Tsuyoshi Hatsuno

Intrahepatic Anastomosis Formation Between The Hepatic Veins In The Graft Liver Of The Living Related Liver Transplantation: Observation By Doppler Ultrasonography

In living related liver transplantation, the right lobe has come to be used as a graft to meet the metabolic demands of adult or adolescent recipients. In harvesting the right lobe as a graft, however, there is controversy as to whether or not the middle hepatic vein (MHV) should be included and reconstructed. Anatomical intrahepatic anastomosis between the right hepatic vein (RHV) and MHV is considered to exist, but the formation process of this functional anastomosis has not been demonstrated by Doppler ultrasonography (US). In our case, a right lobe including a right branch of the MHV was used as a graft. In implanting, the RHV was anastomosed to the inferior vena cava and the right branch of the MHV was ligated. Using Doppler US, we checked the blood flow in the hepatic vein after transplantation. Within 3 days of surgery, no flow was detected in the right branch of the MHV. A flow around the right branch of the MHV was observed at postoperative day 6. At postoperative day 9, a reverse flow was detected in which the right branch of the MHV drained into the RHV via the anastomosis between them. Based on our results, it appears that a functional intrahepatic anastomosis between hepatic veins formed gradually within 10 days of ligation of an afferent branch, during which time the graft function did not deteriorate.

Emergency Pylorus-Preserving Pancreatoduodenectomy Followed by Second-Stage Pancreatojejunostomy for a Gastrointestinal Stromal Tumor of the Duodenum with an Intratumoral Gas Figure: Report of a Case

We report a case of a duodenal gastrointestinal stromal tumor (GIST) necessitating urgent surgery because of a gas figure on computed tomography (CT). A 46-year-old woman, complaining chiefly of upper abdominal pain and tarry stools, consulted a local doctor. A gastrointestinal fiberscopy revealed an ulcer in the second part of the duodenum, and the patient was admitted to our hospital where a dynamic CT scan showed a hypervascular solid tumor in the pancreatic head. A repeat CT scan done 4 days later showed a gas figure in the tumor, necessitating an emergency pylorus-preserving pancreatoduodenectomy (PpPD). First, we performed a tube pancreatostomy for complete external drainage of the pancreatic juice, and planned a second-stage pancreatojejunostomy for the near future. Histopathologically, the tumor was diagnosed as a GIST originating in the duodenum. The patient was discharged on postoperative day 23 after an uneventful postoperative recovery. Her local doctor completed the second-stage pancreatojejunostomy.

Qualitative and quantitative analysis of portal Doppler waveform and a novel factor of portal pulsatility: Systolic spike wave.

BackgroundWe attempted to identify the physiologic circumstances associated with the portal Doppler waveform.MethodThe subjects were 98 patients: 42 had cirrhosis; 23, hepatitis; and 33, no liver disorder. We measured right portal venous peak velocity, minimum velocity, and hepatic arterial peak systolic velocity. Portal venous pulsatility was calculated as portal venous minimum velocity divided by portal venous peak velocity. We analyzed portal waveforms both qualitatively and quantitatively.ResultsPortal Doppler waveforms were classified as nonphasic, monophasic, biphasic, biphasic including spike wave, and triphasic. Portal waveforms were phasic in 84 subjects who had a mild systolic dip during the arterial systolic period. Markedly portal pulsatility (portal venous pulsatility<0.6) was present in only 7 subjects. A systolic spike wave corresponding to a hepatic arterial peak systolic wave was detected in 48 subjects. Hepatic arterial peak systolic velocity was significantly higher in the group with spike wave than in the group without it.ConclusionAlthough portal pulsatility is generally attributed to multiple factors, the present study has pointed out a new factor; transmission via the hepatic artery through the portal vein vasa vasorum. Hepatic venous drainage and hepatic arterial blood flow influence portal waveform.