Evaluation of the type of fetal umblical-portal anastomosis in late-onset fetal growth restriction: A case-control study.

PURPOSE: To evaluate the type of umbilical-portal anastomosis in late-onset fetal growth restriction (LO-FGR) and appropriate for gestational age (AGA) fetuses. To investigate the impact of the type of umbilical-portal anastomosis on the adverse outcomes in LO-FGR. METHOD: This study observed 150 pregnancies with AGA fetuses and 62 pregnancies with fetuses with LO-FGR. In each case, the point of reference for measuring the abdominal circumference was established. The type of umbilical-portal anastomosis was evaluated as T-shaped, X-shaped, and H-shaped according to the shape of main portal vein and portal sinus. Incidences of the type of umbilical-portal anastomosis in AGA and LO-FGR fetuses were evaluated. RESULTS: T-shaped anastomosis was the most common (56.7%) in the AGA group and X-shaped (66.1%) in the LO-FGR group. In LO-FGR, T-shape anastomosis was significantly lower and X-shape anastomosis was significantly higher than AGA (p < 0.001). X-shaped anastomosis was associated with LO-FGR and the RR was 2.3 (95% CI 1.5-3.6; p < 0.001). Incidences of admission to NICU and emergency C/S for fetal distress were higher in fetuses with X -shaped anastomosis in the LO-FGR (p < 0.05). CONCLUSION: X-shaped umbilical-portal anastomosis have a prognostic significance in LO-FGR fetuses.

Bleeding oesophageal varices in a 9 -year old girl as a late complication of neonatal umbilical catheterization.

Bleeding oesophageal varices is a rare condition in children and most of them are usually of extrahepatic causes. Neonatal umbilical catheterization even though safe has been identified as a cause of portal vein thrombosis and oesophaeal varices. We report a 9-year old Nigerian girl who had massive upper gastrointestinal bleeding from oesophageal varices secondary to pulmonary vein stenosis. She had umbilical catheterization for exchange blood transfusion as a neonate. She was sequentially managed with endoscopic sclerotherapy and band ligation We seek to highlight the need for a high index of suspicion of oesophageal varices in children with upper gastrointestinal bleeding who had neonatal umbilical catheterization.">.

Emergency Pacing via the Umbilical Vein and Subsequent Permanent Pacemaker Implantation in a Neonate.

A dying neonate with congenital complete atrioventricular block underwent an emergency temporary pacing via the umbilical vein 1 h after birth. Implantation of a permanent epicardial pacemaker system was performed at the age of 10 days. During the follow-up period of 3 months, the child had been growing well with the VVIR pacemaker.

Ventriculoportal Shunt, a New Transomphalic Extraperitoneal Surgical Technique in Treatment of Hydrocephalus.

AIM: The aim of this article was to report a new transomphalic extraperitoneal surgical technique for treatment of hydrocephalus, called ventriculoportal shunt. MATERIALS AND METHODS: We performed ventriculoportal shunt on an experimental animal (pig). The particularity of ventriculoportal shunt consists in the fact that the distal end of the catheter is inserted transomphalic extraperitoneally in the portal system through reopened umbilical vein. We present technical details regarding this new surgical technique. RESULTS AND DISCUSSION: The animal had favorable outcome, without any postoperative early or late morbidity. We discuss indications, contraindications, possible complications in humans and advantages of ventriculoportal shunt compared with ventriculocardiac and ventriculoperitoneal drainages and possibilities to avoid complications specific to classic shunt procedures. CONCLUSIONS: Ventriculoportal shunt is a new surgical technique for treatment of hydrocephalus. The distal end of the catheter introduced into reopened umbilical vein, drains cerebrospinal fluid into the portal system. Ventriculoportal shunt is safe and easy to perform. With ventriculoportal shunt specific complications of ventriculoperitoneal or ventriculocardiac drainages can be potentially avoided. Ventriculoportal shunt combines advantages of vascular shunt with those of having an immunological barrier for cerebrospinal fluid before entering the systemic circulation. Theoretically, indications for surgery are extended, and ventriculoportal shunt can be performed in patients former contraindicated for ventriculoperitoneal shunt. Further research is needed and this surgical technique must be performed on human subjects with hydrocephalus.

Recanalized umbilico-caval anastomosis as a temporary portosystemic shunt in pediatric living donor liver transplantation: the crossed fingers method.

