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PLOS ONE 14(10), e0222840 (2019). doi:10.1371/journal.pone.0222840, Published by PLOS, San Francisco, California, US

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.

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.

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.

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.

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.

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.

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.

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.

We previously reported that portal veins from mice infected with male Schistosoma mansoni exhibited an increased reactivity to 5-hydroxytryptamine (5-HT). Here, we extended our observations to mice infected by both male and female worms and we further investigated another constrictor agent and the mechanism(s) responsible for the enhanced maximal contraction ( E(max)). Bisexual infection increased the E(max) of 5-HT (from 0.66+/-0.06 mN.s to 1.56+/-0.38 mN.s), in a similar way to the unisexual (male) infection. Infection with male worms increased portal vein reactivity to acetylcholine, as revealed by a higher E(max) (1.03+/-0.2 mN.s) in relation to non-infected control animals ( E(max)= 0.54+/-0.08 mN.s). Sarcoplasmic/endoplasmic reticulum Ca(2+)-ATPase (SERCA) inhibition with 100 nM thapsigargin reduced the E(max) of 5-HT by 35% in both tissues, discharging a deficiency of SERCA pump in infected animals. In contrast, the number of voltage-dependent Ca(2+) channels (L-type) was higher in portal veins from infected than non-infected control mice. Inhibition of Ca(2+)-activated chloride channels (Cl(Ca)) with 10 micro M niflumic acid reduced the E(max) of 5-HT in portal veins more from infected than non-infected animals (remaining tension = 60.9+/-2.2% and 70.4+/-2.3%, respectively). Histopathological analysis revealed an increased content of collagen and elastin in portal veins from male S. mansoni-infected mice, compatible with an increased intraluminal pressure. In conclusion, male S. mansoni altered portal vein physiology, increasing the E(max) of two vasoconstrictors, possibly by increasing membrane depolarisation through a more effective opening of Cl(Ca) channels, with calcium entering through L-type Ca(2+) channels.

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.

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.

We report one case of replaced right hepatic artery coursing ventral to the portal vein. This variation, which was demonstrated by 64-row CT angiography and three-dimensional reformatted images, has never been reported. Surgeons involved in hepatic and biliopancreatic procedures should be aware of this possible variation, which has important surgical implications.

Prior exercise stimulates muscle and liver glucose uptake. A negative arterial-portal venous glucose gradient (a-pv grad) stimulates resting net hepatic glucose uptake (NHGU) but reduces muscle glucose uptake. This study investigates the effects of a negative a-pv grad during glucose administration after exercise in dogs. Experimental protocol: exercise (−180 to −30 min), transition (−30 to −20 min), basal period (−20 to 0 min), and experimental period (0 to 100 min). In the experimental period, 130 mg/dl arterial hyperglycemia was induced via vena cava (Pe, n = 6) or portal vein (Po, n = 6) glucose infusions. Insulin and glucagon were replaced at fourfold basal and basal rates. During the experimental period, the a-pv grad (mg/dl) was 3 ± 1 in Pe and −10 ± 2 in Po. Arterial insulin and glucagon were similar in the two groups. In Pe, net hepatic glucose balance (mg ⋅ kg−1⋅ min−1, negative = uptake) was 4.2 ± 0.3 (basal period) and −1.2 ± 0.3 (glucose infusion); in Po it was 4.1 ± 0.5 and −3.2 ± 0.4, respectively ( P < 0.005 vs. Pe). Total glucose infusion (mg ⋅ kg−1⋅ min−1) was 11 ± 1 in Po and 8 ± 1 in Pe ( P < 0.05). Net hindlimb and whole body nonhepatic glucose uptakes were similar. Conclusions: the portal signal independently stimulates NHGU after exercise. Conversely, prior exercise eliminates the inhibitory effect of the portal signal on glucose uptake by nonhepatic tissues. The portal signal therefore increases whole body glucose disposal after exercise by an amount equal to the increase in NHGU.

