Postoperative Ascites Research Articles

Predicted clinical factors associated with the intensive care unit length of stay after total cavopulmonary connection

ObjectivesA longer length of stay (LOS) in the intensive care unit (ICU) after the total cavopulmonary connection (TCPC) is thought to be a predictive sign of late Fontan failure. This study was performed to determine the clinical risk factors for ICU LOS. MethodsIn total, 483 patients who underwent a TCPC between May 1994 and December 2016 were included the study. Patients’ main diagnosis, morphologic characteristics, palliative procedures, hemodynamic parameters, and perioperative variables, were analyzed to identify risk factors influencing ICU stay based on Cox regression. Causes of longer ICU LOS and the impact of ICU LOS on late outcomes were evaluated. ResultsAge at TCPC, type of TCPC, and fenestration at TCPC did not affect the ICU LOS. With multivariable model, hypoplastic left heart syndrome (P = .001) and anomalous systemic venous drainage (P < .001) were identified as independent morphologic risk factors for prolonged ICU LOS. Of hemodynamic variables, preoperative high transpulmonary gradient (P = .037), and low aortic oxygen saturation (P = .031) were risks for longer ICU LOS. Of postoperative variables, pleural effusion (P < .001), chylothorax (P = .001), ascites (P < .001), and infection (P = .028) were risks for longer ICU LOS. The ICU LOS was found to be significantly associated with late mortality (P < .001) and late cardiac reoperation (P = .007). ConclusionsPatients with hypoplastic left heart syndrome and anomalous systemic venous drainage had longer ICU LOS. Extended cyanosis and elevated pulmonary artery pressure affect the ICU LOS. Special care should be provided during the initial postoperative phase in patients with such risk factors.

Transjugular intrahepatic portosystemic shunt as a bridge to elective abdominal surgery in cirrhotic patients: friend or foe?

Background: While abdominal surgery is associated with higher morbidity and mortality in cirrhotic patients, preoperative TIPS has been suggested as a means to reduce portal hypertension and postoperative complications. This study aims to compare cirrhotic patients with preoperative transjugular intrahepatic portosystemic shunt (TIPS) placement and cirrhotic patients without TIPS, in terms of morbidity and mortality after elective extra hepatic abdominal surgery. Study design: Patients were retrospectively included from 2005 to 2016 in four tertiary referral hospitals. Patients who underwent preoperative TIPS (n=66) were compared to control patients without TIPS (n=68). Postoperative outcome was analyzed using inverse probability of treatment weighting. Results: Ten patients (15%) did not undergo planned surgery after receiving TIPS procedure. Preoperative TIPS placement was associated with less postoperative ascites (HR=0.33, 95 per cent i.c. 0.14 to 0.78) but this did not translate into better postoperative outcomes. Patients with hepatic venous pressure gradient (HVPG) ≤13 mmHg and MELDNa ≤15 seemed to benefit from preoperative TIPS placement in terms of severe postoperative complications (HR=0.21, 0.05 to 1.02 and HR=0.16, 0.03 to 1.05, respectively). TIPS patients in colorectal surgery and HVPG >13 mmHg subgroups required more intraoperative red blood cells transfusions (HR=15.03, 1.71 to 132.17 and HR=4.10 1.16 to 14.47, respectively). Conclusions: Although TIPS placement before elective surgery decreased postoperative ascites, this study failed to demonstrate a benefit in terms of intra and postoperative outcome. Results suggest nevertheless a decrease in severe postoperative complications in patients with mild hepatopathy (HVPG ≤13 mmHg and MELDNa ≤15) but further evaluation is necessary.

