Caval reconstruction techniques in orthotopic liver transplantation

There are several caval reconstruction techniques currently in use for orthotopic liver transplantation. These include caval replacement or the conventional technique, performed with or without venovenous bypass, piggyback technique with anastomosis with two or three hepatic veins with or without cavotomy and modifications of the piggyback technique including end-to-side and side-to-side cavocaval anastomosis. There are few randomized controlled trials comparing the use of these techniques and our knowledge of their comparability is based on a few multi- and many single-center retrospective and prospective reviews. Although there are advantages and disadvantages for each technique, it is advisable that the surgeon perform the technique with which they have the most the experience and at which they are the most skilled as excellent outcomes can be obtained with any of the caval reconstruction options discussed.

Pentadecapeptide BPC 157 resolves suprahepatic occlusion of the inferior caval vein, Budd-Chiari syndrome model in ratsPentadecapeptide BPC 157 resolves suprahepatic occlusion of the inferior caval vein, Budd-Chiari syndrome model in rats

BACKGROUND Recently,as a possible therapy resolving solution,pentadecapeptide BPC 157 therapy,has been used in alleviating various vascular occlusion disturbances.BPC 157 was previously reviewed as novel mediator of Robert cytoprotection and endothelium protection in the stomach,and gut-brain axis,beneficial therapy in gastrointestinal tract,with particular reference to vascular recruitment,ulcerative colitis and tumor cachexia,and other tissues healing.Here we raised new hypothesis about BPC 157 therapy in the Budd-Chiari syndrome in rats,rapid bypassing of the suprahepatic inferior caval vein occlusion,and rats recovery with the active and effective pharmacotherapy treatment.AIM To investigate Budd-Chiari syndrome model(inferior caval vein suprahepatic occlusion)resolution,since BPC 157 resolves various rat vascular occlusion.METHODS We assessed the activated bypassing pathways between the inferior and superior caval veins and portocaval shunt,counteracted caval/portal hypertension,aortal hypotension,venous/arterial thrombosis,electrocardiogram disturbances,liver and gastrointestinal lesions(i.e.,stomach and duodenum hemorrhages,in particular,congestion).Rats with suprahepatic occlusion of the inferior vena cava by ligation were medicated at 1 min,15 min,24 h,or 48 h post-ligation.Medication consisted of 10μg/kg BPC 157,10 ng BPC 157 or 5 m L/kg saline,administered once as an abdominal bath or intragastric application.Gross and microscopic observations were made,in addition to assessments of electrical activity of the heart(electrocardiogram),portal and caval hypertension,aortal hypotension,thrombosis,hepatomegaly,splenomegaly and venography.Furthermore,levels of nitric oxide,malondialdehyde in the liver and serum enzymes were determined.RESULTS BPC 157 counteracted increased P wave amplitude,tachycardia and ST-elevation,i.e.,right heart failure from acute thrombotic coronary occlusion.The bypassing pathway of the inferior vena cava-azygos(hemiazygos)vein-superior vena cava and portocaval shunt occurred rapidly.Even with severe caval portal hypertension,BPC 157 antagonized portal and caval hypertension and aortal hypotension,and also reduced refractory ascites.Thrombosis of portal vein tributaries,inferior vena cava,and hepatic and coronary arteries was attenuated.In addition,there was reduced pathology of the lungs(severe capillary congestion)and liver(dilated central veins and terminal portal venules),decreased intestine hemorrhagic lesions(substantial capillary congestion,submucosal edema and architecture loss),and increased liver and spleen weight.During the period of ligation,nitric oxide-and malondialdehyde-levels in the liver remained within normal healthy values,and increases in serum enzymes were markedly reduced.CONCLUSION BPC 157 counteracts Budd Chiari syndrome in rats.

Improvement of Cardiac Function by Dry Weight Optimization Based on Interdialysis Inferior Vena Caval Diameter (1)

In hemodialysis (HD) patients, the diameter of the inferior vena cava (IVC) serves for evaluation of the amount of body fluid.

