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Resumen La vena porta es un conducto que drena el flujo esplácnico al hígado y se puede ocluir por diferentes patologías, variando su presentación clínica de acuerdo con la causa de la obstrucción. Es muy importante diferenciar la trombosis portal asociada o no a la cirrosis, ya que su tratamiento y pronóstico es diferente. La trombosis venosa portal extrahepática es una condición netamente de origen vascular, y es la principal causa de trombosis portal en niños y adultos. Presentamos tres casos tratados con derivación meso-Rex, con seguimiento a 6 meses. Abstract The portal vein is a conduit that drains splanchnic flow to the liver, it can be occluded by different pathologies and its clinical presentation varies according to the cause of the obstruction. It is very important to differentiate portal thrombosis associated or not with cirrhosis, since its treatment and prognosis is different. Extrahepatic portal vein thrombosis (PEVT) is a condition of purely vascular origin, being the main cause of portal thrombosis in children and adults. We present three cases with meso-Rex shunt, with a 6-month follow-up.

Los tumores hepáticos sólidos benignos están formados por un grupo heterogéneo de lesiones. Las parasitosis hepáticas conforman una causa etiológica poco frecuente de tumores hepáticos sólidos benignos. Objetivo. Reportar el caso de un paciente con tumores hepáticos solidos benignos tratado con embolización portal derecha y posteriormente hepatectomía. Caso clínico. Paciente de 60 años, sexo masculino, al cual se le diagnostican múltiples tumores hepáticos sólidos, debido a cuadro de ictericia generalizada. Debido al cuadro sintomático, y al no poder descartar malignidad con las pruebas complementarias, se decide realizar cirugía. Previamente se realiza volumetría de la glándula hepática y embolización portal derecha para aumentar el remanente hepático futuro. Se realiza hepatectomía derecha y segmentectomía hepática IVa. Evoluciona con mejoría del cuadro ictérico y el resultado anatomopatológico informa lesión vinculable a parasitosis hepática. Conclusión. Ante la presencia de un tumor hepático sólido, es necesario descartar etiología maligna de la lesión. Si no es posible descartar esto, o si el paciente persiste con sintomatología, la resección quirúrgica está indicada, teniendo en cuenta el volumen de la glándula hepática y del remanente hepático futuro.

In patients with abdominal trauma who require laparotomy, up to a quarter or a third will have a vascular injury. The venous structures mainly injured are the vena cava (29%) and the iliac veins (20%), and arterial vessels are the iliac arteries (16%) and the aorta (14%). The initial approach is performed following the ATLS principles. This manuscript aims to present the surgical approach to abdominal vascular trauma following damage control principles. The priority in a trauma laparotomy is bleeding control. Hemorrhages of intraperitoneal origin are controlled by applying pressure, clamping, packing, and retroperitoneal with selective pressure. After the temporary bleeding control is achieved, the compromised vascular structure must be identified, according to the location of the hematomas. The management of all lesions should be oriented towards the expeditious conclusion of the laparotomy, focusing efforts on the bleeding control and contamination, with a postponement of the definitive management. Their management of vascular injuries includes ligation, transient bypass, and packing of selected low-pressure vessels and bleeding surfaces. Subsequently, the unconventional closure of the abdominal cavity should be performed, preferably with negative pressure systems, to reoperate once the hemodynamic alterations and coagulopathy have been corrected to carry out the definitive management.En pacientes con trauma de abdomen que requieren laparotomía, hasta una cuarta o tercera parte, habrán sufrido una lesión vascular. Las estructuras venosas principalmente lesionadas son la vena cava y las iliacas, y de vasos arteriales, son las iliacas y la aorta. El abordaje de este tipo de heridas vasculares se puede ser difícil en el contexto de un paciente hemodinámicamente inestable ya que requiera medidas rápidas que permita controlar la exanguinación del paciente. El objetivo de este manuscrito es presentar el abordaje del trauma vascular abdominal de acuerdo con la filosofía de cirugía de control de daños. La primera prioridad en una laparotomía por trauma es el control de la hemorragia. Las hemorragias de origen intraperitoneal se controlan con compresión, pinzamiento o empaquetamiento, y las retroperitoneales con compresión selectiva. Posterior al control transitorio de la hemorragia, se debe identificar la estructura vascular comprometida, de acuerdo con la localización de los hematomas. El manejo de las lesiones debe orientarse a la finalización expedita de la laparotomía, enfocado en el control de la hemorragia y contaminación, con aplazamiento del manejo definitivo. Lo pertinente al tratamiento de las lesiones vasculares incluyen la ligadura, derivación transitoria y el empaquetamiento de vasos seleccionados de baja presión y de superficies sangrantes. Posteriormente se debe realizar el cierre no convencional de la cavidad abdominal, preferiblemente con sistemas de presión negativa, para consecutivamente reoperar una vez corregidas las alteraciones hemodinámicas y la coagulopatía para realizar el manejo definitivo.

Alveolar echinococcosis (AE) is a rare anthropozoonotic parasitic disease, which can affects the liver, lungs and other organs. R0-radical liver resection is the sole curative therapy for the patients with AE. Size of the parasitic foci, distant dissemination, and involvement of main liver vessels – all this information allows the surgeon to make the right decision about practicability and volume of operation. Formerly, ultrasonography (US) was not method of choice for the qualitative pre-operative diagnostic of AE. Nevertheless nowadays development of new technologies allows US to be an equal to CT and MRI.The aim:to estimate the possibilities of US in the planning of surgery in patients with AE.Materials and methods.The data of 64 patients who were undergone complete liver resection or reduction surgery in A.V. Vishnevsky Surgery Institute in period from January 2008 to December 2016 we respectively analyzed. Specificity and sensitivity of US, CT and MRI were analyzed and ROC-curves were constructed. Statistical significance was calculated using Chi-square.Results.The efficiency of US was significantly comparable to CT and MRI when we analyzed the involved of porta hepatis, vena cava, hepatic veins. Assessment of involvement of liver arteries and vena porta was not statistical significant.Conclusion.Accumulated experience of A.V. Vishnevsky Surgery Institute shows the possibility of qualitative preoperationUS evaluation of AE-lesion, which has to include assessment of distant dissemination and involvement of the liver main vessels. In a big surgical hospitals, which has an experience of AE treatment, pre-operative US can become the method of choice in planning of surgical operation.