A temporary portocaval shunt (TPCS) associated with retrohepatic vena cava preservation prevents the edema caused by splanchnic congestion during liver transplantation (LT), especially for non-cirrhotic cases. We herein report a modified TPCS technique using the recanalized umbilical vein and an end-to-side recanalized umbilico-caval anastomosis for use during pediatric living donor liver transplantation (LDLT). This work evaluated a group of pediatric patients who underwent LDLT between 2001 and 2014 with the conventional TPCS (n=16) vs the recanalized umbilico-caval shunt (the crossed fingers method, n=10). The crossed fingers method was performed by suturing an end-to-side anastomosis of the patent or recanalized umbilical vein to the vena cava using a continuous monofilament suture like "crossing the fingers," that is, placing the left portal vein across the portal vein trunk next to it. The preoperative, surgical, and postoperative characteristics were similar in both groups except for the significantly shorter portal vein clamping time for the crossed fingers method. This method can allow the portal circulation to be totally decompressed before and after implanting the graft and while maintaining the hemodynamic stability throughout all stages of pediatric LDLT.

Skin-to-skin contact with an umbilical venous catheter: prospective evaluation in a level 3 unit.

UNLABELLED: The aim was to assess the incidence of complications related to skin-to-skin contact (SSC) in newborns with an umbilical venous catheter (UVC). We carried out a prospective follow-up study of all UVCs in a level 3 unit where SSC is systematic. A total of 333 babies were included (mean gestational age of 31.3 weeks (24-41), mean birth weight of 1618 g (454-4900). Two hundred sixty-three babies (78.9 %) had SSC, at a mean postnatal age of 24 h (3-144 h). Two babies presented with a significant umbilical bleeding, all in the first 3 h, before SSC. In 17 cases of UVC leaking, this necessitated an unwanted withdrawal of the UVC; of these, 14 UVCs (82 %) were in sub-hepatic position. In five cases of UVC displacement, babies had no SSC. The overall incidence (3 % [95 % CI = 1.4-5.4]) and incidence density (6.2/1000 UVC-day [95 % CI = 3-11.4]) of catheter-associated infections are similar to those identified by the French multicenter network NEOCAT in 2012 (5 % [95 % CI = 4.1-5.9] and 11.3/1000 UVC-day [95 % CI = 9.3-13.2]). CONCLUSION: In this prospective, non-randomized study in a level unit, routine practice of SSC with a UVC does not seem to influence the incidence of mechanical and infectious complications. What is known? • SSC is beneficial for pretem infants. • Fear of mechanical problems and/or infections with a UVC is an obstacle to early use of SSC. What is New: • In this study, SSC for preterm infants with a UVC is associated with low risks of mechanical complications, and does not seem to be associated with any higher risk of catheter-related infections.

Surgical Management of Omphalophlebitis and Long Term Outcome in Calves: 39 Cases (2008-2013).

OBJECTIVE: To describe and evaluate the surgical management of omphalophlebitis and to report the short and long term outcomes in calves. STUDY DESIGN: Retrospective case series. ANIMALS: Calves (n = 39). METHODS: Medical records (2008-2013) of calves diagnosed with omphalophlebitis and that underwent surgical correction were reviewed. Short term (hospital discharge) and long term (≥6 months after surgery) survival rates were obtained. Descriptive statistics were used to describe the population and a Fisher's exact test was used to evaluate the relationship between clinical signs, surgical management, and outcome. RESULTS: Thirty-nine calves (median age 30 days) were included in the study. Eleven calves had septic arthritis associated with omphalophlebitis and 18 had evidence of liver abscesses on ultrasound. Complete surgical en bloc resection was achieved in 18 calves and umbilical vein marsupialization was performed on the other 21 calves. Thirty-five calves were discharged from the hospital and long term followup was obtained for 30 of them. Twenty-nine animals were performing according to the owner's expectation at least 6 months after surgery (14 for marsupialization and 15 for en bloc resection). A better prognosis was detected when en bloc resection was performed (100% survival); however, when marsupialization was performed, the prognosis was good (74%; P = .05). Septic arthritis had a significant negative effect on overall survival (P < .001). CONCLUSION: The overall survival is good with both surgical options, and even calves with liver involvement and septic arthritis associated can be successfully treated with a combination of long term antibiotics and umbilical vein marsupialization.

One-step venous reconstruction using the donor's round ligament in right-lobe living-donor liver transplantation.

