Left Lobe Hepatectomy Research Articles

Result of hepatectomy for hepatolithiasis in Hue University of Medicine and Pharmacy Hospital

Background: Hepatolithiasis is an endemic disease in the Asia-Pacific region with 30 - 50% prevalence. We aimed to evaluate the patient’s characteristics, indications, and short-term outcomes. Method: A cross-sectional descriptive study. Data were analyzed using the Student’s t-test, univariable analysis by SPSS 20.0 software. Results: 33 cases of liver resection due to hepatolithiasis, mean age was 54.2 ± 13.2, 75.6% female, Child-Pugh score (A 97%, B 3%). The top position at the left lobe was 48.5%. ASA1was 36.4%; ASA2 was 54.5%, and ASA3 9.1%. Left lobe hepatectomy was 90.9%. The operative time was 185.2 ± 35 minutes. The hospitalization time was 16.2 ± 4.7 days. Biloma was 3%, the abdominal fluid collection was 15.2%, Wound infection was 3%, pneumonia was 3%, pleural effusion was 6.1%, urinary infection was 3%, and sepsis was 6.1%. The rate of retained and recurrent stones was 24.2%. There was no mortality after surgery. Conclusion: The hepatectomy for hepatolithiasis is safe and feasible. Key words: hepatectomy, hepatolithiasis, treatment, surgery, result.

Mechanism of Dexmedetomidine Intervention on Neurogenic Inflammation in Cognitive Impairment Rats after Partial Hepatectomy.

Objective To study the effect of dexmedetomidine on cognitive function in rats with cognitive impairment after partial hepatectomy and its mechanism. Methods 60 SD rats were randomly divided into 4 groups (n = 15): blank control group (CG group), sham operation group (Sham group), cognitive impairment model group (POCD group), and dexmedetomidine + cognitive impairment model group (DEX group). Rats in the POCD group underwent left lobe hepatectomy and intraperitoneal injection of the same amount of normal saline after resuscitation. Rats in the DEX group underwent left lobe hepatectomy and intraperitoneal injection of dexmedetomidine 50 μg/kg. Group CG was not operated on and the same amount of normal saline was injected intraperitoneally. In the Sham group, liver resection was not allowed after the abdominal incision, and normal saline was injected intraperitoneally. Rats were injected every 24 hours for 5 consecutive days. Morris water maze (MWM) were used to evaluate the effects of dexmedetomidine on learning and memory ability of POCD rats. TUNEL method was used to detect apoptotic neurons in the hippocampus. INOS, Arg-1, IL-6, and TNF-αexpression levels were detected. Western blot detects the expression level of TNF-α, Bcl-2, and NF-κB protein. Result Compared with the CG group, the escape latency of the other three groups was prolonged on the 5th day after the operation, and the number of crossing the platform was reduced. Compared with the Sham group, the escape latency of the POCD group and DEX group was significantly prolonged, and the number of crossing the platform was significantly reduced on day 5 (P < 0.05). Compared with the POCD group, the DEX group shortened the escape latency and increased the number of crossing the platform on the 5th day (P < 0.05). It shows that the spatial learning and memory function of rats has been restored to a certain extent.The number of iNOS and Arg-1 positive cells in the POCD group and DEX group was higher than that in the control group, and the number of Arg-1 positive cells in the DEX group was higher than that in the POCD group (P < 0.05). Western blot results the expression of Bcl-2 and NF-κB protein in POCD group, and DEX group was higher than that of the sham group (P < 0.05). The expression of Bcl-2 and NF-κB protein was the most in POCD group. The expression of Bcl-2 and NF-κB protein in DEX group was lower than that in POCD group (P < 0.05). Conclusion Behavioral results showed that the learning and cognitive ability of POCD model rats after hepatectomy was impaired, and inflammatory factors and activated microglia were found in the hippocampus of POCD rats. Dexmedetomidine may improve the brain function of POCD rats by inhibiting neuronal apoptosis,partly through NF-κB apoptosis pathway.

Application of 3D Simulation Software in Chemotherapy and Hepatoblastoma Surgery in Children.

