Imaging of the intrahepatic portal vein in children with extrahepatic portal vein thrombosis — Comparison of magnetic resonance imaging and retrograde portography

PurposeExtrahepatic portal vein thrombosis (EPVT) is one major cause of portal hypertension in children. Surgical reinstallation of portal venous flow can be achieved in patients with patent intrahepatic portal venous system/Rex recess. Our study aimed to compare the ability of magnetic resonance imaging (MRI) and retrograde portography (RP) to assess patency of the intrahepatic portal venous system in children with EPVT.MethodsAll pediatric patients with EPVT who were examined with contrast enhanced MRI (1.5 T) and invasive RP between 2013 and 2017 were included in this retrospective study. Medical records were reviewed for demographic, biochemical and clinical data. Patency of the Rex recess as detected by MRI and RP was retrospectively reviewed.ResultsSixteen children (7.6 ± 5.0 years) with EPVT were included. Sensitivity, specificity, positive and negative predictive value for the detection of patent Rex recess by MRI compared to RP were 55%, 57%, 63% and 50%. Diagnostic accuracy was 56%. Diagnostic failure of MRI compared to RP was explained by the following: I. Problems differentiating collaterals from portal venous vessels II. Incapability showing dynamic blood flow in compromised portal venous flow III. Poor spatial resolution, especially in small children.ConclusionRP is a reliable method for the visualization of the Rex recess and the intrahepatic portal venous system in children with EPVT, whereas MRI has shown to be unsuitable for the assessment of the intrahepatic portal vein in these patients. In the preoperative setup, we recommend both procedures, RP and MRI for the visualization of the intrahepatic portal venous system, and the extrahepatic vessels, respectively.Level of evidenceLevel III.     

Is pancreaticoduodenectomy with portal vein resection indicated in patients with ductal pancreatic carcinoma?]

Infiltration of the portal vein is almost always regarded as a contraindication for pancreaticoduodenectomy in patients with pancreatic cancer. However, progress in many fields has changed the postoperative situation and mortality of pancreaticoduodenectomy is now below 5%. The aim of the present study was therefore to actually evaluate morbidity, mortality and prognosis of extended pancreaticoduodenectomy combined with protal vein resection for adenocarcinoma of the pancreatic head. Between September 1985 and May 1997 315 patients with a ductal pancreatic carcinoma were treated in our hospital. Resection was possible in 96 cases (partial pancreaticoduodenectomy n = 82, total pancreaticoduodenectomy n = 5, left pancreatic resection n = 9). In 10 cases the portal vein or the mesenteric vein had to be resected. Postoperative complications were seen in 25% of all cases after pancreaticoduodenectomy without portal vein resection and in 20% following extended pancreaticoduodenectomy. The mortality was 5% resp. 0% in both groups. The median survival time of patients after pancreaticoduodenectomy without portal vein resection was 11.9 months (R0 resection: 13.6 months; R1/2 resection 8 months) in contrast to 13.4 months in cases with portal vein resection. In conclusion, these results demonstrate that in special cases of adenocarcinoma of the pancreatic head extended pancreaticoduodenectomy with portal vein resection may be indicated. These patients show a better prognosis than those after palliative procedures. Morbidity and mortality of pancreaticoduodenectomy with portal vein resection is not higher as compared to pancreaticoduodenectomy alone.     

Preoperative portal vein embolization: is it useful?