Usefulness of the milk test to prevent chylous ascites after pancreatectomy

Introduction: The usefulness of the milk test to prevent chylous ascites after pancreatectomy was investigated using a randomized controlled trial. Method: The milk test involves injecting 100 mL milk through a nasogastric tube during pancreatectomy. If a chyle leak is present, the patient tests positive. Drain triglyceride (DTG) was measured on the first and third postoperative day (POD). Results: From November 2013 to June 2017, 253 patients were enrolled; 211 patients underwent pancreatic head resection, 39 underwent distal pancreatectomy, and 3 underwent middle pancreatectomy. The milk test was used in 125 patients (group A) and not used in 128 patients (group B). In group A, the milk test was positive in 29 patients (23.2%). The superior mesenteric artery (11 patients) and middle colic artery (10 patients) were common leakage sites. The incidence of postoperative chylous leaks defined by the ISGPS was on Table 1.Tabled 1TableChyle leakGroup A milk test positiveGroup A milk test negativeGroup BTotalNone2193116230Grade A731020Grade B1023Grade C0000Total2996128253 Open table in a new tab Chylous ascites occurred in 3 patients (1.2%), all during pancreatic head resection. In group B, grade B chyle leaks were observed twice as often as in group A, but the difference was not significant. DTG levels on POD 1/POD 3 were 123.9/83.5 in milk test-positive patients and 63.2/47.1 in milk test-negative patients in group A, 52.8/52.3 in group B patients, 58.1/42.4 in the no chyle leak patients, 144.3/186.9 in grade A and 73.3/62.3 in grade B patients. Conclusion: DTG level was not a predictor of postoperative chylous ascites. Without the milk test, Grade B chyle leaks occurred twice as often, but this was not statistically significant.

Assessment of preoperative liver function in patients undergoing liver resection – The ALICE grade

Objective: Precise preoperative evaluation of the patient's liver function is essential for surgical decision making in patients with hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM). The aim of the study is to validate the usefulness of the new preoperative liver function evaluation system, Albumin-Indocyanine Green Evaluation (ALICE) grading system, for predicting the postoperative outcomes after liver resection in both HCC and CRLM patients. Methods: The ALICE grading system, incorporating only serum albumin level and the indocyanine green retention rate at 15 minutes (ICG R15), was developed based on the overall survival of 1868 HCC patients: linear predictor = 0.663 × log10ICG R15 (%) - 0.0718 × albumin (g/L) (cut-off value: -2.20 and -1.39). We analyzed the predictive power for the postoperative short-term outcome after liver resection in 1025 patients with HCC and 348 patients with CRLM. Results: Determination of the ALICE grade allowed better prediction of the risk of postoperative liver failure than the previously reported model based on the presence/absence of portal hypertension (PH). A combination of ALICE grade and PH further predicted the risk of postoperative liver failure. Determination of the ALICE grade also allowed prediction of the risk of postoperative complications and ascites in patients with CRLM, which was also significant in multivariate analysis. Pathological examination revealed chemotherapy related liver damage in high ALICE grade CRLM patients. Conclusions: This new grading system is a simple method for prediction of the postoperative short-term outcomes in both HCC and CRLM patients.

Evaluation of postoperative ascites after somatostatin infusion following hepatectomy for hepatocellular carcinoma by laparotomy: a multicenter randomized double-blind controlled trial (SOMAPROTECT)

