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Purpose: To evaluate long-term patency of self-expanding Z stents for treatment of benign central venous obstructions unrelated to dialysis., Materials and Methods: Z stents were placed in 19 patients, (ages 26-72 years) with severe symptomatic obstructions of the superior or inferior venae cavae and their large branches and portal vein caused by surgical or catheter injury (n = 8), fibrosis (n = 5), cirrhosis (n = 3), Budd-Chiari syndrome (n = 2), and extrinsic compression (n = 1). Fourteen patients underwent stent placement primarily, five after local urokinase infusion for superimposed thrombosis. Follow-up was performed with ultrasound and venography., Results: Venous congestive symptoms quickly resolved in all patients after stent placement. The follow-up period was from 1 to 94 months. Twelve patients have died during follow-up from 1 to 37 months although all remained asymptomatic until death. Six patients remain alive, asymptomatic, with patent stents, and with follow-up from 24 to 94 months. Primary patency was 83%, and secondary patency was 100%. One patient with a patent stent at 12 months was lost to follow-up. No stent migrations, perforations, infections, or significant complications occurred., Conclusion: Benign central venous obstructions are effectively treated by the placement of self-expandable Z stents. Placed percutaneously into obstructive lesions with a minimum risk, these stents offer long-term durability and patency.

We describe a case of a 59-year-old patient with intrahepatic arterioportal fistula secondary to blunt trauma sustained by a motor vehicle accident 36 years earlier. The fistula was demonstrated 36 years after the accident in a clinical work-up for diarrhea of 1 month's duration, using contrast enhanced three-dimensional breath-hold MRA. A communication between the dilated portal vein and dilated hepatic artery was shown at the level of distal branches. After subsequent demonstration by conventional angiography, the fistula was embolized using steel coils. Following the therapeutic intervention, the patient's diarrhea ceased.

Background: Iodized-oil computed tomography (CT) is useful for the diagnosis of hepatocellular carcinoma, but there may be false-positive results in patients who have undergone some percutaneous transhepatic interventional procedures. The purpose of the present study was to verify the correlation between subsegmental hepatic parenchymal retention of iodized oil on CT and the arterioportal shunt caused by liver biopsy., Methods: Iodized-oil CT scans were reviewed in 24 patients with hepatic tumors who had liver biopsy and subsequent iodized oil chemoembolization. Iodized oil chemoembolization was performed shortly after biopsy (1-10 days; mean = 2.6 days). The results were correlated with hepatic arteriography, with a special emphasis on the presence of hepatic arterioportal shunt., Results: Wedge-shaped subsegmental retention of iodized oil along or adjacent to the biopsy needle path was observed in iodized-oil CT in 17 of the 24 patients. In three patients, there was subsegmental enhancement on prebiopsy helical dynamic liver CT at the same area of iodized oil retention, and therefore iodized oil retention was considered to be due to hepatocellular carcinoma. In the remaining 13 (54%) patients, the peripheral iodized oil retention was considered to be due to biopsy-induced arterioportal shunt. In all these patients, arterioportal shunt was confirmed by hepatic arteriography., Conclusion: Wedge-shaped hepatic parenchymal retention of iodized oil is commonly observed in iodized-oil CT due to biopsy-induced arterioportal shunt, and this appearance should not be confused with a hepatocellular carcinoma.

Objective: To investigate the possibility of applying autogeneous peritoneal tube in the portal vein reconstruction., Methods: Twenty-seven small healthy domestic pigs were used. A section of portal vein about 2.5-3.0 cm long was resected and replaced by autogenous peritoneum tube (APT), autogenous vein and decron artificial blood vessel respectively. Patency and pathological changes of the APT grafts were investigated after the replacement., Results: Twenty-four animals survived the operation. In the early stage of replacement, the APTs were dilated slightly, the cannual patency rate (CPR) was 12/13(92.3%). 3 months later, the fibrous hypertrophy and thickness were observed. The CPR was 8/10(80%). 2 more months later, the CPR was 4/6(66.7%), which was quite similar to that reconstructed by autogeneous vein. All three pigs which were replaced by decron blood vessel were dead within three to five hours after operation because of portal thrombi found by autopsy. After 12 weeks of replacement, scanning electron microscopy revealed that APT grafts were covered with a layer of endothelial-like cells. Endothelial cells and mesothelial cells were seen under transmitted electronic microscopy., Conclusions: The long-term patency of the APTs were slightly lower than that of the autogenous vein, peritoneum might be a perspective self-material for portal vein reconstruction and worth further studying.

