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(Radiology. 1999;211:589-590.)
© RSNA, 1999

Letters to the Editor

Absence of Bifurcation of the Portal Vein

James G. McNulty, MD, FRCR and Faisal Khosa, MD

Department of Radiology, University of Dublin Medical School, St James' Hospital, PO Box 1297, Dublin 8, Ireland

Editor:

We read with much interest the valuable article (1) by Dr Maetani and colleagues in the June 1998 issue of Radiology, "Portal Vein Anomaly Associated with Deviation of the Ligamentum Teres to the Right and Malposition of the Gallbladder." In their introduction, they stated that the anomaly was first described by Matsumoto in 1986 (2). In their discussion of the associated anomalies demonstrated in their computed tomographic study of the liver, they stated that the finding has not been reported outside Japan. We believe that both these statements are inaccurate. We reviewed the literature on this anomaly of absence of bifurcation of the portal vein and found that the finding was first described by Couinaud in 1957 (3). Other reports are those by Hardy and Nye in 1969 (4), Rat et al in 1991 (5), Koh et al in 1994 (6), Hardy and Jones in 1997 (7), and Charny et al in 1997 (8). All of these authors agree with the present report that the anomaly is found in 1.5%–1.9% of cases during liver surgery or biliary exploration and that if it is unrecognized it has serious implications for both liver resection and split liver transplantation. The anomaly may also be depicted with ultrasonography (9). To our knowledge, the associated biliary anomaly was originally described at the autopsy of a 6-day-old infant by Hochstetter in 1886 (10).

References

  1. Maetani Y, Itoh K, Kojima N, et al. Portal vein anomaly associated with deviation of the ligamentum teres to the right and malposition of the gallbladder. Radiology 1998; 207:723-728.[Abstract/Free Full Text]
  2. Matsumoto H. A newer concept of the segments of the liver. Jpn J Med Ultrasonics 1986; 13:551-552.
  3. Couinaud C. Le foie: études anatomiques et chirurgicales Paris, France: Masson, 1957; 74-75.
  4. Hardy KJ, Nye DH. An abnormal portal vein. Surgery 1969; 66:676-681.[Medline]
  5. Rat P, Favre JP, Paris P, Sakka M. Un foie pour deux en transplantation: comment partager le pédicule porte?. Chirurgie 1991; 117:364-371.[Medline]
  6. Koh MK, Ahmad H, Watanapa P, Jalleh RP, Habib NA. Beware the anomalous portal vein. HPB Surg 1994; 7:237-240.[Medline]
  7. Hardy KJ, Jones RM. Failure of the portal vein to bifurcate. Surgery 1997; 121:226-228.[Medline]
  8. Charny CK, Ling P, Bolet J, Blumgart LH. Clinical observation: congenital absence of the left portal vein in a patient undergoing hepatic resection. HPB Surg 1997; 10:323-327.[Medline]
  9. Atri M, Bret PM, Fraser-Hill MA. Intrahepatic portal venous variations: prevalence with US. Radiology 1992; 184:157-158.[Abstract/Free Full Text]
  10. Hochstetter F. Anomalien der pfortader und der nabelvene in verbindung mit defect oder linkslage der gallenblase. Arch Anat Entw 1886; :369-384.

Drs Maetani and colleagues respond:

Yoji Maetani, MD, Kyo Itoh, MD, Noriyuki Kojima, MD, Tatsuya Tabuchi, MD, Toshiya Shibata, MD, Katsuhiro Asonuma, MD, Koichi Tanaka, MD and Junji Konishi, MD

Departments of Radiology and Nuclear Medicine
Transplantation Immunology and Transplant Surgery, Kyoto University Faculty of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan

We thank Drs McNulty and Khosa for their interest in our article (1) and information on important literature. We think that what they called the "absence of bifurcation of the portal vein" is different from the anomaly we described, although the horizontal segment of the left portal vein may be absent in both anomalies.

Our cases primarily represented a developmental abnormality of the umbilical veins as characterized by deviation of the umbilical portion on the right to form the right anterior segmental branch and malposition of the gallbladder. Therefore, Matsumoto (2) called this an anomaly of the "right ligamentum teres and right umbilical portion." In contrast, neither deviation of the umbilical portion of the left portal vein (embryologically, the continuation of the umbilical vein) nor malposition of the gallbladder was mentioned by the eight articles (2–9) cited by Drs McNulty and Khosa; in two cases reported by Hardy and Nye (4) and Hardy and Jones (7), the umbilical portion was in the normal position. Fraser-Hill et al (10) reported on this anomaly and called it the "absence of the horizontal segment of the left portal vein." They mentioned that the umbilical portion, which gave rise to the branches of the left lobe, arose from a large aberrant vessel that ran transversely from the right anterior segmental branch instead of the absent horizontal segment of the left portal vein.

Also, Hochstetter's case (11) differed from ours in that the umbilical vein was not deviated; however, the left portal vein and the gallbladder were absent. However, we incidentally found that other cases reported in the same article were similar to ours in that they showed a common pattern, that is, malposition of the gallbladder and communication of the umbilical vein with the right portal vein (group 2, two cases) or malposition of the gallbladder and ligamentum teres (group 3, three cases). Hochstetter suggested that the group 2 anomaly might have resulted from the persistence of the right umbilical vein (instead of the left), which normally disappears during embryologic development. Therefore, rather than Matsumoto, Hochstetter may be credited with first describing this anomaly to that extent and the right umbilical vein hypothesis.

References

  1. Maetani Y, Itoh K, Kojima N, et al. Portal vein anomaly associated with deviation of the ligamentum teres to the right and malposition of the gallbladder. Radiology 1998; 207:723-728.
  2. Matsumoto H. A newer concept of the segments of the liver. Jpn J Med Ultrasonics 1986; 13:551-552.
  3. Couinaud C. Le foie: études anatomiques et chirurgicales Paris, France: Masson, 1957; 74-75.
  4. Hardy KJ, Nye DH. An abnormal portal vein. Surgery 1969; 66:676-681.
  5. Rat P, Favre JP, Paris P, Sakka M. Un foie pour deux en transplantation: comment partager le pédicule porte?. Chirurgie 1991; 117:364-371.
  6. Koh MK, Ahmad H, Watanapa P, Jalleh RP, Habib NA. Beware the anomalous portal vein. HPB Surg 1994; 7:237-240.
  7. Hardy KJ, Jones RM. Failure of the portal vein to bifurcate. Surgery 1997; 121:226-228.
  8. Charny CK, Ling P, Bolet J, Blumgart LH. Clinical observation: congenital absence of the left portal vein in a patient undergoing hepatic resection. HPB Surg 1997; 10:323-327.
  9. Atri M, Bret PM, Fraser-Hill MA. Intrahepatic portal venous variations: prevalence with US. Radiology 1992; 184:157-158.
  10. Fraser-Hill MA, Atri M, Bret PM, Aldis AE, Illescas FF, Herschorn SD. Intrahepatic portal venous system: variations demonstrated with duplex and color Doppler US. Radiology 1990; 177:523-526.[Abstract/Free Full Text]
  11. Hochstetter F. Anomalien der pfortader und der nabelvene in verbindung mit defect oder linkslage der gallenblase. Arch Anat Entw 1886; :369-384.



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