BackgroundThe majority of patients undergoing hepatectomy for hepatocellular carcinoma (HCC) suffer from underlying liver disease and are exposed to the risk of postoperative ascites, which is favored by an imbalance between portal venous inflow and a diminished hepatic volume. Finding a reversible, non-invasive method for modulating the portal inflow would be of interest as it could be used temporarily during the early postoperative course. Somatostatin, a well-known drug already used in several indications, may limit the risk of postoperative ascites and liver failure by decreasing portal pressure after hepatectomy for HCC in patients with underlying liver disease. We aimed to evaluate the impact of somatostatin postoperative infusion on the incidence of ascites following hepatectomy by laparotomy for HCC in patients with underlying liver disease.Methods/designThe SOMAPROTECT study is a multicenter randomized double-blind placebo controlled phase III trial comparing two arms of patients with underlying liver disease undergoing hepatectomy for HCC by open approach. All patients will have primary abdominal drainage before closure. Patients in the experimental arm will receive a postoperative intravenous infusion of somatostatin during 6 days. Patients in the control group will receive a placebo infusion for the same duration. The primary endpoint will be the presence or absence of postoperative ascites occurring during the 90-day postoperative course, defined as ≥500 ml/24 h of fluid in the drains during at least 3 days or any ascites requiring an invasive procedure comprising percutaneous puncture or drainage. Secondary endpoints will be duration and total volume of ascites, postoperative 90-day mortality and morbidity, liver failure, acute renal failure, length of stay in intensive care unit and hospital stay. The total number of patients to be enrolled was calculated to be 152.DiscussionPostoperative ascites remains a major issue after hepatectomy for HCC as it is associated with increased morbidity, liver and renal failure, the need for specific treatments and prolonged hospital stay. This study represents the first randomized controlled trial to assess the benefits of somatostatin on the risk of postoperative ascites after surgery for HCC.Trial registrationNCT02799212 (ClinicalTrials.gov identifier). Registered prior to conducting the research on 9 June 2016.

Optimal introduction of laparoscopic liver resection for Child-Pugh B.

Surgery for Child-Pugh B liver function is considered risky because of its high morbidity rate and the acceptable indication criteria for laparoscopic liver resection (LLR) for Child-Pugh B patients have not been identified. We conducted a retrospective cohort study to determine the optimal introduction of LLR for Child-Pugh B patients based on our single-institute experience. A total of 17 Child-Pugh B patients underwent LLR between 2005 and 2017. Their clinical outcomes were compared to those of LLR for Child-Pugh A patients (103 cases), conventional open liver resection for Child-Pugh B patients (19 cases), and radiofrequency ablation (RFA) for Child-Pugh B patients (20 cases) during the same period. LLR for Child-Pugh B patients had a significantly higher conversion rate than LLR for Child-Pugh A patients (Child-Pugh A vs B: 3.9% vs 35.3%, P < 0.01). However, patients who successfully underwent laparoscopic resection (11 cases) had fewer postoperative ascites and shorter postoperative hospital stays compared to patients who underwent conventional open liver resection. In comparison to the RFA group, the LLR group more frequently had lesions in the left lateral segment (LLR vs RFA: 50.0% vs 10.0%, P = 0.02) and exophytic tumor (21.4% vs 0%, P = 0.02) than did the RFA group. Also, compared to the RFA group, the LLR group had a lower local recurrence rate (0% vs 15%, P = 0.25) and a longer recurrence-free survival (P = 0.049), but the overall survival was similar between the two groups. In the treatment of Child-Pugh B liver malignancy, the minimal invasiveness of LLR was revealed. Our results suggest that lesions in the left lateral segment and exophytic tumors are good indications for LLR for Child-Pugh B.

Polycystic liver disease: Hepatic venous outflow obstruction lesions of the noncystic parenchyma have major consequences.

Hepatic venous outflow obstruction, including development of venous collaterality and parenchymal changes, is frequent in PLD and has major consequences on intraoperative bleeding and postoperative ascites and liver failure. Hepatic venous outflow obstruction should be taken into account to choose the most appropriate surgical treatment. (Hepatology 2017).

Risk stratification using a novel liver functional reserve score of combination prothrombin time–international normalized ratio to albumin ratio and albumin in patients with hepatocellular carcinoma

