RESUMEN
RESUMEN Los aneurismas de la arteria hepática son una patología poco frecuente. Cuando son sintomáticos, se debe sospechar un sufrimiento aneurismático y su tratamiento está indicado. Presentamos el caso clínico de un paciente con mal terreno cardiovascular, que consultó por un cuadro clínico de dolor epigástrico, repercusión hemodinámica e ictericia. La imagenología evidenció la presencia de un aneurisma de la arteria hepática común complicado con compromiso del origen de la arteria hepática propia y la arteria gastroduodenal. La presencia de una vascularización arterial hepática "no convencional" con una arteria hepática derecha proveniente de la arteria mesentérica superior, en la angiotomografía, permitió cambiar la táctica quirúrgica haciéndose prescindible la realización de un bypass. Este caso resalta la importancia de determinar en el preoperatorio no solo la extensión del aneurisma, sino también la anatomía vascular hepática a fin de planificar mejor la cirugía, disminuyendo así la morbimortalidad de esta enfermedad.
ABSTRACT Hepatic artery aneurysms are rare. Expanding aneurysms should be suspected in case of symptoms and treatment is indicated. We report the case of a patient with a history of cardiovascular disease who sought medical care due to epigastric pain, hemodynamic instability and jaundice. The imaging tests showed the presence of an aneurysm of the common hepatic artery complicated with involvement of the origin of the proper hepatic artery and the gastroduodenal artery. The surgical approach could be changed due to presence of a "non-conventional" hepatic arterial variant with a right hepatic artery originating from the superior mesenteric artery in the computed tomography angiography as bypass surgery was not necessary. This case highlights the importance of determining the extent of the aneurysm in the preoperative period and the anatomy of the hepatic vessels to better plan the surgery, thus reducing morbidity and mortality of this disease.
Asunto(s)
Humanos , Masculino , Anciano , Aneurisma Roto/cirugía , Arteria Hepática/patología , Aneurisma Roto/diagnóstico por imagen , Hemoperitoneo/diagnóstico por imagen , Arteria Hepática/cirugía , LaparotomíaRESUMEN
INTRODUCTION: Routinely, pediatric donor (PD) grafts are allocated to pediatric liver transplantation (LT) recipients; however, occasionally they can be allocated for adult recipients (ARs). Some authors reported decreased patient/graft survival and higher vascular complications, such as hepatic artery thrombosis (HAT), in LT in ARs using PDs. METHODS: It is a retrospective study enrolling 1202 ARs undergoing LT using whole liver grafts during the period of January 2002 to April 2019. The patients were categorized according to donor age in 2 groups: PDs and adult donors (ADs). The variables were collected from the database including the graft to recipient weight ratio (GWRW) and the incidence of HAT and graft primary nonfunction (PNF). RESULTS: The AD group had 1152 patients, and the PD group had 50 patients. PNF occurred in 68 (5.66%) patients, and the distribution between the 2 groups were similar: 65 (5.64%) in the AD group, and 3 (6%) in the PD group (P = .915). HAT was diagnosed in 30 (2.6%) patients in the AD group and in 6 (12%) patients in the PD group. HAT was significantly higher in the PD group (P = .001). In the PD group, the GWRWs among patients diagnosed with HAT were similar (P = .152). CONCLUSION: HAT is higher in PDs, although it is a viable alternative with satisfactory results. Serial Doppler in the first week and early introduction of platelet antiaggregants and/or anticoagulants may be beneficial, albeit it is not clear if it could reduce the incidence of HAT.
