Sonographic and Anatomical Evaluation of the Liver and Portal Vein Reference Values / Evaluación Ecográfica y Anatómica de los Valores de Referencia del Hígado y la Vena Porta

SUMMARY: This paper's aim is a morphometric evaluation of liver and portal vein morphometry using ultrasonography in healthy Turkish population. This study was carried out with 189 subjects (107 females, 82 males). The demographic data and the body surface area were calculated. The longitudinal axis of the liver for two lobes, diagonal axis or liver span, anteroposterior diameter of the liver and portal vein, portal vein transverse diameter, caudate lobe anteroposterior diameter, and portal vein internal diameters as well as longitudinal liver scans in an aortic plane, sagittal plane, transverse plane, and kidney axis were measured. All measurements were analyzed according to age, sex, body mass index, obesity and alcohol consumption. The mean values of the age, height, weight and body mass index were calculated as 44.39 years, 167.05 cm, 74.23 kg, and 27.06kg/m2 in females, respectively. The same values were 44.13 years, 167.70 cm, 75.93 kg and 26.71 kg/m2 in males, respectively. There was significant difference between demographic characteristics, gender, and alcohol consumption in terms of anteroposterior diameter of the liver, portal vein transverse diameter of the right side and liver transverse scan. Also, some measurements including portal vein transverse diameter, liver transverse scan and at kidney axis longitudinal scan of liver showed significant difference between the age groups. There was significant difference in diagonal axis and anteroposterior diameter of liver, portal vein internal diameter, and longitudinal liver scans of the aortic plane parameters between obesity situation. The findings obtained will provide important and useful reference values as it may determine some abnormalities related liver diseases. Also, age, sex, obesity and body mass index values can be effective in the liver and portal vein morphometry related parameters.

El objetivo de este artículo fue realizar una evaluación de la morfometría del hígado y la vena porta mediante ecografía en una población turca sana. Este estudio se llevó a cabo en 189 sujetos (107 mujeres, 82 hombres). Se calcularon los datos demográficos y la superficie corporal. Se midió eleje longitudinal del de dos lóbulos del hígado, el eje diagonal o la extensión del hígado, los diámetros anteroposterior del hígado y de la vena porta, el diámetro transversal de la vena porta, anteroposterior del lóbulo caudado y los diámetros internos de la vena porta, así como las exploraciones longitudinales del hígado en un plano aórtico. Se midieron el plano sagital, el plano transversal y el eje del riñón. Todas las mediciones se analizaron según edad, sexo, índice de masa corporal, obesidad y consumo de alcohol. Los valores medios de edad, talla, peso e índice de masa corporal se calcularon como 44,39 años, 167,05 cm, 74,23 kg y 27,06 kg/m2 en las mujeres, respectivamente. Las mismas variable fueron 44,13 años, 167,70 cm, 75,93 kg y 26,71 kg/m2. Hubo diferencias significativas entre las características demográficas, el sexo y el consumo de alcohol en términos de diámetro anteroposterior del hígado, diámetro transversal de la vena porta del lado derecho y exploración transversal del hígado. Además, algunas mediciones, incluido el diámetro transversal de la vena porta, la exploración transversal del hígado y la exploración longitudinal del hígado en el eje del riñón, mostraron diferencias significativas entre los grupos de edad. Hubo diferencias significativas en el eje diagonal y el diámetro anteroposterior del hígado, el diámetro interno de la vena porta y los parámetros de las exploraciones hepáticas longitudinales del plano aórtico entre situaciones de obesidad. Los hallazgos obtenidos proporcionarán valores de referencia importantes y útiles ya que pueden determinar algunas anomalías relacionadas con enfermedades hepáticas. Además, los valores de edad, sexo, obesidad e índice de masa corporal pueden ser eficaces en los parámetros relacionados con la morfometría del hígado y la vena porta.

Tributaries of the hepatic vein in the ostrich (Struthio camelus) / Afluentes da veia porta-hepática no avestruz (Struthio camelus)

The ostrich (Struthio camelus, Linnaeus 1758) is the largest bird in the world. It is of great economic importance in Africa and is found across several countries. With developments in breeding systems, morphological studies that facilitate the application of the knowledge are necessary, considering the species has unique anatomical features. The objective of the present study was to describe the major tributaries of the hepatic vein in the species. Ten viscera of adult individuals of both sexes, which were injected with Neoprene latex through the hepatic vein, were used to visualize their tributaries. After the vascular repletion, the tissues were fixed and conserved in 10% formaldehyde aqueous solution. The hepatic carrier system was dissected and photo-documented. The left hepatic vein receives blood from the proventricle and gastric ventricle, while the right hepatic vein is responsible for the drainage of blood into the following organs: spleen, through the proventriculosplenic vein; pancreas, through the pancreaticoduodenal vein; jejunum, through the jejunum trunk; and the colon, which forms the cranial mesenteric vein.(AU)

O avestruz (Struthio camelus, Linnaeus 1758) é a maior ave do mundo, com uma importância comercial acentuada na África e expandindo-se para diversos países. Assim, com o desenvolvimento dos sistemas de criação, tornam-se necessários estudos morfológicos que subsidiem as áreas aplicadas, pois a espécie apresenta características anatômicas próprias. O objetivo deste estudo foi a descrição dos principais afluentes da veia porta-hepática nesta espécie. Para a realização do presente trabalho, foram utilizadas dez vísceras de animais adultos, de ambos os sexos, que foram injetados com Neoprene látex por meio da veia porta-hepática para evidenciar os seus afluentes. Após a repleção vascular, os animais foram fixados e conservados em solução aquosa de formaldeído a 10%. O sistema porta-hepático foi dissecado e fotodocumentado. Observou-se que a veia porta-hepática esquerda recebe sangue da região do proventrículo e ventrículo gástrico. A veia porta-hepática direita é a responsável pela drenagem do sangue nos seguintes órgãos: baço, por meio da veia proventriculoesplênica, pâncreas, pela veia pancreaticoduonais, jejuno, por meio do tronco jejunal, e o cólon, que forma a veia mesentérica cranial.(AU)

