Portal flow into the liver through veins at the site of biliary-enteric anastomosis

Abstract

The aim of this study was to establish the role played by jejunal veins in hepatopetal flow after biliary-enteric anastomosis and to evaluate the helical CT features of hepatopetal flow through the anastomosis. We retrospectively analyzed helical CT images of the liver in 31 patients with biliary-enteric anastomosis who underwent hepatic angiography with (n=13) or without (n=18) CT arterial portography within 2 weeks of the CT examination during the last 4 years. Arterial portography showed hepatopetal flow through small vessels located (communicating veins) between the elevated jejunal veins and the intrahepatic portal branches in two (9%) of 22 patients with a normal portal system. Helical CT showed focal parenchymal enhancement around the anastomosis in these two patients. All nine patients with extrahepatic portal vein occlusion (100%) had hepatopetal flow through the anastomosis, and four of the nine had decreased portal flow. CT revealed small communicating veins in two of these four patients. In five patients with normal portal perfusion despite extrahepatic portal vein occlusion, CT detected dilated communicating veins and elevated jejunal veins. The presence of communicating veins and/or focal parenchymal enhancement around the anastomosis indicates hepatopetal flow through the elevated jejunal veins.

Unusual venous collateral pathways allow for reperfusion of the intrahepatic portal venous system in children with portal vein thrombosis after split liver transplantation: Clinical relevance and management implications

“…These neo‐collaterals cross the bilio‐jejunal anastomosis and the adhesions between the loop and the liver and then flow into the portal branches of the graft. This feature mimics a process that is already well described in non‐transplant settings at the level of intestinal or bilio‐jejunal anastomosis . In the distal portion of the Roux‐en‐Y loop, this venous network develops in the sub‐mucosal layer and creates varices .…”

“…A cavernoma can develop in the porta hepatis when it is unoperated on and intact, and it is also well described even after a complete division of the choledocus and a diversion into the Roux‐en‐Y jejunal loop. In the latter cases, a cavernoma develops along the jejunal loop, and the collateral veins cross the surgical anastomosis . In a paediatric LLSG transplant setting, radical resection of the native liver implies a complete section of all of the elements of the porta hepatis (the bile duct and all of the vascular, lymphatic, and nervous structures).…”

“…A cavernomatous transformation after a PVT event typically develops within the porta hepatis through the parabiliary venous system along the entire hepato-choledochal duct, feeding from the pancrea- bilio-jejunal anastomosis. 8,17 In the distal portion of the Roux-en-Y loop, this venous network develops in the sub-mucosal layer and creates varices. 9,10,18 This finding is exceedingly clinically relevant given that similar to oesophageal varices, the former can rupture and cause a haemorrhage; this is relevant because it is common to observe also that children bleeding at least once from these sites tend to present a recurrence of the bleeding in the long term.…”

“…Because the curative options are limited and the major clinical complications do not present themselves in the first years after PVT, most patients with CEPH are usually managed conservatively for long periods, and the therapeutic procedures are limited to endoscopic management of the bleedings. CEPH is associated with the development of venous collaterals and portosystemic shunting as well as numerous neo‐collaterals running through the porta hepatis and along the bile duct towards the liver, forming a “portal cavernoma.” Although this has only been anecdotally mentioned in the literature, cavernoma may develop in the distal portion of a Roux‐en‐Y jejunal loop in patients who have had a bilio‐jejunal reconstruction. In this study, the authors analysed the development of venous neo‐collateral networks in transplanted children with PVT and CEPH, and their relevance for the transplanting physician and the transplant surgeon.…”

“…CEPH is associated with the development of venous collaterals and portosystemic shunting as well as numerous neo-collaterals running through the porta hepatis and along the bile duct towards the liver, forming a "portal cavernoma." Although this has only been anecdotally mentioned in the literature, [8][9][10] cavernoma may develop in the distal portion of a Roux-en-Y jejunal loop in patients who have had a bilio-jejunal reconstruction. In this study, the authors analysed the development of venous neo-collateral networks in transplanted children with PVT and CEPH, and their relevance for the transplanting physician and the transplant surgeon.…”