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Hepatic encephalopathy (HE) is a type of serious brain dysfunction caused by acute or chronic liver failure or portosystemic shunt, with the clinical manifestation of neuropsychiatric abnormalities. The incidence rate of HE is 16%-21% in patients with liver cirrhosis. Spontaneous portosystemic shunt (SPSS) is one of the major pathogenesis of HE and is observed in 60%-70% of the patients with liver cirrhosis, and the size, number, and location of SPSS are directly associated with the development of HE. The development and wide application of imaging technology help to achieve a more convenient and accurate diagnosis of SPSS. Although interventional vascular embolization of SPSS has achieved a satisfactory clinical outcome in some cirrhotic patients with HE, high-quality clinical studies are still needed.
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Background:@#Portosystemic shunts, including surgical portosystemic shunts and transjugular intra-hepatic portosystemic shunt (TIPS), may have benefit over endoscopic therapy (ET) for treatment of variceal bleeding in patients with cirrhotic portal hypertension; however, whether there being a survival benefit among them remains unclear. This study was to compare the effect of three above-mentioned therapies on the short-term and long-term survival in patient with cirrhosis.@*Methods:@#Using the terms "variceal hemorrhage or variceal bleeding or variceal re-bleeding" OR "esophageal and gastric varices" OR "portal hypertension" and "liver cirrhosis," the Cochrane Central Register of Controlled Trials, PubMed, Embase, and the references of identified trials were searched for human randomized controlled trials (RCTs) published in any language with full texts or abstracts (last search June 2017). Risk ratio (RR) estimates with 95% confidence interval (CI) were calculated using random effects model by Review Manager. The quality of the included studies was evaluated using the Cochrane Collaboration’s tool for the assessment of the risk of bias.@*Results:@#Twenty-six publications comprising 28 RCTs were included in this analysis. These studies included a total of 2845 patients: 496 (4 RCTs) underwent either surgical portosystemic shunts or TIPS, 1244 (9 RCTs) underwent either surgical portosystemic shunts or ET, and 1105 (15 RCTs) underwent either TIPS or ET. There was no significant difference in overall mortality and 30-day or 6-week survival among three interventions. Compared with TIPS and ET, separately, surgical portosystemic shunts were both associated with a lower bleeding-related mortality (RR = 0.07, 95% CI = 0.01–0.32; P < 0.001; RR = 0.17, 95% CI = 0.06–0.51, P < 0.005) and rate of variceal re-bleeding (RR = 0.23, 95% CI = 0.10–0.51, P < 0.001; RR = 0.10, 95% CI = 0.04–0.24, P < 0.001), without a significant difference in the rate of postoperative hepatic encephalopathy (RR = 0.52, 95% CI = 0.25–1.00, P = 0.14; RR = 1.09, 95% CI = 0.59–2.01, P = 0.78). TIPS showed a trend toward lower variceal re-bleeding (RR = 0.46, 95% CI = 0.36–0.58, P < 0.001), but a higher incidence of hepatic encephalopathy than ET (RR = 1.78, 95% CI = 1.34–2.36, P < 0.001).@*Conclusions:@#The overall analysis revealed that there seem to be no short-term and long-term survival advantage, but surgical portosystemic shunts are with the lowest bleeding-related mortality among the three therapies. Surgical portosystemic shunts may be the most effective without an increased risk of hepatic encephalopathy and TIPS is superior to ET but at the cost of a higher incidence of hepatic encephalopathy. However, some of findings should be interpreted with caution due to the lower level of evidence and the existence of significant heterogeneity.
