Usefulness of bipolar scissors for rectal cancer surgery with autonomic nerve preservation

BACKGROUND/AIMS: Pelvic autonomic nerve preservation for rectal cancer has become more common in recent years. Therefore, we evaluated the usefulness of bipolar scissors for this procedure. METHODOLOGY: This study included 30 consecutive patients with lower rectal cancer who underwent pelvic autonomic nerve preservation at our hospital between April 1998 and August 2001. The bipolar scissors group comprised 10 patients who received the procedure using bipolar scissors, while the conventional group included 20 patients who received the procedure without the use of bipolar scissors. The two groups were compared in terms of operating time, blood loss, postoperative urinary and sexual function. RESULTS: Blood loss in the bipolar scissors group was 394.4 +/- 201.8mL, which was a significantly lower volume than that in the conventional group (881.8 +/- 582.9ml) (p=0.0049). All the patients in the bipolar scissors group (10/10=100%) and 19 cases in the conventional group (19/20=95.0%) answered that they were satisfied with the results of their voiding function. In the bipolar scissors group, 100% were capable of erection (5/5) and 80.0% preserved ejaculation (4/5). In the conventional group, 100.0% (10/10) and 77.8% (7/9) preserved erection and ejaculation, respectively. CONCLUSIONS: The use of bipolar scissors is quite beneficial when patients with rectal cancer receive pelvic autonomic nerve preservation.     

Evaluation of total hepatic vascular exclusion and pringle maneuver in liver resection

BACKGROUND/AIMS: The effects of total hepatic vascular exclusion and Pringle maneuver on intraoperative course and postoperative recovery were retrospectively studied. METHODOLOGY: Records of 42 patients who underwent a major hepatectomy and six who had a minor hepatectomy were reviewed. Patients with chronic liver disease or obstructive jaundice were excluded. Hepatic vascular exclusion was used in 5 patients who were at high risk for back flow bleeding from the hepatic veins. Pedicular clamping was used in the other 43 patients. Intergroup differences in intraoperative blood loss, postoperative liver function, the serum interleukin-6 concentrations, and clinical outcome were compared. RESULTS: In four patients of the hepatic vascular exclusion group (n = 5), intraoperative blood loss was less than 2000 mL, and 6000 mL in the remaining patient. However the hepatic vascular exclusion group had longer hepatic ischemia time (45.2 +/- 10.3 min vs. 30.6 +/- 10.9 min), a greater blood loss (2304 +/- 2106 L vs. 913 +/- 1130 mL), a higher serum interleukin-6 concentration (347 +/- 320 pg/mL vs. 93 +/- 58 pg/mL), and a higher morbidity rate (80 vs. 7.1%) compared with the pedicular clamping group (n = 43) (P < 0.05). Postoperative liver function tests were comparable, and no patient developed postoperative hepatic failure. In the pedicular clamping group, intermittent pedicular clamping with periods of 15 minutes (n = 12) increased blood loss (662 +/- 421 mL vs. 1427 +/- 1890 mL), but did not reduce serum interleukin-6 concentration, liver cell damage, or morbidity rate postoperatively, compared with continuous or intermittent clamping of longer periods. CONCLUSIONS: Hepatic vascular exclusion is an effective way to limit blood loss in hepatic resection without causing sever liver injury. However, the interleukin-6 production is increased and the morbidity rate is high. Paradoxically, periodic release of pedicular clamping increases the blood loss but does not reduce liver cell injury or interleukin-6 production.     

