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Objective: To compare the safety and efficacy of transmesenteric vein extrahepatic portosystemic shunt (TEPS) and transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of cavernous transformation of the portal vein (CTPV). Methods: The clinical data of CTPV patients with patency or partial patency of the superior mesenteric vein treated with TIPS or TEPS treatment in the Department of Vascular Surgery of Henan Provincial People's Hospital from January 2019 to December 2021 were selected. The differences in baseline data, surgical success rate, complication rate, incidence rate of hepatic encephalopathy, and other related indicators between TIPS and TEPS group were statistically analyzed by independent sample t-test, Mann-Whitney U test, and Chi-square test. Kaplan-Meier survival curve was used to calculate the cumulative patency rate of the shunt and the recurrence rate of postoperative portal hypertension symptoms in both groups. Results: The surgical success rate (100% vs. 65.52%), surgical complication rate (6.67% vs. 36.84%), cumulative shunt patency rate (100% vs. 70.70%), and cumulative symptom recurrence rate (0% vs. 25.71%) of the TEPS group and TIPS group were statistically significantly different (P < 0.05). The time of establishing the shunt [28 (2141) min vs. 82 (51206) min], the number of stents used [1 (12) vs. 2 (15)], and the length of the shunt [10 (912) cm vs. 16 (1220) cm] were statistically significant between the two groups (t = -3.764, -4.059, -1.765, P < 0.05). The incidence of postoperative hepatic encephalopathy in the TEPS group and TIPS group was 6.67% and 15.79% respectively, with no statistically significant difference (Fisher's exact probability method, P = 0.613). The pressure of superior mesenteric vein decreased from (29.33 ± 1.99) mmHg to (14.60 ± 2.80) mmHg in the TEPS group and from (29.68 ± 2.31) mmHg to (15.79 ± 3.01) mmHg in TIPS group after surgery, and the difference was statistically significant (t = 16.625, 15.959, P < 0.01). Conclusion: The best indication of TEPS is in CTPV patients with patency or partial patency of the superior mesenteric vein. TEPS improves the accuracy and success rate of surgery and reduces the incidence of complications.
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Humans , Portal Vein/surgery , Portasystemic Shunt, Transjugular Intrahepatic/methods , Hepatic Encephalopathy/etiology , Treatment Outcome , Hypertension, Portal/complications , Retrospective Studies , Gastrointestinal Hemorrhage/etiologyABSTRACT
Objective:To explore the safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of esophago-gastric variceal bleeding (EGVB) complicated with cavernous transformation of portal vein (CTPV).Methods:From January 1, 2015 to December 31, 2018, the clinical data of liver cirrhosis patients with EGVB and complicated with (CTPV group) or without (non-CTPV group) CTPV receiving TIPS at Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School were retrospectively analyzed. The success rate of operation, stent patency rate, recurrent bleeding rate, incidence and survival rate of hepatic encephalopathy of CTPV group and non-CTPV group were analyzed. Independent samples t test, Mann-Whitney U test and chi-square test were used for statistical analysis. Kaplan-Meier method was used for survival analysis. Results:A total of 37 liver cirrhosis patients with EGVB and CTPV receiving TIPS treatment were screened out, among which 10 patients (27.0%) failed the portal vein puncture during the TIPS and switched to endoscopic treatment, the success rate was 73.0%. A total of 460 liver cirrhosis patients with EGVB and non-CTPV received TIPS treatment, among which TIPS in 18 patients (3.9%) was failed, and the success rate was 96.1%. With 1∶2 ratio propensity matching, 54 patients were enrolled in non-CTPV group. In the CTPV group, after TIPS treatment, the average portal vein pressure decreased from (28.9±5.1) mmHg (1 mmHg=0.133 kPa) to (18.8±4.5) mmHg, and the difference was statistically significant ( t=7.122, P<0.01). The median follow-up time was 33 months(1 to 66 months). There were no significant differences between the CTPV group and the non-CTPV group in one-year of cumulative stent patency rate (75.0% vs. 86.8%), recurrent upper gastrointestinal bleeding rate of hepatic encephalopathy (21.0% vs. 10.0%), the incidence of hepatic encephalopathy (34.8% vs. 22.2%) and the survival rate (80.7% vs. 88.9%)(all P >0.05). Conclusion:TIPS is safe and effective in the treatment of liver cirrhosis patients with EGVB and CTPV, and does not increase the incidence of postoperative complications and long-term mortality.
