Intrahepatic portal venous systems in adult patients with cavernous transformation of portal vein: Imaging features and a new classification

Background: Cavernous transformation of the portal vein(CTPV) due to portal vein obstruction is a rare vascular anomaly defined as the formation of multiple collateral vessels in the hepatic hilum. This study aimed to investigate the imaging features of intrahepatic portal vein in adult patients with CTPV and establish the relationship between the manifestations of intrahepatic portal vein and the progression of CTPV. Methods: We retrospectively analyzed 14 CTPV patients in Beijing Tsinghua Changgung Hospital. All patients underwent both direct portal venography(DPV) and computed tomography angiography(CTA) to reveal the manifestations of the portal venous system. The vessels measured included the left portal vein(LPV), right portal vein(RPV), main portal vein(MPV) and the portal vein bifurcation(PVB). Results: Nine males and 5 females, with a median age of 40.5 years, were included in the study. No significant difference was found in the diameters of the LPV or RPV measured by DPV and CTA. The visualization in terms of LPV, RPV and PVB measured by DPV was higher than that by CTA. There was a significant association between LPV/RPV and PVB/MPV in term of visibility revealed with DPV( P = 0.01), while this association was not observed with CTA. According to the imaging features of the portal vein measured by DPV, CTPV was classified into three categories to facilitate the diagnosis and treatment. Conclusions: DPV was more accurate than CTA for revealing the course of the intrahepatic portal vein in patients with CTPV. The classification of CTPV, that originated from the imaging features of the portal vein revealed by DPV, may provide a new perspective for the diagnosis and treatment of CTPV.

Predicting portal venous anomalies by left-sided gallbladder or rightsided ligamentum teres hepatis: A large scale, propensity scorematched study

BACKGROUND Right-sided ligamentum teres(RSLT)is often associated with portal venous anomalies(PVA)and is regarded as a concerning feature for hepatobiliary intervention.Most studies consider RSLT to be one of the causes of left-sided gallbladder(LGB),leading to the hypothesis that LGB must always be present with RSLT.However,some cases have shown that right-sided gallbladder(RGB)can also be present in livers with RSLT.AIM To highlight the rare variation that RSLT may not come with LGB and to determine whether ligamentum teres(LT)or gallbladder location is reliable to predict PVA.METHODS This study retrospectively assessed 8552 contrast-enhanced abdominal computed tomography examinations from 2018 to 2021[4483 men,4069 women;mean age,59.5±16.2(SD)years].We defined the surrogate outcome as major PVAs.The cases were divided into 4 subgroups according to gallbladder and LT locations.On one hand,we analyzed PVA prevalence by LT locations using gallbladder location as a controlled variable(n=36).On the other hand,we controlled LT location and computed PVA prevalence by gallbladder locations(n=34).Finally,we investigated LT location as an independent factor of PVA by using propensity score matching(PSM)and inverse probability of treatment weighting(IPTW).RESULTS We found 9 cases of RSLT present with RGB.Among the LGB cases,RSLT is associated with significantly higher PVA prevalence than typical LT[80.0%vs 18.2%,P=0.001;OR=18,95%confidence interval(CI):2.92-110.96].When RSLT is present,we found no statistically significant difference in PVA prevalence for RGB and LGB cases(88.9%vs 80.0%,P>0.99).Both PSM and IPTW yielded balanced cohorts in demographics and gallbladder locations.The RSLT group had a significantly higher PVA prevalence after adjusted by PSM(77.3%vs 4.5%,P<0.001;OR=16.27,95%CI:2.25-117.53)and IPTW(82.5%vs 4.7%,P<0.001).CONCLUSION RSLT doesn't consistently coexist with LGB.RSLT can predict PVA independently while the gallbladder location does not serve as a sufficient predictor.