The authors report a case of liver trauma with hematoma complicated with a pseudoaneurysm. The latter was suspected on day 7, with a monophasic helical CT and was demonstrated with helical CT angiography. Arteriography confirmed the lesion and showed an associated arteriovenous fistula, unsuspected on helical CT. The pseudoaneurysm was managed with transcatheter embolization, completed with percutaneous embolization because of vascular spasm.

Purpose: Our goal was to verify the correlation between the arterioportal shunt caused by liver biopsy injury and wedge-shaped early transient subsegmental parenchymal enhancement (TSPE) of the liver during helical dynamic CT., Method: Twenty-one consecutive patients with suspected hepatic tumor underwent percutaneous needle biopsy. Helical dynamic CT scans at arterial, portal venous, and delayed phases were obtained before and after biopsy. CT images were reviewed for the presence of TSPE during the arterial phase of dynamic CT. Hepatic arteriograms were obtained in all patients and reviewed for the presence of arterioportal shunt., Results: Wedge-shaped TSPE was observed on postbiopsy CT in 8 (38%) of the 21 patients along the needle path. In all of these patients subsegmental arterioportal shunt was confirmed by hepatic angiograms., Conclusion: Wedge-shaped TSPE is commonly observed along the biopsy needle path and is due to arterioportal shunt caused by biopsy.

Three cases of intraperitoneal bleeding from extrahepatic portal vein laceration were observed in a series of 104 patients with TIPS. In one patient, bleeding continued after Wallstent placement and the patient died during an emergency laparotomy. Bleeding was stopped in the other two patients by using a stent graft rather than a regular stent. One shunt remained patent and outflow stenosis developed in 3 months. The other shunt thrombosed in 5 months. Both shunts were fully reopened.

Background: The purpose of this study was to find an effective and precise surgical procedure to cope with the major vascular injuries that might be encountered during hepato-biliary and pancreatic surgery., Materials and Methods: Among the 220 cases of hepato-biliary and pancreatic surgery from 1991 to 1995 in our department, 8 patients who sustained 13 different instances of vascular injury were reviewed retrospectively., Results: Five injuries occurred in the portal vein (PV), 4 in the hepatic artery (HA), and 2 in the inferior vena cava (IVC). The repair procedures consisted of 2 direct closures, 2 resections of the injured sites followed by the end to end anastomosis, 2 autologous venous grafts and 1 artificial vascular graft implantation, and 2 diversions of the arterial bloodflow of the middle colic artery and the gastroepiploic artery to the injured HA. The reconstructed vessels showed postoperative obstructions in 2 cases, in which artificial vascular graft implantation and direct closure were used for the reconstruction., Conclusions: Based on the above findings, the use of an artificial graft and a direct closure all contributed to the early postoperative obstruction of the reconstructed vessels. However, a diversion of the arterial bloodflow to the injured hepatic arteries was found to maintain a good postoperative patency in these cases.

The trauma surgeon encounters hepatic arterial injury only rarely. The majority of these injuries appear to be due to penetrating trauma, with few cases of hepatic artery injury secondary to blunt trauma reported in the literature. In the setting of blunt trauma, hepatic artery injury is generally accompanied by other severe injuries, and mortality remains high. We present two patients who sustained an avulsion of the left hepatic artery complicating severe blunt trauma to the abdomen and pelvis. Surgical management included ligation of the involved vessel. Both patients required management in the intensive care unit, one eventually succumbing to multisystem organ failure. The cases highlight management principles in these injuries, and treatment options are discussed.

A 73 year old lady developed abdominal pain, anaemia and obstructive jaundice 18 days after a road traffic accident. The jaundice was due to compression of the biliary confluence by a haematoma which was caused by a laceration of the left portal vein. The portal vein was repaired (lateral venorrhaphy) and post-operative recovery was uncomplicated. Porta hepatis injuries are difficult to diagnose and delayed presentation is not uncommon. Significant morbidity and mortality may ensue if aggressive management is not adopted.

