Combined Hepatic Vein, Umbilicoportal Vein, and Superior Mesenteric Artery Catheterization in Portal Hypertension: Estimation of the Portal Fraction of Total Hepatic Blood Flow in Cirrhotic Patients

Hemodynamic data were obtained in 13 cirrhotic patients with severe portal hypertension, undergoing combined hepatic vein, umbilicoportal vein, and superior mesenteric artery catheterization. The relative clearance of indocyanine green, the portohepatic gradient (difference between the free portal venous pressure and the free hepatic venous pressure), and the estimated hepatic blood flow were measured. The portal fraction (PF) of total hepatic blood flow was calculated in all patients using indicator dilution curves obtained from the portal bifurcation, a right hepatic vein, and when possible a left hepatic vein (six cases) after injection of ⁵¹Cr-labeled red blood cells (⁵¹Cr RBC) into the superior mesenteric artery. Flows were overestimated because of loss of indicator through spontaneous portosystemic shunts; however, the ratio between hepatic and portal indicator dilution curves can be used to calculate the portal fraction of total hepatic blood flow since no extrahepatic shunts existed after the bifurcation of the portal vein (as shown on portography). In 10 patients, 15 series of curves were calculable and the PF varied between 30.1 and 100% (mean ± SE: 71.1 ± 6.2%). In the three other patients, only delayed activity from recirculation was detected from portal and hepatic vein samples and PF was 0%; in these three cases, portography and arteriography revealed spontaneous portacaval shunting with reverse and/or stagnant circulation in the portal vein. In the 13 patients, no correlation existed between PF and the relative clearance of indocyanine green or the portohepatic gradient, parameters generally used as indices of severity in cirrhosis. In 10 patients, no correlation was found between PF and the estimated hepatic blood flow.     

多层螺旋CT门静脉成像在评估肝硬化门脉侧枝血管中的价值

目的：评价多层螺旋CT门静脉成像显示门静脉高压的价值。材料与方法：30例门脉高压患者进行了螺旋CT门脉成像检查,其中10例患者又进行了门静脉造影检查(间接法)。30例患者中全部存在侧枝循环,多数病例有2个或2个以上部位侧枝循环。结果：多层螺旋CT门静脉成像不仅显示了肝内门静脉2-3级分支,还显示了整套门脉侧枝血管系统。在三维门脉像上,脾门静脉曲张29例(占96．7％),其中1例脾静脉因栓子部分闭塞而狭窄,另有1例则完全栓塞血管未显示。胃左静脉曲张28例(占93％),食管或食管旁静脉曲张27例(占90％),胃短静脉(胃后静脉)曲张19例(占63％),胃肾分流血管10例(占33％),腹膜后静脉曲张9例(占30％),脐周静脉曲张伴腹壁静脉曲张6例(占20％)。10例患者CT三维门脉像与间接门静脉造影作比较,前者对门静脉及其侧枝循环的显示好于后者。结论：多层螺旋CT门脉成像是门静脉无创性检查的可靠方法,有较高的临床运用价值。     

不同入肝血流阻断方式对荷瘤小鼠肝功能影响的实验研究

目的:探讨不同血流阻断方式对荷瘤小鼠肝细胞功能的影响。方法:选择昆明小鼠24只随机分为三组,正常对照组(Suspe-nded operation,SO)、肝门阻断组(Occlusion of the portal triad,OPT)、保留肝动脉持续阻断门静脉(Occlusion of portal vein,OPV)各8只。采用门静脉注射肿瘤的方法建立肝癌模型,建模后3天采用阻断范围为左外叶和中叶、阻断时间为60分钟的入肝血流阻断方式,复流后5天后,通过测量3组对肝脏的缺血再灌注损伤程度以及病理学变化来评价不同血流阻断方式对肝细胞功能影响的程度。结果:门静脉注射小鼠肝癌细胞8天后,对照组测量小鼠正常丙氨酸氨基转移酶(ALT)值为66.5±22.3 IU/L,OPT组值为276.3±80.5 IU/L,OPV组值为89.6±28.4 IU/L,两组比较有统计学差异(P0.01);对照组测量小鼠正常天冬氨酸氨基转移酶(AST)值为301.3±126.7 IU/L,OPT组值为1126.4±285.5 IU/L,OPV组值为438.6±150.7 IU/L,两组比较有统计学差异(P0.01),病理组织学OPV组肝细胞损伤程度明显较OPT组轻。结论:保留肝动脉持续阻断门静脉可以减轻荷瘤小鼠肝脏的缺血再灌注损伤。     

