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Justino H. The Significance of Congenital Portosystemic Shunts in Congenital Heart Disease and the Bizarre Phenomenon of Alternating Portosystemic and Systemic-Portal Shunting. Interv Cardiol Clin 2024; 13:307-318. [PMID: 38839165 DOI: 10.1016/j.iccl.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
Congenital portosystemic shunts (CPSSs) are rare vascular anomalies characterized by abnormal connections between the portal/splanchnic veins and the systemic veins. CPSSs often occur as an isolated congenital anomaly, but they can also coexist with congenital heart disease (CHD). Owing to their myriad consequences on multiple organ systems, familiarity with CPSS is of tremendous importance to the care of patients with CHD. The rationale and timing for interventions to embolize CPSS in this scenario are discussed. Specific shunt embolization techniques are beyond the scope of this article.
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Affiliation(s)
- Henri Justino
- Division of Cardiology, Department of Pediatrics, Rady Children's Hospital and University of California, San Diego, USA.
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2
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Uchida H, Shinkai M, Okuyama H, Ueno T, Inoue M, Yasui T, Hiyama E, Kurihara S, Sakuma Y, Sanada Y, Taketomi A, Honda S, Wada M, Ando R, Fujishiro J, Yoshida M, Yamada Y, Uchida H, Tainaka T, Kasahara M. Impact of Portal Flow on the Prognosis of Children With Congenital Portosystemic Shunt: A Multicentric Observation Study in Japan. J Pediatr Surg 2024:S0022-3468(24)00309-9. [PMID: 38839469 DOI: 10.1016/j.jpedsurg.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 04/22/2024] [Accepted: 05/05/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Although congenital portosystemic shunts (CPSSs) are increasingly being recognized, the optimal treatment strategies and natural prognosis remain unclear, as individual CPSSs show different phenotypes. METHODS The medical records of 122 patients who were diagnosed with CPSSs at 15 participating hospitals in Japan between 2000 and 2019 were collected for a retrospective analysis based on the state of portal vein (PV) visualization on imaging. RESULTS Among the 122 patients, 75 (61.5%) showed PV on imaging. The median age at the diagnosis was 5 months. The main complications related to CPSS were hyperammonemia (85.2%), liver masses (25.4%), hepatopulmonary shunts (13.9%), and pulmonary hypertension (11.5%). The prevalence of complications was significantly higher in patients without PV visualization than in those with PV visualization (P < 0.001). Overall, 91 patients (74.6%) received treatment, including shunt closure by surgery or interventional radiology (n = 82) and liver transplantation (LT) or liver resection (n = 9). Over the past 20 years, there has been a decrease in the number of patients undergoing LT. Although most patients showed improvement or reduced progression of symptoms, liver masses and pulmonary hypertension were less likely to improve after shunt closure. Complications related to shunt closure were more likely to occur in patients without PV visualization (P = 0.001). In 25 patients (20.5%) without treatment, those without PV visualization were significantly more likely to develop complications related to CPSS than those with PV visualization (P = 0.011). CONCLUSION Patients without PV visualization develop CPSS-related complications and, early treatment using prophylactic approaches should be considered, even if they are asymptomatic. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan.
| | - Masato Shinkai
- Department of Sugery, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takehisa Ueno
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Mikihiro Inoue
- Department of Pediatric Surgery, Fujita Health University, Toyoake, Aichi, Japan
| | - Toshihiro Yasui
- Department of Pediatric Surgery, Fujita Health University, Toyoake, Aichi, Japan
| | - Eiso Hiyama
- Department of Pediatric Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Sho Kurihara
- Department of Pediatric Surgery, Hiroshima University Hospital, Hiroshima, Japan
| | - Yasunaru Sakuma
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Yukihiro Sanada
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, Shimotsuke, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery 1, Hokkaido University Graduate School of Medicine, Sapporo, Sapporo, Japan
| | - Shohei Honda
- Department of Gastroenterological Surgery 1, Hokkaido University Graduate School of Medicine, Sapporo, Sapporo, Japan
| | - Motoshi Wada
- Department of Pediatric Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Ryo Ando
- Department of Pediatric Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Jun Fujishiro
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mariko Yoshida
- Department of Pediatric Surgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yohei Yamada
- Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takahisa Tainaka
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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Patel S, Thompson D, Sharshar M, Crawford JM, Dagher N, Fahmy AE. Liver Transplantation as a Treatment for Unresectable Hepatic Adenoma in a Patient With Abernethy Syndrome. Cureus 2024; 16:e60683. [PMID: 38903310 PMCID: PMC11187450 DOI: 10.7759/cureus.60683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2024] [Indexed: 06/22/2024] Open
Abstract
Abernethy syndrome is a rare congenital anomaly characterized by an intrahepatic or extrahepatic portosystemic shunt. Most patients are asymptomatic; however, due to the alteration in, or lack of, a portovenous flow, patients with Abernethy syndrome are at high risk of developing sequelae of liver failure. Once these complications develop, the only definitive treatment is transplantation. Patients with Abernethy syndrome are also at a higher risk of developing benign and malignant liver lesions, including hepatic adenomas. Here, we describe the first case of deceased donor liver transplantation as a treatment for a patient with type 1 Abernethy syndrome complicated by large, unresectable hepatic adenoma, found to have focal hepatocellular carcinoma on pathologic examination. Our male patient was found to have elevated liver enzymes at age 33, during a routine outpatient medical appointment. Despite being asymptomatic, his history of prior liver resection prompted CT imaging, which revealed two large liver lesions concerning for hepatic adenomas. When surveillance imaging showed a significant growth of the liver lesions, biopsy was pursued, which confirmed a diagnosis of hepatic adenomas. However, given the size of these lesions, resection was not a viable option for the patient. Instead, the patient underwent liver transplantation at age 41, which he tolerated well. Our case demonstrates the utility of deceased donor liver transplantation as a treatment for patients with Abernethy syndrome complicated by unresectable adenomas.
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Affiliation(s)
- Shreeja Patel
- Division of Transplant Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Dane Thompson
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Mohamed Sharshar
- Division of Transplant Surgery, Department of Surgery, Northwell Health, New York, USA
| | - James M Crawford
- Department of Pathology and Laboratory Medicine, Northwell Health, New York, USA
- Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Nabil Dagher
- Division of Transplant Surgery, Department of Surgery, Northwell Health, New York, USA
| | - Ahmed E Fahmy
- Division of Transplant Surgery, Department of Surgery, Northwell Health, New York, USA
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Bhatte S, Cahill AM, Dunn M, Foran A, Perez A, Acord MR. Endovascular closure of a congenital extrahepatic portosystemic shunt for the treatment of hepatopulmonary syndrome in an infant. Pediatr Radiol 2024; 54:357-361. [PMID: 38141079 DOI: 10.1007/s00247-023-05837-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023]
Abstract
Congenital portosystemic shunts may result in the development of hepatopulmonary syndrome, typically presenting with progressive hypoxemia in later childhood. We describe a case of a 5-month-old male with heterotaxy with polysplenia presenting with new onset hypoxemia. Subsequent evaluation identified an extrahepatic portosystemic shunt arising from the confluence of the main portal and superior mesenteric veins draining into the left renal vein. To treat his hypoxemia and prevent future complications of shunting, the patient underwent a successful single-stage endovascular closure.
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Affiliation(s)
- Sai Bhatte
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Anne Marie Cahill
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle Dunn
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ann Foran
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Adriana Perez
- Division of Pediatric Gastroenterology and Transplant Hepatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael R Acord
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Nakano M, Yamamoto A, Oka H, Yamazaki O, Jogo A, Kageyama K, Takahashi T, Nishida N, Miki Y. Repeated rough coiling technique of portosystemic shunt: A novel treatment for hepatic encephalopathy. Radiol Case Rep 2024; 19:349-356. [PMID: 38028288 PMCID: PMC10663638 DOI: 10.1016/j.radcr.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/03/2023] [Accepted: 10/05/2023] [Indexed: 12/01/2023] Open
Abstract
Hepatic encephalopathy (HE) usually occurs in the end stages of cirrhosis. During these stages, portosystemic shunt (PSS) is one cause of severe HE. Previous reports have demonstrated that shunt embolization is effective in cases involving a large PSS. However, embolization is risky in some patients because severe ascites and esophageal varices may result from aggravation of portal hypertension. Herein, we report a case in which intentional flow reduction was repeatedly performed for spleno-renal shunt using 2 flow reduction methods, debranching and the rough coiling technique, for a patient with severe HE for whom embolization of the whole PSS pathway was risky. Complete embolization was finally achieved by repeated flow reduction over 5 sessions. The patient tolerated treatment well with no ascites for 4 years after total embolization. If embolization of the whole PSS puts the patient at risk for refractory HE, repeatable flow reduction might provide a good alternative path to single-step embolization.
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Affiliation(s)
- Mariko Nakano
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
- Department of Radiology, Housenka Hospital, Osaka, Japan
| | - Hiroko Oka
- Department of Gastroenterology, Housenka Hospital, Osaka, Japan
| | | | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | - Ken Kageyama
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
| | | | - Norifumi Nishida
- Department of Radiology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Yukio Miki
- Department of Diagnostic and Interventional Radiology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
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Steg Saban O, Weissbach T, Achiron R, Pekar Zlotin M, Haberman Y, Anis Heusler A, Kassif E, Weiss B. Intrahepatic portosystemic shunts, from prenatal diagnosis to postnatal outcome: a retrospective study. Arch Dis Child 2023; 108:910-915. [PMID: 37474281 DOI: 10.1136/archdischild-2023-325424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 07/03/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVE Congenital intrahepatic portosystemic shunts (IHPSS) are rare vascular malformations resulting in blood bypassing the liver to the systemic circulation. Previous studies included symptomatic patients diagnosed postnatally, but the outcome of IHPSS diagnosed prenatally is rarely reported. We present a cohort of children prenatally diagnosed with IHPSS and report their natural course and outcome. METHODS AND DESIGN This was a retrospective study of all fetal cases diagnosed by ultrasound with IHPSS between 2006 and 2019 at a single tertiary centre which were prospectively followed up at the paediatric gastroenterology unit. The postnatal outcome was compared between patients with a single versus multiple intrahepatic shunts. RESULTS Twenty-six patients (70.3% boys) were included in the study, of them, eight (30.8%) patients had multiple intrahepatic shunts. The median gestational age at diagnosis was 29.5 weeks. Growth restriction affected 77% of the cohort. Postnatally, spontaneous shunt closure occurred in 96% of patients at a median age of 7.5 months (IQR 2.2-20 months). Failure to thrive (FTT) and mild developmental delay were observed in eight (30.8%) and seven (26.9%) patients, respectively. FTT was significantly more prevalent in patients with multiple shunts compared with patients with a single shunt (62.5% vs 16.7%, p=0.02); however, the rate of shunt closure and age at time of closure were similar between these groups. All patients survived with limited to no sequelae. CONCLUSIONS IHPSS usually close spontaneously by 2 years of age. Children with prenatally detected IHPSS may develop FTT and mild developmental delay. Close surveillance at a paediatric gastroenterology unit may be beneficial.
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Affiliation(s)
- Or Steg Saban
- Pediatrics B Department, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tal Weissbach
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel
| | - Reuven Achiron
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel
| | - Marina Pekar Zlotin
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Obstetrics and Gynecology, Yitzhak Shamir Medical Center Assaf Harofeh, Tzrifin, Israel
| | - Yael Haberman
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Gastroenterology and Nutrition Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Adi Anis Heusler
- Department of OBGYN, Laniado Hospital, Netanya, Israel
- The Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Eran Kassif
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Israel
| | - Batia Weiss
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Gastroenterology and Nutrition Unit, Sheba Medical Center, Tel Hashomer, Israel
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Malik A, Patel ME, Ganger D, Hohlastos E, Riaz A. Percutaneous sequential closure of an Abernethy malformation: A case report. Radiol Case Rep 2023; 18:3135-3139. [PMID: 37388532 PMCID: PMC10302158 DOI: 10.1016/j.radcr.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/05/2023] [Accepted: 06/08/2023] [Indexed: 07/01/2023] Open
Abstract
Abernethy malformation (congenital extrahepatic portosystemic shunt [CEPS]) is rare and is characterized by an aberrant connection between the portal and systemic veins, bypassing the liver. It can have varying presentations and can lead to severe complications if left untreated. It is usually diagnosed incidentally on abdominal imaging. Occlusion venography and measurement of portal pressures (pre- and postocclusion) is an important step in management. Complete occlusion of the malformation in cases where the portal veins in the liver are very small and the gradient is more than 10 mm Hg, can potentially lead to acute portal hypertensive complications, such as porto-mesenteric thrombosis. We report a case of Abernethy malformation diagnosed on an abdominal computed tomography scan that presented with neurological symptoms and was successfully managed by interventional radiology via endovascular closure through placement and sequential occlusion of 2 metal stents.
