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Background: Hepatocellular carcinoma (HCC) is the most common type of liver cancer, with 10-40% of cases involving portal vein tumor thrombosis (PVTT), leading to poor outcomes and a short survival. The effectiveness of PVTT treatment in patients with HCC is still controversial. Methods: This prospective dual-center study cohort comprised 60 patients with HCC and PVTT who underwent PVR-EPRFA-ST using a novel intravascular radiofrequency system followed by vascular stent placement across the PVTT stenosed segment under fluoroscopy guidance. Results: PVR-EPRFA-ST was technically and clinically successful in 54/60 (90%) and 37/54 (68.5%) patients, respectively. The mean tumor size, PVTT length, post-ablation luminal diameter, and median duration of the recanalized PV patency were 8.6 ± 3.4 cm, 4.1 ± 2.1 cm, 10.3 ± 1.8 mm, and 13.4 months. Higher technical and clinical success rates were associated with a longer survival (177 ± 17.3 days, HR: 0.3, 95%CI 0.12-0.71, p = 0.04; and 233 ± 18.3 days, HR: 0.14, 0.07-0.27, p < 0.001). A shorter survival was associated with Child-Pugh C (HR: 2.7, p = 0.04), multiple tumors (HR: 1.81, p = 0.03), and PVTT length (HR: 1.16, p = 0.04). Conclusions: PVR-EPRFA-ST was feasible and effective for the treatment of selected patients with PVTT, especially in patients with Child-Pugh A/B, single tumors, or a shorter PVTT length.

Pylephlebitis is a rare but serious complication, associated with risks such as liver abscesses, sepsis, and acute liver failure that results in post-appendectomy portal vein thrombosis. Therefore, the objective of the study was to evaluate the effectiveness of care and management protocols for post-appendectomy pylephlebitis, in order to identify the best clinical practices and improve patient care. A systematic review of scientific literature was carried out, applying non-probabilistic convenience sampling 40 scientific works published between 2018 and 2023 were selected, using databases such as PubMed/Medline, Elsevier Scopus, Science Direct, and Taylor & Francis. The results revealed that post-appendectomy pylephlebitis has a low incidence, predominantly affecting men, with symptoms such as fever and abdominal pain. The most common causes are diverticulitis and acute appendicitis. The preferred treatment includes broad-spectrum antibiotics and, in some cases, anticoagulants. Research suggests the need for standardized care protocols to optimize the management of this complication., A pileflebite é uma complicação rara, mas grave, associada a riscos como abscessos hepáticos, sepse e insuficiência hepática aguda com repercussões na forma de trombose da veia porta pós-apendicectomia. Portanto, o objetivo do estudo foi avaliar a eficácia dos protocolos de atendimento e gerenciamento para a pileflebite pós-apendicectomia a fim de identificar as melhores práticas clínicas e melhorar o atendimento ao paciente. Foi realizada uma revisão sistemática da literatura científica, aplicando amostragem não probabilística por conveniência. Foram selecionados 40 artigos científicos publicados entre 2018 e 2023, usando bancos de dados como PubMed/Medline, Elsevier Scopus, Science Direct e Taylor & Francis. Os resultados revelaram que a pileflebite pós-apendicectomia tem uma baixa incidência, afetando predominantemente homens, com sintomas como febre e dor abdominal. As causas mais comuns são diverticulite e apendicite aguda. O tratamento preferencial inclui antibióticos de amplo espectro e, em alguns casos, anticoagulantes. Pesquisas sugerem a necessidade de protocolos de atendimento padronizados para otimizar o gerenciamento dessa complicação., La pileflebitis es una complicación rara pero grave, asociada a riesgos como abscesos hepáticos, sepsis, e insuficiencia hepática aguda que repercute como trombosis de la vena porta post-apendicectomía. Por ello el objetivo del estudio fue evaluar la efectividad de los protocolos de atención y manejo para la pileflebitis post-apendicectomía, con el fin de identificar las mejores prácticas clínicas y mejorar el cuidado de los pacientes. Se realizó una revisión sistemática de literatura científica, aplicando un muestreo no probabilístico por conveniencia. Se seleccionaron 40 trabajos científicos publicados entre 2018 y 2023, utilizando bases de datos como PubMed/Medline, Elsevier Scopus, Science Direct, y Taylor & Francis. Los resultados revelaron que la pileflebitis post-apendicectomía presenta una incidencia baja, que afecta predominantemente a hombres, con síntomas como fiebre y dolor abdominal. Las causas más frecuentes son la diverticulitis y la apendicitis aguda. El tratamiento preferido incluye antibióticos de amplio espectro y, en algunos casos, anticoagulantes. La investigación sugiere la necesidad de protocolos de atención estandarizados para optimizar el manejo de esta complicación.

Background. Portal vein embolization is performed weeks before extended hepatic resections to increase the future liver remnant and prevent posthepatectomy liver failure. Portal vein embolization performed closer to the operation also could be protective, but worsening of portal hyper-perfusion is a major concern. We determined the hepatic hemodynamic effects of a portal vein embolization performed 24 hours prior to hepatic operation. Methods. An extended (90%) hepatectomy was performed in swine undergoing (portal vein embolization) or not undergoing (control) a portal vein embolization 24 hours earlier (n = 10/group). Blood tests, hepatic and systemic hemodynamics, hepatic function (plasma disappearance rate of indocyanine green), liver histology, and volumetry (computed tomographic scanning) were assessed before and after the hepatectomy. Hepatocyte proliferating cell nuclear antigen expression and hepatic gene expression also were evaluated. Results. Swine in the control and portal vein embolization groups maintained stable systemic hemodynamics and developed similar increases of portal blood flow (302 ± 72% vs 486 ± 92%, P = .13). Portal pressure drastically increased in Controls (from 9.4 ± 1.3 mm Hg to 20.9 ± 1.4 mm Hg, P < .001), while being markedly attenuated in the portal vein embolization group (from 11.4 ± 1.5 mm Hg to 16.1 ± 1.3 mm Hg, P = .061). The procedure also improved the preservation of the hepatic artery blood flow, liver function, and periportal edema. These effects occurred in the absence of hepatocyte proliferation or hepatic growth and were associated with the induction of the vasoprotective gene Klf2. Conclusion. Portal vein embolization preconditioning represents a potential hepato-protective strategy for extended hepatic resections. Further preclinical studies should assess its medium-term effects, including survival. Our study also supports the relevance of hepatic hemodynamics as the main pathogenetic factor of post-hepatectomy liver fa, Mineco, ISCIII-Fondos FEDER, Sociedad Española de Trasplante Hepático, Depto. de Farmacología y Toxicología, Fac. de Veterinaria, TRUE, pub

BackgroundAlthough non-target puncture (NPT)-related complications are well known to clinicians performing TIPS, there is no NTP-focused study to assess the true clinical sequalae of NTP-related complications. In this study, the aim was to evaluate the incidence, safety, clinical outcomes and complications related to NTPs during the portal access of TIPS procedures.MethodsA retrospective review of 369 TIPS procedures from October 2007 to September 2019 was performed. We identified inadvertent NTPs, including biliary, hepatic artery, lymphatic and capsular punctures. Next, the medical records and images were reviewed and analyzed to assess the safety and clinical outcomes of these cohorts.ResultsA total of 71 NTPs were identified in 56 patients (15.18% of 369 patients). Of 369 TIPS patients, there were (1) 28 biliary punctures (7.6%), (2) 16 extracapsular punctures (4.3%), (3) 15 lymphatic punctures (4.1%) and (4) 12 hepatic artery punctures (3.3%). The overall complication rate was 2.2% (8/369). Based on the Clavien-Dindo classification, three patients (0.8%) had a minor complication. In addition, five patients (1.4%) experienced grade II-V major complications, such as symptomatic hemoperitoneum, arterio-biliary fistula or hemorrhagic shock leading to death. Mortality (0.5%) was only caused by extracapsular puncture combined with other NTP.ConclusionsNTPs during the portal access of TIPS procedures are associated with low complication risk. However, when extracapsular punctures are combined with other NTPs, a more severe complication, including mortality, can occur. Nevertheless, all patients with NTP should be closely monitored at a higher level of care after TIPS placement.