The feasibility of Makuuchi criterion for resection of hepatocellular carcinoma

BACKGROUND/AIMS: The Makuuchi criterion was proposed to select for the appropriate hepatectomy in an impaired liver. However, there are no comparative analyses concerning this criterion. Our purpose is to evaluate the efficacy of it. METHODOLOGY: We conducted our study on 471 patients with hepatocellular carcinoma, resected from January 1986 to April 2004. We defined surgery consistent with Makuuchi criterion as group 1, and other as group 2. We performed comparative analysis of surgical results. RESULTS: Group 1 showed lower intraoperative blood loss (1602 +/- 119 mL vs. 2448 +/- 244mL: P = 0.002), mortality (4.4% vs. 12.5%: P = 0.009), and postoperative serum total bilirubin (3.4 +/- 0.2 mg/dL vs. 6.2 +/- 0.8 mg/ dL: P < 0.0001) than group 2. Five-year survival rates were not significantly different between group 1 (43%) and 2 (35%): P = 0.18. Blood loss in operative deaths was greater than in survivors, both in group 1 (6155 +/- 1725 mL vs. 1391 +/- 83 mL: P < 0.0001) and in group 2 (4381 +/- 946 mL vs. 2172 +/- 231mL: P = 0.002). Blood loss in patients with postoperative liver failure was also greater than in others, both in group 1 (2692 +/- 292 mL vs. 1146 +/- 106 mL: P < 0.0002) and in group 2 (2968 +/- 335 mL vs. 1538 +/- 265 mL: P = 0.004). CONCLUSIONS: Our study showed Makuuchi criterion is helpful for a safe hepatectomy for hepatocellular carcinoma. If inconsistent with it, 2172 mL and 1538 mL blood loss are considered permissible upper limits to avoid operative death and liver failure, respectively.     

Role of ultrasonically activated scalpel in hepatic resection: a comparison with conventional blunt dissection

BACKGROUND/AIMS: Our goal was to compare the benefits and complications of using an ultrasonically activated scalpel (UAS) and conventional blunt dissection in hepatic resection. METHODOLOGY: We evaluated the effectiveness of dividing the liver by UAS (n=18) (the UAS group) compared with conventional blunt dissection (n=34) (the BD group) in patients undergoing hepatic resection. In the UAS group, UAS was used to dissect the superficial parenchyma and a crushing and clamping technique was used to divide the deep parenchyma. RESULTS: No serious complications attributable to the use of UAS were encountered, and there were no significant differences in morbidity or mortality between the two groups. The duration of surgery was significantly longer in the UAS group (281 +/- 81 min) than in the BD group (223 +/- 76 min) (P<0.05), and in the UAS group as a whole there were no advantages in using the new scalpel. However, when we compared only those patients who underwent minor hepatectomy, the intraoperative blood loss was significantly less in the UAS group (657 +/- 588mL) than in the BD group (1447 +/- 984mL) (P=0.03). The duration of drainage from the hepatic stump in these patients was also significantly shorter in the UAS group (P=0.02). CONCLUSIONS: The UAS is a useful new device for transection of the liver during hepatic resection. It may reduce the amount of blood loss during liver surgery, particularly in minor hepatectomy.     

Liver hanging maneuver decreases blood loss and operative time in a right-side hepatectomy

Background/Aims: To clarify the clinical benefits of the maneuver in right-side hepatectomy. Methodology: Eighty-one patients with liver tumor (54 hepatocellular carcinoma, 17 metastatic liver tumor and 10 other tumors) treated with a right-side hepatectomy were prospectively analyzed. The patients were divided into the following three groups: a conventional approach (group A, n=21); liver dissection under the hanging maneuver after liver mobilization (group B, n=19) and liver dissection under the hanging maneuver prior to liver mobilization (group C, n=41). Results: The liver hanging maneuver was safely performed in all the patients in groups B and C. Tumor size had a significantly positive correlation with the amount of intraoperative blood loss (R=0.52, p<0.05) in group A only. The patients in groups B and C had a significantly lower intraoperative use of blood loss (both p<0.01), operation time (p<0.05 and p<0.01) and the frequency of blood product (both p<0.05), in comparison to group A, respectively. The postoperative morbidity and the mortality rates were similar in the three groups. Conclusions: Liver hanging maneuver is a safe procedure, which can decrease intraoperative blood loss and administration of blood product in right-side hepatectomy.     

