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Acute portal vein thrombosis (PVT) is a rare disorder defined by the sudden occlusion of the portal vein, which could be partial or complete. Prothrombotic states, inherited or acquired, are thought to be the cause in patients without cirrhosis or malignancy. However, the aetiology of some cases remains idiopathic despite a multidisciplinary diagnostic approach. The initial diagnostic modality to confirm PVT is either contrast-enhanced abdominal (CT) or MRI; as it can identify predisposing factors, and detect evidence of complications. Eliciting the underlying aetiology is critical to guide overall management and prevent future recurrence. The purpose of treatment is to stop thrombus extension and achieve portal vein patency by anticoagulation to optimise outcomes. Herein, we present an unusual case of spontaneous PVT in a young woman. We will also discuss the evaluation of patients without obvious aetiology.

We report a case of walled off pancreatic necrosis in a patient with alcoholic pancreatitis who underwent endoscopic ultrasound-guided multiple pigtail catheter drainage. 10 days later patient presented with massive haemorrhage likely due to erosion of portal vein pseudoaneurysm caused by decubitus of pigtails. Patient required emergent portal venorrhaphy to arrest haemorrhage.

Background: After portal vein embolization (PVE) 30% fail to achieve liver resection. Malnutrition is a modifiable risk factor and can be assessed by radiological indices. This study investigates, if sarcopenia affects resectability and kinetic growth rate (KGR) after PVE. Methods: A retrospective study was performed of the outcome of PVE at 8 centres of the DRAGON collaborative from 2010 to 2019. All malignant tumour types were included. Sarcopenia was defined using gender, body mass and skeletal muscle index. First imaging after PVE was used for liver volumetry. Primary and secondary endpoints were resectability and KGR. Risk factors impacting liver growth were assessed in a multivariable analysis. Results: Eight centres identified 368 patients undergoing PVE. 62 patients (17%) had to be excluded due to unavailability of data. Among the 306 included patients, 112 (37%) were non-sarcopenic and 194 (63%) were sarcopenic. Sarcopenic patients had a 21% lower resectability rate (87% vs. 66%, p < 0.001) and a 23% reduced KGR (p = 0.02) after PVE. In a multivariable model dichotomized for KGR ≥2.3% standardized FLR (sFLR)/week, only sarcopenia and sFLR before embolization correlated with KGR. Conclusion: In this largest study of risk factors, sarcopenia was associated with reduced resectability and KGR in patients undergoing PVE.

Contains fulltext : 248726.pdf (Publisher’s version ) (Open Access) OBJECTIVE: To evaluate current practice and outcomes of pregnancy in women previously diagnosed with Budd-Chiari syndrome and/or portal vein thrombosis, with and without concomitant portal hypertension. DESIGN AND SETTING: Multicentre retrospective cohort study between 2008 and 2021. POPULATION: Women who conceived in the predefined period after the diagnosis of Budd-Chiari syndrome and/or portal vein thrombosis. METHODS AND MAIN OUTCOME MEASURES: We collected data on diagnosis and clinical features. The primary outcomes were maternal mortality and live birth rate. Secondary outcomes included maternal, neonatal and obstetric complications. RESULTS: Forty-five women (12 Budd-Chiari syndrome, 33 portal vein thrombosis; 76 pregnancies) were included. Underlying prothrombotic disorders were present in 23 of the 45 women (51%). Thirty-eight women (84%) received low-molecular-weight heparin during pregnancy. Of 45 first pregnancies, 11 (24%) ended in pregnancy loss and 34 (76%) resulted in live birth of which 27 were at term (79% of live births and 60% of pregnancies). No maternal deaths were observed; one woman developed pulmonary embolism during pregnancy and two women (4%) had variceal bleeding requiring intervention. CONCLUSIONS: The high number of term live births (79%) and lower than expected risk of pregnancy-related maternal and neonatal morbidity in our cohort suggest that Budd-Chiari syndrome and/or portal vein thrombosis should not be considered as an absolute contraindication for pregnancy. Individualised, nuanced counselling and a multidisciplinary pregnancy surveillance approach are essential in this patient population. TWEETABLE ABSTRACT: Budd-Chiari syndrome and/or portal vein thrombosis should not be considered as an absolute contraindication for pregnancy.

Portal vein aneurysm (PVA) is rarely encountered, and published papers describing this etiology in adults and children typically include only case reports or small case series. We present a clinical case of PVA in a child associated with severe complications, including diffuse thrombosis of the portal venous system. A 10-year-old boy presented with abdominal pain and vomiting, resulting in an initial diagnosis of pancreatic head tumor based on suspicious images on abdominal grayscale ultrasound. Contrast-enhanced computed tomography confirmed a diagnosis of occlusive PVA thrombosis (36 × 37 × 95 mm). Lacking drastic symptoms, the patient was treated with conservative anticoagulant therapy. On follow-up, the thrombosis appeared to shrink gradually and disappeared at 6 months based on Doppler ultrasound imaging. The PVA was reduced in size, and hepatopetal flow was restored. Surgeons and radiologists should be aware of this rare entity to ensure that a precise diagnosis can be established and to provide suitable treatment.

Background Extrahepatic portal vein obstruction (EHPVO) results in severe portal hypertension (PHT) leading to severely compromised quality of life. Often, pharmacological and endoscopic management are unable to solve this problem. Restoring hepatic portal flow using meso-Rex bypass (MRB) may solve it. This procedure, uncommon in adult patients, is considered the treatment of choice for EHPVO in children. Methods From 1997 to 2018, 8 male and 6 female adults, with a median age of 51 years (range 22–66) underwent MRB procedure for EHPVO at the University Hospitals Saint-Luc in Brussels, Belgium. Symptoms of PHT were life altering in all but one patient and consisted of repetitive gastro-intestinal bleedings, sepsis due to portal biliopathy, and/or severe abdominal discomfort. The surgical technique consisted in interposition of a free venous graft or of a prosthetic graft between the superior mesenteric vein and the Rex recess of the left portal vein. Results Median operative time was 500 min (range 300–730). Median follow-up duration was 22 months (range 2–169). One patient died due to hemorrhagic shock following percutaneous transluminal intervention for early graft thrombosis. Major morbidity, defined as Clavien-Dindo score ≥ III, was 35.7% (5/14). Shunt patency at last follow-up was 64.3% (9/14): 85.7% (6/7) of pure venous grafts and only 42.9% (3/7) of prosthetic graft. Symptom relief was achieved in 85.7% (12/14) who became asymptomatic after MRB. Conclusions Adult EHPVO represents a difficult clinical condition that leads to severely compromised quality of life and possible life-threatening complications. In such patients, MRB represents the only and last resort to restore physiological portal vein flow. Although successful in a majority of patients, this procedure is associated with major morbidity and mortality and should be done in tertiary centers experienced with vascular liver surgery to get the best results.

Background Splanchnic vein thrombosis (SVT) is an uncommon manifestation of venous thromboembolism. Historical epidemiological data on SVT-related mortality rate is not available to date. Methods We investigated time trends in SVT-related mortality, 2008–2019, in Veneto, an Italian high-income region of approximatively 5,000,000 inhabitants. SVT-related deaths were identified by the following ICD-10 codes: I81 (portal vein thrombosis), K75.1 (phlebitis of portal vein), K76.3 (liver infarction), K76.5 (hepatic veno-occlusive disease) or I82.0 (Budd-Chiari syndrome). Results During the study period, a total of 557,932 deaths were recorded. SVT was reported in 823 cases; 776 (94%) consisted of portal vein thrombosis. The age-standardized SVT-related mortality rate varied from 1.47 (year 2008) to 1.52 (year 2019) per 100,000 person-years. An increase in the cause-specific annual mortality rate was observed in women (0.56 in 2008 to 1.04 per 100,000 person-years in 2019; average annual percent change +5.7%, 95%CI +3.1; +8.3%). In men, the cause-specific mortality rate moved from 2.53 in 2008 to 2.03 per 100,000 person-years in 2019 (average annual percent change −1.2%, 95%CI -4.0; +1.6%). After conditioning for age and sex, the odds of having a concomitant liver disease were higher for SVT-related deaths (OR 31.6; 95%CI 17.1–37.0) compared with non-SVT-related deaths. This also applies to gastrointestinal cancers (OR 1.28; 95%CI 1.07–1.55), although to a lesser extent. Conclusions We report first epidemiological estimates of SVT-related mortality in a Western country. These values will serve as a reference to weight novel potential factors associated with SVT-related death, putting them into an epidemiological perspective. Summary box What is already known about this subject? Splanchnic vein thrombosis is a rare manifestation of venous thromboembolism, often related to liver diseases. Currently, there is no available data on its impact on the general population in terms of mortality rates. What are the new findings? Splanchnic vein thrombosis-related mortality rate was higher in men than in women and was strongly associated with the presence of liver diseases. In women, the age-standardized splanchnic vein thrombosis-related mortality rate has been increasing since 2008. How might it impact on clinical practice in the foreseeable future? We report first epidemiological estimates of splanchnic vein thrombosis-related mortality rates in a Western country. These values will serve as a reference to weight novel factors or pathologies potentially associated with splanchnic vein thrombosis and interpret them in an epidemiological perspective.