BackgroundAneurysms are rare anomalies of the portomesenteric venous system. Thrombotic complications of these lesions can lead to mesenteric venous ischemia and bowel infarction, potentially requiring surgical intervention. Herein we describe a case of mesenteric ischemia due to a large thrombosed portomesenteric aneurysm treated with endovascular techniques.Case presentationA 37-year-old previously healthy male who presented with abdominal pain to his local emergency department was found to have a thrombosed 12.0 × 5.1 cm portomesenteric venous aneurysm with evidence of mesenteric ischemia on CT. When conservative management with anticoagulation failed, transhepatic pharmacomechanical thrombolysis was initially performed. This was followed by TIPS placement with additional trans-TIPS thrombectomy to improve sluggish portal outflow and prevent re-thrombosis. The patient's symptoms and imaging findings of ischemia resolved after endovascular therapy. No surgical intervention was required, and the patient was discharged on enoxaparin before being transitioned to apixaban. The TIPS remained patent at 2-year follow-up, with no change in the size of the aneurysm or re-thrombosis noted. The patient's synthetic liver function was preserved with no evidence of hepatic encephalopathy during the follow-up period.ConclusionsEndovascular therapies may be used to manage thrombotic complications of portomesenteric venous aneurysms, obviating the need for surgical intervention in selected patients.

BackgroundAneurysms are rare anomalies of the portomesenteric venous system. Thrombotic complications of these lesions can lead to mesenteric venous ischemia and bowel infarction, potentially requiring surgical intervention. Herein we describe a case of mesenteric ischemia due to a large thrombosed portomesenteric aneurysm treated with endovascular techniques.Case presentationA 37-year-old previously healthy male who presented with abdominal pain to his local emergency department was found to have a thrombosed 12.0 × 5.1 cm portomesenteric venous aneurysm with evidence of mesenteric ischemia on CT. When conservative management with anticoagulation failed, transhepatic pharmacomechanical thrombolysis was initially performed. This was followed by TIPS placement with additional trans-TIPS thrombectomy to improve sluggish portal outflow and prevent re-thrombosis. The patient's symptoms and imaging findings of ischemia resolved after endovascular therapy. No surgical intervention was required, and the patient was discharged on enoxaparin before being transitioned to apixaban. The TIPS remained patent at 2-year follow-up, with no change in the size of the aneurysm or re-thrombosis noted. The patient's synthetic liver function was preserved with no evidence of hepatic encephalopathy during the follow-up period.ConclusionsEndovascular therapies may be used to manage thrombotic complications of portomesenteric venous aneurysms, obviating the need for surgical intervention in selected patients.

BACKGROUND: In pancreatic ductal adenocarcinoma patients with suspected venous infiltration, a R0 resection is most of the time not possible without venous resection (VR). To investigate this special kind of patients, this meta-analysis was conducted to compare mortality, morbidity and long-term survival of pancreatic resections with (VR+) and without venous resection (VR-). METHODS: A systematic search was performed in Embase, Pubmed and Web of Science. Studies which compared over twenty patients with VR + to VR-for PDAC with ≥1 year follow up were included. Articles including arterial resections were excluded. Statistical analysis was performed with the random effect Mantel-Haenszel test and inversed variance method. Individual patient data was compared with the log-rank test. RESULTS: Following a review of 6403 papers by title and abstract and 166 by full text, a meta-analysis was conducted of 32 studies describing 2216 VR+ and 5380 VR-. There was significantly more post-pancreatectomy hemorrhage (6.5% vs. 5.6%), R1 resections (36.7% vs. 28.6%), N1 resections (70.3% vs. 66.8%) and tumors were significantly larger (34.6 mm vs. 32.8 mm) in patients with VR+. Of all VR + patients, 64.6% had true pathological venous infiltration. The 90-day mortality, individual patient data for overall survival and pooled multivariate hazard ratio for overall survival were similar. CONCLUSION: VR is a safe and feasible option in patients with pancreatic cancer and suspicion of venous involvement, since VR during pancreatic surgery has comparable overall survival and complication rates.

The "gunsight approach" was initially described as the use of overlapping snares and through- and-through puncture of the portal vein and inferior vena cava for the creation of a transcaval portosystemic shunt. This technique can be adapted for the creation of an extra-anatomic chan- nel between any 2 locations where snares can be deployed. We explain the technique, discuss finer technical points, and describe 2 cases where refractory vascular occlusions are crossed using this technique. The first case involves an extensively calcified femoral arterial chronic total occlusion where subintimal tracking past the occlusion is achieved, but luminal re-entry is ham- pered by dense calcific plaque refractory to multiple re-entry devices. The second case involves a chronic venous occlusion along the femoral vein with loss of in-line flow due to prior stenting. In both cases, the gunsight technique was successfully used as a bailout option after standard recanalization techniques were unsuccessful.

Background: Effective biomarkers are needed to enable personalized medicine for pancreatic cancer patients. This study analyzes the prognostic value, in early pancreatic cancer, of single circulating tumor cell (CTC) and CTC clusters from the central venous catheter (CVC) and portal blood (PV). Methods: In total, 7 mL of PV and CVC blood from 35 patients with early pancreatic cancer were analyzed. CTC were isolated using a positive immunomagnetic selection. The detection and identification of CTC were performed by immunocytochemistry (ICC) and were analyzed by Epi-fluorescence and confocal microscopy. Results: CTC and the clusters were detected both in PV and CVC. In both samples, the CTC number per cluster was higher in patients with grade three or poorly differentiated tumors (G3) than in patients with well (G1) or moderately (G2) differentiated. Patients with fewer than 185 CTC in PV exhibited a longer OS than patients with more than 185 CTC (24.5 vs. 10.0 months; p = 0.018). Similarly, patients with fewer than 15 clusters in PV showed a longer OS than patients with more than 15 clusters (19 vs. 10 months; p = 0.004). These significant correlations were not observed in CVC analyses. Conclusions: CTC presence in PV could be an important prognostic factor to predict poor prognosis in early pancreatic cancer. In addition, the number of clustered-CTC correlate to a tumor negative differentiation degree and, therefore, could be used as a diagnostic biomarker for pancreatic cancer.

The present study was conducted to examine region-dependent glucagon-like peptide-1 (GLP-1) responses to "meal ingestion" under physiological (conscious and unrestrained) conditions using rats with a catheter inserted into either the portal vein (PV) or the ileal mesenteric vein (ILMV). After recovery from the cannulation surgery, blood samples were collected from either PV or ILMV catheter before and after the voluntary ingestion of test diets. After an AIN-93G standard diet ingestion, GLP-1 concentration was higher in ILMV than in PV, and postprandial responses of peptide-YY (PYY) had similar trend, while that of glucose dependent-insulinotropic polypeptide showed an opposite trend to GLP-1/PYY responses. In a separated experiment, a protein-enriched diet containing casein at 25% wt/wt transiently increased GLP-1 concentration only in ILMV; however, a protein-free diet did not increase GLP-1 concentrations in PV or ILMV. These results indicate that postprandial GLP-1 is immediately released from the distal intestine under physiological conditions, and that dietary protein has a critical role in the enhancement of postprandial GLP-1 response.

The present study was conducted to examine region-dependent glucagon-like peptide-1 (GLP-1) responses to "meal ingestion" under physiological (conscious and unrestrained) conditions using rats with a catheter inserted into either the portal vein (PV) or the ileal mesenteric vein (ILMV). After recovery from the cannulation surgery, blood samples were collected from either PV or ILMV catheter before and after the voluntary ingestion of test diets. After an AIN-93G standard diet ingestion, GLP-1 concentration was higher in ILMV than in PV, and postprandial responses of peptide-YY (PYY) had similar trend, while that of glucose dependent-insulinotropic polypeptide showed an opposite trend to GLP-1/PYY responses. In a separated experiment, a protein-enriched diet containing casein at 25% wt/wt transiently increased GLP-1 concentration only in ILMV; however, a protein-free diet did not increase GLP-1 concentrations in PV or ILMV. These results indicate that postprandial GLP-1 is immediately released from the distal intestine under physiological conditions, and that dietary protein has a critical role in the enhancement of postprandial GLP-1 response.

ObjectiveThe aim of the study was to determine the prevalence of clinically important masses among incidental hyperenhancing liver observations on portal venous phase computed tomography (CT) in patients without known malignancy or liver disease.MethodsRetrospective search of portal venous phase CTs was performed to identify hyperenhancing liver observations in patients without cancer or liver disease. Observations were assigned a morphology of homogeneous, hemangioma, or heterogeneous. The reference standard was pathology (n = 2), liver protocol CT/magnetic resonance imaging (n = 40), follow-up portal venous phase CT for 2 years or more (n = 81), or clinical follow-up for 5 years or more (n = 107).ResultsThere were no clinically important masses among 83 observations with homogeneous morphology or 110 with hemangioma morphology. There were 2 clinically important masses (1 hepatocellular carcinoma and 1 hepatic adenoma) among 37 (5.4%) heterogeneous morphology observations.ConclusionsIncidental hyperenhancing liver observations on portal venous phase CT with homogeneous or typical hemangioma morphology in patients without known cancer or liver disease are highly likely benign.

