Study of surgical anatomy of portal vein of liver segments by cast method and its clinical implications

Vidya C. Shrikantaiah,Manjaunatha Basappa,Sangita Hazrika,Roopa Ravindranath 대한해부학회 2018 Anatomy & Cell Biology Vol.51 No.4

Portal vein provides about three-fourths of liver’s blood supply. Portal vein is formed behind the neck of pancreas, at the level of the second lumbar vertebra and formed from the convergence of superior mesenteric and splenic veins. The purpose of this study is to review the normal distribution and variation, morphometry of portal vein and its branches for their implication in liver surgery and preoperative portal vein embolization. It is also helpful for radiologists while performing radiological procedures. A total of fresh 40 livers with intact splenic and superior mesenteric vein were collected from the mortuary of Forensic Department, JSS Medical College and Mysuru Medical College. The silicone gel was injected into the portal vein and different segments were identified and portal vein variants were noted. The morphometry of portal vein was measured by using digital sliding calipers. The different types of portal vein segmental variants were observed. The present study showed predominant type I in 90% cases, type II 7.5% cases, and type III 2.5% cases. Mean and standard deviation (SD) of length of right portal vein among males and females were 2.096±0.602 cm and 1.706±0.297 cm, respectively. Mean and SD of length of left portal vein among males and females were 3.450±0.661 cm and 3.075±0.632 cm, respectively. The difference in the Mean among the males and females with respect to length of right portal vein and left portal vein was found to be statistically significant (P=0.010). Prior knowledge of variations regarding the formation, termination and tributaries of portal vein are very helpful and important for surgeons to perform liver surgeries like liver transplantation, segmentectomy and for Interventional Radiologists.

LDLT for Non-cirrhotic Portal Hypertension from Cavernous Transformation of Portal Vein - A Case Report

( Sung Yeon Hong ),( In-gyu Kim ),( Xu-guang Hu ),( Hee-jung Wang ),( Bong-wan Kim ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: Cavernous transformation of the portal vein (CTPV) is a rare condition with various etiologies and diverse clinical presentations. We present the case of non-cirrhotic young female patient with severe portal hypertension, successfully treated with living donor liver transplantation (LDLT) and the portal inflow was obtained using one prominent collateral vein (engorged paracholedocal vein) from CTPV. Case presentation: A 23-year-old female without liver cirrhosis was admitted due to upper gastrointestinal hemorrhage at Division of Liver Transplantation and Hepatobiliary Surgery in Ajou University Medical Center. From December 2011 to October 2015, she has experienced 6 times of esophageal varix bleeding and esophageal varix ligation. At the third episode of esophageal varix bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) was tried to reduce the portal pressure but it failed due to inadequate portal vein. A baseline liver biopsy was performed in January 13, 2012. Its finding revealed that fragmented hepatic parenchyma was not cirrhotic or ischemic histological evidence. In addition, there is no histological evidence to suggest vascular obstruction due to thrombosis. At that time, the patient was diagnosed as non-cirrhotic portal hypertension. In October 2015, the patient was recommended the living donor liver transplantation to solve the repeated esophageal varix bleeding from her portal hypertension. Preoperative laboratory data revealed normal liver function. Preoperative esophageogastroduodenoscopy showed esophageal varices, F2 Lm Cb RC (+) without active bleeding. Preoperative multidimensional computed tomography (MDCT) revealed massive dilated paracholedochal vein in the hepatoduodenal ligament and suprahilar area, and splenomegaly was found, too. The donor was her 3-year-older sister. The estimated graft volume of the donor’s right lobe calculated by CT volumetry was 679 ml, 63.3% of the whole liver and the estimated graft-to-recipient body weight ratio (GRWR) was 1.41%. Therefore, right lobe graft was planned to transplant on October 21, 2015. Operative finding showed an atretic main portal vein with complex network of tortuous paracholedochal vein, and we performed en bloc hilar dissection of the common bile duct and paracholedochal collateral vein. One thick paracholedochal vein of them looked like an candidate of alternative option for adequate portal inflow. We anastomosed it with donor portal vein in end-to-end fashion. Postoperatve Doppler scan and multi-detector computed tomography showed good portal vein patency to the graft. Six months after the surgery, the patient is doing well with normal liver function. Conclusions: After dissecting the hepatic artery, en bloc hilar dissection of the common bile duct and paracholedochal collateral vein was successfully performed. The thick paracholedochal vein was an alternative option for adequate portal inflow.