Background Venous resection of the superior mesenteric or portal vein is increasingly performed in pancreatic cancer surgery, whereas results of studies on short- and long-term outcomes are contradictory. The aim of this study was to evaluate the impact of the type of venous resection in pancreatoduodenectomy for pancreatic cancer on postoperative morbidity and overall survival. Methods This nationwide retrospective cohort study included all patients who underwent pancreatoduodenectomy for pancreatic cancer in 18 centres (2013-2017). Results A total of 1311 patients were included, of whom 17 per cent underwent wedge resection and 10 per cent segmental resection. Patients with segmental resection had higher rates of major morbidity (39 versus 20 versus 23 per cent, respectively; P < 0.001) and portal or superior mesenteric vein thrombosis (18 versus 5 versus 1 per cent, respectively; P < 0.001) and worse overall survival (median 12 versus 16 versus 20 months, respectively; P < 0.001), compared to patients with wedge resection and those without venous resection. Multivariable analysis showed patients with segmental resection, but not those who had wedge resection, had higher rates of major morbidity (odds ratio = 1.93, 95 per cent c.i. 1.20 to 3.11) and worse overall survival (hazard ratio = 1.40, 95 per cent c.i. 1.10 to 1.78), compared to patients without venous resection. Among patients who received neoadjuvant therapy, there was no difference in overall survival among patients with segmental and wedge resection and those without venous resection (median 32 versus 25 versus 33 months, respectively; P = 0.470), although there was a difference in major morbidity rates (52 versus 19 versus 21 per cent, respectively; P = 0.012). Conclusion In pancreatic surgery, the short- and long-term outcomes are worse in patients with venous segmental resection, compared to patients with wedge resection and those without venous resection.Of 1311 patients who underwent pancreatoduodenectomy, 17 per cent underwent venous wedge resection and 10 per cent underwent venous segmental resection. Venous segmental, but not venous wedge, resection was associated with higher major morbidity rates (odds ratio = 1.93, 95 per cent c.i. 1.20 to 3.11) and worse overall survival (hazard ratio = 1.40, 95 per cent c.i. 1.10 to 1.78), compared to no venous resection. This nationwide study found worse short- and long-term outcomes in patients who had venous segmental resection. The results of this study urge the need for improving outcomes in patients who require venous segmental resection.

The current ischemic models of liver failure are difficult and usually time-consuming to produce. The aim of this study was to develop a simplified and reproducible porcine model of acute liver failure for use in preclinical research. Eighteen Bama miniature pigs were randomly divided into Groups A, B, and C. The hepatic artery and common bile duct were ligated in all groups. While the portal vein was completely preserved in Group A, it was narrowed by 1/3 and 1/2 in Groups B and C, respectively. Results of biochemical analyses, encephalopathy scores, and survival times were compared among the groups. Results of hematoxylin-eosin staining, terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling, Masson staining, and Ki-67 analyses were recorded. Survival times in Groups B and C were 11.67 ± 1.86 and 2.16 ± 0.75 days, respectively, shorter than that in Group A (>15 days). Following surgery, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, alkaline phosphatase, total bilirubin, and direct bilirubin levels significantly increased relative to baseline values in all groups (P

Introduction and aim Portal vein thrombosis (PVT) is associated with a higher risk of liver-related complications. Recent guidelines recommend direct-acting anticoagulants (DOAC) in patients with cirrhosis and non-tumoral PVT. However, data on the efficacy and safety of DOAC in these patients remain limited. We aim to investigate the efficacy and safety of DOAC compared to vitamin K antagonists (VKA) to treat non-tumoral PVT in patients with cirrhosis. Methods We performed a systematic search of six electronic databases using MeSH term and free text. We selected all studies comparing the use of DOACs with vitamin K antagonist to treat PVT in cirrhosis. The primary outcome was PVT recanalization. Secondary outcomes were and PVT progression, major bleeding, variceal bleeding and death. Results From 944 citations, we included 552 subjects from a total of 11 studies (10 observational and 1 randomized trial) that fulfilled the inclusion criteria. We found that DOAC were associated with a higher pooled rate of PVT recanalization (RR = 1.67, 95%CI: 1.02, 2.74, I2 = 79%) and lower pooled risk of PVT progression (RR = 0.14, 95%CI: 0.03–0.57, I2 = 0%). The pooled risk of major bleeding (RR = 0.29, 95%CI: 0.08–1.01, I2 = 0%), variceal bleeding (RR = 1.29, 95%CI: 0.64–2.59, I2 = 0%) and death (RR = 0.31, 95%CI: 0.01–9.578, I2 = 80%) was similar between DOAC and VKA. Conclusion For the treatment of PVT in patients with cirrhosis, the bleeding risk was comparable between DOAC and VKA. However, DOAC were associated with a higher pooled rate of PVT recanalization. Dedicated randomized studies are needed to confirm these findings.

In 1981, we developed the first antithrombogenic bypass catheter for the portal system. This catheter-bypass procedure relieved the time limitation caused by portal occlusion and facilitated safe and easy resection and reconstruction of the portal vein or hepatic artery. We thereafter explored isolated pancreatoduodenectomy, in which pancreatoduodenectomy is performed under non-touch isolation techniques. It is difficult to perform isolated pancreatoduodenectomy because of the complex arterial anatomy of the peripancreatic head region. In 1992, a mesenteric approach was developed for pancreatoduodenectomy. This approach allows dissection from the non-cancerous side and determination of both cancer-free margins and resectability followed by systematic lymphadenectomy around the superior mesenteric artery. This approach also enables early ligation of the inferior pancreatoduodenal artery and dorsal pancreatic artery branches from the superior mesenteric artery, as well as complete excision of the total mesopancreas (which is thought to be the second portion of the pancreatic head nerve plexus). Through this development of the mesenteric approach and antithrombogenic catheter-bypass procedure, our isolated pancreatoduodenectomy was finally established in 1992. This is the ideal surgery for pancreatic head cancer from both surgical and oncological aspects. We herein introduce the precise surgical techniques.

BACKGROUND Portal vein resection and reconstruction in locally advanced pancreatic cancer represents a potentially curative treatment in selected patients without increasing surgical mortality. However, vascular reconstruction after segmental venous resection is challenging. The parietal peritoneum has emerged as a venous substitute but few reports include its use as a tubular graft. We report a retrospective series of portal vein reconstruction using a falciform ligament tubular graft during pancreaticoduodenectomy. MATERIAL AND METHODS Technical aspects and short-term morbidity and mortality after pancreaticoduodenectomy with falciform ligament tubular graft interposition were analyzed. RESULTS Among 21 patients who used parietal peritoneum for venous substitution between 2015 and 2019, eight underwent pancreaticoduodenectomy with venous resection and reconstruction using interposition of falciform ligament tubular graft. The mean duration of surgery and clamping time were 350 and 27 min, respectively. No perioperative blood transfusion was required. All the grafts were patent the day after surgery. No complication related to venous obstruction was detected during the hospital stay. Two patients had postoperative pancreatic fistula. No further intervention was needed. The 90-day mortality was null. CONCLUSIONS The use of interposition of falciform ligament tubular graft for portal venous reconstruction during pancreaticoduodenectomy seems to be a reliable, inexpensive, and safe procedure.

