Portal venous flow pattern as a useful tool for predicting esophageal varix bleeding in cirrhotic patients

The Portal Venous Pulsatility Index and Main Portal Vein Diameter as Surrogate Markers for Liver Fibrosis in Nonalcoholic Fatty Liver Disease and Metabolic-Dysfunction-Associated Steatotic Liver Disease

(1) Background: Despite numerous noninvasive methods for assessing liver fibrosis, effective ultrasound parameters remain limited. We aimed to identify easily measurable ultrasound parameters capable of predicting liver fibrosis in patients with nonalcoholic fatty liver disease (NAFLD) and metabolic-dysfunction-associated steatotic liver disease (MASLD); (2) Methods: The data of 994 patients diagnosed with NAFLD via ultrasound at the Armed Forces Goyang Hospital were retrospectively collected from June 2022 to July 2023. A liver stiffness measurement (LSM) ≥ 8.2 kPa was classified as significant fibrosis. Liver steatosis with cardiometabolic risk factors was defined as MASLD. Two ultrasound variables, the portal venous pulsatility index (VPI) and main portal vein diameter (MPVD), were measured; (3) Results: Of 994 patients, 68 had significant fibrosis. Significant differences in VPI (0.27 vs. 0.34, p < 0.001) and MPVD (10.16 mm vs. 8.98 mm, p < 0.001) were observed between the fibrotic and non-fibrotic groups. A logistic analysis adjusted for age and body mass index (BMI) revealed that only VPI (OR of 0.955, p = 0.022, VPI on a 0.01 scale) and MPVD (OR of 1.501, p < 0.001) were significantly associated with significant liver fibrosis. In the MASLD cohort (n = 939), VPI and MPVD were associated with significant fibrosis. To achieve better accuracy in predicting liver fibrosis, we established a nomogram that incorporated MPVD and VPI. The established nomogram was validated in the test cohort, yielding an area under the receiver operating characteristic curve of 0.821 for detecting significant liver fibrosis; (4) Conclusions: VPI and MPVD, as possible surrogate markers, are useful in predicting significant fibrosis in patients with NAFLD and MASLD.

Four-dimensional Flow MRI as a Marker for Risk Stratification of Gastroesophageal Varices in Patients with Liver Cirrhosis

Purpose To assess the feasibility of four-dimensional (4D) flow MRI as a noninvasive imaging marker for stratifying the risk of variceal bleeding in patients with liver cirrhosis. Materials and Methods This study recruited participants scheduled for both liver MRI and gastroesophageal endoscopy. Risk of variceal bleeding was assessed at endoscopy by using a three-point scale: no varices, low risk, and high risk requiring treatment. Four-dimensional flow MRI was used to create angiograms for evaluating visibility of varices and to measure flow volumes in main portal vein (PV), superior mesenteric vein, splenic vein (SV), and azygos vein. Fractional flow changes in PV and SV were calculated to quantify shunting (outflow) from PV and SV into varices. Logistic analysis was used to identify the independent indicator of high-risk varices. Results There were 23 participants (mean age, 52.3 years; age range, 25-75 years), including 14 men (mean age, 51.7 years; age range, 25-75 years) and nine women (mean age, 53.2 years; age range, 31-72 years) with no varices (n = 8), low-risk varices (n = 8), and high-risk varices (n = 7) determined at endoscopy. Four-dimensional flow MRI-based angiography helped radiologists to view varices in four of 15 participants with varices. Independent indicators of high-risk varices were flow volume in the azygos vein greater than 0.1 L/min (P = .034; 100% sensitivity [seven of seven] and 62% specificity [10 of 16]) and fractional flow change in PV of less than 0 (P < .001; 100% sensitivity [seven of seven] and 94% specificity [15 of 16]). Conclusion Azygos flow greater than 0.1 L/min and portal venous flow less than the sum of splenic and superior mesenteric vein flow are useful markers to stratify the risk of gastroesophageal varices bleeding in patients with liver cirrhosis. © RSNA, 2018 Online supplemental material is available for this article.

Hemodynamic consequences of spontaneous splenorenal shunts in deceased donor liver transplantation

The presence of large spontaneous splenorenal shunts (SSRSs) is a risk factor for poor portal vein flow and liver dysfunction. The disconnection of splenorenal shunts by left renal vein (LRV) ligation has been suggested as a potential solution for improving portal flow. We reviewed the hemodynamic consequences of splenorenal shunts in deceased donor liver transplantation and investigated the role of LRV ligation. In 10 patients who underwent liver transplantation at our institution between January 2006 and April 2010, an SSRS was diagnosed preoperatively. Intraoperative portal and hepatic artery flows were measured with a transit time flowmeter. The shunt was disconnected in 6 patients for whom the portal flow after reperfusion was less than or equal to 1200 mL/minute. LRV ligation resulted in significant increases in the portal flow. There were no differences in renal function for the patients who underwent renal vein ligation and the patients who did not undergo ligation. In conclusion, LRV ligation disconnects splenorenal shunts and modulates the portal inflow without any detrimental effects on renal function.

Lateral approach for laparoscopic splenic vessel-preserving distal pancreatectomy

AIM

We sought to evaluate the feasibility of the lateral approach for laparoscopic splenic vessel-preserving distal pancreatectomy (LA-SVPDP).

BACKGROUND

Complete preservation of the splenic vessels is an ideal outcome in spleen-preserving distal pancreatectomy (SPDP). However, the preservation of the vessels is challenging in laparoscopic surgery because the splenic vein is often embedded in the pancreatic parenchyma. Herein we have described LA-SVPDP, the most feasible method for laparoscopic SPDP, and the outcome of our initial experience.