We herein report the use of an opened round ligament as a venous patch graft for inferior right hepatic vein (IRHV) reconstruction and anastomosis to the inferior vena cava (IVC) in living-donor liver transplantation (LDLT) using a right-lobe (RL) graft. After laparotomy, the donor's round ligament was harvested and opened, and the semi-transparent umbilical vein, which was 7.0 cm in length and 3.0 cm in width, was carefully trimmed on the back table for use as a patch graft. The right hepatic vein of the graft was anastomosed to the harvested patch, and the IRHV was anastomosed to an independent hole made in the wall on the other side of the patch, to form a bridged vascular patch for anastomosis to the IVC. The interposition graft filled promptly and provided a good outflow from the posterior segment. This is the first report of venous reconstruction using a donor's round ligament graft in RL-LDLT.

MANAGEMENT OF OMPHALOPHLEBITIS AND UMBILICAL HERNIA IN THREE NEONATAL GIRAFFE (GIRAFFA CAMELOPARDALIS).

Umbilical disorders, including omphalophlebitis, omphaloarteritis, external umbilical abscesses, urachal abscesses, patent urachus, and umbilical hernias, represent a significant challenge to the health and well-being of a neonate. The three neonatal giraffe (Giraffa camelopardalis) in this report were evaluated for umbilical swellings. Two developed omphalophlebitis, and one had an uncomplicated umbilical hernia. Omphalophlebitis is an inflammation and/or infection of the umbilical vein. Giraffe calves with a failure of passive transfer may be predisposed and should be thoroughly evaluated for the condition. Umbilical hernias result from a failure of the umbilical ring to close after parturition or from malformation of the umbilical ring during embryogenesis. These problems were surgically corrected for all three individuals, although one died due to postsurgical complications. The risks involved include anesthetic complications, surgical dehiscence, and maternal rejection. Early detection and surgical intervention are recommended for the correction of omphalophlebitis and umbilical hernias in neonatal giraffe.

Persistent hepatic encephalopathy secondary to portosystemic shunt occluded with Amplatzer device.

Hepatic encephalopathy is a frequent complication of cirrhosis, when this event becomes persistent, treatment compliance should be verified and any precipitating factor need to be identified. Also the presence of portosystemic shunts, which are a rare cause of decompensation or persistence hepatic encephalopathy need to be ruled out. In this paper we report the case of a 57 year old man with persistent hepatic encephalopathy secondary to the presence of a porto-onfalo-femoral shunt successfully closed with the placement of an Amplatzer device.

The utility of recanalized umbilical vein graft to the hepato-pancreato-biliary surgeon.

BACKGROUND: The authors recently published their experience of recanalizing umbilical veins in deceased liver donors, with recanalized umbilical veins as vascular conduits for meso-Rex bypass procedures. They have since found recanalized umbilical veins to be an excellent, easy to harvest vascular conduit that can be used for multiple vascular procedures and repair. Here, they report their experience using this vessel for bypass and vascular reconstruction. METHODS: They have recanalized umbilical veins and used them in a total of 5 Meso-Rex bypasses; 5 pancreaticoduodenectomies; 1 left hepatic trisegmentectomy with right portal vein (PV) resection and reconstruction; 1 right hepatectomy and 1 adrenalectomy, both with partial inferior vena cava (IVC) resection and reconstruction; 1 coronary-Rex bypass shunt for extrahepatic PV thrombosis; and 1 orthotopic liver transplantation with infrahepatic IVC anastomotic dehiscence patched with umbilical vein graft. Umbilical veins were dilated mechanically and used in situ for the meso-Rex bypass surgery; they were ligated in the space of Rex and then dilated ex vivo otherwise to be used as interposition grafts or a vein patch. RESULTS: A total of 15 hepato-pancreato-biliary procedures were done using the recanalized umbilical vein as graft; 2 patients required thrombectomy postoperatively with reexploration, venotomy, thrombectomy with fogarty catheter, and venotomy closure. CONCLUSION: The umbilical vein graft is a fine vascular conduit and can serve many purposes in hepatobiliary surgery.

Damage control surgery in a <1 kg neonate: a brief report.

Damage control surgery is a feasible and successful approach for the management of unstable neonates with intra-abdominal catastrophes, including liver injuries. We report the case of a premature infant with a liver injury secondary to the placement of an umbilical vein catheter who was successfully managed using damage control surgery techniques.

Surgical retrieval of transected umbilical vein catheter in an extremely preterm neonate.