Tributaries of the hepatic vein in the ostrich (Struthio camelus) / Afluentes da veia porta-hepática no avestruz (Struthio camelus)

The ostrich (Struthio camelus, Linnaeus 1758) is the largest bird in the world. It is of great economic importance in Africa and is found across several countries. With developments in breeding systems, morphological studies that facilitate the application of the knowledge are necessary, considering the species has unique anatomical features. The objective of the present study was to describe the major tributaries of the hepatic vein in the species. Ten viscera of adult individuals of both sexes, which were injected with Neoprene latex through the hepatic vein, were used to visualize their tributaries. After the vascular repletion, the tissues were fixed and conserved in 10% formaldehyde aqueous solution. The hepatic carrier system was dissected and photo-documented. The left hepatic vein receives blood from the proventricle and gastric ventricle, while the right hepatic vein is responsible for the drainage of blood into the following organs: spleen, through the proventriculosplenic vein; pancreas, through the pancreaticoduodenal vein; jejunum, through the jejunum trunk; and the colon, which forms the cranial mesenteric vein.

O avestruz (Struthio camelus, Linnaeus 1758) é a maior ave do mundo, com uma importância comercial acentuada na África e expandindo-se para diversos países. Assim, com o desenvolvimento dos sistemas de criação, tornam-se necessários estudos morfológicos que subsidiem as áreas aplicadas, pois a espécie apresenta características anatômicas próprias. O objetivo deste estudo foi a descrição dos principais afluentes da veia porta-hepática nesta espécie. Para a realização do presente trabalho, foram utilizadas dez vísceras de animais adultos, de ambos os sexos, que foram injetados com Neoprene látex por meio da veia porta-hepática para evidenciar os seus afluentes. Após a repleção vascular, os animais foram fixados e conservados em solução aquosa de formaldeído a 10%. O sistema porta-hepático foi dissecado e fotodocumentado. Observou-se que a veia porta-hepática esquerda recebe sangue da região do proventrículo e ventrículo gástrico. A veia porta-hepática direita é a responsável pela drenagem do sangue nos seguintes órgãos: baço, por meio da veia proventriculoesplênica, pâncreas, pela veia pancreaticoduonais, jejuno, por meio do tronco jejunal, e o cólon, que forma a veia mesentérica cranial.

The human liver: vascular anatomy to determine its segments and divisions / El hígado humano: anatomía vascular para determinar sus segmentos y divisiones

This study aims at understanding the vascularization of the human liver to determine the correct way to divide it into "divisions" (sectors) and segments, for which we dissected 250 livers using the acrylic resin injection method. The results showed the role of the "Porta hepatis" in the hepatic vascular distribution, the existence of seven vascular pedicles for seven portal segments, and the role of portal fissures in the parenchymal division of the liver. Our research provides the definition of a portal segment and demonstrates the role of the hepatic portal vein in originating any liver parenchymal division.

Quisimos estudiar la vascularización del hígado humano para determinar la forma correcta de dividirlo en "divisiones" y segmentos, para lo cual disecamos 250 hígados usando técnicas de inyección acrílica. Los resultados mostraron la función de la Porta hepatis en la distribución vascular del hígado, la existencia de siete pedículos vasculares para siete segmentos portales, y el rol de las fisuras portales en la división parenquimal del hígado. Ofrecemos la definición de lo que es un segmento portal y demostramos el rol de la vena porta hepática en originar cualquier división parenquimal del hígado.

The types of connections between the portal sinus and main portal vein in foetuses / Tipos de conexiones entre el seno portal y la vena porta principal en fetos

In the prenatal period, the three types of connections between the portal sinus and main portal vein have been published in the literature: T, X and H-shaped. The T type is the most frequent in the literature, and the aim of our study is to define the percentage of the connection types during the prenatal period in our population. In this prospective study, 237 women between 20 and 38 weeks of pregnancy without a foetal anomaly or pregnancy-related complications were included, and the precordial veins of the foetuses were examined using a wide-band color Doppler technique. The types of connections were determined by two specialists according to the shape of the colour coded vessels in Doppler examinations. The criteria of Czubalski & Aleksandrowicz (2000) were used. All of the connection types in patients were confirmed using video clips and were stored in the picture archiving and communication system. In 237 patients, the types of connection were determined by the first specialist as 189 foetuses (79.7 %) with the X-shaped or side-to-side connection, 16 foetuses (6.8 %) with the T-shaped or end-to-side type and 32 foetuses (13.5 %) with the H-shaped or parallel-coursed vessels connected with a short segment. The most common types of connections between the portal sinus and main portal vein in foetuses are X shaped or side-to-side, which is contrary to previous studies.