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Arteria Hepática/patología , Trasplante de Hígado/efectos adversos , Trasplante de Hígado/métodos , Complicaciones Posoperatorias/etiología , Trombosis/etiología , Adulto , Niño , Preescolar , Femenino , Supervivencia de Injerto , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Donantes de Tejidos , Adulto JovenRESUMEN
INTRODUCTION: Pancreatic malignant tumors are resectable at diagnosis in only 15% to 20% of cases and invasion of vascular structures is commonly present. Therefore, extended resections are needed for adequate local control and negative margins. However, morbidity and mortality associated with these enlarged resections are limiting factors. The aim of this study was to correlate demographic and technical aspects that influenced early and late outcomes. MATERIALS AND METHODS: Between October 2007 and May 2019, 523 pancreatic surgeries were performed, of which 72 required vascular resections. Clinical and histopathological data, surgical techniques, and perioperative parameters were analyzed in a prospectively collected database. RESULTS: Of the 72 cases of vascular resection, 31 were male and 41 females with a mean age of 60.9 years (34-81). The most commonly affected vascular structure was the portal vein (in 40.3%). Free margins were obtained in 77.8% of cases. Postoperative mortality rate at 60 days was 13.9%. American Society of Anesthesiologists (ASA) and age were the most important predictors of major complications. CONCLUSION: Extended resections with vascular involvement in pancreatic surgeries are feasible and safe; furthermore, patient selection plays are key. ASA and age were the most important factors in the decision-making process for extended resections.
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Venas Mesentéricas/cirugía , Invasividad Neoplásica , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Vena Porta/cirugía , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Brasil/epidemiología , Carcinoma Ductal Pancreático/mortalidad , Carcinoma Ductal Pancreático/patología , Carcinoma Ductal Pancreático/cirugía , Colangiocarcinoma/mortalidad , Colangiocarcinoma/patología , Colangiocarcinoma/cirugía , Estudios de Cohortes , Femenino , Arteria Hepática/patología , Arteria Hepática/cirugía , Humanos , Masculino , Arterias Mesentéricas/patología , Arterias Mesentéricas/cirugía , Venas Mesentéricas/patología , Persona de Mediana Edad , Pancreatectomía , Neoplasias Pancreáticas/mortalidad , Vena Porta/patología , Complicaciones Posoperatorias/epidemiología , Estudios RetrospectivosRESUMEN
BACKGROUND: Hepatic epithelioid hemangioendothelioma (HEHE) is a rare vascular tumor with a high mortality rate. HEHE is now a formally recognized indication for exception point priority in the United States under the new National Liver Review Board. The role of liver transplantation (LT) and exception point waitlist priority in the United States for patients with HEHE remains understudied. METHODS: This was a retrospective cohort study using the United Network for Organ Sharing transplant database. From February 27, 2002 to January 31, 2018, 131 adults waitlisted for LT with HEHE were identified by free-text entry. RESULTS: Exception point applications were submitted for 91.6% (120/131) of patients. All patients with fully reviewed applications received exception points at least once during waitlisting, and 85% (103/120) upon first submission. Among the 88 patients transplanted, median model for end-stage liver disease score at LT was 7 ((interquartile range [IQR]: 6-11) and waiting time 78.5 days (IQR: 29.5-237.5). Unadjusted post-LT survival of HEHE recipients at 1-, 3-, and 5-years from LT was 88.6%, 78.9%, and 77.2%. Unadjusted post-LT patient and graft survival of HEHE patients was not different from patients with hepatocellular carcinoma within Milan receiving exception point priority (P = 0.08). An increased rate of graft failure due to hepatic artery thrombosis ≤14 days from initial LT was observed in HEHE versus non-HEHE patients (4.6% versus 0.5%). CONCLUSIONS: The majority of HEHE recipients receive exception points at a universal approval rate allowing prompt access to deceased donor LT.