PATIENTS

Twenty-three patients underwent laparoscopic SPDP. Before we adopted LA-SVPDP, 8 patients underwent the Warshaw method and 6 underwent SVPDP. After the adoption of LA-SVPDP, 8 patients underwent LA-SVPDP and 1 donor underwent the Warshaw method.

RESULTS

None of patients undergoing LA-SVPDP required conversion to an open operation, whereas 2 patients undergoing the other procedures were converted to open operations. Five out of 8 patients who underwent the Warshaw method showed engorgement of the gastric veins, revealed by computed tomography. However, only 1 of the 5 patients showed mild gastric varices on endoscopy.

CONCLUSION

Although the Warshaw method is acceptable with a low incidence of gastric varices in our analysis, SVPDP is a feasible approach for SPDP. Our LA-SVPDP technique may contribute to safer and easier SVPDP in laparoscopic surgery.

Does gastroesophageal reflux have an influence on bleeding from esophageal varices?

BACKGROUND

Mucosal breaks induced by gastroesophageal reflux of gastric contents were more frequently found on the right anterior wall of the lower esophagus. Bleeding from esophageal varices may be also derived from gastroesophageal reflux. The circumferential location of the ruptured esophageal varices was evaluated to elucidate the relationship between gastroesophageal reflux and variceal rupture.

METHODS

Between January 2004 and December 2006, 26 patients who had primary bleeding from esophageal varices and 74 patients without evidence of bleeding with positive red color signs on varices were enrolled in this study retrospectively. Locations of bleeding spots and nonbleeding red color signs of esophageal varices were retrospectively evaluated by endoscopic photographs, and the relationship between the location of red color signs and the risk of bleeding was evaluated. Other possible predictors for bleeding were also investigated by multivariate regression analysis.

RESULTS

Red color signs were frequently found in the right posterior wall of the lower esophagus. However, bleeding spots of esophageal varices were more frequently seen in the right anterior side (64.0%) than in others. The positive predictor for bleeding from esophageal varices was the presence of red color sign in the right anterior wall of the esophagus, and the administration of proton pomp inhibitor was the negative predictor.

CONCLUSIONS

Gastroesophageal acid reflex may be a risk factor of bleeding from esophageal varices. Attention should be paid to the circumferential location of red color signs in endoscopic screening of patients with esophageal varices to predict future bleeding.

Triple-phase computed tomography and intraoperative flow measurements improve the management of portosystemic shunts during liver transplantation

Ligation of portosystemic shunts in patients with cirrhosis undergoing liver transplantation has been recommended to avoid insufficient portal vein (PV) flow. Shunts are not always recognized pretransplantation because intraoperative PV flow assessment is not routinely attempted. As a result of a posttransplantation PV thrombosis in a recipient with a large portosystemic shunt and a PV flow <1 L/minute, we employed triple-phase computed tomography with vascular reconstruction and intraoperative graft flow measurement to determine the need for inflow modification in our next 16 patients with large portosystemic shunts. Subsequently, 6 patients with large portosystemic shunts and PV flows <or=1 L/minute underwent inflow modification at the time of transplantation to improve venous graft inflow. One patient with PV thrombosis had PV replacement without shunt ligation. Two patients with large splenorenal shunts and extensive PV thrombosis had left renoportal bypass. In 7 patients with large portosystemic shunts and PV flow greater than 1 L/minute, inflow modification was not attempted, to avoid excessive venous inflow that could jeopardize hepatic artery flow via the hepatic artery buffer response. In conclusion, sustained good graft function and inflow were achieved in all 16 patients.

Noninvasive predictors of large varices in patients hospitalized with gastroesophageal variceal hemorrhage

AIM

To identify noninvasive factors predicting the presence of large varices (LV) in patients hospitalized with gastroesophageal variceal hemorrhage (GEVH).

METHODS

Case records of patients admitted with GEVH between January 1998 and June 2005 were retrospectively analyzed. Relevant clinical parameters assessed included Child-Pugh class, ascites (clinical and/or on ultrasound), portosystemic encephalopathy (PSE), splenomegaly (clinical and/or on ultrasound), and hemodynamic instability. The laboratory parameters assessed were hemoglobin level, platelet count, prothrombin time, serum bilirubin, and albumin. The ultrasonographic characteristics noted were splenic size, presence of splenic varices, and portal vein diameter.

RESULTS

A total of 420 patients (264 men) presented with GEVH during the study period. The mean age, gender distribution, and presence of cirrhosis were similar in the two groups. Liver cirrhosis with hepatocellular carcinoma (HCC), Child-Pugh class C, presence of clinically detectable ascites, grade 3-4 PSE, detectable splenomegaly, previous history of GEVH, hemodynamic instability and platelet count <91,000 were more common in the LV group. The frequency of radiologically detected ascites, splenomegaly, and portal vein diameter were similar in both groups. On multivariate analysis, the independent predictors for the presence of LV were cirrhosis with HCC, clinically detectable splenomegaly, hemodynamic instability, a previous history of GEVH, platelet count <91,000, and splenic size >/=158 mm.

CONCLUSION

Cirrhosis with HCC, clinical splenomegaly, hemodynamic instability, a previous history of GEVH, thrombocytopenia (i.e., platelet count <91,000), and splenic size >/=158 mm are independent noninvasive predictors of large varices in patients hospitalized with gastroesophageal variceal hemorrhage.