생후 3개월 미만의 영아에서 정상 담관, 간동맥, 간문맥 직경의 초음파 측정

김상윤,이영석 대한초음파의학회 2009 ULTRASONOGRAPHY Vol.28 No.3

목적: 초음파 검사를 이용하여 생후 3개월 미만의 영아 를 대상으로 간문맥 분지부에서 정상 담관, 간동맥, 간문맥 의 직경을 측정하고, 상호간의 상대적 비율을 구하고자 한 다. 대상 및 방법: 임상 및 검사 소견 상 간담도계와 연관된 이상이 없는 생후 3개월 미만의 영아 (평균 연령: 생후 32.76 일) 50 명을 대상으로 초음파 검사를 시행하였다. 간문맥 분지부에서 17-5MHz 선형 탐촉자를 이용하여 담 관, 간동맥, 간문맥의 직경을 측정하였고, 상호간의 상대적 비율을 구하였다. 담관, 간동맥, 간문맥 직경의 평균값에 유 의한 차이가 있는지를 평가하기 위해 일원배치 분산분석 (one-way ANOVA)을 수행하였고, 어느 측정변수 사이 에 유의한 차이가 있는지 알기 위해 Scheffe 사후 검정을 수행하였다. 세 변수 사이의 상대적 비율을 구하기 위해 담 관 대 간동맥 비율을 간동맥/담관, 간동맥 대 간문맥 비율 을 간문맥/간동맥, 담관 대 간문맥 비율을 간문맥/담관으로 정의하였고, 각각의 평균 ± 표준 편차 (최소값~최대값)를 - 171 - 김상윤 외 : 생후 3개월 미만의 영아에서 정상 담관, 간동맥, 간문맥 직경의 초음파 측정 구하였다. 결과: 50명의 영아 모두에서 담관, 간동맥, 간문맥의 직 경을 측정할 수 있었다. 정상 담관의 평균 직경은 0.85 ± 0.19 mm (0.56~1.47 mm) 이었고, 간동맥은 1.33 ± 0.31 mm (0.90~2.37 mm), 간문맥은3.32 ± 0.68 mm (2.06~5.08 mm) 이었다. 일원배치 분산분석을 수행한 결 과, 유의수준 5%에서 담관, 간동맥, 간문맥 각각의 평균 직 경은 서로 유의한 차이가 있었다 (p < 0.001). Scheffe 사 후 검정 결과 간동맥 직경은 담관보다, 간문맥 직경은 담관 및 간동맥보다 각각 유의하게 크게 측정되었다. 담관 대 간 동맥 비율은 1.60 ± 0.41 (0.77~2.66), 간동맥 대 간문 맥 비율은 2.53 ± 0.69 (1.16~4.30), 담관 대 간문맥 비 율은 3.93 ± 1.04 (2.08~6.60) 이었다. 결론: 본 연구에서 측정된 담관, 간동맥, 간문맥의 평균 직경과 상호간의 상대적 비율은 소아 간담도계 초음파에 유용한 참고 자료가 될 수 있을 것이다. Purpose: This study focused on measuring the diameter of the normal bile duct, hepatic artery and portal vein with high resolution US in infants younger than 3 months, and we wanted to determine the relative ratio of these diameters. Materials and Methods: Fifty US examinations were performed on infants younger than 3 months and who did not have any clinical or laboratory abnormality associated with the hepatobiliary system. We measured the diameter of the bile duct, hepatic artery and portal vein at the level of the portal vein bifurcation with using 17-5 MHz US and we determined the relative ratios of these diameters. To evaluate the statistical difference in the diameter of the bile duct, hepatic artery and portal vein, we performed one-way ANOVA and Scheffe’s multiple comparison test. To determine the relative ratio of these diameters, the ratio of the bile duct to the hepatic artery was defined as the hepatic artery/bile duct, the ratio of the hepatic artery to the portal vein was defined as the portal vein/hepatic artery and the ratio of the bile duct to the portal vein was defined as the portal vein/bile duct. We calculated the averages ± standard deviations of this data (minimum ~ maximum). Results: In all fifty infants, the bile duct, hepatic artery and portal vein were detectable and measurable. The average diameter of a bile duct was 0.85 ± 0.19 mm (0.56 ~ 1.47 mm), it was 1.33 ± 0.31 mm (0.90 ~ 2.37 mm) for the hepatic artery and 3.32 ± 0.68 mm (2.06 ~ 5.08 mm) for the portal vein. The diameter of these structures was significantly different from each other according to one-way ANOVA (p < 0.001). The average diameter of the hepatic artery was significantly larger than that of the bile duct and the average diameter of the portal vein was significantly larger than that of bile duct and hepatic artery on Scheffe’s multiple comparison test. The relative ratio of the bile duct to the hepatic artery was 1.60 ± 0.41 (0.77 ~ 2.66), that of the hepatic artery to the portal vein was 2.53 ± 0.69 (1.16 ~ 4.30) and that of the bile duct to the portal vein was 3.93 ± 1.04 (2.08 ~ 6.60). Conclusions: The diameter of the normal bile duct, hepatic artery and portal vein measured in this study and the relative ratios of these structures could be a useful reference for the US evaluation of infants who are suspected of having hepatobiliary disease.

