Risk factors before hepatectomy, hepatic function after hepatectomy and computed tomographic changes as indicators of mortality from hepatic failure

The mortality rate from hepatic failure after extensive resection should be negligible in the presence of normal results from preoperative liver function tests in patients without pre-existing hepatitis and cirrhosis. Despite conventionally acceptable results from preoperative hepatic function tests in 56 patients undergoing extensive hepatic resection for tumours (47 metastatic, six hepatomas and three adenomas), however, five patients died of hepatic failure. Among the many preoperative and intraoperative risk factors studied, the important factors in the group with hepatic failure were very high levels of serum alkaline phosphatase (p less than 0.05) in the presence of normal levels of bilirubin and large tumor, preoperative administration of chemotherapy, the presence of hepatomas rather than metastatic carcinoma (p = 0.083) and intraoperative blood loss of greater than 5,000 milliliters (p = 0.03). The patients receiving preoperative chemotherapy or those with hepatoma showed a minimal rise of alkaline phosphatase (p less than 0.03) and a minimal regeneration of liver on computed tomographic (CT) scan after hepatic resection. In the group with hepatic failure, a consistent postoperative pattern of increasing bilirubin with normal or subnormal alkaline phosphatase levels corresponded with lack of regeneration of liver on repeated CT scans. Conversely, the pattern of decreasing bilirubin with reciprocal increase in alkaline phosphatase corresponded with hepatic regeneration on CT scan in the group of survivors. Thus, we observe that alkaline phosphatase is a good indicator of hepatic regeneration in the absence of jaundice in patients after hepatectomy. To avoid postoperative hepatic failure, we recommend more discriminant tests than conventional hepatic function tests in patients with large tumors associated with high alkaline phosphatase levels, preoperative chemotherapy and hepatoma even without pre-existing cirrhosis or hepatitis.     

Simultaneous measurement of hepatic arterial and portal venous flows by transit time ultrasonic volume flowmetry

Simultaneous measurement of the hepatic artery and the portal vein was performed successfully upon 15 anesthetized patients during abdominal operations with the use of transit time ultrasonic volume flowmeter. The hepatic arterial flow, portal venous flow and total hepatic flow were 267.3 +/- 21.2, 746.4 +/- 41.3 and 1,010.7 +/- 52.7 milliliters per minute, respectively. The ratio of hepatic arterial flow to portal venous flow was 0.36 +/- 0.03. Temporary occlusion of the portal vein resulted in a significant increase in hepatic arterial flow (23.6 +/- 4.3 per cent, p less than 0.01), whereas temporary occlusion of the hepatic artery did not alter portal venous flow significantly. Occlusion of the common hepatic artery induced a significant decrease in hepatic arterial flow (p less than 0.05), but did not alter portal venous flow significantly. The results of this approach had useful clinical meanings in one patient in whom the Appleby's operation was performed in which sufficient hepatic arterial flow was needed after the common hepatic artery was ligated. Data are presented for hepatic circulation measured by transit time ultrasonic volume flowmeter, which is a good device to use to assess portal venous flow as well as hepatic arterial flow with reproducibility and stability.     

Hepatic rupture associated with preeclampsia,report of three cases and literature review

Background: Hepatic rupture is a complication during pregnancy that, although rare, accounts for high morbidity and mortality rates. It is mainly associated with severe preeclampsia and HELLP syndrome. Incidence is estimated to be at one per 67,000 births or one per 2000 patients with preeclampsia/eclampsia/HELLP, mainly in multiparous women; women in their 40s; after 32 weeks of gestation; and during the first 15?h postpartum.

Cases: This article exposes the institutional experience at Fundación Valle del Lili in Cali, Colombia, in managing and treating hepatic rupture associated with severe preeclampsia and HELLP syndrome in three patients in the 30th, the 26th, and the 27th week of gestation, not resulting in maternal death.

Discussion: A search in Pubmed, Embase, and Ovid from 2000 to 2017 resulted in 35 cases reported in either pregnant or puerperal women. Hepatic rupture is a rare complication in pregnancy associated with preeclampsia and HELLP syndrome. Its pathophysiology is attributed to the presence of vasospasm due to an increase in concentration and sensitivity to circulating vasopressors during pregnancy. There is no standard management, but surgery reduces mortality significantly. It includes endovascular management, partial hepatectomy, or transplant (only one patient required a liver transplant in our search). The most used techniques have been ligation of the hepatic artery, embolization of the hepatic artery, and examination, packing, and drainage of hepatic lesion for bleeding control (27 cases were treated with laparotomy with evacuation of hematoma and hemostasis and four cases were treated with embolization of the hepatic artery). Hepatic artery occlusion both by surgery ligation and by embolization through interventional radiology has reported successful and failing results during pregnancy

Conclusion: Management of pathologies as hepatic rupture associated with severe preeclampsia and HELLP syndrome has to be clearly protocolized for prompt diagnosis and early management. Furthermore, it has to be carried out through multidisciplinary teams in high-complexity obstetrics scenarios.     

