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Clinics ; 76: e2184, 2021. tab, graf
Article in English | LILACS | ID: biblio-1153968


Non-tumoral portal vein thrombosis (PVT) is associated with higher morbidity and mortality in liver transplantation (LT). In this study, we aimed to evaluate the impact of PVT in LT outcomes and analyze the types of surgical techniques used for dealing with PVT during LT. A systematic review was conducted in Cochrane, MEDLINE, and EMBASE databases, selecting articles from January 1990 to December 2019. The MESH-terms used were ("Portal Vein"[Mesh] AND "Thrombosis"[Mesh] NOT "Neoplasms"[Mesh]) AND ("Liver Transplantation"[Mesh]). The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) recommendation was used, and meta-analysis was performed with Review Manager Version 5.3 software. A total of 1,638 articles were initially found: 488 in PubMed, 289 in Cochrane Library, and 861 in EMBASE, from which 27 were eventually selected for the meta-analysis. Surgery time of LT in patients with PVT was longer than in patients without LT (p<0.0001). Intraoperative red blood cell (p<0.00001), fresh frozen plasma (p=0.01), and platelets (p=0.03) transfusions during LT were higher in patients with PVT. One-year (odds ratio [OR] 1.17; p=0.002) and 5-year (OR 1.12; p=0.01) patient survival after LT was worse in the PVT group. Total occlusive PVT presented higher mortality (OR 3.70; p=0.00009) and rethrombosis rates (OR 3.47 [1.18-10.21]; p=0.02). PVT Yerdel III/IV classification exhibited worse 1-year [2.04 (1.21-3.42); p=0.007] and 5-year [0.98 (0.59-1.62); p=0.93] patient survival. Thrombectomy with primary anastomosis was associated with better outcomes. LT in patients with non-tumoral PVT demands more surgical time, needs more intraoperative transfusion, and presents worse 1- and 5-year patient survival. Total occlusive PVT and Yerdel III/IV PVT classification were associated with higher mortality. (PROSPERO, registration number: CRD42020132915).

Humans , Liver Transplantation , Venous Thrombosis , Portal Vein/surgery , Retrospective Studies , Treatment Outcome , Thrombectomy , Liver Cirrhosis
Article in Chinese | WPRIM | ID: wpr-921555


Objective To explore the feasibility of using ultrasound to evaluate stent placement for managing graft stenosis after Meso-rex bypass for cavernous transformation of the portal vein in adults. Methods This study enrolled the patients who underwent Meso-rex bypass due to cavernous transformation of the portal vein,were diagnosed graft stenosis by postoperative ultrasound,and then underwent percutaneous portal vein puncture portography and stent placement.We then compared the ultrasonic measurement indicators and sonographic manifestations before and after stent placement,and evaluated the alleviation of portal hypertension symptoms after stent placement and related clinical indexes. Results Finally,8 patients were enrolled in this study,including 5 males and 3 females,with an average age of(32.4±14.7)years.The median duration of follow-up was 26 months after stent placement.The mean diameter of graft stenosis was(2.74±0.23)mm after Meso-rex bypass and became wider[(7.23±0.68)mm]after stent placement(

Adolescent , Adult , Constriction, Pathologic , Female , Humans , Hypertension, Portal , Male , Middle Aged , Portal Vein/surgery , Portasystemic Shunt, Surgical , Stents , Treatment Outcome , Young Adult
ABCD arq. bras. cir. dig ; 33(1): e1484, 2020. tab, graf
Article in English | LILACS | ID: biblio-1088501


ABSTRACT Background: Hepatectomies promote considerable amount of blood loss and the need to administrate blood products, which are directly linked to higher morbimortality rates. The blood-conserving hepatectomy (BCH) is a modification of the selective vascular occlusion technique. It could be a surgical maneuver in order to avoid or to reduce the blood products utilization in the perioperative period. Aim: To evaluate in rats the BCH effects on the hematocrit (HT) variation, hemoglobin serum concentration (HB), and on liver regeneration. Methods: Twelve Wistar rats were divided into two groups: control (n=6) and intervention (n=6). The ones in the control group had their livers partially removed according to the Higgins and Anderson technique, while the rats in the treatment group were submitted to BCH technique. HT and HB levels were measured at day D0, D1 and D7. The rate between the liver and rat weights was calculated in D0 and D7. Liver regeneration was quantitatively and qualitatively evaluated. Results: The HT and HB levels were lower in the control group as of D1 onwards, reaching an 18% gap at D7 (p=0.01 and p=0.008, respectively); BCH resulted in the preservation of HT and HB levels to the intervention group rats. BCH did not alter liver regeneration in rats. Conclusion: The BCH led to beneficial effects over the postoperative HT and serum HB levels with no setbacks to liver regeneration. These data are the necessary proof of evidence for translational research into the surgical practice.