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Affiliation(s)
- Asad Malik
- Division of Interventional Radiology, Department of Radiology, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL, USA
| | - Muhammed Ebrahim Patel
- Division of Interventional Radiology, Department of Radiology, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL, USA
| | - Daniel Ganger
- Department of Medicine, Section of Gastroenterology/Hepatology, Northwestern University, Chicago, IL, USA
| | - Elias Hohlastos
- Division of Interventional Radiology, Department of Radiology, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL, USA
| | - Ahsun Riaz
- Division of Interventional Radiology, Department of Radiology, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL, USA
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Feng W, Zhang JS, Tao R, Ma Y. Diagnostic and monitoring value of ultrasound, computed tomography angiography, and portal venography in surgical ligation of congenital extrahepatic portosystemic shunts. Eur J Radiol 2023; 165:110945. [PMID: 37369148 DOI: 10.1016/j.ejrad.2023.110945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023]
Abstract
PURPOSE To investigate the diagnostic and monitoring value of ultrasound (US), computed tomography angiography (CTA), and portal venography in surgical ligation of congenital extrahepatic portosystemic shunts (CEPS) in children. METHODS We retrospectively analysed different imaging examinations of 15 children with CEPS. Development of the portal vein before shunt occlusion, shunt location, portal vein pressure, main symptoms, diameter of the main portal vein, and location of secondary thrombosis after shunt occlusion were recorded. Final classification diagnosis was made by portal venography after shunt occlusion, and consistency with other imaging examinations in diagnosing development of the portal vein was calculated using Cohen's kappa. RESULTS Compared with portal venography after shunt occlusion, US, CTA, and portal venography before shunt occlusion had poor consistency in showing the development of hepatic portal veins (Kappa value 0.091-0.194, P > 0.05). Six cases developed portal hypertension (40-48 cmH2O) during the temporary occlusion test, and US showed that portal veins gradually expanded after shunt ligation. Eight patients with haematochezia had inferior mesenteric vein (IMV)-iliac vein (IV) shunts. After surgery, secondary IMV thrombosis was observed in eight cases and secondary splenic vein thrombosis in four cases. CONCLUSION Portal venography with occlusion testing is very important to accurately evaluate the development of the portal vein in CEPS. The portal vein needs to expand gradually, and partial shunt ligation surgery is necessary in cases diagnosed as portal vein absence or hypoplasia before occlusion testing to avoid severe portal hypertension. After shunt occlusion, US is effective in monitoring portal vein expansion, and both US and CTA can be used to monitor secondary thrombi. IMV-IV shunts can cause haematochezia and are prone to secondary thrombosis after occlusion.
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Affiliation(s)
- Wei Feng
- Department of Ultrasound, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, China.
| | - Jin-Shan Zhang
- Department of General Surgery, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, China
| | - Ran Tao
- Department of Radiology, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, China
| | - Ya Ma
- Department of Ultrasound, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, China
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Lin S, Xu Z, Fan Z, Zhang W, Yang G, Qian S, Liu R. Balloon-occluded retrograde transvenous obliteration for treatment of congenital intrahepatic portosystemic venous shunt: A case report. J Interv Med 2023; 6:49-51. [PMID: 37180373 PMCID: PMC10167510 DOI: 10.1016/j.jimed.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/29/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Congenital intrahepatic portosystemic venous shunt (CPSVS), a rare vascular malformation, has been described in both children and adults and can lead to severe neurophysiological complications. However, a standard therapeutic protocol for CPSVS has not been elucidated. With the advantage of minimally invasive techniques, transcatheter embolization has been used to treat CPSVS. The condition is challenging to manage, especially in patients with large or multiple shunts, through which rapid blood flow can cause ectopic embolism. Here, we describe a case of CPSVS with a large shunt that was successfully treated with balloon-occluded retrograde transvenous obliteration with interlocking detachable coils.
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Affiliation(s)
- Shenggan Lin
- Department of Interventional Radiology, Zhongshan Hospital (Xiamen), Fudan University, Xiamen, 361015, China
| | - Zhenyu Xu
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Zhuoyang Fan
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Wei Zhang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Guowei Yang
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Sheng Qian
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Rong Liu
- Department of Interventional Radiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
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Jimenez-Gomez J, Güizzo JR, Betancourth Alvarenga J, Santiago Martínez S, Gaspar Perez M, Pina Perez S, Beltrán VP, Loverdos I, Esteva Miró C, Jimenez Arribas P, Sanchez Vazquez B, San Vicente Vela B, Álvarez García N, Nuñez García B. Correlation of Prenatal and Postnatal Diagnosis in Umbilical-Portal-Systemic Venous Shunts. Eur J Pediatr Surg 2023; 33:90-95. [PMID: 36610389 DOI: 10.1055/s-0042-1760379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Umbilical-portal-systemic venous shunts (UPSVS) are rare anomalies in the development of the fetal venous system. There are several postnatal and prenatal classifications of hepatic venous anomalies but the link between them is missing. We aimed to review the prenatal to postnatal diagnosis correlation in UPSVS at our center. METHODS It is a retrospective study of patients diagnosed with UPSVS between 2019 and 2021 at our institution. Demographic, obstetric, genetic, and neonatal data were reviewed with special focus on prenatal and postnatal ultrasounds. RESULTS A total of seven patients were diagnosed with UPSVS at a median of 24 (20-34) weeks of gestational age. All patients were male and 62% were Caucasian. None of the patients had chromosomopathies or cardiac anomalies. One patient had renal ectopia, another one had a single umbilical artery, and a third one suffered from intrauterine growth retardation. An umbilico-systemic shunt (USS) was found in two patients and a ductus venosus-systemic shunt (DVSS) in the rest. Patients with USS were diagnosed postnatally with intrahepatic portosystemic shunts. One of the DVSS patients was transferred to another hospital and the other four had normal postnatal cardiac ultrasounds, with normal abdominal ultrasounds in two patients and lack of postnatally abdominal control in the other two. All babies were found to be doing well at a median follow-up of 1 month (0-24). CONCLUSION There is a knowledge gap in the natural history of UPSVS between fetal and neonatal life. Building bridges between prenatal and postnatal research is mandatory in order to understand these rare anomalies.
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Affiliation(s)
- Javier Jimenez-Gomez
- Department of Pediatric Surgery, Hospital de Sabadell, Sabadell, Barcelona, Spain
| | | | | | | | - Mireia Gaspar Perez
- Department of Pediatric Surgery, Hospital de Sabadell, Sabadell, Barcelona, Spain
| | - Silvia Pina Perez
- Department of Obstetrics and Gynecology, Hospital de Sabadell, Sabadell, Barcelona, Spain
| | | | - Inés Loverdos
- Deparment of Pediatrics, Hospital de Sabadell, Sabadell, Barcelona, Spain
| | - Clara Esteva Miró
- Department of Pediatric Surgery, Hospital de Sabadell, Sabadell, Barcelona, Spain
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Uchida H, Sakamoto S, Yanagi Y, Shimizu S, Fukuda A, Ono H, Miyazaki O, Nosaka S, Schlegel A, Kasahara M. Significance of a multidisciplinary approach to congenital extrahepatic portosystemic shunt: A changing paradigm for the treatment. Hepatol Res 2023. [PMID: 36650641 DOI: 10.1111/hepr.13882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/20/2022] [Accepted: 01/12/2023] [Indexed: 01/19/2023]
Abstract
AIM To review the current institutional practice to treat patients with congenital extrahepatic portosystemic shunt (CEPS) and to determine the optimal strategy. METHODS We retrospectively reviewed the records of 55 patients diagnosed with CEPS at our center between December 2008 and March 2022. RESULTS Among these 55 patients, 44 (80.0%) received treatment for CEPS at a median age of 4.7 years. The most common indication for treatment was cardiopulmonary complications (45.5%). Therapeutic intervention included shunt closure by endovascular techniques (50.0%) or surgery (40.9%), and liver transplantation (9.1%). A total of 11 were classified as short shunt types, and surgical ligation was performed in all to preserve the major vascular system and prevent complications (p < 0.001). Children who received a surgical ligation were more likely to develop complications after shunt closure (p = 0.02). Among seven patients with portopulmonary hypertension (POPH), one patient, who received a shunt ligation at <1 year-of-age, was only able to completely discontinue medication. Most other CEPS-related complications were completely resolved. Post-treatment complications, including thrombosis and symptoms of portal hypertension, were seen in 16 patients. After shunt closure, one patient was scheduled to undergo liver transplantation for progressive POPH and large residual hepatocellular adenoma. During follow-up, one patient without any treatment for CEPS developed POPH 16 years from the diagnosis. CONCLUSION Earlier therapeutic interventions should be strongly considered for patients with POPH related to CEPS. However, in view of the invasiveness and treatment complications, special attention should be paid to the management of patients with short shunt types.
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Affiliation(s)
- Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Yusuke Yanagi
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Seiichi Shimizu
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Hiroshi Ono
- Division of Cardiology, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Osamu Miyazaki
- Division of Radiology, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Shunsuke Nosaka
- Division of Radiology, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Andrea Schlegel
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.,Center for Preclinical Research, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
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Marra P, Di Fazio B, Dulcetta L, Carbone FS, Muglia R, Bonaffini PA, Valle C, Corvino F, Giurazza F, Muscogiuri G, Venturini M, Sironi S. Embolization in Pediatric Patients: A Comprehensive Review of Indications, Procedures, and Clinical Outcomes. J Clin Med 2022; 11:jcm11226626. [PMID: 36431102 PMCID: PMC9696500 DOI: 10.3390/jcm11226626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/30/2022] [Accepted: 11/02/2022] [Indexed: 11/10/2022] Open
Abstract
Embolization in pediatric patients encompasses a large spectrum of indications, ranging from the elective treatment of congenital diseases of the cardiovascular system to the urgent management of acute hemorrhagic conditions. In particular, the endovascular treatment of central and peripheral vascular malformations and hypervascular tumors represents a wide chapter for both congenital and acquired situations. Thanks to the progressive availability of low-profile endovascular devices and new embolic materials, the mini-invasive approach has gradually overtaken surgery. In this review, the main embolization procedures will be illustrated and discussed, with a focus on clinical indications and expected outcomes. The most recent mini-invasive techniques will be described, with hints on the cutting-edge devices and embolic materials.
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Affiliation(s)
- Paolo Marra
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Barbaro Di Fazio
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
- Correspondence: ; Tel.: +39-347-516-5851 or +39-035-267-4359
| | - Ludovico Dulcetta
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Francesco Saverio Carbone
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Riccardo Muglia
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
| | - Pietro Andrea Bonaffini
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Clarissa Valle
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Fabio Corvino
- Department of Vascular and Interventional Radiology, Cardarelli Hospital, 80131 Naples, Italy
| | - Francesco Giurazza
- Department of Vascular and Interventional Radiology, Cardarelli Hospital, 80131 Naples, Italy
| | - Giuseppe Muscogiuri
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
- Department of Radiology, IRCCS Istituto Auxologico Italiano, San Luca Hospital, 20149 Milan, Italy
| | - Massimo Venturini
- Diagnostic and Interventional Radiology Department, Circolo Hospital, ASST Sette Laghi, Insubria University, 21100 Varese, Italy
| | - Sandro Sironi
- Department of Radiology, ASST Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
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Congenital Absence of the Portal Vein as a Rare Cause of Portopulmonary Hypertension-A Case Study Series. Medicina (B Aires) 2022; 58:medicina58101484. [PMID: 36295644 PMCID: PMC9608572 DOI: 10.3390/medicina58101484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/01/2022] [Accepted: 10/13/2022] [Indexed: 11/05/2022] Open
Abstract
Background. Congenital absence of the portal vein (CAPV) is an extremely rare malformation that is caused by aberrant venous development during embryogenesis and is usually associated with congenital portosystemic shunts (CPSS). This hemodynamic allows mesenteric blood to bypass the liver metabolism and causes an imbalance between vasodilators and vasoconstrictors in the pulmonary circulation, which, again, might lead to the development of secondary portopulmonary hypertension (PoPH). Establishing the exact morphology of the splanchnic venous system is important when evaluating possible therapeutic options (differentiating type I and II CAPV), because some variants enable the closure of the shunt, and this represents a potential cure for pulmonary arterial hypertension (PAH). Once PoPH is diagnosed, complex care in a specialized expert centre is necessary. If possible, CPSS closure is recommended. For long-term successful patient management, specific targeted PAH therapy administration is crucial. Significant morbidity and mortality in these patients may result not only from PAH itself but also due to specific PoPH complications, such as compression of the left main coronary artery by pulmonary artery aneurysm. Case Report. We report on two patients with PoPH due to CAPV and CPSS (without any liver disease) who presented as severe PAH and who, before admission to our expert centre, were misdiagnosed as idiopathic PAH. The case reports also represent our experience with respect to the long-term follow-up and PAH-specific medical treatment of these patients, as well as the possible (even fatal) complications of these rare and complex patients.
