Postoperative Hepatic Failure Research Articles

Novel Models for Assessing and Pathophysiology of Hepatic Ischemia-Reperfusion Injury Mechanisms.

Hepatic ischemia-reperfusion injury (IRI) is a major cause of postoperative hepatic dysfunction and liver failure involving cellular damage to previously ischemic tissues to which blood flow is restored. The reestablishment of blood flow is essential for salvaging ischemic tissues. The reperfusion itself, however, can paradoxically lead to further cellular damage, which involves a multi-factorial process resulting in extensive tissue damage, which can threaten the function and viability of the liver and other organ systems. The following review outlines multiple models for in-lab analysis of the various hepatic IRI mechanisms, including murine, porcine, cell lines, and machine perfusion models.

Soluble suppression of tumourigenicity 2 as a predictor of postoperative hepatic failure.

Posthepatectomy liver failure remains a potentially life-threatening complication after hepatectomy. Soluble suppression of tumourigenicity 2 is an injury-related biomarker. The aim of the study was to assess soluble suppression of tumourigenicity 2 elevation after hepatectomy and whether it can predict posthepatectomy liver failure. This was a single-centre retrospective study including all patients who underwent a liver resection between 2015 and 2019. Plasma concentrations of soluble suppression of tumourigenicity 2 were measured before surgery and at postoperative days 1, 2, 5 and 7. Posthepatectomy liver failure was defined according to the International Study Group of Liver Surgery and the morbidity rate was graded according to the Clavien-Dindo classification. A total of 173 patients were included (75 underwent major and 98 minor resection); plasma levels of soluble suppression of tumourigenicity 2 increased from 43.42 (range 18.69-119.96) pg/ml to 2622.23 (range 1354.18-4178.27) pg/ml on postoperative day 1 (P < 0.001). Postoperative day 1 soluble suppression of tumourigenicity 2 concentration accurately predicted posthepatectomy liver failure ≥ grade B (area under curve = 0.916, P < 0.001) and its outstanding performance was not affected by underlying disease, liver pathological status and extent of resection. The cut-off value, sensitivity, specificity, positive predictive value and negative predictive value of postoperative day 1 soluble suppression of tumourigenicity 2 in predicting posthepatectomy liver failure ≥ grade B were 3700, 92%, 85%, 64% and 97% respectively. Soluble suppression of tumourigenicity 2high patients more frequently experienced posthepatectomy liver failure ≥ grade B (64.3% (n = 36) versus 2.6% (n = 3)) and Clavien-Dindo IIIa higher morbidity rate (23.2% (n = 13) versus 5.1% (n = 6)) compared with soluble suppression of tumourigenicity 2low patients. Soluble suppression of tumourigenicity 2 may be a reliable predictor of posthepatectomy liver failure ≥ grade B as early as postoperative day 1 for patients undergoing liver resection. Its role in controlling hepatic injury/regeneration needs further investigation. Registration number: ChiCTR-OOC-15007210 (www.chictr.org.cn/).

Analysis and experimental validation of IL-17 pathway and key genes as central roles associated with inflammation in hepatic ischemia-reperfusion injury.