Background: Effective biomarkers are needed to enable personalized medicine for pancreatic cancer patients. This study analyzes the prognostic value, in early pancreatic cancer, of single circulating tumor cell (CTC) and CTC clusters from the central venous catheter (CVC) and portal blood (PV). Methods: In total, 7 mL of PV and CVC blood from 35 patients with early pancreatic cancer were analyzed. CTC were isolated using a positive immunomagnetic selection. The detection and identification of CTC were performed by immunocytochemistry (ICC) and were analyzed by Epi-fluorescence and confocal microscopy. Results: CTC and the clusters were detected both in PV and CVC. In both samples, the CTC number per cluster was higher in patients with grade three or poorly differentiated tumors (G3) than in patients with well (G1) or moderately (G2) differentiated. Patients with fewer than 185 CTC in PV exhibited a longer OS than patients with more than 185 CTC (24.5 vs. 10.0 months; p = 0.018). Similarly, patients with fewer than 15 clusters in PV showed a longer OS than patients with more than 15 clusters (19 vs. 10 months; p = 0.004). These significant correlations were not observed in CVC analyses. Conclusions: CTC presence in PV could be an important prognostic factor to predict poor prognosis in early pancreatic cancer. In addition, the number of clustered-CTC correlate to a tumor negative differentiation degree and, therefore, could be used as a diagnostic biomarker for pancreatic cancer.

Background: Effective biomarkers are needed to enable personalized medicine for pancreatic cancer patients. This study analyzes the prognostic value, in early pancreatic cancer, of single circulating tumor cell (CTC) and CTC clusters from the central venous catheter (CVC) and portal blood (PV). Methods: In total, 7 mL of PV and CVC blood from 35 patients with early pancreatic cancer were analyzed. CTC were isolated using a positive immunomagnetic selection. The detection and identification of CTC were performed by immunocytochemistry (ICC) and were analyzed by Epi-fluorescence and confocal microscopy. Results: CTC and the clusters were detected both in PV and CVC. In both samples, the CTC number per cluster was higher in patients with grade three or poorly differentiated tumors (G3) than in patients with well (G1) or moderately (G2) differentiated. Patients with fewer than 185 CTC in PV exhibited a longer OS than patients with more than 185 CTC (24.5 vs. 10.0 months; p = 0.018). Similarly, patients with fewer than 15 clusters in PV showed a longer OS than patients with more than 15 clusters (19 vs. 10 months; p = 0.004). These significant correlations were not observed in CVC analyses. Conclusions: CTC presence in PV could be an important prognostic factor to predict poor prognosis in early pancreatic cancer. In addition, the number of clustered-CTC correlate to a tumor negative differentiation degree and, therefore, could be used as a diagnostic biomarker for pancreatic cancer.

The present study was conducted to examine region-dependent glucagon-like peptide-1 (GLP-1) responses to "meal ingestion" under physiological (conscious and unrestrained) conditions using rats with a catheter inserted into either the portal vein (PV) or the ileal mesenteric vein (ILMV). After recovery from the cannulation surgery, blood samples were collected from either PV or ILMV catheter before and after the voluntary ingestion of test diets. After an AIN-93G standard diet ingestion, GLP-1 concentration was higher in ILMV than in PV, and postprandial responses of peptide-YY (PYY) had similar trend, while that of glucose dependent-insulinotropic polypeptide showed an opposite trend to GLP-1/PYY responses. In a separated experiment, a protein-enriched diet containing casein at 25% wt/wt transiently increased GLP-1 concentration only in ILMV; however, a protein-free diet did not increase GLP-1 concentrations in PV or ILMV. These results indicate that postprandial GLP-1 is immediately released from the distal intestine under physiological conditions, and that dietary protein has a critical role in the enhancement of postprandial GLP-1 response.

[Simple Summary] Effective biomarkers are needed to enable personalized medicine for pancreatic cancer patients. This study analyzes the prognostic value, in early pancreatic cancer, of circulating tumor cells and clusters from the central venous catheter and portal blood. Circulating tumor cells were isolated using an immunomagnetic selection and were detected by microscopy using immunocytochemistry staining. In conclusion, the circulating tumor cell number in portal blood identifies a death risk in patients with early pancreatic cancer., [Abstract] Background. Effective biomarkers are needed to enable personalized medicine for pancreatic cancer patients. This study analyzes the prognostic value, in early pancreatic cancer, of single circulating tumor cell (CTC) and CTC clusters from the central venous catheter (CVC) and portal blood (PV). Methods. In total, 7 mL of PV and CVC blood from 35 patients with early pancreatic cancer were analyzed. CTC were isolated using a positive immunomagnetic selection. The detection and identification of CTC were performed by immunocytochemistry (ICC) and were analyzed by Epi-fluorescence and confocal microscopy. Results. CTC and the clusters were detected both in PV and CVC. In both samples, the CTC number per cluster was higher in patients with grade three or poorly differentiated tumors (G3) than in patients with well (G1) or moderately (G2) differentiated. Patients with fewer than 185 CTC in PV exhibited a longer OS than patients with more than 185 CTC (24.5 vs. 10.0 months; p = 0.018). Similarly, patients with fewer than 15 clusters in PV showed a longer OS than patients with more than 15 clusters (19 vs. 10 months; p = 0.004). These significant correlations were not observed in CVC analyses. Conclusions. CTC presence in PV could be an important prognostic factor to predict poor prognosis in early pancreatic cancer. In addition, the number of clustered-CTC correlate to a tumor negative differentiation degree and, therefore, could be used as a diagnostic biomarker for pancreatic cancer.

Background and aims: In patients with hepatocellular carcinoma (HCC), macrovascular invasion (MaVI) limits treatment options and decreases survival. Detailed data on the relationship between MaVI extension and patients' characteristics, and its impact on patients' outcome are limited. We evaluated the prevalence and extension of MaVI in a large cohort of consecutive HCC patients, analysing its association with liver disease and tumour characteristics, as well as with treatments performed and patients' survival. Methods: We analysed data of 4774 patients diagnosed with HCC recorded in the Italian Liver Cancer (ITA.LI.CA) database (2008-2018). Recursive partition analysis (RPA) was performed to evaluate interactions between MaVI, clinical variables and treatment, exploring the inter-relationship determining overall survival. Results: MaVI prevalence was 11.1%, and median survival of these patients was 6.0 months (95% CI, 5.1-7.1). MaVI was associated with younger age at diagnosis, presence of symptoms, worse Performance Status (PS) and liver function, high alphafetoprotein levels and large HCCs. MaVI extension was associated with worse PS, ascites and greater impairment in liver function. RPA identified patients' categories with different treatment indications and survival, ranging from 2.4 months in those with PS > 1 and ascites, regardless of MaVI extension (receiving best supportive care in 90.3% of cases), to 14.1 months in patients with PS 0-1, no ascites and Vp1-Vp2 MaVI (treated with surgery in 19.1% of cases). Conclusions: MaVI presence and extension, together with PS and ascites, significantly affect patients' survival and treatment selection. The decision tree based on these parameters may help assess patients' prognosis and inform therapeutic decisions.

ObjectivesAlthough traumatic injuries to the superior mesenteric vein (SMV), portal vein (PV), and hepatic vein (HV) are rare, their impact is significant. Small single center reports estimate mortality rates ranging from 29% to 100%. Our aim is to elucidate the incidence and outcomes associated with each injury due to unique anatomic positioning and varied tolerance of ligation. We hypothesize that SMV injury is associated with a lower risk of mortality compared to HV and PV injury in adult trauma patients.MethodsThe Trauma Quality Improvement Program database (2010-2016) was queried for patients with injury to either the SMV, PV, or HV. A multivariable logistic regression model was used for analysis.ResultsFrom 1,403,466 patients, 966 (0.07%) had a single major hepatoportal venous injury with 460 (47.6%) involving the SMV, 281 (29.1%) involving the PV, and 225 (23.3%) involving the HV. There was no difference in the percentage of patients undergoing repair or ligation between SMV, PV, and HV injuries (P > .05). Compared to those with PV and HV injuries, patients with SMV injury had a higher rate of concurrent bowel resection (38.5% vs 12.1% vs 7.6%, P < .001) and lower mortality (33.3% vs 45.9% vs 49.3%, P < .01). After controlling for covariates, traumatic SMV injury increased the risk of mortality (odds ratio [OR] 1.59, confidence interval [CI] = 1.00-2.54, P = .05) in adult trauma patients; however, this was less than PV injury (OR = 2.77, CI = 1.56-4.93, P = .001) and HV injury (OR = 2.70, CI = 1.46-4.99, P = .002).ConclusionTraumatic SMV injury had a lower rate of mortality compared to injuries of the HV and PV. SMV injury increased the risk of mortality by 60% in adult trauma patients, whereas PV and HV injuries nearly tripled the risk of mortality.