Caval replacement with parietal peritoneum tube graft for septic thrombophlebitis after hepatectomy: A case report

BACKGROUND Caval vein thrombosis after hepatectomy is rare, although it increases mortality and morbidity. The evolution of this thrombosis into a septic thrombophlebitis responsible for persistent septicaemia after a hepatectomy has not been reported to date in the literature. We here report the management of a 54-year-old woman operated for a peripheral cholangiocarcinoma who developed a suppurated thrombophlebitis of the vena cava following a hepatectomy.CASE SUMMARY This patient was operated by left lobectomy extended to segment V with bile duct resection and Roux-en-Y hepaticojejunostomy. After the surgery, she developed Streptococcus anginosus, Escherichia coli, and Enterococcus faecium bacteraemias, as well as Candida albicans fungemia. A computed tomography scan revealed a bilioma which was percutaneously drained. Despite adequate antibiotic therapy,the patient's condition remained septic. A diagnosis of septic thrombophlebitis of the vena cava was made on post-operative day 25. The patient was then operated again for a surgical thrombectomy and complete caval reconstruction with a parietal peritoneum tube graft. Use of the peritoneum as a vascular graft is an inexpensive technique, it is readily and rapidly available, and it allows caval replacement in a septic area. Septic thrombophlebitis of the vena cava after hepatectomy has not been described previously and it warrants being added to the spectrum of potential complications of this procedure.CONCLUSION Septic thrombophlebitis of the vena cava was successfully treated with antibiotic and anticoagulation treatments, prompt surgical thrombectomy and caval reconstruction.

Porta-caval fibrous connections-the lesser-known structure of intrahepatic connective-tissue framework:A unified view of liver extracellular matrix

Knowledge about the connective-tissue framework of the liver is not systematized,the terminology is inconsistent and some perspectives on the construction of the hepatic matrix components are contradictory.In addition,until the last two decades of the 20th century,the connective-tissue sheaths of the portal tracts and the hepatic veins were considered to be independent from each other in the liver and that they do not make contact with each other.The results of the research carried out by Professor Shalva Toidze and his colleagues started in the 1970s in the Department of Operative Surgery and Topographic Anatomy at the Tbilisi State Medical Institute have changed this perception.In particular,Chanukvadze I showed that in some regions where they intersect with each other,the connective tissue sheaths of the large portal complexes and hepatic veins fuse.The areas of such fusion are called porta-caval fibrous connections(PCFCs).This opinion review aims to promote a systematic understanding of the hepatic connective-tissue skeleton and to demonstrate the hitherto underappreciated PCFC as a genuine structure with high biological and clinical significance.The components of the liver connective-tissue framework—the capsules,plates,sheaths,covers—are described,and their intercommunication is discussed.The analysis of the essence of the PCFC and a description of its various forms are provided.It is also mentioned that analogs of different forms of PCFC are found in different mammals.

Simulation of the Hydrodynamic Functioning of the Cavally River Using a Coupled 1D-2D Model in the Ity Area (Zouan-Hounien in Côte d’Ivoire)

In recent years, the Cavally River has been subject to multiple activities, including the construction of diversion channels and a bridge that makes it vulnerable to flooding. In order to assess the impact of these hydraulic structures on the river hydrodynamic functioning, a 1D-2D model was realized. The implementation of the 1D-2D model consisted of first running the 1D model, then the 2D model, and finally in coupling them. The 1D-2D model was designed with the 1988 flood hydrograph, a Manning’s coefficient of 0.052 m1/3/s for the minor bed and 0.06 m1/3/s for the major bed. The results of the hydraulic model show that the velocities are almost identical to those of the Cavally in natural operation. The values of the velocities are included between 0.4 m/s and 1.3 m/s at the level of the minor bed of the river and between 0.06 m/s and 0.71 m/s at the level of the floodplains. The average water level for flood propagation is 262.37 ± 0.44 m before construction of the structures and 262.23 ± 0.85 m after construction of the structures. The 0.41 m reduction in water level due to the diversion canal and bridge is negligible compared to the total fluctuations of the Cavally River, which vary from 6 to 7 m over the year.