En el período prenatal, se han publicado en la literatura los tres tipos de conexiones entre el seno portal y la vena porta principal: en forma de T, X y H. El tipo T es el más frecuente, y el objetivo de nuestro estudio fue definir el porcentaje de tipos de conexión durante el período prenatal en nuestra población. En este estudio prospectivo, se incluyeron 237 mujeres entre 20 y 38 semanas de embarazo, sin anomalías fetales o complicaciones relacionadas con el embarazo, y se examinaron las venas precordiales de los fetos utilizando una técnica Doppler de banda ancha. Los tipos de conexiones fueron determinados por dos especialistas según la forma de los vasos codificados por color en los exámenes Doppler. Se utilizaron los criterios del estudio de Czubalski & Aleksandrowicz. Todos los tipos de conexión en los pacientes se confirmaron mediante videoclips y se almacenaron en el sistema de comunicación y en archivo de imágenes. En 237 pacientes, el primer especialista determinó en 189 fetos (79,7 %) la conexión en forma de X o de lado a lado; en 16 fetos (6,8 %) la forma de T o Tipo de extremo a lado; y en 32 fetos (13,5 %) los vasos en forma de H o paralelos, conectados con un segmento corto. Los tipos más comunes de conexiones entre el seno portal y la vena porta principal en los fetos son en forma de X o de lado a lado, lo que es contrario a estudios anteriores.

Seven segmental pedicles at the porta hepatis / Siete pedículos segmentarios en la porta hepatis

SUMMARY: We wanted to know how many segmental portal branches were born from the primary branches of the hepatic portal vein in the porta hepatis, in order to determine the number of portal segments in human liver. We studied 286 human livers, age groups ranging from fetuses to octogenarians, both sexes and all races, using dissection, colored acrylic injection and reconstituted tomographic images. We found the porta hepatis channel formed by each and every portal segment; we found seven segmental terminal pedicles for seven portal segments, three planes of vertical and three planes of horizontal portal fissures. There are seven terminal portal pedicles that are formed in the porta hepatis from the right and left branches of the hepatic portal vein. The only variation was portal branch V emerging from the right branch in 79 % of cases or from the left branch in 21 %. The definition of hepatic portal segment is: Portion of parenchyma irrigated by terminal branches of the portal vein and the hepatic artery proper, isolated from the other segments by planes of portal fissures and forms the parenchymal channel of the porta hepatis where it receives its vascularization. We propose a new and simple portal segmentation based on the previous definition.

RESUMEN: El objetivo de este trabajo consistió en conocer el número de ramas portales segmentarias que nacen de las ramas primarias de la vena porta hepática en la Porta hepatis, con la finalidad de determinar el número de segmentos portales en el hígado humano. Estudiamos 286 hígados, los grupos etarios fueron desde fetos hasta octogenarios, ambos sexos y todas las razas, usamos la disección en fresco, inyección de acrílico coloreado e imágenes tomográficas reconstituidas. El canal de la Porta hepatis estuvo formado por todos y cada uno de los segmentos portales, encontramos siete pedículos terminales segmentarios para siete segmentos portales, el pedículo portal para el segmento V nació de la porta derecha en 79 % de casos y de la porta izquierda en 21 %, encontramos tres planos de fisuras portales verticales y tres horizontales. Existen siete pedículos segmentarios portales terminales que se forman en la Porta hepatis a partir de las ramas derecha e izquierda de la vena porta hepática. La única variación fue que la rama portal para el segmento V nació de la rama derecha en 79 % de casos y de la rama izquierda en 21 %. Concluimos que la definición de segmento portal hepático es: Porción de parénquima irrigado por ramas terminales de la vena porta y la arteria hepática propia, aislada de los otros segmentos por planos de fisuras y que llega a conformar el canal parenquimal de la Porta hepatis donde recibe su vascularización. Proponemos una nueva y sencilla segmentación portal basada en la definición previa.

Measurements between the hepatic veins and portal venous system, in human cirrhotic liver: a cast study.

PURPOSE: To measure the distance between the right and middle hepatic veins and portal vein branches, in human cirrhotic liver casts. Was this measure actually smaller in the cirrhotic liver than in normal one? MATERIALS AND METHODS: This study was authorized by an area Research Ethics Committee, and each study subject or legal representative granted signed informed consent. Acrylic corrosion casts of 21 resected cirrhotic livers were generated. Diameters of hepatic veins and portal branches and pertinent intervening distances were measured. To assess differences in estimated average (relative to reference values), Student's t test for one sample was applied. RESULTS: Mean distances from right hepatic vein to the right portal branch and to portal vein bifurcation were 33 ± 6.4 and 36 ± 7.4 mm, respectively, both significantly less than published reference values in healthy human livers (p < 0.0001 and p < 0.0002, respectively). Mean distances from middle hepatic vein to right and left branches of portal vein were 36 ± 6.8 and 26 ± 8.8 mm, respectively. CONCLUSION: Distances separating right hepatic vein and portal vein (right branch and bifurcation) are diminished in cirrhotic livers compared to healthy ones. Given its caliber and proximity to portal branches, the middle hepatic vein remains as a reasonable alternative for TIPS procedures.

Segmentación portal hepática mediante imágenes tomográficas tridimensionales reconstituidas / Hepatic portal segmentation using reconstructed three-dimensional tomography images

La descripción de las imágenes tridimensionales reconstituidas de tomografías hepáticas (Three-dimensional computed tomographic volume rendering images) tiene alto porcentaje de variaciones anatómicas inexplicables, de tal manera que no orientan en forma definitiva al radiólogo y al cirujano. Este estudio permite ver y describir las ramas segmentarias de la vena porta hepática (A12.3.12.001)*, su relación con las venas hepáticas (A12.3.09.005) y su distribución parenquimal. El estudio es descriptivo y usamos expresiones porcentuales para citar la frecuencia de las características anatómicas, para esto tomamos al azar 56 reconstrucciones tridimensionales de tomografías hepáticas de pacientes adultos. Las ramas segmentarias portales+ y las venas hepáticas fueron identificadas siempre; hallamos siete ramas segmentarias portales en todos los casos, además, que la rama portal segmentaria V (cinco)+ nació de la porta derecha (A12.3.12.002) en 75 % de casos y de la izquierda (A12.3.12.005) en 21,4 %.