Hepatic ischemia-reperfusion injury (HIRI) elicits an immune-inflammatory response that may result in hepatocyte necrosis and apoptosis, ultimately culminating in postoperative hepatic dysfunction and hepatic failure. The precise mechanisms governing the pathophysiology of HIRI remain incompletely understood, necessitating further investigation into key molecules and pathways implicated in disease progression to guide drug discovery and potential therapeutic interventions. Gene microarray data was downloaded from the GEO expression profile database. Integrated bioinformatic analyses were performed to identify HIRI signature genes, which were subsequently validated for expression levels and diagnostic efficacy. Finally, the gene expression was verified in an experimental HIRI model and the effect of anti-IL17A antibody intervention in three time points (including pre-ischemic, post-ischemic, and at 1h of reperfusion) on HIRI and the expression of these genes was investigated. Bioinformatic analyses of the screened characterized genes revealed that inflammation, immune response, and cell death modulation were significantly associated with HIRI pathophysiology. CCL2, BTG2, GADD45A, FOS, CXCL10, TNFRSF12A, and IL-17 pathway were identified as key components involved in the HIRI. Serum and liver IL-17A expression were significantly upregulated during the initial phase of HIRI. Pretreatment with anti-IL-17A antibody effectively alleviated the damage of liver tissue, suppressed inflammatory factors, and serum transaminase levels, and downregulated the mRNA expression of CCL2, GADD45A, FOS, CXCL10, and TNFRSF12A. Injection of anti-IL17A antibody after ischemia and at 1h of reperfusion failed to demonstrate anti-inflammatory and attenuating HIRI benefits relative to earlier intervention. Our study reveals that the IL-17 pathway and related genes may be involved in the proinflammatory mechanism of HIRI, which may provide a new perspective and theoretical basis for the prevention and treatment of HIRI.

Blebbing of the plasma membrane of lymphocytes as a marker of endothelial dysfunction in the development of post-resection insufficiency in patients with focal liver lesions

Purpose of the study. To evaluate the intensity of blebbing of the plasma membrane of lymphocytes and the formation of microparticles of lymphocytic origin in patients with postresection hepatic failure. Material and methods. The study involved 54 patients with focal liver diseases. The study involved 32 (59%) women, 22 (41%) men. The average age was 59.5 [49.75; 66,00]. Patients were divided into groups, 1 group - 10 patients with developed acute liver failure and 2 group - 44 patients with a favorable course of postoperative period. The following surgical interventions were performed: 36 (67%) patients underwent surgery - laparotomy, segmental liver resection, 10 (18%) - left-sided hemihepatectomy and 8 (15%) - right-sided hemihepatectomy. Results. Predictors of early postoperative hepatic failure are a decrease in initial blebbing and an increase in terminal blebbing and free microparticles of lymphocytic origin. Conclusions. Thus, changes in lymphocyte blebbing and the presence of free microparticles of lymphocytic origin are due to the development of endothelial insufficiency and apoptosis of lymphocytes in the context of liver failure and are determined by the reduced function of residual liver volume.

A mitochondria-targeted H2S-activatable fluorogenic probe for tracking hepatic ischemia-reperfusion injury

Hepatic ischemia-reperfusion injury (HIRI) is the cause of postoperative hepatic dysfunction and failure, and even death. As an important biological effector molecule, hydrogen sulfide (H2S) of mitochondria as a gasotransmitter that is usually used to protect against acute HIRI injury. However, the exact relationship between HIRI and mitochondrial H2S remains tangled due to the lack of an effective analytical method. Herein, we have fabricated a mitochondria-targeted H2S-activatable fluorogenic probe (Mito-GW) to explore the stability of mitochondrial H2S and track the changes of mitochondrial H2S during the HIRI. By virtue of pyridinium electropositivity and its amphiphilicity, Mito-GW could accumulate in mitochondria. It goes through an analyte-prompted immolation when reacts with H2S, resulting in the releasing of the fluorophore (GW). Therefore, the extent of Mito-GW conversion to GW can be used to evaluate the changes of mitochondrial H2S level in living cells and tissues. As proof-of-principle, we have used Mito-GW to demonstrate the mitochondria H2S-levels increase and then decrease during HIRI in vitro and in vivo. Our research highlights the tremendous potential of Mito-GW as a mitochondrial H2S fluorogenic probe in elucidating the pathogenesis of HIRI, providing a powerful tool for promoting future research on hepatology.

