Pancreatoduodenectomy with portal-superior mesenteric vein resection and reconstruction can provide radical surgical opportunities for patients with venous invasion and enable them to benefit from the surgery. With the development of minimally invasive concepts and surgical techniques, laparoscopic and robot-assisted pancreatoduodenectomy with portal-superior mesenteric vein resection and reconstruction is being increasingly widely carried out. This surgical procedure is highly technically demanding, and the perioperative management of patients is complex. However, there is a lack of high-quality and high-level evidence-based clinical studies in this regard. In order to better standardize the clinical application of laparoscopic or robot-assisted pancreatoduodenectomy with portal-superior mesenteric vein resection and reconstruction in China, the Study Group of Minimally Invasive Treatment for Pancreatic Cancer in China Anti-Cancer Association, guided by problems and based on evidence, formed 17 recommendations through full discussions among experts. The recommendations involve the safety, oncological benefits, and perioperative patient management of the minimally invasive approach to pancreatoduodenectomy with portal-superior mesenteric vein resection and reconstruction.
Humans ; Pancreaticoduodenectomy/methods* ; Mesenteric Veins/surgery* ; Laparoscopy ; Portal Vein/surgery* ; Robotic Surgical Procedures ; Pancreatic Neoplasms/surgery* ; Consensus

Portal vein thrombosis (PVT) secondary to blunt abdominal trauma associated with liver injury is extremely rare in healthy individuals as well as in minor liver injury, and it carries a high rate of morbidity and mortality. Moreover, acute asymptomatic PVT is difficult to diagnose. We present a young trauma patient with isolated minor liver injury associated with acute PVT. A 27-year-old man presented to the emergency department after a motor vehicle collision. His primary survey findings were unremarkable. His secondary survey showed a large contusion (7 × 7 cm²) at the epigastrium with marked tenderness and localized guarding. The CT angiography of the whole abdomen revealed liver injury grade 3 in hepatic segments 2/3 and 4b (according to the American Association for the Surgery of Trauma classification) extending near the porta hepatis with patent hepatic and portal veins and without other solid organ injury. The follow-up CT of the whole abdomen on post-injury day 7 showed a 1.8-cm thrombus in the left portal vein with patent right portal and hepatic veins, and a decreased size of the hepatic lacerations. A liver function test was repeated on post-injury day 4, and it revealed improved transaminitis. The patient received intravenous anticoagulant therapy with low-molecular-weight heparin according to weight-based dosing for treatment. The CT of the whole abdomen performed 2 weeks after anticoagulant therapy showed small residual thrombosis in the left portal vein. The patient received intravenous anticoagulant therapy for a total of 3 months. On the follow-up visits at 1 month, 2 months, 6 months, and 1 year after the injury, the patients did not have any detectable abnormal symptoms. PVT post-blunt minor liver injury is an extremely rare complication. If the thrombosis is left untreated, serious morbidity and mortality can ensue. However, its diagnosis in asymptomatic patients is still challenging. Periodic imaging is necessary for highly suspected PVT, especially in liver injury with lacerations close to the porta hepatis, even in cases of a minor injury.
Humans ; Portal Vein ; Male ; Adult ; Wounds, Nonpenetrating/complications* ; Venous Thrombosis/diagnostic imaging* ; Liver/injuries* ; Acute Disease ; Accidents, Traffic

