What's new in liver surgery in the year 2000?

More than half a century ago, Ton That Tung, then Lortat-Jacob performed the first anatomic hepatectomies, marking the onset of the conquest of liver surgery. Shortly thereafter, a few pioneers took the leap, making the first attempts at total hepatectomy and liver transplantation. Within years, considerable progress was made in hepatobiliary surgery which rapidly became a full-fledged surgery specialty. Techniques were equally improved with new advances in imaging and technology. The last 15 years have been so rich at in the strict sense of the word, little is new in liver surgery in 2000. What has changed is the general perception that liver surgery is entering a new era in the third millennium: high-tech surgery, a surgery that is safe, self-confident, yet aggressive and ambitious, a surgery that is perfectly integrated into increasingly sophisticated and comprehensive therapeutic schemes.     

New aspect of immunosuppressive treatment in liver transplantation. How could you induce tolerance in liver transplantation?

New immunosuppressive strategies have improved short- and long-term graft survival. The current aim is to decrease the intensity of the immunosuppressive regimen, in an attempt to limit side effects and the direct toxicity of calcineurin inhibitor (CNI) for kidney function. We describe here current experience in liver and liver-kidney transplantation, the mechanism of tolerance and the immunosuppressive strategy used in liver transplantation.     

Auxiliary liver transplantation for management of acute liver failure in children – Systematic review

IntroductionLiver transplantation (LT) remains the standard of care in the treatment of acute pediatric liver failure (PALF) for the replacement of a severely damaged native liver in patients who are unlikely to recover. However, this is burdened by the consequences of long-term immunosuppression.Auxiliary partial liver orthotopic transplantation (APOLT) has emerged as a possible improved approach, by providing a graft that assures liver function until the regeneration of the native liver occurs, and then allows for possible progression to immunosuppression withdrawal.No previous systematic review has assessed APOLT for PALF. The aim of this work is to provide information on survival, postoperative complications, and withdrawal of immunosuppression after APOLT for PALF.MethodsThe study was carried out according to the recommendations of the preferred report items for systematic reviews and meta-analyzes (PRISMA). We searched several electronic databases until October 31st, 2020, using the search terms “acute liver failure”, “auxiliary liver transplant” and the MESH term “liver failure, acute”. All types of clinical publications that presented results on APOLT for PALF, in English or Portuguese, and restricted to humans and for children under 18 years old were included. The following exclusion criteria were applied: “follow-up time <6 months”, “does not report complications” and “does not report immunosuppression regimen (double vs triple)”. Demographic data, clinical characteristics at the time of surgery and postoperative results were analyzed.ResultsA total of 14 references (including 45 patients) were selected, including 3 case series (6–20 patients) and 11 case reports.Of the 45 subjects, 33 (73.3%) were male and 12 (26.7%) female. In most cases (n = 30; 66.7%), the cause of PALF was undetermined. All patients underwent APOLT. Their median age was 9 (range 0.6–17) years. In the postoperative period, the immunosuppression regimen was double in 34 (75.6%) and triple in 11 (24.4%) individuals. The main postoperative complications were rejection and infection. Over a follow-up period of 6 months to 14 years, 10 (22.2%) patients died. The main cause of death was sepsis (70%). Six (13.3%) patients were retransplanted. Of the survivors (n = 35), 68.6% achieved complete withdrawal from the immunosuppression regimen.ConclusionBased on current published evidence, APOLT for the treatment of PALF is a safe option, with an acceptable rate of complications and mortality. It has the great advantage of providing an immunosuppression-free life in the majority (68.6%) of survivors.     

Blunt cardiac rupture in patient with liver laceration

The early diagnosis of cardiac rupture is one of the key factors for a successful outcome.However, the accurate diagnosis is ofter difficult in the early stage of injury,especially when some obvious severs wounds are found in other regions of the body,^1,2 for they are easy to disguise the symptom of the heart.We report a case with cardiac rupture and liver trauma caused by traffic accident.     

Pathomorphological changes after liver impact imjury in rabbits

Objective:To investigate the histopathological changes in the liver and other organs after impact injury.Methods:The rabbits were impacted with a BIM-IVbiological impacting machine at the xiphoid process.The sverith of liver injury was graded and scored through gross anatomy,At the same time,the pathological changes in the liver,heart,and lung were observed by light and electron microscopes.Results:Light microscopy showed that the pathological changes in the liver were:1)loss of normal stucture,hemorrrhage and distortion of hepatic logbles;2)cloudy swelling,degeneration,vacuolation and necrosis of liver cells;3) infiltration of neutrophils,The lungs were injured and there were liver cell emboli in the small pulmonary arteries.Electron microscopy showed that the ultrastructure of the liver cells was severely damaged and the cells had significant features of necrosis.Conclusions:the maior pathomorphological changes in the liver after impact injury are hemorrhage and necrosis.They may be compilcated by exfolistion of liver cells to hepatic sinusoids.These cells circulate with the blood to form emboli in the pulmonary blood vessels.     

Hope or efficacy in donor liver allocation?

Both the number of recipients awaiting liver transplantation and the length of wait are increasing, giving rise to increasing concern by patients, healthcare professionals, and the public. Greater attention has been focused on the criteria for listing patients for transplantation and for allocation of organs. In the U.K., compared with the U.S., the delivery of liver transplant services is more tightly regulated, with fewer transplant centers, lower transplant rates, shorter waiting lists, and shorter waiting times. The reasons for these differences are unclear. In the U.K., patients are listed only if there is a reasonable expectation that the patient will receive a graft. The criteria for listing are based on overall utility rather than individual benefit, so the criterion for listing is that the patient will have at least a greater than 50% probability of being alive 5 years after transplantation with a quality of life that is acceptable to the patient. Although it is reasonable to offer hope to all patients, this hope should have a reasonable probability of being fulfilled. Listing patients with little likelihood of benefiting from transplantation is not helpful either for the patient, their family, or the other potential liver allograft recipients. While different systems for allocation of donor livers may be more appropriate in other settings, the process in the U.K. seems to deliver satisfactorily.     