Intrahepatic arterioportal fistulas may occur after blunt abdominal trauma and lead to severe portal hypertension, which can be prevented by early diagnosis and treatment. The diagnostic workup of an asymptomatic young male with elevated transaminases revealed an arterioportal fistula secondary to a traumatic liver rupture during childhood, 23 yr earlier. Three years after initial diagnosis, the patient presented with gastrointestinal hemorrhage. Progression of portal hypertension had resulted in esophageal varices and ascites. After ligation of the right hepatic artery, the esophageal varices and ascites disappeared. Twelve months after surgery, the patient is asymptomatic without any signs of liver decompensation or recurrence of gastrointestinal hemorrhage. Our case demonstrates that rapid progression of portal hypertension with severe complication can occur in patients with arterioportal fistula after a long-lasting asymptomatic course of 23 yr. Simultaneous chronic hepatitis C may have a contributory role.

Portal vein thrombosis complicating a trauma is rare. We report a case of portal vein thrombosis associated with esophageal rupture after a blast injury due to the explosion of a pressurized nitrogen bottle. Portal vein thrombosis was discovered during oesophageal reconstruction, 70 days after the initial injury. A favorable outcome was observed.

We report the case of a posttraumatic arteriovenous fistula between the right hepatic artery and the right portal vein remarkable in that clinical manifestations, including portal hypertension and mesenteric insufficiency findings, appeared latently and progressively worsened. This hepatoportal fistula was diagnosed by Doppler sonography and successfully treated by transcatheter embolization of feeding hepatic artery branch with steel coils. We emphasize the interest of pulsed Doppler in the diagnosis of hepatoportal fistula, in assessment of hemodynamic changes related to the fistula and in follow-up after treatment.

Objective: Injuries to the portal triad are a rare and complex challenge in trauma surgery. The purpose of this review is to better characterize the incidence, lethality, and successful management schemes used to treat these injuries., Design: A retrospective review of the experience of eight academic level I trauma centers over a combined 62 years., Results: A retrospective review of the experience of eight anatomical structures of the portal hepatis: 118 injuries to the anatomical structures of the portal hepatis: 55 extrahepatic portal vein injuries, 28 extrahepatic arterial injuries, and 35 injuries to the extrahepatic biliary tree. Sixty-nine percent of the injuries were by penetrating mechanism and 31% were by blunt mechanism. All patients had associated injuries with a mean Injury Severity Score of 34 in blunt trauma patients. Overall mortality was 51%, rising to 80% in patients with combination injuries. Sixty-six percent of deaths occurred in the operating room, primarily from exsanguination; 18% of deaths occurred within 48 hours of injury from refractory shock, coagulopathy, or cardiac arrest; 16% occurred late. Ten percent of patients undergoing portal vein ligation survived, compared to 58% managed by primary repair. Survival after hepatic artery ligation was 42%, compared to 14% after primary repair. Survival after biliary-enteric anastomosis as treatment of extrahepatic bile duct injury was 89%, compared to 50% after primary repair and 100% after ligation of lobar bile duct injuries. Missed bile duct injuries had a high (75%) severe complication rate., Conclusions: Injuries to the anatomical structures of the portal triad are rare and often lethal. Intraoperative exsanguination is the primary cause of death, and hemorrhage control should be the first priority. Bile duct injuries should be identified by intraoperative cholangiography and repaired primarily or by enteric anastomosis; lobar bile ducts can be managed by ligation.

A 2 1/2-year-old girl underwent a living-related liver transplantation for biliary atresia, following which four percutaneous liver biopsies were performed uneventfully during her hospital stay for the evaluation of recurrent rejection. Her condition improved without any complications, and she was discharged from hospital in a stable condition on postoperative day (POD) 51. However, 3 months later she was readmitted with marked ascites and a moderate elevation of her liver function tests. A color Doppler ultrasound (US) confirmed hepatofugal portal blood flow, and selective celiac arteriography demonstrated an intrahepatic arterioportal (A-P) fistula. An attempt to embolize the fistula failed and a surgical approach was attempted without success. The patient died from irreversible liver failure on POD 152. A review of the previous histologic analyses revealed that arterial components were present in the fourth biopsy specimen; for this reason it was hypothesized that this procedure may have led to the development of the A-P fistula.

