Nutritional aspects in patient undergoing liver resection

In the past two decades, hepatic surgery has achieved important technical breakthroughs resulting in a drastic reduction of the onset of complications and in an improved post-resective survival. Pre-operative nutritional status is one of the key points for the success of a liver resection. Modern surgical achievement such as the development of living-related liver donation, and the possibility to perform more laparoscopic liver resection gave us the opportunity to extend post-operative protocol focused on early intestinal feeding to tumor patients. The aims of this review were to report the current status of the knowledge regarding nutritional aspects in liver resection patients.     

Liver resection for neoplasm

Major hepatic resections can now be performed with much greater safety than formerly. This is largely a consequence of improved surgical and anesthetic techniques, which have in turn resulted from better understanding of the anatomy, physiology and biochemistry of the liver. The treatment of liver tumours by resection must be reappraised in the light of these advances. This paper reports twelve patients who have undergone major hepatic resection for neoplasm at the Royal Prince Alfred Hospital over a ten-year period. The current indications for such surgery in the treatment of benign and malignant liver tumours are reviewed, and the results discussed.     

肝血管旁间隙外科理念及其临床应用

作者通过回顾总结肝脏胚胎学衍生过程,并深入理解肝脏功能性、应用性外科解剖以及肝脏外科手术技术提出了一种肝脏外科理念——肝血管旁间隙外科理念.肝血管旁间隙理论是以肝内外血管为中心,同时更强调肝内外血管与周围组织器官等各"单元"之间的间隙,以肝组织胚胎学、肝脏功能性及应用性解剖为基础,以服务于临床医生为目的,使广大的临床医...     

LIVER RESECTION FOR NEOPLASM

Major hepatic resections can now be performed with much greater safety than formerly. This is largely a consequence of improved surgical and anaesthetic techniques, which have in turn resulted from better understanding of the anatomy, physiology and biochemistry of the liver. The treatment of liver tumours by resection must be reappraised in the light of these advances. This paper reports twelve patients who have undergone major hepatic resection for neoplasm at the Royal Prince Alfred Hospital over a ten-year period. The current indications for such surgery in the treatment of benign and malignant liver tumours are reviewed, and the results discussed.     

肝肾综合征的诊治现状

肝肾综合征(HRS)是重症肝病患者常见的严重并发症之一,病死率极高。尽管国际腹水俱乐部于2007年修订了HRS的诊断标准,但因缺乏特异性的诊断指标,目前HRS尤其是早期阶段,仍然很难被确诊。近年来,血管收缩药物联合白蛋白治疗Ⅰ型HRS取得了较大的成就,改变了HRS内科治疗几乎无效的状态。然而,药物治疗效果有限,目的主要是为肝移植作准备,肝移植术仍是HRS患者目前唯一可靠的、有效的治疗手段。随着对HRS认识的提高,相关学者越来越强调早期预防HRS的重要性。     

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??Management strategy of hepatic venous system bleeding in laparoscopic hepatectomy ZHENG Shu-guo.Institute of Hepatobiliary Surgery of PLA, Southwest Hospital, the Third Military Medical University, Chongqing 400038, China
Abstract Hepatic vein bleeding is one of the problems faced in laparoscopic liver resection. It’s important that active prevention of bleeding through accurate preoperative imaging evaluation and meticulous laparoscopic operation, as far as possible to avoid the passive treatment after hemorrhage. Intensive anesthesia management as well as controlled low central venous pressure is necessary for successful operation. Emphasis should be put on the diagnosis, prevention and emergency treatment of CO2 gas embolism in the pneumoperitoneum conditions. During the operation, if the hepatic veins injury and bleeding occurred, the severity of bleeding and if it can be controlled laparoscopically should be timely and accurately determined. Once the bleeding has been controlled or reduced, the injured vessel should be isolated, and its diameter, direction and the size and location of the split must be confirmed. Corresponding measures should be applied to make hemostasis rapidly and effectively according to the type and severity of the venous vascular injury, when necessary, conversion to open surgery should be taken rapidly. In recent years, with the accumulation of surgical experiences, the understanding of laparoscopic anatomy of the liver and the constantly updated surgical instruments, the technical level of hepatic vein system bleeding control and treatment during laparoscopic liver resection as well as the safety of the operation has been improved significantly.     

