Portal vein resection without reconstruction during Appleby operation in a patient with pancreatic body carcinoma with cavernous transformation.

The prognosis of pancreatic body carcinoma has been poor due to cancerous invasion of major vessels. Resection of the involved vessels may improve resectability and prognosis. We report a patient who had a pancreatic body carcinoma with cavernous transformation of the portal vein, in whom the portal vein was resected without reconstruction during an Appleby operation. A 67 year-old man was admitted for evaluation of back pain. Enhanced computed tomography showed no main trunk of the portal vein but a developed collateral circulation. Celiac angiography revealed encasement of the common hepatic, splenic and celiac artery. Venous angiography revealed obstruction of the portal and splenic veins with cavernous transformation surrounding these veins. Pre-operative diagnosis was carcinoma in the pancreatic body, which invaded the portal vein, the celiac and common hepatic arteries. The Appleby operation combined with resection of the portal vein without reconstruction could be performed, by preserving collateral vessels and monitoring hepatic venous oxygen saturation (ShvO2) to prevent hepatic ischemia caused by occlusion of the portal vein. The post-operative course was uneventful.     

Distal pancreatectomy with resection of the celiac axis and reconstruction of the hepatic artery for carcinoma of the body and tail of the pancreas

Distal pancreatectomy with resection of the celiac axis can increase resectability of carcinoma of the body and tail of the pancreas. We performed reconstruction of the hepatic artery to avoid complications caused by a decrease in hepatic arterial flow. We carried out distal pancreatectomy with resection of the celiac axis for carcinoma of the body and tail of the pancreas in four patients. When pulsation in the proper hepatic artery was weak after occlusion of the celiac axis, we performed reconstruction of the hepatic artery, using the splenic artery, which had been taken beforehand from the resected specimen. In two patients, we performed reconstruction of the hepatic artery. These two patients underwent reconstruction of the portal vein combined with prolonged clamping of the portal vein. Levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were elevated just after the operation, but recovered to normal levels within 10 days. No complications related to hepatic ischemia were observed. These results suggested that reconstruction of the hepatic artery allowed us to safely perform distal pancreatectomy with resection of the celiac axis for carcinoma of the body and tail of the pancreas.     

Safety of portal vein resection using centrifugal pump-assisted venous bypass between the superior mesenteric vein and the umbilical vein

BACKGROUND/AIMS: To achieve complete resection of pancreatic cancer, portal vein resection has been performed with increasing frequency at the time of pancreaticoduodenal resection (pancreaticoduodenectomy or total pancreatectomy). In the meantime, visceral congestion and liver ischemia are of great concern during the procedure. We investigated safety of portal vein resection using a centrifugal pump-assisted bypass between the superior mesenteric vein and the umbilical vein. METHODOLOGY: A retrospective comparison was performed in 49 consecutive patients who underwent pancreatoduodenal resection with or without portal vein resection using the bypass for pancreatic cancer. Twenty-two patients underwent portal vein resection using the bypass (group 1). The other 27 patients undergoing pancreatoduodenal resection without portal vein resection comprise the control group (group 2). RESULTS: Total operative time was 756 +/- 159 min and 526 +/- 109 min (p<0.001) and median blood loss was 2090 mL and 1200 mL in groups 1 and 2, respectively. However, the centrifugal pump-assisted bypass allowed stable bypass flow, and neither intestinal edema nor ischemic change of the liver was observed during portal vein resection and the subsequent reconstruction. Postoperatively, the peak postoperative AST, ALT and total bilirubin levels showed no significant difference and postoperative day of starting a liquid diet was similar between the groups (9.0 +/- 5.4 vs. 9.8 +/- 3.8 days, p=0.48). In addition, the rates of morbidity (55% vs. 48%) including biliary and pancreatic leak as well as mortality (9% vs. 4%) did not significantly differ between the 2 groups. CONCLUSIONS: The centrifugal pump-assisted bypass may be useful to prevent hepatic ischemia and visceral congestion during portal vein resection procedures, resulting in similar postoperative outcomes to the control after pancreaticoduodenal resection for pancreatic cancer.     

