Search

Introduction: Damage control laparotomy with vacuum assisted closure (VAC) is used for selective cases in trauma. In liver transplantation, VAC has also been applied for management of intra-operative hemorrhage. The primary objective was to evaluate peri-operative blood loss and blood product utilization in VAC compared to primary abdominal closure (PAC) at the index transplant operation., Methods: Retrospective review of all adults undergoing deceased donor liver transplantation (2007-2011) at a single center tertiary care institution., Results: 201 deceased donor liver transplantations were performed, with 167 PAC and 34 VAC cases. Intra-operative blood loss (4.4L vs 10.7L), cell saver return (1399 ml vs 3998 ml), FFP (7.6U vs 15.9U) and PLT requirements (8.5U vs 18.3U), were all significantly elevated in VAC compared to PAC. VAC patients had significantly increased RBC, FFP, PLT, and total volume requirements during initial ICU admission. 30 PAC cases required on demand laparotomy and most commonly for post-operative bleeding., Conclusion: In liver transplantation, application of VAC secondary to massive intra-operative exsanguination was safely utilized. Further evaluation is required to identify long-term morbidity and mortality., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Choledochal cysts (CDC) are rare congenital cystic lesions of the biliary tract. In North America the incidence of CDC is estimated as 1/150,000; it is not clear that the disease pattern in North America is similar to that in Asia., Methods: Retrospective chart review. Statistical analysis was under taken using Fisher's exact test., Results: Presentation, epidemiology, diagnosis, and outcome were evaluated in 51 patients with CDC. Malignant transformation was identified in 4 patients presenting uniformly with jaundice (P = .027). Type 4a cysts (54.9%) were the most common cyst identified. Four (14%) type IVa and two (13%) type I cysts developed postoperative stricture. No patient developed cholangiocarcinoma after complete resection of their cyst., Conclusions: Types I and IVa cysts can be treated similarly with excellent outcome. However, our observation of a high proportion of type 4a cysts may represent a specific North American pattern of this disease requiring a re-evaluation of the classification system.

Background: Bile duct injuries remain one of the most devastating injuries during laparoscopic cholecystectomy. Few studies target surgeons who have experienced bile duct injuries for their insight, their perspective, and their suggestions concerning this problem., Methods: A confidential questionnaire was sent to all practicing general surgeons under the age of 65 years in British Columbia, Canada., Results: Seventy-five percent of surgeons responded to the survey. Of the 114 questionnaires completed, more than 97% of respondents had completed formal training in laparoscopic cholecystectomy. One half of surgeons reported experience with laparoscopic bile duct injury. A significant difference in years in practice between surgeons with injury and surgeons without injury was noted. The majority of injuries occurred after the surgeons's first 100 cholecystectomies performed. The first thoughts of surgeons after injury uniformly concerned the patient's well being. The next most common thoughts were in relation to obtaining help or a second opinion from another surgeon. Surgeons cited inflammation and short or anomalous cystic ducts as the most responsible factors contributing to injury. The majority of surgeons felt that these injuries are unavoidable and less than half felt that it was always a surgical error. Fewer than 15% thought injuries could be avoided by performing a cholangiogram. Surgeons suggested meticulous dissection and less haste to divide structures may prevent an injury. Surgeons recommend educating colleagues to remove the stigma of failure associated with conversion to laparotomy., Conclusions: General surgeons in British Columbia have a one in two chance of experiencing a bile duct injury in their career. There were more injuries in surgeons who had already been in practice for 10 years at the time of introduction of laparoscopic cholecystectomy. The injuries are likely to occur despite high volumes of procedures and increased experience. The incidence of bile duct injuries does not seem to be different in surgeons who perform routine cholangiography and most surgeons feel that cholangiography would have little effect on injury incidence. Surgeons tend to have patient-centered concerns after injury and little concern for medicolegal issues. The majority of surgeons felt that these injuries could not be anticipated and as such it is an inherent risk of this procedure.