BackgroundLiver function in patients with hepatocellular carcinoma is generally graded according to the Child-Pugh system; however, some variables in the Child-Pugh grade are subjective. We developed a novel, objective score called the prothrombin time–international normalized ratio to albumin ratio. The aim of this study was to evaluate the prognostic value of this new score in patients with hepatocellular carcinoma after hepatic resection. MethodsThe study comprised 199 patients who underwent elective hepatic resection for hepatocellular carcinoma between January 2003 and December 2014. We investigated retrospectively the relation between prothrombin time–international normalized ratio to albumin ratio, disease-free survival, and overall survival and compared the value of liver functional reserve between prothrombin time–international normalized ratio to albumin ratio and Child-Pugh grade. ResultsThe optimal cut-off level of the prothrombin time–international normalized ratio to albumin ratio was 0.288. In multivariate analysis, the independent and significant predictors of cancer recurrence consisted of hepatitis C virus infection (P = .043), preoperative retention rate of indocyanine green at 15 minutes ≥15% (P = .039), the presence of multiple tumors (P = .001) or microvascular invasion (P < .001), and prothrombin time–international normalized ratio to albumin ratio ≥0.288 (P = .022). The independent predictors of poor overall survival were microvascular invasion (P = .001) and prothrombin time–international normalized ratio to albumin ratio ≥0.288 (P = .001). In patients with a high prothrombin time–international normalized ratio to albumin ratio, pathologic liver cirrhosis (P < .001), postoperative ascites (P = .039), and postoperative liver failure (P = .040) were greater than for their counterparts. ConclusionThe prothrombin time–international normalized ratio to albumin ratio may reflect liver function and may be a novel indicator of poor long-term outcome in patients with hepatocellular carcinoma after hepatic resection.

A novel scoring system to predict ascites development post hepatectomy for BCLC stage B hepatocellular carcinoma

Background: To develop a novel scoring system to predict the development of post-operative ascites by analyzing clinicopathological characteristics and risk factors of BCLC stage B hepatocellular carcinoma. Methods: Prospective analysis was performed on consecutive patients with BCLC stage B hepatocellular carcinoma, who underwent hepatectomy from January 2005 to December 2014. Results: A total of 181 patients were enrolled, of whom 34.3% (62/181) developed post-operative ascites. Comparing with patients without ascites, patients who developed ascites had longer drain placement, more incidence of pleural effusion, more incidence of intra-abdominal infection and longer inpatient stay. All differences were statistically significant (P Conclusions: The development of post-operative ascites was associated with various clinicopathological factors. The scoring system, which incorporates these factors, provided a valuable means for predicting the development of post-operative ascites. Early identification of these at-risk patients might help to improve their perioperative outcome.

A novel scoring system to predict ascites development post hepatectomy for BCLC stage B hepatocellular carcinoma

Background: To develop a novel scoring system to predict the development of post-operative ascites by analyzing clinicopathological characteristics and risk factors of BCLC stage B hepatocellular carcinoma.

Benefits of Laparoscopic Approach for Resection of Liver Tumors in Cirrhotic Patients

