Heterotopic thyroid tissue at the porta hepatis in a fetus with trisomy 18

Heterotopic thyroid tissue at the porta hepatis in a fetus with trisomy 18 is described. The fetus had an eutopic thyroid gland without any abnormalities. The heterotopic thyroid was found at the porta hepatis and showed histological features similar to the eutopic thyroid. Immunohistochemically, the heterotopic follicles were positive for thyroglobulin, but no calcitonin- positive cells were found. Intra-abdominal heterotopic thyroid is exceedingly rare in locations other than the ovary, and to our knowledge, this is the first report of a fetal case. The present case provides clear evidence that abdominal heterotopic thyroid can occur as a congenital anomaly. Migration abnormality of the median anlage of the thyroid is the most likely histogenesis of heterotopic thyroid at the porta hepatis. Received: 14 September 1999 / Accepted: 5 November 1999     

第一肝门的腹腔镜肝脏手术入路解剖学研究

目的:为腹腔镜肝脏外科提供第一肝门的应用解剖及手术入路设计。方法:成人尸体肝脏标本30例结合临床手术入路设计,研究肝门静脉主干及其属支的管径、汇合形式及分支直径、长度(从分叉至进入肝实质),横沟的长度、门静脉分叉点与肝方叶尖、尾状叶尖的距离。观察肝门静脉左、右支在横沟内与左、右肝动脉及肝左、右管的伴行关系。结果:①肝门静脉在胰颈或胰体之后由肠系膜上静脉、脾静脉[直径分别为(11.42±2.85)mm、(7.91±3.06)mm]汇合而成。其汇合类型分为3型;②横沟呈槽状,长度为(4.19±0.36)cm;③肝门静脉左支长为(1.45±0.17)cm,直径为(11.97±1.65)mm;④门静脉右支长为(1.57±0.05)cm,直径为(11.75±0.98)mm。结论:腹腔镜下解剖分离第一肝门是可行的;肝门阻断入路操作简单,效果切实;还可以进行手术区域的肝门管道预处理及肝门静脉保护。     

The developing human biliary system at the porta hepatis level between 11 and 25 weeks of gestation: A way to understanding biliary atresia. Part 2

In biliary atresia, inflammation and destruction of extra-hepatic and intrahepatic bile ducts with eventual fibrous obliteration occurs, causing neonatal obstructive jaundice. The onset of the disorder may start antenatally and progress after birth, and the porta hepatis is a constant site of involvement. To date, little is known about the intrauterine development of the bile ducts at the porta hepatis. The present work gives an account of the developmental pattern of bile ducts at the level of the porta hepatis in the normal human fetus from the 11th to the 25th weeks of gestation. It has been observed that the proximal portion of the hilar bile ducts derives from the intrahepatic biliary ductal plate. This occurs following a predictable remodeling sequence by which, from many ductal plate-derived ductules, those destined to become definitive bile ducts are enveloped in a concentric cuff of mesenchyma. Those which are not are deleted. The distal portions of the right and left main hepatic ducts develop from the extrahepatic bile duct. There was no gestational period in which the extrahepatic bile duct and the intrahepatic blliary system were separated. Furthermore, the developing intrahepatic bile ducts maintain lumina continuity with the common bile duct from the start of organogenesis. Biliary atresia may result from: (i) failure to establish a definitive type of bile duct; (ii) leakage of bile from primitive bile ducts resulting in an interstitial inflammatory reaction in the adjacent mesenchyma; and (iii) continuous proliferation of primitive bile ducts at the level of the porta hepatis beyond the 25th week of gestation, as a failed compensatory mechanism.     