Hepatoportography via the Umbilical Vein: A Superior Approach to Diagnosis in Liver Disease

The umbilical vein in adults is patent but collapsed. There is a membranous valve at its entrance into the left portal vein. Cannulation of the portal vein via the umbilical vein permits direct access to the portal system for portography and hepatography. This procedure was performed under local or general anesthesia in 30 patients and was successful in 22. It is useful in the investigation of patients with portal hypertension, and suspected intrahepatic tumours or abscesses. It gives excellent contrast visualization of the liver and definition of lesions as small as 1.0 cm. This technique is superior to both hepatic scanning and splenoportography.     

Rex Shunt Preoperative Imaging: Diagnostic Capability of Imaging Modalities

The purpose of this study was to evaluate the diagnostic capability of imaging modalities used for preoperative mesenteric-left portal bypass (“Rex shunt”) planning. Twenty patients with extrahepatic portal vein thrombosis underwent 57 preoperative planning abdominal imaging studies. Two readers retrospectively reviewed these studies for an ability to confidently determine left portal vein (PV) patency, superior mesenteric vein (SMV) patency, and intrahepatic left and right PV contiguity. In this study, computed tomographic arterial portography allowed for confident characterization of left PV patency, SMV patency and left and right PV continuity in 100% of the examinations. Single phase contrast-enhanced CT, multi-phase contrast-enhanced CT, multiphase contrast-enhanced MRI, and transarterial portography answered all key diagnostic questions in 33%, 30%, 0% and 8% of the examinations, respectively. In conclusion, of the variety of imaging modalities that have been employed for Rex shunt preoperative planning, computed tomographic arterial portography most reliably allows for assessment of left PV patency, SMV patency, and left and right PV contiguity in a single study.     

Efficacy and Safety of Right Hemihepatectomy Through the Right Retrohepatic Tunnel

We wished to study the efficacy and safety of the retrograde ligation of short hepatic veins (SHVs) and the right hepatic vein (HV) through the retrohepatic tunnel in patients who underwent hemihepatectomy due to large hepatic carcinoma in the right lobe of the liver. Right hemihepatectomy was performed in 23 patients with tumors larger than 8 cm in diameter. The liver was separated at the secondary porta, and the interspace between right HVs and middle HVs was expanded. The right hepatic portal vein and hepatic artery were freed and ligated, followed by the retrograde dissection of SHVs and the right HV along the right retrohepatic space anterior to the inferior vena cava. A blocking belt was set at the left side of the midline, after which the right liver was cut off. The procedure was successfully completed in all patients. The average amount of intraoperative blood loss was 640 ml. The change in hepatic function was observed on the third postoperative day. Twenty-two patients exhibited satisfactory results; one patient died from postoperative hepatic failure. In conclusion, this procedure can be safely performed in most hemihepatectomy patients with liver tumors.     

A portal-arterial glucose concentration gradient as a signal for an insulin-dependent net glucose uptake in perfused rat liver

Since in the usual perfusion of isolated rat liver via the portal vein an insulin-dependent increase of hepatic glucose uptake could not be demonstrated, the possibility was considered that hepatic glucose uptake might not be a function of the absolute concentration of this substrate but of its concentration gradient between the portal vein and the hepatic artery. Therefore a new method was established for the simultaneous perfusion of isolated rat liver via both the hepatic artery (20-35% flow) and the portal vein (80-65% flow). When glucose was offered in a concentration gradient, 9.5 mM in the portal vein and 6 mM in the hepatic artery, insulin given via both vessels caused a shift from net glucose release to uptake. This insulin-dependent shift was not observed when glucose was offered without a gradient or with an inverse gradient, 6 mM in the portal vein and 9.5 mM in the hepatic artery. Using a portal-arterial glucose gradient as a signal the liver might be able to differentiate between endogenous and exogenous glucose.     