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Carcinoma Hepatocelular/cirugía , Enfermedad Hepática en Estado Terminal/cirugía , Hemangioendotelioma Epitelioide/cirugía , Neoplasias Hepáticas/cirugía , Trasplante de Hígado/estadística & datos numéricos , Adulto , Carcinoma Hepatocelular/diagnóstico , Carcinoma Hepatocelular/mortalidad , Carcinoma Hepatocelular/patología , Bases de Datos Factuales/estadística & datos numéricos , Enfermedad Hepática en Estado Terminal/diagnóstico , Enfermedad Hepática en Estado Terminal/mortalidad , Enfermedad Hepática en Estado Terminal/patología , Femenino , Rechazo de Injerto/epidemiología , Rechazo de Injerto/etiología , Supervivencia de Injerto , Hemangioendotelioma Epitelioide/diagnóstico , Hemangioendotelioma Epitelioide/mortalidad , Hemangioendotelioma Epitelioide/patología , Arteria Hepática/patología , Humanos , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/mortalidad , Neoplasias Hepáticas/patología , Trasplante de Hígado/efectos adversos , Masculino , Persona de Mediana Edad , Selección de Paciente , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Trombosis/epidemiología , Trombosis/etiología , Trombosis/patología , Resultado del Tratamiento , Estados Unidos , Listas de Espera/mortalidadRESUMEN
RESUMEN El pseudoaneurisma de arteria uterina es una causa de hemorragia puerperal poco frecuente y de gran gravedad cuya principal manifestación es el sangrado puerperal tardío. Esta complicación suele ocurrir de manera tardía tras una cirugía pélvica, aunque también está descrito tras el parto. La prueba de elección para el diagnóstico de esta complicación es la angiografía que permite además su tratamiento en el mismo acto, asociando una menor morbilidad y preservando la fertilidad de la paciente. Presentamos el caso de un pseudoaneurisma de arteria uterina tras cesárea cuya manifestación fue un hemoperitoneo masivo a los 17 días de la cesárea y que se resolvió mediante angiografía con embolización supraselectiva del mismo.
ABSTRACT Uterine artery pseudoaneurysm is a serious complication but an uncommon cause of postpartum haemorrhage which can mainly manifest as a severe bleeding in the late puerperium. This complication usually occurs after pelvic surgery, although it is also described after vaginal delivery. Angiography is the best diagnosis method which joins not only the diagnosis but also the treatment at the same moment, reducing the morbidity and preserving fertility. We report a case of a uterine artery pseudoaneurysm after cesarean delivery whose clinical manifestation was a massive haemoperitoneum after 17 days of the cesarean. It was treated by angiographic selective embolization of uterine artery pseudoaneurysm.
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Humanos , Femenino , Embarazo , Adulto , Aneurisma Falso/terapia , Aneurisma Falso/diagnóstico por imagen , Arteria Hepática/patología , Complicaciones del Embarazo , Angiografía , CesáreaRESUMEN
Resumen Introducción: La enfermedad multianeurismática es una entidad patológica poco conocida, la cual presenta diversas etiologías, por lo que su localización, morfología y formas de presentación varían de un caso a otro. Caso clínico: Mujer de 51 años dislipémica. Acude por epigastralgia. Se realiza TC abdominal con resultados de hematoma retroperitoneal y aneurisma en arteria pancreática duodenal. Se practica cirugía urgente para evacuación del hematoma sin encontrarse más hallazgos. Durante el ingreso presenta crisis hipertensivas y se realiza nuevo AngioTC donde se visualizan múltiples lesiones en distintas arterias viscerales con posibilidad diagnóstica de vasculitis. Se decide no intervención en el momento actual y estudio de filiación. Discusión: La enfermedad multianeurismática es una entidad poco común, cuya etiología se determina de acuerdo con su correlación clínica e histopatológica con diversas posibles causas; sin embargo, establecer un diagnóstico en donde el cuadro clínico coincida al 100%, es un desafío. Es muy frecuente la afectación de las arterias viscerales a diferencia de los aneurismas de origen ateroesclerótico. El tratamiento quirúrgico es seguro y deberá iniciarse en los segmentos que estén causando la sintomatología. El tratamiento endovascular es menos invasivo siendo la técnica de elección en pacientes con elevada comorbilidad y en los casos de cirugía complicada con rotura.
Introduction: Multiple artery aneurysms are a rare pathological condition which may be caused by different etiologies. Therefore, its location, morphology and clinical presentation may vary in a case to case basis. Case report: A 51-year-old woman, prior history of dyslipedemia presents with upper abdominal pain. Abdominal tomographic scans showed aneurysm of the pancreaticduodenal artery and retroperitoneal hematoma. Emergent surgical evacuation of the hematoma was performed, with no other findings. In the postoperative period, the patient suffers hypertensive crisis and a new tomographic scan is conducted observing multiple dilations in different visceral arteries. The patient is treated conservatively and is being studied for a possible vasculitis. Discussion: Multi-aneurysmatic artery disease is a very rare entity, its etiology is determined by clinical and histopathological correlation. Although establishing a diagnosis in which the clinical presentation completely corresponds, is a real challenge. Unlike degenerative aneurysms due to atherosclerosis, multi-aneurysmatic disease commonly involves visceral arteries. Open surgery is considered safe treatment option and should be established in the segments causing symptoms. Endovascular treatment is less invasive, being the technique of choice in patients with high comorbidity and in cases of complicated surgery with rupture.