Perioperative anaesthetic considerations for rotator cuff repair surgeries: A current concept review

Surgeries for Rotator Cuff (RC) pathologies are required for either trauma or degenerative related aetiologies. Various surgical techniques from open to arthroscopic repair, are being undertaken by orthopaedic surgeons. Peri-operative anaesthetic management of the patients undergoing rotator cuff repair requires understanding the surgical procedure and patient status for optimal anaesthetic planning. Such management mandates a thorough pre-operative evaluation, including clinical history, examination, and relevant investigations. Patients with acute trauma associated Rotator Cuff (RC) tears should be assessed for visceral injuries using appropriate injury evaluation systems before such repairs. On the other hand, patients with degenerative tears tend to be older with associated comorbidities. Hence pre-operative optimisation is necessary according to risk stratification. Anaesthetic techniques for Rotator Cuff (RC) surgery include general anaesthesia or regional anaesthesia. These are individualised according to patient assessment and surgical procedure planned. Knowledge of relevant surgical anatomy is essential for intra-operative, and post-operative neural blockade techniques since optimal peri-operative analgesia improve overall patient recovery. The occurrence of a peri-operative complication should be recognised as timely management improves the patient-related surgical outcomes. We describe the relevance of surgical anatomy, the effect of patient positioning, irrigating fluids, various anaesthetic techniques and an overview of regional and medical interventions to manage pain in patients undergoing for Rotator Cuff (RC) surgery.     

Liver resection: Part I. Anatomy and operative planning]

Hepatic surgery has grown considerably in importance during the past two decades. Major roles in this development have been played by improvements in imaging diagnostics and intensive care as well as general advancements in hepatic surgical technique. Enormous strides in liver transplantation resulted in new methods also finding use in resective surgery. We present findings on functional and segmental anatomy of the liver on which current hepatic surgery is based, along with technical and oncological aspects requiring consideration for indication. Operative planning and anesthesiological management are discussed.     

Technik der Leberresektion

Hepatic surgery has grown considerably in importance during the past two decades. Major roles in this development have been played by improvements in imaging diagnostics and intensive care as well as general advancements in hepatic surgical technique. Enormous strides in liver transplantation resulted in new methods also finding use in resective surgery. We present findings on functional and segmental anatomy of the liver on which current hepatic surgery is based, along with technical and oncological aspects requiring consideration for indication. Operative planning and anesthesiological management are discussed.     

Intra-arterial thrombolysis in the carotid territory

Background: In patients who sustain abdominal trauma the liver is the most frequently injured organ. Although treatment for haemodynamically unstable patients remains urgent surgery, there has been a shift of management in haemodynamacally stable patients towards non-operative management. We performed an outcome assessment of traumatic hepatic injury.

Methods: A retrospective study was performed to assess incidence, mechanisms, management and outcome of traumatic liver injury in the region of ’s-Hertogenbosch, the Netherlands, in the period 1999–2007.

Results: A total of 47 patients were identified. Thirty-six patients had blunt hepatic trauma, eleven sustained penetrating hepatic injury. In 67% (n = 24) of the blunt hepatic trauma patients the initial intention was to treat non-operatively. Yet, two patients underwent explorative laparotomy after one and two days. In the penetrating liver trauma patients, 91% (n = 10) underwent urgent surgery. In total, 31 of 47 patients were treated conservatively.

Conclusion: Blunt hepatic trauma is the most common cause of hepatic trauma. Most patients sustaining hepatic trauma can be managed conservatively at a dedicated ICU and/or surgical trauma ward.     

Usefulness of intraoperative fluorescence imaging to evaluate local anatomy in hepatobiliary surgery

BACKGROUND/PURPOSE: One of the major complications encountered in hepatobiliary surgery is the incidence of bile duct and blood vessel injuries. It is sometimes difficult during surgery to evaluate the local anatomy corresponding to hepatic arteries and bile ducts. We investigated the potential utility of an infrared camera system as a tool for evaluating local anatomy during hepatobiliary surgery. METHODS: An infrared camera system was used to detect indocyanine green fluorescence in vitro. We also employed this system for the intraoperative fluorescence imaging of the arteries and biliary system in a pig. Further, we evaluated blood flow in the hepatic artery, portal vein, and liver parenchyma during a human liver transplant and we investigated local anatomy in patients undergoing cholecystectomy. RESULTS: Fluorescence confirmed that indocyanine green was distributed in serum and bile. In the pig study, we confirmed the fluorescence of the biliary system for more than 1 h. In the liver transplant recipient, blood flow in the hepatic artery and portal vein was confirmed around the anastomosis. In most of the patients undergoing cholecystectomy, fluorescence was observed in the gallbladder, cystic and common bile ducts, and hepatic and cystic arteries. CONCLUSIONS: Intraoperative fluorescence imaging in hepatobiliary surgery facilitates better understanding of the anatomy of arteries, the portal vein, and bile ducts.     