Risk factors for massive blood loss during liver resection for hepatocellular carcinoma in patients with cirrhosis

BACKGROUND/AIMS: Liver resection for hepatocellular carcinoma in patients with cirrhosis carries risk of major hemorrhage and sometimes requires blood transfusion. We investigated risk factors for massive blood loss during liver resection and indications for storing blood for autologous intraoperative transfusion. METHODOLOGY: We analyzed clinical records of 100 patients with cirrhosis who underwent liver resection for hepatocellular carcinoma. Autologous blood was stored preoperatively for 19 patients. RESULTS: Intraoperative blood loss ranged from 5 to 3000 mL (mean, 640). Liver resection was performed without transfusion in 67 patients and with autologous blood storage in 17 patients not receiving homologous blood. In the other 16 patients, homologous blood was transfused. Univariate analysis identified youth, large tumors (> 4cm), major hepatectomy, portal tumor involvement, hepatic vein involvement, and prolonged operation time as risk factors for massive blood loss; multivariate analysis identified portal involvement and hepatic vein involvement as independent risk factors. Blood loss exceeded 1000 mL in the 4 transfused group B patients and 3 of the 4 patients had hepatic vein involvement. CONCLUSIONS: Portal involvement and hepatic vein involvement were risk factors for massive blood loss during liver resection for hepatocellular carcinoma in patients with cirrhosis. Autologous blood storage is indicated in patients with such risk factors.     

Effects of prostaglandin E1 administration during hepatectomy for cirrhotic hepatocellular carcinoma

BACKGROUND/AIMS: Prostaglandin E1 has been used in hepatectomy based on a few limited clinical studies suggesting that PGE1 improves liver function. The aim of this study was to evaluate the effects of PGE1 administration during hepatectomy for cirrhotic hepatocellular carcinoma. METHODOLOGY: Forty-three patients undergoing hepatectomy for cirrhotic hepatocellular carcinoma were divided into 2 groups: hepatectomy with Prostaglandin E1 treatment (PG group; n = 19) and without Prostaglandin E1 treatment (control group; n = 24). Prostaglandin E1 (0.02-0.07 microgram/kg/min) was administered intravenously from beginning to end of surgery in the PG group. RESULTS: There were no significant differences between groups with respect to age, gender, preoperative liver and renal function, or intraoperative variables such as blood loss, weight of resected liver and total clamping time by the Pringle maneuver. No patient had severe postoperative complications. Initial postoperative maximum concentrations of serum total bilirubin, creatinine, and blood urea nitrogen in the PG group were significantly lower than those in the control group. CONCLUSIONS: Prostaglandin E1 administration during hepatectomy for cirrhotic heptocellular carcinoma resulted in improved renal and hepatic function.     

Splenic arterial ligation prevents liver injury after a major hepatectomy by a reduction of surplus portal hypertension in hepatocellular carcinoma patients with cirrhosis.

BACKGROUND/AIMS: In this study, we investigated whether a reduction of surplus portal hypertension after a major hepatectomy by SPL (splenic arterial ligation) prevents a liver injury in cirrhotic patients with hepatocellular carcinoma. METHODOLOGY: Six hepatocellular carcinoma patients (SPL group) with liver cirrhosis (67 +/- 10 years old, ICGR15: 21.0 +/- 9.8%, T.Bil: 1.1 +/- 1.2 mg/dL) underwent major hepatectomy with splenic arterial ligation in order to reduce excessive portal hypertension after hepatectomy from 1998 to 2000, July. The patients (n = 15, 60 +/- 9 years old, ICGR15: 11.5 +/- 5.9%, T.Bil: 0.66 +/- 0.15 mg/dL) who underwent liver resection above subsegmentectomy in the same period (control group) served as the control for SPL group. RESULTS: In the SPL group, the portal pressures before hepatectomy were 26 +/- 7 cm H2O and those after hepatectomy were 29 +/- 6 cm H2O. The portal pressure after splenic arterial ligation decreased to 24.5 +/- 6.3 cm H2O. The splenic tissue blood flows before SPL were 16.8 +/- 5.6 mL/min/100 g, while those after SPL were 7.2 +/- 2.2 mL/min/100 g. The portal pressures before hepatectomy were 17 +/- 2 cm H2O and those after hepatectomy were 19 +/- 2 cm H2O in the six control patients. At the peak levels of liver function after surgery, T.Bil was 2.6 +/- 1.5 mg/dL, GOT was 165 +/- 59 IU/L, and GPT was 107 +/- 49 IU/L. All patients could discharge without complications except for one case with bile leakage in SPL. At the peak levels of liver function in control group, T.Bil was 3.7 +/- 1.9 mg/dL, GOT was 404 +/- 227 IU/L, and GPT was 322 +/- 171 IU/L. At the peak levels of liver function after surgery, T.Bil was 3.4 +/- 1.3 mg/dL, GOT was 398 +/- 289 IU/L, and GPT was 319 +/- 220 IU/L. Conversely, there were 11 episodes of complications (11/15), including two cases of hospital death resulting from liver failure in patients who underwent right lobectomy, in the control patients. CONCLUSIONS: The decompression of surplus portal hypertension by SPL might be effective in the prevention of post hepatectomized liver injury and the improvement of postoperative mortality and morbidity.     

