Search

Background: Orthotopic liver transplantation (OLT) is rarely indicated after hepatic trauma but it can be the only therapeutic option in some patients. There are scarce data analyzing the surgical outcomes of OLT after trauma., Methods: We used the UNOS data set to identify patients who underwent OLT for trauma from 1987 to 2022 and compared them to a cohort of patients transplanted for other indications. Cox proportional hazard and multivariable logistic regression analyses were performed to assess predictors of graft and patient survival., Results: Seventy-two patients underwent OLT for trauma during the study period. Patients with trauma were more frequently on mechanical ventilation at the time of transplantation (26.4% vs. 7.6%, p < 0.001) and had a greater incidence of pretransplant portal vein thrombosis (12.5% vs. 4%, p = 0.002). Our 4:1 matched analysis showed that trauma patients had significantly shorter wait times, higher incidence of pretransplant portal vein thrombosis and prolonged length of stay. Trauma was associated with decreased overall graft survival (hazards ratio, 1.42; 95% confidence interval, 1.01-1.98), and increased length of stay ( p = 0.048). There were no significant differences in long-term patient survival., Conclusion: Unique physiological and vascular challenges after severe hepatic trauma might be associated with decreased graft survival in patients requiring liver transplantation., Level of Evidence: Prognostic and Epidemiological; Level III., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: Repair of portal vein injury in a hostile abdomen can be very challenging, complicated by massive hemorrhage or stenosis. It can seldom be successfully carried out, even by experienced hepatobiliary surgeons. The ideal venous clamping technique is often not feasible and increases the risk of lethal portal vein laceration. The common mistake being the forceful use of clamps around the vein in the attempt to obtain vascular control, resulting in additional injuries., Methods: We provide a descriptive report of two cases detailing a careful step-by-step technique for the management of portal vein injury by inserting an endovascular balloon inflated with serum to control bleeding and repair the vein., Results: In patients who required this technique, no bleeding recurrence, nor portal vein thrombosis or stenosis was detected by CT-scan during follow-up., Conclusion: The endovascular balloon occlusion technique for the reconstruction of portal vein injuries in hostile abdomen is a safe and life-saving procedure that should be part of the armamentarium of visceral surgeons.

Objectives: Although traumatic injuries to the superior mesenteric vein (SMV), portal vein (PV), and hepatic vein (HV) are rare, their impact is significant. Small single center reports estimate mortality rates ranging from 29% to 100%. Our aim is to elucidate the incidence and outcomes associated with each injury due to unique anatomic positioning and varied tolerance of ligation. We hypothesize that SMV injury is associated with a lower risk of mortality compared to HV and PV injury in adult trauma patients., Methods: The Trauma Quality Improvement Program database (2010-2016) was queried for patients with injury to either the SMV, PV, or HV. A multivariable logistic regression model was used for analysis., Results: From 1,403,466 patients, 966 (0.07%) had a single major hepatoportal venous injury with 460 (47.6%) involving the SMV, 281 (29.1%) involving the PV, and 225 (23.3%) involving the HV. There was no difference in the percentage of patients undergoing repair or ligation between SMV, PV, and HV injuries ( P > .05). Compared to those with PV and HV injuries, patients with SMV injury had a higher rate of concurrent bowel resection (38.5% vs 12.1% vs 7.6%, P < .001) and lower mortality (33.3% vs 45.9% vs 49.3%, P < .01). After controlling for covariates, traumatic SMV injury increased the risk of mortality (odds ratio [OR] 1.59, confidence interval [CI] = 1.00-2.54, P = .05) in adult trauma patients; however, this was less than PV injury (OR = 2.77, CI = 1.56-4.93, P = .001) and HV injury (OR = 2.70, CI = 1.46-4.99, P = .002)., Conclusion: Traumatic SMV injury had a lower rate of mortality compared to injuries of the HV and PV. SMV injury increased the risk of mortality by 60% in adult trauma patients, whereas PV and HV injuries nearly tripled the risk of mortality.

Introduction: Portal vein (PV) and superior mesenteric vein (SMV) injuries are lethal. We hypothesised outcomes have improved with modern trauma care., Methods: We reviewed patients presenting to our Level 1 trauma centre over ten-years with PV/SMV injuries, analysing physiology, operative management, associated injuries, and outcomes., Results: Twenty-four patients had 7 PV and 15 SMV injuries, 2 had both; all had operative exploration. Sixty-seven percent had penetrating trauma. While many had normal vitals, profound acidosis was common. All patients had ≥2 additional abdominal injuries, liver most common (50%). Additional abdominal vascular injuries were more common in non-survivors than survivors: IVC 46% vs 22%, common hepatic artery 20% vs 0%, SMA 26% vs 11%. The mean injury severity score (ISS) was 32.4, and the mean new injury severity score (NISS) was 44.5. Mortality was 63%. Eleven patients died from exsanguination, two from SMV thrombosis, and two from sequelae of other injuries. All survivors had venorrhaphy, as did 8 non-survivors. Non-survivors were also shunted; had ligation; or bypass, shunting, and ligation. Three exsanguinated prior to repair. Two survivors had SMV related complications. One with proximal SMV injury developed severe venous congestion and multiple enterocutaneous fistulae. Another developed an arterioportal fistula, managed with embolisation and percutaneous portal vein stenting., Conclusion: Despite advances (REBOA, damage control surgery and resuscitation, liberal use of ED thoracotomy), PV and SMV injuries remain lethal. Injuries to other structures are ubiquitous. Early exsanguination is the major cause of death. All survivors had successful venorrhaphy; those who required more complex repairs died. Compromised mesenteric venous flow causes morbidity and mortality., (Copyright © 2019. Published by Elsevier Ltd.)