OBJECTIVES: To establish a three-dimensional (3D) visualization-based classification of the left hepatic portal vein (LHPV) and left hepatic vein (LHV) systems using 3D reconstruction technology to facilitate precise segmental/subsegmental resection of left liver lesions. METHODS: Thin-slice contrast-enhanced CT datasets from 244 patients were reconstructed using MI-3DV Works software. The spatial anatomy (origins, branching patterns, and spatial relationships) of the LHPV and LHV branches was analyzed to determine their 3D classifications and segmental liver divisions for guiding surgical planning for anatomical left liver resections. RESULTS: The 3D models of the third- and fourth-order branches of the LHPV and LHV were successfully reconstructed for all the 244 patients. Two types of the LHPV system were identified, where the LHPV either had independent origins [242 cases (99.1%)] or had right anterior portal branches arising from the LHPV trunk [2 cases (0.9%)]. 3D classifications identified two types of the Segment II of the LHPV (based on branch number), 3 types of the Segment III (by spatial distribution of the branches), compact vs dispersed types of the left lateral lobe (determined by Segment II/III branches proximity), 3 types of the Segment IV (by branch number and origin), and 3 types the fourth hilar vessels (transverse branches of the left portal vein) for their supplied segments. The LHV system had two drainage types into the inferior vena cava, and the umbilical fissure veins were classified into 3 types by drainage patterns and distance to the venous roots. These classifications combined with liver segmentations allowed individualized surgical planning for segment-specific resections. CONCLUSIONS The 3D classification of the LHPV and LHV provides valuable clinical guidance for precise anatomical resections of left liver lesions using liver segments or subsegments as anatomical units to enhance surgical accuracy and improve the outcomes of hepatobiliary surgery.
Humans ; Hepatectomy/methods* ; Imaging, Three-Dimensional ; Hepatic Veins/anatomy & histology* ; Portal Vein/anatomy & histology* ; Liver/surgery* ; Liver Neoplasms/blood supply* ; Tomography, X-Ray Computed ; Female

Objective: To investigate the features of contrast-enhanced ultrasound (CEUS) in hepatic epithelioid hemangioendothelioma (HEHE) in order to improve the preoperative diagnosis rate. Methods: CEUS images of 32 pathologically-proven cases of hepatic epithelioid hemangioendothelioma from January 2004 to August 2021 were collected. Lesions were analyzed to observe the features of enhancement mode, enhancement intensity, and distinct enhancement phases. Results: Among the 32 cases, one had a solitary lesion, 29 had multiple lesions, and two had diffuse-type lesions. Contrast-enhanced ultrasound revealed a total of 42 lesions in 32 cases. In terms of arterial phase enhancement, 18 lesions had overall enhancement, six lesions had uneven dendritic enhancement, 16 lesions had rim-like enhancement, and two lesions had just slight peripheral spot enhancement around the lesions. Among the three cases, there were multiple lesions that had overall enhancement and ring enhancement. In terms of the enhancement phase, 20 lesions showed "fast progression", 20 lesions showed "same progression", and two lesions showed "slow progression". During the late arterial or early portal venous phases with rapid washout, all lesions manifested as hypoechoic. With peaked enhanced intensity, 11 lesions had a lower enhancement intensity than the surrounding normal liver parenchyma; 11 lesions had the same enhancement degree as the surrounding normal liver parenchyma; and 20 lesions had a higher enhancement degree than the surrounding normal liver parenchyma. All 16 ring-enhancing lesions had marked hyperenhancement. In the typical enhancing lesions, four showed hyperenhancement, five showed low enhancement, and nine showed isoenhancement. In the dendrite-enhancing lesions, there were two isoenhancing and four hypoenhancing. Contrast-enhanced ultrasound delineated the boundaries of all lesions more clearly than two-dimensional ultrasound. Conclusion: Contrast-enhanced ultrasound has certain value in the diagnosis of hepatic epithelioid hemangioendothelioma.
Humans ; Hemangioendothelioma, Epithelioid/pathology* ; Contrast Media ; Retrospective Studies ; Liver Neoplasms/pathology* ; Portal Vein/pathology* ; Ultrasonography

