[Percutaneous transhepatic portal vein stenting for portal hypertension caused by local recurrence of intrahepatic cholangiocarcinoma]

A 62-year-old woman underwent an extended left hepatectomy with a combined resection of portal vein and extrahepatic bile duct for intrahepatic cholangiocarcinoma (ICC). After 7 years, she presented with repeated tarry black stool and severe anemia. The source of bleeding was not identified on upper and lower gastrointestinal endoscopy. Computed tomography (CT) revealed a small hypodence lesion at portal hepatis, by which portal vein (PV) stenosis was induced in the absence of sufficient development of portal venous collateral. Positron emission tomography revealed an accumulation of fluorodeoxy glucose around PV obstruction. Based on these findings, we diagnosed that the local recurrence of ICC, which resulted in mesenteric hypertension and small bowel varices. Therefore, portal stent placement was carried out under percutaneous transhepatic portgraphy to maintain portal blood flow. An uncovered expandable metallic stent was inserted into the stenotic region. Portgraphy after the stent replacement showed a relief of the PV stenosis and disappearance of the collateral pathways. After this procedure, the patient had no additional episode of gastrointestinal hemorrhage. Our experience suggests that stent placement for postoperative PV stenosis is recommended as a useful treatment for gastrointestinal bleeding caused by portal hypertension that is less invasive.

[Portal vein stenting for portal hypertension caused by local recurrence following hepato-pancreatoduodenectomy for bile duct cancer]

The patient was a 73-year-old man diagnosed with bile duct cancer. He underwent hepato-pancreatoduodenectomy and a combined resection of portal vein in July 2002. The post operative course was uneventful. In December 2003 he had a loss of consciousness, and was admitted to our hospital as an emergency patient. Abdominal CT scan and angiography revealed the presence of portal vein stenosis due to local recurrence of bile duct cancer resulting in portal hypertension. Thus, a metallic stent was placed in the portal vein to maintain portal blood flow. A non-covered metallic stent, 10 mm in diameter and 80 mm in length (SMART stent, Cordis Endovascular), was deployed through the stenotic portal vein. Portography after the stent placement showed a relief of the portal vein stenosis. Intravenous heparin administration was performed at a dose of 5,000 IU per day for 5 days after the stent placement, and this was followed by oral warfarin potassium administration. The clinical course was uneventful and the patient was discharged 21 days after portal stent placement. Portal stenting successfully improved portal hypertension due to stenosis of the portal vein without any complication. Our experience suggests that the portal vein stenting using the SMART stent is useful palliative therapy for portal vein stenosis.

Evaluation of total hepatic vascular exclusion and pringle maneuver in liver resection

BACKGROUND/AIMS

The effects of total hepatic vascular exclusion and Pringle maneuver on intraoperative course and postoperative recovery were retrospectively studied.

METHODOLOGY

Records of 42 patients who underwent a major hepatectomy and six who had a minor hepatectomy were reviewed. Patients with chronic liver disease or obstructive jaundice were excluded. Hepatic vascular exclusion was used in 5 patients who were at high risk for back flow bleeding from the hepatic veins. Pedicular clamping was used in the other 43 patients. Intergroup differences in intraoperative blood loss, postoperative liver function, the serum interleukin-6 concentrations, and clinical outcome were compared.

RESULTS

In four patients of the hepatic vascular exclusion group (n = 5), intraoperative blood loss was less than 2000 mL, and 6000 mL in the remaining patient. However the hepatic vascular exclusion group had longer hepatic ischemia time (45.2 +/- 10.3 min vs. 30.6 +/- 10.9 min), a greater blood loss (2304 +/- 2106 L vs. 913 +/- 1130 mL), a higher serum interleukin-6 concentration (347 +/- 320 pg/mL vs. 93 +/- 58 pg/mL), and a higher morbidity rate (80 vs. 7.1%) compared with the pedicular clamping group (n = 43) (P < 0.05). Postoperative liver function tests were comparable, and no patient developed postoperative hepatic failure. In the pedicular clamping group, intermittent pedicular clamping with periods of 15 minutes (n = 12) increased blood loss (662 +/- 421 mL vs. 1427 +/- 1890 mL), but did not reduce serum interleukin-6 concentration, liver cell damage, or morbidity rate postoperatively, compared with continuous or intermittent clamping of longer periods.

CONCLUSIONS

Hepatic vascular exclusion is an effective way to limit blood loss in hepatic resection without causing sever liver injury. However, the interleukin-6 production is increased and the morbidity rate is high. Paradoxically, periodic release of pedicular clamping increases the blood loss but does not reduce liver cell injury or interleukin-6 production.

Anti-inflammatory response in patients with obstructive jaundice caused by biliary malignancy

BACKGROUND

Obstructive jaundice potentially modulates the host defense mechanism resulting in perioperative infection. It has been reported that a systemic inflammatory response occurs in patients with obstructive jaundice. An anti-inflammatory response was studied in 29 jaundiced patients undergoing biliary drainage.

RESULTS

Plasma concentrations of interleukin (IL)-10, soluble tumor necrosis factor receptor (STNFR) p55, STNFR p75, IL-1 receptor antagonist (IL-1ra), IL-6 and soluble CD14 (sCD14) were measured by using immunoassay. Plasma concentrations of IL-10, STNFR p55, STNFR p75, IL-1ra, IL-6 and sCD14 were significantly higher in jaundiced patients than in the controls (P < 0.01). After biliary drainage, the concentrations of IL-10, the three cytokine antagonists, and IL-6 decreased significantly (P < 0.05). The sCD14 concentration did not decrease. At the time of drainage, the concentrations of STNFR p55 and STNFR p75 were significantly higher in 10 patients with positive bile cultures than in 19 patients with negative bile cultures (P < 0.05). Bile cultures became positive 14 days after drainage in 10 patients, and remained negative in nine. The concentration of STNFR p55 before drainage was significantly higher in the former group (P = 0.05). The plasma concentrations of IL-10 and STNFRs were significantly correlated with the IL-6 concentration, body temperature and the white blood cell count (P < 0.05). Serum total bilirubin levels did not affect plasma levels of anti-inflammatory mediators, and sCD14.

CONCLUSION

Jaundiced patients exhibited an anti-inflammatory immune response that potentially modulates the host defense mechanism and results in anergy and increased susceptibility to infection. Biliary infection may be one of the major stimuli of the immune response.