The effects of hepatic-portal glucose or saline infusions on intake and the temporal distribution of licking (lick microstructure) were evaluated in nondeprived and in 20.5-h food-deprived rats. Rats received portal infusions of isotonic glucose or saline (0.1 ml/min) for 2 h before and then throughout a 90-min period of access to a spout that delivered 12.5% glucose. Overall, a significant treatment-related intake suppression was obtained in nondeprived but not in deprived groups. For both groups, however, there was a significant positive linear relationship between the amount individual rats consumed under the saline (baseline) infusion condition and the extent to which portal glucose infusion suppressed intake. The linear fit for the deprived group was similar in slope, but right shifted, relative to the best fit for the nondeprived group. The individual-subject and group differences in response to portal glucose infusion are discussed in relation to the inconsistent literature on this treatment’s short-term intake effects. We focused analysis of the licking pattern on those rats for which a prominent portal glucose infusion effect was obtained (i.e., nondeprived rats with higher than average baseline intakes). Features of the lick pattern associated with taste evaluation (1st min lick rate; lick burst duration) were not significantly affected by portal glucose infusion. Rather, the minute-by-minute rate of ingestion under glucose infusion declined more rapidly than under baseline tests, indicating that portal glucose infusion enhanced the inhibitory influence of the accumulating postingestive load.

To investigate the parenchymal units in the liver of the rat three-dimensionally, 15 micrometer cryosections were used for the demonstration of glucose-6-phosphatase (G6Pase) activity to visualize the borders of the individual units. Together with the supplying and draining vessels, they were traced through a sequence of 146 sections and reconstructed. A cone-shaped secondary unit with a height of 2.1 mm and a volume of 3.3 mm3 was reconstructed. It was "covered" by a continuous vascular surface, consisting of portal tracts and vascular septa, connecting the portal venular branches. The secondary unit was subdivided by portal tracts and vascular septa, and by branches of a draining central venular tree into 14 primary units. Most of them were tri- to heptahedral in shape. The height varied between 330 and 840 micrometer, and the volume varied between 0.094 and 0.621 mm3. The branches of the portal venular tree, with diameters from 28 +/- 5 micrometer to 61 +/- 14 micrometer, were oriented preferentially along the vertical axis of the units. Most of the primary units were drained by single branches of the central venular tree, located in the center and oriented along the vertical axis of the units. Vessel diameters ranged from 62 +/- 14 micrometer to 216 +/- 9 micrometer. The average length of the sinusoids was 355 +/- 3 micrometer. From the results of this reconstruction study, it was concluded that the concept of the liver acinus cannot be applied to the liver of the rat.

To evaluate triple-phase helical computed tomography (CT) of carcinoid liver metastases.Triple-phase helical CT was performed in 31 patients with proved carcinoid liver metastases. Hepatic arterial-dominant phase (HAP) and portal venous-dominant phase (PVP) images were obtained 20 and 70 seconds after intravenous iopamidol injection. Four independent readers reviewed each phase for lesion number, conspicuity, and attenuation relative to liver. Three readers reviewed each phase to determine which phase best showed the lesions.The lesions detected by readers 1-4 were as follows: noncontrast phase, 164, 177, 204, and 229 lesions; HAP, 178, 177, 214, and 238 lesions; and PVP, 180, 189, 215, and 250 lesions (P.05). On HAP images, readers found that 80, 73, 96, and 102 lesions were hyperattenuating. Consensus indicated there were 206 focal lesions. Of these 206 lesions, 72, 72, and 62 lesions were best seen on the noncontrast phase, HAP, and PVP images, respectively. Six, 28, and six lesions were seen only on the noncontrast phase, HAP, and PVP images, respectively. Two patients had lesions seen only on the HAP images.The HAP and, to a lesser extent, the noncontrast phase provide added value in evaluating carcinoid liver metastasis.