Indications for posthepatectomy hepatic vein reconstruction from functional and morphological studies: clamping test and hepatic vein branch distribution determined by three-dimensional computed tomography.

BACKGROUND/AIMS: Indications for hepatic vein reconstruction for preserving remnant liver function after hepatectomy were assessed using the clamping test and the findings of preoperative 3D-CT (3-dimensional computed tomography). METHODOLOGY: Fifteen patients who underwent hepatectomy for malignant tumors in segment VII or VIII, or both, were examined with preoperative 3D-CT and an intraoperative clamping test. RESULTS: On the basis of changes in right hepatic venous pressure during clamping, we classified all patients into 3 types: the persistent elevation type (P-type, 8 patients), the no elevation type (N-type, 3 patients) and the transitory elevation type (T-type, 4 patients). Hepatic venous hemoglobin oxygen saturation (ShvO2) decreased significantly in the P type but hardly changed in the T and N types during the clamping test. Both the inferior right hepatic vein (IRV6) and the tributary of the middle hepatic vein draining segment V (MV5) were detected by preoperative 3D-CT in the T and N types. CONCLUSIONS: Assessments of hepatic vein branch distribution using preoperative 3D-CT served to predict the results of the hepatic vein clamping test. The results of preoperative 3D-CT were useful as indications for hepatic vein reconstruction.     

The significance of intraoperative Doppler ultrasonography in evaluating hepatic arterial flow when assessing the indications for the Appleby procedure for pancreatic body cancer

Background/purpose

The Appleby procedure has been used in the surgical treatment of advanced gastric cancer. This procedure consists of a combined resection of the whole of the stomach, the body and tail of the pancreas, and the spleen, as well as resection of the celiac artery. This procedure can also be used for operative resection of cancer of the body of the pancreas. The hepatic arterial flow is supplied from the arcade of the supramesenteric artery. In the past, the extent of hepatic arterial flow after the celiac artery had been clamped was evaluated by finger palpation. However, this is not an objective method.

Methods

Here, we describe two patients with pancreatic body cancer, in one of whom the Appleby procedure was followed. However, in the other, this operation could not be performed because the residual blood supply to the liver would have been inadequate. The hepatic arterial flow was assessed using intraoperative Doppler ultrasonography (US) of the intrahepatic artery (arterial flow of segment 3).

Results

In case 1 (a 45-year-old man), the hepatic arterial flow prior to clamping of the celiac artery was 68.4?cm/s, and this flow was reduced to 22.1?cm/s after the clamping. The color and consistency of the liver surface remained good. Because there was adequate hepatic arterial flow after the celiac artery was clamped, the Appleby procedure was performed. However, in case 2 (a 65-year-old man), the hepatic arterial flow after the celiac artery had been clamped was reduced from 47.9?cm/s to 14.3?cm/s. The liver surface became dark and the liver shrank. In addition, there were various preoperative medical conditions in this patient. We decided not to proceed with the Appleby procedure.

Conclusions

Intraoperative Doppler US measurement of the hepatic arterial flow is a useful technique, particularly in combination with the assessment of the color and tension of the liver, the age of the patient, and the extent of preoperative comorbidity, in determining whether an Appleby procedure is feasible.     

Gonadal vein graft for hepatic artery reconstruction.

