Clinical significance of right hepatectomy along the main portal fissure on donors in living donor liver transplantation

There might be discordance between inter‐lobar borders of the main portal fissure (MPF) using the middle hepatic vein (MHV) and of the portal segmentation. Forty‐five living donors who underwent right hepatectomy for the adult recipients from 2007 to 2011 in a tertiary hospital were retrospectively analyzed. The donors were classified into conventional right hepatectomy along the MPF (cRL group, n = 26) and modified right hepatectomy along right‐side shifted transection plane from the MPF (mRL group, n = 19). The cRL donors had higher postoperative peak level of INR (1.84 vs. 1.62; P = 0.022), and bilirubin (3.37 mg/dl vs. 2.74 mg/dl; P = 0.065) than the mRL donors. cRL donors experienced greater depression of platelet count (144 per nL vs. 168 per nL; P = 0.042) and enlargement of splenic volume (52% vs. 37%; P = 0.025) than mRL donors for 7 days after hepatectomy. The regeneration of the left lateral sector was more accelerated in the cRL donors than the mRL donors for postoperative 3 months (148% vs. 84%; P = 0.015). There were no differences in the post‐transplant graft function, incidence of complications, and graft survival rates between the two groups of recipients (P > 0.05). This study suggests that the conventional right hepatectomy along the MHV might increase donor risk by reducing parenchymal liver volume of the segment IV.     

Intra‐operative colloid administration increases the clearance of a post‐operative fluid load

Background: It is unknown whether an intra‐operative colloid infusion alters the dynamics of a crystalloid load administered post‐operatively. Methods: Ten patients received 12.5 ml/kg of Ringer's lactate over 30 min 1–3 days before and 4 h after laparoscopic cholecystectomy, during which 10 ml/kg of a colloid solution, hydroxyethylstarch (HES 130/0.4), was infused. The total body clearance of the pre‐ and post‐operative test infusions was taken as the ratio between the urinary excretion and the Hb‐derived dilution of venous plasma over 150 min. The plasma clearance of the infused fluid was calculated using volume kinetics based on the plasma dilution alone. The pre‐operative plasma clearance was compared with the post‐operative plasma clearance and patients served as their own control. Results: The urinary excretion averaged 350 ml for the pre‐operative infusion and 612 ml post‐operatively, which corresponds to 46% and 68% of the pre‐ and post‐operative infusions, respectively. The total body clearance of the crystalloid fluid was 30 ml/min before surgery and 124 ml/min after surgery (P<0.01). The plasma clearance, as obtained from the plasma dilution alone, was 28 and 412 ml/min, respectively. The maximal increase in plasma volume was 410 ml pre‐operatively vs. 220 ml post‐operatively. Conclusions: Infusion of a colloid solution in combination with a crystalloid during laparoscopic cholecystectomy increased the plasma clearance of a post‐operative crystalloid infusion.     

Mild hepatic macrovesicular steatosis may be a risk factor for hyperbilirubinaemia in living liver donors following right hepatectomy

Background:

The aim of this study was to evaluate the effects of mild macrovesicular steatosis on the outcome of living liver donors following right hepatectomy.

Methods:

The medical records of 46 living liver donors who underwent right hepatectomy were studied. Ten donors had mild macrovesicular steatosis (5–10 per cent in seven and 11–20 per cent in three patients). Five donors with other liver pathology were excluded. Outcome in these ten donors (group 1) was compared with that in the remaining 31 donors with normal liver histology (group 2).

Results:

The median duration until normalization of total bilirubin levels was 14 and 5 days in groups 1 and 2 respectively (P = 0·028). The peak total bilirubin level was significantly higher in group 1 than in group 2 (80·4 versus 49·6 µmol/l; P = 0·033). Multivariable analysis showed mild macrovesicular steatosis to be an independent risk factor for hyperbilirubinaemia (odds ratio 7·94 (95 per cent confidence interval 1·17 to 54·03); P = 0·034).

