活体右半肝供者肝脏血管和胆道解剖变异分析

目的:探讨活体肝移植右半肝供者血管、胆道解剖学特点。方法:依据门静脉分型、肝静脉解剖分型、胆道分型及肝动脉解剖分型,观察90例右半肝活体肝移植供者的肝静脉、门静脉、肝动脉及胆道的解剖学特点。结果:正常门静脉的比例为94.4%(85/90),三叉型门静脉的比例为5.6%(5/90);肝动脉变异率较高;正常胆道的比例为66.7%(60/90),三叉型胆道占20%(18/90),3型胆道的比例为12.2%(11/90),4型胆道占1.1%(1/90);肝中静脉和肝左静脉共干的比例为70.0%(63/90),大于5mm的肝右下静脉出现概率为26.6%(24/90),左内叶上段静脉汇入肝左静脉的比例为68.8%(62/90),共同汇入肝左静脉和肝中静脉的比例为21.1%(19/90),汇入肝中静脉的比例为10.0%(9/90)。结论:肝脏血管和胆道的解剖变异很常见,准确的术前评估对于活体肝移植至关重要。     

Creating a place for caregivers in personal health: the iHealthSpace copilot program and diabetes care

Background

As America’s baby boom generation reaches retirement, the number of elders, and, in turn, the number of lay individuals who support them, will continue to increase. With the important services caregivers provide, it is critical that we recognize and provide assistance to the informal caregivers who play this important role in our society. The network of support provisioned by relatives, partners, friends, and neighbors suggests that the dyadic, unidirectional caregiver–care recipient relationship assumed by caregiver research so far and by resources deployed to assist caregivers may be insufficient to ascertain and meet the needs of the care community.

Methods

In this article, we describe the extension of a Web-based personal health record system, iHealthSpace, for explicitly and openly incorporating caregivers into the care community.

Results

Using this portal, a set of business rules was implemented to support the creation of custodial accounts. These business rules will be used to create modules that support diabetes care in an adult population.

Conclusions

We successfully extended an existing patient portal to accommodate the creation of custodial accounts. We will use this portal to assess the impact of custodial access in the care of older patients with diabetes.     

The optimal cut-off for predicting large oesophageal varices using transient elastography is disease specific

The diagnosis of cirrhosis requires screening for oesophageal varices by upper gastrointestinal endoscopy. In many countries, serological tests and elastography are replacing liver biopsy for diagnosing cirrhosis. The aims of this study were to see whether there was an optimal cut-off of liver stiffness that could predict the presence of large (>F2) oesophageal varices and whether this was disease specific. A total of two hundred and twenty-two patients with all cause cirrhosis (Child class A) were screened, and 211 had successful elastography and are included in the analysis. Of the patients studied, one hundred and thirty-two patients had no or small F1 varices and 79 had large varices. Liver stiffness of 19.8 kPa had a negative predictive value of 91% and a positive predictive value of 55% with an area under the curve (AUC) on receiver operating characteristics (ROC) of 0.73 in differentiating between small and large varices. Seven patients with large varices would have been incorrectly classified. In the 157 patients with hepatitis C as the aetiology of cirrhosis, the negative predictive value was 98% and only one patient was misclassified. Liver stiffness was superior in diagnostic accuracy to platelet count in all patients. A liver stiffness of >19.8 kPa could be utilized as a cut-off for endoscopy and beta blocker utilization, particularly in patients with hepatitis C.     

Hepatocellular carcinoma with portal vein tumor thrombosis: Improved treatment outcomes with external beam radiation therapy

The treatment of advanced hepatocellular carcinoma (HCC) associated with portal vein tumor thrombosis (PVTT) is very challenging because of HCC's grave prognosis. Despite many efforts to improve the treatment results, patient survival has been limited to several months. In this situation, radiotherapy has been considered as an alternative treatment modality because of the growth of knowledge about the radiotolerance of normal tissue and the advances of radiotherapy techniques such as three dimensional conformal radiotherapy, intensity modulated radiotherapy, stereotactic body radiotherapy and proton therapy. More restoration of the liver function and longer survival of the patients can be achieved by the better response after radiotherapy. However, considering the high risk of intrahepatic advanced tumor or extrahepatic dissemination by PVTT at disease presentation, a combination of radiation therapy and systemic agents will be desirable. Therefore, performing prospective randomized clinical trials is important to assess the benefits of radiotherapy and to develop combination treatment strategies.     