Introduction: Vasculobiliary and vascular injuries following cholecystectomy are the most serious complications requiring complex surgical management resulting in greater patient morbidity and mortality., Methodology: The study was performed at a tertiary teaching hospital of North India. Records of patients referred for biliary or vascular injury sustained during cholecystectomy were reviewed retrospectively to identify patients with vascular injury between January 2009 and March 2018. Clinical profile, hospital course and outcome of these patients were analysed., Results: Over nine years, 117 patients were referred for cholecystectomy related complications. Total incidence of vascular injury was 5.1% (6/117). Combined vasculobiliary injury (VBI) occurred in 3.4% (4/117) while isolated vascular injury was present in 1.7% patients (2/117). Most (5/6) patients were operated for uncomplicated gall stone disease. Incidences of portal vein (PV) and right hepatic artery (RHA) injuries were equal (3/6). PV injuries were repaired either during cholecystectomy (1/3) or during re-exploration after damage control packing (2/3). RHA injuries presented as pseudoaneurysm and were managed surgically (2/3) or by coil embolization (1/3). All VBI referrals (4/117) were following open cholecystectomy. In VBI patients, vascular injury was diagnosed intra-operatively in two while it was diagnosed several weeks after cholecystectomy in two others. Biliary injury manifested as bile leak post-operatively in all four of them. Nature of biliary injury could be characterized in only 50% (2/4) patients. Definitive repair of biliary injury was performed in one patient only. There was one mortality in our series., Conclusion: Vascular injury is an uncommon complication of cholecystectomy with catastrophic outcome if not managed timely and properly. Adequate surgeon training, keeping the possibility of aberrant vasculobiliary anatomy in all cases, and proper surgical technique is crucial for prevention of such injuries. However in such an event, proper documentation and referral to tertiary centre will help in decreasing morbidity and further litigation., (Copyright © 2018 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Background: Portal vein injury is uncommon, and the optimal treatment is controversial. We compared the outcomes of ligation vs repair of portal injury using the National Trauma Data Bank., Methods: Adult patients who suffered portal injury were identified from the National Trauma Data Bank (2002-2014) by International Classification of Diseases, Ninth Revision diagnosis codes. Patients were stratified by treatment modality into no surgery, ligation, and surgical repair using International Classification of Diseases procedure codes. Outcomes including hospital mortality, bowel resection, and length of stay between ligation and surgical repair were compared by Kruskal-Wallis or Fisher exact test as appropriate. Multivariable analyses were performed with logistic regression., Results: Among 752 patients with portal vein injury, 345 patients (45.9%) underwent no surgery, 103 patients (13.7%) had ligation, and 304 (40.4%) underwent surgical repair. Overall mortality was 49%. Age, sex, Injury Severity Score, Glasgow Coma Scale score, presenting blood pressure, and heart rate were similar between groups that underwent ligation and surgical repair. The hospital mortality (59.2% vs 47.7%; P = .08), bowel resection (1.9% vs 1.0%; P = .55), and length of stay (12.5 vs 15.0 days; P = .08) were also comparable between ligation and repair in univariate analysis. In multivariable analysis, hospital mortality for surgical repair was similar to ligation (risk ratio, 0.69; 95% confidence interval, 0.41-1.16; P = .16)., Conclusions: Portal vein injury is associated with significant mortality and morbidity. Surgical repair showed a trend for lower postoperative mortality than ligation, but this was not statistically significant on multivariate analysis. Repair of a traumatic portal vein injury should be attempted, but ligation is an acceptable alternative without an increase in bowel resection rates or a statistically significant increase in mortality., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