Cystic lesions in the liver: benign or malignant?

A 65-year old patient is presented with an ultrasound showing multiple cysts in liver and both kidneys. Computed tomography scan (CT-scan) showed a cyst in the right liver lobe with a largest diameter of 12 cm, suspicious for cystadenocarcinoma. Further staging showed no extrahepatic metastasis. Considering possible malignancy, aspiration of the cyst was not an option because of the risk for ent-metastasis. Resection of the tumour was considered as the best treatment. Peroperatively the cyst was localized with ultrasound, after which an extended right hepatectomy was performed. No peroperative complications occurred. Histological diagnosis was a cyst, originating in dilated von Meyenburg complexes. No signs of a biliary cystadenoma or malignant deformation were observed. A CT-scan 1 year postoperatively showed some other small cysts in the left liver lobe, the patient was free of any complaints. The differential diagnosis in cases of asymptomatic liver cysts will be discussed.     

Is ketamine a safe anesthetic for percutaneous liver biopsy in a liver transplant recipient immunosuppressed with cyclosporine?

A 6-yr-old male patient underwent live related left lateral segment liver transplant for cryptogenic cirrhosis with portal hypertension. One month after the liver transplant the patient had an isolated liver transaminases increase. He was posted for percutaneous liver biopsy for suspected graft rejection under general anesthesia. The patient was administered ketamine 7 mg/kg along with glycopyrrolate 0.01 mg/kg IM in the preoperative area. He developed generalized tonic clonic seizures just before the biopsy and was treated with IV midazolam 1 mg and thiopental 60 mg. Percutaneous liver biopsy was obtained once the convulsions subsided. Both ketamine and cyclosporine have been implicated as having proconvulsant properties and may have been responsible for the seizures in our patient. Our experience prompted us to suggest that ketamine in a patient immunosuppressed with cyclosporine may not be safe and that alternative anesthetics may need to be considered for such procedures.     

Changes in portal vein flow after adult living-donor liver transplantation: Does it influence postoperative liver function?

In adult living donor liver transplantation, using small grafts in cirrhotic patients with severe portal hypertension may have unpredictable consequences. The so-called small-for-size syndrome is present in most series worldwide. The goal of this study was to prospectively evaluate the influence of hemodynamic changes on postoperative liver function and on the percentage of liver volume increase, in the setting of living donor liver transplantation. Twenty-two consecutive adult living donor liver transplantations were performed at our institution in a 2-year period. We measured right portal flow and right hepatic arterial flow with an ultrasonic flow meter in the donor, and then in the recipient 1 hour after reperfusion. Postoperative liver function was measured by daily laboratory work. We also performed duplex ultrasounds on postoperative days 1, 2, and 7. Liver volume increase was estimated by magnetic resonance imaging graft volumetry at 2 months posttransplantation. We compared the blood flow results with the immediate liver function and its liver volume increase rate at 2 months. There was a significant increase in portal flow in the recipients compared with the donors (up to fourfold in some cases). Higher portal flow increase rates significantly correlated with faster prothrombin time normalization and faster liver volume increases. Median graft volume increase at 2 months was 44.9%. The increase in blood flow to the graft is well tolerated by the liver mass not affecting hepatocellular function as long as the graft-to body weight ratio is maintained (>0.8) and adequate outflow is provided. (Liver Transpl 2003;9:564-569.)     

Is there occult tissue ischemia in chronic end-stage liver disease?

Whether pathological oxygen supply dependency exists in patients with chronic end-stage liver disease (CESLD) is unknown, although the frequently occurring multiorgan dysfunction seen in these patients may be the result of occult tissue ischemia. In this study, 15 adult patients with CESLD were evaluated for the presence of pathological oxygen supply dependency and, thus, occult tissue ischemia before undergoing orthotopic liver transplantation. Whole-body oxygen consumption (VO2) was measured using indirect calorimetry at baseline, at reduced oxygen delivery (DO2) using positive end-expiratory pressure, and at increased DO2 using volume infusion. As a group, no significant increase or decrease in VO2 was observed with changes in DO2. However, 4 patients showed increases in VO2 of 14%, 10.8%, 9.6%, and 8.2% when DO2 was increased. The study results suggest that pathological oxygen supply dependency is present in a subset of patients with CESLD, and the existence of occult tissue ischemia is speculated.     

Ischemia–reperfusion injury in patients with fatty liver and the clinical impact of steatotic liver on hepatic surgery

Hepatic steatosis is one of the most common hepatic disorders in developed countries. The epidemic of obesity in developed countries has increased with its attendant complications, including metabolic syndrome and non-alcoholic fatty liver disease. Steatotic livers are particularly vulnerable to ischemia/reperfusion injury, resulting in an increased risk of postoperative morbidity and mortality after liver surgery, including liver transplantation. There is growing understanding of the molecular and cellular mechanisms and therapeutic approaches for treating ischemia/reperfusion injury in patients with steatotic livers. This review discusses the mechanisms underlying the susceptibility of steatotic livers to ischemia/reperfusion injuries, such as mitochondrial dysfunction and signal transduction alterations, and summarizes the clinical impact of steatotic livers in the setting of hepatic resection and liver transplantation. This review also describes potential therapeutic approaches, such as ischemic and pharmacological preconditioning, to prevent ischemia/reperfusion injury in patients with steatotic livers. Other approaches, including machine perfusion, are also under clinical investigation; however, many pharmacological approaches developed through basic research are not yet suitable for clinical application.