The anatomical description of reconstructed three-dimensional images of hepatic CT scans (Three-dimensional computed tomographic volume rendering images) has a high percentage of unexplained anatomical variations, so that they do not definitively orient the radiologist and the surgeon. This study allows to observe and to describe the segmental branches of the Hepatic portal vein (A12.3.12.001), its relation with the hepatic veins (A12.3.09.005) and its parenchymal distribution. The study is descriptive and we used percentage expressions to describe the frequency of anatomical characteristics. For this we randomly took 56 three-dimensional reconstructions of liver CTs from adult patients. Portal segmental branches+ and hepatic veins were always identified; we found seven portal segmental branches in all cases. In addition, the segmental portal branch V (five)+ originated from the right portal (A12.3.12.002) in 75 % of cases and from the left (A12.3.12.005) in 21.4 %.

Hígado: el segmento portal V / Liver: the portal segment V

Algunos autores han propuesto la existencia de un número variable de segmentos portales hepáticos (A05.8.01.033)*. Sin embargo, estas diferencias radican en la manera de describir el segmento medial derecho+ (segmento V), lo cual ha provocado confusión al estudiar la anatomía del hígado (A05.8.01.001). Para explicar la correcta anatomía del segmento portal V (A05.8.01.047), estudiamos la estructura vascular intrahepática de 200 hígados humanos de individuos de ambos sexos, de diferentes edades, desde fetos hasta octogenarios. Ciento cincuenta hígados fueron inyectados con acrílico a través de la vena porta hepática (A12.3.12.001), arteria hepática propia (A12.2.12.029), conducto hepático común (A05.8.01.061), vena cava inferior (A12.3.09.001) y venas hepáticas (A12.3.09.005). Los 50 hígados restantes fueron disecados en fresco, basándonos en los moldes acrílicos obtenidos previamente. Se encontró solo una rama portal segmentaria para la división medial derecha (A05.8.01.046) entre la fisura portal derecha (A05.8.01.036) y la fisura portal principal (A05.8.01.035). Esta rama fue la más voluminosa (10 mm de diámetro en su base) entre las siete ramas portales segmentarias + encontradas. La misma, luego de penetrar 2 cm en el parénquima en dirección a la porción superior del hígado (A05.8.01.003), dio ramas anteriores, laterales, posteriores y mediales, que se distribuyeron desde la placa hiliar+ hasta la cúpula hepática, desde la fisura portal derecha hasta la fisura portal principal, desde el margen inferior (A05.8.01.024) hasta la vena cava inferior por detrás. En 80 % de los hígados, esta rama nació de la vena porta derecha (A12.3.12.002), y en 20 % de la vena porta izquierda (A12.3.12.005); en estos casos el lóbulo izquierdo (A05.8.01.027) era más voluminoso que el derecho (A05.8.01.026). Estos hallazgos llevan a plantear nuevas definiciones y conceptos, los que se proponen en la discusión.

To determinate the characteristics of the segment V in the liver, we studied the intrahepatic vascular structure of 200 human livers taken from necropsies of males and females of different ages, from fetuses to octogenarians, all races. 150 livers were injected with acrylic in the portal vein, hepatic artery, biliary ducts, inferior cava vein and hepatic veins. We dissected 50 livers based on the knowledge obtained from the acrylic injected livers. We found that the segment V has only one branch, the largest of the seven portal segmental branches. After penetrates 2 cm in the hepatic parenchyma gives anterior branches, lateral branches, posterior branches and medial branches. This segmentary branch emerged from the right portal vein in 80 % of cases and from the left portal vein in 20 %.

Modified technique for preparation of venous circulation resin casts in the cirrhotic liver.

This study describes two major adaptations for the preparation of resin casts in human cirrhotic liver, harvested at the time of transplantation. The first is the way of fixing the catheter in the ostia of the hepatic and portal veins through a cerclage, so as to prevent displacement of the catheter and / or leakage of the resin during its injection. The second is the extension of corrosion time in the NaOH solution, averaging 6.8 days, with daily replacement the solution until complete removal of parenchymal tissue. We applied the method in 14 cirrhotic livers, with good filling and coloring of the portal and hepatic vein territories, using different colors. This allows an anatomical study of these vessels, able to complement the knowledge of the histopathology in research work, and the planning of therapeutic procedures, such as the Trans-Jugular Intrahepatic Port-Systemic Shunt (TIPS). RESUMO Este estudo descreve duas importantes adaptações para o preparo de moldes de resina em fígado humano cirrótico, captado no momento do transplante: a primeira, é a maneira de fixação dos cateteres nos "óstios" das veias hepáticas e porta, através de uma "cerclagem" dos mesmos, de modo a evitar o deslocamento do cateter e/ou extravasamento da resina durante sua injeção, e a segunda, é o prolongamento do tempo de corrosão na solução de NaOH, atingindo a média de 6,8 dias, com a substituição diária da solução, até a remoção completa do tecido parenquimatoso. O método foi empregado em 14 fígados cirróticos com bom preenchimento e coloração dos territórios das veias porta e hepáticas, utilizando cores distintas. Isto permite um estudo anatômico desses vasos, capaz de complementar os conhecimentos da histopatologia em trabalhos de pesquisa, e planejar procedimentos terapêuticos como a derivação porto-sistêmica intra-hepática transjugular (TIPS - Transjugular Intrahepatic Postosystemic Shunt).