Background/Purpose Portal vein embolization (PVE) before hepatectomy is aimed to induce an atrophy of the embolized lobe to be resected, with a compensatory hypertrophy of the counterlobe to be preserved.Methods To answer the question Is it useful?, we reviewed the clinical outcome in 161 patients undergoing major hepatectomy after PVE for various hepatobiliary tumors.Results All the patients tolerated PVE well, and hepatic functional data returned to the baseline levels within a week. The left liver volume increased by a median of 8% (range 2%–14%) after the right PVE. The 20 patients undergoing right hepatectomy for hepatocellular carcinoma had a mean indocyanine green retention rate at 15min of 16% (SD 4%), and the 24 patients with liver metastases underwent right hepatectomy with additional left liver resection. Hepatectomy procedures comprised right or extended right hepatectomy (n = 105), left or extended left hepatectomy (n = 13), hepatopancreatoduodenectomy (n = 12), and less extensive hepatectomies (n = 31). As a whole, the operative morbidity and mortality rates were 19% and 1.2%, respectively. Hepatopancreatoduodenectomy carried no operative mortality. The cumulative 5-year survival rates were 44% in patients with hepatocellular carcinoma and 60% in patients with metastatic tumor.Conclusions PVE is useful for performing extensive hepatectomy in patients with mild hepatic dysfunction, in those with bilobar tumors, or in those undergoing hepatopancreatoduodenectomy.     

Isolated ectopic jejunal varices in a patient with extrahepatic portal vein obstruction – A case report

Introduction and importanceAmong the various causes for lower gastrointestinal bleeding, ectopic varices constitute a small chunk. Though rare, these can pose a diagnostic challenge with recurrent bleed leading to multiple admission and blood transfusions.Case presentationA 41-year-old male presented to our department with multiple episodes of melena. On further evaluation with CT angiography, a diagnosis of extrahepatic portal vein obstruction with moderate splenomegaly and ectopic jejunal varix was made. He underwent splenectomy with resection of involved jejunal segment with side to side anastomosis.Clinical discussionThe diagnosis of ectopic varices remains elusive in a large number of cases in view of the varied etiology. Various newer endoscopic and imaging modalities can play a diagnostic as well as therapeutic role but this also further complicates the management as there is a lack of substantial guidelines directing the treatment protocol. As a result, we have to resort to a case by case approach for the optimal management in these cases.ConclusionThe main modality of management for bleeding ectopic varices is percutaneous or endoscopic. Surgery is reserved for refractory cases, with decompressive shunts combined with segmental resection of involved intestine being at the forefront of surgical options.     

Ultrasonographic detection of portal branches and hepatic vein gas associated with mesenteric artery occlusion: a new finding correlated with patient prognosis?

The diagnosis of bowel infarction is still a challenge. In some cases, portal venous gas is an associated feature and in these patients, the prognosis is very poor. We report on our experience with two consecutive cases in which ultrasonography showed gas in the portal venous branches, and also in the hepatic veins in one of them. At laparotomy, advanced bowel necrosis was found, and both patients died within 24 hours. Other cases of portal venous gas associated with bowel infarction have been reported, but this is the first report of gas also being found in the hepatic veins. There may be a relationship between the amount of gas in the intrahepatic veins and the stage of bowel ischemia. Confirmation of this might improve the selection of patients and eliminate unnecessary procedures.     

Elevated portal vein drug levels of sirolimus and tacrolimus in islet transplant recipients: local immunosuppression or islet toxicity?

The recent success of islet transplantation using the Edmonton protocol involved the use of sirolimus, tacrolimus, and daclizumab for immunosuppression. Islets were infused into the portal circulation after transhepatic access. This protocol provided a unique opportunity to measure sirolimus and tacrolimus levels from the portal vein and compare them to systemic venous levels. A total of 11 portal venous samples with a corresponding peripheral venous sample were obtained from patients undergoing a first or second islet infusion and medication levels were obtained on both types of specimens. The portal-to-systemic drug level ratio ranged from 0.95 to 2.71 for sirolimus and 1.0 to 3.12 for tacrolimus. Given the potential toxicity of these agents to islets, the findings in this study may have implications for designing the next generation of immunosuppressive protocols for islet transplantation.     