A portal vein aneurysm is the dilatation of the portal vein due to a defect in the vein wall. This rare disease manifestation is difficult to predict and has the potential for severe complications. We describe the case of a 68-year-old man involved in a motor vehicle collision who presented with abdominal hemorrhage found on ultrasound, hypotension, and vague abdominal pain. The patient underwent an exploratory laparotomy to control bleeding. Surgery and a subsequent abdominal computed tomography revealed the presence of a portal vein pseudoaneurysm and shock bowel. This case highlights the importance of radiologists to consider the prospect of portal vein aneurysm in the differential diagnosis of hypotension following abdominal trauma., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to assess the incidence of major hemorrhage after transjugular intrahepatic portosystemic shunt (TIPS) insertion using a stent graft at the main portal vein bifurcation., Patients and Methods: TIPS insertion using stent grafts was performed in 215 patients due to non-variceal hemorrhage indications. There were 137 men and 78 women, with a mean age of 57 years±10.6 (SD) (range: 19-90 years). Based on retrospective review of portal venograms, TIPS inserted within 5mm from the portal vein bifurcation were considered "bifurcation TIPS", while those inserted 2cm or greater from the bifurcation were considered intrahepatic. Suspicion for acute major periprocedural hemorrhage were categorized as low, moderate, and high, based on the number of signs of hemorrhage., Results: Of 215 TIPS inserted for purposes other than hemorrhage, the TIPS was inserted at the portal bifurcation in 41 patients (29 men, 12 women; mean age, 55.9±11.7 (SD); range: 26-79 years) and intrahepatic in 62 patients (37 men, 25 women; mean age, 57.6±10.6 (SD), range: 34-82 years), whereas 112 were indeterminate in location. No active extravasations were identified on post-TIPS portal venograms. Suspicion for acute major hemorrhage was moderate or high in 3/41 (7%) of patients in the TIPS bifurcation group compared to 5/62 (8%) in the intrahepatic TIPS group (P>0.99). There were no significant differences in 30-day mortality rates (1/41 [2%] and 3/62 [5%] respectively; P> 0.99). No deaths or interventions were attributed to acute hemorrhage., Conclusion: TIPS insertion at the portal bifurcation with stent grafts did not incur an elevated risk of hemorrhagic complications., (Copyright © 2017 Editions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.)

A 26-year-old man presented with gunshot wound to the epigastrium. At surgery, he was hemodynamically stable and had a tense hematoma with thrill in zone 2 (right side) and porta triad. After liver injury was controlled, he underwent percutaneous stenting of a renal artery-vena cava fistula and the hepatic artery injury was followed. Historically, penetrating injury to zone 2 has mandated operative exploration. However, with the advent of endovascular options, in stable patients, catheter-based options offer a reasonable alternative with less risk of blood loss and possible nephrectomy. Renal artery stenting has been advocated for renal artery cava fistulas. The role of timing, hybrid operating suites, and traditional operative exposure will vary based on presentation and institutional capabilities.

An 11-year-old Thoroughbred mare with colic unresponsive to medical treatment underwent exploratory laparotomy. During surgery the cecum was found entrapped within the epiploic foramen from left to right. The entrapped cecum was reduced through the foramen by gentle traction. After reduction of the cecum, rupture of the portal vein was detected. Loss of a large amount of blood prompted euthanasia during surgery.

An injury of major vessels is a life - threating complication in laparoscopic urology. Review of the literature and analysis of own cases have been performed. The authors offer original surgical management with using hand-assistant technic. It has advantages of open and laparoscopic approach.

Purpose: Transjugular intrahepatic portosystemic shunt (TIPS) creation is used to treat portal hypertension complications. Often the most challenging and time-consuming step in the procedure is the portal vein (PV) puncture. TIPS procedures are associated with prolonged fluoroscopy time and high patient radiation exposures. We measured the impact of transabdominal ultrasound guidance for PV puncture on duration of fluoroscopy time and dose., Methods: We retrospectively analyzed the radiation dose for all TIPS performed over a four-year period with transabdominal ultrasound guidance for PV puncture (n=212, with 210 performed successfully and data available for 206); fluoroscopy time, dose area product (DAP) and skin dose were recorded., Results: Mean fluoroscopy time was 12 min 9 s (SD, ±14 min 38 s), mean DAP was 40.3±73.1 Gy·cm2, and mean skin dose was 404.3±464.8 mGy., Conclusion: Our results demonstrate that ultrasound-guided PV puncture results in low fluoroscopy times and radiation doses, which are markedly lower than the only published dose reference levels.

