Selective Ligation Research Articles

Associated Liver Partition and Portal Vein Ligation (ALPPS) vs Selective Portal Vein Ligation (PVL) for Staged Hepatectomy in a Rat Model. Similar Regenerative Response?

Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a two-stage hepatectomy technique which can be associated with a hypertrophic stimulus on the future liver remnant (FLR) stronger than other techniques–such as portal vein ligation (PVL). However, the reason of such hypertrophy is still unclear, but it is suggested that liver transection combined with portal vein ligation (ALPPS) during the first stage of this technique may play a key role. The aim of this study is to compare the hypertrophic stimulus on the FLR and the clinical changes associated with both ALPPS and PVL in a rat surgical model. For this purpose, three groups of SD rats were used, namely ALPPS (n = 30), PVL (n = 30) and sham-treated (n = 30). The second stage of ALPPS (hepatectomy of the atrophic lobes), was performed at day 8. Blood and FLR samples were collected at 1, 24, 48 hours, 8 days and 12 weeks after the surgeries. ALPPS provoked a greater degree of hypertrophy of the FLR than the PVL at 48 hours and 8 days (p<0.05). The molecular pattern was also different, with the highest expression of IL-1β at 24h, IL-6 at 8 days, and HGF and TNF-α at 48 hours and 8 days (p<0.05). ALPPS also brought about a mild proliferative stimulus at 12 weeks, with a higher expression of HGF and TGF-β (p<0.05) than PVL. Clinically, ALPPS caused a significant liver damage during the first 48 hours, with a recovery of liver function at day 8. In conclusion, ALPPS seems to induce higher functional hypertrophy on the FLR than PVL at day 8. Such regenerative response seems to be leaded by a complex interaction between pro-mitogenic (IL-6, HGF, TNF-α) and antiproliferative (IL1-β and TGF-β) cytokines.

Spleen hydatidosis treated by hemi-splenectomy: A low-morbidity, cost-effective management by a recently improved surgical technique

BackgroundSplenic hydatidosis is a rare condition and is usually managed by total splenectomy, which is associated to various complications, including overwhelming post-splenectomy sepsis and thrombosis. Probably due to supposed technical difficulties, the partial splenectomy is rarely performed being often unknown to physicians, infectious disease specialists and surgeons. MethodsDemographic, clinical and surgical data were collected of four consecutive patients undergoing partial (or hemi-) splenectomy using an original, recently improved technique as a treatment for polar splenic hydatid cyst. The procedure implies a selective vascular ligation, a mechanical stapler-assisted section and haemostatic agents (Surgicel®) application on the cutting surface. Three patients were treated by laparotomy (including one affected by both liver and spleen localizations) whereas the last one was approached laparoscopically. ResultsPartial splenectomy operative time reached 74 min (range: 60–94 min) and blood loss was 8 ml (range: 5–10 ml). Hospital stay was 5.6 days (range: 5–7 days). At a mean follow-up of 20 months (range: 12–36 months), outcomes were uneventful. ConclusionsPartial splenectomy for hydatidosis is effective and safe. Physicians and surgeons should be aware of such an easy-to-catch option when dealing with benign splenic conditions, such as parasitic cysts. Cost-effectiveness, low morbidity and the possible prevention of splenectomy-related infectious complications should plead in favor of this technique in developing countries, where hydatidosis is endemic and post-splenectomy drugs and vaccines may be lacking.

Ca2+ -independent sortase-A exhibits high selective protein ligation activity in the cytoplasm of Escherichia coli.

A Staphylococcus aureus transpeptidase, sortase A (SrtA), which catalyzes a peptide ligation with high substrate specificity, is a useful tool to site-specifically attach proteinaceous/peptidic functional molecules to target proteins. However, its strong Ca(2+) dependency makes SrtA difficult for use under low Ca(2+) concentrations and in the presence of Ca(2+)-binding substances. To overcome this problem, we designed a SrtA mutant that Ca(2+)-independently demonstrates a high catalytic activity. The heptamutant (P94R/E105K/E108A/D160N/D165A/K190E/K196T), which resulted from a combination of known mutations at the Ca(2+) -binding site and around the substrate-binding site, successfully catalyzed a selective protein-protein ligation in the cytoplasm of Escherichia coli. Selective protein modification in living cells is a promising approach for investigating cellular events and regulating cell functions. This SrtA mutant may prove to be a versatile tool for adding new functionalities to proteins of interest by incorporating functional proteins and chemically modified peptides in living cells, which usually retain low Ca(2+) concentrations.