OBJECTIVES: To develop a deep learning-based algorithm to automatically identify optimal portal venous phase timing (PVP-timing) so that image analysis techniques can be accurately performed on post contrast studies. METHODS: 681 CT-scans (training: 479 CT-scans; validation: 202 CT-scans) from a multicenter clinical trial in patients with liver metastases from colorectal cancer were retrospectively analyzed for algorithm development and validation. An additional external validation was performed on a cohort of 228 CT-scans from gastroenteropancreatic neuroendocrine cancer patients. Image acquisition was performed according to each centers' standard CT protocol for single portal venous phase, portal venous acquisition. The reference gold standard for the classification of PVP-timing as either optimal or nonoptimal was based on experienced radiologists' consensus opinion. The algorithm performed automated localization (on axial slices) of the portal vein and aorta upon which a novel dual input Convolutional Neural Network calculated a probability of the optimal PVP-timing. RESULTS: The algorithm automatically computed a PVP-timing score in 3 seconds and reached area under the curve of 0.837 (95% CI: 0.765, 0.890) in validation set and 0.844 (95% CI: 0.786, 0.889) in external validation set. CONCLUSION: A fully automated, deep-learning derived PVP-timing algorithm was developed to classify scans' contrast-enhancement timing and identify scans with optimal PVP-timing. The rapid identification of such scans will aid in the analysis of quantitative (radiomics) features used to characterize tumors and changes in enhancement with treatment in a multitude of settings including quantitative response criteria such as Choi and MASS which rely on reproducible measurement of enhancement.

ObjectivesAlthough traumatic injuries to the superior mesenteric vein (SMV), portal vein (PV), and hepatic vein (HV) are rare, their impact is significant. Small single center reports estimate mortality rates ranging from 29% to 100%. Our aim is to elucidate the incidence and outcomes associated with each injury due to unique anatomic positioning and varied tolerance of ligation. We hypothesize that SMV injury is associated with a lower risk of mortality compared to HV and PV injury in adult trauma patients.MethodsThe Trauma Quality Improvement Program database (2010-2016) was queried for patients with injury to either the SMV, PV, or HV. A multivariable logistic regression model was used for analysis.ResultsFrom 1,403,466 patients, 966 (0.07%) had a single major hepatoportal venous injury with 460 (47.6%) involving the SMV, 281 (29.1%) involving the PV, and 225 (23.3%) involving the HV. There was no difference in the percentage of patients undergoing repair or ligation between SMV, PV, and HV injuries (P > .05). Compared to those with PV and HV injuries, patients with SMV injury had a higher rate of concurrent bowel resection (38.5% vs 12.1% vs 7.6%, P < .001) and lower mortality (33.3% vs 45.9% vs 49.3%, P < .01). After controlling for covariates, traumatic SMV injury increased the risk of mortality (odds ratio [OR] 1.59, confidence interval [CI] = 1.00-2.54, P = .05) in adult trauma patients; however, this was less than PV injury (OR = 2.77, CI = 1.56-4.93, P = .001) and HV injury (OR = 2.70, CI = 1.46-4.99, P = .002).ConclusionTraumatic SMV injury had a lower rate of mortality compared to injuries of the HV and PV. SMV injury increased the risk of mortality by 60% in adult trauma patients, whereas PV and HV injuries nearly tripled the risk of mortality.

BackgroundCirculating endotoxin (lipopolysaccharide, LPS) increases the gut paracellular permeability. We hypothesized that glucagon-like peptide-2 (GLP-2) acutely reduces LPS-related increased intestinal paracellular permeability by a mechanism unrelated to its intestinotrophic effect.MethodsWe assessed small intestinal paracellular permeability in vivo by measuring the appearance of intraduodenally perfused FITC-dextran 4000 (FD4) into the portal vein (PV) in rats 1-24 h after LPS treatment (5 mg/kg, ip). We also examined the effect of a stable GLP-2 analog teduglutide (TDG) on FD4 permeability.ResultsFD4 movement into the PV was increased 6 h, but not 1 or 3 h after LPS treatment, with increased PV GLP-2 levels and increased mRNA expressions of proinflammatory cytokines and proglucagon in the ileal mucosa. Co-treatment with a GLP-2 receptor antagonist enhanced PV FD4 concentrations. PV FD4 concentrations 24 h after LPS were higher than FD4 concentrations 6 h after LPS, reduced by exogenous GLP-2 treatment given 6 or 12 h after LPS treatment. FD4 uptake measured 6 h after LPS was reduced by TDG 3 or 6 h after LPS treatment. TDG-associated reduced FD4 uptake was reversed by the VPAC1 antagonist PG97-269 or L-NAME, not by EGF or IGF1 receptor inhibitors.ConclusionsSystemic LPS releases endogenous GLP-2, reducing LPS-related increased permeability. The therapeutic window of exogenous GLP-2 administration is at minimum within 6-12 h after LPS treatment. Exogenous GLP-2 treatment is of value in the prevention of increased paracellular permeability associated with endotoxemia.

Although sequelae of chronic liver disease are the most common causes of altered pressure dynamics in the portal and splanchnic circulations, there are other mechanisms resulting in increased venous pressures with subsequent development of splenic and gastric varices. We report a case of a patient without portal hypertension, but with bleeding gastric varices with a presumed splenorenal shunt (SRS) on CT. Venography revealed flow reversal through the shunt (directed from the renal vein, into the splenic vein and out the portal vein; a renal-splent shunt (RSR)) and thus an anatomically similar but functionally distinct systemic to mesenteric variant. While being anatomically similar to the well-known SRS, the different flow dynamics necessitate a different approach for treatment and important considerations for the use of any liquid embolic.

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Abdominal vascular trauma accounts for a small percentage of military and a moderate percentage of civilian trauma, affecting all age ranges and impacting young adult men most frequently. Penetrating causes are more frequent than blunt in adults, while blunt mechanisms are more common among pediatric populations. High rates of associated injuries, bleeding, and hemorrhagic shock ensure that, despite advances in both diagnostic and therapeutic technologies, immediate open surgical repair remains the mainstay of treatment for traumatic abdominal vascular injuries. Because of their devastating nature, abdominal vascular injuries remain a significant source of morbidity and mortality among trauma patients. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seek to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of abdominal vascular injuries. LEVEL OF EVIDENCE Review study, level IV.

BACKGROUND: Vascular access port (VAP) systems are widely used in human medicine to provide long-term venous access. However, in veterinary medicine the use of VAP systems is not common practice and publications on their potential applications have been limited. A VAP system was used as part of an experimental study on liver regeneration and implanted in the canine portal vein to create direct access to the portal venous circulation of the liver. The aim of the present study is to describe the surgical technique, its use, and the complications of a VAP system in three research dogs.RESULTS: The VAP system was successfully used for the intraoperative measurement of portal blood pressure, the administration of cell suspensions, and the collection of portal venous blood samples. Long-term complications consisted of dislocation of the VAP system in one dog (2 months after implantation) and thrombus formation at the catheter tip in two dogs (3 months after implantation). Both complications prevented further use of the VAP but had no adverse clinical implications.CONCLUSIONS: This pilot study suggests that the VAP system is an effective and safe technique to obtain long term access to the portal venous system in dogs. However, complications with port detachment and thrombosis may limit long term use of VAPs in the portal system of dogs.

The aim of this paper was to study distribution of the hepatic artery and portal vein of the portal system of the liver in ground squirrels (Spermophilus citellus) and compare these data with those concerning the rats, rabbits, guinea pigs and nutrias. The liver of the ground squirrel receives the oxygen and nutrients through blood from two large blood vessels: portal vein and hepatic artery (a. hepatica propria). The portal vein is formed by the confluence of three main venous blood vessels: v. gastropancreaticoduodenalis, v. gastrolienalis and v. mesenterica cranialis. It collects venous blood from the stomach, pancreas, spleen and all of intestines except the rectum. The portal vein enters the porta hepatis on the liver together with the hepatic artery. Five venous branches of different size separate from the portal vein and ramify into the respective liver lobes. Blood leaves the liver through the hepatic veins that start with the central veins. Three large hepatic veins and two venous trunks drain lobes of the liver and enter the caudal vena cava as it passes through the liver. A. hepatica propria supplies the liver and gallbladder with oxygenated blood. It raises from the hepatic artery (a. hepatica) wich is the third branch of the celiac artery. A. hepatica propria in the portal fissure is divided into two branches, of which the left branch brings arterial blood to the left hepatic lobe, and the right branch brings it into other liver lobes.