Low central venous pressure reduces blood loss in hepatectomy

AIM:To investigate the effect of low central venouspressure(LCVP)on blood loss during hepatectomy forhepatocellular carcinoma(HCC).METHODS:By the method of sealed envelope,50 HCC patients were randomized into LCVP group(n=25)and control group(n=25).In LCVP group,CVP was maintained at 2-4 mmHg and systolic bloodpressure(SBP)above 90 mmHg by manipulation of thepatient's posture and administration of drugs duringhepatectomy,while in control group hepatectomy wasperformed routinely without lowering CVP.The patients'preoperative conditions,volume of blood loss duringhepatectomy,volume of blood transfusion,length ofhospital stay,changes in hepatic and renal functionswere compared between the two groups.RESULTS:There were no significant differences inpatients' preoperative conditions,maximal tumordimension,pattern of hepatectomy,duration of vascularocclusion,operation time,weight of resected liver tissues,incidence of post-operative complications,hepatic andrenal functions between the two groups.LCVP group hada markedly lower volume of total intraoperative bloodloss and blood loss during hepatectomy than the controlgroup,being 903.9±180.8 mL vs 2 329.4±2 538.4(W=495.5,P<0.01)and 672.4±429.9 mL vs 1662.6±1932.1(W=543.5,P<0.01).There were no remarkabledifferences in the pre-resection and post-resection bloodlosses between the two groups.The length of hospitalstay was significantly shortened in LCVP group ascompared with the control group,being 16.3±6.8 d vs21.5±8.6 d(W=532.5,P<0.05). CONCLUSION:LCVP is easily achievable in technique.Maintenance of CVP≤4 mmHg can help reduce bloodloss during hepatectomy,shorten the length of hospitalstay,and has no detrimental effects on hepatic or renalfunction.     

Inhibition of 5-lipoxygenase promotes the regeneration of the liver after partial hepatectomy in normal and icteric rats

The role of leukotriene (LT) on liver regeneration after hepatectomy is still unknown. LTB4 stagnates in the liver with obstructive jaundice, because LTB4 is excreted in the bile; therefore, LTB4 may have an effect on liver regeneration after hepatectomy with obstructive jaundice. Release of obstructive jaundice and simultaneous 70% hepatectomy was performed in rats to study the effect of 5-lipoxygenase inhibitor (AA-861) on liver regeneration. Group 1 underwent hepatectomy with administration of 0.1 mL dimethyl sulfoxide (DMSO), group 2 underwent hepatectomy with administration of AA-861 (20 mg/kg/d) dissolved in 0.1 mL DMSO, group 3 underwent hepatectomy with administration of AA-861 (40 mg/kg/d) dissolved in 0.1 mL DMSO, group 4 underwent release of obstructive jaundice and hepatectomy with administration of 0.1 mL DMSO, and group 5 underwent relief of obstructive jaundice and hepatectomy with administration of AA-861 (20 mg/kg/d). DMSO or AA-861 was administered 24 hours before, during, and 24 hours after hepatectomy in each group. Whole blood LTB4 and serum alanine aminotransferase (ALT), total bilirubin, and bromodeoxyuridine labeling index (LI) were measured before and after hepatectomy. The LTB4 level increased during obstructive jaundice and after hepatectomy. LTB4 and serum ALT levels were significantly lower after hepatectomy in the rats that were administered AA-861, and a significantly higher LI was observed at 24 hours after hepatectomy in rats receiving AA-861. Inhibition of 5-lipoxygenase promotes liver regeneration and decreases hepatocyte injury after hepatectomy associated with obstructive jaundice. (Hepatology 1996 Mar;23(3):544-8)     

