Major Hepatic Surgery Research Articles

ICG Clearance Test and 99mTc-GSA SPECT/CT Fusion Images

Preoperative estimation of future remnant liver function is critical for major hepatic surgery to avoid postoperative morbidity and mortality. Among several liver function tests, the indocyanine green (ICG) clearance test is still the most popular dynamic method. The usefulness of ICG clearance test parameters, such as ICGR15, K_ICG, or PDR_ICG, has been reported by many investigators. The transcutaneous non-invasive pulse dye densitometry system has made the ICG clearance test more convenient and attractive, even in Western countries. The concept of future remnant K_ICG (rem K_ICG), which combines the functional aspect and the volumetric factor of the future remnant liver, seems ideal for determining the maximum extent of major hepatic resection that will not cause postoperative liver failure. For damaged livers with functional heterogeneity among the hepatic segments, fusion images combining technetium-99m-diethylenetriaminepentaacetic acid-galactosyl human serum albumin single photon emission computed tomography (99mTc-GSA SPECT) and X-ray CT are helpful to precisely estimate the functional reserve of the future remnant liver. Another technique for image-based liver function estimation, gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid(Gd-EOB)-enhanced magnetic resonance imaging, may be an ideal candidate for the preoperative determination of future remnant liver function. Using these methods effectively, morbidity and mortality after major hepatic resection could be reduced.

Method of Direct Segmental Intra-hepatic Delivery Using a Rat Liver Hilar Clamp Model

Major hepatic surgery with inflow occlusion, and liver transplantation, necessitate a period of warm ischemia, and a period of reperfusion leading to ischemia/reperfusion (I/R) injury with myriad negative consequences. Potential I/R injury in marginal organs destined for liver transplantation contributes to the current donor shortage secondary to a decreased organ utilization rate. A significant need exists to explore hepatic I/R injury in order to mediate its impact on graft function in transplantation. Rat liver hilar clamp models are used to investigate the impact of different molecules on hepatic I/R injury. Depending on the model, these molecules have been delivered using inhalation, epidural infusion, intraperitoneal injection, intravenous administration or injection into the peripheral superior mesenteric vein. A rat liver hilar clamp model has been developed for use in studying the impact of pharmacologic molecules in ameliorating I/R injury. The described model for rat liver hilar clamp includes direct cannulation of the portal supply to the ischemic hepatic segment via a side branch of the portal vein, allowing for direct segmental hepatic delivery. Our approach is to induce ischemia in the left lateral and median lobes for 60 min, during which time the substance under study is infused. In this case, pegylated-superoxide dismutase (PEG-SOD), a free radical scavenger, is infused directly into the ischemic segment. This series of experiments demonstrates that infusion of PEG-SOD is protective against hepatic I/R injury. Advantages of this approach include direct injection of the molecule into the ischemic segment with consequent decrease in volume of distribution and reduction in systemic side effects.

Method of Direct Segmental Intra-hepatic Delivery Using a Rat Liver Hilar Clamp Model

Major hepatic surgery with inflow occlusion, and liver transplantation, necessitate a period of warm ischemia, and a period of reperfusion leading to ischemia/reperfusion (I/R) injury with myriad negative consequences. Potential I/R injury in marginal organs destined for liver transplantation contributes to the current donor shortage secondary to a decreased organ utilization rate. A significant need exists to explore hepatic I/R injury in order to mediate its impact on graft function in transplantation. Rat liver hilar clamp models are used to investigate the impact of different molecules on hepatic I/R injury. Depending on the model, these molecules have been delivered using inhalation, epidural infusion, intraperitoneal injection, intravenous administration or injection into the peripheral superior mesenteric vein. A rat liver hilar clamp model has been developed for use in studying the impact of pharmacologic molecules in ameliorating I/R injury. The described model for rat liver hilar clamp includes direct cannulation of the portal supply to the ischemic hepatic segment via a side branch of the portal vein, allowing for direct segmental hepatic delivery. Our approach is to induce ischemia in the left lateral and median lobes for 60 min, during which time the substance under study is infused. In this case, pegylated-superoxide dismutase (PEG-SOD), a free radical scavenger, is infused directly into the ischemic segment. This series of experiments demonstrates that infusion of PEG-SOD is protective against hepatic I/R injury. Advantages of this approach include direct injection of the molecule into the ischemic segment with consequent decrease in volume of distribution and reduction in systemic side effects.

