Is there a future for adsorption techniques in sepsis?

During sepsis toxins released from, e.g., bacteria induce reactions of various cascade systems that may cause progression of the patient into septic shock, disseminated intravascular coagulation, multiorgan dysfunction syndrome and subsequent death. The use of conventional treatments using antibiotics, fluid substitution, inotropic drugs, respiration aid and dialysis is not enough to reverse the serious prognosis. The addition of various other drugs such as antibodies against various cytokines and cytokine receptors, pentoxiphylline, immunoglobulins or high doses of steroids is usually without benefit for the prognosis of the patient. Another possibility to reduce the extent of toxins and other harmful compounds in the circulation is the use of apheresis (removal by technical devices). This can be done either in a nonselective way (plasma exchange, plasmapheresis) or more selectively using various adsorbers such as polymyxin B. The survival in studies varies between 50 and 80%. Besides the use of nonselective apheresis, the development of various selective adsorption techniques may be one approach to improve survival of these severely ill patients.     

Is there a future for liver-assist devices?

Patients with fulminant hepatic failure fall into two categories: those who will not recover without hepatic replacement, and those with severe but potentially reversible liver injury whose livers have the potential to recover and/or regenerate. Liver support systems must provide physiologic support, rendering the patient hemodynamically stable and “bridging” the patient to transplantation, or allowing the native liver to recover and/or regenerate. Recent limited successes with bioartificial liver support for patients with fulminant liver failure are encouraging. However, these preliminary results come without randomization or control groups and without stratification by disease etiology or severity. It is hoped that randomized, controlled trials will answer important questions about the efficacy of these systems.     

Is minimally invasive heart valve surgery a paradigm for the future?

During the past 5 years, there has been considerable progress in the development of less invasive techniques for heart valve surgery. Both aortic and mitral valve surgery can now be performed through small chest wall incisions. Recent evidence confirms patient benefit with minimally invasive heart valve surgery. Although several approaches can be used, a partial upper sternotomy offers several advantages for minimally invasive heart valve surgery.     

Giant cavernous hemangioma of the liver: is tumor size a risk factor for hepatectomy?

The aim of this study was to evaluate whether hepatic giant cavernous hemangioma (GCH) tumor size is a risk factor for hepatectomy. Twenty patients with GCH of the liver were treated by hepatic resection. Eleven patients with maximum resected specimen tumor size of >10 cm (mean tumor size, 18.5 cm; group 1) were compared with the 9 patients with tumor size. <10 cm (mean tumor size, 8.6 cm; group 2). The incidence of major hepatectomy in group 1 was significantly higher than that in group 2 (P = 0.0241). Although there were no significant differences in preoperative liver function, or in fibrinogen or platelet counts between the two groups, the level of preoperative fibrin degradation product (FDP) in group 1 was significantly higher than that in group 2 (P = 0.0116). Mean intraoperative hemorrhage volume, blood transfusion volume, and operation time in group 1 vs group 2 were 7003 ml vs 1092 ml (P = 0.0251), 2927 ml vs 556 ml (P = 0.0169), and 431 min vs 216 min (P < 0.0001), respectively. The incidence of postoperative complications in group 1 (45.5%) was higher than that in group 2 (22.2%), although not significantly so. There was no operative mortality in either group. Tumor size significantly correlated with intraoperative blood loss, operation time, weight of resected liver, intraoperative blood transfusion volume, and preoperative FDP levels. GCH tumor size is a significant risk factor for hepatectomy mainly because of the massive intraoperative blood loss and blood transfusion associated with major hepatic resection. More careful preoperative management to decrease tumor size may increase the safety of surgery for GCH of the liver.     

Is laparoscopic hepatectomy superior to open hepatectomy for hepatocellular carcinoma?

The low perioperative morbidity and shorter hospital stay associated with laparoscopic hepatectomy have made it an often-used option at many liver centers, despite the fact that many patients with hepatocellular carcinoma have cirrhosis, which makes the procedure more difficult and dangerous. Type of surgical procedure proves not to be a primary risk factor for poor outcomes after hepatic resection for hepatocellular carcinoma, the available evidence clearly shows that laparoscopic hepatectomy is an effective alternative to the open procedure for patients with early-stage hepatocellular carcinoma, even in the presence of cirrhosis. Whether the same is true for patients with intermediate or advanced disease is less clear, since laparoscopic major hepatectomy remains a technically demanding procedure.     

Is there a role for liver biopsy in primary sclerosing cholangitis?

OBJECTIVE: Liver biopsies are performed in patients with primary sclerosing cholangitis (PSC) to stage disease and to rule out coexisting liver disease. The purpose of this study was to examine how often routine liver biopsies provide important information in patients with PSC. METHODS: We reviewed the charts of 138 patients with a cholangiographic diagnosis of PSC to determine whether information from liver biopsy had an impact on clinical management. RESULTS: A total of 30 patients did not have a liver biopsy, whereas 29 patients had a biopsy before cholangiography. In 79 patients the liver biopsy was performed after the diagnosis of PSC was established by cholangiography (median time from cholangiography to liver biopsy, 21 days). In 78 of 79 patients (98.7%) the liver biopsy revealed no atypical findings and did not affect clinical management. In one patient the liver biopsy revealed findings of an overlap syndrome with autoimmune hepatitis, and the patient was treated with corticosteroids and azathioprine. This patient had biochemical features consistent with autoimmune hepatitis. One patient developed a bile leak after liver biopsy, requiring hospitalization (complication rate 0.9%). CONCLUSIONS: Liver biopsies rarely contribute new information that affects the management of patients with PSC. Given the risks of the procedure, liver biopsies for patients with a diagnosis of PSC established by cholangiography may not routinely be necessary.