed up for a median duration of 52 (range, 12-125) mo. The 30 d mortality rate was 7.0% (8/114) and 7 patients died within 90 d. Among all subjects, the inferior vena cava (IVC)-related complication rates were 17.5% (11/63) in group A and 16.3% (7/43) in group B. IVC stenosis was found in 12 patients (10.5%), whereas thrombus was formed in 6 patients (5.3%). Twenty-two patients had grade III or higher complications, with the complication rates being 17.2%, 16.3%, and 57.1% in the three groups. The average postoperative hospital stay in the three groups was 32.3 ± 19.8, 26.7 ± 18.2, and 51.3 ± 29.4 d (P = 0.03), respectively.CONCLUSIONELRA can be considered a safe and feasible option for end-stage hepatic AE patients with RHIVC infiltration. The RHIVC reconstruction methods should be selected appropriately depending on the defect degree of AE lesions in IVC lumen. The RHIVC resection without any reconstruction method should be considered with caution.     

Transjugular percutaneous inoue balloon mitral commissurotomy in a patient with inferior vena cava obstruction after liver transplantation.

Percutaneous transvenous mitral commissurotomy was performed successfully via the transjugular approach in a patient with severe rheumatic mitral stenosis and obstruction of the inferior vena cava due to prior liver transplantation. This case demonstrates the advantage of the jugular approach in patients with difficult anatomy.     

MiR-122通过靶向SIRT1抑制肝癌细胞的增殖、迁移和侵袭

目的?探讨微小RNA-122（microRNA-122, miR-122）通过靶向沉默信息调节因子1（silent information regulator 1, SIRT1）对肝癌细胞增殖、迁移和侵袭的影响。方法?用实时荧光定量PCR（real-time quantitative PCR, RT-qPCR）法检测肝癌组织和细胞中miR-122和SIRT1 mRNA表达水平;用生物信息学和双荧光素酶报告基因分析并验证miR-122和SIRT1靶向关系。培养肝癌细胞HepG2,将其分为空白对照组（control组）、miR-122过表达阴性对照组（miR-NC mimic组）、miR-122过表达组（miR-122 mimic组）、miR-122过表达和SIRT1过表达阴性对照组（miR-122 mimic+pcDNA组）、miR-122过表达和SIRT1过表达组（miR-122 mimic+pcDNA-SIRT1组）。用细胞计数试剂（cell counting kit-8, CCK-8）和5-乙炔基-2’脱氧尿嘧啶核苷分析各组细胞增殖情况;划痕愈合实验和Transwell实验分析各组细胞迁移和侵袭能力;用Western blot法分析各组细胞中增殖、迁移和侵袭相关蛋白p53、细胞周期蛋白D1、E-钙粘蛋白、N-钙粘蛋白和波形蛋白及SIRT1蛋白表达水平。结果?MiR-122表达水平在肝癌组织和细胞中下调,SIRT1 mRNA表达水平在肝癌组织和细胞中上调（P＜0.05）。MiR-122负靶向调控SIRT1表达（P＜0.05）。过表达miR-122抑制HepG2细胞增殖、迁移和侵袭,降低SIRT1、细胞周期蛋白D1、N-钙粘蛋白和波形蛋白蛋白水平,升高p53和E-钙粘蛋白蛋白水平（P＜0.05）。然而,SIRT1过表达可部分逆转过表达miR-122对HepG2细胞的作用（P＜0.05）。结论?MiR-122通过负靶向调控SIRT1抑制肝癌细胞增殖、迁移和侵袭。     

High prevalence of hepatitis B virus infection and inferior vena cava obstruction among patients with liver cirrhosis or hepatocellular carcinoma in Nepal