Interventional radiological treatment of non-colorectal liver metastases

Transcatheter treatment was performed in 81 patients with unresectable non-colorectal liver metastases. Effectiveness increased in the following order: hepatic artery infusion--arterial chemoembolization--combined, arterial and portal vein oily chemoembolization. The mean survival rates for these methods were 8.2 +/- 5.3, vs 11.7 +/- 12.9 vs 13.6 +/- 6.8 mo, and 1-year survival rates 29% vs 46% vs 65%, respectively. Chemoembolization with doxorubicin-in-oil and gelatin sponge was the most effective technique. Interventional radiological procedures were effective in neuroendocrine liver metastases. The mean survival, 1- and 3-year survival rates were as high as 34 mo, 100% and 80%, respectively, for hepatic metastases from resected malignant carcinoid tumors. Also good results were achieved after chemoembolization of metastatic ovarian carcinoma and arterial infusion for gastric carcinoma metastatic to the liver. Transcatheter treatment was ineffective in liver metastases from pancreatic carcinoma, gallbladder cancer, and unknown (and non-resected) tumors. The initial results of the use of interventional radiological procedures in non-colorectal liver metastases are promising, so following clinical trails are needed.     

三氧化二砷栓塞联合肝动脉介入治疗转移性肝癌的疗效并33例临床观察

目的：观察并探讨三氧化二砷碘油栓塞联合置管介入化疗治疗转移性肝癌的临床效果。方法：选取辽宁省肿瘤医院介入治疗科2008-2010年收治的转移性肝癌患者33例,进行肝动脉造影及间接门脉造影,根据肝动脉造影或门脉造影结果,根据肝动脉供血情况分别采取肝动脉化疗栓塞及肝动脉灌注化疗方法治疗,3．4周为1治疗周期,共完成4个治疗周期,治疗结束后评价患者,陆床有效率,随访半年、1年、2年患者生存率。结果：①介入治疗后,患者,临床症状均改善,KPS得分明显高于化疗前（P〈0．05）,临床总有效率81．82％。②随访半年、1年、2年生存率分别为90．9l％、66．67％、33.33％,肝动脉化疗栓塞组患者中远期生存率明显高于肝动脉灌注化疗的患者。结论：三氧化二砷可从多角度抑制癌细胞,临床应用安全有效;对于不能手术和不适宜手术的转移性肝癌患者,根据肝动脉供血情况和特点选择合适的介入治疗,可获得满意疗效。     

肝萎缩增生复合征及肝萎缩病理和代谢功能研究进展

肝萎缩增生复合征(atrophy-hypertrophy complex,AHC)是指肝组织萎缩和代偿性增生的一种临床病理特征,常见的病因有门静脉流入受阻、肝静脉流出受阻、胆道梗阻等。AHC常伴有区域性肝组织的解剖、病理、代谢功能的改变,包括肝脏沿肝门轴的旋转、萎缩肝叶的纤维化和门管区小门静脉的狭窄或血栓形成等。肝萎缩-增生复合征萎缩肝组织仍具有部分代谢功能和生物转化功能,并可能对维持病变肝脏的正常肝功能具有重要的作用,萎缩肝组织仍具有部分代谢功能和生物转化功能,对萎缩肝组织的代谢分区和代谢功能的进一步研究具有重要意义。本文通过分析近年来国内外有关AHC的文献,探讨AHC的病因、病理变化及萎缩肝组织的代谢功能分化特征的研究进展。     

Splanchnic glucagon kinetics in exercising alloxan-diabetic dogs.

The purpose of this study was to define the relationship between arterial immunoreactive glucagon (IRG) and IRG that perfuses the liver via the portal vein during exercise in the diabetic state. Dogs underwent surgery >16 days before the experiment, at which time flow probes were implanted in the portal vein and the hepatic artery, and Silastic catheters were inserted in the carotid artery, portal vein, and hepatic vein for sampling. Dogs were made diabetic with alloxan injected intravenously approximately 3 wk before study (AD) or were studied in the nondiabetic state (ND). Each study consisted of a 30-min basal period and a 150-min moderate-exercise period on a treadmill. The findings from these studies indicate that the exercise-induced increment in portal vein IRG can be substantially greater in AD compared with ND, even when arterial and hepatic vein increments are not different. The larger IRG gradient from the portal vein to the systemic circulation in AD dogs is a function of a twofold greater increase in nonhepatic splanchnic IRG release and a fivefold greater hepatic fractional IRG extraction during exercise. In conclusion, during exercise, arterial IRG concentrations greatly underestimate the IRG levels to which the liver is exposed in ND, and this underestimation is considerably greater in dogs with poorly controlled diabetes.     

