Hepatic Artery Ligation Research Articles

Evaluation of the Hepa Wash®treatment in pigs with acute liver failure

BackgroundMortality of patients with acute liver failure (ALF) is still unacceptably high. Available liver support systems are still of limited success at improving survival. A new type of albumin dialysis, the Hepa Wash® system, was newly introduced. We evaluated the new liver support system as well as the Molecular Adsorbent Recycling System (MARS) in an ischemic porcine model of ALF.MethodsIn the first study animals were randomly allocated to control (n=5) and Hepa Wash (n=6) groups. In a further pilot study, two animals were treated with the MARS-system. All animals received the same medical and surgical procedures. An intraparenchymal intracranial pressure was inserted. Hemodynamic monitoring and goal-directed fluid therapy using the PiCCO system was done. Animals underwent functional end-to-side portacaval shunt and ligation of hepatic arteries. Treatment with albumin dialysis was started after fall of cerebral perfusion pressure to 45 mmHg and continued for 8 h.ResultsAll animals in the Hepa Wash group survived the 13-hour observation period, except for one that died after stopping treatment. Four of the control animals died within this period (p=0.03). Hepa Wash significantly reduced impairment of cerebral perfusion pressure (23±2 vs. 10±3 mmHg, p=0.006) and mean arterial pressure (37±1 vs. 24±2 mmHg, p=0.006) but had no effect on intracranial pressure (14±1 vs. 15±1 mmHg, p=0.72). Hepa Wash also enhanced cardiac index (4.94±0.32 vs. 3.36±0.25 l/min/m2, p=0.006) and renal function (urine production, 1850 ± 570 vs. 420 ± 180 ml, p=0.045) and eliminated water soluble (creatinine, 1.3±0.2 vs. 3.2±0.3 mg/dl, p=0.01; ammonia 562±124 vs. 1382±92 μg/dl, p=0.006) and protein-bound toxins (nitrate/nitrite 5.54±1.57 vs. 49.82±13.27 μmol/l, p=0.01). No adverse events that could be attributed to the Hepa Wash treatment were observed.ConclusionsHepa Wash was a safe procedure and improved multiorgan system failure in pigs with ALF. The survival benefit could be the result of ameliorating different organ functions in association with the detoxification capacity of water soluble and protein-bound toxins.

Hepatic Artery Ligation for Arterial Rupture Following Liver Transplantation: A Reasonable Option

Hepatic artery (HA) rupture after liver transplantation is a rare complication with high mortality. This study aimed to review the different managements of HA rupture and their results. From 1997 to 2007, data from six transplant centers were reviewed. Of 2649 recipients, 17 (0.64%) presented with HA rupture 29 days (2-92) after transplantation. Initial management was HA ligation in 10 patients, reanastomosis in three, aorto-hepatic grafting in two and percutaneous arterial embolization in one. One patient died before any treatment could be initiated. Concomitant biliary leak was present in seven patients and could be subsequently treated by percutaneous and/or endoscopic approaches in four patients. Early mortality was not observed in patients with HA ligation and occurred in 83% of patients receiving any other treatment. After a median follow-up of 70 months, 10 patients died (4 after retransplantation), and 7 patients were alive without retransplantation (including 6 with HA ligation). HA ligation was associated with better 3-year survival (80% vs. 14%; p=0.002). Despite its potential consequences on the biliary tract, HA ligation should be considered as a reasonable option in the initial management for HA rupture after liver transplantation. Unexpectedly, retransplantation was not always necessary after HA ligation in this series.

