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Background Anomalies of the portal venous system can be congenital or acquired, the latter being related to spontaneous thrombosis or iatrogenic alterations such as complications of perinatal catheterization of the umbilical vein. These conditions can be clinically silent for years and then manifest abruptly causing severe clinical emergencies. Case presentation This case report describes the diagnosis and interventional management of a singular abnormality in the portal venous system of an 8-year-old female that led to severe portal hypertension and acute variceal bleeding. Peculiar imaging findings were not pathognomonic for any of the known congenital and acquired portal vein anomalies: absence of a normal extrahepatic portal vein; splenic and mesenteric veins merging into a dilated left gastric vein; presence of an aberrant mesenteric venous collateral with a stenotic connection with the intrahepatic right portal branch; and absence of porto-systemic shunt. The case was successfully managed with percutaneous transhepatic portography and angioplasty. Conclusions Prompt non-invasive imaging characterization allowed to understand the singular vascular abnormality and mini-invasive interventional radiology management resolved portal hypertension and variceal bleeding.

BACKGROUND Minimally invasive distal pancreatectomy (MIDP) is increasingly performed worldwide; however, the surgical anatomy required to safely perform MIDP has not yet been fully considered. This review evaluated the literature concerning peripancreatic vascular anatomy, which is considered important to conduct safe MIDP. METHODS A database search of PubMed and Ichushi (Japanese) was conducted. Qualified studies investigating the anatomical variations of peripancreatic vessels related to MIDP were evaluated using SIGN methodology. RESULTS Of 701 articles yielded by our search strategy, 76 articles were assessed in this systematic review. The important vascular anatomy required to recognize MIDP included the pancreatic parenchymal coverage on the root and the running course of the splenic artery, branching patterns of the splenic artery, confluence positions of the left gastric vein and the inferior mesenteric vein, forms of pancreatic veins including the centro-inferior pancreatic vein, characteristics of the left renal vein, and collateral routes perfusing the spleen following Warshaw's technique. Very few articles evaluating the relationship between the anatomical variations and surgical outcomes of MIDP were found. CONCLUSIONS The precise knowledge of peripancreatic vessels is important to adequately complete MIDP. More detailed anatomic analyses and descriptions will benefit surgeons and their patients who are facing these operations.

The oesophagus is a conduit between the pharynx and stomach. It may be described as consisting of cervical, thoracic and abdominal parts. The oesophagus is lined throughout by stratified squamous epithelium. The blood supply of the oesophagus is derived from branches of the inferior thyroid artery, multiple small branches arising directly from the thoracic aorta and from oesophageal branches of the left gastric artery. At the lower end of the oesophagus, within the mucosa and submucosa, is an important porta-systemic venous anastomosis between oesophageal tributaries of the left gastric vein and oesophageal tributaries of the azygos vein. This anastomosis assumes great clinical significance in portal hypertension. Both at its proximal and distal ends, the oesophagus possesses a sophisticated sphincter mechanism. The proximal sphincter acts to regulate and control entry of food and liquid into the oesophagus. At the distal end, there is no demonstrable anatomical sphincter. Nevertheless, a number of factors acting in concert provide a very efficient ‘physiological’ sphincter mechanism that prevents reflux of acidic gastric contents into the oesophagus. The oesophagus is susceptible to a number of pathological conditions, both congenital and acquired, which may require surgical management. These include congenital oesophageal atresia, functional disorders such as achalasia cardia and hiatus hernia, corrosive strictures, traumatic oesophageal perforation and oesophageal cancer. This article describes, in detail, those aspects of the topographical anatomy of the oesophagus which are of particular relevance to clinical diagnosis and surgical management.