Liver resection in cirrhotic patients is associated with increased morbidity and mortality. The objective of this study was to compare short-term results of laparoscopic resection (LR) and open surgery (OS) for minor liver resection in patients with hepatocellular carcinoma (HCC) hepatocellularcarcinoma on nontumor cirrhotic liver (HCC/F4) and patients with colorectal cancer liver metastases (CRLMs) colorectal liver metastases on healthy liver (CRLM/F0). Between January 2005 and December 2014, all patients undergoing liver resection (n = 754) were included in this study. Liver resections for cholangiocarcinoma or benign tumor, major liver resection (≥3 segments), HCC on healthy liver, CRLM on cirrhotic liver, and liver resection with technically difficult accessibility (segments I, VII, and VIII) were excluded. The primary endpoint of the study was a validated composite endpoint (CEP), which included specific liver surgery complications (Clavien ≥III), allowing comparison of the postoperative course after LR versus OR for HCC/F4 patients and CRLM/F0 patients using propensity score (PS) analysis. Secondary endpoints were major postoperative morbidity according to the Clavien-Dindo classification (≥III) and intensive care unit (ICU) length of hospital stay (LOS) and overall LOS. The test group was defined as HCC/F4 patients operated by LR, and the control group was defined as HCC/F4 patients and CRLM/F0 patients operated by OS and CRLM/F0 patient operated by LR. Sixty patients (38.7%) underwent LR and 95 patients (61.3%) underwent OS. Surgery was performed for CRLM in 93 patients (60%) and for HCC in 62 patients (40%). No difference was demonstrated between HCC/F4 patients and CRLM/F0 patients in the LR group in terms of the CEP (7% versus 18.1%; P = .23), while a significant difference for the CEP was observed between HCC/F4 patients and CRLM/F0 patients after OS (50% versus 21%; P = .021). A higher rate of CEP was observed for HCC/F4 patients operated by OS compared to HCC/F4 patients operated by LR (50% versus 7.8%; P = .009). No significant difference in Clavien-Dindo score ≥III was observed between HCC/F4 patients and CRLM/F0 patients operated by LR (10% versus 4.5%; P = .98). A higher postoperative ascites rate was observed for HCC/F4 patients operated by OS compared to CRLM/F0 patients operated by OS (25% versus 2.8%; P = .006). This difference was no longer observed when HCC/F4 patients were compared to CRLM/F0 operated by LR (7.8% versus 2.8%; P = .09). The postoperative mortality rate was 1.8% and was not correlated with nontumor liver or surgical approach. A shorter LOS was observed for HCC/F4 patients operated by LR compared to HCC/F4 patients operated by OS (7.53 versus 17.13; P = .011). The laparoscopic approach for malignant liver tumor is associated with a lower specific complication rate. LR for HCC/F4 could eliminate excess morbidity and decrease LOS in patients with cirrhotic liver.

Indocyanine Green Retention Rates at 15min Predicted Hepatic Decompensation in a Western Population.

ICGR15 is widely used in Asia to evaluate the liver reserve before hepatectomy, but not in Western countries where patients are selected using the MELD score and/or platelet count. Postoperative liver failure is rare nowadays, but hepatic decompensation (HD), defined by 3-month postoperative ascites, impairs quality of life and survival. The aim of this study was to evaluate the relevance of indocyanine green retention rate at 15min (ICGR15) before liver resection in Western countries, in order to predict HD. This prospectively designed study included consecutive adult patients undergoing hepatectomy for hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) in three French HPB centres. Between 2012 and 2014, 147 patients were included (80% of HCC and 20% of ICC). The Child-Pugh status was grade A for all patients. In the overall population and in F3/F4 patients (n=83), ICGR15 (P=0.02) and platelet counts (P=0.02) were predictive of HD under multivariate analysis. Among F3/F4 patients undergoing minor hepatectomy with preoperative ICGR15>15%, the rate of HD was 36%. In the overall population, ICGR15 was predictive of HD (P=0.02) and postoperative ascites (P=0.03). The ROC curve identified a cut-off point of 15% as being associated with increased HD, with good accuracy for ICGR15 in the study population (AUROC 0.73), mainly before minor hepatectomy (AUROC 0.79). In patients with HCC and ICC selected using the MELD score and platelet rate, an ICGR15>15% is a relevant, non-invasive and clearly accurate method to predict HD specially before minor hepatectomy.

Impact of Chylous Ascites on Colon Cancer in Laparoscopic Surgery

Objectives: To investigate the epidemiology and risk factors of chylous ascites. Methods: We identified the cases of 913 consecutive patients who underwenturgery for colorectal cancerat our University Hospital between January 2005and December2016. We divided the patients into thosewith and those without chylous ascites and compared the two groups by age, gender, body mass index, tumor location, T, N factor, stage, operation time, intra-operative bleeding, and duration of postoperative hospital stay. Results: Chylous ascites developed in 8 of the 913 patients (0.8%). Neither age, sex, tumor location, and body mass indexnor number of lymph nodeswereassociated with postoperative chylous ascites. Ascites occurred significantly less frequently in the early stage of colorectal cancer than in the late stage (p = 0.04). There was no significant difference between the groups in operative factors, including operation time and blood loss. Postoperative hospital stays were longer in patients with chylous ascites (20.5 days) than in those without (11 days) (p = 0.02). Conclusions: Late stage was one of the risk factors for chylous ascites in the present study. Other risks, such as tumor location and blood loss,will vary from institution to institution.

