Association between biliary complications and technique of hilar division (extrahepatic vs. intrahepatic) in major liver resections

BACKGROUND: Division of major vascular and biliary structures during major hepatectomies can be carried out either extrahepatically at the porta hepatic or intrahepatically during the parenchymal transection. In this retrospective study we test the hypothesis that the intrahepatic technique is associated with less early biliary complications. METHODS: 150 patients who underwent major hepatectomies were retrospectively allocated into an intrahepatic group (n = 100) and an extrahepatic group (n = 50) based on the technique of hilar division. The two groups were operated by two different surgical teams, each one favoring one of the two approaches for hilar dissection. Operative data (warm ischemic time, operative time, blood loss), biliary complications, morbidity and mortality rates were analyzed. RESULTS: In extrahepatic patients, operative time was longer (245 ± 50 vs 214 ± 38 min, p < 0.05) while the overall complication rate (55% vs 52%), hospital stay (13 ± 7 vs 12 ± 4 days), bile leak rate (22% vs 20%) and mortality (2% vs 2%) were similar compared to intrahepatic patients. However, most (57%) bile leaks in extrahepatic patients were grade II (leaks that required non-operative interventional treatment, while most (70%) leaks in the intrahepatic group were grade I (leaks that resolved and presented two injuries (4%) of the remaining bile ducts (p < 0.05). CONCLUSION: Intrahepatic hilar division is as safe as extrahepatic hilar division in terms of intraoperative blood requirements, morbidity and mortality. The extrahepatic technique is associated with more severe bile leaks and biliary injuries

Splenic Artery Ligation: An Ontable Bail-Out Strategy for Small-for-Size Remnants after Major Hepatectomy: A Retrospective Study

It has been reported that the prevention of acute portal overpressure in small-for-size liver grafts leads to better postoperative outcomes. Accordingly, we aimed to investigate the feasibility of the technique of splenic artery ligation in a case series of thirteen patients subjected to major liver resections with evidence of small-for-size syndrome and whether the maneuver results in the reduction of portal venous pressure and flow. The technique was successful in ten patients, with splenic artery ligation alleviating portal hypertension significantly. Three patients required the performance of a portocaval shunt for the attenuation of portal hypertension. Portal inflow modulation via splenic artery ligation is a technically simple technique that can prove useful in the context of major hepatectomies as well as in liver transplantations and the early evaluation and modification of portal venous pressure post hepatectomy can be used as a practical tool to guide the effect of the intervention

Transdiaphragmatic approach facilitates resection of large (&gt; 12cm) liver tumors

Background/Purpose. Various (mostly transthoracic) techniques have been proposed to facilitate access to large tumors located in the upper part of the liver, close to the confluence of the major hepatic veins. The purpose of this study was to investigate the safety and efficacy of a transdiaphragmatic mobilization technique for resection of such tumors. Methods. Twenty-one patients, with tumors ranging from 12 to 22cm in diameter, underwent liver resections using our technique of diaphragmatic splitting, with the intention of achieving adequate exposure of the inferior vena cava and the hepatocaval junction. Results. The technique described provided, in all patients, an effective method to achieve the vascular control required for a safe liver resection. Median weight of the excised tumors was 1100g (range, 817-2860g). Conclusions. Large liver tumors (&gt; 12cm) in the upper part of the liver may be approached through a standard bilateral subcostal incision, combined with splitting of the hemidiaphragm, without the need for any kind of thoracic incision

Conservative treatment of acute appendicitis: heresy or an effective and acceptable alternative to surgery?

For more than a century, emergency appendectomy has been a ‘surgical dogma’ in the management of acute appendicitis (AA). During recent decades, however, there is an increasing body of evidence suggesting that selected patients with AA could be treated conservatively. This approach has many advantages, including high success and low recurrence rates, reduced morbidity and mortality, less pain, shorter hospitalization and sick leave, and reduced costs. Despite that conservative management of AA cannot be used for all patients with AA (for example, in the presence of peritonitis), it could be preferred in a large percentage of patients with mild infection (as evidenced by clinical, laboratory, and imaging findings). Eur J Gastroenterol Hepatol 23:121-127 (C) 2011 Wolters Kluwer Health vertical bar Lippincott Williams &amp; Wilkins

Interval routine appendectomy following conservative treatment of acute appendicitis: Is it really needed

