Subcapsular hematoma of the graft after liver transplantation

Subcapsular hematoma of the graft is an underreported complication of liver transplantation (LT). Among 408 LT performed from September 1, 1985, to September 1, 2000, eight patients developed a subcapsular hematoma within 30 days after LT (8/408 = 2.0%). Among the six early cases observed, five required further surgical approaches due to hematoma progression, rupture, and hemorrhage. One patient underwent liver retransplantation due to uncontrollable hepatic hemorrhage. The two more recent cases were successfully treated by early opening of the Glisson's capsule with hemostasis of the hepatic raw bleeding surface. The five patients who developed acute renal failure required dialysis. Three patients died during hospitalization. Among the survivors, two were discharged on the postoperative (PO) day 15; the others on PO day 37, 38, and 56. In conclusion, subcapsular hematoma of the graft is a potentially serious complication of LT that may produce severe hemorrhage, shock, and in extreme cases, graft loss or even death. The severity of the complication is related to the extension of the decapsulated area of the graft. An early surgical approach with intentional opening of the hematoma before progression of the lesion seems to facilitate hemostasis and improve results.     

Subcapsular hematoma after right-lobe living-donor liver transplantation

Because right-lobe living-donor liver transplantation was introduced in adult-to-adult liver transplantation to mitigate the problems of small-for-size grafts, some technical controversies have been reported. This report describes a case of graft subcapsular hematoma due to parenchymal injury. A 53-year-old woman underwent a right-lobe living-donor liver transplantation for acute-on-chronic liver failure due to primary biliary cirrhosis. A huge subcapsular hematoma was discovered by routine Doppler echogram examination on the first posttransplantation day. Relaparotomy findings revealed that rotation of the graft for the hemostasis procedure during the transplant operation had induced a compression injury to the graft by the xiphoid process. It was speculated that a small laceration in the graft parenchyma led to the major subcapsular hematoma. This experience suggests that the graft liver must be handled with special care to prevent potential mechanical injury.     

Large subcapsular liver hematoma following single-incision laparoscopic cholecystectomy

Background and Objectives:

Many laparoscopic surgeons are now transitioning from standard multiple-port laparoscopic cholecystectomy to single-incision laparoscopic surgery (SILS) in an attempt to improve cosmetic outcomes and decrease postoperative morbidity. However, little has been published regarding the potential complications of SILS operations.

Methods:

We report the case of a patient undergoing SILS cholecystectomy who developed the complication of a large hepatic hematoma, resulting in significant postoperative morbidity, blood transfusion requirement, and reoperation.

Results:

After an in-depth internal review of the postoperative morbidity of this case, it appears that the causative factor may be instrument shaft torque on the liver surface.

Conclusion:

Single-incision laparoscopic surgery may pose significant and unique risks that warrant additional operative caution. Quantitative comparison of SILS to the gold-standard laparoscopic cholecystectomy is needed to further elucidate definitive benefits and complications of this novel technique.     

Ruptured subcapsular hematoma after laparoscopic cholecystectomy attributed to ketorolac-induced coagulopathy

Ketorolac is the first injectable nonsteroidal antiinflammatory drug used as an analgesic in the perioperative period. However, gastrointestinal bleeding is a risk associated with its perioperative administration. A 23-year-old woman was admitted for elective laparoscopic cholecystectomy. Her medical history was unremarkable except for a complaint of intermittent right upper quadrant pain for several months. The operative procedure was uneventful. Thirty milligrams of ketorolac were given intravenously just prior to termination of surgery. Eighteen hours after surgery, the patient developed right upper quadrant pain associated with tachycardia and hypotension. Abdominal computed tomography (CT) scan demonstrated a large subcapsular hematoma of the liver. A few hours later, the hemodynamic condition worsened, and the patient was taken to the operating room. Laparoscopic exploration showed a ruptured subcapsular hematoma with active bleeding. No evidence of parenchymal injury of the gallbladder bed was found. The hematoma was evacuated and hemostasis was performed laparoscopically. Ketorolac has a strong antiplatelet activity and further acts by the inhibition of platelet function, which may last as long as 24 h after the last administration. Surgeons and anesthesiologists should be aware that ketorolac may cause or aggravate bleeding.     