Abstract No. 270 - Multimodality imaging to assess immediate response to irreversible electroporation in a rat liver tumor model

Purpose The purpose was to compare induced changes within US, CT, and MRI images shortly after irreversible electroporation (IRE) ablation of normal liver parenchyma and hepatic tumors. Materials and Methods All procedures were approved by IACUC. 48 rats were divided into 8 groups, 24 were implanted with N1-S1 tumors. US, CT, and MRI measurements were performed in both normal and tumor tissues pre/post-IRE. MRI was also performed in one group pre/post-IRE after hepatic vessel ligation. Pre/post-IRE US images were graded by 3 radiologists to determine echogenicity changes (0: no change; 1: slight change; 2: clear change; 3: dramatic change). Hounsfield units (HU) were measured based on CT and signal to noise ratio (SNR) measured within T2W MR images pre/post-IRE. Results The average grade was 2.0 for echogenicity change in ablated normal liver and 1.3 for ablated tumor. HU of ablated normal liver (62.53±2.24) was significantly different (p=0.0001) from unablated parenchyma (46.99±5.259); while small, HU difference between ablated tumor (42.11±2.11) and control tumor (45.14±2.64) did trend toward significance (p=0.0524). SNR in ablated normal liver was significantly increased post-IRE (PRE: 47.37±18.31, POST: 90.88±37.15, p=0.0227). SNR difference between tumors pre/post-IRE was not significant (PRE: 102.13±31.36, POST: 101.09±21.66, p=0.9401). No post-IRE signal changes were observed for rats that underwent portal vein and hepatic artery ligation prior to MRI-monitored IRE. IRE ablation zones were confirmed with HandE and micro-structural changes observed with transmission electron microscopy. Conclusion IRE induces rapid changes within US, CT, and MRI images. However, these imaging methods characterized IRE-induced signal changes more effectively in normal parenchyma than in tumors. MRI findings following hepatic ligation indicate that early signal changes are likely the result of local fluid accumulation in the treated zones. Future studies are necessary to develop superior imaging methods to better characterize electroporation-induced changes in tumors.

Propranolol as a First‐line Treatment for Diffuse Infantile Hepatic Hemangioendothelioma

Propranolol as a First‐line Treatment for Diffuse Infantile Hepatic Hemangioendothelioma

Effects of hyperbaric oxygen on hypoxia inducible factor-1 and p53 in liver hypoxia injury

Objective To investigate the effects of hyperbaric oxygen (HBO) on hypoxia inducible factor-1 (HIF-1),p53 and hepatocyte apoptosis,and the protective effects of hyperbaric oxygen on liver injury with hepatic artery hypoxia.Methods Ninety-six male Sprague-Dawley rats were randomly divided into three groups:control group,hepatic artery ligation (HAL) group and HBO therapy group.All animals underwent laparotomy and skeletonized-liver followed by heparin Ringer' s solution perfusion.HAL was carried out in the HAL group and HBO group.HBO therapy was given in HBO group,twice daily,60 min each time,0.25 MPa 2 h after operation.Blood and liver samples were collected at 1st,3rd,7th,and 14th day after operation.The expression of HIF-1 mRNA in the liver tissue was detected by using reverse transcription-polymerase chain reaction (RT-PCR).The expression of HIF-1 and p53 was detected by using immunohistrochemical staining.Apoptosis of hepatocytes was evaluated by the terminal deoxynucleotidyl transferase mediated dUTP-rhodamine nick end labeling (TUNEL).Serum aspartate aminotransferase (ALT) level was determined and histopathologic changes were observed to evaluate the liver injury.Results The expression of HIF-1 mRNA and protein was decreased significantly in HBO group as compared with that in HAL group,and it reached the peak at 3rd and 7th day [(0.484 ± 0.071)％ vs (0.834 ±0.129) ％,P ＜ 0.01 ; (3.3 ± 3.2) ％ vs (7.8 ± 3.1) ％,P ＜ 0.05].The expression of p53 in HBO group was significantly lower than that in HAL group at 3rd,7th and 14th day post-operation [(17.3 ± 8.6)％vs (29.2 ±8.1)％,P＜0.05; (19.2 ±8.3)％ vs (41.2 ±9.1)％,P＜0.01; (16.0 ±5.6)％ vs (28.0 ± 8.3) ％,P ＜ 0.05].Apoptosis index of hepatocytes at 3rd and 7 th day post-operation was lower in HBO group than in HAL group [(10.2±4.5)％ vs (16.6 ±3.5)％; (11.7 ±6.4)％ vs (21.3±7.4)％,P ＜0.05].Serum ALT level was significantly decreased in HBO group as compared with that in HAL group.There were neovessels in the periphery of the liver and no hepatic cell necrosis in HBO group.Conclusion HBO down-regulates the expression of HIF-1 and P53 mRNA,and inhibits apoptosis of heptocytes,exerting the protective effects against liver hypoxia injury. Key words: Hyperbaric oxygen; Hepatic artery ligation; Hypoxia inducible factor-1 ; p53 ; Apoptosis

