Assessment by pulse dye-densitometry indocyanine green (ICG) clearance test of hepatic function of patients before cardiac surgery: its value as a predictor of serious postoperative liver dysfunction.

OBJECTIVE: Patients with preoperative liver dysfunction occasionally have a poor prognosis after cardiac surgery because the liver condition is aggravated. The pulse dye-densitometry indocyanine green (ICG) clearance test was used as a preoperative evaluation technique. DESIGN: Prospective, clinical evaluation. SETTING: Surgical intensive care unit of a national cardiovascular center. SUBJECTS: Twenty-seven patients with preoperative liver dysfunction were studied. They were divided into four groups depending on the cause of their liver dysfunction. INTERVENTIONS: With the patient's informed consent, a bolus of ICG, 20 mg, was injected, and the disappearance of ICG was measured noninvasively by pulse dye-densitometry. MEASUREMENTS AND MAIN RESULTS: The ICG retention rate at 15 minutes (ICG-R15) was calculated for the regression time. The patients were assessed in terms of ICG-R15 and the cause of liver dysfunction. The ICG-R15 values obtained for all 27 patients were 30% +/- 16% (mean +/- standard deviation). The 21 survivors had ICG-R15 values of 24% +/- 12%, whereas the 6 patients who died after surgery had significantly greater ICG-R15 values of 50% +/- 13% (p < 0.05). The mean values of ICG-R15 in patients with congestive liver, viral hepatitis accompanied by congestive liver, viral hepatitis, and cirrhosis were 34%, 23%, 13%, and 42%, respectively. The 6 of 27 patients who died after surgery had ICG-R15 values greater than 40%. Five of the seven patients with cirrhosis died. CONCLUSION: These results suggest that (1) compared with Child-Pugh classification, the value of ICG-R15 provides a more accurate surgical indication; and (2) liver dysfunction from cirrhosis causes postoperative deterioration of liver function, especially when the ICG-R15 value exceeds 40%.     

肝切除术后第3天ICG-R15对肝细胞肝癌术后肝功能不全的预测价值

目的:探讨术后第3天吲哚菁绿15 min潴留率(ICG-R15)预测肝细胞肝癌术后肝功能不全发生的价值。方法:回顾2015年1月—2016年2月期间行肝切除的119例肝细胞肝癌患者资料,分析患者术后肝功能不全的发生与术前及术后第3天ICG-R15的关系,并比较术前与术后ICG-R15在预测术后肝功能不全发生的差异。结果:119例患者中共有33例(27.7%)术后发生肝功能不全。发生与未发生肝功能不全患者术前ICG-R15平均值分别为9.7%、5.2%,术后第3天ICG-R15平均值分别为11.8%、5.3%,术前与术后ICG-R15在发生与未发生肝功能不全患者间差异均有统计学意义(均P0.05)。分层分析显示,术后肝功能不全的发生率均随术前或术后第3天的ICG-R15增加而升高,且均在ICG-R1510%与20%的患者间有明显统计学差异(均P0.05)。术后第3天ICG-R15预测术后肝功能不全发生的ROC曲线下面积较术前ICG-R15大,前者的临界值为7.75(灵敏度为66.7%,特异度为83.7%),后者为3.35(灵敏度为84.8%,特异度为46.5%)。结论:术后第3天ICG-R15与术前ICG-R15一样可预测肝细胞肝癌术后肝功能不全的发生,且可能优于术前ICG-R15。     