Unresectable hepatic metastases from carcinoma of the colon and rectum

To alter the dismal prognosis of multiple unresectable metastases to the liver from carcinoma of the colon and rectum, 30 patients underwent hepatic dearterialization (ligation of the hepatic artery, transection of hepatic ligaments and cholecystectomy) and distal hepatic artery cannulation with prolonged infusion chemotherapy by a portable infusion pump followed by systemic intravenous chemotherapy. Involvement of the liver by carcinoma was less than 50 per cent in 16 and more than 50 per cent in 14 patients. The results of follow-up examinations, LFT, CEA and CT scan studies showed more than 50 per cent regression of the tumor and a decrease in alkaline phosphatase values and CEA in 29 patients (97 per cent); six had complete regression of tumor. The duration of response ranged from five to 39 months with the median of 17 or more months. The results of sequential LFT showed immediate increase in liver enzymes with return to normal in seven to 14 days. The mean CEA value decreased by 69 per cent within the first week and further decreased by 88 per cent in two months at the end of infusion chemotherapy. The over-all and adjusted survival rates from diagnosis were 79 and 91 per cent at 12 months; 56 and 81 per cent at 18 months, and 40 and 65 per cent at 24 months. The over-all and adjusted median survival rate after the treatment was 17 and 23 months, respectively. Of the 14 patients who failed this program, 11 had recurrences at sites other than the liver, with hepatic disease in remission in the majority. Of the 17 patients who died, six died of causes unrelated to the recurrence of disease. Thus, hepatic dearterialization and infusion regional chemotherapy can "effectively" control the hepatic disease and increase over-all survival time from three to six months to 23 months. However, recurrences of extrahepatic carcinoma and other causes are responsible for death and the over-all guarded prognosis.     

Reduction of mortality and morbidity associated with pelvic exenteration.

Eighty-seven pelvic exenterations performed on the Gynecology Service at Roswell Park Memorial Institute are reviewed in terms of postoperative mortality and morbidity. Sixty-five of these patients (75%) had one or more significant postoperative complications, and 22 patients (25%) died as a result of these complications. Thirty-four patients (39%) required one or more major reoperations. Complications were associated with dose of previous pelvic radiotherapy, type of exenteration, prolonged operations and excessive blood loss, pelvic lymphadenectomy, hypogastric artery ligation, type of pelvic occlusion, and the diversion of ureters into functional colon. A postexenteration hepatic stress syndrome is described and appears to occur in the majority of patients undergoing this operation. Methods of surgical technique and pre- and postoperative care are discussed which will potentially lead to a reduction in mortality and morbidity.     

腹腔镜双侧髂内动脉临时阻断下子宫修补联合宫腔镜清宫术在Ⅲ型剖宫产瘢痕部位妊娠中的应用

目的 探讨腹腔镜下髂内动脉可逆性结扎及子宫修补联合宫腔镜下清宫术在Ⅲ型剖宫产瘢痕部位妊娠术中的疗效和安全性.方法 回顾性分析2017年11月～2020年11月广州医科大学附属广州市妇女儿童医疗中心收治的剖宫产瘢痕部位妊娠患者135例,其中Ⅲ型患者32例,根据术前处理措施不同,分为髂内动脉临时阻断组(21例)和子宫动脉栓...     

Hepatic hemangioendotheliomas in infancy

Multicentric hepatic hemangioendotheliomas are vascular lesions of the liver that usually present in the infant with hepatomegaly, high output congestive heart failure and cutaneous hemangiomas. The diagnosis, pathologic and physiologic conditions and treatment were discussed. Two of the patients we studied and 117 from the literature were reviewed. A total of 38 patients survived and 57 died with or without medical treatment. Thirteen patients survived and five died after ligation of the hepatic artery. Five patients survived and three died after embolization of the hepatic artery. (formula; see text) Of 119 patients with MHH, 81 (68 per cent) had congestive heart failure; 40 survived and 41 died. Of 56 patients with localized hepatic angiomas, 19 had congestive heart failure. Only two of the patients died of heart failure. Fifty localized hepatic angiomas in infancy that were treated with local resection or lobectomy were reviewed. Forty-six patients survived and four died of hemorrhage. Four patients survived and two died with or without medical treatment. Plans for management of multiple hepatic hemangioendotheliomas and localized hepatic angiomas in infancy were proposed.     