Comparative Effectiveness of Median Sternotomy vs Minimal Access Cardiopulmonary Bypass and Circulatory Arrest for Resection of Renal Cell Carcinoma with Inferior Vena Caval Extension

Introduction: The use of cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA) is an adjunctive surgical technique that can be employed for the resection of renal cell carcinoma (RCC) with venous thrombus extension superior to the level of the hepatic veins. Median Sternotomy (MS) or Minimal Access (MA) incisions may be used to establish CPB during the resection of these extensive tumors. We review our experience with both incisional approaches and compareoperative details, perioperative complications, and recurrence free survival. Materials and Methods: From 1986 to 2012, 70 radical nephrectomies with concomitant inferior vena cava (IVC) thrombectomies were performed at our institution using MS (23 patients) and MA (47 patients) techniques. Preoperative patient characteristics, pathologic data, and organ specific postoperative complications and follow-up data were compared between groups. Estimates of overall and recurrence-free survival were constructed using Kaplan-Meier curves and compared using log-rank testing. Results: There were no significant differences with respect to patient demographics or preoperative comorbid conditions between the MA and MS groups. The MA group showed a significant reduction (p 0.05) in the duration of postoperative mechanical ventilation, length of stay, operative time, and number of blood transfusions compared to MS patients. Overall and organ-system specific complications demonstrated a decreased incidence of wound infection (37.9% v. 12.5%, p = 0.0135) and sepsis (14.3% v. 0%, p = 0.0137) in patients undergoing MA approach. Perioperative mortality was significantly reduced in the MA group (30.4% v. 8.5% p = 0.0179). Recurrence-free survival in the MS group was 0.59 years and 1.2 years in the MA group (p = 0.06). Conclusions: Minimal access surgical approaches for CPB and DHCA during the resection of RCC with extensive tumor thrombus provide similar oncologic control with decreased duration of mechanical ventilation, length of stay and infection related complications. Our findings suggest that MA techniques provide significant advantages over MS.

The Mesenteric-Caval Fistula: First Results of a New Technique in a Transperitoneal Reconstruction of the Caval Vein by Fulminant Thrombosis of the Inferior Vena Cava Based on Homozygous Antithrombin III-Deficiency

Recurrent thrombotic occlusions are one major problem in patients with thrombosis of the inferior vena cava. Due to this, we report a new surgical strategy for the construction of aorto-caval (mesenteric-caval) fistula in a patient with homozygous Antithrombin III (ATIII)-Deficiency. The patient survived postoperatively and only surgical complications grade I and II (Clavien-Dindo classification) were reported after short-term and one year follow-up. After one year, the CT-angiography did not show any caval thrombosis or stenosis and no restriction or occlusion of the fistula. Thus, the mesenteric-caval fistula could be safely performed and resulted in a satisfactory patency.

Roberto Cavalli野性艺术

意大利的艺术史上绝不缺少天才画家,生活于16世纪末至17世纪初的卡拉瓦乔便是其中相当著名的一位,他色彩浓郁、笔触细腻的画作,启发了设计师RobertoCavalli的灵感,这个米兰时装周上最为"野性"的品牌,在2013秋冬季,呈现出了令人迷醉的艺术气息,Roberto Cavalli将卡拉瓦乔的画作幻化为斑斓多姿的花朵图案,与浓密丰厚的皮草、精雕细琢的昆虫造型珠宝首饰相映成趣.

1D-2D Hydraulic Modeling of a Diversion Channel on the Cavally River in Zouan-Hounien,Cote d’Ivoire

On the Cavally River, located on the border between C?te d’Ivoire and Liberia, several hydraulic structures such as bridges and diversion channels are planned to be made in recent years in the operating perimeter of the Ity mining company. A 1D-2D hydraulic model was developed to design a diversion channel to cut a meander of the Cavally River in order to ensure hydraulic operation similar to the initial conditions of the river (water levels, flow and velocities). This model was designed with a flow rate of 240 m3/s and a Manning coefficient of 0.052 m1/3·s-1 for the minor bed and 0.06 m1/3·s-1 for the major bed. The results from the hydraulic model show that the hydraulic conditions (water levels, velocities) in the channel before and after the diversion remain almost like those of the Cavally River.