ICG pulse spectrophotometry for perioperative liver function in hepatectomy

BACKGROUND: The indocyanine green (ICG) clearance test has been used to estimate liver functional reserve before hepatectomy. However, changes in ICG clearance after hepatectomy have not been investigated, and their extent remains unknown. PATIENTS AND METHODS: The ICG(K) value, signifying the ICG elimination rate constant, was measured with pulse-dye densitometry before operation and 1, 2, 3, 5, and 7 days postoperatively in 22 patients who underwent liver resection of various extent. CT volumetry was used to calculate the residual liver volume ratio. The relationship between the pre- and postoperative ICG(K) value and the residual liver volume ratio was examined statistically. RESULTS: There was a significant drop in ICG(K) value, from 0.193 +/- 0.011 before operation to 0.160 +/- 0.013 on Postoperative Day 1, and then it remained significantly low at the postoperative examination times. The residual liver volume ratio was 70.2 +/- 5.4%. The estimated ICG(K) value, calculated by the preoperative ICG(K) value and the residual liver volume ratio, showed a significant correlation with the actual postoperative value (r = 0.859 on Postoperative Day 1, P < 0.0001). In five patients with prolonged jaundice, the estimated ICG(K) value was significantly lower than in those without it (0.077 +/- 0.028 versus 0.153 +/- 0.012, P = 0.0136). CONCLUSIONS: The perioperative ICG(K) value measured by pulse-dye densitometry revealed a significant decrease in ICG(K) after operation depending on the reduction in liver volume, and the estimated ICG(K) based on the residual liver volume was useful in predicting postoperative morbidity.     

Major hepatic resection under total vascular exclusion.

Over a 9-year period, major resection was successfully performed on 51 occasions with total vascular exclusion using supra- and infrahepatic caval and portal vein clamping. The main indications for hepatic resection were centrally located tumor in liver metastases (62%) and hepatocellular carcinoma with no evidence of co-existing cirrhosis (25%). Major resections included extended and regular right hepatectomy, extended left hepatectomy, and segmentectomy. The mean duration of vascular exclusion was 46.5 +/- 5.0 minutes (range 20 to 70 minutes) and mean blood transfusion requirement was 1.4 +/- 0.4 units during vascular exclusion. There were significant correlations between postoperative fall in factor II levels and the number of segments removed (r = 0.37, p = 0.015) and between serum alanine aminotransferase levels at day 2 and the duration of vascular exclusion (r = 0.35, p = 0.02). One patient died 45 days after the procedure of multi-organ failure and sepsis. Nonfatal complications occurred in 7 patients (14%) and included respiratory infection (7 patients), biliary fistula (3 patients), and collection at the site of hepatic resection (3 patients). Total vascular exclusion is a safe and useful technique in resection of major hepatic lesions that involve hepatic veins.     

吲哚菁绿试验对小肝癌治疗策略选择的临床应用分析

目的 探讨吲哚菁绿试验在小肝癌治疗策略选择中的临床应用。方法 回顾性分析2017年1月至2019 年1 月解放军总医院海南医院肝胆外科60 例小肝癌患者的临床资料。根据治疗方式不同分为肝切除术组（36 例）和射频消融术组（24 例）,再根据术后是否出现肝衰竭分别把两组分为术后肝衰竭亚组及术后非肝衰竭亚组,比较不同组别的临床资料、吲哚菁绿15 min滞留率（ICG-R15）、Child-Pugh（CP）分值的差异。根据不同的ICG-R15,将肝切除术组及射频消融术组患者再分为ICG-R15 ＜20%亚组、20%≤ICGR15＜30%亚组和ICG-R15 ≥30%亚组,比较相应分组手术后肝衰竭发生率。结果 肝切除术组和射频消融术组术前检查及临床资料差异均无统计学意义（P＞0.05）,ICG-R15、CP分值差异两组有统计学意义（P＜0.05）。ICG-R15 ＜20%亚组、20%≤ICG-R15 ＜30%亚组和ICG-R15 ≥30%亚组的肝切除术患者肝衰竭率分别为6.3%、33.3%、37.5%,射频消融术组对应的肝衰竭率分别为0、12.5%、28.6%。两组的20%≤ICG-R15＜30%亚组肝衰竭率具有统计学差异（P＜0.05）;ICG-R15＜20%及ICG-R15≥30%亚组肝衰竭率无统计学差异（P＞0.05）。结论 ICG-R15是术前评估肝储备功能的可靠指标,对小肝癌手术方式选择具有指导意义。当ICG-R15＜20%,手术切除和射频消融治疗小肝癌安全性都高;当20%≤ICG-R15＜30%,射频消融术较肝切除术安全性更高;当ICG-R15 ≥30%,两种手术方式出现肝衰竭风险都较大,应纠正肝功能后再进一步评估手术方式。     