BACKGROUND/AIMS: Resection of hepatic arteries is often obligatory on resecting pancreatic, gastric and hepatobiliary malignancies. Hepatic artery reconstruction is required to preserve liver function and blood flow to the bile duct. We applied the gonadal vein to hepatic artery reconstruction. METHODOLOGY: Hepatic artery reconstruction using a gonadal vein graft was performed in two patients: one with gallbladder cancer and the other with recurrent gastric cancer. RESULTS: The right ovarian vein, 2 mm in diameter and 4 cm in length, was grafted for reconstruction between the proper hepatic and the posterior hepatic artery in one patient who underwent modified central hepatic bisegmetectomy and common bile duct resection. The left spermatic vein, 3 mm in diameter and 6 cm in length, was grafted for reconstruction between the celiac artery and the right hepatic artery in the other, who underwent upper abdominal exenteration. The former graft was occluded due to tumor invasion at 4 months after surgery, the latter one was patent at 8 weeks after surgery. CONCLUSIONS: The gonadal vein had an ideal diameter and sufficient length to accomplish hepatic arterial reconstruction. The gonadal vein graft will be a new and preferable addition to the selection of an optimal graft for hepatic arterial reconstruction.     

“可能切除的”胰腺癌的外科治疗策略

“可能切除的”胰腺癌介于“可切除”与“不可切除”之间,其定义的主要内涵是肠系膜上静脉、门静脉、肠系膜上动脉或肝总动脉是否为肿瘤侵犯及是否可切除重建,是目前的热点课题。“可能切除的”胰腺癌所涉及的外科相关问题包括：联合血管切除的安全性、有效性;淋巴清扫范围;标本切缘检测的标准化等。治疗方面建议对此类患者行新辅助放化疗,以增加R0切除的几率及可能性,但具体方案尚不统一,亦无RCT研究佐证。在目前多学科治疗模式及理念下,R1切除的价值及意义值得重新审视。     

Surgical technique of hepatectomy combined with simultaneous resection of hepatic artery and portal vein for perihilar cholangiocarcinoma (with video)

Perihilar cholangiocarcinomas often involve the bifurcation of the portal vein and the hepatic artery at initial presentation. Previously, vascular invasion was a major obstacle for R0 resection; therefore, such tumors were regarded as locally advanced, unresectable disease. Recently, in leading centers, these tumors have been resected using a specific technique, vascular resection and reconstruction. Vascular resection is classified into three types: portal vein resection alone, hepatic artery resection alone, and simultaneous resection of both the portal vein and hepatic artery. Of these, portal vein resection is widely performed, whereas hepatic artery resection remains controversial. Therefore, hepatectomy combined with simultaneous resection of the portal vein and hepatic artery represents one of the most complicated and challenging procedures in hepatobiliary surgery. The survival benefit of this extended procedure remains unproven, and there is only a single study reporting an unexpectedly favorable outcome in 50 patients. Considering the dismal survival in patients with unresectable disease, hepatic artery resection and/or portal vein resection may be a promising option of choice. However, the technique is highly demanding and has not been standardized. Therefore, this extended surgery may be allowed only in selected hepatobiliary centers.     

Pancreatic head tumors with portal vein involvement: an alternative surgical approach.

BACKGROUND/AIMS: One of the determining factors for the unresectability of pancreatic head tumors is the involvement of the portal venous system. Recent reports show that the resection of tumors with portal vein involvement has similar results to lesions with same stage without portal vein invasion. The aim of this study is to present a technique that allows the resection of portal vein segments without the use of grafts and with a shorter period of intraoperative venous occlusion. METHODOLOGY: Fifteen patients with pancreatic head tumors and portal vein involvement were submitted to pancreaticoduodenectomy according to this technique. The main feature of the technique is starting the pancreatic dissection at the posterior aspect of the head of the pancreas. The superior mesenteric artery is completely dissected from the pancreatic tissues leaving the section of the pancreas and the resection of the portal vein to the last step. RESULTS: Portal vein flow occlusion did not exceed 10 minutes. There were no major postoperative complications or mortality. CONCLUSIONS: This maneuver allows an easier resection of the mobilized portal vein with a shorter period of venous clamping and reconstruction without the need of venous graft.     