PurposeThis study aims to explore the clinical value of a computer-assisted surgery system (Hisense CAS) in hepatoblastoma (HB) surgery in children after neoadjuvant chemotherapy.Patients and MethodsThe clinical medical records of children with HB treated after neoadjuvant chemotherapy at the Affiliated Hospital of Qingdao University from January 2016 to January 2019 were analyzed retrospectively.ResultsA total of 21 children were enrolled in this study, including 13 boys and 8 girls. All cases successfully underwent three-dimensional (3D) reconstruction of the liver and tumor using Hisense CAS, simulated hepatectomy, and hepatectomy according to the preoperative operation plan. There were twelve cases of right hemihepatectomy, four cases of right trefoil hepatectomy, one case of left lobe hepatectomy, and three cases of middle lobe hepatectomy, and one case of V and VI segment hepatectomy. All children recovered well after the operation. The follow-up ranged from 5 months to 3 years. One child died of systemic metastasis 8 months after the operation. One child received one course of chemotherapy after the operation. Due to the serious reaction to the chemotherapy, the family refused further treatment and follow-up. The remaining 19 children had no complications or recurrence.ConclusionHisense CAS can clearly and intuitively display the position and shape of the HB before and after chemotherapy and its relationship with the intrahepatic pipeline system and accurately evaluate the changes in tumor volume and the distance between important blood vessels, which is conducive to the operator selecting the best operation opportunity, timely formulating the best operation plan and implementing individualized and accurate liver tumor resection.

Extreme living donation: A single center simultaneous and sequential living liver-kidney donor experience with long-term outcomes under literature review.

Living liver and kidney donor surgeries are major surgical procedures applied to healthy people with mortality and morbidity risks not providing any direct therapeutic advantage to the donor. In this study, we aimed to share our simultaneous and sequential living liver-kidney donor experience under literature review in this worldwide rare practice. Between January 2007 and February 2018, a total of 1109 living donor nephrectomies and 867 living liver donor hepatectomies were performed with no mortality to living-related donors. Eight donors who were simultaneous or sequential living liver-kidney donors in this time period were retrospectively reviewed and presented with their minimum 2- year follow-up. Of the 8 donors, 3 of them were simultaneous and 5 of them were sequential liver-kidney donation. All of them were close relatives. Mean age was 39 (26-61) years and mean BMI was 25.7 (17.7-40). In 3 donors, right lobe, in 4 donors, left lateral sector, and in 1 donor, left lobe hepatectomy were performed. Median hospital stay was 9 (7-13) days. Two donors experienced early and late postoperative complications (Grade 3b and Grade 1). No mortality and no other long-term complication occurred. Expansion of the donor pool by utilizing grafts from living donors is a globally-accepted proposition since it provides safety and successful outcomes. Simultaneous or sequential liver and kidney donation from the same donor seems to be a reasonable option for combined liver-kidney transplant recipients in special circumstances with acceptable outcomes.

Lobectomy Reveals Co-infection of Streptococcus Anginosus and Extrapulmonary Tuberculosis

Isolated Mycobacterium Tuberculosis (TB) infection of the liver without signs of other organ involvement in immunocompetent patients is extremely rare and accounts for <0.5% of all forms of primary TB. We present a case of a young male whose diagnosis was only achieved after multiple admissions,treatment of Streptococcus Anginosus (SAG), and surgical lobectomy which finally revealed the masquerader. Only a handful of cases have ever been reported of pyogenic abscesses occurring due to this co-infection. A 24 year old Pakistani male was admitted for fever and weakness after returning from a recent trip to Pakistan. He had three weeks of right upper quadrant pain. ROS revealed he had night sweats, fatigue, weakness, and 15lb weight loss. He denied recent sick contacts. Vitals included a temperature of 101.3F, HR 100 bpm. RR 12 and BP 108/57 mmHg. Labs were notable for WBC 14,400/uL,Hb 12.8g/dl,ALT 38U/L,AST 30U/L,Alk. phos 326U/L,total bilirubin 1.1mg/dL,INR 1.5.2329_A Figure 1. MRI of Hepatomegaly and Abscess2329_B Figure 2. Ultrasound of Liver Abscess2329_C Figure 3. Portal Vein ThrombosisAbdominal CT and Ultrasound revealed left liver lobe abscesses with thrombosis of the left portal vein. CXR was negative. PPD was inconclusive due to history of exposure during childhood and sputum AFB tests were negative. Liver biopsy showed granulomatous inflammation and cultures revealed (SAG). Left portal vein, liver FNA, blood cultures, acid-fast bacilli smears were negative for TB. He was discharged with 10 days of antibiotics but continued to decompensate. Liver biopsy was negative for malignancy. He deteriorated requiring left lobe hepatectomy and cholecystectomy. Initial pathology results from liver showed caseating granulomas, but stain was negative for AFB. 16 days later TB was isolated and treated. The possibility of co-infections causing pyogenic abscesses must not be excluded. A case series evaluating 618 patients with hepatic TB revealed microscopic analysis of liver visualizing AFB had a median sensitivity of 25%, caseating granulomas 68%, and PCR had a sensitivity of 86%. Obtaining tissue to diagnose extrapulmonary TB is the gold standard. The sensitivities of culture and PCR are 77% and 72%. SAG is a commensal of the GI tract and can produce a liver abscess. One study showed 51% of their cases associated with SA. Isolated tubercular liver abscess without any other foci of infection is an extremely rare presentation of tuberculosis with a prevalence of only 0.34%. Isolated Tuberculosis liver abscess (TLA), with a prevalence of just 0.34%, must always remains in your differential.