Partial hepatectomy on cirrhotic liver with a right lateral tumor

A total of 24 patients with cirrhotic liver and solitary, small hepatocellular carcinoma (HCC) located at the lateral part of the right lobe underwent surgery with our technique of hepatic clamping and finger dissection. There were no operative mortality or acute or chronic hepatic failure. Total operating time was 129 +/- 20 minutes; actual resection time was only 22.7 +/- 4.9 minutes. The average amount of blood transfused during this procedure was 1552 +/- 909 ml. The preoperative serum bromsulphalein retention rate proportionately reflected the postoperative peak serum conjugated bilirubin concentration if the weight of the resected specimen was less than 310 gm (p less than 0.001). An evaluation of the enzymes (SGOT, SGPT, and lactate dehydrogenase) released from liver cells on the first postoperative day found that more prominent elevation was observed in the group of patients with hypotension than in those without hypotension (all p less than 0.001). Although all enzyme levels returned to the preoperative level on the fourteenth postoperative day, the excretory capacity of liver cells as measured by serum bromsulphalein retention rate on day 14 time was still abnormally high (p less than 0.001) and took 2 to 3 months to decline to a level that still exceeded preoperative levels (p less than 0.05). In conclusion, partial hepatectomy on cirrhotic liver by hepatic clamping and finger dissection was a simple, rapid technique without any serious side effects.     

Early detection of liver failure after hepatectomy by indocyanine green elimination rate measured by pulse dye-densitometry

BACKGROUND/PURPOSE: Following a major hepatectomy, some degree of clinical and biochemical dysfunction occurs. Surgeons usually check serum total bilirubin levels to diagnose postoperative liver dysfunction. However, we cannot predict liver failure by biochemical data alone within the early postoperative period. Using newly developed pulse dye-densitometry (PDD), we measured serial postoperative indocyanine green elimination rate (ICG-K) values and investigated the possible relation between postoperative ICG-K values and complications. METHODS: Fifty-one patients scheduled for hepatectomy between January 2000 and December 2002 were enrolled. Pulse-dye densitometry was used to evaluate postoperative liver function. We analyzed the relation between postoperative ICG-K and postoperative outcome, assessed in terms of morbidity and mortality. RESULTS: Liver failure was seen in seven patients. The ICG-K value on postoperative day 1 in patients with liver failure was significantly lower than that in patients without liver failure (0.070 +/- 0.018 vs 0.152 +/- 0.056/min respectively; P < 0.001). There were no differences between preoperative ICG-K values in patients with and without liver failure. The sensitivity and specificity of an ICG-K value of less than 0.07 on postoperative day 1 were 71.4% and 95.5%, respectively, for predicting liver failure. CONCLUSIONS: We can measure the ICG-K value by PDD at the bedside without time delay, and we can predict liver failure in the early postoperative period by the ICG-K values on postoperative day 1. ICG-K values measured by PDD can provide important information for perioperative management.     

Sinusoidal injury increases morbidity after major hepatectomy in patients with colorectal liver metastases receiving preoperative chemotherapy

OBJECTIVE: To investigate whether sinusoidal injury (SI) was associated with a worse outcome after hepatectomy in patients with colorectal liver metastases (CRLM). BACKGROUND: Correlation between SI and oxaliplatin-based chemotherapy (OBC) was recently shown in patients with CRLM. However, it has yet to be fully clarified whether SI affects liver functional reserve and outcome after hepatectomy. PATIENTS AND METHODS: Between 2003 and 2005, 90 patients with CRLM who underwent an elective hepatectomy after preoperative chemotherapies were included. Diagnosis of SI was established pathologically in the nontumoral liver parenchyma of the resected specimens, and perioperative data were assessed in these patients. RESULTS: OBC was significantly associated with a higher incidence of SI. Preoperative indocyanine green retention rate at 15 minutes (ICG-R15) and postoperative value of total-bilirubin were significantly higher, and hospital stay was significantly longer in patients presenting with SI. Multivariate analysis showed that female gender, administration of 6 cycles or more of OBC, abnormal value of preoperative aspartate aminotransferase >36 IU/L, or abnormal value of preoperative ICG-R15 (>10%) were preoperative factors significantly associated with SI. Among patients undergoing a major hepatectomy, SI was significantly associated with higher morbidity and longer hospital stay. CONCLUSION: The present study suggests that SI resulted in a poorer liver functional reserve and in a higher complication rate after major hepatectomy. Therefore, female patients who received 6 cycles or more of OBC, or presenting with abnormal preoperative aspartate aminotransferase and ICG-R15 values should be carefully selected before deciding to undertake a major hepatectomy.     