The effect of fluid resuscitation on the effective circulating volume in patients undergoing liver surgery: a post-hoc analysis of a randomized controlled trial

To assess the significance of an analogue of the mean systemic filling pressure (Pmsa) and its derived variables, in providing a physiology based discrimination between responders and non-responders to fluid resuscitation during liver surgery. A post-hoc analysis of data from 30 patients undergoing major hepatic surgery was performed. Patients received 15 ml kg−1 fluid in 30 min. Fluid responsiveness (FR) was defined as an increase of 20% or greater in cardiac index, measured by FloTrac-Vigileo®. Dynamic preload variables (pulse pressure variation and stroke volume variation: PPV, SVV) were recorded additionally. Pvr, the driving pressure for venous return (=Pmsa–central venous pressure) and heart performance (EH; Pvr/Pmsa) were calculated according to standard formula. Pmsa increased following fluid administration in responders (n = 18; from 13 ± 3 to 17 ± 4 mmHg, p < 0.01) and in non-responders (n = 12; from 14 ± 4 to 17 ± 4 mmHg, p < 0.01). Pvr, which was lower in responders before fluid administration (6 ± 1 vs. 7 ± 1 mmHg; p = 0.02), increased after fluid administration only in responders (from 6 ± 1 to 8 ± 1 mmHg; p < 0.01). EH only decreased in non-responders (from 0.56 ± 0.17 to 0.45 ± 0.12; p < 0.05). The area under the receiver operating characteristics curve of Pvr, PPV and SVV for predicting FR was 0.75, 0.73 and 0.72, respectively. Changes in Pmsa, Pvr and EH reflect changes in effective circulating volume and heart performance following fluid resuscitation, providing a physiologic discrimination between responders and non-responders. Also, Pvr predicts FR equivalently compared to PPV and SVV, and might therefore aid in predicting FR in case dynamic preload variables cannot be used.

Elective hepatic resection is feasible and safe in a regional centre.

Hepatic resectional surgery remains a highly specialized area of general surgery usually reserved for completion at tertiary metropolitan referral centres. Port Macquarie, on the Mid North Coast of New South Wales, is the only regionally based hospital offering surgery of this nature in mainland Australia. The purpose of this study is to review the data for patients undergoing hepatic resectional surgery in this non-metropolitan centre in order to illustrate that these operations can be carried out safely in a regional setting with comparable results to tertiary-level centres. A retrospective review of consecutive patients undergoing elective hepatic resections at Port Macquarie from February 2008 to 31 October 2015 was completed. Pre-morbid patient clinical and demographic factors, histopathological details, post-operative complications, survival and mortality data were all noted. A total of 66 consecutive elective liver resections were performed during the study period. Metastatic colorectal cancer was the most commonly observed pathology (n = 33, 50.0%). The 90-day mortality was 4.5% (n = 3) whilst 17 patients (n = 17, 25.8%) experienced major complications (Clavien-Dindo grade 3 or 4). The median overall survival following hepatectomy for colorectal metastases was 48 months (95% confidence interval 37-59 months). Our study shows excellent morbidity, mortality and survival for hepatic resectional surgery performed in a regional centre and is comparable data to major metropolitan centres. Our study confirms that major hepatic resectional surgery in this setting is safe and effective.

Stentgraft Implantation for the Treatment of Postoperative Hepatic Artery Pseudoaneurysm.