Hemobilia Due to Cystic Artery Stump Pseudoaneurysm Following Laparoscopic Cholecystectomy: Case Presentation and Literature Review

Hemobilia is the process of bleeding into the biliary tree and is an unusual cause of upper gastrointestinal hemorrhage. When this event results from a cystic artery pseudoaneurysm, it is a particularly rare phenomenon; fewer than 20 cases are described in the literature. Alongside the literature review, we report a case of a 34-year-old woman presenting 3 months post laparoscopic cholecystectomy with hematemesis. Computed tomography (CT) angiography revealed a cystic artery pseudoaneurysm. Following an ineffective hyperselective arterial embolization, the patient was successfully treated by surgical ligation of the right hepatic artery. Even though this complication is uncommon, all surgeons need to be aware of its presentation and of available therapeutic options.

Significance of celecoxib on enhanced metastatic potential due to hepatic artery occlusion in hepatocellular carcinoma

Objective To investigate the local or systemic inflammatory reaction after hepatic artery ligation ( HAL),and to explore the therapeutic effect of celecoxib on HAL-enhanced metastatic potential of hepatocellular carcinoma (HCC).Methods The spontaneous metastatic model in nude mice was established with MHCC97 cells via orthotopic implantation and further to HAL.The proinflammatory cytokines such as tumor necrosis factor (TNF)-α,interleukin (IL)-6,and hepatocyte growth factor ( HGF ) in serum in HAL group were compared with those in sham-operation group by enzyme linked immunosorbent assay (ELISA).The signs of inflammation in primary tumor or the lung from two groups were observed by immunohistochemistry and the expression of cyclooxgenase 2 (COX-2) in xenografts was evaluated.The influence of celecoxib at different doses on tumor growth,pulmonary metastatic ratio,and COX-2 expression in tumor tissues due to HAL was investigated.Results The serum levels of proinflammatory cytokines (TNF-α,IL-6 and HGF) were elevated after HAL (3.78 times; 2.91 times; 1.82 times,P ＜ 0.05 ).Also the necrotic area in the xenograft as scored with hepatic replacement area (HRA) was increased by HAL [ HAL group:(5 1.27 ± 19.39 ) ％ vs.sham-operation group:( 19.69 ± 5.49 ) ％ ; P ＜ 0.01 ].Especially,the lungs of nude mice in the HAL group showed more inflammatory damage,characterized by intense inflammatory infiltration,thickening of alveolar walls,and severe vascular margination.As compared with normal saline (NS) treatment following HAL,HAL in combination with high dose of celecoxib (50 mg/kg every day) resulted in significantly reduced tumor size [( 1091.81 ± 870.14) mm3 vs. (2735.06 ±474.97 ) mm3,P ＜0.01 ],decreased pulmonary metastasis (0/6 vs.8/10,P ＜0.01 ),and prolonged survival [ ( 81.67 ± 8.51 ) days vs.( 60.17 ± 5.42 ) days,P ＜ 0.05 ].HAL followed by celecoxib at a dose of 12.5 mg/kg every day neither slowed down residual tumors growth nor prolonged survival,but inhibited the formation of pulmonary metastatic nodules though the difference (compared with sham operation) was not statistically significant (2/6 vs.8/10,P ＞0.05).Interestingly,as shown in supplementary study,we did not detect the conspicuous changes of COX-2 expression in tumor tissues-derived HAL with low dose celecoxib-trcated mice,while the striking decrease of COX-2 expression was observed in treatments by HAL combined with moderate or high dose celecoxib.Conclusion HLA leads to local or systemic inflammatory reaction,which is inhibited by celecoxib as accompanied with arrest of HAL-induced metastatic potential in residual HCC cells. Key words: Hepatic artery blocking; Hepatocellular carcinoma; Inflammation; Celecoxib