Distribution of fluorodeoxyuridine uptake in the liver and colorectal hepatic metastases of human beings after arterial infusion

Little is known about drug distribution in tumor metastases or in the liver after hepatic arterial infusion. This information is important for planning strategies to enhance tumor drug uptake and to improve tumor response to therapy. Dye injection studies have demonstrated hepatic tumor vascular supplies in an anatomic manner, but offer no physiologic data. To evaluate hepatic drug distribution in patients with metastases to the liver and colon and rectum (6-3H) 5-fluorodeoxyuridine (FUdR) and 99m-technetium (TC) macroaggregated albumin (MAA) were infused through the hepatic artery prior to lobectomy of the right hepatic lobe in three patients and before wedge resection of a metastasis in one patient. Forty to 100 specimens of the tumor and liver taken at biopsy were assayed in order to map drug and albumin distribution. Nuclide scanning of the specimen was performed upon two patients. A linear relationship between levels of 3H (representing fluoropyrimidine metabolites) and 99mTc (representing blood flow) was demonstrated in both the tumor (correlation coefficients 0.69 to 0.87, p less than 0.01) and liver (correlation coefficients 0.76 to 0.90, p less than 0.001). The liver immediately adjacent to the tumor retained substantially more 99mTc-MAA than either the tumor itself or liver remote from the tumor, as demonstrated by both nuclide scanning and tissue biopsies. The rim of the liver adjacent to the tumor with enhanced 99mTc uptake had a different histologic appearance from a "normal" liver at a distance from the tumor in all instances. A radionuclide hepatic scan showing increased tumor uptake of 99mTc-MAA after arterial injection predicts an increased likelihood of tumor response to treatment. The results of this study demonstrate for the first time, in human beings, that increased 3H-FUdR uptake occurs in portions of the tumor which retain more 99mTc-MAA and explains the capacity of the arterial 99mTc-MAA perfusion scan to predict tumor response in the treatment of metastases to the liver and colon and rectum.     

Protection of liver ischemia due to inflow occlusion using prior perfusion with hepatic protective solution in dogs.

Temporary occlusion of hepatic inflow is a useful maneuver to reduce hemorrhage from liver trauma and difficult hepatic resections. The liver can be protected with a hepatic protective solution before inflow occlusion, just as the stopped heart is protected by a cardioplegic solution during open heart surgery. Twenty dogs were divided into two groups. The portal inflow of group A was infused via the mesenteric venous branch with a hepatic protective solution composed of 250 mg of hydrocortisone, 15 mEq of KC1, 6 mL of 0.1 N HC1, 5 mL of 10% magnesium sulfate and 250 mg of dextrose in one liter of cold lactated Ringer's solution. Group B was infused with cold lactated Ringer's solution as a control. The hepatic artery and portal vein were isolated and then clamped for 30 minutes. The elevation of serum GOT and GPT after release of the clamps was significantly greater in group B, especially during the first 48 hours. The levels of alkaline phosphatase and total bilirubin were also higher in group B until the 7th day. The results liver biopsies 3 hours after release of the clamps revealed marked congestion and destruction of hepatocytes in group B. We conclude that liver perfusion with a hepatic protective solution before inflow occlusion results in less damage to liver tissue and less impairment of liver function. Such protection is important in liver surgery.     

Selective ligation of the hepatic artery for trauma of the liver.

Selective ligation of sundry hepatic arteries in patients with hepatic trauma obviated death from hepatic bleeding in 59 of 60 patients treated with this method of hemostasis. Hepatic insufficiency did not occur in survivors. Reconstitution of intrahepatic arterial flow is rapidly accomplished by collateral arteries. When the source of hemorrhage is perihepatic, that is, hepatic veins and retrohepatic vena cava, hepatic artery ligation is ineffective. Two patients died from this kind of hemorrhage.     

