Patency Rates of Portal Vein/Superior Mesenteric Vein Reconstruction After Pancreatectomy for Pancreatic Cancer

Background

Pancreatectomy with venous reconstruction (VR) for pancreatic cancer (PC) is occurring more commonly. Few studies have examined the long-term patency of the superior mesenteric-portal vein confluence following reconstruction.

Methods

From 2007 to 2013, patients who underwent pancreatic resection with VR for PC were classified by type of reconstruction. Patency of VR was assessed using surveillance computed tomographic imaging obtained from date of surgery to last follow-up.

Results

VR was performed in 43 patients and included the following: tangential resection with primary repair (7, 16 %) or saphenous vein patch (9, 21 %); segmental resection with splenic vein division and either primary anastomosis (10, 23 %) or internal jugular vein interposition (8, 19 %); or segmental resection with splenic vein preservation and either primary anastomosis (3, 7 %) or interposition grafting (6, 14 %). All patients were instructed to take aspirin after surgery; low molecular weight heparin was not routinely used. An occluded VR was found in four (9 %) of the 43 patients at a median follow-up of 13 months; median time to detection of thrombosis in the four patients was 72 days (range 16–238).

Conclusions

Pancreatectomy with VR can be performed with high patency rates. The optimal postoperative pharmacologic therapy to prevent thrombosis requires further investigation.     

Conservative Hepatectomy for Tumors Involving the Middle Hepatic Vein and Segment 1: The Liver Tunnel

Background

For lesions invading the middle hepatic vein (MHV) at caval confluence (CC) the mini-mesohepatectomy(MMH) was proposed.1 If the lesion is extended to the paracaval portion of segment 1(S1) in contact or invading the MHV a new procedure is proposed.

Methods

Case-1: mass forming cholangiocarcinoma (MFCCC) 4cm in size invading the MHV and in contact with right (RHV) and left hepatic vein (LHV) at the CC. In Case-2, two colorectal liver metastases (CLM) both 2cm in size occupied S1 (T1) and S8 (T2): T1 was located between RHV and the inferior vena cava (IVC), T2 was in contact with MHV at CC. According to tumor-vessel intraoperative-ultrasound classification2 and color-flow analysis3 parenchyma-sparing procedure was performed.

Results

In Case-1 a communicating vein (CV) between RHV and MHV was detected at color-flow-IOUS. Contacts between MFCCC with RHV and LHV were confirmed at IOUS as detachable. In Case-2 contact between T1 with MHV was confirmed at IOUS as detachable. Liver-tunnel with IVC and main portal vein bifurcation exposure was performed resecting the MHV in Case-1 and preserving it in Case-2. Both patients had ad an uneventful postoperative course and were discharged on the 8th postoperative day.

Conclusion

For tumors involving S1, S4s and/or S8 and infiltrating or in contact with the MHV at the CC, can be removed in a conservative manner by means of the herein described ‘‘Liver Tunnel’’ approach. The latter introduces a further step in favour of parenchyma-sparing policy for centrally located lesions with complex tumor-vessel relationship.     

Use of Cold-Stored Vein Allografts for Venous Reconstruction During Pancreaticoduodenectomy

Introduction

Venous resections and reconstructions of portal vein and/or superior mesenteric vein in course of pancreaticoduodenectomy are becoming a common practice and many surgical options have been described, from simple tangential resection and venorrhaphy to large segmental resections followed by interposition grafting. The aim of this study was to report the first experience of using fresh cadaveric vein allografts for venous reconstruction during pancreaticoduodenectomy focusing on technical feasibility and postoperative outcomes.

Methods

From January 2001 to October 2012, out of 151 patients undergoing pancreaticoduodenectomy for pancreatic head tumor, 22 (14.5 %) received a vascular resection of the mesentericoportal axis. In five of these patients, vascular reconstruction was accomplished by using cold-stored venous allografts of iliac and femoral veins from donor cadaver. Patients’ data, surgical techniques, and clinical outcomes were analyzed.

Results

Five patients undergoing pancreaticoduodenectomy were selected to receive a vascular reconstruction using a fresh venous allograft for patch closure in three cases, conduit interposition in one case and a Y-shaped graft in the last case. No graft thrombosis or stenosis occurred postoperatively and at long-term follow-up. Mortality rate was zero.

