Liver

Vascular occlusion ( MCQ with free answer)

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Q) During hepatic resection, there was excessive bleeding and Pringle's maneuvre was performed. What is false about vascular occlusion for hepatic surgery?

A. Portal triad clamping along with clamping of supra hepatic and infra hepatic IVC allows adequate bleeding control
B. Prolonged intermittent clamping is usually used in longer surgeries
C. Portal triad clamping can be done for 60 minutes under normothermia
D. Liver tolerates vascular clamping well

Ans b is false, Short intermittent clamping is better

Hepatic vascular exclusion (HVE) combines total inflow and outflow vascular occlusion of the liver. Total isolation of the liver
from the systemic circulation is intended during resection of large tumors adjacent to or involving the major hepatic veins
and/or the IVC.  ( BG 1619)

Intermittent inflow occlusion (Pringle, 1908) to control blood flow to the remnant, usually maintaining inflow occlusion for
periods of 15 minutes, interspersed by 5 minute periods of relief to allow perfusion of the remnant and decompression of
the bowel.

The superiority of intermittent inflow occlusion versus continuous or total occlusion is now widely accepted

According to the Cochrane database, in elective resection, intermittent portal triad clamping seems better than continuous clamping, especially in patients with diseased parenchyma. Therefore, intermittent triad clamping could be recommended as the “gold
standard” method of clamping

Clamps are applied for up to 60 minutes in patients with normal liver ( BG 1619)

c)  is true A number of studies have

established that ≤ 90 min of complete PTC is safe in normal livers. Nonetheless, many surgeons will not clamp the inflow continuously for > 45 min because of concern about occult liver damage and most resections can be accomplished within this time frame.

d) is true Although the liver is relatively resistant to periods of warm ischaemia, it is vulnerable to anoxic conditions and may be more severely vulnerable if it has been chronically damaged by either cirrhosis or chemotherapy.

EHPVO with Portal Hypertension

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Q) An young male with cholangitis, EHPVO + Portal Biliopathy was drained with a plastic biliary stent next step?

a) Repeat biliary Stenting every 3 months then followed up

b) Replace plastic to bare metal stent

c) Prepare for Lineorenal shunt surgery

d) Do MRCP and proceed accordingly

Points  about Portal Biliopathy

Portal biliopathy (PB) is a clinical condition defined as the presence of abnormalities in the biliary tree (including biliary tree and gallbladder) in patients with non-cirrhotic/non-neoplastic extrahepatic portal vein obstruction (EHPVO) and portal cavernoma.

The spectrum of biliary abnormalities include both  intra- and extra-hepatic biliary stenosis (single or multiple)

With or without consensual above dilation

Bile duct wall irregularity or thickening

Bile duct angulation

Varicose veins located at the ductular walls and gallbladder