Predicting hepatic failure with a new diagnostic technique by preoperative liver scintigraphy and computed tomography: a pilot study in 123 patients undergoing liver resection

Background

A novel index, total liver LU15, has been identified as a surrogate marker for liver function. We evaluated the ability of preoperative remnant liver LU15 values to predict postoperative hepatic failure.

Methods

Preoperative risk factors for postoperative hepatic failure and remnant liver LU15 were evaluated in 123 patients undergoing liver resection for several diseases from September 1st, 2007 to December 1st, 2016. We calculated the remnant liver LU15 value from the total liver LU15 value and the functional remnant liver ratio. Risk factors for postoperative hepatic failure was determined by univariate and multivariate analysis.

Results

Hepatic failure grade B/C developed postoperatively in six patients of seven patients within Makuuchi criteria / without criteria for remnant liver LU15. Operative time (p?=?0.0242) and criteria for remnant liver LU15 (p?=?0.0001) were prognostic factors for hepatic failure according to the univariate analysis. And criteria for remnant liver LU15 (p?=?0.0009) was only prognostic factor by multivariate analysis.

Conclusion

Based on the findings form this pilot study, it appears that patients with a remnant liver LU15 value of 13 or less may have a high risk of postoperative hepatic failure.

     

Portal Vein Embolization Reduces Postoperative Hepatic Insufficiency Associated with Postchemotherapy Hepatic Atrophy

Background

The risk of postoperative hepatic insufficiency (PHI) is increased among patients with significant postchemotherapy hepatic atrophy. The primary aim of this study was to evaluate whether the liver regeneration stimulated by portal vein embolization (PVE) can protect against PHI.

Methods

Clinicopathological features of 177 patients treated with preoperative chemotherapy followed by PVE and hepatectomy were reviewed. Degree of atrophy was defined as the ratio of percentage difference in total liver volume (estimated by manual volumetry) to standardized liver volume. Kinetic growth rate (KGR, degree of hypertrophy [absolute % change in future liver remnant volume] divided by the number of weeks after PVE) and PHI events were compared between patients with degree of atrophy <10 vs ≥10%. Risk factors for the PHI were assessed using logistic regression.

Results

Seventy patients (40%) experienced significant hepatic atrophy ≥10% following preoperative chemotherapy. PHI rates were not significantly increased in patients who experienced significant hepatic atrophy (5.6 vs 8.6%, P = 0.443). KGR <2%/week (odds ratio, 8.10, P = 0.037) was the sole independent preoperative predictor of PHI. KGR ≥2% was associated with decreased PHI in both patients with <10% atrophy (0 vs 9.5%, P = 0.035) and ≥10% atrophy (2.6 vs 16.0%, P = 0.044).

Conclusions

Even in high-risk patients with ≥10% degree of atrophy from preoperative chemotherapy, KGR ≥2% mitigates the deleterious effects of hepatic atrophy and significantly reduces PHI to almost zero. In these high-risk patients, PVE with KGR calculation remains the most important preoperative technique to reduce liver failure after major hepatectomy.

     

Monitoring of liver function in a 73-year old patient undergoing ‘Associating Liver Partition and Portal vein ligation for Staged hepatectomy’: case report applying the novel liver maximum function capacity test

Background

The two-stage liver resection combining in situ liver transection with portal vein ligation, also referred to as ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy), has been described as a promising method to increase the resectability of liver tumors. However, one of the most important issues regarding the safety of this procedure is the optimal timing of the second stage at the point of sufficient hypertrophy of the future liver remnant. The recently developed liver maximum function capacity test (LiMAx) can be applied to monitor the liver function postoperatively and hence could be a useful tool for decision-making regarding the timing of the second stage of ALPPS.