Blunt liver trauma: a descriptive analysis from a level I trauma center

BackgroundWe aimed to review liver injury experience in a level 1 trauma center; namely clinical presentation, grading, management approach and clinical outcomes.MethodsIt is a retrospective analysis to include all blunt liver injury patients who were admitted at the Level 1 trauma center over a 3-year period. Data were compared and analyzed based on the liver injury grades and management approaches.ResultsBlunt liver injury accounted for 38% of the total blunt abdominal trauma cases with a mean age of 31 ± 13 years. Liver injury grade II (44.7%) was most common followed by grade I (28.8%), grade III (19.1%), grade IV (7.0%) and grade V (0.4%). Blood transfusion was more frequently required in patients with grade IV (p = 0.04). Out of 257 patients with blunt liver trauma, 198 were initially treated conservatively, that was successful in 192 (97%), whereas it failed in 6 (3%) patients due to delayed bleeding from hepatic hematoma, associated splenic rupture and small bowel injury which mandate surgical intervention. Fifty-nine patients (23%) underwent emergent surgery in terms of packing, resection debridement, left lobe hepatectomy and splenectomy. Hepatic complications included biloma, pseudoaneurysm and massive liver necrosis. Subanalysis of data using the World Society of Emergency Surgery (WSES) classification revealed 19 patients were categorized as a WSES grade IV who needed surgical intervention without having an initial computerized tomography scanning. The overall mortality was 7.8% which was comparable among the conservative and operative group.ConclusionsIn our center, low grade liver injury in young males prevails. NOM is successful even for high graded injuries. All conservatively treated patients with high-grade liver injuries should be closely monitored for signs of failure of the non-operative management. Introducing the new WSES classification makes clear how is important the hemodynamic status of the patients despite the lesion. However, further larger prospective and multicenter studies are needed to support our findings.

The impact of septic stimuli on the systemic inflammatory response and physiologic insult in a preclinical non-human primate model of polytraumatic injury

BackgroundEstablished animal trauma models are limited in recapitulating the pathophysiology of human traumatic injury. Herein, we characterize the physiologic insult and inflammatory response in two clinically relevant non-human primate (NHP) trauma models.MethodsMauritian Cynomolgus Macaques underwent either a laparoscopic closed abdomen liver injury (laparoscopic 60% left-lobe hepatectomy) in an established uncontrolled severe hemorrhage model (THM), or a polytrauma hemorrhage model (PHM) involving combined liver and bowel injury, uncontrolled severe hemorrhage as well as an open full-thickness cutaneous flank wound. Fixed volume resuscitation strategies were employed in the THM and goal directed resuscitation was used in the PHM. Complete peripheral blood and critical clinical chemistry parameters, serum biomarkers of systemic inflammation, tissue perfusion parameters, as well as survival, were compared between the models throughout the 2-week study period.ResultsNHPs in both the THM (n = 7) and the PHM (n = 21) demonstrated tissue hypoperfusion (peak lactate 6.3 ± 0.71 mmol/L) with end organ injury (peak creatinine 3.08 ± 0.69 mg/dL) from a similar liver injury (60% left hemi-hepatectomy), though the PHM NHPs had a significantly higher blood loss (68.1% ± 12.7% vs. 34.3% ± 2.3%, p = 0.02), lower platelet counts (59 ± 25 vs. 205 ± 46 K/uL, p = 0.03) and a trend towards higher mortality (90.5% vs. 33.3%, p = 0.09). The inflammatory response was robust in both models with peak cytokine (IL-6 > 6000-fold above baseline) and peak leukocyte values (WBC 27 K/uL) typically occurring around t = 240 min from the time of hepatic injury. A more robust systemic inflammatory response was appreciated in the PHM resulting in marked elevations in peak serum IL-6 (7887 ± 2521 pg/mL vs.1076 ± 4833 pg/mL, p = 0.02), IL-1ra (34,499 ± 5987 pg/mL vs. 2511 ± 1228 pg/mL, p < 0.00), and IL-10 (13,411 pg/mL ± 5598 pg/mL vs. 617 pg/mL ± 252 pg/mL, p = 0.03).ConclusionThis comparative analysis provides a unique longitudinal perspective on the post-injury inflammatory response in two clinically relevant models, and demonstrates that the addition of septic stimuli to solid organ injury increases both the hemorrhagic insult and inflammatory response.

