A report of a case: unusual portosystemic shunt in a hernia sac who has portal hypertension due to cirrhosis.

BACKGROUND: Variations in the origin and branching pattern of splenic vein (SV) are relatively rare and asymptomatic. We describe here only the first case in the literature of accessory SV in hernia sac due to previous operation and increased portal pressure because of cirrhosis. CASE PRESENTATION: This report describes a 66-year-old female, with a history of total abdominal hysterectomy (TAH) due to uterine myomatosis, signs of cirrhosis onset due to hepatitis B, who had been presented with recurrent abdominal pain attacks. Ultrasonography (USG) findings were nothing pathologic except a gallstone in the gallbladder without cholecystitis signs. Incisional hernia was found to contain an accessory SV in the hernia sac arising from a branch of main SV in the hilum, ongoing to the subcutaneous fat tissue and draining to the superficial femoral vein on computed tomography (CT). Videoendoscopy showed wide gastritis and multiple ulcers. The patient's symptoms diminished with proton pump inhibitor (PPI) treatment and they then underwent a hernia repair surgery with Prolene mesh patch as elective surgery. CONCLUSIONS: A thorough knowledge of the normal anatomy, most frequent variations and congenital or acquired anomalies of the spleno-portal axis has great importance for hepatopancreaticobiliary and emergency surgical procedures. It is, therefore, essential for preoperative evaluation of the anatomical details of the spleno-portal venous axis and should be evaluated with imaging methods in detail.

Atypical/malignant solitary fibrous tumor of the pancreas with spleen vein invasion: Case report and literature review.

INTRODUCTION: Solitary fibrous tumor (SFT) is an uncommon mesenchymal tumor that is most common in the pleura. However, according to previous studies, the SFT of the pancreas is extremely rare; only 20 cases have been reported so far. Here, we conduct a literature review and report the first case of atypical/malignant SFT of the pancreas with spleen vein invasion. PATIENT CONCERNS: The patient is a 61-year-old Chinese male who presented with 1 week of upper abdominal pain. Abdominal magnetic resonance imaging showed a huge mass (>10 cm) at the distal end of the pancreas, and the mass obstructing the splenic vein. DIAGNOSIS: Atypical/malignant SFT of the pancreas with splenic vein tumor thrombus. INTERVENTIONS: The patient underwent laparoscopic distal pancreatectomy with splenectomy procedure to achieve a radical resection, and did not undergo chemotherapy or radiotherapy. OUTCOMES: Abdominal computed tomography scans were performed at 1 and 4 months after resection, and no signs of recurrence or metastasis were found (. B).(Figure is included in full-text article.) CONCLUSION:: The clinical symptoms of atypical/malignant SFT of the pancreas with spleen vein invasion are not atypical, and imaging feature is lack of specificity. Preoperative diagnosis is difficult, and there is a potential for malignancy. However, due to the paucity of randomized control trials, there is no established, globally accepted treatment strategy, radiation therapy and chemotherapy regimens have not demonstrated global effectiveness, and no standardized treatments have been identified. Therefore, we recommend complete surgical resection and close clinical follow-up.

Non-cirrhotic Extra-Hepatic Porto-Systemic Shunt Causing Adult-Onset Encephalopathy Treated with Endovascular Closure.

INTRODUCTION: Encephalopathy secondary to hyperammonemia due to Congenital Extra-hepatic Porto-systemic shunt (CEPS) in the absence of liver cirrhosis is an exceptionally unusual condition. We describe the case of a 54-year-old woman admitted to the Emergency Department complaining of recurrent episodes of confusion and worsening cognitive impairment. At admission, the patient displayed slowing cognitive-motor skills with marked static ataxia and impaired gait. Hyperammonemia was detected in the serum. An abdominal computed tomography (CT) excluded portal hypertension and liver cirrhosis, detecting a congenital extra-hepatic porto-systemic shunt which is a highly unusual vascular malformation. The patient was treated by interventional radiologists with a successful endovascular closure. AREAS COVERED: We have performed a review of the last three decades of the literature, starting from the introduction of CT scanning in common clinical practice. Eighteen studies (case reports) described 29 patients with encephalopathy secondary to hyperammonemia due to CEPS in the absence of liver cirrhosis: They underwent treatment similar to our case report of CEPS. EXPERT COMMENTARY: Encephalopathy secondary to hyperammonemia in the absence of hepatic dysfunction is an important diagnostic dilemma to many clinicians. An interventional radiologic approach is currently preferred.

Spontaneous splenoazygos shunt in a patient with portal hypertension: an exceedingly rare occurrence.

We present a case of a spontaneous splenoazygos shunt in a patient with liver cirrhosis and portal hypertension, detected by abdominal magnetic resonance imaging. Multiplanar reconstruction demonstrated communication of the splenic vein with the azygos vein that was dilated with a winding course along the mediastinum. This pathway for decompression of the portal vein is an exceedingly rare occurrence.

Hepatic encephalopathy secondary to a splenorenal shunt that manifested a long time after a liver transplantation.

