Management of acute post-operative portal venous thrombosis

Portal vein thrombosis and hepatic infarction due to hepatic mobilization after primary debulking surgery for advanced ovarian cancer: A case report

Hepatic mobilization is essential in debulking surgery for resecting diaphragmatic lesions in advanced ovarian cancer. However, hepatic mobilization potentially induces postoperative portal vein thrombosis and hepatic infarction. No reports exist regarding these postoperative complications of gynecological surgeries. Thus, we reported a case of portal vein thrombosis and hepatic infarction after ovarian cancer surgery with upper abdominal surgery. The 51-year-old female patient who had been diagnosed with advanced ovarian and early endometrial cancer underwent primary debulking surgery. Ultimately, she underwent the following surgical procedures: a hysterectomy, bilateral salpingo-oophorectomy, total parietal peritonectomy, low anterior resection, ileostomy, and appendicectomy. The hepatic enzymatic and D-dimer levels were elevated, postoperatively. Contrast-enhanced computed tomography revealed portal vein thrombosis and an infarction of the hepatic S3 region. The portal vein thrombosis resolved post-administration of unfractionated heparin. The hepatic infarction improved. Meticulous intra- and postoperative management should encompass the deliberation of the potential risk of these postoperative complications.

Portal vein thrombosis after right hepatectomy: impact of portal vein resection and morphological changes of the portal vein

BACKGROUND

Right hepatectomy occasionally requires portal vein resection (PVR) and causes postoperative portal vein thrombosis (PVT).

METHODS

A total of 247 patients who underwent right hepatectomy were evaluated using a three-dimensional analyzer to identify the morphologic changes in the portal vein (PV). The patients' characteristics were compared between the PVR group (n = 73) and non-PVR group (n = 174), and risk factors for PVT were investigated. The PVR group were subdivided into the wedge resection (WR) group (n = 38) and segmental resection (SR) group (n= 35).

RESULTS

Postoperative PVT occurred in 20 patients (8.1%). Multivariate analyses in all patients revealed that postoperative left PV diameter/main PV diameter (L/M ratio) <0.56 (odds ratio [OR] 4.00, p = 0.009) and PVR (OR 3.31, p = 0.031) were significant risk factors for PVT. In 73 patients who underwent PVR, PVT occurred in 14 (19%) and WR (OR 11.5, p = 0.005) and L/M ratio <0.56 (OR 5.51, p = 0.016) were significant risk factors for PVT.

CONCLUSION

PVR was one of the significant risk factors for PVT after right hepatectomy. SR rather than WR may be recommended for preventing PVT.

Prognostic Analysis of Distal Pancreatectomy for Pancreatic Body and/or Tail Cancer Involving the Portal Vein: Is Pancreatic Body and/or Tail Cancer Involving the Portal Vein Resectable?

OBJECTIVES

To the best of our knowledge, the prognostic impact of distal pancreatectomy (DP) for pancreatic body and/or tail cancer involving portal vein (PV) has not been analyzed.

METHODS

A total of 155 patients with pancreatic body and/or tail cancer who were eligible candidates for resection between 2002 and 2017 were analyzed.

RESULTS

Twenty-seven patients had PV contact ≤180°. Fifteen patients underwent preoperative treatment; finally, 132 patients underwent DP, and 21 underwent DP with celiac axis resection. The overall survival (OS) of the PV contact group (n = 27, median survival time [MST], 25.6 months) was worse than the non-PV contact group (n = 128; MST, 58.4 months; P = 0.002); however, it was better than the unresectable group (MST, 14.2 months; P = 0.011). The OS of the PV contact with preoperative chemotherapy group (MST, not available) was comparable to the non-PV contact group and better than the PV contact without preoperative chemotherapy group (MST, 13.4 months; P = 0.017). The multivariate analysis identified PV contact ( P = 0.046) as one of the independent prognostic factors of OS.

CONCLUSIONS

Pancreatic body and/or tail cancer contact with PV ≤180° should be considered borderline resectable because of poor survival.

Recurrent acute portal vein thrombosis with severe abdominal infection after right hemihepatectomy in a patient with perihilar cholangiocarcinoma: A case report and literature review

Introduction and importance

Portal vein thrombosis (PVT) is a serious complication after hepatobiliary-pancreatic surgery. There have been few studies on recurrent PVT after hepatectomy for perihilar cholangiocarcinoma.

Case presentation

We report the case of a 66-year-old woman who was diagnosed with perihilar cholangiocarcinoma and treated with right hemihepatectomy. On the sixth day, the patient developed acute portal vein thrombosis, and emergency portal vein incision and surgical thrombectomy were performed. On the seventh day after thrombectomy, the patient developed acute portal vein thrombosis again, and portal vein thrombectomy+portal vein bridging was performed again. There was still thrombosis after the operation. The patient was then treated with superior mesenteric arteriography + indirect portal vein catheterization thrombolysis and local thrombolysis + anticoagulation and systemic anticoagulation therapy. The patient had a complicated abdominal infection. The total hospital stay was 84 days. There was no thrombosis in the portal vein at discharge.

Clinical discussion

Although the procedure was carefully performed with a preoperative plan and fine intraoperative vascular anastomosis, postoperative PVT occurred. There are many factors of portal vein thrombosis, and there are many treatment methods.

Conclusion

PVT often develops in patients with liver cirrhosis postoperatively and after liver transplantation. Recurrent PVT after hepatectomy for perihilar cholangiocarcinoma is a rare complication.

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Recurrent PVT after hepatectomy for perihilar cholangiocarcinoma is rare.

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Artificial blood vessels can avoid portal vein angulation.

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Surgery combined with interventional therapy and drug therapy are available.

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The final outcome of the patient is usually good.

