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This report describes the successful treatment (without hepatectomy) of a patient who underwent laparotomy and bullet removal for a gunshot injury to the liver at another institution. The patient was later referred for hemobilia and was found to have an unrecognized tangential injury to the right portal vein branch, resulting in portal vein thrombosis, diagnosed on the twelfth day after injury. The patient subsequently developed severe cholangitis. Hepatic arteriography did not identify the source of hemobilia. Following thrombectomy of the main portal vein and its left branch, along with portal vein repair, bilateral external biliary drainage from the common hepatic duct was performed. Hemobilia ceased after portal revascularization. A low-volume biliary fistula developed in the early postoperative period but resolved within 17 days with gradual removal of abdominal drains. The patient experienced no further complications during six months of follow-up. Standard biochemical blood tests remained within normal limits, except for slightly elevated alkaline phosphatase (167 U/L: 40-129) and gamma-glutamyl transpeptidase (100 U/L: 8-61) levels. Follow-up contrast-enhanced computed tomography scans on postoperative day 10 and at six months confirmed patency of the main portal vein and its left branch. Additionally, right lobe atrophy and left lobe hypertrophy were observed. In conclusion, applying principles from elective hepatopancreatobiliary surgery to trauma care, and avoiding major hepatectomy in the setting of severe cholangitis, played a crucial role in achieving a successful outcome.

This study assesses the efficacy and safety of Portal Vein Recanalization with Intrahepatic Portosystemic Shunt (PVR-TIPS) in non-cirrhotic patients with chronic portal vein occlusion (CPVO), cavernomatous transformation, and symptomatic portal hypertension (PH) and/or portal vein thrombotic progression. Medical records of 21 non-cirrhotic patients with CPVO and portal cavernoma undergoing PVR-TIPS were analyzed. Hemodynamic (intraprocedural reduction in portosystemic pressure gradient), clinical (data on gastrointestinal bleeding, abdominal pain, ascites, and presence of esophageal varices from imaging exams) and technical success (PVR-TIPS) assessed efficacy. Safety was determined through complications classified according to the CIRSE Classification System. PVR-TIPS was successfully performed in all patients, resulting in a significant reduction in portal pressure gradient by 10 mmHg (21.475 ± 9.7 mmHg - 11.454 ± 5,4 mmHg, p < 0.001), alleviating portal hypertension symptoms without thrombotic progression. Clinical success included resolution or reduction of ascites (p = 0.016), gastroesophageal varices (p = 0.004), abdominal pain (p = 0.0021), and cessation of gastrointestinal bleeding (p = 0.021). Complications occurred in 33% of patients, including six grade III events (1 perioperative liver bleeding, 5 delayed stent occlusions) and one grade VI event resulting in death (4.8%). Primary patency rate was 76% (21.3 months, range:0.2-82), secondary patency 100% (4 months, range:3.8-40.8). Survival at follow-up was 90.4%, with one unrelated death. One patient underwent liver transplantation, three became eligible post-recanalization. PVR-TIPS proves effective and safe in reducing portal pressure gradient, thereby alleviating PH symptoms without evidence of portal thrombosis progression in non-cirrhotic patients with CPVO and portal cavernoma. It expands therapeutic options, including liver transplantation.

Background Several treatments induce liver hypertrophy for patients with liver malignancies but insufficient future liver remnant (FLR). Herein, the aim of this study is to compare the efficacy and safety of existing surgical techniques using network meta-analysis (NMA). Methods We searched PubMed, Web of Science, and Cochrane Library from databases for abstracts and full-text articles published from database inception through Feb 2022. The primary outcome was the efficacy of different procedures, including standardized FLR (sFLR) increase, time to hepatectomy, resection rate, and R0 resection margin. The secondary outcome was the safety of different treatments, including the rate of Clavien-Dindo≥3a and 90-day mortality. Results Twenty-seven studies, including three randomized controlled trials (RCTs), three prospective trials (PTs), and twenty-one retrospective trials (RTs), and a total number of 2075 patients were recruited in this study. NMA demonstrated that the Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) had much higher sFLR increase when compared to portal vein embolization (PVE) (55.25%, 95% CI 45.27–65.24%), or liver venous deprivation(LVD) (43.26%, 95% CI 22.05–64.47%), or two-stage hepatectomy (TSH) (30.53%, 95% CI 16.84–44.21%), or portal vein ligation (PVL) (58.42%, 95% CI 37.62–79.23%). ALPPS showed significantly shorter time to hepatectomy when compared to PVE (−32.79d, 95% CI −42.92–22.66), or LVD (−34.02d, 95% CI −47.85–20.20), or TSH (−22.85d, 95% CI −30.97–14.72), or PVL (−43.37d, 95% CI −64.11–22.62); ALPPS was considered as the highest resection rate when compared to TSH (OR=6.09; 95% CI 2.76–13.41), or PVL (OR =3.52; 95% CI 1.16–10.72), or PVE (OR =4.12; 95% CI 2.19–7.77). ALPPS had comparable resection rate with LVD (OR =2.20; 95% CI 0.83–5.86). There was no significant difference between them when considering the R0 marge rate. ALPPS had a higher Clavien-Dindo≥3a complication rate and 90-day mortality compared to other treatments, although there were no significant differences between different procedures. Conclusions ALPPS demonstrated a higher regeneration rate, shorter time to hepatectomy, and higher resection rate than PVL, PVE, or TSH. There was no significant difference between them when considering the R0 marge rate. However, ALPPS developed the trend of higher Clavien-Dindo≥3a complication rate and 90-day mortality compared to other treatments.

