Major hepatic resection under total vascular exclusion.

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

Variations on a theme: splitting ratio

An expression for the splitting ratio (bypass gas/gas through vaporizing compartment) is derived formally. The factors affecting volatile agent gaseous fraction and, more importantly, partial pressure are discussed in relation to changes in temperature and barometric pressure. Low-boiling point, high saturated vapour pressure anaesthetics are more susceptible to the influence of barometric pressure variations.     

Aortic occlusion and vascular isolation allowing avascular hepatic resection

Occlusion of the supraceliac abdominal aorta and hepatic vascular isolation were employed in a series of 15 patients as a definitive method to allow avascular hepatic resection. The series was compared with an earlier group of patients treated conventionally. In the avascular hepatic resection group there was no mortality; hypotension did not occur at the time of hepatic vascular isolation; rapid, accurate excision of the hepatic lesions could be achieved in a bloodless field; resection of midline lesions and those involving the great veins was possible; and "segmentectomies," or resections crossing segmental boundaries, could be performed where previously formal hepatic lobectomies were required. Concomitantly, the greatest amount of uninvolved hepatic parenchyma remained in situ. There was increased ease of operative management, reduced blood loss, and reduced operating time (mean, 2.8 hours).     

Variations on the theme of postoperative intracranial hemorrhage

Summary Five unusual cases of postoperative intracranial hemorrhage are reported. In three the bleeding occurred within the subdural space, symptoms appearing within the immediate postoperative period in one case and after an interval of several weeks in the other two. In the remaining two cases the hemorrhage was epidural in location, contralateral to the site of the primary lesion in one and bifrontal in the other; the bleeding in both cases was probably related to a rapid reduction of intracranial pressure.

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Zusammenfassung Es wird über 5 ungewöhnliche Fälle mit postoperativen intrakraniellen Blutungen berichtet. Bei 3 Fällen kam es zur Blutung in den Subduralraum. Dabei traten die Symptome bei einem Fall in der ersten postoperativen Zeit auf, während sie bei den beiden anderen nach einem Intervall von mehreren Wochen in Erscheinung traten. Die übrigen beiden Fälle hatten epidurale Nachblutungen, in einem Fall kontralateral zur Seite der primären Läsion, im anderen frontal gelegen. In diesen beiden Fällen wurde die Blutung wahrscheinlich durch eine rasche Senkung des intrakraniellen Drucks verursacht.

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Resumen Se describen 5 casos de hemorragias intracraneales postoperatorias. En 3 de los casos la hemorragia se produjo en el interior del espacio subdural; los síntomas se manifestaron en un caso inmediatamente después de la intervención y en los otros dos casos después de varias semanas. Por último en los dos casos restantes la hemorragia estaba localizada en la porción epidural contralateral a la lesión primaria en un caso y bifrontal en el otro. La hemorragia en estos dos útimos casos fué debida probablemente a una rápida bajada de la presión intracraneal.

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Résumé 5 cas exceptionnels d'hémorragies intra-craniennes postopératoires sont décrits.Dans 3 des cas, l'hémorragie s'est produite à l'intérieur de l'espace subdural; les symptômes se sont manifestés, dans un cas, immédiatement après l'intervention; dans deux autres cas, seulement après plusieurs semaines. Enfin, dans les deux cas restants, l'hémorragie était localisée dans la partie épidurale, contralatérale par rapport à la lésion primaire dans un cas, bifrontale dans l'autre. L'hémorragie, dans ces deux cas, était probablement dûe à une rapide baisse de la pression intra-cranienne.

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Riassunto L'A. riferisce su 5 casi di emorragie endocraniche postoperatorie. In tre di essi il sanguinamento si verificò nello spazio subdurale, con comparsa dei sintomi in un caso nel periodo immediatamente seguente all'intervento e negli altri due dopo un intervallo di alcune settimane.Nei rimanenti due casi l'emorragia si ebbe in sede epidurale, dal lato opposto a quello della lesione primaria, in uno dei due casi, e bifrontalmente nell'altro; in entrambi questi casi il sanguinamento era probabilmente in correlazione con una rapida riduzione della pressione endocranica.

     

Cavo-atrial tumor resection under total circulatory arrest without a sternotomy

Surgical management of intracardiac tumors arising in the inferior vena cava often requires total circulatory arrest for safe and adequate resection. Total circulatory arrest has traditionally been accomplished by accessing the great vessels through a sternotomy. Combination of a sternotomy and a large abdominal incision results in excellent exposure but also creates the potential for significant morbidity. We report here the resection of cavoatrial tumors by achieving total circulatory arrest through femoral arterial and venous cannulation without requiring a sternotomy. This minimal-access total circulatory approach has the potential to greatly diminish morbidity when managing tumors of the inferior vena cava.     

Liver resection for hepatic adenoma.