We report a patient on warfarin prophylaxis who had major intraperitoneal hemorrhage 17 days following percutaneous liver biopsy (PLBx). Selective hepatic angiography revealed a pseudoaneurysm of a branch of the right hepatic artery, associated with an arterio-portal venous fistula. Ultrasound with Doppler studies showed flow through the pseudoaneurysm. Embolization with platinum micro-coils resulted in cessation of flow through the pseudoaneurysm, and closure of the arterio-portal venous fistula. Anticoagulation was then resumed without recurrent bleeding. Pseudoaneurysms and arteriovenous fistulas may be mechanisms by which delayed bleeding occurs after PLBx. Doppler ultrasonography and hepatic angiography are useful in the evaluation and management of this event.

A 42-year old man with a penetrating laceration of the right liver lobe with complete transection of the right hepatic artery, right portal vein and left hepatic duct presented with minimal clinical signs and haemorrhage. Selective coeliac angiography and computer tomography (CT) revealed the vascular injuries. Forty-three hours after hospital admission the patient underwent right hepatectomy and bilioenteric anastomosis of the transected left bile duct to a Roux-en-Y segment of upper jejunum without stenting. Abscess formation and thrombosis of the inferior caval vein complicated recovery, but the patient was discharged from the hospital six weeks after this major hepatic injury, which usually presents with an exsanguinating massive haemorrhage.

The incidence of arterioportal fistulas (APFs) following percutaneous transhepatic procedures is quoted to be between 5 and 20%; the majority of them remain clinically asymptomatic and do not require any treatment. However, an APF large enough to cause a reversal of blood flow in the portal vein is rather uncommon especially in a transplanted liver where it may have potentially hazardous consequences. We report on a 21-year-old female patient who received a liver transplantation on account of a Budd-Chiari syndrome. Following a liver biopsy, a large APF developed in the right lobe of the graft. Despite the known risks associated with catheterization of graft vessels, a successful coil occlusion of the fistula could be carried out thus rendering surgery unnecessary.

It is generally accepted that the transjugular intrahepatic portosystemic shunt (TIPS) procedure has lower morbidity and mortality rates than those of surgical shunting. Nevertheless, complications occur. The authors have reviewed their experience and that of other institutions in compiling an extensive list of complications. Complications are categorized according to those related to transhepatic needle puncture, transvenous access to the portal vein, portal venous cannulation, the stent, the puncture site, portosystemic shunting, and contrast material. Excluding hepatic encephalopathy and delayed stenosis or occlusion of the shunt, an overall complication rate of less than 10% can be expected for TIPS. The prevalence of aggravated or new cases of encephalopathy is 5%-35%, and over the long term, up to 75% of shunts may undergo stenosis or occlusion. The direct procedural mortality rate is less than 2%, and the 30-day mortality rate ranges from 4% to 45%, depending on several factors. The role to which TIPS is relegated will be influenced by the long-term success rate in the prevention of recurrent variceal hemorrhage.

Fourteen cases of vascular injury during pancreatobiliary surgery have been treated at our institution. The patients' mean age was 49 years, and nine were males. Six operations were performed for chronic pancreatitis, six for cancer, and two for an inflammatory process. Operations included 11 pancreatic resections and one laparoscopic cholecystectomy, one sphincteroplasty, and one pseudocyst drainage. Vessels injured included the portal vein (7), superior mesenteric vein (6), superior mesenteric artery (3), hepatic arteries (4), splenic vein (3). Six patients experienced more than one vascular injury. In all but one case, the injury was recognized and repaired during the initial operation. Primary repair was possible in seven cases. Six cases utilized autogenous tissue for repair. The one unrecognized injury was a right hepatic artery ligation, and a delayed repair was not possible. Follow-up demonstrated two occlusions, one following a portal vein repair without clinical sequela and a superior mesenteric artery repair which resulted in a small bowel stricture. The one unrecognized hepatic artery injury resulted in necrosis of the proximal common hepatic duct. Vascular injury following pancreatobiliary injury tends to occur in the presence of pancreatitis or cancer with its associated dense adhesions and inflammatory process. The variable anatomy of this area contributes to vascular injuries. Immediate recognition of the injury and repair appears to yield excellent results.

The cause of liver infarction previously reported [1-4] are mainly due to occlusion of hepatic artery. Herein, we report the case of liver infarction resulted from simultaneous occlusion of hepatic artery and portal vein due to trauma and therapeutic transcatheter arterial embolization (TAE), and we followed up the infarcted lesion with computed tomography (CT), ultra sonography (US) and magnetic resonance imaging (MR imaging) until it disappeared.