第二肝门血管的腹腔镜应用解剖研究

目的:研究第二肝门血管的形态及其在腹腔镜肝脏外科的意义。方法:用30例动脉灌注乳胶标本测量肝上缘至膈肌距离,肝上缘可分出的各肝静脉的直径、长度、间距、与右冠状韧带的距离。观察肝静脉的汇入情况。结果:肝上缘至膈肌距离为(1.15±0.29)cm,有20例可于肝上缘分出肝左后上缘静脉,可于肝上缘分出右后上缘静脉的只有2例;有86.7%肝左静脉与肝中静脉共干,另有2例有2支肝中静脉,左支与肝左共干,右支单独存在。各肝静脉之间有外科间隙。结论:紧贴肝上缘打开肝周韧带,不易损伤膈肌和肝静脉,出血少、速度快,可以使第二肝门获得良好的手术显露;腹腔镜肝切除时一般在肝实质内切断肝静脉,在个别情况也可以预先在第二肝门结扎切断肝静脉。     

The developing human biliary system at the porta hepatis level between 29 days and 8 weeks of gestation: A way to understanding biliary atresia. Part 1

The developing biliary system in normal human embryos from 29 days to 8 weeks post-fertilization was studied. The primitive extrahepatic bile duct that originates from the embryonic hepatic foregut diverticulum is in contact with the hepatic anlage from the start of organogenesis and remains so throughout the gestational ages examined. The primitive extrahepatic bile duct maintains continuity with the ductal plate from which intrahepatic bile ducts are eventually formed. Contrary to long-held concepts of biliary development, no 'solid stage' of entodermal occlusion of the common bile duct lumen was found at any stage of gestation in the material investigated. Therefore, biliary atresia is not caused by incomplete vacuolization of the 'solid stage'.     

Absence of the portal bifurcation at the hilum of the liver due to intrahepatic origin of the left branch of the portal vein

Abstract The authors report a rare anomaly of portal vascularization which was detected by CT-scan and MRI and then confirmed surgically. There was no portal bifurcation at the hilum of the liver. After giving off its right dorsal branch, the portal vein entered the right liver and divided in the parenchyma into the right ventral and left branches. The arterio-biliary distribution was normal. Only a few similar cases have been reported. The left branch of the portal vein is reported to have few variations in contrast with the right one, which has many. The venous structure of the liver varies increasingly with the distance from the left umbilical vein. During a right hepatectomy, the possibility of such a vascularization makes it necessary to ensure that the left branch of the portal vein starts upstream before dividing a portal branch entering the right liver.     

Absence of bifurcation of the portal vein

Background  Absence of the horizontal segment of the left portal vein (PV) or absence of bifurcation of the portal vein (ABPV) is extremely rare anomaly. The aim of this study was to study the extra-hepatic PV demonstrating the importance of its careful assessment for the purpose of split-liver transplantation. Method  Human cadaver livers (n = 60) were obtained from routine autopsies. The cutting plane of the liver consisted of a longitudinal section made immediately on the left of the supra-hepatic inferior vena cava through the gallbladder bed preserving the arterial, portal and biliary branches in order to obtain two viable grafts (right lobe—segments V, VI, VII, and VIII and left lobe—segments II, III, and IV) as defined by the main portal scissure. The PV was dissected out and recorded for application of the liver splitting. Results  The PV trunk has been divided into right and left branch in 50 (83.3%) cases. A trifurcation of the PV was found in 9 (15.2%) cases, 3 (5%) was a right anterior segmental PV arising from the left PV and 6 (10%) a right posterior segmental PV arising from the main PV. ABPV occurred in 1 (1.6%) case. Conclusion  Absence of bifurcation of the portal vein is a rare anatomic variation, the surgeon must be cautious and aware of the existence of this exceptional PV anomaly either pre or intra-operatively for the purpose of hepatectomies or even split-liver transplantation.     

Spectral analysis of spontaneous contractions of the isolated portal vein of rats

Summary The spontaneous contractions of segments of rat portal veins have been examined in vitro under isotonic and isometric conditions. The power density spectra of recorded time series lasting 10–60 min were calculated. The spectra usually consist of harmonic frequency components. Only during shorter periods of analysis (10 min time series) we sometimes found additional non-harmonic components. All frequency components are proportionally shifted by changes of the bath temperature according to an average Q₁₀ of 2.0. Increase of the load decreases the frequency of the contractions.The results of the spectral analysis, indicating a preponderance of a single source of periodicity, were supported by direct evidence of a pacemaker region. By recording contractions after systematic dissections of the portal vein segment, we found that spontaneous activity is generated at the central end of the segment.This work was supported by the Austrian Research Fund     