Segmental hepatic resection utilizing the ultrasonic dissector

Hepatic resection continues to become a more widely accepted therapeutic modality, with increased use as improved imaging modalities more precisely define the nature and extent of various liver abnormalities. The surgical anatomy of the liver indicates that there are eight segments with single or multiple segmental resections able to be performed. The use of the ultrasonic dissector facilitates the performance of transparenchymatous segmental resection without obtaining vascular inflow or outflow control. This report describes the segmental anatomy of the liver and the use of the ultrasonic dissector. Thirteen patients have undergone segmental hepatic resection with the ultrasonic dissector. Five patients had cirrhosis. Mean +/- 1 SD operative time required for segmental resection was 128 +/- 57 minutes, and blood loss was 830 +/- 623 mL. Utilization of the ultrasonic dissector to perform segmental hepatic resection may increase our versatility in the management of various hepatic and biliary tract diseases.     

肝脏外科的历史和现状

Liver surgery is composed of hepatic anatomy and relevant surgical techniques.The research of hepatic anatomy promotes the development of surgical techniques,and then the science of liver surgery get evolved.The knowledge of the liver anmomy,hepatic functional reserve,capacity to regenerate,and prevention of hemorrhage is essential for a successful hepatectomy.Hepatectomy has advanced remarkably in the past 30 years,but major challenges remain,which include developing more efficient minimally invasive surgical techniques,improving patient selection for any given treatment modality,and eliminating the chance of tumor recurrence,particularly in the liver.     

The principles of liver resection

Liver resection offers the only potential for curative treatment for many primary and secondary hepatic malignancies. With ongoing advances in both surgical technique and postoperative management, the indications for surgery continue to expand; however, perioperative risk remains significant as increasingly complex cases are considered. The fundamental principle is to achieve complete resection of disease with preservation of an adequate functional liver remnant. Successful outcomes rely on detailed knowledge of both intra- and extrahepatic anatomy and demand meticulous attention to patient selection, surgical technique and perioperative care. This article reviews the essential considerations in contemporary hepatobiliary surgery.     

围肝门外科技术治疗侵犯肝门的肝内胆管癌

侵犯肝门的肝内胆管癌兼有肝门部胆管癌和胆囊癌的临床特点与生物学特性,又合并肝脏基础疾病的病理生理学改变,具有三个肝门解剖艰难、肝脏切除复杂、肝脏合并病变处理困难、对放化疗不敏感等治疗难点,导致根治性切除率低,手术难度大、风险高和预后差。围肝门外科技术体系针对其特殊的临床特点、手术方式和病理生理学特征,通过术前全面、精确的肿瘤可切除性评估和三个肝门解剖的评估,以及保留侧肝功能的评估,采用顺逆结合的肝门显露路径、精准切肝技术、精确高质量的胆肠吻合和预估与管控并发症等措施,提高手术根治性与安全性,降低手术风险与并发症发生率,从而提高病人的总体生存时间。     

Treatment of liver failure post one anastomosis gastric bypass by revising to normal anatomy: A case report

IntroductionObesity and the associated metabolic syndrome are global health problems. Significant weight loss after bariatric surgery can cause a substantial difference in those comorbidities in obese patients. In this case, we described a rare complication of a patient who developed acute liver failure after an uneventful one anastomosis gastric bypass treated conservatively and revision of the one anastomosis gastric bypass to normal anatomy.Case presentationWe present a 52-year-old female known to have hypothyroidism and morbid obesity with a BMI of 45. For that, she underwent uneventful one anastomosis gastric bypass. Later, she developed liver failure and hepatic encephalopathy, which was managed conservatively and revision surgery to normal anatomy.DiscussionBariatric surgery plays an integral role in treating obese patients for its associated impacts, like facilitating weight loss and related metabolic syndrome improvement. The effects of bariatric surgery on liver functioning are controversial. Some malabsorptive procedures are linked to postoperative hepatic complications. However, it is uncommon in a recent new technique in bariatric surgery. Liver transplant and revision of the bariatric surgery have been described as management. However, optimal nutrition support without a liver transplant along with revision surgery is possible in experienced hands.ConclusionEarly detection of liver impairment and early intervention by a revision to normal anatomy by an experienced surgeon is considered the safest and most effective procedure for such patients. However, late detection where liver failure occurs, liver transplantation is the only effective treatment for preventing fatal outcomes.     