The diverse changes of βcatenin induced by hypoxia in hepatocellular carcinoma

Objective To investigate the effect of hypoxia on expression of β-catenin in hepatocellular carcinoma (HCC) and its molecular background.Methods Human HCC cell lines with different metastatic potentials (PLC/PRF/5,Hep3B,HepG2 and MHCC97) were grown under hypoxic (induced by 100 μmol/L CoCl2 ) and normoxic conditions,respectively.The alterations of β-catenin due to hypoxia were examined by quantitative reverse transcription-polymerase chain reaction (RT-PCR),Western blotting and immunofluensence staining in above cells.The results in vitro were confirmed in the in vivo hypoxic model by using hepatic arterial ligation (HAL).Its underlying mechanisms were investigated by analyzing the expression of glycogen synthase kinase 3β (GSK-3β) and proteasome inhibiting assay.Results Hypoxia induced a pronounced increase in total β-catenin levels in PLC/PRF/5 and HepG2 cells ( ＞ 2.3-fold),but not in Hep3B and MHCC97 cells.The latter exhibited a marked intracellular translocation of β-catenin ( ＞ 1.7-fold),but no change in its total amount ( ＜ 1.1-fold).These results were confirmed by subcellular fractionation assays and immunofluoresence staining.In the in vivo MHCC97 and HepG2 xenograft models,Western blotting and immunostaining showed that HAL increased β-catenin expression in HepG2 xenografts ( ＜ 1.3-fold),compared to its sham-operated controls,while intracellular translocation was achieved in MHCC97 xenografts.The elevated β-catenin level in HCC cells was attributed to downregulation of GSK-3β expression and proteasome inhibition.Conclusion Hypoxia promotes overexpression and intracellular accumulation of β-catenin in HCC cells,which was correlated with hypoxia-induced metastatic potential. Key words: Carcinoma,hepatocellular; β-catenin; Hypoxia

Reduction of β-catenin expression in hepatocellular carcinoma inhibited the enhanced metastatic potential of hypoxia

Objective To explore the role of β-catenin in the proinvasive consequences of hypoxia in hepatocellular carcinoma (HCC).Methods We established in vitro and in vivo hypoxic models using the highly metastatic MHCC97 and the stable red fluorescent protein-expressing MHCC97-R cells.The role of β-catenin in hypoxia-mediated aggressiveness was investigated by β-catenin knockdown.Results Hypoxia caused a pronounced arrest of proliferation in MHCC97 cells,suppressed tumor growth in MHCC97-R xenografts,but promoted in vitro invasiveness and in vivo metastasis.β-Catenin-silencing by short hairpin significantly inhibited the enhanced invasiveness of MHCC97 cells due to hypoxia,reduced the increase in distant metastasis by hepatic arterial ligation,but failed to further restrain cell proliferation.Conclusion β-Catenin in HCC cells plays an essential role in the hypoxia-induced metastatic potential.A reduction of βcatenin expression inhibited the proinvasive consequences of hypoxia in HCC. Key words: β-catenin; Hepatocellular carcinoma; Hypoxia; Malignant potential

Management of hepatic artery aneurysms

Hepatic artery aneurysm (HAA) is a rare clinical entity that can lead to potentially life threatening complications. We reported our personal experience of 4 cases, in which we used different procedures. The first case had a pseudo-aneurysm involving the right hepatic artery. The second case had a pseudo-aneurysm, which was localized distal to the accidentally ligated right hepatic artery from the previous cholecystectomy operation. The third case had multiple aneurysms with accompanying dissecting abdominal aortic aneurysm. The fourth case had a pseudo-aneurysm originating from the proper hepatic artery. A covered stent was successfully placed in the case 1. In the second case, the right hepatic artery was ligated distal to the aneurysm. In the third case, vascular structures were not appropriate for vascular reconstruction, and a covered stent placement and embolization were unsuccessful. In the fourth case, ligation of the proper hepatic artery and cholecystectomy was performed. The third case with multiple aneurysms died from multi-organ failure due to sepsis. The remaining cases (case 1, 2, and 4) are disease free and alive. HAAs are more commonly observed clinical entities, and their treatment should be handled for each patient separately. Computerized tomography-Angiography and intraoperative Doppler ultrasound are useful radio-diagnostics for determination of aneurysm and planning the operative procedure (Fig. 5, Ref. 15).