Objective: To analyze the safety and efficacy of using novel oral anticoagulants (rivaroxaban and others) in patients with cirrhosis accompanied with portal vein thrombosis (PVT). Methods: Clinical research literature published from the establishment of the database to June 20, 2021, was retrieved from PubMed, Web of Science, CNKI, Wanfang, and Weipu databases by combining subject terms and free words. RevMan software was used for the random group meta-analysis model. Results: In terms of PVT recanalization, the novel oral anticoagulants (such as low molecular weight heparin and others) had a higher recanalization rate than traditional anticoagulants (OR = 13.75, 95%CI 3.58-52.9, P = 0.000 1). In terms of bleeding, the novel oral anticoagulants did not increase the risk of bleeding compared with traditional anticoagulants (OR = 2.42, 95%CI 0.62-9.41, P = 0.20). Conclusion: The novel oral anticoagulant drugs are superior to traditional anticoagulants in terms of the occurrence of PVT recanalization; however, there is no statistically significant difference in terms of the occurrence of bleeding between the two groups.
Humans ; Portal Vein/pathology* ; Treatment Outcome ; Venous Thrombosis/complications* ; Liver Cirrhosis/pathology* ; Anticoagulants/therapeutic use* ; Hemorrhage

Objective: To examine the clinical effect of auxiliary liver transplantation with ultra-small volume graft in the treatment of portal hypertension. Methods: Twelve cases of portal hypertension treated by auxiliary liver transplantation with small volume graft at Liver Transplantation Center,Beijing Friendship Hospital, Capital Medical University between December 2014 and March 2022 were studied retrospectively. There were 8 males and 4 females,aged 14 to 66 years. Model for end-stage liver disease scores were 1 to 15 points and Child scores were 6 to 11 points. The grafts was derived from living donors in 9 cases,from split cadaveric donors in 2 cases,from whole cadaveric liver of child in 1 case. The graft recipient body weight ratios of 3 cadaveric donor livers were 0.79% to 0.90%, and of 9 living donor livers were 0.31% to 0.55%.In these cases, ultra-small volume grafts were implanted. The survivals of patient and graft, complications, portal vein blood flow of residual liver and graft, abdominal drainage and biochemical indexes of liver function were observed. Results: All the grafts and patients survived. Complications included outflow tract torsion in 2 cases, acute rejection in 1 case, bile leakage in 1 case, and thyroid cancer at the later stage of follow-up in 1 case, all of which were cured. The torsion of outflow tract was attributed to the change of anastomotic angle after the growth of donor liver. After the improvement of anastomotic method, the complication did not recur in the later stage. There was no complication of portal hypertension. The measurement of ultrasonic portal vein blood flow velocity showed that the blood flow of residual liver decreased significantly in the early stage after operation, and maintained a very low blood flow velocity or occlusion in the long term after operation, and the blood flow of transplanted liver was stable. Conclusions: Auxiliary liver transplantation can implant ultra-small donor liver through compensation of residual liver. This method may promote the development of living donor left lobe donation and split liver transplantation. However, the auxiliary liver transplantation is complex, and it is difficult to control the complications. Therefore, this method is currently limited to centers that are skilled in living related liver transplantation and that have complete ability to monitor and deal with complications.
Male ; Child ; Female ; Humans ; Liver Transplantation/methods* ; End Stage Liver Disease/surgery* ; Retrospective Studies ; Living Donors ; Severity of Illness Index ; Neoplasm Recurrence, Local ; Liver/blood supply* ; Hypertension, Portal/surgery* ; Portal Vein ; Cadaver