Background Portal vein stenosis develops in 3.4–14% of split liver transplantation 1 – 3 and its early detection and treatment are essential to achieve long-term graft survival, 2 – 5 although the diagnostic capability of conventional modalities such as Doppler ultrasound and computed tomography is limited. 1 , 4 , 5 Methods This study used computational fluid dynamics to analyze portal vein hemodynamics in the management of post-transplant portal vein stenosis. To perform computational fluid dynamics analyses, three-dimensional portal vein model was created using computed tomographic DICOM data. The inlet flow condition was set according the flow velocity measured on Doppler ultrasonography. Finally, portal vein flow was simulated on a fluid analysis software (Software Cradle, Japan). Results An 18-month-old girl underwent liver transplantation using a left lateral graft for biliary atresia. At the post-transplant 1-week evaluation, the computational fluid dynamics streamline analysis visualized vortices and an accelerated flow with a velocity ratio < 2 around the anastomotic site. The wall shear stress analysis revealed a high wall shear stress area within the post-anastomotic portal vein. At the post-transplant 6-month evaluation, the streamline analysis illustrated the increased vortices and worsening flow acceleration to reach the proposed diagnostic criteria (velocity ratio > 3:1). 3 , 5 The pressure analysis revealed a positive pressure gradient of 3.8 mmHg across the stenotic site. Based on the findings, the patient underwent percutaneous transhepatic portal venoplasty with balloon dilation. The post-treatment analyses confirmed the improvement of a jet flow, vortices, a high wall shear stress, and a pressure gradient. Discussion The computational fluid dynamics analyses are useful for prediction, early detection, and follow-up of post-transplant portal vein stenosis and would be a promising technology in post-transplant management.

The hepatic portal vein is the main vascular route responsible for collecting blood from the liver, spleen, pancreas, stomach, gallbladder, and intestines. Its key function is to metabolize the components acquired from the blood. The objective of this study was to analyze the characteristics of HPV variants and understand the possible clinical considerations that arise with them. The databases Medline, Scopus, Web of Science, Google Scholar, Cumulative Index to Nursing and Allied Health Literature and Latin American and Caribbean Literature in Health Sciences were researched until January 2024. Tree authors independently performed the search, study selection and data extraction. Methodological quality was evaluated with an assurance tool for anatomical studies. Pooled prevalence was estimated using a random effects model. A total of 31 studies met the established selection criteria. In this study, 21 articles were included for the meta-analysis with a total of 51,244 subjects. Of these 21 articles, the topics studied came mainly from Europe and Asia, with three (n = 554; 1.08%) and 11 articles (n = 50,090; 97.75%) respectively, also having six articles from North America (n = 442; 0.86%) and one from Africa (n = 158; 0.31%), discarding the articles from Oceania and South America. For the HPV trifurcation variant, it was 8% (CI = 7-10%). Apropos the right posterior portal vein variant, as the primary tributary from the main HPV, it was 7% (CI = 4-11%). About the right anterior portal vein variant originating from the left portal vein, it was 4% (CI = 1-6%). Finally, the prevalence of the isolated variants was 2% (CI = 1-3%). The knowledge of HPV and its anatomical variants is of utmost importance for both medical professionals and anatomists, as it is one of the vessels that collects blood from many important viscera found in the abdominal cavity, any structural alteration could be crucial in diagnosis and surgical procedures.

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing liver regeneration therapies prior to major hepatectomies, including portal vein embolization, double vein embolization and liver venous deprivation. It has been developed by an expert writing group under the guidance of the CIRSE Standards of Practice Committee. It encompasses all clinical and technical details required to perform liver regeneration therapies, revising the indications, contra-indications, outcome measures assessed, technique and expected outcomes.