Conclusion

The use of fresh vein allografts is a feasible and effective technique for venous reconstruction during pancreaticoduodenectomy. However, prospective surveys including large cohorts of patients are necessary to confirm these results.     

New Surgical Approach to Large Splenorenal Shunt in Living Donor Liver Transplantation: Diversion of SMV and SPV Blood Flow

Introduction

The management of a large splenorenal shunt is important because it affects recipient outcome, particularly in living donor liver transplantation.

Methods

To manage large splenorenal shunts in living donor liver transplantation, we diverted superior mesenteric vein and splenic portal vein blood flow by ligation at the root of the splenic portal vein.

Result

This procedure was applied for five patients in whom superior mesenteric vein blood flow had been completely stolen by a splenorenal shunt preoperatively. Postoperative course was excellent in all cases.

Conclusion

This technique completely prevents morbidity related to large splenorenal shunts after living donor liver transplantation.     

Surgical Anatomy of the Superior Mesenteric Vessels Related to Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis

Background and Purpose

Mesopancreas dissection with central vascular ligation and the superior mesenteric artery (SMA)-first approach represent the cornerstone of current principles for radical resection for pancreatic head cancer. The surgeon dissecting around the SMV and SMA should be aware regarding the anatomical variants in this area. The aims of this systematic review and meta-analysis are to detail the surgical anatomy of the superior mesenteric vessels and to propose a standardized terminology with impact in pancreatic cancer surgery.

Methods

We conducted a systematic search to identify all published studies in PubMed/MEDLINE and Google Scholar databases from their inception up to March 2017.

Results

Seventy-eight studies, involving a total of 18,369 specimens, were included. The prevalence of the mesenteric-celiac trunk, replaced/accessory right hepatic artery (RRHA), common hepatic artery, and SMV inversion was 2.8, 13.2, 2.6, and 4.1%, respectively. The inferior pancreaticoduodenal artery has its origin into the first jejunal artery, SMA, and RRHA, in 58.7, 35.8, and 1.2% of cases, respectively. The SMV lacks a common trunk in 7.5% of cases. The first jejunal vein has a trajectory posterior to the SMA in 71.8% of cases. The left gastric vein drains into the portal vein in 58%, in splenic vein (SV) in 35.6%, and into the SV-PV confluence in 5.8% of cases.

Conclusions

Complex pancreaticoduodenal resections require detailed knowledge of the superior mesenteric artery and vein, which is significantly different from the one presented in the classical textbooks of surgery. We are proposing the concept of the first jejunopancreatic vein which impacts the current oncological principles of pancreatic head cancer resection.

     

Portomesenteric venous thrombosis associated with rectal venous malformations

Purpose

We report thrombosis of portal and mesenteric veins in patients with a pattern of rectal venous malformations (VMs) and ectatic major mesenteric veins.

Methods

Eight patients having rectal VMs with either ectatic mesenteric veins and/or evidence of portomesenteric venous thrombosis (PVT), evaluated from 1995-2009, were reviewed.

Results

Portomesenteric venous thrombosis was evident in 5 patients at presentation. Three had patent ectatic mesenteric veins, 2 with demonstrated reversal of flow, and 2 of whom went on to thrombosis during observation. Six patients developed portal hypertension. Five remain on long-term anticoagulation. After recognizing this pattern, one patient underwent preemptive proximal ligation of the inferior mesenteric vein (IMV) to enhance antegrade portal vein flow and prevent propagation or embolization of venous thrombus from the IMV to the portal vein.

Conclusion

Rectal VMs should be evaluated for associated ectatic mesenteric veins. The ectatic vein siphons flow from the portal vein down to the rectal VM, leading to stagnation of blood in the portal vein and resultant thrombosis. Primary thrombosis in the stagnant rectal VM and/or mesenteric vein can also predispose to embolization up into the portal vein. This pattern of rectal VM and ectatic mesenteric vein should be considered a risk factor for devastating PVT.     

Significance of Portal Vein Invasion and Extent of Invasion in Patients Undergoing Pancreatoduodenectomy for Pancreatic Adenocarcinoma

Introduction

Several studies have confirmed the safety of pancreatoduodenectomy with portal/mesenteric vein resection and reconstruction in select patients. The effect of vein invasion and extent of invasion on survival is less clear. The purpose of this study was to examine the association between tumor invasion of the portal/mesenteric vein and long-term survival.