Intrahepatic arterioportal fistulas (APF) are uncommon complications following hepatic trauma. Large fistulas can result in portal hypertension and cardiovascular compromise. A 46-year-old patient is described who presented with portal hypertension, variceal bleeding, and high output cardiac failure due to a large intrahepatic APF. Surgical closure of the APF by hepatic resection successfully resolved the portal hypertension, prevented further variceal hemorrhage, and restored normal cardiovascular function.

Objective: To report our experience in the management of accidental injuries to the structures of the hepatoduodenal ligament., Design: Retrospective study of medical records., Setting: University department of surgery., Subjects: 8 patients admitted after accidents (road traffic accidents, n = 4; falls, n = 2; and gunshot and stab wounds, n = 1 each) who were found at laparotomy to have injuries of the structures of the hepatoduodenal ligament., Interventions: Laparotomy in all cases., Main Outcome Measures: Morbidity and mortality., Results: One patient died (13%) of multiple organ failure after a gunshot wound of the portal vein, liver, inferior vena cava, right renal artery, and right kidney. All patients had associated injuries. There were 3 complete transsections of the common bile duct, two of which were treated by Roux-en-Y cholecystojejunostomy and one by choledochojejunostomy over a T tube. Two lacerations of the common hepatic duct were treated by T tube choledochostomy. All injuries to blood vessels were sutured. Only one patient survived without any complications, and two developed cholangitis after cholecystojejunostomy that required further operation 5 and 16 months after the initial operation., Conclusions: Blunt injuries to the hepatoduodenal ligament are easily overlooked, leading to delayed morbidity. Complete transsections of the bile duct are best managed by choledochojejunostomy with a Roux-en-Y loop; T tube choledochostomy is usually sufficient when treating small partial lesions of lobar bile ducts; and most non-circumferential vascular lesions are best treated by suture.

Between January 1987 and September 1991, 68 severely traumatized patients underwent emergency laparotomy because of blunt abdominal trauma. Intraoperatively, 54.4% of the patients had a major injury to one organ, 23.5% had injuries to two organs, 16.2% had injuries to three organs and 5.9% to four or more organs. Additionally, in 11.8% of these cases (n = 8) a major vascular injury (portal vein n = 5, vena cava n = 2, mesenteric root n = 1) was found. Injuries to the portal vein were always associated with complete rupture of the pancreas, requiring distal pancreatic resection in four cases and a duodenum preserving resection of the head of the pancreas in one. In two of these patients the portal vein had to be reconstructed with a Goretex prosthetic graft. Mortality was 14.7% for the whole group (n = 68) and 0% for patients with additional portal venous injuries.

Paracentesis is an important and commonly performed procedure in patients with ascites. It is a safe procedure when carried out in the midline below the umbilicus, with a complication rate of less than 1%. We report an instance in which a large midline varix was entered during paracentesis. The utility of different imaging techniques in detecting such anomalies in the portal hypertensive patient with portal hypertension and ascites is discussed. The approach and management of this complication are outlined.

Between 1/87 and 7/90 54 severely traumatized patients underwent emergency laparotomy because of blunt abdominal trauma. In 55.5% of the cases one intraabdominal organ, in 20.4% two organs, in 16.6% three and in 7.4% four or more organs were injured. Additionally in 14.8% of these cases (n = 8) a major vascular injury (portal vein n = 5, vena cava n = 2, mesenteric root n = 1) was found intraoperatively. Injuries of the portal vein were always associated with complete rupture of the pancreas, requiring left pancreatic resection in 4 cases and a duodenum preserving resection of the pancreas head in one case. In 2 of these patients the portal vein had to be reconstructed with a prosthesis. Lethality was 9.3% for the whole group (n = 54) and 25% for the patients (n = 8) with additional vascular injuries.

Concomitant injury to the large vessels and other abdominal organs are related to the category of severe injuries with high postoperative mortality rates. The authors discuss 21 patients with the trauma, 9 of them with injury to the inferior vena cava. Early operation, adequate compensation for the blood loss, and co-operation with angiosurgeons will improve the number of favourable outcomes.