RESUMO Racional: As hepatectomias compreendem considerável perda sanguínea e utilização de hemoderivados, o que diretamente estão relacionados com maior morbimortalidade. A hepatectomia hemoconservadora (HH) é modificação da técnica de oclusão vascular seletiva em hepatectomia. Ela pode ser alternativa cirúrgica para evitar ou diminuir o uso de hemoderivados no perioperatório. Objetivo: Avaliar os efeitos da HH sobre o volume globular (VG), concentração de hemoglobina (HB) e sobre a regeneração hepática em ratos. Métodos: Dois grupos de ratos Wistar foram constituídos: controle (n=6) e intervenção (n=6). Os do grupo controle foram submetidos à hepatectomia parcial de Higgins e Anderson e os do grupo Intervenção à HH. VG e HB foram medidos nos dias D0, D1 e D7. A relação peso do fígado/peso do rato foi calculada em D0 e D7. A regeneração hepática foi analisada qualitativamente e quantitativamente. Resultados: Houve diminuição dos níveis de VG e HB nos ratos do grupo controle a partir de D1, atingindo decréscimo de 18% em D7 (p=0,01 e p=0,008 respectivamente); a HH permitiu a manutenção dos níveis de VG e HB nos ratos do grupo intervenção. A HH não alterou a regeneração hepática. Conclusão: HH resultou em níveis maiores de VG e HB pós-operatórios sem alterar a regeneração hepática. Pode-se considerar estes dados como a prova necessária para a translação à pesquisa clinicocirúrgica.

Animals , Male , Rats , Veins/physiology , Hepatectomy/methods , Liver/surgery , Liver/blood supply , Liver Regeneration , Portal Vein/surgery , Postoperative Period , Blood Volume/physiology , Hepatic Veno-Occlusive Disease/physiopathology , Hemoglobins/analysis , Rats, Wistar , Hematocrit
Einstein (Säo Paulo) ; 18: eRC4934, 2020. graf
Article in English | LILACS | ID: biblio-1056036


ABSTRACT Varicose gastrointestinal bleeding is one of the major causes of morbidity and mortality in patients with chronic liver disease. Endoscopic treatment is the first therapeutic line for these patients, however, for those whom this therapeutic modality fail, a broad knowledge of alternative treatment options may improve the prognosis. We describe a case of a patient who were successfully embolized from gastroesophageal varices via transsplenic access.

RESUMO O sangramento gastrointestinal varicoso está entre as maiores causas de morbimortalidade nos paciente com doença hepática crônica. O tratamento endoscópico é a primeira linha terapêutica neste pacientes, porém naqueles que apresentam falha nesta modalidade terapêutica, o amplo conhecimento de opções alternativas de tratamento pode melhorar o prognóstico. Descrevemos um caso de paciente submetido à embolização com sucesso de varizes gastresofágicas por acesso transesplênico.

Humans , Female , Adult , Splenic Vein/surgery , Esophageal and Gastric Varices/surgery , Embolization, Therapeutic/methods , Gastrointestinal Hemorrhage/surgery , Portal Vein/surgery , Splenic Vein/diagnostic imaging , Angiography/methods , Esophageal and Gastric Varices/diagnostic imaging , Tomography, X-Ray Computed/methods , Treatment Outcome , Ultrasonography, Doppler/methods , Venous Thrombosis/surgery , Gastrointestinal Hemorrhage/diagnostic imaging
Article in Chinese | WPRIM | ID: wpr-879917


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.

Child , Humans , Portal Vein/surgery , Portography , Retrospective Studies
Chinese Journal of Surgery ; (12): 835-840, 2020.
Article in Chinese | WPRIM | ID: wpr-878273


Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can speed up the regeneration of future liver remnant (FLR) in short period of time, and offer a chance for surgical resection for patients without sufficient FLR. However, ALPPS still remains controversy due to its high perioperative morbidity and mortality, as well as the uncertain long-term oncological benefits. How to solve these problems is the key to ensure the safety of surgery.This article focus on the indication selection, liver function reserve evaluation and timing to perform the second stage surgery, surgical mode evolution and comparison with portal venous embolization/portal venous ligation+two-stage hepatectomy.

Embolization, Therapeutic , Hepatectomy/methods , Humans , Ligation , Liver/surgery , Liver Neoplasms/surgery , Liver Regeneration , Portal Vein/surgery , Treatment Outcome
Acta cir. bras ; 34(11): e201901103, Nov. 2019. tab, graf
Article in English | LILACS | ID: biblio-1054680


Abstract Purpose: To evaluate liver regeneration after selective ligation of portal vein and hepatic artery by 3D Computed Tomography in an experimental model. Methods: Sixteen Wistar rats were randomized into four equal groups: Group I- control (sham), Group II- isolated selective ligation of the hepatic artery, Group III- isolated selective ligation of the portal vein and Group IV- combined ligation of portal vein and hepatic artery. Before procedure and five days after a 3D CT Scan was performed to analyze the hypertrophy, weight and function of the remnant liver. Results: The largest regeneration rate and increase of weight in the hypertrophied lobe was detected in group IV, the first with an average of 3.99 (p=0.006) and the last varying from 6.10g to 9.64g (p=0.01). However, total liver weight and the R1 ratio (Hypertrophied Lobe Weight/Total Liver Weight) was higher in group III (P<0.001) when compared with groups I, II and IV and showed no difference between them. The immunohistochemical examination with PCNA also found higher percentages with statistical significance differences in rats of groups III and IV. It was possible to confirm a strong correlation between hypertrophied lobe weight and its imaging volumetric study. Liver function tests only showed a significant difference in serum gamma-glutamyltransferase and phosphorous. Conclusion: There is a largest liver regeneration after combined ligation of portal vein and hepatic artery and this evidence may improve the knowledge of surgical treatment of liver injuries, with a translational impact in anima nobile.