Cilj ovog rada je bio da se ispita distribucija arterije i portalne vene portalnog sistema jetre tekunice (Spermophilus citellus) i dobijeni podaci uporede sa onima kod pacova, kunića, zamorčeta i nutrije. Jetra tekunice prima kiseonik i hranljive materije preko krvi iz dva velika krvna suda: portalne vene (v. portae) i jetrene arterije (a. hepatica propria). Portalna vena nastaje iz sliva tri glavne vene: v. gastropancreaticoduodenalis, v. gastrolienalis i v. mesenterica cranialis. Portalna vena skuplja vensku krv iz želuca, pankreasa, slezine, svih creva osim pravog creva (rectum). Portalna vena ulazi u portalni žleb na jetri zajedno sa jetrenom arterijom. Pet venskih grana različitih veličina odvajaju se od portalne vene i granaju se u odgovarajuće režnjeve jetre. Krv iz jetre odvode jetrene vene koje počinju sa centralnim venama u jetri. Tri velike jetrene vene i dva venska stabla odvode krv iz svih režnjeva jetre u kaudalnu šuplju venu u toku njenog prolaska kroz jetru. A. hepatica propria snabdeva jetru i žučnu kesu oksigenisanom krvlju. A. hepatica propria izlazi iz jetrene arterije (a. hepatica), koja je treća grana celijačne arterije. U portalnom žlebu, a. hepatica propria se deli u dve grane, od kojih leva grana dovodi arterijsku krv u levi režanj jetre, a desna grana u ostale režnjeve jetre., The aim of this paper was to study distribution of the hepatic artery and portal vein of the portal system of the liver in ground squirrels (Spermophilus citellus) and compare these data with those concerning the rats, rabbits, guinea pigs and nutrias. The liver of the ground squirrel receives the oxygen and nutrients through blood from two large blood vessels: portal vein and hepatic artery (a. hepatica propria). The portal vein is formed by the confluence of three main venous blood vessels: v. gastropancreaticoduodenalis, v. gastrolienalis and v. mesenterica cranialis. It collects venous blood from the stomach, pancreas, spleen and all of intestines except the rectum. The portal vein enters the porta hepatis on the liver together with the hepatic artery. Five venous branches of different size separate from the portal vein and ramify into the respective liver lobes. Blood leaves the liver through the hepatic veins that start with the central veins. Three large hepatic veins and two venous trunks drain lobes of the liver and enter the caudal vena cava as it passes through the liver. A. hepatica propria supplies the liver and gallbladder with oxygenated blood. It raises from the hepatic artery (a. hepatica) wich is the third branch of the celiac artery. A. hepatica propria in the portal fissure is divided into two branches, of which the left branch brings arterial blood to the left hepatic lobe, and the right branch brings it into other liver lobes.

Differentiating tumor versus bland portal vein thrombosis (PVT) is essential in determining liver transplantation (LT) candidacy for patients with hepatocellular carcinoma (HCC). We aimed to evaluate radiographic and clinical features that could noninvasively distinguish tumor PVT from bland PVT in HCC patients. Of 467 patients with HCC listed for LT from 2004 to 2011, 59 (12.6%) had PVT and 12 of 59 (20.3%) were deemed malignant. When comparing tumor versus bland PVT, thrombus enhancement was seen in 100% versus 8.5%; venous expansion was seen in 91.7% versus 10.6%; neovascularity was seen in 58.3% versus 2.1%; and being adjacent to HCC or prior treatment site was seen in 100% versus 21.3% (all P < 0.001). Combining these 4 imaging characteristics with alpha-fetoprotein (AFP) >1000 ng/dL, the presence of ≥3 criteria best characterized tumor PVT with 100% sensitivity, 93.6% specificity, 80% positive predictive value, and 100% negative predictive value. No LT recipients with presumed bland PVT had macrovascular invasion on explant. There were no differences in post-LT survival or HCC recurrence with bland PVT versus no PVT. In conclusion, we proposed noninvasive criteria that could accurately differentiate tumor PVT from bland PVT called A-VENA, which is based on the presence of ≥3 of the following: AFP >1000 ng/dL; venous expansion; thrombus enhancement; neovascularity; and adjacent to HCC. Use of the A-VENA criteria can assist in standardizing the evaluation of PVT in patients with HCC being considered for LT.

In the past, hepatic blood flow in cows was invasively characterized to investigate different pathologies and physiological conditions. However, hepatic blood flow can be easily evaluated with transabdominal Doppler ultrasound. Sixteen healthy adult non-lactating, non-pregnant Holstein-Friesian cows were examined using B-mode and Doppler ultrasound between the right flank and 9th intercostal space to establish the best approach to the different parts of the portal and hepatic vein systems, and determine normal blood flow characteristics. The main portal vein was characterized by a turbulent, high-velocity flow due to the opposing confluence of the splenic and cranial mesenteric veins, while hepatic and caudal vena cava veins have laminar blood flow, in which the phasicity is considered mainly respiratory in origin. Reference values were determined in relation to the anatomical point of observation. In conclusion, transabdominal Doppler ultrasound of the portal system is a simple technique that allows non-invasive characterization of portal and hepatic blood haemodynamics in cows

Cilj ovog rada je bio da se ispita distribucija arterije i portalne vene portalnog sistema jetre tekunice (Spermophilus citellus) i dobijeni podaci uporede sa onima kod pacova, kunića, zamorčeta i nutrije. Jetra tekunice prima kiseonik i hranljive materije preko krvi iz dva velika krvna suda: portalne vene (v. portae) i jetrene arterije (a. hepatica propria). Portalna vena nastaje iz sliva tri glavne vene: v. gastropancreaticoduodenalis, v. gastrolienalis i v. mesenterica cranialis. Portalna vena skuplja vensku krv iz želuca, pankreasa, slezine, svih creva osim pravog creva (rectum). Portalna vena ulazi u portalni žleb na jetri zajedno sa jetrenom arterijom. Pet venskih grana različitih veličina odvajaju se od portalne vene i granaju se u odgovarajuće režnjeve jetre. Krv iz jetre odvode jetrene vene koje počinju sa centralnim venama u jetri. Tri velike jetrene vene i dva venska stabla odvode krv iz svih režnjeva jetre u kaudalnu šuplju venu u toku njenog prolaska kroz jetru. A. hepatica propria snabdeva jetru i žučnu kesu oksigenisanom krvlju. A. hepatica propria izlazi iz jetrene arterije (a. hepatica), koja je treća grana celijačne arterije. U portalnom žlebu, a. hepatica propria se deli u dve grane, od kojih leva grana dovodi arterijsku krv u levi režanj jetre, a desna grana u ostale režnjeve jetre., The aim of this paper was to study distribution of the hepatic artery and portal vein of the portal system of the liver in ground squirrels (Spermophilus citellus) and compare these data with those concerning the rats, rabbits, guinea pigs and nutrias. The liver of the ground squirrel receives the oxygen and nutrients through blood from two large blood vessels: portal vein and hepatic artery (a. hepatica propria). The portal vein is formed by the confluence of three main venous blood vessels: v. gastropancreaticoduodenalis, v. gastrolienalis and v. mesenterica cranialis. It collects venous blood from the stomach, pancreas, spleen and all of intestines except the rectum. The portal vein enters the porta hepatis on the liver together with the hepatic artery. Five venous branches of different size separate from the portal vein and ramify into the respective liver lobes. Blood leaves the liver through the hepatic veins that start with the central veins. Three large hepatic veins and two venous trunks drain lobes of the liver and enter the caudal vena cava as it passes through the liver. A. hepatica propria supplies the liver and gallbladder with oxygenated blood. It raises from the hepatic artery (a. hepatica) wich is the third branch of the celiac artery. A. hepatica propria in the portal fissure is divided into two branches, of which the left branch brings arterial blood to the left hepatic lobe, and the right branch brings it into other liver lobes.