Portal bifurcation reconstruction using own hepatic vein grafts due to portal vein anomaly of the living donor for the patient with portal vein thrombosis

Akira Umemura,Hiroyuki Nitta,Takeshi Takahara,Yasushi Hasegawa,Hirokatsu Katagiri,Shoji Kanno,Megumi Kobayashi,Taro Ando,Taku Kimura,Akira Sasaki 한국간담췌외과학회 2020 Annals of hepato-biliary-pancreatic surgery Vol.24 No.4

A 57-year-old Japanese female was considered for living donor liver transplantation (LDLT) due to end-stage liver cirrhosis caused by primary biliary cholangitis with portal vein thrombosis (PVT) formation. A 26-year-old daughter of the patient was selected as a living donor; however, a computed tomography examination revealed trifurcated-type portal vein anomaly (PVA). Preoperative liver volumetry showed that the right lobe graft was necessary for the recipient; therefore, reconstruction of the portal vein bifurcation during LDLT was necessary. We planned to extract the recipient’s own hepatic vein grafts after total hepatectomy, and these would be attached with anterior and posterior portal branches as jump grafts. We performed laparoscopic donor hepatectomy as usual, and the recipient’s hepatic vein grafts were anastomosed on the bench. Then, the liver graft was inserted, and the hepatic vein reconstruction was routinely performed. We confirmed the alignment between the recipient’s portal vein and the bridged hepatic vein graft of the liver graft’s posterior branch, and anastomosed these two vessels. Moreover, we confirmed the front flow and expansion of the reconstructed posterior branch by declamping only the suprapancreatic side of the portal vein. The decision regarding the punch-out location was crucial. We confirmed the alignment between the reconstructed posterior branch and the bridged hepatic vein graft of the anterior branch, and anastomosed these two vessels employing the punched-out technique. In LDLT, liver transplant surgeons occasionally encounter living donors with PVA or recipients with PVT. Our contrivance may be useful when the liver graft needs reconstruction of portal vein bifurcation.

백서의 간이식 모델에서 문맥 협착 및 혈전 예방을 위한 문맥 문합법

윤명희(Myunghee Yoon) 한국간담췌외과학회 2008 한국간담췌외과학회지 Vol.12 No.1

Purpose: To overcome donor shortage, reduced-size liver transplantation, spilt-liver transplantation and partial liver transplantation from living donors for children are frequently used all over the world. Despite the difficulties of a adequate volume reduction and the age difference between donor and the recipient, all these techniques also share the problem of size mismatch between the vessels of the adult liver and those of the pediatric recipient. portal vein reconstruction in a crucial factor for a successful transplantation because it allows blood flow to the liver graft, which ends the ischemic period for the graft, as well as the anhepatic period for the recipient. Methods: In GroupⅠ(n=10, no growth factor), a partial liver of Sprague-Dqwley(SD) rat was transplanted heterotopically, via microsurgical technique, to a SD rat with performing end-to-end portal vein anastomosis without applying growth factor to the suture of the portal vein. In GroupⅡ(n=10, 50-60% growth factor), a partial liver of a SD rat was trnasplanted heterotopically to a SD rat, via microsurgical technique, with applying growth factor to 50-60% of the diameter of the portal vein. In GroupⅢ(n=10, 80-100% growth factor), the portal vein was anastomosed, via microsurgical technique, with using growth factor to 80-100% of the diameter of the portal vein. Results: In GroupⅡ, only one case has portal vein stenosis on the postoperative 14th day following portal vein anastomosis with growth factor. In GroupⅠ, 3 cases showed portal vein stenosis on the postoperative 7th day, and 5 cases showed portal vein thrombosis on the postoperative 14th day. In GroupⅢ, 6 cases died due to bleeding after declamping of the portal vein anastomosis with using 80-100% growth factor on the diameter and 1 case has portal vein thrombosis on the postoperative 14th day. Conclusion: Several surgical factors might have an important role in preventing vascular stenosis and thrombosis, and especially when transplanting a technical-variant liver graft like a difference in caliber between the donor and recipient vessels, the growth-factor suture technique having 50-60% of one diameter might be helpful because it allows for expansion along the suture line and it also prevents a purse-string effect.