Portal blood supply to locally progressed hepatocellular carcinoma after transcatheter arterial chemoembolization: Observation on CT during arterial portography

Aim: To analyze the clinical features of locally progressed hepatocellular carcinoma (HCC) supplied by portal blood (PB) after transcatheter arterial chemoembolization (TACE). Methods: This cohort included 12 tumors (mean diameter ± SD, 1.8 ± 0.8 cm) in 10 patients. PB supply to tumors was judged by CT during arterial portography (CTAP). Imaging data and the clinical course were retrospectively evaluated. Results: Six tumors initially had a small tumor portion supplied by PB. In four tumors, TACE was incomplete because of technical problems. PB supply to recurrent tumors was demonstrated 7.3 ± 3.7 months after TACE. On follow‐up arteriography, all embolized branches were occluded or severely attenuated. Four tumors showing a partial stain were treated by additional TACE (n = 3) or TACE plus radiofrequency (RF) ablation (n = 1), one without staining was treated by RF ablation, and seven were followed‐up. All tumors progressed except for one treated by RF ablation. On serial CTAP images, relatively large‐diameter portal veins directly entered 11 tumors (91.7%) and connected with intratumoral vessels in nine (75%). During follow‐up, partial arterial supply was demonstrated in two tumors and additional TACE was performed. Nine patients died after 31.4 ± 16.2 months due to tumor progression (n = 8), or hepatic failure (n = 1). One patient has survived for 53 months despite multiple tumors. Conclusions: PB supply to locally progressed tumor after TACE became apparent on CTAP. Arterial damage by TACE, incomplete TACE, and preexisting tumor tissues supplied by PB may be the main causes.     

Predictive factors for long‐term survival in patients with clinically significant portal hypertension following resection of hepatocellular carcinoma

Background: Hepatic resection for hepatocellular carcinoma (HCC) is not currently recommended for patients with clinically significant portal hypertension (PHT); however, recent studies have shown similar post‐operative outcomes between patients with and without clinically significant PHT. Aim: To clarify the post‐operative prognostic relevance of clinically significant PHT in Child–Pugh A cirrhotic patients. Methods: A total of 100 Child–Pugh A cirrhotic patients who underwent curative resection of HCC were eligible for this analysis. Patients were divided into two groups: PHT group (n=47) and non‐PHT group (n=53). Results: Clinicopathological variables showed no significant differences except for prothrombine time. Liver‐related complications were significantly higher in the PHT group (P=0.015), and the 5‐year overall survival rate was significantly higher in the non‐PHT group (78.7 vs. 37.9%, P<0.001). The proportion of patients who died because of complications of cirrhosis was significantly higher in the PHT group (P=0.001). Multivariate analysis indicated that the presence of clinically significant PHT was the most powerful adverse prognostic factor for overall survival. Multivariate analysis of the 47 patients with clinically significant PHT indicated that gross vascular invasion and non‐single nodular type were poor prognostic factors. The 5‐year survival rate of patients with single nodular type and without gross vascular invasion (n=17) was 78.4%. Conclusions: In Child–Pugh A cirrhotic patients, the presence of clinically significant PHT was significantly associated with post‐operative hepatic decompensation and poor prognosis after resection of HCC. However, in patients with clinically significant PHT, those with single nodular tumours lacking gross vascular invasion may be good surgical candidates.     

改良Sugiura手术治疗门静脉高压症18例疗效观察

目的探讨改良Sugiura术治疗门脉高压症的临床疗效。方法回顾性分析有上消化道出血病史的18例门静脉高压症经腹吻合器行改良Sugiura术的临床资料。结果本组无手术死亡病例。术后无吻合口瘘发生。发生吻合口狭窄1例,经食管镜下扩张后缓解,门静脉血栓形成5例,经综合治疗顺利出院,本组16例获得随访,平均时间24.0(3～35)月,无再出血发生。结论经腹吻合器行改良Sugiura手术治疗门脉高压症,具有断流充分、止血彻底、创伤小、术后并发症少等优点,且操作相对简单,值得推广。     

Traumatic pancreatic fistula with sinistral portal hypertension: Surgical management

Combined ductal and vascular injuries are awesome complications of pancreatic injury. We report on a 29-year-old male unrestrained driver who sustained a blunt abdominal injury from the steering wheel in a high velocity head-on car collision. He developed a pancreatic fistula, portosplenic venous thrombosis and sinistral portal hypertension as a result of complete duct disruption at the pancreatic neck. We describe a safe surgical strategy of spleen-preserving distal pancreatectomy after failed medical and endoscopic management.