Utility of liver function tests after laparoscopic cholecystectomy

Many surgeons routinely obtain liver function tests (LFTs) after all laparoscopic cholecystectomies. Others argue that LFTs provide no useful information and add time and expense to the patient's hospitalization. This purpose of this study was to determine if routine postoperative LFTs predict complications. One hundred ninety-nine consecutive patients undergoing laparoscopic cholecystectomy were included in the analysis. Nine (4.5%) patients had postoperative complications: eight with retained common bile duct stones and one with a cystic duct stump leak. All were diagnosed with postoperative endoscopic retrograde cholangiopancreatography. Only four of the nine patients had hyperbilirubinemia. Overall, 39 patients had postcholecystectomy hyperbilirubinemia, with four (10%) patients having complications (three retained stones and one had a bile leak). For the entire study population, there was no difference between pre- and postoperative total bilirubin and aspartate aminotransferase levels (0.6 vs 0.6 mg/dL; P = 0.623 and 25 vs 41 U/L; P = 0.111, respectively). There was a statistically significant difference in pre- and postoperative alanine aminotransferase and alkaline phosphatase (31 vs 50 U/L; P = 0.003 and 95 vs 90 U/L; P = 0.001, respectively). Postoperative elevations in liver function tests are frequently seen after laparoscopic cholecystectomy. These elevations do not predict postoperative complications. LFTs should be obtained only when clinically indicated.     

Subcapsular liver hematoma causing cardiac tamponade in HELLP syndrome

HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome is an obstetric complication with heterogeneous presentation, multisystem involvement and variable prognosis, but which usually resolves after delivery. We report a case of HELLP syndrome with subcapsular hematoma of the liver causing extrapericardial cardiac tamponade. The subcapsular hematoma and cardiac tamponade were managed conservatively.     

腹腔镜胆囊切除术后肝脏功能改变原因探讨

目的 探讨腹腔镜胆囊切除术(Laparoscopic Choelecystectomy,LC)后肝功能改变的原因。方法 将肝功能正常的慢性胆囊炎、胆囊结石患者随机分为A、B、C三组,A组32名,B组30名,C组34名。A组在LC术中除胆囊管及胆囊动脉钛铗夹闭外,采用电刀切除胆囊,CO_2空腹压力维持在7.5mmHg以下,称电刀组;B组患者在LC术中除不易用钳夹止血的出血点偶用电刀止血外,用弯剪游离胆囊,CO_2气腹压力维持15mmHg柱以下,称非电刀高腹压组;C组切除胆囊方法同B组,但CO_2气腹压力维持在7.5mmHg以下,称非电刀低腹压组。术后1、3、5、7天抽取患者外周静脉血进行肝功能测定。结果 A组患者术后1天外周血AST、ALT、γ-GGT、TBIL均显著升高,5天以后开始下降,1周后基本恢复正常;B组、C组患者术后1天外周静脉血仅AST、ALT略升高,术后3天均恢复正常。统计学处理显示:A组患者术后1、3、5天外周静脉血AST、ALT、γ-GGT、TBIL与B组及C组患者相比存在显著差异(P<0.05),术后第7天血浆AST、ALT、γ-GGT、TBIL差异已无临床意义(P>0.05)。但是B组与C组患者术后1、3、5、7天患者血浆AST、ALT、γ-GGT、TBIL无显著差异(P>0.05)。全部患者均恢复良好,肝功能改变与患者预后无明显关系。结论 电刀热损伤是LC术后肝功能改变的主要原因,而与CO_2气腹引起的腹腔     

Hemoperitoneum from rupture of liver subcapsular hematoma after laparoscopic cholecystectomy attributed to ketorolac. Report of a case

Ketorolac is one of the most common nonsteroidal anti-inflammatory drugs used to control postoperative pain. However, peri- and postoperative administration of ketorolac is associated with an increased risk of gastrointestinal bleeding as described in the literature. Notwithstanding this event is not frequent, it can expose the patient to serious complications that should be quickly recognised and effectively treated. We present a report about a female patient with cholelithiasis who underwent a laparoscopic cholecystectomy. After the operation, the patient had a haemorrhage that we attributed to surgery in a first time and then to administration of ketorolac.     