Liver abscess developed after cadaveric liver transplantation due to ligation of an accessory right hepatic artery of the donor graft

It is important that extrahepatic arteries are identified precisely at the time of graft procurement. We present a case where the accessory right hepatic artery of the liver was ligated leading to postoperative liver abscess formation in the liver graft. A forty-seven-year-old female patient diagnosed with liver cirrhosis underwent orthotopic cadaveric liver transplantation due to altered mentality. The donor graft showed a variant of the hepatic artery anatomy where an accessory right hepatic artery arose from the superior mesenteric artery. This artery was accidentally transected during procurement. Since the back bleeding test using perfusion fluid was good, the artery was ligated. Postoperative abdominal computed tomography scan revealed a 6 cm low attenuating lesion in the liver. The patient underwent conservative treatment. We believe that even small accessory arteries (1 to 2 mm) should be reconstructed whenever possible to avoid postoperative complications such as liver abscess.

Critical infantile hepatic hemangioma: results of a nationwide survey by the Japanese Infantile Hepatic Hemangioma Study Group

Background The current survey aimed to describe the clinical features of critical infantile hepatic hemangioma (IHH) and the implications of recent treatments. Materials and Methods A nationwide survey of critical IHH patients treated between 2005 and 2010 was performed in all 117 registered pediatric surgical hospitals in Japan. As a result, 19 patients were identified and reviewed using a statistical analysis. Results Abdominal distention (47.4%), high-output cardiac failure (47.4%), coagulopathy (42.1%), and respiratory distress (31.6%) were the major symptoms. Three patients died (1 of coagulopathy, 1 of cardiac failure, and 1 of both). An accompanying portovenous shunt was also highlighted. Infantile hepatic hemangioma was totally insensitive to steroid treatment in 3 (23.1%) of the 13 patients, and 9 (47.4%) of the 19 patients required other treatments. Surgical resection and β-blocker improved the hematologic data, whereas hepatic arterial ligation and embolization seemed to produce a limited effect. Among the dead patients, several hematologic parameters were significantly worse: the thrombocyte count (pretherapeutic: 73 000 vs 300 000/mm 3, dead vs survivor, respectively [ P < .03]; posttherapeutic: 66 000 vs 388 700/mm 3 [ P < .003]) and the prothrombin time (posttherapeutic, 35.0 vs 12.1 seconds [ P < .0001], dead vs survivor, respectively). Conclusion For critical IHH cases with steroid-insensitive hematologic disorders, alternative treatments including β-blocker therapy, surgery, and liver transplantation should be considered.

Laparoscopic common hepatic artery ligation and staging followed by distal pancreatectomy with en bloc resection of celiac artery for advanced pancreatic cancer