Introduction Portal vein obstruction (PVO) is a significant vascular complication after liver transplantation (LT) in pediatric patients. Current treatment strategies include percutaneous transluminal angioplasty (PTA), with or without stent placement, mesorex bypass (MRB), splenorenal shunt, mesocaval shunt, endovascular recanalization (EVR), splenic artery embolization and splenectomy. However, specific characteristics of patients undergoing intervention and selection of individual treatment and its efficacy have remained unclear. This review systematically analyzed biochemical and clinical characteristics, selection of treatment, efficacy, and post-procedural complications. Methods We systematically searched PubMed and Embase between January 1995 and March 2021 for studies on the management of PVO after LT. We analyzed the reports for biochemical and clinical characteristics at the timing of the intervention in different patients, selection of treatment, and reported efficacies. Results We found 22 cohort studies with 362 patients who had the following characteristics: biliary atresia (83%), living-donor LT (85%), thrombocytopenia (73%), splenomegaly (40%), ascites (16%), or gastrointestinal bleeding (26%). The 3-year primary patency of PTA without stent placement was similar to that with stent placement (70%–80% and 43%–94%, respectively). MRB was used as an initial treatment with a 3-year patency of 75% to 100%. One study showed that 5-year primary patency of EVR was 80%. Secondary patency was 90% to 100% after 3 years in all studies with PTA alone, PTA/stent placement, and stent placement alone. Conclusion This is the first review of all treatment protocols in PVO after pediatric LT. We showed that an important group of patients has severe symptoms of portal hypertension. Efficacy of all treatment modalities was high in the included studies which make them important modalities for these patients.

Purpose Porto-systemic pressure gradient is used to prognosticate rebleeding and resolution of ascites after TIPS. This study investigates the reliability of portal pressure characteristics as quantified immediately after TIPS placement and at short-term control. Patients and Methods Portal venous pressure (PVP) and right atrial pressure (RAP) were prospectively obtained before and after TIPS as well as ≥ 48 h after TIPS procedure. Porto-systemic pressure gradients (PSG) and pressure changes were calculated. A multivariate regression analysis was performed to predict portal hemodynamics at short-term control. Results The study included 124 consecutive patients. Indications for TIPS were refractory ascites, variceal bleeding or combinations of both. Pre- and post-interventional PSG yielded 16.4 ± 5.3 mmHg and 5.9 ± 2.7 mmHg, respectively. At that time, 105/124 patients (84.7%) met the target (PSG ≤ 8 mmHg). After 4 days (median), PSG was 8.5 ± 3.5 mmHg and only 66 patients (53%) met that target. In patients exceeding the target PSG at follow-up, PVP was significantly higher and RAP was lower resulting in the increased PSG. The highly variable changes of RAP were the main contributor to different pressure gradients. In the multivariate regression analysis, PVP and RAP immediately after TIPS were predictors for PSG at short-term control with moderately predictive capacity (AUC = 0.75). Conclusion Besides the reduction of portal vein pressure, the highly variable right atrial pressure was the main contributor to different pressure gradients. Thus, immediate post-TIPS measurements do not reliably predict portal hemodynamics during follow-up. These findings need to be further investigated with respect to the corresponding clinical course of the patients.

Background In adult right lobe living donor liver transplantation (LDLT), venous drainage of the anterior sector is usually reconstructed on the bench to form a neo-middle hepatic vein (MHV). Reconstruction of the MHV for drainage of the anterior sector is crucial for optimal graft function. The conduits used for reconstruction include cryopreserved allografts, synthetic grafts, or the recipient portal vein. However, the ideal choice remains a matter of debate. This study compares the efficacy of the native recipient portal vein (RPV) with PTFE grafts for reconstruction of the neo-MHV. Methods Patients in this equivalence-controlled, parallel-group trial were randomized to either RPV (62 patients) or PTFE (60 patients) for use in the reconstruction of the neo-MHV. Primary endpoint was neo-MHV patency at 14 days and 90 days. Secondary outcomes included 90-day mortality and post-transplant parameters as scored by predefined scoring systems. Results There was no statistically significant difference in the incidence of neo-MHV thrombosis at 14 days (RPV 6.5 per cent versus PTFE 10 per cent; P = 0.701) and 90 days (RPV 14.5 per cent versus PTFE 18.3 per cent; P = 0.745) between the two groups. Irrespective of the type of graft used for reconstruction, 90-day all-cause and sepsis-specific mortality was significantly higher among patients who developed neo-MHV thrombosis. Neo-MHV thrombosis and sepsis were identified as risk factors for mortality on Cox proportional hazards analysis. No harms or unintended side effects were observed in either group. Conclusion In adult LDLT using modified right lobe graft, use of either PTFE or RPV for neo-MHV reconstruction resulted in similar early patency rates. Irrespective of the type of conduit used for reconstruction, neo-MHV thrombosis is a significant risk factor for mortality. Registration number CTRI/2018/11/016315 (www.ctri.nic.in).

BACKGROUND: Portal vein thrombosis (PVT) is no longer a contraindication for liver transplantation (LT). While therapeutic anticoagulation (tAC) is recommended during the waiting period, there is no evidence for its usefulness in the prevention of PVT recurrence after LT.OBJECTIVES: The aim of our study was to evaluate the role of tAC post-LT in the prevention of PVT recurrence.PATIENTS/METHODS: All adult LTs performed in 2 high volume centres between 2003 and 2018, were retrospectively analysed. Only patients with PVT classified as Yerdel grade I or II and with standard portal reconstruction were included. PVT recurrence and tAC-associated morbidity within 1 year were compared between patients receiving tAC or not.RESULTS: During the study period, out of 2612 LTs performed, 235 (9%) patients with PVT were included. 113 patients (48.1%) received post-LT tAC (tAC group) while 122 (51.9%) did not (non-tAC group). The incidence of bleeding events was significantly higher in the tAC group (26 (23%) vs. 5 (4.1%), pCONCLUSION: Therapeutic anticoagulation is not necessary in the prevention of grade I/II PVT recurrence and is associated with higher morbidity and longer hospital stay.

To reveal the effect of drug-eluting beads transarterial chemoembolization and Lipiodol transarterial chemoembolization on portal perfusion, and to identify factors predisposing portal vein damage after transarterial chemoembolization, based on evaluation by computed tomography during arterial portography.This retrospective cohort analysis included 49 patients with hepatocellular carcinoma who underwent transarterial chemoembolization and preprocedural/follow-up computed tomography during arterial portography between October 2013 and April 2015. The preprocedural and follow-up computed tomography during arterial portography were compared to identify the following new changes suggestive of portal vein damage in the follow-up computed tomography during arterial portography: small perfusion defects, large perfusion defects, and narrowing/disappearance or portal vein obstruction. The frequency of portal vein damage after drug-eluting beads transarterial chemoembolization and Lipiodol transarterial chemoembolization was calculated, and relationships between portal vein damage and clinical variables were analyzed. Finally, a multivariate logistic regression analysis with adjustments for potentially confounding factors was performed to identify factors predisposing portal vein damage.The analysis included 24 patients who underwent drug-eluting beads transarterial chemoembolization and 25 who underwent Lipiodol transarterial chemoembolization. Emergence of small perfusion defects and narrowing/disappearance or obstruction of portal vein were observed at a significantly higher frequency following drug-eluting beads transarterial chemoembolization than following Lipiodol transarterial chemoembolization (70.8% [17/24] vs. 20% [5/25]; p0.001; 41.7% [10/24] vs. 12% [3/25]; p = 0.019). Drug-eluting beads transarterial chemoembolization and selectivity of transarterial chemoembolization (selective [subsegmental], segmental or lobar) were significantly associated with portal vein damage (p0.001 and p = 0.016, respectively). However, multivariate logistic regression analysis identified drug-eluting beads transarterial chemoembolization as a significant independent predictor of portal vein damage (odds ratio: 34.95; 95% confidence interval: 1.137-1073.99; p = 0.042).Portal vein damage occurred at a significantly higher frequency following drug-eluting beads transarterial chemoembolization than following Lipiodol transarterial chemoembolization, and drug-eluting beads transarterial chemoembolization was an independent predictor of portal vein damage after transarterial chemoembolization.

