Total endoscopic sublay mesh repair for umbilical hernias

Umbilical hernias constitute some of the most common surgical diseases addressed by surgeons. Endoscopic techniques have become standard of care together with the conventional open techniques for the treatment of umbilical hernias. Several different approaches were described to achieve laparoscopic sublay repair.We prospectively collected and reviewed the medical records of 10 patients with umbilical hernias underwent total endoscopic sublay repair (TES) at our institution from November 2017 to November 2019. All operations were performed by a same surgical team. The demographics, intraoperative details, and postoperative complications were evaluated.All TES procedures were successfully performed without conversion to an open operation. No intraoperative morbidity was encountered. The average operative time was 109.5 minutes (range, 80–140 minutes). All the patients resumed an oral diet within 6 hours after the intervention. The mean time to ambulation was 7.5 hours (range, 4–14 hours), and mean postoperative hospital stay was 2.2 day (range, 1–4 days). One patient developed postoperative seroma. No wound complications, chronic pain, or recurrence were registered during the follow-up.Initial experiences with this technique show that the TES is a safe, and effective procedure for the treatment of umbilical hernias.     

疝环充填式无张力疝修补术治疗肝硬化腹水并发腹壁疝患者的应用体会

目的探讨疝环充填式无张力疝修补术在肝硬化腹水并发腹壁疝患者中的临床应用价值。方法回顾性分析1999-02～2008-12采用疝环充填式无张力疝修补术治疗肝硬化腹水并发腹壁疝患者25例的临床资料。结果手术全部成功,出现并发症6例,均痊愈出院。结论疝环充填式无张力疝修补术是治疗肝硬化腹水并发腹壁疝患者的理想术式,具有手术安全、创伤小、恢复快、近期疗效满意和复发率低等优点。     

芒硝敷脐治疗肝硬化腹水的Meta分析

目的系统评价芒硝敷脐治疗肝硬化腹水的疗效。方法从中国知网、维普、万方、Pub Med数据库检索有关芒硝敷脐治疗肝硬化腹水的文献。应用随机效应模型进行荟萃分析,组间连续性资料的比较结果应用标准化均数差(SMD)表达,组间分类性资料的比较结果应用优势比(OR)表达。结果共11项随机对照研究被纳入。与对照组相比,芒硝敷脐治疗组的腹水缓解率明显更高(OR=3.19,P0.000 1),腹围(SMD=1.69,P0.000 1)及体质量(SMD=2.77,P0.000 1)降低程度更加明显。与治疗前相比,芒硝敷脐治疗后ALT水平明显降低(SMD=1.92,P=0.000 9),白蛋白水平明显增高(SMD=-1.78,P=0.000 6),但AST(SMD=2.14,P=0.056)及TBil(SMD=3.39,P=0.25)水平并未显著改变。结论芒硝敷脐对治疗肝硬化腹水有一定疗效,但对肝功能改善尚不确定。     

Surgical repair of intractable chylous ascites following laparoscopic anterior resection

Chylous ascites is the accumulation of a milk-like peritoneal fluid rich in triglycerides and it is an unusual complication following surgical treatment of colorectal cancer. Conservative management is usually sufficientin patients with chylous ascites after surgery. However,we describe a patient with intractable chylous ascites after laparoscopic anterior resection for sigmoid colon cancer who failed initial conservative treatment. This patient was successfully managed by surgery.     

Evaluation of hernia repair operation in Child-Turcotte-Pugh class C cirrhosis and refractory ascites

BACKGROUND AND AIM: Abdominal wall hernia is a common feature of decompensated liver cirrhosis and frequently causes life-threatening complications or severe pain. However, there have been no data reported on postoperative mortality, hepatic functional deterioration and recurrence rate according to Child-Turcotte-Pugh (CTP) class and to the presence of refractory ascites. METHODS: The study population comprised 53 liver cirrhosis patients who underwent hernia repair operation. Comparisons were made of 30-day mortality among the different CTP classes, and between those with or without refractory ascites. Liver function was also analyzed just before the operation, in the immediate postoperative period, and in the remote postoperative period. RESULTS: Seventeen patients were in CTP class A, 27 patients in class B, and 9 patients in class C. The median follow-up duration was 24 months. There was single 30-day postoperative mortality in class C, and no CTP class deterioration after 30 days of operation. There was no mortality or recurrences in 17 patients with medically refractory ascites. The difference in 30-day mortality according to CTP class and the presence of refractory ascites did not show statistical significance (P = 0.17 and 0.97, respectively). CONCLUSION: Hernia operation could be done safely in CTP class A and B with low rate of recurrences, and there was no definitive increase in the operative risk in class C. In addition, refractory ascites did not increase operative risk and recurrence rate. Therefore, surgical repair might be recommended even in patients with refractory ascites and poor hepatic function to prevent life-threatening complications or severe pain.     