Methods

A retrospective review of a prospectively maintained database of patients who underwent pancreatoduodenectomy for pancreatic adenocarcinoma at a single academic medical center (2000–2014) was performed. Survival was compared using the Kaplan–Meier method and log-rank test. P?<?0.05 was considered statistically significant.

Results

After non-pancreatic periampullary adenocarcinomas and patients with non-segmental (lateral wall only) resection of portal/mesenteric vein were excluded, there were 567 eligible patients. Of these, segmental vein resection was performed in 90 (16 %) with end-to-end primary anastomosis (67) or interposition graft reconstruction (23). Patients with vein resection more likely received neoadjuvant systemic therapy (59 vs. 4 %, p?<?0.0001). Histopathology of patients undergoing vein resection revealed a distribution of T stage toward larger tumors and higher rates of perineural invasion. Portal/mesenteric vein resection, however, was not associated with differences in hospital stay, postoperative complications, or operative mortality. Patients with or without vein resection had comparable overall survival rates at 1-, 3-, and 5-years. On final surgical histopathology, only 52 of 90 (58 %) vein resections had adenocarcinoma involvement of the venous wall. Of these, depth of invasion was at the level of the adventitia (9), media/intima (34), and full thickness/intraluminal (9). Venous wall invasion (52) did not significantly influence overall survival (14 vs. 21 months, p?=?0.08) but was associated with significantly shorter median disease-free survival (11.3 vs. 15.8 months, p?=?0.03), predominantly due to local recurrence. The extent of invasion (adventitia, media/intima, full thickness/intraluminal) did not impact overall survival or disease-free survival (14.4 vs. 15.5 vs. 7.4 months, p?=?0.08 and 11.2 vs. 12.2 vs. 5 months, 0.59, respectively). Portal/mesenteric vein resection, histopathologic invasion, or the extent of invasion were not independent predictors of overall survival in Cox regression analysis.

Conclusion

Although Portal/mesenteric vein resection is associated with increased 90-day mortality, venous resection is not prognostic of overall survival. Although a subgroup analysis showed that a direct tumor invasion into the vein wall on final histopathology was associated with a higher rate of local recurrence but with no difference in overall survival (even when stratified according to extent of venous wall invasion), larger studies with an increased power will be needed to confirm these findings.

     

Minimesohepatectomy for Colorectal Liver Metastasis Invading the Middle Hepatic Vein at the Hepatocaval Confluence

Background

In case of liver tumors invading the middle hepatic vein (MHV) at the hepatocaval confluence (HC) major resection is recommended. We describe a new ultrasound-guided conservative operation for patients with colorectal liver metastasis (CLM) invading the MHV at the HC.

Methods

The case of a 65-year-old woman with two CLMs is described. One CLM was in segments 4-superior (S4-superior) and 8-ventral (S8-ventral) with invasion of the MHV 2 cm from the HC, while the other was in segment 8-dorsal (cranial portion). J-shaped laparotomy and intraoperative ultrasonography (IOUS) were carried out. Anterior surface of the HC was exposed, and compression using the surgeon’s fingertips was applied at the MHV. Once reversal flow in the peripheral portion of the MHV, and/or shunting collaterals with right or left hepatic vein, and/or hepatopetal flow in portal branches to right paramedian section (P5-8) and/or to segment 4-inferior (P4-inferior) were detected by color Doppler IOUS (CD-IOUS), partial resection of S4-superior and S8-ventral with vascular resection of MHV was performed.

Results

The disclosure of those three criteria by CD-IOUS enables the performance of minimesohepatectomy. No congestion of the remnant liver was found. Ninety-day mortality and morbidity were nil. The patient was discharged 8 days after surgery. At 11 months of follow-up the patient underwent percutaneous radiofrequency ablation for a new 15-mm CLM in segment-8-dorsal (caudal portion). Currently, the patient is alive and free of disease at 17 months after surgery.

Conclusions

The use of CD-IOUS may allow conservative resection of liver tumors invading the MHV at the HC. This might limit the need for larger resections, and broadens the role of IOUS in optimizing surgical strategy.     