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Introduction: The right hepatic lobe transplantation is usually the procedure of choice to provide adequate livervolume to the recipient. Variant vascular and biliary anatomy is more common in the right lobe. Knowledge ofanatomical variants is valuable in preoperative planning, particularly in considering donor candidates foradult-to-adult liver transplantation, whereby typically the right lobe of the donor is transplanted to the recipient.The present study was done to identify the branching patterns of right portal vein and to know their importancein management of living donor liver transplantation surgeries.Material and Methods: The present study was conducted on 84 liver specimens of human cadavers fixed with10% formalin, collected from the Department of Anatomy and Forensic Medicine, MMC&RI, Mysore.Results: Bifurcation of RPV was seen in 30 specimens (35.7%). Trifurcation of RPV was seen in 5 specimens (6%).Quadrification of RPV was seen in 18 specimens (21.4%). Arched pattern of RPV was seen in 15 specimens(17.9%). Premature origin of segment V and segment VIII vein from RPV, then trunk of RPV dividing terminally intosegment VI and segment VII vein was seen in 2 specimens (2.4%). Unusual pattern of division of RPV was seen in10 specimens (12%). In rest of 4 specimens there was no RPV as Right anterior and Right posterior portal veinswere directly arising from Main portal vein.Conclusion: Anatomical variations of the liver vasculature and bile ducts are common and their recognition andmanagement is critical in living donor liver transplantation. Although anomalies of the right lobe are commonlyencountered, a relatively limited number of cases will significantly complicate the resection and transplantation.Main advantage of right lobe transplantation is the large size of graft and surgical management of both donorand recipient anatomical variations is considerably simpler than with left sided graft
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Objective To evaluate the color Doppler ultrasonography and contrast enhanced ultrasound (CEUS) findings of congenital intrahepatic portosystemic venous shunts (IPSVS).Methods Nineteen patients of congenital IPSVS were examined with color Doppler ultrasonography and CEUS.All patients were confirmed by CT angiography.The hepatic artery arrival time (HAAT),portal vein arrival time (PVAT),and hepatic vein arrival time (HVAT) on CEUS were recorded.The interval time between hepatic artery arrival time and hepatic vein arrival time (HA-HVTT) and the interval time between portal vein arrival time and hepatic vein arrival time (PV-HVTT) were calculated.Results The types of IPSVS between portal and systemic veins were based on Park's classification.Color Doppler ultrasonography showed abnormal communication between the portal vein branch and the hepatic veins,duplex Doppler ultrasonography showed abnormal spectral pattern from the portal vein such as undulating,triphasic waveform mimicked that of the hepatic vein.CEUS demonstrated abnormal communication between portal vein branch and hepatic vein.HVAT,HA-HVTT,and PV-HVTT were shorter statistically in congenital IPSVS group than those in cirrhosis and normal groups.Conclusions Congenital IPSVS is a rare vascular abnormality that is usually asymptomatic.Color Doppler ultrasonography is a useful tool for diagnosis of congenital IPSVS.CEUS provides helpful data for the diagnosis and differential diagnosis of congenital IPSVS.
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No abstract available.
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Humans , Male , Hepatic Encephalopathy/congenital , Liver Neoplasms/congenital , Portal Vein/abnormalities , Septal Occluder DeviceABSTRACT
PURPOSE: Congenital intrahepatic portosystemic shunts are rare disease and clinically asymptomatic shunts may be detected by chance on ultrasonogram before and after birth. We studied clinical course, treatment and prognosis of congenital intrahepatic portosystemic shunt at prenatal or neonatal period. METHODS: Medical records of 8 patients which were diagnosed in intrahepatic portosystemic shunt in Cheil General Hospital from 2006 through 2010 were reviewed retrospectively. RESULTS: Eight patients with congenital intrahepatic portosystemic shunts were identified. Six patients were diagnosed at prenatal radiological screening, including three cases of intrauterine growth restriction and two cases of preterm baby. One case with increased serum ammonia underwent coil embolization. In four cases including one case that presented elevated direct bilirubin, shunts were closed spontaneously within 11th month after birth. Two patients were diagnosed on abdominal sonogram after birth because of elevated direct hyperbilirubinemia, all of whom presented intrauterine growth restriction. Closure of shunts was confirmed during 4th month to 6th month. CONCLUSION: Congenital intrahepatic portosystemic shunts are clinically asymptomatic mostly and spontaneous closure is expected within 2 years age. But occasionally they have severe complication, so clinical and radiological observation is needed. Specially in cases of intrauterine growth retardation without evident cause, the possible diagnosis of congenital intrahepatic portosystemic shunts should be considered and prenatal and postnatal examination should be performed. When prenatal diagnosis is made, fetal wellbeing should be monitored periodically until spontaneous closure of shunts.