Infarct exclusion repair of postmyocardial infarction ventricular septal rupture with a hybrid patch and septal occluder device compared with patch only

ObjectiveWe developed a hybrid technique for repairing post-myocardial infarction (MI) ventricular septal defect (VSD) that combines infarct exclusion with patch and a nitinol-mesh septal occluder device (SOD) to provide a scaffold to support the damaged septal wall. Here, we compare outcomes of patients with post-MI VSD repaired using patch only or hybrid patch/SOD. MethodsPatients undergoing post-MI VSD repair at our institution from 2013 to 2022 who received patch alone or patch/SOD repair were analyzed. Primary outcome was survival to hospital discharge. Clinical outcomes and echocardiograms were also analyzed. ResultsOver a 9-year period, 24 patients had post-MI VSD repair at our institution with either hybrid patch/SOD (n = 10) or patch only repair (n = 14). VSD size was 18 ± 5.8 mm for patch/SOD and 17 ± 4.6 mm for patch only. In the patch/SOD repair cohort, average size of SOD implant was 23.6 ± 5.6 mm. Mild left ventricular dysfunction was present prerepair and was unchanged postrepair in both groups; however, moderate-to-severe right ventricular (RV) dysfunction was common in both groups before repair. RV function worsened or persisted as severe in 10% of hybrid versus 54% of patch-only patients postrepair. Tricuspid annular systolic excursion and RV:left ventricle diameter ratio, quantitative metrics of RV function, improved after patch/SOD repair. No intraoperative mortality occurred in either group. Postoperative renal, hepatic, and respiratory failure requiring tracheostomy was common in both groups. Survival to hospital discharge in both cohorts was 70%. ConclusionsPost-MI VSD repair with patch/SOD has comparable short-term outcomes with patch alone. Addition of a SOD to patch repair provides a scaffold that may enhance the repair of post-MI VSD with patch exclusion.

ЭФФЕКТИВНОСТЬ МЕТОДОВ ОККЛЮЗИИ ВОРОТНОГО КРОВОТОКА ПРИ ПЛАНИРОВАНИИ ОБШИРНЫХ РЕЗЕКЦИЙ У ПАЦИЕНТОВ С ЭХИНОКОККОЗОМ ПЕЧЕНИ

Background. Surgery is the main and an effective treatment option for liver echinococcosis. The choice of surgical strategy for advanced liver echinococcosis given suspected poor liver functional reserve and post-operative hepatic failure remains challenging. Objective. To present and analyze the effectiveness of portal blood flow occlusion techniques in planning two-stage extensive resections in patients with advanced liver echinococcosis. Material and methods. The article presents the outcomes of surgical treatment of 22 patients (8/36,4% men, 14/63,6% women) operated on for advanced liver echinococcosis in the surgical department No.2 of State Autonomous Healthcare Institution ‘Kuzbass Clinical Emergency Hospital named after A.I. M. A. Podgorbunsky’ (Kemerovo). The application of a two-stage extensive resection protocol was used as an entry criterion. Stage I included right portal vein branch occlusion techniques aimed at achieving vicarious hypertrophy of the contralateral lobe. A two-stage extensive resection protocol was applied in case of both expected poor hepatic functional reserve and insufficient future remnant liver volume, accounting for inability of safe implementation of a one-stage extensive resection due to predicted postoperative hepatic failure and a fatal outcome. Results. The applied two-stage resection techniques for the prevention of post-operative hepatic failure are effective in relation to the following indicators: CT volumetry (p&lt;0,05), OK15 ICG (p&lt;0,05), statistical model value (p&lt;0.05). Though the laparotomic technique of the right portal vein branch ligation is of a comparable effectiveness with the laparoscopic one, the latter being less traumatic, which can significantly reduce postoperative hospital stay (p&lt;0,05). Moreover, the laparoscopic technique was not found to cause any specific and nonspecific complications. Conclusions. The applied methods of portal blood flow occlusion are considered to be effective and safe when planning two-stage extensive resections in specialized hepatology centers and can be recommended in case of initial poor hepatic functional reserve and insufficient future remnant liver volume.

Left-sided Hepatectomy Leads to Less Postoperative Liver Failure and Comparable Overall Survival to Right-sided Hepatectomy in Type II or IV Perihilar Cholangiocarcinoma.

