A Comprehensive Approach to Hepatic Vascular Disease.

The liver has a complex vascular supply, which involves the inflow of oxygenated blood through the hepatic artery (systemic circulation) and deoxygenated blood through the portal vein (portal circulation), as well as the outflow of deoxygenated blood through the hepatic veins to the inferior vena cava. A spectrum of vascular variants can involve the liver. Some of these variants may result in areas of enhancement that can mimic more serious pathologic conditions. In this article, the authors discuss a spectrum of variants and pathologic conditions that may involve the liver vasculature. These include variants, anomalies, and diseases involving the portal vein, such as rudimentary portal vein, thrombosis, cavernous transformation, thrombotic angiitis, thrombophlebitis, transient hepatic attenuation difference or transient hepatic intensity difference, portal venous aneurysm, and portal vein gas. The hepatic artery can be involved by various diseases, including thrombosis, stenosis, and aneurysm or pseudoaneurysm. Unusual "third inflow" sources of venous inflow are also discussed, including aberrant right gastric vein, aberrant left gastric vein, epigastric-paraumbilical veins, and cholecystic vein. A spectrum of variants and diseases involving the inferior vena cava and hepatic veins, including thrombosis, Budd-Chiari syndrome, veno-occlusive disease, stenosis, torsion, congestive hepatopathy, and peliosis hepatis, are discussed. Vascular shunts are illustrated, including portosystemic shunts (intra- and extrahepatic), arterioportal shunt, shunts of hereditary hemorrhagic telangiectasia, and acquired arteriovenous fistula. Familiarity with the pathogenesis and imaging features of these vascular entities can aid radiologic diagnoses and guide appropriate patient management. ©RSNA, 2017.

The value of cholangiography through Jackson-Pratt drains in the management of postoperative biliary injuries.

Iatrogenic biliary injury is the most significant complication after laparoscopic cholecystectomy. We present our experience with an alternative diagnostic approach using transcatheter cholangiography (TCC) through a Jackson-Pratt (JP) drain and discuss potential benefits and limitations of the technique. From March 2002 to February 2012, 40 patients with major postoperative biliary injury underwent biliary reconstruction at our institution. Mean age was 51.7 ± 18.1 years (range, 19 to 86 years) with 30 (75%) females. Seventeen (42.5%) injuries were detected intraoperatively and in 13 (32.5%) cases, JP drains were placed for biliary drainage. Lesions were classified according to Bismuth grade: I (10 patients [25%]), II (10 patients [25%]), III (six patients [15%]), IV (10 patients [25%]), and V (four patients [10%]). TCC was performed in seven patients with JP drains (53.8%). It fully defined the injury site in three cases of limited magnetic resonance cholangiopancreatography (MRCP) such as common hepatic duct and common bile duct leaks and in four cases (57.1%) that endoscopic retrograde cholangiopancreatography (ERCP) was limited as a result of clipping of the distal common bile duct. TCC showed promising results in cases of limited MRCP and ERCP such as fistulous orifices or leakage. It may represent an alternative adjunct in the diagnostic armamentarium of complex biliary injuries.

The role of MR cholangiopancreatography in preoperative assessment for repair of major iatrogenic biliary injury: 10-year experience.

BACKGROUND/AIMS: Major iatrogenic biliary injury is a potentially life-threatening complication after laparoscopic cholecystectomy. Early diagnosis is essential to improve outcomes, however, to date, there is no consensus regarding the best imaging approach for preoperative assessment of these injuries. METHODOLOGY: From March 2002 to February 2012, 40 patients with postoperative major biliary injury underwent biliary reconstruction at our Institution. Mean age was 51.7 ± 18.1 years (19-86) with 30 (75%) females. Magnetic resonance cholangiopancreatography (MRCP) were compared with different diagnostic modalities and definitive intraoperative findings. RESULTS: Of 40 patients, 10 (25%) had Bismuth type I, 10 (25%) Bismuth type II, 6 (15%) Bismuth type III injury, 10 (25%) Bismuth type IV and, 4 (10%) Bismuth type V. MRCP has similar accuracy to define injury site, but is superior in delineating proximal ductal anatomy that was often not visualized with endoscopic retrograde cholangiopancreatography (ERCP). CONCLUSION: MRCP is a reliable, accurate and readily available diagnostic tool to assess complex biliary injuries. It provides adequate visualization of the proximal and distal biliary trees and may be considered as first-line test in the management of major iatrogenic biliary injuries. Revision of current guidelines for diagnostic approach of this condition is warranted.

Biliary-colonic fistula caused by cholecystectomy bile duct injury.

Biliary-colonic fistula is a rare complication after laparoscopic cholecystectomy. We present a case of post-cholecystectomy iatrogenic biliary injury that resulted in a fistula between the common hepatic duct and large bowel. Magnetic resonance cholangiopancreatography provided good visualization of injury even with concurrent normal level of alkaline phosphatase. Radiologic findings and surgical management of this condition are discussed in detail.

The perforated duodenal diverticulum.

OBJECTIVE: To perform a literature review of perforated duodenal diverticulum with attention to changes in management. DATA SOURCES: We searched PubMed for relevant studies published from January 1, 1989, through August 1, 2011. In addition, we identified and reviewed 4 cases at our institution. STUDY SELECTION: Search phrases were perforated duodenal diverticulum and duodenal diverticulitis. DATA EXTRACTION: Patient demographics, clinical characteristics, radiologic findings, treatment, and outcomes were obtained. RESULTS: We reviewed 39 studies producing 57 cases, which were combined with the 4 at our institution for a total of 61 patients. The addition of 2 previous series revealed a total of 162 patients in the world literature. Perforations were most commonly located in the second or third portion of the duodenum (60 of 61 cases [98%]), and the most frequent cause was diverticulitis (42 of 61 [69%]). There has been a dramatic improvement in the preoperative diagnosis of perforated diverticula. Only 13 of 101 reported cases (13%) were correctly diagnosed before 1989, and 29 of 61 (48%) in the present series were identified with radiologic examinations. Most patients in the current series (47 of 61) underwent operative treatment for their perforation, although 14 underwent successful nonoperative management. Complications were reported in 17 of 47 patients in the surgical group (36%), whereas only 1 complication was seen in patients undergoing nonoperative management. Mortality in the surgical group was 6% (3 of 47), and no deaths were reported in the nonoperative group. CONCLUSIONS: Perforation of a duodenal diverticulum is rare, with only 162 cases reported in the world literature. Nonoperative management has emerged as a safe, practical alternative to surgery in selected patents.

Right trisectionectomy of the liver for intrahepatic cholangiocarcinoma with bile duct invasion in a Jehovah's Witness.

Intrahepatic cholangiocarcinoma (ICC) is well known to have a very poor prognosis. Aggressive surgical strategies in the treatment of ICC, including major hepatectomy, have been reported to afford patients the best chance for significant survival. Recent advancements in surgical techniques concerning live donor liver transplantation have dramatically improved the results of major hepatectomy. However, surgical treatment of biliary malignancy is complex and is known to increase the likelihood of blood transfusion. We describe a Jehovah's Witness patient with ICC and concomitant bile duct invasion who had a successful right trisectionectomy with bile duct resection, lymph node dissection, and Rouxen-Y hepatico-jejunostomy without blood transfusion. A multidisciplinary preparation was crucial in obtaining this positive outcome. Importantly, bloodless liver transection techniques with inflow clamping, meticulous dissection, and hemostasis should be utilized for major hepatectomy in a Jehovah's Witness. The success of this case may alert clinicians to consider a hepatectomy as a possible option in the treatment of ICC in a Jehovah's Witness.