腹腔镜胆囊切除术后肝功能变化的原因

目的:探讨腹腔镜胆囊切除术后肝功能变化的原因。方法:将胆囊结石62例患者随机分为2组,A组32例,常规应用电刀切除胆囊,胆囊床普遍电凝处理;B组(对照组)30例,应用弯剪刀分离切除胆囊,钛夹钳闭止血。术后1、3、5、7d抽血测TBIL、ALT、AST、GGT、ALP含量。结果:A组术后第1天TBIL、ALT、AST明显升高,B组无升高,两组差异有显著性(P<0.01),A组术后第3天ALT、AST虽有下降,但仍高出正常值范围,差异仍有显著性(P<0.01),GGT、ALP两组均无明显升高。结论:电热损伤局部肝组织和肝外胆管的热电效应是术后肝功能变化的主要原因。     

腹腔镜胆囊切除术对患者肝功能及C反应蛋白水平的影响

目的：探讨腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）与开腹胆囊切除术（open cholecystectomy,OC）两种术式对患者肝功能的影响。方法：随机将慢性胆囊炎合并胆囊结石患者75例分为LC组40例,OC组35例,分别于术前及术后第1、3、5天抽取外周静脉血2ml,检测以下指标：血清总胆汁酸（TBA）、丙氨酸氨基转移酶（ALT）、天冬氨酸氨基转移酶（AST）、血清总胆红素（TBIL）、γ-谷氨酸转肽酶（γ-GT）、碱性磷酸酶（ALP）以及C反应蛋白（CRP）。结果：LC组和OC组手术后第1天与第3天TBA、ALT、AST、TBIL及CRP均升高,LC组的CRP升高较OC组更加显著（P〈0.05）。手术后第5天两组各项指标均恢复至正常水平,两组无显著差异。结论：腹腔镜胆囊切除术与开腹胆囊切除术相比,对肝功能的影响无明显差异,实施腹腔镜胆囊切除术安全可行。     

Sleep after laparoscopic cholecystectomy

The sleep pattern and oxygenation of 10 patients undergoing laparoscopic cholecystectomy were studied on the night before operation and the first night after operation. Operations were performed during general anaesthesia and postoperative analgesia was achieved without the administration of opioids. There were no significant changes in the total time awake or the number of arousals on the postoperative night compared with the night before operation. During the postoperative night, we found a decrease (P = 0.02) in slow wave sleep (SWS) with a corresponding increase in stage 2 sleep (P = 0.01). SWS was absent in four of the patients after operation, whereas in six patients it was within the normal range (5-20% of the night). The proportion of rapid eye movement (REM) sleep was not significantly changed after operation. There were no changes in arterial oxygen saturation on the postoperative compared with the preoperative night. Comparison of our results with previous studies on SWS and REM sleep disturbances after open laparotomy, suggests that the magnitude of surgery or administration of opioids, or both, may be important factors in the development of postoperative sleep disturbances.      

Pain after laparoscopic cholecystectomy

It is postulated that laparoscopic cholecystectomy as patient-friendly surgery leads to more comfort and in particular to less pain. A prospective study on pain was performed on all patients undergoing the operation over the period of 1 year (n=382) out of a series of more than 1,000 patients who have undergone the operation in our clinic. Pain was measured by a 100-point visual analogue scale (VAS), by a five-point verbal rating scale, and by the consumption of analgesics. Pain was the most frequent symptom, both before and after the operation. The mean level of pain was 37 VAS points 5 h after the operation and declined to 16 points on the third day. In 106 patients (27.8%) the intensity of pain was higher than 50 VAS points. Analgesics were used by 282 patients (73.8%), opioids by 112 (29.3%). Pain was significantly higher in female than male patients (P<0.05), but consumption of analgesics was similar in both groups. The most severe pain was localized to the abdominal wall wounds by 157 (41.1%) and to the right upper abdomen by 138 patients (36.1%) on the first postoperative day. Patients who needed opioids and/or had a pain level of >50 VAS points (n=138) had higher preoperative pain levels (P=0.018) and preoperatively complained more frequently about nausea, vomiting, bloating, and a feeling of abdominal pressure (P=0.003–0.031). However, predictive values of these variables were too small to be of clinical benefit. The duration of operation, intraoperative events (loss of bile, blood, or gallstones), and additional laparoscopic procedures (adhesiolysis, lavage, extension of an incision, suture of fascia) did not influence the intensity of postoperative pain. We conclude that laparoscopic cholecystectomy did cause significant postoperative pain in one-third of our patients only up to the first postoperative day. As predictors for high intensity of pain were not identified, pain should be monitored and analgesics should be delivered liberally.     