肝圆韧带重建门静脉/肠系膜上静脉的可行性探讨

目的探讨肝圆韧带重建门静脉／肠系膜上静脉的可行性。方法对4例实施胰十二指肠联合门静脉／肠系膜上静脉切除的患者．手术中用肝圆韧带重建切除的静脉。结果静脉切除长度3．5～6．5cm．重建切除静脉时利用肝圆韧带长度4．0～7．0cm，术中门静脉阻断时间30～126min，无手术死亡者。术后随访10～39个月。门静脉／肠系膜上静脉通畅，无血栓形成。结论在胰十二指肠联合门静脉／肠系膜上静脉切除术中利用肝圆韧带重建切除的静脉是可行的。     

Left trisegmentectomy and combined resection of the inferior vena cava, without reconstruction, for giant cystadenocarcinoma of the liver

A 54-year-old woman with giant liver cystadenocarcinoma underwent left trisegmentectomy with combined resection of the inferior vena cava (IVC) and the right hepatic vein. As a result, only the right inferior hepatic vein was preserved as a drainage vein. Because the perivertebral plexus and the azygos vein were both well developed, neither veno-venous bypass nor IVC reconstruction was performed. The developed collateral veins acted as the venous drainage pathway to maintain a stable systemic circulation. On the seventh postoperative day, portal vein flow dramatically decreased and the patient tended to liver failure. Prostaglandin E₁ (PGE₁) was administrated via the superior mesenteric artery. The portal flow then gradually increased and liver failure was avoided. Six months after the operation, she was re-admitted due to obstructive jaundice and presented with complete stenosis of the common bile duct (CBD). The jaundice persisted and liver dysfunction progressed. The patient died seven months after the operation. The confluence of the right inferior vein and the IVC could have been deformed, causing outflow blockade. The intrinsic shunt was not good enough to act as the drainage pathway, and IVC reconstruction may have been needed.     

Hepatectomy and pancreatectomy with combined vascular resection in patients with hepato-biliary and pancreas diseases at a single cancer institute

BACKGROUND/AIMS: In advanced cancers of hepatobiliary and pancreatic lesions, major vascular resection and reconstruction are necessary to accomplish curative resection, which may provide better patient outcomes. METHODOLOGY: Surgical records, morbidity and mortality, and prognosis were examined in patients with combined vascular resection. Thirty-six patients underwent 18 hepatectomies and 18 pancreatectomies. RESULTS: In 18 patients who underwent hepatic resection, the resected vessels were the portal vein (PV) in 10, vena cava or hepatic vein in 9 and right hepatic artery (RHA) in 3. An artificial graft was used in 2 to replace the vena cava. Vascular bypass was performed in 5 patients. Morbidity was due to biliary stricture in 1 patient and adult respiratory distress syndrome in another who died during hospital stay. Fourteen (82%) had cancer recurrence, of whom 12 died of cancer, one died of other disease, and 2 survived cancer-free. The 5-year survival was 28%. In 18 patients who underwent pancreatectomy, resected vessels were PV in 18 and RHA in 1. An artificial graft was used in 3 and vascular passive bypass was performed in 6. One patient died of sepsis after total pancreatectomy during hospital stay. Eleven (64%) had cancer recurrence, of whom 11 died of cancer, 2 died of other disease, and 4 survived cancer-free. The 3-year survival was 27%. CONCLUSIONS: Complete surgical resection (R0) combined with main vascular resection could be safely performed in many patients with disease of the hepatobiliary and pancreas, which achieved longer survival in some patients even in the advanced stage.     