Case presentation

A 73-year-old female patient presented with metachronous colorectal liver metastasis comprising the complete right liver lobe as well as segment IV. Due to an insufficient future liver remnant (19.3 %; segments II and III of the liver) and a low future liver remnant:body weight ratio (0.28 %) the decision was made to perform an ALPPS-procedure in order to avoid development of postoperative small-for-size syndrome. Despite a formally sufficient increase of the FLR to 30.8 % within 7 days after the first step of ALPPS, the liver function was seen to only slowly increase as expressed by a LiMAx value of 245 μg/h/kg (baseline of 282 μg/h/kg prior to surgery). By means of the LiMAx test, sufficient increase of liver function eventually was detected by postoperative day 11 (LiMAx value of 371 μg/h/kg; FLR 35.2 %) so that the second step of ALPPS (completion of hepatectomy) was performed with no signs of liver failure during further clinical course.

Conclusion

Performing ALPPS we have observed a significant difference between the increase in future liver remnant volume and function applying the LiMAx test. The latter tool thus might proof valuable for application in two-stage liver resection to avoid postoperative small-for-size syndrome.

     

Rapid Liver Hypertrophy After Portal Vein Occlusion Correlates with the Degree of Collateralization Between Lobes—a Study in Pigs

Background

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) induces more rapid liver growth than portal vein ligation (PVL). Transection of parenchyma in ALPPS may prevent the formation of collaterals between lobes. The aim of this study was to determine if abrogating the formation of collaterals through parenchymal transection impacted growth rate.

Methods

Twelve Yorkshire Landrace pigs were randomized to undergo ALPPS, PVL, or “partial ALPPS” by varying degrees of parenchymal transection. Hepatic volume was measured after 7 days. Portal blood flow and pressure were measured. Portal vein collaterals were examined from epoxy casts.

Results

PVL, ALPPS, and partial ALPPS led to volume increases of the RLL by 15.5% (range 3–22), 64% (range 45–76), and 32% (range 18–77), respectively, with significant differences between PVL and ALPPS/partial ALPPS (p < 0.05). In PVL and partial ALPPS, substantial new portal vein collaterals were found. The number of collaterals correlated inversely with the growth rate (p = 0.039). Portal vein pressure was elevated in all models after ligation suggesting hyperflow to the portal vein-supplied lobe (p < 0.05).

Conclusions

These data suggest that liver hypertrophy following PVL is inversely proportional to the development of collaterals. Hypertrophy after ALPPS is likely more rapid due to reduction of collaterals through transection.

     

A Nomogram to Predict Hypertrophy of Liver Segments 2 and 3 After Right Portal Vein Embolization

Background

Portal vein embolization (PVE) reduces the risks of hepatic insufficiency after major hepatectomy for small predicted liver remnant. The extent of liver hypertrophy after PVE depends on various clinical factors. We sought to develop a nomogram for predicting the increase in the volume of segments 2 and 3 after right PVE (RPVE).

Method

In 360 patients who underwent RPVE from 1998 through 2013, clinicopathologic data were analyzed, including body mass index (BMI), diabetes, aspirin use, viral hepatitis status, preoperative albumin level, total bilirubin level, prothrombin time, platelet count, type of liver neoplasm, preoperative chemotherapy, previous laparotomy or hepatectomy, segment 4 embolization, two-stage hepatectomy, and liver volumes before and after PVE. Multivariate linear regression analysis was used to identify variables predicting the degree of hypertrophy of segments 2 and 3.

Results

Multivariate regression analysis revealed that BMI (p?=?0.002), previous hepatectomy (p?=?0.03), RPVE in the setting of two-stage hepatectomy (p?<?0.001), and segment 4 embolization (p?=?0.003) independently predicted the degree of hypertrophy of segments 2 and 3. Based on the fitted model, a nomogram was constructed.

Conclusion

The constructed nomogram predicts the degree of hypertrophy of segments 2 and 3 after RPVE and can be used in clinical decision making for patients undergoing right hepatectomy.

     

ALPPS for Hepatocellular Carcinoma Is Associated with Decreased Liver Remnant Growth

Background

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been widely described for colorectal liver metastases with insufficient future liver remnant (FLR). However, its role in hepatocellular carcinoma (HCC) remains poorly defined and not widely accepted.

Methods

A retrospective comparison of clinical data, liver volumetry, histological characteristics, and surgical outcomes between nine HCC and four non-HCC patients who underwent ALPPS was performed.