Major liver resection without clamping: a prospective reappraisal in the era of modern surgical tools

BACKGROUND: Hemorrhage and transfusions remain the main causes of mortality and morbidity from liver resection. In cases of extended resection, especially performed on diseased liver, ischemia-reperfusion injury related to pedicle clamping may be a significant risk factor of postoperative liver dysfunction. The ideal alternative would be to perform major hepatectomy without clamping and without significant bleeding. STUDY DESIGN: This prospective study aimed to reconsider the risk of major hepatectomy performed without pedicle clamping and under low venous pressure in the light of modern surgical tools. Inclusion criteria were adults requiring a resection of more than three segments on healthy or pathologic livers but not on preoperative documented cirrhosis. RESULTS: Fifty patients, with a mean age of 53 +/- 15 years were included. Twenty-two patients had underlying liver disease. The main indications were colorectal metastases, primary liver tumors, and living donation. Twenty-six right hepatectomies, 17 extended right hepatectomies, and 7 extended left hepatectomies were performed. Unclamping method was successful in 96% of patients on an intention-to-treat basis. Seventy-four percent of patients were not transfused and no patients died. Surgical complication rate was 16% but no complication led to reoperation. Medical complication rate was 20%, including three transient liver dysfunctions. CONCLUSIONS: Major hepatectomy without clamping can be performed safely. The low rate of postoperative liver dysfunction, especially in cases of underlying liver disease, suggests good preservation of the small and diseased remnant liver.     

Recovery from liver failure after hepatectomy for hepatocellular carcinoma in cirrhosis: meaning of the model for end-stage liver disease

BACKGROUND: Hepatectomy for hepatocellular carcinoma in cirrhosis is followed by an impairment of liver function that can lead to patient death. The model for end-stage liver disease (MELD) is considered an index of hepatic functional reserve, and its assessment on postoperative course may properly identify individuals at risk of liver failure. STUDY DESIGN: Two hundred hepatectomies for hepatocellular carcinoma in cirrhosis were reviewed. Irreversible postoperative liver failure was defined as an impairment of liver function after hepatectomy that led to patient death or required transplantation. The MELD scores at postoperative days (POD) 1, 3, 5, and 7 were calculated and kinetics of changes investigated with t-test; logistic regression was applied to identify predictive variables of postoperative liver failure. RESULTS: Kinetics of postoperative MELD score showed an impairment of liver function between PODs 1 and 3; 185 patients in whom postoperative liver failure did not develop showed a considerable decrease in MELD score between PODs 3 and 5 (11.9+/-2.8 and 10.6+/-2.4, respectively, p<0.001). On the contrary, 15 patients, who experienced the event, showed an increase in MELD score between PODs 3 and 5 (18.2+/-3.9 and 18.3+/-3.6, respectively; p=0.845). Multivariate analysis showed preoperative MELD score (p<0.001), major hepatectomy (p=0.028), and MELD score increase between PODs 3 and 5 (p=0.011) as independent predictors of irreversible postoperative liver failure. Scores are reported as mean+/-SD. CONCLUSIONS: Recovery from liver impairment after hepatectomy for hepatocellular carcinoma in cirrhosis starts from POD 3; MELD scores increasing between PODs 3 and 5 may identify patients at risk of liver failure and represents the trigger for beginning intensive treatment or evaluating salvage transplantation.     