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14
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Leshen MA, Devanagondi R, Saul D, Chaturvedi A. Physiological fetal vascular shunts and failure to regress: what the radiologist needs to know. Pediatr Radiol 2022; 52:1207-1223. [PMID: 35166890 DOI: 10.1007/s00247-022-05302-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/13/2021] [Accepted: 01/27/2022] [Indexed: 10/19/2022]
Abstract
The fetal circulation is characterized by the presence of three physiological vascular shunts - the ductus arteriosus, the foramen ovale and the ductus venosus. Acting in concert, these shunts preferentially stream blood flow in a pattern that maximizes efficiency of blood oxygenation by the maternofetal unit. Shortly following the transition to extrauterine life, a quick and predetermined succession of events results in closure of these embryological structures with consequent establishment of postnatal vascular flow patterns. While this transition is often seamless, the physiological shunts of the fetus occasionally fail to regress. Such failure to regress can occur in isolation or in association with other congenital malformations. This failed regression challenges the circulatory physiology of the neonate and might have implications for the optimum functioning of several organ systems. When symptomatic, these shunts are treated. Interventions, when undertaken, might be medical, endovascular or surgical. The radiologist's role continues to expand in the assessment of these shunts, in providing a roadmap for treatment and in prompt identification of treatment-related complications. This review is to familiarize radiologists with the embryology, pre- and post-treatment imaging appearances, and associated complications of persistent fetal vascular shunts.
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Affiliation(s)
- Michael A Leshen
- Department of Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Ave., Rochester, NY, 14642, USA.
| | - Rajiv Devanagondi
- Division of Pediatric Cardiology, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - David Saul
- Department of Medical Imaging, A. I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Apeksha Chaturvedi
- Pediatric Imaging Section, Department of Imaging Sciences, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
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15
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Tessier S, Ido F, Zanders T, Longo S, Nanda S. Congenital Porto-Azygous Shunt (Abernethy Malformation Type II) in an Elderly Patient: A Too-Often-Forgotten Occult Abnormality. Cureus 2022; 14:e24460. [PMID: 35651430 PMCID: PMC9132755 DOI: 10.7759/cureus.24460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/05/2022] Open
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16
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Ponce-Dorrego MD, Hernández-Cabrero T, Garzón-Moll G. Endovascular Treatment of Congenital Portosystemic Shunt: A Single-Center Prospective Study. Pediatr Gastroenterol Hepatol Nutr 2022; 25:147-162. [PMID: 35360378 PMCID: PMC8958053 DOI: 10.5223/pghn.2022.25.2.147] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/16/2022] [Accepted: 02/27/2022] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To design a prospective study on endovascular closure of congenital portosystemic shunts. The primary endpoint was to assess the safety of endovascular closure. The secondary endpoint was to evaluate the clinical, analytical and imaging outcomes of treatment. METHODS Fifteen patients (age range: 2 days to 21 years; 10 male) were referred to our center due to congenital portosystemic shunts. The following data were collected prior to treatment: age, sex, medical history, clinical and analytical data, urine trimethylaminuria, abdominal-US, and body-CT. The following data were collected at the time of intervention: anatomical and hemodynamic characteristics of the shunts, device used, and closure success. The following data were collected at various post-intervention time points: during hospital stay (to confirm shunt closure and detect complications) and at one year after (for clinical, analytical, and imaging purposes). RESULTS The treatment was successful in 12 participants, migration of the device was observed in two, while acute splanchnic thrombosis was observed in one. Off-label devices were used in attempting to close the side-to-side shunts, and success was achieved using Amplatzer™ Ductus-Occluder and Amplatzer™ Muscular-Vascular-Septal-Defect-Occluder. The main changes were: increased prothrombin activity (p=0.043); decreased AST, ALT, GGT, and bilirubin (p=0.007, p=0.056, p=0.036, p=0.013); thrombocytopenia resolution (p=0.131); expansion of portal veins (p=0.005); normalization of Doppler portal flow (100%); regression of liver nodules (p=0.001); ammonia normalization (p=0.003); and disappearance of trimethylaminuria (p=0.285). CONCLUSION Endovascular closure is effective. Our results support the indication of endovascular closure for side-to-side shunts and for cases of congenital absence of portal vein.
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Affiliation(s)
| | | | - Gonzalo Garzón-Moll
- Department of Interventional Radiology, Hospital General Universitario La Paz, Madrid, Spain
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Ghasemi-Rad M, Smuclovisky E, Cleveland H, Hernandez JA. Endovascular treatment of a portosystemic shunt presenting with hypoglycemia; case presentation and review of literature. Clin Imaging 2022; 83:131-137. [DOI: 10.1016/j.clinimag.2021.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/13/2021] [Accepted: 12/23/2021] [Indexed: 11/03/2022]
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Bahadori A, Kuhlmann B, Debray D, Franchi-Abella S, Wacker J, Beghetti M, Wildhaber BE, McLin VA. Presentation of Congenital Portosystemic Shunts in Children. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9020243. [PMID: 35204963 PMCID: PMC8870378 DOI: 10.3390/children9020243] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/31/2021] [Accepted: 01/25/2022] [Indexed: 12/12/2022]
Abstract
Background: Congenital portosystemic shunts (CPSS) are rare vascular anomalies resulting in communications between the portal venous system and the systemic venous circulation, affecting an estimated 30,000 to 50,000 live births. CPSS can present at any age as a multi-system disease of variable severity mimicking both common and rare pediatric conditions. Case presentations: Case A: A vascular malformation was identified in the liver of a 10-year-old girl with tall stature, advanced somatic maturation, insulin resistance with hyperinsulinemia, hyperandrogenemia and transient hematuria. Work-up also suggested elevated pulmonary pressures. Case B: A young girl with trisomy 8 mosaicism with a history of neonatal hypoglycemia, transient neonatal cholestasis and tall stature presented newly increased aminotransferase levels at 6 years of age. Case C: A 3-year-old boy with speech delay, tall stature and abdominal pain underwent abdominal ultrasound (US) showing multiple liver nodules, diagnosed as liver hemangiomas by hepatic magnetic resonance imaging (MRI). Management and outcome: After identification of a venous malformation on liver Doppler US, all three patients were referred to a specialized liver center for further work-up within 12 to 18 months from diagnosis. Angio-computed tomography (CT) scan confirmed the presence of either an intrahepatic or extrahepatic CPSS with multiples liver nodules. All three had a hyperintense signal in the globus pallidus on T1 weighted cerebral MRI. Right heart catheterization confirmed pulmonary hypertension in cases A and C. Shunts were closed either using an endovascular or surgical approach. Liver nodules were either surgically removed if there was a risk of malignant degeneration or closely monitored by serial imaging when benign. Conclusion: These cases illustrate most of the common chief complaints and manifestations of CPSS. Liver Doppler US is the key to diagnosis. Considering portosystemic shunts in the diagnostic work-up of a patient with unexplained endocrine, liver, gastro-intestinal, cardiovascular, hematological, renal or neurocognitive disorder is important as prompt referral to a specialized center may significantly impact patient outcome.
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Affiliation(s)
- Atessa Bahadori
- Pediatric Specialties Division, Department of Pediatrics, Gynecology, and Obstetrics, University Hospitals Geneva (HUG), University of Geneva, 1211 Geneva, Switzerland; (J.W.); (M.B.)
- Correspondence:
| | - Beatrice Kuhlmann
- Pediatric Endocrinology, Cantonal Hospital Aarau, 5001 Aarau, Switzerland;
| | - Dominique Debray
- Pediatric Liver Unit, Necker Hospital, APHP, Paris Centre University, 75015 Paris, France;
| | - Stephanie Franchi-Abella
- Pediatric Radiology, Paris-Saclay University, Hôpital Bicêtre, Hôpitaux Paris-Saclay APHP, 94270 Paris, France;
| | - Julie Wacker
- Pediatric Specialties Division, Department of Pediatrics, Gynecology, and Obstetrics, University Hospitals Geneva (HUG), University of Geneva, 1211 Geneva, Switzerland; (J.W.); (M.B.)
- Pulmonary Hypertension Program, University Hospitals Geneva (HUG), University of Geneva, 1211 Geneva, Switzerland
- Pediatric Cardiology Unit, Department of Pediatrics, Gynecology, and Obstetrics, University Hospitals Geneva (HUG), University of Geneva, 1211 Geneva, Switzerland
| | - Maurice Beghetti
- Pediatric Specialties Division, Department of Pediatrics, Gynecology, and Obstetrics, University Hospitals Geneva (HUG), University of Geneva, 1211 Geneva, Switzerland; (J.W.); (M.B.)
- Pulmonary Hypertension Program, University Hospitals Geneva (HUG), University of Geneva, 1211 Geneva, Switzerland
- Pediatric Cardiology Unit, Department of Pediatrics, Gynecology, and Obstetrics, University Hospitals Geneva (HUG), University of Geneva, 1211 Geneva, Switzerland
| | - Barbara E. Wildhaber
- Swiss Pediatric Liver Center, University Hospitals Geneva (HUG), University of Geneva, 1211 Geneva, Switzerland; (B.E.W.); (V.A.M.)
- Child and Adolescent Surgery Division, Department of Pediatrics, Gynecology, and Obstetrics, University Hospitals Geneva (HUG), University of Geneva, 1211 Geneva, Switzerland
| | - Valérie Anne McLin
- Swiss Pediatric Liver Center, University Hospitals Geneva (HUG), University of Geneva, 1211 Geneva, Switzerland; (B.E.W.); (V.A.M.)
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Department of Pediatrics, Gynecology, and Obstetrics, University Hospitals Geneva (HUG), University of Geneva, 1211 Geneva, Switzerland
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Sieverding L, Hofbeck M, Michel J, Hornung A, Scheckenbach C, Grözinger G, Sturm E, Warmann SW, Hanser A. A new variant of Abernethy malformation treated by transhepatic interventional closure: a case report. BMC Gastroenterol 2022; 22:53. [PMID: 35130851 PMCID: PMC8822688 DOI: 10.1186/s12876-022-02123-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Congenital portosystemic shunts (CPSS) are rare vascular malformations and can be classified into extrahepatic and intrahepatic shunts. Extrahepatic CPSS, also termed Abernethy malformations are associated with severe long-term complications including portopulmonary hypertension, liver atrophy, hyperammoniemia and hepatic encephalopathy. We report a hitherto undescribed variant of Abernethy malformation requiring an innovative approach for interventional treatment. Case presentation We describe a 31-year-old patient following surgical repair of atrioventricular septal defect at the age of 6 years. In the long-term follow-up he showed persistent pulmonary hypertension which deteriorated despite dual pulmonary vasodilative treatment. When he developed arterial desaturation and symptomatic hyperammoniemia detailed reassessment revealed as underlying cause a hitherto undescribed variant of Abernethy malformation connecting the portal vein with the right lower pulmonary vein. Following interdisciplinary discussions we opted for an interventional approach. Since the malformation was un-accessible to interventional closure via antegrade venous or retrograde arterial access, a transhepatic percutaneous puncture of the portal vein was performed. Temporary balloon occlusion of the malformation revealed only a slight increase in portal venous pressure. Interventional occlusion of the large vascular connection was achieved via this transhepatic approach by successive implantation of two large vascular occluding devices. The postinterventional course was unremarkable and both ammonia levels and arterial saturation normalized at follow-up of 12 months. Conclusions Portal vein anomalies should be included in the differential diagnoses of pulmonary hypertension or pulmonary arterio-venous malformations. Based on careful assessment of the anatomy and testing of portal vein hemodynamics interventional therapy of complex Abernethy malformations can be performed successfully in specialized centers.
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Affiliation(s)
- Ludger Sieverding
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Jörg Michel
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Andreas Hornung
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Christian Scheckenbach
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany
| | - Gerd Grözinger
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Ekkehard Sturm
- Department of Pediatric Gastroenterology and Hepatology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Steven W Warmann
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Anja Hanser
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Hoppe-Seyler-Str. 1, 72076, Tübingen, Germany.
