Behavior of the portal vein system in man after laparotomy.

At the end of an abdominal operation, a Teflon catheter was inserted into the portal vein, where it remained for nine days. Thus, blood samples could be withdrawn for analyses, and pressures could be recorded. The investigations were carried out in 41 patients who had a gastric or intestinal operation and had an uncomplicated postoperative course. The pressures in the portal vein and the arterioportal oxygen content difference were constant with 7 to 8 millimeters of mercury and by 2 volume per cent, respectively, during the period of all nine postoperative days. The pressure gradient between portal and central veins was about 6 millimeters of mercury. By infusing 350 to 500 milliliters of dextran 60 on day one or two postoperatively, the cardiac output was elevated about one-third, the central venous pressure increased from 0.9 to 4.9 millimeters of mercury and the portal venous pressure increased from 7.8 to 9.7 millimeters of mercury. This means that the pressure difference between the portal and central veins diminished. Simultaneously, the oxygen content difference between the systemic and pulmonary artery decreased from 4.7 to 3.3 volume per cent and between the systemic artery and portal vein, from 1.8 to 1.3 volume per cent. By assuming a constancy of the oxygen consumption in the region of the mesenteric circulation during infusion, it can be calculated from the behavior of the arterioportal oxygen content difference that the flow increase in the portal vein nearly equals that of cardiac output. The physical transhepatic resistance decreased about 50 per cent.     

First report of an unusual,rare complication of pregnancy: rupture of multiple lienal vein aneurysms

Lienal vein aneurysms are a very unusual pathology. Usually they are extremely rare incidental findings, associated with many diseases as hepatic cirrhosis, portal hypertension and other conditions as pregnancy. We report here the case of death of a mother and her fetus at the third trimester of her third pregnancy due to haemoperytoneum for rupture of aneurysm. The autoptic examination revealed the presence of three fusiform and saccular aneurysms of the lineal vein. The histopathological features of aneurysms’ wall are described. The aetiopathogenetic hypothesis of the lesion is discussed. To our knowledge this is the first case report describing the sudden death of pregnant woman and fetus from a rupture of maternal lineal vein aneurysm, complication of multiple aneurysms.     

Management of portal venous thrombosis in hepatic transplant recipients

Portal venous thrombosis in hepatic transplant candidates is considered a relative contraindication to transplantation. In addition to thrombectomy, which is often technically impossible, donor portal venous arterialization or extra-anatomic venous bypass have been described. Two patients who underwent portal venous resection and subsequent anatomic reconstruction are presented herein. In the first patient, a graft with donor common iliac vein was interposed, and in the second, the donor portal vein was long enough to be anastomosed to the mesentericosplenic venous confluens. One patient is well 12 months after transplantation with patent portal vein and the other died of fungal sepsis after rejection treatment (the portal vein being open and unobstructed at autopsy).     

动脉血管血流动力学数值模拟

为了对脑动脉可能发生病变的位置加以分析，进行了此次脑动脉血流动力学数值模拟。本文采用ANSYSWorkbench双向流固耦合的方法，模拟入口压力随时间波动，脑动脉血管内的血液流动情况和血管壁的变形情况。结果发现在血管交叉处会出现流速紊乱、液面压力较为集中的现象，且在交叉处的变形较为明显。临床观测发现，脑动脉液面的压力、血液的流速和血管的变形情况都是使脑动脉产生病变的因素，因此本研究方法有助于发现脑动脉的病变可能部位，为临床诊断提供指导。     

Portal vein blood flow-effects of pregnancy, gravity, and exercise

OBJECTIVE: We sought to test the hypotheses that pregnancy increases portal vein blood flow and that regular exercise training during pregnancy limits the flow redistribution away from the splanchnic and uterine circulations in response to either gravitational or exercise-induced hemodynamic stress. STUDY DESIGN: Portal vein blood flow, which probably reflects changes in uterine blood flow, was estimated with ultrasonography in 6 regularly exercising and 6 physically active control subjects before and during pregnancy after 15 minutes of rest in the left lateral recumbent position, after 5 minutes of standing rest, and immediately and 5 minutes after 20 minutes of treadmill exercise at 55% +/- 3% of maximal aerobic capacity. RESULTS: Portal vein blood flow rose significantly during early and mid pregnancy at recumbent rest (from 660 +/- 110 to 1090 +/- 120 mL/min), standing rest (580 +/- 70 to 790 +/- 120 mL/min), immediately after exercise (160 +/- 30 to 360 +/- 60 mL/min), and at 5 minutes of recovery (520 +/- 60 to 760 +/- 110 mL/min). Before pregnancy, exercise training did not blunt the decremental effects of either gravity or exercise on portal vein blood flow. During mid and late pregnancy, exercise training had no effect on the fall in portal vein blood flow with gravitational stress, but it markedly reduced the decremental effects of exercise (average for the 2 time points, -510 +/- 80 vs -840 +/- 100 mL/min) and improved recovery at 5 minutes after exercise (940 +/- 140 vs 600 +/- 130 mL/min). CONCLUSIONS: Portal vein blood flow rises significantly during pregnancy, and flow redistribution away from the splanchnic and uterine circulations in response to severe hemodynamic stress is reduced by exercise training in mid and late pregnancy.     