Background: Radiofrequency ablation (RFA) is commonly used to locally treat hepatocellular carcinoma (HCC). However, when tumors are close to the Glisson's capsule, RFA may induce injury in this region, complicating therapeutic efforts. We investigated the impact of RFA-induced Glisson's capsule-associated complications on liver function and prognosis of HCC patients., Methods: We retrospectively reviewed our patient database and found 170 early-stage HCC patients treated via RFA from April 2004 to December 2012. We defined RFA-induced Glisson's capsule-associated complication as lasting hepatic arterioportal (AP) fistula, major intrahepatic bile-duct dilatation (affecting two or more subsegments), or hepatic infarction. We also defined liver failure as initial occurrence of either total bilirubin increase (>3.0 mg/dL), uncontrolled ascites, or encephalopathy., Results: In our cohort, 15 patients had RFA-induced Glisson's capsule-associated complications (incidence of related complications, with some overlap: lasting AP fistula, n = 9; major intrahepatic bile-duct dilatation, n = 7; and hepatic infarction, n = 2). The cumulative incidence of liver failure before stage progression was significantly higher and the median overall survival (OS) was significantly lower (52.3 months) in HCC patients with Glisson's capsule-associated complications than in those without Glisson's capsule-associated complications (95.0 months). In addition, multivariate analysis demonstrated that Glisson's capsule-associated complication was a significant independent factor associated with OS., Conclusions: In this study, we have shown that early-stage HCC patients with RFA-induced Glisson's capsule-associated complications may have higher risks in poor prognosis., Competing Interests: All authors who took part in this study indicated that they did not have anything to declare regarding funding or conflict of interest with respect to this study.

We describe a man who presented with a traumatic portal vein pseudoaneurysm, which was subsequently managed with a percutaneous transhepatic stent graft. This case demonstrates a rarely seen condition in the traumatic population and a novel management strategy, which should be considered in the management of this challenging injury.

The laparoscopic approach has replaced open surgery as the gold standard for cholecystectomy. This technique is, however, associated with a greater incidence of bile duct injuries (BDIs). We report a case of portobiliary fistula (PBF), a rare complication of BDI, occurring post laparoscopic cholecystectomy (LC). PBF has been reported after procedures such as endoscopic retrograde cholangiopancreatography and pathologies such as liver abscesses, but only once previously in the setting of LC. We discuss the management of this patient with apparent dual pathology, and summarise other aetiologies that may give rise to this condition.

Despite its relatively protected position, the liver is the most frequently injured solid intra-abdominal organ. 1 Most liver injuries can be managed conservatively, but about 5% to 10% require urgent laparotomy, usually when the mechanism of injury involves a vehicle accident and hemodynamic instability persists, in spite of 40 mL/kg of blood transfusion. 2 , 3 In particular, grades IV and V liver injuries may pose a challenge to the surgeon trying to control hemorrhage, the leading cause of mortality. 4 Traumatic injuries to the portal vein are rare but devastating. The mortality rate for portal vein injury ranges from 50% to 70%. A recent study of portal triad injuries has highighted the higher mortality rates associated with combination injuries involving multiple portal triad components, especially those that include portal vein injury. 5 This case study describes a unique case of relatively minor trauma in a child resulting in portal triad injury, sudden demise, and surgical repair.

Nitrative stress is considered as an important pathological process of hepatic ischemia and reperfusion injury but its regulating mechanisms are largely unknown. In this study, we tested the hypothesis that caveolin-1 (Cav-1), a plasma membrane scaffolding protein, could be an important cellular signaling against hepatic I/R injury through inhibiting peroxynitrite (ONOO(-))-induced cellular damage. Male wild-type mice and Cav-1 knockout (Cav-1(-/-)) were subjected to 1h hepatic ischemia following 1, 6 and 12h of reperfusion by clipping and releasing portal vessels respectively. Immortalized human hepatocyte cell line (L02) was subjected to 1h hypoxia and 6h reoxygenation and treated with Cav-1 scaffolding domain peptide. The major discoveries included: (1) the expression of Cav-1 in serum and liver tissues of wild-type mice was time-dependently elevated during hepatic ischemia-reperfusion injury. (2) Cav-1 scaffolding domain peptide treatment inhibited cleaved caspase-3 expression in the hypoxia-reoxygenated L02 cells; (3) Cav-1 knockout (Cav-1(-/-)) mice had significantly higher levels of serum transaminases (ALT&AST) and TNF-α, and higher rates of apoptotic cell death in liver tissues than wild-type mice after subjected to 1h hepatic ischemia and 6hour reperfusion; (4) Cav-1(-/-) mice revealed higher expression levels of iNOS, ONOO(-) and 3-nitrotyrosine (3-NT) in the liver than wild-type mice, and Fe-TMPyP, a representative peroxynitrite decomposition catalyst (PDC), remarkably reduced level of ONOO(-) and 3-NT and ameliorated the serum ALT, AST and TNF-α levels in both wild-type and Cav-1(-/-) mice. Taken together, we conclude that Cav-1 could play a critical role in preventing nitrative stress-induced liver damage during hepatic ischemia-reperfusion injury., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Intrahepatic portal vein injuries secondary to blunt abdominal trauma are difficult to diagnose and can result in insidious bleeding. We aimed to compare computed tomography arterial portography (CTAP), reperfusion CTAP (rCTAP), and conventional computed tomography (CT) for diagnosing portal vein injuries after blunt hepatic trauma., Methods: Patients with blunt hepatic trauma, who were eligible for nonoperative management, underwent CTAP, rCTAP, and CT. The number and size of perfusion defects observed using the three methods were compared., Results: A total of 13 patients (seven males/six females) with a mean age of 34.5±14.1 years were included in the study. A total of 36 hepatic segments had perfusion defects on rCTAP and CT, while there were 47 hepatic segments with perfusion defects on CTAP. The size of perfusion defects on CT (239 cm3; interquartile range [IQR]: 129.5, 309.5) and rCTAP (238 cm3; IQR: 129.5, 310.5) were significantly smaller compared with CTAP (291 cm3; IQR: 136, 371) (both, P = 0.002)., Conclusion: Perfusion defects measured by CTAP were significantly greater than those determined by either rCTAP or CT in cases of blunt hepatic trauma. This finding suggests that CTAP is superior to rCTAP and CT in evaluating portal vein injuries after blunt liver trauma.