ResumenAntecedentesEl trasplante hepático realizado en pacientes con cirrosis hepática, trombosis venosa portal y transformación cavernomatosa de la vena porta, es un procedimiento de alta complejidad y elevada posibilidad de disfunción del injerto hepático; se realiza en el 2-19% de los trasplantes hepáticos y tiene una mortalidad significantemente alta en el postoperatorio. Se ha descrito la perfusión portal alterna, no obstante no hay reportes de perfusión alterna con la vena gastroepiploica derecha.Caso clínicoMujer de 20 años de edad con diagnóstico de cirrosis hepática criptogénica Chil-Pugh: «B» 7 puntos, MELD: 14 con trombosis y degeneración cavernomatosa de la vena porta, hipertensión portal severa, esplenomegalia con antecedentes de sangrado del tubo digestivo alto, por varices esofágicas y agenesia de riñón izquierdo. Fue realizado protocolo de trasplante hepático y se observó la vena gastroepiploica derecha con un diámetro de 1 cm drenando a la vena cava infrahepática y vena suprarrenal derecha. Se realizó el trasplante hepático ortotópico de donante fallecido el día 30 de enero del 2005 con técnica de Piggy-Back, la perfusión venosa portal se realizó a través de la vena gastroepiploica derecha y la evolución fue satisfactoria, la paciente fue egresada sin complicaciones, 13 días posterior al trasplante.ConclusionesEl trasplante hepático fue realizado de forma satisfactoria y con buen resultado en el presente caso, ya que la perfusión portal fue llevada a cabo con adecuado flujo a través de la vena gastroepiploica derecha.AbstractBackgroundLiver transplantation in patients with liver cirrhosis, portal vein thrombosis, and cavernous transformation of the portal vein, is a complex procedure with high possibility of liver graft dysfunction. It is performed in 2-19% of all liver transplants, and has a significantly high mortality rate in the post-operative period. Other procedures to maintain portal perfusion have been described, however there are no reports of liver graft perfusion using right gastroepiploic vein.Clinical caseA 20 year-old female diagnosed with cryptogenic cirrhosis, with a Child-Pugh score of 7 points (class “B”), and MELD score of 14 points, with thrombosis and cavernous transformation of the portal vein, severe portal hypertension, splenomegaly, a history of upper gastrointestinal bleeding due to oesophageal varices, and left renal agenesis. The preoperative evaluation for liver transplantation was completed, and the right gastroepiploic vein of 1-cm diameter was observed draining to the infrahepatic inferior vena cava and right suprarenal vein. An orthotopic liver transplantation was performed from a non-living donor (deceased on January 30, 2005) using the Piggy-Back technique. Portal vein perfusion was maintained using the right gastroepiploic vein, and the outcome was satisfactory. The patient was discharged 13 days after surgery.ConclusionsLiver transplantation was performed satisfactorily, obtaining an acceptable outcome. In this case, the portal perfusion had adequate blood flow through the right gastroepiploic vein.

espanolIntroduccion: las comunicaciones porto-sistemicas congenitas intrahepaticas (sindrome de Abernethy) son variantes anatomicas muy poco frecuentes, estando clasificadas en funcion del tipo de union que exista entre la vena porta y el sistema venoso central. En el adulto, su diagnostico suele ser incidental, aunque algunos casos puede presentarse con clinica de encefalopatia en pacientes sin hepatopatia asociada. Casos clinicos: presentamos dos casos de shunt porto-sistemico, uno con desarrollo de encefalopatia y otro hallado de forma casual. Su tratamiento, por medio de radiologia intervencionista se decidio en funcion de si presentaban o no sintomatologia. Ambos casos (tratado y control) se presentan al control en consultas externas asintomaticos, sin asociar complicaciones derivadas de la decision terapeutica. Este control se realiza anualmente con pruebas de imagen (ecografia/TAC) y analisis sanguineo. Discusion: dada la escasa prevalencia de este tipo de malformacion y su diagnostico habitual en edades mas tempranas (asociada a importantes alteraciones cognitivas) su tratamiento en adultos no esta protocolizado. En estos casos la decision del tratamiento estaria condicionada a la sintomatologia asociada, siendo el tratamiento minimamente invasivo mediante radiologia intervencionista una opcion terapeutica a valorar en el adulto sintomatico. Por su parte la observacion por medio de pruebas de imagen y control en consultas externas, sin tratamiento asociado, seria de eleccion en adultos en los que no se presenta sintomatologia asociada. EnglishBackground: portosystemic intrahepatic venous connections (Abernethy syndrome) are rare anatomical variants, which are classified according to the type of union between the portal venous circulation and the central venous system. In adults, the diagnosis is often incidental, although some cases can be presented with an encephalopathy without associated liver disease. Case reports: here we present two cases of portosystemic shunt, one with encephalopathy development, and the other casually caught. Its treatment by interventionist radiology, was decided in function of clinic symptoms. Both patients were asymptomatic at controls in the outpatient consultation. No complications derived from the therapeutic decision. The control is carried out annually with image tests and blood analysis. Discussion: given the low prevalence of malformation and its usual diagnosis at younger ages (associated with important cognitive alterations) its treatment in adults is not protocolized. In these cases the decision of the treatment would be conditioned to the associated symptomatology, being the minimally invasive treatment (by interventional radiology) a therapeutic option in the symptomatic adult. Observation by imaging tests and control in outpatient consultation (without associated treatment) would be a choice in asymptomatic adults.

We report the case of a 29-year-old patient who presented with a short history of lower gastrointestinal bleeding. A diagnosis of Abernethy syndrome was made (congenital extrahepatic portosystemic shunt) after this uncommon clinical presentation. The prevalence of this congenital malformation is very low and usually manifests during the pediatric age, according to previously published reports.

La pancreatoduodenectomía (cirugía de Whipple) es un procedimiento realizado frecuentemente para el manejo de neoplasias pancreáticas. Las complicaciones hemorrágicas de este procedimiento son bien conocidas, sin embargo, existe escasa información sobre el desarrollo de pseudoaneurisma portal como complicación de esta cirugía. Aquí presentamos un caso de pseudoaneurisma portal en una paciente de 76 años que evoluciona con hemorragia tardía post pancreatoduodenectomía. Se realiza una tomografía computada de abdomen que demuestra el pseudoaneurisma de la vena porta, que se corrobora quirúrgicamente como un desgarro de 2 centímetros en esta estructura. El pseudoaneurisma se desarrolla adyacente a un tubo de drenaje abdominal y en el intraoperatorio se evidencia filtración de la anastomosis, hallazgos también descritos en otro caso de pseudoaneurisma portal post pancreatoduodenectomía, situación que sugiere que estas condiciones pudiesen ser factores de riesgo para el desarrollo de esta complicación.

Le traitement de l’aponevrosite plantaire est avant tout medical, la chirurgie ne devant etre proposee qu’en deuxieme intention. L’inconvenient du traitement chirurgical a ciel ouvert est d’etre pourvoyeur de complications cutanees, infectieuses ou encore d’aboutir a des interruptions prolongees d’activites. Le traitement chirurgical endoscopique a pour principal avantage de diminuer ces inconvenients. Quel peut etre l’apport d’un traitement endoscopique a une voie dans le cadre de l’aponevrosite plantaire ? Nous avons utilise le materiel dit d’Agee avec couteau monte sur une piece a main. Apres une etude cadaverique prealable portant sur huit pieds, nous avons realise une serie prospective monocentrique depuis janvier 2008. La serie se compose de cinq femmes et de trois hommes dont l’âge moyen est de 57 ans, operes par un meme operateur. L’IMC moyen est de 28. L’intervention est survenue en moyenne apres 20,3 mois de symptomatologie et de traitement medical. Nous ne notons aucune complication precoce ou secondaire. La cicatrice est esthetique et de petite taille. La statique du pied ne presente aucun trouble iatrogene. La boiterie, presente dans 75 % des cas, a disparu. L’acte chirurgical dure en moyenne 11 minutes. Le but de notre etude est de reveler les avantages du traitement chirurgical endoscopique a une voie par rapport aux autres techniques chirurgicales. La chirurgie conventionnelle a ciel ouvert est pourvoyeuse de douleurs postoperatoires, de problemes de cicatrisation. Elle comporte un risque infectieux et expose aussi a une impotence fonctionnelle. Bien que le recul moyen ne soit que de 8,4 mois, nous ne notons aucune complication cutanee, infectieuse ou fonctionnelle, la statique du pied etant preservee par le respect du fascia lateral de l’aponevrose.