Perioperative Strategies and Thrombophilia in Children with Extrahepatic Portal Vein Obstruction Undergoing the Meso-Rex Bypass

Background/Purpose

Extrahepatic portal vein obstruction (EHPVO) is an important cause of chronic portal hypertension in children. Although usually idiopathic in etiology, genetic and acquired thrombophilia have been implicated in EHPVO. Meso-Rex bypass is increasingly used to treat EHPVO in children.

Objective

The objective of this study is to assess the relationship of postoperative anticoagulation strategies and thrombophilic risk factors to the development of bypass thrombosis following the meso-Rex bypass.

Methods

Records of children who underwent meso-Rex bypass for EHPVO at a single institution from 1999 to 2009 were reviewed, and preoperative thrombophilia testing, perioperative anticoagulation strategies, and postoperative bypass patency based on imaging at last follow-up were examined.

Results

Sixty-five children with EHPVO underwent a first time meso-Rex bypass during the study period, and 9 of 65 (14 %) developed bypass thrombosis. The use of warfarin in the postoperative period was more common among children with thrombosed shunts than among those with open shunts [63 % vs. 20 %; OR, 6.5 (95 % CI, 1.3–31.5), p?=?0.022]. The contribution of genetic or acquired thrombophilia to shunt thrombosis was inconclusive given variability in testing.

Conclusions

Choice of anticoagulation following meso-Rex bypass may affect postoperative incidence of bypass thrombosis. Role of thrombophilic risk factors in the development of shunt thrombosis remains unclear.     

Analysis of anatomic variants of mesenteric veins by 3-dimensional portography using multidetector-row computed tomography

Background

It is important to be aware of mesenteric venous variants to perform peripancreatic surgery. We investigated the usefulness of 3-dimensional (3-D) portography.

Methods

Vessels were reconstructed using computer software in 102 patients undergoing multidetector-row computed tomography (MDCT) scheduled for gastrointestinal or hepatobiliary-pancreatic surgery.

Results

The superior mesenteric vein (SMV) was composed of single and double trunks around the splenoportal confluence in 78 and 24 patients, respectively. The inferior mesenteric vein joined the splenic vein (68.5%), SMV (18.5%), and splenoportal confluence (7.6%). The left gastric vein joined the splenic vein (46.3%), portal vein (39.0%), and splenoportal confluence (14.7%). Seventy-nine patients showed a gastrocolic trunk, mostly composed of the right gastroepiploic vein and veins from the colonic hepatic flexure. Intraoperative findings were identical to 3-D diagnosis in 68 gastrectomized and 9 pancreatectomized patients.

Conclusion

Although mesenteric venous tributaries are complex, 3-D portography is helpful for surgeons to safely perform peripancreatic surgery.     

Outcome of modified portal vein anastomosis for recipients with portal vein thrombosis or stenosis before living donor liver transplantation

Background

Portal vein thrombosis (PVT) or stenosis (PVS) often requires challenging techniques for reconstruction in living donor liver transplantation (LDLT).

Materials and Methods

A total of 57 LDLTs were performed between October 1996 and December 2010. There were 16 cases (28%) with PVT/PVS that underwent modified portal vein anastomosis (m-PVa). The m-PVa techniques were classified into 3 groups: patch graft (Type-1), interposition graft (Type-2), and using huge shunt vessels (Type-3). The reconstruction patterns were evaluated with regard to age, graft vessels, PV flow, and complication rate.

Results

The m-PVas were Type-1 in 10 cases, Type-2 in 3 cases, and Type-3 in 3 cases. The vessel graft in Type-1 was the inferior mesenteric vein (IMV) in 8 and the jugular vein in 2 cases, whereas the vessel graft in Type-2 was IMV in 2 and the saphenous vein in 1 case; in Type-3, the vessel grafts were renoportal, gonadal-portal, and coronary-portal anastomoses, respectively. The postoperative PV flow was sufficient in all types and slightly higher in Type-3. The postoperative complications occurred in 20% of the patients who underwent Type-1, in 33% who underwent Type-2, and in 0% who underwent Type-3.

Conclusion

The m-PVa was effective to overcome the surgical difficulty during transplantation. Pretransplant planning for the selection of the type of reconstruction is important for recipients with PVT/PVS.     