Animals , Male , Portal Vein/surgery , Hepatic Artery/surgery , Liver/diagnostic imaging , Liver Regeneration/physiology , Organ Size/physiology , Immunohistochemistry , Random Allocation , Tomography, X-Ray Computed/methods , Reproducibility of Results , Treatment Outcome , Rats, Wistar , Imaging, Three-Dimensional/methods , Hepatomegaly/physiopathology , Hepatomegaly/diagnostic imaging , Ligation , Liver/blood supply , Liver/pathology
Arq. gastroenterol ; 56(3): 246-251, July-Sept. 2019. tab, graf
Article in English | LILACS | ID: biblio-1038717


ABSTRACT BACKGROUND: Pancreaticoduodenectomy (PD) with the resection of venous structures adjacent to the pancreatic head, even in cases of extensive invasion, has been practiced in recent years, but its perioperative morbidity and mortality are not completely determined. OBJECTIVE: To describe the perioperative outcomes of PD with venous resections performed at a tertiary university hospital. METHODS: A retrospective study was conducted, classified as a historical cohort, enrolling 39 individuals which underwent PD with venous resection from 2000 through 2016. Preoperative demographic, clinical and anthropometric variables were assessed and the main outcomes studied were 30-day morbidity and mortality. RESULTS: The median age was 62.5 years (IQ 54-68); 55% were male. The main etiology identified was ductal adenocarcinoma of the pancreas (82.1%). In 51.3% of cases, the portal vein was resected; in 35.9%, the superior mesenteric vein was resected and in the other 12.8%, the splenomesenteric junction. Regarding the complications, 48.7% of the patients presented some type of morbidity in 30 days. None of the variables analyzed was associated with higher morbidity. Perioperative mortality was 15.4% (six patients). The group of individuals who died within 30 days presented significantly higher values for both ASA (P=0.003) and ECOG (P=0.001) scores. CONCLUSION: PD with venous resection for advanced pancreatic neoplasms is a feasible procedure, but associated with high rates of morbidity and mortality; higher ASA e ECOG scores were significantly associated with a higher 30-day mortality.

RESUMO CONTEXTO: A duodenopancreatectomia (DP) com ressecção de estruturas venosas adjacentes à cabeça do pâncreas, mesmo em casos de invasão extensa, tem sido praticada nos últimos anos, mas sua morbidade e mortalidade perioperatórias não são completamente determinadas. OBJETIVO: Descrever os resultados perioperatórios de DP com ressecções venosas realizadas em um hospital terciário universitário. MÉTODOS: Foi realizado estudo retrospectivo, classificado como coorte histórica, envolvendo 39 indivíduos submetidos à DP com ressecção venosa entre 2000 e 2016. Foram estudadas variáveis demográficas, clínicas e antropométricas pré-operatórias e os desfechos principais foram a morbidade e mortalidade em 30 dias. RESULTADOS: A mediana de idade foi 62,5 anos (IQ 54-68), sendo 55% dos indivíduos do sexo masculino. A principal etiologia identificada foi o adenocarcinoma ductal de pâncreas (82,1%). Em 51,3% dos casos, a veia porta foi submetida à ressecção; em 35,9%, a veia mesentérica superior foi ressecada e nos outros 12,8%, a junção esplenomesentérica. Em relação às complicações, 48,7% dos pacientes apresentaram algum tipo de morbidade em 30 dias. Nenhuma das variáveis analisadas associou-se à maior morbidade. A mortalidade perioperatória foi 15,4% (seis pacientes). O grupo de indivíduos que cursou com mortalidade em 30 dias apresentou escores significativamente mais altos de ASA (P=0,003) e ECOG (P=0,001). CONCLUSÃO: A DP com ressecção venosa para neoplasias avançadas do pâncreas é um procedimento factível, porém que se acompanha de altos índices de morbidade e mortalidade; escores de ASA e ECOG altos são fatores significativamente associados à maior mortalidade.

Humans , Male , Female , Adult , Aged , Pancreatic Neoplasms/surgery , Adenocarcinoma/surgery , Pancreaticoduodenectomy/methods , Pancreatic Neoplasms/mortality , Portal Vein/surgery , Postoperative Complications , Brazil/epidemiology , Adenocarcinoma/mortality , Retrospective Studies , Morbidity , Pancreaticoduodenectomy/mortality , Intraoperative Complications , Mesenteric Veins/surgery , Middle Aged
Yonsei Medical Journal ; : 162-166, 2018.
Article in English | WPRIM | ID: wpr-742488


The creation of transjugular intrahepatic portosystemic shunt (TIPS) is a widely performed technique to relieve portal hypertension, and to manage recurrent variceal bleeding and refractory ascites in patients where medical and/or endoscopic treatments have failed. However, portosystemic shunt creation can be challenging in the presence of chronic portal vein occlusion. In this case report, we describe a minimally invasive endovascular mesocaval shunt creation with transsplenic approach for the management of recurrent variceal bleeding in a portal hypertension patient with intra- and extrahepatic portal vein occlusion.