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Humanos , Femenino , Persona de Mediana Edad , Arteria Esplénica/diagnóstico por imagen , Arteria Hepática/diagnóstico por imagen , Aneurisma/diagnóstico por imagen , Arterias Mesentéricas/diagnóstico por imagen , Arteria Esplénica/patología , Angiografía por Tomografía Computarizada , Arteria Hepática/patología , Arterias Mesentéricas/patologíaRESUMEN
Biliary atresia (BA) is classically described at the neonatal age. However, rare cases of BA in older infants have also been reported. We report four cases of late-onset BA in infants older than 4 weeks (3 males, 1 female), and describe the diagnostic and management difficulties. One of the cases had a late-onset (29 weeks) presentation with a successful surgical procedure. We highlight the importance of this unusual differential diagnosis in infants with cholestatic syndrome, who may benefit from Kasai surgery, regardless of age.
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Humanos , Masculino , Femenino , Lactante , Atresia Biliar/diagnóstico , Enfermedades de Inicio Tardío/diagnóstico , Hígado/patología , Atresia Biliar/patología , Atresia Biliar/cirugía , Biopsia , Diagnóstico Diferencial , Arteria Hepática/patología , Enfermedades de Inicio Tardío/patología , Enfermedades de Inicio Tardío/cirugíaRESUMEN
Biliary atresia (BA) is classically described at the neonatal age. However, rare cases of BA in older infants have also been reported. We report four cases of late-onset BA in infants older than 4 weeks (3 males, 1 female), and describe the diagnostic and management difficulties. One of the cases had a late-onset (29 weeks) presentation with a successful surgical procedure. We highlight the importance of this unusual differential diagnosis in infants with cholestatic syndrome, who may benefit from Kasai surgery, regardless of age.
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Atresia Biliar/diagnóstico , Enfermedades de Inicio Tardío/diagnóstico , Hígado/patología , Atresia Biliar/patología , Atresia Biliar/cirugía , Biopsia , Diagnóstico Diferencial , Femenino , Arteria Hepática/patología , Humanos , Lactante , Enfermedades de Inicio Tardío/patología , Enfermedades de Inicio Tardío/cirugía , MasculinoRESUMEN
BACKGROUND: Biliary atresia (BA) is an infantile disorder characterized by progressive sclerosing cholangiopathy leading to biliary obstruction. First-line treatment of BA is hepatoportoenterostomy, the prognosis of which is related to age at surgery and to histological variables such as extent of fibrosis and ductular reaction. Hepatic arterial medial thickening (MT) suggests an arteriopathy in BA pathogenesis. We evaluated the expression of angiopoietin (ANGPT)/tyrosine kinase with immunoglobulin-like and epidermal growth factor-like domains 2 (TIE2) system in liver samples obtained from patients with BA, correlating it with MT, variables associated with disease severity, and postoperative prognosis. METHODS: ANGPT1, ANGPT2, and TIE2 expression levels were assessed by quantitative PCR in liver samples obtained from BA patients (n = 23) at portoenterostomy and age-matched infants with intrahepatic cholestasis (IHC; n = 7). Histological variables were morphometrically assessed. RESULTS: ANGPT1 and ANGPT2 were overexpressed in BA in comparison with IHC (P = 0.024 and P = 0.029, respectively). In BA, ANGPTs expression was positively correlated with MT (ANGPT1: rs = 0.59, P = 0.013; ANGPT2: rs = 0.52, P = 0.032), not with the variables associated with disease severity. TIE2 and ANGPTs expression levels were negatively correlated (ANGPT1: rs = -0.73, P < 0.001; ANGPT2: rs = -0.54, P = 0.007). CONCLUSION: In BA, there is overexpression of both ANGPT1 and ANGPT2, which is correlated with MT but not with age at portoenterostomy or with the histological variables associated with disease severity at the time of procedure.