Thrombektomie der Vena mesenterica superior bei sekundärer Mesenterialvenenthrombose

Introduction

The clinical presentation of mesenteric venous thrombosis may range from an asymptomatic state to a severe, acute illness.

Patients and methods

A 58 year old woman presented reporting increasing abdominal pain for 3 days. Her leucocytes were not elevated, lactate normal, CRP elevated and she had bloody diarrhoea. The typical CT appearance of superior mesenteric venous thrombosis revealed an enlargement of the thrombotic vein, with a central area of low attenuation containing a clot in the lumen surrounded by a well defined, contrast-enhanced venous wall. The approach to the superior mesenteric vein (SMV) is similar to that for superior mesenteric artery embolectomy. The vein is to the right of the artery and is much more fragile. A transverse venotomy in the SMV was carried out. A white Fogarty catheter was used to retrieve the centrally located thrombus in the proximal superior mesenteric vein. The clots from peripheral parts of the SMV were removed by a green Fogarty catheter. Suturing of the venotomy followed with 5/0 prolene using the single stitch technique. A resection of the small bowel was not necessary. The patient was able to leave the hospital 12 days after surgery.

Conclusion

Surgeons may not be familiar with the surgical approach to portomesenteric venous thrombectomy. The improved ability for diagnosis of superior mesenteric venous thrombosis by CT means, that this disease does not invariably proceed to intestinal infarction or death, if a venous thrombectomy can be applied.     

Living donor liver transplantation for the patients with portal vein thrombosis: use of an interpositional venous graft passed posteriorly to the pancreatic parenchyma without using jump graft

Background

It is difficult to reconstruct the portal vein (PV) using a long interpositional venous graft in living donor liver transplant (LDLT) patients with portal vein thrombosis (PVT), which involves the confluence of the superior mesenteric vein (SMV) and splenic vein (SV). We successfully performed LDLT for three patients with PVT using an interpositional vascular conduit passing posterior to the pancreas without a jump graft.

Methods

Three of 130 patients who underwent LDLT in our hospital between March 2002 and June 2011 required this technique. After indentifying the location of the SMV, SV and gastrocolic trunk, we ligated and cut the posterior superior pancreaticoduodenal vein and other short branches from the PV. The PV was drawn inferiorly to the pancreas and transected at the confluence of SMV and SV. The external iliac vein or internal jugular vein was sacrificed as a graft for anastomosis to the cut end of the SMV using 6-0 polypropylene running sutures. Then the venous graft was drawn superiorly to the pancreas by passing it posterior to the pancreas parenchyma for anastomosis to the liver graft PV. The interpositional vein was placed posterior to the pancreas where the PV used to be.

Results

All three patients displayed favorable postoperative courses with the Doppler ultrasound demonstrating good portal flow perioperatively. The postoperative portogram demonstrated patency of the vascular graft.

Conclusion

This method is easy and helpful to treat portal vein thrombosis, by providing the shortest route between the PV of the donor and the SMV of the recipient.     

How to Reconstruct Middle Hepatic Vein Branches With Explanted Portal Vein and Inferior Mesenteric Vein Graft: A Case Report

Objective

The middle hepatic vein reconstruction is one of the crucial parts in adult living donor liver transplantation. Numerous techniques had been reported by using cadaveric iliac vessel or synthetic graft. The limitations of reported techniques are availability of the vessel and complication of synthetic graft. We report the technique of using explanted portal vein and inferior mesenteric vein graft in sequential fashion.

Surgical Outcomes of Pancreaticoduodenectomy for Pancreatic Cancer with Proximal Dorsal Jejunal Vein Involvement

Background/Purpose

The proximal jejunal vein which branches from the dorsal side of the superior mesenteric vein (SMV) usually drains the inferior pancreatoduodenal veins (IPDVs) and contacts the uncinate process of the pancreas. We focused on this vein, termed the proximal dorsal jejunal vein (PDJV), and evaluated the anatomical classification of the PDJV and surgical outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) with PDJV involvement (PDJVI).