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Compression by hepatic hydatid lesions may invade the portal vein and cause cavernous transformation of the portal vein (CTPV), which has difficulties and high risks in surgery, and conventional hepatectomy cannot achieve radical treatment. This article reviews the etiology, classification, clinical manifestations, and auxiliary examinations of hepatic echinococcosis with CTPV and summarizes the treatment strategies for this disease. It is believed that the treatment of hepatic echinococcosis with CTPV should combine the resection of hydatid lesions with the effective relief of portal hypertension, and revascularization and ex-vivo liver resection with auto-transplantation play an important role in radical resection.
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Objective:To explore the feasibility, safety and effectivity of applying transmesenteric vein extrahepatic portosystemic shunt (TEPS) to treat extrahepatic portal vein obstructive disease (EHPVOD).Methods:From December 2020 to April 2021, 12 patients with EHPVOD in the Vascular Surgery Department of Zhengzhou University People′s Hospital were prospectively enrolled in the study. The infra-umbilical median longitudinal minilaparotomy was performed to expose the branch of superior mesenteric vein (SMV). RUPS-100 was introduced into the trunk of SMV. A balloon with a diameter of 20 mm was introduced through right internal jugular vein (RIJV) into inferior vena cava (IVC). Under fluoroscopy, RUPS-100 was used to puncture the balloon in IVC. A stiff guide wire was used to establish the pathway between RIJV and SMV. Finally the portosystemic shunt between IVC and SMV was established with a covered stent-graft. The total operative time, the time of establishing portosystemic shunt alone, the dosage of contrast agent, the preoperative and postoperative pressure of SMV were recorded. Paired t test was used to compare the preoperative and postoperative pressure of SMV. Results:All 12 patients were successfully performed TEPS. The total operative time was (113±32) min, the time of establishing portosystemic shunt alone was (31±5) min, the dosage of contrast agent was (129±48) ml. The postoperative pressure of SMV [(14.3±2.1) mmHg] decreased significantly ( t=20.125, P<0.01) compared to baseline [(27.8±2.7) mmHg]. All portal hypertension symptoms released after the operations.There was 1 case of delayed incision healing, 1 case of bacteremia and 1 case of slight hepatic encephalopathy, but all of them were cured. There was no death case. Postoperative CT showed all portosystemic shunts were patent. Conclusion:TEPS is a new, safe, effective and feasible treatment method for patients of acute and chronic EHPVOD.
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OBJECTIVE@#To assess the clinical application of preoperative retrograde portal venography for children with cavernous transformation of the portal vein (CTPV).@*METHODS@#The clinical data of 8 cases of CTPV admitted in the Children's Hospital of Zhejiang University from January 2018 to September 2019 were retrospectively analyzed. Preoperative retrograde portography was performed to determine the corresponding vascular morphology and size of portal vein system. If the retrograde portography showed that the left branch of the shadow portal vein was unobstructed and its diameter was greater than 3 mm, Rex shunt would be performed after anatomic exploration of Rex recess; if retrograde portography showed that the diameter of left portal vein was less than 3 mm, but the diameter of left renal vein dissected during shunt operation was greater than 5 mm, Warren operation was selected. The patients were followed up for 1, 3 and 6 months after discharge, and then were followed up every 6 months.@*RESULTS@#Retrograde portal venography was successfully performed in 8 child patients.The anatomical position and size of main portal vein and its left and right branches, left renal vein and other important vessels were determined. Among them, there was the well-developed left and right branches of portal vein in 4 child patients, in which the left and right branches of portal vein converged together, but did not communicate with the main portal vein. In addition, the left branch diameter of the portal vein was greater than 3 mm, and the anatomical exploration results during shunt were consistent with it, so Rex shunt was performed. In the other 4 cases, the left branch diameter of the portal vein was small (less than 3 mm) in 3 cases, and the right branch was not clearly developed. Moreover, the left branch of the portal vein was poorly developed and almost occluded in 1 case. However, the left renal vein in these 4 child patients was well developed, the blood flow was unobstructed and the diameter was greater than 5 mm, so Warren operation was performed. Seven patients recovered well after the operation, and the other one had digestive tract rudimentary one year after operation, and the condition was stable after conservative treatment.@*CONCLUSIONS@#The preoperative retrograde portal venography can be used to evaluate the portal vein system in children with CTPV, which provides important clinical basis for making appropriate treatment plan before surgery.