Background: Hepatocellular carcinoma (HCC) occur in livers with injury-remodeling, accomplished by enzymes called matrix metalloproteinases (MMP). Metastasis involves basement membrane invasion also caused by MMP activity. Alterations in MMP expression and their endogenous inhibitor (TIMP) may factor in HCC metastasis., Methods: HCC specimens and lymph nodes (n = 7), and normal lymph tissue from organ donors (n = 8), were snap-frozen in liquid nitrogen and the mRNA precipitated. A series of reverse transcription-polymerase chain reactions (RT-PCR) were performed using MMP (MMP2, MMP7, MMP9) primers and TIMP (TIMP1, TIMP2) primers. These were semiquantitatively analyzed by comparing concentration with constitutive GADPH expression., Results: There is an increase in MMP2:TIMP2 mRNA expression ratio in the normal and tumor margin tissue compared to the tumor. There are increases in all MMP and TIMP mRNA expression (except TIMP1) and alterations in all of the MMP:TIMP expression ratios in the draining lymph node., Conclusions: Alterations exist in MMP2:TIMP2: expression at the margin, and all of the MMPs in the draining lymph nodes. This likely reflects a host-tumor interaction that regulates tumor metastasis.

Background: Critical shortages of organ donors for transplantation require appropriate utilization of this scarce resource. The purpose of this study was to assess whether use of physiological parameters of preliver transplant recipients is helpful in determining eventual outcome., Methods: Between October 1989 and June 1999, 215 liver transplants were performed on 199 patients at the Vancouver Hospital nad Health Sciences Centre. Thirty-one patients undergoing transplantation between May 1993 and June 1994 were retrospectively evaluated to obtain a minimum 5-year follow-up. Variables examined included pretransplant activation status (status 1, at home; status 2, hospitalized; status 3, admitted to intensive care; status 4, mechanical ventilation), simplified acute physiological score (SAPS), Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II, and APACHE III scores at the time of transplantation. The scores were correlated to posttransplant mortality and functional outcome., Results: The 5-year mortality for status 1 patients was 14.3% versus 30% for patients listed as status 2 or greater (P = not significant). There were no significant differences in any of the physiological scoring assessments with regard to posttransplant mortality or functional assessment. Of the surviving patients, 18 of 22 who were employed, in school, or active at home pretransplant returned to their pretransplant activity., Conclusions: Detailed physiological scoring systems are no more accurate in predicting outcome after liver transplant than current listing status parameters.

Background: Formal anatomic (lobar) or extended hepatectomies are recommended for liver malignancies located centrally within the liver (Couinaud's segments IVA, IVB, V, and VIII). Mesohepatectomy, resection of central hepatic segments and leaving the right and left segments in situ, removes large central tumors preserving more functioning liver tissue than either extended left or right hepatectomy. Mesohepatectomy is a seldom used, technically demanding procedure, and its application is yet to be defined., Methods: Medical charts of 244 consecutive liver resection patients were reviewed retrospectively. Eighteen patients were treated with mesohepatectomy. Six patients had metastatic liver tumor (MLT), 11 had hepatocellular carcinoma (HCC), and 1 had gallbladder adenocarcinoma. The operative results were compared with groups of patients treated by lobar hepatectomy (n = 71) and extended left or right hepatectomy (n = 43)., Results: The mean mesohepatectomy operative time was 238 versus 304 minutes in the extended group. Inflow occlusion mean time was longer in the mesohepatectomy group than in extended procedures, 45 versus 39 minutes (P = not significant). Comparing the extended hepatectomy group, the mesohepatectomy group had a mean operative estimated blood loss 914 cc versus 1628 cc (P <0.01), postoperative hospital stay 9 versus 16 days (P = 0.054) and volume of resected liver 560cc versus 1500cc (P <0.01) respectively. The late complication rate was lower in the mesohepatectomy group than in the extended group and was comparable to the lobar hepatectomy group (P = 0.05)., Conclusions: Despite its technical demands, mesohepatectomy should be considered as an alternative to extended hepatectomy for selected patients with primary and secondary hepatic tumors localized in middle liver segments, as its complication rate, postoperative recovery, and preserved liver tissue compare favorably with extended hepatic resection.