Results

Patients with HCC were more likely to have histological evidence of hepatic fibrosis (HCC vs. non-HCC, 66.7 vs. 0%, p?=?0.049). Baseline demographic and disease characteristics were otherwise comparable between both groups. FLR growth after ALPPS-Stage 1 was significantly less in HCC patients (HCC vs. non-HCC, 154.5 vs. 251.0 ml, p?=?0.012). FLR growth was also significantly decreased in patients with hepatic fibrosis (fibrosis vs. non-fibrosis, 157.5 vs. 247.5 ml, p?=?0.033). There was no difference in post-hepatectomy liver failure (HCC vs. non-HCC, 28.6 vs. 25%, p?=?0.721) or 90-day mortality (HCC vs. non-HCC, 11.1 vs. 0%, p?=?NS).

Discussion

In our study, HCC patients demonstrated significantly less FLR growth after ALPPS-Stage 1 compared to non-HCC patients. Hepatic fibrosis was also found to negatively impact FLR growth. When considering suitability for ALPPS, patients with HCC may benefit from additional pre-operative assessment of fibrosis.

     

Biological Substrate of the Rapid Volumetric Changes Observed in the Human Liver During the Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy Approach

Background

The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) strategy induces rapid future liver remnant (FLR) hypertrophy. Hepatocyte cellular and molecular changes associated with liver hypertrophy during ALPPS remain ill-defined in humans.

Methods

Patients undergoing the ALPPS approach between June 2011 and October 2014 were extracted. Biopsies from the FLR were obtained during the first and second stages. Hematoxylin–eosin staining and immunohistochemical analysis for expression of the proliferating cell nuclear antigen (PCNA) and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) were performed. The proliferative index was defined as: PCNA–TUNEL ratio.

Results

Eleven of 34 patients treated were studied during both stages. Median FLR hypertrophy was 104 % in 6 days, with a mean difference between preoperative and postoperative volume of 361 ml (P?<?0.001). The mean hepatocyte number increased from 52.7 cells/mm² in the first stage to 89.6 cells/mm² in the second stage (P?=?0.001). PCNA expression increased by 190 % between stages with a linear correlation (r?=?0.58) with macroscopic hypertrophy. The proliferative index increased from ?3.78 cells/mm² in first stage to 2.32 cells/mm² in the second stage (P?=?0.034).

Conclusions

The results of the present study indicate that the rapid FLR volumetric increase observed in ALPPS is accompanied by histological and molecular features of hepatocyte cell proliferation.

     

Posthepatectomy Liver Failure Affects Long-Term Function After Resection for Hepatocellular Carcinoma

Background

This study examined whether the severity of posthepatectomy liver failure (PLF) affected the long-term postoperative liver recovery of patients with hepatocellular carcinoma (HCC).

Methods

We performed a retrospective cohort study of 395 HCC patients who underwent hepatectomy from 2004 to 2012 at the Kyoto University Hospital. The severity of PLF between postoperative days 5 and 10 was categorized according to the International Study Group of Liver Surgery criteria. We compared the Child-Pugh (C-P) score, platelet count (PLT), and the ratio of future remnant liver volume (FRLV) to the total liver volume (%RLV) at 3, 6, and 12 months after hepatectomy in the non-PLF, grade A, and grade B groups.

Results

The non-PLF, grade A, and grade B groups contained 272, 63, and 56 patients, respectively. The C-P score in the grade A group recovered from 5.37 points before hepatectomy to 5.38 points at 12 months after hepatectomy. The C-P score in the grade B group increased from 5.51 to 6.81 points at 3 months and was significantly higher (6.00 points) at 12 months than in the non-PLF group (5.47 points). The PLT significantly decreased at 12 months in the grade B group compared with the non-PLF group. The %RLV at 12 months in the non-PLF, grade A, and grade B groups were 84, 83, and 78 %, respectively. The remnant liver hypertrophy in the grade B group was significantly slower than that in the non-PLF group.

Conclusions

PLF severity affects long-term liver function recovery and remnant liver hypertrophy after hepatectomy.