Fetal intrahepatic gallbladder and topographical anatomy of the liver hilar region and hepatocystic triangle

The fetal gallbladder (GB) is embedded in a deep fossa surrounded by the liver parenchyma. Using 15 specimens with intrahepatic GB (crown-rump length 45-92 mm; approximately 9-13 weeks of gestation), we assessed the fetal topographical anatomy of the hepatocystic triangle and the porta hepatis. The cystic duct displayed a long upward course (0.9-4.5 mm along the supero-inferior axis) from the GB, along the duodenum, to the common bile duct in the hepatoduodenal ligament, via an independent mesentery separated from liver parenchyma by a recess of the peritoneal cavity. Notably, the course varied in length among specimens, not among stages. At the porta hepatis, we were able to distinguish the supraportal course of the posterior right hepatic duct overriding a portal vein branch to segment 8 (6/15) from the other, infraportal course (9/15). In the latter type, the portal vein bifurcation was superior to the cystic duct course. Two margins of the hepatocyctic triangle were very long in fetuses because of the inferiorly located intrahepatic GB. Thus, the triangle seems to be difficult to identify in prenatal ultrasound. During changes in location after 9 weeks, the GB fundus remains attached to the liver because the cystic artery was often embedded in the liver parenchyma. A failure in the embedding and re-exposure process of the GB may result in anomalous peritoneal folds around the GB.     

肝脏面的形态学观测

对52例成人尸肝进行脏面结构观测，检出肝圆韧带隧道14例（26．9％），腔静脉管3例（5．8％），肝门右侧额外裂40例（76．9％），尾状叶下纵沟37例（71．2％），此外，对肝尾状突的长径，肝圆韧带裂，静脉韧带等结构的宽度作了测量，所得数据对解剖结构的数据化及应用解剖学和影像解剖学有参考价值。     

A common hepatic artery passing in front of the portal vein

A variation in liver vascularization was discovered in a 50-year-old man. A single common hepatic artery was found to be responsible for vascularization of the entire liver. This artery was unusual in that it formed the first branch of the superior mesenteric artery, crossing the portal trunk shortly after its origin, and passed in front of the portal vein to reach the hilum of the liver, where it divided into a right and a left branch. This artery was a true common hepatic artery because a gastroduodenal artery emerged from it 2 cm after its origin. A common hepatic artery originating from the mesenteric artery and passing in front of the portal vein has never been described before. The patient had a second anatomical variation: the left gastric artery and the splenic artery arose directly from the aorta, without celiac trunk separation. This observation confirms the importance of carrying out a precise vascular assessment before all types of hepatic or pancreatic surgery, to identify possible variations in the number or trajectory of hepatic arteries.With the collaboration of the association Arold (Boulogne, France)     

Effects of calcium and sodium on contracture tension in the smooth muscle of the rat portal vein

Summary The purpose of the present study was to determine the quantitative relationship between membrane potential (or [K⁺]₀) and contracture tension in the smooth muscle of the rat portal vein, and to examine the influence of Ca⁺⁺ and Na⁺ on this relationship. However, electrical all-or-none responses were successfully abolished only in Na⁺-free sucrose-Krebs due to hyperpolarization and in K⁺-high Krebs due to depolarization. It did not seem possible to eliminate spike discharge at intermediate levels of membrane potential without the simultaneous loss of contractility. In the hyperpolarized state the muscle remained relaxed despite the very low levels of [Na⁺]₀ and despite increases in [Ca⁺⁺]₀ up to 20 mM. The depolarized portal vein developed a contracture which was intimately dependent on [Ca⁺⁺]₀, the threshold concentration being of the order of 0.1 to 0.3 mM. Spike-induced, phasic contractions showed a similar Ca⁺⁺-dependence. Variations in [Na⁺]₀ had only a slight and irregular influence on the Ca⁺⁺ dose-response curve of the depolarized muscles.Differences in the effects of Na⁺ on the rate of rise and the rate of fall of the contracture tension, respectively, suggested that Na⁺ is more important for the removal of Ca⁺⁺ from the contractile system than for the supply of Ca⁺⁺ to the system. With regard to the interaction of Ca⁺⁺ and Na⁺ in the excitation-contraction coupling the vascular smooth muscle seemed to differ from both heart muscle and skeletal muscle.The present study was supported by grants from the Swedish Medical Research Council (B 70-14x-28-06 A), from Air Force Office of Scientific Research through the European Office of Aerospace Research, OAR, United States Air Force under Contract F 1052-68-C-0044, from U.S. Public Health Service (HE-05678-08), from AB Hässle, Göteborg, and from the Deutsche Forschungsgemeinschaft (Bi 122/1).     