Methods

The jejunal veins that branch from the dorsal side of the SMV above the inferior border of the duodenum are defined as PDJVs. We investigated 121 patients who underwent upfront pancreaticoduodenectomy for PDAC between 2011 and 2017; PDJVs were resected in all patients. The anatomical classification of PDJV was evaluated using multidetector computed tomography. Surgical and prognostic outcomes of pancreticoduodenectomy for PDAC with PDJVI were evaluated.

Results

The PDJVs were classified into seven types depending on the position of the first and second jejunal veins relative to the superior mesenteric artery. In all patients, the morbidity and mortality rates were 15.7 and 0.8%, respectively. The rates for parameters including SMV resection, presence of pathological T3–4, R0 resection, and 3-year survival were 46.2, 92.3, 92.3, and 61.1%, respectively, when there was PDJVI (n?=?13). When there was no PDJVI (n?=?108), the rates were 60.2, 93.5, 86.1, and 58.3%, respectively. Overall, there were no significant differences.

Conclusions

Pancreaticoduodenectomy with PDJV resection is feasible for PDAC with PDJVI and satisfactory overall survival rates are achievable. It may be necessary to reconsider the resectability of PDAC with PDJVI.

     

Spectrum of perforation peritonitis in Pakistan: 300 cases Eastern experience

Background

Portal vein gas is an ominous radiological sign, which indicates a serious gastrointestinal problem in the majority of patients. Many causes have been identified and the most important was bowel ischemia and mesenteric vascular accident. The presentation of patients is varied and the diagnosis of the underlying problem depends mainly on the radiological findings and clinical signs. The aim of this article is to show the clinical importance of portal vein gas and its management in emergency surgery.

Methods

A computerised search was made of the Medline for publications discussing portal vein gas through March 2008. Sixty articles were identified and selected for this review because of their relevance. These articles cover a period from 1975–2008.

Results

Two hundreds and seventy-five patients with gas in the portal venous system were reported. The commonest cause for portal vein gas was bowel ischemia and mesenteric vascular pathology (61.44%). This was followed by inflammation of the gastrointestinal tract (16.26%), obstruction and dilatation (9.03%), sepsis (6.6%), iatrogenic injury and trauma (3.01%) and cancer (1.8%). Idiopathic portal vein gas was also reported (1.8%).

Conclusion

Portal vein gas is a diagnostic sign, which indicates a serious intra-abdominal pathology requiring emergency surgery in the majority of patients. Portal vein gas due to simple and benign cause can be treated conservatively. Correlation between clinical and diagnostic findings is important to set the management plan.     

Laparoscopic Right Hepatectomy Extended to Middle Hepatic Vein After Right Portal Vein Embolization

Background

Laparoscopic right hepatectomy (LRH) is a complex but feasible procedure. Preoperative portal vein embolization (PVE) can add difficulties that warrant particular technical modifications. A LRH extended to middle hepatic vein after PVE is presented, with special attention paid to specific operative findings and to useful technical modifications.

Methods

A 62-year-old female patient with a body mass index of 30.5 kg/m² was diagnosed with a 3-cm unresectable centrally located intrahepatic cholangiocarcinoma with infiltration of the retrohepatic vena cava, segment VII portal branch, and adjacent to the middle hepatic vein and portal bifurcation. After four cycles of GEMOX, partial response was observed, disappearing vascular infiltration. PVE was required to perform an extended LRH. Consequently, during pedicle dissection, significant inflammation was found in the vicinity of the right portal vein. Thus, the section of the portal and biliary elements was delayed until the transection of the parenchyma reached the hilum. The opening of the parenchyma improved exposure, allowing the safe management of these structures individually.

Results

The total operative time was 438 min. Three periods of 15-min pedicle occlusion resulted in <100 ml bleeding. Hospital stay was 4 days. Pathological examination revealed residual cholangiocarcinoma with intense posttreatment changes (pT1) and tumor-free margins. After an 18-month follow-up, the patient was alive and free of disease.

Conclusions

LRH is feasible and safe, even after PVE. Nevertheless, periportal inflammation can hinder hilar dissection. In this setting, delaying section of portal and biliary elements until parenchymal transection reaches the hilar region may result in a useful and safe strategy.     