     

Surgical Strategy Based on Indocyanine Green Test for Chemotherapy-Associated Liver Injury and Long-Term Outcome in Colorectal Liver Metastases

Background

It remains unclear whether the presence of chemotherapy-induced liver injury (CALI) or impaired liver functional reserve affects the long-term outcome. This study assessed the applicability and long-term effects of using criteria based on the indocyanine green (ICG) test results in selecting the operative procedure among patients with colorectal liver metastases (CRLM) who had a risk of CALI.

Study Design

CRLM patients who received preoperative chemotherapy including oxaliplatin and/or irinotecan prior to a curative hepatectomy between 2007 and 2017 were included. For each case, the minimum required future remnant liver volume and operative procedure were decided based on the ICG retention rate at 15 min (ICG R15). Patients with an ICG R15 >?10% and who had undergone a major hepatectomy were categorized in a marginal liver functional reserve (MHML) group.

Results

Overall, 161 patients were included; 77 of them had an ICG R15 >?10%, and 57 had pathological liver injury (PLI). After the median follow-up time of 30.9 months, the 5-year overall survival rate was 36.1%. The presence of an impaired ICG test result or CALI did not negatively impact the overall and recurrence-free survival outcomes. A multivariate analysis revealed that the presence of four or more nodules of liver metastases was the only independent predictor of a poor overall survival. A significantly larger proportion of patients in the MHML group (n?=?37) had a 25% or larger increase in splenic volume (30 vs. 13%; P?=?0.024).

Conclusion

The presence of an impaired ICG test result or PLI did not affect the long-term outcome after individually selected operative procedure. However, patients undergoing MHML had a higher possibility of developing a >?25% splenic volume increase after hepatectomy.

     

Hepatic Hemodynamic Changes Following Stepwise Liver Resection

Aim

Extended liver resection has increased during the last decades. However, hepatic hemodynamic changes after resection and the consequent complications like post hepatectomy liver failure are still a challenging issue. The aim of this study was to systematically evaluate the role of stepwise liver resection on hepatic hemodynamic changes.

Methods

To evaluate this effect we performed 25, 50, and 75 % sequential liver resections in 10 pigs. Before and after each resection, the hepatic artery flow and portal vein flow in relation to the remnant liver volume (RLV) as well as hepatic vascular pressures were measured and compared between the groups.

Results

Following sequential liver resection, the hepatic artery flow /100 g decreases and the portal vein flow increases up to 17 and 167 % following extended liver resection (75 %), respectively. Also, during stepwise liver resection, the portal vein pressure increases gradually up to 33 % following extended hepatectomy (75 %).

Conclusion

Sequential decrease in the RLV decreases the hepatic artery flow /100 g and increases the portal vein flow /100 g and portal vein pressure. As the consequence, the liver goes under more poor-oxygenated blood supply and higher pressure. This may be one of the most important mechanisms of the post hepatectomy liver failure in case of extended liver resection.

     

Elevation of the serum liver enzyme levels during tolvaptan treatment in patients with autosomal dominant polycystic kidney disease (ADPKD)

Background

In 2014, tolvaptan, a vasopressin receptor antagonist, was approved for the treatment of autosomal dominant polycystic kidney disease (ADPKD) in Japan. Clinical trials of tolvaptan revealed frequent occurrence of the liver function abnormality. According to the package insert in Japan, liver function tests should be performed once a month in patients receiving tolvaptan. Furthermore, immediate discontinuation of tolvaptan is recommended in the appearance of liver function abnormalities.

Methods

Seven patients of ADPKD who was discontinued tolvaptan because of elevation of the serum liver enzyme levels were described in detail and analyzed.

Results

None of them fulfilled the criteria for applicability of Hy’s law, which predicts a high risk of severe, potentially fatal, drug-induced liver injury (DILI). In our patients, the rate of increase of total kidney volume (TKV) significantly decreased during tolvaptan administration, but increased after discontinuation; in Cases 1–5, mean annual growth rate of TKV during administration was ??10.15%/year, and during discontinuation was +?23.72%/year. After the serum liver enzyme levels returned to normal range, tolvaptan was resumed in six patients with informed consent. Except one patient, tolvaptan has been continued without increase of the serum liver enzyme levels.

