Variaciones anatómicas de la arteria hepática: patrones vasculares observados en 140 hígados de donante cadavérico / Anatomical variations of the hepatic artery: vascular patterns observed in 140 cadaveric donor livers

RESUMEN: El objetivo de este trabajo es analizar las variantes de la arteria hepática observadas en hígados de donantes cadavéricos empleados para trasplante ortotópico de hígado en nuestra población. Se efectuó un estudio retrospectivo de una cohorte de 140 trasplantes entre junio del año 2011 y enero del año 2021. La anatomía vascular arterial de los injertos hepáticos fue clasificada de acuerdo a la descripción de Hiatt. Variante clásica de la arteria hepática - Tipo I: 62 casos (65,7 %). Variante no clásica de la arteria hepática: 48 casos (34,3 %), correspondientes a: Tipo II: 12 casos (8,6 %), Tipo III: 18 casos (12,9 %), Tipo IV: 7 casos (5 %), Tipo V: 10 casos (7,1 %). No se encontró ningún caso de variante Tipo VI. Se halló 1 caso (0,7 %) no descrito en esta clasificación correspondiente a una arteria hepática izquierda accesoria que se originaba de la aorta. El conocimiento preciso de las variaciones más prevalentes, y también de las menos frecuentes, es fundamental para los procedimientos quirúrgicos que se realizan en el abdomen superior.

SUMMARY: The purpose of this article is to analyze the hepatic artery variations observed from the use of cadaveric donor livers for orthotopic transplantation among our population. A retrospective study of a liver transplant cohort including 140 donor livers was conducted between June 2011 and January 2021. The vascular arterial anatomy of the transplanted livers was classified according to Hiatt's classification system. Classic hepatic artery variant: Type I: 62 cases (65.7 %). Non-classic hepatic artery variants: 48 cases (34.3 %), corresponding to: Type II: 12 cases (8.6 %), Type III: 18 cases (12.9 %), Type IV: 7 cases (5 %), Type V: 10 cases (7.1 %). No case of Type VI variant was identified. One case (0.7 %) not included in Hiatt's classification was found, corresponding to an accessory left hepatic artery originating from the aorta. Precise knowledge regarding the most prevalent variations, as well as those that are the least common, is fundamental to upper abdominal surgical procedures.

Doppler hepático na pré-eclâmpsia e na síndrome HELLP / Doppler ultrasonography of the liver in pre-eclampsia and HELLP syndrome

O fígado está entre os múltiplos órgãos que podem ser afetados na pré-eclâmpsia, e a função hepática pode ser gravemente prejudicada na síndrome HELLP. A ultrassonografia com Doppler constitui um método não invasivo que pode ser usado para o estudo da circulação hepática durante a gravidez. Com o objetivo de apresentar as evidências científicas disponíveis sobre as alterações do fluxo hepático na gravidez, foi realizada pesquisa da literatura mundial por meio das bases de dados MEDLINE/PubMed e LILACS. Em estudos de Dopplerfluxometria e Dopplervelocimetria, isoladamente ou associados ao eletrocardiograma e cardiografia por impedância, foram observadas alterações na circulação hepática durante a gravidez complicada por pré?eclâmpsia e síndrome HELLP. Entre os desafios para a pesquisa nesse campo destacamos a necessidade de aperfeiçoamento da técnica de exame, o estabelecimento de curvas de normalidade para as gestantes brasileiras, de indicadores de agravamento da pré?eclâmpsia e a aplicação potencial do método para o estudo da hipertensão crônica na gravidez.(AU)

The liver is among multiple organs that may be affected in pre-eclampsia, and liver function can be impaired in HELLP syndrome. Doppler ultrasonography of the liver provides a noninvasive method to study liver circulation during pregnancy. This paper reviews scientific evidence available in MEDLINE/ Pubmed and LILACS databases. Doppler studies on hepatic blood flow, flow velocities and vascular resistance indices, isolated or combined with Doppler?electrocardiography and impedance cardiography, observed changes in pregnancies complicated by pre?eclampsia and HELLP syndrome. Challenges to this research topic include improvements in Doppler examination techniques, establishment of normal values for Brazilian pregnant women, predictors for severe pre?eclampsia and potential use of hepatic Doppler use in chronic hypertension as well.(AU)

Resecciones hepáticas sin tecnología de punta: ocho años de experiencia / Liver resection without advanced technologies: eight years experience