Background: For deceased-donor liver graft retrieval, the warm dissection technique of hilar dissection before perfusion had been the standard procedure in the early period of liver transplantation. Thereafter, the cold dissection technique of in situ flushing and hilar dissection after perfusion has been preferred in many transplantation centers for rapid procurement of multiple organs. This study intended to assess the safety and usefulness of the warm dissection technique used in deceased-donor liver transplantation., Methods: This study analyzed a single surgeon's experience of the warm dissection technique for 165 cases of liver graft retrieval, regarding the prolongation of retrieval operation time, retrieval-associated graft injury, and recipient outcomes., Results: An additional 20 to 40 minutes was required for warm dissection. The incidence of retrieval-associated graft injury was 13 (7.9%), in which hepatic parenchymal injury was detected in 7 (capsular tear in 6 and subcapsular hematoma in 1) and vascular injury in 6 (celiac axis injury in 5 and common hepatic artery injury in 1). There was no other episode of injury at the branch artery, vena cava, portal vein, and bile duct. There was no significant difference of 1-year graft survival rates between liver grafts with and without graft injury (83% vs 83.3%, P = .73)., Conclusions: When the vital signs of deceased donor are stable, the warm dissection technique may be helpful to decrease the cold ischemic preservation time because the risk of graft injury is acceptably low and it provides more time for recipient preparation, thus giving potential advantages for marginal liver grafts., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Vasculobiliary injury composed of bile duct, portal vein and hepatic artery injury is a rare, but the most severe, complication after cholecystectomy that may require hepatectomy or even urgent liver transplantation., Case Presentation: We present a case of a 36-year-old Caucasian woman with a biliary sepsis and a large right liver lobe abscess due to an extreme vasculobiliary injury after laparoscopic cholecystectomy. Bismuth type IV biliary duct injury, portal vein thrombosis and injury of right hepatic artery were identified, resulting in life-threatening septic episodes. Right hepatectomy with Roux-en-Y hepaticojejunostomy and reconstruction of her portal vein with a vein allograft were performed. She fully recovered and remained well during 3 years of follow-up., Conclusions: Although rare, the impact of vasculobiliary injuries after cholecystectomy highlights the need for constant alertness and prompt management in order to minimize the risk of the routine operative procedure. Hepatectomy with biliary and vascular reconstruction should be considered early in the management of vasculobiliary injury to avoid the development of life-threatening consequences.

Liver trauma is the most common abdominal emergency with high morbidity and mortality. Now, non-operative management (NOM) is a selective method for liver trauma. The aim of this study was to determine the success rate, mortality and morbidity of NOM for isolated liver trauma. Medical records of 81 patients with isolated liver trauma in our unit were analyzed retrospectively. The success rate, mortality and morbidity of NOM were evaluated. In this series, 9 patients with grade IV-V liver injuries underwent emergent operation due to hemodynamic instability; 72 patients, 6 with grade V, 18 grade IV, 29 grade III, 15 grade II and 4 grade I, with hemodynamic stability received NOM. The overall success rate of NOM was 97.2% (70/72). The success rates of NOM in the patients with grade I-III, IV and V liver trauma were 100%, 94.4% and 83.3%. The complication rates were 10.0% and 45.5% in the patients who underwent NOM and surgical treatment, respectively. No patient with grade I-II liver trauma had complications. All patients who underwent NOM survived. NOM is the first option for the treatment of liver trauma if the patient is hemodynamically stable. The grade of liver injury and the volume of hemoperitoneum are not suitable criteria for selecting NOM. Hepatic angioembolization associated with the correction of hypothermia, coagulopathy and acidosis is important in the conservative treatment for liver trauma.