Application of 128 Slice 4D CT Whole Liver Perfusion Imaging in Hepatic Tumor

To investigate the clinical significance of 128 slice whole liver four dimensional computed tomography (4D CT) in diagnosis and differential diagnosis of hepatic disease, by characterizing and comparing perfusion maps in two common hepatic tumors: hepatocellular carcinoma (HCC) and liver hemangioma. 45 patients with HCC and 40 patients with liver hemangioma were subjected to 128 slice 4D CT of the whole liver perfusion scan, perfusion images were obtained, and data were processed by the perfusion software. Four perfusion parameters generated automatically were used to characterize and compare the perfusion of tumor tissue and surrounding hepatic parenchyma: blood flow perfusion (BF), arterial liver perfusion (ALP), portal venous perfusion (PVP), and hepatic perfusion index (HPI). Volumetric CT perfusion data then reconstructed to yield 4D CT angiography. Morphological observation was made regarding to the blood supply of tumor, intrahepatic vasculature. (1) In both HCC and hepatic hemangioma, BF, ALP, HPI were higher (P < 0.01), whereas PVP were lower (P < 0.01) in tumor tissue than the surrounding hepatic parenchyma (within 1 cm of lesion). Compared with liver hemangioma tumor tissue, BF, ALP, PVP were lower in HCC tumor tissue (P < 0.05; 0.01; 0.01), but HPI is higher (P < 0.05). For the perfusion of the surrounding parenchyma, BF and ALP were higher (P < 0.001), PVP was lower (P < 0.001) in HCC, while HPI was unchanged. (2) Among 45 cases with HCC, cancer feeding artery was found in 28 cases. In 20 cases feeding artery was shown as thickening, rigid, or distorted. Tumor thrombus in portal vein was found in 14 cases. For total of 40 cases with liver hemangioma, in 23 cases blood vessels are shifted due to compression from tumor mass, the rest 17 cases show normal vasculature. With application of 128 slice 4D CT, whole liver perfusion scan can reliably reflect the hemodynamic characteristics of HCC and hepatic hemangioma, proving to be a valuable adjunct to conventional imaging techniques of liver for early detection, differential diagnosis, and determining surgical resection range as well as estimating prognosis for hepatic tumors.     

脾切除及贲门周围血管离断术对肝硬化门静脉高压患者肝脏血流动力学的影响及其术后门静脉血栓形成的因素分析

目的:探讨脾切除及贲门周围血管离断术对肝硬化门静脉高压患者肝脏血流动力学的影响,并分析患者术后门静脉血栓形成的危险因素。方法:选择2016年1月-2017年12月在我院进行脾切除及贲门周围血管离断术的96例肝硬化门静脉高压患者,于术前、术后1d、3d、7d采用彩色多普勒超声对患者的肝脏血流动力学指标进行动态监测。统计术后7d内患者门静脉血栓的发生率,并将患者分为血栓组(n=28)和无血栓组(n=68),对两组患者的一般资料、手术指标、彩色多普勒超声监测指标等进行单因素分析,并采用Logistic多因素回归分析门静脉血栓形成的危险因素。结果:患者在术前、术后1d、3d、7d时的门静脉内径、最大流速、血流量呈逐渐降低的趋势,肝动脉内径、最大流速、血流量呈逐渐升高的趋势,且各时间点间两两比较差异有统计学意义(P0.05)。术后7d内有28例患者出现门静脉血栓,发生率为29.17%。血栓组和无血栓组患者在性别、年龄、体质量指数、手术时间、术前门静脉流速比较差异无统计学意义(P0.05);血栓组患者Child-Pugh分级为B级比例、术中出血量、脾质量、腹水量、术前门静脉内径均高于无血栓组,术后门静脉内径、术后门静脉流速均低于无血栓组(P0.05)。经Logistic多因素回归分析显示,患者术后门静脉内径、术后门静脉流速是门静脉血栓形成的危险因素(P0.05)。结论:行脾切除及贲门周围血管离断术的肝硬化门静脉高压患者术后进行肝脏血流动力学监测,有助于患者术后的疗效判断,且术后门静脉内径、术后门静脉流速是门静脉血栓形成的危险因素。     

