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Computed tomography in the preoperative study of portal hypertension
The American Journal of Surgery (2015) -, -
Letter to the Editor
Computed tomography in the preoperative study of portal hypertension To the Editor: We read with great interest the article by Duan et al,1 concerning surgery for hepatocellular carcinoma, including splenectomy, in patients with portal hypertension. In cirrhotic patients, before any surgical decision, we estimate with great importance a precise morphodynamic study of the portal system that today can be obtained by contrastenhanced computed tomography.2 It is well known that unexpected diseases, such as thrombosis of the portal or splenic vein, ectopic varices, arterioportal fistulas, and so on, can be discovered, therefore orientating any therapeutic decision; besides, 2 other particular situations can interest the surgeon. First, a particular condition of severe portal hypertension, predisposing to a hepatofugal portal flow, must not be disregarded. The computed tomography’s most important signs consist of an attenuated contrast of the liver parenchyma compared with that of the spleen, a scant and sometimes distorted intrahepatic portal vascular tree, a diameter of the portal vein smaller than that of the splenic vein, and an enlarged left gastric vein sometimes surrounded by collaterals.3 Color Doppler ultrasound usually shows a blood flow with a decreased velocity or even with a reversed hepatofugal direction.4 This abnormal hemodynamics is usually connected to a severely deteriorated hepatic function: in a selected cohort of 30 cirrhotic patients with this pathology of the portal system, we scored 20 of them (66.66%) as Child-Pugh C. In these cases, more complications can arise intra- or postoperatively. Second, we recall attention to the different development of the portal venous collaterals that can accompany an enlarged spleen and sustain important splenorenal or spleno-retroperitoneal shunts. In a group of 25 cirrhotic patients, with a greatly augmented mean splenic volume (597 cm3), we observed this condition in 4 (16%) of them.5 This particular assessment of the portal venous collaterals
0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved.
can be abolished by splenectomy, performed with the purpose of reducing the portal inflow, and, possibly, improve its hemodynamics.6 In conclusion, a careful morphodynamic evaluation of the portal venous system must accompany the clinicometabolic scoring of liver cirrhosis. Antonio Manenti, M.D. Alberto Farinetti, M.D. Serena Calderoni, M.D. Department of Surgery, University of Modena, Modena, Italy Dario Colasanto, M.D. Department of Radiology, University of Modena, Modena, Italy http://dx.doi.org/10.1016/j.amjsurg.2014.12.053
References 1. Duan YF, Li XD, Sun DL, et al. A preliminary study on surgery for hepatocellular carcinoma patients with portal hypertension. Am J Surg 2014. http://dx.doi.org/10.1016/j.amjsurg.2014.08.022. 2. Sangster GP, Previgliano CH, Nader M, et al. MDCT imaging findings of liver cirrhosis: spectrum of hepatic and extrahepatic abdominal complications. HPB Surg 2013;2013:129396. 3. Wachsberg RH, Bahramipour CT, Sofocleous C, et al. Hepatofugal flow in the portal venous system: pathophysiology, imaging findings, and prognostic pitfalls. Radiographics 2002;22:123–40. 4. Baik SK. Haemodynamic evaluation by Doppler ultrasonography in patients with portal hypertension: a review. Liver Int 2010;30:1403–13. 5. Harris A, Kamishima T, Hao HY, et al. Splenic volume measurements on computed tomography utilizing automatically contouring software and its relationship with age, gender, and anthropometric parameters. Eur J Radiol 2010;75:e79–101. 6. Kawanaka H, Akahoshi T, Kingo N, et al. Effect of laparoscopic splenectomy on portal haemodynamics in patients with liver cirrhosis and portal hypertension. Br J Surg 2014;101:1585–93.
Letter to the Editor
Computed tomography in the preoperative study of portal hypertension To the Editor: We read with great interest the article by Duan et al,1 concerning surgery for hepatocellular carcinoma, including splenectomy, in patients with portal hypertension. In cirrhotic patients, before any surgical decision, we estimate with great importance a precise morphodynamic study of the portal system that today can be obtained by contrastenhanced computed tomography.2 It is well known that unexpected diseases, such as thrombosis of the portal or splenic vein, ectopic varices, arterioportal fistulas, and so on, can be discovered, therefore orientating any therapeutic decision; besides, 2 other particular situations can interest the surgeon. First, a particular condition of severe portal hypertension, predisposing to a hepatofugal portal flow, must not be disregarded. The computed tomography’s most important signs consist of an attenuated contrast of the liver parenchyma compared with that of the spleen, a scant and sometimes distorted intrahepatic portal vascular tree, a diameter of the portal vein smaller than that of the splenic vein, and an enlarged left gastric vein sometimes surrounded by collaterals.3 Color Doppler ultrasound usually shows a blood flow with a decreased velocity or even with a reversed hepatofugal direction.4 This abnormal hemodynamics is usually connected to a severely deteriorated hepatic function: in a selected cohort of 30 cirrhotic patients with this pathology of the portal system, we scored 20 of them (66.66%) as Child-Pugh C. In these cases, more complications can arise intra- or postoperatively. Second, we recall attention to the different development of the portal venous collaterals that can accompany an enlarged spleen and sustain important splenorenal or spleno-retroperitoneal shunts. In a group of 25 cirrhotic patients, with a greatly augmented mean splenic volume (597 cm3), we observed this condition in 4 (16%) of them.5 This particular assessment of the portal venous collaterals
0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved.
can be abolished by splenectomy, performed with the purpose of reducing the portal inflow, and, possibly, improve its hemodynamics.6 In conclusion, a careful morphodynamic evaluation of the portal venous system must accompany the clinicometabolic scoring of liver cirrhosis. Antonio Manenti, M.D. Alberto Farinetti, M.D. Serena Calderoni, M.D. Department of Surgery, University of Modena, Modena, Italy Dario Colasanto, M.D. Department of Radiology, University of Modena, Modena, Italy http://dx.doi.org/10.1016/j.amjsurg.2014.12.053
References 1. Duan YF, Li XD, Sun DL, et al. A preliminary study on surgery for hepatocellular carcinoma patients with portal hypertension. Am J Surg 2014. http://dx.doi.org/10.1016/j.amjsurg.2014.08.022. 2. Sangster GP, Previgliano CH, Nader M, et al. MDCT imaging findings of liver cirrhosis: spectrum of hepatic and extrahepatic abdominal complications. HPB Surg 2013;2013:129396. 3. Wachsberg RH, Bahramipour CT, Sofocleous C, et al. Hepatofugal flow in the portal venous system: pathophysiology, imaging findings, and prognostic pitfalls. Radiographics 2002;22:123–40. 4. Baik SK. Haemodynamic evaluation by Doppler ultrasonography in patients with portal hypertension: a review. Liver Int 2010;30:1403–13. 5. Harris A, Kamishima T, Hao HY, et al. Splenic volume measurements on computed tomography utilizing automatically contouring software and its relationship with age, gender, and anthropometric parameters. Eur J Radiol 2010;75:e79–101. 6. Kawanaka H, Akahoshi T, Kingo N, et al. Effect of laparoscopic splenectomy on portal haemodynamics in patients with liver cirrhosis and portal hypertension. Br J Surg 2014;101:1585–93.