Adolescent , Chronic Disease , Esophageal and Gastric Varices/complications , Esophageal and Gastric Varices/diagnostic imaging , Esophageal and Gastric Varices/therapy , Female , Gastrointestinal Hemorrhage/complications , Gastrointestinal Hemorrhage/diagnostic imaging , Gastrointestinal Hemorrhage/therapy , Humans , Jejunum/pathology , Portacaval Shunt, Surgical , Portal Vein/diagnostic imaging , Portal Vein/pathology , Portal Vein/surgery , Tomography, X-Ray Computed , Treatment Outcome , Venous Thrombosis/complications , Venous Thrombosis/diagnostic imaging , Venous Thrombosis/therapy
Int. j. morphol ; 35(3): 1083-1090, Sept. 2017. ilus
Article in Spanish | LILACS | ID: biblio-893097


La disfunción hepática postoperatoria del remanente hepático que ocurre en pacientes sometidos a grandes resecciones hepáticas, es un problema complejo y temido, dado su pronóstico incierto. La asociación de partición hepática y ligadura portal para hepatectomía por etapas (ALPPS), es un enfoque novedoso para pacientes portadores de enfermedad hepática oncológica que anteriormente eran considerados "no resecables". El procedimiento se realiza en dos etapas. La primera, comprende la ligadura de la rama derecha de la vena porta. Luego, se realiza la transección del parénquima hepático; incluyendo o no, la sección y ligadura de la vena hepática media. A continuación se empaqueta el hígado tumoral en una bolsa de polietileno y el abdomen es cerrado. La segunda etapa, se realiza 7 a 15 días después. Una vez abierto el abdomen, se retira la bolsa de polietileno; se ligan y seccionan la arteria, el conducto biliar y la vena hepática derechos; y se elimina el hígado tumoral. Pueden instalarse drenes y se procede al cierre de la laparotomía. La técnica ALPPS puede permitir entonces, la resección curativa de hígados tumorales en pacientes con lesiones considerados previamente como no resecables. El objetivo de este artículo fue describir las indicaciones y aspectos técnicos del ALPPS a propósito del primer caso realizado en nuestra ciudad, en una paciente de 47 años con un cáncer de vesícula biliar avanzado y metástasis bilobares.

Postoperative hepatic malfunction subsequent to insufficiency of hepatic remnant is a complex and dire problem in patients subjected to large hepatic resections. The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS), is a novel approach for oncology patients whose hepatic tumors were previously considered non-resectable. The technique is performed in two phases. The first one comprises the ligation of the right portal vein branch. Subsequently, a parenchymal transection is performed, including or not, the middle hepatic vein. A plastic bag is employed to cover the tumoral liver, and the abdomen is closed. The second one is performed at 7 to 15 days interval. After laparotomy, the plastic bag is removed. The right artery, bile duct and hepatic vein are sectioned and the tumoral liver is removed. Drain was placed at the resection surface, and the abdomen is closed. ALPPS can enable curative resection of hepatic metastasis in patients with tumors previously considered non-resectable. The aim of this manuscript was to describe the indications and technical aspects of ALPPS in relation to the first case carried out in our city, in a 47-year-old woman with advanced gallbladder cancer with bilobar metastases.

Humans , Female , Middle Aged , Hepatectomy/methods , Liver Neoplasms/surgery , Liver Neoplasms/secondary , Portal Vein/surgery , Gallbladder Neoplasms/surgery , Gallbladder Neoplasms/pathology , Ligation/methods
Einstein (Säo Paulo) ; 15(2): 178-185, Apr.-June 2017. tab, graf
Article in English | LILACS | ID: biblio-891376


ABSTRACT Objective To analyze the influence of portal vein ligation in hepatic regeneration by immunohistochemical criteria. Methods Ten pigs divided into two groups of five animals underwent hepatectomy in two stages, and the groups were differentiated by ligation or not of the left portal vein tributary, which is responsible for vascularization of the left lateral and medial lobes of the pig liver. Five days after the procedure, the animals underwent liver biopsies for further analysis of histological and immunohistochemical with marker Ki67. Results The group submitted to hepatectomy with vascular ligation showed an increase of approximately 4% of hepatocytes in regeneration status, as well as a greater presence of Kupffer and inflammatory cells as compared to control. Conclusion As a result of positive cell replication observed through the Ki67 marker, we can suspect that the ligation of a tributary of the portal vein associated with liver resection promoted a greater stimulus of liver regeneration when compared to liver resection alone.