To evaluate qualitatively and quantitatively the current procedures for radiologic delineation of the segmental and subsegmental anatomy of the liver.Vascular casts of 10 livers were examined with helical computed tomography (CT). Liver segmental and subsegmental anatomy were determined on the CT scans according to customary radiologic practice guidelines. CT anatomic findings were compared with authentic anatomic territories seen at anatomic examination. The differences were assessed quantitatively in five of the 10 livers.For the marginal (cranial and caudal) portions of the liver, an average (+/- 1 standard deviation) of 17.3% +/- 6.5 of the hepatic area visualized on axial CT scans was attributed to an incorrect subsegment. For the central zones (those adjacent to the right and left branches of the portal vein), this error amounted to 51.6% +/- 19.9. Expressed in absolute numbers, the error amounted to 40 mm on axial CT scans.The radiologic determination of portal venous territories within the liver must be revised. The indirect landmarks currently used are not reliable for proper delineation. Only procedures that account for the portal venous distribution pattern, including peripheral branches, will result in correct depiction of the complex and variable anatomic reality.

Both celiac disease and non-cirrhotic portal fibrosis are known to be associated with various autoimmune diseases and have numerous immunological abnormalities. Herein two patients with celiac disease having associated non-cirrhotic portal fibrosis are reported. An autoimmune link between the two conditions is likely to explain coexistence in the same patient.

We have previously shown that a selective increase of 84 pmol/l in either arterial or portal vein insulin (independent of a change in insulin in the other vessel) can suppress tracer-determined glucose production (TDGP) and net hepatic glucose output (NHGO) by ∼50%. In the present study we investigated the interaction between equal increments in arterial and portal vein insulin in the suppression of TDGP and NHGO. Isotopic ([3-3H]glucose) and arteriovenous difference methods were used in conscious overnight fasted dogs. A pancreatic clamp was used to control the endocrine pancreas. A 40-min basal period was followed by a 180-min test period, during which arterial and portal vein insulin levels were simultaneously and equally increased 102 pmol/l. Hepatic sinusoidal glucagon levels remained unchanged, and euglycemia was maintained by peripheral glucose infusion. TDGP was suppressed ∼60% by the last 30 min of the experimental period. In contrast, NHGO was suppressed 100% by that time. Coincidentally, hepatic glucose uptake (net hepatic [3H]glucose balance) increased significantly (∼4 μmol ⋅ kg−1⋅ min−1). The effects of simultaneous equal increases in peripheral and portal venous insulin were not additive in the suppression of TDGP. However, they were additive in decreasing NHGO as a result of an increase in the uptake of glucose by the liver.

The purpose of this study was to evaluate the effect of portal flow augmentation on hepatic computed tomographic (CT) enhancement.Thirteen patients undergoing follow-up CT of the liver within 6 months of initial study ingested 470 mL of Ensure 30 min before the second examination. Contrast medium injection and scanning parameters were identical for both studies.The time to peak and the maximum and mean liver enhancements were 68 s, 56 HU, and 46 HU, respectively, for the examinations without Ensure and 68 s, 53 HU, and 44 HU for the examinations with Ensure. No significant difference was found between the two groups when mean liver enhancement was calculated over 3-s time intervals.Portal venous flow augmentation induced by a meal had no effect on liver enhancement.

We report a case of an asymptomatic portal vein aneurysm diagnosed at ultrasonography and documented with multidetector computed tomography. We describe the features found at quadriphasic multidetector computed tomography with three-dimensional computed tomographic angiography.

Background The management of portal vein (PV) involvement by pancreatic adenocarcinoma during pancreaticoduodenectomy (PD) is controversial. The aim of this study was to compare the outcomes of unplanned and planned PV resections as part of PD. Methods An analysis of PD over 11 years was performed. Patients who had undergone PV resection (PV-PD) were identified, and categorized into those who had undergone planned or unplanned resection. Postoperative and oncological outcomes were compared. Results Of 249 patients who underwent PD for pancreatic adenocarcinoma, 66 (26·5 per cent) had PV-PD, including 27 (41 per cent) planned and 39 (59 per cent) unplanned PV resections. Twenty-five of 27 planned PV resections were circumferential PV-PD, whereas 25 of 39 unplanned PV resections were partial PV-PD. Planned PV resections were performed in slightly younger patients (mean(s.d.) 60(9) versus 65(10) years; P = 0·031), and associated with longer operating times (mean(s.d.) 602(131) versus 458(83) min; P < 0·001) and more major complications (26 versus 5 per cent; P = 0·026). Planned PV resections were associated with a lower rate of positive margins (4 versus 44 per cent; P < 0·001) despite being carried out for larger tumours (mean(s.d.) 3·9(1·4) versus 2·9(1·0) cm; P = 0·002). There was no difference in survival between the two groups (P = 0·998). On multivariable analysis, margin status was a significant predictor of survival. Conclusion Although planned PV resections for pancreatic adenocarcinoma were associated with higher rates of postoperative morbidity than unplanned resections, R0 resection rates were better.