Surgical approaches for unresectable primary carcinoma of the hepatic hilus

Thirteen patients with proximal malignant obstruction of the biliary tract secondary to primary cholangiocarcinoma are presented. Seven of these patients had bilateral involvement of the major vessels of the porta hepatis, and 12 had bilateral involvement of the main hepatic ducts up to the level of segmental bifurcation. Resection of the tumor was carried out in all of the patients. Extensive resection of the liver with resection of the regional vascular structures was done in six. Another six underwent resection of the liver without resection of the regional vascular structures. The remaining patient underwent resection of the tumor and of the regional revascular structures alone. Vascular resection included resection and reconstruction of both the portal vein and hepatic artery in four patients or only of the portal vein in three. Biliary drainage was carried out by intrahepatic cholangiojejunostomies between segmental hepatic ducts and a Roux-en-Y loop. Two patients died and ten are alive. The quality of postoperative life is satisfactory and the patients are free of sequelae and symptoms secondary to operation or disease. This approach is recommended for the management of a number of patients with bilateral vascular or biliary involvement secondary to primary cholangiocarcinoma of the porta hepatis. For those patients, this approach offers a promising alternative.     

Isolated gastric varices due to focal splenic vein stenosis.

Left-sided portal hypertension due to splenic vein stenosis is a very rare disease. We report a case of this condition in a 21-year-old woman who suffered from a first episode of tarry stool passage with fresh blood vomiting. Panendoscopy showed isolated gastric varices while sonography showed a normal liver but the presence of splenomegaly with prominent collateral circulations. Further imaging studies, including abdominal computed tomography, splenoportography and percutaneous transhepatic portography, revealed a focal stenotic proximal splenic vein resulting in left-sided portal hypertension. The collateral circulation ran from the short gastric veins via the left gastric veins into the main portal vein. The intraportal venous pressure was within normal limits. Splenectomy was performed and near normal wedge liver biopsy pathology confirmed non-cirrhotic extrahepatic portal hypertension. The patient had no further variceal bleeding after surgery.     

To tell or not to tell--what parents think about telling their children that they were born following donor insemination

Pioneering legislation regarding donor insemination was introduced in Sweden in 1985. The law gives the child, upon reaching sufficient maturity, the right to obtain information about the donor and his identity. One hundred and forty-eight Swedish couples with children conceived through donor insemination after the law was introduced have answered questions about disclosure and donation in a questionnaire. This article addresses the reasoning employed by individual couples in their decision whether or not to inform the children about their origin. Parental reflections on their decision and the children's reactions to receiving this information are also presented. Five categories of parental arguments are reported. These included 'reasons to tell', 'reasons not to tell', 'reasons why the question about telling or not would not be answered at all', 'inconclusive types of reasoning, that can still influence the fundamental decision' and 'context-dependent reasons associated with actual circumstances'. Through this meta-classification of arguments it was possible to identify clues to how professionals could facilitate parental decision-making and promote disclosure. Parents who had informed their children did not regret their decision. All of the parents who responded to the question of whether it had been beneficial to the child to tell answered 'yes'.     