Background: Portal vein velocity (PVV) has shown a reasonable correlation with the presence of portal hypertension in patients with cirrhosis. This study aims to evaluate the value of PVV for diagnosing clinically significant portal hypertension (CSPH) and predicting the risk of variceal hemorrhage (VH) in patients with hepatitis B virus (HBV)-related cirrhosis. Material and Methods: A cohort of 166 consecutive adult patients with HBV-related cirrhosis was recruited in this retrospective study from two high-volume liver centers in China between April 2015 and April 2017. The performance of PVV and other non-invasive parameters for diagnosing CSPH and predicting the risk of VH was studied. Results: PVV demonstrated the best performance for diagnosing CSPH (defined as an HVPG ≥10 mmHg) in patients with HBV-related cirrhosis among the included non-invasive predictors with the area under the receiver operating characteristic curve (AUC), specificity, and sensitivity of 0.745, 50%, and 93.5%, respectively. Other non-invasive markers, including APRI, AAR, LS, FIB-4, and diameter of the portal vein, did not show sufficient performance with the AUCs of 0.565, 0.560, 0.544, 0.529, and 0.474, respectively. With regard to predicting the risk of VH (defined as an HVPG ≥12 mmHg), PPV also exhibited a moderate performance with an AUC of 0.762, which was superior to that of the aforementioned markers. By using two cutoff values of PVV to rule-out (11.65 cm/s) and rule-in (20.20 cm/s) CSPH, 30 (33.7%) patients showed definite results categories, with 23 (76.7%) patients were well classified and 7 (23.3%) were misclassified. Fifty-nine (66.3%) patients were with indeterminate results. By using PVV values of 13.10 cm/s and 21.40 cm/s to rule-out and rule-in HVPG ≥ 12mmHg, 34 (38.2%) patients has definite results, among whom 26 (76.5%) were well classified and 8 (23.5%) were misclassified. And 55 (61.8%) patients required further evaluation. Conclusion: PPV is insufficient to serve as a non-invasive parameter for identifying CSPH and predicting the risk of VH in patients with HBV-related cirrhosis.

BACKGROUND Optimal treatment strategies for advanced hepatocellular carcinoma (HCC) with macroscopic portal vein tumor thrombus (PVTT) remain controversial. Therefore, this study aimed to assess the impact and predictive factors of hepatectomy for HCC with macroscopic PVTT. METHODS This study included 100 patients who presented with intraoperatively confirmed PVTT extending to the first portal branch (Vp3), main portal trunk, or opposite-side portal branch (Vp4) between June 2000 and December 2019. Their postoperative outcomes and predictive factors for survival were evaluated. RESULTS Of the 100 patients, 37 (37%) and 63 (63%) had Vp3 and Vp4 PVTTs, respectively. Moreover, 42 (42%) and 58 (58%) patients underwent R0/1 and R2 hepatectomies, respectively. The median survival time (MST) of all patients with Vp3/4 PVTT was 14.5 months; the 1- and 3-year overall survival rates were 59.6 and 16.8%, respectively. The MSTs of patients with Vp3 and Vp4 PVTTs were 16.1 and 14.3 months, respectively (P = 0.7098). The MSTs of patients who underwent R0/1 and R2 hepatectomies were 14.3 and 14.9 months, respectively (P = 0.3831). All assessed tumor factors (including the Vp status [Vp3 or Vp4], type of resection [R0/1 or R2], intrahepatic maximal tumor size, intrahepatic tumor number, and the existence of extrahepatic metastasis) did not influence the overall survival significantly. CONCLUSIONS Tumor factors, such as the presence of a Vp3/4 PVTT, have a strong impact on survival; however, other multiple tumor factors have a limited impact. Hepatectomy can be an effective treatment option for HCC with Vp3/4 PVTT, and its indications should be considered.

Endoscopic ultrasound (EUS) is one of the significant breakthroughs in the field of advanced endoscopy. In the last two decades, EUS has evolved from a diagnostic tool to a real-time therapeutic modality. The luminal gastrointestinal (GI) tract provides a unique opportunity to access multiple vascular structures, especially in the mediastinum and abdomen, thus permitting a variety of EUS-guided vascular interventions. The addition of the doppler and contrast-enhanced capability to EUS has further helped provide real-time visualization of blood flow in vessels through the GI tract. EUS-guided vascular interventions rely on standard endoscopic accessories and interventional tools such as fine-needle aspiration needles and fine-needle biopsy. EUS allows the visualization of various structures in real-time by differentiating tissue densities and vascularity, thus, avoiding radiation exposure. EUS-guided techniques also allow real-time microscopic examination after target biopsy. Furthermore, many necessary interventions can be done during the same procedure after diagnosis. This article provides an overview of EUS-guided vascular interventions such as variceal, non-variceal bleeding interventions, EUSguided portal vein (PV) access with the formation of an intrahepatic portosystemic shunt, and techniques related to diagnosis of GI malignancies. Furthermore, we discuss current insights and future outlook of therapeutic modalities like PV embolization, PV sampling, angiography, drug administration, and portal pressure measurement.

BACKGROUND Total pancreatectomy with islet autotransplantation (TPIAT) involves pancreatectomy, splenectomy, and reinjection of the patient's pancreatic islets into the portal vein. This process triggers a local inflammatory reaction and increase in portal pressure, threatening islet survival and potentially causing portal vein thrombosis. Recent research has highlighted a high frequency of extreme thrombocytosis (platelets ≥1000 × 109/L) after TPIAT, but its cause and association with thrombotic risk remain unclear. METHODS This retrospective single-site study of a contemporary cohort of 409 pediatric and adult patients analyzed the frequency of thrombocytosis, risk factors for thrombosis, and antiplatelet and anticoagulation strategies. RESULTS Of 409 patients, 67% developed extreme thrombocytosis, peaking around postoperative day 16. Extreme thrombocytosis was significantly associated with infused islet volumes. Thromboembolic events occurred in 12.2% of patients, with portal vein thromboses occurring significantly earlier than peripheral thromboses. Portal vein thromboses were associated with infused islet volumes and portal pressures but not platelet counts or other measures. Most thromboembolic events (82.7%) occurred before the postoperative day of maximum platelet count. Only 4 of 27 (14.8%) of portal vein thromboses occurred at platelet counts ≥500 × 109/L. Perioperative heparin was given to all patients. Treatment of reactive thrombocytosis using aspirin in adults and hydroxyurea in children was not associated with significantly decreased thromboembolic risk. CONCLUSIONS These results suggest that post-TPIAT thrombocytosis and portal vein thromboses may be linked to the islet infusion inflammation, not directly to each other, and further reducing this inflammation may reduce thrombosis and thrombocytosis frequencies simultaneously.