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The diagnostic accuracy of ultrasound and upper gastrointestinal contrast studies for locating atresia/stenosis and intestinal malrotation and detecting annular pancreas in pediatric patients with duodenal atresia/stenosis. J Med Ultrason (2001) 2022; 49:299-309. [PMID: 34988762 DOI: 10.1007/s10396-021-01176-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/15/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This study aimed to evaluate the diagnostic performance of ultrasound to locate atresia/stenosis and other abdominal anomalies in pediatric patients with duodenal atresia/stenosis, including intestinal malrotation and annular pancreas. METHODS We classified 36 retrospective cases of duodenal atresia/stenosis based on intestinal malrotation status, and evaluated the diagnostic performance of ultrasound/upper gastrointestinal contrast studies to locate atresia/stenosis and intestinal malrotation, as well as ultrasound for detecting additional anomalies such as annular pancreas. The incidence of annular pancreas was compared between groups using Fisher's exact test. RESULTS Atresia/stenosis was correctly located by ultrasound in 33 (91.7%) cases and by upper gastrointestinal contrast study in 36 (100%) cases. Of the eight cases with intestinal malrotation, five and two were correctly diagnosed by ultrasound and upper gastrointestinal contrast study, respectively. Ultrasound correctly diagnosed annular pancreas in 6/14 cases. The incidence of annular pancreas was significantly different between the groups (present/absent in groups with vs. without intestinal malrotation: 6/2 vs. 8/20, P = 0.036). CONCLUSIONS Ultrasound has a relatively high capability in locating atresia/stenosis. However, some cases are misdiagnosed. In clinical practice, upper gastrointestinal contrast studies should be used complementarily during diagnosis. Additional anomalies may not be detected by preoperative examinations; therefore, surgeons should carefully evaluate for additional anomalies during surgery, especially coexisting intestinal malrotation and annular pancreas.
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21
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Doi Y, Kim SH, Ishigaki M, Sato K, Yoshimoto J, Mitsushita N, Nii M, Yamoto M, Urushihara N, Tanaka Y. Angiographic diagnosis for accurate assessment of congenital porto-systemic shunt and extrahepatic portal vein obstruction in children. Pediatr Int 2022; 64:e14856. [PMID: 34048141 DOI: 10.1111/ped.14856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 04/16/2021] [Accepted: 05/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Congenital porto-systemic shunt (CPSS) is a rare disease and can cause fatal complications. Accurate angiographic assessment is mandatory for proper treatment. Although technically difficult, we developed assessment techniques and assessed their accuracy. One technique came from evaluating patients with extrahepatic portal vein obstruction (EHPVO). METHODS We conducted a single center retrospective study to evaluate the efficacy of angiographic diagnostic procedure for the assessment of CPSS and EHPVO, and its impact on patients' subsequent interventions and clinical course. Eight patients with CPSS and two patients with EHPVO who underwent diagnostic angiography were included. Assessment of the intrahepatic portal vein was performed in all patients. The route of the shunt, and portal vein pressure under shunt occlusion, were also evaluated for patients with CPSS. Evaluation was first attempted with a balloon angiographic catheter (standard method). Three additional techniques were performed as needed: (i) direct wedge-catheter injection without balloon inflation, (ii) use of occlusion balloon in two patients, and (iii) hybrid angiography with sheath placement directly into the superior mesenteric vein. RESULTS The standard method was sufficient in four patients. On the other hand, all three techniques were required in two patients each. One lost contact during follow up, but all other patients underwent optimal intervention. There were no complications related to the angiographic procedure. CONCLUSIONS Use of direct wedge-catheter injection without balloon inflation, occlusion balloon, and hybrid catheterization improved the diagnostic yield in patients with CPSS or EHPVO.
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Affiliation(s)
- Yuji Doi
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka-City, Shizuoka, Japan
| | - Sung-Hae Kim
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka-City, Shizuoka, Japan
| | - Mizuhiko Ishigaki
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka-City, Shizuoka, Japan
| | - Keisuke Sato
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka-City, Shizuoka, Japan
| | - Jun Yoshimoto
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka-City, Shizuoka, Japan
| | - Norie Mitsushita
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka-City, Shizuoka, Japan
| | - Masaki Nii
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka-City, Shizuoka, Japan
| | - Masaya Yamoto
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka-City, Shizuoka, Japan
| | - Naoto Urushihara
- Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka-City, Shizuoka, Japan
| | - Yasuhiko Tanaka
- Department of Cardiology, Shizuoka Children's Hospital, Shizuoka-City, Shizuoka, Japan
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22
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Kardos M, Kitzmueller E, Olejnik P, Michel-Behnke I. Percutaneous treatment of a huge patent ductus venosus and severe portal vein hypoplasia using a Figulla Flex II atrial septal defect occluder in a 2-year-old infant: a case report. Eur Heart J Case Rep 2021; 5:ytab455. [PMID: 34934900 PMCID: PMC8684806 DOI: 10.1093/ehjcr/ytab455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/19/2021] [Accepted: 11/04/2021] [Indexed: 11/13/2022]
Abstract
Abstract
Background
Intra- or extrahepatic porto-caval shunts (PCSs) can account for multiorgan dysfunction with pulmonary arterial hypertension and portosystemic encephalopathy as the most serious consequences of bypass of the hepatic circulation. The ductus venosus (DV) represents a rare foetal PCS and might be persistently patent in newborns after birth. Treatment strategies include surgical ligation and percutaneous device closure. The degree of portal vein hypoplasia limits therapy making liver transplantation the only option in some of them.
Case summary
In a newborn female patient a huge persistently patent DV, known already prenatally, resulted in severe secondary portal vein hypoplasia. She presented with hyperammonaemia, elevated liver enzymes, and pulmonary hypertension. With only diminutive portal venous branches and exceedingly high portal venous pressures during test-occlusion of the DV, shunt closure was not possible. At the age of 2 years more favourable portal venous pressures allowed transcatheter device closure with a nitinol atrial septal defect occlusion device. Pulmonary artery pressures and ammonia levels normalized after the procedure without any signs of portal hypertension.
Discussion
The case highlights the importance of meticulous imaging using balloon occlusion angiography of PCSs like the DV, to search for intrahepatic portal veins. Moreover, portal vein pressure during test-occlusion can identify patients amenable for surgical or endovascular shunt closure. Occlusion devices licensed for other indications like atrial septal defect closure can be used safely in huge PCS vessels in a one-step or staged procedure. Optimal timing of the intervention should be tailored to the patient’s needs
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Affiliation(s)
- Marek Kardos
- Department of Functional Diagnostics, Pediatric Cardiac Center, National Institute of Cardiovascular Diseases, Pod Krasnou horkou 1, 833 48 Bratislava, Slovakia
| | - Erwin Kitzmueller
- Division of Pediatric Cardiology, University Hospital for Children and Adolescents, Pediatric Heart Centre, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Peter Olejnik
- Department of Pediatric Cardiology, Pediatric Cardiac Center, National Institute of Cardiovascular Diseases, Pod Krasnou horkou 1, 833 48 Bratislava, Slovakia
- Department of Pediatric Cardiology, Faculty of Medicine, Comenius University, Pod Krasnou horkou 1, 833 48 Bratislava, Slovakia
| | - Ina Michel-Behnke
- Division of Pediatric Cardiology, University Hospital for Children and Adolescents, Pediatric Heart Centre, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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Rao S, Karuppasamy K, Radhakrishnan K, Fagan TE. Restriction of congenital portosystemic shunt using the modified microvascular plug. Catheter Cardiovasc Interv 2021; 98:1358-1362. [PMID: 34487406 DOI: 10.1002/ccd.29934] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 08/21/2021] [Indexed: 11/07/2022]
Abstract
Congenital portosystemic shunts (CPSS) may produce a variety of severe, clinically detrimental presentations. When indicated, closure is recommended; however, if the intrahepatic portal venous system (IPVS) is underdeveloped complete closure may not be possible and may result in severe acute portal hypertension. Staged restriction of CPSS flow by both surgical and complex transcatheter interventions has been successful in augmenting development of the IPVS such that complete occlusion of the CPSS can be performed. We report use of a modified microvascular plug to restrict CPSS flow with subsequent IPVS development and safe complete occlusion of CPSS.
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Affiliation(s)
- Sruti Rao
- Department of Pediatric Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | - Kadakkal Radhakrishnan
- Department of Pediatric Gastroenterology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Thomas E Fagan
- Department of Pediatric Cardiology, Valley Children's Healthcare, 9300 Valley Children's, Pl, Madera, CA, USA
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24
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Andrade G, Facas J, Marques P, Mónica AN, Donato P. Congenital extrahepatic portosystemic shunt type II occluded with cardiac closure device. Radiol Case Rep 2021; 16:3802-3806. [PMID: 34691344 PMCID: PMC8511717 DOI: 10.1016/j.radcr.2021.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 11/21/2022] Open
Abstract
Congenital extrahepatic portosystemic shunts are a rare cause of lower gastrointestinal bleeding in children. They result from the connection of a systemic vessel with the portomesenteric vasculature before the division of the main portal vein. Herein, we report a case of a congenital extrahepatic portosystemic shunts type II in a 4-year-old male diagnosed by Doppler ultrasonography during the investigation of abdominal pain and recurrent hematochezia, later confirmed by computed tomography. Conventional angiography with a balloon occlusion test revealed patent intrahepatic portal branches not depicted by previous imaging techniques. Successful shunt closure was achieved by endovascular approach with an Amplatzer Septal Occluder without complications.
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Affiliation(s)
- Gisela Andrade
- Department of Radiology, Hospital Prof. Doutor Fernando Fonseca EPE, Amadora, Portugal
| | - João Facas
- Medical Imaging Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Pedro Marques
- Department of Radiology, Hospital Prof. Doutor Fernando Fonseca EPE, Amadora, Portugal
| | - Ana Nassauer Mónica
- Department of Radiology, Hospital Prof. Doutor Fernando Fonseca EPE, Amadora, Portugal
| | - Paulo Donato
- Medical Imaging Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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25
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AKDULUM İ, AKYÜZ M, GÜRÜN E, ÖZTÜRK M, SIĞIRCI A, BOYUNAĞA Ö. CT-angiography and doppler ultrasound evaluation of congenital portosystemic shunts. ACTA MEDICA ALANYA 2021. [DOI: 10.30565/medalanya.828133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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26
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Uchida H, Sakamoto S, Kasahara M. Reply. Liver Transpl 2021; 27:1214. [PMID: 33787073 DOI: 10.1002/lt.26059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 01/13/2023]
Affiliation(s)
- Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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27
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Laverdure N, Lallier M, Dubois J, Paganelli M. Congenital absence of the portal vein: Define the portosystemic shunt, avoid liver transplantation. CANADIAN LIVER JOURNAL 2021; 4:322-327. [DOI: 10.3138/canlivj-2020-0011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 06/02/2020] [Indexed: 11/20/2022]
Abstract
Liver transplantation has been historically recommended for patients with congenital absence of the portal vein associated with extrahepatic congenital portosystemic shunts. Here, based on a case report of a 2-year-old girl and a thorough review of all published cases from 1974 to 2020, we show that such a diagnosis most often conceals a hypoplastic portal vein, which can be successfully re-permeabilized through the closure of the shunt in order to re-establish a physiological vascular anatomy. This highlights the importance of achieving a detailed anatomical description of extrahepatic congenital portosystemic shunts with a balloon occlusion test in order to plan the best surgical approach and avoid unnecessary liver transplantation.