A study on the number and arrangement of the structures passing through the porta hepatis in South Indian population / Estudio sobre el número y disposición de las estructuras que pasan por la fisura porta hepática en individuos del sur de la India

The porta hepatis of the liver is a very important area surgically. The knowledge of the variations in the structures passing through the porta hepatis might be of great help in reducing the risks of surgery in this area. In the current study 59 livers from South Indian cadavers were observed for the number and arrangement of the structures passing through the porta hepatis. In all the livers the portal vein was posteriormost and the hepatic duct was the anteriormost structure. The hepatic artery and its branches were in between the duct and the vein. The mean weight of the liver was 1.025 kg. The mean length of porta hepatis was 4.825 cm and the mean breadth was 2.433 cm. The number varied from one to three for the duct and vein but for the artery it was between one and four. In 51% of livers, only one vein and in 80% of cases only one duct passed through the porta hepatis. In 56% of cases two arteries passed through the porta hepatis.

La fisura porta hepática del hígado es un área quirúrgica muy importante. El conocimiento de las variaciones en las estructuras que pasan a través de la fisura porta hepática puede ser de gran ayuda para reducir los riesgos de la cirugía de esta región. En el presente estudio se observaron 59 hígados procedentes de cadáveres del Sur de la India, en relación al número y disposición de las estructuras que pasan a través de la fisura porta hepática. En todos los hígados, la vena porta hepática fue el elemento más posterior y el conducto hepático común el más anterior. La arteria hepática y sus ramas se ubicaban entre el conducto hepático común y la vena porta hepática. El peso medio de los hígados fue 1,025 kg. La longitud media de la fisura porta hepática fue 4,825 cm y el ancho medio de 2,433 cm. El número varió de uno a tres para el conducto y la vena. El número de arterias varió entre una y cuatro. En 51% de los hígados, sólo una vena pasaba a través de la fisura porta hepática y en el 80% de los casos sólo pasaba un conducto. En el 56% de los casos, dos arterias pasaban a través de la fisura porta hepática.

Multiple anatomical variations of the hepatic pedicle: case report and clinical application / Múltiples variaciones anatómicas del pedículo hepático: reporte de caso y aplicación clínica

The knowledge in detail of the anatomy of the hepatic pedicle is critical when operating it and its surroundings. The presence of anatomic variations is higher at the arterial component level than at the bile component level or venous component level, which in the 90% of the cases it appears as the classic description. The presented case in this work implies a very low frequency of appearance. For this reason, the surgeon must be alert at the moment of making a decision so as to avoid injuries that may put the patient´s life at risk.

El conocimiento en detalle de la anatomía del pedículo hepático es fundamental al momento de intervenir quirúrgicamente sobre el mismo y su vecindad. La presencia de variaciones anatómicas es mayor a nivel del componente arterial, luego biliar y finalmente venoso, el cual en el 90% de los casos se dispone de acuerdo con la descripción clásica. El caso presentado en este trabajo supone una muy baja frecuencia de aparición, siendo precisamente estas disposiciones poco habituales las que obligan al cirujano a mantenerse alerta en el momento de actuar para evitar injurias que puedan comprometer la vida del paciente.

Os achados de imagem para avaliação da tríade portal são confiáveis para realização do transplante hepático com doador vivo? / Are the imaging findings used to assess the portal triad reliable to perform living-donor liver transplant?

RACIONAL: Um aspecto crucial do transplante hepático inter-vivos é o risco imposto ao doador, devido ser procedimento realizado em pessoa saudável, com possibilidade de alta morbidade pós-operatória. OBJETIVO: Correlacionar os achados de imagem do pré e intra-operatório dos doadores adultos vivos de fígado. MÉTODOS: No período de 2003 a 2008 foram revisados os prontuários de 66 doadores. Foram 42 homens (64%) e 24 mulheres (36%), com média de idade de 30 anos (± 8 anos). A anatomia pré-operatória foi analisada através de colangiografia por ressonância nuclear magnética para estudo dos ductos biliares e angiografia por tomografia computadorizada para artéria hepática e veia porta. Critérios de normalidade foram estabelecidos de acordo com estudos prévios da literatura. RESULTADOS: Variações anatômicas dos ductos biliares foram encontradas em 59,1% dos doadores; da artéria hepática em 31,8% e da veia porta em 30,3% dos casos no pré-operatório. A colangiografia por ressonância nuclear magnética apresentou achados concordantes em 44 (66,6%) doadores e discordantes em 22 (33,3%). Com relação à artéria hepática em todos os doadores os achados do exame de imagem foram concordantes com os do intra-operatório. Para a veia porta a tomografia computadorizada apresentou achados concordantes em 59 (89,4%) doadores e discordantes em sete (10,6%). CONCLUSÕES: As variações anatômicas dos ductos biliares são frequentes, com a colangiografia por ressonância nuclear magnética apresentando acurácia moderada (70%) na reprodução dos achados cirúrgicos; a tomografia computadorizada reproduziu os achados do intra-operatório da artéria hepática em 100% dos doadores, e reproduziu os achados intra-operatórios em 89,4% dos casos em relação à veia porta, apresentando acurácia elevada (89%).