Portomesenteric and portosystemic venous reconstructions in children using balloon-expandable endoprostheses

BACKGROUND

Portomesenteric and portosystemic venous occlusive disease may lead to portomesenteric hypertension, variceal bleeding, ascites and hypersplenism. Data regarding endovascular reconstructive strategies in children, however, are limited.

OBJECTIVE

To report technical success, outcome and patency of portomesenteric and portosystemic venous reconstruction using VIABAHN VBX balloon-expandable endoprostheses in pediatric patients.

MATERIALS AND METHODS

Five pediatric patients (median age: 15 years, range: 4-18 years), including 3 (60%) boys and 2 (40%) girls, with portomesenteric or portosystemic venous occlusion or recurrent stenosis, underwent balloon-expandable stent graft reconstruction. Presenting symptoms included acute variceal bleeding, without (n = 2, 40%) or with (n = 1, 20%) splenomegaly, and transfusion-dependent chronic melena (n = 1, 20%). One patient was asymptomatic (n = 1, 20%). Preprocedural imaging included Doppler ultrasound and contrast-enhanced computed tomography (CT) in all patients. Initial imaging showed 4 (80%) occlusions and 1 (20%) recurrent stenosis greater than 50%. Technical aspects of the reconstructions, technical successes, clinical outcomes and adverse events were recorded. Technical success was defined as completion of stent graft reconstruction. Adverse events were categorized according to Society of Interventional Radiology criteria. Clinical success was defined as resolution of the presenting symptoms and/or prevention of portal hypertensive sequela.

RESULTS

Venous reconstruction was technically successful in all five patients. Stent graft locations included the main portal vein in 2 (40%), the superior mesenteric vein in 1 (20%), autologous Meso-Rex shunt in 1 (20%) and splenocaval shunt in 1 (20%). Six stent grafts were placed (two stent grafts placed in a single patient). Stent grafts had a median diameter of 7 mm (range: 6-10 mm) and a median length of 59 mm (range: 19-79 mm). Median fluoroscopy time was 36.6 min (range: 13.4-95.8 min) and median air kerma was 301.0 mGy (range: 218.0-1,148.2 mGy). No adverse events occurred. Median clinical follow-up was 18 months (range: 6-29 months). Median imaging follow-up was 17 months (range: 2-29 months). Clinical success was achieved in all patients and maintained during the follow-up period. One patient required follow-up intervention with superior mesenteric vein side extension with a self-expanding bare metal stent due to perigraft stenosis detected on CT 3 months after stent placement. There were no stent graft occlusions.

CONCLUSION

Portomesenteric and portosystemic venous reconstruction using balloon-expandable stent grafts in pediatric patients was feasible and clinically successful in this preliminary experience. Additional studies are warranted.

Low level of postoperative plasma antithrombin III is associated with portal vein thrombosis after liver surgery

PURPOSE

Although decreased antithrombin-III (AT-III) is a risk factor for portal vein thrombosis (PVT) in patients with liver cirrhosis, the association between postoperative PVT and postoperative AT-III levels is unknown in patients undergoing hepatectomy.

METHODS

Patients who underwent hepatectomy between 2015 and 2018 were retrospectively analyzed. Postoperative PVT was assessed on CT at days 6-9 after hepatectomy. One-to-one propensity score (PS) matching was used to match the baseline characteristics.

RESULTS

Of the 295 patients included in this analysis, 19 patients (6.4%) were diagnosed with postoperative PVT. The AT-III level on postoperative day (POD) 3 predicted postoperative PVT with a sensitivity/specificity of 74%/59% (AUC, 0.644; cut-off value, 60%; p = 0.032). Multivariate analysis revealed that AT-III levels ≤ 60% on POD3 (OR, 3.01; 95% CI 1.02-8.89; p = 0.046), cirrhosis (OR, 5.88; 95% CI 1.92-18.0; p = 0.002) and right-sided hepatectomy (OR, 4.16; 95% CI 1.45-11.9; p = 0.0079) were significant risk factors for postoperative PVT. After PS matching, 56 patients with and without AT-III supplementation were analyzed. The two groups had a similar incidence of PVT (p = 0.489).

CONCLUSIONS

Patients with AT-III levels ≤ 60% on POD3 should be carefully followed up regarding postoperative PVT. Our results did not support the efficacy of routine AT-III supplementation for the prophylaxis of postoperative PVT.

Prediction of portal vein thrombosis after hepatectomy for hepatocellular carcinoma

PURPOSE

Portal vein thrombosis (PVT) following hepatectomy is potentially life-threatening. We aimed to evaluate the incidence of PVT after hepatectomy for hepatocellular carcinoma and identify coagulation and fibrinolytic factors that could predict early-stage postoperative PVT.

METHODS

A retrospective analysis was conducted on 65 hepatocellular carcinoma patients who underwent radical hepatectomy. The risk factors for postoperative PVT were identified based on univariate and multivariate analyses, and the levels of coagulation and fibrinolytic factors were measured during the perioperative period.

RESULTS

The incidence of PVT after hepatectomy was 20.0%. The patients were divided into two groups: those with PVT (n=13; PVT group) and those without PVT (n=52; no-PVT group). The frequency of the use of the Pringle maneuver during surgery was higher in the PVT group than in the no-PVT group, and the postoperative/preoperative ratios of thrombin-antithrombin III complex (TAT) and of D-dimer were significantly higher in the PVT group.

CONCLUSION

A high incidence of PVT was found in hepatocellular carcinoma patients after hepatectomy. The frequency of the Pringle maneuver is a potential risk factor for postoperative PVT, and the postoperative/preoperative TAT and D-dimer ratios may be used as early predictors of PVT after hepatectomy for hepatocellular carcinoma.