3D simulation assisted resection of giant hepatic mesenchymal hamartoma in children

Objective: To evaluate the usefulness of Hisense Computer Assisted Surgery System (Hisense CAS) in pre-operative surgical planning and intra-operative navigation for resection of pediatric giant hepatic mesenchymal hamartoma (HMH).Methods: Five children with HMH underwent hepatectomy in our hospital. Pre-operative abdominal enhanced CT was performed for diagnosis and treatment planning. Using CT DICOM files, three-dimensional reconstruction was performed in three cases for operation planning and intra-operative navigation, with SID carrying out precise liver resection during the operation with Hisense CAS.Result: Two patients underwent right and left lobe hepatectomy, respectively, based only on enhanced CT. In 3 patients, by using the Hisense CAS system, three-dimensional reconstruction of the liver and tumors was successfully completed, and virtual hepatectomy performed successfully according to surgical plans. Hisense CAS could clearly and directly indicate the HMH location and shape, as well as its relationship with the intra-hepatic Glisson system, assisting safe hepatectomy. All five patients recovered well from surgery without any complications, and pathological examinations confirmed that all cases were HMH. No recurrence was observed during the follow-up period of 3 months to 5 years.Conclusion: Hisense CAS system is useful for preoperative planning and intra-operative navigation, assisting safer hepatectomy.

Inflammatory Profile in Response to Uncontrolled Hemorrhage in a Non-Human Primate (Rhesus Macaque) Model.

Uncontrolled hemorrhage (UH), the leading cause of potentially survivable combat-related death, elicits a deleterious inflammatory response. Our group previously reported an increased secretion of pro-inflammatory cytokines in a novel non-human primate model of UH; however, to better understand the molecular profile of the inflammatory response to UH, we performed a comprehensive evaluation of inflammation at the proteomic and transcriptomic level. Anesthetized rhesus macaques (n = 8) underwent UH by 60% left lobe hepatectomy T = 0 min. At T = 5 min, animals received 11 mL of 5% albumin followed by normal saline infusion to a total resuscitation volume of 20 mL/kg by T = 120 min. Blood (T = 0, 5, 20, 120, 480 min) was collected for qPCR and multiplex cytokine quantification. Results from each non-human primate (NHP) per time-point are shown. Statistical analysis by one-way ANOVA with repeated measures, P <0.05 was considered significant. Luminex analysis in serum revealed significant up-regulation compared with baseline of 8 cytokines/chemokines starting T = 120 min postinjury and significant down-regulation of 4 cytokines/chemokines as early as T = 20 min postinjury. Gene expression analysis in white blood cells uncovered 10 genes that were up-regulated greater than 3-fold compared with baseline and 29 genes that were down-regulated greater than 3-fold. The present study confirms the presence of systemic inflammation after UH at the proteomic and transcriptomic level providing insight into the inflammatory mediators that are involved as well as their kinetics following UH. The data demonstrates that NHP hemorrhage models may be suitable for evaluating therapeutics to control inflammation following hemorrhage.