Biliary and portal vein strictures following treatment of Hodgkin’s lymphoma

Treatment of abdominal lymphoma can be associated with bowel stricture or perforation. Rarely, the common bile duct or portal vein can be involved. This is the first case of stricture formation of both the portal vein and common bile duct in a patient following successful treatment of lymphoma. The development of extensive hilar varices rendered surgical management high risk. A staged approach to treatment was used. First, a percutaneous portal vein stent was placed, resulting in resolution of the hilar varices. This was followed by a surgical hepaticojejunostomy, performed without complication. Gastrointestinal complications are rare following treatment of lymphoma but may affect a variety of sites. The safe and effective treatment of this case highlights the benefit of a multidisciplinary approach to complex medical and surgical problems.     

Mechanism of liver regeneration after liver resection and portal vein embolization (ligation) is different?

Whether or not liver regeneration after portal branch embolization (PE) (ligation, PVL) in the non-embolized (ligated) lobe is by the same mechanism as regeneration in the remnant lobe after liver resection has been reviewed. Portal vein branch embolization and heat shock protein are then discussed. Tumor growth accelerated in the remnant liver after hepatectomy. In contrast, PE or PVL resulted in marked contralateral hepatic hypertrophy and significant reduction of tumor growth in the non-embolized (non-ligated) lobes. Follistatin administration significantly increased liver regeneration after hepatectomy in rats. In contrast, regeneration of non-ligated lobes after PVL was not accelerated by exogenous follistatin. Tumor growth also was not accelerated. The liver regeneration rate peaked at 48–72 h in the nonligated lobe after PVL, a delay of 24 h compared with the remnant liver after hepatectomy. In the postoperative early stage, the expression of activin βA, βC, and βE mRNAs was stronger in PVL than in hepatectomy. At 72 h the expression of activin receptor type IIA mRNA reached a peak in hepatectomy, but was significantly lower in PVL. Thus, regulation of activin signaling through receptors is one of the factors determining liver regeneration after hepatectomy and PVL. These serial experimental results imply that the mechanism of liver regeneration after portal branch ligation (embolization) is different from that after hepatectomy. Heat shock protein was induced in the liver experimentally by intermittent ischemic preconditioning and could play some beneficial role in the recovery of liver function after hepatectomy, even in cirrhotic patients. When heat shock protein following right portal vein embolization in both the embolized and non-embolized hepatic lobes was investigated in clinical cases, a two to fourfold increase in HSP70 was induced in the non-embolized lobe compared with the embolized lobe. Oral administration of geranylgeranylacetone (a non-toxic HSP inducer) suppressed inflammatory responses and improved survival after 95% hepatectomy by induction of HSP70 in rats.     

Changes in portal vein flow after adult living-donor liver transplantation: Does it influence postoperative liver function?

In adult living donor liver transplantation, using small grafts in cirrhotic patients with severe portal hypertension may have unpredictable consequences. The so-called small-for-size syndrome is present in most series worldwide. The goal of this study was to prospectively evaluate the influence of hemodynamic changes on postoperative liver function and on the percentage of liver volume increase, in the setting of living donor liver transplantation. Twenty-two consecutive adult living donor liver transplantations were performed at our institution in a 2-year period. We measured right portal flow and right hepatic arterial flow with an ultrasonic flow meter in the donor, and then in the recipient 1 hour after reperfusion. Postoperative liver function was measured by daily laboratory work. We also performed duplex ultrasounds on postoperative days 1, 2, and 7. Liver volume increase was estimated by magnetic resonance imaging graft volumetry at 2 months posttransplantation. We compared the blood flow results with the immediate liver function and its liver volume increase rate at 2 months. There was a significant increase in portal flow in the recipients compared with the donors (up to fourfold in some cases). Higher portal flow increase rates significantly correlated with faster prothrombin time normalization and faster liver volume increases. Median graft volume increase at 2 months was 44.9%. The increase in blood flow to the graft is well tolerated by the liver mass not affecting hepatocellular function as long as the graft-to body weight ratio is maintained (>0.8) and adequate outflow is provided. (Liver Transpl 2003;9:564-569.)