Ultrasonic aspiration hepatectomy for 136 patients with hepatocellular carcinoma

AIM：To study the operativ injury,post-operative complications,the hospitalization time,the post-operative survival rate of ultrasonic aspiration hepatectomy with a domestic new type of ultrasonic surgical device in comparison with that of conventional techniques of hepatectomy.METHODS:A total136patients with hepatocellular carcinoma(HCC,including 13patinents in 1991and 124consecutive patients from July1995to December2000)underwent ultrasonic aspiration in liver resection(groupT)and 179 HCCpatients received conventional hepatectomy during the corresponding period(groupC).The results of the two groups were compared statistically.RESULTS:There was no significant difference in the mean operation time between groupT(152&#177;11min)and C(144&#177;11min).No operation or hospital edath occurred in both groups.In groupT,the mean volumes of bleeding(463&#177;15ml)and bolld transfusion(381&#177;12ml)were markedly less than those in groupC(557&#177;20ml,and507&#177;18ml,respectively,P&lt;0.05).The mean hospitalization time of groupT(8.9&#177;0.6d)was markedly shorter than that of groupC(11.7d&#177;0.6d)(P&lt;0.05).The incidence of complications in groupTwas markedly lower than in groupC,post-operative jaundice occurred in4/136and31/179,respectively(P&lt;0.05).liver failurein0/136and2/179,cholorrhea in0/136and6/179,hydrothoraxin21/136and39/179(P&lt;0.05).ascices in9/136and2/179,cholrrheain0/136and6/179,hydrothorax in21/136and 39/179(P&lt;0.05),ascices in 9/136and 54/179,respectively(P&lt;0.05),while the 3-year survival rate of groupT(64.2%)increased markedly as compared with that of groupC(55.7%)(P&lt;0.01).CONCLUSION:The ultrasonic aspiration hepatectomy with a domestic new type of ultrasonic surgical device could evidently reduce the operative injury and post-operative complications,shorten the hospitalization,time and prolong the survivals of HCC,patients.     

Double-Blind,Randomized Trial Comparing Harmonic Scalpel™ Hemorrhoidectomy,Bipolar Scissors Hemorrhoidectomy,and Scissors Excision

PURPOSE: The aim of this study was to compare the outcome of patients receiving hemorrhoidectomy using Harmonic Scalpel, bipolar scissors, and the conventional scissors excision-ligation technique. METHODS: Eighty-six patients with irreducible prolapsing piles were randomly assigned to receive 1) Milligan-Morgan hemorrhoidectomy using scissors excision-ligation technique or 2) bipolar scissors hemorrhoidectomy and Harmonic Scalpel hemorrhoidectomy. Neither the patient nor the independent assessor were aware of the technique used at operation. Patients were followed up at 4 and 12 weeks after operation. The measured outcomes included 1) operation time; 2) blood loss; 3) postoperative hospital stay; 4) pain score; 5) pain expectation score; 6) date of first bowel movement; 7) number of pethidine injections; 8) number of dologesic tablets taken; 9) time off work or normal activity; 10) wound healing; 11) satisfaction score; and 12) postoperative complications, including anal stenosis and fecal or flatus incontinence. RESULTS: There was no difference among the three groups in the operation time, hospital stay, pain expectation score, day of first bowel movement, number of dologesic tablets taken, time off work or normal activity, wound healing, and satisfaction score. The complication rate also did not differ in the three groups. Both Harmonic Scalpel hemorrhoidectomy and bipolar scissors hemorrhoidectomy were superior to Milligan-Morgan hemorrhoidectomy in terms of reduced blood loss. Harmonic Scalpel hemorrhoidectomy had the best pain score when compared with bipolar scissors hemorrhoidectomy and Milligan-Morgan hemorrhoidectomy, and patients required significantly less pethidine injection after Harmonic Scalpel hemorrhoidectomy than after Milligan-Morgan hemorrhoidectomy. Although the time required to return to work or normal activity remained similar, patients after Harmonic Scalpel hemorrhoidectomy had the best satisfaction score among the three groups. CONCLUSION: The study shows that Harmonic Scalpel hemorrhoidectomy is as good as bipolar scissors hemorrhoidectomy in terms of reduced blood loss but is superior because it is associated with less postoperative pain and hence, better patient satisfaction. However, these observed benefits are small, and the time off work or normal activity remains similar.     