Hepatic artery pseudoaneurysms are a rare but potentially life-threatening complication of major pancreaticobiliary surgery. We evaluated the safety and efficacy of endovascular stentgraft implantation for the management of such vascular lesions. Between May 2013 and October 2015, ten patients with postoperative hepatic artery pseudoaneurysm, of which eight presented with active hemorrhage, were treated with endovascular stentgraft implantation. All patients had undergone major pancreatic or hepatic surgery before (pylorus-preserving pancreaticoduodenectomy, pancreatectomy, hemihepatectomy, extended hemihepatectomy). The pseudoaneurysms were diagnosed 13-202 days after surgery and were associated with postsurgical complications (e.g., leakage of pancreaticojejunal anastomosis). In 9/10 patients, the pseudoaneurysm was completely excluded via stentgraft implantation. In 1/10 patient, the pseudoaneurysm ruptured during the procedure and was successfully treated by immediate open surgery. In 1/10 patient, a second intervention was performed after 6 days because of rebleeding; this was successfully treated by implantation of a second overlapping stentgraft. Mean follow-up time is 51 days. None of the patients died due to stentgraft- or aneurysm-related complications. Further episodes of hemorrhage were not observed. In one patient, clinically asymptomatic complete occlusion of the stentgraft was discovered at follow-up imaging. Stentgraft implantation is a safe and effective technique to treat hepatic artery pseudoaneurysms related to major pancreatic or hepatic surgery, especially in the setting of acute hemorrhage.

The temporal pattern of postoperative coagulation status in patients undergoing major liver surgery

IntroductionAfter major liver surgery, there are risks of both postoperative bleeding and thrombosis. Routine coagulation monitoring is indicated, but may not provide adequate clinical guidance. Thus, we described the clotting status in a pilot study using broader coagulation testing. We analysed the temporal pattern of coagulation tests to assess whether thromboelastometry (ROTEM®) would improve the quality of the postoperative monitoring of the coagulation status in patients undergoing major hepatic resections. Material and methodsSixteen patients undergoing major liver resections were examined prior to surgery, on postoperative day 1, and subsequently, every three postoperative days during hospitalization. At the same time, the clinical signs of bleeding and thrombotic complications were monitored. ResultsOn postoperative day 1, increases in bilirubin, PT-INR, APTT, and D-dimers were observed, together with concomitant decreases in fibrinogen, platelet count, antithrombin (AT), protein C and protein S compared to preoperative values. On postoperative days 4 and 7, all of the variables had returned to the normal range except for D-dimers, AT and protein C. The ROTEM® median values remained within the normal range. There were no significant episodes of postoperative bleeding. Two patients were diagnosed with a pulmonary embolism. ConclusionDespite the abnormalities observed in routine coagulation monitoring, thromboelastometry indicated a balanced coagulation status following major hepatic surgery. The levels of both pro- and anticoagulant proteins changed over time during this period. The exact clinical role for thromboelastometry in major hepatic surgery remains to be established.

0078. Establishing a detailed short-term rat model of partial ischaemia/reperfusion injury

Liver ischaemia/reperfusion (I/R) injury may be observed after major hepatic surgery or resuscitation from severe trauma/haemorrhage. Well-characterised and representative animal models are needed to better understand mechanisms of injury, apply effective treatments and prevent complications.

Inhibition of neogenin dampens hepatic ischemia-reperfusion injury.

Liver ischemia and reperfusion injury is a common source of significant morbidity and mortality following liver transplantation, hemorrhagic shock, or major hepatic surgery. Based on studies showing a critical role for the neuronal guidance receptor neogenin (Neo1) outside the nervous system in mediating tissue adaption during acute inflammation, we hypothesized that Neo1 enhances hepatic ischemia and reperfusion injury. Animal study. University-based experimental laboratory. Wid-type, neogenin deficient and chimeric mice. Neogenin expression was evaluated during inflammatory stimulation in vitro and during ischemia and reperfusion injury in vivo, intravital microscopy performed to study intravascular flow characteristics. The extent of liver injury was evaluated using histology, serum levels of lactate dehydrogenase, aspartate, and alanine aminotransferase. The functional role of Neo1 during liver IR was evaluated in mice with gene targeted repression of neogenin (Neo1-/-), bone marrow chimeric animals and controls. In addition, functional inhibition of neogenin was performed using antibody injection. We observed an induction of Neo1 during inflammation in vitro and ischemia and reperfusion in vivo. Intravital microscopy demonstrated a decreased ability of Neo1 leukocytes to attach to endothelial vascular wall during inflammation. Subsequent studies in Neo1 mice showed attenuated serum levels of lactate dehydrogenase, aspartate, alanine, and proinflammatory cytokines during hepatic ischemia and reperfusion injury. This was associated with improved hepatic histology scores. Studies in chimeric animals demonstrated that the hematopoietic Neo1 expression to be crucial for the observed results. Treatment with an anti-Neo1 antibody resulted in a significant reduction of experimental hepatic ischemia and reperfusion injury, involving attenuated variable of lactate dehydrogenase, alanine, aspartate, and cytokine levels. These data provide a unique role for Neo1 in the development of hepatic ischemia and reperfusion injury and identified Neo1 as a potential target to prevent liver dysfunction in the future.