The principles of liver resection

Liver resection is now a well-established and routine treatment for malignant and some benign liver diseases. However, its associated mortality and morbidity should not be underestimated, especially as increasingly complex procedures in patients with increasing degrees of comorbidity are now being undertaken. A number of fundamental principles are important to consider, in terms of patient selection and perioperative care, as well as technical and anatomical tenets that, if adhered to, aid achievement of the best possible clinical outcomes for patients undergoing liver surgery. The introduction of modern technologies such as minimally invasive surgery and other techniques has made sound understanding of such principles all the more vital. This article will discuss many of these key underlying principles, illustrated with relevant surgical anatomy and how they pertain to modern techniques in liver resection.     

同期联合根治性手术治疗肝肾泡型棘球蚴病10例临床分析

目的探讨同期联合根治性手术治疗肝肾泡型棘球蚴病(AE)的可行性、安全性和有效性。方法回顾性分析2013年4月至2019年9月在新疆医科大学第一附属医院接受手术治疗的连续10例肝肾AE患者的临床资料,男性8例,女性2例,年龄(42.5±10.3)岁(范围:27~52岁)。7例曾行姑息性治疗但服药依从性差。10例均存在肝右叶和右肾的联合病灶,2例分别合并肝左外叶和左肾小病灶。病灶体积为(726.4±576.1)cm³(范围:117.0~1998.0 cm³)。病灶侵犯右侧膈肌7例、下腔静脉7例、右肾上腺6例、腹壁2例、右侧腰大肌1例、十二指肠1例和右肺下叶2例。采用同期联合根治性手术和血管重建等方法治疗肝肾及邻近器官的AE病灶。半肝及以上肝切除8例,离体肝切除自体肝移植2例,肝部分切除1例;右肾全切除7例,右肾部分切除3例,左肾部分切除1例;清除肝肾外受侵组织器官的病灶,并进行相应修补或重建。结果手术均顺利完成。术后无肝肾功能不全。3例患者出现胸腔积液,经保守治疗后改善;1例出现右肾周围尿漏,置入双“J”管并保守治疗后改善。随访6~81个月,中位随访时间21个月,无死亡病例,无发生肝肾功能不全、急慢性肾病者。1例术后7个月时发生腹壁切口疝,接受腹腔镜疝修补术。随访中无复发,10例患者均获得临床治愈。结论采用同期联合根治性手术治疗复发性或原发性肝肾AE安全可行,可同时有效清除其他邻近器官的病灶。     

Operative timing and patient survival following distal splenorenal shunt

The importance of "operative timing" in cirrhotic patients with variceal hemorrhage is often underemphasized. To evaluate the effects of immediate versus delayed selective portasystemic decompression on hepatic function, operative mortality, and long-term patient survival, we reviewed the records of 77 patients who underwent distal splenorenal shunts (DSRS) over a 14-year period. A hepatic risk status score was calculated at the time of the index bleed (HRS1) or presentation and again just prior to operation (HRS2). Variables analyzed included age, sex, prior bleeding episodes, time from index bleed to operation, transfusion requirements, and etiology of cirrhosis. Operative mortality rates for immediate versus delayed DSRS were 46.2 per cent and 17 per cent, respectively. HRS improved significantly in elective DSRS patients from 1.46 to 1.30. Predictors of HRS2 included HRS1 and time in days from the index bleed to operation. The most important predictor of early survival for all patients after elective DSRS was the HRS2; however, for patients who underwent elective DSRS and survived, HRS1 was a better predictor of length of survival than HRS2. No other variable analyzed accurately predicted survival. We conclude that HRS can be expected to improve with supportive inhospital therapy; improved HRS at the time of operation is associated with decreased operative mortality; and the extent of liver disease as determined by HRS1 appears to be the chief determinant of long-term patient survival.