Impact of Different Dominant Hepatic Vein Patterns in Left-Lobe Donors of Adult Living Donor Liver Transplantation

ObjectiveOptimal hepatic venous tributary flow is correlated with liver function and regeneration. In left-lobe graft living donor liver transplantation, the stump of segment 5 and 8 hepatic veins (S5V and S8V) are ligated without performing hepatic tributary reconstruction. The aim of this article was to evaluate the different dominate hepatic vein patterns that affect left-lobe living donor safety. Materials and MethodsA total of 44 donors who underwent left-lobe hepatectomy were divided into 2 groups, middle hepatic vein (MHV) dominance (group 1) and right hepatic vein (RHV) dominance (group 2), according to the dominant venous territory drainage from S5V and S8V or RHV. The clinical pathological data, postoperative laboratory data, complication, remnant liver volume and remnant liver regeneration rate at 6 months after surgery were compared. ResultsNo difference was found in blood loss, postoperative liver function such as alanine transaminase value, complications, and hospital stays between groups. Group 1 had slightly higher total bilirubin level than group 2 (1.99 vs 1.79; P = .49). Group 2 had significantly better remnant liver regeneration rate than group 1 (89.2% vs 82.5%; P = .026). ConclusionIt is important to recognize the dominant MHV group. Ligation large S5V and S8V in dominant MHV donors led to lower remnant liver regeneration in our series. This might be critical in extremely small RHV territory and potential large remnant liver congestion donors. Adjusting surgical planning, such as hepatic vein reconstruction, in this kind of donor might be appropriate for donor safety.

Rapid assessment of shock in a nonhuman primate model of uncontrolled hemorrhage: Association of traditional and nontraditional vital signs to mortality risk.

Heart rate (HR), systolic blood pressure (SBP) and mean arterial pressure (MAP) are traditionally used to guide patient triage and resuscitation; however, they correlate poorly to shock severity. Therefore, improved acute diagnostic capabilities are needed. Here, we correlated acute alterations in tissue oxygen saturation (StO2) and end-tidal carbon dioxide (ETCO2) to mortality in a rhesus macaque model of uncontrolled hemorrhage. Uncontrolled hemorrhage was induced in anesthetized rhesus macaques by a laparoscopic 60% left-lobe hepatectomy (T = 0 minute). StO2, ETCO2, HR, as well as invasive SBP and MAP were continuously monitored through T = 480 minutes. At T = 120 minutes, bleeding was surgically controlled, and blood loss was quantified. Data analyses compared nonsurvivors (expired before T = 480 minutes, n = 5) with survivors (survived to T = 480 minutes, n = 11) using repeated-measures analysis of variance with Bonferroni correction. All p < 0.05 was considered statistically significant. Results were reported as mean ± SEM. Baseline values were equivalent between groups for each parameter. In nonsurvivors versus survivors at T = 5 minutes, StO2 (55% ± 10% vs. 78% ± 3%, p = 0.02) and ETCO2 (15 ± 2 vs. 25 ± 2 mm Hg, p = 0.0005) were lower, while MAP (18 ± 1 vs. 23 ± 2 mm Hg, p = 0.2), SBP (26 ± 2 vs. 34 ± 3 mm Hg, p = 0.4), and HR (104 ± 13 vs. 105 ± 6 beats/min, p = 0.3) were similar. Association of values over T = 5-30 minutes to mortality demonstrated StO2 and ETCO2 equivalency with a significant group effect (p ≤ 0.009 for each parameter; R(2) = 0.92 and R(2) = 0.90, respectively). MAP and SBP associated with mortality later into the shock period (p < 0.04 for each parameter; R(2) = 0.91 and R(2) = 0.89, respectively), while HR yielded the lowest association (p = 0.8, R(2) = 0.83). Acute alterations in StO2 and ETCO2 strongly associated with mortality and preceded those of traditional vital signs. The continuous, noninvasive aspects of Food and Drug Administration-approved StO2 and ETCO2 monitoring devices provide logistical benefits over other methodologies and thus warrant further investigation.

Control of severe intra-abdominal hemorrhage with an infusible platelet-derived hemostatic agent in a nonhuman primate (rhesus macaque) model.