We reviewed the management and clinical course of 21 patients with extrahepatic injuries to the portal triad seen over the past 11 years at a Level I trauma center. These represented only 0.21% of patients with multiple trauma admitted during this time. Portal triad injury was never specifically diagnosed preoperatively. Extrahepatic bile duct injury occurred in 4 patients, portal vein injury in 14, and hepatic artery injury in 7; 3 patients had combined injuries. Eleven patients (52%) died, all due to uncontrolled hemorrhage from either an injured portal vein or associated intra-abdominal injuries. Management of the bile duct injuries included drainage alone, bile duct ligation, and Roux-Y hepaticojejunostomy. Survivors of portal vein injury were managed with lateral venorrhaphy. Ligation of the hepatic artery appeared to be optimal for injuries incurred by this vessel. Complications necessitating reoperation or percutaneous drainage procedures were encountered in 8 of 10 surviving patients (80%). Injuries to the portal triad are uncommon, difficult to diagnose, and technically challenging. Mortality is most directly related to uncontrolled intraabdominal hemorrhage, and salvage requires rapid control of bleeding as the first treatment priority.

Anatomic distortion and displacement of hilar structures due to liver lobe atrophy and hypertrophy occasionally complicates the surgical approach for biliary stricture repair. Benign biliary stricture following hepatic resection deserves special consideration in this regard because the inevitable hypertrophy of the residual liver causes marked rotation and displacement of the hepatic hilum that if not anticipated may render exposure for repair difficult and dangerous. Three patients with biliary stricture after hepatectomy illustrate the influence of hepatic regeneration on attempts at subsequent stricture repair. Following left hepatectomy, hypertrophy of the right and caudate lobes causes an anteromedial rotation and displacement of the portal structures. After right hepatectomy, the rotation is posterolateral, and a thoracoabdominal approach may be necessary for adequate exposure. Radiographs obtained in the standard anteroposterior projection may be deceptive, and lateral views are recommended to aid in operative planning.

Intrahepatic arterioportal fistula (APF) was found in five out of 65 consecutive patients following blunt hepatic trauma. In four patients the fistula was located peripherally and the blood flow was small. These fistulas closed spontaneously within 3 months. However, a centrally located fistula with early visualization of the trunk of the portal vein persisted in one patient and necessitated transcatheter embolization. The APF in this patient caused portal dilatation which was detectable by CT scan. We conclude that spontaneous closure can be expected when an APF is located peripherally and the shunt flow is small, while centrally located APF with large flow require active treatment, preferably by transcatheter embolization. An APF detectable by CT scan suggests the need of intervention.

An interesting and rare case of traumatic superior mesenteric artery-to-portal vein arteriovenous fistula is presented. Initial operative control of the bleeding superior mesenteric artery injury required ligation of the superior mesenteric artery at its origin to prevent exsanguination in an extremely unstable patient with multiple injuries. Early postoperative visceral arteriography documented ligation of the superior mesenteric artery with a proximal superior mesenteric artery-to-portal vein arteriovenous fistula. Percutaneous catheter embolization of the arteriovenous fistula was undertaken successfully at this time. Superior mesenteric artery ligation was surprisingly well tolerated. Major arterioportal fistulas require treatment to prevent long-term complications of intestinal ischemia, portal hypertension, and cirrhosis. Although traditional treatment involves ligation of the arteriovenous fistula and arterial bypass, percutaneous embolization is becoming a viable alternative. Arteriography remains the cornerstone of diagnosis and treatment planning.

The authors observed 24 patients with wounds of the liver and injuries of extrahepatic bile ducts and vessels. In 14 patients with stab-cut injuries of the liver catgut sutures were used, in 3 patients catgut sutures with suturing the portion of the greater omentum on the pedicle. The microsurgery technique was used in order to reestablish the integrity of the hepatic artery, portal vein and common bile duct. Three patients died.

With the increasing number of traumatic injuries being seen in emergency departments, physicians must be aware of the less common and less obvious types of serious injury. Portal vein injury is serious (death rate 50%) and may be diagnosed only at laparotomy. Fortunately this injury is rare. Its management can be difficult, but an awareness of the possible methods of treatment could be life-saving. The authors report their experience with this injury and survey the literature on the subject.

Complications from barium enema are rare (0.035 per cent). A patient with venous intravasation during barium enema complicated by pylephlebitis and portal vein obstruction is the tenth to be reported on, the fourth to survive. This accident was associated with colon disease in eight of the patients studied, five of whom had diverticular disease.