The posterior approach in pancreaticoduodenectomy: preliminary results

BACKGROUND/AIMS: We present our technical version of pancreaticoduodenectomy by posterior approach that enables a complete dissection of the right side of the mesenteric superior artery and of the portal vein, as well as a complete excision of the retroportal pancreatic process (or lamina), and report the preliminary outcomes of the first 10 selected patients. METHODOLOGY: Between 1 December 2005 and 1 March 2006 10 patients (7 males and 3 females) with a mean age of 60.6 years (range 45-81 years) were operated on using this technique. The patients were diagnosed with carcinoma of the pancreatic head (8 cases), ampullary carcinoma (1 case), and carcinoma of the distal part of the common bile duct (1 case). Invasion of the portal vein occurred in 2 of the 8 cases of carcinoma of the pancreatic head. RESULTS: No significant intraoperative incident was recorded. The mean operative time was 225 minutes (ranging between 180 and 240 minutes) and the mean blood loss was 372,25cc (range 150-800cc). Two cases of carcinoma of the pancreatic head that had a segmental resection of the portal vein needed vascular reconstruction which was performed by Goretex graft interpositing. The pylorus-preserving procedure was used in 2 cases (ampullary carcinoma, and carcinoma of the distal part of the common bile duct, respectively). Postoperative complications consisted of intraabdominal hemorrhage from an arterial source of the pancreatic capsule (on the day of the operation necessitating reoperation for hemostasis) in one case, and pancreatic fistula (that required conservative treatment) in another case. No postoperative diarrhea, delayed gastric emptying episodes or postoperative deaths were recorded. There were no postoperative deaths. The mean length of hospitalization was 12.2 days (range 10-24 days). CONCLUSIONS: The posterior approach in pancreaticoduodenectomy offers an early selection of patients during the operation (in terms of resectability). As compared to the standard procedure, it enables an adequate lymphadenectomy that can be safely performed (by early dissection and isolation of the superior mesenteric artery), and avoids possible intraoperative accidents secondary to anatomical arterial abnormalities. This approach is particularly recommended in cases with portal vein invasion because it allows a "no-touch" resection.     

Portal vein arterialization technique for liver transplantation patients

Liver transplantations were performed on two patients with hepatic failure caused by liver cirrhosis. Hard obsolete thrombi and portal venous sclerosis were observed in the major portal veins of both patients. The arteria colica media of one recipient and the portal vein of the donor were anastomosed end-to-end. The hepatic artery of the first donor was anastomosed end-to end with the gastroduodenal artery of the first recipient; meanwhile, the portal vein of the second donor was simultaneously anastomosed end- to-end with the common hepatic artery of the second recipient. The blood flow of the portal vein, the perfusion of the donor liver and liver function were satisfactory after surgery. Portal vein arterialization might be an effective treatment for patients whose portal vein reconstruction was difficult.     

应用CTA技术和超声评估肝移植术患者术前肝脏血供状态研究*

目的 研究计算机断层扫描血管成像(CTA)和超声检测评估肝移植术患者术前肝脏血管解剖变异和管腔通畅性。方法 2014年5月～2020年5月我院收治的接受肝移植手术患者138例,术前均行腹部三期CT增强扫描、CTA后处理[包括容积再现(VR)和最大密度投影(MIP)等重建和超声检查。分析肝动脉、门静脉、肝静脉和下腔静脉及其侧支循环情况。结果 138例患者中,CTA显示107例(77.5%)肝动脉解剖起源和走行正常(Michels aⅠ型),31例(22.5%)存在肝动脉解剖变异,肝动脉管腔未出现狭窄和异常扩张情况,1例(0.7%)合并脾动脉瘤;136例患者术中肝动脉解剖与术前CTA评估一致;CTA诊断血栓和瘤栓的灵敏度和准确度分别为83.3%和68.6%,而超声检查诊断为58.3%(P<0.05)和60.0%;超声和CTA诊断肝静脉和下腔静脉通畅性的准确率均为99.3%。结论 相对于超声检查,CTA检查可准确评估肝移植术前肝动脉解剖变异情况,对门静脉栓子定性诊断的准确性也较高,且可清晰显示门静脉侧支循环开放情况。     

Tips and tricks of surgical technique for pancreatic cancer: portal vein resection and reconstruction (with videos)

Surgical resection is the only hope for cure in patients with pancreatic cancer. To improve the resectability and achieve better prognosis of this lethal disease, extended resection for pancreatic cancer has been applied. We have performed portal vein resection aggressively for pancreatic cancer with portal vein invasion. We also established a method of portal vein reconstruction using the left renal vein graft for tumors widely extended to the portal vein. Our data show similar survival between patients with portal vein obstruction and those without invasion. We also show that portal vein reconstruction using the left renal vein graft can be performed safely without severe liver damage. With video, we introduce our surgical technique for portal vein resection and reconstruction, especially focusing on the usage of the left renal vein graft, providing several tips for a safe and successful procedure.     