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Affiliation(s)
- Noémie Laverdure
- Pediatric Gastroenterology Hepatology and Nutrition, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
- Service d’Hépato-gastroenterologie et nutrition pediatrique, Hopital Femme Mere Enfant, Lyon, France
| | - Michel Lallier
- Pediatric Surgery, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Josée Dubois
- Pediatric Radiology, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Massimiliano Paganelli
- Pediatric Gastroenterology Hepatology and Nutrition, CHU Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
- Liver Tissue Engineering and Cell Therapy Laboratory, CHU Sainte-Justine Research Centre, Montréal, Québec, Canada
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28
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Uchida H, Sakamoto S, Kasahara M, Kudo H, Okajima H, Nio M, Umeshita K, Ohdan H, Egawa H, Uemoto S. Longterm Outcome of Liver Transplantation for Congenital Extrahepatic Portosystemic Shunt. Liver Transpl 2021; 27:236-247. [PMID: 37160013 DOI: 10.1002/lt.25805] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/01/2020] [Accepted: 05/01/2020] [Indexed: 02/07/2023]
Abstract
Liver transplantation (LT) is often viewed as the last resort for the treatment of congenital extrahepatic portosystemic shunt (CEPS) due to advancement of imaging and interventional radiology techniques. However, some patients still require LT, and criteria for LT are yet to be determined. We conducted a national survey of patients undergoing LT for CEPS between June 1998 and August 2018 and evaluated the clinical data and outcomes with a review of previously reported patients from the English-language medical literature. A total of 26 patients underwent LT in Japan at a median age of 5.2 years old. The most common indications for LT were persistent hyperammonemia (54%) and liver mass (50%), followed by pulmonary complications (38%). Pulmonary complications in all patients, including intrapulmonary shunt and pulmonary hypertension (PH), were improved after LT. Regarding the 29 previously reported patients in the English-language literature, a liver nodule (49%), including hepatoblastoma and hepatocellular carcinoma, was the most common indication for LT, followed by pulmonary complications (34%). A total of 25 (96%) patients in our survey and 26 (90%) patients in the literature review were alive with a median follow-up period of 9.5 and 1.6 years, respectively. Although LT has a limited role in management of CEPS, our study indicated that LT was safe as an alternative treatment for select patients with malignant tumor or pulmonary complications and those with complications related to new portosystemic collateral vessels after shunt closure, such as PH or hepatopulmonary syndrome.
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Affiliation(s)
- Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hironori Kudo
- Department of Pediatric Surgery, Tohoku University, Miyagi, Japan
| | - Hideaki Okajima
- Department of Pediatric Surgery, Kanazawa Medical University, Ishikawa, Japan
| | - Masaki Nio
- Department of Pediatric Surgery, Tohoku University, Miyagi, Japan
| | - Koji Umeshita
- Department of Surgery, Osaka University, Osaka, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Applied Life Sciences, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroto Egawa
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shinji Uemoto
- Department of Surgery, Kyoto University, Kyoto, Japan
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29
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Chiang J, Chiu HK, Moriarty JM, McWilliams JP. Hyperandrogenism and malignant degeneration of hepatic adenomas in the setting of Abernethy malformation. Radiol Case Rep 2020; 15:2701-2705. [PMID: 33117471 PMCID: PMC7581830 DOI: 10.1016/j.radcr.2020.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/10/2020] [Accepted: 10/10/2020] [Indexed: 12/26/2022] Open
Abstract
Abernethy malformation refer to a congenital absence of intrahepatic portal veins leading to a primarily extrahepatic congenital portosystemic shunt. The lack of intrahepatic portal veins leads to a characteristic set of physical exam and imaging findings that may include hyperandrogenism and liver masses such as hepatic adenomas or focal nodular hyperplasia. In this case report, we describe a 20-year-old female who presented with an enlarging hepatic adenoma. A separate hepatic adenoma had previously been biopsied and noted to have undergone malignant degeneration into hepatocellular carcinoma. For each lesion, she was treated with combination transarterial embolization and microwave ablation. On follow-up imaging after therapy, it was then noted that her extrahepatic portal vein drained directly into the inferior vena cava, consistent with congenital portosystemic shunt. Recognition of this vascular anomaly is critical in treatment planning, as early intervention with either medical therapy or surgery can prevent the metabolic sequela of this unique constellation of symptoms.
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Affiliation(s)
- Jason Chiang
- Department of Radiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
- Corresponding author.
| | - Harvey K. Chiu
- Division of Pediatric Endocrinology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - John M. Moriarty
- Department of Radiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Justin P. McWilliams
- Department of Radiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
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30
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Bueno J, Pérez M, Lopez-Ben S, Guillén G, Molino JA, López S, Venturi C, Diez I, López M. Radiological and surgical differences between congenital end-to-side (Abernethy malformation) and side-to-side portocaval shunts. J Pediatr Surg 2020; 55:1897-1902. [PMID: 32067808 DOI: 10.1016/j.jpedsurg.2020.01.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 01/21/2020] [Accepted: 01/23/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Distinguishing retrohepatic end-to-side portocaval shunts (ES-PCS) and side-to-side portocaval shunts (SS-PCS) can be difficult, but it is essential for determining the treatment strategy. Our experience with retrohepatic PCS is analyzed. METHODS Since 2007, 9 children (5/9 ES-PCS and 4/9 SS-PCS) were surgically treated. Radiology studies included Doppler-ultrasound, CT/MRI and angiography/occlusion test (8/9). RESULTS CT in 5/5 ES-PCS revealed the portal vein (PV) entering the left side of the vena cava with a uniform shape. 4/4 SS-PCS showed aneurysmal PV containing the origin of the main intrahepatic portal branches (IHPB) entering the cava anterior aspect or slightly to the right with a variable length (from long to short/wide). ES-PCS anatomy showed caudate lobe absence with the fistula entering the left cava aspect free of parenchyma, but anterior through the caudate lobe in SS-PCS. With the angiography/occlusion test, the IHPB was undeveloped in ES-PCS (portal pressure > 38 mmHg) and hypoplasic in SS-PCS (portal pressure < 25 mmHg). ES-PCS treatment included: 1/5 hepatectomy and 4/5 definitive banding (one by laparoscopy); while in SS-PCS: 1/4 liver transplantation, 2/4 1-step closure (one by laparoscopy), and 1/4 definitive banding. CONCLUSION Fistula shape, cava relationship, IHPB and portal pressures differ between the two shunt types. A question arises regarding the need for secondary complete closure after banding. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Javier Bueno
- Pediatric Surgery Department, University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain.
| | - Mercedes Pérez
- Interventional Radiology Unit, University Hospital Vall d'Hebron. Autonomous University of Barcelona, Barcelona, Spain
| | | | - Gabriela Guillén
- Pediatric Surgery Department, University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - José A Molino
- Pediatric Surgery Department, University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Sergio López
- Pediatric Surgery Department, University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
| | - Carla Venturi
- CAP Roquetas. Institut Catala Salut. Barcelona, Spain
| | - Iratxe Diez
- Interventional Radiology Unit, University Hospital Vall d'Hebron. Autonomous University of Barcelona, Barcelona, Spain
| | - Manuel López
- Pediatric Surgery Department, University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain
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31
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Guérin F, Franchi Abella S, McLin V, Ackermann O, Girard M, Cervoni JP, Savale L, Hernandez-Gea V, Valla D, Hillaire S, Dutheil D, Bureau C, Gonzales E, Plessier A. Congenital portosystemic shunts: Vascular liver diseases: Position papers from the francophone network for vascular liver diseases, the French Association for the Study of the Liver (AFEF), and ERN-rare liver. Clin Res Hepatol Gastroenterol 2020; 44:452-459. [PMID: 32279979 DOI: 10.1016/j.clinre.2020.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/03/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Florent Guérin
- Department of Visceral Pediatric surgery, FHU Hépatinov, Bicêtre Hospital, AP-HP, Paris-Saclay, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France; UMRS-1193, Inserm, Paris-Saclay University, 91400 Orsay, France.
| | - Stéphanie Franchi Abella
- Department of Pediatric Radiology, FHU Hépatinov, Bicêtre Hospital, AP-HP, Paris-Saclay, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Valérie McLin
- Swiss Pediatric Liver Center, Pediatric Gastroenterology, Hepatology, and Nutrition Unit, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Geneva, Switzerland
| | - Oanez Ackermann
- UMRS-1193, Inserm, Paris-Saclay University, 91400 Orsay, France; Department of Pediatric Hepatology, FHU Hépatinov, Bicêtre Hospital, AP-HP, Paris-Saclay, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France; French Network for Rare Liver Diseases (FILFOIE), European Reference Network (ERN) "Rare-Liver" Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Muriel Girard
- French Network for Rare Liver Diseases (FILFOIE), European Reference Network (ERN) "Rare-Liver" Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France; Department of Pediatric Hepatology, Hôpital Necker - enfants maladies, AP-HP, 149, rue de Sèvres, 75743 Paris cedex 15, France
| | - Jean Paul Cervoni
- Department of Hepatology, Jean Minjoz Hospital, University Hospital of Besançon, 3, boulevard Alexandre-Fleming, 25030 Besançon cedex, France
| | - Laurent Savale
- Department of Pulmonary Medicine, Bicêtre Hospital, AP-HP, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - Virginia Hernandez-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona. Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd). Health Care Provider of the European Reference Network onRare Liver Disorders (ERN-Liver), Spain
| | - Dominique Valla
- French Network for Rare Liver Diseases (FILFOIE), European Reference Network (ERN) "Rare-Liver" Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France; Department of Hepatology, DHU Unity, Beaujon Hospital, AP-HP, 100, boulevard du Général-Leclerc, 92118 Clichy, France; Inserm, center for research in inflammation, University of Paris, 75018 Paris, France
| | - Sophie Hillaire
- Department of Internal medicine, Foch Hospital, 40, rue Worth, 92150 Suresnes, France
| | - Danielle Dutheil
- Department of Hepatology, Association of patients with vascular liver diseases (AMVF), Beaujon Hospital, 100, boulevard du Général-Leclerc, 92118 Clichy, France
| | - Christophe Bureau
- Department of Gastroenterology and Hepatology, Rangueil Hospital, University Hospital of Toulouse, 1, avenue du Professeur-Jean-Poulhès, 31400 Toulouse, France
| | - Emmanuel Gonzales
- UMRS-1193, Inserm, Paris-Saclay University, 91400 Orsay, France; Department of Pediatric Hepatology, FHU Hépatinov, Bicêtre Hospital, AP-HP, Paris-Saclay, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France; French Network for Rare Liver Diseases (FILFOIE), European Reference Network (ERN) "Rare-Liver" Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Aurélie Plessier
- French Network for Rare Liver Diseases (FILFOIE), European Reference Network (ERN) "Rare-Liver" Saint-Antoine Hospital, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France; Department of Hepatology, DHU Unity, Beaujon Hospital, AP-HP, 100, boulevard du Général-Leclerc, 92118 Clichy, France
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32
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Chen L, Wei B, Xiang B, Wu H. Revascularization of Portal Venous System after Occlusion of Congenital Intrahepatic Portosystemic Shunt. J Pediatr 2020; 223:222-223. [PMID: 32482391 DOI: 10.1016/j.jpeds.2020.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 04/15/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Liuxiang Chen
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bo Wei
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bo Xiang
- Department of Pediatric Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hao Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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33
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Rajeswaran S, Johnston A, Green J, Riaz A, Thornburg B, Mouli S, Lautz T, Lemoine C, Superina R, Donaldson J. Abernethy Malformations: Evaluation and Management of Congenital Portosystemic Shunts. J Vasc Interv Radiol 2020; 31:788-794. [DOI: 10.1016/j.jvir.2019.08.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 07/31/2019] [Accepted: 08/06/2019] [Indexed: 11/29/2022] Open
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34
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Tang H, Song P, Wang Z, Han B, Meng X, Pan Y, Meng X, Duan W. A basic understanding of congenital extrahepatic portosystemic shunt: incidence, mechanism, complications, diagnosis, and treatment. Intractable Rare Dis Res 2020; 9:64-70. [PMID: 32494552 PMCID: PMC7263991 DOI: 10.5582/irdr.2020.03005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Extrahepatic portosystemic shunt belongs to a family of rare vascular abnormalities. The clinical importance and manifestations of this vascular abnormality range from asymptomatic cases to liver or metabolic dysfunctions of various degrees. Congenital extrahepatic portosystemic shunt, also termed as Abernethy malformation, is a very rare congenital vascular malformation in which splenomesenteric blood drains into a systemic vein, bypassing the liver through a complete or partial extrahepatic shunt. So far, limited cases of congenital extrahepatic portosystemic shunt have been reported. In this review, incidence, mechanisms, complications, diagnoses and treatments of congenital extrahepatic portosystemic shunt are described.