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Child , Humans , Portal Vein/surgery , Portography , Retrospective StudiesABSTRACT
OBJECTIVE:To study the effect of modified meso-rex surgery combined with umbilical vein recanalization and primary stent implantation in the treatment of portal vein portal vein cavernous transformation.METHODS:A retrospective study was conducted in Beijing Tsinghua Changgung Hospital. A patient underwent classic or thotopic total liver transplantation for more than 9 years, admitted in February 2018 was selected.Her main portal vein occlusion and portal vein cavernous transformation were followed by portal hypertension, esophageal and gastric varices, and gastrointestinal bleeding. Surgical treatment of Meso-rex bypass were performed. During operation, hyperplasia of the left liver was noted. After wedge resection of part of the left liver parenchyma, the stump of ligamentum teres hepatis was exposed. Left portal vein was difficult to be dissected and exposed. After the umbilical vein was recanalized to the left branch of the portal vein, vascular anastomosis and stent implantation were completed. Postoperative anticoagulant therapy was given,and the blood flow was monitored.RESULTS:The shunt procedure was successful. The bypass patent, and blood flow was unobstructed 1-year post-operation. No gastrointestinal bleeding occurred ever.CONCLUSION:Meso-rex bypass combined with umbilical vein recanalization and primary stent implantation can be used to treat patients with portal vein cavernous transformation whose left portal vein is patent but difficult to be exposed.The long-term effect is worth expecting and more cases are needed for further verification.
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Objective To evaluate the application value of MSCT in preoperative diagnosis and postoperative evaluation in children with cavernous transformation of the portal vein (CTPV).Methods 11 children diagnosed with CTPV by surgery were included in this study in our hospital.All patients underwent both plain and enhanced MSCT scans before surgery,and ultrasound or MSCT scan after surgery.Results In all 11 cases,preoperative CT showed different degrees of splenomegaly and the plain CT showed abnormal soft tissue mass in the hepatic hilar area.Enhanced CT showed stenosis or occlusion of portal vein trunk,earthworm-like blood vessels in the hilar region,and that the left and/or right branch of intrahepatic portal vein were replaced by multiple densely-distributed blood vessels (typeⅡ). Superior mesenteric-intrahepatic left portal shunt (Rex surgery)was performed in all 11 cases with successful results.All patients were followed up for 2-20 months after surgery.Imaging examinations showed anastomotic patency in 9 cases and stenosis in 2 cases.Conclusion MSCT findings of CTPV in children have certain characteristics.MSCT plays an important role in preoperative diagnosis and postoperative evaluation of CTPV in children.
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Objective To evaluate the application value of MSCT in preoperative diagnosis and postoperative evaluation in children with cavernous transformation of the portal vein (CTPV).Methods 11 children diagnosed with CTPV by surgery were included in this study in our hospital.All patients underwent both plain and enhanced MSCT scans before surgery,and ultrasound or MSCT scan after surgery.Results In all 11 cases,preoperative CT showed different degrees of splenomegaly and the plain CT showed abnormal soft tissue mass in the hepatic hilar area.Enhanced CT showed stenosis or occlusion of portal vein trunk,earthworm-like blood vessels in the hilar region,and that the left and/or right branch of intrahepatic portal vein were replaced by multiple densely-distributed blood vessels (typeⅡ). Superior mesenteric-intrahepatic left portal shunt (Rex surgery)was performed in all 11 cases with successful results.All patients were followed up for 2-20 months after surgery.Imaging examinations showed anastomotic patency in 9 cases and stenosis in 2 cases.Conclusion MSCT findings of CTPV in children have certain characteristics.MSCT plays an important role in preoperative diagnosis and postoperative evaluation of CTPV in children.