Assessment of Nutritional Status and Prediction of Postoperative Liver Function from Serum Apolioprotein A-1 Levels with Hepatectomy

Background We investigated the usefulness of apolipoprotein A-1 (apoA) as an indicator of nutritional status, and the correlation of the preoperative apoA level with changes in postoperative liver function following hepatectomy. Methods One hundred patients underwent hepatectomy. Serum levels of apoA, prealbumin (prealb), retinol-binding protein (RBP), lectin-cholesterol acyltransferase (LCAT), hyarulonate (HA), indocyanine green dye retention at 15 minutes (ICG), and the receptor index of Tc-GSA scintigraphy (LHL15) were measured at preoperation and on postoperative days (POD) 7 and 14. Partial resection was carried out in 62 cases, segmentectomy in nine cases, and bisegmentectomy in 29 cases. Co-existent liver conditions were normal liver (NL) in 43 cases, chronic hepatitis (CH) in 29 cases, and liver cirrhosis (LC) in 28 cases. Results In most cases the serum apoA level had decreased on POD 7, and recovered on POD 14. There were no significant differences in the changes of apoA between the individual operative procedures. Although preoperative apoA had almost the same value in the NL, CH, and LC cases, apoA in LC cases on POD 14 was the lowest of all cases. The apoA level showed significant correlations with prealb, LCAT, and HA on POD 14. All cases were divided into two groups (group N: apoA over 91 mg/dl; group L: apoA under 90 mg/dl) based on the preoperative serum apoA level. On POD 14, the ICG, LHL15, and HA of group L were significantly deteriorated compared with those of group L. Conclusion The serum level of apoA reflects the changes in hepatic protein synthetic ability after hepatectomy; therefore, it may be possible to estimate recovery of nutritional status after hepatectomy from serum apoA. Moreover, we can predict postoperative deterioration of liver function from the preoperative apoA level.     

术前应用靛氰绿检测联合三维重建成像评估肝门部胆管癌肝脏储备功能

目的探讨肝门部胆管癌患者肝切除术前肝脏储备功能的评估方法及意义。方法单治疗组手术的肝门部胆管癌患者72例。比较通过靛氰绿(ICG)检测、三维成像(3D)重建评估后手术患者并发症发生率。结果 72例患者中,67例患者行ICG检测,56例ICG 15分钟滞留率(R15)10%,11例ICG R1510%。3D重建评估预留肝体积为(860.32±235.41)cm3,预留脏脏体积/全肝体积为38%~75%。32例患者术前采用ICG联合3D重建。术后并发胆漏5例,腹腔积液11例,并发症发生率为22.2%。各组间术后并发症发生率悲剧差异有统计学意义(P0.05)。结论术前ICG检查联合3D重建评估可定量评价患者肝脏储备功能,做出准确手术规划,减少术后并发症。     

Complete versus selective portal triad clamping for minor liver resections: a prospective randomized trial

OBJECTIVE: To evaluate the feasibility, safety, efficacy, amount of hemorrhage, postoperative complications, and ischemic injury of selective clamping in patients undergoing minor liver resections. SUMMARY BACKGROUND DATA: Inflow occlusion can reduce blood loss during hepatectomy. However, Pringle maneuver produces ischemic injury to the remaining liver. Selective hemihepatic vascular occlusion technique can reduce the severity of visceral congestion and total liver ischemia. PATIENTS AND METHODS: Eighty patients undergoing minor hepatic resection were randomly assigned to complete clamping (CC) or selective clamping (SC). Hemodynamic parameters, including portal pressure and the hepatic venous pressure gradient (HVPG), were evaluated. The amount of blood loss, measurements of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST), and postoperative evolution were also recorded. RESULTS: No differences were observed in the amount of hemorrhage (671 +/- 533 mL versus 735 +/- 397 mL; P = 0.54) or the patients that required transfusion (10% versus 15%; P = 0.55). There were no differences on postoperative morbidity between groups (38% versus 29%; P = 0.38). Cirrhotic patients with CC had significantly higher ALT (7.7 +/- 4.6 versus 4.5 +/- 2.7 mukat/L, P = 0.01) and AST (10.2 +/- 8.7 versus 4.9 +/- 2.1 mukat/L; P = 0.03) values on the first postoperative day than SC. The multivariate analysis demonstrated that high central venous pressure, HVPG >10 mm Hg, and intraoperative blood loss were independent factors related to morbidity. CONCLUSIONS: Both techniques of clamping are equally effective and feasible for patients with normal liver and undergoing minor hepatectomies. However, in cirrhotic patients selective clamping induces less ischemic injury and should be recommended. Finally, even for minor hepatic resections, central venous pressure, HVPG, and intraoperative blood loss are factors related to morbidity and should be considered.     