Objective: To compare the safety and efficacy of transmesenteric vein extrahepatic portosystemic shunt (TEPS) and transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of cavernous transformation of the portal vein (CTPV). Methods: The clinical data of CTPV patients with patency or partial patency of the superior mesenteric vein treated with TIPS or TEPS treatment in the Department of Vascular Surgery of Henan Provincial People's Hospital from January 2019 to December 2021 were selected. The differences in baseline data, surgical success rate, complication rate, incidence rate of hepatic encephalopathy, and other related indicators between TIPS and TEPS group were statistically analyzed by independent sample t-test, Mann-Whitney U test, and Chi-square test. Kaplan-Meier survival curve was used to calculate the cumulative patency rate of the shunt and the recurrence rate of postoperative portal hypertension symptoms in both groups. Results: The surgical success rate (100% vs. 65.52%), surgical complication rate (6.67% vs. 36.84%), cumulative shunt patency rate (100% vs. 70.70%), and cumulative symptom recurrence rate (0% vs. 25.71%) of the TEPS group and TIPS group were statistically significantly different (P < 0.05). The time of establishing the shunt [28 (2141) min vs. 82 (51206) min], the number of stents used [1 (12) vs. 2 (15)], and the length of the shunt [10 (912) cm vs. 16 (1220) cm] were statistically significant between the two groups (t = -3.764, -4.059, -1.765, P < 0.05). The incidence of postoperative hepatic encephalopathy in the TEPS group and TIPS group was 6.67% and 15.79% respectively, with no statistically significant difference (Fisher's exact probability method, P = 0.613). The pressure of superior mesenteric vein decreased from (29.33 ± 1.99) mmHg to (14.60 ± 2.80) mmHg in the TEPS group and from (29.68 ± 2.31) mmHg to (15.79 ± 3.01) mmHg in TIPS group after surgery, and the difference was statistically significant (t = 16.625, 15.959, P < 0.01). Conclusion: The best indication of TEPS is in CTPV patients with patency or partial patency of the superior mesenteric vein. TEPS improves the accuracy and success rate of surgery and reduces the incidence of complications.
Humans ; Portal Vein/surgery* ; Portasystemic Shunt, Transjugular Intrahepatic/methods* ; Hepatic Encephalopathy/etiology* ; Treatment Outcome ; Hypertension, Portal/complications* ; Retrospective Studies ; Gastrointestinal Hemorrhage/etiology*

OBJECTIVES: Heparin is mainly used as an anticoagulant in clinic, and it also has a certain anti-inflammatory effect. At present, after portal vein islet transplantation in diabetic patients, heparin is mainly infused through the peripheral veins of the limbs to achieve the purpose of anticoagulation and protection of the graft, rather than through the portal vein. In this study, animal experiments were conducted to investigate the effect of heparin infusion via the portal vein and marginal ear vein on the instant blood-mediated inflammatory reaction (IBMIR) after portal vein islet transplantation, which is the choice of anticoagulation methods for clinical islet transplantation to provide a basis for decision-making. METHODS: A total of 50 neonatal pigs (Xeno-1 type, 3-5 days) were selected. Islets were isolated and purified from the pancreas of neonatal pigs. Ten non-diabetic Landrace pigs (1.5-2.0 months) served as recipients, and 12 000 IEQ/kg neonatal porcine islets were transplanted into the liver through the portal vein. All recipients received bolus injection of 50 U/kg of heparin 10 minutes before transplantation. After the bolus injection of heparin, the experimental group received heparin via the portal vein [10 U/(kg·h), 5 recipients], and the control group received heparin via the marginal ear vein [10 U/(kg·h), 5 recipients]. The superior vena cava blood was collected from the 2 groups pre-operation at 1, 3, 24 h post-operation of the transplantation. The portal vein blood was collected from the experimental group at 1 and 3 h after the transplantation as well. The levels of complement C3a, C5a, thrombin-antithrombin complex (TAT), β-thromboglobulin (β-TG), and D-dimer as well as activated partial thromboplastin time (APTT) in superior vena cava blood from 1 and 3 h post-transplantation were detected in the 2 groups, and the levels of anti-Xa and anti-IIa in the portal vein and superior vena cava blood from 1 and 3 h post-transplantation in the experimental group were detected. Twenty four hours after the transplantation, the liver tissues in the 2 groups were collected for pathological examination to observe the inflammatory cell infiltration and peripheral thrombosis around the islets graft in liver. RESULTS: Before transplantation, there was no statistically significant difference in C3a, C5a, TAT, β-TG, D-dimer levels and APTT between the 2 groups (all P>0.05). At 1 and 3 h after transplantation, the C3a, TAT, and D-dimer levels in the experimental group were significant decreased than those in the control groups (all P<0.05), and at 3 h after transplantation the C5a was significant decreased than that in the control group (P<0.05). At 1 and 3 h after transplantation, the anti-Xa and anti-IIa levels in the portal vein blood were significantly increased than those in the superior vena cava blood in the experimental group (all P<0.05). Pathological results showed the presence of islet cell clusters in the liver blood vessels. The thrombus formation and neutrophil infiltration around islet graft was not obvious in the experimental group, while massive thrombus formation and neutrophil infiltration in the control group. CONCLUSIONS Compared with marginal ear vein infusion of heparin, the direct infusion of heparin in the portal vein has a certain inhibitory effect on complement system, coagulation system activation and inflammatory cell infiltration in portal vein islet transplantation, which may attenuate the occurrence of IBMIR.
Animals ; Anticoagulants/therapeutic use* ; Heparin/therapeutic use* ; Humans ; Islets of Langerhans/pathology* ; Islets of Langerhans Transplantation/physiology* ; Portal Vein ; Swine ; Vena Cava, Superior