Attitudes of patients and care providers to enhanced recovery after surgery programs after major abdominal surgery

BackgroundEnhanced recovery after surgery (ERAS) is a well-established pathway of perioperative care in surgery in an increasing number of specialties. To implement protocols and maintain high levels of compliance, continued support from care providers and patients is vital. This survey aimed to assess the perceptions of care providers and patients of the relevance and importance of the ERAS targets and strategies. Materials and methodsPre- and post-operative surveys were completed by patients who underwent major hepatic, colorectal, or oesophagogastric surgery in three major centers in Scotland, Norway, and The Netherlands. Anonymous web-based and article surveys were also sent to surgeons, anesthetists, and nurses experienced in delivering enhanced recovery protocols. Each questionnaire asked the responder to rate a selection of enhanced recovery targets and strategies in terms of perceived importance. ResultsOne hundred nine patients and 57 care providers completed the preoperative survey. Overall, both patients and care providers rated the majority of items as important and supported ERAS principles. Freedom from nausea (median, 10; interquartile range [IQR], 8–10) and pain at rest (median, 10; IQR, 8–10) were the care components rated the highest by both patients and care providers. Early return of bowel function (median, 7; IQR, 5–8) and avoiding preanesthetic sedation (median, 6; IQR, 3.75–8) were scored the lowest by care providers. ConclusionsERAS principles are supported by both patients and care providers. This is important when attempting to implement and maintain an ERAS program. Controversies still remain regarding the relative importance of individual ERAS components.

Peripancreatic pseudoaneurysms: a management-based classification system

Background Peripancreatic pseudoaneurysms can arise in a number of different clinical settings but are associated mostly with pancreatitis and pancreatobiliary surgery. The aim of this study is to review the current literature and to propose a management classification system based on the pathophysiological processes and the exact anatomical site of peripancreatic pseudoaneurysms.MethodsA systematic review of the literature from 1995 to 2012 was performed. Articles on studies describing peripancreatic pseudoaneurysms in the setting of pancreatitis or major hepatic or pancreatic surgery with more than ten patients were included. Seventeen eligible studies were identified and reviewed.ResultsThe demographic characteristics of the patients in all studies were similar with a predominance of males and a mean age of 55 years. The overall mortality rate varied greatly among the studies, ranging from 0 to 60 %. Embolisation was the first line of management in the majority of the studies, with surgery reserved for failed embolisation or for haemodynamically unstable cases. Embolisation of the hepatic artery or its branches was associated with high rates of morbidity (56 %) and hepatic failure (19 %). More recent studies show that stents are used increasingly for vessels that cannot be embolised safely. Late bleeding, a major cause of mortality and morbidity, is generally underreported. The proposed classification system is based on three factors: (1) the type of artery from which the pseudoaneurysm arises, (2) whether communication with the gastrointestinal tract is present, and (3) whether there is high concentration of pancreatic juice at the bleeding site.ConclusionThe management of peripancreatic pseudoaneurysms usually comprises a combination of interventional radiology and surgery and this may be assisted by a logical classification system.