Occlusion of the splenic vein, without occlusion of the portal vein, can lead to a localized, regional splenic hypertension, referred as sinistral or left-sided portal hypertension in the human radiology literature. In people, may cause gastrointestinal hemorrhages from the esophageal and gastric varices and the primary pathology usually includes pancreatitis and pancreatic neoplasms. The final diagnosis of localized splenic hypertension necessitates accompanying normal liver functions and a patent extrahepatic portal vein. Following obstruction, the resultant elevated splenic bed venous pressure causes formation of collateral routes, the extent of which depends upon the level and degree of obstruction. In this retrospective descriptive study, authors assessed the collateral pathways in dogs with isolated splenic vein occlusion and possible regional splenic vein hypertension. Out of the 46 patients initially recruited, 25 were excluded due to the presence of concomitant portal thrombosis and direct/indirect CT signs of portal hypertension. The remaining 21 dogs had clinicopathological tests suggesting normal liver function. The causes of obstruction identified included splenic pedicle torsion, tumoral splenic vein invasion, and splenic vein thrombosis. Four of 21 dogs with isolated splenic vein obstruction showed collateral pathways through the left gastroepiploic vein (4/4), left gastric vein (2/4), and splenogonadal vein (1/4). The diagnosis of isolated, regional splenic hypertension should be based on clinical, biochemical, and radiological evaluation. Computed tomography is an excellent tool to assess the collateral patterns and to determine the underlying cause.

This study investigated the morphologic changes of portal cavernoma in children with extrahepatic portal venous obstruction and explored the relationship with prognosis.From February 2008 to October 2017, there were 107 patients with cavernous transformation of the portal vein admitted to our hospital. Rex shunts were performed in 99 cases, Warren shunts in 7 cases, and laparoscopic splenic vessel ligation in 1 case. Intraoperative superior mesenteric venography was used to determine the structure of the portal venous system. According to the morphologic features of the portal vein shown by portal venography, groups were assigned as follows: patients with the cotton form of portal cavernoma; patients with visible collateral veins of portal cavernoma; patients with and without a visible left gastric vein; and patients with and without a clearly visible intrahepatic portal vein. The preoperative and postoperative portal pressure, preoperative incidence of esophageal varices, time at onset, incidence of postoperative rebleeding, preoperative and postoperative size of the spleen, and age at time of operation were compared between these groups.The preoperative incidence of esophageal varices, time at onset, postoperative size of spleen, and age at time of operation were significantly lower in the group with the cotton form than in those with visible collateral veins (P .05). There was a significant correlation between the visible left gastric vein and esophageal varices (P = .002). The time at onset, preoperative and postoperative size of the spleen, and age at time of operation were markedly lower in the group with a good visible intrahepatic portal vein than in those without a clearly visible intrahepatic portal vein (P .05). The visible left gastric vein was notably associated with the performance of a gastroportal shunt (P = .000), and the group with a visible left gastric vein had a higher ratio of children undergoing a gastroportal shunt.The cotton form, an early-stage manifestation of cavernous transformation of the portal vein, typically occurs in younger children with a shorter time to onset. Children with the cotton form of portal cavernoma typically have a better prognosis after Rex shunt.

Portal hypertension is one of the most important causes of morbidity and mortality in cirrhotic patients. A color Doppler evaluation of the left gastric vein (LGV) has proven utility in the prediction of esophageal varices and variceal bleeding in patients with portal hypertension. The purpose of this review is to discuss the ultrasound evaluation, imaging findings, and clinical application of Doppler ultrasound in the assessment of the LGV. Knowledge of the color Doppler technique and imaging findings of the LGV may help clinicians improve the monitoring of portal hypertension and predict patients with a high risk of esophageal varices.

The aim of this study was to explore predictive factors for portal or splenic vein thrombosis (VT) that might cause serious problems after distal pancreatectomy (DP). A total of 230 patients who underwent DP between 2008 and 2017 were retrospectively reviewed to identify predictive factors for portal or splenic VT. Ultimately, 164 patients were analyzed. Portal or splenic VT was significantly correlated with age

Combined portal vein (PV) resection is performed for pancreatic head cancer to achieve clear resection margins. This can be complicated by the formation of varices due to sinistral portal hypertension after pancreaticoduodenectomy (PD) with combined PV resection. However, clinical strategies to prevent varices formation due to sinistral portal hypertension remain controversial. Moreover, the critical vein among splenic vein (SPV), inferior mesenteric vein, left gastric vein, or middle colonic vein requiring preservation to prevent the development of varices remains unclear.We retrospectively analyzed patients with pancreatic cancer who underwent PD with combined PV resection over 18 years at our institution. Varices were evaluated using enhanced computed tomography (CT) and endoscopy. Preoperative types of porto-mesenterico-splenic confluence, venous drainage, and venous resection types were determined by operative records and CT findings.Of the 108 subjects, the incidence of postoperative varices was observed in 24.1% of cases over 5.6 months. These varices were classified into five types based on location, as pancreaticojejunostomy anastomotic (11.5%), gastrojejunostomy anastomotic (11.5%), esophageal (11.5%), splenic hilar-gastric (23.1%), and right colonic (65.4%) varices. No case of variceal bleeding occurred. Multivariate analysis showed SPV ligation as the greatest risk factor of varices (P 0.001), with a higher incidence of left-sided varices in patients with all the SPV venous drainage sacrificed (60%) than in the others (16.7%). Therefore, sacrificing all the SPV venous drainage was the only independent risk factor of varices (P = 0.049).Preservation of SPV venous drainage should be considered during SPV ligation to prevent post-PD varices.