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Background: Acute portomesenteric venous thrombosis (PMVT) is a potentially life-threatening condition and urgent treatment is required. Purpose: To retrospectively evaluate the efficacy and safety of treating acute PMVT by the creation of a transjugular intrahepatic portosystemic shunt (TIPS) followed by thrombectomy. Material and Methods: Six patients (all men, age range = 39-51 years) presenting with acute PMVT were treated with transjugular thrombectomy (TT) through a TIPS created in the same session. The intervention included iterated venography through the TIPS one to three times within the first week after diagnosis and repeated thrombectomy if needed (n = 5). Results: Recanalization was successful with persistent blood flow through the main superior mesenteric vein, portal vein, and TIPS in all six patients. Five patients were treated primarily with thrombectomy through a TIPS with clinical improvement. The final patient was initially treated with surgical thrombectomy and bowel resection. TIPS and TT was performed two days after surgery due to re-thrombosis but the patient deteriorated and died of multi-organ failure. Procedure-related complications were transient hematuria (n = 3) and transient encephalopathy (n = 2). In-hospital time was <14 days in four of the five patients with primary TIPS and TT. No sign of re-thrombosis was noted during follow-up (mean = 18 months, range = 8-28 months). Conclusion: Thrombectomy through a TIPS is feasible and can be effective in recanalization and symptom-relief in acute PMVT.

Background and aimsPortal hypertension is a serious adverse event of liver cirrhosis. Recently, we developed a simple novel technique for EUS-guided portal pressure gradient (PPG) measurement (PPGM). Our animal studies showed excellent correlation between EUS-PPGM and interventional radiology-acquired PPGM. In this video we demonstrate the results of the first human pilot study of EUS-PPGM in patients with liver disease.MethodsEUS-PPGM was performed by experienced endosonographers using a linear echoendoscope, a 25-gauge FNA needle, and a novel compact manometer. The portal vein and hepatic vein (or inferior vena cava) were targeted by use of a transgastric or transduodenal approach. Feasibility was defined as successful PPGM in each patient. Safety was based on adverse events captured in a postprocedural interview.ResultsTwenty-eight patients underwent EUS-PPGM with 100% technical success and no adverse events. PPG ranged from 1.5 to 19 mm Hg and had excellent correlation with clinical parameters of portal hypertension, including the presence of varices (P = .0002), PH gastropathy (P = .007), and thrombocytopenia (P = .036).ConclusionThis novel technique of EUS-PPGM using a 25-gauge needle and compact manometer is feasible and appears safe. Given the availability of EUS and the simplicity of the manometry setup, EUS-guided PPG may represent a promising breakthrough for procuring indispensable information in the management of patients with liver disease.

Актуальність. Перихілярна холангіокарцинома — рідкісний вид злоякісних новоутворень і становить 3–7 випадків на 100 000 населення. Хірургічний метод є єдиним радикальним методом лікування, що дозволяє поліпшити віддалені результати виживання. Особливу складність представляють випадки з пухлинною інвазією ворітної вени. Метою цього дослідження було вивчення результатів хірургічного лікування пацієнтів з перихілярною холангіокарциномою з інвазією в ворітну вену. Матеріали та методи. З 2003 по 2017 рік у відділенні трансплантації та хірургії печінки Націо­нального інституту хірургії і трансплантології ім. А.А. Шалімова НАМН України зроблені великі і розширені резекції печінки 141 хворому з перихілярною холангіокарциномою. Результати. Для встановлення характеру ураження біліарного дерева використовували анатомічну класифікацію перихілярної холангіокарциноми Bismuth — Corlette. Зі 141 хворого у 61 (46,6 %) випадку виконали резекцію ворітної вени з подальшою реконструкцією. Одно-, 3- і 5-річна виживаність в групі пацієнтів із резекцією ворітної вени становила 85,6, 56 і 42 % відповідно. Висновки. Агресивна тактика хірургічного лікування перихілярної холангіокарциноми забезпечує максимальну радикальність, дозволяє збільшити резектабельність при пухлинній інвазії ворітної вени з прий­нятною летальністю і віддаленим виживанням., Актуальность. Перихилярная холангиокарцинома — редкий вид злокачественных новообразований и составляет 3–7 случаев на 100 000 населения. Хирургический метод является единственным радикальным методом лечения, позволяющим улучшить отдаленные результаты выживаемости. Особую сложность представляют случаи с опухолевой инвазией воротной вены. Целью настоящего исследования явилось изучение результатов хирургического лечения пациентов с перихилярной холангиокарциномой с инвазией в воротную вену. Материалы и методы. С 2003 по 2017 год в отделении трансплантации и хирургии печени Национального института хирургии и трансплантологии им. А.А. Шалимова НАМН Украины произведены обширные и расширенные резекции печени 141 больному с перихилярной холангиокарциномой. Результаты. Для установления характера поражения билиарного дерева использовали анатомическую классификацию перихилярной холангиокарциномы Bismuth — Corlette. Из 141 больного в 61 (46,6 %) случае выполнили резекцию воротной вены с последующей реконструкцией. Одно-, 3- и 5-летняя выживаемость в группе пациентов с резекцией воротной вены составила 85,6, 56 и 42 % соответственно. Выводы. Агрессивная тактика хирургического лечения перихилярной холангиокарциномы обеспечивает максимальную радикальность, позволяет увеличить резектабельность при опухолевой инвазии воротной вены с приемлемой летальностью и отдаленной выживаемостью., Background. Perihilar cholangiocarcinoma is a rare type of malignant neoplasms and accounts for 3–7 cases per 100,000 population. Surgery is the only radical method of treatment which improves long-term survival results. The cases with tumor invasion of the portal vein are of particular complexity. The purpose of this research was to study the results of surgical treatment in patients with perihilar cholangiocarcinoma and portal vein invasion. Materials and methods. From 2003 to 2017, at the department of transplantation and surgery of the liver, extensive and advanced liver resections were performed in 141 patients with perihilar cholangiocarcinoma. Results. To establish the nature of the biliary tree lesions, Bismuth-Corlette anatomical classification of perihilar cholangiocarcinoma was used. In 61 of 141 (46.6 %) cases, a portal vein resection was performed with subsequent reconstruction. One-, three- and five-year survival rate in the group of patients with portal vein resection was 85.6, 56 and 42 %, respectively. Conclusions. Aggressive surgical treatment for perihilar cholangiocarcinoma provides maximum radicality, allows increasing resectability in case of tumor invasion of the portal vein with acceptable mortality and long-term survival rate.

Актуальність. Перихілярна холангіокарцинома — рідкісний вид злоякісних новоутворень, який становить 3–7 випадків на 100 000 населення. Хірургічний метод є єдиним радикальним методом лікування, що дозволяє поліпшити віддалені результати виживання. Особливу складність становлять випадки з пухлинною інвазією ворітної вени. Метою цього дослідження було вивчення результатів хірургічного лікування пацієнтів з перихілярною холангіокарциномою з інвазією в ворітну вену. Матеріали та методи. З 2003 по 2017 рік у відділенні трансплантації та хірургії печінки НІХтТ НАМН України ім О.О. Шалімова зроблено великі та розширені резекції печінки 153 хворим із перихілярною холангіокарциномою. Результати. Для встановлення характеру ураження біліарного дерева використовували анатомічну класифікацію перихілярної холангіокарциноми Bismuth-Corlette. З 153 хворих у 66 (43 %) випадках виконали резекцію ворітної вени з подальшою реконструкцією. 1, 3 і 5-річна виживаність в групі пацієнтів з резекцією ворітної вени становила 81,8, 40,9 і 31,8 % відповідно. Висновки. Агресивна тактика хірургічного лікування перихілярної холангіокарциноми забезпечує максимальну радикальність, дозволяє збільшити резектабельність при пухлинній інвазії ворітної вени з прийнятною летальністю і віддаленою виживаністю., Актуальность. Перихилярная холангиокарцинома — редкий вид злокачественных новообразований, который составляет 3–7 случаев на 100 000 населения. Хирургический метод является единственным радикальным методом лечения, позволяющим улучшить отдаленные результаты выживаемости. Особую сложность представляют случаи с опухолевой инвазией воротной вены. Целью настоящего исследования явилось изучение результатов хирургического лечения пациентов с перихилярной холангиокарциномой с инвазией в воротную вену. Материалы и методы. С 2003 по 2017 г. в отделении трансплантации и хирургии печени НИХиТ НАМН Украины им А.А. Шалимова произведены обширные и расширенные резекции печени 153 больным с перихилярной холангиокарциномой. Результаты. Для установления характера поражения билиарного дерева использовали анатомическую классификацию перихилярной холангиокарциномы Bismuth-Corlette. Из 153 больных в 66 (43 %) случаях выполнили резекцию воротной вены с последующей реконструкцией. 1, 3 и 5-летняя выживаемость в группе пациентов с резекцией воротной вены составила 81,8, 40,9 и 31,8 % соответственно. Выводы. Агрессивная тактика хирургического лечения перихилярной холангиокарциномы обеспечивает максимальную радикальность, позволяет увеличить резектабельность при опухолевой инвазии воротной вены с приемлемой летальностью и отдаленной выживаемостью., Background. Perichilar cholangiocarcinoma is a rare type of malignant neoplasm, and its incidence is 3–7 cases per 100,000 population. Surgery is the only radical method of treatment allowing to improve long-term survival results. The cases with tumor invasion of the portal vein are of particular complexity. The purpose of this research was to study the results of surgical treatment of patients with perihilar cholangiocarcinoma with invasion of the portal vein. Materials and methods. From 2003 to 2017, in the department of transplantation and surgery of the liver, extensive and advanced liver resections were preformed in 153 patients with perihilar cholangiocarcinoma. Results. To establish the nature of the lesion of the biliary tree, Bismuth-Corlette anatomical classification of the perihilar cholangiocarcinoma was used. Out of 153 patients, in 66 (43 %) cases, a portal vein resection was performed with subsequent reconstruction. One-, three- and five-year survival rate in the group of patients with portal vein resection was 81.8, 40.9 and 31.8 %, respectively. Conclusions. Aggressive surgical treatment of perihilar cholangiocarcinoma provides maximum radicality, allows to increase resectability in case of tumor invasion of the portal vein with acceptable mortality and long-term survival.

