Hepatography G. Skalkeas, MD, Athens, A. Rlgas, MD, Athens,
Greece
Greece
J. Antiras, MD, Athens,
Greece
P. Fluthas, MD, Athens,
Greece
P. Kritikou, MD, Athens,
Greece
N. Hatzioannou, MD, Athens, N. Exarhos, MD, Athens,
Greece
Greece
The importance of roentgenologic visualization of the liver through the hepatic veins was first demonstrated by Rappaport [I] in 1951. Subsequent reports showed increasing interest in the method which produced valuable information in the diagnosis and differential diagnosis of various hepatic diseases [2-101. Methods of approach to hepatic visualization have varied among investigators and include the following: (1) infusion of contrast medium throughout the venous system of the liver by means of paracentesis of the liver parenchyma [6,9]; (2) catheterization of the hepatic veins via the femoral vein and inferior vena cava [7,11]; (3) catheterization of the hepatic veins via the superior and inferior venae cavae [8,10]. In the infusion method, the following three phases are carried out: (1) An x-ray film of the hepatic veins is taken during infusion of the contrast medium (ramifying form). (2) After infusion, usually of 20 cc of contrast medium, an x-ray film of the entire liver parenchyma is taken (parenchymal form). (3) After a few minutes it is possible to opacify anastomoses which are generally of two types: (a) anastomoses of the veins of the same or different hepatic segments and (b) anastomoses of hepatic veins and the entire inferior vena cava. The existence of these anastomoses does not seem to be of any pathologic significance [IO]. The former anastornoses depend on the position of the catheter whereas the latter depend on the infusion pressure as well as the respiratory time [5]. Hepatic venography has been used in the diagnosis of cirrhosis, hepatic abscess, tumors, hepatic cysts, and the Banti syndrome and to analyze hepatic bulging due to right cardiac insufficiency
[lOI. From the Experimental Laboratory of the 2nd Propedeutic Surgical Clin-
ic. the Universityof Athens, Athens, Greece. Reprint requests shbuldbe addressedto AnastesiosRiges. MD, 17 Lycabetous Street, Athens (1. 135), Greece.
Volume 131, February 1976
Material and Methods Twelve healthy dogs weighing between 12 and 18 kg were used in the present study. (Table I.) Each animal waS intubated and anesthetized with pentobarbital sodium. The animal was connected to a Manley breathing apparatus and the external jugular vein exposed through a small skin incision. The vein was meticulously prepared and sutured centrally with a catheter placed distally. Swan and Cook type catheters were used, although a variety of other catheters such as the Cournand type, three way balloon catheter, and selective arteriography catheter have been described in the literature. In most of our experiments the Cook catheter was used because the Swan catheter was easily carried away TABLE
I
Analysis of Study Material
Animal
Body Weight (kg)
1 2 3 4 5
12 14 17 15 18
6
16
7
15
8
12
9
16
10
18
11
17
12
15
Creation of Technical Hepa- Defectic tive ViRup- osualization tu re
Contrast Medium Urografin Opaque Lipiodol Micropaque Micropaque Urografin Biligrafin Forte Biligrafin Forte Biligrafin Forte Biligrafin Forte Biligrafin Forte Biligrafin Forte Biligrafin Forte
+
Creation of Positive Opacification
-
-
-
-
-
-
-
-
-
-
-
+
-
-
+
-
+
-
+
-
-
+
-
235
Skalkeas et al
Figure 1. Hepatography using 1Yrografin. Figure 2. Hepatography using L!#iOdol.
by the blood and forced into the pulmonary artery. The Cook catheter could easily be introduced into the hepatic veins via the external jugular vein and thereafter through the superior and inferior venae cavae. Roentgenologic visualization by infusion of a small quantity of contrast medium was employed to determine the position of the catheter. Various contrast media were used to study the contrast opacity and possible untoward reaction of each. (Table I.) The quantity administered was 20 cc with the usual infusion pressure being that of the free fall of the plunger in the syringe. X-ray films were taken shortly before completion of the infusion. After simple hepatography and the selection of the appropriate contrast medium, rupture of the
236
Figure 3. Hepatography cropague.
using Mi-
Figure 4. Hepatography cropaque-Urogra fin.