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Objective To explore the efficacy and safety of percutaneous transhepatic portal vein or transjugular intrahepatic portosystemie shunt (TIPS)to implant the portal vein metallic stent in treatment of cavernous transformation of portal vein (CTPV).Methods Clinical and imaging data of 8 patients with CTPV were retrospectively analyzed who were treated in our hospital.All patients were treated with metallic stent implantation in portal vein including 3 patients by TIPS and 5 by percutaneous transhepatic portal vein.Results All patients were successful in the stent implantation without any occurrence of serious complications such as intra-abdominal hemorrhage and so on.Intraoperative angiography showed blood circulated freely in these stents.1 day-2 weeks later,the patients symptoms of abdominal pain and gastrointestinal bleeding were obviously relieved or disappeared.Follow up 1 month-3 years,1 patient with stent occlusion after one year of operation,the blood flow recovery after stent reimplantation,and the remaining patients,color doppler ultrasound reflected patency of blood flows in their stents.No one suffered from gastrointestinal bleeding or abdominal pain again.Conclusion Implantation of portal vein metallic stent via percutaneous transhepatic portal vein or via TIPS in treatment of cavernous transformation of portal vein is safe and effective.
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Objective To investigate the multi -slice CT angiography(MSCTA)findings and explore the clinical value of cavernous transformation of the portal vein(CTPV).Methods CT and clinical materials of 29 cases CTPV were retrospectively analyzed.Results Portal vein obstruction and surrounding fine dialated portoportal collat-erals were found in all 29 cases,Gastroesophageal varices and abnormal hepatic perfusion signs were detected in 25 patients and 8 cases respectively.Pericholedochal venous plexus and cystic vein were dilated and varicose in 9 cases. Conclusion Multi -slice CT has an important clinical role in CTPV diagnosis and treatment,and it can be used to evaluate the the portal vein obstructed status,the collateral vessels,and the accompanied complications of CTPV.
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Objective To study the therapeutic efficacy of Rex shunt in treating pediatric patients with prehepatic portal hypertension (PHPH).Methods Five children with PHPH who were admitted from October 2014 to May 2015 were reviewed.There were three boys and two girls,with age ranging from 50 to 95.5 months [(75.8 ± 1.9) months].They all suffered from recurrent upper gastrointestinal (GI) bleeding.Their red blood cell (RBC),white blood cell (WBC) and platelet (PLT) counts were decreased,but laboratory findings revealed no liver dysfunction.Ultrasound and CT scan diagnosed cavernous transformation of portal vein (CTPV) and splenomegaly.The mean splenic length was (42.8 ± 8.2) cm.Indirect portal venography revealed patent left portal vein.All patients underwent Rex shunt and were followed up for 3 ～ 7 months.Results The mean duration of operation was (566.0 ± 39.7) min.Intraoperative bleeding varied from 10 to 50 ml.The portal pressure significantly decreased after surgery from [(25.6 ± 1.5) mmHg,1 mmHg =0.133 kPa] preoperatively to (19.2 ± 3.3) mmHg postoperatively (P ＜ 0.05).Portal venography indicated patent left portal vein after the Rex shunt.The postoperative course was uneventful in the five patients with a mean hospital stay of (26 ± 9.3) days.There was no further GI bleeding.The RBC,WBC and PLT counts increased.Ultrasound indicated patent anastomotic stomas and decreased splenic size.Conclusion A Rex shunt in treating patients with PHPH is safe,feasible and efficacious.
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The present report describes the case of a child that after blunt abdominal trauma presented with portal thrombosis followed by progressive splenomegaly and jaundice. Ultrasonography and percutaneous cholangiography revealed biliary dilatation secondary to choledochal stenosis caused by dilated peribiliary veins, characterizing a case of portal biliopathy. The present case report is aimed at presenting an uncommon cause of this condition.
Relata-se o caso de uma criança que após trauma abdominal fechado apresentou trombose portal, seguida por esplenomegalia progressiva e icterícia. Os achados da ultrassonografia e da colangiografia percutânea mostraram dilatação de vias biliares secundária à constrição do colédoco por veias pericoledocianas dilatadas, configurando caso de colangiopatia portal. O objetivo deste relato é a apresentação de causa incomum desta condição.