Right-side hepatectomy (RH) is used in oncological resection for perihilar cholangiocarcinoma (PHC); however, the decision between performing left-side hepatectomy (LH) or RH is still controversial. We compared surgical and oncologic outcomes of LH and RH in PHC type II or IV where either hepatectomy was expected to have a negative margin. From 2001 to 2020, 99 patients underwent major liver resection for type II or IV PHC. Patients with unilateral vascular invasion, unilateral tumor growth, and atrophy of unilateral liver were excluded. Preoperative characteristics, perioperative, and long-term outcomes were compared between the remaining RH and LH patients. After excluding 47 cases with side predominance, the RH group (n = 29) and LH group (n = 23) were compared. Clinical characteristics and disease severity did not differ between the groups. Portal vein embolization (RH: 48.3% vs. LH: 0.0%, p < 0.001) and days from diagnosis to operation (RH: 31.0 ± 16.2 vs. LH: 18.8 ± 13.4, p = 0.006) were significantly higher in the RH group. The RH group had statistically higher rate of postoperative hepatic failure (RH: 55.2% vs. LH: 21.7%, p = 0.015) and a higher mortality rate that was not significant (RH: 13.8% vs. LH: 0%, p = 0.120). The R0 resection rate (RH: 72.4% vs. LH: 78.3%, p = 0.629), median disease-free (p = 0.620), and overall (p = 0.487) survival did not differ between groups. R1 resection and lymph node metastasis were significant risk factors for disease-free survival in multivariate analysis. In type II or type IV PHC where either LH or RH was feasible, LH provided a shorter period of preoperative preparation, lower postoperative hepatic failure rate, similar R0 rate, and comparable long-term outcomes. LH should be considered a reasonable option in type II or IV PHC.

Caudodorsal approach combined with in situ split for laparoscopic right posterior sectionectomy

BackgroundLaparoscopic right posterior sectionectomy (LRPS) was technically challenging and lack of standardization. There were some approaches for LRPS, such as caudal approach and dorsal approach. During our practice, we initiated pure LRPS using the caudodorsal approach with in situ split and present several advantages of this method.MethodsFrom April 2018 to December 2021, consecutive patients who underwent pure LRPS using the caudodorsal approach with in situ split at our institution entered into this retrospective study. The key point of the caudodorsal approach was that the right hepatic vein was exposed from peripheral branches toward the root and the parenchyma was transected from the dorsal side to ventral side. Specially, the right perihepatic ligaments were not divided to keep the right liver in situ before parenchymal dissection for each case.Results11 patients underwent pure LRPS using the caudodorsal approach with in situ split. There were 9 hepatocellular carcinoma, 1 sarcomatoid hepatocellular carcinoma, and 1 hepatic hemangioma. Five patients had mild cirrhosis and 1 had moderate cirrhosis. All the procedures were successfully completed laparoscopically. The median operative time was 375 min (range of 290–505 min) and the median blood loss was 300 ml (range of 100–1000 ml). Five patients received perioperative blood transfusion, of which 1 patient received autologous blood transfusion and 2 patients received blood transfusion due to preoperative moderate anemia. No procedure was converted to open surgery. Two patients who suffered from postoperative complications, improved after conservative treatments. The median postoperative stay was 11 days (range of 7–25 days). No postoperative bleeding, hepatic failure, and mortality occurred.ConclusionThe preliminary clinical effect of the caudodorsal approach with in situ split for LRPS was satisfactory. Our method was feasible and expected to provide ideas for the standardization of LRPS. Further researches are required due to some limitations of this study.

Anaesthesia for Hepatic Resection Surgery.

This article will focus on the perioperative management of hepatic resection for colorectal cancer (CRC) liver metastases (CLRMs) (the liver is the dominant metastatic site for CRC) within the context of the Enhanced Recovery After Surgery (ERAS) paradigm. It discusses the epidemiology and outcomes along with the history of hepatic resection surgery and pertinent anatomy. The discussion of the preoperative phase includes patient selection, assessment of liver functional status, and new developments in prehabilitation. The intraoperative phase details developments in surgical and anesthetic techniques to minimize liver hemorrhage and reduce the risk of postoperative hepatic failure. Newer analgesic options are included. Management of potential complications is outlined in the postoperative section followed by a description of current evidence for ERAS and future directions.

