Experimental study on hepatic vascular exclusion with atrioportacaval shunt in dogs.

The main effects of hepatic vascalar exclusion(HVE) on the body are hemodynarnic changes and metabolic disorders.We developed a new technique-atrioportacaval shunt(APCS) both to increase the blood-return volame and to decompress the portal system and the inferior vena cava below the occlusion during     

Piggyback liver transplant techniques in the surgical management of urological tumors with inferior vena cava tumor thrombus

Background An important characteristic of renal cell carcinomas and adrenal tumors is that these tumors may expand into the renal vein and inferior vena cava, and transform into tumor thrombi. This study was to evaluate the use of piggyback liver transplant techniques for surgical management of urological tumors with inferior vena cava tumor thrombus. Methods Nineteen patients with renal cell carcinomas or adrenal tumors with inferior vena cava tumor thrombus were treated from November 1995 to April 2008. Their ages ranged from 29 years to 76 years （mean 54 years）. The extent of tumor thrombus was infrahepatic （level Ⅰ） in 2, retrohepatic （level Ⅱ） in 7, suprahepatic （level Ⅲ） in 6, and intra-atrial （level Ⅳ） in 4 patients. We used cardiopulmonary bypass with deep hypothermic circulatory arrest to remove the thrombi in 3 cases of level IV and in 2 cases of level Ⅲ. In all level Ⅱ, 4 level Ⅲ, and 2 level IV cases, we used piggyback liver transplant techniques to mobilize the liver off of the inferior vena cava and to separate the inferior vena cava from the posterior abdominal wall. Results Mean operative time was 5.1 hours, mean estimated blood loss was 2289 ml and mean blood transfusion was 12.84 U. One patient with adrenal cortical carcinoma and level Ⅳ thrombus died in the immediate postoperative period. Three patients were lost to follow up, and the other 15 survivors were followed from 5 months to 56 months. Eight of these 15 patients died due to metastasis; however 7 were still alive at the last follow-up. Conclusions An aggressive surgical approach is the only hope for curing patients diagnosed with urological tumors combined with inferior vena cava tumor thrombus. The use of piggyback liver transplant techniques to mobilize the liver off of the inferior vena cava provides excellent exposure of the inferior vena cava. Patients with a level Ⅱ or level Ⅲ inferior vena cava thrombus may be treated without using cardiopulmonary bypass.     

An improved technique for bloodless hepatic resection on in situ cold perfused liver.

An improved technique for bloodless hepatic resection using in situ isolation and asanguinous hypothermic perfusion was described to deal with huge liver tumors involved in the liver hilum, the main hepatic veins and retrohepatic inferior vena cava. The original Fortner's technique was modified, including the choice of incision; semi-isolated perfusion of the liver portion preserved through the single portal vein; suprahepatic outlet of the perfusate and the shortening of the period of hepatic ischemia by reperfusion of hepatic artery prior to the repair or reconstruction of the portal vein. The initial successful experience of the technique applied to 2 pediatric cases with giant liver tumors was reported, and the indications, intraoperative and early postoperative courses were discussed.

     