Different accessibility from the artery and the portal vein of alpha- and beta-receptors involved in the sympathetic nerve action on glycogenolysis and hemodynamics in perfused rat liver

In perfused rat liver perivascular nerve stimulation (7.5 Hz, 20 V, 2 ms, 5 min) at the liver hilus caused an increase in glucose and lactate output and a decrease in flow. The influence of the alpha 1-receptor blocker prazosine and the beta-blocker propranolol on these nerve effects was studied in the isolated rat liver perfused classically via the portal vein only and, as developed recently, via both the hepatic artery and the portal vein. 1) In livers perfused via the portal vein only the nerve stimulation-dependent metabolic alterations were nearly completely inhibited by prazosine (5 microM), but not influenced by propranolol (10 microM). The hemodynamic changes were lowered to only 33% by prazosine and not altered by propranolol either. 2) In livers perfused via the hepatic artery (100 mm Hg, 20-40% of flow) and the portal vein (10 mm Hg, 80-60% of flow)--similar to portal perfusions--the nerve stimulation--dependent metabolic alterations were almost completely blocked by arterial, portal or simultaneously applied arterial and portal prazosine. However--in contrast to portal perfusions--the metabolic alterations were reduced to about 20% (glucose) and 50% (lactate) also by propranolol independently of its site of application. The decrease in flow was reduced by prazosine to about 60%, 50% and 30% when applied via the artery, the portal vein or via both vessels, respectively. The hemodynamic alterations were not influenced by propranolol. These results allow the following conclusions: A subpopulation of beta-receptors can play a permissive role in the alpha 1-receptor-mediated sympathetic nerve action on glucose and lactate metabolism.(ABSTRACT TRUNCATED AT 250 WORDS)     

Liver parenchyma heterogeneity in the response to extracellular NAD+

The perfused rat liver responds intensely to NAD+ infusion (20-100 microM). Increases in portal perfusion pressure and glycogenolysis and transient inhibition of oxygen consumption are some of the effects that were observed. The aim of the present work was to investigate the distribution of the response to extracellular NAD+ along the hepatic acinus. The bivascularly perfused rat liver was used. Various combinations of perfusion directions (antegrade and retrograde) and infusion routes (portal vein, hepatic vein and hepatic artery) were used in order to supply NAD+ to different regions of the liver parenchyma, also taking advantage of the fact that its extracellular transformation generates steep concentration gradients. Oxygen uptake was stimulated by NAD+ in retrograde perfusion (irrespective of the infusion route) and transiently inhibited in antegrade perfusion. This indicates that the signal causing oxygen uptake inhibition is generated in the periportal area. The signal responsible for oxygen uptake stimulation is homogenously distributed. Stimulation of glucose release was more intense when NAD+ was infused into the portal vein or into the hepatic artery, indicating that stimulation of glycogenolysis predominates in the periportal area. The increases in perfusion pressure were more pronounced when the periportal area was supplied with NAD+ suggesting that the vasoconstrictive elements responding to NAD+ predominate in this region. The response to extracellular NAD+ is thus unequally distributed in the liver. As a paracrine agent, NAD+ is likely to be released locally. It can be concluded that its effects will be different depending on the area where it is released.     