Noncompressible truncal hemorrhage and brain injury currently account for most early mortality of warfighters on the battlefield. There is no effective treatment for noncompressible truncal hemorrhage, other than rapid evacuation to a surgical facility. The availability of an effective field treatment for noncompressible truncal hemorrhage could increase the number of warfighters salvaged from this frequently-lethal scenario. Our intent was to develop a porcine model of noncompressible truncal hemorrhage with a ∼ 50% one-hour mortality so that we could develop new treatments for this difficult problem. Normovolemic normothermic domestic swine (barrows, 3 months old, 34-36 kg) underwent one of three injury types through a midline incision: 1) central stellate injury (N = 6); 2) excision of a portal vein branch distal to the main PV trunk (N = 6); or 3) hemi-transection of the left lateral lobe of the liver at its base (N = 10). The one-hour mortality of these injuries was 0, 82, and 40%, respectively; the final mean arterial pressure was 65, 24, and 30 mm Hg, respectively; and the final hemoglobin was 8.3, 2.3, and 3.6 g/dL, respectively. Hemi-transection of the left lateral lobe of the liver appeared to target our desired mortality rate better than the other injury mechanisms.

Hepatic arterioportal fistulae (APF) are abnormal communications between the hepatic artery and the portal vein. In this report, we present the second case in the literature of a symptomatic APF presenting as a gastric variceal bleeding. A 55-year-old female presented to our facility with hematemesis. Upper endoscopy revealed a bleeding gastric varix. A computed tomography scan identified a large left hepatic lobe APF between the left hepatic artery and the left portal vein. Through angiography coil embolization was performed and with resultant loss of arterial flow, the APF was decompressed. On hospital day 3, the patient developed new melena. Portovenogram was performed and a TIPS stent was deployed. The patient subsequently did well. Hepatic arterioportal fistulae can result in portal hypertension secondary to arterial blood flowing directly into the portal vein bypassing the hepatic sinusoids. Iatrogenic causes (e.g. percutaneous liver biopsy) represent more than 50% of published cases of APFs. Most APFs resolve spontaneously as they are small and peripherally located. In rare instances, when APFs are centrally located, clinical symptoms develop. There have been 30 reported cases of symptomatic intrahepatic APFs following percutaneous liver biopsy. Of those, only one case presented as a gastric variceal bleed. Digital subtraction angiography is the gold standard in the diagnosis and treatment of APFs. In addition to initial embolization, we elected to treat the patient with TIPS due to the magnitude of her bleed. Although rare, intrahepatic APF should be kept on the differential of a patient presenting with isolated gastric varices.

Purpose: To report on first results of the embolization of transhepatic and transsplenic puncture tracts using an Amplatzer Vascular Plug (AVP) after percutaneous portal vein intervention., Materials and Methods: Embolization of transhepatic and transsplenic puncture tracts with AVP was attempted in 5 patients (3 females; age range: 3 - 71 years). Portal vein access was gained by a transhepatic (n = 4) or transsplenic (n = 1) approach, and stenosis (n = 2) or thrombosis (n = 3) of the portal vein was successfully treated by percutaneous stenting or thrombus aspiration and thrombolysis using 6 to 10 French sheaths. Due to the relatively large bore and/or short transparenchymal puncture tracts, it was considered favorable to use AVPs as an embolic agent. The medical records, the radiological reports and images of these 5 patients were retrospectively evaluated., Result: In three cases one AVP II (diameter, 4 mm), in one case one AVP IV (diameter, 4 mm) and in one case two AVPs II (diameter, 8 and 6 mm) were used for embolization of the puncture tract. In all five cases embolization was technically successful. There was no bleeding from the puncture tract. During a median follow-up of 14 months (range, 21 days to 21 months), one patient developed a focal liver abscess adjacent to the AVP which was successfully treated by antimicrobial and drainage therapy. There were no further embolization-related complications., Conclusion: AVPs are suited to embolize large bore and/or short transhepatic and transsplenic puncture tracts effectively, safely, and precisely. Caution is required in patients with an increased risk for infectious complications., Key Points: • Embolization of transhepatic and transsplenic puncture tracts with AVPs is feasible• Large and/or short puncture tracts can be effectively embolized with AVPs• The risk of infectious complications has to be considered Citation Format: • Dollinger M, Goessmann H, Mueller-Wille R et al. Percutaneous Transhepatic and Transsplenic Portal Vein Access: Embolization of the Puncture Tract Using Amplatzer Vascular Plugs. Fortschr Röntgenstr 2014; 186: 142 - 150., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The incidence of vascular injury after a cholecystectomy is often underestimated. Although injuries to the portal vein are rare, they are devastating. The aim of the present study was to analyze suitable therapeutic strategies regarding portal vein injury in the absence of biliary injury., Materials and Methods: Eleven patients with portal vein injuries after laparoscopic or open cholecystectomy were referred to our hospital between 2004 and 2010. The clinical presentation, diagnosis, and management of patients with severe portal vein injuries were reviewed. All the patients were discharged without outstanding clinical conditions. During retrospective analysis, these patients were divided into early, middle, and late stages., Results: All the 11 patients had a portal vein and/or right hepatic artery injury, but no biliary injuries were observed. Among these patients, different management strategies were managed according to the stage of the injury. Eight patients received a direct suture at the time of injury by an experienced hepatobiliary surgeon. Two patients received thrombolytic and anticoagulation therapy after cholecystectomy, without additional surgery. One patient received a liver transplant 3 mo after the injury. After long-term follow-up, these patients had no clinical conditions., Conclusions: Direct repair or suture is important during the early stage of portal vein injury. Conservative thrombolytic and anticoagulation therapy may serve an important role in the treatment of acute massive thrombus in portal vein injury during the middle stage. Liver transplantation is a salvage therapy that should be used during the late stage., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: The management of portal vein (PV) involvement by pancreatic adenocarcinoma during pancreaticoduodenectomy (PD) is controversial. The aim of this study was to compare the outcomes of unplanned and planned PV resections as part of PD., Methods: An analysis of PD over 11 years was performed. Patients who had undergone PV resection (PV-PD) were identified, and categorized into those who had undergone planned or unplanned resection. Postoperative and oncological outcomes were compared., Results: Of 249 patients who underwent PD for pancreatic adenocarcinoma, 66 (26·5 per cent) had PV-PD, including 27 (41 per cent) planned and 39 (59 per cent) unplanned PV resections. Twenty-five of 27 planned PV resections were circumferential PV-PD, whereas 25 of 39 unplanned PV resections were partial PV-PD. Planned PV resections were performed in slightly younger patients (mean(s.d.) 60(9) versus 65(10) years; P = 0·031), and associated with longer operating times (mean(s.d.) 602(131) versus 458(83) min; P < 0·001) and more major complications (26 versus 5 per cent; P = 0·026). Planned PV resections were associated with a lower rate of positive margins (4 versus 44 per cent; P < 0·001) despite being carried out for larger tumours (mean(s.d.) 3·9(1·4) versus 2·9(1·0) cm; P = 0·002). There was no difference in survival between the two groups (P = 0·998). On multivariable analysis, margin status was a significant predictor of survival., Conclusion: Although planned PV resections for pancreatic adenocarcinoma were associated with higher rates of postoperative morbidity than unplanned resections, R0 resection rates were better., (© 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd.)