Narrowing of the remnant portal vein diameter and decreased portal vein angle are risk factors for portal vein thrombosis after perihilar cholangiocarcinoma surgery

PURPOSE

To evaluate the incidence, risk factors, management options, and outcomes of portal vein thrombosis following major hepatectomy for perihilar cholangiocarcinoma.

METHODS

A total of 177 perihilar cholangiocarcinoma patients who (1) underwent major hepatectomy and (2) underwent investigating the portal vein morphology, which was measured by rotating the reconstructed three-dimensional images after facilitating bone removal using Aquarius iNtuition workstation between 2002 and 2018, were included. Risk factors were evaluated using the Kaplan-Meier method and Cox proportional hazard models.

RESULTS

Six patients developed portal vein thrombosis (3.4%) within a median time of 6.5 (range 0-22) days. Portal vein and hepatic artery resection were performed in 30% and 6% patients, respectively. A significant difference in the probability of the occurrence of portal vein thrombosis (PV) within 30 days was found among patients with portal vein resection, a postoperative portal vein angle < 100°, remnant portal vein diameter < 5.77 mm, main portal vein diameter > 13.4 mm, and blood loss (log-rank test, p = 0.003, p = 0.06, p < 0.0001, p = 0.01, and p = 0.03, respectively). Decreasing the portal vein angle and narrowing of the remnant PV diameter remained significant predictors on multivariate analysis (p = 0.027 and 0.002, respectively). Reoperation with thrombectomy was performed in four patients, and the other two patients were successfully treated with anticoagulants. All six patients subsequently recovered and were discharged between 25 and 70 days postoperatively.

CONCLUSION

Narrowing of the remnant portal vein diameter and a decreased portal vein angle after major hepatectomy for perihilar cholangiocarcinoma are significant independent risk factors for postoperative portal vein thrombosis.

New classification-oriented treatment strategy for portal vein thrombosis after hepatectomy

AIM

This study sought to evaluate the incidence, risk factors, and clinical outcomes of portal vein thrombosis after hepatectomy. Furthermore, we proposed a novel classification and treatment strategy for portal vein thrombosis after hepatectomy.

METHODS

We retrospectively analyzed 398 patients who underwent hepatectomy and enhanced computed tomography imaging within 14 days after surgery in our hospital from 2009 to 2019. Portal vein thrombosis was classified into three categories according to the location of the thrombus - main, hilar, and peripheral - with main portal vein thrombosis further subclassified into three grades. Each patient's treatment strategy was determined based on their portal vein thrombosis classification and grading. From 2015, enhanced computed tomography imaging was performed routinely on patients who underwent anatomical hepatectomy on postoperative day 7.

RESULTS

Portal vein thrombosis was diagnosed in 57 patients (14.3%) during the study period. Multivariate analysis revealed that a Pringle maneuver time of 75 minutes or longer was a significant predictor of portal vein thrombosis (P = .012). In total, 52 patients (91%) with portal vein thrombosis recovered by surgery, anticoagulant therapy, or without specific treatment. There was no instance of mortality recorded.

CONCLUSIONS

Patients who undergo hepatectomy are at high risk for portal vein thrombosis, especially when the Pringle maneuver time is long. The proposed classification and treatment strategy may be useful for clinical management of patients with portal vein thrombosis after hepatectomy.

Portal flow dynamics after total pancreatectomy and autologous islet cell transplantation

BACKGROUND

Portal vein thrombosis (PVT) is a serious complication of total pancreatectomy and autologous islet cell transplant (TPAIT); therefore, portal flow dynamics are monitored by Doppler ultrasound postoperatively. The practical value of scheduled Doppler ultrasound examinations and the relationship between portal vein velocity, liver function, and complications have not been clearly studied.

METHODS

A retrospective review of 16 TPAIT was performed. Correlation analysis of portal vein velocity with indices of liver function, portal pressure, and volume of islet cells infused was conducted.

RESULTS

There was no correlation between portal vein velocity and postoperative liver function tests (LFTs). Larger volume of islet cells infused and higher intraoperative portal pressure correlated with decreased postoperative portal flow. There was no significant difference in portal pressure, portal vein velocity, or LFTs between those with normal and abnormal pre-infusion liver histopathology. While no PVT occurred, there were two cases of postoperative bleeding related to anticoagulation.

CONCLUSION

Segmental portal vein velocities are low in the setting of high tissue volume and portal pressure, but are not associated with variation in LFTs. Therefore, patient management in response to changes in velocities without clinical symptoms may be unnecessary.

Portomesenteric Venous Complications after Pancreatic Surgery with Venous Reconstruction: Imaging and Intervention

Pancreatic surgery with en bloc venous resection and reconstruction is becoming increasingly common in the current era of expanding neoadjuvant oncologic therapies and advanced surgical techniques for patients with more anatomically complex tumors. However, patients who have alterations in their venous outflow are at increased risk for postoperative portomesenteric venous stenosis and/or thrombosis. Cross-sectional imaging for postoperative surveillance, including multiphase CT or MRI, is critical for recognizing portomesenteric venous complications and thus implementing early intervention and preventing complications related to portomesenteric venous hypertension. Hypertension-related complications include ascites, variceal or gastrointestinal bleeding, postprandial abdominal pain, intestinal edema, protein-losing enteropathy, malabsorptive diarrhea, and splenomegaly. Percutaneous transhepatic, transsplenic, and transjugular portomesenteric interventions, including venoplasty, stent placement, and thrombectomy or thrombolysis, are safe and effective options for restoring patency to the portomesenteric venous system. Preintervention CT or MRI and diagnostic catheter venography are important for procedural planning, while postintervention CT or MRI surveillance is critical for detecting recurrent stenosis or thrombosis, or de novo portomesenteric venous disease. Online supplemental material is available for this article. ^©RSNA, 2020.