Introducción. Las hepatectomías son intervenciones quirúrgicas de gran envergadura. En la mayoría de los centros que las realizan, la tecnología es un importante soporte para su ejecución. El objetivo del estudio fue comparar los resultados obtenidos sin tecnología de última generación con los logrados en centros donde sí se utiliza. Diseño. Es un estudio retrospectivo, observacional y transversal. Se llevó a cabo en la Clínica Sucre, centro privado de tercer nivel. Material y métodos. Se analizaron 72 resecciones hepáticas en 68 pacientes. Los datos recolectados fueron: sexo, edad, enfermedad, tipo de resección practicada, procedimientos quirúrgicos asociados, volumen de sangre transfundida, estadía hospitalaria, morbilidad y mortalidad. La sección parenquimatosa se hizo con una técnica denominada “kellyclasia”. En la superficie de corte se colocó una compresa embebida en solución fisiológica caliente durante unos minutos. Resultados. De las 72 resecciones, 21 fueron mayores; en 19 ocasiones se asoció otro procedimiento quirúrgico. Catorce pacientes tenían cirrosis hepática. Se requirió transfusión de sangre en 26 pacientes, con una media de 807,6 ml, en 6 de los cuales se utilizó la técnica de autotransfusión por hemodilución normovolémica. El tiempo operatorio tuvo una media de 112 minutos. La morbilidad fue de 34,72 % y la mortalidad, de 5,5 %. Conclusión. Los resultados obtenidos son similares a los presentados en diferentes series. La ausencia de tecnología de última generación no es indispensable a la hora de obtener buenos resultados.

Background: Liver resection is a major type of surgery. Advanced technology as used in different centers constitutes an important support for its adequate performance. Aim: To compare our results without the use of advanced technologies with those of centers that have them available. Hypothesis: Technology is not indispensable in liver resection. Setting: Clínica Sucre, a tertiary level of care private Center. Design: Observational retrospective and transverse analysis. Material and methods: 72 hepatectomies performed in 68 patients were analyzed. Sex, age, pathology, type of liver resection, associated procedures, blood transfusion, hospital stay, morbidity and mortality rates were evaluated. Parenchymal section was made with “kellyclasie”. In the transection surface a warm water soaked-up compress was placed for a few minutes. Results: there were 21 major hepatectomies. In 19 opportunities an associate procedure was required. Cirrothic liver was present in 14 patients. Blood transfusion was used in 26 cases (transfusional media 807.6 ml), 6 of them with normovolemic hemodilution. Surgical time showed a media of 112 minutes. Morbidity rate was 34.72 % and mortality rate 5.5 %. Conclusion: Our results are similar to those published by centers that use advanced technology for liver resection.

Acesso venoso trans-hepático percutâneo para hemodiálise: uma alternativa para pacientes portadores de insuficiência renal crônica / Percutaneous transhepatic venous access for hemodialysis: an alternative route for patients with end-stage renal failure

CONTEXTO: Acesso venoso trans-hepático percutâneo para hemodiálise é uma opção para pacientes que já exauriram acessos venosos tradicionais. OBJETIVO: Apresentar uma série de casos que demonstram a factibilidade e a funcionalidade da implantação dos cateteres semi-implantáveis por meio de acesso venoso trans-hepático percutâneo em pacientes sem possibilidades de outros acessos. MÉTODOS: Análise observacional retrospectiva dos prontuários de seis pacientes que foram submetidos à implantação de nove cateteres trans-hepáticos percutâneos para hemodiálise. Os cateteres foram implantados na ausência de acessos venosos periféricos disponíveis. No seguimento dos pacientes, procurou-se avaliar: sucesso técnico do procedimento, taxa de complicação, taxa de infecção e patência do acesso. RESULTADOS: Quatro homens e duas mulheres com idades entre 31 e 85 anos (média: 55 anos). Sucesso técnico obtido em 100 por cento. A média de duração dos cateteres foi de 300,5 dias (2 a 814 dias). Médias de patência primária e secundária foram de 179,60 e 328,33 dias, respectivamente. Taxa de trombose dos cateteres foi de 0,05 por 100 cateteres-dias, assim como a taxa de infecção. Houve três complicações precoces (30 primeiros dias de implantação dos cateteres): dois deslocamentos dos cateteres e uma infecção. Duas complicações tardias foram observadas: uma trombose e uma migração. Três pacientes (50 por cento) tiveram que trocar seus cateteres. Taxa de mortalidade em 30 dias foi de 33 por cento, porém não relacionada ao procedimento. CONCLUSÃO: Implantação do cateter para hemodiálise por meio do acesso venoso trans-hepático percutâneo parece ser uma técnica segura, porém a utilização desse acesso deve ser aplicada somente em casos de esgotamento de outros acessos vasculares profundos.