Conclusion

In patients with mild elevation of the serum liver enzyme, as is less than three times the upper limit of normal (ULN), resumption of tolvaptan may be considered after the serum liver enzyme levels return to normal range.

     

A novel surgical technique to prevent pancreatic fistula in distal pancreatectomy using a patch of the falciform ligament

Purpose

Pancreatic fistula (PF) is a serious complication of pancreatectomy and many techniques and devices have been designed to prevent PF and abdominal bleeding after pancreatectomy. We report a modified technique using a patch of the falciform ligament to prevent PF formation after distal pancreatectomy (DP).

Method

On completion of DP, the main pancreatic duct is sutured. The remnant pancreas is then closely patched and sutured vertically to the falciform ligament using 3-0 polypropylene suture. We compared the results of this method (group 1) with those of the simple method of covering the remnant pancreas with the falciform ligament (group 2).

Results

We performed this method in 14 patients undergoing DP. The rate of grade B or C PF in group 1 (7.1 %) was lower than that in group 2 (46 %).

Conclusion

This is a simple and effective method of preventing PF fistula in DP.

     

Simultaneous resection for colorectal cancer and synchronous liver metastases

Purposes

The correct timing of hepatectomy in patients with synchronous colorectal liver metastases is unclear. The aim of this study was to assess the clinical value of simultaneous resection (SR) for patients with colorectal cancer and synchronous liver metastases.

Methods

Between January 2006 and December 2013, 158 patients underwent resection of primary colorectal cancer and liver metastases. Sixty-three patients possessed synchronous colorectal liver metastases. Of those with synchronous colorectal liver metastases, 41 patients (65 %) underwent SR, and 22 (35 %) underwent delayed resection (DR). The clinicopathologic and operative data and the surgical outcomes of the patients in the SR and DR groups were retrospectively analyzed.

Results

The type of primary/liver resection, liver resection time, total blood loss volume, R0 resection rate, and morbidity rate were similar between the two groups. The SR group was associated with a shorter total postoperative hospital stay (21 vs 32 days, p < 0.001). However, the overall survival rate was similar between the two groups (3-year survival, 65.6 % in the SR group versus 66.8 % in the DR group, p = 0.054).

Conclusion

Simultaneous resection of colorectal cancer and synchronous liver metastases is associated with a comparable morbidity rate and shorter hospital stay, even when following rectal resection and major hepatectomy.

     

Phase I clinical trial of olprinone in liver surgery

Purpose

Post-hepatectomy liver failure is one of the most serious complications liver surgeons must overcome. We previously examined olprinone, a selective phosphodiesterase III inhibitor, and demonstrated its hepatoprotective effects in rats and pigs. We herein report the results of a phase I clinical trial of olprinone in liver surgery (UMIN000004975).

Methods

Twenty-three patients who underwent hepatectomy between 2011 and 2015 were prospectively registered. In the first 6 cases, olprinone (0.1 μg/kg/min) was administered for 24 h from the start of surgery. In the remaining 17 cases, olprinone (0.05 μg/kg/min) was administered from the start of surgery until just before the transection of the liver parenchyma. The primary endpoint was safety, and the secondary endpoint was efficacy. For the evaluation of efficacy, the incidence of post-hepatectomy liver failure in 20 hepatocellular carcinoma patients was externally compared with 20 propensity score-matched patients.

Results

No intraoperative side effects were observed, and the morbidity rates in the analyzed cohorts were acceptable. The rate of post-hepatectomy liver failure frequency tended to be lower in the olprinone group.

Conclusions

The safety of olprinone in liver surgery was confirmed. The efficacy of olprinone will be re-evaluated in clinical trials.

     

The liver hanging maneuver in laparoscopic liver resection: a systematic review

Purpose

Laparoscopic surgery has gained the acceptance of the hepatobiliary surgical community and expert teams are now advocating major laparoscopic liver resections (LLRs). In this setting, the liver hanging maneuver (LHM) has been described in numerous series. We conducted a systematic review to investigate the effectiveness of the LHM in LLR.