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Affiliation(s)
- Haowen Tang
- Department of Hepatobiliary Surgery, First Medical Center of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, China
| | - Peipei Song
- The Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Zhiqiang Wang
- Department of Hepatobiliary Surgery, Qinghai Red Cross Hospital, Xining, China
| | - Bing Han
- Department of General Surgery, Shanxian Central Hospital, Heze, China
| | - Xiangfei Meng
- Department of Hepatobiliary Surgery, First Medical Center of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, China
| | - Yingwei Pan
- Department of Hepatobiliary Surgery, First Medical Center of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, China
| | - Xuan Meng
- Department of Hepatobiliary Surgery, First Medical Center of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, China
- Address correspondence to:Weidong Duan and Xuan Meng, Department of Hepatobiliary Surgery, First Medical Center of Chinese PLA General Hospital, Chinese PLA Medical School, 28 Fuxing Road, Haidian, Beijing 100853, China. E-mail: (Duan WD), (Meng X)
| | - Weidong Duan
- Department of Hepatobiliary Surgery, First Medical Center of Chinese PLA General Hospital, Chinese PLA Medical School, Beijing, China
- Address correspondence to:Weidong Duan and Xuan Meng, Department of Hepatobiliary Surgery, First Medical Center of Chinese PLA General Hospital, Chinese PLA Medical School, 28 Fuxing Road, Haidian, Beijing 100853, China. E-mail: (Duan WD), (Meng X)
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35
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Bayona Molano MDP, Krauthamer A, Barrera JC, Luna C, Castillo P, Swersky A, Bhatia S. Congenital intrahepatic portosystemic venous shunt embolization: A two-case experience. Clin Case Rep 2020; 8:761-766. [PMID: 32274053 PMCID: PMC7141714 DOI: 10.1002/ccr3.2784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/16/2020] [Accepted: 02/12/2020] [Indexed: 12/23/2022] Open
Abstract
Congenital intrahepatic portosystemic venous shunts are rare vascular malformations which are incidentally discovered on imaging or once hepatic encephalopathy becomes clinically apparent. Surgical ligation and endovascular embolization are potential treatments.
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Affiliation(s)
| | - Andres Krauthamer
- University of Miami Miller School of Medicine/Jackson Memorial HospitalMiamiFLUSA
| | | | - Cibele Luna
- Central University of VenezuelaCaracasVenezuela
| | - Patricia Castillo
- University of Miami Miller School of Medicine/Jackson Memorial HospitalMiamiFLUSA
| | - Adam Swersky
- University of Miami Miller School of Medicine/Jackson Memorial HospitalMiamiFLUSA
| | - Shivank Bhatia
- University of Miami Miller School of Medicine/Jackson Memorial HospitalMiamiFLUSA
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36
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Baiges A, Turon F, Simón-Talero M, Tasayco S, Bueno J, Zekrini K, Plessier A, Franchi-Abella S, Guerin F, Mukund A, Eapen CE, Goel A, Shyamkumar NK, Coenen S, De Gottardi A, Majumdar A, Onali S, Shukla A, Carrilho FJ, Nacif L, Primignani M, Tosetti G, La Mura V, Nevens F, Witters P, Tripathi D, Tellez L, Martínez J, Álvarez-Navascués C, Fraile López ML, Procopet B, Piscaglia F, de Koning B, Llop E, Romero-Cristobal M, Tjwa E, Monescillo-Francia A, Senzolo M, Perez-LaFuente M, Segarra A, Sarin SK, Hernández-Gea V, Patch D, Laleman W, Hartog H, Valla D, Genescà J, García-Pagán JC. Congenital Extrahepatic Portosystemic Shunts (Abernethy Malformation): An International Observational Study. Hepatology 2020; 71:658-669. [PMID: 31211875 DOI: 10.1002/hep.30817] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 05/21/2019] [Indexed: 12/27/2022]
Abstract
Congenital extrahepatic portosystemic shunt (CEPS) or Abernethy malformation is a rare condition in which splanchnic venous blood bypasses the liver draining directly into systemic circulation through a congenital shunt. Patients may develop hepatic encephalopathy (HE), pulmonary hypertension (PaHT), or liver tumors, among other complications. However, the actual incidence of such complications is unknown, mainly because of the lack of a protocolized approach to these patients. This study characterizes the clinical manifestations and outcome of a large cohort of CEPS patients with the aim of proposing a guide for their management. This is an observational, multicenter, international study. Sixty-six patients were included; median age at the end of follow-up was 30 years. Nineteen patients (28%) presented HE. Ten-, 20-, and 30-year HE incidence rates were 13%, 24%, and 28%, respectively. No clinical factors predicted HE. Twenty-five patients had benign nodular lesions. Ten patients developed adenomas (median age, 18 years), and another 8 developed HCC (median age, 39 years). Of 10 patients with dyspnea, PaHT was diagnosed in 8 and hepatopulmonary syndrome in 2. Pulmonary complications were only screened for in 19 asymptomatic patients, and PaHT was identified in 2. Six patients underwent liver transplantation for hepatocellular carcinoma or adenoma. Shunt closure was performed in 15 patients with improvement/stability/cure of CEPS manifestations. Conclusion: CEPS patients may develop severe complications. Screening for asymptomatic complications and close surveillance is needed. Shunt closure should be considered both as a therapeutic and prophylactic approach.
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Affiliation(s)
- Anna Baiges
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Universitat de Barcelona, Barcelona, Spain
| | - Fanny Turon
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Universitat de Barcelona, Barcelona, Spain
| | - Macarena Simón-Talero
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, VHIR, CIBERehd, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Stephanie Tasayco
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, VHIR, CIBERehd, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Javier Bueno
- Pediatric Surgery Department, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Kamal Zekrini
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, Hôpital Beaujon, AP-HP, Clichy, France
| | - Aurélie Plessier
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, Hôpital Beaujon, AP-HP, Clichy, France
| | - Stéphanie Franchi-Abella
- Service d'Hépatologie et de Transplantation Hépatique et de radiologie Pédiatriques, Groupement Hospitalier Paris Sud (GHUPS), Hôpital Bicêtre, Le Kremlin Bicetre, France
| | - Florent Guerin
- Service d'Hépatologie et de Transplantation Hépatique et de radiologie Pédiatriques, Groupement Hospitalier Paris Sud (GHUPS), Hôpital Bicêtre, Le Kremlin Bicetre, France
| | - Amar Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - C E Eapen
- Hepatology Department, Christian Medical College, Vellore, India
| | - Ashish Goel
- Hepatology Department, Christian Medical College, Vellore, India
| | | | - Sandra Coenen
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Andrea De Gottardi
- Hepatology, Clinic of Visceral Surgery and Medicine, Inselspital and Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Avik Majumdar
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, United Kingdom
| | - Simona Onali
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, United Kingdom
| | - Akash Shukla
- Department of Gastroenterology, Seth G S Medical College & KEM Hospital, Mumbai, Maharashtra, India
| | - Flair José Carrilho
- Digestive Organ Transplantation Division, Department of Gastroenterology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Lucas Nacif
- Digestive Organ Transplantation Division, Department of Gastroenterology, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Massimo Primignani
- A. M. e A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Giulia Tosetti
- A. M. e A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Vicenzo La Mura
- A. M. e A. Migliavacca Center for Liver Disease, Division of Gastroenterology and Hepatology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Medicina Generale Emostasi e Trombosi, Milano, Italy
| | - Frederik Nevens
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Peter Witters
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Dhiraj Tripathi
- Liver Unit, Queen Elisabeth Hospital, Birmingham, United Kingdom
| | - Luis Tellez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, University of Alcalá, CIBERedh, Madrid, Spain
| | - Javier Martínez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, University of Alcalá, CIBERedh, Madrid, Spain
| | | | | | - Bogdan Procopet
- Department of Gastroenterology, 3rd Medical Clinic, University of Medicine and Pharmacy "Iuliu Hatieganu", Regional Institute of Gastroenterology and Hepatology "O Fodor", Cluj-Napoca, Romania
| | - Fabio Piscaglia
- Unit of Internal Medicine, Department of Medical and Surgical Sciences, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Barbara de Koning
- Division of Pediatric Gastroenterology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Elba Llop
- Liver Unit, Hospital U. Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Mario Romero-Cristobal
- Digestive Diseases and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas Hospital General Universitario Gregorio Marañón Instituto de Investigación Sanitaria Gregorio Marañón Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Eric Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Alberto Monescillo-Francia
- Digestive Disease Department, Complejo Hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, España
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Mercedes Perez-LaFuente
- Interventional Radiology Unit, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Segarra
- Interventional Radiology Unit, Hospital Universitari Vall d'Hebrón, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Virginia Hernández-Gea
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Universitat de Barcelona, Barcelona, Spain
| | - David Patch
- Sheila Sherlock Liver Unit and UCL Institute for Liver and Digestive Health, Royal Free Hospital and UCL, London, United Kingdom
| | - Wim Laleman
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, UOC Medicina Generale Emostasi e Trombosi, Milano, Italy
| | - Hermien Hartog
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dominique Valla
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Centre de Référence des Maladies Vasculaires du Foie, Hôpital Beaujon, AP-HP, Clichy, France
| | - Joan Genescà
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, VHIR, CIBERehd, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Universitat de Barcelona, Barcelona, Spain
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Glonnegger H, Schulze M, Kathemann S, Berg S, Füllgraf H, Tannapfel A, Gerner P, Grohmann J, Niemeyer C, Hettmer S. Case Report: Hepatic Adenoma in a Child With a Congenital Extrahepatic Portosystemic Shunt. Front Pediatr 2020; 8:501. [PMID: 32984213 PMCID: PMC7477041 DOI: 10.3389/fped.2020.00501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 07/15/2020] [Indexed: 12/19/2022] Open
Abstract
Congenital extrahepatic portosystemic shunts (CEPS), previously also described as Abernethy malformations, are rare malformations in which the extrahepatic portal system directly communicates with the vena cava inferior, thereby bypassing the liver. A hypoplastic portal vein (PV) exists in most cases. CEPS have been associated with the development of liver nodules, ranging from mostly focal nodular hyperplasia (FNH) to hepatic adenoma (HA) and even hepatocellular carcinoma (HCC). Tumor development in CEPS may be due to changes in perfusion pressures, oxygen supply or endocrine imbalances. It is important to rule out CEPS in children with liver tumors, because resection could impede future shunt occlusion procedures, and benign masses may regress after shunt occlusion. Here, we review the case of a 9-years-old male with CEPS and hepatic nuclear Factor 1-alpha (HNF-1-alpha) inactivated HA to raise awareness of this condition and review histopathological changes in the liver of CEPS.
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Affiliation(s)
- Hannah Glonnegger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg im Breisgau, Germany
| | - Maren Schulze
- Department of Transplant and General Surgery, University Hospital Essen, Essen, Germany
| | - Simone Kathemann
- Department of Transplant and General Surgery, University Hospital Essen, Essen, Germany
| | - Sebastian Berg
- Division of Pediatric Radiology, Department of Radiology, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg im Breisgau, Germany
| | - Hannah Füllgraf
- Department of Pathology, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg im Breisgau, Germany
| | - Andrea Tannapfel
- Faculty of Medicine, Medical Center, Institute for Pathology, Ruhr-University Bochum, Bochum, Germany
| | - Patrick Gerner
- Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jochen Grohmann
- Department of Congenital Heart Defects and Pediatric Cardiology, Faculty of Medicine, University Heart Center Freiburg-Bad Krozingen, University of Freiburg, Freiburg im Breisgau, Germany
| | - Charlotte Niemeyer
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg im Breisgau, Germany
| | - Simone Hettmer
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Freiburg im Breisgau, Germany
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Thirapattaraphan C, Treepongkaruna S, Ruangwattanapaisarn N, Sae-Guay S. Congenital extrahepatic portosystemic shunt (Abernethy malformation) treated with surgical shunt ligation: A case report and literature review. Int J Surg Case Rep 2019; 66:4-7. [PMID: 31783328 PMCID: PMC6889787 DOI: 10.1016/j.ijscr.2019.11.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/03/2019] [Accepted: 11/06/2019] [Indexed: 11/30/2022] Open
Abstract
Abernethy malformation is a rare congenital abnormality characterized by an extrahepatic portosystemic shunt. Doppler ultrasonography is usually the initial investigation. Computerized tomography (CT) scan or magnetic resonance imaging (MRI) scan is helpful in confirming the diagnosis. Preoperative angiography with balloon occlusion test is highly recommended to determine the most appropriate intervention. We propose guidelines for approaching and management this condition.
Introduction Congenital extrahepatic portosystemic shunt is also known as Abernethy malformation. It is a rare anomaly of the portal venous system where partial or complete portal blood flow drains directly into the systemic vein via this abnormal shunt, bypassing the liver. Occasionally, this condition is incidentally detected on imaging studies performed for other indications. An early diagnosis is challenging due to the lack of specific symptoms—often leading to delayed diagnosis and development of subsequent complications. Presentation of case A 4-year-old boy presented with multiple cutaneous hemangiomas with concomitant splenomegaly. While the diagnostic work-up for the definite cause of splenomegaly was in progress, an Abernethy malformation was incidentally noted by abdominal ultrasonography. After computerized tomography (CT) imaging confirmed the diagnosis, the patient underwent a successful surgical shunt ligation without any complications through a one-year follow-up period. Discussion Various imaging studies, including Doppler ultrasonography, CT imaging, and Magnetic Resonance Imaging (MRI), are useful tools to diagnose an Abernethy malformation. Preoperative angiography with a balloon occlusion of the shunt is highly recommended in order to opt for the most appropriate intervention—including one-or-two-step surgical closure, endovascular occlusion, and liver transplantation. Conclusion An Abernethy malformation should be considered in the differential diagnosis of unexplained portal hypertension or any of its associated complications in pediatric patients. Early diagnosis and proper management of this condition can lead to a favorable prognosis, as in this case. Accordingly, a pre-operative evaluation is important to determine the proper therapeutic method.