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Angiopoyetina 1/fisiología , Angiopoyetina 2/fisiología , Atresia Biliar/patología , Arteria Hepática/patología , Angiopoyetina 1/genética , Angiopoyetina 2/genética , Atresia Biliar/fisiopatología , Atresia Biliar/cirugía , Expresión Génica , Humanos , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
BACKGROUND: Postoperative poor graft function is a serious complication that can lead to graft loss requiring retransplantation or even death. The postoperative complications of primary nonfunction (PNF), early graft dysfunction (EGD), bleeding due to coagulopathy, and hepatic artery thrombosis (HAT) can lead to graft loss requiring retransplantation or even death. We determined the causes of death after liver transplantation. METHODS: This was an observational descriptive study on adult liver transplant recipients from September 1991 to December 2011. The cutoff for the definition of death was 30 days after surgery. We included patients older than 18 years of age who underwent liver grafts using the piggyback technique, excluding those who had retransplantations or liver-kidney transplantations. RESULTS: We analyzed 561 liver transplantations through chart review. After application of exclusion criteria we had 81 patients for analysis. Overall mortality was classified into 3 main causes: PNF (34/81; 42%), EGD (10/81; 12%), and abdominal bleeding due to coagulopathy (9/81; 11%). CONCLUSION: Despite advances, mortality in the first 30 days after surgery is still high, mainly related to the occurrence of PNF and EGD, whose causality was associated with red blood cell transfusion (>5 U).
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Causas de Muerte , Rechazo de Injerto/mortalidad , Hemorragia/mortalidad , Arteria Hepática/patología , Trasplante de Hígado , Trombosis/mortalidad , HumanosRESUMEN
BACKGROUND: Surgical resection remains the principal treatment for advanced gastric cancer. However, one of the difficulties in radical D2 lymphadenectomy is the identification of the vascular abnormalities around the stomach, especially abnormal hepatic artery. The hepatic artery arising from the superior mesenteric artery shows great variations, and whether or not the lymphatic tissues around the abnormal artery should be dissected is still controversial. METHOD: Eighty-six gastric cancer patients who underwent radical D2 lymphadenectomy by the same surgeon in our department in the past 2 years were included in this study. All patients underwent multislice spiral computed tomography angiography for preoperative evaluation of the abnormal hepatic artery arising from the superior mesenteric artery. Postoperative immunohistochemistry of the lymphoid tissues around the abnormal hepatic artery was performed using CK20 and CEA antibodies to determine the occurrence of lymph node micrometastasis around the abnormal artery. RESULTS: In our study, we found 14 cases with an abnormal hepatic artery arising from the superior mesenteric artery. The hepatic artery ran in front of the pancreas in 1 case and behind the pancreas in 13 cases. Immunohistochemical analyses revealed no micrometastasis in the lymphoid tissues surrounding the abnormal artery. CONCLUSIONS: Abnormal hepatic arteries arising from the superior mesenteric artery can be classified into pre-pancreas and post-pancreas types. Lymph nodes around the abnormal artery may not need to be dissected in radical D2 lymphadenectomy.
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Adenocarcinoma/cirugía , Arteria Hepática/anomalías , Escisión del Ganglio Linfático , Recurrencia Local de Neoplasia/cirugía , Complicaciones Posoperatorias , Neoplasias Gástricas/cirugía , Adenocarcinoma/patología , Adulto , Anciano , Anciano de 80 o más Años , Angiografía , Femenino , Estudios de Seguimiento , Gastrectomía , Arteria Hepática/patología , Humanos , Metástasis Linfática , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/patología , Estadificación de Neoplasias , Pronóstico , Neoplasias Gástricas/patologíaRESUMEN
Hepatic artery aneurysm (HAA) was first reported at autopsy in 1809, represents one fifth of visceral aneurysms and the mortality from spontaneous rupture is high in most of cases. We are reporting a case of an asymptomatic 48-year-old woman with an extrahepatic HAA, diagnosed initially and incidentally with abdominal ultrasonography, confirmed by a three-dimensional contrast-enhanced magnetic resonance imaging and angiography. Endovascular treatment was considered feasible and was successfully treated with coil embolization.