Efficiency and safety of radiofrequency-assisted hepatectomy for hepatocellular carcinoma with cirrhosis:A single-center retrospective cohort study

AIM: To assess the efficiency and safety of radiofrequencyassisted hepatectomy in patients with hepatocellular carcinoma(HCC) and cirrhosis.METHODS: From January 2010 to December 2013, 179 patients with HCC and cirrhosis were recruited for this retrospective study. Of these, 100 patients who received radiofrequency-assisted hepatectomy(RF+ group) were compared to 79 patients who had hepatectomy without ablation(RF- group). The primary endpoint was intraoperative blood loss. The secondary endpoints included liver function, postoperative complications, mortality, and duration of hospital stay.RESULTS: The characteristics of the two groups were closely matched. The Pringle maneuver was not used in the RF+ group. There was significantly less median intraoperative blood loss in the RF+ group(300 vs 400 m L, P = 0.01). On postoperative days(POD) 1 and 5, median alanine aminotransferase was significantly higher in the RF+ group than in the RF- group(POD 1: 348.5 vs 245.5, P = 0.01; POD 5: 112 vs 82.5, P = 0.00), but there was no significant difference between the two groups on POD 3(260 vs 220, P = 0.24). The median AST was significantly higher in the RF+ group on POD 1(446 vs 268, P = 0.00), but there was no significant difference between the two groups on POD 3 and 5(POD 3: 129.5 vs 125, P = 0.65; POD 5: 52.5vs 50, P = 0.10). Overall, the rate of postoperative complications was roughly the same in these two groups(28.0% vs 17.7%, P = 0.11) except that post hepatectomy liver failure was far more common in the RF+ group than in the RF- group(6% vs 0%, P = 0.04).CONCLUSION: Radiofrequency-assisted hepatectomy can reduce intraoperative blood loss during liver resection effectively. However, this method should be used with caution in patients with concomitant cirrhosis because it may cause severe liver damage and liver failure.     

Risk factors for postoperative liver failure after hepatectomy for hepatocellular carcinoma

BACKGROUND/AIMS: Selection of patients for hepatectomy for hepatocellular carcinoma conventionally has been based upon Child-Pugh grading. However, postoperative liver failure after hepatectomy is a major cause of hospital mortality. A new predictor of postoperative liver failure is required. The objective of this study was to identify risk factors for postoperative liver failure after hepatectomy. METHODOLOGY: Perioperative risk factors for liver failure after hepatectomy were analyzed in 112 patients with hepatocellular carcinoma Eight of these patients died of liver failure. Stepwise multivariate logistic regression was performed to investigate significant independent factors among 17 variables, including the serum alkaline phosphatase ratio (ALPR) on the first day after hepatectomy. ALPR was calculated as the postoperative ALP level divided by the ALP level before surgery. RESULTS: Significant risk factors of postoperative liver failure were ALPR on postoperative day 1 (ALPR1), sex, operative blood loss, and operative procedure. As an indicator of liver failure, the diagnostic accuracy of the ALPR1 was 93.7% when the ALPR was less than 0.4 on the first postoperative day. The ALPR and the serum total bilirubin concentration after hepatectomy were uncorrelated. CONCLUSIONS: ALPR1 is a useful predictor of liver failure after hepatectomy.     

Preoperative identification of intraoperative blood loss of more than 1,500?mL during elective hepatectomy

Background

Despite recent advances in surgical techniques, hepatectomies remain one of the most hemorrhagic procedures in abdominal surgery. It is important to identify preoperatively patients who are at high risk of suffering massive intraoperative blood loss.

Methods

The clinical records of 251 patients who underwent an elective hepatectomy for liver tumors between September 2007 and December 2009 were reviewed retrospectively. A multivariate logistic regression analysis of preoperative factors potentially influencing intraoperative blood loss was performed. We set the cut-off value of the amount of blood loss for safe hepatectomy as less than 1,500?mL because no patients with blood loss of less than 1,500?mL received blood transfusion in this study. A scoring system to predict blood loss of more than 1,500?mL was constructed and validated in a cohort of 59 subsequent patients.