Clinical application of hepatic venous occlusion for hepatectomy

Background Most liver resections require clamping of the hepatic pedicle （Pringle maneuver） to avoid excessive blood loss. But Pringle maneuver can not control backflow bleeding of hepatic vein. Resection of liver tumors involving hepatic veins may cause massive hemorrhage or air embolism from the injuries of the hepatic veins. Although total hepatic vascular exclusion can prevent bleeding of the hepatic veins effectively, it also may result in systemic hemodynamic disturbance because of the inferior vena cava being clamped. Hepatic venous occlusion, a new technique, can control the inflow and outflow of the liver without clamping the vena cava. Methods A total of 71 cases of liver tumors underwent resection with occlusion of more than one of the main hepatic veins. All tumors involved the second porta hepatis and at least one main hepatic vein. Ligation or occlusion with serreflnes, tourniquets and auricular clamps were used in hepatic venous occlusion. Results Of the 71 patients, ligation of the hepatic veins was used in 28 cases, occlusion with a tourniquet in 26, and occlusion with a serrefine in 17. Right hepatic veins were occluded in 38 cases, both right and middle hepatic veins in 2, the common trunk of the left and middle hepatic veins in 24, branches of the left and middle hepatic veins in 2, and all three hepatic veins in 5. Thirty-five cases underwent hemihepatic vascular occlusion, 4 alternate hemihepatic vascular occlusion, 23 portal triad clamping plus selective hepatic vein occlusion, and 9 portal triad clamping plus total hepatic vein occlusion. The third porta hepatis was isolated in 26 cases. The amount of intraoperative blood loss averaged （540±2.83） （range 100 to 1000） ml in the group of total hemihepatic vascular occlusion and in the group of alternate hemihepatic vascular occlusion, （620±317） （range 200-6000） ml in the group of portal triad clamping plus selective or total hepatic vein occlusion. All tumors were completely removed. Conclusions Hepatic venous occlusion     

Research of combined liver-kidney transplantation model in rats

Objective： To set up a simple and reliable rat model of combined liver-kidney transplantation. Methods： SD rats served as both donors and recipients. 4℃ sodium lactate Ringer＇s was infused from portal veins to donated livers,and from abdominal aorta to donated kidneys, respectively. Anastomosis of the portal vein and the inferior vena cava （IVC） inferior to the right kidney between the graft and the recipient was performed by a double cuff method, then the superior hepatic vena cava with suture. A patch of donated renal artery was anastomosed to the recipient abdominal aorta. The urethra and bile duct were reconstructed with a simple inside bracket. Results： Among 65 cases of combined liver-kidney transplantation, the success rate in the late 40 cases was 77.5%. The function of the grafted liver and kidney remained normal. Conclusion： This rat model of combined liver-kidney transplantation can be established in common laboratory conditions with high success rate and meet the needs of renal transplantation experiment.     

Application and evaluation of non-invasive examination for Budd-Chiari syndrome

Budd-Chiari syndrome （BCS） is symptomatic obstruction or occlusion of the hepatic vein （HV）and/or upper inferior vena cava （IVC）. It can be divided into two groups： obstruction of the HV causes hepatomegaly, abdominal distension, portal vein hypertension and ascites; Obstruction of the IVC causes varicosities of the chest and abdominal wall, edema and ulcers of the lower limbs, etc.     

Ex vivo liver resection followed by autotransplantation for end-stage hepatic alveolar echinococcosis

Background  For patients with end-stage hepatic alveolar echinococcosis (AE), in vivo resection of the involved parts of the liver is usually very difficult, therefore, allogenic liver transplantation is indicated. However, we hypothesize that for selected patents, ex vivo liver resection for thorough elimination of the involved tissues and liver autotransplantation may offer a chance for clinical cure.

Methods  We presented a 24-year-old women with a giant hepatic AE lesion who was treated with hepatectomy, ex vivo resection of the involved tissue and hepatic autotransplantation. The patient had moderate jaundice and advanced hepatic AE lesion which involved segments I, IV, V, VI, VII, VIII and retrohepatic inferior vena cava. The lateral segments (II and III) of the left liver remained normal with over 1000 ml in its volume. No extrahepatic metastases (such as to the lung or brain) could be found. As the first step of treatment, X-ray guided percutaneous transhepatic cholangiodrainage (PTCD) was performed twice for bile drainage in segment III and II separately until her serum total bilirubin decreased gradually from 236 to 88 µmol/L. Total liver resection was then performed, followed by extended right hepatic trisegmentectomy and the entire retrohepatic vena cava was surgically removed en bloc while her hemodynamics parameters were stable. Neither veino-veinous bypass nor temporary intracorporeal cavo-caval or porto-caval shunt was used during the 5.7-hour anhepatic phase. The remained AE-free lateral segments of the left liver were re-implanted in situ. The left hepatic vein was directly anastomosed end-to-end to the suprahepatic inferior vena cava due to the lack of the retrohepatic inferior vena cava with AE total infiltration. Because compensatory retroperitoneal porto-caval collateral circulation developed, we enclosed remained infrahepatic inferior vena cava at renal vein level without any haemodynamics problems.