Umbilical catheters are used in the care of critically ill neonates for intravenous treatment. It is generally considered a safe procedure, although complications can occur. Of these, catheter breakage and intravenous migration are rare but potentially life-threatening events. Due to the low frequency of which these events occur, obtaining detailed descriptions of removal techniques can pose a challenge. Here, we describe a case of a broken umbilical vein catheter and the surgical retrieval of the retained fragment. We also present a thorough literature search of cases of broken umbilical catheters and the method by which they were removed.

Use of the recanalised umbilical vein for islet autotransplantation following total pancreatectomy.

INTRODUCTION: Islet autotransplantation requires access to the portal vein or tributaries. We originally infused islets into the liver via the middle or right colic veins, but since 2005 we have used the recanalised umbilical vein. Here, we describe the technique, the advantages and the early results achieved. MATERIALS AND METHODS: After removal of the pancreas and restoration of the biliary and enteric continuity, the ligamentum teres is transected. The obliterated umbilical vein is identified and recanalised with Bakes dilators giving access to the left portal vein. A Vygon® Nutricath 'S' 11-Fr catheter is inserted and used for the islet infusion. If the ligamentum teres is to be exteriorised for postoperative measurements or subsequent access, it is pulled through a 10-mm laparoscopic port in the epigastrium, sutured to the skin and covered with a dressing. RESULTS: We have used this approach in 17 patients and exteriorised the falciform ligament in 4. There have been no intra- or postoperative complications. CONCLUSIONS: The recanalised umbilical approach is safe and allows for venous sampling and postoperative measurements of the portal pressure. Under local anaesthetic, the umbilical vein can be approached above the umbilicus and exteriorised if repeated transplants are required for allograft patients. and IAP.

Tumor thrombectomy via a surgically reopened umbilical vein combined with right hemihepatectomy in a patient with hepatocellular carcinoma.

This report presents a case of a patient with a huge hepatocellular carcinoma in the right lobe of the liver with an extensive portal venous tumor thrombus extending into the main portal trunk and left portal branch. The patient underwent extended right hemihepatectomy with tumor thrombectomy with direct extraction from an opening of the ventral wall of the right portal vein and using a balloon catheter to push the tumor thrombus via the surgically reopened umbilical vein. This technique seems useful in cases of tumor thrombus that extend deep into the umbilical portion of the left portal vein. In addition, this technique may have minimized the intraoperative migration of the tumor thrombus into the future remnant liver by occluding portal flow with the balloon catheter during the thrombectomy.

Temporary transumbilical stenting of the ductus venosus in neonates with obstructed infradiaphragmatic total anomalous pulmonary venous return.

Newborns with obstructed infradiaphragmatic total anomalous pulmonary venous return (TAPVR) are often clinically unstable. Temporary relief of the pulmonary venous obstruction may improve their clinical status before surgical repair. Three neonates (two premature and one full-term) with obstructed infradiaphragmatic TAPVR at the ductus venosus (DV) underwent stenting of the DV by way of an umbilical venous approach. Their clinical condition stabilized, thus allowing subsequent elective surgical repair.

Recanalized umbilical vein as a conduit for mesenterico/porto-Rex bypass for patients with extrahepatic portal vein obstruction.

PURPOSE: Mesenterico-left portal vein (meso-Rex) bypass is as an effective modality for restoring intrahepatic portal perfusion in patients with extrahepatic portal vein obstruction. Achieving sufficient patency is difficult with end-to-side anastomosis of a bypass graft to a small or hypoplastic left portal vein in the Rex recessus. Here, we describe the use of a recanalized umbilical vein in the round ligament as a conduit for bypass construction in two patients. METHODS: Case 1 was an 11-year-old boy diagnosed with rupture of the esophageal varices and hypersplenism due to congenital extrahepatic portal hypertension. Because of persistent hypersplenism and thrombocytopenia, he underwent meso-Rex bypassing with a left iliac vein graft interposed between the umbilical vein and the superior mesenteric vein. Case 2 was a neonate with a large hepatic tumor (mesenchymal hamartoma) that developed abdominal compartment syndrome at birth. The tumor was removed by right hepatectomy with excision of the portal vein bifurcation at 3 days of age. Porto-Rex bypassing was accomplished by end-to-end anastomosis between the portal vein trunk and the umbilical vein. RESULTS: Sufficient hepatopetal portal flow through the umbilical vein was achieved in both patients and maintained for over 16 and 13 months, respectively. Although hypersplenism remained in Case 1, intrahepatic portal vein branches gradually widened and the cavernoma in the hepatic hilum disappeared within 2 months. Neither patient had symptoms or signs of portal hypertension at the most recent follow-up. CONCLUSION: Using the umbilical vein as a vein conduit may facilitate construction of a meso/porto-Rex bypass and restore intrahepatic portal vein perfusion in patients with extrahepatic portal vein obstruction.