Hemorrhage remains the leading cause of potentially survivable trauma mortality. Recent reports indicate that injuries sustained in noncompressible anatomic locations (i.e., truncal and junctional) account for 86.5% of hemorrhage-related deaths. Infusible human platelet-derived hemostatic agents (hPDHAs) represent a promising strategy to reduce blood loss from noncompressible injuries. Here, we evaluate the hemostatic efficacy of a lyophilized hPDHA in a rhesus macaque model of severe, uncontrolled hemorrhage. Hemorrhage was induced via laparoscopic 60% left-lobe hepatectomy in anesthetized rhesus macaques (T = 0 minute). Treatment infusion began with an 11-mL bolus (T = 5-6 minutes) of either 5% albumin solution (control; n = 8) or hPDHA (1.2 × 10(10) platelet equivalents, n = 8), followed by 2.8-mL/min 0.9% normal saline at T = 6-20 minutes. Resuscitation continued with normal saline (0.22 mL/kg/min) to a total volume of 20 mL/kg at T = 120 minutes, at which time surgical hemostasis was achieved and percent blood loss quantified. Animals were monitored until T = 480 minutes and then euthanized, and necropsy was performed with emphasis on intravascular and end-organ thrombi. Data are expressed as mean ± SEM; significance, p < 0.05. Both groups exhibited a ∼70% decrease in mean arterial pressure (MAP) from T = 0-5 minutes. Percent blood loss was 44.2 ± 3.9% in hPDHA animals, and 44.3 ± 3.3% in controls. Survival rates were 4 of 8 for hPDHA animals and 7 of 8 for controls. Regardless of treatment, percent blood loss was greater (p < 0.02) in nonsurviving animals (55 ± 2%, n = 5) compared with surviving animals (42% ± 3%, n = 11). No pathologic intravascular thrombi were observed in either group. The isolated administration of hPDHA did not significantly reduce blood loss; however, thrombocytopenia was not present in the model, and clinically, platelets would be administered in combination with plasma. Mortality was not statistically different between groups (p = 0.14) but was related to blood loss. Future studies should consider the use of hPDHA in combination with additional therapeutics (e.g., factors) and a model that incorporates thrombocytopenia or platelet dysfunction.

Pyogenic Liver Abscess after Bile Duct Exploration Drained with Endoscopic Techniques

Background: Pyogenic liver abscess (PLA) after surgery may lead to sepsis.Endoscopic techniques provide an alternative choice for PLA drainage. Methods: We describe a 49-year-old woman who developed a right PLA after left lobe hepatectomy and common bile duct (CBD) exploration due to intra-and extra-hepatic bile duct stones. Results: The patient suffered from persistent high fever and hyperbilirubinemia with unknown reason after surgery despite amount of antibiotic applied until a liver abscess in right lobe was found .It was treated with ultrasound-guided percutaneous transhepatic drainage(PTD). However, outcome of the PTD was worse because of no fluid collected in abscess cavity at that time. T-tube drainage suddenly stop work after post-operative day 4. Emergent Endoscopic Retrograde Cholangiopancreatography (ERCP) and Endoscopic Nasobiliary Drainage (ENBD) was performed. The patient recovered rapidly a week later. Conclusions: PLA induced by regional closed-loop biliary obstruction is an important reason of abdominal infection after surgery.Endoscopic techniques with ERCP and ENBD can resolve PLA in early stage especially when PTD inadequently drained.

Development of a Nonhuman Primate (Rhesus Macaque) Model of Uncontrolled Traumatic Liver Hemorrhage.

Hemorrhage is the leading cause of potentially survivable trauma mortality, necessitating the development of improved therapeutic interventions. The objective of this study was to develop and characterize a reproducible clinically translatable nonhuman primate model of uncontrolled severe hemorrhage. Such a model is required to facilitate the development and meaningful evaluation of human-derived therapeutics. In Rhesus macaques, a laparoscopic left-lobe hepatectomy of 25% (n = 2), 50% (n = 4), or 60% (n = 6) was performed at T = 0 min, with no attempt at hemorrhage control until T = 120 min. A constant-rate infusion of normal saline was administered between T = 15 and 120 min to a total volume of 20 mL/kg. At T = 120 min, a laparotomy was performed to gain surgical hemostasis and quantify blood loss. Physiological parameters were recorded, and blood samples were collected at defined intervals until termination of the study at T = 480 min. Statistical analyses used Student t tests, with P < 0.05 considered statistically significant. Results are reported as mean ± SEM. The calculated percent blood loss for the 25% hepatectomy group was negligible (2.3% ± 0.2%), whereas the 50% and 60% hepatectomy groups exhibited 26.6% ± 7.1% and 24.9% ± 3.8% blood loss, respectively. At T = 5 min, blood pressure for the 25%, 50%, and 60% hepatectomy groups was reduced by 13.8%, 60.8%, and 63.2% from the respective baseline values (P < 0.05). In the 60% hepatectomy group, alterations in thromboelastometry parameters and systemic inflammatory markers were observed. The development of a translatable nonhuman primate model of uncontrolled hemorrhage is an ongoing process. This study demonstrates that 60% hepatectomy offers a significant reproducible injury applicable for the evaluation of human-derived therapeutics.