Portal vein thrombosis (PVT) is a rare but severe entity that can cause clinically significant sequela such as worsening portal hypertension or mesenteric ischemia. Those cases refractory to medical management may be referred for endovascular intervention. Several technical considerations have been described in the literature, but a cohesive comparison of these multiple techniques is lacking.The purpose of this article is to review the diagnosis and endovascular management of PVT, including areas in which further research is warranted.Cases of PVT can be readily diagnosed using ultrasound, computed tomography, or magnetic resonance imaging. Treatment often begins with systemic anticoagulation and endovascular interventions may be used in selected cases. Determining the optimal approach to accessing the portal venous system depends on the underlying disease and chronicity of the thrombus and the degree of occlusion. Once access to the portal venous system is established, catheter-directed therapy may be performed to achieve recanalization.Despite the heterogeneity in patient presentation, cases of PVT can be readily diagnosed across several imaging modalities. Strategizing interventional approaches involves evaluation of the underlying disease and the chronicity of the thrombus.· This review will enable interventionalists to establish a framework for treating portal vein thrombosis by identifying patient risk factors and thrombus characteristics that determine patient management.. · The unique risks and benefits for transhepatic, transsplenic, and transmesenteric approaches for establishing portal venous access will be discussed.. · Advantages and complications of thrombolysis, thrombectomy, and transjugular intrahepatic portosystemic shunt creation for treating portal vein thrombosis will be reviewed in detail based on our extensive institutional experience..· Ju C, Li X, Gadani S et al. Portal Vein Thrombosis: Diagnosis and Endovascular Management. Fortschr Röntgenstr 2022; 194: 169 - 180.Die Pfortaderthrombose (PVT) ist eine seltene, aber schwere Erkrankung, die klinisch signifikante Folgeerscheinungen wie eine Verschlechterung der portalen Hypertonie oder eine mesenteriale Ischämie verursachen kann. Fälle, die auf eine medizinische Behandlung nicht ansprechen, können zur endovaskulären Intervention überwiesen werden. In der Literatur sind verschiedene technische Gesichtspunkte beschrieben worden, aber ein umfassender Vergleich dieser verschiedensten Methoden fehlt.In diesem Artikel werden die Diagnose und die endovaskuläre Behandlung der PVT besprochen, einschließlich der Bereiche, in denen weitere Forschung erforderlich ist.PVT-Fälle lassen sich mit Ultraschall, Computertomografie oder Magnetresonanztomografie leicht diagnostizieren. Die Behandlung beginnt häufig mit einer systemischen Antikoagulation, und in ausgewählten Fällen können endovaskuläre Interventionen eingesetzt werden. Die Bestimmung des optimalen Zugangs zum Pfortadersystem hängt von der Grunderkrankung und der Chronizität des Thrombus sowie vom Grad der Okklusion ab. Sobald der Zugang zum Pfortadersystem hergestellt ist, kann eine Katheter-gesteuerte Therapie durchgeführt werden, um eine Rekanalisierung zu erreichen.Trotz der Heterogenität der Patienten bei Vorstellung können Fälle von PVT mit verschiedenen bildgebenden Verfahren leicht diagnostiziert werden. Bei der Planung von Interventionen müssen die Grunderkrankung und die Chronizität des Thrombus berücksichtigt werden.· Diese Übersicht ermöglicht es den interventionell tätigen Ärzten, Rahmenbedingungen für die Behandlung von Pfortaderthrombosen zu schaffen, indem Risikofaktoren für Patienten und Thrombusmerkmale identifiziert werden, die das Patientenmanagement bestimmen.. · Die besonderen Risiken und Vorteile transhepatischer, transsplenischer und transmesenterialer Ansätze zur Etablierung eines portalvenösen Zugangs werden diskutiert.. · Vorteile und Komplikationen der Thrombolyse, der Thrombektomie und der Anlage eines transjugulären intrahepatischen portosystemischen Shunts zur Behandlung von Pfortaderthrombosen werden basierend auf der umfangreichen Erfahrung in unserem Institut im Detail besprochen..

Continuous heart failure can lead to complications to other systems, one of which is the hepatic system. Heart failure results in venous congestion in the portal vein so that the portal vein pressure increases, which is called portal hypertension. Portal hypertension causes fluid to pass through the walls of blood vessels and into the tissues. Management of decompensatory heart failure accompanied by comorbi d disease in cardiac cirrhosis includes drugs management that does not aggravate the liver, namely angiotensin converting enzyme inhibitors and loop diuretic agents. Also, non-pharmacological management such as resting position and a diet sufficient in protein and low salt help improve the patient's general condition. This case report aims to present a de compensated heart failure accompanied by cardiac cirrhosis and anaemia of chronic disease in a child.

Abdominal pain is one of the most common presenting complaints encountered in the pediatric emergency department. The use of point-of-care ultrasonography by emergency physicians has been shown to expedite the diagnosis of a large variety of conditions and can be used to accurately identify intra-abdominal pathology in children. We describe the case of a pediatric patient who presented to the pediatric emergency department with acute abdominal pain, in whom point-of-care ultrasonography helped expedite the diagnosis of acute portal vein thrombosis and liver abscess.

Background Resection of the portal venous confluence is frequently necessary for radical resection during pancreatoduodenectomy for cancer. However, ligation of the splenic vein can cause serious postoperative complications such as gastric/splenic venous congestion and left-sided portal hypertension. A splenorenal shunt (SRS) can maintain gastric and splenic venous drainage and mitigate these complications. Purpose This study describes the surgical technique, postoperative course, and surgical outcomes of SRS after pancreatoduodenectomy. Methods Ten patients who underwent pancreatoduodenectomy and SRS between September 2017 and April 2019 were evaluated. After resection an end-to-side anastomosis between the splenic vein and the left renal vein was performed. Postoperative shunt patency, splenic volume, and any SRS-related complications were recorded. Results The rates of short- and long-term shunt patency were 100% and 60%, respectively. No procedure-associated complications were observed. No signs of left-sided portal hypertension, such as gastrointestinal bleeding or splenomegaly, and no gastric/splenic ischemia were observed in patients after SRS. Conclusion SRS is a safe and effective measure to mitigate gastric congestion and left-sided portal hypertension after pancreatoduodenectomy with compromised gastric venous drainage after resection of the portal venous confluence.

AIM: To evaluate the possibilities of flow detection using high resolution flow (HR Flow) and Glazing Flow technique in patients with liver parenchymal changes and flow changes in comparison to color-coded Doppler sonography (CCDS). MATERIAL AND METHODS: All examinations were performed using a multi frequency matrix convex probe with high resolution technique (SC6-1U/Resona7, Mindray, Shenzhen, China) by one experienced examiner to evaluate the venous, portal venous and arterial liver flow with digital documentation of the dynamic flow parameters like peak systolic flow, end-diastolic flow and resistance index. For liver parenchymal stiffness changes shear wave elastography was performed with at least 10 measurements. By two independent readers an elevation was performed to evaluate the image quality and the degree of flow artefacts, from 0 = not available to 5 points with excellent image quality without flow artefacts. RESULTS: All 40 patients (24 men, 16 women, age 27–83 years, mean 56±5 years) showed morphology changes from B-Mode of the liver parenchyma to inhomogeneous tissue with higher stiffness evaluated by the shear wave elastography (1.45 m/s up to 2.79 m/s±1.79 m/s, considering F1 up to F4 fibrosis) and in 15 cases histopathologically proven liver cirrhosis. In 9 cases after non-acute thrombosis flow reduction of the portal vein was the reason for the diameter less than 5 mm. Flow parameters for the venous flow were between 8 cm/s up to 29 cm/s, mean 14±4 cm/s, for the hepatic portal vein 5 cm/s up to 57 cm/s, mean 17±5 cm/s, for the hepatic artery systolic flow between 50 cm/s up to 127±33 cm/s, end-diastolic flow from 22 cm/s up to 47±8 cm/s. Resistance index for the hepatic artery was between 0.41 up to 0.73, mean 0.67±0.25. The image quality for CCDS over all cases was evaluated for CCDS between 1 up to 4. The mean quality was 2.5±0.5, for HR Flow in combination with Glazing Flow 3±0.5, with significant differences for the 2 readers (P

BACKGROUND: Hepatocellular carcinoma (HCC) aggressiveness factors include serum levels of alpha-fetoprotein (AFP), maximum tumor diameter (MTD), tumor multifocality and presence of portal vein thrombosis (PVT). AIMS: The inter-dependence of these factors has not been closely studied. METHODS: A large HCC database was examined for the presence of patients with PVT and multifocality and was analyzed retrospectively for the relationship of these 2 parameters to each other and to MTD and survival. RESULTS: Multifocality was found to increase with increase in MTD in the whole cohort and especially in patients with PVT. PVT also increased with increasing MTD. Neither increases in multifocality nor in PVT depended on elevated serum AFP levels, although they each increased with higher AFP levels. PVT increased in monofocal tumors as MTD increased, but increased further in multifocal tumors. CONCLUSIONS: Multifocality and PVT appear to be separate processes, each increasing with increase in MTD and AFP levels. The data support the hypothesis that in hepatocarcinogenesis, various factors cause increase in MTD, that in turn causes increased multifocality and PVT, which are non-co-dependent. However, both multifocality and PVT mechanisms involve both HCC cell growth and invasiveness, multifocality in liver parenchyma and PVT in the portal vein.