肝脏移植术前受体64 排CT 血管成像临床应用价值

目的:探讨肝脏移植术前受体64排螺旋CT血管成像(computed tomography angiography CTA)在临床的应用价值。方法:对28例晚期肝病患者进行64排增强后动脉期、门脉期及静脉期扫描,使用多种重建方法,由两名以上有经验的医师对肝脏血管进行分析评价,并与18例移植术后结果比较,探讨64排CT血管成像对肝移植术前准备的意义。结果:发现肝动脉变异6例,腹腔干起始部狭窄2例,腹腔干动脉瘤1例,脾动脉瘤2例,肝脏主要供血动脉直径<3mm 3例,肝门静脉海绵样变3例,肝外门静脉主干栓塞5例,伴有肝内门静脉栓塞3例,肝外门静脉主干栓塞伴肠系膜上静脉广泛栓塞2例,下腔静脉癌栓3例,其中癌栓达右心房2例。结论:64排CT血管成像无创、可靠,通过多种重建方法,能清晰显示肝脏血管,对肝脏移植术前血管做出评价,具有可靠的临床指导意义。     

Fluorescence microscopical and chemical characterization of the adrenergic innervation in mammalian liver tissue

Liver tissue from 12 different mammalian species was studied with a fluorescence histochemical technique for the cellular localization of amines (Falck-Hillarp technique) and with a chemical method for the determination of norepinephrine (HPLC-technique). Adrenergic nerve plexus were found in interlobular blood vessels derived from the portal vein and hepatic artery. Varicose adrenergic nerve fibres were, generally, seen to branch from the fibres around the blood vessels and to enter the liver parenchyma, where they formed a randomly distributed intralobular network. The density of these intralobular fibres showed marked species variation. Human liver and liver from the rhesus monkey, baboon, cynomolgus monkey and guinea pig showed a high density of parenchymal adrenergic nerves. Rabbit, cat, pig, cow and horse liver formed an intermediate group, having fewer varicose adrenergic nerve fibres but an unequivocal distribution of these nerves to the liver parenchyma. In rat and mouse liver no parenchymal innervation could be demonstrated. The density of the parenchymal innervation generally correlated with the concentration of norepinephrine in the liver tissue.     

Expression of connective tissue growth factor in the human liver with idiopathic portal hypertension

Idiopathic portal hypertension (IPH) is a disorder of unknown etiology, clinically associated with portal hypertension in the absence of cirrhosis. This study was designed to delineate the characteristics of IPH RNA expression in liver specimens from patients with IPH. Liver specimens from patients with IPH and patients without liver diseases underwent cDNA expression analysis and in situ hybridization studies. Connective tissue growth factor (CTGF) levels in serum were examined in 76 patients with IPH, 84 patients with hepatitis C virus infection (including those with cirrhosis), and 38 healthy volunteers. Among 588 genes sorted on macroarray, seven up-regulated genes, including CTGF, were detected. In situ hybridization studies showed that positive reactions for CTGF mRNA were most intense in the epithelial cells of proliferating bile ducts within portal tracts in patients with IPH. In the liver parenchyma, there was no appreciable staining of hepatocytes, sinusoidal endothelial cells, or hepatic stellate cells (HSCs), and there were few positive signals for CTGF mRNA in normal liver. The serum CTGF level in patients with IPH was significantly higher than the value in healthy volunteers. Six (8%) of the 76 patients with IPH had serum CTGF levels greater than 80 ng/mL, far exceeding the level of any patient with cirrhosis. In conclusion, overexpression of CTGF is one of the most important features of IPH.     

不同方案治疗直径小于10cm肝细胞癌合并门静脉癌栓患者影响生存率的观察

目的：探讨两种不同方案治疗直径小于10cm肝细胞癌合并门静脉癌栓患者影响生存率。方法：将我院100例直径小于10cm肝细胞癌合并门静脉癌栓患者按照抽签法随机地均分为A、B两组,A组行单纯肝动脉插管化疗栓撒（TACE）治疗,B组肝癌手术切除联合癌栓切除＋TACE术,比较两组患者治疗前后DLIA蛋白与VEGF蛋白阳性表达率、五年生存率以及影响患者生存率的因素。结果：（1）A组治疗前后DLL4蛋白与VEGF蛋白阳性表达率差异无统计学意义（P〉0．05）,B组治疗前后上述蛋白阳性表达率差异具有统计学意义（P〈0．05,P〈0．01）;（2）根据Kaplan—Meir计算方法,B组五年生存率均明显大于A组（P〈0．001）;（3）经Pearson单因素与COX多因素分析,影响患者预后的危险独立因素为肿瘤大小与手术方式。结论：综合治疗方案用于治疗直径小于10cm肝细胞癌合并门静脉癌栓患者之中,疗效显著,患者五年生存率明显提高。