Long term results of treatment of Budd-Chiari syndrome by side to side portacaval shunt

This is a report of a long term prospective study of 13 seriously ill patients with Budd-Chiari syndrome as a result of occlusion of the hepatic veins who were treated by side to side portacaval shunt from four to 78 weeks after the onset of symptoms and who were under observation for three to 16 years. The patient population was young, ranging in age from 19 to 45 years; seven were men and six were women. The presumed cause was the use of oral contraceptives in three, polycythemia rubra vera in two, Behcet disease in one patient and unknown in seven patients. All of the 13 patients had abdominal pain, marked ascites, hepatosplenomegaly, wasting and disturbed liver function. Diagnosis was based on the symptoms and signs: angiographic demonstration of hepatic vein occlusion and a patent inferior vena cava; pressure measurements that showed an inferior vena caval pressure that was normal or within the usual range for patients with massive ascites and an elevated wedged hepatic vein pressure that was much higher than the inferior vena caval pressure, and the results of biopsy of the liver showing centrilobular congestion and necrosis. Side to side portacaval shunt was very effective in decompressing the liver, reducing the mean corrected portal pressure from 240 millimeters of saline solution before to 7 millimeters of saline solution after the shunt. Operative survival rate was 92 per cent, and the long term survival rate for three to 16 years is 85 per cent. All of the survivors are free of ascites without requiring diuretic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of splenectomy on portal pressure in short- and long-term portal hypertensive rats.

Different hemodynamic patterns were noted in short- and long-term portal hypertensive rats, induced by partial portal vein ligation (PVL) performed two weeks and six months earlier. In order to investigate the effect of splenectomy on the portal pressure of portal hypertensive rats with different hemodynamics, an operation was performed on these two groups of animals and the portal pressure measured thereafter at different time points. Splenectomy in the short-term group produced an immediate, but transient, drop in portal pressure from 14.1 +/- 2.7 to 11.0 +/- 3.0 mmHg, which bounced back to pre-splenectomy values in 20 seconds. Two weeks later, the portal pressure in these splenectomized rats was 15.2 +/- 4.2 mmHg, which was indistinguishable from that of the pre-splenectomy condition of the short-term group. However, after an additional two weeks, portal pressure in the splenectomized rats rose to 16.4 +/- 2.1 mmHg, which was significantly higher than that of the pre-splenectomy condition of the short-term group. This difference in portal pressure became even more pronounced at six months. Sustained portal hypertension was observed in the long-term group, but the pressure was significantly lower than that in the short-term group. Splenectomy in the long-term group produced neither an immediate drop nor a delayed rebound in portal pressure. We conclude that splenectomies in portal hypertensive rats at different stages of disease produce different effects.     

Aneurysm of the umbilical vein: case report and review of literature

We report a case of aneurysm of the umbilical vein, causing fetal death at 41 weeks gestation. We conclude that these aneurysms are a complication of congenital thinning of the vessel wall and want to emphasize that in stillbirths the cause of death may only be revealed by careful placental examination, including the umbilical cord.     

The disclosure decision: Concerns and issues of parents of children conceived through donor insemination

OBJECTIVE: The purpose of our study was to examine the disclosure decision by parents of children conceived by donor insemination. STUDY DESIGN: A qualitative component of a self-administered questionnaire mailed to 184 couples who had become parents by donor insemination encouraged respondents to volunteer their written comments, concerns, or opinions about their disclosure decision. RESULTS: A total of 70 men and 86 women submitted written comments indicating that 54% did not plan to disclose the donor insemination treatment (nondisclosers), 30% indicated they would (disclosers), and 16% remained undecided. The only significant relationship between the disclosure decision and expressed concern was with regard to confidentiality and honesty (χ² = 99.9, p < 0.05). CONCLUSIONS: Whether parents viewed the disclosure issue as one of honesty (disclosers) or confidentiality (nondisclosers) was the major determinant in the decision of whether to tell children about their donor insemination origin. There was no association between disclosure status or gender and expressed concerns about parenting, children, or family relations. (Am J Obstet Gynecol 1998;178:1165-70.)     

Pre-eclampsia-associated alterations in decorin, biglycan and versican of the umbilical cord vein wall

OBJECTIVE: The role of proteoglycans in the rearrangement of the extracellular matrix of the umbilical cord vein wall in pre-eclampsia is not known. Decorin, biglycan and versican are the main proteoglycans of the umbilical cord vein wall. We decided to test whether the amounts of these proteoglycans alter in pre-eclampsia. STUDY DESIGN: Study was performed on the umbilical cord veins taken from 10 newborns delivered by healthy mothers (control group) and from 10 newborns delivered by mothers with pre-eclampsia. Proteoglycans were extracted in dissociative conditions, purified by Q-Sepharose anion exchange chromatography and lyophilised. Decorin, biglycan and versican were analysed by SDS-PAGE followed by Western blotting before and after treatment with chondroitinase ABC. The amounts of decorin, biglycan and versican core proteins were assessed by ELISA method. RESULTS: We found that both control and pre-eclamptic umbilical cord vein wall contained all the three proteoglycans. ELISA assay showed the amounts of the core proteins of decorin, biglycan and versican were distinctly higher in pre-eclamptic material in comparison to control vessel. Western blotting confirmed that the expression of all these proteoglycan core proteins increased in pre-eclampsia. They featured in the same electrophoretic mobility-45 and 47 kDa for decorin, 45 kDa for biglycan, and 300 and 320 kDa for versican. CONCLUSION: The content of decorin, biglycan and versican in the umbilical cord vein wall is elevated in pre-eclampsia in comparison to the corresponding control vessel. These alterations may affect the mechanical properties of this vessel and disturb foetal blood circulation.     