Aim. To present the first Russian experience in the management of portal hypertension of various etiology by creating a selective portosystemic shunt between left gastric vein and inferior vena cava (leftgastric vein caval bypass).Material and methods. “Left gastric vein to inferior vena cava” bypass was performed in 6 patients with portal hypertension: 4 men and 2 women (mean age 40.4 years). The follow-up period ranged from 10 to 36 months.Results. “Left gastric vein to inferior vena cava” bypass was effective in the management of portal hypertension and its complications in 5 out of 6 patients. Complete eradication of esophagogastric varices and no variceal bleeding were observed in long-term period. These patients demonstrated no clinical or laboratory signs of hepatic encephalopathy and/or hepatic failure within the follow-up. One patient with thrombophilia and extrahepatic portal vein obstruction (factor V Leiden mutation) had thrombosis of the shunt and recurrent variceal bleeding in 6 months after surgery because of unauthorized abandonment of the anticoagulation.Conclusion. “Left gastric vein to inferior vena cava” bypass is an effective procedure for prevention of variceal bleeding (or recurrence) in patients with portal hypertension. The limitation of this technique is insufficient diameter of left gastric vein in many patients. This procedure has certain pathophysiological advantages over other types of portosystemic anastomoses due to highly selective nature of the shunt. Thus, this approach should be introduced into surgical treatment of these patients.

BACKGROUND: The left gastric vein (LGV) plays an important role in laparoscopic radical gastrectomy (LRG). However, the anatomy of the LGV is complicated with significant variation, and it is often damaged and bleeding during LRG. The purpose of this study was to observe and analyze the anatomic types of the LGV in patients undergoing LRG and to explore its clinical significance. METHODS: A total of 217 patients who underwent LRG from June 2016 to December 2020 were included. LGVs were divided into four types according to the relationship between the LGV and peripheral arteries [celiac artery (CA)/common hepatic artery (CHA)/splenic artery (SA)] and the pancreas during LRG. If a LGV was damaged during surgery (resulting in bleeding), it was included in the bleeding group. Non-bleeding groups were included if there was no impairment to the LGV. RESULTS: A total of four types of LGVs were observed, of which type I was the most prevalent, accounting for 58.8% (n=121). In 21 patients (9.7%), the LGV was injured and hemorrhagic during LRG; and the type IV LGV injury bleeding rate was as high as 41.7% (5/12). Univariate analysis revealed that the extent of lymph node dissection (LND), pathological stage, tumor (T) stage, and type of LGV were significantly associated with LGV injury and hemorrhage (P

Background Resection of the porto-mesenterico-splenic confluence is at times necessary during pancreatoduodenectomy with portal vein resection for pancreatic cancer. Although splenic vein ligation can cause sinistral portal hypertension, the incidence of clinically relevant sinistral portal hypertension remains unknown, and the roles of the preservation of potential collateral veins and splenic vein reconstruction are controversial. Methods Patients with pancreatic cancer who underwent pancreatoduodenectomy with porto-mesenterico-splenic confluence resection were assessed for incidence of development of varices by computed tomography at 6 months after pancreatoduodenectomy. We evaluated the risk factors for sinistral portal hypertension and the impact of splenic vein reconstruction on sinistral portal hypertension. Results Of the 118 patients who underwent pancreatoduodenectomy with porto-mesenterico-splenic confluence resection, 31 (26%) underwent splenic vein reconstruction, 44 patients (37%) developed gastroesophageal varices, and 5 (11%) experienced varix rupture. Sacrifice of all 3 potential collateral veins (what we refer to as the critical veins: left gastric vein, middle colic vein, and superior right colic vein arcade) and absence of any spontaneous splenorenal shunt had a substantial impact on formation of varices. The risk of variceal formation could be stratified based on the number of preserved critical veins, and patent splenic vein reconstruction was associated with a decreased incidence of varices (60% versus 100%, P = .018) among the patients without preservation of the critical veins. In contrast, patients with multiple intact critical veins developed no varices, regardless of splenic vein reconstruction. Conclusions Sinistral portal hypertension is not uncommon after pancreatoduodenectomy with porto-mesenterico-splenic confluence resection, and the number of preserved critical veins helps to predict the risk of sinistral portal hypertension. Thus, the indication for splenic vein reconstruction should be tailored according to individual risk factors.