Laparoscopic cholecystectomy in cirrhotic patients with symptomatic cholelithiasis

Background Gallstones are twice as common in cirrhotic patients as in the general population. Although laparoscopic cholecystectomy (LC) has become the gold standard for symptomatic gallstones, cirrhosis has been considered an absolute or relative contraindication. Many authors have reported on the safety of LC in cirrhotic patients. We reviewed our patients retrospectively and assessed the safety of LC in cirrhotic patients at our unit of Zagazig University Hospital. Patients and methods From January 2014 to December 2016, a total of 200 patients underwent LC for symptomatic gallstone disease. All the cirrhotic patients with Child–Pugh class A and B cirrhosis undergoing LC were included in the study. Cirrhosis was diagnosed based on clinical, biochemical, ultrasonography, and intraoperative findings of the nodular liver and histopathological study. Results Of the 200 patients undergoing LC, 20 (10%) were cirrhotic. Of these 20, 12 (60%) were Child’s group A and eight (40%) were group B; 65% had hepatitis C, 5% had hepatitis B, 20% had combined C and B hepatitis, and 10% were had hepatitis. Preoperative diagnosis of cirrhosis was possible in 90% of cases, and 10% were diagnosed during surgery. The morbidity rate was 20% and no mortality was seen. One patient had hemorrhage, one patient developed postoperative ascites, one patient showed wound infection, and another one had trocar site hematoma. The mean hospital stay was 2.9±0.1 days. Of the 20 cases, two (10%) were converted to open cholecystectomy. The mean operation time was 75.2±32.54 min. Conclusion LC is an effective and safe treatment for symptomatic gallstone disease in select patients with Child–Pugh A and B cirrhosis. The advantages over open cholecystectomy are the lower morbidity rate and reduced hospital stay.

Does BLOODCARE Powder Prevent Postoperative Chylous Ascites After Lymphadenectomy for Gynecological Malignancies?

The aim of this study was to evaluate the effect of an intraoperative hemostatic cellulose agent (BLOODCARE powder [Life Line, Brno, Czech Republic]) on reducing the incidence of postoperative chylous ascites (PCA) after complete pelvic and para-aortic lymphadenectomy (PPALN) in patients with gynecological cancers treated with laparotomy. This case control study reviewed 150 patients with gynecological cancer who underwent PPALN. In the study group (n = 75), BLOODCARE powder was applied below the left renal vein and bilateral obturator fossa. In the control group (n = 75), no sealant agent was used after the procedure, such as fibrin glue or a hemostatic cellulose agent. The demographic and surgical characteristics of the patients in both groups were similar. Chylous ascites occurred in 9 cases (6%). The incidence of PCA was lower in the study group (1 [1.3%] vs 8 [10.7%]; P = 0.03). Logistic regression analysis indicated that using BLOODCARE powder during the surgery independently protected against the development of PCA. Using BLOODCARE powder during retroperitoneal surgery may prevent PCA. This simple, effective agent should be used after PPALN for gynecological cancers.

The relationship of preoperativelymphocyte-monocyte ratio and the clinicopathological characteristics and prognosis of patients with epithelial ovarian cancer