Adeno-carcinomas of pancreatic body are usually asymptomatic and progress to advanced stage with involvement of major arteries. Resection of advanced cancer along with en bloc resection of a common hepatic artery and celiac trunk enables a "curative" resections and only possible treatment. However, the celiac axis resection always has a risk of compromising blood supply to liver, resulting in the hepatic insufficiency. We evaluated practicability of a two-stage procedure for the advanced pancreases body cancer, laparoscopic clamping of a common hepatic artery followed by open distal pancreatectomy with en bloc celiac arterial resection to prevent the hepatic insufficiency. Seventy-five-year-old woman diagnosed with a 50-mm pancreatic body mass, invading splenic artery, common hepatic artery, splenic vein, and portal vein at the confluence. STAGE-1: At laparoscopy, after confirming absence of the peritoneal, superficial liver metastases and negative peritoneal cytology; we approached the common hepatic artery through the lesser sac and ligated. STAGE-2: Her liver function tests were normal after 2 weeks, and CT angiography showed complete blockage of the common hepatic artery with sufficient collateral circulation to the liver through inferior pancreatico-duodenal artery and gastro-duodenal artery. We performed an open distal pancreatectomy with en bloc resection of celiac artery. Histopathology examination confirmed R0 resection. The celiac axis resection with distal pancreatectomy improves the chance of R0 resection and potentially, survival of the patient. Preoperative laparoscopic ligation of the common hepatic artery is a safe, effective, and in-expensive technique to prevent postoperative hepatic insufficiency and improves the safety of en bloc celiac artery resection with a distal pancreatectomy. Also these patients have high risk of peritoneal dissemination. Diagnostic laparoscopy is useful to detect occult metastasis, which are missed by per-operative CT scan.

Hepatic arterial occlusion promotes epithelial-mesenchymal transition of peritumoral liver cells in hepatocellular carcinoma

Objective To investigate the effects of the hepatic arterial occlusion on biological characteristics of peritumoral liver cells in hepatocellular carcinoma (HCC).Methods Using a metastatic human HCC orthotopic nude mice model ( MHCC97H cells),the effects of hepatic artery ligation (HAL)on the expression of hypoxia-inducible factor-1α (HIF-1α),E-cadherin or N-cadherin,and pimonidazole positive staining were evaluated.To clarify the molecular background,the changes consistent with epithelial-mesenchymal transition (EMT) in normal liver cells L-02 were explored by using Western blotting and immunofluorescence staining under hypoxic conditions.Results HAL not only induced intratumoral hypoxia,but also led to peritumoral hypoxia as evidenced by higher HIF-1α level and augment number of pimonidazole positive cells ( HAL:9 ±3 vs.sham-operation:4 ±2,P ＜0.05).Besides the changes associated with EMT were observed in HCC cells as demonstrated previously,and the molecular changes of EMT were also found in peritumoral liver cells,which were characterized by down-regulation of E-cadherin and up-regulation of N-cadherin.We introduced 100 μ mol/L CoCl2 to mimic hypoxic conditions in vitro and found the HIF-1α expression was increased in L-02 cells.Moreover,the changes of EMT as described in vivo were also observed in these hypoxic cells by Western blotting or immunofluorescence staining.Conclusion HAL triggers the changes associated with EMT in tumor and peritumor tissues through inducing hypoxia. Key words: Carcinoma,hepatocellular; Peritumoral tissues; Hepatic artery occlusion; Hypoxia; Epithelial-mesenchymal transition

Clinical and pathological analysis of hepatic artery aneurysm in a patient with systemic lupus erythematosus: Report of a case

A hepatic artery aneurysm is an unusual but life-threatening hepatobiliary complication occurring in patients with systemic lupus erythematosus (SLE), and early diagnosis and treatment of this complication are essential. A 31-year-old man with SLE presented with recurring epigastric pain and jaundice for 2 months; he was diagnosed with choledocholithiasis and underwent surgery. Hemobilia was found intraoperatively, and two hepatic artery aneurysms were identified in the left lateral lobe during postoperative arteriography. Major hemobilia occurred 6 days after the operation, and the patient was immediately treated with selective embolization of the hepatic artery. However, the major hemobilia recurred 2 days later, and he was treated with a left lateral lobectomy and ligation of the proximal hepatic artery. The patient recovered uneventfully and is in good condition. A histological analysis revealed small- and medium-sized arteritis as well as hepatic artery aneurysm. Systemic lupus erythematosus complicated by a hepatic artery aneurysm should be considered in the differential diagnosis of patients showing symptoms of abdominal pain, jaundice, or gastrointestinal bleeding.