BACKGROUND: A crucial aspect of living-donor liver transplant is the risk imposed to the donor due to a procedure performed in a healthy individual that can lead to a high postoperative morbidity rate AIM: To correlate the pre- and intraoperative hepatic imaging findings of living adult donors. METHODS: From 2003 to 2008 the medical charts of 66 donors were revised; in that, 42 were males (64%) and 24 females (36%), mean age of 30±8 years. The preoperative anatomy was analyzed by magnetic resonance cholangiography to study the bile ducts and by computed tomography angiography to evaluate the hepatic artery and portal vein. Normalcy criteria were established according to previously published studies. RESULTS: Anatomic variations of the bile ducts were found in 59.1% of donors, of the artery hepatic in 31.8% and of the portal vein in 30.3% of the cases during the preoperative period. The magnetic resonance cholangiography findings were in agreement in 44 (66.6%) of donors and in disagreement in 22 (33.3%). With regards to hepatic artery, in all donors the findings of the imaging examination were in agreement with those of the intraoperative period. As to the portal vein, the computed tomography findings were in agreement in 59 (89.4%) donors and in disagreement in seven (10.6%). CONCLUSIONS: The bile duct anatomic variations are frequent, and the magnetic resonance cholangiography showed moderate accuracy (70%) in reproducing the surgical findings; the computed tomography reproduced the intraoperative findings of the hepatic artery in 100% of donors, and of the portal vein in 89.4% of the cases, thus demonstrating high accuracy (89%).

A modified microsurgical model for end-to-side selective portacaval shunt in the rat. Intraoperative microcirculatory investigations.

PURPOSE: To investigate the intraoperative microcirculatory changes of the affected organs (small bowel, liver and kidney) during the making of a modified selective portacaval (PC) shunt. METHODS: On ten anaesthetized Sprague-Dawley rats the selective end-to-side mesocaval anastomosis was performed, where only the rostral mesenteric vein is utilized and the portal vein with the splenic vein are left intact. Morphometric and microcirculatory investigations using a LDF device determining flux units (BFU) were carried out. RESULTS: After completing the shunts the microcirculatory flux values did not recover in the same manner on the surface of the small intestine, the liver or the kidney. BFU values showed deterioration in the small intestine and in the liver (p<0.001). During the reperfusion the BFU values improved, but not in the same manner. The small intestine values left behind the kidney and liver data. CONCLUSIONS: Technically, the advantages of the models include the selective characteristic, the mesocaval localization and the relatively easy access to those vessels. However, its major disadvantage is the time needed for positioning the vessels without coiling or definitive stretching. Intraoperative LDF may provide useful data on the microcirculatory affection of the organs suffering from hypoperfusion or ischemia during creating the shunts.

A modified microsurgical model for end-to-side selective portacaval shunt in the rat: intraoperative microcirculatory investigations

PURPOSE: To investigate the intraoperative microcirculatory changes of the affected organs (small bowel, liver and kidney) during the making of a modified selective portacaval (PC) shunt. METHODS: On ten anaesthetized Sprague-Dawley rats the selective end-to-side mesocaval anastomosis was performed, where only the rostral mesenteric vein is utilized and the portal vein with the splenic vein are left intact. Morphometric and microcirculatory investigations using a LDF device determining flux units (BFU) were carried out. RESULTS: After completing the shunts the microcirculatory flux values did not recover in the same manner on the surface of the small intestine, the liver or the kidney. BFU values showed deterioration in the small intestine and in the liver (p<0.001). During the reperfusion the BFU values improved, but not in the same manner. The small intestine values left behind the kidney and liver data. CONCLUSIONS: Technically, the advantages of the models include the selective characteristic, the mesocaval localization and the relatively easy access to those vessels. However, its major disadvantage is the time needed for positioning the vessels without coiling or definitive stretching. Intraoperative LDF may provide useful data on the microcirculatory affection of the organs suffering from hypoperfusion or ischemia during creating the shunts.

Are the imaging findings used to assess the portal triad reliable to perform living-donor liver transplant?

BACKGROUND: A crucial aspect of living-donor liver transplant is the risk imposed to the donor due to a procedure performed in a healthy individual that can lead to a high postoperative morbidity rate AIM: To correlate the pre- and intraoperative hepatic imaging findings of living adult donors. METHODS: From 2003 to 2008 the medical charts of 66 donors were revised; in that, 42 were males (64%) and 24 females (36%), mean age of 30 ± 8 years. The preoperative anatomy was analyzed by magnetic resonance cholangiography to study the bile ducts and by computed tomography angiography to evaluate the hepatic artery and portal vein. Normalcy criteria were established according to previously published studies. RESULTS: Anatomic variations of the bile ducts were found in 59.1% of donors, of the artery hepatic in 31.8% and of the portal vein in 30.3% of the cases during the preoperative period. The magnetic resonance cholangiography findings were in agreement in 44 (66.6%) of donors and in disagreement in 22 (33.3%). With regards to hepatic artery, in all donors the findings of the imaging examination were in agreement with those of the intraoperative period. As to the portal vein, the computed tomography findings were in agreement in 59 (89.4%) donors and in disagreement in seven (10.6%). CONCLUSIONS: The bile duct anatomic variations are frequent, and the magnetic resonance cholangiography showed moderate accuracy (70%) in reproducing the surgical findings; the computed tomography reproduced the intraoperative findings of the hepatic artery in 100% of donors, and of the portal vein in 89.4% of the cases, thus demonstrating high accuracy (89%).

Vascular mechanisms involved in angiotensin II-induced venoconstriction in hypertensive rats.