Evaluation of Technical Success, Efficacy, and Safety of Portomesenteric Venous Intervention following Nontransplant Hepatobiliary or Pancreatic Surgery

PURPOSE

To evaluate technical success, efficacy and safety of portomesenteric venous (PMV) intervention for PMV stenosis or occlusion following nontransplant hepatobiliary or pancreatic (HPB) surgery.

MATERIALS AND METHODS

A retrospective review identified 42 patients (mean age 60 y) with PMV stenosis (n = 33; 79%) or occlusion (n = 9; 21%) who underwent attempted PMV intervention following HPB surgery between June 1, 2011, and April 1, 2018. Main outcomes were technical success, primary patency rates, and complications. Technical success was compared by venous pathology and primary PMV patency based on anticoagulation status after the procedure using Fisher exact test. Rates of primary patency by stent group were estimated using Kaplan-Meier method.

RESULTS

Technical success was 91% (n = 38/42) and significantly higher in patients with stenosis (n = 33/33; 100%) vs occlusion (n = 5/9; 56%) (P = .001). Primary presenting symptom resolved in 28 (87%) patients, including 6 (100%) patients with gastrointestinal bleeding. At mean imaging follow-up of 8.6 months ± 8.8, primary stent patency was 76%. There was no significant difference in primary stent patency based on anticoagulation status after the procedure (P = .48). There were 2 (4.8%) periprocedural complications.

CONCLUSIONS

Portomesenteric venoplasty and stent placement following nontransplant HPB surgery is safe with a high rate of technical success if performed before chronic occlusion.

Portal Cavernoma Complicating a Persistent Postoperative Bile Leak after Liver Hydatid Cyst Surgery: -a Report Case-

INTRODUCTION: Hydatid cyst is a parasitic infection caused by the larval form of Echinococcus granulosis. Portal hypertension is an unusual postoperative complication after a liver hydatid cyst surgery. CASE PRESENTATION: To illustrate this rare condition, we present the case of a 32-year-old patient operated for a liver hydatid cyst with late-onset postoperative complications. The patient suffered from secondary digestive bleeding because of portal hypertension and was therefore treated with a distal splenorenal shunt (Warren). CONCLUSION: Surgery of hydatid cyst may cause severe complications like portal hypertension and in certain cases, distal splenorenal anastomosis might represent an important treatment option that needs to be performed in specialised centres. Keywords: Liver cyst, Portal hypertension, Splenorenal shunt.

Delayed development of portal vein thrombosis in a patient initially detected with portal venous gas and pneumatosis intestinalis: a case report

Background

Portal venous gas (PVG) and pneumatosis intestinalis (PI) are rare pathologic findings, and a delayed appearance of portal vein thrombosis (PVT) in such patients is extremely rare.

Case Presentation

A 51‐year‐old man complaining of epigastric pain was referred to our hospital. Computed tomography (CT) at admission revealed massive PVG and extensive PI, but no PVT. Emergency laparotomy was carried out, but bowel resection was unnecessary. On follow‐up CT on postoperative day 5, thrombosis was noted in the portal venous system, and anticoagulant was started immediately. This patient was discharged and continued to take the anticoagulant. Seven months after discharge, PVT had disappeared on CT without any thromboembolic complications.

Conclusion

If acute PVT is detected, anticoagulant is needed to prevent bowel ischemia and/or portal hypertension due to the growth of the thrombus. Clinicians should be aware of the potential for such a complication, and make their best efforts to exclude this entity using CT or sonography.

Analysis of risk factors for portal vein thrombosis after liver resection

Purpose

We evaluated the risk factors for posthepatectomy thrombosis including portal vein thrombosis (PVT) and clinical outcomes.

Methods

We retrospectively analyzed 563 patients who had undergone hepatectomy from February 2009 to December 2014. Twenty-nine patients with preoperatively confirmed thrombosis and tumor recurrence-related thrombosis were excluded. We identified the location of the thrombosis as main portal vein (MPV), peripheral portal vein (PPV) and other site such as hepatic vein or inferior vena cava. Patients with MPV thrombosis and PPV thrombosis with main portal flow disturbance were treated with anticoagulation therapy. We performed operative thrombectomy before anticoagulation therapy who did combined portal vein (PV) segmental resection.

Results

Of the 534 patients, 22 (4.1%) developed posthepatectomy thrombosis after hepatectomy. Among them, 19 (86.4%) had PVT. The mean duration of Pringle's maneuver was significant longer in the PVT group than the no-thrombosis group (P = 0.020). Patients who underwent combined PV segmental resection during hepatectomy were more likely to develop posthepatectomy PVT (P = 0.001). Thirteen patients who had MPV thrombosis and PPV thrombosis with main portal flow disturbance received anticoagulation therapy immediately after diagnosis and all of them were improved. Among them, 2 patients who developed PVT at the PV anastomosis site after PV segmental resection, underwent operative thrombectomy before anticoagulation therapy and both were improved. There were no patients who developed complications related to anticoagulation therapy.

Conclusion

Long duration of Pringle's maneuver and PV segmental resection were risk factors. Anticoagulation therapy or operative thrombectomy should be considered for PVT without contraindications.

Liver Doppler Findings in Pediatric Patients After Total Pancreatectomy and Islet Autotransplantation

OBJECTIVES

This study was intended to establish normal values for velocities in the hepatic artery and portal veins in pediatric patients after total pancreatectomy and islet autotransplantation (TPIAT).

METHODS

A retrospective review was performed of liver Doppler studies in pediatric patients after TPIAT over 6 years at an academic children's hospital. Doppler velocities in the liver vasculature and the hepatic artery resistive index were recorded.