Aneurisma da artéria hepática (AAH) foi relatado pela primeira vez através de autópsia em 1809, representa um quinto dos aneurismas viscerais, e a mortalidade por ruptura espontânea é alta na maioria dos casos. Relatamos o caso de uma mulher de 48 anos de idade com um AAH extra-hepático assintomático, diagnosticado inicialmente, e incidentalmente, com ultrassonografia abdominal e confirmado através de angiorressonância tridimensional e angiografia contrastada. O tratamento endovascular foi considerado viável, sendo tratada com sucesso através de embolização com molas.
Asunto(s)
Humanos , Femenino , Adulto , Aneurisma/diagnóstico , Arteria Hepática/patología , Enfermedades Vasculares/terapia , Embolización Terapéutica , Angiografía , AbdomenRESUMEN
The purpose of this study was to correlate morphologic and hemodynamic Doppler ultrasound findings as indicators of the degree of inflammation and fibrosis and to diagnose chronic vital hepatitis complications and progression. A prospective, descriptive study of a case series was conducted that analyzed Doppler ultrasound images of the liver and portal system and used the portal vein congestion index, hepatic and splenic artery impedance indices, and the liver vascular index. Of 50 patients positive for antibodies against hepatitis C virus, morphologic changes highlighted increased hepatic parenchyma echogenicity in 24%, and increased gall blander echogenicity and wall thickness in 4%. The most common hemodynamic changes observed were reduced flow velocity in the portal vein trunk in 26%, congestion index changes in 12%, liver vascular index changes in 16%, and splenic and hepatic artery impedance index changes in 14%. These indices were shown to be associated with alanine aminotransferase levels, which suggested that they are important liver damage indicators in the early phase of infection with hepatitis C virus.
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Hepacivirus/aislamiento & purificación , Hepatitis C Crónica/diagnóstico por imagen , Hepatitis C Crónica/fisiopatología , Cirrosis Hepática/diagnóstico , Ultrasonografía Doppler en Color , Adulto , Alanina Transaminasa/metabolismo , Brasil , Femenino , Vesícula Biliar/diagnóstico por imagen , Vesícula Biliar/patología , Hemodinámica , Arteria Hepática/diagnóstico por imagen , Arteria Hepática/patología , Humanos , Hígado/irrigación sanguínea , Hígado/diagnóstico por imagen , Hígado/patología , Masculino , Persona de Mediana Edad , Vena Porta/diagnóstico por imagen , Vena Porta/patología , Estudios Prospectivos , Factores de Riesgo , Bazo/diagnóstico por imagen , Bazo/patología , Arteria Esplénica/diagnóstico por imagen , Arteria Esplénica/patologíaRESUMEN
PURPOSE: To report on our clinical experience with and the success rate and safety of percutaneous transcatheter embolization with N-butyl cyanoacrylate (NBCA) as the lone primary embolic agent used for arterial embolization of hemorrhagic liver lesions. MATERIALS AND METHODS: This retrospective study enrolled all patients who presented to the emergency room with hemorrhagic liver lesions during a two-year period and were treated by percutaneous transcatheter embolization with NBCA. RESULTS: Eight consecutive patients were evaluated, and 13 lesions were embolized exclusively with NBCA: eight pseudoaneurysms and five active bleeds. All patients were treated successfully using percutaneous transcatheter embolization with NBCA without re-bleedings or major complications. CONCLUSION: Percutaneous transcatheter embolization with NBCA is a safe and effective method for treating hemorrhagic lesions.