using Mi-
liver was produced in some of the experimental animals and opacifying contrasts (positive and negative) were created by intrahepatic injection of Vaseline and Lipiodol. Of the various contrast media used in this investigation, the best results were obtained with Biligrafin Forte@, which was finally chosen for use in hepatography. The reason for this is analyzed in detail. The remaining contrast media, such as Urografine, Hypaquee, Lipiodole, and Micropaquee, can also be used; however, they have certain disadvantages of side effects: (1) Urografin and Hypaque give an opacification of doubtful diagnostic significance because they are readily received by the blood. (Figure 1.) (21 Lipiodol,
The American Journal of Surgery
Hepatography
Figure 5. Hepatography usin Biligrafin Forte. Figure 6. Hepatography using Biligrafin Forte in a normal liver. Figure 7. Hepatography using Blligrafin Forte after infusion of vaseline, thus creating rupture at the left hepatic lobe.
Figure 6. Hepatography using Biiigrafin Forte with lntrahepatic infusion of Lipiodol. Figure 9. Hepatography using Biligrafin Forte after creation of rupture at the right hepatic lobe. insert shows rupture site. Figure 10. Hepatography using Biligrafin Forte after creation of large rupture at the left hepatic lobe as shown by arrow. when received by the blood, provokes fatty pulmonary microemboli. (Figure 2.) (3) Micropaque, although producing a good picture of the hepatic veins but, to a lesser extent, of the parenchymal tissue, is associated with side effects. (Figures 3 and 4.) We therefore selected Biligrafin Forte which presented no untoward reactions even when used in large doses in some of our experimental animals. Moreover, there were no histologic changes in the hepatic parenchyma. This preparation, remaining in the liver, allows complete visualization during the parenchymal phase. (Figure 5.) The value of Biligrafin Forte was analyzed in four groups of dogs: (1) those with a normal liver (two dogs); (2) those subjected to an intrahepatic injection of vaseline, thus simulating a parenchymal process (two dogs); (3) those subjected to an intrahepatic injection of Lipio-
Volwne 131, February 1976
dol, thus producing positive opacification (one dog); (4) those subjected to parenchymal rupture both small and extensive (two dogs). Thus, with this method, after introducing the Cook catheter and infusing 20 cc of Biligrafin Forte, we were able to obtain normal hepatograms in two dogs. (Figure 6.) The dogs that had received an injection of Vaseline demonstrated a parenchymal process after an infusion of Biligrafin Forte, which displaced the normal hepatic tissue. (Figure 7.) In the animal that had received an injection of Lipiodol intrahepatically, the opacifying contrast of the two media, Lipiodol and Biligrafin Forte, is conspicuous. (Figure 8.) Finally, in the two animals in which rupture of the hepatic parenchyma was produced, after laparotomy, Biligrafin Forte gave a clear picture of the rupture site (Figure 9) as well as a complete change from the normal pattern of the liver (Figure 10).
237
Skalkeas et al
Comments Hepatography is a method of opacifying the liver that gives direct and complete visualization of the liver parenchyma. Previous methods of hepatic visualization in which transcutaneous hepatic venography or catheterization of the femoral vein was used are not without complications. We therefore used the external jugular and superior and inferior venae cavae and found this route of administration to be practical, applicable, and free from complications. Furthermore, the use of Biligrafin Forte increased the value of this method, thus giving good visualization of the liver, Of slight and short duration are anaphylactic phenomena arising from the use of Biligrafin Forte, as cited in the literature [12]. However, its administration remains harmless, the main contraindications being (1) acute febrile hepatic damage; (2) acute cholangitis; (3) severe toxemia; (4) severe Basedow’s disease [12]. Of the roentgenologic phases previously outlined, we used the parenchymal phase, which gave the best opacifying results. During the roentgenologic procedure, various hepatic views as well as tomographic control are possible, thus adding to the diagnostic interest of the method. Summary A method of hepatography in dogs is described in which contrast medium is infused via the external jugular and superior and inferior venae cavae and hepatic veins. Hepatograms taken by infusing
238
different contrast media in the normal liver and in the liver subjected to parenchymatous damage are also analyzed in detail.