L’echographie semble remplir les conditions necessaires d’un examen de surveillance: 1) elle est reproductible, fiable, non invasive, peu couteuse; 2) ses resultats peuvent influencer l’attitude therapeutique, voire meme le pronostic et la survie des patients cirrhotiques; 3) l’utilisation du doppler est indispensable (liberte des veines, vitesse et sens du flux); 4) la description du systeme porte est necessaire avant tout geste chirurgical chez un patient cirrhotique. Tous ces items doivent etre systematiquement notes dans des comptes rendus standardises afin d’avoir un suivi efficace des patients cirrhotiques.

Summary A method of auxiliary liver Homotransplantation in dogs is described. The experiments, which are of a preliminary nature, were done on 12 dogs of the native breed which received grafts from small donors of the same breed, sex and blood group. The idea included the replacement of the graft at the site of the spleen, with anastomosis of the graft's vena cava, portal vein and aorta to the recipient's left renal vein, splenic vein and splenic artery, respectively. The method proved to be technically satisfactory. Survival times up to 76 hours were obtained. Taking into consideration the results obtained from the pathological observations and the probable causes of death in the dogs and with the use of improved immunosuppressive regimes, we hope to obtain better results in future experiments. Zusammenfassung Allogen-heterotope Leberhomotransplantation beim Hund III. Transplantationstechnik und allgemeine Betrachtungen Die Leberhomotransplantation beim Hund wird beschrieben. Die Experimente (Tastversuche) wurden an 12 Hunden ausgefuhrt. Diese erhielten Transplantate von kleinen Donatoren der gleichen Rasse, des gleichen Geschlechtes und der gleichen Blutgruppe. Das Transplantat ersetzte die Milz und die linke Niere. Die Pfortader des Transplantates wurde mit der Milzvene des Rezipienten verbunden. Die posthepatische Vena cava des Transplantates wurde mit der linken Nierenvene vereinigt. Die Milzarterie des Rezipienten wurde mit der Aorta bzw. A. coeliaca des Transplantates verbunden. Die Methode erwies sich in technischer Hinsicht als befriedigend. Die Uberlebenszeiten betrugen bis zu 76 Stunden. Mit Hilfe besserer immunorepressiven Behandlungsmethoden durften in Zukunft bessere Resultate erzielt werden. Resume Homotransplantation allogene heterotope de foie canin. III. Technique de transplantation et considerations generales On decrit une methode d'homotransplantation de foie chez les chiens. Les experiences preliminaires sont pratiquees sur 12 chiens de la race du pays, ayant recu des greffes de petits donneurs de la meme race, du meme sexe et du meme groupe sanguin. Le projet consistait a placer la greffe a l'endroit de la rate, avec une anastomose de la veine cave, de la veine porte et de l'aorte de l'animal greffe a la veine renale gauche, la veine splenique et satisfaisante. On obtient des survies atteignant 76 heures. En considerant les resultats des observations pathologiques et les causes probables de la mort des chiens, on espere obtenir de meilleurs resultats dans des experiences ulterieures a l'aide de methodes immunosuppressives. Resumen Homotrasplante alogenico-heterotopico del higado en el perro. III. Tecnica de trasplantacion y consideraciones generales Describese un metodo de homotrasplantacion auxiliar de higado en perros. Los experimentos, de naturaleza preliminar, se ejecutaron en 12 perros. Estos perros recibieron trasplantes de donadores pequenos de las misma raza, sexo y grupo sanguineo. El trasplante reemplazo el bazo y el rinon izquierdo. La vena porta del trasplante se anastomoso con la vena esplenica del receptor. La vena cava posthepatica del trasplante se acoplo a la vena renal izquierda. La arteria esplenica del receptor se unio a la aorta o a la arteria celiaca, respectivamente, del trasplante. El metodo resulto satisfactorio en cuanto al aspecto tecnico. Los tiempos de supervivencia fueron hasta de 76 horas. Con ayuda de procedimientos inmunorrepresivos mejores, se podrian obtener en el futuro resultados mas halaguenos.

Summary Segmental or subsegmental ligation of the hepatic artery in the pig is fully compensated by intrahepatic collateral circulation. Subtotal and total elimination of the hepatic artery results in varying degrees of extensive necrosis of the liver, its restitution occurring with the development of the extrahepatic collateral circulatory system. Ligation of the portal vein of varying degrees in the pig and the dog provoked marked multiplication, dilation and undulation of the arteries in the ligated area with the tendency to compensate for the eliminated portal circulation. Atrophy of the area of liver deprived of its supply of the portal blood and marked hypertrophy of other parts of the liver demonstrate that the hepatic artery is not able to replace fully the portal vein in its functional respect. The portal circulatory system readily responds by forming a strongly developed, characteristic intrahepatic collateral circulatory system. With its development, gradual return to normality sets in. In my experiments I found no arterio-portal, or arteriohepatic communications. Porto-hepatic communications developed as a result of pathological changes. Zusammenfassung Morphologische Untersuchungen uber die funktionellen Beziehungen zwischen der A. hepatica und V. portae Segmentale und subsegmentale Unterbindungen der A. hepatica beim Schwein werden durch intrahepatische Kollateralkreislaufe voll kompensiert. Totale und subtotale Ausschaltungen der A. hepatica verursachen ausgedehnte Lebernekrosen, deren Behebung von der Entwicklung von extrahepatischen Kollateralkreislaufen in Zusammenhang abhangt. Eine Blockierung der V. portae verschiedenen Grades fuhrt beim Schwein und beim Hund zu einer Vermehrung, Erweiterung und Schlangelung der Arterien in den affizierten Arealen und zur Tendenz einer Kompensation des ausgeschalteten Pfortaderkreislaufes. Die Atrophie desjenigen Lebergebietes, welches nicht mehr mit Portalblut versorgt wird, und die Hypertrophie der ubrigen Leberteile weisen darauf hin, das die Leberarterie nicht imstande ist, die Funktionen der V. portae voll zu ersetzen. Der Pfortaderkreislauf vermag starke intrahepatische Kollateralen zu bilden, mit deren Entwicklung die affizierten Leberareale ihre Funktionen sukzessive wieder ubernehmen. Arterio-portale Gefasverbindungen wurden nicht gefunden. Solche Verbindungen entwickeln sich erst als Resultat pathologischer Umstellungen. Resume Morphologie des relations fonctionnelles entre l'artere hepatique et la veine porte Une ligature segmentaire ou sub-segmentaire de l'artere hepatique du porc est entierement compensee par la circulation collaterale intrahepatique. Une elimination subtotale ou totale de l'artere hepatique donne lieu a des necroses extensives du foie, a des degres variables; sa restitution se produisant par le developpement du systeme circulatoire collateral extrahepatique. Une ligature d'importance variable de la veine porte du porc et du chien provoque une multiplication prononcee, une dilatation et une ondulation des arteres de la region ligaturee, tendant a compenser l'interruption de la circulation porte. L'atrophie de la region du foie privee de son apport de sang porte et l'hypertrophie prononcee des autres parties du foie montrent que l'artere hepatique ne parvient pas a remplacer completement la veine porte dans ses fonctions. Le systeme circulatoire porte repond immediatement en formant un systeme circulatoire collateral intrahepatique, caracteristique, tres developpe. Par ce developpement, on retourne graduellement a la normale. Dans mes experiences, j'ai trouve des communications arterio-porte ou arterio-hepatiques. Les communications porto-hepatiques se developpent a la suite des modifications pathologiques. Resumen Morfologia de las relaciones funcionales entre la arteria hepatica y la vena porta La ligadura segmentaria o subsegmentaria de la arteria hepatica en el cerdo es compensada de lleno por la circulacion colateral intrahepatica. La eliminacion subtotal y total de la arteria hepatica redunda en grados variables de necrosis extensiva del higado, aconteciendo su restitucion con el desarrollo del sistema circulatorio extrahepatico colateral. La ligadura de la vena porta en grados varios en el cerdo y en el perro provocan multiplicacion marcada, dilatacion y ondulacion de las arterias en el area ligada con la tendencia de compensar la circulacion portal eliminada. La atrofia del area hepatica privada de su abastecimiento de sangre portal y la hipertrofia marcada de otras partes del higado demuestran que la arteria hepatica no es capaz de reemplazar por completo la vena porta en su aspecto funcional. El sistema circulatorio portal responde pronto formando un sistema circulatorio intrahepatico colateral caracteristico, desarrollado vigorosamente. Con su desarrollo, se establece la vuelta gradual a la normalidad. En mis experimentos no halle comunicaciones arterioportales o arteriohepaticas. Las comunicaciones portohepaticas se desarrollan como resultado de cambios patologicos.