Splenorenal shunts are a rare cause of hyperammonemia and hepatic encephalopathy in the absence of cirrhosis. We report the case of a woman, who presented hepatic encephalopathy, with a normal functioning graft, after 14 years of liver transplantation, confirmed by liver biopsy.

A Case of Left Renal Vein Ligation in a Patient with Solitary Left Kidney Undergoing Liver Transplantation to Control Splenorenal Shunt and Improve Portal Venous Flow.

BACKGROUND Adequate portal venous flow is required for successful liver transplantation. Reduced venous flow and blood flow 'steal' by collateral vessels are a concern, and when there is a prominent splenorenal shunt present, ligation of the left renal vein has been recommended to improve portal venous blood flow. CASE REPORT A 51-year-old man who had undergone right nephrectomy in childhood required liver transplantation for liver cirrhosis and hepatocellular carcinoma due to hepatitis C virus (HCV) infection. The patient had no other comorbidity and no history of hepatorenal syndrome. At transplantation surgery, portal venous flow was poor and did not improve with ligation of shunt veins, but ligation of the left renal vein improved portal venous flow. On the first and fifth postoperative days, the patient was treated with basiliximab, a chimeric monoclonal antibody to the IL-2 receptor, and methylprednisolone. The calcineurin inhibitor, tacrolimus, was introduced on the fifth postoperative day. On the sixteenth postoperative day, renal color Doppler ultrasound showed normal left renal parenchyma; hepatic Doppler ultrasound showed good portal vein flow and preserved hepatic parenchyma in the liver transplant. CONCLUSIONS This case report has shown that in a patient with a single left kidney, left renal vein ligation is feasible and safe in a patient with no other risk factors for renal impairment following liver transplantation. Modification of postoperative immunosuppression to avoid calcineurin inhibitors in the very early postoperative phase may be important in promoting good recovery of renal function and to avoid the need for postoperative renal dialysis.

Classification and techniques of en bloc venous reconstruction for pancreaticoduodenectomy.

BACKGROUND: Surgical resection is the only cure for hepato-pancreato-biliary (HPB) malignancy. In the era of multidisciplinary approaches and neoadjuvant therapies for locally advanced, borderline resectable tumors, the feasibility and efficacy of en bloc vascular resection has been validated across multiple studies. However, the variability of venous anatomy within the perihepatic and peri-portal regions necessitates familiarity with alternative resection and reconstruction techniques appropriate to the specific region of tumor invasion. METHODS: To organize these paradigms, the venous system has been divided into five zones: 1) hepatic hilum; 2) hepatoduodenal ligament; 3) portal vein/splenic vein confluence, which is further subdivided into right (3a) and left (3b); 4) infra-confluence; and 5) splenic vein. RESULTS: This study systematically analyzes the anatomic considerations and clinical scenarios specific to each zone to organize the necessary preparative maneuvers, surgical procedures, and vascular reconstruction techniques to achieve an R0 resection. The anatomic and tumor-specific factors which deem a specimen unresectable are also explored. Surgical videos demonstrating these techniques are presented. DISCUSSION: Preparation and familiarity with venous reconstruction maneuvers is essential for an oncologically effective operation, and can be safely achieved by utilizing this logical anatomic and procedural framework.

Morphology of splenocaval congenital portosystemic shunts in dogs and cats.

OBJECTIVE: To describe the anatomy of congenital portosystemic shunts involving the splenic vein communicating with the caudal vena cava at the level of the epiploic foramen. MATERIALS AND METHODS: A retrospective review of a consecutive series of dogs and cats managed for congenital portosystemic shunts. RESULTS: Ninety-eight dogs and eight cats met the inclusion criteria of a congenital portosystemic shunt involving the splenic vein communicating with the prehepatic caudal vena cava plus recorded intra-operative mesenteric portovenography or computed tomography angiography and gross observations at surgery. All cases (both dogs and cats) had a highly consistent shunt that involved a distended gastrosplenic vein that communicated with the caudal vena cava at the level of the epiploic foramen via an anomalous left gastric vein. CLINICAL SIGNIFICANCE: The morphology of the shunt type described appeared to be a result of an abnormal communication between the left gastric vein and the caudal vena cava and the subsequent development of preferential blood flow through an essentially normal portal venous system. The abnormal communication (shunt) was through the left gastric vein and not the splenic vein, as might have been expected. This information may help with surgical planning in cases undergoing shunt closure surgery.

Idiopathic splenic arteriovenous fistula without splenic artery aneurysm.

Splenic arteriovenous fistula (SAVF) without a splenic arterial aneurysm is a rare entity and may either be congenital or acquired. Acquired SAVFs are commonly due to adjacent splenic arterial aneurysm rupture, trauma or infection. We report a large idiopathic SAVF in a 50-year-old woman who had no symptoms. CT showed that the fistula was around the splenic hilum and no other specific findings. SAVF has a risk of sudden onset of portal hypertension and it should be treated as soon as diagnosed. Endovascular treatment for SAVF is now being performed successfully with increasing frequency, however, there is still no definitive evidence of treatment for SAVF. Treatment options should be determined appropriately depending on individual case characteristics and vascular anatomical variations. Our case was treated successfully with splenectomy, and long-term results are good without need of reintervention.