Conclusion:

Mild macrovesicular steatosis may be related to adverse outcome in living liver donors who undergo right hepatectomy and, in terms of donor safety, is of potential concern in donor selection. Copyright © 2009 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Liver transplantation from non–heart beating donors in rats: Influence of viscosity and temperature of initial flushing solutions on graft function

BACKGROUND: We evaluated the effect of warm (37 degrees C) versus cold (4 degrees C) solutions as the initial flush for liver preservation from non-heart beating donors in rats. METHODS: An initial flush was performed just before donor hepatectomy with cold or warm University of Wisconsin solution (UW), UW without hydroxyethyl starch, sodium lactobionate sucrose solution, or lactated Ringer's solution as the control group. A separate group also used as control received no initial flushing. Liver transplantation was performed, and the graft function was determined by survival and assessment of enzyme release. The viscosity of each solution and the vascular resistance of the graft were measured. RESULTS: The 7-day survival rate was 83% and 100% in the warm and cold sodium lactobionate sucrose solution groups and 60% and 50% in the warm and cold lactated Ringer's solution groups, respectively. In the no-initial-flush group, rats did not survive. The 7-day survival rate was 67% and 0% in the warm and cold UW groups, respectively. Eliminating the hydroxyethyl starch from the cold UW improved the survival to 67%. Serum alanine aminotransferase levels 1 day after transplantation in the no-initial-flush and the cold UW groups were significantly higher than those of the remaining groups. At 4 degrees C the viscosity was higher in the UW (86.2 cp) compared to hydroxyethyl starch-free UW solution (30.9 cp), lactated Ringer's solution (24.5 cp), and sodium lactobionate sucrose solution (32.7 cp). The viscosity of UW at 37 degrees C was 34.7 cp. Vascular resistance correlated well with the viscosity. Livers flushed with solutions with a low viscosity showed lower vascular resistance than those flushed with cold UW and led to better survival. CONCLUSIONS: These data suggest that the viscosity of the initial flushing solution may play an important role in determining the outcome of organ procurement from non- heart beating donors. (Liver Transpl Surg 1997 Jan;3(1):39-45)     

Superiority of acetate compared with lactate in a rodent model of severe hemorrhagic shock

Background

Recently, we have shown that the use of lactated Ringer's (LR) solution is inferior to pure Ringer's solution (RS) in treatment of severe hemorrhagic shock in rats. The present study was performed to evaluate whether this is a specific effect of lactate or also applies to another metabolizable anion, namely acetate.

Material and methods

We subjected male Wistar rats to hemorrhagic shock by dropping the mean arterial blood pressure to 25–30 mm Hg for 60 min, resuscitated with acetated Ringer's (AR) solution, LR solution, RS, or normal saline (NS) within 30 min, and further observed the animals for 180 min.

Results

Administration of AR solution prolonged median survival to 115 min compared with 50 min for resuscitation with LR solution or 85 and 90 min for NS and RS, respectively. Resuscitation with AR solution and LR solution clearly improved metabolic acidosis compared with NS and RS but tissue injury, indicated by plasma enzyme activities, was most pronounced in the LR solution group, medium in the NS and RS groups, and least in the AR solution group.

Conclusions

In severe hemorrhagic shock, resuscitation with both RS and NS is superior to administration of LR solution but initial outcome is even further improved if AR solution is used. Mere amelioration of the acid–base status by AR solution may explain its superior role compared with RS and NS but cannot be responsible for its superiority compared with LR solution. Here, direct injury by lactate has to be discussed.     

Differences of perioperative liver function, transfusion, and complications according to the type of hepatectomy in living donors

Numerous living donor hepatectomy are being performed safely. However, donors are still exposed to various complications including hepatic failure. We examined the donor's potential risk and morbidity depending on the type of hepatectomy: left lateral segmentectomy (group LLS, n = 30), left lobectomy (group LL, n = 15), and right lobectomy (group RL, n = 128). The charts and computerized hospital data of 173 donors from March 2000 to September 2003 were retrospectively reviewed. We analyzed liver function tests (LFT), RBC transfusion, and complications. Although the graft weight was greatest, and surgical and anesthetic times were longest in the group RL, there were no significant differences in postoperative hospital stay, RBC transfusion, and major complications among the groups. However, minor complications were significantly higher in group RL than group LLS. Postoperative prothrombin time and total bilirubin were significantly higher in the group RL than the other groups (P < 0.05). Living donor hepatectomy is relatively safe, and it is evidenced by rapid recovery of LFT and low occurrence of major complications. However, noticeable depression of LFT and frequent minor complications occur after hepatectomy, especially RL.     