BACKGROUND: Little is known about the prevalence of hepatitis B virus (HBV) DNA and the genotype distribution among patients with liver diseases in Nepal, where obstruction of the hepatic portion of the inferior vena cava (IVCO) is common. The aim of the present paper was to assess the roles of HBV infection and IVCO in liver cirrhosis (LC) and hepatocellular carcinoma (HCC) in Nepal. METHODS: Serum samples from 121 patients (89 male, 32 female; age, 55.0 +/- 13.6 years) with or without IVCO consisting of 70 LC patients and 51 HCC patients in Nepal, were tested for HBV-DNA. RESULTS: The HBV-DNA was detected in 68 patients (56%) including 20 hepatitis B surface antigen (HBsAg)-negative patients: 33 LC patients (47%) and 35 HCC patients (69%) had detectable HBV-DNA (P = 0.0303). Among the 89 patients with IVCO, HBV-DNA was detected in HCC patients significantly more frequently than in LC patients (80%vs 43%, P = 0.0005). The frequency of HBV viremia was significantly higher among HCC patients with IVCO than those without (80%vs 44%, P = 0.0236), and that of HBV viremia with IVCO was significantly higher among HCC patients than among LC patients (55%vs 27%, P = 0.0153). The HBV genotypes A and D were predominant, and genotype A was significantly more frequent among HCC patients than among LC patients (22%vs 6%, P = 0.0090). Among HCC patients, those with genotype A HBV were significantly younger than those with genotype D (43 +/- 13 vs 57 +/- 12 years, P = 0.0252). CONCLUSION: Hepatitis B virus alone (especially genotype A) or in concert with IVCO may be responsible for development of HCC in Nepal.     

血吸虫病肝硬变患者肝段下腔静脉内径的超声研究

目的探讨血吸虫病肝硬变患者硬变肝段下腔静脉内径的变化，了解肝硬变程度与肝段下腔静脉内经变化的关系。方法对92例血吸虫病肝硬变患者和36例健康志愿者（对照组）行超声检查，平静呼吸状态下及深吸气后测量肝段下腔静脉最大横断面的长轴、短轴及其最大横截面积。结果健康对照组的肝段下腔静脉在深吸气后与平静呼吸状态下比较最大横断面的长轴、短轴及其最大横截面积差异均有非常显著性（t=21.16，P〈0.01;t=19.28，P〈0.01;t=17.78，P〈0.01）。肝硬变组的肝段下腔静脉在深吸气后与平静呼吸状态下比较最大横断面的长轴、短轴及其横截面积在肝硬变A级（按Child-Pugh分级）差异有非常显著性（t=19.87，P〈0.01;t=16.78，P〈0.01;t=17.96，P〈0.01），B级差异有显著性（t=5.73，P=0.0214;t=4.96，P=0.035;t=5.21，P=0.029），C级差异无显著性（t=1.72，P=0.297;t=1.24，P=0.236;t=1.94，P=0.372）。结论肝硬变患者肝段下腔静脉横断面的长轴、短轴及其横截面积在深吸气后与平静呼吸状态下的变化随着肝硬变的程度增加逐渐变小。     

Systematic review of prognostic importance of extramural venous invasion in rectal cancer

AIM: To systematically review the survival outcomes relating to extramural venous invasion in rectal cancer.METHODS: A systematic review was conducted using PRISMA guidelines. An electronic search was carried out using MEDLINE, EMBASE, CINAHL, Cochrane library databases, Google scholar and Pub Med until October 2014. Search terms were used in combination to yield articles on extramural venous invasion in rectal cancer. Outcome measures included prevalence and 5-year survival rates. These were graphically displayed using Forest plots. Statistical analysis of the data was carried out.RESULTS: Fourteen studies reported the prevalence of extramural venous invasion(EMVI) positive patients. Prevalence ranged from 9%-61%. The pooled prevalence of EMVI positivity was 26% [Random effects: Event rate 0.26(0.18, 0.36)]. Most studies showed that EMVI related to worse oncological outcomes. The pooled overall survival was 39.5% [Random effects: Event rate 0.395(0.29, 0.51)].CONCLUSION: Historically, there has been huge variation in the prevalence of EMVI through inconsistent reporting. However the presence of EMVI clearly leads to worse survival outcomes. As detection rates become more consistent, EMVI may be considered as part of risk-stratification in rectal cancer. Standardised histopathological definitions and the use of magnetic resonance imaging to identify EMVI will improve detection rates in the future.     

Placement of the inferior vena cava filter proximal to the renal vein in a patient with left-sided inferior vena cava complicated by pulmonary embolism: a case report]

A 55-year-old man was admitted to our hospital complaining of dyspnea and chest pain. Transthoracic echocardiography showed dilation of the right ventricle. Chest computed tomography with contrast medium showed multiple emboli in the pulmonary arteries. Venography of the lower extremities showed multiple thrombi in the right popliteal vein and the presence of left-sided vena cava. This unusual case of left-sided vena cava was complicated by deep vein thrombosis due to hemostasis. A Greenfield filter was placed in the vena cava proximal to the right renal vein in a right internal jugular vein approach.