The Evolution of Aortic Aneurysm Repair: Past Lessons and Future Directions

The history and evolution of aortic aneurysm repair demonstrates an important paradigm within surgery, namely the importance of surgical pioneers and innovators who have\ud strived to achieve technical excellence and improve patient care. It also highlights the wider evolution of surgery from traditional open operative techniques to the modern minimally invasive procedures. The following chapter discusses the surgical innovators and the techniques they have described that have enabled the repair of both thoracic aortic aneurysms (TAA) and abdominal aortic aneurysms (AAA).\ud Aortic aneurysms represent a significant health risk particularly for the elderly population. AAA is the 14th-leading cause of death for the 60- to 85-year–old age group in the United States (10.8 deaths per 100,000 population). TAA by contrast is less frequent with an incidence of 10.4 per 100,000. Both AAA and TAA are known to increase in prevalence with advancing age and have an increased prevalence in males. The risk of aneurysm rupture increases with increasing aneurysm diameter over 5.5-6.0 cm and is the primary indication for the repair of both TAA and AAA.Therefore surgery to repair both AAA and TAA is either pre-emptive to prevent rupture or emergent to repair a rupture. Repair of TAA and AAA by either open or minimally invasive techniques significantly reduces the risk of rupture and improves patient mortality. The establishment of these techniques has required the development of procedures from embryonic thoughts in the minds of the surgeons of antiquity through to the utilisation of ever increasing modern technologies

Autophagy and the Liver

Autophagy is a cellular process that involves lysosomal degradation and recycling of intracellular organelles and proteins to maintain energy homeostasis during times of cellular stress [1]. It also serves to remove damaged cellular components such as mitochondria and long-lived proteins. Autophagy is catabolic mechanism and although hepatic autophagy performs the standard functions of degrading damaged organelles/aggregated proteins and regulating cell death it also regulates lipid accumulation within the liver. Autophagy can be divided into three distinct sub-groups that are discussed below. This chapter focuses upon the role of autophagy in a variety of liver diseases including hepatocellular carcinoma (HCC) and viral hepatitis. The increased understanding of the cellular machinery regulating autophagy within the liver may foster the development of therapeutic strategies that will ultimately help treat liver disease

Robotic Liver Surgery

Robotic liver surgery is an evolving specialty within liver surgery. The robotic platform allows some of the limitations in both open and laparoscopic surgery to be overcome. Indeed as the technology develops there is scope for the number of robotic liver resections to increase as well as their complexity. In this chapter we discuss the current robotic platform, review the current role of robotics in liver surgery and review the available data in the literature on patient outcome

Predictors of early recurrence after resection of colorectal liver metastases

BACKGROUND: Early recurrence after resection of colorectal liver metastases (CLM) is common. Patients at risk of early recurrence may be candidates for enhanced preoperative staging and/or earlier postoperative imaging. The aim of this study was to determine if there are any risk factors that specifically predict early liver-only and systemic recurrence. METHODS: Retrospective analysis of prospective database of patients undergoing liver resection (LR) for CLM from 2004 to 2006 was undertaken. Early recurrence was defined as occurring within 18 months of LR. Patients were classified into three groups: early liver-only recurrence, early systemic recurrence and recurrence-free. Preoperative factors were compared between patients with and without early recurrence. RESULTS: Two hundred and forty-three consecutive patients underwent LR for CLM. Twenty-seven patients (11%) developed early liver-only recurrence. Dukes C stage and male sex were significantly associated with early liver-only recurrence (P < 0.05). Sixty-six patients (27%) developed early systemic recurrence. Tumour size ≥3.6 cm and tumour number (>2) were significantly associated with early systemic recurrence (P < 0.001). CONCLUSIONS: It is possible to stratify patients according to the risk of early liver-only or systemic recurrence after resection of CLM. High-risk patients may be candidates for preoperative MRI and/or computed tomography-positron emission tomography (CT-PET) scan and should receive intensive postoperative surveillance

The role of oxidative stress and CD154-mediated reactive oxygen species in regulating hepatocyte cell death during hypoxia and hypoxia-reoxygenation