Results  During a 60-day following-up after operation, the patient had a good recovery except for a mildly elevated serum total bilirubin.

Conclusions  As a radical approach, ex vivo liver resection and liver autotransplantation in a case has shown a optimal potential for treatment of the end-stage hepatic AE. Strict compliance with its indications, evaluation of vessels of patients pre-operatively, and precise surgical techniques are the keys to improve the prognosis of patients.

     

Selective total vascular occlusion for major hepatic resection.

Selective total vascular occlusion for the resection of large tumors on the right lobe of the liver or central hepatic tumors was described. The occlusion of the portal triad, infrahepatic vena cava and the total hepatic circulation was selectively used in combination to control bleeding in the process of hepatectomy. Within a year, major resection was successfully performed with this technique on 10 patients (extended right lobectomy 4 patients, right lobectomy 4, central segmentectomy 2). The mean duration of total vascular exclusion was 19.35 +/- 19.32 minutes and mean blood transfusion requirement was 7 +/- 4.5 units during surgery.

     

Laparoscopic left hemihepatectomy under occlusion of the left inflow and outflow

Laparoscopic hepatectomy seems to be difficult because of the ease of bleeding from the liver parachyma during resection. This is not easily controlled under the laparoscope, especially during right or left hemihepatectomy, except for resection of the peripheral liver or left lateral segment when porta hepatis dissection is not indicated. Although both inflow and outflow control seems to be ideal in laparoscopic left hepatectomy, there have not been many reports of this. In addition to the high technical demands and the time required, any injury of the main hepatic veins or vena cava during the procedure will cause catastrophic bleeding and air embolism. Recently, we succeeded in achieving inflow and outflow occlusion during laparoscopic left hemihepatectomy in four cases, with satisfactory results.     

Liver,biliary tract,pancreas,spleen

<正>209338 Guard against "block phenomenon" for inferior vena cava being in compression during open cholecystectomy/Liu Guoying(刘国英,Dept Anesthesiol,Hangzhou 5th Peop Hosp,Hangzhou 311100)…∥Chin J Hepatobil Surg.-2009,15(6).-457～458Objective To explore the existence of "block phenomenon" of he inferior venal cava being in compression during open cholecystectomy.Methods A total of 30 patients receiving open cholecystectomy under the general anesthesia and epidural anesthesia in our hospital were selected.The right internal jugular vein and femoral vein catheterization was performed after the anesthesia induction and intubation to continuously monitor CVP and the in ferior vena cava pressure (IVCP).Meanwhil,the changes in CVP,MAP,HR,IVCP before abdominal opening,upon pulling gallbladder as well as 5 min,10 min and 15 minutes after the opening of deep retractors were observed,recorded and compared.Results The HR of patients during cholecystectomy did not changed significantly(P>0.05) but MAP an CVP were decreased markedly(P<0.01).Furtherore,there was remarkable increase of pressure in the inferior vena(P<0.01).These changes were the most obvious during the filling of saline gauze pads in the abdominal cavity and within the first 15 min of deep retractors led.After the closure of abdominal wall,the levels of CVP,MAP and IVCP returned to those before the abdominal opening.Conclusion The "block phenomenon" of the inferior vena cava during open cholecystectomy do exist in different degress and it is the main reason for the patients’ hemodynamic variety.This requires the anesthesiologists to hint the surgeon in the management of anesthesia to consider changing the posture and strength of retractors while the blood pressure is decreasing to avoid cardiovascular and cerebrovascular events.5 refs,1 tab.