Renal Transplantation by Automatic Anastomotic Device in a Porcine Model.

Automatic vascular staplers for vascular anastomoses in kidney transplantation may dramatically reduce the operative time and, in particular, warm ischemia time, thus increasing the outcome of transplantation. Ten pigs underwent kidney auto-transplantation by automatic anastomotic device. Kidneys were collected by laparotomy with selective ligations at the renal hilum and perfused with cold storage solution. To overcome the shortage in length of renal hilum, a tract of the internal jugular vein was harvested to increase the length of the vessels. The anastomoses were totally performed by the use of the anastomotic device. On 10 kidney transplants, nine were successful and no complications occurred. Renal resistive indexes showed a slight increase in the immediate postoperative period returning normal at 10 days of follow-up. We demonstrated the possibility to perform renal vascular anastomoses by means of an automatic anastomotic device. This instrument developed for coronary bypass surgery by virtue of the small caliber of the vessels could be adopted on a larger scale for renal transplantation. The reduced warm ischemia time needed for anastomosis may help to achieve a better outcome for the graft and expand the pool of marginal donors in renal transplantation.

Une malformation artérioveineuse utérine acquise traitée avec succès par ligature sélective de l’artère iliaque interne

Uterine arteriovenous malformations can be congenital or acquired. When acquired, they result from abnormal arteriovenous communication between one or more uterine arteries and a myometrial and/or endometrial venous plexus, without the interposition of a vascular nidus. Arteriovenous malformations are composed of a tortuous net of fragile low-resistant arteriovenous shunts. Uterine arteriovenous malformations create a rare and potentially life-threatening condition. The method of treatment is determined by symptoms, desire for future fertility, extent, and location of the malformation. The first treatment option for uterine arteriovenous malformation is hysterectomy, and the second option is uterine artery embolization. Selective ligation of the vessels supplying the malformation is an effective treatment option when conservative methods have failed. The present report describes a patient whose uterine arteriovenous malformation was successfully managed by selective ligation of the internal iliac artery.

Synthesis of onion-peel nanodendritic structures with sequential functional phosphorus diversity.

The preparation of novel families of phosphorus-based macromolecular architectures called "onion peel" phosphorus nanodendritic systems is reported. This construct is based on the versatility of methods of synthesis using several building blocks and on the capability of these systems to undergo regioselective reactions within the cascade structure. Sustainable metal-free routes such as the Staudinger reaction or Schiff-base condensation, involving only water and nitrogen as byproducts, allow access to several dendritic macromolecules bearing up to seven different phosphorus units in their backbone, each of them featuring specific reactivity. The presence of the highly aurophilic P=N-P=S fragment enables selective ligation of Au(I) within the dendritic framework.

Development of bioorthogonal reactions and their applications in bioconjugation.

Biomolecule labeling using chemical probes with specific biological activities has played important roles for the elucidation of complicated biological processes. Selective bioconjugation strategies are highly-demanded in the construction of various small-molecule probes to explore complex biological systems. Bioorthogonal reactions that undergo fast and selective ligation under bio-compatible conditions have found diverse applications in the development of new bioconjugation strategies. The development of new bioorthogonal reactions in the past decade has been summarized with comments on their potentials as bioconjugation method in the construction of various biological probes for investigating their target biomolecules. For the applications of bioorthogonal reactions in the site-selective biomolecule conjugation, examples have been presented on the bioconjugation of protein, glycan, nucleic acids and lipids.

Comment to: Selective high ligation of the saphenofemoral junction decreases the neovascularization and the recurrent varicose veins in the operated groin by Mariani F, Mancini S, Bucalossi M, Allegra C. Int Angiol 2014 Jul 16 [Epub ahead of print