References 1. Rappaport AM: Hepatic veinography. Acta Radio/ (Stockh). 36: 165, 1951. 2. Tori G: Hepatic veinography in man. Acta Radio/ (Stockh) 38: 89, 1953. 3. Belli L, Galmarini D, Difrancesco U: Phlebographie selective du foie appliquee a I’etude de la cirrhose, Presse &fed 60: 2276. 1961. 4. Charleux H. Hernandez C, Leger L. et al: Exploration des cirrhoses du foie par phlebographie cave-sus-hepatique. Presse Mbd70: 1215, 1962. 5. Leger L, Lenriot JP, Guillemot R, Bron R, loan 0: Sus hepato-portographie. J Chir (Paris) 10 1: 15 1, 197 1. 6. Moreno AH, Rousselot LM. Burchell AR, Bono R, Burke JH: Studies on the outflow tracts of the liver. On a method for the functional demonstration of the outflow tracts of the liver and its application to the study of hepatic hemodynamics in normal and cirrhotic rats. Ann Surg 155: 412, 1962. 7. Rousseau J, Tavernier J, Mas JP, Staeffen J, Reboul J, Moretti G: Le catheterisme des veines sus-hepatiques par voie femoral. Premiers resultats. Sem H6p Paris 38: 395. 1963. 8. Rappaport AM, Holmes RB, Stolberg HO, MC lntyre IL. Baird RJ: Hepatic veinography. Gastroenterology 46: 115, 1964. 9. Leger L. Premont M, Lefort J: Phlebographie sus-hepatique par injection dans le parenchyme hepatique. Presse A&d 70: 1855, 1962. 10. Le Bras M, Lamouche P. Ekra A, Chauvet J, Tonne1 J, Bertand E: La phlebographie sus hepatique au tours des affections hepato-pot-tales. J Chir 106: 457, 1973. 11. Rousseau J: Le catheterisme des veines sus-hepatiques par-voie femorale. Technique, resultats, applications. These medecine, Bordeaux, 1962. 12. Constantes J: The importance of intravenous biligraphin cholangiography in disturbances of hepatic function. Doctoral Thesis, Athens, 1959.
The American Journalof Surgery
Greece
Greece
J. Antiras, MD, Athens,
Greece
P. Fluthas, MD, Athens,
Greece
P. Kritikou, MD, Athens,
Greece
N. Hatzioannou, MD, Athens, N. Exarhos, MD, Athens,
Greece
Greece
The importance of roentgenologic visualization of the liver through the hepatic veins was first demonstrated by Rappaport [I] in 1951. Subsequent reports showed increasing interest in the method which produced valuable information in the diagnosis and differential diagnosis of various hepatic diseases [2-101. Methods of approach to hepatic visualization have varied among investigators and include the following: (1) infusion of contrast medium throughout the venous system of the liver by means of paracentesis of the liver parenchyma [6,9]; (2) catheterization of the hepatic veins via the femoral vein and inferior vena cava [7,11]; (3) catheterization of the hepatic veins via the superior and inferior venae cavae [8,10]. In the infusion method, the following three phases are carried out: (1) An x-ray film of the hepatic veins is taken during infusion of the contrast medium (ramifying form). (2) After infusion, usually of 20 cc of contrast medium, an x-ray film of the entire liver parenchyma is taken (parenchymal form). (3) After a few minutes it is possible to opacify anastomoses which are generally of two types: (a) anastomoses of the veins of the same or different hepatic segments and (b) anastomoses of hepatic veins and the entire inferior vena cava. The existence of these anastomoses does not seem to be of any pathologic significance [IO]. The former anastornoses depend on the position of the catheter whereas the latter depend on the infusion pressure as well as the respiratory time [5]. Hepatic venography has been used in the diagnosis of cirrhosis, hepatic abscess, tumors, hepatic cysts, and the Banti syndrome and to analyze hepatic bulging due to right cardiac insufficiency
[lOI. From the Experimental Laboratory of the 2nd Propedeutic Surgical Clin-
ic. the Universityof Athens, Athens, Greece. Reprint requests shbuldbe addressedto AnastesiosRiges. MD, 17 Lycabetous Street, Athens (1. 135), Greece.