Intra-abdominal resection of the umbilical vein and urachus of bovine fetuses using laparoscopy and celiotomy: surgical time and feasibility (cadaveric study).

Surgical intervention for umbilical diseases in calves, when indicated, is a complementary and indispensable therapeutic resource for the treatment of umbilical conditions and is commonly performed using celiotomy. However, laparoscopy has demonstrated feasibility in many diagnostic and therapeutic procedures. The aim of this study was to assess the feasibility of the techniques and the surgical time of laparoscopy and celiotomy used in intra-abdominal resection of the umbilical vein and urachus of bovine fetuses (cadavers). Resection of the umbilical vein and urachus using laparoscopy and celiotomy was performed in 26 anatomical specimens (bovine fetuses obtained from an official slaughterhouse). Resection of umbilical structures was feasible with both techniques, but shorter surgical time and minimal tissue damage were achieved using laparoscopy. Laparoscopy requires specialized training and appropriate instruments and is an important tool for diagnostic and therapeutic exploration of the umbilical structures, liver, bladder, and associated/adjacent structures.

Changes in umbilical venous volume flow after fetoscopic laser occlusion of placental vascular anastomoses in twin-to-twin transfusion syndrome.

OBJECTIVE: To examine effects of fetoscopic laser occlusion of placental vascular anastomoses on umbilical venous volume flow in twin-to-twin transfusion syndrome. STUDY DESIGN: Absolute umbilical venous volume flow, measured preoperatively and 48 hours after fetoscopic laser occlusion was related to Doppler studies, bladder filling in donors, and anastomoses. RESULTS: Among 45 patients, recipients had decreased ductus venosus pulsatility index (ductus venosus-pulsatility index for veins, 1.16 vs 1.01; P < .001) and unchanged umbilical venous volume flow after fetoscopic laser occlusion (74.7 vs 74.5 mL; P = .407). Donors had decreased umbilical artery pulsatility (1.34 vs 1.11; P = .008), increased ductus venous-pulsatility index for veins (0.75 vs 0.91; P < .014), and significantly increased umbilical venous volume flow per kilogram by 52.3% (136.6 vs 208.0 mL/Kg/min; P < .001). Donor bladder filling occurred at higher umbilical venous volume flow per kilogram (142.7 vs 221.4 mL/Kg/min; P < .012). Increase in umbilical venous volume flow per kilogram correlated with the net difference in arteriovenous anastomoses (Pearson r = 0.403, P = .006). CONCLUSION: Fetoscopic laser occlusion in twin-to-twin transfusion syndrome corrects intertwin differences in umbilical venous volume flow by predominant effects in the donor. Reappearance of donor bladder filling correlates with correction of volume flow.

Direct puncture of the recanalized paraumbilical vein for portal vein targeting during transjugular intrahepatic portosystemic shunt procedures: assessment of technical success and safety.

PURPOSE: To assess the success of direct percutaneous puncture of the recanalized paraumbilical vein (RPUV) for access and visualization of the portal vein (PV) to guide transhepatic puncture during transjugular intrahepatic portosystemic shunt (TIPS) creation. The predictive value of successful catheterization based on preprocedural vein diameter was analyzed. MATERIALS AND METHODS: A retrospective review of all TIPS procedures from 2002 to 2008 performed at a single institution was conducted, and a subset of procedures in which portal venography was attempted via the paraumbilical vein were identified. In this subset, TIPS outcomes and diameters of the RPUV near the skin puncture site and left PV junction were measured and analyzed with a two-tailed Student t test. RESULTS: During the study period, 114 TIPSs were created. RPUV punctures were found in 22 patients (19.3%) and portal venography was successful in 14 of the 22 patients (64%), all without complications. In the remainder (n = 8), access via the RPUV failed secondary to a small vein diameter (< 0.3 cm; n = 3), moderate to severe vessel tortuosity (n = 4), and distal thrombosis (n = 1). Puncture, catheterization, and portal venography was successful when the paraumbilical vein measured a mean of 0.75 cm at the skin and a mean of 0.84 cm at the junction with the left PV when analyzed against the failed attempts. CONCLUSIONS: Portal venography via the RPUV is a feasible and probably safe alternative to other methods of PV opacification during TIPS procedures.