The variability of consecutive cine phase-contrast MR flow measurements could significantly affect their use for clinical decisions, especially during provocative testing. The purposes of this study were to determine the normal variability of flow and consecutive flow measurements in the main portal vein on MR images and to determine how intraobserver variability, interobserver variability, and MR imager variability affect these measurements.MR flow measurements were acquired four consecutive times at the same location in the main portal vein of 12 subjects and three consecutive times at the same location in a nonpulsatile vessel model. All acquisitions were completed within 10 min. All main portal vein MR data sets were evaluated manually in a blinded review by two independent observers during three separate sessions spaced a mean of 4.5 weeks apart. Flow model data sets were evaluated during a single session by one observer. Variabilities were subsequently calculated by a components-of-variance analysis and by the coefficient of variation (SD/mean x 100).Of the total variance, 90% was due to flow variability among subjects (intersubject), 6% to flow variability within one subject (intrasubject), 2% to intraobserver variability, and 2% to interobserver variability. The coefficient of variation of consecutive MR portal vein flow measurements within a single subject was 11% +/- 5% (range, 3-23%). Intra- and interobserver variabilities were 5% +/- 2% (range, 1-11%) and 4% +/- 4% (range, 0-17%), respectively. MR imager variability was 1% +/- 1% (range, 0-2%).The mean variability of consecutive cine phase-contrast MR flow measurements in the main portal vein is 11% +/- 5% and could affect research and clinical protocols that employ this technique.

To compare results of transjugular intrahepatic portosystemic shunt (TIPS) placement with 10- and 12-mm Wallstents.Forty-six TIPS procedures in 47 patients were retrospectively reviewed. Wallstents that were 10 mm in diameter were used in 23 patients, and those that were 12 mm in diameter were used in 23 patients. Immediate results were compared, which included initial portosystemic gradient and Doppler measurements of blood flow velocity through the shunt at 1 day. Long-term patency and velocities were also assessed.TIPS were successfully created in 46 of 47 patients (98%). In one patient in the 10-mm group, the portal vein could not be accessed. When compared with TIPS in the 10-mm group, TIPS placed in the 12-mm group required dilation to larger diameters (mean, 11.1 vs 9.2 mm; P.0001) to achieve an identical target gradient of 10 mm Hg and exhibited lower 1-day velocities (mean, 1.3 m/sec vs 1.7 m/sec; P.03). The 1-day occlusion rate was 17% (four of 23 patients) in the 12-mm group versus 0% in the 10-mm group (P.02). Patient survival was statistically significantly less in the 12-mm group (P.03).Twelve-millimeter Wallstents yield statistically significantly poorer short- and long-term results in TIPS procedures. This is most likely due to the decreased radial strength of the larger stent, which is 50% less than that of the 10-mm stent.

Clinical progress in the field of liver transplantation has been largely supported by animal models(1,2). Since the publication of the first orthotopic rat liver transplantation in 1979 by Kamada et al.(3), this model has remained the gold standard despite various proposed alternative techniques(4). Nevertheless, its broader use is limited by its steep learning curve(5). In this video paper, we show a simple and easy-to-establish revision of Kamada's two-cuff technique. The suprahepatic vena cava anastomosis is performed manually with a running suture, and the vena porta and infrahepatic vena cava anastomoses are performed utilizing a quick-linker cuff system(6). Manufacturing the quick-linker kit is shown in a separate video paper.