BACKGROUND: Percutaneous transhepatic venous access is an option for hemodialysis patients who have exhausted all traditional sites of venous access. OBJECTIVES: To present a small sample regarding the possibility and the functionality of transhepatic implantation of long-term catheters for hemodialysis in patients with no other possible access routes. METHODS: Retrospective observational analysis was made of the charts of six patients in which nine tunneled dialysis catheters were implanted by the percutaneous transhepatic route. Transhepatic catheters were placed in the absence of an available peripheral venous site. Patients were monitored to evaluate technical success, the complication rate, the infection rate and the duration of catheter patency. RESULTS: Four men and two women aged 31 to 85 years (mean age: 55 years). Technical success was 100 percent. The mean duration of catheter function was 300.5 days (range: 2 to 814 days). Means of primary and secondary patency were 179.60 and 328.33 days, respectively. The catheter thrombosis rate was 0.05 per 100 catheter-days as the infection rate. There were three early complications (within the first 30 days of catheter implantation): two catheter displacement and one infection. Two late complications were observed: one thrombosis and one migration. Three patients (50 percent) needed to have their catheters changed. The 30-day mortality rate was 33 percent but with no relation to the procedure. CONCLUSION: It may be suggested that this technique is safe, however transhepatic hemodialysis catheters may be used in patients with no other options for deep venous access for hemodialysis, albeit as a last resort access route.

Study on the influence of the postoperative hepatic function in hemihepatectomy for hepatoma / 中国基层医药

Objective To explore the clinical significance and safety in hemihepatectomy for hepatoma without inflow occlusion.Methods A total of 62 patients with liver cancer were divided into 2 groups.The inflow was occluded in group A (n = 28) and not occluded in group B (n = 34) during hepatectomy.Subsequently,the influence of the two approaches on the parameters including intraoperative blood loss,postoperative hepatic function and complications incidence rate was comparatively analyzed.Results Hepatectomy was successfully performed in the two groups.There was no significant difference between the two groups in intraoperative blood loss (P ＞ 0.05).Significant difference existed between the two groups in postoperative hepatic function and complications incidence rate (P ＜ 0.05).Conclusions The hemihepatectomy for hepatoma without inflow occlusion can reduce complications incidence rate and profit the recovery of postoperative hepatic function parameters.

Importancia quirúrgica de la expresión morfológica de la arteria hepática y sus colaterales / Surgical importance of the morphological expression of the hepatic artery and its collaterals

La irrigación hepática ha sido ampliamente estudiada en diferentes grupos poblacionales mediante técnicas anatómicas directas e imaginológica, sin embargo los estudios se han caracterizado por mostrar los resultados de una manera que hacen difícil su comprensión al predominar el componente descriptivo de las muestras evaluadas o clasificaciones que por su complejidad no han sido adecuadamente asimiladas por la comunidad académica. Recientemente se clasificaron estas variantes según el origen de la irrigación hepática, agrupando en 3 grupos, cada uno con varios tipos. Se asimilaron los hallazgos de diferentes autores a esta clasificación y se promediaron, siendo el Grupo 1 tipo I considerado como patrón común el más frecuente (70.4%), además en el grupo 2 los tipos I y II tuvieron una frecuencia significativa. El conocimiento de los diferentes patrones de la irrigación hepática es indispensable para lograr abordajes exitosos durante procedimientos complejos, como el trasplante hepático, gastrectomías e intervenciones en la vía biliar, lo cual puede disminuir las complicaciones durante la realización de los mencionados intervenciones quirúrgicas; además el conocimiento del amplio espectro de la irrigación hepática se convierte en requisito que permite adecuadas interpretaciones imaginológicas; son estas las motivaciones que condujeron a la realización de esta revisión temática.

The hepatic irrigation has been widely studied in different population groups by means of anatomical direct skills imaginologic. However the studies have been characterized for showing the results in a way that its comprehension was difficult on having predominated over the descriptive component of the evaluated samples or classifications that for its complexity have not been assimilated properly by the academic community. Abdullah et al (2006) classified these variants as the origin of the hepatic irrigation, grouping in 3 groups, each one with several types. The finds of different authors resembled this classification and they were equally, being the Group 1 the type I considered as the most frequent common pattern (70.4%), also in the Group 2 the types I and II had a significant frequency. The knowledge of the different patterns of the hepatic irrigation is indispensable to achieve successful approaches during complex procedures as; the hepatic transplant, gastrectomies and interventions in the bile duct, which can diminish the complications during the achievement of the mentioned surgical interventions, furthermore the knowledge of this great spectrum of the hepatic irrigation turns into requisite for imaginologic interpretations, being this the motivation that led to the achievement of this thematic review.