Outcomes of Left-Lobe Donor Hepatectomy for Living-Donor Liver Transplantation: A Single-Center Experience

Living-donor liver transplantation (LDLT) is an excellent option for patients with end-stage liver disease in situations of donor shortage. The aims of this study were to evaluate our experience with left-lobe donor hepatectomy for LDLT and to grade postoperative complications using the 5-tier Clavien classification system. Data from medical records of 60 adult living liver donors (30 men, 30 women) who underwent left-lobe hepatectomy between November 2006 and April 2012 were reviewed. The median donor age was 31.7 ± 8.9 (range, 19–63) years. Sixteen complications were observed in 12/60 (20%) donors. Complications developed in 6/15 (40%) donors who underwent left hepatectomy and in 6/45 (13.3%) donors who underwent left lateral segmentectomy. Seven of 16 (43.7%) complications were Grade I and 2 (12.5%) were Grade II. Major complications consisted of 4 (25%) Grade IIIa and 3 (18.7%) Grade IIIb complications; no Grade IVb or V complications occurred. The most common complication was biliary, occurring in 7 (11.6%) donors and comprising 43.7% of all 16 complications. The mean duration of follow-up was 30 ± 7.1 (range, 2–58) months. No donor mortality occurred. Left-lobe donor hepatectomy for LDLT, which does not benefit the completely healthy donor, was performed safely and with low complication rates, but carries the risk of morbidity. Low morbidity rates following living-donor hepatectomy can be expected when surgical and clinical monitoring and follow-up are adequate and the surgeon has gained increased experience.

Spontaneous intraperitoneal rupture of a hepatic hydatid cyst with subsequent anaphylaxis: a case report.

Hydatid cyst rupture into the abdomen is a serious complication of cystic hydatid disease of the liver (Cystic Echinococcosis) with an incidence of up to 16% in some series and can result in anaphylaxis or anaphylactoid reactions in up to 12.5% of cases. At presentation, 36–40% of hydatid cysts have ruptured or become secondarily infected. Rupture can be microscopic or macroscopic and can be fatal without surgery. Hydatid disease of the liver is primarily caused by the tapeworm Echinococcus granulosus and occurs worldwide, with incidence of up to 200 per 100,000 in endemic areas. Our case describes a 24-year-old Bulgarian woman presenting with epigastric pain and evidence of anaphylaxis. Abdominal CT demonstrated a ruptured hydatid cyst in the left lobe of the liver. A partial left lobe hepatectomy, cholecystectomy, and peritoneal washout was performed with good effect. She was treated for anaphylaxis and received antihelminthic treatment with Albendazole and Praziquantel. She made a good recovery following surgery and medical treatment and was well on follow-up. Intraperitoneal rupture with anaphylaxis is a rare occurrence, and there do not seem to be any reported cases from UK centres prior to this.

Diffuse Liver Hemangiomatosis: An Atypical Liver Transplantation Indication in Adult

Introduction: Patients with diffuse liver hemangiomatosis (DLH) showed symptoms of abdominal pain and a palpable abdominal mass. The natural history and its etiology are uncertain, although in the literature have been cited the role of steroids and metoclopramide. DLH usually occurs in neonates characterized by hemangiomas of the skin and involvement of at least two visceral organs. DLH without extrahepatic lesions is extremely rare in adults. The prognosis is still unclear because it occurs so rarely and has variable clinical courses in affected patients. When patients became symptomatic, liver transplantation is a good choice of treatment if surgical resection can not be performed. Material and methods: We present 2 patients who underwent orthotopic liver transplantation (OLT) for diffuse liver hemangiomatosis. The first one is a 50 years old woman, who showed a 2-year history of progressive abdomen distention and abdominal pain. Firstly, she was diagnosed of a giant liver hemangioma. Left lobe hepatectomy was performed without incidences. Later, the patient developed a DLH with compressive symptoms, so liver transplantation from brain death donor was performed. Postoperative course was uneventful, and after 8 years there has been no incidences. The second case is a 41 year old patient who presented painless hepatomegaly, coagulopathy and thrombocytopenia. DLH with portal vein thrombosis was diagnosed in imaging tests, and the patient is currently on the waiting list for liver transplantation. Conclusions: Difusse liver hemangiomatosis without extrahepatic lesions is extremely rare in adults. The presence of symptoms suggesting extrinsic compression of adjacent structures should be considered for surgical resection. Liver transplantation must be indicated in patients with symptomatic and unresectable disease.