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Affiliation(s)
- Chollasak Thirapattaraphan
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Tung Phayathai, Ratchathewi, Bangkok 10400, Thailand
| | - Suporn Treepongkaruna
- Division of Gastroenterology, Department of Paediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Tung Phayathai, Ratchathewi, Bangkok 10400, Thailand
| | - Nichanan Ruangwattanapaisarn
- Department of Diagnostic and Therapeutic Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Tung Phayathai, Ratchathewi, Bangkok 10400, Thailand
| | - Suthida Sae-Guay
- Division of Pediatric Surgery, Department of Surgery, Phramongkutklao Hospital, 315 Rajavithi Road, Tung Phayathai, Ratchathewi, Bangkok, 10400, Thailand.
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Ponce-Dorrego MD, Garzón-Moll G. Endovascular Closure Resolves Trimethylaminuria Caused by Congenital Portosystemic Shunts. Pediatr Gastroenterol Hepatol Nutr 2019; 22:588-593. [PMID: 31777726 PMCID: PMC6856509 DOI: 10.5223/pghn.2019.22.6.588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/11/2019] [Indexed: 11/14/2022] Open
Abstract
This study aimed to report three new cases of an association between two rare conditions, congenital portosystemic shunts (CPSS) and trimethylaminuria (TMAU), and the efficacy of endovascular closure of the CPSS for resolving TMAU. Between November 2014 and April 2017, 15 patients with CPSS were enrolled in this prospective study to assess the efficacy of percutaneous endovascular shunt closure. Three patients presented with clinical symptoms of TMAU that were confirmed by urine analysis of trimethylamine (TMA) and TMA n-oxide. One year after endovascular closure of the congenital portosystemic shunt, the same parameters were evaluated were obtained and the values were compared to the pretreatment values. The results indicated the disappearance of clinical symptoms of TMAU and normalization of the urine test parameters in two patients and no changes in one patient, who developed new portosystemic communications.
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Affiliation(s)
| | - Gonzalo Garzón-Moll
- Interventional Radiologist, Hospital General Universitario La Paz, Madrid, Spain
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Lemoine C, Nilsen A, Brandt K, Mohammad S, Melin-Aldana H, Superina R. Liver histopathology in patients with hepatic masses and the Abernethy malformation. J Pediatr Surg 2019; 54:266-271. [PMID: 30528201 DOI: 10.1016/j.jpedsurg.2018.10.083] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 10/30/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND/PURPOSE The Abernethy malformation (AM) is a congenital venous malformation in which the splanchnic venous return bypasses the liver and drains directly into the systemic circulation. This deprives the liver of hepatotrophic growth factors and allows metabolic products of digestion to enter the systemic veins without the benefit of passing through the liver. The histologic features of liver biopsies in children with an AM were reviewed. METHODS A retrospective review of liver biopsies in patients with AM between 1997 and 2017 was performed. Patients were divided into two groups for comparison of histologic features: presence (M+) or absence (M-) of a coexistent liver mass on imaging. Biopsies were reviewed by a pediatric pathologist. Chi-square test was used for statistical analysis between groups. Significance was assigned to p values <0.05. RESULTS Eighteen liver biopsies were reviewed. Masses were present in only 6 patients who had a liver biopsy. Masses were observed with similar frequencies in either type of the Abernethy malformation (I or II). Nine of 12 M- patients and 3/6 M+ patients had the type I AM. Histologically, all patients were noted to have small or absent portal veins. Isolated capillaries were seen more frequently in patients with a known liver mass (p = 0.045), while crowding of portal tracts was more commonly seen in patients without a liver mass (p = 0.019). CONCLUSION Liver biopsies in patients with AM demonstrate abnormal vascular and parenchymal histologic features. Livers with coexistent masses were more commonly found to have features suggesting an increased dependence on arterial blood supply. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Caroline Lemoine
- Division of Transplant Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | - Annika Nilsen
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | - Katherine Brandt
- Division of Transplant Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | - Saeed Mohammad
- Division of Gastroenterology, Hepatology & Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | - Hector Melin-Aldana
- Department of Pathology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA
| | - Riccardo Superina
- Division of Transplant Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA.
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Mori T, Yamada Y, Abe K, Takahashi N, Kano M, Fujimura T, Watanabe T, Nakatsuka S, Hoshino K, Kuroda T. Laparoscopic Partial Closure for Congenital Portosystemic Shunt-Indications, Postoperative Management, and Subsequent Complete Closure. J Laparoendosc Adv Surg Tech A 2019; 29:573-578. [PMID: 30614751 DOI: 10.1089/lap.2018.0581] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Extrahepatic congenital portosystemic shunts (CPSSs) can be occluded by surgical or endovascular approaches. However, when the estimated portal vein (PV) pressure after the closure is high enough to induce symptoms associated with portal hypertension, partial closure is recommended to avoid life-threatening events. In this study, we attempted laparoscopic partial closure of a CPSS in two patients. Along with intraoperative real-time measuring of the PV pressure and angiography, laparoscopic partial closure was performed to achieve a PV pressure of ≤25 mmHg. Subsequently, the intrahepatic portal system grew in both patients. The partially ligated CPSS closed spontaneously in the first patient. In the second patient, laparoscopic complete closure was performed for the residual CPSS 6 months after the first operation. To our knowledge, this is the first report of laparoscopic partial closure for CPSS. Minimally invasive laparoscopic partial ligation of CPSS is technically feasible and useful when the estimated PV pressure is too high to tolerate one-step complete closure.
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Affiliation(s)
- Teizaburo Mori
- 1 Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Yamada
- 1 Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kiyotomo Abe
- 1 Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Nobuhiro Takahashi
- 1 Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Motohiro Kano
- 1 Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Takumi Fujimura
- 1 Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Toshihiko Watanabe
- 2 Department of Pediatric Surgery, Tokai University School of Medicine, Kanagawa, Japan
| | - Seishi Nakatsuka
- 3 Department of Radiology, Keio University School of Medicine, Tokyo, Japan
| | - Ken Hoshino
- 1 Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuo Kuroda
- 1 Department of Pediatric Surgery, Keio University School of Medicine, Tokyo, Japan
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Azad S, Arya A, Sitaraman R, Garg A. Abernethy malformation: Our experience from a tertiary cardiac care center and review of literature. Ann Pediatr Cardiol 2019; 12:240-247. [PMID: 31516281 PMCID: PMC6716315 DOI: 10.4103/apc.apc_185_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Abernethy malformation, also called as congenital extrahepatic portosystemic venous shunt, is a rare anomaly involving the portal venous system. Although rare, it is increasingly being reported and is important to diagnose given the adverse clinical consequences in untreated patients. It has myriad of clinical presentations, from being completely asymptomatic to causing hepatic carcinoma, hepatic encephalopathy, severe pulmonary hypertension, and diffuse pulmonary arteriovenous malformation. We describe our experience with five cases in a tertiary pediatric cardiac care center with Abernethy malformation, with review of literature and also discuss possible therapeutic implications.
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Affiliation(s)
- Sushil Azad
- Department of Pediatric Cardiology and Congenital Heart Disease, Fortis Escorts Heart Institute, New Delhi, India
| | - Adhi Arya
- Department of Pediatric Cardiology and Congenital Heart Disease, Fortis Escorts Heart Institute, New Delhi, India
| | - Radhakrishnan Sitaraman
- Department of Pediatric Cardiology and Congenital Heart Disease, Fortis Escorts Heart Institute, New Delhi, India
| | - Amit Garg
- Department of Radiodiagnosis, Fortis Escorts Heart Institute, New Delhi, India
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De Vito C, Tyraskis A, Davenport M, Thompson R, Heaton N, Quaglia A. Histopathology of livers in patients with congenital portosystemic shunts (Abernethy malformation): a case series of 22 patients. Virchows Arch 2019; 474:47-57. [PMID: 30357455 PMCID: PMC6323085 DOI: 10.1007/s00428-018-2464-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/24/2018] [Accepted: 09/27/2018] [Indexed: 12/12/2022]
Abstract
Congenital portosystemic shunt (CPSS) is a congenital anomaly resulting in partial or complete diversion of the portal blood into the systemic circulation. The literature on the histological changes in livers of patients with CPSS is limited. Liver histology of 22 consecutive patients managed in our institution between 2001 and 2016 was reviewed. Twenty-one patients were children at the time of diagnosis. Thirty-two specimens were available and consisted of three explant livers and 29 biopsy samples from 19 patients. Sixteen samples were from wedge biopsies taken at the time of shunt closure. Thirteen were from core needle biopsies taken during clinical work-up. A variable proportion of portal tracts contained prominent thin-walled channels (PTWCs) and arterio-biliary dyads. The proportion of portal tracts containing triads, arterio-biliary dyads and biliary monads varied considerably in the different samples. Dilated inlet venules, increase in the number of portal arteries or the presence of portal arteries of increased size, deposition of copper-associated protein, sinusoidal dilatation, capillarization and intralobular individual arteries were present. Physiological nuclear vacuolation of periportal hepatocytes was absent in most samples from our paediatric patients. Presence of PTWCs, arterial-biliary dyads, increased arterial profiles in portal tracts and lobule and lack of the physiological periportal vacuolated hepatocytes in children are the most characteristic histological changes of CPSS in the liver periphery.
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Affiliation(s)
- Claudio De Vito
- King's College Hospital, Institute of Liver Studies, London, UK
- Division of Clinical Pathology, Geneva University Hospital, Geneva, Switzerland
| | | | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, London, UK
| | - Richard Thompson
- King's College Hospital, Institute of Liver Studies, London, UK
- Paediatric Liver, GI & Nutrition Centre, King's College Hospital London, London, UK
| | - Nigel Heaton
- King's College Hospital, Institute of Liver Studies, London, UK
| | - Alberto Quaglia
- King's College Hospital, Institute of Liver Studies, London, UK.
- Department of Cellular Pathology Royal Free Hospital, University College, London, UK.
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Prepared for the Unexpected: Accessory Ovaries with Abernethy Malformation. J Minim Invasive Gynecol 2018; 26:977-980. [PMID: 30553034 DOI: 10.1016/j.jmig.2018.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/25/2018] [Accepted: 12/08/2018] [Indexed: 11/22/2022]
Abstract
Supernumerary and accessory ovaries are collectively coined ectopic ovaries. These are rarely encountered by the benign gynecologist and are often discovered incidentally during evaluation for other gynecologic, gastrointestinal, or urologic pathologies. We report the presentation of a patient with multiple accessory ovaries in addition to a rare congenital anomaly of the splanchnic vasculature called an Abernethy malformation. Incidental identification of ectopic ovaries necessitates a search for additional malformations outside of the genitourinary tract that can have larger implications for long-term health.
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Laparoscopic ligation of a congenital extrahepatic portosystemic shunt for children with hyperammonemia: a single-institution experience. Surg Today 2018; 49:323-327. [PMID: 30392166 DOI: 10.1007/s00595-018-1731-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 10/06/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE A congenital extrahepatic portosystemic shunt (CEPS) associated with hyperammonemia requires occlusion of the shunt vessels. We evaluated the effectiveness and safety of laparoscopic ligation of a CEPS in children with hyperammonemia. METHODS The subjects of this retrospective study were seven children with hyperammonemia who underwent laparoscopic ligation of a CEPS. Their median age was 5.2 years (range 1-16 years). Before the laparoscopic procedure, a catheter was inserted through the femoral vein and placed in the portal vein via the shunt vessel. The shunt vessel was dissected and taped laparoscopically. After measuring the portal vein pressure under temporal occlusion, the shunt vessels were ligated. RESULTS The types of shunts according to location were patent ductus venosus (n = 2), splenorenal shunt (n = 2), gastrorenal shunt (n = 2), and superior mesenteric vein-inferior vena cava shunt (n = 1). Laparoscopic ligation of the shunt vessel was completed uneventfully in all patients. The median portal vein pressure was 19 mmHg after ligation. The median preoperative blood ammonia level was 94 µg/dL (range 71-259 µg/dL), which decreased after ligation in all patients. There was no incidence of postoperative liver failure. CONCLUSION Laparoscopic ligation of a CEPS is safe and effective for children with hyperammonemia.