Background: Radiofrequency ablation (RFA) has recently been used to treat liver tumors, but few clinical reports have described the pathological characteristics of radiofrequency ablation in human specimens. This study delineates the gross pathologic and histochemical changes induced by RFA in benign and malignant human liver tissue and confirms the tumor necrosis described in early clinical reports., Methods: Ten patients with metastatic tumors of the liver received a single treatment of ultrasound-guided percutaneous RFA to 12 tumors. Hepatic resection was carried out within 6 weeks of RFA. Specimens were stained with standard hematoxylin and eosin stain followed by oxidative stain to determine if there was evidence of viable tumor within the zone of ablation., Results: Nine of the 12 ablations were resected. Microscopic examination within the zone of ablation showed successful ablation in 8 of the 9 resected ablations., Conclusions: Percutaneous RFA creates well-circumscribed areas of tumor necrosis with apparent cell death using an oxidative stain. Further investigation is encouraged to determine the clinical effectiveness of radiofrequency ablation in the complete destruction of liver tumors for palliative or curative intent.

Background: Objectives of partial medium aperture mesocaval shunts (MCS) include reduction of portal hypertension to prevent recurrent variceal hemorrhage, preservation of portal flow through liver while maintaining an intact porta hepatis to facilitate a future liver transplant (OLTx)., Patients and Methods: Fifteen patients were retrospectively analyzed to review the indications for the procedure, its short- and long-term complications as well as patency and functional status of the shunt. They were followed for a period of 21 months., Results: The perioperative and long-term mortality rate was 0%. Rebleeding rate perioperatively and in follow-up was 0%. Early shunt nonfunction was 13% and post-shunt encephalopathy (PSE) was 20%. The encephalopathy was grade I to II and controlled medically. Abdominal ultrasound and Doppler confirmed 13 patent shunts (2 patients did not agree to ultrasound) with preserved hepatopetal flow in 10., Conclusions: Medium aperture MCS utilizing ringed polytetrafluoroethylene (PTFE) grafts safely and reliably prevent recurrent variceal hemorrhage. Encephalopathy is infrequent and mild. This technique preserves the portal venous anatomy making a future OLTx technically easier.

Background: Bleeding complications and blood product consumption have been a major concern during liver transplantation. Prevention of plasminogen activation and fibrinolysis by aprotinin administration has been shown to reduce perioperative bleeding during operations associated with high blood-product consumption., Patients and Methods: Use of blood-products (packed red cells, frozen plasma, platelets, and cryoprecipitate) was analyzed both during the three stages of orthotopic liver transplantation and during total hospitalization of the 26 patients transplanted without aprotinin and the subsequent 40 patients with aprotinin. A similar analysis was performed for 15 patients immediately before and after the introduction of aprotinin to eliminate the "learning curve" effect for liver transplantation. The effect of epsilon-amino-caproic acid was analyzed as 13 patients received neither epsilon-aminocaproic acid nor aprotinin and 13 patients received epsilon-aminocaproic acid but not aprotinin., Results: There was a significant reduction in total hospital use of cryoprecipitate, frozen plasma, platelets, and red cells in the aprotinin-treated patients. This reduction was seen during the anhepatic and reperfusion stages of liver transplantation. There was no difference in blood product consumption between the groups who were or were not treated with epsilon-aminocaproic acid., Conclusion: Aprotinin significantly reduces the need for red cell, frozen plasma, platelet, and cryoprecipitate transfusion use during orthotopic liver transplantation, and appears to be more efficacious than epsilon-aminocaproic acid.