Between 1970 and 1978, eight hepatic adenomas were resected. Four of the eight patients took oral contraceptive pills before the hepatic adenoma was identified; one patient was male. Four patients had evidence of bleeding at the time of presentation. The original histologic diagnosis in the first five patients was malignant hepatoma. There has been no known recurrence of tumor and all patients are well. The use of oral contraceptives in these patients has been prohibited. Formal anatomic resection is recommended for hepatic adenoma when this procedure can be done without mortality or serious morbidity; however, in the future, less drastic treatments, such as occlusion of the hepatic arterial circulation to the tumor or discontinuation of oral contraceptives, may prove as effective as tumor resection.     

Liver resection and laser hyperthermia.

Table 2 provides a comparison of these interstitial and in situ techniques, assessing several criteria and utilizing and expanding on an excellent review by Masters et al. The rapid advance of technology and cross-fertilization between groups using different interstitial techniques will lead to a clear understanding of the benefits and limits of each. However, there is essentially no information at the present time to suggest that these techniques should be used in lieu of hepatic resection in an attempt to cure patients who are good operative risks. There are insufficient data of a controlled nature to determine that there has been a survival or palliative benefit in many of the patients so treated. Nevertheless, as it is clear that these treatments cause tissue destruction in an appropriate nonmorbid way and that they are well tolerated with low risk to the patients, it is entirely conceivable that interstitial techniques will replace hepatic resection in some instances in the future, particularly for lesions smaller than 3 cm.     

Liver resection. Preoperative and postoperative care

Liver resection is an increasingly common procedure. Despite a wide variety of indications, the preoperative and postoperative care required is similar. Experience with liver resection and transplantation has brought to light the significant alterations in fluid and electrolytes, hemostasis, metabolism, and pulmonary function that may result. A thorough understanding of these changes is required to minimize the morbidity and mortality rates of these procedures. Postoperative hepatic failure is a devastating complication, and careful patient selection is required to avoid this. More work is needed to identify better methods of evaluating functional hepatic reserve.     

Liver resection: a regional hospital experience

Background: Liver resection is a significant operation usually limited to large metropolitan hospitals. Liver resections were first performed at the Launceston General Hospital (LGH), a regional centre (bed capacity 280), in May 2000. This is a summary of liver resection at LGH. Methods: Data of liver resections performed between May 2000 and March 2008 at LGH were collected retro‐prospectively and reviewed with attention to patient survival, post‐operative complications and mortality. Results: There were 102 consecutive liver resections during the study period. Metastatic colorectal adenocarcinoma was the most frequent pathology (n = 61). Six patients had metastases from primaries other than colorectal cancer. There were 13 resections for primary liver malignancy, 2 from invasion by gallbladder carcinoma, 1 for contiguous invasion by gastric cancer and 19 were for benign conditions. Thirteen patients had post‐operative wound infections and six had significant bile leaks. There were five deaths in‐hospital (surgical mortality 4.9%). At the end of the study period, 51 cancer patients were still alive (14 with disease recurrences) and 30 have died (23 from recurrent diseases). Patients operated for colorectal cancer metastases achieved a 44% 5‐year survival rate (median survival = 46 months). Patients with hepatocellular carcinoma had 3‐year survival rate of 15% (median survival = 24 months). Conclusion: Resection provides the best hope of cure for patients with primary or secondary hepatic malignancy. With adequate expertise, liver resections can be performed safely in a regional hospital.     

Mechanical vascular division in lung resection.

BACKGROUND: There is little information available regarding the relative advantage of stapling over ligation for major pulmonary vessels in lung resection. The thin and fragile structure of pulmonary vascular walls for their large luminal size might have made surgeons reluctant to use staplers. This study was intended to demonstrate the feasibility of pulmonary vascular division by staplers. METHODS: A total of 842 mechanical vascular divisions were performed for pulmonary artery (PA, n=376), pulmonary vein (PV, n=462), and azygos vein (AV, n=4) in 603 consecutive pulmonary resections from 1997 to 1999 at the National Cancer Center Hospital, Tokyo. In this series, 99.8% of mechanical vascular divisions were performed with endostaplers (840 vessels), and only 0.2% was performed with conventional TA-type staplers (two vessels). The prevalence of problems related to mechanical stapling (stapling failure) and postoperative bleeding was studied retrospectively. RESULTS: There was only one incidence of stapling failure, in which the superior pulmonary vein was divided without the formation of staples (overall stapling failure rate, 0.1%). The bleeding was controlled by ligation of each divided stump during thoracotomy. There was no stapling failure for PAs or AVs. In no case did postoperative bleeding require rethoracotomy at the stapled line of the vessels. CONCLUSIONS: Although temporary oozing was sometimes seen along the staple line, vascular division with endostaplers was highly reliable with only a 0.1% incidence of stapling failure for all kinds of vascular structures in the thorax.     

Liver resection: prt II. Operative procedure]

Hepatic surgery has grown considerably in importance during the last two decades. Major roles in this development have been played by improvements in imaging diagnostics and intensive care and particularly advancements in general hepatic surgical techniques. We present the terminology of functional and segmental anatomy of the liver on which current hepatic surgery is based, along with operative strategies for standard, nonconventional, and repeat resections. Intraoperative complications are also discussed.