Synergistic effect of lidocaine with pingyangmycin for treatment of venous malformation using a mouse spleen model.

AIMS: To explore whether lidocaine has the synergistic effect with pingyangmycin (PYM) in the venous malformations (VMs) treatment. METHODS: The mouse spleen was chosen as a VM model and injected with different concentration of lidocaine or PYM or jointly treated with lidocaine and PYM. After 2, 5, 8 or 14 days, the mouse spleen tissues were acquired for hematoxylin-eosin (HE) staining, transmission electron microscopy (TEM) analysis, TUNEL assay and quantitative RT-PCR analysis to examine the toxicological effects of lidocaine and PYM on splenic vascular endothelial cells. RESULTS: 0.4% of lidocaine mildly promoted the apoptosis of endothelial cells, while 2 mg/ml PYM significantly elevated the apoptotic ratios. However, the combination of 0.2% lidocaine and 0.5 mg/ml PYM notably elevated the apoptotic ratios of splenic cells and severely destroyed the configuration of spleen, compared to those of treatment with 0.5 mg/ml PYM alone. CONCLUSION: Lidocaine exerts synergistic effects with PYM in promoting the apoptosis of mouse splenic endothelial cells, indicating that lidocaine possibly promotes the therapeutic effects of PYM in VMs treatment via synergistically enhancing the apoptosis of endothelial cells of malformed venous lesions.

Gastric variceal bleeding precipitated by a mycotic splenic arteriovenous fistula in a cirrhotic patient: radiological diagnosis and endovascular treatment.

Splenic arteriovenous fistula (SAVF) is an unusual cause of portal hypertension, and is rarely associated with an infective aetiology. It is often difficult to identify SAVF clinically, and thus, radiological modalities are invariably required for diagnosis and treatment. We herein describe a case of SAVF occurring in a patient with compensated cirrhosis as a sequel to salmonella gastroenteritis, and presenting with acute gastric variceal bleeding. Selective transcatheter embolisation of the splenic artery was effective in controlling bleeding.

Hepatic myelopathy with spastic paraparesis: report of two cases and review of the literature.

PURPOSE: The present report illustrates two men aged for 59 and 43 years, respectively, who presented with slowly progressive spastic paraparesis. STUDY DESIGN: Two case reports and review of literature. METHODS: The patent's history, clinical examination, biology, magnetic resonance imaging (MRI) findings and treatment are reported. We also discuss the pathogenesis and various treatment options. RESULTS: Neurologic examination showed spastic paraparesis without other neurological disorders. MRI of the spinal cord and brain were normal. Cytologic examination of cerebrospinal fluid from each patient was normal. Hemogram disclosed a pancytopenia. Partial thromboplastin time was prolonged. Liver function tests revealed raised serum bilirubin, normal alanine aminotransferase and aspartate aminotransferase, reduced total protein and albumin. Plasma ammonia was elevated. Blood vitamin B12 and folate values were in normal ranges. Serum antibodies to human T cell lymphotropic virus, human immunodeficiency virus, syphilis and hepatitis C virus were absent. Hepatitis B virus antibody assay was positive. The electromyographic evaluation for second motor neuron involvement was also normal. Endoscopy revealed esophageal varices and a spleno-renal shunt. CONCLUSIONS: Hepatic myelopathy remains a default diagnosis assigned only after the exclusion of other causes of spastic paraparesis and partial transverse myelopathy. An accurate history, along with appropriate imaging and laboratory findings, is crucial.

Portal hypertension secondary to splenic arteriovenous fistula.

Portal hypertension is a common condition in association with chronic liver disease; however, it is rarely caused by vascular shunting from splenic arteriovenous fistula (SAVF). We are presenting a case of non-cirrhotic portal hypertension due to SAVF. This condition is usually seen in multiparity women; however, other causes like trauma or mycotic infection are reported in the literatures with equal gender prevalence. Most of the patients present with gastric and esophageal varices, splenomegaly or upper abdominal pain. Clinical history and examination are the first step for diagnosis followed by ultrasound or contrast enhanced computer tomography. Splenic arteriovenous fistula must be then confirmed by selective celiac or splenic arteriography which is the gold standard tool. The condition is treatable either surgical ligation or intra-arterial embolization. Due to less invasive procedure, the later one is more favorable in unstable patients. Both procedures have been reported to be equally successful in managing SAVF.

Melena-associated regional portal hypertension caused by splenic arteriovenous fistula.

Regional portal hypertension is a rare cause of upper gastrointestinal bleeding. We reported an extremely rare case in which regional portal hypertension was associated with both the splenic arteriovenous fistula and chronic pancreatitis. In June 2010, our patient, a 41-year-old man, was admitted to a local hospital due to a sudden melena and dizziness without haematemesis and jaundice. The splenic arteriovenous fistula in this patient was successfully occluded through transcatheter arterial embolization. At the 12-mo follow-up, our patient was in good condition.