Background/aims We evaluated the usefulness of three-dimensional (3D) images for pancreatoduodenectomy (PD), including the classification of the bile duct and vascular arrangement, i.e., hepatic artery, inferior mesenteric vein (IMV) and left gastric vein (LGV). We evaluated the extent to which this simulation affected the perioperative outcomes of PD. Methods In all, 117 patients who underwent PD were divided into the without-3D (n = 53) and with-3D (n = 64) groups, and perioperative outcomes were compared. We evaluated the arrangement of the accessory bile duct and the hepatic artery (type I: the right hepatic artery arising from the superior mesenteric artery, type II: the left hepatic artery arising from the left gastric artery, type III: the most common pattern) and the confluence pattern of the LGV and the IMV [type i: portal vein (PV):splenic vein (SV), type ii: PV:superior mesenteric vein (SMV), type iii: SV:SV, and type iv: SV:SMV] between the two groups. Results Two patients had an accessory bile duct. The 3D images were classified as type I (n = 4), type II (n = 10), type III (n = 48) and other patterns (n = 2); type ii (n = 27) was the most frequent confluence pattern (p, Highlights • 3D simulation was particularly useful for understanding the bile duct anatomy. • 3D simulation was assumed to lead to a reduction in intraoperative blood loss. • 3D simulation was useful for preoperative assessment before pancreatoduodenectomy.

Introduction: Postoperative complications and worse prognosis still burden liver transplantations (LT) with complex portal vein thrombosis (CPVT). When an engorged left gastric vein (LGV) is present, the portal inflow is restorable with an anastomosis between the graft portal vein and the LGV of the recipient. We analyzed short- and long-term results of this procedure in 12 LT with CPVT. Methods: Between 2005 and 2019, 55 patients with CPVT underwent LT. We applied this technique in 12 patients. In six cases, we placed a vascular graft to obtain a tension-free structure. We evaluated patency, short- and long-term results. Results: No intraoperative complication was observed. The median duration of LT, blood transfusion, deceased donor age, and MELD score of the recipients were 7h, 1250mL, 72years, and 19. Seven patients were affected by hepatocellular carcinoma. No major complications or PVT recurrence were observed. One patient required a liver re-transplantation for primary non-functioning syndrome. The mean hospital stay was 20days. The actuarial patient survival was 85% with a mean FU of 4years. The two late deaths were due to hepatocellular carcinoma recurrence and sepsis for cholangitis. Conclusions: This technique in presence of both CPVT and engorged LGV is feasible and safe for patients, with good short- and long-term results.

Background and Aims We previously reported a new and combined EUS-guided intervention in a patient with portal hypertension, consisting of obliteration of varices and partial splenic embolization (PSE). Performing PSE is known to diminish the increase in portal venous pressure after endoscopic intervention for varices. The aim of this study was to use multidetector CT portal venography to evaluate the anatomy of esophagogastric varices (EGV) and the impact on hemodynamics of portosystemic collaterals shortly after the concomitant procedures. Methods From October 2019 to December 2020, 5 patients with cirrhosis and with clinically significant portal hypertension who had variceal bleeding history and hypersplenism were treated with combined endoscopic obliteration for varices and EUS-guided PSE. Multidetector CT portal venography was applied to assess the anatomic drainage patterns of the EGV, diameters of feeders and drainage vessels, and splenic embolization rate. Results Within 5 days after concomitant endoscopic interventions, we observed decreased mean diameters of the left gastric vein, short gastric vein, and azygos vein as .3 mm, 1.0 mm, and 5.2 mm compared with 3.11 mm, 7.1 mm, and 5.4 mm before the procedures, respectively. Patients showed increased white blood cells (mean count of 2.7 × 109/L before vs 5.8 × 109/L after) and platelets (mean count of 52.8 × 109/L before vs 95.8 × 109/L after). The mean splenic embolization rate was 64.5% (range, 28.8%-84.6%). Conclusions Our experience may illustrate an alternative technique of combining EUS-guided PSE with endoscopic therapy of varices to treat patients with portal hypertension.