Effects of partial portal vein arterialization on the hilar bile duct in a rat model

Liver revascularization is frequently required during the enlarged radical operation for hilar cholangiocarcinoma involving the hepatic artery. Researchers have carried out a number of experiments applying partial portal vein arterialization (PVA) in clinical practice. In this study we aimed to establish a theoretical basis for clinical application of partial PVA and to investigate the effects of partial PVA on rat hilar bile duct and hepatic functions. Thirty rats were randomly and equally assigned into 3 groups: control (group A), hepatic artery ligation+bile duct recanalization (group B), and partial PVA+bile duct recanalization (group C). Proliferation and apoptosis of rat hilar bile duct epithelial cells, arteriolar counts of the peribiliary plexus (PBP) of the bile duct wall, changes in serum biochemistry, and pathologic changes in the bile duct were assessed 1 month after operation. The proliferation of hilar bile duct epithelial cells in group B was greater than in groups A and C (P<0.01). No apoptotic hilar bile duct epithelial cells were detected in any of the groups. The PBP arteriolar counts of the hilar bile duct wall were similar in groups A and C (P>0.05), but the count was lower in group B than in group A (P<0.01). No statistically significant differences in alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase and albumin were found in the 3 groups. The gamma-glutamyltransferase value was higher in group B than in groups A and C (P<0.01). The hepatic tissues of groups A and C showed no significant abnormality. Chronic inflammatory changes in the hilar bile duct walls were observed only in group B. Partial PVA can restore the arterial blood supply of the hilar bile duct and significantly extenuate the injury to hilar bile duct epithelial cells resulting from hepatic artery ligation.

Quinckeʼs Triad: A Rare Complication of a Common Outpatient Procedure

Purpose: We describe the case of a 64 year old male who presented to our hospital with RUQ pain five days after ultrasound-guided liver biopsy at an outside hospital. The pain was intermittent, sharp and worsened by deep breathing and movement. It was associated with black stool, pruritus and dark urine. He was found to have icteric sclera and mild pallor. His abdomen was soft, non-distended and mildly tender in the RUQ. Rectal exam was positive for melenic stool. Lab results revealed an elevated total bilirubin of 8 mg/dl along with elevated amylase and lipase of 4022 and 3957 U/L respectively. AST, ALT and ALP were elevated at 264, 118 and 269 U/L respectively. Hemoglobin was marginally decreased at 10.4 g/dL. Stool was heme positive and urine positive for urobilinogen and bilirubin. Abdominal ultrasound showed echogenic matter in the gallbladder suspicious for blood. On upper endoscopy blood was seen in the second part of the duodenum with a clot adherent to the ampulla of Vater. Upon irrigation, the clot was removed and there was active bleeding from the common bile duct. Hepatic angiography was done however the culprit vessel could not be found despite two separate attempts by two separate interventional radiologists. After staying ten days and receiving fourteen units of blood, the hemobilia resolved spontaneously and the patient was discharged. DISCUSSION: Hemobilia was first published by Francis Glisson in 1654. Its incidence after liver biopsy has been reported as less than one in a thousand. The first case of hemobilia following liver biopsy was reported in 1967. It is usually due to bleeding from an intrahepatic branch of the hepatic artery into a biliary duct. The time between liver biopsy and onset of hemobilia averages about five days. In 1870, Heinrich Quincke described the triad of jaundice, biliary colic and gastrointestinal bleeding in a patient with a ruptured hepatic artery aneurysm who developed hemobilia. This triad only presents in 22% of cases. The first report of acute pancreatitis attributed to hemobilia came in 1975 as a complication of a percutaneous transhepatic cholangiogram. Management of hemobilia involves careful observation and early consultation with the interventional radiologist. The technique of choice is superselective transcatheter embolization using metallic coils with polyvinyl alcohol beads. The success rate is approximately 95% and it avoids hepatic artery ligation. Fortunately, in our patient, there was spontaneous cessation of bleeding and follow-up revealed no further episodes of bleeding.

High incidence of biliary complications in rat liver transplantation: can we avoid it?