Clinical practice using associating liver partition and portal vein ligation for staged hepatectomy(ALPPS) or its modified procedures in treatment of primary hepatocellular carcinoma(HCC) with insufficient future liver remnant(FLR) in the past 10 years has failed to meet our expectations both in achieving decreased perioperative complications and mortality.The efficacy of ALPPS in improving long-term survival outcome of HCC still remains poor.Due to the trauma of two surgery within a short period,and patients with inadequate FLR are all diagnosed at advanced disease stages,ALPPS can only achieve surgical rather than biological tumor-curability.Previous studies have demonstrated comparable 5-year survival rates between early and advanced stages of HCC who underwent regional treatments.Therefore,tumor biological conversion is the key strategy prior to liver remnant volume conversion in improving treatment outcomes for HCC patients with insufficient FLR.Target therapy,immunotherapy together with locally treatment were expected to improve the conversion efficacy.Looking back at the development of ALPPS for the last decade,the rapid proliferation of FLR should be passed on,while the technology costs high risks and result in poor long-term outcome must be cautiously selected.
Carcinoma, Hepatocellular/surgery* ; Hepatectomy ; Humans ; Ligation ; Liver ; Liver Neoplasms/surgery* ; Portal Vein/surgery* ; Technology ; Treatment Outcome

This article presented an overview of the therapeutic effects of Chinese medicine (CM) preparations for promoting blood circulation and removing blood stasis for patients with portal vein thrombosis (PVT) after splenectomy. Based on published clinical researches of CM preparations for PVT after splenectomy in patients with cirrhotic portal hypertension (CPH), this paper evaluated the incidence of PVT, and explored potential active components and mechanisms of CM preparations. Safflower Yellow Injection, Danshen Injection () Danhong Injection (), and Compound Danshen Dropping Pill () achieved good curative effect alone or combined with anticoagulant therapy. In addition, Compound Biejia Ruangan Tablet () and Anluo Huaxian Pill () can also significantly improve the hemodynamic disorders of portal vein system in patients with cirrhosis. Considering the role of CM preparations in ameliorating the incidence of PVT after splenectomy in patients with CPH, we suggested that future research should provide more attention to CM alone or CM combined with anticoagulant for cirrhosis with PVT.
Anticoagulants/therapeutic use* ; Humans ; Hypertension, Portal/drug therapy* ; Liver Cirrhosis/surgery* ; Medicine, Chinese Traditional/adverse effects* ; Portal Vein ; Risk Factors ; Splenectomy/adverse effects* ; Venous Thrombosis/etiology*