Methods

We performed an electronic literature search using PubMed, EMBASE, and COCHRANE databases. The final search was carried out in December, 2015.

Results

We found 11 articles describing a collective total of 104 surgical procedures that were eligible for this study. Laparoscopic LHM was used in LLR for both benign and malignant conditions, and also in living donor liver transplantation (LDLT). The LHM was used mainly in right hepatectomy and only two authors reproduced the original LHM. We investigated the intraoperative parameters, preservation of postoperative liver function, and oncological outcomes. The clear benefit of using the LHM in LLR is for better identification of the parenchymal transection plane with less blood loss. The other benefits of LHM could not be corroborated by solid data on its positive value.

Conclusions

In view of the data published in the literature, our findings are not strong enough to support the systematic use of LHM in LLR.

     

Classification of remnant stomach shape after distal gastrectomy with Billroth-I reconstruction and a comparison of the postoperative outcomes

Purpose

To classify the shape of the remnant stomach after Billroth-I (B-I) reconstruction and evaluate the relationship between the shape of the remnant stomach and the postoperative clinical outcomes.

Methods

One hundred and ninety-five consecutive patients with gastric cancer underwent distal gastrectomy with B-I reconstruction between May 2006 and October 2014. We retrospectively reviewed their medical records and radiological findings. Finally, the shapes of the remnant stomach of 150 patients were classified as either straight type (type A) or stagnant type (type B). The clinical outcomes were compared with respect to the types of remnant stomach.

Results

The incidence of anastomotic leakage was significantly higher in the type A group than in the type B group (9.4 vs. 1.5%, p?=?0.044). The body weight change ratio after surgery was significantly lower in the type B group than in the type A group [p?=?0.0068, two-way repeated measures analysis of variance (ANOVA)], while the serum albumin levels showed marginally significant improvement in the type B group compared with the type A group (p?=?0.0542, two-way repeated measures ANOVA).

Conclusion

The shape of the remnant stomach after distal gastrectomy with B-I reconstruction might influence the degree of anastomotic leakage and long-term nutritional status.

     

Regeneration of Liver Function Capacity After Partial Liver Resection is Impaired in Case of Postoperative Bile Leakage

Background

Postoperative bile leakage (PBL) is a major surgical complication after partial liver resection resulting in increased perioperative morbidity and mortality. Previous experimental studies have shown an adverse effect on functional liver regeneration, but there are still no data available concerning these effects in humans.

Materials and methods

A retrospective matched pair analysis was carried out comparing the postoperative course of 51 patients with PBL to 51 patients without PBL. The influence of PBL on actual liver function was determined by means of LiMAx, Indocyanine green plasma disappearance rate (ICG-PDR), and standard liver function tests.

Results

The analyzed groups were matched regarding demographic, preoperative, and operative data. Bilirubin, ICG-PDR and LiMAx showed delayed postoperative functional recovery after partial liver resection in the PBL group compared to the non-PBL group. LiMAx was the single parameter to assess differing liver regeneration continuously from the 3rd to 14th postoperative day between the groups. A subanalysis revealed an early recovery from impaired functional regeneration if the bile leakage was diagnosed until the 5th postoperative day (POD) or successfully treated until the 14th POD.

Conclusion

These are the first data evaluating the impact of PBL on functional regeneration after liver surgery. Liver regeneration after partial liver resection is impaired by PBL. However, a nearly normal recovery is possible if the bile leak is diagnosed early and immediately treated. Moreover, patients presenting with delayed functional recovery in the postoperative course are likely to have complications, e.g., bile leakage.

     

Dynamic Change of Total Bilirubin after Portal Vein Embolization is Predictive of Major Complications and Posthepatectomy Mortality in Patients with Hilar Cholangiocarcinoma

Objectives

This study aims to evaluate the role of dynamic change in total bilirubin after portal vein embolization (PVE) in predicting major complications and 30-day mortality in patients with hilar cholangiocarcinoma (HCCA).