Background Transcatheter arterial chemoembolization has been widely used in patients with hepatocellular carcinoma. However, double blood supply and the existence of portal vein tumor thrombus influence the efficacy of transcatheter arterial chemoembolization. Main body Theoretically, portal vein embolization combined with transcatheter arterial chemoembolization may bring a breakthrough in the therapeutic effect of hepatocellular carcinoma. The feasibility, efficacy, long-term survival benefits, and side effects of the combined treatment have been explored in previous studies. Chemotherapeutic agents may also be added in the portal vein embolization procedure to further improve the treatment response. Conclusion In this study, we review the existing data and studies on the combined treatment in patients with hepatocellular carcinoma and provide an overall view of the strategy.

Background Acute portal vein thrombosis is a major cause of fulminant allograft failure in pediatric liver transplantation. Timely intervention is critical to save the graft and patient. Serial interventional radiologic management of this condition is scarcely reported in the literature. Case Summary A recently transplanted 17-year-old male presented to the emergency department with abdominal pain. Rising liver enzymes prompted discovery of a diffuse portal thrombus, which precipitated fulminant liver failure. The adolescent developed respiratory failure, vasodilatory shock, acute kidney injury, and hepatic encephalopathy, complicating treatment. Multiple interventions attempted to clear the thrombus, including interventional radiologic and medical therapies. Uniquely, a continuous infusion catheter was placed at the thrombosis, delivering local tissue plasminogen activator during a 5-day period. Upon thrombus clearance, the patient made a full recovery with no complications during 12 months of follow-up. Conclusions When used as a component of multidisciplinary management, continuous locally directed tissue plasminogen activator may be a useful tool for clearance of persistent portal vein thrombosis.

Although patients with cirrhosis are known to be in a state of “rebalance” in that pro- and anticoagulant factors increase the risk for both bleeding and thrombosis, the prevalence of portal vein thrombosis (PVT) in patients with cirrhosis can be up to 26%. Therefore, physicians should consider anticoagulation for the prevention and management of PVT in patients with cirrhosis who are at high risk of PVT. Vitamin K antagonist or low molecular weight heparin is suggested as the standard treatment for PVT in cirrhosis. With the advent of new direct-acting oral anticoagulants (DOACs), there is a paradigm shift of switching to DOACs for the treatment of PVT in patients with cirrhosis. However, the safety and efficacy of DOACs in the treatment of PVT was not well-known in patients with cirrhosis. Therefore, this review focused on the current knowledge about the efficacy, safety concerns, and hepatic metabolism of DOACs in patients with cirrhosis and PVT.

Background and Aims: Intraabdominal hypertension (IAH) is poorly diagnosed condition that cause splanchnic hypoperfusion and abdominal organs ischemia and can lead to multiple organ failure. There are no scientific data regarding effect of intraabdominal pressure (IAP) on splanchnic circulation in children. Material and Methods: Ninety-four children after surgery for appendicular peritonitis were enrolled in the study. After IAP measurement children were included in one of two groups according IAP levels: “without IAH” (n = 51) and “with IAH” (n = 43). Superior mesenteric artery (SMA) and portal vein (PV) blood flows (BFSMA, BFPV, mL/min) were measured, and SMA and PV blood flow indexes (BFISMA, BFIPV, ml/min*m2) and abdominal perfusion pressure (APP) were calculated in both groups. Results: Median BFISMA and BFIPV in group “with IAH” were lower by 54.38% (P < 0.01) and 63.11% (P < 0.01) respectively compared to group “without IAH”. There were strong significant negative correlation between IAP and BFISMA (rs = –0.66; P < 0.0001), weak significant negative correlation between IAP and BFIPV (rs = –0.36; P = 0.0001) in group “with IAH” and weak significant negative correlation between IAP and BFISMA (rs = –0.30; P = 0.0047) in group “without IAH”. There were no statistically significant correlations between IAP and BFIPV in group “without IAH”, between BFISMA and APP in both groups and between BFIPV and APP in both groups. Conclusion: Elevated IAP significantly reduces splanchnic blood flow in children with appendicular peritonitis. BFISMA and BFIPV negatively correlate with IAP in these patients. There is no correlation between BFISMA/BFIPV and APP in children with IAH due to appendicular peritonitis.

Background While a certain degree of tumor infiltration of the portal vein is common in patients with perihilar cholangiocarcinoma (pCCA) scheduled for surgery, complete tumor-associated portal vein occlusion (PVO) is less frequently observed. Here, we analyzed the impact of PVO on perioperative and oncological outcomes in pCCA patients. Methods Between 2010 and 2019, 127 patients with pCCA underwent surgery in curative intent at our department of which 17.3% (22/127) presented with PVO. Extensive group comparisons were conducted and the association of cancer-specific (CSS) and disease-free survival (DFS) with PVO and other clinico-pathological characteristics were assessed using Cox regression models. Results Patients without PVO showed a median CSS of 65 months (3-year-CSS = 64%, 5-year-CSS = 53%) compared to 31 months (3-year-CSS = 43%, 5-year-CSS = 17%) in patients with PVO (p = 0.025 log rank). Patients with PVO did also display significant perioperative mortality (22.7%, 5/22) compared to patients without PVO (14.3%, 15/105, p = 0.323). Further, PVO (CSS: HR = 5.25, p = 0.001; DFS: HR = 5.53, p = 0.001) was identified as independent predictors of oncological outcome. Conclusions PVO has been identified as an important prognostic marker playing a role in inferior oncological outcome in patients with pCCA. As PVO is also associated with notable perioperative mortality, surgical therapy should be considered carefully in pCCA patients.

Background To evaluate our experience of liver resection for hepatocellular carcinoma (HCC) patients associated with macroscopic portal vein invasion (PVI). Methods Consecutive HCC patients who underwent liver resection for HCC between November 2009 & June 2019 were included. To overcome selection bias between patients with and without macroscopic PVI, we performed 1:1 match using propensity score matching (PSM). Results Macroscopic PVI was detected in 37 patients (12.8%). We divided our patients into two groups according to the presence of macroscopic PVI. After PSM, 36 patients of PVI group were matched with 36 patients from Non-PVI group. After PSM, both groups were well balanced regarding tumor site, number, liver resection extent and type. Longer operation time and more blood loss were noted in PVI group. Higher incidence of post-operative morbidities occurred in PVI group especially, post-hepatectomy liver dysfunction. The 1-, 2-, and 3-y overall survival rates for Non-PVI group were 85.3%, 64.6%, and 64.6% & 69.8%, 42%, and 0% for PVI group, respectively (P = 0.009). There were no significant differences regarding the recurrence rate, site, and its management. The 1-, 2-, and 3-y disease-free survival (DFS) rates for Non-PVI group were 81.7%, 72.3%, and 21.7% & 67.7%, 42.3%, and 0% for PVI group, respectively (P = 0.172). Conclusion Surgical management of advanced HCCs with macroscopic PVI is feasible, and associated with comparable DFS but poorer overall survival, compared to patients without PVI.

BACKGROUND. Drug-eluting bead transarterial chemoembolization (DEB-TACE) has emerged as an alternative to conventional TACE (cTACE) for treatment of hepatocellular carcinoma (HCC), although selecti...

Background Portal vein thrombosis (PVT) is a common complication following splenectomy. It affects between 5 and 55% of patients undergoing surgery with no clearly defined pre-operative risk factors. The aim of this study was to determine the pre-operative risk factors of PVT. Patients and method Single centre, retrospective study of data compiled for every consecutive patient who underwent splenectomy at Toulouse University Hospital between January 2009 and January 2019. Patients with pre- and post-surgical CT scans have been included. Results 149 out of 261 patients were enrolled in the study (59% were males, mean age 52 years). The indications for splenectomy were splenic trauma (30.9%), malignant haemopathy (26.8%) and immune thrombocytopenia (8.0%). Twenty-nine cases of PVT (19.5%) were diagnosed based on a post-operative CT scan performed on post-operative day (POD) 5. Univariate analysis identifies three main risk factors associated with post-operative PVT: estimated splenic weight exceeding 500 g with an OR of 8.72 95% CI (3.3–22.9), splenic vein diameter over 10 mm with an OR of 4.92 95% CI (2.1–11.8) and lymphoma with an OR of 7.39 (2.7–20.1). The role of splenic vein diameter with an OR of 3.03 95% CI (1.1–8.6), and splenic weight with an OR of 5.22 (1.8–15.2), as independent risk factors is confirmed by multivariate analysis. A screening test based on a POD 5 CT scan with one or two of these items present could indicate sensitivity of 86.2% and specificity of 86.7%. Conclusion This study suggests that pre-operative CT scan findings could predict post-operative PVT. A CT scan should be performed on POD 5 if a risk factor has been identified prior to surgery.