Volume 131, February 1976
Material and Methods Twelve healthy dogs weighing between 12 and 18 kg were used in the present study. (Table I.) Each animal waS intubated and anesthetized with pentobarbital sodium. The animal was connected to a Manley breathing apparatus and the external jugular vein exposed through a small skin incision. The vein was meticulously prepared and sutured centrally with a catheter placed distally. Swan and Cook type catheters were used, although a variety of other catheters such as the Cournand type, three way balloon catheter, and selective arteriography catheter have been described in the literature. In most of our experiments the Cook catheter was used because the Swan catheter was easily carried away TABLE
I
Analysis of Study Material
Animal
Body Weight (kg)
1 2 3 4 5
12 14 17 15 18
6
16
7
15
8
12
9
16
10
18
11
17
12
15
Creation of Technical Hepa- Defectic tive ViRup- osualization tu re
Contrast Medium Urografin Opaque Lipiodol Micropaque Micropaque Urografin Biligrafin Forte Biligrafin Forte Biligrafin Forte Biligrafin Forte Biligrafin Forte Biligrafin Forte Biligrafin Forte
+
Creation of Positive Opacification
-
-
-
-
-
-
-
-
-
-
-
+
-
-
+
-
+
-
+
-
-
+
-
235
Skalkeas et al
Figure 1. Hepatography using 1Yrografin. Figure 2. Hepatography using L!#iOdol.
by the blood and forced into the pulmonary artery. The Cook catheter could easily be introduced into the hepatic veins via the external jugular vein and thereafter through the superior and inferior venae cavae. Roentgenologic visualization by infusion of a small quantity of contrast medium was employed to determine the position of the catheter. Various contrast media were used to study the contrast opacity and possible untoward reaction of each. (Table I.) The quantity administered was 20 cc with the usual infusion pressure being that of the free fall of the plunger in the syringe. X-ray films were taken shortly before completion of the infusion. After simple hepatography and the selection of the appropriate contrast medium, rupture of the
236
Figure 3. Hepatography cropague.
using Mi-
Figure 4. Hepatography cropaque-Urogra fin.
using Mi-
liver was produced in some of the experimental animals and opacifying contrasts (positive and negative) were created by intrahepatic injection of Vaseline and Lipiodol. Of the various contrast media used in this investigation, the best results were obtained with Biligrafin Forte@, which was finally chosen for use in hepatography. The reason for this is analyzed in detail. The remaining contrast media, such as Urografine, Hypaquee, Lipiodole, and Micropaquee, can also be used; however, they have certain disadvantages of side effects: (1) Urografin and Hypaque give an opacification of doubtful diagnostic significance because they are readily received by the blood. (Figure 1.) (21 Lipiodol,
The American Journal of Surgery
Hepatography
Figure 5. Hepatography usin Biligrafin Forte. Figure 6. Hepatography using Biligrafin Forte in a normal liver. Figure 7. Hepatography using Blligrafin Forte after infusion of vaseline, thus creating rupture at the left hepatic lobe.
Figure 6. Hepatography using Biiigrafin Forte with lntrahepatic infusion of Lipiodol. Figure 9. Hepatography using Biligrafin Forte after creation of rupture at the right hepatic lobe. insert shows rupture site. Figure 10. Hepatography using Biligrafin Forte after creation of large rupture at the left hepatic lobe as shown by arrow. when received by the blood, provokes fatty pulmonary microemboli. (Figure 2.) (3) Micropaque, although producing a good picture of the hepatic veins but, to a lesser extent, of the parenchymal tissue, is associated with side effects. (Figures 3 and 4.) We therefore selected Biligrafin Forte which presented no untoward reactions even when used in large doses in some of our experimental animals. Moreover, there were no histologic changes in the hepatic parenchyma. This preparation, remaining in the liver, allows complete visualization during the parenchymal phase. (Figure 5.) The value of Biligrafin Forte was analyzed in four groups of dogs: (1) those with a normal liver (two dogs); (2) those subjected to an intrahepatic injection of vaseline, thus simulating a parenchymal process (two dogs); (3) those subjected to an intrahepatic injection of Lipio-
Volwne 131, February 1976
dol, thus producing positive opacification (one dog); (4) those subjected to parenchymal rupture both small and extensive (two dogs). Thus, with this method, after introducing the Cook catheter and infusing 20 cc of Biligrafin Forte, we were able to obtain normal hepatograms in two dogs. (Figure 6.) The dogs that had received an injection of Vaseline demonstrated a parenchymal process after an infusion of Biligrafin Forte, which displaced the normal hepatic tissue. (Figure 7.) In the animal that had received an injection of Lipiodol intrahepatically, the opacifying contrast of the two media, Lipiodol and Biligrafin Forte, is conspicuous. (Figure 8.) Finally, in the two animals in which rupture of the hepatic parenchyma was produced, after laparotomy, Biligrafin Forte gave a clear picture of the rupture site (Figure 9) as well as a complete change from the normal pattern of the liver (Figure 10).