Highlights • Portosystemic shunt follows portal hypertension associated with cirrhosis. • Portosystemic shunts are generally treated using non-invasive procedures. • However, surgical treatment is required for the cases refractory to non-invasive procedures. • Inokuchi shunt procedure closes portal blood outflow via coronary vein and improves liver function. • Hybrid laparoscopic approach is less invasive than an open surgery, with better postoperative cosmesis., Introduction Portosystemic shunts associated with portal hypertension are generally treated using non-invasive procedures, with open surgery required for refractory cases. Herein, we present a case of refractory pleural fluid and ascites associated with primary biliary cirrhosis (PBC), successfully treated using a hybrid laparoscopic Inokuchi shunt procedure. Case presentation The patient was a 74-year-old woman with a history of PBC, presenting with breathing difficulty. Computed tomography revealed massive pleural fluid and ascites and engorged coronary and azygos veins, indicative of a portosystemic circulation shunt and a 3-cm wide hepatocellular carcinoma (HCC) on liver segment 2. The Child-Pugh score was 11. With the portosystemic shunt outflow considered as the cause of pleural fluid and ascites; therefore, we proceeded with a hybrid laparoscopic selective Inokuchi shunt procedure and tumor enucleation. Laparoscopically, the greater omentum was divided for devascularization, a 7-cm right subcostal skin incision was made, and the abdomen was opened for HCC enucleation under direct vision. The left gastric vein was divided at its junction with the portal vein and connected to the vena cava using a left external iliac vein graft through the omental foramen. After this procedure, the pleural effusion and ascites disappeared, blood ammonium level decreased to normal, and Child-Pugh score decreased to 9. Discussion Using the Inokuchi shunt procedure, the portosystemic shunt, via the left gastric vein, was closed to increase portal blood flow and improve liver function. Conclusion As a less invasive procedure, hybrid laparoscopic approach should be considered for portosystemic shunt via the left gastric vein.

Portal hypertension is most commonly caused by chronic liver disease. As liver damage progresses, portal pressure gradually elevates and hemodynamics of the portal system gradually change. In normal liver, venous returns from visceral organs join the portal trunk and flow into the liver (hepatopetal blood flow). As portal pressure increases due to liver damage, congestion of some veins of the visceral organ occurs (blood flow to and from). Finally, the direction of some veins (the left gastric vein in particular) of the visceral organ change (hepatofugal blood flow) and develop as collateral veins (portosystemic shunt) to reduce portal pressure. Therefore, esophagogastric varices serve as drainage veins for the portal venous system to reduce the portal pressure. In chronic liver disease, as intrahepatic vascular resistance is increased (backward flow theory) and collateral veins develop, adequate portal hypertension is required to maintain portal flow into the liver through an increase of blood flow into the portal venous system (forward flow theory). Splanchnic and systemic arterial vasodilatations increase the blood flow into the portal venous system (hyperdynamic state) and lead to portal hypertension and collateral formation. Hyperdynamic state, especially around the spleen, is detected in patients with portal hypertension. The spleen is a regulatory organ that maintains portal flow into the liver. In this review, surgical treatment, interventional radiology, endoscopic treatment, and pharmacotherapy for portal hypertension (esophagogastric varices in particular) are described based on the portal hemodynamics using schema.