Background: Hemorrhage within an intact abdominal cavity remains a leading cause of preventable death on the battlefield. Despite this need, there is no existing closed-cavity animal model to assess new hemostatic agents for the preoperative control of intra-abdominal hemorrhage., Methods: We developed a novel, lethal liver injury model in non-coagulopathic swine by strategic placement of two wire loops in the medial liver lobes including the hepatic and portal veins. Distraction resulted in grade V liver laceration with hepato-portal injury, massive bleeding, and severe hypotension. Crystalloid resuscitation was started once mean arterial pressure (MAP) fell below 65 mm Hg. Monitoring continued for up to 180 min., Results: We demonstrated 90% lethality (9/10) in swine receiving injury and fluid resuscitation, with a mean survival time of 43 min. Previous efforts in our laboratory to develop a consistently lethal swine model of abdominal solid organs, including preemptive anticoagulation, a two-hit injury with controlled hemorrhage prior to liver trauma, and the injury described above without resuscitation, consistently failed to result in lethal injury., Conclusion: This model can be used to screen other interventions for pre hospital control of noncompressible., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Needlefish injuries to humans are extremely rare. An extensive review of the medical literature reveals only 22 cases previously reported. Most injuries reported have occurred in the Indo-Pacific region, but there are scattered reports worldwide., Objective: To report two cases of life-threatening penetrating abdominal injuries from needlefish impalement., Case Report: A 19-year-old man and a 40-year-old woman were both struck in the abdomen by a needlefish and required emergent exploratory laparotomy for instability. Their injuries were a laceration of a branch of the left portal vein and a small bowel perforation, respectively. Both patients survived and recovered without incident., Conclusion: Although rare, penetrating injuries from needlefish can be life threatening. Treatment should be directed at the organ injured with appropriate antibiotic coverage., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: To compare local injection of hemostatic agents and radiofrequency (RF)-assisted hemostasis in the management of bleeding from the portal vein with varying diameters and blood flow velocities., Material and Methods: Sixteen Bama pigs were used. Laparotomy was performed to expose the liver and inner diameters and blood flow velocities of the pre-injured portal vein in the hepatic segments and subsegments were measured. Vascular injuries in the portal vein were produced (4 in each pig). The pigs were randomly divided into two groups and local injection of hemostatic agents was performed in one group and RF-assisted hemostasis in the other, both techniques monitored by contrast-enhanced ultrasonography (CEUS). Time to hemostasis was measured, and the extent of liver injury was determined 2 h after treatment., Results: In the local injection group, the rates of successful hemostasis were 100, 88.9, and 50% with portal veins with inner diameters of < 1 mm, 1-2 mm, and 2-3 mm, respectively, and the maximum time to achieve hemostasis was 24.0 ± 7.2 s. Hemostasis was not successful when the diameter was > 3 mm. In the RF-assisted group, hemostasis was successfully at all sites regardless of vessel diameter; however, the maximum time to achieve hemostasis was 156.8 ± 31.2 s. Injury to surrounding tissue was significantly greater in the RF-assisted group., Conclusion: Both methods can achieve hemostasis with small diameter portal vein injuries; however, RF-assisted hemostasis is necessary for larger vessels, though it is associated with greater damage to surrounding tissue.