Background and aimsPortal hypertension is a serious adverse event of liver cirrhosis. Recently, we developed a simple novel technique for EUS-guided portal pressure gradient (PPG) measurement (PPGM). Our animal studies showed excellent correlation between EUS-PPGM and interventional radiology-acquired PPGM. In this video we demonstrate the results of the first human pilot study of EUS-PPGM in patients with liver disease.MethodsEUS-PPGM was performed by experienced endosonographers using a linear echoendoscope, a 25-gauge FNA needle, and a novel compact manometer. The portal vein and hepatic vein (or inferior vena cava) were targeted by use of a transgastric or transduodenal approach. Feasibility was defined as successful PPGM in each patient. Safety was based on adverse events captured in a postprocedural interview.ResultsTwenty-eight patients underwent EUS-PPGM with 100% technical success and no adverse events. PPG ranged from 1.5 to 19 mm Hg and had excellent correlation with clinical parameters of portal hypertension, including the presence of varices (P = .0002), PH gastropathy (P = .007), and thrombocytopenia (P = .036).ConclusionThis novel technique of EUS-PPGM using a 25-gauge needle and compact manometer is feasible and appears safe. Given the availability of EUS and the simplicity of the manometry setup, EUS-guided PPG may represent a promising breakthrough for procuring indispensable information in the management of patients with liver disease.

PurposeTo conduct a large single-institution comparison of transarterial chemoembolization (TACE) and stereotactic body radiation therapy (SBRT) outcomes in similar groups of patients with hepatocellular carcinoma (HCC).Methods and materialsFrom 2006 to 2014, 209 patients with 1 to 2 tumors underwent TACE (n=84) to 114 tumors or image guided SBRT (n=125) to 173 tumors. Propensity score analysis with inverse probability of treatment weighting was used to compare outcomes between treatments while adjusting for imbalances in treatment assignment. Local control (LC), toxicity, and overall survival (OS) were retrospectively analyzed.ResultsThe TACE and SBRT groups were similar with respect to the number of tumors treated per patient, underlying liver disease, and baseline liver function. Patients treated with SBRT were older (65 vs 61 years, P=.01), had smaller tumors (2.3 vs 2.9 cm, P<.001), and less frequently underwent liver transplantation (8% vs 18%, P=.01). The 1- and 2-year LC favored SBRT: 97% and 91%, respectively, for SBRT and 47% and 23% for TACE (hazard ratio 66.5, P<.001). For patients treated with TACE, higher alpha-fetoprotein (hazard ratio 1.11 per doubling, P=.008) and segmental portal vein thrombosis (hazard ratio 9.9, P<.001) were associated with worse LC. Predictors associated with LC after SBRT were not identified. Grade 3+ toxicity occurred after 13% and 8% of TACE and SBRT treatments, respectively (P=.05). There was no difference in OS between patients treated with TACE or SBRT.ConclusionsStereotactic body radiation therapy is a safe alternative to TACE for 1 to 2 tumors and provides better LC, with no observed difference in OS. Prospective comparative trials of TACE and SBRT are warranted.

This article describes three complicated cases in rheumatology and pregnancy. The first case elucidates the challenges in treating SLE in conjunction with pulmonary arterial hypertension, while the second case features an SLE-affected pregnancy with development of portal hypertension secondary to portal vein thrombosis related to APS. The third case is a pregnant woman with stable SLE who developed thrombotic microangiopathy caused by atypical haemolytic uraemic syndrome, and failed to improve despite multiple measures including biopsy and elective preterm delivery. There are grave and unique challenges for women with autoimmune disease, but adverse outcomes can sometimes be avoided with careful and multidisciplinary medical management. Pre-conception counselling with regard to medications and disease treatment should also include discussion of the advisability of pregnancy, which may be difficult for a patient, but present the best course for optimizing health outcomes.

Background: The prevalence of calreticulin (CALR) mutations in splanchnic vein thrombosis (SVT) varies among studies. The role of routine screening for CALR mutations in SVT patients remains a debate. Aim: To synthesize the prevalence of CALR mutations according to the different types (i.e., Budd-Chiari syndrome [BCS] and portal vein thrombosis [PVT]) and characteristics (i.e., with and without myeloproliferative neoplasms [MPNs] and JAK2V617F mutation) of SVT patients. Methods: Eligible studies were searched by the PubMed and Embase databases. The study quality was assessed according to the STROBE checklist. The proportion of CALR mutations was pooled by using a random-effects model. The heterogeneity and publication bias were calculated. Results: Eleven papers were included. The study quality was moderate to high. The pooled proportion of CALR mutations was 1.21%, 1.41%, and 1.59% in SVT, BCS, and PVT patients, respectively; 1.52%, 1.03%, and 1.82% in these patients without JAK2V617F mutation, respectively; 3.71%, 2.79%, and 7.87% in these patients with MPN, respectively; and 15.16%, 17.22%, and 31.44% in these patients with MPN but without JAK2V617F mutation, respectively. Only the meta-analysis examining the prevalence of CLAR mutations in BCS patients with MPN but without the JAK2V617F mutation showed statistically significant heterogeneity. Statistically significant publication bias was seen only in the meta-analysis examining the prevalence of CALR mutations in SVT patients without the JAK2V617F mutation. Conclusion: Screening for CALR mutations may have a role in SVT patients with a high probability of MPN in whom the JAK2V617F mutation has been excluded.

New response patterns to anticancer drugs have led tumor size-based response criteria to shift to also include density measurements. Choi criteria, for instance, categorize antiangiogenic therapy response as a decrease in tumor density > 15% at the portal venous phase (PVP). We studied the effect that PVP timing has on measurement of the density of liver metastases (LM) from colorectal cancer (CRC). Pretreatment PVP computed tomography images from 291 patients with LM-CRC from the CRYSTAL trial (Cetuximab Combined With Irinotecan in First-Line Therapy for Metastatic Colorectal Cancer; ClinicalTrials.gov identifier: NCT00154102) were included. Four radiologists independently scored the scans' timing according to a three-point scoring system: early, optimal, late PVP. Using this, we developed, by machine learning, a proprietary computer-aided quality-control algorithm to grade PVP timing. The reference standard was a computer-refined consensus. For each patient, we contoured target liver lesions and calculated their mean density. Contrast-product administration data were not recorded in the digital imaging and communications in medicine headers for injection volume (94%), type (93%), and route (76%). The PVP timing was early, optimal, and late in 52, 194, and 45 patients, respectively. The mean (95% CI) accuracy of the radiologists for detection of optimal PVP timing was 81.7% (78.3 to 85.2) and was outperformed by the 88.6% (84.8 to 92.4) computer accuracy. The mean ± standard deviation of LM-CRC density was 68 ± 15 Hounsfield units (HU) overall and 59.5 ± 14.9 HU, 71.4 ± 14.1 HU, 62.4 ± 12.5 HU at early, optimal, and late PVP timing, respectively. LM-CRC density was thus decreased at nonoptimal PVP timing by 14.8%: 16.7% at early PVP ( P < .001) and 12.6% at late PVP ( P < .001). Nonoptimal PVP timing should be identified because it significantly decreased tumor density by 14.8%. Our computer-aided quality-control system outperformed the accuracy, reproducibility, a