Use of middle hepatic vein in right lobe living donor liver transplantation

The harvesting of the middle hepatic vein (MHV) with the right lobe graft for living‐donor liver transplantation allows an optimal venous drainage for the recipient; however, it is an extensive operation for the donor. This is a prospective, nonrandomized study evaluating liver functions and early clinical outcome in donors undergoing right hepatectomy with or without MHV harvesting. From August 2005 to July 2007, a total of 100 donor right hepatectomies were performed with (n = 49) or without (n = 51) the inclusion of the MHV. The decision to take MHV was based on an algorithm that considers various donor and recipient factors. There was no donor mortality in donors in either group. Overall complication rate was higher in MHV (+) donor group, however when remnant liver volume was kept above 30%, complication rates were similar between the groups. The results of this study show that right hepatectomy including the MHV neither affects morbidity nor impairs early liver function in donors when remnant volume is kept above 30%. The decision, therefore, of the extent of right lobe donor hepatectomy should be tailored to the particular conditions considering the graft quality and metabolic demand of the recipient.     

Beneficial effects of a hypertonic solution for resuscitation in the presence of acute hemorrhage

Crystalloid solutions such as Ringer's lactate have become the standard for initial volume replacement after hemorrhage. Although the relative merits of blood, colloid, and crystalloid have been extensively studied, little attention has been directed toward determining the optimal composition of the crystalloid solution. Based on the beneficial properties of hypertonic lactated saline solution in burn resuscitation, we have extended its use to acute hemorrhage. Using an awake canine model analogous to the clinical situation, we compared hypertonic lactated saline solution with Ringer's lactate solution for resuscitation in the presence of acute blood loss. The hypertonic lactated saline solution group required less fluid to restore and maintain cardiac output and blood pressure while maintaining better urine output. Although the Ringer's lactate solution group had increased shunt function indicative of pulmonary dysfunction, the shunt function in the hypertonic lactated saline solution group did not differ from that in the control group. Serum sodium and osmolality values were higher in the hypertonic lactated saline solution group, but at no time did they approach toxic levels.     

Pure laparoscopic living donor hepatectomy: Focus on 55 donors undergoing right hepatectomy

Although laparoscopic donor hepatectomy is increasingly common, few centers with substantial experience have reported the results of pure laparoscopic donor right hepatectomy (PLDRH). Here, we report the experiences of 60 consecutive liver donors undergoing pure laparoscopic donor hepatectomy (PLDH), with most undergoing right hepatectomy. None of the 60 donors who underwent PLDH had intraoperative complications and none required transfusions, reoperation, or conversion to open hepatectomy. Forty‐five donors who underwent PLDRH between November 2015 and December 2016 were compared with 42 who underwent conventional donor right hepatectomy (CDRH) between May 2013 and February 2014. The total operation time was longer (330.7 vs 280.0 minutes; P < .001) and the percentage with multiple bile duct openings was higher (53.3% vs 26.2%; P = .010) in the PLDRH group. However, the length of postoperative hospital stay (8.4 vs 8.2 days; P = .495) and rate of complications (11.9% vs 8.9%; P = .733) and re‐hospitalizations (4.8% vs 4.4%; P = 1.000) were similar in both groups. PLDH, including PLDRH, is feasible when performed by a highly experienced surgeon and transplant team. Further evaluation, including long‐term results, may support these preliminary findings of comparative outcomes for donors undergoing PLDRH and CDRH.     

Safety of donors with fatty liver in liver transplantation

Steatotic liver graft transplantation affect donor safety as well as recipient survival. We investigated safety of donors according to the extent of fatty change. We retrospectively reviewed donors who underwent right hepatectomy from September 1999 to April 2005, dividing them into three groups according to degree of macrovesicular fatty change upon intraoperative liver biopsy. Group 1 included patients with macrovesicular steatosis of 0 approximately 9%: group 2, 10 approximately 19% and group 3, at least 20%. Two hundred forty-five donors were enrolled with a male to female ratio of 2.02:1 and mean age of 31.8 years. There were 163 donors in group 1, 75 in group 2, and seven in group 3. There was no statistically significant difference in body mass index, operative time, blood loss, postoperative peak serum bilirubin, and aspartate transaminase levels among groups 1, 2, and 3. Overall complication rate, including reoperation, biliary stricture, wound infection, ileus, transfusion, bile leak and fluid collection were not different between the groups. Postoperative hospital stay was also not different. Peak alanine transaminase level was different between each group, and prothrombin time between group 1 and 3, but days until return to normal levels in all measured laboratory parameters were not different. Residual liver volume percent was significantly smaller among group 1 compared to others. In conclusion, fatty livers with less than 30% macrovesicular steatosis may be good donor candidates without significant complications as long as sufficient residual liver volume is left for the donor.     