Portomesenteric thrombosis is an important but rarely reported complication following bariatric surgery. It has been suggested that the incidence of portal vein thrombosis is directly related to many risk factors inherent in the bariatric population as well as factors related to local and systemic effects of laparoscopic surgery. Possible aetiologies vary from systemic inherited hypercoagulable states to a direct inflammatory reaction of portosystemic vessels. Here we present a case report of a 47-year-old obese women who underwent a robotic sleeve gastrectomy with subsequent development of a main portal vein, complete right intrahepatic portal vein and splenic vein thrombosis ultimately found to have a compound mutation of the methylenetetrahydrofolate reductase C677T and A1298C alleles.

Traditionally, liver transplantation for hepatocellular carcinoma with portal vein tumor thrombosis is not recommended. However, with recent developments in locoregional therapies for hepatocellular carcinoma, more aggressive treatments have been attempted for advanced hepatocellular carcinoma. Recently, various studies on locoregional therapies for downstaging followed by living donor liver transplantation reported inspiring overall survival and recurrence-free survival of patients. These downstaging procedures included three-dimensional conformal radiation therapy, trans-arterial chemoembolization, stereotactic body radiation therapy, trans-arterial radioembolization, hepatic arterial infusion chemotherapy and combinations of these therapies. Selection of the optimal downstaging protocol should depend on tumor location, biology and background liver status. The risk factors affecting outcome include pre-downstaging alpha-fetoprotein values, delta alpha-fetoprotein values, disappearance of portal vein tumor thrombosis on imaging and meeting the Milan criteria or not after downstaging. For hepatocellular carcinoma with portal vein tumor thrombosis, downstaging procedure with liver transplantation in mind would be helpful. If the reaction of the downstaged tumor is good, liver transplantation may be performed.

Background/aim The impact of venous resections and reconstruction techniques on morbidity after surgery for pancreatic cancer (PDAC) remains controversial. Patients and methods A total of 143 patients receiving pancreatoduodenectomy (PD) for PDAC between 2013 and 2018 were identified from a prospective database. Morbidity and mortality after PD with tangential resection versus end-to-end reconstruction were assessed. Results Fifty-two of 143 (36.4%) patients underwent PD with portal venous resection (PVR), which was associated with longer operation times [398 (standard error (SE) 12.01) vs. 306 (SE 13.09) min, p 0.99) were not different. Tangential venous resection was associated with similar CDC grade IIIa-IV (42.9% vs. 50.0%, p=0.781) and 30-day mortality rates (3.5% vs. 4.1%, p=0.538) as segmental resection and end-to-end venous reconstruction. Conclusion Both tangential and segmental PVR appear feasible and can be safely performed to achieve negative resection margins.

Background Microscopic portal vein invasion (microPVI) and tumor multifocality are hepatocellular carcinoma (HCC) prognosis factors. To investigate whether microPVI and multifocality are directly related to each other. Methods We retrospectively analyzed the relationships between microPVI, multifocality, and maximum tumor diameter (MTD) in prospectively collected transplanted HCC patients. Results HCCs with 1, 2, or ≥ 3 foci had more microPVI in larger than in smaller HCCs, with microPVI being present in 52.24% of single large foci. Conversely, microPVI patients had similar percentages of single and multifocal lesions. A linear regression model of MTD, showed microPVI best associated with MTD, with 2.49 as coefficient, whereas multifocality had a 0.83 coefficient. A logistic regression model of microPVI showed significant association with tumor multifocality, especially for small HCCs. Trends for microPVI and multifocality in relation to MTD revealed that both increased with MTD but more significantly for microPVI. Survival was similar in patients with small HCCs, with or without microPVI, but was significantly worse in microPVI patients with larger HCCs. No patient survival differences were found in relation to focality. Conclusions MTD had stronger associations with microPVI than with multifocality. microPVI was associated with worse survival in patients with large HCCs, but survival was not impacted by number of tumor foci. microPVI and multifocality appear weakly related, having different behavior in relation to MTD and survival.

Hepatocellular carcinoma (HCC) with portal vein tumoral thrombosis (PVTT) represents a major concern especially in the field of deceased donor liver transplantation (DDLT). However, when receiving transarterial radioembolization (TARE), a considerable percentage of such patients are able to achieve a radiologic complete response with adequate survival rates. In this pilot prospective study, we evaluated the effect of TARE in downstaging HCC patients with PVTT to meet criteria for DDLT. Between May 2013 and November 2016, patients were evaluated to be enrolled into our “Superdownstaging” protocol. Patients received yttrium-90 TARE and were enlisted for DDLT in case of complete and sustained (6months) radiological response. Patients with tumor thrombus in the main trunk and/or in the contralateral portal vein branch were excluded. TARE was effective in downstaging and receiving DDLT in 5/17 patients (29.4%). The 5-year overall survival was significantly higher in patients who underwent DDLT compared with those who were not transplanted (60.0% versus 0.0%, P=0.03). Three out of 5 patients developed recurrence within 1year after LT. The current series showed a clear survival gain in those patients who were able to receive DDLT after TARE but careful selection for DDLT is however advised.

To date, the optimal treatment for portal vein thrombosis (PVT) in cirrhotic patients has not been established in guidelines or consensus. We conducted a systematic review and meta-analysis to evaluate the effect of anticoagulation therapy in patients with cirrhosis and PVT. PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched (until 31st October 2020) for studies evaluating the effect of anticoagulation therapy on treating PVT in patients with cirrhosis. Odds ratios (ORs) and their 95% confidence intervals (CIs) were pooled using the Mantel–Haenszel method. A total of 13 studies were included in the analysis, comprising 6005 patients. Of these, three were prospective cohort studies, nine were retrospective cohort studies and one was case–control study. Compared to no treatment, anticoagulation therapy was associated with higher rates of PVT recanalization (OR 4.29; 95% CI 3.01–6.13). Anticoagulation therapy demonstrated a significant 74% reduction in PVT extension compared to no treatment (OR 0.26; 95% CI 0.14–0.49). Anticoagulation therapy was associated with a nonsignificantly lower risk of death (OR 0.53; 95% CI 0.20–1.40). However, anticoagulation therapy was associated with slightly higher risk of bleeding compared to no treatment (OR 1.16; 95% CI 1.02–1.32). In cirrhotic patients with PVT, anticoagulation therapy helps increase rate of PVT recanalization and improve survival, but may also carry higher risks of bleeding compared to no treatment. Our findings support the use of anticoagulation in cirrhotic patients with PVT.

Background Congenital biliary atresia is a type of obstruction of the bile ducts inside and outside the liver, which can lead to cholestatic liver cirrhosis and eventually liver failure. The preduodenal portal vein (PD-PV) is a rare developmental malformation of the PV. The PV courses in front of the duodenum. However, very few cases of neonatal biliary atresia combined with PD-PV have been reported in the scientific literature. Case summary A 1-mo-and-4-d-old child was admitted to the hospital in January because of yellowish skin. After surgical consultation, surgical intervention was recommended. The child underwent Hilar-jejunal anastomosis, duodenal rhomboid anastomosis, and abdominal drainage under general anesthesia. During the operation, the PV was located at the anterior edge of the duodenum. Conclusion Diagnoses: (1) Congenital biliary atresia; (2) PD-PV; and (3) Congenital cardiovascular malformations. Outcomes: Recommendation for liver transplantation. Lessons: The choice of treatment options for neonatal biliary atresia combined with PD-PV.