To investigate the venoconstrictor effect of angiotensin II (Ang II) in spontaneously hypertensive rats (SHR), we used preparations of mesenteric venular beds and the circular muscle of the portal veins. Vessels were tested with Ang II in the presence or absence of losartan, PD 123319, HOE 140, L-NAME, indomethacin, or celecoxib. In the mesenteric venular bed of SHR, the effect of Ang II (0.1 nmol) was nearly abolished by losartan and enhanced by HOE 140, indomethacin, and celecoxib, while PD123319 and L-NAME had no effect. In portal vein preparations, cumulative-concentration response curves (CCRC) to Ang II (0.1-100 nmol/L) exhibited a lower maximal response (E(max)) in SHR compared to Wistar rats. AT(1) receptor expression was similar in the two strains, while AT(2) receptor levels were lower in SHR portal veins when compared to Wistar. In SHR portal veins, losartan shifted the CCRC to Ang II to the right, while indomethacin and HOE 140 increased the E(max) to Ang II. PD 123319, celecoxib, and L-NAME had no effect. Taken together, our results suggest that Ang II-induced venoconstriction in SHR is mediated by activation of AT(1) receptors and this effect may be counterbalanced by kinin B(2) receptor and COX metabolites. Furthermore, our data indicate that there are different cellular and molecular mechanisms involved in the regulation of venous tonus of normotensive and hypertensive rats. These differences probably reflect distinct factors that influence arterial and venous bed in hypertension.

Influence of the inversion of the portal/splenic vein diameter in the results of the surgical treatment of schistossomotic portal hypertension.

OBJECTIVE: To evaluate the morbidity and mortality in surgical treatment of schistosomal portal hypertension in patients with inversion of the Portal/Splenic Vein diameter ratio. METHODS: We conducted a retrospective cross-sectional study of patients undergoing surgical treatment of portal hypertension in the period between September 1993 and January 2004. The study population was divided into two groups: a) Inversion--splenic vein diameter greater than or equal to portal vein's--and b) control group (portal vein diameter greater than the splenic vein's). Statistical comparisons used the Student t test for averages difference, chi-square test for proportions difference and Fisher's exact test for small samples. RESULTS: 169 patients were analyzed, with follow-up averaging 23.6 months. Twenty-one patients (12.4%) had splenic vein caliber greater of equal than the portal vein's (Inversion--study group). The mean preoperative diameter of the portal and splenic veins were respectively 1.49 and 1.14 cm in the control group, and 0.98 versus 1.07 cm in the inversion group. The portal vein diameter was significantly higher in the control group when compared to the inversion group (p <0.05). Varices in the gastric fundus were found in 33.3% of the inversion group and in 38.5% of patients in the control group. Postoperative rebleeding occurred in 23.1% of patients in the inversion group and in 13.4% of the control group ones (p > 0.05). In the postoperative evaluation with Doppler ultrasonography of portal vessels, no cases of portal vein thrombosis were observed in the inversion group, whilst in the control group portal thrombosis was identified in 16.9% of the patients (p <0.05). Death occurred in one (4.8%) individual from the inversion group; mortality was 4.1% in the control group (p>0.05). The mean serum level of platelets was significantly lower (65,950/mm²) in the inversion group than in the controls (106,647/mm²) (p<0.05). CONCLUSION: The results suggest that the reversal of portal/splenic vein caliber ratio does not represent a contraindication to surgical treatment of schistosomal portal hypertension.

Influência da inversão do diâmetro veia porta/veia esplênica nos resultados do tratamento cirúrgico da hipertensão portal esquistossomótica / Influence of the inversion of the portal/splenic vein diameter in the results of the surgical treatment of schistossomotic portal hypertension

OBJETIVO: Avaliar a morbidade e a mortalidade no tratamento cirúrgico da hipertensão portal esquistossomótica em pacientes portadores de inversão do diâmetro entre a veia porta e veia esplênica. MÉTODOS: Estudo transversal retrospectivo, de pacientes submetidos ao tratamento cirúrgico da hipertensão no período entre setembro de 1993 e Janeiro de 2004. A população do estudo foi distribuída em dois grupos: a) Inversão - calibre da veia esplênica maior ou igual ao da veia porta) e b) grupo controle (calibre da veia porta maior que o da veia esplênica). Na análise estatística foram utilizados o teste t de student para diferença de médias, quiquadrado para diferença de proporções e o exato de Fisher para amostras reduzidas. RESULTADOS: 169 pacientes foram analisados com seguimento pós-operatório médio de 23,6 meses. 21 pacientes (12,4 por cento) apresentavam a veia esplênica de igual ou maior calibre que a veia porta (Inversão - grupo de estudo). A média dos diâmetros pré-operatórios das veias porta e esplênica foram, respectivamente, 1,49/1,14cm no grupo controle, e 0,98/1,07cm no grupo de inversão. O diâmetro da veia porta foi significativamente maior no grupo controle quando comparado ao grupo de inversão (p<0,05). A presença de varizes de fundo gástrico foi identificada em 33,3 por cento do grupo de inversão e em 38,5 por cento dos pacientes do grupo controle. Recidiva hemorrágica pós-operatória ocorreu em 23,1 por cento dos pacientes do grupo de inversão e em 13,4 por cento no grupo controle (p>0,05). Na avaliação pós-operatória com ultrassonografia Doppler de vasos portais, não houve casos de trombose portal no grupo de inversão, e no grupo controle a trombose portal foi identificada em 16,9 por cento dos pacientes (p<0,05). O óbito ocorreu em um (4,8 por cento) paciente do grupo inversão, e a mortalidade foi de 4,1 por cento no grupo controle (p>0,05). A média do nível sérico de plaquetas foi significativamente menor (65.950/mm□) no grupo de inversão do que no grupo controle (106.647/mm□) (p<0,05). CONCLUSÃO: Os resultados sugerem que a inversão do calibre veia porta/esplênica não representa uma contraindicação ao tratamento cirúrgico da hipertensão portal esquistossomótica.