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Aneurisma Falso/terapia , Embolización Terapéutica/métodos , Enbucrilato/farmacología , Hemorragia Gastrointestinal/terapia , Arteria Hepática/patología , Adolescente , Adulto , Aneurisma Falso/diagnóstico , Cateterismo Periférico/métodos , Niño , Preescolar , Estudios de Cohortes , Servicio de Urgencia en Hospital , Tratamiento de Urgencia/métodos , Femenino , Estudios de Seguimiento , Hemorragia Gastrointestinal/diagnóstico , Arteria Hepática/diagnóstico por imagen , Humanos , Angiografía por Resonancia Magnética/métodos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Medición de Riesgo , Administración de la Seguridad , Tomografía Computarizada por Rayos X/métodos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: En-bloc liver resection with the extrahepatic bile duct is mandatory to obtain tumour-free surgical margins and better long-term outcomes in hilar cholangiocarcinoma (CC). One of the most important criteria for irresectability is local extensive invasion to major vessels. As hilar CC Bismuth type IIIB often requires a major left hepatic resection, the invasion of the right hepatic artery (RHA) usually contraindicates this procedure. METHODS: The authors describe a novel technique that allowed an oncological resection in two patients with hilar CC Bismuth type IIIB and contralateral arterial invasion. Arterial reconstruction between the posterior branch of the RHA and the left hepatic artery (LHA) was performed as the first surgical step. Once arterial vascular flow was restored, a left trisectionectomy with caudate lobe resection and portal vein reconstruction was performed. RESULTS: In both patients an R0 resection was achieved. Both patients made a full recovery and were discharged within 14 days of surgery. Both patients remain free of disease at 18 months. CONCLUSIONS: This new technique allows a R0 resection to be achieved in patients with Bismuth type IIIB hilar CC with contralateral arterial involvement.
Asunto(s)
Neoplasias de los Conductos Biliares/cirugía , Conductos Biliares Intrahepáticos , Colangiocarcinoma/cirugía , Arteria Hepática/cirugía , Procedimientos de Cirugía Plástica/métodos , Neoplasias Vasculares/cirugía , Procedimientos Quirúrgicos Vasculares/métodos , Anciano , Neoplasias de los Conductos Biliares/patología , Colangiocarcinoma/patología , Femenino , Estudios de Seguimiento , Arteria Hepática/patología , Humanos , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias Vasculares/patologíaRESUMEN
In biliary atresia (BA), a cholangiopathy of elusive etiology invariably leads to cirrhosis, and a disturbed angiogenesis may be involved. We evaluated the hepatobiliary immunolocalization of vascular endothelial growth factor (VEGF) A, VEGF receptor 1 (R1), and R2 in BA. We analyzed biopsies obtained at portoenterostomy from infants with BA (n=52), including embryonic (n=14) and perinatal (n=38) types. Controls were infants with intrahepatic cholestasis (IC; n=7). In BA, VEGF A immunolocalization was also evaluated in explants (n=33) and at the porta hepatis (n=16). We morphometrically assessed the percentage of CK7 (PCK7) positivity in BA and the ratio medial layer thickness/luminal diameter in hepatic artery branches in BA and IC. We found that arteries were more frequently positive for VEGF A in BA at portoenterostomy (P=0.006) than in other groups. In explants, VEGF A immunolocalization was mainly lobular (P<0.001). VEGFR2 was less frequently positive in BA than IC in bile ducts (P=0.023) and hepatocytes (P=0.011). A higher PCK7 positivity was associated with arterial (P<0.001) and biliary (P=0.040) VEGF A positivity. PCK7 was correlated with biliary (P=0.031), arterial (P=0.031), and hepatocytic (P=0.032) VEGF A positivity in BA at portoenterostomy. VEGF A was positive in arteries and bile ducts at the porta hepatis mainly in the perinatal BA type (P=0.013). Biliary (P=0.016) and arterial (P=0.044) VEGF A positivity were associated with higher ratio medial layer thickness/luminal diameter values. Our findings suggest that hypoxia/ischemia affects the portal structures in BA at portoenterostomy, beginning at the porta hepatis, and it is associated both with the extent of biliary proliferation and medial layer thickening.