Role of Mitochondrial Pathways in Cell Apoptosis during He-Patic Ischemia/Reperfusion Injury.

Hepatic ischemia-reperfusion injury is a major cause of post-operative hepatic dysfunction and liver failure after transplantation. Mitochondrial pathways can be either beneficial or detrimental to hepatic cell apoptosis during hepatic ischemia/reperfusion injury, depending on multiple factors. Hepatic ischemia/reperfusion injury may be induced by opened mitochondrial permeability transition pore, released apoptosis-related proteins, up-regulated B-cell lymphoma-2 gene family proteins, unbalanced mitochondrial dynamics, and endoplasmic reticulum stress, which are integral parts of mitochondrial pathways. In this review, we discuss the role of mitochondrial pathways in apoptosis that account for the most deleterious effect of hepatic ischemia/reperfusion injury.

Surgical Outcomes of Left Side Hepatectomy Compared with Right Side Hepatectomy in Type II or IV Hilar Cholangiocellular Carcinoma

Introduction: Right-side hepatectomy (RH) has been considered an oncological resection for hilar cholangiocarcinoma (HCCC), however, decision for left-side hepatectomy (LH) or RH is still a controversial issue. We compared surgical and oncologic outcomes of LH and RH in HCCC type II or IV in which either side of hepatectomy was expected to have a negative margin. Method: From 2001 to 2020, 85 patients underwent major liver resection for type II or IV HCCC. Among them, 52 patients who had no vascular invasion, no unilateral tumor growth and no atrophy of unilateral liver were enrolled. Preoperative characteristics, perioperative outcomes and long-term outcomes were compared between RH (n=29) and LH (n=23) group. Results: Clinical characteristics and disease severity did not differ between two groups. Portal vein embolization rate(RH: 48.3% vs LH: 0.0%, p<0.001) and duration of diagnosis to operation (RH: 31.0±16.2 vs LH: 18.8±13.4, p=0.006) were significantly higher in RH group. Postoperative hepatic failure(over grade B) was more frequent in RH group (RH: 55.2% vs LH: 21.7%, p=0.015). R0 resection rate (RH: 72.4% vs LH: 78.3%, p=0.629), median disease free (p=0.620) and overall survival (p=0.487) did not differ between two groups. R1 resection and number of lymph node metastasis were significant risk factor for DFS in multivariate analysis. Conclusions: In type II or type IV HCCC in which either LH or RH was a feasible option, LH provided shorter period of preoperative preparation, lower postoperative hepatic failure rate, similar R0 rate and comparable long-term outcomes compared with RH. LH should be considered reasonable option to type II or IV HCCC.

Risk Factors for Postoperative Mortality in Patients with Acute Stanford Type A Aortic Dissection.

ObjectiveThe present study explored the risk factors of postoperative mortality in patients with acute Stanford type A aortic dissection (AD).MethodsThe study included 149 patients with acute Stanford type A AD who were treated at the Fourth Hospital of Hebei Medical University, China, from October 2016 to October 2018. The patients were divided into a death (n = 42) and survival group (n = 107) according to individual prognosis. Univariate analysis of all possible related risk factors was conducted; multivariate logistic regression analysis of the potential risk factors that showed statistical differences in the univariate analysis was also performed.ResultsThe results of the univariate analysis showed that a body mass index (BMI) ≥25 kg/m2, surgery duration, duration of cardiopulmonary bypass, duration of cardiopulmonary bypass assistance, total transfusion of red blood cells, postoperative APACHE II score, sequential organ failure assessment (SOFA) score, low cardiac output, acute kidney injury (AKI), hypoxemia, diffuse intravascular coagulation (DIC), hepatic failure and other related complications, as well as postoperative stay duration in the intensive care unit (ICU), were closely correlated with a poor prognosis among patients. Multivariate logistic regression analysis showed that a BMI ≥25 kg/m2, SOFA score >8, duration of cardiopulmonary bypass assistance >70 minutes, postoperative low cardiac output, and postoperative DIC were independent risk factors for postoperative death in patients with acute Stanford type A AD.ConclusionA BMI ≥25 kg/m2, SOFA score >8, duration of cardiopulmonary bypass assistance >70 min, postoperative DIC, and postoperative low cardiac output were the independent risk factors for postoperative death in acute Stanford type A AD. Intraoperative blood transfusion, postoperative hepatic failure, and AKI, among others, correlated with an increased risk of death but were not independent risk factors for death.