Nonalcoholic fatty liver disease often progresses to cirrhosis and causes liver cancer, but mechanisms of its progression are yet to be elucidated. Although nonalcoholic fatty liver disease is often associated with abnormal portal circulation, there have not been any experimental studies to test its pathogenic role. Here, whether decreased portal circulation affected the pathology of nonalcoholic steatohepatitis (NASH) was examined using congenital portosystemic shunt (PSS) in C57BL/6J mice. Whereas PSS significantly attenuated free radical-mediated carbon tetrachloride injury, it augmented pericellular fibrosis in the centrilobular area induced by a 0.1% methionine choline-deficient l-amino acid-defined high-fat diet (CDAHFD). PSS aggravated ductular reaction and increased the expression of connective tissue growth factor. Pimonidazole immunohistochemistry of the liver revealed that the centrilobular area of PSS-harboring mice was more hypoxic than that of control mice. Although tissue hypoxia was observed in the fibrotic area in CDAHFD-induced NASH in both control and PSS-harboring mice, it was more profound in the latter, which was associated with higher carbonic anhydrase 9 and vascular endothelial growth factor expression and neovascularization in the fibrotic area. Furthermore, partial ligation of the portal vein also augmented pericellular fibrosis and ductular reaction induced by a CDAHFD. These results demonstrate that decreased portal circulation, which induces hypoxia due to disrupted intralobular perfusion, is an important aggravating factor of liver fibrosis in NASH.

Background There is currently no widely-accepted consensus for the management of hepatocellular carcinoma with portal vein tumor thrombus. We evaluate the safety and efficacy of ultrasound-guided percutaneous brachytherapy with iodine-125 seeds for the treatment of hepatocellular carcinoma with portal vein-branch tumor thrombus (PVBTT). Methods Sixty-nine hepatocellular carcinoma patients with PVBTT were enrolled; 34 received transarterial chemoembolization (TACE) combined with iodine-125 seeds implanted in the PVBTT; 35 were treated with TACE alone. Adverse events, objective response rate, disease control rate, progression-free survival, and overall survival were compared between the two groups. Tumor responses of PVBTT and intrahepatic tumor were correlated. Multivariate and subgroup analyses were conducted for overall survival. Results No grade 3 or 4 adverse events were recorded, and there was no difference in grade 1 or 2 adverse events between the two groups. Objective response rate and disease control rate for PVBTT were 58.9 and 91.2%, respectively, in the combined treatment group, which were significantly greater than the 5.7 and 54.3% rates, respectively, in the TACE-alone group (both p’s ≤ 0.001). Intrahepatic tumor response was positively correlated with the PVBTT response (γ = 0.782, p p p = 0.003). Multivariate analysis revealed that application of brachytherapy and lower grade PVBTT (Vp1 + Vp2 vs. Vp3) were protective predictors of overall survival. In stratified analysis, the benefit of overall survival was more significant in the subgroup of PVBTT Vp1 + Vp2 rather than in Vp3. Conclusions The combination of iodine-125 seed brachytherapy guided by ultrasound and TACE is a convenient, safe, and effective treatment for patients with HCC and PVBTT, conferring a better survival benefit than TACE alone.

Introduction Diffuse splanchnic vein thrombosis (DSVT) remains a serious challenge in liver transplantation (LT). Reno-portal anastomosis (RPA) has previously been reported as a valid option for management of patients with DSVT during LT. The aim of this study was to evaluate posttransplant renal function and surgical outcomes of patients with DSVT who underwent RPA during LT. Methods Between January 2005 and December 2017, 1,270 patients underwent LT at our institution, including 16 with DSVT managed with RPA (RPA group). We compared renal function and surgical outcomes in these patients to outcomes in 48 propensity-score (PS) matched patients without thrombosis (control group), using a 1:3 matching model. Results The two groups had similar rates of postoperative portal vein thrombosis (PVT), renal dysfunction as measured by estimated glomerular filtration rate (eGFR), and overall postoperative complications (Clavien grade III), although the RPA group had a higher incidence of postoperative upper gastrointestinal (GI) bleeding (31.3% vs 4.2%; p=0.009) that had no clinical consequence. There were no significant differences in five-year graft and patient survival rates between the groups (p=0.133 and p=0.166, respectively). Conclusion RPA is an established technique in the management of patients with DSVT during LT, with comparable outcomes to patients without thrombosis. Our report is the first to demonstrate similar surgical outcomes, including long-term renal function, in LT recipients with or without RPA.

The effectiveness of laparoscopic Kasai portoenterostomy (Laparoscopic-KPE) for biliary atresia (BA) has been reported but remains controversial. We reviewed our own cases and cases described in previous studies of liver transplantation (LT) for BA after Laparoscopic-KPE to investigate the efficacy of Laparoscopic-KPE. Subjects were children of ≤ 2 years old with LT for BA after KPE who underwent Laparoscopic-KPE (n = 10) or Open-KPE (n = 115) between 2009 and 2020. Propensity score matching was performed to reduce the effect of treatment selection bias. The clinical data regarding the preoperative characteristics and surgical results were compared. The rates of hypoplastic portal vein and retrograde portal vein flow were lower in the Laparoscopic-KPE group than in the Open-KPE group (0 vs. 40.0%, p = 0.02 and 0 vs. 35.0%, p = 0.04). There was no marked difference in the operation time or duration of hepatectomy. For portal vein reconstruction, a vein graft was not required in the Laparoscopic-KPE group (0 vs. 35.0%, p = 0.03). No patients in the Laparoscopic-KPE group developed portal vein complications or required re-laparotomy for bowel perforation or re-bleeding, in contrast to the Open-KPE group (0 vs. 15.0% and 0 vs. 10.0%, respectively). Laparoscopic-KPE may reduce postoperative complications that necessitate re-laparotomy in LT.

Background Clinically, the total and residual liver volume must be accurately calculated before major hepatectomy. However, liver volume might be influenced by pneumoperitoneum during surgery. Changes in liver volume change also affect the accuracy of simulation and augmented reality navigation systems, which are commonly first validated in animal models. In this study, the morphologic changes in porcine livers in vivo under 13 mm Hg pneumoperitoneum pressure were investigated. Materials and methods Twenty male pigs were scanned with contrast-enhanced computed tomography without pneumoperitoneum and with 13 mm Hg pneumoperitoneum pressure. Results The surface area and volume of the liver and the vascular diameter of the aortic lumen, inferior vena cava lumen, and portal vein lumen were measured. There were statistically significant differences in the surface area and volume of the liver (P=0.000), transverse diameter of the portal vein (P=0.038), longitudinal diameter of the inferior vena cava (P=0.033), longitudinal diameter of the portal vein (P=0.036), vascular cross-sectional area of the inferior vena cava (P=0.028), and portal vein (P=0.038) before and after 13 mm Hg pneumoperitoneum pressure. Conclusions This study indicated that the creation of pneumoperitoneum at 13 mm Hg pressure in a porcine causes liver morphologic alterations affecting the area and volume, as well as the diameter of a blood vessel.

Pylephlebitis is a rare and potentially lethal complication of acute appendicitis. It leads to the development of liver abscesses and sepsis. Usually, this complication is the result of late diagnosis. Only rare cases of successful treatment of pylephlebitis in the context of acute appendicitis are published in special literature. The aim of the demonstration is to analyze of the diagnosis and medical tactic mistakes as a case of pylephlebitis in a patient with acute appendicitis; show the possibilities of modern methods of diagnosis and treatment, which made it possible to achieve a success. The case of successful treatment patient with pylephlebitis was shown in the article. Late diagnosis of acute appendicitis was associated with the patient’s refusal and with some diagnostic and tactic mistakes that were analyzed. The case presented by jaundice, liver failure and fever. Thrombosis of portal vein diagnosed by U/S, CT scan with intravenous contrast on day 11 of the illness. Appendectomy was performed. Intensive care with extracorporeal therapy, antibacterial and anticoagulant therapy were also provided. Septic thrombosis of portal vein was complicated by an abscess of the right lobe of the liver and sepsis. The case of successful treatment of patient with septic thrombosis of portal vein and superior mesenteric vein complicated by liver abscess and sepsis is considered in the article. Intensive therapy, extracorporeal detoxification and abdominal abscess drainage under the U/S control have resulted in a fully repatency of portal vein that was confirmed by CT scan data.