OBJECTIVE: To evaluate the morbidity and mortality in surgical treatment of schistosomal portal hypertension in patients with inversion of the Portal/Splenic Vein diameter ratio. METHODS: We conducted a retrospective cross-sectional study of patients undergoing surgical treatment of portal hypertension in the period between September 1993 and January 2004. The study population was divided into two groups: a) Inversion - splenic vein diameter greater than or equal to portal vein's - and b) control group (portal vein diameter greater than the splenic vein's). Statistical comparisons used the Student t test for averages difference, chi-square test for proportions difference and Fisher's exact test for small samples. RESULTS: 169 patients were analyzed, with follow-up averaging 23.6 months. Twenty-one patients (12.4 percent) had splenic vein caliber greater of equal than the portal vein's (Inversion - study group). The mean preoperative diameter of the portal and splenic veins were respectively 1.49 and 1.14 cm in the control group, and 0.98 versus 1.07 cm in the inversion group. The portal vein diameter was significantly higher in the control group when compared to the inversion group (p <0.05). Varices in the gastric fundus were found in 33.3 percent of the inversion group and in 38.5 percent of patients in the control group. Postoperative rebleeding occurred in 23.1 percent of patients in the inversion group and in 13.4 percent of the control group ones (p> 0.05). In the postoperative evaluation with Doppler ultrasonography of portal vessels, no cases of portal vein thrombosis were observed in the inversion group, whilst in the control group portal thrombosis was identified in 16.9 percent of the patients (p <0.05). Death occurred in one (4.8 percent) individual from the inversion group; mortality was 4.1 percent in the control group (p>0.05). The mean serum level of platelets was significantly lower (65,950/mm□) in the inversion group than in the controls (106,647/mm□) (p<0.05). CONCLUSION: The results suggest that the reversal of portal/splenic vein caliber ratio does not represent a contraindication to surgical treatment of schistosomal portal hypertension.

Aspectos morfológicos da ultra-sonografia hepática de ovinos / Morphologic aspects of hepatic ultrasonography in sheep

A ultra-sonografia (US) é uma das técnicas de exame complementar eletivas para o diagnóstico de enfermidades hepáticas de diversas espécies domésticas. Em ovinos, no entanto, existem poucos relatos sobre o aspecto ultra-sonográfico de enfermidades hepáticas e não há definição precisa dos padrões anatômicos da US normal do fígado. Neste estudo foram utilizados 58 ovinos da raça Santa Inês: n1=8 machos, n2=10 fêmeas não gestantes e n3=40 fêmeas gestantes. Os animais foram escaneados do 12º ao 8º espaços intercostais (EI) para se observar a localização da veia cava caudal (VC), veia porta (VP) e vesícula biliar (VB) e para se aferir a espessura do fígado sobre a VC e VP no 11º e 10º EI. O fígado foi examinado de forma satisfatória do 12º até o 8º EI. Nesta área, tanto a VC como a VP, foram observadas do 12º ao 9º EI, porém a VC não foi examinada de forma adequada em 11 animais, 10 com peso acima de 50kg. Entre os dois grupos de fêmeas, a VC e a VP foram observadas com maior freqüência no 11º e 10º EI e em todos os machos examinados do 12º ao 10º EI. A localização da vesícula biliar oscilou entre o 10º e o 8º EI, com maior incidência a nível do 9º e 8º EI nas fêmeas gestantes e não gestantes, e sobre o 9º EI nos machos. Comparativamente, a ecogenicidade do parênquima hepático foi mais intensa do que a do córtex renal. Houve correlação significativa entre o peso do fígado e a espessura hepática sobre a veia porta no 11º e o 10º EI no grupo de fêmeas gestantes. A US forneceu informações importantes quanto a topografia e ecogenicidade do fígado e mostrou ser uma ferramenta útil para estimar o peso do órgão.(AU)

The ultrasonography (US) is a complementary technique of choice for the diagnostic of hepatic diseases in many domestics' species. In sheep however there are few reports about ultrasonography in hepatic diseases and there is not precise definition about the anatomic standards of normal liver limits in ultrasonographic examination. In this study 58 Santa Inês sheep breed were used and divided in 3 groups: n1=8 males, n2=10 not pregnant females and n3=40 pregnant females. The animals were scanned from the 12º to 8º intercostal spaces (EI) to observe the localization of the vena cava caudal (VC), gallbladder (VB) and to measure the liver thickness above the VC and vena portae VP under the 11º and 10º EI. The liver was examined on satisfactory way from the 12º till the 8º EI. Both the VC and the VP where observed from the 12º to 9º EI, however the VC could not be observed in 11 animals, 10 of them were over 50 kg. Between the two female groups the VC and VP where observed most frequently from the 11º to 10º EI and in all males examined from the 12º to 10º EI. The location of the gallbladder varies between the 10º to the 8º EI, with bigger incidence between the 9º and the 8º EI in pregnant and no pregnant females groups and underneath the 9º EI on the male group. Comparatively, the ecogenicity of the liver parenchyma was more intense than kidney cortex. There was a significant correlation between liver's weight and hepatic thikness above the vena portae on the 11º and 10º EI on the pregnant females group. The US supplied to important information about the topography and echogenicity of the liver and showed to be a useful tool to esteem the liver's weight.(AU)