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Extensive thrombosis of the portal and splenomesenteric veins combined with cavernous transformation of the portal vein (CTPV) has been considered to be a contraindication for living donor liver transplantation (LDLT) due to technical difficulties and perioperative risks. In recent years, several surgical innovations including cavoportal hemitransposition, renoportal anastomosis, and portal arterialization have been introduced to overcome diffuse portal vein thrombosis (PVT) and CTPV, but their outcomes were unsatisfactory with significant morbidity and mortality. Herein, we report two successful cases of adult LDLT in diffuse PVT with CTPV managed using the paracholedochal vein as portal inflow to the graft.
Subject(s)
Adult , Humans , Liver Transplantation , Living Donors , Mortality , Portal Vein , Thrombosis , Transplants , Veins , Venous ThrombosisABSTRACT
Objective To retrospectively analyze the therapeutic effect of ligaturing pericardial blood vessel combined splenectomy for treating children with gastrointestinal bleeding and hypersplenism secondary to cavernous transformation of portal vein (CTPV).Methods Retrospectively analyzed 30 cases of children with CTPV admitted by Beijing Children's Hospital in General Surgery Department from Jan.2005 to Dec.2012,and evaluated the clinical efficacy of ligaturing pericardial blood vessel combined splenectomy for treating children with gastrointestinal bleeding and hypersplenism secondary to CTPV.Results All of 30 cases admitted operation without serious complication.All children admitted follow-up from 6 to 60 months.Seven cases of 22 patients with gastrointestinal bleeding relapsed bleeding post operation and were cured by conservative treatment.Four cases of 7 relapsing bleeding children had NSAID.All cases of 8 children with simple hypersplenism suggested normal results of blood routine post operation,2 children occurred bloody stools who were cured by conservative treatment.None of patients had serious infection correlating with splenectomy.The size of spleen of patients with gastrointestinal bleeding is larger than patients with simple hypersplenism.Conclusions (1) Ligaturing pericardial blood vessel combined splenectomy is a good choice for children with gastrointestinal bleeding and hypersplenism secondary to CTPV.(2) NSAID may increase the recurrence rate of gastrointestinal bleeding post operation.(3) There may be a negative correlation between the size of spleen and the risk of gastrointestinal bleeding for children with CTPV.
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Objective To evaluate the therapeutic efficacy of percutaneous transhepatic portal vein balloon angioplasty in treating cavernous transformation of portal vein following operation of congenital choledochal cyst. Methods From 2012 to 2014, a total of 6 patients with cavernous transformation of portal vein which occurred after the operation of congenital choledochal cyst were encountered at authors’ hospital. The clinical data were retrospectively analyzed. Before treatment, all patients presented symptoms of different degrees of hematemesis. Percutaneous transhepatic portal vein balloon angioplasty was carried out in all patients, and embolization of gastric coronary vein with coils was employed if angiography showed that coronary vein of stomach was pronouncedly dilated. The clinical manifestations, the imaging materials and the complications were analyzed. All the patients were followed up for 3 - 31 months. Results Of the 6 patients, portal vein main stem occlusion was found in 5 and severe localized stenosis was seen in one. Cavernous transformation of portal vein was revealed in all the 6 patients. Percutaneous transhepatic portal vein balloon angioplasty was successfully accomplished in 5 patients and failed in one patient. Embolization of gastric coronary vein with coils was performed in two patients. After the treatment, no treatment-related severe complications occurred in all patients. The follow-up period ranged from 3 to 31 months. During the follow-up period portal vein maintained patent in 5 patients. No recurrent hematemesis occurred in all patients. Conclusion For the treatment of cavernous transformation of portal vein occurring after the operation of congenital choledochal cyst, percutaneous transhepatic portal vein balloon angioplasty is a safe, effective and minimally - invasive therapeutic means.