Steatorrhea and hypoalbuminemia in cirrhosis with ascites

Summary Steatorrhea associated with advanced cirrhosis of the liver was studied by means of the I¹³¹-labeled oleic acid absorption test. The validity of the use of this test as a measure of fat absorption by the small intestine was reviewed. Malabsorption of oleic acid was demonstrated in each of the 6 cirrhotic patients examined. The impaired absorption of oleic acid was attributed to pathologic changes in the mucosa of the small intestine secondary to portal hypertension. The clinical implications of this finding were discussed.The possibility that a protein-losing enteropathy might contribute to the hypoalbuminemia of advanced cirrhosis was investigated by means of intravenously administered I¹³¹-labeled polyvinylpyrrolidone and I¹³¹-labeled serum albumin. However, no significant loss of protein through the gastrointestinal tract was demonstrated in the 4 cirrhotic patients examined for this condition.Supported, in part, by research grants from the U. S. Public Health Service and performed under the tenure of a U. S. Public Health Postdoctoral Research Fellowship.     

Management of ascites in cirrhosis

Ascites is one of the earliest and most common complications of patients with cirrhosis. A typical circulatory dysfunction characterized by arterial vasodilation, high cardiac output and stimulation of vasoactive systems is commonly present in these patients and is associated with a poor prognosis. The treatment of ascites has been based on the combination of a low-sodium diet and the administration of diuretics. The reintroduction of paracentesis and the recent introduction of the transjugular intrahepatic portosystemic shunt (TIPS) are the most relevant innovations in the treatment of ascites during the past two decades, although controlled trials in large series of patients are needed to delineate whether TIPS is a safe and useful treatment for these patients.     

排放腹水治疗肝硬化顽固性腹水32例分析

目的　观察排放腹水治疗肝硬化顽固性腹水的疗效。方法　对 6 4例肝硬化顽固性腹水患者 ,随机分成两组 ,两组均给以补充人体白蛋白、复方丹参注射液、限钠、限水 ,同时注意维持内环境的平衡。治疗组排放腹水 ,对照组使用利尿合剂。结果　治疗组显效 6 2 .50 % ( 2 0 / 32 ) ,有效 31.2 5% ( 10 / 32 ) ,无效 6 .2 5% ( 2 / 32 ) ,总有效率 93.75% ( 30 / 32 ) ;对照组显效 37.50 % ( 12 / 32 ) ,有效 34 .38% ( 11/ 32 ) ,无效 2 8.12 % ( 9/ 32 ) ,总有效率71.88% ( 2 3/ 32 )。治疗组明显优于对照组。严重并发症 (血钾 <3.0 ml/ L、肝肾综合征、肝性脑病等 )的发生率 ,治疗组为 15.6 3% ,对照组为 59.38%。治疗组并发症明显少于对照组。结论　排放腹水的治疗方法可能是治疗肝硬化顽固性腹水的一种较好的方法 ,且并发症较少     

Management of ascites in cirrhosis

Ascites is a common complication of liver cirrhosis associated with a poor prognosis. The treatment of ascites requires dietary sodium restriction and the judicious use of distal and loop diuretics, sequential at an earlier stage of ascites, and a combination at a later stage of ascites. The diagnosis of refractory ascites requires the demonstration of diuretic non-responsiveness, despite dietary sodium restriction, or the presence of diuretic-related complications. Patients with refractory ascites require second-line treatments of repeat large-volume paracentesis (LVP) or the insertion of a transjugular intrahepatic portosystemic shunt (TIPS), and assessment for liver transplantation. Careful patient selection is paramount for TIPS to be successful as a treatment for ascites. Patients not suitable for TIPS insertion should receive LVP. The use of albumin as a volume expander is recommended for LVP of >5-6 L to prevent the development of circulatory dysfunction, although the clinical significance of post-paracentesis circulatory dysfunction is still debated. Significant mortality is still being observed in cirrhotic patients with ascites and relatively preserved liver and renal function, as indicated by a lower Model for End-Stage Liver Disease (MELD) score. It is proposed that patients with lower MELD scores and ascites should receive additional points in calculating their priority for liver transplantation. Potential new treatment options for ascites include the use of various vasoconstrictors, vasopressin V(2) receptor antagonists, or the insertion of a peritoneo-vesical shunt, all of which could possibly improve the management of ascites.     