Surgical outcomes of left side hepatectomy compared with right side hepatectomy in type I, II or IV hilar cholangiocellular carcinoma

Right-side hepatectomy (RH) has been considered an oncological resection for hilar cholangiocarcinoma (HCCC), however the decision for left-side hepatectomy (LH) or RH is still a controversial issue. We compared surgical and oncologic outcomes of LH and RH in HCCC type I, II or IV in which either side of hepatectomy was expected to have a negative margin. From 2001 to 2020, 85 patients underwent major liver resection for type I, II or IV HCCC. Among them, 52 patients who had no vascular invasion, no unilateral tumor growth and no atrophy of unilateral liver were enrolled. Preoperative characteristics, perioperative outcomes and long-term outcomes were compared between RH (n = 29) and LH (n = 23) group. Clinical characteristics and disease severity did not differ between two groups. Portal vein embolization rate (RH: 48.3% vs. LH: 0.0%, p < 0.001) and duration of diagnosis to operation (RH: 31.0 ± 16.2 vs. LH: 18.8 ± 13.4, p = 0.006) were significantly higher in RH group. Postoperative hepatic failure (over grade B) was more frequent in RH group (RH: 55.2% vs LH: 21.7%, p = 0.015). R0 resection rate (RH: 72.4% vs. LH: 78.3%, p = 0.629), median disease free (p = 0.620) and overall survival (p = 0.487) did not differ between two groups. R1 resection and number of lymph node metastasis were significant risk factor for DFS in multivariate analysis. In type I, II or type IV HCCC in which either LH or RH was a feasible option, LH provided shorter period of preoperative preparation, lower postoperative hepatic failure rate, similar R0 rate and comparable long-term outcomes compared with RH. Therefore, LH should be considered reasonable option to type I, II or IV HCCC.

Prevention of Liver Failure in Extended Hepatic Resection

Background. Postoperative failure is a major cause of adverse outcomes in extensive liver resection. Post-resection liver failure requires intensive, including extracorporeal, care. Issues in correcting liver failure warrant novel approaches to prevent severe cases.Materials and methods. A retrospective analysis of 228 various-extent liver resections included minor (55.7 %), major (26.8 %) and extended (17.5 %) operations for malignant, benign and parasitic liver lesions. The post-resection liver failure rate has ben graded according to ISGLS.Results and discussion. Postoperative hepatic failure developed in 58 (25.4 %) cases, including 5 of 127 minor (3.9 %) resections, 18 major (29.5 %) and 35 of 40 extended resections (87.5 %). Mild class A liver failures were reported in 12.3 %, and severe classes B and C — in 9.2 % and 3.9 % cases, respectively.CT volumetry in place of the number of resected segments is suggested as a criterion to grade the expected post-resection residual liver, with &gt;70 % defining a minor, 36–70 % — major and 25–35 % — extended expected residual liver.A two-staged extended hepatic resection approach is proposed to reduce postoperative liver failure, with vascular radiology-guided right portal vein embolisation (RPVE) or associating liver partition and portal vein ligation (ALPPS) at stage 1.A comparison of extended hepatic resection outcomes (n = 40) showed a significantly higher rate and severity of liver failure in single- vs. two-staged operations (p &lt; 0.05).Conclusion. Liver failure is a leading cause of death in major and extended hepatic resection. Preoperative CT volumetry allows a more accurate volumetric control of expected post-resection residual liver. Two-staged extended hepatic resection can reliably reduce the rate and severity of postoperative liver failure.