Resume Introduction Les abces du psoas sont une entite clinique rare. Ils sont le plus souvent secondaires a un foyer infectieux intra-abdominal ou retroperitoneal. Nous rapportons deux cas d’abces du psoas a streptocoque beta-hemolytique du groupe A secondaires a une porte d’entree cutanee. Observations Le premier patient, âge de 50 ans, etait febrile et presentait des lesions cutanees ulceronecrotiques evocatrices d’ecthyma evoluant depuis trois mois, associees depuis peu a une masse douloureuse de la fosse iliaque gauche entrainant des difficultes a la marche. La seconde patiente, une femme de 35 ans aux antecedents de toxicomanie intraveineuse, etait transferee en reanimation dans un contexte de sepsis severe a streptocoque beta-hemolytique du groupe A de localisation initiale cutanee (placard inflammatoire du membre inferieur gauche). Elle restait subfebrile dix jours apres le debut d’une antibiotherapie par amoxicilline, sans point d’appel infectieux. Un examen tomodensitometrique abdominopelvien confirmait le diagnostic d’abces du psoas gauche chez les deux patients. Pour le premier, le meme streptocoque beta-hemolytique du groupe A etait isole a la fois sur le liquide de drainage et sur les lesions cutanees. L’evolution etait favorable dans les deux cas sous antibiotherapie intraveineuse prolongee (amoxicilline) et drainage percutane (premier patient seulement). Discussion L’abces du psoas peut etre secondaire, par contiguite avec un foyer infectieux locoregional. La porte d’entree initiale est alors le plus souvent digestive, articulaire, gynecologique ou urologique et les germes en cause sont varies. L’abces du psoas peut aussi etre primitif ; le microorganisme le plus frequemment retrouve est alors le staphylocoque dore. Dans nos deux observations, il s’agit d’abces du psoas secondaires a une porte d’entree cutanee. La triade evocatrice de fievre prolongee, douleur et psoitis est souvent tardive et il faut savoir evoquer le diagnostic devant un etat infectieux prolonge ou une douleur abdominale febrile inexpliquee. Le diagnostic de certitude repose sur la tomodensitometrie abdominale. Le traitement fait generalement appel a une antibiotherapie intraveineuse a large spectre associee a un drainage percutane ou chirurgical. Le taux de mortalite de ces patients reste eleve et la survie est conditionnee par la rapidite de la prise en charge.

The ability to longitudinally monitor portal and splanchnic pressures would greatly enhance the understanding of acute and chronic liver disease by helping to assess the immediate and long-term impact of therapeutic manipulations. However, a technique for measuring portal pressures in the ambulatory setting is not currently available. To overcome this difficulty, we utilized an approach that involved the implantation of a miniature telemetric device, equipped with a specially-designed pressure transmission catheter, into the spleen of an anesthetized mouse. Using this approach, portal pressures were measured continuously over 5 d in conscious, unrestrained animals, the availability of which will help facilitate studies of the portal circulation requiring long-term stability.

Resume Nous rapportons un cas de stenose de la veine porte survenant six mois apres une transplantation hepatique. Dans cette observation, c’est l’apparition d’une symptomatologie d’ischemie mesenterique veineuse qui a conduit au diagnostic. La realisation d’une angioplastie avec mise en place d’une prothese porte a permis une resolution rapide des symptomes.

Purpose To investigate the imaging features of portal biliopathy with emphasis on MR cholangiopancreatography (MRCP). The ancillary vascular findings of portal biliopathy were also evaluated by accompanying MR portography, dynamic contrast-enhanced (CE) CT, and dynamic CE MRI studies. Materials and methods Sixteen patients with portal cavernoma were included in the study. Patients had undergone MRCP (n = 16) studies accompanied by MR portography (n = 13), dynamic CE CT (n = 3) or dynamic CE MRI (n = 2) of the liver. Two patients had undergone both dynamic CE CT and dynamic CE MRI. Two radiologists evaluated all the examinations together, retrospectively. MRCP images were analyzed for the presence of biliary stenosis, upstream (prestenotic) dilatation, wavy appearance of the bile ducts, angulation of the common bile duct (CBD), and choledocholithiasis. MR portography, dynamic CE CT and dynamic CE MRI studies were evaluated for the existence of portal cavernomas, and the presence of gall bladder/choledochal varices. Results All patients had signs of portal biliopathy on MRCP. Frequencies of the biliary findings on MRCP were as follows: biliary stenosis, 93.7%; upstream dilatation, 68.7%; wavy appearance of the biliary tree, 87.5%; angulation of the CBD, 75%. None of the patients had choledocholithiasis. Frequencies of the ancillary vascular findings detected on CE studies were as follows: gall bladder varices, 100%, choledochal varices, 93.7%. Conclusion MRCP features of portal biliopathy in order to their frequencies were as follows: biliary stenosis, wavy appearance of the bile ducts, angulation of the CBD, and upstream dilatation of the bile ducts.

Minimal hepatic encephalopathy (MHE) leads to deterioration in patient quality of life and could be a marker for future episodes of clinical hepatic encephalopathy (HE) in liver cirrhosis. Whether MHE predicts HE in extrahepatic portal vein obstruction (EHPVO) is not known. We studied the incidence of overt HE in EHPVO patients with MHE.Consecutive patients (from October 2006 to July 2007) with a diagnosis of EHPVO were followed up at 3-month intervals. MHE was diagnosed by abnormal psychometry (2 s.d.) and/or P300 auditory event-related potential (P300 ERP) (2.5 s.d.), and HE was diagnosed as per West-Heaven criteria. Critical flicker frequency (CFF) was also measured at baseline and after 1 year.Thirty-two EHPVO patients (age, 23.2+/-10.8 years; M/F 22:10) were followed up for 1 year. Of 32 patients, P300 ERP was prolonged in 8 (25%) (371.8+/-13.9 ms), 9 (28%) had abnormal psychometric tests, and CFF was38 Hz in 8 (25%) patients after a follow-up of 13.5+/-2.4 months. Of 12 patients who had MHE at baseline, 9 (75%) patients continued to have MHE, and in 3 (25%) patients it disappeared. One (5%) of the remaining 20 patients developed MHE during the follow-up. Venous ammonia level was higher in patients with MHE (79.7+/-17.0 micromol/l; range 33-124) compared with patients without MHE (46.6+/-19.8 micromol/l; range 24-78, P0.001) on follow-up. Similarly, patients who had spontaneous shunts (n=10) had significantly higher venous ammonia levels (82.4+/-20.3 vs. 47.1+/-16.7 micromol/l; P=0.001) than those who had no shunt (n=22). Neither patients who had MHE nor those who did not have MHE at baseline developed HE.Seventy-five percent of extrahepatic portal vein obstruction patients with MHE continued to have MHE, and new-onset MHE developed in 5% over 1 year. In this small sample, patients with EHPVO and MHE did not progress to overt encephalopathy within the relatively short time frame studied.