Methods

Retrospective analysis of prospectively maintained data of 64 HCCA patients who underwent PVE before hepatectomy in our institution was used. Total bilirubin and other parameters were measured daily in peri-PVE period. The difference between them and the baseline value from days 0–5 to day ?1 (?D₁) and days 5–14 to day ?1 (?D₂) were calculated. The relationship between ?D₁ and ?D₂ of total bilirubin and major complications as well as 30-day mortality was analyzed.

Results

Out of 64 patients, 10 developed major complications (15.6 %) and 6 patients (9.3 %) had died within 30 days after surgery. The ?D₂ of total bilirubin after PVE was most significantly associated with major complications (P?<?0.001) and 30-day mortality (P?=?0.002). In addition, it was found to be an independent predictor of major complications after PVE (odds ratio (OR)?=?1.050; 95 % CI 1.017–1.084). ASA >3 (OR?=?12.048; 95 % CI 1.019–143.321), ?D₂ of total bilirubin (OR?=?1.058; 95 % CI 1.007–1.112), and ?D₂ of prealbumin (OR?=?0.975; 95 % CI 0.952–0.999) were associated with higher risk of 30-day mortality after PVE. Receiver operating characteristic curves showed that ?D₂ of total bilirubin were better predictors than ?D₁ for major complications (AUC (?D₂) 0.817; P?=?0.002 vs. AUC (?D₁) 0.769; P?=?0.007) and 30-day mortality (ACU(?D₂) 0.868; P?=?0.003 vs. AUC(?D₁) 0.721;P?=?0.076).

Conclusion

Patients with increased total bilirubin in 5–14 days after PVE may indicate a higher risk of major complications and 30-day mortality if the major hepatectomy were performed.

     

Umbilical paracentesis for incarcerated umbilical hernia in patients with end-stage liver disease

Purpose

Patients with cirrhosis and ascites are prone to abdominal wall complications largely predominate by umbilical hernia. Elective surgery is indicated in select patients but a high morbidity and mortality rate occurs if it is performed in emergency conditions.

Methods

We present a clinical case of a patient with advanced alcoholic liver disease who came to the emergency room for an acutely incarcerated umbilical hernia. Due to the high surgical risk, we had to discuss other treatment options.

Results

The use of umbilical paracentesis for incarcerated hernia reduction in cirrhotic patients with tense ascites is a safe and reproducible technique.

Conclusions

Umbilical paracentesis could be considered as an alternative to emergency surgery in these high-risk patients.

     

Early chest tube removal after thoracoscopic lobectomy with the aid of an additional thin tube: a prospective multi-institutional study

Objectives

There is no evidence concerning the appropriate drainage volume for indicating chest tube removal after pulmonary lobectomy. A prospective multi-institutional cohort study was designed to elucidate the safety of early chest tube removal after thoracoscopic lobectomy.

Methods

Between April 2009 and November 2011, 310 patients with suspected or histologically documented lung cancer were screened. Patients without air leakage or bloody, chylous, or purulent pleural effusion underwent chest tube removal on the day after thoracoscopic lobectomy, independent of the drainage volume. The subjects were classified into three groups as tertiles according to the drainage volume that was observed for approximately 24 h after surgery. The associations between the drainage volume and the development of complications were investigated, with several clinical factors taken into account.

Results

The 162 patients who were enrolled underwent early chest tube removal via this protocol and were classified into three groups according to their drainage volume (0–219 mL, n?=?52; 220–349 mL, n?=?56; and ≥?350 mL, n?=?54). A 7F backup tube placed within the dead space to prevent troubles was removed by postoperative day 4 in all patients because nothing happened. Univariate and multivariate analyses showed that the drainage volume was not associated with the risk of complications.

Conclusions

Early removal of the chest tube on the day after thoracoscopic lobectomy appears to be a safe treatment protocol in patients without air leakage or bloody, chylous, or purulent pleural effusion; however, careful surveillance is needed for patients who have a drainage volume of ≥?350 mL/day.

Clinical registration number

University Hospital Medical Information Network Clinical Trials Registry, 000028971 (Japan).