Advances In Liver Surgery Research Articles

Hepatic vein reconstruction for resection of hepatic tumors.

Involvement of the hepatic veins requiring reconstruction has traditionally been considered a contraindication to resection for advanced tumors of the liver because the surgical risks are high and the long-term prognosis poor. Recent advances in liver surgery gleaned from split and live donor liver transplantation that necessitate hepatic vein reconstruction can be applied to hepatic resection in some cases. Sixteen patients who underwent hepatic resection requiring hepatic vein reconstruction from 1996-2001 were reviewed. The mean age was 43 years (range 2-61). Nine patients were resected for hepatocellular carcinoma (HCC), five patients for colorectal metastases, and one patient each for hepatoblastoma and cholangiocarcinoma. In six patients with HCC and cirrhosis, the right hepatic vein was reconstructed to provide venous outflow to liver segments not adequately drained by a remaining major hepatic vein. Four of these six patients required the use of Gore-Tex (W. L. Gore & Associates, Inc., Newark, DE) interposition grafts. In the 10 other cases the entire venous outflow from the remnant liver was reconstructed or reimplanted into the inferior vena cava primarily (n = 8) or using segments of the portal vein from the resected side of the liver as a graft (n = 2). Ex-vivo procedures with the use of veno-venous bypass were required in two cases and in-situ cold perfusion of the liver was used in one case. There were two perioperative deaths (12%). One patient died of liver failure 3 weeks after right trisegmentectomy with reconstruction of the left hepatic vein and one patient died at 3 months after resection due to sepsis from a segment of small bowel that perforated into a diaphragmatic hernia. Four patients had evidence of postoperative liver failure that resolved with supportive management and one patient required temporary dialysis. All vascular reconstructions were patent at last followup. With median followup of 23 months, 3 patients have died of recurrent malignancy at 14, 18 and 30 months, while an additional patient went on to die of progressive liver failure at 22 months. Actuarial 1 and 3 year survival was 88% and 50% respectively. Hepatic vein involvement by hepatic malignancy does not necessarily preclude resection. Liver resection with reconstruction of the hepatic veins can be performed in selected cases. The increased risk associated with the procedure appears to be balanced by the possible benefits, particularly when the lack of alternative curative approaches is considered.

Glycohydrolases As Markers of Hepatic Ischemia–Reperfusion Injury and Recovery

Advances in liver surgery and transplantation have lead to a steady increase in the number of these interventions. Prompt quantitative assessment of hepatic of hepatic function and a patient's subsequent morbidity and mortality following surgery remain difficult despite the currently utilized historic markers of hepatic parenchymal injury (e.g., aspartate transaminase [AST], lactate dehydrogenase [LDH] gamma-glutamyl transpeptidase [GGT]). Increases in serum glycohydrolase activities appear to provide sensitive and quantitative markers of hepatic ischemia/reperfusion injury. In 10 male swine (25 to 35 kg body weight) following 30, 45, and 90 minutes of acute hepatic ischemia, the systemic release of eight different glycohydrolases and lipid peroxides into serum were determined and compared with pre- and postischemic serum levels of LDH, GGT, and AST. The rapid release of glycohydrolases into serum was directly proportional to the length of the ischemic period from 30 to 90 minutes; e.g., beta-glucosidase, mean 1.9-fold increase at 30 minutes; 8.3-fold at 45 minutes; and 22.8-fold at 90 minutes; P < .002) and the activities peaked within the first 3 hours postischemia. In constrast, AST, LDH, and GGT were released slowly and peaked 20 to 30 hours after hepatic blood flow was restored. In swine with fatal outcomes (90 minutes of ischemia), all enzyme levels increased continuously during the final hours of life. However, in swine that survived hepatic ischemia/reperfusion injury (45 minutes of ischemia) the glycohydrolases, but not AST, LDH, and GGT, declined after 2 to 3 hours' postischemia and the serum lipid peroxide levels followed the same pattern. Serum beta-galactosidase and beta-glucosidase levels are sensitive markers that rise as quickly as traditional enzyme markers (AST, LDH, GGT) following hepatic ischemic injury; moreover, the glycohydrolases have the added value of serving as predictors of survival.