— The continuous thermodilution method was applied to the percutaneous measurement of portal blood flow in the piglet by inserting a thermodilution probe into the portal vein via the transhepatic transvenous route. The method was compared to electromagnetic flowmetry in three piglets; the two methods yielded statistically identical results. The coefficient of variation of the continuous thermodilution measurements was 4%. The method allows portal blood flow measurements that are instantaneous, reliable, reproducible, and repetitive. It was applied to a study of rapid flow variations in piglets receiving an infusion of posterior pituitary extract.

Resume Les pylephlebites septiques sont le plus souvent secondaires a un foyer infectieux intra-abdominal situe dans le territoire de drainage de la veine porte. Nous rapportons deux cas de thrombose mesenterico-porte aigue associee a une septicemie a Fusobacterium necrophorum , pour lesquels il n’a pas ete mis en evidence de foyer infectieux intra-abdominal par les examens d’imagerie usuels. Dans un des deux cas, le traitement anticoagulant debute precocement a permis une repermeabilisation de la veine porte et de sa branche droite. De meme que pour Bacteroides , il nous semble necessaire de rechercher systematiquement une thrombose portale en cas de septicemie a Fusobacterium d’origine inconnue. Cela peut permettre de debuter precocement un traitement anticoagulant afin de repermeabiliser les vaisseaux thromboses et de lever une hypertension portale prehepatique.

Background Patient Internet portals have created new opportunities for assessment and management of chronic conditions. Objective To conduct an online screening survey for a study recruitment using a secure patient Internet portal to identify primary care patients with untreated depression, chronic pain, or mobility difficulty before nonurgent office visits. Design Internet-based screening survey for a randomized trial. Participants Patients who were registered portal users who had scheduled primary care appointments. Approach Electronic study invitations via the portal were sent to 4,047 patients with scheduled visits to 34 primary care physicians participating in the study. After clicking on a link in the study invitation, patients were consecutively shown the study description, consent form, and lastly, the screening survey to determine final eligibility for study participation. Results Of the 2,113 (52%) patients who opened the study invitation, 1,001 consented online to join the study and 981 (98%) of these completed the screening survey. Of the respondents, 319 (33%) screened positive for 1 or more of the 3 conditions. Conclusions The online screening survey conducted through the patient portal was effective in identifying patients with chronic conditions in advance of scheduled primary care visits for participation in an intervention study.

We describe three cases of idiopathic thrombosis of the superior mesenteric and portal veins, in one case with additional thrombosis of the splenic vein. All patients suffered from unspecific, slowly increasing pain. The cause of the same could be detected only via CT. After anticoagulation the patients became symptom-free. A follow-up CT showed recanalisation of the affected veins.

RESUME Les progres des techniques chirurgicales ont reduit le risque operatoire et les malades operes de lesions malignes du foie ont une amelioration de leur survie. Ces resultats contribuent a augmenter les indications de resection hepatique dont il convient d’evaluer le risque. Ce risque depend: — du terrain incluant l’âge et les fonctions renale et cardio-respiratoire; — de la fonction hepatique qui doit etre appreciee sur des arguments dynamiques; — de la nature du parenchyme hepatique non tumoral avec une graduation des facteurs de surcharge, de fibrose et d’inflammation et — de l’extension et de la localisation de l’exerese parenchy-mateuse. La prevention de ces risques doit conduire a limiter le nombre de resections pour lesions benignes; a developper les abords coelioscopiques; a augmenter le volume du futur foie restant en utilisant les techniques d’obstruction vasculaire; a reduire les pertes sanguines et a assurer le meilleur fonctionnement du futur foie restant avec un excellent drainage veineux.

The purpose of this before-after observational survey was to evaluate compliance with good clinical practice guidelines for gastrointestinal hemorrhage related to portal hypertension and the impact of the French Consensus Workshop held in Paris in 2003.Data were recorded concerning episodes of gastrointestinal hemorrhage occurring in cirrhotic patients using a survey questionnaire in 2003 before the workshop and again in 2004.Seventy-six index episodes were included in 2003 and 84 in 2004 in patients attending French hospitals. Before hospital admission, primary prophylaxis was similar in 2003 and 2004, but beta blockers were used alone more often in 2004 for secondary prophylaxis (42% vs 19%, P=0.018). The time from onset of bleeding to hospital admission was greater than 12 hours for 43 and 42% of patients and was not shorter in the event of recurrent hemorrhage. At admission, vasoactive drugs were given earlier in 2004 (2h: 68% vs 35%, P0.001). Use of antibiotic prophylaxis was similar in 2003 and 2004 (70% vs 61%, P=0.098), and was more common for Child-Pugh B or C patients (P=0.044).The Paris Consensus Workshop enabled improved clinical practices. Weak points were insufficient screening for cirrhosis, long delay before admission, insufficient use of antibiotic prophylaxis which should be systematic.

Die Abernethy-Malformation, der angeborene portosystemische Shunt, ist eine seltene Fehlbildung (bislang sind knapp 100 Falle publiziert), bei der das Blut aus dem mesenterialen Kreislauf unter Umgehung der Leber entweder vollstandig (Typ 1, totaler portosystemischer Shunt) oder teilweise (Typ 2, partieller portosystemischer Shunt) direkt der V. cava inferior zugefuhrt wird. Die Diagnose erfolgt zumeist primar sonographisch. Mit Hilfe der Computertomographie (CT) und Magnetresonanztomographie (MRT) kann die Gefasfehlbildung genauer klassifiziert, assoziierte Lebertumoren und begleitende Fehlbildungen zusatzlich detektiert bzw. ausgeschlossen werden. Die Therapieoptionen reichen von konservativen Masnahmen bis hin zur Lebertransplantation. Die Prognose ist nicht zuletzt von den haufig begleitenden Lebertumoren und den evtl. assoziierten weiteren Fehlbildungen abhangig. Wir berichten uber 2 junge Patienten mit einem Typ-1-Shunt, hepatischer Enzephalopathie und assoziierten Lebertumoren, bei denen unter Abwagung aller Aspekte schlieslich die Lebertransplantation erfolgreich durchgefuhrt wurde.