Results

Intraoperative blood loss of more than 1,500?mL was recognized in 35 of 251 patients (13.9%). Prothrombin activity?<?70%, non-peripheral location of the tumor, involvement of hepatic veins, body mass index????23.0, and major hepatectomy were independently associated with intraoperative blood loss of more than 1,500?mL. The score was calculated by assigning 1 point for each of the 5 risk factors. The area under the receiver operating characteristic curve (AUC) was 0.814 (95% CI 0.731?C0.898). This scoring system was highly predictive in the subsequent validation group of 59 patients (AUC?=?0.839, 95% CI 0.710?C0.969).

Conclusion

This predictive scoring system is considered to be useful for identifying before hepatectomy those patients with a high risk of intraoperative blood loss of more than 1,500?mL.     

Anterior vs conventional approach right hepatic resection for large hepatocellular carcinoma: A systematic review and meta-analysis

AIM To compare the clinical outcomes of right hepatectomy for large hepatocellular carcinoma via the anterior and conventional approach.METHODS We comprehensively performed an electronic search of Pub Med, EMBASE, and the Cochrane Library for randomized controlled trials(RCTs) or controlled clinical trials(CCTs) published between January 2000 and May 2017 concerning the anterior approach(AA) and the conventional approach(CA) to right hepatectomy. Studies that met the inclusion criteria were included, and their outcome analyses were further assessed using a fixed or random effects model.RESULTS This analysis included 2297 patients enrolled in 16 studies(3 RCTs and 13 CTTs). Intraoperative blood loss [weighted mean difference =-255.21; 95% confidence interval(95%CI):-371.3 to-139.12; P 0.0001], intraoperative blood transfusion [odds ratio(OR) = 0.42; 95%CI: 0.29-0.61; P 0.0001], mortality(OR = 0.59; 95%CI: 0.38-0.92; P = 0.02), morbidity(OR = 0.77; 95%CI: 0.62-0.95; P = 0.01), and recurrencerate(OR = 0.62; 95%CI: 0.47-0.83; P = 0.001) were significantly reduced in the AA group. Patients in the AA group had better overall survival(hazard ratio [HR] = 0.71; 95%CI: 0.50-1.00; P = 0.05) and disease-free survival(HR = 0.67; 95%CI: 0.58-0.79; P 0.0001) than those in the CA group.CONCLUSION The AA is safe and effective for right hepatectomy for large hepatocellular carcinoma and could accelerate postoperative recovery and achieve better survival outcomes than the CA.     

Selective suppression of initial cytokine response facilitates liver regeneration after extensive hepatectomy in rats

BACKGROUND/AIMS: After extensive hepatectomy, the cytokine network plays an important role in injury to the remnant liver and subsequent impairment of liver regeneration. Tumor necrosis factor alpha (TNF alpha) and interleukin 1beta (IL-1beta) are thought to be the initial cytokines associated with liver injury as well as with regeneration. We investigated the effect of the suppression of these cytokines on liver function and on liver regeneration after subtotal hepatectomy in rats. METHODOLOGY: Following 90% hepatectomy, rats were divided into two groups. Animals in the FR group received intraperitoneal FR167653, a selective inhibitor of TNF alpha and IL 1beta, while those in the Control group received vehicle only. Liver chemistry and serum levels of TNF alpha and IL-6 were measured serially. Liver specimens were obtained 48 hr after surgery and regenerative activity assessed by proliferating cell nuclear antigen (PCNA) expression and remnant liver weight. RESULTS: The survival rate was significantly better in the FR group (76.4+/-11.7 hrs) than in the Control group (26.8+/-4.3 hrs, p=0.0014). Liver enzyme and blood sugar levels after surgery were higher in the FR group compared to the Control group (p=0.03 or less). Changes in serum levels of both TNF alpha and IL-6 were suppressed in FR group rats after surgery. Microscopically, hepatocellular damage and steatosis was less prominent in FR group livers. PCNA labeling index and residual liver weights were higher in the FR group (p<0.001). CONCLUSIONS: Following extensive hepatectomy in rats, suppression of early cytokine induction improved liver function and facilitated liver regeneration. Suppression of selective cytokine responses could allow extended liver resection and reduced risk of liver failure.     