Hepatic venous pressure gradient: Inaccurately estimates portal venous pressure gradient in alcoholic cirrhosis and portal hypertension

BACKGROUND Portal hypertension(PHT)in patients with alcoholic cirrhosis causes a range of clinical symptoms,including gastroesophageal varices and ascites.The hepatic venous pressure gradient(HVPG),which is easier to measure,has replaced the portal venous pressure gradient(PPG)as the gold standard for diagnosing PHT in clinical practice.Therefore,attention should be paid to the correlation between HVPG and PPG.METHODS Between January 2017 and June 2020,134 patients with alcoholic cirrhosis and PHT who met the inclusion criteria underwent various pressure measurements during transjugular intrahepatic portosystemic shunt procedures.Correlations were assessed using Pearson’s correlation coefficient to estimate the correlation coefficient(r)and determination coefficient(R^(2)).Bland-Altman plots were constructed to further analyze the agreement between the measurements.Disagreements were analyzed using paired t tests,and P values<0.05 were considered statistically significant.RESULTS In this study,the correlation coefficient(r)and determination coefficient(R2)between HVPG and PPG were 0.201 and 0.040,respectively(P=0.020).In the 108 patients with no collateral branch,the average wedged hepatic venous pressure was lower than the average portal venous pressure(30.65±8.17 vs.33.25±6.60 mmHg,P=0.002).Hepatic collaterals were identified in 26 cases with balloon occlusion hepatic venography(19.4%),while the average PPG was significantly higher than the average HVPG(25.94±7.42 mmHg vs 9.86±7.44 mmHg;P<0.001).The differences between HVPG and PPG<5 mmHg in the collateral vs no collateral branch groups were three cases(11.54%)and 44 cases(40.74%),respectively.CONCLUSION In most patients,HVPG cannot accurately represent PPG.The formation of hepatic collaterals is a vital reason for the strong underestimation of HVPG.

Hepatic portal venous gas in pancreatic solitary metastasis from an esophageal squamous cell carcinoma

BACKGROUND:Hepatic portal venous gas(HPVG) is a rare entity commonly associated with intestinal necrosis and fatal outcome,and various underlying diseases have been reported.Pancreatic solitary metastasis without local extension is also rare in esophageal squamous cell carcinoma.METHODS:This report describes an interesting and unusual case of HPVG arising from pancreatic tumor.Autopsy revealed pathogenesis of HPVG and synchronous tumors of the esophagus and pancreas.RESULTS:A 73-year-old man developed synchronous double tumor in the esophagus and pancreas several months before acute abdomen and his death,which were generated by HPVG.Autopsy revealed that HPVG was caused by gastric wall infarction owing to expansion of an isolated pancreatic metastasis from esophageal squamous cell carcinoma.CONCLUSIONS:This is the first case of HPVG that was derived from pancreatic tumor infiltration.If he had been diagnosed with solitary pancreatic metastasis from esophageal squamous cell carcinoma in the first time,he might have an option for chemotherapy,which could let him live longer.

Significance of pathological positive superior mesenteric/portal venous invasion in pancreatic cancer

BACKGROUND： Pancreaticoduodenectomy with superior mesenteric/portal venous resection for pancreatic ductal ad- enocarcinoma （PDAC） is frequently performed with no added morbidity or mortality in case of tumor abutment to the superior mesenteric or portal vein so as to obtain a margin negative resection. True histopathological portal vein invasion is found only in a small subset of such patients. The aim of this review aimed to discuss the significance of histopathological venous invasion in PDAC.DATA SOURCES： For this review available data was searched from PubMed and analyzed. No randomized trials have been published on this topic. RESULTS： Existing data on prognostic factors in histopathological venous invasion by PDAC are limited and recent studies indicate worse survival in this subgroup of patients. In addition, venous invasion in PDAC has been associated with large tumors, involved lymph nodes, perineural invasion and R1 resection. The survival of patients with portal venous re- section but without histologic venous invasion is reportedly better than those with histopathological venous invasion; though conflicting studies do exist on the subject. Some studies also relate the depth of venous invasion to prognosis after surgical resection of PDAC. CONCLUSIONS： Frank/＇histopathological＇ invasion of superior mesenteric/portal venous and R1 resection indicate a very poor survival. Such patients may be given the opportunity of benefit of neoadjuvant treatment.