Laparoscopic Hepatectomy with Selective Hepatic Artery Clamping for A Hyperintense Hepatic Adenoma on Hepatospecific Gadolinium-Enhanced Magnetic Resonance Imaging: The Great Pretender

Introduction: Focal nodular hyperplasia and hepatocellular adenoma are benign hepatic tumors and differential diagnosis is important as hepatic adenomas may complicate with hemorrhage and malignant transformation. Magnetic resonance imaging with gadolinium-enhanced contrast agents is the best noninvasive diagnostic tool for benign hepatic tumors. Nevertheless, atypical radiological findings can make differential diagnosis a challenge. Presentation of case: We report a young female patient with large hepatic benign tumor with intralesional hemorrhage that disclosed hyper-intensity on hepatobiliary phase on a gadolinium-enhanced magnetic resonance imaging study, suggestive of focal nodular hyperplasia. As this type of tumor usually do not complicate with bleeding, surgical resection was proposed and a laparoscopic right posterior hepatic sectionectomy with selective hepatic artery clamping was performed. Pathology disclosed an inflammatory hepatic adenoma. Discussion: Hepatic adenomas may present as hyper-intense tumors on hepatobiliary phase of gadoliniumenhanced magnetic resonance imaging. Surgical resection still has a role on the treatment of benign hepatic tumors. Laparoscopic liver resections must be considered, even when a major hepatectomy is planned, as this approach has proved safe and effective. Selective hepatic artery clamping during minimally invasive liver surgery may be an option to reduce intraoperative bleeding, remnant liver ischemia and postoperative hepatic failure. Conclusion: We reported a young female patient with a benign hepatic tumor complicated with hemorrhage suggestive of a focal nodular hyperplasia on gadolinium-enhanced magnetic resonance imaging study. A laparoscopic hepatectomy was performed and final pathology disclosed an inflammatory hepatocellular adenoma.

Novel endoscopic treatment strategy for early esophageal cancer in cirrhotic patients with esophageal varices.

The safety and efficacy of endoscopic submucosal dissection (ESD) and radiofrequency ablation for early esophageal cancer (EEC) in cirrhotic patients has not been thoroughly investigated to date. The present study aimed to establish a standard treatment strategy for EEC in cirrhotic patients with esophageal varices. Six cirrhotic patients with early flat-type EECs (high-grade intraepithelial neoplasia) on or adjacent to esophageal varices were enrolled. Esophageal varix ligation (EVL) or transjugular intrahepatic portosystemic shunt (TIPS) were used for the initial management of esophageal varices. Follow-up endoscopy was performed two months following the initial procedure. The mean longitudinal length of the lesions was 4.3 cm (range, 2-6 cm). The average procedure time was 72.8 min (range, 34-135 min) and the average longitudinal length of the resected specimens was 45.6 mm (range, 30-90 mm). One case had a tumor-positive lateral margin with lymphovascular infiltration. Both complete and curative resection rates were 80% (4/5 lesions). Large intraoperative bleeding was detected in patients undergoing EVL compared with TIPS prior to the ESD procedure. No severe complications or mortality-associated events, including massive postoperative bleeding, perforation or hepatic failure, were observed. No recurrence and metastasis were observed during the follow-up period. The current study suggested a novel treatment strategy for EECs complicated by esophageal varices in cirrhosis with good treatment results, no neoplastic progression and an acceptable adverse event profile.

Pure laparoscopic right posterior sectionectomy using the caudate lobe-first approach.