Portal hypertension is a key pathophysiology of chronic liver diseases typified with cirrhosis or noncirrhotic portal hypertension. The development of collateral vessels is a characteristic feature of impaired portal hemodynamics. The paraumbilical vein (PUV), left gastric vein (LGV), posterior gastric vein (PGV), short gastric vein (SGV), splenorenal shunt (SRS), and inferior mesenteric vein (IMV) are major collaterals, and there are some rare collaterals. The degree and hemodynamics of collateral may affect the portal venous circulation and may compensate for the balance between inflow and outflow volume of the liver. Additionally, the development of collateral shows a relation with the liver function reserve and clinical manifestations such as esophageal varices (EV), gastric varices, rectal varices and the other ectopic varices, hepatic encephalopathy, and prognosis. Furthermore, there may be an interrelationship in the development between different collaterals, showing additional influences on the clinical presentations. Thus, the assessment of collaterals may enhance the understanding of the underlying pathophysiology of the condition of patients with portal hypertension. This review article concluded that each collateral has a specific function depending on the anatomy and hemodynamics and is linked with the relative clinical presentation in patients with portal hypertension. Imaging modalities may be essential for the detection, grading and evaluation of the role of collaterals and may help to understand the pathophysiology of the patient condition. Further investigation in a large-scale study would elucidate the basic and clinical significance of collaterals in patients with portal hypertension and may provide information on how to manage them to improve the prognosis as well as quality of life.

Objective To re-evaluate the anatomy and classification of congenital extrahepatic portosystemic shunts entering the caudal vena cava at the level of the omental foramen. Material and methods A retrospective review of a consecutive series of dogs undergoing CT angiography as part of the diagnostic work-up for a congenital extrahepatic portosystemic shunt. Results In total, 53 dogs met the inclusion criteria revealing four anatomically distinct omental foramen shunt types; one of which (32 of 53 dogs) showed no shunting blood flow through the right gastric vein and three of which (21 of 53 dogs) involved shunting flow through this vessel. The anatomy of these four distinct shunt types, as defined by CT angiography, was found to be highly consistent. In all cases, regardless of the tributary vessels, the left gastric vein was the final vessel that communicated with the caudal vena cava. Using these findings, a more accurate naming classification for congenital portosystemic shunts entering the caudal vena cava at the level of the omental foramen was proposed. Clinical significance A precise pre-treatment anatomical classification of congenital extrahepatic portosystemic shunts entering the caudal vena cava at the level of the omental foramen is important for a more complete understanding of the severity of clinical signs and prognosis, and for the better communication between clinicians and researchers in this clinical field.

Background There have been no reports on the effectiveness of the administration of antithrombin III (AT III) for post-transplant portal vein thrombosis (PVT). We herein report a case of post-transplant PVT that was resolved by AT III treatment after living donor liver transplantation (LDLT). Case presentation The patient was a 57-year-old man who had been diagnosed with decompensate liver cirrhosis by hepatitis C virus infection. He presented with repeated hepatic coma and refractory ascites. Computed tomography (CT) revealed PVT of Yerdel classification grade II before LDLT. He underwent ABO-identical LDLT using a right lobe graft. A liver function test revealed elevated liver enzyme levels on post-operative day (POD) 14. The CT examination on POD 15 revealed PVT in the left side of the main portal vein at the side of left gastric vein ligation. AT III treatment from POD 15 to POD 24 was performed. Magnetic resonance imaging revealed that the PVT had decreased 10% on POD 27. Furthermore, AT III treatment from POD 28 to POD 32 was performed. The CT examination demonstrated the disappearance of PVT on POD 69 and thereafter, he had no recurrence of PVT on 10 post-operative month (POM). Conclusions The present case suggests that the administration of AT III is safe and suitable for the treatment of post-transplant PVT.

Background and objectives: Variceal bleeding is a serious complication caused by portal hypertension, frequently encountered among cirrhotic patients. The purpose of this study was to determine whether the aspect of the collateral, porto-systemic circulation, as detected by CT are associated with the presence variceal hemorrhage (VH). Materials and Methods: 81 cirrhotic patients who underwent a contrast-enhanced CT examination were retrospectively included in the study. Patients were divided into two groups: Cirrhotic patients with variceal hemorrhage during the hospital admission concomitant, with the CT examination (n = 33) and group 2-cirrhotic patients, without any variceal hemorrhage in their medical history (n = 48). The diameter of the left gastric vein, the presence or absence and dimensions of oesophageal and gastric varices, paraumbilical veins and splenorenal shunts were the indicators assessed on CT. Results: The univariate analysis showed a significant association between the presence of upper GI bleeding and the diameters of paraoesophageal veins, paragastric veins and left gastric vein respectively, all of these CT parameters being higher in patients with variceal bleeding. In the multivariate logistic regression analysis, only the diameter of the left gastric vein was independently associated with the presence of variceal hemorrhage (OR = 1.6 (95% CI: 1.17&ndash, 2.19), p = 0.003). We found an optimal cut-off value of 3 mm for the diameter of the left gastric vein useful to discriminate among patients with variceal hemorrhage from the ones without it, with a good diagnostic performance (AUC = 0.78, Se = 97%, Sp = 45.8%, PPV = 55.2%, NPV = 95.7%).Conclusions: Our observations point out that an objective CT quantification of porto-systemic circulation can be correlated with the presence of variceal hemorrhage and the diameter of the left gastric vein can be a reliable parameter associated with this condition.