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Ponziani FR, Faccia M, Zocco MA, Giannelli V, Pellicelli A, Ettorre GM, De Matthaeis N, Pizzolante F, De Gaetano AM, Riccardi L, Pompili M, Rapaccini GL. Congenital extrahepatic portosystemic shunt: description of four cases and review of the literature. J Ultrasound 2018; 22:349-358. [PMID: 30357760 DOI: 10.1007/s40477-018-0329-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 09/24/2018] [Indexed: 12/12/2022] Open
Abstract
Congenital extrahepatic portosystemic shunt (CEPS), also known as Abernethy malformation, is a rare condition in which the splenomesenteric blood drains directly into a systemic vein, bypassing the liver through a complete or partial shunt. The diagnosis is frequently made during childhood in the setting of neonatal cholestasis, hypergalactosemia, failure to thrive, mental retardation or other congenital defects. In adulthood, CEPS is usually found incidentally during diagnostic work-up for abdominal pain, liver test abnormalities, liver nodules, portopulmonary hypertension, portopulmonary syndrome or portosystemic encephalopathy. The diagnosis depends on imaging and portal venography, but sometimes only liver biopsy can be resolutive, demonstrating the absence of venules within the portal areas. Here we report four recent cases of Abernethy malformation diagnosed in young adults, in which ultrasound (US) was the initial imaging technique and allowed to suspect the diagnosis. Furthermore, we reviewed clinical presentations, associated anomalies and treatment of the 310 cases of CEPS previously reported in the literature.
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Affiliation(s)
- Francesca Romana Ponziani
- Internal Medicine, Gastroenterology and Hepatology, Fondazione IRCCS Agostino Gemelli Hospital, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Mariella Faccia
- Internal Medicine, Gastroenterology and Hepatology, Fondazione IRCCS Agostino Gemelli Hospital, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Maria Assunta Zocco
- Internal Medicine, Gastroenterology and Hepatology, Fondazione IRCCS Agostino Gemelli Hospital, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | | | | | - Giuseppe Maria Ettorre
- Division of General Surgery and Liver Transplantation, San Camillo Hospital, Rome, Italy
| | - Nicoletta De Matthaeis
- Internal Medicine, Gastroenterology and Hepatology, Fondazione IRCCS Agostino Gemelli Hospital, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Fabrizio Pizzolante
- Internal Medicine, Gastroenterology and Hepatology, Fondazione IRCCS Agostino Gemelli Hospital, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | | | - Laura Riccardi
- Internal Medicine, Gastroenterology and Hepatology, Fondazione IRCCS Agostino Gemelli Hospital, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Maurizio Pompili
- Internal Medicine, Gastroenterology and Hepatology, Fondazione IRCCS Agostino Gemelli Hospital, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Gian Ludovico Rapaccini
- Internal Medicine, Gastroenterology and Hepatology, Fondazione IRCCS Agostino Gemelli Hospital, Largo Agostino Gemelli 8, 00168, Rome, Italy
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47
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Romano R, Grasso F, Gallo V, Cirillo E, Prencipe R, Mamone G, Mollica C, Ursini VM, De Ville De Goyet J, Pignata C, Giardino G. A case of incontinentia pigmenti associated with congenital absence of portal vein system and nodular regenerative hyperplasia. Br J Dermatol 2018; 180:674-675. [PMID: 30328117 DOI: 10.1111/bjd.17319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- R Romano
- Department of Translational Medical Sciences, Federico II University, via S. Pansini 5-80131, Napoli, Italy
| | - F Grasso
- Department of Translational Medical Sciences, Federico II University, via S. Pansini 5-80131, Napoli, Italy
| | - V Gallo
- Department of Translational Medical Sciences, Federico II University, via S. Pansini 5-80131, Napoli, Italy
| | - E Cirillo
- Department of Translational Medical Sciences, Federico II University, via S. Pansini 5-80131, Napoli, Italy
| | - R Prencipe
- Department of Translational Medical Sciences, Federico II University, via S. Pansini 5-80131, Napoli, Italy
| | - G Mamone
- Department of Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - C Mollica
- Biostructure and Bioimaging Institute, International Council of Research, Napoli, Italy
| | - V M Ursini
- International Institute of Genetics and Biophysics Adriano Buzzati Traverso, International Council of Research, Napoli, Italy
| | - J De Ville De Goyet
- Department for Treatment and Study of Paediatric Abdominal Diseases and Abdominal Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - C Pignata
- Department of Translational Medical Sciences, Federico II University, via S. Pansini 5-80131, Napoli, Italy
| | - G Giardino
- Department of Translational Medical Sciences, Federico II University, via S. Pansini 5-80131, Napoli, Italy
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48
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Sanada Y, Mizuta K. Congenital absence of the portal vein: translated version. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:359-369. [PMID: 30160060 DOI: 10.1002/jhbp.572] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Congenital portosystemic shunt (CPS) is classified into type I (congenital absence of the portal vein) and type II, depending on the presence or absence of the intrahepatic portal vein. Reports still exist on cases in which psychiatric diseases or mental retardation was diagnosed or cases in which diagnosis and treatment are not performed until severe pulmonary complications occur, indicating the need to recognize CPS. Herein, we reviewed epidemiology, etiology, classification, symptom, diagnosis, and treatment based on clinical view points of CPS. For clinical view points, classification according to (1) the presence or absence of the intrahepatic portal venous system (IPVS) and (2) the extrahepatic or intrahepatic of shunt sites, facilitates the understanding of pathophysiological conditions and is useful in selecting a treatment for symptomatic CPS. Radiological and pathological examinations are important in IPVS evaluations, and IPVS evaluations are currently essential to make diagnoses by portography with balloon occlusion and liver biopsy. Symptomatic CPS (hepatic nodular lesions, portosystemic encephalopathy, and pulmonary complications, etc.) is an indication of treatment by shunt closure, but an indication of treatment for asymptomatic CPS is the challenge going forward.
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Affiliation(s)
- Yukihiro Sanada
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi 329-0498, Japan
| | - Koichi Mizuta
- Department of Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke City, Tochigi 329-0498, Japan
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49
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Franchi-Abella S, Gonzales E, Ackermann O, Branchereau S, Pariente D, Guérin F. Congenital portosystemic shunts: diagnosis and treatment. Abdom Radiol (NY) 2018; 43:2023-2036. [PMID: 29730740 DOI: 10.1007/s00261-018-1619-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Congenital portosystemic shunts (CPSS) are rare vascular malformations that create an abnormal connection between portal and systemic veins resulting in complete or partial diversion of the portal flow away from the liver to the systemic venous system. Different anatomic types exist and several classifications have been proposed. They can be associated with other malformations especially cardiac and heterotaxia. The main complications include hepatic encephalopathy, liver tumors, portopulmonary hypertension, and pulmonary arteriovenous shunts. Diagnosis relies on imaging, and prenatal diagnosis is possible. Spontaneous closure of the CPSS is possible in some anatomic forms during the first year of life. When the CPSS remains patent, radiologic or surgical closure of the CPSS may prevent, resolve, or stabilize complications. Interventional radiology plays a key role for both the preoperative evaluation with occlusion test to assess the exact anatomy and to measure portal pressure after occlusion of the CPSS. Endovascular closure is the first option for treatment when possible.
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Affiliation(s)
- Stéphanie Franchi-Abella
- Pediatric Radiology Department, Hôpital Bicêtre, Hôpitaux Universitaire Paris-Sud, Assistance Publique Hôpitaux de Paris, 78 rue du Général Leclerc, 94278, Le Kremlin-Bicêtre, France.
- Pediatric Liver Transplantation Unit, National Reference Centre for Rare Pediatric Liver Diseases and Filfoie, Paris, France.
- Hepatinov, University Paris -Sud, Orsay, France.
- IR4 M-UMR 8081- University Paris -Sud, Orsay, France.
| | - Emmanuel Gonzales
- Pediatric Hepatology, Hôpital Bicêtre, Hôpitaux Universitaire Paris-Sud, Assistance Publique Hôpitaux de Paris, National Centre for Biliary Atresia, Le Kremlin-Bicêtre, France
- Pediatric Liver Transplantation Unit, National Reference Centre for Rare Pediatric Liver Diseases and Filfoie, Paris, France
- Hepatinov, University Paris -Sud, Orsay, France
- INSERM UMR-S1174, Orsay, France
| | - Oanez Ackermann
- Pediatric Hepatology, Hôpital Bicêtre, Hôpitaux Universitaire Paris-Sud, Assistance Publique Hôpitaux de Paris, National Centre for Biliary Atresia, Le Kremlin-Bicêtre, France
- Pediatric Liver Transplantation Unit, National Reference Centre for Rare Pediatric Liver Diseases and Filfoie, Paris, France
- Hepatinov, University Paris -Sud, Orsay, France
| | - Sophie Branchereau
- Pediatric Surgery Department, Hôpital Bicêtre, Hôpitaux Universitaire Paris-Sud, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- Pediatric Liver Transplantation Unit, National Reference Centre for Rare Pediatric Liver Diseases and Filfoie, Paris, France
- Hepatinov, University Paris -Sud, Orsay, France
| | - Danièle Pariente
- Pediatric Radiology Department, Hôpital Bicêtre, Hôpitaux Universitaire Paris-Sud, Assistance Publique Hôpitaux de Paris, 78 rue du Général Leclerc, 94278, Le Kremlin-Bicêtre, France
- Pediatric Liver Transplantation Unit, National Reference Centre for Rare Pediatric Liver Diseases and Filfoie, Paris, France
- Hepatinov, University Paris -Sud, Orsay, France
| | - Florent Guérin
- Pediatric Surgery Department, Hôpital Bicêtre, Hôpitaux Universitaire Paris-Sud, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- Pediatric Liver Transplantation Unit, National Reference Centre for Rare Pediatric Liver Diseases and Filfoie, Paris, France
- Hepatinov, University Paris -Sud, Orsay, France
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50
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Sharma S, Bobhate PR, Sable S, Kumar S, Yadav K, Maheshwari S, Amin S, Chauhan A, Varma V, Kapoor S, Kumaran V. Abernethy malformation: Single-center experience from India with review of literature. Indian J Gastroenterol 2018; 37:359-364. [PMID: 30187299 DOI: 10.1007/s12664-018-0884-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 08/05/2018] [Indexed: 02/04/2023]
Abstract
Abernethy malformation is a rare congenital anomaly in which there is direct communication between the portal and systemic venous circulation. The clinical presentation ranges from asymptomatic with incidental detection on imaging to secondary complications of disease or related to associate anomalies. This is a retrospective analysis of data from nine patients with Abernethy malformation at a single center. This is a referral center for Pediatric Cardiology and for Hepatobiliary and Pancreatic Surgery. The patients presented to the Pulmonary Hypertension Clinic/the Hepatobiliary Surgery Clinic. Out of nine patients, four were male. Type II Abernethy malformation was present in five patients whereas three patients had type I malformation. One of the patients had communication between inferior mesenteric vein and internal iliac vein. Five out of nine patients were erroneously diagnosed as idiopathic primary pulmonary hypertension and were treated with vasodilators. One patient required living donor liver transplant. One patient was managed with surgical shunt closure whereas two patients required transcatheter shunt closure. The rest of the patients were managed conservatively. Abernethy malformation is more common than previously thought and the diagnosis is often missed. There are various management options for Abernethy malformation, which includes surgical or transcatheter shunt closure and liver transplant. Management of Abernethy malformation depends upon type, presentation, and size of shunt.
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Affiliation(s)
- Swapnil Sharma
- Department of Liver Transplant and HPB Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India.
| | - Prashant R Bobhate
- Department of Pediatric Cardiology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Shailesh Sable
- Department of Liver Transplant and HPB Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Suneed Kumar
- Department of Liver Transplant and HPB Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Kapildev Yadav
- Department of Liver Transplant and HPB Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Sharad Maheshwari
- Department of Radiology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Saista Amin
- Department of Pediatric Hepatology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Ashutosh Chauhan
- Department of Liver Transplant and HPB Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Vibha Varma
- Department of Liver Transplant and HPB Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Sorabh Kapoor
- Department of Liver Transplant and HPB Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
| | - Vinay Kumaran
- Department of Liver Transplant and HPB Surgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Achutrao Patwardhan Marg, Andheri (West), Mumbai, 400 053, India
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