To investigate how to reduce the incidence of biliary complications in rat orthotopic liver transplantation. A total of 165 male Wistar rats were randomly divided into three groups: Group A, orthotropic liver transplantation with modified "two-cuff" technique; Group B, bile duct was cut and reconstructed without transplantation; and Group C, only laparotomy was performed. Based on the approaches used for biliary reconstruction, Group A was divided into two sub-groups:A1 (n = 30), duct-duct reconstruction, and A2 (n = 30), duct-duodenum reconstruction. To study the influence of artery reconstruction on bile duct complication, Group B was divided into four sub-groups: B1 (n = 10), duct-duct reconstruction with hepatic artery ligation, B2 (n = 10), duct-duct reconstruction without hepatic artery ligation, B3 (n = 10), duct-duodenum reconstruction with hepatic artery ligation, and B4 (n = 10), duct-duodenum reconstruction without hepatic artery ligation. The samples were harvested 14 d after operation or at the time when significant biliary complication was found. In Group A, the anhepatic phase was 13.7 ± 1.06 min, and cold ischemia time was 50.5 ± 8.6 min. There was no significant difference between A1 and A2 in the operation duration. The time for biliary reconstruction was almost the same among all groups. The success rate for transplantation was 98.3% (59/60). Significant differences were found in the incidence of biliary complications in Groups A (41.7%), B (27.5%) and C (0%). A2 was more likely to have biliary complications than A1 (50% vs 33.3%). B3 had the highest incidence of biliary complications in Group B. Biliary complications are almost inevitable using the classical "two cuff" techniques, and duct-duodenum reconstruction is not an ideal option in rat orthotopic liver transplantation.

Selective ligation of portal vein and hepatic artery for ruptured hepatocellular carcinoma in a 13-year-old boy

Hepatocellular carcinoma (HCC) in children is rare, and the prognosis has been poor because of its advanced stage at diagnosis and unresponsiveness to chemotherapy. We report a 13-year-old boy with ruptured HCC in the left trisegment. When hemostasis of the ruptured surface was achieved in the emergency operation, the left branch of the portal vein and the left hepatic artery were ligated at the same time. The volume of the future liver remnant (FLR), that is, his right posterior sector, increased from 56% on admission to 70% of his standard liver volume on day 2. Blood level of serum protein induced by vitamin K absence or antagonist ІІ started to decrease immediately. Left trisegmentectomy was successfully performed 10 days later, followed by chemotherapy. He has been well with a 2-year survival without recurrence. When the FLR is considered relatively small for a major hepatic resection, the selective ligation of the portal vein and the hepatic artery, which feed HCC, seems to be beneficial. This is because it may induce enlargement of the FLR, increasing the safety of the hepatectomy as preoperative portal vein embolization does before a major hepatectomy in adult patients with HCC, and the latter suppresses the tumor while waiting for the planned hepatectomy.

Liver function alterations after laparoscopy-assisted gastrectomy for gastric cancer and its clinical significance

To evaluate the factors associated with liver function alterations after laparoscopy-assisted gastrectomy (LAG) for gastric cancer. We collected the data of gastrectomy patients with gastric cancer and divided them into 2 groups: open gastrectomy (OG) and LAG. We also collected the data of patients with colon cancer to evaluate the effect of liver manipulations during surgery on liver function alterations. Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin, and alkaline phosphatase were measured on the preoperative day and postoperative day 1 (POD1), POD3, POD5, and POD7. No changes in liver function were observed after the operation in patients with colon cancer (n = 121). However, in gastric cancer patients (n = 215), AST and ALT levels increased until POD5 compared to those in colon cancer patients and these findings were observed both in the LAG and OG without a significant difference except at POD1. The mean hepatic enzyme levels at POD1 in the LAG group were significantly higher than those in the OG group (P = 0.047 for AST and P = 0.039 for ALT). The factors associated with elevated ALT on POD1 in patients with gastric cancer were body mass index (P < 0.001), operation time (P < 0.001), intraoperative hepatic injury (P = 0.048), and ligation of an aberrant left hepatic artery (P = 0.052) but not type of operation (OG vs LAG, P = 0.094). We conclude that the liver function alteration after LAG may have been caused by direct liver manipulation or aberrant hepatic artery ligation rather than the CO₂ pneumoperitoneum.