Umbilical vein and middle cerebral artery blood flow response to partial occlusion by external compression of the umbilical vein (pressure test)

Objectives: We studied the responses of flow in the umbilical vein and of the circulation in the proximal segment of the middle cerebral artery (MCA) during partial external compression of the umbilical vein. Methods: Partial occlusion of the umbilical vein was achieved by the pressure test, consisting of applying external pressure on the maternal abdominal wall for 1-2 s. Results: During 60 pressure tests in 45 fetuses with nuchal cords, we observed complete cessation of the umbilical vein flow, while blood flow in the umbilical arteries was preserved, and proximal MCA flow was moderately or markedly decreased. Blood flow in other segments of the MCA was unchanged. This effect, which was more pronounced before the 32nd week of gestation, was also observed in association with spontaneous fetal movements. Conclusion: The pressure test decreases flow in the proximal MCA, and interrupts umbilical vein blood flow. Further analysis of this response suggested the presence of associated vasoconstriction of the proximal MCA.     

The effect of anterior vaginal wall prolapse on urethral pressure profile

OBJECTIVE: To evaluate whether anterior vaginal wall prolapse will cause a decrease in urethral pressure. METHODS: Two hundred ninety-four patients with uterovaginal prolapse served as study cases. In addition, 127 patients without uterovaginal prolapse were included as controls. The urethral pressure profile measurement was performed using a microtransducer and the fluid-bridge method with the patient in the lithotomy position. The parameters of the urethral pressure profile and its associated variables were compared between the control and study groups. RESULTS: The proximal portion of urethral pressure and the resting and stress urethral closure pressures in women with anterior vaginal wall prolapse were significantly lower than those of the control group. An indentation segment (or a plateau pressure zone) in the proximal portion of the urethral pressure profile curve was noted in patients with anterior vaginal wall prolapse, especially for stage I (64.2%) and stage II (73.0%). Anterior vaginal wall prolapse and genuine stress incontinence had a statistically significant odds ratio for predicting the presence of an indentation segment (or a plateau pressure zone) in the proximal portion of the urethral pressure profile curve (1.58 and 3.19, respectively). CONCLUSIONS: An indentation segment (or a plateau pressure zone) of the proximal portion of the urethral pressure profile curve was observed in most of our patients with anterior vaginal wall prolapse. Defects in the anterior vaginal wall supports may attenuate the proximal urethral support, and these defects will contribute to a reduction in the proximal urethral pressure.     

Prediction of HELLP syndrome with assessment of maternal dual hepatic blood supply by using Doppler ultrasound

Objective: Early structural and functional changes in the systemic vasculature have been proposed to play a major pathogenetic role in HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. Our objective was to assess whether the evaluation of maternal hepatic blood supply is instructive to the prediction of onset of HELLP syndrome. Design: Prospective observation study. Population: Fifty-eight women with severe preeclampsia and 60 healthy pregnant controls at 25–36 weeks gestation. Methods: Angle-corrected time-averaged flow velocity and the cross-sectional area of common hepatic artery and portal vein were measured by using Doppler ultrasonography in 58 women with severe preeclampsia and in 60 healthy pregnant controls at 25–36 weeks gestation. Intravascular flow volumes were calculated from the product of the time-averaged velocity and the cross-sectional area. The total liver blood flow was taken as the sum of flow volumes in the hepatic artery and portal vein. Results: The total liver blood flow decreased significantly to about 40% of control in 9 women with severe preeclampsia who developed HELLP syndrome within 4 days after the examination, but not in 49 women with severe preeclampsia without HELLP syndrome. Conclusion: The results indicated that the decrease in dual hepatic blood supply preceded the onset of HELLP syndrome.     

Relationship between proteolytic enzymes and atherosclerosis in aortic aneurysms.