Choledochal cysts are an unusual cause of biliary obstruction with up to 85% of reported cases being of the type I variety, that is, fusiform dilations of the common bile duct. Recommended management of this type I cyst is complete surgical excision; however, difficulties arise in type IVa cysts when the cystic dilation extends up into the intrahepatic biliary tree. The purpose of this study is to review the management of choledochal cysts with particular reference to the type IVa variety. Statistical analysis of outcome differences was undertaken using Fisher's exact test. A total of 23 consecutive patients with choledochal cysts seen at our institution in a 5-year period were reviewed: 8 patients had type I cysts, 1 patient had a type III cyst, and 14 patients had type IVa cysts. All type I cysts underwent complete cyst excision with hepaticojejunostomy and modified Houston loop formation. Of 14 patients with type IVa cysts, 13 underwent complete excision of the extrahepatic portion of the cyst with hepatico- and cystojejunostomy and modified Hutson loop formation. One patient required hepatic lobectomy. With a mean follow-up of 33 months, 4 patients with type IVa choledochal cyst have had episodes of recurrent cholangitis, with access to the library tree being achieved via the Hutson loop in 3 of the 4 patients. Three of these cases represented anastomotic strictures that were treated nonoperatively. We concluded that recurrent cholangitis and anastomotic stricture after resection of type IVa choledochal cysts is frequent and recommend Hutson loop formation at the time of primary resection.

The development of increasingly sensitive imaging techniques along with improved follow-up and screening of high-risk patients has led to hepatic tumors, both primary and secondary, being detected while still at an early stage. Improved understanding of hepatic anatomy along with advances in surgical technique has led to the ability to undertake hepatic resections based on the segmental hepatic anatomy as described by Couinaud. The purpose of this paper is to assess the safety, technique, and oncologic efficacy of segmental hepatic resection. Fifty consecutive patients undergoing segmental hepatic resection during a 3-year time period ending in January 1992 were reviewed. Parametric statistical analysis was undertaken using Student's t-tests. Overall mortality was 2% with a morbidity rate of 8%. Transfusion requirements were 1 +/- 1.5 U; however, cirrhotic patients showed a significantly increased transfusion requirement of 2.0 +/- 1.3 U versus 0.7 +/- 1.3 U (p = 0.03). Sixty percent of patients required no transfusion at all. The mean duration of inflow occlusion was 42 +/- 17 minutes. Resection margins were clear of tumor by greater than 1 cm in 48 of 50 patients. Segmental hepatic resection is a safe and effective technique that occasionally may offer advantages over formal resection. Some aspects of the technique are reviewed.

Twenty-two cirrhotic patients who underwent hepatic resection from July 1989 to March 1991 at Vancouver General Hospital were analyzed prospectively in order to determine whether there was any preoperative evaluation of liver function that would help identify those patients who would not survive hepatic resection. Patients were analyzed on the basis of age, type of resection, and a variety of so-called standard liver function tests. In addition, all patients were evaluated preoperatively with an indocyanine green (ICG) clearance test, a relatively new test that we attempted to evaluate in terms of its role in hepatic resection in cirrhotic patients. Parametric statistical evaluation used included Student's t-test and multivariate regression, as well as discriminate analysis. The nonparametric evaluation used was the Wilcoxon rank sum test. Overall, the 30-day mortality rate was 18%, with those patients who did not survive resection having a significantly lower ICG clearance than those who underwent successful resection (p less than 0.0001). No other liver function test was useful in determining the outcome of resection. Similarly, neither age nor type of resection appeared to influence outcome. Use of discriminate analysis (p = 0.0029) allowed the identification of a cutoff point for ICG clearance below which hepatic resection should not be attempted.

Hepatocellular carcinoma is a very malignant tumor that affects both Caucasian and Oriental populations. In the Caucasian patient, it frequently arises in a background of cirrhosis, most commonly the alcoholic type. In the present study, the alpha-feto-protein level was increased in less than half of the Caucasian patients. In comparison, hepatocellular carcinoma in Oriental patients most often occurs in livers with postinfectious cirrhosis. In the present study, both hepatitis B surface antigen and an increased alpha-fetoprotein level were present in three of four patients. If the tumor is present, however, it appears to behave similarly in both ethnic groups. Without resection, the prognosis is poor, regardless of the presence or absence of underlying cirrhosis or hepatitis B surface antigen status. A tissue diagnosis of hepatocellular carcinoma is most readily made by ultrasonographically guided fine-needle aspiration, which has an 81 percent sensitivity. The most important factor affecting survival is surgical resection. Clearly, the stage at diagnosis is also crucial, but even in more advanced disease, operation can improve survival. It also appears that an increased carcinoembryonic antigen level above normal or a markedly increased alpha-fetoprotein level or both are associated with poor survival. However, whether this is a reflection of tumor size alone, or in fact represents a more aggressive tumor is uncertain and will require further study.