Fate of allogeneic or syngeneic cells in intravenous or portal vein injection: Possible explanation for the mechanism of tolerance induction by portal vein injection

In this report we examine the fate of donor cells injected via different routes. When PKH-26-labeled C57BL/6 (B6) spleen cells were intravenously (i.v.) injected into BALB/c mice, the donor cells were rejected within 3 days. In contrast, when the same B6 spleen cells were portal venously (p.v.) injected, they were trapped in the recipient liver. When allogeneic or syngeneic whole bone marrow cells (BMC) or cells in a hemopoietic stem cell (HSC)-enriched fraction were either i.v. or p.v. injected, the cells accumulated in the liver. The cells trapped in the liver were found to be wheat germ agglutinin (WGA)-positive HSC. When B6 thymocytes were p.v. or i.v. injected into BALB/c mice, they were rapidly rejected. When BALB/c mice were i.v. preimmunized with unlabeled B6 spleen cells, BMC or thymocytes, the p.v. or i.v. injected PKH-26-labeled B6 spleen cells were rejected rapidly (within 2 days). In contrast, when BALB/c mice were p.v. preimmunized with B6 spleen cells or BMC, the p.v. or i.v. injected PKH-26-labeled B6 spleen cells were not rejected. The cells responsible for the tolerance induction were found to be HSC trapped in the liver. Delayed-type hypersensitivity assays revealed that the tolerance could be maintained for more than 49 days by p.v. injection plus i.v. injection (at intervals of 2 weeks) of HSC. These findings indicate that HSC trapped in the liver play a crucial role in the induction and maintenance of p.v. tolerance.     

The diameter of the originating vein determines esophageal and gastric fundic varices in portal hypertension secondary to posthepatitic cirrhosis

OBJECTIVE:

The aim of this study was to determine whether and how the diameter of the vein that gives rise to the inflowing vein of the esophageal and gastric fundic varices secondary to posthepatitic cirrhosis, as measured with multidetector-row computed tomography, could predict the varices and their patterns.

METHODS:

A total of 106 patients with posthepatitic cirrhosis underwent multidetector-row computed tomography. Patients with and without esophageal and gastric fundic varices were enrolled in Group 1 and Group 2, respectively. Group 1 was composed of Subgroup A, consisting of patients with varices, and Subgroup B consisted of patients with varices in combination with portal vein-inferior vena cava shunts. The diameters of the originating veins of veins entering the varices were reviewed and statistically analyzed.

RESULTS:

The originating veins were the portal vein in 8% (6/75) of patients, the splenic vein in 65.3% (49/75) of patients, and both the portal and splenic veins in 26.7% (20/75) of patients. The splenic vein diameter in Group 1 was larger than that in Group 2, whereas no differences in portal vein diameters were found between groups. In Group 1, the splenic vein diameter in Subgroup A was larger than that in Subgroup B. A cut-off splenic vein diameter of 8.5 mm achieved a sensitivity of 83.3% and specificity of 58.1% for predicting the varices. For discrimination of the varices in combination with and without portal vein-inferior vena cava shunts, a cut-off diameter of 9.5 mm achieved a sensitivity of 66.7% and specificity of 60.0%.

CONCLUSION:

The diameter of the splenic vein can be used to predict esophageal and gastric fundic varices and their patterns.     