RESULTS

Sixty-five pediatric patients were evaluated. There were no cases of portal vein thrombosis or other hepatic vascular complications. The mean hepatic artery peak systolic velocity was 157.6 cm/s (SE, 60.9 cm/s), with a mean resistive index of 0.57 (SE, 0.09). The mean main portal vein velocity was 31.9 cm/s (SE, 12.9 cm/s).

CONCLUSIONS

Portal vein thrombosis is rare in pediatric patients after TPIAT. A wide range of hepatic artery and portal vein velocities are encountered in children immediately after TPIAT without hepatic vascular complications and can be considered normal.

A case of portal vein thrombosis caused by blunt abdominal trauma in a patient with low protein C activity

Portal vein thrombosis (PVT) is caused by several conditions including infection, malignancies, surgery, medications, and coagulation disorders. However, PVT caused by low-energy injury is very rare. A 51-year-old man visited a clinic with a 2-day history of abdominal pain following blunt abdominal trauma. Contrast-enhanced computed tomography (CT) revealed thrombosis in both the portal vein and splenic vein, and he was transferred to our hospital with a diagnosis of PVT. Anticoagulant therapy was initiated using unfractionated heparin. A repeat CT scan revealed enlargement of the thrombus, which occluded the main trunk and first right branch of the portal vein. Laboratory data before heparin administration suggested low protein C activity. Anticoagulation therapy was continued with intermittent assessment of the size of the thrombus and degree of coagulation. On day 23, enhanced CT showed marked shrinkage of the thrombus compared with that on day 8. On day 30, the patient was discharged with a therapeutic prothrombin time-international normalized ratio. Here we present a case of PVT caused by low-energy trauma of the upper abdomen in a patient with a background of low protein C activity that was successfully treated without invasive surgery.

Acute portal vein thrombosis after hepatectomy in a patient with hepatolithiasis: A case report and review of the literature

RATIONALE

Portal vein thrombosis is defined as any thrombosis that develops in the portal vein system. It is considered a very rare and extremely lethal complication of hepatopancreatobiliary surgery.

PATIENT CONCERNS

Acute portal vein thrombosis after hepatectomy in patients with hepatolithiasisis very rare. Acute portal vein thrombosis is considered as a dangerous complication after hepatectomy. It is easy to ignore the symptom of acute portal vein thrombosis. Once the appropriate time of treatment is past, it would lead to patients' death.

DIAGNOSE

Acute portal vein thrombosis after hepatectomy in a patient with hepatolithiasis INTERVENTIONS:: We consider anticoagulation therapy and percutaneous transhepatic portal vein puncture and thrombectomy once the diagnosis of acute portal vein thrombosis is confirmed.

OUTCOMES

The patient's liver function continued to deteriorate, eventually resulting in death.

LESSONS

Acute portal vein thrombosis after hepatectomy is difficult to diagnose. The management of acute portal vein thrombosis remains controversial according to its severity, location or time of discovering.

Successful recanalization of acute extensive portal vein thrombosis by aspiration thrombectomy and thrombolysis via an operatively placed mesenteric catheter: a case report

Portal vein thrombosis (PVT) after hepatobiliary surgery is rare but can cause lethal and severe complications. If early diagnosis and recanalization can be achieved, the PVT is expected to be eliminated. A 70-year-old male was diagnosed as having hepatocellular carcinoma occupying the right lobe of the liver. As oligometastatic lung tumors were simultaneously detected on contrast-enhanced CT (CECT), hepatectomy was not indicated. However, the primary tumor was very large, and as large tumor size can be associated with an unfavorable prognosis, and owing to the strong desire of the patient, he underwent right lobe hepatectomy. Jaundice appeared on post-operative Day (POD) 2 and CECT displayed slight intraheptatic bile duct dilation. However, a PVT did not exist at this time. Percutaneous transhepatic biliary drainage was performed and Doppler echo displayed intrahepatic and extrahepatic PVT on post-operative Day 5. Emergent thrombectomy was performed using a Vasplyser Plus^TM thrombus aspiration catheter (Johnson & Johnson K.K. Medical Company, Tokyo, Japan) via the ileocolic vein under laparotomy. The mesenteric catheter was placed at the distal point of the residual PVT. Thrombolysis and anticoagulant therapy were performed using heparin and urokinase. In the CECT performed 16 days after the additional operation, the PVT had disappeared and the portal vein was completely recanalized. The mesenteric catheter was removed on the same day and oral anticoagulant therapy was continued. At the time of writing, 14 months have passed with no recurrence of PVT. Early diagnosis of PVT enables treatment with emergent thrombectomy, thrombolysis, and anticoagulant therapy. These treatments result in the improvement of portal vein flow and the complete disappearance of PVT.

The Spleen as an Optimal Site for Islet Transplantation and a Source of Mesenchymal Stem Cells

This review demonstrates the unique potential of the spleen as an optimal site for islet transplantation and as a source of mesenchymal stem cells. Islet transplantation is a cellular replacement therapy used to treat severe diabetes mellitus; however, its clinical outcome is currently unsatisfactory. Selection of the most appropriate transplantation site is a major factor affecting the clinical success of this therapy. The spleen has long been studied as a candidate site for islet transplantation. Its advantages include physiological insulin drainage and regulation of immunity, and it has recently also been shown to contribute to the regeneration of transplanted islets. However, the efficacy of transplantation in the spleen is lower than that of intraportal transplantation, which is the current representative method of clinical islet transplantation. Safer and more effective methods of islet transplantation need to be established to allow the spleen to be used for clinical transplantation. The spleen is also of interest as a mesenchymal stem cell reservoir. Splenic mesenchymal stem cells contribute to the repair of damaged tissue, and their infusion may thus be a promising therapy for autoimmune diseases, including type 1 diabetes mellitus and Sjogren’s syndrome.