OC-041 Enhanced Monocyte Function and Surface TLR Expression Predict Post-Operative Systemic Inflammatory Response Syndrome in Patients Immediately following Major Hepatic and Pancreatic Resection

<h3>Introduction</h3> Patients undergoing major surgery are at risk of systemic inflammatory response syndrome (SIRS) and life-threatening post-operative sepsis. Early identification of high-risk patients would allow for tailored post-operative care. We tested the hypothesis that post-operative SIRS could be predicted by differences in innate immune function in peripheral blood mononuclear cells (PBMC) taken from patients undergoing major abdominal surgery in the perioperative period. <h3>Methods</h3> Serial blood samples were taken from consenting, adult patients undergoing major hepatic or pancreatic surgery pre-operatively and on days one and two postoperatively. Patients with inflammatory co-morbidities, pre-operative sepsis and those taking anti-inflammatory or immunomodulatory medication were excluded. PBMCs were isolated, stimulated for 24 hours with lipopolysaccharide (LPS) or flagellin and cytokine production was quantified by ELISA. PBMC surface expression of CD14, TLR4 and TLR5 was assessed by flow cytometry. SIRS was defined by the American College of Chest Physicians/Society of Critical Care Medicine consensus criteria. <h3>Results</h3> We included 32 patients, nine of whom developed SIRS on day five or later. There were no significant pre-operative differences between the SIRS and the non-SIRS groups in TLR-induced IL-6 and TNFa production nor TLR4 and TLR5 expression. LPS- and flagellin- induced IL-6 concentrations were significantly greater in the SIRS group on day two (1532pg/µl vs 153pg/µl; p &lt; 0.0002). Monocyte expression of both TLR4 and TLR5 was significantly greater in the SIRS group on both day one (p &lt; 0.002) and day two (p &lt; 0.001). There was no significant difference in CRP or other clinical predictors of SIRS between the groups in the early post-operative period. <h3>Conclusion</h3> Patients who develop SIRS show increased cytokine production in response to TLR stimulation in the early post-operative period. This is associated with elevated surface TLR4 and TLR5 expression in monocytes. These data indicate that there are early functional differences in innate immune responses in patients who develop SIRS compared to those who do not, and that these differences are detectable days before the onset of clinical symptoms. Such assays can help to identify at-risk patients in whom intensive therapy can be targeted. <h3>Disclosure of Interest</h3> None Declared

Reduced sevoflurane consumption in cirrhotic compared to non-cirrhotic patients undergoing major hepatic surgery

BackgroundThere is evidence in literature that chronic hepatic patients need less anesthesia compared with healthy ones. Liver cirrhosis leads to a reduction in liver mass and hepatic blood flow with an effect on drug clearance and cardiovascular stability.AimTo evaluate sevoflurane consumption during entropy monitored general anesthesia in cirrhotic and non-cirrhotic patients during transition from consciousness to unconsciousness and throughout the procedure of major hepatic surgical procedures.Patients and methodsForty patients scheduled for major hepatic resection at the National Liver Institute, Menofiya University, Egypt, were studied prospectively and randomized into two equal groups. Group I (n. 20) cirrhotic patients (Child Pugh Grade A) with focal lesion, Group II (n. 20) healthy live liver donors undergoing major hepatectomies. Sevoflurane inhalational concentration was adjusted to achieve a state and response entropy of 40–60, and when RE increases 5–10 units above SE; more intravenous analgesics were given.ResultsMean (SD) Sevoflurane consumption in Group II showed higher consumption 23.5 (3.23) ml, compared to Group I 16 (2.19) ml. Mean (SD) sevoflurane consumption after 4 and 6 h from induction also showed a lower value in Group I 10.7(1.94), 9(1.22) ml, than in Group II 17.2(1.69), 14.1(2.19) ml, respectively. Mean (SD) end tidal sevoflurane concentration was lower in Group I 1.4(0.12) after 2 h from induction than in Group II 1.7(0.11). After 4 and 6 h from induction Group I demonstrated a lower value compared to Group II (P < 0.05.). Mean blood pressure, heart rate, urine output and CVP showed no significant changes during maintenance between the two groups.ConclusionThis study demonstrated that cirrhotic patients require less sevoflurane consumption and lower end-tidal concentration to maintain general anesthesia with entropy guidance. This could also have an important impact on the economic costs when applied on a larger scale.