The Internet is a widely used information resource for patients with inflammatory bowel disease, but there is variation in the quality of Web sites that have patient information regarding Crohn's disease and ulcerative colitis. The purpose of the current study is to systematically evaluate the quality of these Web sites.The top 50 Web sites appearing in Google using the terms "Crohn's disease" or "ulcerative colitis" were included in the study. Web sites were evaluated using a (a) Quality Evaluation Instrument (QEI) that awarded Web sites points (0-107) for specific information on various aspects of inflammatory bowel disease, (b) a five-point Global Quality Score (GQS), (c) two reading grade level scores, and (d) a six-point integrity score.Thirty-four Web sites met the inclusion criteria, 16 Web sites were excluded because they were portals or non-IBD oriented. The median QEI score was 57 with five Web sites scoring higher than 75 points. The median Global Quality Score was 2.0 with five Web sites achieving scores of 4 or 5. The average reading grade level score was 11.2. The median integrity score was 3.0.There is marked variation in the quality of the Web sites containing information on Crohn's disease and ulcerative colitis. Many Web sites suffered from poor quality but there were five high-scoring Web sites.

To evaluate the additional value of contrast-enhanced multiphase CT in comparison with low-dose non-contrast CT in combined positron emission tomography (PET)/CT protocols for oncological imaging, we retrospectively analysed 100 patients with different malignant tumours. All patients underwent a PET/CT consisting of a multiphase CT protocol including a low-dose non-enhanced attenuation scan and an arterial and portal-venous contrast-enhanced scan followed by a whole-body PET. PET/CT studies were analysed by different categories to determine the added value of contrast-enhanced CT. The additional value was defined as new information provided by diagnostic CT and not available from the low-dose CT, resulting in change of PET/CT interpretation. The results were validated either by histopathology or by clinical-radiological follow up ator =6 months. The clinical impact was evaluated with respect to changes in patient management. Diagnostic multiphase CT was of additional value in 52 out of 100 patients with 85 suspected lesions. In 40 out of 100 patients, no additional value could be detected. Eight patients were excluded due to inconclusive diagnosis in both methods including fusion. The analysis showed the greatest benefit of diagnostic CT in the categories localization of pathological fluorodeoxyglucose (FDG) uptake and precise tumour delineation, changing PET/CT interpretation in 42% and 31% of patients, respectively. The benefit of diagnostic CT was influenced by the tumour type demonstrating the highest impact in gastrointestinal, lung and neuroendocrine tumours. Diagnostic CT changed clinical management in 21 patients (21%). Diagnostic multiphase CT as part of the combined PET/CT protocol has the potential to provide considerable additional value in specific clinical conditions with resultant change of management in a substantial proportion of patients.

Akute gastrointestinale Blutungen sind bei Leberzirrhosepatienten mit einer hohen Mortalitat verbunden. Ileale Varizen und Kollateralen aus anderen ektopen Gefasen des Darms sind extrem selten und treten bei weniger als 5% aller Zirrhosepatienten auf. Die Diagnosestellung erfolgt oft verspatet, da die ublichen diagnostischen Untersuchungsmethoden wie Gastroskopie oder Koloskopie in den meisten Fallen die Blutungsquelle nicht ausreichend darstellen. Wir berichten uber einen ungewohnlichen Fall von massiver und unkontrollierbarer unterer gastroinstestinaler (GI-)Blutung aus ilealen Varizen mit Verbindung zur rechten V. ovarica einer 56-jahrigen Frau, bei der anamnestisch eine Leberzirrhose und abdominelle Operationen sowie Operationen im Bereich des Beckens bekannt waren. Die genaue angiographische und computertomographische Diagnose erlaubte eine rasche Dekompression des Portalvenensystems mittels eines transjugularen portosystemischen Shunts.

' Le facteur etiologique local le plus frequent correspond aux foyers septiques intra-abdominaux (qui conduisent a une pylephlebite septique). ' Meme quand un facteur local a ete mis en evidence, une ou plusieurs affections prothrombotiques sont identifiees dans pres de 70 % des cas. ' Les syndromes myeloproliferatifs representent la premiere cause de thrombose de la veine porte d'origine extrahepatique. A cote de leurs formes classiques, il existe des formes occultes ou frustes sans anomalie evocatrice du sang peripherique. Le diagnostic peut alors etre fait a la fois par la mise en evidence de colonies erythrtiblastiques spontanees lors de la culture des precurseurs medullaires sur milieu pauvre en erythropoietine et par l'analyse histologique de la biopsie osteomedullaire. ' Les principales complications de la thrombose du systeme porte sont l'infarctus veineux mesenterique. les hemorragies digestives dues a l'hypertension portale sous-hepatique et la compression des voies biliaires par les veines du cavernome. ' Le traitement anticoagulant permet souvent la repermeabilisation des vaisseaux thromboses a la phase aigue et a pour but d'eviter la recidive de thrombose splanchnique ou extra-splanchnique a la phase de cavernome portal.

Arthroscopic subscapularis repair can be technically challenging. This article summarizes a number of technical tips that can greatly simplify and expedite what otherwise might be a daunting surgical procedure. Specific tips and pearls include the following: 1. A description of a new clinical test--the bear-hug test--for detecting subscapularis tears on physical examination. 2. How to accurately place portals for precise subscapularis repair. 3. How to safely and accurately perform a coracoplasty. 4. How to identify and mobilize a retracted subscapularis tear. 5. How the comma sign can be used to simplify arthroscopic subscapularis repair. 6. How to securely repair all sizes of subscapularis tear. 7. A description of postoperative immobilization and rehabilitation to optimize results of arthroscopic subscapularis repair.

Verification of geometric accuracy at the time of treatment delivery has always been a necessary part of the radiotherapy process. Since the introduction of conformal and intensity-modulated radiotherapy, the consequences of patient positioning errors are more serious. Portal imaging has played a large part in fulfilling the need for improved geometric accuracy. This review examines how portal imaging has progressed through the development and evolution of electronic portal imaging devices (EPIDs). Changes in technology, including the current commercial systems, and how image quality has changed are presented. The clinical usage of EPIDs and the technological innovations being devised for further improvements in image quality and systems are considered.

Resumen La duodenopancreatectomia cefalica (DPC) combinada con reseccion venosa portomesenterica (RVPMS) amplia la tasa de resecabilidad de los tumors pancreaticos. Realizada en casos seleccionados y por equipos quirurgicos experimentados, presenta la misma morbimortalidad y supervivencia a largo plazo que la DPC sin reseccion vascular, siempre que se obtengan unos margenes quirurgicos libres de tumor. La trombosis completa de la vena porta o mesenterica superior, la invasion de la arteria mesenterica superior o del tronco celiaco y la afectacion ganglionar periaortica o a distancia contraindican este procedimiento. La reconstruccion venosa puede realizarse mediante sutura lateral, anastomosis termino-terminal o mediante interposicion de injerto. Creemos que la interposicion de vena yugular autologa es un procedimiento que facilita la reseccion y minimiza los fenomenos de estasis venosa. Presentamos un caso de adenocarcinoma de cabeza de pancreas intervenido en nuestro hospital que infiltraba la confluencia venosa portomesenterica. Se practico una DPC con RVP-MS y reconstruccion con vena yugular autologa. Comentamos los aspectos tecnicos mas relevantes.