The classical radical high ligation (RHL) performed with the Babcock technique is defined as the traditional gold standard technique: superficial tributaries dissection, followed, when possible, back to the secondary branch points, division and ligation; GSV ligation flush to the junction. In the present study the authors analyze, as an alternative, the selective high ligation (SHL) of the Junction with 5/12 years follow-up. The rationale is that SFJ tributary veins coming from the abdominal wall have an important role in draining the venous flow to the deep veins or to the opposite vein network, particularly when the venous abdominal flow is modified for physiological condition (i.e. pregnancy) or external compression or obstruction (i.e. deep venous thrombosis) . In SHL the veins coming from the abdominal wall, as the superior epigastric vein (SEV) or the superior iliac circumflex vein (SICV), are spared, while the superior external pudendal vein (SEPV) and the others tributaries which have an acute angle with the saphenic axis or a T branch from the thigh, are carefully isolated and ligated with 2/0 or 3/0 non absorbable thread; the GSV is ligated and dissected flush the confluence of the spared tributary veins, usually about 1 cm from the SFJ, to maintain its drainage into the GSV stump. The study included a homogenous cohort of 360 patients (mean aged 51.9 years range 18 to 75 years - CEAP C2S Ep), that underwent unilateral varicose vein surgery from January 2001 to December 2008. The neovascularization and the recurrences in the groin were found in seven patients (1.9%) of the total cases: 3 patients were symptomatic, 4 asymptomatic. The recurrences were due to inadequate groin surgery: the anterior lateral thigh vein, the posterior medial thigh or a T branch of tributaries left, a GSV stump exceeding 1 cm. The GSV stumps and the spared tributaries were open to venous flow; no venous reflux in the groin at Valsalva in standing position was present; the compression ultrasonography of the GSV stump was negative in all the patients. During the past 10 years minimal invasive surgery or endovascular approaches with radiofrequency and endolaser ablation have developed. These techniques leave all or nearly all tributaries of the SFJ and the results in terms of recurrences from the saphenous stump seem to be better than the Babcock’s RHL. The selective high ligation is a reliable technique, decreasing the incidence of neovascularization and recurrent varicose veins in the operated groin.

Is the striated urethral sphincter at risk by standard suture ligation of the dorsal vascular complex in radical prostatectomy? An anatomic study.

To perform an anatomic study of the dorsal vascular complex (DVC) and the underlying striated sphincter (SS) to investigate if the SS might be harmed by standard suture ligation in radical prostatectomy. Transverse wholemount serial sections were created from adult male autopsy cadavers. The total surface area of the DVC and the SS were measured at the prostatic apex and 5 mm distal to it using the ImageJ software. The dorsal boundary of the DVC and the ventral border of the SS were defined digitally. The percentage of the surface area of the SS that would be entrapped by a ligation stitch including the entire DVC was then calculated. In addition, 3-dimensional reconstruction of the lower urinary tract was performed using the SURFdriver software. Five adult male cadavers were investigated. The mean surface area of the SS was 116.1 ± 80.7 and 78.0 ± 63.3 mm(2) at the apex and 5 mm distal to it, respectively. On average, 36.7% (42.6 ± 41.4 mm(2)) and 29.9% (23.3 ± 13.6 mm(2)) of the surface area of the SS were located ventral to the lower boundary of the DVC at the apex and 5 mm distal to it, respectively, and would thus be entrapped by standard suture ligation. Our anatomic findings suggest that standard suture ligation of the DVC is associated with the risk of affecting sphincter tissue. Our study is in accordance with recent clinical studies showing improved early postoperative continence rates by primary transection of the DVC followed by selective suture ligation.

Permanent cardiac sarcomere changes in a rabbit model of intrauterine growth restriction.

BackgroundIntrauterine growth restriction (IUGR) induces fetal cardiac remodelling and dysfunction, which persists postnatally and may explain the link between low birth weight and increased cardiovascular mortality in adulthood. However, the cellular and molecular bases for these changes are still not well understood. We tested the hypothesis that IUGR is associated with structural and functional gene expression changes in the fetal sarcomere cytoarchitecture, which remain present in adulthood.Methods and ResultsIUGR was induced in New Zealand pregnant rabbits by selective ligation of the utero-placental vessels. Fetal echocardiography demonstrated more globular hearts and signs of cardiac dysfunction in IUGR. Second harmonic generation microscopy (SHGM) showed shorter sarcomere length and shorter A-band and thick-thin filament interaction lengths, that were already present in utero and persisted at 70 postnatal days (adulthood). Sarcomeric M-band (GO: 0031430) functional term was over-represented in IUGR fetal hearts.ConclusionThe results suggest that IUGR induces cardiac dysfunction and permanent changes on the sarcomere.