Continuous versus intermittent portal triad clamping for liver resection: a controlled study

OBJECTIVE: The authors compared the intra- and postoperative course of patients undergoing liver resections under continuous pedicular clamping (CPC) or intermittent pedicular clamping (IPC). SUMMARY BACKGROUND DATA: Reduced blood loss during liver resection is achieved by pedicular clamping. There is controversy about the benefits of IPC over CPC in humans in terms of hepatocellular injury and blood loss control in normal and abnormal liver parenchyma. METHODS: Eighty-six patients undergoing liver resections were included in a prospective randomized study comparing the intra- and postoperative course under CPC (n = 42) or IPC (n = 44) with periods of 15 minutes of clamping and 5 minutes of unclamping. The data were further analyzed according to the presence (steatosis >20% and chronic liver disease) or absence of abnormal liver parenchyma. RESULTS: The two groups of patients were similar in terms of age, sex, nature of the liver tumors, results of preoperative assessment, proportion of patients undergoing major or minor hepatectomy, and nature of nontumorous liver parenchyma. Intraoperative blood loss during liver transsection was significantly higher in the IPC group. In the CPC group, postoperative liver enzymes and serum bilirubin levels were significantly higher in the subgroup of patients with abnormal liver parenchyma. Major postoperative deterioration of liver function occurred in four patients with abnormal liver parenchyma, with two postoperative deaths. All of them were in the CPC group. CONCLUSIONS: This clinical controlled study clearly demonstrated the better parenchymal tolerance to IPC over CPC, especially in patients with abnormal liver parenchyma.     

Postoperative change of serum protease inhibitor and C-reactive protein level--with special reference to surgical resection of liver cirrhosis]

Changes in the activities of blood protease inhibitors and acute-phase reactive substances during surgical resection of liver cirrhosis were investigated by measuring the pre- and postoperative blood concentrations of alpha 1-antitrypsin (alpha 1AT), alpha 2-macroglobulin (alpha 2MG), pancreatic secretory trypsin inhibitor (PSTI), urinary trypsin inhibitor (UTI) and C-reactive protein (CRP), in patients with liver cirrhosis who underwent hepatectomy (Group A, n = 19), those without liver cirrhosis who underwent hepatectomy (Group B, n = 6) and those without liver cirrhosis who underwent surgeries other than hepatectomy (Group C, n = 5). On examining the preoperative blood levels of protease inhibitors, Group A had an increased level of alpha 2MG and a decreased level of UTI compared to Groups B and C. alpha 1AT and CRP began to increase on the first day following hepatectomy and formed peaks on the third postoperative day. The increases were significantly higher in Group B than Group A (p less than 0.01). To investigate factors causative of these differences, alpha 1AT and CRP on the third postoperative day were compared in relation to the time of operation, amount of intraoperative bleeding, weight of the resected liver and preoperative ICGR15. alpha 1AT and CRP were significantly correlated to only preoperative ICGR15. PSTI was increased postoperatively but showed no difference between Groups A and B.     