LG限量版 Roberto Cavalli

Roberto Cavalli时尚手机源自其独特的设计理念,采用独有的手绘动物图案,把最具个性的豹纹、蛇纹再分别配以恰到好处的黄晶玉、葡萄酒红的颜色渲染,散发着宜古宜今的贵族气质,透露出浑然天成的曲线自信,

Rain-Flow Modeling Using a Multi-Layer Artificial Neural Network on the Watershed of the Cavally River(Cote d’Ivoire)

Water resources management is nowadays a significant stake for the world. However, missing or bad quality of the hydro-climatic historical data available of the studied area makes sometimes hydrological studies difficult. Generally, conceptual rain-flow models are designed to bring an appropriate answer with the correction of gaps and prediction of the flows. Historical hydro-climatic data of the Ity station, located on Cavally River, contain gaps which must be bridged. This study aims to establish a rainfall-runoff model through artificial neural networks for filling the gaps into the flow data series of the hydrometric station of Ity on the watershed of Cavally River. A multi-layer perceptron of feed forwards with two entries (monthly average rain and evapotranspiration) and an exit (flows) was established with flow evapotranspiration data. Comparison of the criteria of performance of the various architectures of the neural network model showed that architecture 2-3-1 gives best results. This architecture provides Nash coefficients of 75.79% and correlation linear coefficient of 95.64% for the calibration and Nash coefficients of 73.32% and correlation linear coefficient of 98.33% for the validation. The correlations between simulated flows and observed flows are strong. The correlation coefficients are 83.89% and 83.08% respectively for the calibration and validation.

新的梦境 Roberto Cavalli

大面积的兽纹,性感的礼服、裸露的肌肤……Roberto Cavalli的秀场似乎留给大家的都是这样的固有印象,但是当Roberto Cavalli 2013舂夏女装秀开场的白色Look亮相时,这位永远充满激情的设计师带给我们的惊喜和变革也就拉开了序幕.

Decompensated porto-pulmonary hypertension in a cirrhotic patient with thrombosis of portocaval shunt

We report a case of decompensated porto-pulmonary hypertension closely associated with the development of intra-portocaval shunt thrombosis. A woman with Laennec's cirrhosis was hospitalized because of severe dyspnea and edema. She underwent surgical portocaval anastomosis ten years ago. Imaging studies showed massive intra-shunt thrombosis,portal hypertension,ascites,pleuro-pericardial effusions and enlargement of right cardiac cavities. Cardiac catheterization allowed to rule out coronary and left-sided heart abnormalities and led to the diagnosis of pre-capillary pulmonary hypertension. Antithrombotic treatment with low molecular weight heparin was instituted. The management also included ACE inhibitors,spironolactone,low-salt diet and lactulose. The patient was discharged and three months later we observed the disappearance of edema,ascites and pleuro-pericardial effusions,a marked body weight reduction and improved dyspnea and liver function tests. A possible link between the development of intra-shunt thrombosis and clinical decompensation in our patient was hypothesized. In fact,it has been demonstrated that the increased portal pressure,caused by occlusion of portosystemic shunt,reduces renal plasma flow and increases systemic endothelin-1 concentration. In our patient the disappearance of edematous state and improved dyspnea observed after recanalization of the shunt strongly support this hypothesis.

Renal cell carcinoma with vena caval tumor thrombus extending into the right atrium

The incidence of the inferior vena cava （IVC） tumor thrombus is reported to be 4%-10% in patients with renal cell carcinoma （RCC）. Tumor thrombus may extend through to the right atrium. Management of patients with level Ⅲ/Ⅳ tumor thrombus is usually difficult. We report two cases of level Ⅳ thrombus in our hospital in 2002 and 2004.