Background/aimsTreatment responses of advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) remain unacceptably low and treatment modalities are limited. We compared the efficacy and safety of sorafenib and hepatic arterial infusion chemotherapy (HAIC).MethodsIn this randomized, prospective, comparative study, data on 58 patients with advanced HCC with PVTT, with Child–Turcotte–Pugh (CTP) scores of 5–7, were collected from six university hospitals between January 2013 and October 2015. Twenty-nine patients were treated with sorafenib and twenty-nine with HAIC.ResultsThe median overall survival (OS) and time to progression (TTP) were significantly longer in the HAIC group than in the sorafenib group (14.9 vs.7.2 months, p = 0.012 and 4.4 vs. 2.7 months, p = 0.010). The objective response (OR) rates were 27.6 and 3.4% in the HAIC and sorafenib groups, respectively (p = 0.001). In univariate analysis, sex, main portal vein invasion and treatment modality were significant prognostic factors of OS (p = 0.044, 0.040, 0.015), whereas cause of HCC, tumor number, tumor location and treatment modality were significant prognostic factors of TTP (p = 0.040, 0.002, 0.034, 0.014). In multivariate analysis, sex and treatment modality were significant prognostic factors of OS (p = 0.008, 0.005), whereas cause of HCC, tumor number, tumor location and treatment modality were significant prognostic factors of TTP (p = 0.038, 0.038, 0.015, 0.011). Major complications included hyperbilirubinemia (44.8%), AST elevation (34.5%), ascites (13.8%) and catheter-related complications (3.4%) in the HAIC group and hyperbilirubinemia (34.5%), hand-foot syndrome (31.0%) and AST elevation (27.6%) in the sorafenib group.ConclusionsFor managing advanced HCC with PVTT, HAIC may be a valuable treatment modality.

Splanchnic vein thrombosis (SVT) including portal, mesenteric, splenic vein thrombosis and the Budd-Chiari syndrome, is a manifestation of unusual site venous thromboembolism. SVT presents with a lower incidence than deep vein thrombosis of the lower limbs and pulmonary embolism, with portal vein thrombosis and Budd-Chiari syndrome being respectively the most and the least common presentations of SVT. SVT is classified as provoked if secondary to a local or systemic risk factor, or unprovoked if the causative trigger cannot be identified. Diagnostic evaluation is often affected by the lack of specificity of clinical manifestations: the presence of one or more risk factors in a patient with a high clinical suspicion may suggest the execution of diagnostic tests. Doppler ultrasonography represents the first line diagnostic tool because of its accuracy and wide availability. Further investigations, such as computed tomography and magnetic resonance angiography, should be executed in case of suspected thrombosis of the mesenteric veins, suspicion of SVT-related complications, or to complete information after Doppler ultrasonography. Once SVT diagnosis is established, a careful patient evaluation should be performed in order to assess the risks and benefits of the anticoagulant therapy and to drive the optimal treatment intensity. Due to the low quality and large heterogeneity of published data, guidance documents and expert opinion could direct therapeutic decision, suggesting which patients to treat, which anticoagulant to use and the duration of treatment.

In clinical medicine, little is known about the use of allografts for portal vein (PV) reconstruction after pancreaticoduodenectomy (PD). Portal and caval systems are physiologically different, therefore the properties of allografts from caval and portal systems were studied here in a pig model. PD with PV reconstruction with allogeneic venous graft from PV or inferior vena cava (IVC) was performed in 26 pigs. Biochemical analysis and ultrasonography measurements were performed during a 4-week monitoring period. Computer simulations were used to evaluate haemodynamics in reconstructed PV and explanted allografts were histologically examined. The native PV and IVC grafts varied in histological structure but were able to adapt morphologically after transplantation. Computer simulation suggested PV grafts to be more susceptible to thrombosis development. Thrombosis of reconstructed PV occurred in four out of five cases in PV group. This study supports the use of allografts from caval system for PV reconstruction in clinical medicine when needed.

This study evaluated the impact of reconstructed portal vein/superior mesenteric vein (PV/SMV) morphology on the long-term nutritional status following pancreatoduodenectomy (PD) using computational fluid dynamics (CFD). Twenty-four patients who underwent PD with PV/SMV resection and reconstruction without tumor recurrence for over 9 months after the operation were enrolled in the study. Three-dimensional models were constructed from computed tomography images obtained 3–6 months postoperatively. The pressure ( p ) at the inlet and turbulence dissipation rate ( ε ) at the outlet were investigated in the models. Patients with values of either p or ε above the upper interquartile range were classified as the poor flow group. The prognostic nutritional index improvement rate was significantly lower at 9 postoperative months in the poor flow group than in the good flow group ( P  = 0.016). This finding indicates the utility of a CFD analysis for evaluating the reconstructed PV/SMV morphology.