Radiopharmaceuticals are administered to a large number of individuals each year, and at any given time can be found at detectable levels in about one in 2600 Americans. Such individuals are among the population crossing international borders where equipment has been deployed for radiation detection, and the resulting “nuisance” alarms produced by these individuals must be resolved by further inspection like all other alarms. During 2001, a total of approximately 14.4 million medical procedures using radionuclides were performed in the US. This number rose to over 16.5 million in 2004. Of this total number of procedures, approximately 98% were diagnostic procedures and 2% were therapeutic procedures. Although there were over 45 different commercially-available products used in over 75 different types of medical procedures, only 17 different radioisotopes comprise the complete set of active radionuclides in the commercially-available radiopharmaceuticals in the US. There are other experimental radiopharmaceuticals in use, but their presence in the population is rare. Of these 17 radioisotopes, nine are customarily administered to outpatients and produce sufficiently energetic photons that can readily be detected. The radioisotope 99m Tc is administered in about 90% of the procedures and is the one most likely to be detected by radiation screening equipment. This paper reports on various impacts of radiopharmaceuticals observed in people at border crossings. Calculations were performed to simulate the response of multi-lane portal radiation monitor deployments to these types of sources. Results are given for the time period during which radiopharmaceuticals might be detectable by radiation screening equipment at border crossings.

Resume Introduction. – L'infection a cytomegalovirus est souvent asymptomatique, les formes graves sont l'apanage de l'immunodeprime. Nous rapportons un nouveau cas d'hepatite aigue a cytomegalovirus (CMV) compliquee de thrombose portale chez un immunocompetent. Exegese. – Un homme de 29 ans presenta une hepatite aigue a CMV confirmee par la presence de la proteine pp65 et de l'ADN viral dans le sang. Elle fut compliquee d'une thrombose portable d'evolution rapidement favorable sous traitement anticoagulant. Aucune autre cause de thrombose portale ne fut decelee. Onze cas de thrombose majeure compliquant une infection aigue a CMV chez un immunocompetent ont ete rapportes dans la litterature anglosaxonne et francaise. L'absence de cause locale et generale, la resolution en l'absence de traitement anticoagulant, le risque eleve de thrombose chez les sujets seropositifs a la fois pour le virus de l'immunodeficience humaine et le CMV, et chez les transplantes renaux seropositifs pour le CMV suggerent une relation causale. Diverses hypotheses physiopathogeniques ont ete evoquees : presence d'anticorps antiphospholipides, absents dans notre observation, induction d'un phenotype procoagulant des cellules endotheliales infectees, induction d'une proliferation des cellules musculaires lisses. Conclusion. – L'infection aigue a CMV peut etre consideree comme une cause possible de thrombose majeure.

Recent trials demonstrating a survival benefit with locoregional radiotherapy (LRRT) to the chest wall and regional nodes in women with node-positive breast cancer have led to increased use of complex techniques to match three or more radiation fields, but information on setup reproducibility with LRRT for breast cancer is scarce. This study reports the magnitude and directions of random and systematic deviations in LRRT for breast cancer using an offline electronic portal imaging verification protocol. Electronic portal images (EPIs) of 46 consecutive women treated with LRRT for breast cancer from March 2001 to February 2002 with LRRT were analysed. Comparisons of EPIs to the corresponding digitally reconstructed radiographs were performed offline with anatomy matching. Displacements in mm were recorded in the superior–inferior (SI), medial–lateral (ML), and anterior–posterior (AP) directions. Random errors ranged from 2.0 mm to 2.5 mm for the breast/chest wall tangential treatments and 2.3 mm to 3.9 mm ...

We report on the first documented case of rupture of a pancreatic pseudocyst into the portal vein diagnosed with MRI.

OBJECTIVE. The objective of our study was to classify, understand, and illustrate abnormalities of the embryologic development of the umbilical vein and the portal system resulting in umbilicoportosystemic shunts. According to our data and a review of the literature, we propose an anatomic, biometric, and hemodynamic assessment of umbilicoportosystemic shunts.CONCLUSION. Umbilicoportosystemic shunts encompass different congenital vascular abnormalities that should be recognized because they may interfere with fetal growth and circulation.

Purpose: To develop a software tool that analyzes the anatomy of the portal vein branches and assigns segmental and subsegmental branches according to Couinaud's classification system and to evaluate its accuracy. Materials and Methods: The algorithm was developed in C++ on a PC. The algorithm recognizes the three major branching patterns of the portal vein. Segmental and subsegmental branches are assigned to 8 segments following Couinaud and encoded by 8 colors. The software was evaluated using CT data sets of 39 patients. After the individual segmental anatomy of each patient was determined by an experienced radiologist, automatic classification was performed and the results were compared on a branch by branch basis. Results: The numbering was accurate according to Couinaud's system in 358 of 409 segmental and subsegmental branches (88%). The assignment failed in 51 of 409 branches due to unexpected anatomy or software problems. Conclusion: Automatic classification of portal vein branches and their appendant parenchyma is possible. The automatic designation of liver segments enables the three-dimensional visualization of the segmental anatomy. In the future, automatic analysis might facilitate the reporting and communication of CT findings.

Objectif: Nous presentons les methodes et les resultats du traitement interventionnel de l'hypertension portale (HP) secondaire a une obstruction de la veine porte. Materiels et Methodes: Cinq enfants, quatre garcons et une fille, âges de 8 a 14 ans presentaient des symptomes d'HP secondaires a une obstruction de la veine porte. Tous les enfants avaient eu un ou plusieurs episodes d'hemorragie de varices oesophagiennes, une splenomegalie et une thrombocytopenie. Quatre enfants avaient eu une embolisation splenique partielle la recanalisation de la partie obstruee de la veine porte etait realisee par voie transjugulaire chez quatre, par voie transhepatique chez quatre et par voie transsplenique chez trois. Resultats: Il n'y a pas eu de complications importantes. Nous avons constate un retour a la normale des taux de plaquettes, une diminution de la splenomegalie et une regression totale des saignements œsophagiens. La pose d'un stent a permis la recanalisation de la partie obstruee de la veine porte chez un enfant. Une recanalisation partielle par stent etait realisee chez un autre. Chez un troisieme enfant, un shunt transjugulaire intrahepatique portosystemique (TIPS) avec une portion extrahepaque intra-peritoneale etait cree. Lors du suivi (moyenne 22 mois, extremes 5-46 mois) une dilatation supplementaire par ballon et une insertion de nouveaux stents etaient necessaires chez deux enfants. Conclusion: Les methodes interventionnelles sont utiles pour le traitement de symptomes secondaires a l'obstruction de la veine porte chez les enfants. Un traitement individualise et un suivi regulier sont necessaires.

The purpose of this study was to clarify the hemodynamic changes associated with hepatocarcinogenesis using CT angiography.Eighty-six hepatocellular lesions were confirmed at pathology in 49 patients who underwent CT with both hepatic arteriography and arterioportography. These images were compared with lesion-to-liver vascular ratios of cumulative arteries, preexisting hepatic arteries, and portal veins in resected specimens. Lesions were classified in five groups according to intranodular hemodynamics determined by CT hepatic arteriography and CT during arterioportography: group 1, isoattenuating on both procedures; group 2, hypoattenuating on CT hepatic arteriography and isoattenuating on CT during arterioportography; group 3, hypoattenuating on both procedures; group 4, isoattenuating on CT hepatic arteriography and hypoattenuating on CT during arterioportography; and group 5, hyperattenuating on CT hepatic arteriography and hypoattenuating on CT during arterioportography.Among 86 lesions, we identified seven low-grade dysplastic nodules, eight high-grade dysplastic nodules, 14 well-differentiated hepatocellular carcinomas, 45 moderately differentiated hepatocellular carcinomas, and 12 poorly differentiated hepatocellular carcinomas. The lesions were classified as group 1 (n = 5), group 2 (n = 13), group 3 (n = 6), group 4 (n = 2), or group 5 (n = 60). Intranodular hemodynamics was significantly correlated with pathologic grading (p0.001). For correlations between combinations of the groups and pathologic gradings, the order "groups 1-2-3-4-5" was the most significant (p0.001).During hepatocarcinogenesis, most hepatocellular nodules show deterioration of arterial blood flow before loss of portal blood flow. Vascular imaging of hepatic nodules may predict malignant abnormality via the early loss of hepatic arterial flow seen before portal flow changes.