Objective: To investigate the relationship of preoperative lymphocyte-monocyte ratio (LMR) and the clinicopathological characteristics and prognosis of patients with epithelial ovarian cancer (EOC). Methods: Clinical data of 364 cases of EOC patients with initial treatment were collected in Harbin Medical University Cancer Hospital from 2005-2011 and analyzed retrospectively.The optimal cut-off points of preoperative LMR to predict the postoperative survival period of EOC patients were determined by the establishment of receiver operating characteristic (ROC) curve. The patients were divided into low LMR group and high LMR group according to the optimal cut-off points, and the relationship of LMR and the clinicopathological factors and prognosis of EOC patients were analyzed. Results: The best cut-off point of preoperative LMR to predict the postoperative survival period of EOC patients was 3.84. The preoperative LMR of EOC patients was significantly associated with the postoperative FIGO stage, ascites and CA125 level (all P<0.05). The median follow-up time was 37 months, the median progression-free survival (PFS) time of low LMR group was 56 months, significantly shorter than 88 months of high LMR group (P<0.01). And the median overall survival (OS) time of low LMR group was 69 months, significantly shorter than 100 months of high LMR group (P<0.01). The univariate analysis showed that the postoperative FIGO stage, pathological grade, ascites, lymph node metastasis, CA125 level, adjuvant therapy, preoperative LMR were all significantly associated with PFS (all P<0.05). In addition, the age, postoperative FIGO stage, pathological grade, ascites, lymph node metastasis, CA125 level, adjuvant therapy, preoperative LMR were all significantly associated with OS (all P<0.05). Cox multivariate analysis showed that postoperative FIGO stage Ⅲ-Ⅳ, low differentiation, positive lymph node metastasis, without postoperative adjuvant therapy and LMR≤3.84were independent risk factors of PFS and OS of EOC patients (P<0.05). Conclusion: The preoperative LMR is an independent influence factor of PFS and OS of EOC patients, and can be used to evaluate the prognosis of patients with EOC.

Preoperative regional maximal removal rate of technetium-99m-galactosyl human serum albumin is correlated with liver functional parameters, but did not predict postoperative morbidity.

Recently, posthepatectomy complications have been predicted by advances of new liver functional parameters, and the technetium-99m-galactosyl human serum albumin (GSA) liver scintigraphy has been applied widely for this purpose. We evaluated the clinical significance of the regional maximal removal rate (GSA-Rmax) in patients with various liver diseases as predictors of posthepatectomy complications. Between 2012 and March 2016, we examined 200 patients who underwent hepatectomy for liver and biliary diseases. The patients' background liver conditions included chronic viral liver diseases in 147 patients, normal liver in 44 patients, and others in nine patients. Hepatectomy-related postoperative complications (i.e. long-term ascites, intra-abdominal infection, and hepatic failure) occurred in 69 (35%) patients. A multivariate logistic analysis was carried out to detect the predictive parameters for complications. The median and mean preoperative GSA-Rmax was 0.420 and 0.448±0.148 mg/min, respectively. The GSA-Rmax was significantly correlated with liver functional parameters of ICGR15, LHL15, HH15, platelet count, prothrombin activity, and serum hyaluronic acid level (P<0.01), and was significantly correlated with postoperative total bilirubin level and C-reactive protein level (P<0.05). With respect to patient outcomes, GSA-Rmax was significantly lower in patients with long-term ascites (P<0.05). The predictive cutoff value for posthepatectomy long-term ascites for GSA-Rmax was 0.421 mg/min. However, the multivariate logistic regression analysis identified that a higher serum hyaluronic acid level and a lower platelet count were significant, independent factors, but not lower GSA-Rmax. GSA-Rmax is one of the liver functional parameters and is a complementary parameter to predict postoperative hyperbilirubinemia, inflammatory responses, and ascites when Tc-GSA scintigraphy is performed.

Double-blind randomized controlled trial of the routine perioperative use of terlipressin in adult living donor liver transplantation.