Comparison of the effect of rapid infusion of lactated and that of acetated Ringer's solutions on maternal and fetal metabolism and acid-base balance]

The maternal and neonatal metabolism and acid-base balance were investigated in 20 parturients undergoing combined spinal and epidural anesthesia for cesarean delivery. Patients received intravenous infusion at a rate of either 25 ml.kg-1.h-1 of lactated (LR group, n = 10) or acetated (AR group, n = 10) Ringer's solution before anesthesia, to prevent hypotension during anesthesia. We obtained venous blood samples as follows; maternal control before anesthesia, maternal sample A after the infusion, umbilical sample B, and neonatal pedal sample C 5 h after birth, and determined lactate, pyruvate, bicarbonate, and base excess concentrations, and pH in each sample. In sample A, the lactate level was significantly higher and base excess level was significantly lower in the LR group than in the AR group. The pH of sample A and B was significantly higher in the AR group than in the LR group. However, no differences in all parameters of sample C between the two groups were observed. These results demonstrated that acetated Ringer's solution is better than lactated Ringer's solution in rapid infusion before cesarean section because of the correction of neonatal lactic acidosis.     

Comparison of pure laparoscopic and open living donor right hepatectomy after a learning curve

This study aims to compare the early outcomes between pure laparoscopic living donor right hepatectomy (PLDRH) and open living donor right hepatectomy (ODRH) after those learning curve. Our analysis was based on 78 consecutive cases of living liver donor, who underwent right hepatectomy, of which 43 underwent ODRH and 35 PLDRH. The learning curve for each group was analyzed. Donor characteristics were comparable between the two groups. Two donors in the PLDRH required conversion to an open due to bleeding and large graft size (open conversion rate: 6.06%). The following outcomes during the study period were comparable between the two groups: operative time (P = .64); estimated blood loss (EBL; P = .86); intra‐operative transfusion (P = .57); hospital stay (P = .41); and postoperative complications (P = .51). The operative time stabilized for the ODRH group after 17 cases and for the PLDRH group after 15 cases. After the learning curve, the EBL was lower for PLDRH than ODRH (P = .04). Pure laparoscopic living donor right hepatectomy can be performed as safely as ODRH and with a lower volume of EBL once the surgeon has attained an appropriate level of learning.     

Effects of Crystalloid and Colloid Preload on Blood Volume in the Parturient Undergoing Spinal Anesthesia for Elective Cesarean Section

Background: The role of crystalloid preloading to prevent hypotension associated with spinal anesthesia in parturients during cesarean section has been challenged. Direct measurement of blood volume should provide insight regarding the volume-expanding effects. The aim of the current study was to clarify the effects of volume preload with either crystalloid or colloid solution on the changes in blood volume of parturients undergoing spinal anesthesia for cesarean section.

Methods: Thirty-six healthy parturients scheduled for elective cesarean section during spinal anesthesia were allocated randomly to one of three groups receiving 1.5 l lactated Ringer's solution (LR; n = 12), 0.5 l hydroxyethylstarch solution, 6% (0.5 l HES; n = 12), and 1.0 l hydroxyethylstarch solution, 6% (1.0 l HES; n = 12), respectively. Blood volume and cardiac output were measured before and after volume preloading with indocyanine green (ICG), and the indocyanine green blood concentrations were monitored by noninvasive pulse spectrophotometry.