Arterial and vena caval resections combined with pancreaticoduodenectomy in highly selected patients with periampullary malignancies

BACKGROUND/AIMS: To obtain a margin-negative resection and increase the indication for resection of periampullary malignancies, pancreaticoduodenectomy with a SM-PVR (superior mesenterico-portal vein resection) has been performed. However, an arterial resection, other vascular resections except SM-PVR (e.g., an inferior vena caval resection), or a metastatic tumor resection combined with pancreaticoduodenectomy has yet to be fully elucidated because of the high risk of postoperative complications and extremely poor long-term survival in patients undergoing these exceptional procedures. The present report focused on highly selected patients undergoing an arterial resection or a vena caval resection associated with pancreaticoduodenectomy. METHODOLOGY: Besides 31 patients with periampullary tumors undergoing pancreaticoduodenectomy associated with SM-PVR in our department, a group of 4 patients underwent arterial resections and another patient underwent pancreaticoduodenectomy combined with a resection of liver metastasis together with an inferior vena caval resection. These five patients were reported in the present study. RESULTS: A 27 year-old-woman presented pancreatic ductal adenocarcinoma of the pancreatic head and a liver metastasis in which involvements of the superior mesenterico-portal vein and the inferior vena cava were shown. Pancreaticoduodenectomy was performed with SM-PVR associated with a left hemihepatectomy combined with a segment 1 resection and an inferior vena caval resection. The patient did not present severe postoperative complications and experienced a good quality of life during 16 months after surgery. Four other patients underwent arterial resections. These arterial resections were performed only when a margin-negative resection was feasible. The superior mesenteric artery was resected and reconstructed with a Goretex graft in one patient. The right hepatic artery was resected and reconstructed with a saphenous graft in two patients. The other patient underwent a resection of the common hepatic artery and reconstruction was performed with the splenic artery. Three of the four patients presented postoperative complications but were conservatively treated. Two patients are still alive 25 months and 8 months after surgery. One patient died of sepsis 5 months after surgery, and the other died of cancer progression 19 months after surgery. CONCLUSIONS: The indication for retropancreatic arterial resection associated with pancreaticoduodenectomy should be carefully evaluated only when a margin-negative resection can be achieved. An appropriate bypass method of arterial reconstruction should be selected because a direct end-to-end anastomosis is not always feasible. Hepatectomy for metastases of pancreatic ductal carcinoma should be also regarded as an exceptional procedure.     

Oxygen metabolism of the liver during an HA clamp: HV saturation and free radicals

BACKGROUND/AIMS: To clarify changes in the hepatic oxygen metabolism and tissue damage resulting from oxygen-derived free radical generation from polymorphonuclear cells during a hepatic arterial clamp. METHODOLOGY: Subjects were 32 male Wistar rats. Hepatic tissue blood flow, and hepatic venous chemiluminescence, indicating oxygen-derived free radicals from polymorphonuclear cells, and liver lipid peroxide were measured, and hepatic and portal venous blood gas analysis were performed before and after 130 minutes of hepatic arterial clamping. RESULTS: Hepatic tissue blood flow decreased by hepatic arterial clamp. The values of hepatic arterial oxygen pressure (HTBF), hepatic venous oxygen saturation (ShvO2), and O2 contents after hepatic arterial clamp were lower than those before hepatic arterial clamp (P = 0.035, 0.024, and 0.028, respectively). Hepatic venous chemiluminescence decreased and the lipid peroxide level of the liver increased by hepatic arterial clamp (P = 0.001). CONCLUSIONS: ShvO2 is useful for the evaluation of hepatic oxygen metabolism and hepatic tissue blood flow during acute hepatic arterial clamp. This condition should prepare the following tissue damage due to oxygen-derived free radicals from polymorphonuclear cells.     