Estudo morfométrico comparando duas alternativas de reconstrução da via de efluxo venoso do enxerto no método piggyback de transplante de fígado / Morphometric study comparing two methods of hepatic venous outflow reconstruction in piggyback liver transplantation

INTRODUÇÃO: No método piggyback de transplante de fígado (Tx), o pinçamento da veia cava inferior (VCI) do receptor é apenas parcial, permitindo a manutenção do retorno venoso durante a fase anepática sem a necessidade de utilização de desvio veno-venoso. A essa vantagem, contrapõe-se uma maior incidência de obstrução da drenagem venosa do enxerto, complicação que está relacionada com o tipo de reconstrução empregado. A implantação da VCI do enxerto no óstio das veias hepáticas média e esquerda (ME) do receptor tem sido evitada devido a uma maior freqüência de bloqueio venoso. Essa incidência diminui quando são empregadas a anastomose látero-lateral (LL) ou a implantação da VCI do enxerto no óstio das veias hepáticas direita, média e esquerda (DME) do receptor. Entretanto, essas reconstruções reduzem a eficiência do retorno venoso na fase anepática do Tx devido à constrição mais pronunciada da VCI durante o pinçamento necessário para a confecção da anastomose. A alternativa de utilizar o óstio formado pelas veias hepáticas direita e média (DM) pode propiciar uma constrição menor da VCI. Entretanto, esse benefício só se justifica se a via de efluxo venoso obtida não apresentar restrições anatômicas. O objetivo deste trabalho é comparar a congruência do perímetro da VCI com o perímetro das bocas anastomóticas e dos óstios de drenagem na VCI, obtidos por meio da utilização das modalidades DM e DME para a reconstrução do efluxo venoso no Tx piggyback. MÉTODO: Foram estudados prospectivamente 16 cadáveres frescos. Após a hepatectomia total, realizou-se o estudo morfométrico da confluência hepatocaval aferindo-se o perímetro da VCI (PVCI) e, nas reconstruções DM e DME, o perímetro das bocas anastomóticas (PDM e PDME) e dos óstios de desembocadura na VCI (PoDM e PoDME). Foram obtidas imagens digitalizadas de todos os perímetros. As medidas foram realizadas por meio do programa analisador de imagens KS300. A análise estatística foi realizada por meio de análise...

INTRODUCTION: In piggyback liver transplantation (LT), partial clamping of the recipient inferior vena cava (IVC) preserves the venous return of the lower extremities during the anhepatic phase precluding the use of venovenous bypass. The incidence of hepatic venous outflow obstruction after piggyback LT varies according to the type of venous reconstruction. Anastomosis between the cranial portion of the graft IVC and common stump of the middle and left hepatic veins (ME) of the recipient has been avoided due to a higher frequency of hepatic venous outflow obstruction. This incidence decreases when a cavo-caval side-to-side anastomosis (SS) or the ostium of the three main hepatic veins of the recipient (RML) are used. On the other hand, venous return is reduced in these modalities due to a more pronounced constriction during the IVC clamping. The use of the ostium formed by the right and middle hepatic veins (RM) may limit IVC constriction. However, this benefit is only justified if a hepatic venous outflow tract with no anatomical restrictions can be obtained. The aim of this study is to compare the congruence of the IVC perimeter with the perimeter of the venous outflow tract at the anastomotic site and also its opening into the IVC both in the RM and RML modalities. METHODS: Sixteen fresh human cadavers were prospectively studied. After total hepatectomy, a morphometric study of the hepatocaval confluence was done by measuring the perimeter of the IVC (IVCP) and, in RM and RML reconstructions, the perimeter of the venous outflow tract at the anastomotic site (RMP and RMLP) and at its opening into the IVC (RMoP and RMLoP). Digital images of all perimeters were obtained. The measurements were accomplished utilizing the KS300 image analysis software. The statistical analysis was performed using analysis of variance (ANOVA) for repeated measures. Statistical significance was established when the p value was less than 0.05. RESULTS: Examinations were...

Liver Circulation Obstruction in Advanced Chronic Cor Pulmonale in the Acute Attack Period / 中国医师杂志

Objective To study the change of live circulation in advanced chronic cor pulmonale.Methods Determination of blood gas,liver function and rheohepatogram were performed in twenty-eight patients with chronic cor pulmonale in acute attack period before treatment,and accounted for the cardiac output(CO),hepatic blood flow(HBF),hepatic artery blood flow(HABF) and portal vein blood flow(PVBF).Results The experimental group was compared with the control group,the HBF,HABF and PVBF were decreased,which was more dramatic in the patients with chronic cor pulmonale,who had right ventricular failure complication in the acute attack period.Conclusion In acute attack period of chronic cor pulmonale,the liver circulation obstruction occurs early,and it is the main cause of liver damage for the patients.