Postoperative Liver Dysfunction in Living Donors After Left-Sided Graft Hepatectomy: Portal Venous Occlusion of the Medial Segment After Lateral Segmentectomy and Hepatic Venous Congestion After Left Lobe Hepatectomy

BackgroundThe aim of this study was to evaluate how sacrifice of the portal vein and/or hepatic vein affects remnant liver dysfunction after lateral segmentectomy or left lobe hepatectomy. Materials and methodsAmong 130 patients who underwent donor hepatectomy between March 2002 and July 2011, we enrolled lateral segment (n = 15) and left lobe donors (n = 40). We evaluated the postoperative courses and the territory of venous obstruction or congestion based on the sacrificed portal vein or hepatic vein after the donor operation: lateral segment grafts (P4a, P4b, LV4) and left lobe grafts (MV5, MV8) according to the results analyzed by MeVis Distant Service. ResultsAmong lateral segment donors, the predicted sacrificed territory of portal vein and hepatic vein was 14.3% (7.3%–19.4%) in P4a + 4b: (P4a: 8.6%, P4b: 5.8%) and 2.9% (0%–8.4%) in LV4, respectively. On the other hand, in left lobe donors, the predicted congestive territory of the hepatic vein was 17.6% (2.8%–33.0%) in MV5 + 8 (7.8% in MV5 and 9.8% in MV8, respectively). The incidence of patients whose postoperative peak aspartate aminotransferase (AST) or alanine aminotransferase levels were higher than 500 IU/L was 20% in the lateral segment donors and 5% in the left lobe donors. The peak postoperative AST levels and territory of MV5 + 8 showed a significant positive correlation (R = 0.569, P < .05) among left lobe donors. ConclusionTerritories of P4 in lateral segment donors and MV5 + 8 in left lobe donors impacted postoperative liver dysfunction. It is important to recognize the precise territory of the portal vein and the hepatic vein before the donor operation.

Multiple cerebral infarction and paradoxical air embolism during hepatectomy using the Cavitron Ultrasonic Surgical Aspirator -A case report-

A venous air embolism and paradoxical air embolism (PAE) are serious complications in patients undergoing a hepatectomy. We report a case of PAE and cerebral infarctions in a patient undergoing a hepatic resection using a Cavitron Ultrasonic Surgical Aspirator (CUSA®). A 65-year-old woman underwent a left lobe hepatectomy. During the middle phase of the liver resection with CUSA®, there was a sudden decrease in arterial blood pressure, end-tidal carbon dioxide and SpO2. With resuscitation, intraoperative ultrasonography revealed massive air emboli in both her left and right heart, which lasted for 40 min. The hepatectomy was completed after the disappearance of the air emboli from her heart. After surgery, her mental status was stuporous. The brain CT and MRI revealed multiple acute cerebral infarctions. Finally, she died from septic shock. This case highlights the need for anesthetists and surgeons to be aware of the potential for CUSA®-related massive PAE.

Analysis of postsurgical complications in 75 living liver transplantation donors

Seventy-five living donor liver hepatectomies were performed at our transplantation center between April 1990 and December 2004. We collected the data from patient charts, files, and the Baskent University Liver Registry. There were 39 male and 36 female donors (mean age, 35.1 +/- 9.3 years). We have performed 29 (38.6%) left hepatic lobectomies, 18 (24%) left lateral segmentectomies, 26 (34.6%) right lobectomies, and two (2.6%) donors had simultaneous living donor nephrectomy plus left lobe hepatectomy. The mean remnant liver volume was 598 +/- 168 cm(3) (range, 410-915 cm(3)). The mean percentage of remnant liver for the donor was 55.2%. Mean postoperative hospital stay was 10 +/- 4.4 days. After surgery, there was no mortality or reoperation. We saw 15 (20%) postsurgical complications in 14 donors. Intra-abdominal collection was seen in five (6.6%) patients. Biliary leak was seen in four patients. Portal vein thrombosis was seen in one patient, and a pulmonary embolus developed in one liver donor. Patient safety must be the primary focus in living-donor liver transplantation. These donors face significant risks, including substantial morbidity and death. More experience, improved surgical techniques, and meticulous donor evaluation will help minimize morbidity and mortality for both living liver donors and recipients.