Management of ascites in cirrhosis

Onset of ascites in cirrhosis of the liver is associated with worsened quality of life, increased risk of spontaneous bacterial peritonitis, and renal failure. Portal hypertension produces splanchnic vasodilation that triggers the cascade of events leading to release of Na retentive vasoconstrictor hormones. Management of ascites caused by cirrhosis is based on improving the Na excretion with diuretics and Na restriction in diet. Refractory ascites and hepatorenal syndrome are the complications of ascites that carry a very high mortality. Large volume paracentesis and transjugular intrahepatic porto-systemic shunts are useful in managing patients with refractory ascites. Liver transplant is the only way to improve survival in ascites caused by cirrhosis.     

Hypernatremia following gastrointestinal bleeding in cirrhosis with ascites

3 patients with hepatic cirrhosis and ascites underwent increased diuresis on six occasions, closely related to episodes of gastrointestinal bleeding. In each instance the increased urine volume was preceded by a sharp increase in blood urea nitrogen, presumably due to absorption of nitrogenous compounds from the gastrointestinal tract, suggesting a mechanism of osmotic diuresis. In each case there was a significant increase in serum sodium and osmolality, related to the greater-water-than-sodium diuresis induced by urea, which was promptly reversed by the administration of water or isotonic solution. Clinically this syndrome may be defined as the association of hypernatremia and hyperosmolality due to osmotic diuresis from urea appearing in a cirrhotic patient with ascites and gastrointestinal bleeding.     

Portopulmonary hypertension in decompensated cirrhosis with refractory ascites

BACKGROUND: The prevalence of portopulmonary hypertension (PPHTN) in patients with cirrhosis and refractory ascites is unknown. Its presence may preclude patients from receiving a transjugular intrahepatic portosystemic shunt or liver transplantation as a definitive treatment for their end stage cirrhosis. PURPOSE: To determine the prevalence, possible aetiological factors, and predictive factors for the development of PPHTN in these patients. METHODS: Sixty two patients (53 males, nine females; mean age 54.5 (1.4) years) with biopsy proven cirrhosis and refractory ascites underwent angiographic measurements of pulmonary and splanchnic haemodynamics. Endothelin 1 levels were measured from the pulmonary artery. Forty nine patients underwent radionuclide angiography for measurements of central blood volume, pulmonary vascular, and cardiac chamber volumes. Forty seven patients also underwent two dimensional echocardiography for measurements of cardiac structural and functional parameters. Cardiac output, and systemic and pulmonary vascular resistance were calculated. RESULTS: Ten patients (16.1%) fulfilled the criteria for PPHTN (mean pulmonary artery pressure >/= 25 mm Hg and pulmonary vascular resistance >/= 120 dynxs/cm(5)), with significantly higher mean right atrial (15.4 (1.2) v 7.9 (0.5) mm Hg; p<0.001), and right ventricular pressures (24.7 (1.5) v 14.7 (0.6) mm Hg; p<0.001), and endothelin 1 levels (3.04 (0.40) v 1.98 (0.12) pg/ml; p=0.02). No significant differences in any of the other parameters measured were detected between the two groups. A right atrial pressure of >/= 14 mm Hg had a 83% positive predictive value for the presence of PPHTN. CONCLUSIONS: Portopulmonary hypertension is common in cirrhosis with refractory ascites, possibly due to excess endothelin 1 in the pulmonary circulation. An elevated right atrial pressure >/= 14 mm Hg predicts the presence of PPHTN, which may be helpful in deciding management options in these patients.     