Extended Right Hepatectomy in a Liver with a Non-bifurcating Portal Vein: the Hanging Maneuver Protects the Portal System in the Presence of Anomalies

Introduction

Variations in portal vein anatomy occur in 20–35 % of individuals. A non-bifurcating portal vein (PV) was suspected on preoperative imaging in a patient with a large right lobe hepatocellular carcinoma. The single PV curved within the liver parenchyma from right to left supplying second-order branches along its course.

Case Report

Utilizing the hanging maneuver, an extended right hemihepatectomy was safely performed. This approach allowed for preservation of the main PV and its left-sided branches while easily identifying the second-order right branches for ligation.

Conclusion

Knowledge of portal vein variations and identification preoperatively by cross-sectional imaging are critical. The hanging maneuver aids in the preservation of the main portal vein and its left-sided branches during right hemihepatectomy in the presence of portal vein anomalies, and this technique can be used to improve safety in hepatobiliary surgery.     

The value of the serum I-FABP level for diagnosing acute mesenteric ischemia

Purpose

This study examined the feasibility of using the serum intestinal fatty acid binding protein (I-FABP) level for the early diagnosis of acute mesenteric ischemia, and investigated whether it contributes to the clinical decision-making process.

Method

Thirty patients diagnosed with acute mesenteric ischemia, 27 patients with other types of acute abdomen who presented with acute abdomen symptoms but were not diagnosed with acute mesenteric ischemia, and 20 healthy people were included in the study. Mesenteric ischemia was confirmed by a pathological evaluation in patients who underwent intestinal resection due to detection of mesenteric ischemia during surgery.

Results

There was no significant difference in the leukocyte counts and d-dimer levels between subjects with mesenteric ischemia and acute abdomen due to other causes (p > 0.05). There was a significant difference in the serum I-FABP level between these groups (p < 0.001).

Conclusion

The I-FABP level is a more reliable parameter for diagnosing acute mesenteric ischemia compared to leukocytosis and d-dimer elevation.     

Surgical Outcomes in Hepatocellular Carcinoma Patients with Portal Vein Tumor Thrombosis

Background

Different approaches to surgical treatment of portal vein tumor thrombosis (PVTT) have been advocated. This study investigated the outcomes of different surgical approaches in hepatocellular carcinoma (HCC) patients with PVTT.

Methods

We reviewed prospectively collected data for all patients who underwent hepatectomy for HCC at our hospital between December 1989 and December 2010. Patients were excluded from analysis if they had extrahepatic disease, PVTT reaching the level of the superior mesenteric vein, or hepatectomy with a positive resection margin. The remaining patients were divided into three groups for comparison: group 1, with ipsilateral PVTT resected in a hepatectomy; group 2, with PVTT extending to or beyond the portal vein bifurcation, treated by en bloc resection followed by portal vein reconstruction; group 3, with PVTT extending to or beyond the portal vein bifurcation, treated by thrombectomy.

Results

A total of 88 patients, with a median age of 54 years, were included in the analysis. Group 2 patients were younger, with a median age of 43.5 years versus 57 in group 1 and 49 in group 3 (p = 0.017). Group 1 patients had higher preoperative serum alpha-fetoprotein levels, with a median of 8,493 ng/mL versus 63.25 in group 2 and 355 in group 3 (p = 0.004), and shorter operation time, with a median of 467.5 min versus 663.5 in group 2 and 753 in group 3 (p = 0.018). No patient had thrombus in the main portal vein. Two (2.8 %) hospital deaths occurred in group 1 and one (10 %) in group 2, but none in group 3 (p = 0.440). The rates of complication in groups 1, 2, and 3 were 31.9, 50.0, and 71.4 %, respectively (p = 0.079). The median overall survival durations were 10.91, 9.4, and 8.58 months, respectively (p = 0.962), and the median disease-free survival durations were 4.21, 3.78, and 1.51 months, respectively (p = 0.363). The groups also had similar patterns of disease recurrence (intrahepatic: 33.8 vs. 28.6 vs. 40.0 %; extrahepatic: 16.9 vs. 14.3 vs. 0 %; both: 28.2 vs. 42.9 vs. 40.0 %; no recurrence: 21.1 vs. 14.3 vs. 20.0 %; p = 0.836).

Conclusions

The three approaches have similar outcomes in terms of survival, complication, and recurrence. Effective adjuvant treatments need to be developed to counteract the high incidence of recurrence.