Evaluation of Hemostatic Factors in Patients Undergoing Major Hepatic Resection and Other Major Abdominal Surgeries

The aim of this study was to evaluate the role for additional testing of coagulation in perioperative management of patients undergoing major hepatic resection. Major outcome measures were perioperative measurements of hemostatic factors (activated partial prothrombin time [aPTT], prothrombin time/international normalized ratio, fibrinogen, antithrombin-III). We conducted a prospective, single-blind study comparing hemostatic factors in patients undergoing major hepatectomy, Whipple procedures, and other gastrointestinal operations. Ninety-five consecutive patients were enrolled. No values differed significantly at baseline. Immediately postoperative, only international normalized ratio was significantly lower comparing major hepatectomy with Whipple (P < 0.005) and other procedures (P < 0.0032). Twenty-four hours postoperative, antithrombin-III was lower for major hepatectomy than Whipple (P < 0.028) and others (P < 0.0001); fibrinogen was lower compared with Whipple (P < 0.014) and others (P < 0.0009); international normalized ratio was lower to compared with Whipple (P < 0.0001) and others (P < 0.0001). aPTT measurements never differed significantly between groups at any time. Antithrombin-III and fibrinogen only correlated with international normalized ratio and aPTT for the other procedures. Additional hemostatic values beyond the standard evaluations of aPTT and international normalized ratio are needed to better assess patients undergoing major hepatic surgery.

Systematic review and meta-analysis of steatosis as a risk factor in major hepatic resection

The risk of major hepatic resection in patients with hepatic steatosis remains controversial. A meta-analysis was performed to establish the best estimate of the impact of steatosis on patient outcome following major hepatic surgery. A systematic search was performed following Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. Risk ratios (RRs) for complication and mortality rates were calculated for patients with no, less than 30 per cent and at least 30 per cent steatosis, and a meta-analysis was carried out. Of six observational studies identified, four including a total of 1000 patients were subjected to meta-analysis; two others were tabulated separately. Compared with patients without steatosis, those with less than 30 per cent and at least 30 per cent steatosis had a significantly increased risk of postoperative complications, with a RR of 1.53 (95 per cent confidence interval (c.i.) 1.27 to 1.85) and 2.01 (1.66 to 2.44) respectively. Patients with at least 30 per cent steatosis had an increased risk of postoperative death (RR 2.79, 95 per cent c.i. 1.19 to 6.51). Patients with steatosis had an up to twofold increased risk of postoperative complications, and those with excessive steatosis had an almost threefold increased risk of death.

235 HEPATOCELLULAR CARCINOMA AND UNDERLYING LIVER CIRRHOSIS; INFLUENCE ON TREATMENT OR A PROGNOSTIC VALUE?

Background: Despite its benign nature, hepatocellular adenomas (HA) have a potential for malignant degeneration or spontaneous rupture and bleeding. Therefore, surgical resection is the treatment of choice in selected patients. However, radio frequency ablation (RFA) could offer a viable alternative, and might prevent these patients from undergoing major hepatic surgery with associated morbidity and costs. Aim: To investigate the safety and efficacy of RFA for the treatment of HA. Methods: From 2000 to 2009, 168 patients diagnosed with HA in a tertiary hepato-biliary centre were included in a database. For patients undergoing RFA, clinicopathologic data with regard to diagnosis, treatment and outcome were collected. RFA was considered successful if no residual HA tissue was visualized on contrast enhanced CT or MRI 4–6 weeks post-RFA. Results: Of 61 patients undergoing treatment for HA, 17 patients (28%) underwent RFA. Mean age was 29 years. All patients were female with a history of hormonal contraceptive use. Nine patients (53%) had multiple HA, with a median number of 2 lesions (range 1–10) per patient. Median size of the largest HA at the time of RFA was 3.9 cm (range 1.5–6.7). 39 lesions were ablated in 25 sessions (open n=5, percutaneous n =20). Complete remission was acquired in eight patients after one (n =4) or two (n =4) RFAsessions. Another five patients (29%) had radiological evidence of residual HA tissue (≤15mm) bordering the thermal lesion, but due to low clinical importance no further treatment was administered. All of these lesions have remained stable or regressed during followup. Four patients are currently awaiting further therapy or followup. Post-operatively, one patient developed a liver abscess requiring re-intervention and one patient suffered from amajor but reversible complication related to concomitant hemi-hepatectomy. Median hospital stay was 7 days in the open group and 2 days in the percutaneous group. Conclusion: HA can be safely treated using both open and percutaneous RFA. However, often multiple sessions are required and signs of residual adenoma persist in some patients despite repetitive treatment. RFA might be especially beneficial for patients not amenable for surgery or those that would require major hepatic resection otherwise.