Parameters associated with changes in liver volume in patients undergoing portal vein embolization

BACKGROUND: To identify predictors of changes in hepatic volumes after portal vein embolization (PVE) before hepatectomy, we examined the relationship between clinicopathological parameters and changes in volume of embolized and nonembolized liver and regeneration of remnant liver after hepatectomy. MATERIALS AND METHODS: The subjects were 25 patients who underwent laparotomy. PVE was performed through transileocolic vein (n = 15) and percutaneous transhepatic puncture (n = 10). RESULTS: Significant atrophy and hypertrophy of the embolized and nonembolized liver were observed after PVE, respectively, and further increase of remnant liver volume was observed after hepatectomy. Background liver disease did not seem to influence the results. Alkaline phosphatase (ALP) level correlated negatively with atrophy of embolized lobe (r = -0.433). Platelet count correlated positively with hypertrophy of nonembolized lobe (r = 0.412, P < 0.05) and percent increase between lobes and (r = 0.515, P < 0.05). Seven (32%) patients developed postoperative complications, such as long-term ascites or cholestasis. Changes in embolized liver and percent increase between lobes in patients with postoperative cholestasis (-94 +/- 97 cm(3) and 9.6 +/- 5.1% gain) were significantly lower than those in patients without cholestasis (17 +/- 54 cm(3) and 6.6 +/- 1.3% gain, P < 0.05). CONCLUSION: ALP and platelet counts might be able to predict PVE effect and were related to postoperative course. Identification of more specific predictors is desirable.     

Impact of temporary hilar clamping during laparoscopic partial nephrectomy on postoperative renal function: a prospective study

PURPOSE: Laparoscopic partial nephrectomy for small renal tumors has been increasingly performed in the last few years. We prospectively evaluated preoperative and postoperative differential renal function by renal scan in patients with contralaterally functioning kidneys who underwent laparoscopic partial nephrectomy with hilar clamping. MATERIALS AND METHODS: From July 2002 to June 2003, 17 consecutive patients were included in this prospective protocol and underwent laparoscopic partial nephrectomy for exophytic tumors using en bloc hilar clamping. Preoperative renal scan with differential function was performed 1 month before and 3 months after surgery in all patients. technetium labeled diethylenetetraminepentaacetic acid scan was performed in all patients. RESULTS: Mean warm ischemia time was 22.50 +/- 9.78 minutes (range 10 to 44). Preoperative differential renal function and glomerular filtration rate (GFR) in the affected kidneys were 50.20% +/- 4.90% (range 43 to 58) and 75.56 +/- 16.45 ml per minutes (range 39.4 to 105). At postoperative month 3 differential renal function and GFR in the affected kidney were 48.07% +/- 7.16% (range 39% to 63%) and 72.03 +/- 18.17 ml per minutes (range 31 to 101). There was a nonsignificant negative association between hilar clamp time and change in renal function (postoperative - preoperative) of the affected kidney (r = -0.26, p = 0.31), and a positive correlation between clamp time and change in GFR (r = 0.39, p = 0.12) that did not reach statistical significance. CONCLUSIONS: In patients with contralaterally functioning kidney, temporary hilar clamping with a mean warm ischemia time of 22.5 minutes results in preservation of renal function in the affected kidney. Larger studies with longer followup are necessary to study the impact of warm ischemia further.     

Clinicopathologic Features of Hepatocellular Carcinoma Patients with Compensated Cirrhosis Surviving More than 10 Years after Curative Hepatectomy

BACKGROUND: The aim of this study was to clarify the clinicopathologic features of hepatocellular carcinoma (HCC) patients with compensated cirrhosis surviving more than 10 years after initial hepatectomy. STUDY DESIGN: Among 250 patients who underwent hepatectomy for HCC between 1987 and 1994 at our institute, 145 patients who had Child-Pugh class A liver function and who underwent curative resection were included in this study. Clinicopathologic factors in 10-year survivors and patients who died within 10 years (nonsurvivors) were compared, and the prognostic factors affecting survival were identified. RESULTS: There were 29 patients who survived for more than 10 years after initial hepatectomy, and 9 of those patients survived without cancer recurrence. The 3-, 5-, and 10-year survival rates were 76.2%, 53.0%, and 26.9% respectively. The corresponding disease-free survival rates were 43.1%, 25.7%, and 9.9% respectively. In multivariate analysis, liver fibrosis grade F0-2, female gender, ICG-R15 value of less than 15%, and absence of microscopic vascular invasion were favorable independent factors associated with 10-year survival. Disease-free interval after initial hepatectomy in 10-year survivors with recurrence was significantly longer than that in nonsurvivors with recurrence, 5.1 and 1.9 years respectively (P = 0.0004). The number of intrahepatic recurrent nodules in 10-year survivors tended to be fewer than that in nonsurvivors. CONCLUSIONS: Based on the results of our study, liver fibrosis grade F0-2, female gender, ICG-R15 value of less than 15% and absence of microscopic vascular invasion at initial hepatectomy might be biologically favorable conditions for long-term survival. Close follow-up as well as multimodal treatment could contribute to prolongation of survival in such patients, even if HCC recurrence develops.     