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Atresia Biliar/diagnóstico , Arteria Hepática/metabolismo , Hígado/metabolismo , Túnica Media/patología , Factor A de Crecimiento Endotelial Vascular/metabolismo , Atresia Biliar/metabolismo , Atresia Biliar/patología , Atresia Biliar/fisiopatología , Biopsia , Colestasis Intrahepática/diagnóstico , Colestasis Intrahepática/metabolismo , Colestasis Intrahepática/patología , Colestasis Intrahepática/fisiopatología , Femenino , Arteria Hepática/patología , Humanos , Inmunohistoquímica , Recién Nacido , Queratina-7/metabolismo , Hígado/patología , Masculino , Microscopía , Portoenterostomía Hepática , Receptor 1 de Factores de Crecimiento Endotelial Vascular/metabolismo , Receptor 2 de Factores de Crecimiento Endotelial Vascular/metabolismoRESUMEN
Arterial steal syndrome after orthotopic liver transplantation (OLT) is characterized by arterial hypoperfusion of the graft, which is caused by a shift in blood flow into the splenic or gastroduodenal arteries. It causes hepatic hypoperfusion with attendant clinical manifestations of elevated liver function enzymes, allograft dysfunction, and cholestasis. Left untreated, the condition has a significant potential risk for postoperative morbidity and graft loss. Herein we have reported the case of a 68-year-old woman who developed splenic artery steal syndrome (SASS) after deceased donor liver transplantation. She was diagnosed by duplex Doppler ultrasonography and celiac trunk angiography, and subsequently treated with splenic artery embolization.
Asunto(s)
Embolización Terapéutica/métodos , Cirrosis Hepática Biliar/cirugía , Trasplante de Hígado/efectos adversos , Complicaciones Posoperatorias/patología , Arteria Esplénica/patología , Arteria Esplénica/cirugía , Adulto , Anciano , Bilirrubina/sangre , Femenino , Arteria Hepática/patología , Humanos , Fallo Hepático Agudo/cirugía , Masculino , Resultado del TratamientoRESUMEN
Involvement of the celiac trunk and common hepatic artery are two of the most common forms of vascular invasion by tumours of the distal pancreas, and until recently this finding was considered a contra-indication to resection. We described a modified Appleby operation for locally advanced distal pancreatic cancer with compromised hepatic collateral flow that needed hepatic arterial revascularization, successfully accomplished by left external iliac-hepatic arterial bypass with Dacron prosthesis. Patient recovery was uneventful and he was discharged on the 10th postoperative day. Postoperative angio-CT disclosed a patent arterial bypass. Patient is well and asymptomatic 13 months after operation. At the time of this writing, postoperative CT scan showed no evidence of disease and CA 19-9 level is normal. There is a well established rationale to perform extended resection of pancreatic carcinomas that compromise vascular structures. Modified Appleby procedure can safely be performed, has oncological advantages to palliative procedures and provides relief of pain but is reserved for selected patients. Preservation of hepatic arterial flow has utmost importance to avoid hepatobiliary complications as liver necrosis, liver abscess, gallbladder necrosis or cholecystitis. In this case, hepatic revascularization was particularly challenging, but was successfully accomplished by left external iliac--hepatic arterial bypass. To our knowledge this type of arterial bypass has never been described so far in the English literature and its description may be important for surgeons dealing with advanced pancreatic cancer.
Asunto(s)
Implantación de Prótesis Vascular , Arteria Hepática/cirugía , Arteria Ilíaca/cirugía , Circulación Hepática , Pancreatectomía/métodos , Neoplasias Pancreáticas/cirugía , Anciano , Anastomosis Quirúrgica , Arteria Hepática/patología , Humanos , Arteria Ilíaca/patología , Masculino , Invasividad Neoplásica , Neoplasias Pancreáticas/patologíaRESUMEN
This report describes a variation in blood vessels of the liver and abnormal entry of hepatic arteries into the liver found during routine dissection in an approximately 43-year-old male cadaver. An accessory hepatic artery arose from the superior mesenteric artery and entered the liver at the porta hepatis, whereas the proper hepatic artery was seen entering the left liver lobe at the fissure for ligamentum venosum. Clinical implications of such variation are discussed in the article.
Este relato descreve uma variação nos vasos hepáticos e uma entrada anormal de artérias hepáticas no fígado, encontradas durante uma dissecção de rotina em um cadáver masculino de aproximadamente 43 anos. Uma artéria hepática acessória surgiu da artéria mesentérica superior e entrou no fígado no porta hepatis, ao passo que se constatou que a artéria hepática própria entrava no lobo hepático na fissura do ligamento venoso. Implicações clínicas desta variação são discutidas neste artigo.