Conservative management of acute appendicitis (AA) is gradually being adopted as a valuable therapeutic choice in the treatment of selected patients with AA. This approach is based on the results of many recent studies indicating that it is a valuable and effective alternative to routine emergency appendectomy. Existing data do not support routine interval appendectomy following successful conservative management of AA; indeed, the risk of recurrence is low. Moreover, recurrences usually exhibit a milder clinical course compared to the first episode of AA. The role of routine interval appendectomy is also questioned recently, even in patients with AA complicated by plastron or localized abscess formation. Surgical judgment is required to avoid misdiagnosis when selecting a conservative approach in patients with a presumed “appendiceal” mass

Deferoxamine Attenuates Lipid Peroxidation, Blocks Interleukin-6 Production, Ameliorates Sepsis Inflammatory Response Syndrome, and Confers Renoprotection After Acute Hepatic Ischemia in Pigs

We have previously shown that deferoxamine (DFO) infusion protected myocardium against reperfusion injury in patients undergoing open heart surgery, and reduced brain edema, intracranial pressure, and lung injury in pigs with acute hepatic ischemia (AHI). The purpose of this research was to study if DFO could attenuate sepsis inflammatory response syndrome (SIRS) and confer renoprotection in the same model of AHI in anesthetized pigs. Fourteen animals were randomly allocated to two groups. In the Group DFO (n = 7), 150 mg/kg of DFO dissolved in normal saline was continuously infused in animals undergoing hepatic devascularization and portacaval anastomosis. The control group (Group C, n = 7) underwent the same surgical procedure and received the same volume of normal saline infusion. Animals were euthanized after 24 h. Hematological, biochemical parameters, malondialdehyde (MDA), and cytokines (interleukin [IL]-1 beta, IL-6, IL-8, IL-10, and tumor necrosis factor-a) were determined from sera obtained at baseline, at 12 h, and after euthanasia. Hematoxylineosin and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling were used to evaluate necrosis and apoptosis, respectively, in kidney sections obtained after euthanasia. A rapid and substantial elevation (more than 100-fold) of serum IL-6 levels was observed in Group C reaching peak at the end of the experiment, associated with increased production of oxygen free radicals and lipid peroxidation (MDA 3.2 +/- 0.1 nmol/mL at baseline and 5.5 +/- 0.9 nmol/mL at the end of the experiment, P &lt; 0.05) and various manifestations of SIRS and multiple organ dysfunction (MOD), including elevation of high-sensitivity C-reactive protein, severe hypotension, leukocytosis, thrombocytopenia, hypoproteinemia, and increased serum levels of lactate dehydrogenase (fourfold), alkaline phosphatase (fourfold), alanine aminotransferase (14-fold), and ammonia (sevenfold). In sharp contrast, IL-6 production and lipid peroxidation were completely blocked in DFO-treated animals offering remarkable resistance to the development of SIRS and MOD. Profound proteinuria, strips of extensive necrosis of tubular epithelial cells, and occasional apoptotic tubular epithelial cells were already present in Group C, but not in Group DFO animals at the time of euthanasia. DFO infusion attenuated lipid peroxidation, blocked IL-6 production, and substantially diminished SIRS and MOD, including tubulointerstitial damage in pigs after acute ischemic hepatic failure. This finding shows that iron, IL-6, and lipid peroxidation are important participants in the pathophysiology of renal injury in the course of generalized inflammation and provides novel pathways of therapeutic interventions for renal protection

Thyroid hormones alterations during acute liver failure: possible underlying mechanisms and consequences

Thyroid hormones are now recognized to change in different disease states with important consequences on severity and prognosis of disease. However, little is known about thyroid hormones’ alterations in acute liver failure (ALF). To study the changes in thyroid hormones and cardiac thyroid receptors during ALF, we subjected seven female pigs to surgical liver devascularization. Liver function biochemical markers, thyroid hormones, endogenous opioids, malondialdehyde (MDA), and interleukins 1 and 6 were measured in serum for 24 h postoperatively. Heart biopsies were harvested at the end of the experiment. Baseline heart biopsies were taken from five additional animals. Serum thyroxin (T-4) and triiodothyronine (T-3) levels markedly decreased, whereas free-triiodothyronine and thyroxin-stimulating hormone levels did not change. T-4 and T-3 levels correlated with the degree of liver failure and with MDA and interleukin-6 levels. Beta-endorphin levels initially increased, whereas levels of leucine-enkephalin did not change. Thyroid hormone receptor-alpha 1 protein expression in the heart decreased 1.6-fold after ALF, whereas myocardial myosin isoform expression remained unchanged. The downregulation of T-4 and T-3 levels during ALF seems to correlate well with the severity of disease. This downregulation related to inflammation and oxidative stress and resulted in changes in myocardial thyroid receptors