Preoperative application of combination of portal venous injection of donor spleen cells and intraperitoneal injection of rapamycin prolongs the survival of cardiac allografts in mice

Objective:To investigate the effects of preoperative portal venous injection of donor spleen cells(PVIDSC) and intraperitoneal injection of rapamycin in the acute rejection of cardiac allograft in mice and the underlying mechanisms. Methods:Homogenous female B6 mice and BALB/c mice were used as recipients and donors of heart transplantation. These mice were randomly divided into different groups and received PVIDSC alone,rapamycin alone,or PVIDSC and rapamycin combined therapy. In addition,the underlying mechanism was studied by measuring a number of cytokines. Results:Preoperative combination of PVIDSC and intraperitoneal injection of rapamycin significantly prolonged the survival of heterotopic cardiac allograft in mice,but had no effects on the survival time of cardiac allografts in mice pre-sensitized by skin grafting. Preoperative combination of PVIDSC and intraperitoneal injection of rapamycin increased the expression of IL-10 and Foxp3 and reduced the expression of INF-γ. Short-term preoperative administration of rapamycin promotes the expression of CD4^+CD25^+Foxp3^+ regulator T cells. However,preoperative using alone of rapamycin,or combination of PVIDSC and rapamycin had no effects on the inhibition of proliferation of memory T cells. Conclusions:Preoperative application of combination of PVIDSC and rapamycin significantly prolonged the survival time of cardiac allografts in mice but not in mice pre-sensitized by skin grafting. This may be explained by the fact that combination of PVIDSC and rapamycin inhibited the cellular immune response and induced the expression of IL-10 from Tr1 cells and CD4^+CD25^+FoxP3^+ regulatory T cells.

Hepatic portal venous gas without definite clinical manifestations of necrotizing enterocolitis in a 3-day-old full-term neonate:A case report

BACKGROUND Neonatal hepatic portal venous gas(HPVG)is associated with a high risk of necrotizing enterocolitis(NEC)and was previously believed to be associated with an increased risk of surgery.CASE SUMMARY A 3-day-old full-term male infant was admitted to the pediatrics department after presenting with"low blood glucose for 10 min".Hypoglycemia was corrected by intravenous glucose administration and oral breast milk.On the 3rd d after admission,an ultrasound examination showed gas accumulation in the hepatic portal vein;this increased on the next day.Abdominal vertical radiograph showed intestinal pneumatosis.Routine blood examination showed that the total number of white blood cells was normal,but neutrophilia was related to age.There was a significant increase in C-reactive protein(CRP).The child was diagnosed with neonatal NEC(early-stage).With nil per os,rehydration,parenteral nutritional support,and anti-infection treatment with no sodium,his hepatic portal vein pneumatosis resolved.In addition,routine blood examination and CRP examination showed significant improvement and his symptoms resolved.The patient was given timely refeeding and gradually transitioned to full milk feeding and was subsequently discharged.Follow-up examination after discharge showed that the general condition of the patient was stable.CONCLUSION The presence of HPVG in neonates indicates early NEC.Early active anti-infective treatment is effective in treating NEC,minimizes the risk of severe NEC,and reduces the need for surgery.The findings of this study imply that early examination of the liver by ultrasound in a sick neonate can help with the early diagnosis of conditions such as NEC.

A new choice of stent for transjugular intrahepatic portosystemic shunt creation: Viabahn ePTFE covered stent/bare metal stent combination

Objectives:To compare the clinical outcomes in terms of structure and function between the insertion of a transjugular intrahepatic portosystemic shunt(TIPS) created with the Viabahn ePTFE covered stent/bare metal stent(BMS) combination and the Fluency ePTFE covered stent/BMS combination.Methods:A total of 101 consecutive patients who received a TIPS from February 2016 to August 2018 in our center were retrospectively analyzed.Sixty-four subjects were enrolled in the Viabahn group and 37 were enrolled in the Fluency group.The geometry characteristics of the TIPS were calculated,and the associated occurrence of shunt dysfunction,survival,overt hepatic encephalopathy,and variceal rebleeding were evaluated.Results:The technical success rate was 100%.After the insertion of the TIPS,the rate of shunt dysfunction during the first 3 months was significantly different between the Viabahn and Fluency groups(1.6% and 13.5%,respectively;p=0.024).Multivariate analysis indicated that the angle of portal venous inflow(α) was the only independent risk factor for shunt dysfunction(hazard ratio=1.060,95% confidence interval=1.009-1.112,p=0.020).In addition,3 months after the TIPS insertion,the a angle distinctly increased from 20.9°±14.3°-26.9°±20.1°(p=0.005) in the Fluency group but did not change significantly in the Viabahn group(from 21.9°±15.1°-22.9°± 17.6°,p=0.798).Conclusions:Shunt dysfunction was related to the a angle owing to the slight effect on the a angle after the implantation of the TIPS.The Viabahn ePTFE covered stent/BMS combination was more stable in structure and promised higher short-term stent patency compared with the Fluency ePTFE covered stent/BMS combination.