Treatment of uterine myomas with transvaginal uterine artery occlusion: possibilities and limitations

The objective of this pilot study was to evaluate the feasibility of a transvaginal clamp prototype used for temporary uterine artery occlusion as a treatment for myomas. In particular, we aimed to evaluate technical aspects of successful occlusion with angiography and magnetic resonance imaging (MRI) and to evaluate possible ureter occlusion with pyelography. Ten premenopausal women aged 34 to 37 years with menorrhagia and myomas were treated with a temporary uterine artery occlusion for 6 hours. Five patients did not complete the clamping procedure because of unsuccessful clamping. While the clamp was in position, angiographic examination of the uterine arteries and pyelography were performed in 8 of the patients. The clamps occluded both uterine arteries in 4 patients and 1 side in another 2. Two procedures occluded the ureter unilaterally. MRI with contrast was done before, the day after, and 3 months after the procedure. Three of 5 patients who completed the clamp treatment had reduced or no contrast enhancement at MRI afterward. Clinical effects were obtained in 3 patients. Difficulties with application of the vaginal clamp were related to initial learning and size of the myomas. Our initial experience shows that the treatment is feasible in some patients with symptomatic myomas. However, improvement of the technique and equipment is needed. Care with regard to the ureters is required during further studies aimed at evaluating this approach.     

Surgical approaches for unresectable primary carcinoma of the hepatic hilus

Thirteen patients with proximal malignant obstruction of the biliary tract secondary to primary cholangiocarcinoma are presented. Seven of these patients had bilateral involvement of the major vessels of the porta hepatis, and 12 had bilateral involvement of the main hepatic ducts up to the level of segmental bifurcation. Resection of the tumor was carried out in all of the patients. Extensive resection of the liver with resection of the regional vascular structures was done in six. Another six underwent resection of the liver without resection of the regional vascular structures. The remaining patient underwent resection of the tumor and of the regional revascular structures alone. Vascular resection included resection and reconstruction of both the portal vein and hepatic artery in four patients or only of the portal vein in three. Biliary drainage was carried out by intrahepatic cholangiojejunostomies between segmental hepatic ducts and a Roux-en-Y loop. Two patients died and ten are alive. The quality of postoperative life is satisfactory and the patients are free of sequelae and symptoms secondary to operation or disease. This approach is recommended for the management of a number of patients with bilateral vascular or biliary involvement secondary to primary cholangiocarcinoma of the porta hepatis. For those patients, this approach offers a promising alternative.     

Liver capsule rupture in eclampsia: treatment with hepatic artery embolisation

Introduction: Spontaneous hepatic rupture associated with pregnancy is a rare and very serious complication associated with eclampsia or pre-eclampsia. Case report: We report a case of hepatic rupture following eclampsia at 27 weeks gestation which was managed successfully by selective hepatic artery embolisation as an adjunct to liver packing. Conclusion: Selective embolisation of the hepatic artery is an effective means of therapy for hepatic artery bleeding and is an adjunct to liver packing in spontaneous hepatic rupture in eclamptic patients.     

Spontaneous rupture of liver during pregnancy: current therapy

Spontaneous hepatic rupture secondary to severe pregnancy-induced hypertension is associated with a high rate of maternal and fetal mortality. Numerous types of surgical management have been described, but a uniform surgical approach has not been accepted. The purpose of this review was to examine modes of surgical therapy reported in the literature since 1976, as well as the 11-year experience at our institution. Twenty-eight cases were extracted from the literature and seven more were identified at our institution. The incidence in our population was one per 45,145 live births. Among 27 cases managed by packing and drainage, an 82% overall survival was achieved, whereas only 25% of eight patients undergoing hepatic lobectomy survived (P = .006). Hepatic hemorrhage with persistent hypotension unresponsive to blood products should be managed by evacuating the hematoma, packing the damaged liver, and draining the operative site. More aggressive surgical techniques, such as hepatic artery ligation or hepatic lobectomy, should be reserved for refractory cases.     

Assessment of pattern and treatment of intrahepatic recurrence after resection of hepatocellular carcinoma.

From 1980 to 1988, 161 patients underwent total extirpation of primary hepatocellular carcinoma. There were 18 operative or hospital deaths. Recurrence of tumor was diagnosed in 69 of the remaining 143 patients during follow-up treatment with monthly serum alpha-fetoprotein measurements and imaging studies that were performed every three months. There were 61 men and eight women whose ages ranged from 33 to 78 years. The histologic factors noted were cirrhosis of the liver in 60 patients and chronic hepatitis in nine. There were multiple or diffuse recurrences (Type A) in 34 instances, one to three nodular recurrences (Type B) in 21, marginal recurrences (Type C) in 11 and a mixed form of the latter two in three instances. Two-thirds of the recurrences were found within 1.5 years and the second peak was noted between 2.0 and 2.5 years. Sex of patient, hepatitis B virus, type of tumor, capsule, extent of hepatic resection and postoperative chemotherapy did not influence the rate of recurrence, but cirrhotic livers had a significantly higher recurrence rate. A second hepatic resection was performed upon 20 patients with a five year survival rate of 26.8 per cent. Good results were obtained by chemoembolization of the hepatic artery. Prevention and adequate treatment of intrahepatic recurrence are of paramount importance in achieving better surgical results for hepatocellular carcinoma.     