간접문맥조영에서 주문맥과 우문맥의 해부학적 변이 : 동맥조영술과 CT를 고려한 해 부학적 이해

박원규 대한영상의학회 1996 대한영상의학회지 Vol.35 No.2

Purpose : To describe variations of the main and right portal veins as visualized by indirect portograms andto examine the surgical implications of these findings. Materials and Methods : A retrospective review wasconducted of 632 indirect portograms of 632 patients in whom third-order branches were visualized. All patientsalso underwent dynamic CT and AP and oblique hepatic angiography. Results : Variations of the main portal veinwere found in 165 patients(26.1%) and involved an immediate trifurcation of the main portal vein in 102patients(16.1%), early division of the right posterior portal vein in 53(8.4%), simultaneous division into fourbranches in three (0.5%), five branches in two (0.3%), a replaced P4 originating from the right portal vein in two(0.3%), and an accessory P6 originating from the main portal vein, a replaced P6 originating from the main portalvein, or a replaced left lateral portal vein originating from the right portal vein in one (0.2%), respectively.Of 468 patients who had a common right portal vein, absence of the right posterior portal vein was seen in 26patients(5.6%) and an accessory subsegmental branch originating from the right portal vein in 17 patients(3.6%).Conclusions : Recognition of such variations of the portal vein assists in the localization and appreciation ofthe hepatic segmental anatomy, in preoperative evaluations for hepatic resections, and in radiologicinterventional procedures through the portal vein.

Portal vein embolization in intrahepatic portal vein injury after blunt trauma: a case report

Cho Sung Hoon,Lee Sang Yub,차중근,홍지훈,Lee Sangcjeol,임경훈 대한외상학회 2022 大韓外傷學會誌 Vol.35 No.-

Mortality from hepatic injury has declined over the last several decades for various reasons, including nonoperative management, such as angioembolization, in more than 80% of cases. Conversely, surgical treatment is preferred in intrahepatic portal vein injury due to several reasons. Here, we report a case that treatment of blunt traumatic liver injury accompanied by intrahepatic portal vein injury through portal vein embolization. A 29-year-old female patient was transferred to our trauma center for vehicular accident injuries. Contrast-enhanced abdominal computed tomography showed a massive hemoperitoneum and liver laceration (grade IV) with contrast extravasation suspected of the right portal vein branch but no other organ injury. Since vital signs were stable, we decided to perform nonsurgical radiologic intervention. Portography showed active bleeding of the posterior branch of the right portal vein. A pseudoaneurysm in the portal vein was embolized through percutaneous transhepatic portal vein puncture. On follow-up liver dynamic computed tomography performed 2 days after embolization, the posterior branch of the right portal vein was sufficiently embolized, and no liver parenchymal necrosis was observed. The patient was discharged without any complications 2 weeks later. This report suggests portal vein embolization as a good alternative treatment method for portal vein injury in patients with stable vital signs.

Doppler 초음파검사로 진단된 문맥의 해면상 변형

최흥재(Heung Jai Choi),김원호(Won Ho Kim),배형미(Hyung Mi Bae),함기백(Ki Baik Hahm),송시영(Si Young Song),전재윤(Chae Yoon Chon),강진경(Jin Kyung Kang),박인서(In Suh Park) 대한내과학회 1991 대한내과학회지 Vol.40 No.5

N/A Following portal vein occlusion, hepatopetal collaterals develop, undergo compensatory enlargement, bypass the obstructed extrahepatic occlusion and reconstitute the intrahepatic portal branches. Angiographically, the collateral veins are seen as multiple tortuous winding vessels in the porta hepatis and are described as a cavernous transformation of the portal vein. Ultrasonography is thc procedure of choice for the detection of various abnormalities of the portal vein and surrounding structures. Doppler ultrasonography adds hemodynamic information. We analyzed the clinical, ultrasonogaphic, angiographic, and Doppler ultrasonographic findings in 11 patients with cavernous transformation of the portal vein. Ultrasonographic findings suggesting cavernous transformation of the portal vein are 1) failure of visualization of the extrahepatic portal vein or portal division, 2) demonstration of high-level echoes in the region of the porta hepatis (diamond sign), and 3) visualization of multiple serpiginous vascular channels around the obstructed portal vein. Doppler ultrasonographic detection of flow signals from those collaterals, which are similar to the flow signals of the portal vein, confirms the diagnosis. We conclude that Doppler ultrasonography is a simple, noninvasive and very useful way to confirm the diagnosis of cavernous transfromation of the portal vein.