Portal Vein Thrombosis After Splenic and Pancreatic Surgery

The portal vein is formed by the confluence of the splenic and superior mesenteric veins, which drain the spleen and small intestine respectively. Occlusion of the portal vein by thrombus typically occurs in patients with cirrhosis and/or prothrombotic disorders. However, portal vein thrombosis (PVT) can also happen after determined surgeries. Moreover, PVT can have serious consequences depending on the location and extent of the thrombosis, including hepatic ischemia, intestinal ischemia, portal hypertension… In this chapter, we will review the incidence, management and prophylaxis of PVT after splenectomy, pancreas transplantation, pancreatic surgery and in the setting of acute and chronic pancreatitis.

Complication of portal vein thrombosis after right hemihepatectomy in a patient lacking the portal vein bifurcation

Absence of portal vein bifurcation is a rare anomaly. We report a patient with this anomaly who underwent right hemihepatectomy for treatment of hepatocellular carcinoma. Although the procedure was carefully performed with a preoperative three-dimensional simulation and intraoperative cholangiography, postoperative portal vein thrombosis occurred. J. Med. Invest. 63: 315-318, August, 2016.

Islet autotransplantation in a patient with hypercoagulable disorder

Total pancreatectomy and islet auto transplantation is a good option for chronic pancreatitis patients who suffer from significant pain, poor quality of life, and the potential of type 3C diabetes and pancreatic cancer. Portal vein thrombosis is the most feared complication of the surgery and chances are increased if the patient has a hypercoagulable disorder. We present a challenging case of islet auto transplantation from our institution. A 29-year-old woman with plasminogen activator inhibitor-4G/4G variant and a clinical history of venous thrombosis was successfully managed with a precise peri- and post-operative anticoagulation protocol. In this paper we discuss the anti-coagulation protocol for safely and successfully caring out islet transplantation and associated risks and benefits.

Primary prevention and treatment of venous thromboembolic events in patients with gastrointestinal cancers - Review

Venous thromboembolism event (VTE) is a common and morbid complication in cancer patients. Patients with gastrointestinal cancers often suffer from symptomatic or incidental splanchnic vein thrombosis, impaired liver function and/or thrombocytopenia. These characteristics require a thorough risk/benefit evaluation for individual patients. Considering the risk factors for the development of VTE and bleeding events in addition to recent study results may be helpful for correct initiation of primary pharmacological prevention and treatment of cancer-associated thrombosis (CAT), preferably with low molecular weight heparins (LMWH). Whereas thromboprophylaxis is most often recommended in hospitalized surgical and non-surgical patients with malignancy, there is less agreement as to its duration. With regard to ambulatory cancer patients, the lack of robust data results in low grade recommendations against routine use of anticoagulant drugs. Anticoagulation with LMWH for the first months is the evidence-based treatment for acute CAT, but duration of secondary prevention and the drug of choice are unclear. Based on published guidelines and literature, this review will focus on prevention and treatment strategies of VTE in patients with gastrointestinal cancers.

Postoperative portal vein thrombosis and gastric hemorrhage associated with late-onset hemorrhage from the common hepatic artery after pancreaticoduodenectomy

Portal vein thrombosis (PVT) is a rare but serious postoperative complication of pancreaticoduodenectomy (PD). We reported a case of late-onset postoperative PVT with hemorrhage from the common hepatic artery (CHA) in a 73-year-old man who underwent pylorus-preserving pancreaticoduodenectomy (PPPD) for duodenum papilla cancer, followed by reconstruction using the modified Child's technique. The pancreaticojejunostomy was achieved by end-to-side, 2-layer invagination anastomosis without pancreatic duct stenting. Drain removal and hospital discharge were scheduled on postoperative day (POD) 18, but blood-stained fluid in the drain and sudden hematemesis were noted. Emergency surgery was performed because PVT and imaging findings were suggestive of necrosis of the lifted jejunum. Although no jejunal necrosis was identified during surgery, bleeding from the side of the CHA was detected and the bleeding point was suture-closed to achieve hemostasis. We suspected late-onset postoperative arterial hemorrhage and subsequent hematoma formation, which caused portal vein compression and PVT formation. We chose a conservative treatment strategy for PVT, taking into account the operation time, intraoperative vital signs and blood flow in the portal vein. Despite the complicated postoperative course, he was discharged home in a fully ambulatory state on POD 167.

Acute Cholecystitis Complicated with Portal Vein Thrombosis: A Case Report and Literature Review

Patient: Male, 31

Final Diagnosis: Acute cholecystitis complicated with portal vein thrombosis

Symptoms: Abdominal discomfort • fever • vomiting

Medication: —

Clinical Procedure: Abdominal ultrasound and MRI

Specialty: Gastroenterology and Hepatology

Incidence, risk factors, and management options for portal vein thrombosis after hepatectomy: a 14-year, single-center experience

BACKGROUND

Portal vein thrombosis (PVT) after hepatectomy is rare; however, it increases mortality and morbidity. Few studies have been conducted that focused on PVT following major hepatectomy.

METHODS

Patients who underwent hepatectomy at a single institution were retrospectively reviewed, and risk factors and management options were evaluated.

RESULTS

Of the 1,193 patients undergoing hepatectomy, 25 patients developed PVT. Right-sided hepatectomy, caudate lobectomy, splenectomy, and postoperative bile leakage were independent risk factors for PVT following hepatectomy. PVT occurred more frequently after major hepatectomy compared with minor hepatectomy. Increased instability and reduced portal venous flow caused by kinking was the reason for increasing the risk of PVT after right-sided hepatectomy with caudate lobectomy. The new operative procedure, suturing the posterior wall of the portal vein with the anterior wall of the inferior vena cava, was effective for reducing the risk of PVT following right-sided hepatectomy. Operative thrombectomy showed significant benefits for PVT detected within 5 days after hepatectomy.