Aortic elastase and aortic collagenase were assayed in 38 patients who underwent an operation for thoracic or infrarenal aneurysm or infrarenal aortic occlusive disease and in 15 control patients (heart or kidney donors). Elastase was elevated in normal aortas of the infrarenal region (1.10 milliunits per gram, p less than 0.05), and in atherosclerotic descendens aneurysms (1.24 milliunits per gram, p less than 0.05), compared with the ascending aorta, when normal; aneurysmatic specimens revealed similar low elastolytic activities (0.10 milliunits per gram). The highest elastase content was found in infrarenal aneurysms (4.65 milliunits per gram). Collagenase assays yielded no significant differences, although higher activities were extracted from aortas of the infrarenal region. Coexistent atherosclerosis and wall destruction were evaluated by macroscopic and histologic investigation. All infrarenal specimens demonstrated severe atherosclerotic wall degeneration with depletion of elastic fibers. As the atherosclerotic specimens did not differ from normal aortas by protease assay, the higher elastase of infrarenal samples compared with the thoracic aorta suggests a more rapid fiber metabolism in the infrarenal region. The significantly elevated elastolytic activity of infrarenal aneurysms points to the decisive role of elastase in infrarenal aneurysm formation.     

In vivo use of human umbilical vessels and the ductus venosus arantii.

Clinical use of umbilical vessels in the neonate is commonplace. In the adult, surgical reopening of the umbilical vein is feasible in the majority of patients, providing direct access to the portal circulation. Umbilical vein catheterization allows for portal manometry in the intact, unanesthetized state. Prolonged catheterization has served to facilitate physiologic and pharmacologic studies hitherto unavailable. Selective splanchnic catheterization with hepatoportography permits roentgenographic studies, important in the evaluation of patients with hepatobiliary diseases. Clinically, the umbilical vein has been used in the study of portal hemodynamics, portal decompression and hemofiltration, portal arterialization and in evaluating hepatic trauma. This method of access to the portal circulation has provided a route for study of the effects of drugs, hormones and other biologic materials on the portal circulation and for administration of antibiotics and other chemotherapeutic agents into the portal system. The procedure of umbilical vein catheterization is simple and repeated catheterization is possible. The ductus venosus, on the other hand, is not clinically usable and pertinent information has been reviewed. The ex vivo use of neonatal umbilical veins as vascular conduits is not included in this review.     

Subsequent therapeutic options and outcome in couples who fail to fertilize despite in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI)

PURPOSE: Failed fertilization with ICSI in women having at least five mature oocytes retrieved is uncommon. The present study evaluated 19 such patients to determine--based on this outcome--what option they would choose next and what the outcome would be. METHODS: The study requirements included females age < or = 43 and use of ejaculated sperm. RESULTS: Five of 19 women (26.3%) had severe oligoasthenozoospermia. Options chosen were 1) donor egg (n = 3), 2) donor embryo (n = 1), 3) donor sperm (n = 1), 4) treatment cessation (n = 3), 5) resuming IVF-ET and ICSI (n = 11). Live deliveries occurred in 1) (n = 2), 2) (n = 1), and 5) (n = 4). CONCLUSIONS: When faced with failed fertilization with ICSI a small majority of women (11/19, 57.9%) chose to still try with their own gametes and some succeeded (36.3%). These data may be helpful in counseling couples who fail fertilization despite IVF with ICSI in making a decision as to their next therapeutic choice.     

An anatomic investigation of radical resection of tumor in the hepatic duct confluence

The fetal umbilical vein in the ligamentum teres can be reopened to provide a 10 centimeter long vein, as wide as the left portal vein or the central splenic vein, that gives access to the left portal vein in the umbilical fissure of the liver. By cutting the ligamentum teres, this potential autologous venous graft is lost and, therefore, the ligamentum teres should never be sacrificed without reason. The umbilical side of the reopened umbilical vein can be anastomosed with the splenic vein to form a portal vein bypassing conduit that enters the liver in the umbilical fissure and take over function of the portal vein. From the results of this postmortem investigation, it can be concluded that radical block resection of the area consisting of the hepatic duct confluence, classic right hepatic lobe and complete hepatoduodenal ligament, preceded by construction of a complete separate afferent blood supply of the classic left hepatic lobe, is possible both anatomically and technically. There is no indication denying the supposition that the result of such a procedure is functionally analogous to standard extended right lobectomy with bilioenteric reconstruction.