Objectives: Extreme vasculobiliary injuries usually involve major hepatic arteries and portal veins. They are rare, but have severe consequences, including rapid infarction of the liver. The pathogenesis of these injuries is not well understood. The purpose of this study was to elucidate the mechanism of injury through an analysis of clinical records, particularly the operative notes of the index procedure., Methods: Biliary injury databases in two institutions were searched for data on extreme vasculobiliary injuries. Operative notes for the index procedure (cholecystectomy) were requested from the primary institutions. These notes and the treatment records of the tertiary centres to which the patients had been referred were examined. Radiographs from the primary institutions, when available, as well as those from the tertiary centres, were studied., Results: Eight patients with extreme vasculobiliary injuries were found. Most had the following features in common. The operation had been started laparoscopically and converted to an open procedure because of severe chronic or acute inflammation. Fundus-down cholecystectomy had been attempted. Severe bleeding had been encountered as a result of injury to a major portal vein and hepatic artery. Four patients have required right hepatectomy and one had required an orthotopic liver transplant. Four of the eight patients have died and one remains under treatment., Conclusions: Extreme vasculobiliary injuries tend to occur when fundus-down cholecystectomy is performed in the presence of severe inflammation. Contractive inflammation thickens and shortens the cystic plate, making separation of the gallbladder from the liver hazardous., (© 2011 International Hepato-Pancreato-Biliary Association.)

Cholecystectomy remains one of the most commonly performed procedures in general surgery. Although the incidence, diagnosis, and treatment of bile duct (BD) injuries have been well described, studies characterizing associated vascular injuries are limited. The objective of this study was to analyze the frequency and management of associated vascular and BD injury after cholecystectomy. A total of 50 patients were referred to a tertiary institution for BD injuries from 1996 to 2010. Thirty-nine (78%) of the patients were female with the mean age of 49 years (range, 14 to 86 years). Seventy-five per cent of the injuries were Strasberg Type E. Nine patients (18%) had associated vascular injuries. Six patients had injuries to the right hepatic artery; in one patient, both the right and left hepatic arteries were damaged. Five patients had right portal vein injuries; three of these subsequently died. In conclusion, as a result of the high incidence of associated vascular injury, a thin-collimation CT angiogram and/or mesenteric angiogram with portal venous imaging should be considered as part of the preoperative evaluation in patients with BD injury.

Purpose: To evaluate the damage caused by microwave ablation to vessels inside and outside the ablation zone in an in vivo swine model., Materials and Methods: Four pigs underwent microwave liver ablation with a 2.45-GHz generator and a 14-gauge water-cooled antenna with a miniature choke. Each animal underwent four 15-minute microwave ablations (two at 40 W, two at 60 W). Mean minimum and maximum diameters of ablation areas were calculated on gross pathologic and histologic examination. At minimum, a whole-mount section and two to four specimens were obtained from each ablation and stained with hematoxylin and eosin. Specimens were analyzed to verify the presence of damaged vessels in and outside the ablation area., Results: Mean ablation diameters at gross pathologic examination, including the hemorrhagic halo, were 3.1 cm ± 0.5 at 40 W and 3.6 cm ± 1.1 at 60 W. All ablation zones presented a characteristic pattern consisting of three concentric zones: (i) a central area consisting of coagulative necrosis (mean maximum diameter, 8.5 mm ± 2.6), (ii) a larger area characterized by irreversibly damaged hepatocytes (mean maximum thickness, 11.7 mm ± 3.4), and (iii) a hemorrhagic halo. Twenty-one veins outside the ablation zone were evaluated (mean diameter, 5.6 mm), three of which (14%) showed diffuse endothelial damage. All three represented a continuation of a portal vein within the ablation area., Conclusions: In a small percentage of microwave ablation cases, endothelial damage can extend from a portal vessel included in the ablation zone to a segment of the vessel situated outside the ablation zone. Further investigation of the clinical significance of this finding is needed., (Copyright © 2011 SIR. Published by Elsevier Inc. All rights reserved.)

Arterioportal fistulas are rare and mostly a result of late complication of gastric and biliary surgery. Surgical excision has been the therapy of reference. Endovascular treatment is emerging as a real alternative to surgery. The present study reports a case of postsurgical arterioportal fistula involving the gastroduodenal artery, the cause of portal hypertension, which was successfully treated by transarterial embolization using embospheres. Portal hypertension improved dramatically., (Copyright © 2011 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)