Despite technical advances in management, the complication of late stricture formation and biliary sepsis still occur in bile duct reconstruction. In an attempt to avoid bilioenteric anastomosis, which bypasses the biliary sphincter mechanism, various biologic and artificial materials have been employed clinically and experimentally to replace the damaged bile duct. No satisfactory biliary replacement material has yet been found. In the experimental model of bile duct stricture that has been presented, human amnion bile duct injuries mimicking those seen in clinical practice were repaired using human amnion as a free graft. Noncircumferential duct loss appeared to be satisfactorily repaired using amnion, and the amnion repair was found to be as good as or superior to plastic repair; however, circumferential duct loss was not adequately repaired with the amnion graft.

Congenital cystic dilation of the biliary tree is rarely considered as cause of cholangitis in the adult patient. Emergency operation in seven adults with unsuspected choledochal cysts resulted in reoperation in all seven. Each patient presented with right upper quadrant pain, a mass, and cholangitis or jaundice. Abdominal ultrasonography incorrectly identified the cyst as a dilated gallbladder in three of the patients. All initial emergency drainage procedures required subsequent modification to cyst excision and Roux-Y reconstruction. From review of the experience presented and the literature to date, we recommend that otherwise stable patients be managed nonsurgically and undergo endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography to plan primary single-stage excisional operation. Patients requiring emergency decompression should have cholecystostomy or choledochostomy for good control without compromising subsequent operation. At the time of excision, a technical consideration not previously reported is the presence of small daughter cysts in Calot's triangle which must be distinguished from the hepatic bile ducts. The surgical literature has frequently addressed the problems of elective surgery for choledochal cysts; however, emergency complications requiring urgent operative intervention are seldom addressed. We believe emergency intervention should correct the urgent complication without compromising the definitive surgical treatment.

Typhlitis is a neutropenic enterocolitis of varying severity. Its incidence is increasing, particularly in patients with acute myelogenous leukemia undergoing high dose cytosine arabinoside chemotherapy. The onset is heralded by prodromal fever, watery or bloody diarrhea, abdominal distension, and nausea during the phase of severe neutropenia. The symptoms may then localize to the right lower quadrant with an associated increase in systemic toxicity. The diagnosis can be confirmed in these and other less specific cases by serial reexamination and abdominal radiographs, ultrasonography, computerized tomograms, or radionucleotide scans. The mainstay of management is complete bowel rest with nasogastric suction and total parenteral nutrition. Broad-spectrum combination antibiotics are essential, as is the avoidance of laxatives or antidiarrheal agents. Granulocyte support may be helpful. Patients with a history of nonspecific gastrointestinal complaints or of true typhlitis, successfully managed nonoperatively, should have prophylactic bowel rest and total parenteral nutrition instituted at the beginning of further chemotherapy. Patients with ongoing severe systemic sepsis who do not respond to chemotherapy and those with overt perforation, obstruction, massive hemorrhage, or abscess formation require surgical intervention. All necrotic material must be resected, usually by a right hemicolectomy, ileostomy, and mucous fistula. Divided ileostomy for less severe cases may be useful. Failure to remove the necrotic focus in these severely immunocompromised patients is fatal. With adequate recognition of typhlitis and its precipitating factors, the incidence of complications can be reduced through prevention and timely surgical intervention. Although typhlitis developed in a quarter of our acute myeloblastic leukemia patients, use of this combined approach was successful in all cases.