CONCLUSIONS

PVT frequently occurs following major hepatectomy. Urgent operative thrombectomy is strongly recommended for PVT with early detection.

Follow-up results of acute portal and splenic vein thrombosis with or without anticoagulation therapy after hepatobiliary and pancreatic surgery

Purpose

Acute portal and splenic vein thrombosis (APSVT) after hepatobiliary and pancreatic (HBP) surgery is a rare but serious complication and a treatment strategy has not been well established. To assess the safety and efficacy of anticoagulation therapy for treating APSVT after HBP surgery.

Methods

We performed a retrospective case-control study of 82 patients who were diagnosed with APSVT within 4 weeks after HBP surgery from October 2002 to November 2012 at a single institute. We assigned patients to the anticoagulation group (n = 32) or nonanticoagulation group (n = 50) and compared patient characteristics, complications, and the recanalization rate of APSVT between these two groups.

Results

APSVT was diagnosed a mean of 8.6 ± 4.8 days after HBP surgery. Patients' characteristics were not significantly different between the two groups. There were no bleeding complications related to anticoagulation therapy. The 1-year cumulative recanalization rate of anticoagulation group and nonanticoagulation group were 71.4% and 34.1%, respectively, which is statistically significant (log-rank test, P = 0.0001). In Cox regression model for multivariate analysis, independent factors associated with the recanalization rate of APSVT after HBP surgery were anticoagulation therapy (P = 0.003; hazard ration [HR], 2.364; 95% confidence interval [CI], 1.341-4.168), the absence of a vein reconstruction procedure (P = 0.027; HR, 2.557; 95% CI, 1.111-5.885), and operation type (liver resection rather than pancreatic resection; P = 0.005, HR, 2.350; 95% CI, 1.286-4.296).

Conclusion

Anticoagulation therapy appears to be a safe and effective treatment for patients with APSVT after HBP surgery. Further prospective studies of larger patient populations are necessary to confirm our findings.

Portal vein thrombosis after hepatectomy

BACKGROUND

Although various complications after hepatectomy have been reported, there have been no large studies on postoperative portal vein thrombosis (PVT) as a complication. This study evaluated the incidence, risk factors, and clinical outcomes of PVT after hepatectomy.

METHODS

The preoperative and postoperative clinical characteristics of patients who underwent hepatectomy were retrospectively analyzed.

RESULTS

A total of 208 patients were reviewed. The incidence of PVT after hepatectomy was 9.1 % (n = 19), including main portal vein (MPV) thrombosis (n = 7) and peripheral portal vein (PPV) thrombosis (n = 12). Patients with MPV thrombosis had a significantly higher incidence of right hepatectomy (p < 0.001), larger resection volume (p = 0.003), and longer operation time (p = 0.021) than patients without PVT (n = 189). Multivariate analysis identified right hepatectomy as a significant independent risk factor for MPV thrombosis (odds ratio 108.9; p < 0.001). Patients with PPV thrombosis had a significantly longer duration of Pringle maneuver than patients without PVT (p = 0.002). Among patients who underwent right hepatectomy, those with PVT (n = 6) had a significantly lower early liver regeneration rate than those without PVT (n = 13; p = 0.040), and those with PVT had deterioration of liver function on postoperative day 7. In all patients with MPV thrombosis who received anticoagulation therapy, PVT subsequently resolved.

CONCLUSIONS

Postoperative PVT after hepatectomy is not rare. It is closely related to delayed recovery of liver function and delayed liver regeneration.

Complications following hepatectomy

As the number of liver resections in the United States has increased, operations are more commonly performed on older patients with multiple comorbidities. The advent of effective chemotherapy and techniques such as portal vein embolization, have compounded the number of increasingly complex resections taking up to 75% of healthy livers. Four potentially devastating complications of liver resection include postoperative hemorrhage, venous thromboembolism, bile leak, and post-hepatectomy liver failure. The risk factors and management of these complications are herein explored, stressing the importance of identifying preoperative factors that can decrease the risk for these potentially fatal complications.

Efficacy of postoperative anticoagulation therapy with enoxaparin for portal vein thrombosis after hepatic resection in patients with liver cancer

BACKGROUNDS

Enoxaparin, low-molecular-weight heparin, has become a routine thromboprophylaxis in general surgery.

STUDY DESIGN

A retrospective cohort study was performed in 281 patients who underwent hepatic resections for liver cancers from 2011 to 2013. These patients were divided into two groups; an enoxaparin (-) group (n=228) and an enoxaparin (+) group (n=53). Short-term surgical results including venous thromboembolism (VTE) and portal vein thrombosis (PVT) were compared.

RESULTS

In the enoxaparin (+) group, the patients' age (65 vs. 69 years; p=0.01) and BMI (22.9 vs. 24.4; p<0.01) were significantly higher. According to the symptomatic VTE, symptomatic pulmonary embolism occurred in one patient (0.4%) in the enoxaparin (-) group, but the complication rate was not significantly different (p=0.63). The complication rate of PVT was significantly lower in the enoxaparin (+) group (10 vs. 2%; p=0.04). The independent risk factors for PVT were an operation time ≥ 300 minutes (Odds ratio 6.66) and non-treatment with enoxaparin (Odds ratio 2.49).

CONCLUSIONS

Postoperative anticoagulant therapy with enoxaparin could prevent PVT in patients who underwent hepatic resection for liver cancers.

Portal venous thrombosis after distal pancreatectomy: clinical outcomes

AIM

Outcomes of patients developing portal vein (PV) thrombosis (PVT) after distal pancreatectomy (DP) are unknown. The goal of this study was to identify risk factors for PVT and describe the long-term outcomes in these patients.