In our process of standardizing laparoscopic right-sided anatomical hepatectomy, we found several advantages of the caudate lobe-first approach. We herein describe our standardized procedure of laparoscopic right posterior sectionectomy (Lap-RPS) using this approach. Between January 2011 and January 2018, 31 patients underwent pure Lap-RPS in our hospital. The mean patient age was 68years (range 47-85years), and the number of male patients was more than that of female patients (64.5%). Of 31 patients, 20 had metastatic liver tumor, 7 had hepatocellular carcinoma, 3 had intrahepatic cholangiocellular carcinoma, and 1 had hemangioma. All 31 patients had Child-Pugh class A liver function. The surgical technique was recorded on video. Cumulative sum (CUSUM) analyses were applied to assess the learning curve. The mean operative time was 420min (range 263-639min), and the mean amount of blood loss was 304g (range 10-900g). No procedure was converted to open surgery. Postoperative bleeding, bile leakage, hepatic failure, and mortality did not occur. CUSUM analyses showed a decrease in the operative time and blood loss after using the caudate lobe-first approach. Our standardized procedure of Lap-RPS using the caudate lobe-first approach is not only feasible but also expected to provide an advantage for laparoscopic anatomical hepatectomy.

Acute Hepatic Failure

Acute liver failure (ALF) is a rare but highly morbid condition that is optimally managed by a multidisciplinary team of surgeons, hepatologists, and intensivists at a tertiary care center that specializes in liver disorders. ALF is caused by four primary mechanisms, including viral infections (most commonly Hepatitis A and B); toxicity from acetaminophen overdose or other substances; postoperative hepatic failure ; and miscellaneous causes such as autoimmune hepatitis, genetic disorders, or idiopathic etiologies. Unlike chronic liver failure in which the body develops compensatory, protective mechanisms, ALF may be associated with severe multisystem organ involvement, including respiratory distress syndrome, renal failure, and cerebral edema. Fulminant hepatic failure represents a rapidly progressive form of ALF that portends worse prognosis. Prompt diagnosis and management of multisystem organ dysfunction in an intensive care setting is paramount to survival. However, a subset of patients will fail to improve with medical management alone. Early identification of these individuals for emergent transplant listing has been shown to improve outcomes. Multiple predictive models for ALF survival have been developed, which are based on weighted evaluation of clinical and laboratory parameters. These models may be used to facilitate treatment, predict prognosis, and guide transplant listing. In this chapter, we provide an in-depth review these concepts, focusing on the classification, epidemiology, diagnosis, and management of ALF. This review contains 5 tables and 69 references. Key Words: acute liver failure, acute respiratory distress syndrome, coagulopathy, cerebral edema, fulminant hepatic failure, hepatic necrosis, liver transplantation, metabolic disarray, multidisciplinary intensive care, prognostication

Acute Hepatic Failure

Acute liver failure (ALF) is a rare but highly morbid condition that is optimally managed by a multidisciplinary team of surgeons, hepatologists, and intensivists at a tertiary care center that specializes in liver disorders. ALF is caused by four primary mechanisms, including viral infections (most commonly Hepatitis A and B); toxicity from acetaminophen overdose or other substances; postoperative hepatic failure ; and miscellaneous causes such as autoimmune hepatitis, genetic disorders, or idiopathic etiologies. Unlike chronic liver failure in which the body develops compensatory, protective mechanisms, ALF may be associated with severe multisystem organ involvement, including respiratory distress syndrome, renal failure, and cerebral edema. Fulminant hepatic failure represents a rapidly progressive form of ALF that portends worse prognosis. Prompt diagnosis and management of multisystem organ dysfunction in an intensive care setting is paramount to survival. However, a subset of patients will fail to improve with medical management alone. Early identification of these individuals for emergent transplant listing has been shown to improve outcomes. Multiple predictive models for ALF survival have been developed, which are based on weighted evaluation of clinical and laboratory parameters. These models may be used to facilitate treatment, predict prognosis, and guide transplant listing. In this chapter, we provide an in-depth review these concepts, focusing on the classification, epidemiology, diagnosis, and management of ALF. This review contains 5 tables and 69 references. Key Words: acute liver failure, acute respiratory distress syndrome, coagulopathy, cerebral edema, fulminant hepatic failure, hepatic necrosis, liver transplantation, metabolic disarray, multidisciplinary intensive care, prognostication