Subject(s)
Humans , Ammonia , Bilirubin , Fetal Growth Retardation , Hospitals, General , Hyperbilirubinemia , Mass Screening , Medical Records , Parturition , Portasystemic Shunt, Surgical , Prenatal Diagnosis , Prognosis , Rare DiseasesABSTRACT
Objective To study the effects of ePTFE-covered stents versus bare stents on portal hemodynamics in portal hypertensive patients receiving TIPS. Methods Sixty patients with portal hypertension underwent TIPS with 8 mm diameter bare stents and ePTFE-covered stent from April 2007 to April 2009. The clinical outcomes were observed after TIPS, and the hemodynamics of potal vein system were studied before and after TIPS and during the follow up using direct portography and color Doppler ultrasound technique. Results TIPS procedures were successful in all patients without major complications. The follow-up of patients with bare stents were (8 ± 4) months and follow-up of ePTFEcovered stents group were (6 ± 4) months. Immediately after the TIPS the portosystemic pressure gradient of the two groups decreased by 60% and 58%, respectively(t =0.79, P >0.05). During the follow-up,portosystemic pressure gradient of bare stents group increased gradually, while that in ePTFE-covered stents group maintained low portosystemic pressure gradient (13.2 ± 1.2) mm Hg vs. (9. 5 ± 2. 9) mm Hg, P =0. 015. The blood velocity and volume of venous return of potal vein system were significantly higher in ePTFE-covered stents group than in bare stents group during the follow-up using color Doppler ultrasound method. The blood velocity and volume of the shunts were significantly higher in covered stents group than in bare stents group after 1 year, (125 ±20) cm/s vs. (88 ±13) cm/s, and (1816 ±380) ml/min vs.(1074 ±239) ml/min, respectively P<0. 01. Conclusions In TIPS patients with ePTFE-covered stents high blood velocity and low portosystemic pressure gradient sustained in contrast with those using bare stents.
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Objective To test the hypothesis that locally direct gene transfer of human vascular endothelial growth factor(phVEGF) 165 could passivate hepatic venous metallic stents by accelerating endothelialization and augmenting biocompatibility of endovascular stent. Methods The complexes of pAdTrackCMV and lipofectamine was smeared homogeneously to the surface of stent coating with poly-1-lysine. Bare stainless steel stents were used as controls. All stents were implanted into the hepatic right vein by the procedure of transjugular intrahepatic venous stent deployment. Results At the end of 1 week after implantation, the site -specific expression of phVEGF was detected by RT-PCR. Green fluorescence and the expression of phVEGF gene were detected in the transfered stented vessel of the treatment group. These phenomena were not observed in the control group. Scanning electron microscopy revealed that the endothelialization of stent was more pronounced in the treatment group than that in control group. At the end of 8 weeks after implantation, quantitative angiography analysis showed the degree of internal diameter stenosis was less severe in the treatment group compared with the control group. Mean neointima thickness, mean neointima areas and percent cross-sectional area narrowing in treatment group was significantly fewer than that in the control group, respectively. Immunohistochemistry analysis revealed that the proliferation of vascular smooth muscle cells was more active in control group than that in the treatment group. Conclusions Local gene transfer of phVEGF165 can passivate endovascular stents by accelerating stents endothelization and enhancing their biocompatibility in hepatic vein, resulting in reducing thrombus formation and attenuating intimal hyperplasia.