RESUMO Objetivo Analisar a influência da ligadura da tributária da veia porta no estímulo regenerativo hepático por meio de critérios imuno-histoquímicos. Métodos Dez suínos, divididos em dois grupos de cinco animais, foram submetidos à hepatectomia em dois estágios, sendo que os grupos foram diferenciados pela ligadura ou não da tributária da veia porta, responsável pela vascularização dos lobos lateral e medial esquerdos do fígado do suíno. Cinco dias após o procedimento, os animais foram reabordados para retirada de amostras hepáticas para posterior análise de histológica e imunoistoquímica com o marcador Ki67. Resultados O grupo submetido à hepatectomia com ligadura vascular apresentou incremento de 4% aproximadamente de hepatócitos em processo de regeneração, bem como grande número de células de Kupffer e células inflamatórias, quando comparado ao controle. Conclusão Em virtude da análise positiva da replicação celular observada por meio do marcador Ki67, pode-se observar que a ligadura de uma tributária da veia porta promoveu um maior estímulo de regeneração hepática, efeito observado com menor intensidade no grupo submetido apenas à ressecção hepática.

Animals , Portal Vein/surgery , Parenchymal Tissue/surgery , Hepatectomy/methods , Liver/surgery , Liver Regeneration , Swine , Random Allocation , Ki-67 Antigen/metabolism , Hepatocytes/metabolism , Models, Animal , Parenchymal Tissue/pathology , Leukocytes , Ligation/methods , Liver/pathology
Rev. chil. cir ; 67(2): 185-190, abr. 2015. ilus, graf, tab
Article in Spanish | LILACS | ID: lil-745080


Introduction: Hepatic resection is the standard treatment for the liver tumors and in most cases the only potentially curative option. The most feared complication, in the major hepatic resection, is the postoperative liver failure. A new technique has recently been published in the literature: Liver partition associated to a portal vein ligation for staged hepatectomy. This technique allows an accelerated hipertrophy of the remnant liver, facilitates greater resection surgery, reducing the risk of postoperative hepatic ischemia. The results reported in the literature are promising. We report the first case in Chile with its evolution to 2 years and a discussion about the topic.

La resección hepática es el tratamiento estándar para los tumores hepáticos malignos y en la mayoría de los casos la única opción potencialmente curativa. La complicación más temida, en las grandes resecciones, es la insuficiencia hepática postquirúrgica. Una nueva técnica ha sido recientemente publicada en la literatura: La partición hepática asociada a la ligadura de la vena portal para realizar una hepatectomía por etapas. Esta técnica permite una hipertrofia acelerada del hígado remanente que posibilita una cirugía resectiva mayor, disminuyendo el riesgo de isquemia hepática postquirúrgica. Los resultados expuestos en la literatura son promisorios. Presentamos el primer caso clínico en Chile con su evolución a 2 años y una discusión del tema.

Humans , Adult , Female , Hepatectomy/methods , Liver Regeneration , Liver Neoplasms/surgery , Portal Vein/surgery , Ligation
Yonsei Medical Journal ; : 586-590, 2015.
Article in English | WPRIM | ID: wpr-38889


Severe portal vein thrombosis (PVT) is often considered a relative contraindication for living donor liver transplantation due to high associated risks and morbidity. Meanwhile, improvement in operative techniques, resulting in higher success rates has removed PVT from the list of contraindications in deceased donor liver transplantation (DDLT). In this report, we describe a surgical technique for DDLT using polytetrafluoroethylene graft from the inferior mesenteric vein for portal inflow in patient with portomesenteric thrombosis.

End Stage Liver Disease/complications , Humans , Liver Transplantation/methods , Male , Mesenteric Veins/surgery , Middle Aged , Polytetrafluoroethylene , Portal Vein/surgery , Tissue Donors , Treatment Outcome , Ultrasonography, Doppler , Vascular Grafting , Venous Thrombosis/etiology
ABCD arq. bras. cir. dig ; 27(4): 268-271, Nov-Dec/2014. tab, graf
Article in English | LILACS | ID: lil-735681


BACKGROUND: Due to their complexity and risks, mesenteric-portal axis resection and reconstruction during the pancreatectomy procedure were not recommended back in the early nineties. However, as per technical improvements and the reduction in morbidity and mortality rates, they have been routinely indicated in large medical centers. AIM: To show results from cases of patients subjected to mesenteric-portal axis resection during pancreatectomy. METHOD: Patients subjected to mesenteric-portal axis resection during pancreatectomy were prospectively and consecutively assessed. The procedure was indicated according to anatomical criteria defined by imaging exams or intraoperative assessment. RESULTS: Ten patients, half of them were male, with mean age of 55.7 years (40-76) were included. The most frequent underlying diseases were pancreatic adenocarcinoma and Frantz tumor. The circumferential resection of the portal vein associated with the superior mesenteric vein with splenic vein ligature (4 cases=40%) and the primary anastomosis of the vascular stumps (5 cases=50%) were, respectively, the most performed types of vascular resection and reconstruction. Surgery time ranged from 480 to 600 minutes (average=556 minutes) and postoperative hospitalization time ranged from 9 to 114 days (average=34.8 days). Morbidity rate was 60%, and clinical pancreatic fistula (grade B and C) was the most common complication (3 cases=30%). Mortality rate was 10% (1 case). CONCLUSION: Mesenteric-portal axis resection is a valid technical procedure. It should be taken into account after a clinical assessment that included not only the patients' clinical condition but also the technical and anatomical conditions of the mesenteric-portal axis tumor infiltration as well as life expectancy based on the patient's cancer prognosis. .