237
Skalkeas et al
Comments Hepatography is a method of opacifying the liver that gives direct and complete visualization of the liver parenchyma. Previous methods of hepatic visualization in which transcutaneous hepatic venography or catheterization of the femoral vein was used are not without complications. We therefore used the external jugular and superior and inferior venae cavae and found this route of administration to be practical, applicable, and free from complications. Furthermore, the use of Biligrafin Forte increased the value of this method, thus giving good visualization of the liver, Of slight and short duration are anaphylactic phenomena arising from the use of Biligrafin Forte, as cited in the literature [12]. However, its administration remains harmless, the main contraindications being (1) acute febrile hepatic damage; (2) acute cholangitis; (3) severe toxemia; (4) severe Basedow’s disease [12]. Of the roentgenologic phases previously outlined, we used the parenchymal phase, which gave the best opacifying results. During the roentgenologic procedure, various hepatic views as well as tomographic control are possible, thus adding to the diagnostic interest of the method. Summary A method of hepatography in dogs is described in which contrast medium is infused via the external jugular and superior and inferior venae cavae and hepatic veins. Hepatograms taken by infusing
238
different contrast media in the normal liver and in the liver subjected to parenchymatous damage are also analyzed in detail.
References 1. Rappaport AM: Hepatic veinography. Acta Radio/ (Stockh). 36: 165, 1951. 2. Tori G: Hepatic veinography in man. Acta Radio/ (Stockh) 38: 89, 1953. 3. Belli L, Galmarini D, Difrancesco U: Phlebographie selective du foie appliquee a I’etude de la cirrhose, Presse &fed 60: 2276. 1961. 4. Charleux H. Hernandez C, Leger L. et al: Exploration des cirrhoses du foie par phlebographie cave-sus-hepatique. Presse Mbd70: 1215, 1962. 5. Leger L, Lenriot JP, Guillemot R, Bron R, loan 0: Sus hepato-portographie. J Chir (Paris) 10 1: 15 1, 197 1. 6. Moreno AH, Rousselot LM. Burchell AR, Bono R, Burke JH: Studies on the outflow tracts of the liver. On a method for the functional demonstration of the outflow tracts of the liver and its application to the study of hepatic hemodynamics in normal and cirrhotic rats. Ann Surg 155: 412, 1962. 7. Rousseau J, Tavernier J, Mas JP, Staeffen J, Reboul J, Moretti G: Le catheterisme des veines sus-hepatiques par voie femoral. Premiers resultats. Sem H6p Paris 38: 395. 1963. 8. Rappaport AM, Holmes RB, Stolberg HO, MC lntyre IL. Baird RJ: Hepatic veinography. Gastroenterology 46: 115, 1964. 9. Leger L. Premont M, Lefort J: Phlebographie sus-hepatique par injection dans le parenchyme hepatique. Presse A&d 70: 1855, 1962. 10. Le Bras M, Lamouche P. Ekra A, Chauvet J, Tonne1 J, Bertand E: La phlebographie sus hepatique au tours des affections hepato-pot-tales. J Chir 106: 457, 1973. 11. Rousseau J: Le catheterisme des veines sus-hepatiques par-voie femorale. Technique, resultats, applications. These medecine, Bordeaux, 1962. 12. Constantes J: The importance of intravenous biligraphin cholangiography in disturbances of hepatic function. Doctoral Thesis, Athens, 1959.
The American Journalof Surgery