Complications after laparoscopic cholecystectomy

The diagnostic and therapeutic approaches used for patients referred for bile duct injuries and other major complications after laparoscopic cholecystectomy (LC) were reviewed and the results of a coordinated radiologic, endoscopic, and surgical approach were assessed.From April 1991 to October 1993, 23 patients were observed. Seven patients had biliary strictures, five had biliary lesions, five presented with retained common bile duct (CBD) stones, and one had a minor cystic duct leak. Five patients had miscellaneous abdominal fluid collections; in addition, biloma or bile ascites were present in 10/23 cases. Correct definition of iatrogenic lesions was mainly made by endoscopic retrograde cholangiography (ERCP) (n=15), associated in six cases also with percutaneous cholangiography (PTC). Minimally invasive treatment included the full range of endoscopic and interventional radiological procedures. Six patients with biliary strictures, one patient with a biliary lesion, all five patients with residual CBD stones, and four patients with abdominal collections were treated by minimally invasive techniques: Therefore, laparotomy was avoided in 70% of cases (16/23 patients). Open surgery was necessary in 7/23 patients (30%), because of ductal lesion (n=4), ductal stricture by endoloop (n=1), iliac artery injury (n=1), and phlegmon of gallbladder bed (n=1).It appears that careful assessment of complications after LC is mandatory and often requires the combined use of ERCP/PTC and cross-sectional imaging. After a first diagnostic phase, complications should be managed by a multidisciplinary approach wherein the radiologist and the endoscopist strictly cooperate with the surgeon in order to obtain an immediate relief of the initial clinical problem, such as jaundice, bile leak, or infection, and then plan a definitive treatment which is tailored to each patient's problem. Using this approach the whole event of LC and its complications can be managed within the field of minimally invasive therapy in most cases.     

Pain after laparoscopic cholecystectomy

BACKGROUND: Although laparoscopic cholecystectomy (LC) results in less pain than open chole-cystectomy, it is not a pain-free procedure. Many methods of analgesia for pain after laparoscopy have been evaluated. METHODS: Forty-two randomized controlled trials assessing interventions to reduce pain after LC are reviewed, as are the mechanisms and nature of pain after this procedure. RESULTS: Non-steroidal anti-inflammatory drugs, wound local anaesthetic, intraperitoneal local anaesthetic, intraperitoneal saline, a gas drain, heated gas, low-pressure gas and nitrous oxide pneumo-peritoneum have been shown to reduce pain after LC. The clinical significance of this pain reduction is questionable. CONCLUSION: Pain after LC is multifactorial. Although many methods of analgesia produce short-term benefit, this does not equate with earlier discharge or improved postoperative function. However, single trials evaluating low-pressure insufflation, heated gas and multimodal analgesia suggest that clinically relevant benefits can be achieved.     

Ectopic liver encountered during laparoscopic cholecystectomy

Ectopic liver is hepatic tissue that histologically resembles the mother tissue but is located at a site away from its usual location. Initially thought to be a rare anatomical anomaly of no clinical significance, it is now increasingly recognised to be capable of causing clinically relevant pathology. More specifically, it has been associated with a higher incidence of hepatocellular carcinoma, cholelithiasis and cholecystitis. Here, we report a case of ectopic liver encountered incidentally during laparoscopic cholecystectomy.     

Complications after laparoscopic cholecystectomy]

In 1780 patients the results of laparoscopic cholecystectomy (LCH) conduction for 1992-1997 period were analysed. In 1123 (63%) patients the operation was conducted for chronical and in 657 (37%)--for an acute cholecystitis. In 162 (9.1%) patients the choledocholithiasis features were revealed before the operation. In 46 (2.6%) patients the conversion to open laparotomy was accomplished. The LCH operation duration was from 35 to 190 min, (50 +/- 12) min in average. The frequency of an early complications occurrence was 8.8%, and in 18 (1.4%) patients the complications were revealed in late follow-up period. All the patients survived.