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Objective To explore more safe and effective method for the treatment of common bile duct stones combined with cavernous transformation of the portal vein (CTPV).Methods We report 2 cases of post-treated patients in this series.In order to avoid severe bleeding caused by dissection of bile duct,we applied different methods to remove common bile duct stones compared with traditional operation.We removed common bile duct stones in one patient through cystic duct approach during operation.Two years later,we performed endoscopic duodenal incision (endoscopic sphincterotomy,EST) for him because of lower common bile duct stenosis with sand like stone.Another patient,on the other hand,we conducted the duodenal papilla incision during operation and removed common bile duct stones with choledochoscope through the bottom of common bile duct.Result Of the two patients,all of the three kinds of operation had good curative effects.Conclusions For the patients with common bile duct stones combined with CTPV,we should select appropriate treatments to avoid dissection of bile duct in front of the dilated and tortuous collateral veins during the operation,which is the key to guarantee the safety and success of the operation.EST is the preferred method of the treatment.Open operation with choledochoscopy via cystic duct approach or duodenal papilla incision through distal common bile duct to perform stone extraction also appears to be effective and safe.
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The main clinical symptoms of the patients are upper gastrointestinal tract haematemesis,hypersplenotrophy and hypersplenia.Most cases can be detected by ultrasonography,digital subtraction angiography(DSA),multislice CT(MSCT) or magnetic resonance angiography(MRA).Rex surgery,Hassab surgery or combination the shunt and disconnection combined operation et al are the preferred operation,therapy for children's cavernous transformation of portal vein will be further developed.The relevant literatures were collected in recent years to review the advancement of surgical therapy for children's cavernous transformation of portal vein.
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ObjectiveTo investigate the value of MRI in the diagnosis of cavernous transformation of the portal vein (CTPV).MethodsPlain MRI,dynamic enhanced and (or) dynamic contrast enhanced magnetic resonance angiography(DCE-MRA) findings in 30 patients of clinical-proved CTPV were retrospectively analyzed.ResultsAmong 30 CTPV patients on plain MRI,obliteration of main and (or) branched portal vein were found,and mass-like or reticular abnormal soft-tissue signals were around the vein,which were produced by collateral vessels.On dynamic enhanced MRI,abnormal hepatic perfusion during arterial phase and abnormal enhanced collateral veins during portal phase could be seen.The above signs became more obvious on DCE-MRA.ConclusionsMRI and DCE-MRA can clearly visualize the anatomical features of CTPV.It is important and can provide the reliable evidence for planning properly therapeutic protocol to recognize and directly evaluate the CTPV.
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Cavernous transformation of portal vein accounts for about 40％ in children portal hypertension.Compared with other causes of portal hypertension disease cavernous transformation of portal vein presents early age of disease onset,high risk of bleeding and normal liver function.Because the pathology is relatively simple and most children have no other diseases,so a reasonable treatment of the disease has decisive significance.The current concept for diagnosis and treatment of the disease is different between home and abroad,Controlling upper gastrointestinal bleeding is the main purpose in out country.Reliving hypersplenism,improving liver blood supply and quality of life are much important abroad,The article aims to summarize latest foreign literature to introduce latest research for the disease abroad.
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Objective: To summarize the major ultrasonic manifestations of various hepatic vascular anomaly(HVA), so as to improve the ultrasonic diagnosis rate of HVA. Methods: The chief complaints, timing and mode of ultrasonic diagnosis of 18 patients with congenital HVA or post-liver transplantation HVA were retrospectively analyzed. Six of the 18 patients were subjected to detailed analysis. The major ultrasonic manifestations of various HVA were observed and experience of ultrasonic diagnosis was summarized. Results: The major vascular abnormalities in our group included hepatic vascular fistula (including fistulas between artery and vein, artery and portal vein, portal vein and hepatic vein, also a complex fistula among artery, portal vein and hepatic vein), portal aneurysm, congenital portal atresia and portal vein cavernous transformation; among which the portal atresia and the complex hepatic fistula involving hepatic artery, hepatic vein and portal vein were rarely described in the literature. Color Doppler ultrasound was the first choice for detection and diagnosis of HVA; contrast-enhanced ultrasound was sensitive and specific in diagnosis of all vascular fistulas due to its ability to display homodynamic phase. Conclusion: The wide application of Doppler and contrast-enhanced ultrasound examination improves the detection and diagnosis of HVA; diagnosis should be made based on scientific diagnosis mode and precise diagnosis planning.