Hepatic caudate lobe compensation function in rats

Objective To assess the safety and effectiveness of caudate lobe-sparing subtotal hepatoectomy after rapid hypertrophy of the caudate lobe following selective portal vein branches ligation except caudate lobe's in rats.Methods Forty SD rats were randomly divided into portal vein branches ligation group and sham group.Portal vein branches except caudate lobe's were ligated by laparotomy.Alanine transaminase (ALT),aspartate aminotransferase (AST),albumin,total bilirubin and direct bilirubin were assessed at 3rd,7th,14th and 21st day after portal vein ligation in 5 rats each day,followed by rats sacrifice.The morphological changes of both ligated and non-ligated liver lobes were observed by microscope.The expression of proliferation cell nuclear antigen (Ki-67) was detected by immunohistochemistry.Twenty-one days after the first operation,caudate lobe-sparing subtotal hepatoectomy was undertaken on other 20 rats of each group.Survival rate was assessed in both groups after the second operation.Results ALT levels were higher in experimental group than in control group on the 3rd,7th and 14th day [(57.28 ± 8.95) vs.(165.07±19.15)U/L,(67.03 ±13.46) vs.(131.24±9.51) U/L,and (67.03 ±13.46) vs.(100.16 ± 5.20) U/L,P ＜ 0.01].AST levels were also elevated on the 3rd,7th and 14th day [(148.89±37.64) vs.(853.61 ±276.33) U/L,(146.34 ±39.06) U/Lvs.(730.19 ±169.81) U/L,P ＜0.01 ; (143.13 ±23.30) vs.(129.82 ± 18.80) U/L,P ＜0.05].Albumin levels were only elevated at day 7 [(39.65 ± 2.49) vs.(25.91 ± 2.21) g/L,P ＜ 0.01].Total bilirubin and direct bilirubin showed no significant diffence between two groups.The hypertrophy rate of caudate lobe was very quick in former 3 days,and then got slower on the day 14.The experimental group had a higher survival rate of 10 days (16/20 vs.4/20,P ＜ 0.01).Conclusion It is safe and effective to undertake caudate lobe-sparing subtotal hepatoectomy after selective portal vein branches ligation in rats. Key words: Portal vein ligation; Caudate lobe; Hepatoectomy

PO-0487 Constraining The Need For Ligating A Significant Patent Ductus Arteriosus After Ibuprofen Therapy In Preterms. A Retrospective Analysis From 10/2009–12/2013

<h3>Background and aim</h3> The need for ligation of a patent ductus arteriosus with a haemodynamically significant left to right shunt (hPDA) on echocardiography remains controversial. Aim was to determine echocardiographic and clinical differences of preterms with hPDA after ibuprofen therapy who underwent ligation and those who had no further intervention. <h3>Methods</h3> Echocardiographic and clinical parameters of preterms with hPDA (&lt; 30 weeks of gestation) were retrieved for the “ligation group” before surgical ligation and for the “non-ligation group” after the last ibuprofen cycle. Recruitment criteria for hPDA were an enddiastolic maximal velocity of the left pulmonary artery (LPAdia) ≥ 0,2 m/s and/or a ratio of the left atrium/aorta (LA/Ao-ratio) ≥ 1,4. Preterms who died before ligation/ductal closure were excluded. <h3>Results</h3> In 53 of 461 preterms a hPDA was still present after ibuprofen. Thirty-nine preterms were included to the “ligation-group”, 14 to the “non-ligation group”. Significant differences were detected for diastolic and systolic blood pressure, LPAdia, LA/Ao-ratio, stroke volume, backward flow in the aorta abdominalis and the period until total enteral nutrition. Further differences were detected in airway support, hPDA flow patterns, gestational age, intraventricular haemorrhage and necrotising enterocolitis before and after ductal closure. <h3>Conclusions</h3> The hPDA of the “ligation-group” was haemodynamically more relevant and preterms were more morbid than in the “non-ligation group”. The observed differences reflect our policy of constraining the need for ligating a hPDA on echocardiography to selective ligation subject to both the severity of echocardiographic findings and the hPDA´s clinical impact.