Resection of hilar cholangiocarcinoma with left hepatectomy after pre-operative embolization of the proper hepatic artery

Background:

Right or right-extended hepatectomy including the caudate lobe is the most common treatment for hilar cholangiocarcinoma (HC). A 5-year survival of up to 60% can be achieved using this procedure if R0-resection is obtained. However, for some patients a left-sided liver resection is necessary to obtain radical resection. The close relationship between the right hepatic artery and the HC in these patients frequently limits the ability to achieve a radial R0-resection without difficult vascular reconstruction. The aim of the present study was to describe the outcome of patients who underwent pre-operative embolization of the proper hepatic artery in an effort to induce development of arterial collaterals thus allowing the resection of the proper and right hepatic artery without vascular reconstruction.

Methods:

In patients presenting with HC who were considered to require a left hepatic lobectomy and in whom pre-operative work up revealed possible tumour invasion of the right hepatic artery, transcatheter arterial embolization (TAE) of the proper hepatic artery or the left and right hepatic arteries was performed. Three weeks later, a left-sided hepatectomy with resection of all portal structures except the portal vein was performed.

Results:

In six patients, pre-operative embolization of the proper hepatic artery was performed. Almost instantaneously in all six patients arterial flow signals could be detected in the liver using Doppler ultrasonography. No patient died peri-operatively. In all six patients an R0 radial resection was achieved and in three an R0 proximal transection margin was obtained. All post-operative complications were managed successfully using percutaneous drainage procedures. No patient developed local recurrence and two patients remain disease free more than 7 years after surgery.

Summary:

After pre-operative embolization of the proper hepatic artery, resection of the HC with left hepatectomy is a promising new approach for these technically demanding patients, giving them the chance of a cure.     

Enhanced inflammatory cytokine production at ischemia/reperfusion in human liver resection

BACKGROUND/AIMS: Clinical implications of acute reactant cytokine responses remain to be clarified in the setting of ischemia/reperfusion of human liver during liver resection and transplantation. METHODOLOGY: In serial samples of portal and systemic venous blood we examined acute inflammatory cytokine activities at the time points--before i), at the end of clamping ii), and one hour iii) and day 1 iv) after continuous hepatic inflow occlusion in 25 patients undergoing elective hepatectomy (15 major and 10 minor). Responses of tumor necrosis factor-alpha, interleukin-1 beta, interleukin-6 and interleukin-8 were compared with intraoperative parameters such as the duration of hepatic inflow occlusion and portal venous pressure during the occlusion, postoperative hepatocyte injury markers such as serum transaminases and bilirubin and also related complications. RESULTS: Portal interleukin-6 levels were significantly elevated during hepatic inflow occlusion, as compared with the systemic events (P < 0.02, at time point ii), but there were no differences in the interleukin-8 levels between the portal and systemic circulation. The increase in portal interleukin-6 levels during liver resection (time points, ii and iii) significantly correlated with the duration of hepatic inflow occlusion (48 +/- 9 min, mean +/- SD), portal venous pressure (500 +/- 127 mmH2O), and postoperative serum levels of transaminases (day 1; S-ALT, 705 +/- 1023 U/L; S-AST 892 +/- 1255 U/L) and maximum bilirubin (2.6 +/- 2.5 mg/dL). Interleukin-8 levels in the portal circulation showed no such correlation, but the levels in systemic blood showed significant positive relationships with the intra- and postoperative parameters. One patient who died had an enhanced generation of the cytokines in the presence of an elevated portal venous pressure. CONCLUSIONS: These observations suggest that overproduction of acute reactant cytokines (interleukin-6 from the portal system and interleukin-8 from the systemic circulation) in hepatic ischemia/reperfusion relates positively with postoperative hepatocyte injury in humans. We propose that hepatectomy done under a prolonged continuous inflow occlusion should be reconsidered when an enhanced generation of acute cytokines is anticipated, especially in case of a markedly high portal pressure during hepatic pedicle clamping.