Perioperative terlipressin (Tp) during living donor liver transplantation (LDLT) has been shown to reduce intraoperative portal pressures and improve renal function. Its role and safety profile have never been evaluated in a double-blind randomized controlled trial (RCT). The aim was to evaluate the hemodynamic effects, clinical benefits, and safety of perioperative Tp infusion in adult LDLT. This was a single-center double-blind RCT. Consenting adults with chronic liver disease and low risk of posttransplant renal dysfunction undergoing their first LDLT were randomized. The study group (terlipressin group [TpG]) received an initial bolus of Tp during surgery followed by a Tp infusion for 72 hours in the postoperative period. The placebo group (PbG) received a saline infusion. The primary endpoint was portal pressure after arterial reperfusion. Multiple intraoperative and postoperative variables served as secondary endpoints. A total of 41 patients were enrolled in the trial (TpG, 21; PbG, 20). There were no significant differences in intraoperative portal pressures, blood loss, fluid requirement, vasopressor requirement, or urine output. Peak intraoperative and end of surgery lactate levels were significantly higher in the Tp group. There was no difference in postoperative liver function tests. Incidence of acute kidney injury as assessed by Risk, Injury, Failure, Loss, and End-Stage Kidney Disease criteria was lower in the Tp group (27% versus 60%; P = 0.04). The TpG had less postoperative ascites, a lower need for percutaneous interventions, and a shorter hospital stay. Incidence of bradycardia requiring pharmacological intervention and withdrawal from study was significantly higher in the TpG. In conclusion, this study has not demonstrated a reduction in postreperfusion portal pressure with Tp. However, Tp infusion reduced postoperative ascitic drain output resulting in less frequent percutaneous interventions and reduced hospital stay. Intraoperative hyperlactatemia and symptomatic bradycardia are major concerns. Its use should be restricted to patients with high-volume ascites, and it needs close monitoring during drug infusion. Liver Transplantation 23 1007-1014 2017 AASLD.

Determinants of large drain losses early after pediatric liver transplantation.

The goal of this study was to evaluate postoperative ascites to correlate it with graft dysfunction and other complications. We therefore reviewed the files of patients transplanted between 2009 and 2014 to correlate drain losses with indication, patient and organ size, PELD, graft type, GRWR, NRBW, NGWD, cold ischemia time, histologically proven graft dysfunction, and surgical complications. Of 120 LTs in 104 patients, 48 (40%) were complicated by graft dysfunction, 43 (36%) by surgical complications, and 25 (21%) by cellular rejection. Large drain losses correlated with younger age (P=.05), graft dysfunction (P<.01), surgical complications (P<.01), chylous ascites (P=.05); there was no association with PELD, GRWR, NRBW, or NGWD. Graft dysfunction was predicted by >20mL/kg/d of ascites at age 0-2years (AUROC 0.671), and >10mL/kg/d above 2years (AUROC 0.710). The measurement of drain losses after pediatric LT could be used as a non-invasive marker of graft dysfunction. Younger recipients tend to develop larger amounts of ascites, and its persistence is associated with early complications.

Associating liver partition and portal vein ligation for bleeding hepatocellular carcinoma in HBV cirrhosis: a safety strategy

The incidence of hepatocellular carcinoma (HCC) spontaneous tumor rupture varies between 3% and 26%. For resectable HCC ruptures, emergency hepatectomy or staged hepatectomy after transcatheter arterial embolization (TAE) are life-saving procedures, and efficient therapeutic methods. We report a multimodal therapy including TAE, associating liver partition and portal vein ligation (ALPPS) and immunoglobuline infusion for a huge bleeding HCC with portal vein tumor thrombosis (PVTT) in hepatitis B virus (HBV) cirrhosis. ALPPS first step began with an abdominal toilette due to the massive hemoperitoneum and a portal vein incision at the bifurcation of the right and left portal veins was performed. A freely floating left part of the thrombus was extracted from the left portal vein in order to restore the left portal vein. The right portal vein with complete thrombosis was closed. Liver partition was then performed. The second step was performed without complications. A HCC Edmondson grade 4 (pT3b) and a cirrhotic liver parenchyma were described. Postoperative ascites decompensation was treated and patient was discharged in postoperative day 21. The reported triple strategy allowed us to prolong patient live. A multimodal therapy including TAE, ALPPS and immunoglobuline is a good option for a life treatment in case of huge bleeding hepatocellular carcinoma with PVTT in HBV cirrhosis.