Background and aimsPortal hypertension (PH) is a serious adverse event of liver cirrhosis. The hepatic venous pressure gradient or portal pressure gradient (PPG) accurately reflects the degree of PH and is the single best prognostic indicator in liver disease. This is usually obtained by interventional radiology (IR), although it is not routinely performed. Recently, we developed a simple novel technique for EUS-guided PPG measurement (PPGM). Our animal studies showed excellent correlation between EUS-PPGM and IR-PPGM. We present the first human pilot study of EUS-PPGM in patients with liver disease.MethodsEUS-PPGM was performed by experienced endosonographers using a linear echoendoscope, a 25-gauge fine-needle aspiration needle, and a novel compact manometer. The portal vein and hepatic vein (or inferior vena cava) were targeted using a transgastric-transduodenal approach. Clinical parameters of PH were evaluated in each patient. Feasibility was defined as successful PPGM in each patient. Safety was based on adverse events captured in a postprocedural interview.ResultsTwenty-eight patients underwent EUS-PPGM with 100% technical success and no adverse events. PPG ranged from 1.5 to 19 mm Hg and had excellent correlation with clinical parameters of portal hypertension including the presence of varices (P = .0002), PH gastropathy (P = .007), and thrombocytopenia (P = .036). PPG was increased in patients with high clinical evidence of cirrhosis (P = .005).ConclusionThis novel technique of EUS-PPGM using a 25-gauge needle and compact manometer is feasible and appears safe. Given the availability of EUS and the simplicity of the manometry setup, EUS-guided PPG may represent a promising breakthrough for procuring indispensable information in the management of patients with liver disease.

BACKGROUND AND AIMS: Portal hypertension (PH) is a serious adverse event of liver cirrhosis. The hepatic venous pressure gradient or portal pressure gradient (PPG) accurately reflects the degree of PH and is the single best prognostic indicator in liver disease. This is usually obtained by interventional radiology (IR), although it is not routinely performed. Recently, we developed a simple novel technique for EUS-guided PPG measurement (PPGM). Our animal studies showed excellent correlation between EUS-PPGM and IR-PPGM. We present the first human pilot study of EUS-PPGM in patients with liver disease. METHODS: EUS-PPGM was performed by experienced endosonographers using a linear echoendoscope, a 25-gauge fine-needle aspiration needle, and a novel compact manometer. The portal vein and hepatic vein (or inferior vena cava) were targeted using a transgastric-transduodenal approach. Clinical parameters of PH were evaluated in each patient. Feasibility was defined as successful PPGM in each patient. Safety was based on adverse events captured in a postprocedural interview. RESULTS: Twenty-eight patients underwent EUS-PPGM with 100% technical success and no adverse events. PPG ranged from 1.5 to 19 mm Hg and had excellent correlation with clinical parameters of portal hypertension including the presence of varices (P = .0002), PH gastropathy (P = .007), and thrombocytopenia (P = .036). PPG was increased in patients with high clinical evidence of cirrhosis (P = .005). CONCLUSION: This novel technique of EUS-PPGM using a 25-gauge needle and compact manometer is feasible and appears safe. Given the availability of EUS and the simplicity of the manometry setup, EUS-guided PPG may represent a promising breakthrough for procuring indispensable information in the management of patients with liver disease.

AimTo evaluate the utility of the portal venous phase on multiphasic computed tomography (CT) after treatment of hepatocellular carcinoma (HCC) with trans-arterial chemoembolisation (TACE).Materials and methodsThis was a retrospective review of patients who underwent TACE for HCC between 1 April 2012 and 21 December 2014, with appropriate multiphasic, pre- and post-procedural CT examinations. The maximum non-contrast, arterial phase, and portal venous phase attenuation values of the tumour and tumour bed were evaluated within a region of interest (ROI), with values adjusted against background hepatic parenchyma. Linear regression analyses were performed for both the arterial and venous phases, to assess the level of enhancement and to determine if the venous phase had additional value in this setting.ResultsA total of 86 cases from 51 patients were reviewed. All pre-procedural CT examinations of lesions demonstrated arterial phase enhancement with portal venous and delayed phase washout compatible with HCC. The post-procedural CT examinations following TACE revealed expected decreased arterial enhancement. Sixty-five cases (76%) showed persistent non-enhancement on the portal venous phase following embolisation therapy. A total of 21 cases (24%), however, demonstrated progressive portal venous hyper enhancement. Linear regression analysis demonstrated a statistical significance between the difference in maximal arterial and portal venous enhancement in these cases.ConclusionFollowing TACE, the treated lesion may demonstrate portal venous phase hyper-enhancement within the tumour bed. As such, full attention should be given to these images for comprehensive evaluation of tumour response following treatment.

OBJECTIVES: Subharmonic imaging (SHI) is a technique that uses the nonlinear oscillations of microbubbles when exposed to ultrasound at high pressures transmitting at the fundamental frequency ie, f METHODS: Eight waveforms with different envelopes were optimized with respect to acoustic power at which the SHAPE study is most sensitive. The study was run with four input transmit cycles, first in vitro and then in vivo in three canines to select the waveform that achieved the best sensitivity for detecting changes in portal pressures using SHAPE. A Logiq 9 scanner with a 4C curvi-linear array was used to acquire 2.5 MHz radio-frequency data. Scanning was performed in dual imaging mode with B-mode imaging at 4 MHz and a SHI contrast mode transmitting at 2.5 MHz and receiving at 1.25 MHz. Sonazoid, which is a lipid stabilized gas filled bubble of perfluorobutane, was used as the contrast agent in this study. RESULTS: A linear decrease in subharmonic amplitude with increased pressure was observed for all waveforms (r from -0.77 to -0.93; P < .001) in vitro. There was a significantly higher correlation of the SHAPE gradient with changing pressures for the broadband pulses as compared to the narrowband pulses in both in vitro and in vivo results. The highest correlation was achieved with a Gaussian windowed binomial filtered square wave with an r-value of -0.95. One of the three canines was eliminated for technical reasons, while the other two produced very similar results to those obtained in vitro (r from -0.72 to -0.98; P CONCLUSIONS: Using this waveform is an improvement to the existing SHAPE technique (where a square wave was used) and should make SHAPE more sensitive for noninvasively determining portal hypertension.

PurposeTo develop a free-breathing multidelay pseudocontinuous arterial spin labeling (pCASL) technique for quantitative measurement of liver perfusion of the hepatic artery and portal vein, respectively.Materials and methodsA navigator-gated pCASL sequence with balanced steady-state free precession (bSSFP) readout was developed and applied on five healthy young volunteers at 3T. Two labeling schemes were performed with the labeling plane applied on the descending aorta above the liver, and perpendicular to the portal vein before its entry to liver to label the hepatic artery and portal vein, respectively. For each labeling scheme, pCASL scans were performed at five or six postlabeling delays between 200 and 2000 msec or 2500 msec with an interval of 400 or 500 msec. Multidelay pCASL images were processed offline with nonrigid motion correction, outlier removal, and fitted for estimation of liver perfusion and transit time.ResultsEstimated liver perfusion of the hepatic artery and hepatic portal vein were 21.8 ± 1.9 and 95.1 ± 8.9 mL/100g/min, with the corresponding transit time of 1227.3 ± 355.5 and 667.2 ± 85.0 msec, respectively. The estimated liver perfusion and transit time without motion correction were less reliable with greater residual variance compared to those processed with motion correction (P < 0.05).ConclusionThe liver perfusion measurement using multidelay pCASL showed good correspondence with values noted in the literature. The capability to noninvasively and selectively label the hepatic artery and portal vein is a unique strength of pCASL as compared to other liver perfusion imaging techniques, such as computed tomography perfusion and dynamic contrast-enhanced MRI.

Tromboza portne vene (TPV) je retko oboljenje splanhničke cirkulacije, koje najčešće nastaje sadejstvom više lokalnih i/ili sistemskih faktora. Ukoliko TPV komplikuje osnovnu bolest, ona pogoršava njenu prognozu, a konkomitantno se leče obe. Iako se najčešće javlja u sklopu ciroze jetre, malignih bolesti abdominalnih organa i nekih hemopatija, postoji i idiopatska TPV, koja se definiše ekskluzijom svih poznatih uzroka TPV. U ovom radu je prikazan slučaj hronične idioptaske TPV., Portal vein thrombosis (PVT) is a rare disorder of splanchnic circulation, frequently caused by concomitant presence of local and/or systemic factors. When portal vein thrombosis complicates causative diseases, it will worsen their prognosis, and in such a case, the causative disease and PVT are treated concomitantly. Despite the fact that PVT frequently complicates liver cirrhosis, intraabdominal malignancies, and some hematological diseases, after all causes are excluded, one can define idiopathic portal vein thrombosis. In this study we have described the case of idiopathic chronical portal vein thrombosis.