吲哚菁绿清除试验在肝癌术前评估肝脏储备功能的临床应用

【摘要】 目的 探讨吲哚菁绿清除试验(ICGR15)在肝癌术前评估肝储备功能的临床应用价值。方法〓回顾性分析2012年6月至2013年7月我院63例肝细胞癌手术病人临床资料,根据术前ICGR15分组,对比不同组别术后肝功能恢复情况,并对相关临床资料进行多因素非条件Logistic回归分析。结果〓ICGR15≥10%组术后肝功能代偿不全的发生率显著高于ICGR15<10%组(68.2% vs 19.5%,P<0.05)。Child-pugh评分中B级组ICGR15分值较A级组显著升高(19.01%±11.14% vs7.57%±8.34%,P<0.05);ICGR15分值与Child-pugh评分有较好的相关性(P<0.05,r=0.313)。ICGR15预测肝癌术后肝功能不全的特异度为82.5%,明显高于OGTT(P<0.05),而敏感度为65.2%,特异度为82.5%,阳性预测值为68.2%,阴性预测值为80.5%,但与OGTT比较均无统计学差异(P>0.05)。ICGR15与术后肝功能恢复情况有相关性(P<0.05,r=0.434),而OGTT与术后肝功能恢复情况无明显相关性(P>0.05)。Logistic回归分析示ICGR15、脉管癌栓、术中出血量以及术后其他相关并发症是发生术后肝功能代偿不全的独立危险因素。结论 ICGR15是肝癌术前评估肝脏储备功能较理想的临床指标,能较准确预测术后肝功能恢复情况。     

Ischemic preconditioning for major liver resection under vascular exclusion of the liver preserving the caval flow: a randomized prospective study

BACKGROUND: Two randomized prospective studies suggested that ischemic preconditioning (IP) protects the human liver against ischemia-reperfusion injury after hepatectomy performed under continuous clamping of the portal triad. The primary goal of this study was to determine whether IP protects the human liver against ischemia-reperfusion injury after hepatectomy under continuous vascular exclusion with preservation of the caval flow. STUDY DESIGN: Sixty patients were randomly divided into two groups: with (n=30; preconditioning group) and without (n=30; control group) IP (10 minutes of portal triad clamping and 10 minutes of reperfusion) before major hepatectomy under vascular exclusion of the liver preserving the caval flow. Serum concentrations of aspartate transferase, alanine transferase, glutathione-S-transferase, and bilirubin and prothrombin time were regularly determined until discharge and at 1 month. Morbidity and mortality were determined in both groups. RESULTS: Peak postoperative concentrations of aspartate transferase were similar in the groups with and without IP (851 +/- 1,733 IU/L and 427 +/- 166 IU/L respectively, p=0.2). A similar trend toward a higher peak concentration of alanine transferase and glutathione-S-transferase was indeed observed in the preconditioning group compared with the control group. Morbidity and mortality rates and lengths of ICU and hospitalization stays were similar in both groups. CONCLUSIONS: IP does not improve liver tolerance to ischemia-reperfusion after hepatectomy under vascular exclusion of the liver with preservation of the caval flow. This maneuver does not improve postoperative liver function and does not affect morbidity or mortality rates. The clinical use of IP through 10 minutes of warm ischemia in this technique of hepatectomy is not currently recommended.