Hypoxia and hypoxia-reoxygenation (H-R) are pathogenic factors in many liver diseases and lead to hepatocyte death as a result of reactive oxygen species (ROS) accumulation. Activation of the Tumour Necrosis Factor-a (TNFa) super-family member CD40 by its cognate ligand CD 154 can induce hepatocyte apoptosis via induction of autocrine/paracrine F as Ligand/CD178 expression but the relationship between CD40 activation, ROS generation and hepatocyte cell death is poorly understood. Therefore, human hepatocytes were isolated from liver tissue and exposed to an in vitro model of hypoxia and H-R in the presence or absence of CD154 and/or various inhibitors. Hepatocyte ROS production, apoptosis, necrosis and autophagy were determined by a four-colour reporter flow cytometry assay. The in vivo regulation of liver injury by CD40 and CD 154 was determined using a murine model of partial liver ischaemia. Exposure of human hepatocytes to recombinant CD 154 or platelet-derived soluble CD 154 augmented ROS accumulation during H-R resulting in NADPH oxidase-dependent apoptosis and necrosis. The cyto-protectivc mechanism of autophagy limited apoptotic cell death during hypoxia and H-R. CD40 and CD 154 knockout mice but not wild type mice were protected from ischaemic liver injury. Hence, CD40:CD154 mediate hepatocytes cell death in vitro and in vivo during hypoxia and H-R

Colonic tumour precipitating caecal volvulus within a diaphragmatic hernia

An 85-year-old woman presented with sudden onset of generalised abdominal pain and absolute constipation for 4 d. On examination she had a distended abdomen. Plain abdominal radiograph revealed a gas filled viscous within the left upper quadrant. Subsequent computed tomography suggested caecal volvulus herniated through a left diaphragmatic hernia. The patient underwent reduction of the internal hernia, right hemicolectomy and mesh repair of the diaphragmatic hernia. Postoperative recovery was uneventful. Histology revealed a Dukes’ A colonic cancer within the caecum. Herniation of caecal volvulus through a diaphragmatic hernia is a very rare condition and may have been precipitated by the colonic tumour

Surgery for gallstone disease during pregnancy does not increase fetal or maternal mortality:a meta-analysis

BACKGROUND: Pregnancy was traditionally considered a contraindication to cholecystectomy but is now becoming the favoured option for gallstone-related disease (GRD) during pregnancy. METHODS: To assess if cholecystectomy during pregnancy increases the risk of preterm labour, fetal mortality and maternal mortality. PubMed and MEDLINE databases for the period from January 1966 through December 2013. Studies were both conservative and surgical intervention was utilised in the management of GRD were included. The results of the included studies were pooled using meta-analysis techniques. RESULTS: Surgical intervention for GRD in pregnancy does not increase the risk of preterm labour, fetal mortality or maternal mortality. CONCLUSIONS: Cholecystectomy during pregnancy for GRD is associated with low complications for the fetus and mother and should be considered in all suitable patients

Postoperative day one serum alanine aminotransferase does not predict patient morbidity and mortality after elective liver resection in non-cirrhotic patients

Serum aminotransferases have been used as surrogate markers for liver ischemia-reperfusion injury that follows liver surgery. Some studies have suggested that rises in serum alanine aminotransferase (ALT) correlate with patient outcome after liver resection. We assessed whether postoperative day 1 (POD 1) ALT could be used to predict patient morbidity and mortality following liver resection. We reviewed our prospectively held database and included consecutive adult patients undergoing elective liver resection in our institution between January 2013 and December 2014. Primary outcome assessed was correlation of POD 1 ALT with patient's morbidity and mortality. We also assessed whether concurrent radiofrequency ablation, neoadjuvant chemotherapy and use of the Pringle maneuver significantly affected the level of POD 1 ALT. A total of 110 liver resections were included in the study. The overall in-hospital patient morbidity and mortality were 31.8% and 0.9%, respectively. The median level of POD 1 ALT was 275 IU/L. No correlation was found between POD 1 serum ALT levels and patient morbidity after elective liver resection, whilst correlation with mortality was not possible because of the low number of mortalities. Patients undergoing concurrent radiofrequency ablation were noted to have an increased level of POD 1 serum ALT but not those given neoadjuvant chemotherapy and those in whom the Pringle maneuver was used. Our study demonstrates POD 1 serum ALT does not correlate with patient morbidity after elective liver resection.</p