RACIONAL: Devido à complexidade e riscos, a ressecção e reconstrução do eixo mesentérico-portal durante pancreatectomia até o início dos anos noventa não era recomendada. Entretanto, com o aprimoramento técnico e redução da morbimortalidade ela tem sido indicada de forma rotineira nos grandes centros. OBJETIVO: Demostrar os resultados de uma série de casos submetida à ressecção do eixo mesentérico-portal durante a pancreatectomia. MÉTODO: Foram avaliados prospectivamente e consecutivamente pacientes submetidos à ressecção do eixo mesentérico-portal durante pancreatectomias. A indicação do procedimento baseou-se em critérios anatômicos definidos por exames de imagem ou por avaliação intra-operatória. RESULTADOS: Foram incluídos 10 pacientes, metade do sexo masculino, com idade média de 55,7 anos (40-76). As doenças de base mais frequentes foram o adenocarcinoma de pâncreas e o tumor de Frantz. O tipo de ressecção e reconstrução vascular mais realizado foi respectivamente a ressecção circunferencial da veia porta associada à veia mesentérica superior com ligadura da veia esplênica (4 casos=40%) e a anastomose primária dos cotos vasculares (5 casos=50%). O tempo operatório variou entre 480 e 600 minutos (média=556 minutos) e o tempo de internação pós-operatória variou de 9 a 114 dias (média=34,8 dias). A morbidade foi de 60%, sendo a fístula pancreática clínica (grau B e C) a complicação mais frequente (3 casos=30%). A mortalidade foi de 10% (um caso). CONCLUSÃO: A ressecção do eixo mesentérico-portal é artifício técnico válido. Deve ser considerada após consideração que contemple não apenas as condições clínicas dos pacientes, as condições técnicas e anatômicas da infiltração tumoral do eixo mesentérico-portal, mais também, e de forma não menos importante, a expectativa de sobrevida com base no prognóstico oncológico do paciente. .

Adult , Aged , Female , Humans , Male , Middle Aged , Mesenteric Veins/surgery , Pancreatectomy/methods , Portal Vein/surgery , Prospective Studies , Treatment Outcome
ABCD arq. bras. cir. dig ; 27(4): 280-284, Nov-Dec/2014. tab, graf
Article in English | LILACS | ID: lil-735688


BACKGROUND: Partial portal vein ligation causes an increase in portal pressure that remains stable even after the appearance of collateral circulation, with functional adaptation to prolonged decrease in portal blood flow. AIM: To assess whether different constriction rates produced by partial ligation of the vein interfere with the results of this experimental model in rats. METHODS: Three groups of five rats each were used; in group 1 (sham-operated), dissection and measurement of portal vein diameters were performed. Portal hypertension was induced by partial portal vein ligation, reducing its size to 0.9 mm in the remaining 10 animals, regardless of the initial diameter of the veins. Five animals with portal hypertension (group 2) underwent reoperation after 15 days and the rats in group 3 after 30 days. The calculation of the constriction rate was performed using a specific mathematical formula (1 - π r 2 / π R2) x 100% and the statistical analysis with the Student t test. RESULTS: The initial diameter of the animal's portal vein was 2.06 mm, with an average constriction rate of the 55.88%; although the diameter of the veins and the constriction rate in group 2 were lower than in group 3 (2.06 mm - 55,25% and 2.08 mm - 56.51%, respectively), portal hypertension was induced in all rats and no significant macroscopic differences were found between the animals that were reoperated after 15 days and after 30 days respectively, being the shorter period considered enough for the evaluation. Comparing the initial diameter of the vein and the rate of constriction performed in groups 2 and 3, no statistic significance was found (p>0.05). CONCLUSION: Pre-hepatic portal hypertension in rat can be induced by the reduction of the portal vein diameter to 0.9 mm, regardless the initial diameter of the vein and the vessel constriction rate. .

RACIONAL: A ligadura parcial da veia porta acarreta aumento da pressão portal que se mantém estável mesmo após o aparecimento da circulação colateral, havendo adaptação funcional à diminuição prolongada do fluxo sanguíneo hepático. OBJETIVO: Avaliar se diferentes taxas de constrição produzidas por esta ligadura interferem em modelo experimental no rato. MÉTODOS: Foram utilizados três grupos de cinco animais; no grupo 1 (sham-operated) foi realizada dissecção e medida do diâmetro da veia porta. A hipertensão portal foi induzida pela ligadura parcial da veia porta, reduzindo seu calibre para 0,9 mm nos 10 animais restantes, independente do diâmetro inicial das veias. Cinco animais com hipertensão portal (grupo 2) foram reoperados após 15 dias e os ratos do grupo 3 após 30 dias. O cálculo da taxa de constrição foi realizado através de fórmula matemática específica (1 - π r2 / π R2) x 100% e a análise estatística com o teste t de Student. RESULTADOS: O diâmetro médio inicial da veia porta dos animais foi de 2,06 mm, com taxa de constrição média de 55,88%; embora o diâmetro das veias e a taxa de constrição no grupo 2 tenha sido menor que no grupo 3 (2,06 mm - 55,25% e 2,08 mm - 56,51% respectivamente), em todos conseguiu-se induzir hipertensão portal e não foram encontradas diferenças macroscópicas significativas entre os animais reoperados após 15 ou 30 dias, sendo considerado o prazo menor suficiente para avaliação. Quando comparados o diâmetro inicial da veia e a taxa de constrição realizadas nos grupos 2 e 3 não houve significância estatística (p>0,05). CONCLUSÃO: A hipertensão portal pré-hepática no rato pode ser induzida pela redução de calibre da veia porta para 0,9 mm de diâmetro, independente do diâmetro inicial da veia e da taxa de constrição a que este vaso foi submetido. .