区段肝蒂肝切除术治疗肝胆管结石患者疗效及其血清白三烯B4和肝组织一氧化碳的变化*

目的 探讨采取区段肝蒂肝切除术治疗肝胆管结石患者的疗效及其血清白三烯B4(LTB₄)、肝组织一氧化碳(CO)和外周血T淋巴细胞亚群的变化。方法 2015年1月～2019年12月我院普外科收治的肝胆管结石患者60例,随机分为观察组30例和对照组30例,分别采取区段肝蒂肝切除术和超声引导下肝切除术治疗。采用ELISA法测定血清LTB₄水平,术中,在腹部切口接气腹管,以便携式CO测定仪的探头直接测定肝组织CO浓度。结果 观察组术中出血量为(351.7±104.2)mL,显著低于对照组【(492.6±153.8)mL,P<0.05】,引流量为(279.8±79.2)mL,显著低于对照组【(361.7±113.7)mL,P<0.05】;血清LTB₄水平为(22.6±11.7)ng/L,显著低于对照组【(43.5±12.2)ng/L,P<0.05】,肝组织CO水平为(41.3±5.8)ppm,显著低于对照组【(65.5±4.3)ppm,P<0.05】;观察组并发症发生率为23.3%,显著低于对照组的50.0%(P<0.05)。结论 采取区段肝蒂肝切除术可有效降低肝胆管结石患者术中出血量和术后引流量,术后恢复快,可能与降低了术中炎症反应有关。     

Analysis of risk factors for hyperbilirubinemia occurring after hepatectomy

Background

To further improve the outcomes of liver resection, it is important to identify and prevent the causes of the hyperbilirubinemia occurring after hepatectomy and postoperative liver failure.

Methods

Between 2004 and 2009, 591 consecutive patients underwent a hepatectomy at our center. Twenty-two patients who developed hyperbilirubinemia (postoperative total bilirubin over 5?mg/dL) after hepatectomy were classified as Hi-Bi group and another 569 whose total bilirubin did not increase beyond 5?mg/dL were classified as non-Hi-Bi group.

Results

A preoperative prothrombin test of less than 80% and a blood loss of more than 1000?mL were identified as independent risk factors for the Hi-Bi group by multivariate analysis. The hyperbilirubinemia of 16 cases improved, while that of 6 cases was prolonged. One of these patients died of liver failure without responding to treatment. The mortality rate for postoperative liver failure in this study was 0.16% (1/591).

Conclusion

It is important to reduce the length of surgery and intraoperative blood loss to prevent hyperbilirubinemia after hepatectomy. Additionally, decision-making using our algorithm and full examination of the accurate evaluation results, including those for prothrombin time, residual liver function and liver damage, can help reduce the development of hyperbilirubinemia.     

Effects of recombinant human growth hormone on remnant liver after hepatectomy in hepatocellular carcinoma with cirrhosis

AIM: To explore the effects of recombinant human growth hormone (rhGH) on the remnant liver after hepatectomy in hepatocellular carcinoma with liver cirrhosis. METHODS: Twenty-four patients with hepatocellular carcinoma who underwent hepatectomy were randomly divided into 2 groups: parenteral nutrition (PN) group (n=12) and rhGH+PN group (n=12). Liver function, blood glucose, AFP, serum prealbumin and transferrin were detected before operation, at post-operative d 1 and d 6. Albumin (ALB) mRNA in liver biopsy specimens was detected by RT-PCR at post-operative d 6. Liver Ki67 immunohistochemical staining was studied. RESULTS: On post-operative d 6, compared with PN group, the levels of blood glucose, serum prealbumin, transferrin, the expression of hepatic ALB mRNA and liver Ki67 labeling index were higher in rhGH+PN group. CONCLUSION: rhGH can improve protein synthesis and liver regeneration after hepatectomy in hepatocellular carcinoma with liver cirrhosis.