Portal and hepatic vein thrombosis after transjugular intrahepatic portosystemic shunt: Incidence in follow-up imaging and clinical implications

Partha Mandal,Barrett P. O’Donnell,Eric Reuben Smith,Osamah Al-Bayati,Adam Khalil,Serena Jen,Mario Vela,Jorge Lopera 소화기인터벤션의학회 2022 Gastrointestinal Intervention Vol.11 No.1

Background: This study investigated the incidence and clinical outcomes of portal and hepatic vein thrombosis (VT) on imaging after transjugular intrahepatic portosystemic shunt (TIPS). Methods: A retrospective review of records at a single liver transplant center between 2010 and 2018 revealed 423 patients who underwent TIPS. Contrast-enhanced computed tomography and magnetic resonance images within 1 year post-TIPS were available for 138 patients and compared to assess the imaging findings of VT and liver infarction. The associations of VT with overall survival, patient characteristics, stent size, pre- and post- TIPS Model for End-Stage Liver Disease (MELD) scores, and post-TIPS hepatic encephalopathy at 90 days were analyzed. Results: The prevalence of VT on imaging within 1 year was 63.0% (n = 87). VT within the right portal vein was more common: 41 cases were in the right portal vein, 25 in the posterior portal vein, and two in the anterior right portal vein. Ten patients had VT in the left portal vein. Four had VT in the main portal vein (MPV), and one had shunt thrombosis extending into the superior mesenteric vein. Hepatic VT was seen in the right hepatic vein in 17 patients and in the middle hepatic vein in six patients. VT was associated with liver infarction (n = 9, P = 0.018). There was no relationship between VT and sex, age, cirrhosis etiology, indication for TIPS, stent size, or hepatic encephalopathy at 90 days. VT in the MPV had poorer survival (P < 0.001). Older age (P = 0.028) and higher pre-TIPS MELD score (P = 0.049) were poor prognostic factors. VT was not treated. Conclusion: Portal and hepatic VTs were common imaging findings after TIPS without worsened clinical outcomes unless VT involved the MPV. VT may cause liver infarction, but infarcts were not independently associated with poorer survival.

Portal and hepatic vein thrombosis after transjugular intrahepatic portosystemic shunt: Incidence in follow-up imaging and clinical implications

Partha Mandal,Barrett P. O’Donnell,Eric Reuben Smith,Osamah Al-Bayati,Adam Khalil,Serena Jen,Mario Vela,Jorge Lopera 소화기인터벤션의학회 2022 International journal of gastrointestinal interven Vol.11 No.1

Background: This study investigated the incidence and clinical outcomes of portal and hepatic vein thrombosis (VT) on imaging after transjugular intrahepatic portosystemic shunt (TIPS). Methods: A retrospective review of records at a single liver transplant center between 2010 and 2018 revealed 423 patients who underwent TIPS. Contrast-enhanced computed tomography and magnetic resonance images within 1 year post-TIPS were available for 138 patients and compared to assess the imaging findings of VT and liver infarction. The associations of VT with overall survival, patient characteristics, stent size, pre- and post- TIPS Model for End-Stage Liver Disease (MELD) scores, and post-TIPS hepatic encephalopathy at 90 days were analyzed. Results: The prevalence of VT on imaging within 1 year was 63.0% (n = 87). VT within the right portal vein was more common: 41 cases were in the right portal vein, 25 in the posterior portal vein, and two in the anterior right portal vein. Ten patients had VT in the left portal vein. Four had VT in the main portal vein (MPV), and one had shunt thrombosis extending into the superior mesenteric vein. Hepatic VT was seen in the right hepatic vein in 17 patients and in the middle hepatic vein in six patients. VT was associated with liver infarction (n = 9, P = 0.018). There was no relationship between VT and sex, age, cirrhosis etiology, indication for TIPS, stent size, or hepatic encephalopathy at 90 days. VT in the MPV had poorer survival (P < 0.001). Older age (P = 0.028) and higher pre-TIPS MELD score (P = 0.049) were poor prognostic factors. VT was not treated. Conclusion: Portal and hepatic VTs were common imaging findings after TIPS without worsened clinical outcomes unless VT involved the MPV. VT may cause liver infarction, but infarcts were not independently associated with poorer survival.