Prognostic index for portal vein tumor thrombosis in patients with hepatocellular carcinoma treated with radiation therapy

We performed a retrospective review of 281 hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) treated with radiation therapy (RT) between 1998 and 2008 to develop a prognostic model for those patients. Of the 281 patients, PVTT and intrahepatic main masses completely disappeared in 10 patients (3.6%), and shown a partial response in 141 patients (50.2%). The median survival was 11.6 months. Patients who had more than PR have shown significantly longer survival than the others (22.0 months vs 5.0 months, P < 0.001). On the multivariate analysis, pre-treatment poor prognosticators for overall survival were ECOG performance status, Child-Pugh class, multiple tumors, main PVTT, complete portal vein occlusion, lymph node metastasis, and primary tumor size. Prognostic index of RT for PVTT of HCC (PITH) scores were defined as the number of pre-treatment poor prognostic factors. PITH scores correlated well with overall survival. In the analysis of 1 and 2 yr overall survival rate, patients who had PITH scores of 3 or greater showed a significantly lower rate of overall survival than the others (33.0%, 17.3% vs 70.1%, 40.8%, respectively, P < 0.001). The PITH scoring model, proposed in the current study in HCC patients with PVTT, reliably predict overall survival.     

肝门静脉海绵样变性模型大鼠组织抑制因子及基质金属蛋白酶表达 与周围血管新生

背景：目前国内外尚无有效治疗肝门静脉海绵样变性的策略,且其病因的基础研究报道较为鲜见。 目的：拟建立大鼠门静脉海绵样变性模型,检测基质金属蛋白酶2,9,基质金属蛋白酶组织抑制剂1,2在大鼠门静脉及其周围组织的表达及周围血管新生中的作用。 方法：SD大鼠80只随机分为3组。以门静脉部分缩窄法复制门静脉海绵样变性的大鼠模型,以21 G钝针头操作。模型组和假手术组分别设术后2,4,6周3个时间点,对照组即不做任何处理的正常SD大鼠(造影后取材)。各组分别于处理后不同时间点行门静脉造影,免疫组织化学检测血管内皮细胞标记物CD31观察门静脉周围血管变化,并使用实时荧光定量PCR和免疫组织化学法检测大鼠门静脉及其周围组织的基质金属蛋白酶2,9,基质金属蛋白酶组织抑制剂1,2 mRNA的含量和蛋白的表达。 结果与结论：门静脉造影及血管内皮细胞标记物CD31免疫组织化学显示,模型组门静脉周围新生血管明显增多。RT-PCR与免疫组织化学结果分析显示：对照组和假手术组基质金属蛋白酶2 mRNA及蛋白表达均较同期模型组低(P < 0.01,P < 0.05),基质金属蛋白酶9 mRNA及蛋白表达均较同期模型组低。模型组基质金属蛋白酶组织抑制剂1,2各个时间段的表达水平与对照组和假手术组相比差异无显著性意义(P > 0.05);模型组造模后第2周基质金属蛋白酶2/基质金属蛋白酶组织抑制剂2比值明显高于对照组和假手术组同期(P < 0.05)。结果提示,构建的门静脉海绵样变性的模型大鼠死亡率低,成模率高,且比较稳定。基质金属蛋白酶2,9表达升高以及基质金属蛋白酶2/基质金属蛋白酶组织抑制剂2的比值失衡,可能是大鼠门静脉海绵样变周围血管新生的分子机制之一。 中国组织工程研究杂志出版内容重点：肾移植;肝移植;移植;心脏移植;组织移植;皮肤移植;皮瓣移植;血管移植;器官移植;组织工程全文链接：     

Preferential differentiation of the bile ducts along the portal vein in the development of mouse liver

Summary The development of bile ducts in the mouse liver was studied histochemically, with special reference to their preferential differentiation around the portal vein. Both portal vein and hepatic vein shared a common origin, the omphalomesenteric vein. In the early development of the liver, haematopoietic cells were predominant around both veins. With the progressive development of intrahepatic bile ducts, the following three steps were observed: cluster formation of type I hepatocytes around the portal vein, formation of primitive bile duct structures and basal lamina, then formation of ducts surrounded by connective tissue structures composed of type I and type III collagens and lectin-binding sites, which were predominant around the portal vein compared to the hepatic vein. These results suggest that the deposition of abundant connective tissue structures around the portal vein is a prerequisite for the cell differentiation and basal lamina formation in the bile duct precursors. A possible mechanism of the aggregation of type I hepatocytes around the portein vein is also discussed.