Percutaneous transhepatic portal catheterization guided by ultrasound technology for islet transplantation in rhesus monkey

BACKGROUND:Pig islet xenotransplantation has the potential to overcome the shortage of donated human islets for islet cell transplantation in type 1 diabetes.Testing in nonhuman primate models is necessary before clinical application in humans.Intraportal islet transplantation in monkeys is usually performed by surgical infusion during laparotomy or laparoscopy.In this paper,we describe a new method of percutaneous transhepatic portal catheterization(PTPC) as an alternative to current methods of islet transplantation in rhesus monkeys.METHODS:We performed ultrasound-guided PTPC in five adult rhesus monkeys weighing 7-8 kg,with portal vein catheterization confirmed by digital subtraction angiography.We monitored for complications in the thoracic and abdominal cavity.To evaluate the safety of ultrasound-guided PTPC,we recorded the changes in portal pressure throughout the microbead transplantation procedure.RESULTS:Ultrasound-guided PTPC and infusion of 16 000 microbeads/kg body weight into the portal vein was successful in all five monkeys.Differences in the hepatobiliary anatomy of rhesus monkeys compared to humans led to a higher initial complication rate.The first monkey died of abdominal hemorrhage 10 hours post-transplantation.The second suffered from a mild pneumothorax but recovered fully after taking only conservative measures.After gaining experience with the first two monkeys,we decreased both the hepatic puncture time and the number of puncture attempts required,with the remaining three monkeys experiencing no complications.Portal pressures initially increased proportional to the number of transplanted microbeads but returned to preinfusion levels at 30 minutes post-transplantation.The changes in portal pressures occurring during the procedure were not significantly different.CONCLUSIONS:Ultrasound-guided PTPC is an effective,convenient,and minimally invasive method suitable for use in non-human primate models of islet cell transplantation provided that care is taken with hepatic puncture.Its advantages must be weighed against the risks of procedure-related complications.

The spectrum of pneumatosis intestinalis in the adult.A surgical dilemma

Pneumatosis intestinalis(PI) is a striking radiological diagnosis. Formerly a rare diagnostic finding, it is becoming more frequently diagnosed due to the wider availability and improvement of computed tomography scan imaging. Once associated only with poor outcome, its clinical and prognostic significance nowadays has to be cross-referenced to the nature of the underlying condition.Multiple mechanisms of pathogenesis have been debated and multiple causes have been detected during the years. All this contributes to creating a broad range of clinical and radiological presentations. The management of patients presenting PI is related to the determining cause if it is identified. Otherwise, in particular if an association with portal venous gas and/or pneumoperitoneum is present, the eventual decision between surgery and non-operative management is challenging,even for stable patients, since this clinical condition is traditionally associated to intestinal ischemia and consequently to pending clinical collapse if not treated.Considering the wide variety of origin and outcomes, PI still remains for surgeons a demanding clinical entity. The manuscript is an updated narrative review and gives some suggestions that may help make the decisional process easier,identifying patients who can benefit from surgical intervention and those who can benefit from non-operative management avoiding unnecessary procedures.

Effects of portal venous arterialization on acute occlusion of hepatic artery in rats

Background A fatal complication after liver transplantation is anastomotic embolization of the hepatic artery. In order to solve this problem, the portal venous arterialization （PVA） is used to reconstruct the hepatic arterial blood flow. The purpose of this study was to investigate the influence of PVA on rats with acute occlusion of hepatic artery. Methods Rat PVA models were established and then randomly divided into Group 1 （control group）, Group 2 （jaundice group）, Group 3 （bile duct recanalization group）, and Group 4 （portal vein arterilization group）. Recanalization of the common bile duct and PVA were performed 5 days after bile duct ligation in the rats. The influence of the PVA on general conditions, hepatic changes of structure and function, portal vein pressure and hepatic micrangium were observed for one month. Results Five days after common bile duct ligation the serum bilirubin, transaminase and alkaline phosphatase levels were significantly increased. Compared with group 1, there was a statistically significant difference （P 〈0.01）. These rats then underwent bile duct recanalization and PVA. After a month, the liver functions and microscopic structures completely returned to normal and, compared with group 1, there was no statistically significant difference in portal vein pressure （P 〉0.05）. Vascular casting samples showed that hepatic sinusoids were slightly thicker and more filled than normal ones and although they had some deformations, the hepatic sinusoids were still distributed around the central vein in radial form. Conclusion Within a month after operation, bile duct recanalization and PVA do not show obvious adverse effects on liver hemodynamics and hepatic micrangium, and the liver function and microscopic structure can return to normal.