To investigate the prevalence and patterns of aberrant gastric venous drainage and associated atrophy of the hepatic segment on contrast-enhanced computed tomography (CT). Two radiologists retrospectively reviewed contrast-enhanced CT images from 2021 patients who underwent cone-beam CT-guided chemoembolization between January 2013 and December 2018. They determined the presence or absence of an aberrant gastric vein(s) and its drainage site by consensus, and qualitatively analyzed the presence or absence of atrophy of segments II or III. In cases of disagreement between the two reviewers regarding the presence of atrophy, quantitative analysis was performed using dedicated software. A total of 31 aberrant right gastric veins were revealed on CT (1.5%), most of which drained into P2 (n = 8), the S2/3 border zone (n = 8), S2 (n = 6), or S4 (n = 5). An aberrant left gastric vein was observed in 21 (1.0%) patients, and P2 was the most common drainage site (n = 13) in these patients. Atrophy of segment II was more frequently observed among patients with aberrant gastric veins than among those without (26.9% versus 4.1%; p

Hepatic encephalopathy that occurs long after liver transplantation (LT) is an uncommon condition. Here, we describe the successful case of a 65-year-old patient who underwent interventional radiology (IVR) using a transmesenteric approach under minilaparotomy for hepatic encephalopathy because of a portosystemic shunt 11 years after ABO-incompatible living donor LT with splenectomy. Enhanced computed tomography confirmed a huge portosystemic shunt and left gastric vein (LGV)-esophageal-azygos vein, which was not treated during LT. Liver stiffness measurements based on transient elastography did not show severe fibrosis in the liver graft. Since the hyperammonemia could not be managed with conventional medical treatment, balloon-occluded retrograde transvenous obliteration (BRTO) was indicated. However, it was difficult to perform because the drainage vein could not be approached from the inferior vena cava (IVC). Surgical shunt ligation was also difficult because of the history of multiple laparotomies. Although intraperitoneal adhesion was severe, the portosystemic shunt was successfully embolized with metallic coils and a plug by IVR using a transmesenteric approach under minilaparotomy. No complications occurred during the operation. His symptoms improved after the operation. The ammonia level and portal flow by ultrasound also improved. He was discharged 14 days after surgery without any complications.

Background Total pancreatectomy is performed for chronic pancreatitis, tumors involving the entire pancreas or remnant pancreas after pancreatectomy. Gastric venous congestion and bleeding may be associated with total pancreatectomy. We report the case of a patient who underwent left gastric vein to splenic vein bypass to relieve gastric venous congestion during total pancreatectomy for remnant pancreatic cancer. Case presentation A 60-year-old woman underwent subtotal stomach-preserving pancreaticoduodenectomy for cancer of the pancreatic head. A follow-up computed tomography revealed a low-density tumor of the remnant pancreas. The pathological diagnosis was adenocarcinoma on endoscopic ultrasound-fine needle aspiration. Total resection of the remnant pancreas was performed for the tumor 3 years after the initial surgery. We ligated the splenic vein at the point of distal side of the left gastric vein confluent. Immediately, the vein congestion around the stomach was confirmed. We found the stenosis of the confluent between the left gastric vein and splenic vein. We subsequently anastomosed the left gastric vein and splenic vein, following which the gastric venous congestion was relieved. Conclusion In cases wherein all the drainage veins from the stomach are removed, an anastomosis between the left gastric vein and splenic vein can be effectively used to prevent gastric venous congestion and bleeding after total pancreatectomy.