METHODS

Patients undergoing DP without repair or reconstruction of the PV between 2001 and 2011 were included. Patients that showed evidence of PVT on pre-operative imaging were excluded from the study. Location and extent of thrombosis was determined by post-operative computed tomography or ultrasound imaging in all patients. Evidence of systemic thrombosis (if present) in addition to PVT was also documented.

RESULTS

In the study period, 991 patients underwent DP and 21 (2.1%) patients were diagnosed with PVT. Pancreatic neoplasm was the most frequent indication for operation (n = 11). Thrombus occurred in the main PV in 15 and the right branch of the PV in 8 patients. Complete PV occlusion occurred in nine patients with a median time to diagnosis of 16 days (range 5-85 days). Seventeen patients were anticoagulated for a median duration of 6 months (range 3.3-36 months) after the diagnosis of PVT. Over a median follow-up of 22 months, resolution of PVT occurred in seven patients. Predictors of non-resolution of PVT included anesthesia time >180 min (p = 0.025), DM type II (p = 0.03), BMI >30 Kg/m(2) (p = 0.03), occlusive PVT (p < 0.001), or thrombus in a sectoral branch (p = 0.02). Anticoagulation therapy did not influence the frequency of thrombus resolution and was complicated by gastrointestinal hemorrhage in four patients. There was no mortality as a direct result of PVT or anticoagulation.

CONCLUSION

PVT after distal pancreatectomy is a rare complication. Serious complications as a direct result of PVT in this setting are uncommon and are not dependent on thrombus resolution. Although anticoagulation does not appear to influence the rate of PVT resolution in this small retrospective series, we support the use of anticoagulation until larger, controlled studies define clear advantages or disadvantages.

Strategy for clinical setting in intramuscular and subcutaneous islet transplantation

Intraportal islet transplantation has a long history as a procedure for clinical islet transplantation. However, many recent studies revealed that the intraportal procedure has some disadvantages in transplant efficiency and safety. Many candidates as an optimal transplant site for islets have been assessed, but further studies and clinical trials are still necessary. Intramuscular and subcutaneous spaces are important candidates, because the transplant and biopsy procedures are simple approaches with minimal invasion and few complications. Although they are sites with hypovascularity and hypoxia, which contribute to the poor transplant efficiency, many experimental trials for improving the outcome in intramuscular and subcutaneous islet transplantations have been performed, focusing on early angiogenesis and scaffolds for engrafting transplanted islets. We review current progress in intramuscular and subcutaneous islet transplantations and discuss ways to develop them as optimal transplant sites for islets.

Portal system thrombosis in puerperium: a case report and literature review

BACKGROUND

The general features of the portal system thrombosis (PST) in puerperium are not known. Our aim was to evaluate the clinical characteristics of PST, including the portal, superior mesenteric and splenic veins in puerperium.

METHODS

A case with PST in puerperium is reported and nine cases with PST in puerperium reported in the literatures are discussed. An analysis was carried out on these 10 cases.

RESULTS

The mean age of the 10 cases that were analyzed was 31.6 years (range: 22-39 years). Five patients were over 35 years of age. The mean onset time of PST in puerperium was 10.3 days (5-17 days) after the delivery or cesarean. Two or three veins were occupied by the thromboses simultaneously in six cases. All patients were presented with abdominal pain. Among 10 cases, there were two deaths, which were complicated with intestinal infarction and were reported before the 1970s.

CONCLUSIONS

PST in puerperium usually happens in women of advanced maternal age within 3 weeks after the delivery or cesarean. The scope of thrombosis was extensive. The main symptom was abdominal pain. The mortality rate of PST in puerperium is not higher than that of the general PST cases.

A Review of Autologous Islet Transplantation

Autologous islet transplantation after total or semitotal pancreatectomy aims to preserve insulin secretory function and prevent the onset of diabetes. The major indication for pancreatectomy is chronic pancreatitis with severe abdominal pain, a benign pancreatic tumor, and trauma. The metabolic outcome of autologous islet transplantation is better than that of allogeneic transplantation and depends on the number of transplanted islets. Achieving islet isolation from a fibrous or damaged pancreas is one of the biggest challenges of autologous islet transplantation; a major complication is portal vein thrombosis after crude islet infusion. However, the incidence of portal vein thrombosis has decreased as islet preparation techniques have improved over time.

Splenic artery switch for revascularization of the liver: a salvage procedure for inflammatory arterial hemorrhage

BACKGROUND

Hemorrhage caused by inflammatory vessel erosion represents a life-threatening complication after upper abdominal surgery such as pancreatic head resection. The gold standard therapeutic choice is an endovascular minimally invasive technique such as embolization or stent placement. Hepatic arterial hemorrhage in presence of pancreatitis and peritonitis is a particular challenge is if a standard therapeutic option is not possible.

METHODS

The management of five patients with massive bleeding from the common hepatic artery is described. All patients underwent a splenic artery switch. The splenic artery was dissected close to the splenic hilum and transposed end-to-end to the common hepatic artery after resection of the eroded part. Patients' medical records, radiology reports, and images were reviewed retrospectively. Technical success was defined as immediate cessation of hemorrhage and preserved liver vascularization. Clinical success was defined as hemodynamic stability and adequate long-term liver function.

RESULTS

Total pancreatectomy and splenectomy were performed in four of the five cases. Hemodynamic stability and good liver perfusion was achieved in these patients.

CONCLUSIONS

Splenic artery switch is an effective, safe procedure for revascularization of the liver in case of hepatic arterial hemorrhage following pancreatic surgery, pancreatitis, and/or peritonitis. The technique is a promising option if a standard procedure-e.g., stent implantation, embolization and surgical repair with alloplastic prosthesis or autologous venous interposition graft-is not possible.