Hemihepatic Occlusion Research Articles

Attenuation of Reperfusion-Induced Hepatocyte Apoptosis is Associated with Reversed bcl-2/bax Ratio in Hemi-Hepatic Artery-Preserved Portal Occlusion

This study aimed to examine the hepatocyte apoptosis in a hepatic blood inflow occlusion rat model without hemi-hepatic arterial control and its association with the expressions of the apoptosis-regulating genes bcl-2 and bax. Wistar rats were equally and randomly assigned to undergo sham operation (control group, n = 8), Pringle's maneuver (group PR, n = 32), hemi-hepatic occlusion (group HH, n = 32), or hemi-hepatic artery-preserved portal occlusion (group HP, n = 32). The hepatic blood inflow was interrupted for 30 min using a microvascular clip in the three experimental groups. The clips were removed to achieve hepatic reperfusion for up to 24 h. Blood samples and liver specimens were collected following reperfusion to perform pathologic examination, serum transferase assay, apoptosis analysis, and determination of bcl-2 and bax mRNA and protein expressions. The reperfusion-related hepatocytic injuries were more severe in the PR group than in the HH and HP groups, both pathologically and biochemically. More reperfused hepatocytes became apoptotic in the PR group than in the HH and HP groups. However, the values of the HH and HP groups were comparable in cellularity, levels of serum transferases, and apoptosis rate following reperfusion. The ratios of bcl-2/bax were reversed, which was more evident in the HH and HP groups than in the PR group. Hemi-hepatic artery-preserved portal occlusion had little effect on hepatocyte apoptosis compared with Pringle's maneuver and caused minor ischemia-reperfusion injury as shown by the reversed bcl-2/bax ratio.

Hepatic vascular occlusion during liver resection

This article reviews the various techniques of vascular occlusion that can be applied to reduce blood loss during liver resection and liver transplantation as well as the level of current evidence in regard to their application. Hepatoduodenal ligament occlusion can be either continuous or intermittent. The impact on cardiac preload, cardiac index, systemic vascular resistance and splanchnic congestion is minimal. Hemihepatic or segmental vascular occlusion selectively interrupts inflow to the tumour bearing hemi-liver/segment, offers obvious demarcation of the resection limits, protects the remnant liver from ischaemia and avoids splanchnic congestion and haemodynamic consequences. Should backflow from the hepatic veins cause major blood loss during portal clamping or should the tumour infiltrate the IVC or caval-hepatic junction, total hepatic vascular exclusion (THVE) may be applied. THVE is associated with haemodynamic intolerance in 10–20% of patients and requires close haemodynamic monitoring and anesthetic expertise. Alternatively extraparenchymal hepatic vein occlusion allows THVE without interruption of the IVC flow. Infrahepatic inferior vena caval clamping may be used in order to reduce backflow bleeding during portal clamping is to reduce CVP with minor negative haemodynamic consequences. The future of pharmacological strategies lessening or preventing ischaemia/reperfusion injury lies in a combination of drugs acting on several steps of the ischaemia/reperfusion injury cascades. Separating the molecular basis and differences after ischaemia/reperfusion injury in normal and marginal organs will finally lead to strategies for preconditioning, and organ preservation.

Laparoscopic liver resection for hepatic hemangioma: a clinic analysis of 22 cases

Objective To investigate technical features and efficacy of laparoscopic liver resec-tion for hepatic hemangioma. Methods The clinic data of 22 patients with hepatic hemangioma receiv-ing laparoscopic liver resection in our hospital from March 2007 to February 2008 were retrospectively analyzed. Results Twenty patients received successful total laparoseopie liver resection and 2 conver-sion to laparotomy. Anatomical liver resection was performed in 14 patients including 5 with left hemi-hepateetomy, 5 with left lateral segmentectomy (1 combined with radiofrequeney ablation for the tumor in the right liver lobe) and 4 with segment Ⅵ resection. Eight patients underwent nonanatomi-cal hepatectomy. The liver parenchyma of 10 patients were transected under regional hemi-hepatic blood occlusion, 7 under intermittent Pringle's manoeuvre, and 5 without hepatic blood inflow block-age. The mean operative duration was 209 rain (92-375 min) and mean blood loss 360ml (50-1300 ml). No operative death and postoperative complications occurred, and the patients recovered well. The mean postoperative hospital stay was 6 d (4-10 d). All the patients were followed up for 2-14 months and no recurrence was found. Conclusion The advantages of laparoseopie liver resection for hepatic hemangioma are safe operation, less complications, and quick postoperative recovery. The key points are right choice of surgical approach, effective control of hepatic blood inflow, proper man-agement of cutting surface of liver, and liver parenchyma amputation being performed 0. 5-1 cm to tumor margin in the normal parenchyma or anatomical liver resection. Key words: Laparoscopy; Liver resection; Hepatic hemangioma

Vascular Control during Hepatectomy: Review of Methods and Results

The various techniques of hepatic vascular control are presented, focusing on the indications and drawbacks of each. Retrospective and prospective clinical studies highlight aspects of the pathophysiology, indications, and morbidity of the various techniques of hepatic vascular control. Newer perspectives on the field emerge from the introduction of ischemic preconditioning and laparoscopic hepatectomy. A literature review based on computer searches in Index Medicus and PubMed focuses mainly on prospective studies comparing techniques and large retrospective ones. All methods of hepatic vascular control can be applied with minimal mortality by experienced surgeons and are effective for controlling bleeding. The Pringle maneuver is the oldest and simplest of these methods and is still favored by many surgeons. Intermittent application of the Pringle maneuver and hemihepatic occlusion or inflow occlusion with extraparenchymal control of major hepatic veins is particularly indicated for patients with abnormal parenchyma. Total hepatic vascular exclusion is associated with considerable morbidity and hemodynamic intolerance in 10% to 20% of patients. It is absolutely indicated only when extensive reconstruction of the inferior vena cava (IVC) is warranted. Major hepatic veins/ and limited IVC reconstruction has been also achieved under inflow occlusion with extraparenchymal control of major hepatic veins or even using the intermittent Pringle maneuver. Ischemic preconditioning is strongly recommended for patients younger than 60 years and those with steatotic livers. Each hepatic vascular control technique has its place in liver surgery, depending on tumor location, underlying liver disease, patient cardiovascular status, and, most important, the experience of the surgical and anesthesia team.