Results: After volume preload, the blood volume significantly increased in all three groups (P< 0.01). The volume of infused solution remaining in the vascular space in the LR, 0.5-l HES, and 1.0-l HES groups were 0.43 +/- 0.20 l, 0.54 +/- 0.14 l, and 1.03 +/- 0.21 l, respectively, corresponding to 28% of lactated Ringer's solution and 100% of hydroxyethylstarch solution infused. Significant increases in cardiac output were observed in the 0.5-l and 1.0-l HES groups (P< 0.01). A significant correlation between the percentage increase in blood volume and that of cardiac output was observed by volume preloading (r2 = 0.838;P< 0.001). The incidence of hypotension was 75% for the LR group, 58% for the 0.5-l HES group, and 17% for the 1.0-l HES group, respectively.     

Liver transplantation from living donors with Gilbert's syndrome is a safe procedure for both donors and recipients

Liver transplantation (LT) has become a favorable therapeutic option for patients with end‐stage liver diseases. Gilbert's syndrome (GS) is a benign condition characterized by intermittent mild jaundice due to unconjugated hyperbilirubinemia. It is not obvious whether living‐donor liver transplantation (LDLT) from a donor with GS could result in a normal outcome for both the recipient and the donor. We aimed to determine whether right lobe hepatectomy is a safe procedure for living donors with GS and LT recipients. Between September 2011 and March 2015, 305 LDLT procedures using right lobe grafts were performed at Atasehir Memorial Hospital, Istanbul, Turkey. Nineteen of 305 LT candidates who had been diagnosed with GS were included in the current study. After a 12‐h overnight fast, total and indirect bilirubin levels of donors and recipients were measured. The median follow‐up after transplant was 16 months (range 3–36 months). The median age of donors was 25 (range 20–55 yr). Four donors (21%) were female, and 15 donors (89%) were male. The median age of donors was 51 (range 23–68 yr). Eleven recipients (57%) were female, and 8 (43%) were male. The median preoperative total bilirubin level of donors was 1.69 mg/dL (range 1.26–2.43 mg/dL) (normal range <1.2 mg/dL). The median total bilirubin level of donors on postoperative day 7 was 1.04 mg/dL (range 0.71–3.23 mg/dL). As our study has included a large number of donors with GS, it produced reliable evidence that right lobe hepatectomy is a safe procedure for living donors with GS and LT recipients.     

Impact of hepatic macrovesicular and microvesicular steatosis on the postoperative liver functions after right hepatectomy in living donors

Purpose

The aim of this study was to evaluate the impact of macrovesicular (MaS) and microvesicular steatosis (MiS) on postoperative liver function in living donors undergoing right hepatectomy.

Methods

We retrospectively reviewed the medical records of 450 living liver donors who underwent right hepatectomy between 2000 and 2009. First, we divided the donors into two groups according to the degree of MaS regardless of MiS: group MaS_5 (n = 250), donors with <5% MaS and group MaS_30 (n = 200), donors with 5% to 30% MaS. Second, we stratified donors according to the degree of MiS regardless of Mas: group MiS_5 (n = 163), donors with < 5% MiS, group MiS_30 (n = 287), and 5% - 30% MiS. We evaluated the peak values of total bilirubin (TB), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) until the thirtieth postoperative day (POD). Next, we assessed the relation between MaS or MiS and postoperative peak liver function tests using regression analysis.

Results

Peak values of postoperative AST (227 ± 77 vs 203 ± 67, respectively) and ALT (232 ± 85 vs. 198 ± 72, respectively) were significantly higher in the group MaS_30 than MaS_5. Similarly, the peak values of AST (225 ± 80 vs 194 ± 50, respectively) and ALT (228 ± 85 vs 186 ± 60, respectively) were significantly higher in the group MiS_30 than the group MiS_5. Regression models showed a significant modifying influence of MiS (P < 0.001) on postoperative peak ALT levels in addition to MaS (P < .036), suggesting have comparable influences of both MiS and MaS on hepatic injury.

Conclusion

Our results suggested that a mild degree of either MaS or MiS was associated with higher postoperative peak AST and ALT values. A regression analysis showed both MaS and MiS to display similar impacts on postoperative liver functions after living donor right hepatectomy.     