Glycohydrolases as markers of hepatic ischemia-reperfusion injury and recovery

Advances in liver surgery and transplantation have lead to a steady increase in the number of these interventions. Prompt quantitative assessment of hepatic of hepatic function and a patient's subsequent morbidity and mortality following surgery remain difficult despite the currently utilized historic markers of hepatic parenchymal injury (e.g., aspartate transaminase [AST], lactate dehydrogenase [LDH] γ-glutamyl transpeptidase [GGT]). Increases in serum glycohydrolase activities appear to provide sensitive and quantitative markers of hepatic ischemia/reperfusion injury. In 10 male swine (25 to 35 kg body weight) following 30, 45, and 90 minutes of acute hepatic ischemia, the systemic release of eight different glycohydrolases and lipid peroxides into serum were determined and compared with pre- and postischemic serum levels of LDH, GGT, and AST. The rapid release of glycohydrolases into serum was directly proportional to the length of the ischemic period from 30 to 90 minutes; e.g., β-glucosidase, mean 1.9-fold increase at 30 minutes; 8.3-fold at 45 minutes; and 22.8-fold at 90 minutes; P < .002) and the activities peaked within the first 3 hours postischemia. In constrast, AST, LDH, and GGT were released slowly and peaked 20 to 30 hours after hepatic blood flow was restored. In swine with fatal outcomes (90 minutes of ischemia), all enzyme levels increased continuously during the final hours of life. However, in swine that survived hepatic ischemia/reperfusion injury (45 minutes of ischemia) the glycohydrolases, but not AST, LDH, and GGT, declined after 2 to 3 hours postischemia and the serum lipid peroxide levels followed the same pattern. Serum β-galactosidase and β-glucosidase levels are sensitive markers that rise as quickly as traditional enzyme markers (AST, LDH, GGT) following hepatic ischemic injury; moreover, the glycohydrolases have the added value of serving as predictors of survival. (Hepatology 1996 Jul;24(1):157-62)

Surgical and anesthetic management of patients undergoing major hepatectomy using total vascular exclusion.

Total vascular exclusion (TVE) of the liver is accomplished by complete occlusion of inflow and outflow of the liver during hepatectomy. It affords the opportunity for bloodless, anatomically precise parenchymal transection but has not been widely used in this country. TVE should make it possible to treat large or unfavorably located lesions safely. To evaluate the benefit of this modality, we have examined the results of TVE in 49 major resections. Forty-nine patients with liver tumors (mean age, 50 +/- 17 years; range 3 to 75 years) were treated by the authors over 5 years with a mean age of 50 +/- 17 years (range 3-75). Thirty-five (71%) patients were females and 38 (78%) had malignant tumors (hepatocellular CA n = 15, liver metastases n = 20, other n = 3), whereas 11 (22%) had benign tumors (hemangiomas n = 7 other n = 4). Six (12%) had histological cirrhosis but normal liver function test results. Twenty two (45%) had previous surgery. Forty-seven (96%) underwent total or extended lobectomies. Two patients had segmental resection of benign tumors (one in segment 4 and one in segment 8). Mean surgical time was 4.7 hours (2.5-8.3 hours) and mean red blood cell requirement was 2.2 U (0 to 11). Twenty-two (45%) procedures were performed without transfusions. Hospital mortality rates were 0%. The mean postoperative hospital duration was 11 days (5 to 41 years). Complications occurred in 18 (36%), requiring reoperation in 1 case for wound debridement and in another for lysis of postoperative adhesions. Hepatic insufficiency occurred transiently in 2 patients with prolongation of protime and cholestasis and resolved within 4 days in 1 patient and 10 days in the other (with cirrhosis). The perception of hepatic resection as a prohibitive undertaking with high mortality rate may limit the use of resection in patients who might benefit from this modality. Our data document the effectiveness and safety of major hepatectomy even in cirrhotic patients using TVE. Expanded use of TVE and other advances in liver surgery should be considered to decrease the morbidity rate of resection and make the benefits of this therapy more widely available.