下肢深静脉血栓的介入治疗

目的探讨下肢深静脉血栓(LEDVT)介入治疗的效果。方法237例LEDVT患者接受下肢静脉造影和介入性治疗,其中102例植入永久下腔静脉滤器(IVCF),11例植入临时IVCF;151例血管内留置导管溶栓;86例导管血栓碎吸基础上导管溶栓;26例股、髂静脉单纯PTA,37例并支架植入。结果介入治疗有效率97.89%,肺栓塞(PE)13例,经介入溶栓均抢救成功。结论经皮经腔介入治疗LEDVT疗效较好。使用插管溶栓、机械性血栓碎吸等个体化组合应用可提高成功率、降低并发症率。

膀胱压、上腔静脉压、下腔静脉压与腹腔内压的关系研究

目的:研究膀胱压、上腔静脉压、下腔静脉压与腹腔内压的关系。方法:对8只健康雄性杂种犬,分别行上腔静脉、下腔静脉置管,接压力换能器监测静脉压力,放置尿管接换能器监测膀胱压。腹腔穿刺置管监测腹腔内压并注入生理盐水,分别监测腹腔内压在基础状态及15、20、30、40 mmHg(1 mmHg=0.133 kPa)时膀胱压、上腔静脉压和下腔静脉压的变化。记录不同腹腔内压条件下犬的心率(HR)、右股动脉平均动脉压(MAP)。结果:犬的基础腹腔内压为(10±1)mmHg,随着腹腔内压增高,犬右股动脉MAP较基础值也明显增高(P<0.05)。当腹腔内压逐步增加至15、20、30、40 mmHg时,膀胱压、上腔静脉压力、下腔静脉压力随之增加(P<0.05)。不同腹腔内压条件下,膀胱压、上腔静脉压、下腔静脉压与腹腔内压明显相关(分别为r=0.95,P<0.05;r=0.92,P<0.05;r=0.94,P<0.05)。结论:在犬模型中,通过监测膀胱压、上腔静脉压、下腔静脉压可以较好地反映腹腔内压。

下腔静脉滤器血栓形成局部置管溶栓与外周静脉溶栓治疗的比较

目的对比局部置管溶栓和外周静脉溶栓治疗在下腔静脉滤器血栓形成中的溶栓疗效,缩短滤器植入时间,提高滤器取出率,降低滤器永久植入后中远期合并症。方法采用单中心前瞻性研究的方法,收集2013年2月至2014年8月期间北京积水潭医院血管外科收治的创伤性下肢骨折合并深静脉血栓并放置可回收性腔静脉滤器(Opt Ease)的患者,下腔静脉造影或彩超发现滤器下血栓≥1.0 cm者,采用随机数字表法分组,进行外周溶栓或导管溶栓治疗,对滤器的取出率进行对比分析讨论。结果外周溶栓组30例,滤器取出11例,取出率36.7%,导管溶栓组30例,滤器取出24例,取出率80.0%,导管溶栓组取出率明显高于外周溶栓取出率(P<0.05);两组间溶栓治疗后血栓大小变化的对比,导管溶栓组的溶栓效果优于外周溶栓组(P<0.05)。滤器取出后无再发肺栓塞表现。结论在下腔静脉滤器血栓形成中局部置管溶栓效果明显优于外周静脉溶栓治疗。

国产ZQL型可回收式腔静脉滤器临床应用研究

目的评价ZQL型可回收式腔静脉滤器预防肺动脉血栓栓塞的安全和有效性。方法144例具有下腔静脉滤器植入适应证患者,常规经股静脉（37）或颈静脉（107）置入144枚滤器,滤器置入后定期腹部平片和下腔静脉彩超评价下腔静脉和滤器位置、通畅情况。滤器植入后如果下肢深静脉血栓在2周内清除,则取出滤器。取出前分别摄腹部平片及行下腔静脉、肺动脉造影。否则该滤器将作为永久滤器长期留置后并继续进行随访观察。结果144滤器均成功置入预定部位,未发生滤器展开不良。置入技术成功率为100%,一次置入成功率为98.61%,2次植入成功率为100%。随访成功137例（随访率为95.14%）,其中43枚滤器于置入后7～14天（中位12天）取出。余94例随访7天～39个月（中位随访期为17个月）,未发生滤器移位、倾斜、滤器断裂或滤器穿透静脉壁造成血肿并发症。无下腔静脉闭塞发生,随访期内全部患者未再发生症状性肺动脉栓塞。结论本研究结果表明ZQL型可回收式腔静脉滤器预防肺动脉血栓栓塞是安全、有效的。其独特的支架式设计具有稳定性好、捕获效能高、置入与取出容易,符合临床需求的特性。