前列腺素E_1对肝切除术后肝脏保护作用的临床研究

目的 探讨肝切除术后前列腺素E_1(prostaglandin E_1,PGE_1)对肝脏的保护作用.方法 采用随机对照的方法将82例肝切除病例分为对照组(41例)和PGE_1治疗组(41例,即在对照组治疗的基础上加用PGE_1脂微球载体治疗),观察住院天数、术前后各项指标以及术后3 d内尿量和腹腔引流量的变化.结果 PGE_1治疗组患者较对照组的住院天数明显缩短,中位天数为22 d,明显少于对照组的26 d;术后丙氨酸转氨酶(ALT)、天门冬氨酸转氨酶(AST)、总胆红素(TBIL)、白蛋白(ALB)的恢复也较对照组显著,术后3 d内的尿量明显增多,腹腔引流量则显著减少.而凝血酶原时间(PT)未见明显改变.结论 PGE_1能有效改善肝切除术后肝功能,降低胆红素水平,并减少术后腹水的形成,缩短住院天数,而对凝血功能无明显影响,用于肝切除术后的保护是安全的.     

Comparison of Effects of Levobupivacaine and Ropivacaine Infiltration on Cutaneous Wound Healing in a Rat Model

ABSTRACT

Purpose: To compare the effects of fluid resuscitation with lactated Ringer's solution (LR) and saline-based 6% hydroxyethyl starch 130/0.4 (HES) on the inflammatory response and oxidative stress in the small intestine as well as on bacterial translocation to the liver. Methods: Sprague–Dawley rats were subjected to blood pressure-controlled hemorrhagic shock and then resuscitated with LR or HES. At 1, 3, 6, 12, and 24 hr after resuscitation, liver tissues were collected to count the bacterial colonies, and small intestines were harvested to analyze the levels of inflammatory (TNF-α and HO-1) and oxidative stress (MPO) mediators as well as the intestinal injury by immunohistochemistry, colorimetry and hematoxylin &; eosin staining, respectively. Results: The expression level of TNF-α in the LR group was stable from 1 to 6 hr but decreased at 12 hr and then abruptly increased at 24 hr. The expression level of TNF-α in the LR group was significantly lower than that in the HES group, especially during the first 12 hr post-fluid infusion. MPO activity decreased to its lowest level at 3 hr but increased from 6 to 12 hr, with no difference at 24 hr between the two groups. Although a decreasing tendency was observed from 6 hr, HO-1 expression levels remained higher in the LR group than in the HES group at 12 and 24 hr, particularly at 12 hr. During the initial 12 hr, the LR group exhibited significantly lower colony-forming units in the liver tissues than the HES group. Chiu's score in the intestine decreased regardless of which resuscitative fluids were used. Conclusions: During early resuscitation (within 12 hr), LR may be superior to HES in reducing intestinal injuries by suppressing inflammatory and oxidative mediators.     

Intraoperative colloid administration reduces postoperative nausea and vomiting and improves postoperative outcomes compared with crystalloid administration

The debate over colloid versus crystalloid as the best solution for intraoperative fluid resuscitation is not resolved. Published studies have shown that mortality is not related to the specific fluid used for resuscitation. In addition, the quality of postoperative recovery between colloid and crystalloid has not been well investigated. In a prospective, blinded fashion, we investigated the effects of colloid and crystalloid resuscitation on nausea and vomiting and on the postoperative patient recovery profile. Patients undergoing major elective noncardiac surgery were randomized to receive 6% hetastarch in saline (HS-NS), 6% hetastarch in balanced salt (HS-BS), or lactated Ringer's solution (LR) on the basis of a fluid administration algorithm. The anesthetic was standardized. Hemodynamic targets included maintenance of arterial blood pressure, heart rate, and urine output within a predefined range. A postoperative morbidity survey was performed at baseline and daily after surgery. Ninety patients participated in the study, with 30 patients in each group. The amounts of study fluid (mean +/- SD) administered were 1301 +/- 1079 mL, 1448 +/- 759 mL, and 5946 +/- 1909 mL for the HS-NS, HS-BS, and LR groups, respectively (P < 0.05, HS-NS and HS-BS versus LR). Both the HS-NS and HS-BS (colloid) groups had a significantly less frequent incidence of nausea and vomiting, use of rescue antiemetics, severe pain, periorbital edema, and double vision. We concluded that intraoperative fluid resuscitation with colloid, when compared with crystalloid administration, is associated with an improvement in the quality of postoperative recovery.     

Outcome of donors with a remnant liver volume of less than 35% after right hepatectomy.