Animals , Female , Rats , Disease Models, Animal , Hypertension, Portal , Constriction, Pathologic , Ligation/methods , Portal Vein/surgery , Rats, Wistar
ABCD arq. bras. cir. dig ; 26(3): 206-212, jul.-set. 2013. ilus
Article in Portuguese | LILACS | ID: lil-689679


RACIONAL: O aumento da pressão no sistema venoso portal, induzido pela redução do aporte sanguíneo ao fígado, provoca o desenvolvimento de circulação colateral para que o sangue dos vasos esplâncnicos alcance o sistema venoso da veia cava superior. O baço funciona como um sistema de capacitância que auxilia a compensação do aumento da pressão portal, podendo ocorrer esplenomegalia. OBJETIVO: Reproduzir modelo experimental de hipertensão portal pré-hepática por meio da redução do calibre da veia porta do rato, permitindo o estudo das alterações de volume do baço nesta situação. MÉTODO: Foram utilizados 15 ratos da linhagem Wistar, divididos em três grupos de cinco. Todos os animais foram operados; os primeiros cinco foram utilizados como controle (grupo 1), e reoperados após 15 dias (sham-operated), assim como cinco animais onde foi induzida a hipertensão portal (grupo 2). Os cinco últimos animais, também com hipertensão portal, foram reoperados após 30 dias (grupo 3). A hipertensão portal do tipo pré-hepática foi provocada através da ligadura parcial da veia porta no hilo hepático. O baço foi medido durante a primeira e a segunda operação, permitindo o cálculo de seu volume nos três grupos estudados através de fórmula matemática específica. RESULTADOS: Não foram encontradas diferenças macroscópicas significativas ou alterações maiores do volume do baço quando foram comparados os animais que foram reoperados após 15 dias (grupo 2) e os reoperados após 30 dias (grupo 3), sendo considerado o prazo menor (15 dias), suficiente para avaliação das repercussões no volume após a ligadura parcial da veia porta. Embora o volume dos baços estudados tanto no grupo 2 quanto no grupo 3 tenha aumentado após a primeira operação - variando em média de 0,5417 cm³ para 0,6345 cm³ na reoperação, com aumento de aproximadamente 17% entre a primeira e a segunda fase do estudo -, estes resultados não apresentaram significância estatística (p>0,05). CONCLUSÃO: Não houve aumento com significância estatística do volume do baço após a ligadura parcial da veia porta quando se comparou o volume calculado na primeira operação com o volume encontrado na reoperação. Também não houve diferença quando foram comparados os volumes dos baços dos animais do grupo de reoperados após 15 dias, com o grupo reoperado após 30 dias.

BACKGROUND: Pressure increase in the portal venous system, caused by reduction of blood supply to the liver, develops collateral circulation of splanchnic vessel that reaches the venous system of superior vena cava. The spleen works as an auxiliary capacitance system which compensates the increase in portal pressure that may cause splenomegaly. AIM: To reproduce experimental model of pre-hepatic portal hypertension by reducing the caliber of the vein, allowing the study of alterations in the rat's spleen in this situation. METHODS: Fifteen Wistar rats were divided into three groups of five. All animals were operated, being the first five used as control (group 1) and reoperated after 15 days (sham-operated), along with five other animals had portal hypertension induced (group 2). The last five animals, also with portal hypertension were reoperated after 30 days (group 3). Prehepatic portal hypertension was caused in experimental animals by partial ligation of portal vein in hepatic hilum. The spleen was measured during the first and second operations, allowing the calculation of its volume in the three groups studied using specific mathematical formula. RESULTS: No macroscopic changes in spleen were significant when compared the animals reoperated after 15 days (group 2) to the ones after 30 days (group 3), being 15 days considered enough for the evaluation of effects on spleen after partial ligation. Although the volume of spleens studied in groups 2 and 3 have increased after the first operation - ranging on average from 0.5417 cm³ to 0.6345 cm³ at reoperation with increase of approximately 17% in volume between the first and second phase - the rsults were not statistically significant (p> 0.05). CONCLUSION: There was no statistically significant increase in the spleen volume after partial ligation of the portal vein when comparing the calculated volume in the first operation to the volume found at reoperation. There was no difference when comparing the spleen volumes of the animals reoperated after 15 days and the ones reoperated after 30 days.