Hepatoportal arteriovenous fistula in primary carcinoma of the liver.

The correlation between the portal circulation and esophageal varices was evaluated in 80 patients with a primary carcinoma of the liver, with special regard being given to the significance of an hepatoportal arteriovenous fistula. Hepatoportal arteriovenous fistula was found in eight patients. Esophageal varices were observed 32 of all patients with a hepatoma. On the other hand, variceal lesions were found in 17 of 52 patients without compared with all patients with an hepatoportal arteriovenous fistula. A fatal hemorrhage was frequently encountered in the patients with the fistula. It was suggested that a rational treatment for those with the triple lesions--hepatoma, esophageal varices and hepatoportal arteriovenous fistula--may be ligation of the hepatic artery.     

Laparoscopic ligature of the hypogastric artery in the case of bleeding in advanced cervical cancer.

BACKGROUND: Massive bleeding from an exophytic tumor is a serious complication in advanced cases of cervical carcinoma. With persistent bleeding the embolization or ligation of an artery is required. CASE: This report describes the technique of laparoscopic ligation of the hypogastric artery in patients with massive bleeding in advanced cases of cervical cancer (FIGO Stage III). Laparoscopy was performed before or at the beginning of radiation therapy. Three cases are presented. CONCLUSIONS: Laparoscopic ligature of the hypogastric artery can replace laparotomy in patients with advanced cervical cancer and persistent bleeding. The laparoscopic procedure is less traumatic than laparotomy and enables the continuation of external radiotherapy without delay.     

Indications for cholecystectomy in ligation of the hepatic artery

Ligation of the hepatic artery has been successfully used in the management of massive bleeding, secondary to hepatic trauma, and in the treatment of metastatic neoplastic disease. The indications for a concomitant cholecystectomy are less well defined. It is generally accepted that cholecystectomy should be performed when ligation is used to control bleeding. In our study, ligation of the hepatic artery was performed, leaving the gallbladder in situ. At autopsy, no pathologic process could be detected in the gallbladder. Microscopic analysis showed fibrosis in the mucosal surface, mild chronic inflammation and nonspecific mononuclear infiltration. We conclude that the changes are insufficient to warrant the removal of a normal gallbladder when ligation of the hepatic artery is performed as treatment for neoplastic disease.     

Anterior approach to laparoscopic uterine artery ligation

Herein is described an anterior approach to uterine artery ligation during laparoscopic myomectomy and total laparoscopic hysterectomy. The anterior leaf of the broad ligament is opened and the uterine artery is clipped lateral to its crossing over the ureter. Outcome measures were completion of the procedure laparoscopically and the need for transfusion postoperatively. Thirty-eight myomectomies and 28 difficult total laparoscopic hysterectomies (primarily uteri with large myomas) were performed, with 1 conversion to laparotomy during myomectomy and 1 during hysterectomy, and 1 transfusion after total laparoscopic hysterectomy. The anterior approach to uterine artery ligation is an alternative method for treatment of uterine artery occlusion during laparoscopic myomectomy or hysterectomy performed to treat large myomas.     

Combined hepatic and pancreaticoduodenal procurement for transplantation

We have used a procurement method whereby both the liver and whole pancreas grafts are procured from the same donor and successfully transplanted. During the combined procurement, the hepatic artery is completely mobilized; the splenic artery is transected from the hepatic artery and the gastroduodenal artery is ligated from the hepatic artery. The portal vein is mobilized 2 centimeters from the head of the pancreas. The whole pancreas graft includes the splenic artery and the superior mesenteric artery, which are reconstructed. The hepatic graft includes the entire length of the hepatic artery with the celiac axis, and no further reconstruction is required. Using this technique, we have performed nine combined hepatic and whole pancreas procurements; only one liver was not transplanted because of technical complications. When a replaced right hepatic artery is identified from the superior mesenteric artery, we have abandoned the pancreatic retrieval. All combined retrievals have included successful renal retrieval, and the majority have been associated with cardiac retrieval also. Combined hepatic and whole pancreas procurement is feasible with minimal technical complications with the liver or the pancreatic graft and should be standard in most procurements.