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Summary.: A large series of plasma albumin (ALB, g/dl) and simultaneous blood and clinical measurements were prospectively performed on 92 liver resection patients, and processed to assess the correlations between ALB, other plasma proteins, additional variables and clinical events. The measurements were performed preoperatively and at postoperative day 1, 3 and 7 in all patients, and subsequently only in those who developed complications or died. In patients who recovered normally ALB was 4.3 ± 0.4 g/dl (mean ± SD) preoperatively, 3.7 ± 0.7 at day 1 and 3, and 3.9 ± 0.4 at day 7. In patients with complications its decrease was more prolonged. In non-survivors it was 3.4 ± 0.4 preoperatively, 3.0 ± 0.4 at day 1, and then decreased further. Regression analysis showed direct correlations between ALB and pseudo-cholinesterase (CHE, U/l, nv 5300-13000), cholesterol (CHOL, mg/dl), iron binding capacity (IBC, mg/dl), prothrombin activity (PA, % of standard reference) and fibrinogen, an inverse correlation with blood urea nitrogen (BUN, mg/dl) for any given creatinine level (CREAT, mg/dl), and weaker direct correlations with hematocrit, other variables and dose of exogenous albumin. An inverse relationship found between ALB and age (AGE, years) became postoperatively (POSTOP) also a function of outcome, showing larger age-related decreases in ALB associated with complications (COMPL: sepsis, liver insufficiency) or death (DEATH). Main overall correlations: CHE = 287.4(2.014)ALB, r = 0.73; CHOL = 16.5(1.610)ALB (1.001)ALKPH, r = 0.71; IBC = 68.6(1.391)ALB, r = 0.64; PA = 13.8 + 16.0(ALB), r = 0.51; BUN = 21.3 + 20.2(CREAT) – 6.2(ALB), r = 0.91; ALB = 5.0–0.013(AGE) – {0.5 + 0.003(AGE) COMPL + 0.012(AGE) DEATH } POSTOP , r = 0.74 [p < 0.001 for each regression and each coefficient; ALKPH = alkaline phosphatase, U/l, nv 98-279, independent determinant of CHOL; discontinuous variables in italics label the change in regression slope or intercept associated with the corresponding condition]. These results suggest that altered albumin synthesis (or altered synthesis unable to compensate for albumin loss, catabolism or redistribution) is an important determinant of hypoalbuminemia after hepatectomy. The correlations with age and postoperative outcome support the concept that hypoalbuminemia is a marker of pathophysiologic frailty associated with increasing age, and amplified by the challenges of postoperative illness.

Background: Laparoscopic fenestration is considered the best treatment for symptomatic simple liver cysts. Conversely, the laparoscopic approach for the management of hydatid simple liver cysts is not widely accepted because of the risk for severe complications. Despite improvement in imaging techniques, the probability of preoperatively mistaking a hydatid liver cyst for a simple liver cyst remains about 5%. Therefore, laparoscopic fenestration, planned for a liver cyst could be performed unintentionally for an undiagnosed hydatid liver cyst. Methods: From January 2000 to January 2001, 15 patients with a diagnosis of liver cyst underwent laparoscopy for fenestration. In all cases preoperative serologic and imaging assessment had excluded hydatid liver cyst. To further exclude hydatid liver cyst, preliminary aspiration of the cyst with assessment of cystic fluid characteristics was performed. Results: In two patients with presumedly simple liver cyst, hydatid liver cyst was diagnosed instead at laparoscopy by aspiration of cystic fluid. The procedure was converted to laparotomy with subtotal pericystectomy. Conclusions: The risk of misdiagnosing a hydatid liver cyst for a simple liver cyst, especially in the presence of a solitary cyst, should be considered before laparoscopic fenestration is performed. Intraoperative aspiration of cyst fluid before fenestration can minimize this risk, thus avoiding severe intraoperative and late complications.

Objective:: To assess correlates of hypocholesterolemia in moderate to critical surgical illness. Design: Prospective analysis of laboratory and clinical data. Setting: Department of surgery in a university hospital. Patients: 135 patients undergoing uncomplicated abdominal surgery or with sepsis, liver failure, hemorrhage, severe cholestasis, or multiple organ dysfunction syndrome (MODS). Interventions: Surgical and/or medical therapy according to clinical status. Measurements and main results: Determinations of total cholesterol, additional variables, and clinical data. Cholesterol decreased after surgery, in sepsis, liver failure, acute hemorrhage, and MODS and increased in cholestasis. Hypocholesterolemia correlated with decreases in plasma proteins and indices of hepatic protein synthetic adequacy, with hemodilution from blood loss, and was moderated or prevented by cholestasis. Conclusions: These results help to explain the dynamics of the development, clinical relevance, and negative prognostic value of hypocholesterolemia in critical illness.

This preliminary paper compares encephalography and computed tomography as regards the duration of the examinations, the technical difficulties and their diagnostic values. Some examples are reported to demonstrate the complementary importance of the two techniques.

In sepsis tissue O2 uptake may be abnormally limited because of a depressed O2 consumption/O2 transport relationship. This study has been performed to assess patterns of O2 consumption, CO2 production and O2 transport in septic patients undergoing total parenteral nutrition; more in particular, this study has investigated the interdependence between the patterns of blood O2 uptake and simultaneous CO2 release, and the availability of substrates (amino acids, glucose and fat). It has been shown that the O2 consumption/O2 transport relationship is significantly influenced by the exogenous amino acid load, which tends to increase O2 uptake and O2 consumption at any given O2 transport, thus suggesting a favourable effect of amino acid administration on energy metabolism. The data on CO2 production and CO2 release, in addition to reconfirming the results of previous studies, have shown that the changes in O2 uptake and in CO2 production mediated by substrate doses have a quantifiable impact on blood O2-CO2 exchange interactions.

Background Reduction of operative blood transfusions is a primary goal in resective surgery of the liver. Temporary vascular inflow occlusion is an effective method to decrease hemorrhage during hepatic resection. This study was performed to assess the impact of normothermic ischemia on intraoperative bleeding and outcome after hepatic resection. Methods. Sixty-one hepatic resections were performed by using pedicle clamping alone or associated with total vascular exclusion of the liver. The mean duration of normothermic ischemia was 40+/-18 minutes (range, 7 to 98 minutes). Major resections were performed in 32 cases (52.5%). Results. Operative mortality was nil. Major complications occurred in 11.5% of cases. Twenty-five patients (41%) received intraoperative blood transfusions; mean +/- SD of transfused blood units was 2.4+/-1.3. Twelve major resections (37.5%) did not require any transfusion. Postoperative changes in liver function test results were moderate and transient. Conclusions. The results of this study confirm the benefit of vascular occlusion techniques in reducing intraoperative bleeding and postoperative complications. The routine use of these techniques during hepatic resections, if applied properly and with the necessary precautions, is not associated with severe adverse effects on liver function.

Sixty patients with cerebral ischemia were studied by both CT and angiography. The results are:1.Thrombosis of the internal carotid artery: CT shows a hypodensity lateral to the frontal horn.2.Thrombosis of the middle cerebral artery: the hypodensity occupies the convexity of the frontal, parietal, and temporal lobes.3.In thrombosis of the posterior cerebral artery there is an occipital hypodensity, while in thrombosis of the vertebral artery the hypodensity occupies a cerebellar hemisphere.4.Circulatory disturbances without occlusion of the major cerebral vessles: there is a disproportion between the serious CT lesion and paucity of the angiographic findings.