Pancreatic neuroendocrine carcinoma in a pregnant woman:A case report and review of the literature

BACKGROUND Portal venous thromboembolism caused by malignant pancreatic neuroendocrine tumor metastasis,as the initial presentation of portal hypertension and upper gastrointestinal bleeding,is a rare entity.To our knowledge,there are no reports of this entity in pregnant women.We describe a case of pancreatic neuroendocrine carcinoma during pregnancy with hematemesis and hematochezia as the initial presentation and review the literature to analyze the demographic,clinical,and pathological features to provide a reference for clinical diagnosis and treatment.CASE SUMMARY A 40-year-old woman presented with hematemesis and hematochezia at 26-wk gestation;she had no other remarkable medical history.The physical examination revealed normal vital signs,an anemic appearance,and lower abdominal distension.Abdominal color Doppler ultrasonography showed portal vein thrombosis,splenomegaly,intrauterine pregnancy,and intrauterine fetal death.Esophagogastroduodenoscopy revealed esophageal and gastric varicose veins and portal hypertensive gastropathy.Contrast-enhanced computed tomography demonstrated multiple emboli formation in the portal and splenic veins,multiple round shadows in the liver with a slightly lower density,portal vein broadening,varicose veins in the lower esophagus and gastric fundus,splenomegaly,bilateral pleural effusion,ascites and pelvic effusion,broadening of the common bile duct,and increased uterine volume.According to the results of Positron emission tomography-computed tomography and immunohistochemical staining,the final diagnoses were that the primary lesion was a pancreatic neuroendocrine tumor and that there were secondary intrahepatic metastases and venous cancer thrombogenesis.CONCLUSION Upper gastrointestinal bleeding in a pregnant woman may be caused by portal hypertension due to a malignant pancreatic neuroendocrine tumor.

Portal Hypertension in Nonalcoholic Fatty Liver Disease: Challenges and Paradigms

Portal hypertension in cirrhosis is defined as an increase in the portal pressure gradient(PPG)between the portal and hepatic veins and is traditionally estimated by the hepatic venous pressure gradient(HVPG),which is the difference in pressure between the free-floating and wedged positions of a balloon catheter in the hepatic vein.By convention,􀀫HVPG≥10mmHg indicates clinically significant portal hypertension,which is associated with adverse clinical outcomes.Nonalcoholic fatty liver disease(NAFLD)is a common disorder with a heterogeneous clinical course,which includes the development of portal hypertension.There is increasing evidence that portal hypertension in NAFLD deserves special considerations.First,elevated PPG often precedes fibrosis in NAFLD,suggesting a bidirectional relationship between these pathological processes.Second,HVPG underestimates PPG in NAFLD,suggesting that portal hypertension is more prevalent in this condition than currently believed.Third,cellular mechanoresponses generated early in the pathogenesis of NAFLD provide a mechanistic explanation for the pressurefibrosis paradigm.Finally,a better understanding of liver mechanobiology in NAFLD may aid in the development of novel pharmaceutical targets for prevention and management of this disease.

Portal venous gas resulting from umbilical vein catheterization in a very-low-birth-weight infant with no interruption in early feeding

Introduction Portal venous gas(PVG)is common in necrotizing enterocolitis and occasionally occurs in neonates after umbilical vein catheterization(UVC).Therefore,determining the cause of PVG requires further clinical evaluation in these cases.Case presentation We report the case of a very-low-birth-weight infant who underwent UVC after birth.PVG was an unexpected finding on ultrasound following catheterization.The UVC was immediately removed and replaced with a peripherally inserted central catheter.The infant’s physical examination was unremarkable.Bedside X-ray revealed neither PVG nor pneumatosis intestinalis,which would indicate the onset of necrotizing enterocolitis.After full evaluation,breastfeeding was started on the same day.The infant did not develop feeding intolerance,necrotizing enterocolitis,or other disorders.Conclusion PVG occasionally occurs in neonates who undergo UVC and is considered to be caused by exogenous gases.PVG is more easily detected with ultrasound than with X-ray and does not affect early feeding in premature infants.