Dilutional hyponatremia in patients with cirrhosis and ascites

OBJECTIVES: To analyze the predisposing factors, modifications of vasoactive systems, and prognosis of patients with cirrhosis and hyponatremia. PATIENTS AND METHODS: Fifty-four patients with hyponatremia (serum sodium level of <130 mEq/L after 5 days of hyponatremic diet and no diuretic therapy). Twenty cirrhotic patients served as controls. We measured plasma renin activity and levels of plasma aldosterone, norepinephrine, and antidiuretic hormone. Follow-up identified the development of hepatorenal syndrome and death. RESULTS: A higher percentage of patients with hyponatremia had decreased liver size, higher levels of plasma renin activity, and higher serum concentrations of aldosterone and norepinephrine. Renal insufficiency was detected in 31 of them (57%). Precipitating factors (hemorrhage or infections) were detected in 27 patients (50%). Incidence of hepatorenal syndrome and death were higher in patients with spontaneous development of hyponatremia (n = 23 [85%] and n = 25 [93%], respectively) than in patients with precipitating factors (n = 15 [56%] and n = 12 [44%], respectively) and cirrhotic controls (n = 1 [5%] and n = 5 [25%], respectively) (P<.001). Results of multivariate analysis showed that Child-Pugh index, presence of hepatocarcinoma, and serum concentration of urea were associated with mortality. After excluding those patients with kidney failure at the time of admission, only Child-Pugh index and norepinephrine concentrations were independent predictors of mortality. CONCLUSIONS: Hyponatremia is an alteration in patients with advanced liver disease. Although survival is significantly reduced in patients with spontaneous development of hyponatremia, a reduced sodium concentration cannot be considered as a independent predictor of the risk for death.     

Prognostic value of spontaneous hyponatremia in cirrhosis with ascites

Spontaneous hyponatremia in cirrhosis with ascites is generally considered to be due to an impaired renal ability to excrete free water, to be a contraindication of diuretics, and to be a bad prognostic sign. These concepts are reviewed in this paper. 55 cirrhotics with ascites were divided into three groups. Group I consisted of 13 patients with hyponatremia and very low free-water clearance ( , 0.07±0.26 ml/min). These patients also had poor renal function: low inulin clearance (C _INU , 40.6±25.9 ml/min) and paraamino-hippurate clearance (C _PAH , 383±275 ml/min). Group II consisted of 8 patients who also had hyponatremia. , C _INU , and C _PAH in these patients were fairly high: 5.85±1.53 ml/min, 85.7±26.2 ml/min, and 651±294 ml/min. These values are similar to those of the 34 patients without hyponatremia who make up Group III: (6.37±4.27 ml/min, 94.7±33.1 ml/min, and 598±199 ml/min). Hyponatremia in Group I could be related to the impaired free-water clearance. The mechanism of hyponatremia in Group II patients is not clear. Patients with hyponatremia and low C _INU and C _PAH had a negative response to diuretics and a poor prognosis. Patients with hyponatremia but with relatively good renal function had a good prognosis, similar to Group III patients. They responded to diuretics with no worsening of their hyponatremia.Presented in part at the Eighth Meeting of the European Association for the Study of the Liver, September, 1973, Vittel, France.     

Human umbilical cord mesenchymal stem cells improve liver function and ascites in decompensated liver cirrhosis patients

Decompensated liver cirrhosis (LC), a life-threatening complication of chronic liver disease, is one of the major indications for liver transplantation. Recently, mesenchymal stem cell (MSC) transfusion has been shown to lead to the regression of liver fibrosis in mice and humans. This study examined the safety and efficacy of umbilical cord-derived MSC (UC-MSC) in patients with decompensated LC. A total of 45 chronic hepatitis B patients with decompensated LC, including 30 patients receiving UC-MSC transfusion, and 15 patients receiving saline as the control, were recruited; clinical parameters were detected during a 1-year follow-up period. No significant side-effects and complications were observed in either group. There was a significant reduction in the volume of ascites in patients treated with UC-MSC transfusion compared with controls (P < 0.05). UC-MSC therapy also significantly improved liver function, as indicated by the increase of serum albumin levels, decrease in total serum bilirubin levels, and decrease in the sodium model for end-stage liver disease scores. UC-MSC transfusion is clinically safe and could improve liver function and reduce ascites in patients with decompensated LC. UC-MSC transfusion, therefore, might present a novel therapeutic approach for patients with decompensated LC.     

肝硬化顽固性腹水治疗现状

目的 腹水是失代偿期肝硬化的常见表现,其中顽固性腹水的发病率为5%～10%,患者生存率低。国内外大量研究对顽固性腹水的治疗进行了研究报道,并取得了一定的进展。本文针对目前顽固性腹水的治疗现状和进展进行了较为系统的综述。