To overcome the barrier of size match, right lobe graft has been widely used in living donor liver transplantation (LDLT). We assessed donor outcome, with a focus on remnant liver volume (RLV) after right hepatectomy based on the experiences of 2 LDLT centers, as a means of guiding the establishment of safe RLV limits for donor right hepatectomy. Between January 2002 and December 2003, a consecutive 146 liver donors who underwent right hepatectomy with at least 12 months of follow-up were enrolled in this study. Donors were grouped into 2 groups according to RLV: group 1 (n = 74), <35% (range, 26.9-34.9) and group 2 (n = 72), > or = 35% (35.0-46.8). No donors died or suffered a life-threatening complication. Mean peak serum postoperative aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (IU/L) levels were 219.5 +/- 79.9 and 231.5 +/- 83.3 in group 1 and 210.3 +/- 81.6 and 225.8 +/- 93.0 in group 2 (P = 0.497 and 0.699), respectively. Mean peak serum total bilirubin (TB) (mg/dL) level in group 1 (3.4 +/- 1.6) was higher than in group 2 (2.8 +/- 1.4; P = 0.023). Overall 23 (15.8%) major morbidities, 10 in group 1 (13.5%) and 13 in group 2 (18.1%), occurred according to Clavien's system (P = 0.939). These included bleeding (n = 3 in group 1 and n = 6 in group 2; P = 0.282), ileus (n = 3 and 1; P = 0.324), biliary leakage (n = 4 and 4; P = 0.968), and pneumonia (n = 0 and 2; P = 0.149). Minor morbidities were also comparable in the 2 groups. In conclusion, the outcome of donors with an RLV of <35% was not different from that of donors with an RLV of > or = 35%, with the exception of transient cholestasis. Therefore, a remnant RLV of <35% does not appear to be a contraindication for right liver procurement in living donors.     

Hepatic and pulmonary apoptosis after hemorrhagic shock in swine can be reduced through modifications of conventional Ringer's solution

BACKGROUND: Cytotoxic properties of racemic (D-,L-isomers) lactated Ringer's solution detected in vitro and in small animal experiments, have not been confirmed in large animal models. Our hypothesis was that in a clinically relevant large animal model of hemorrhage, resuscitation with racemic lactated Ringer's solution would induce cellular apoptosis, which can be attenuated by elimination of d-lactate. METHODS: Yorkshire swine (n = 49, weight 40-58 kg) were subjected to uncontrolled (iliac arterial and venous injuries) and controlled hemorrhage, totaling 40% of estimated blood volume. They were randomized (n = 7/group) to control groups, which consisted of (1) no hemorrhage (NH), (2) no resuscitation (NR), or resuscitation groups, which consisted of (3) 0.9% saline (NS), (4) racemic lactated Ringer's (DL-LR), (5) L-isomer lactated Ringer's (L-LR), (6) Ketone Ringer's (KR), (7) 6% hetastarch in 0.9% saline (Hespan). KR was identical to LR except for equimolar substitution of lactate with beta-hydroxybutyrate. Resuscitation was performed in three phases, simulating (1) prehospital, (2) operative, (3) postoperative/recovery periods. Arterial blood gasses, circulating cytokines (TNF-alpha, IL-1, -6, -10), and markers of organ injury were serially measured. Metabolic activity of brain, and liver, was measured with microdialysis. Four hours postinjury, organs were harvested for Western blotting, ELISA, TUNEL assay, and immunohistochemistry. RESULTS: All resuscitation strategies restored blood pressure, but clearance of lactic acidosis was impeded following DL-LR resuscitation. Metabolic activity decreased during shock and improved with resuscitation, without any significant inter-group differences. Levels of cytokines in circulation were similar, but tissue levels of TNF in liver and lung increased six- and threefolds (p < 0.05) in NR group. In liver, all resuscitation strategies significantly decreased TNF levels compared with the NR group, but in the lung resuscitation with lactated Ringer (DL and L isomers) failed to decrease tissue TNF levels. DL-LR resuscitation also increased apoptosis (p < 0.05) in liver and lung, which was not seen after resuscitation with other solutions. CONCLUSIONS: In this large animal model of hemorrhagic shock, resuscitation with conventional (racemic) LR solution increased apoptotic cell death in liver and lung. This effect can be prevented by simple elimination of D-lactate from the Ringer's solution.