Purpose: To establish the normal limits of portal vein diameter according to age, height and weight. Materials and methods: One hundred and sixty-eight healthy children, ages ranging from 1 month to 15 years were examined by ultrasound. Portal vein diameters at hepatic port, weight and height were recorded. Results: A range of normal limits for portal veneous diameter according to age, weight and height are obtained and presented in tables. Conclusion: Knowing the normals for portal venous diameter in every age group in children is mandatory in differentiating disease. The tables according to age, weight and height will definitely be helpful in the work-up process. © 2009 Elsevier Ireland Ltd.

During a 3-year period, sonographic evidence of portal venous gas (PVG) was found in 11 patients. Of these, 10 patients were examined for clinically suspected necrotizing enterocolitis (NEC). In the 11th patient, suffering from nephroblastoma, PVG was detected by routine sonography. Radiographic examination, performed in nine of 11 patients did not show any PVG. Intestinal pneumatosis was radiographically identifiable in only four of these children, whereas eight of 11 patients with sonographically detectable PVG also had sonographic evidence of intramural gas. Follow-up examinations in five patients showed cessation of PVG soon after onset of adequate therapy, indicating that ultrasonography is also a reliable method for monitoring NEC. Sonographic evidence of PVG, however, may be limited to the time before onset of therapy.

The features of cromakalim responsible for its potassium channel activiting property were investigated. A hypothesis relating three-dimensional structure to binding to a putative receptor was developed and used successfully to design the potent and structurally novel agents, 2-(2,2-dimethylbenzopyran-4-yl)-pyridine-1-oxides.

Congenital portosystemic venous shunt (PSVS), considered to be a rare disease, can lead to hepatic encephalopathy (HE). With improvements in diagnostic imaging techniques, the number of infants and children with documented PSVS has increased. The natural course of the disease and indications for surgical closure of the shunt vessel have not been well defined. We reviewed 51 cases of congenital PSVS in Japan; 34 patients had an intrahepatic PSVS, and 17 had an extrahepatic PSVS. There were 12 patients with HE at the time of diagnosis. The frequency of HE increased in subjects over 60 years of age. Children with HE had a shunt ratio exceeding 60%. When the shunt ratio was less than 30%, HE did not occur. Twenty of 28 patients under the age of 15 years had hypergalactosemia at the time of neonatal screening. Part of the congenital intrahepatic PSVS spontaneously closed. Surgical closure of a PSVS may be an approach expected to prevent HE when the shunt ratio exceeds 60%.

To evaluate 16-slice CT portography technique and appearances of cavernous transformation of portal vein (CTPV) and the correlation with surgical procedure of orthotopic liver transplantation (OLT).Twenty-four patients with CTPV underwent triphase scanning using a 16-slice CT scanner. Twenty-one of the 24 patients were OLT candidates. After plain scan, enhanced CT scan was performed. The parameters were as follows: thickness of 2.5 mm, reconstruction interval of 1.3 mm, flow rate of 3-4 mL/s, contrast agent of 100 mL, delayed time of 20, 50, and 70 s, respectively. Imaging reformation, including MIP, VR, and SSD, were performed by one radiologist. Two radiologists assessed the thrombosis location and degree, collateral vessels, and superior mesenteric vein (SMV) or splenic vein (SV). The details of collateral vessels, thrombosis location were graded and recorded. One score was partial thrombosis of the main PV; 2 score, complete thrombosis of the main PV; 3 score, complete thrombosis of the main PV plus thrombosis of proximal SV or SMV, and the normal diameter of remaining veins; 4 score, complete thrombosis of the main PV plus thrombosis of more than a half of SV or SMV, and thin diameter of remaining veins; 5 score, complete nonvisualization of the main PV, one or both of SV and SMV, and thin diameter of remaining veins. Thirteen patients thereafter underwent OLT. Operation record was reviewed case by case.All cases obtained MIP images, 16 patients got VR images, and five cases had SSD images. These images can display thrombosis location, degree, and collateral vessels. All patients had hepatopetal collateral vessels. Eleven of the 21 OLT candidates had 1 score, two patients 2 score, four patients 3 score, one patient 4 score, and three patients had 5 score. Fourteen of the 21 candidates were performed end-to-end anastomosis between the donor's and recipient's portal veins, in which 11 patients had 1 score, two patients had 2 score, and two patients 3 score. Both patients with 3 score had normal SV; end-to-end anastomoses were performed between the donor portal vein and recipient SV. Two patients are waiting for donors. OLT was canceled or changed in the six patients with 4 score or 5 score. Correlation coefficient between the score of portal vein and surgical decision was 0.813 (P-value less than 0.001, nonparametric correlation).Using 16-slice CT portography can noninvasively diagnose CTPV. The appearances of CTPV on the 16-slice CT portography can provide helpful information for surgeons to make an accurate preoperative decision. MIP is the optimal technique for displaying CTPV.