Steatosis Is a Risk Factor for Complications and Mortality Following Major Hepatic Resection: A Systematic Review and Meta-Analysis

Introduction: With the increasing prevalence of obesity and the metabolic syndrome, about 20% of patients undergoing liver resection and up to 25% of donors for liver transplantation have some degree of steatosis. While extensive surgery can be safely performed on healthy livers, the risk of major hepatic resection in patients with steatosis remains the subject of controversy. We performed a meta-analysis to establish the best estimate of the impact of steatosis on patient outcome following major hepatic surgery.

Multimodal approach to liver neoplasm in elderly patients. A single center experience

Surgical therapy remains the gold standard for treatment of liver neoplasms. In the last 20 years we assisted to an increase of survival in patients with a diagnosis of hepatocellular carcinoma (HCC), according to screening programs, and a multimodal therapeutical approach. In the last years it was an increase of elderly patients with HCC cause of the increase of infection of HCV and an increase of geriatric patients; together with HCC, hepatic metastases represent the main topics of our investigation. Is justified an aggressive approach to liver neoplasms in the elderly? Recent studies show as elderly is not a contraindication to major hepatic surgery. The aim of this study is to evaluate the effective advantage of multimodal approach to hepatic surgery in elderly population (70 years old and older).

Clinical results of N-acetylcysteine after major hepatic surgery: a review

Ischemia/reperfusion injury is thought to play an important role in postoperative liver dysfunction and morbidity following major liver surgery. N-acetylcysteine may be protective by serving as a precursor to glutathione and replenishing intracellular stores, in addition to other mechanisms. The purpose of this review is to summarize the clinical evidence that N-acetylcysteine may reduce liver dysfunction and the postoperative complications following major liver surgery. A PubMed (MEDLINE) search was performed using the search terms "N-acetylcysteine", "Mucomyst", "liver", and "surgery" to identify all relevant articles published in English prior to February 2007. Seventy-three articles were identified, and of these, there were seven studies that involved human patients undergoing orthotopic liver transplantation (six randomized controlled trials and one retrospective study). The evidence that routine use of N-acetylcysteine reduces ischemia/reperfusion injury and prevents complications after major liver surgery is not conclusive. The available studies may have been limited by small sample sizes, and heterogeneous outcome measures prevent conclusions being made across studies and prevent pooling of the data. Further study with more relevant clinical endpoints and larger sample sizes is warranted.

Morbidity and Mortality Following Multivisceral Resections in Complex Hepatic and Pancreatic Surgery

Complex multivisceral resections in major hepatic and pancreatic surgery are relatively infrequent, and information regarding the morbidity and mortality associated with such resections is scant. The purpose of this paper is to describe the outcomes following such aggressive surgical treatment. A retrospective review of the outcomes following multiorgan resection in the setting of major liver or pancreatic resection was conducted from 2002 until July 2006. Patients who had a major hepatic or pancreatic resection plus resection of at least one other organ were included. The primary outcome measures analyzed were the postoperative morbidity and mortality. Secondary outcomes included recurrence rates and survival. Twenty-seven patients met the inclusion criteria. There were two postoperative deaths (7%). Complications occurred in 59% of patients. Complications were minor in 26% and severe in 33%. Complications were more frequent in older patients and in patients with pancreatic resections. Mortality was significantly increased in the setting of a pancreaticoduodenectomy. These more aggressive procedures should be considered to carry a higher risk of complications, particularly in patients undergoing pancreaticoduodenectomies. Patients should be selected carefully when undertaking complex multivisceral resections in major hepatic and pancreatic surgery.