Animals , Female , Rats , Disease Models, Animal , Hypertension, Portal , Splenomegaly , Ligation , Liver , Portal Vein/surgery , Rats, Wistar
Acta cir. bras ; 28(9): 625-631, Sept. 2013. ilus, tab
Article in English | LILACS | ID: lil-684435


PURPOSE: To investigate the intraoperative microcirculatory changes of the affected organs (small bowel, liver and kidney) during the making of a modified selective portacaval (PC) shunt. METHODS: On ten anaesthetized Sprague-Dawley rats the selective end-to-side mesocaval anastomosis was performed, where only the rostral mesenteric vein is utilized and the portal vein with the splenic vein are left intact. Morphometric and microcirculatory investigations using a LDF device determining flux units (BFU) were carried out. RESULTS: After completing the shunts the microcirculatory flux values did not recover in the same manner on the surface of the small intestine, the liver or the kidney. BFU values showed deterioration in the small intestine and in the liver (p<0.001). During the reperfusion the BFU values improved, but not in the same manner. The small intestine values left behind the kidney and liver data. CONCLUSIONS: Technically, the advantages of the models include the selective characteristic, the mesocaval localization and the relatively easy access to those vessels. However, its major disadvantage is the time needed for positioning the vessels without coiling or definitive stretching. Intraoperative LDF may provide useful data on the microcirculatory affection of the organs suffering from hypoperfusion or ischemia during creating the shunts.

Animals , Rats , Microcirculation/physiology , Microsurgery/methods , Portacaval Shunt, Surgical/methods , Portal Vein/surgery , Vena Cava, Inferior/surgery , Anastomosis, Surgical , Intraoperative Period , Models, Animal , Mesenteric Veins/anatomy & histology , Portal Vein/anatomy & histology , Rats, Sprague-Dawley , Reference Values , Reproducibility of Results
ABCD arq. bras. cir. dig ; 26(1): 40-43, jan.-mar. 2013. tab
Article in Portuguese | LILACS | ID: lil-674140


RACIONAL: Insuficiência hepática pós-operatória devido à remanescente hepático pequeno tem sido complicação temida em pacientes que são submetidos à ressecção hepática extensa. A ligadura da veia porta associada à bipartição do fígado para hepatectomia em dois estágios (ALPPS) foi desenvolvida recentemente com a finalidade de induzir rápida e significante regeneração do fígado para pacientes em que o tumor é previamente considerado irressecável. OBJETIVO: Apresentar a experiência brasileira com o ALPPS. MÉTODO: Foram analisados 39 pacientes submetidos ao procedimento ALPPS em nove hospitais. Ele foi realizado em duas etapas. A primeira operação consistiu em ligadura do ramo direito da veia porta e bipartição hepática. Na segunda, os ramos direito da artéria hepática, via biliar e veia hepática foram ligados e o lobo hepático direito estendido foi removido. Foram 22 pacientes do sexo masculino (56,4%) e 17 do feminino (43,6%). A média de idade foi 57,3 anos (variando de 20 a 83 anos). RESULTADOS: A indicação mais comum foi metástase hepática em 32 pacientes (82,0%), seguida por colangiocarcinoma em três pacientes (7,7%). Dois morreram neste intervalo e não foram submetidos à segunda operação. O intervalo médio da primeira para a segunda operação foi de 14,1 dias (variando de 5-30 dias). O volume do segmento lateral esquerdo apresentou aumento de 83% (variando de 47-211,9%). Morbidade significante foi observada em 23 pacientes (59,0%). A mortalidade foi de 12,8% (cinco pacientes). CONCLUSÃO: O procedimento ALPPS permite ressecção hepática em pacientes com lesões consideradas previamente irressecáveis por induzir rápida hipertrofia do fígado evitando a insuficiência hepática na maioria dos pacientes. Porém ainda apresenta elevada morbidade e mortalidade.

BACKGROUND: Postoperative liver failure consequent to insufficiency of remnant liver is a feared complication in patients who underwent extensive liver resections. To induce rapid and significant hepatic hypertrophy, associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been recently developed for patients which tumor is previously considered unresectable. AIM: To present the Brazilian experience with ALPPS approach. METHOD: Were analyzed 39 patients who underwent hepatic resection using ALPPS in nine hospitals. The procedure was performed in two steps. The first operation was portal vein ligation and in situ splitting. In the second operation the right hepatic artery, right bile duct and the right hepatic vein were isolated and ligated. The extended right lobe was removed. There were 22 male (56.4%) and 17 female (43.6%). At the time of the first operation, the median age was 57.3 years (range: 20-83 years). RESULTS: The most common indication was liver metastasis in 32 patients (82.0%), followed by cholangiocarcinoma in three (7.7%). Two patients died (5.2%) during this period and did not undergo the second operation. The mean interval between the first and the second operation was 14.1 days (range: 5-30 days). The volume of the left lateral segment of the liver increased 83% (range 47-211.9%). Significant morbidity after ALPPS was seen in 23 patients (59.0%). The mortality rate was 12.8% (five patients). CONCLUSION: The ALPPS approach can enable resection in patients with lesions previously considered unresectable. It induces rapid liver hypertrophy avoiding liver failure in most patients. However still has high morbidity and mortality.

Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Young Adult , Hepatectomy/methods , Liver Neoplasms/surgery , Portal Vein/surgery , Brazil , Ligation