Resume Un traumatisme abdominal est une cause classique mais rare de thrombose porte. Nous rapportons l’observation d’un malade presentant une thrombose avec cavernome porte associee a une hypertension portale mise en evidence l’occasion d’un syndrome douloureux abdominal. L’anamnese identifiait la notion d’un violent accident de la voie publique avec traumatisme thoraco-abdominal 6 mois auparavant. Le bilan de thrombophilie mettait en evidence une mutation heterozygote G20210A dans le gene du facteur II. Cette observation originale conforte le concept de la conjonction de facteurs locaux et generaux dans la genese de la thrombose porte.

The objective of this study was to evaluate the changes in the portal vein cross-sectional area (PV CSA) and flow during a stand test associated with orthostatic intolerance. Eighteen subjects underwent a 90-day head-down tilt (HDT) bed rest at 6°: 9 controls (Con) and 9 with flywheel exercise countermeasures (CM). At post-HDT, nine subjects (5 CM, 4 Con) were tolerant, and nine were intolerant. The PV CSA was measured by echography. We found that at HDT day 85, the PV CSA at rest had increased less in the CM subjects than in the Con (+12 vs. +27% from pre-HDT supine; P < 0.05), whereas it increased similarly in tolerant and intolerant subjects (23 and 16%, respectively). Two days after the HDT, there was a decrease in the PV CSA supine compared with the pre-HDT PV CSA supine that was similar for all groups (Con: −11%, CM: −21%; tolerant: −10%, intolerant: −16%; P < 0.05). The PV CSA decreased significantly less from supine to standing in the Con than in the CM group (−2 vs. −10% compared with the pre-HDT stand test; P < 0.05). The PV CSA also decreased significantly from supine to standing compared with the pre-HDT stand test in the tolerant group but not in the intolerant group (−20 vs. +2%; P < 0.05). From these findings, we conclude the following. 1) Because the portal vein is the only output from the splanchnic vascular area, we suggest that the lower reduction in the PV CSA and flow associated with orthostatic intolerance was related to a lower splanchnic arterial vasoconstriction. 2) The flywheel exercise CM helped to reduce the distention of the splanchnic network at rest and to maintain partially the splanchnic vasoconstriction, but it did not reduce the orthostatic intolerance.

Based upon bilateral carpal tunnel syndrome (CTS) we undertook a prospective randomised intra-individual comparison between open (OR) and 2-portal endoscopic release (2-PER) to establish if there is any demonstrable advantage in undertaking either technique in a 1 year follow-up. Ten patients with bilateral CTS were enrolled in this study and underwent a 2-PER on the one and an OR with two minimised incisions on the contralateral hand. Both hands were examined pre- and postoperatively after 2, 4, 6 and 12 weeks and after 6 and 12 months, respectively. Preoperatively both hands revealed statistically no significant differences in all the parameters recorded. Comparing both techniques no significant differences could be detected in the follow-up period. Nevertheless, both techniques showed significant improvements in the severity of symptoms and pain, in sensory nerve testing and in electro-diagnostic parameters, when comparing pre- with postoperative data after 1 year. The endoscopic approach revealed no distinct advantages over the open technique not only in the late but also in the early postoperative follow-up period when performing intra-individual comparison. Considering the higher complication rate and costs when performing 2-PER the OR with two minimised incisions seems to be a good alternative in order to keep the recovery period as short as possible.