Primary portal venous aneurysms are rare; however, they are the most common visceral venous aneurysms, and their pathogenesis is not fully understood. Complications include thrombosis, rupture, and mass effect on adjacent structures. The optimal management of these patients is not known. We describe a patient whose large (6-cm) portal vein aneurysm underwent complete spontaneous regression over several years of serial observation. To our knowledge, this observation has not been reported in the English literature.

Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) is a novel surgical technique that provides fast and effective growth of liver remnant volume, allowing surgical resection of hepatic lesions initially considered unresectable. Short and long-term results and the convenience of carrying out this technique are issues that still remain under debate while waiting for the final outcomes of the multicenter registries with larger number of cases. The aim of this paper is to describe, from a critical point of view, the outcomes of the cases performed at our centre (n=8). On the other hand, it is possible to leave only one hepatic segment as a liver remnant and we illustrate this new surgical procedure (ALPPS monosegment) performed in one patient.

Resume L’insuffisance hepatocellulaire est une complication grave des hepatectomies larges, en particulier lorsqu’il existe une hepatopathie sous jacente. L’interruption prealable de la vascularisation portale des territoires que l’on souhaite resequer, permet d’induire leur atrophie et, par hypertrophie compensatrice, d’augmenter le volume du parenchyme qui persistera au terme de cette exerese. Cette obstruction peut etre provoquee par une ligature chirurgicale ou par l’injection percutanee sous controle echographique de colles ou de substances sclerosantes. Une embolisation portale est habituellement indiquee lorsque le volume residuel previsible represente moins de 25 a 40 % du volume hepatique total. L’embolisation percutanee a une faisabilite proche de 100 % et son risque est comparable a celui d’une biopsie percutanee. Elle est cliniquement tres bien toleree et les consequences biologiques sont minimes chez les patients n’ayant pas d’insuffisance hepatocellulaire. L’hypertrophie est maximale au cours des 15 premiers jours puis se ralentit mais persiste pendant environ six semaines. Son intensite est proportionnelle au volume de parenchyme embolise ; elle est diminuee lorsqu’il existe un diabete, un ictere ou une hepatopathie chronique active sous jacente. L’hepatectomie est realisee deux a six semaines apres l’embolisation. Les etudes retrospectives et une etude prospective suggerent que les patients ainsi prepares ont un risque operatoire diminue et que leur pronostic carcinologique est comparable a celui de patients d’emblee operables.

Resume But de l’etude : L’allogreffe intraportale d’ilots de Langerhans parait etre un des traitements prometteurs du diabete de type I, mais de nombreux facteurs limitant persistent. Une activation de la coagulation au contact des ilots, recemment mise en evidence in vitro, pourrait jouer un role decisif dans le declenchement d’une reaction inflammatoire non specifique et faire le lit du rejet immun specifique. L’objectif de cette etude experimentale etait de confirmer in vivo cette activation initiale de la coagulation. Materiel et methodes : Nous avons injecte par voie portale chez des porcs Large White ( n = 26) une preparation d’ilots allogeniques ou un materiel controle (microbilles inertes), associe ou non a un traitement anticoagulant (heparine). Des facteurs de l’hemostase standard et specifiques ont ete doses chez le porc durant les 72 heures suivant l’injection du materiel etudie. Resultats : Une hausse importante des complexes thrombine–antithrombine et une chute des plaquettes, en rapport avec une activation de la coagulation ont ete trouvees dans les groupes recevant des preparations d’ilots. Cette activation etait proportionnelle au volume injecte et a ete prevenue partiellement par l’administration d’heparine. Elle n’etait pas observee chez les porcs recevant le materiel controle. Conclusion : L’activation de la coagulation et la reaction inflammatoire non specifique pourraient donc etre un des obstacles au succes de la greffe d’ilots de Langerhans. L’emploi d’une therapeutique anticoagulante et anti-inflammatoire, utilisable en clinique, permettrait peut-etre en prevenant ces reactions, d’ameliorer les resultats actuels de cette greffe.

Resumen Introduccion La oclusion portal preoperatoria (OPP) produce una hipertrofia del higado contralateral. Gracias a ello podemos aumentar el indice de resecabilidad de algunos pacientes considerados inicialmente irresecables en funcion de un futuro remanente hepatico insuficiente. Objetivo Valorar la seguridad de la OPP y su eficacia en mejorar la resecabilidad de 8 pacientes inicialmente irresecables. Metodos Desde enero de 1997 hasta diciembre de 1999 hemos realizado resecciones hepaticas por metastasis hepaticas de carcinoma colorrectal a 136 pacientes. En 8 casos (5,8%) el futuro parenquima hepatico remanente, segun la TC helicoidal, fue considerado insuficiente ( Resultados La OPP pudo realizarse en todos los casos. No hubo complicaciones relacionadas con el procedimiento. La reseccion hepatica se practico a los 52 dias de media post-OPP. La morbilidad fue del 50% (fistula biliar, absceso subfrenico, ascitis). La mortalidad postoperatoria fue de un caso por insuficiencia hepatica. Conclusion La OPP es una tecnica segura y que aumenta el indice de resecabilidad de los pacientes con metastasis hepaticas de carcinoma colorrectal.

To determine the magnetic resonance (MR) imaging findings of small nontumorous hepatic arterial-portal venous (arterioportal) shunts in the liver.MR images in 25 patients with 38 small nontumorous arterioportal shunts verified with surgery or follow-up imaging were included in this study. The causes of arterioportal shunts were iatrogenic causes in 11 patients and/or cirrhotic changes in the remaining patients. Nonenhanced T1- and T2-weighted images and multiphase contrast material-enhanced dynamic images were retrospectively reviewed and compared with conventional hepatic arteriograms to determine the MR characteristics related to the focal hemodynamic changes.On arterial-dominant-phase dynamic MR images, 29 (76%) of the 38 arteriographically suggested nontumorous arterioportal shunts displayed abnormal findings distinguished against the surrounding hepatic parenchyma, including wedge-shaped (n = 14), nodular (n = 9), or irregularly outlined (n = 6) areas of focal contrast enhancement. The signal intensity on nonenhanced T1- and T2-weighted images of the corresponding areas appeared unremarkable except for three wedge-shaped high-signal-intensity areas (three [8%] of 38) on T2-weighted images accompanied by prolonged contrast enhancement. Most (24 [83%] of 29) areas of abnormal signal intensity were located at the periphery of the liver parenchyma.A small nontumorous arterioportal shunt should be considered one of the causes of focal parenchymal hyperperfusion abnormalities on contrast-enhanced dynamic MR images of the liver in the absence of abnormal signal intensity on static MR images.

Purpose: To compare patency rates of transjugular intrahepatic portosystemic shunts (TIPS) after placement of long-medium Palmaz stents or Wallstents.