Doppler-guided ligation of hemorrhoidal arteries with mucopexy: A technique for the future

The transanal hemorrhoidal de-arterialization (THD) procedure is an effective treatment of hemorrhoidal disease. The ligation of hemorrhoidal arteries ("de-arterialization") can provide a significant reduction of arterial blood flow to the hemorrhoidal tissues. Plication of redundant rectal mucosa/submucosa ("mucopexy") can reposition prolapsing tissue to its original anatomical site. In this paper the surgical technique using a specific device (THD(®) Doppler) and peri-operative patient management are illustrated. After appropriate clinical assessment, patients undergo the THD procedure under general or spinal anesthesia, in either the dorsal lithotomy or prone jackknife position. A specifically designed device is used. In all patients, THD is performed, consisting of selective ligation of hemorrhoidal arteries identified by Doppler and marked with a mucosal stitch overlying the artery. In patients with hemorrhoidal or mucosal prolapse, a mucopexy is also performed using continuous suture(s) that include the redundant prolapsing mucosa and submucosa. In long-term follow-up, THD results in resolution of symptoms in the majority of patients. The most common complication is transient but sometimes-painful tenesmus. Rectal bleeding occurs in only a very limited number of patients. There is little or no risk of fecal incontinence or chronic pain. Ano-rectal manometry and endo-anal ultrasound show no evidence of injury to physiologic sphincteric function. THD is a safe procedure and is, at present, one of the most effective treatments of hemorrhoidal disease.

Dynamic expression of desmin, α-SMA and TGF-β1 during hepatic fibrogenesis induced by selective bile duct ligation in young rats.

We previously described a selective bile duct ligation model to elucidate the process of hepatic fibrogenesis in children with biliary atresia or intrahepatic biliary stenosis. Using this model, we identified changes in the expression of alpha smooth muscle actin (α-SMA) both in the obstructed parenchyma and in the hepatic parenchyma adjacent to the obstruction. However, the expression profiles of desmin and TGF-β1, molecules known to be involved in hepatic fibrogenesis, were unchanged when analyzed by semiquantitative polymerase chain reaction (RT-PCR). Thus, the molecular mechanisms involved in the modulation of liver fibrosis in this experimental model are not fully understood. This study aimed to evaluate the molecular changes in an experimental model of selective bile duct ligation and to compare the gene expression changes observed in RT-PCR and in real-time quantitative PCR (qRT‐PCR). Twenty-eight Wistar rats of both sexes and weaning age (21-23 days old) were used. The rats were separated into groups that were assessed 7 or 60 days after selective biliary duct ligation. The expression of desmin, α-SMA and TGF-β1 was examined in tissue from hepatic parenchyma with biliary obstruction (BO) and in hepatic parenchyma without biliary obstruction (WBO), using RT-PCR and qRT‐PCR. The results obtained in this study using these two methods were significantly different. The BO parenchyma had a more severe fibrogenic reaction, with increased α-SMA and TGF-β1 expression after 7 days. The WBO parenchyma presented a later, fibrotic response, with increased desmin expression 7 days after surgery and increased α-SMA 60 days after surgery. The qRT‐PCR technique was more sensitive to expression changes than the semiquantitative method.

Liver-directed therapies: surgical approaches, alone and in combination with other interventions.

When feasible, surgical resection is typically the preferred therapeutic option in patients with both primary and secondary hepatic malignancies. Improved patient selection, preoperative management, and advances in perioperative care have had a considerable effect on short-term and long-term outcomes following hepatic resection. Parenchymal transection of the liver can be performed using many different techniques such as digitoclasia, clamp crushing, vessel sealing system, harmonic scalpel, water-jet, Cavitron Ultrasonic Surgical Aspirator, or radiofrequency dissecting sealer. At the time of surgery, one of the main factors that influences postoperative morbidity and mortality is blood loss. Different techniques are used to decrease blood loss, such as the Pringle maneuver, selective ligation of the right, left, or smaller branches of the portal system; extrahepatic dissection; isolation; and transection of the hepatic artery and portal vein and the total vascular exclusion. Liver resection is on occasion accompanied by a concomitant procedure. Given that colorectal liver metastasis is a common indication for liver resection, colon resection is one of the more common concurrent procedures, but also surgical management of other disease in the lung or pancreas may sometimes be indicated. A subset of patients with primary or secondary liver malignancies may also require the addition of an ablative therapy to treat the extent of disease in the liver. Moreover, occasionally, hepatic resection takes place following intra-arterial therapy administration to the liver. Although many of these patients may benefit from surgical therapy, a multidisciplinary team approach remains critical.

Uterus preservation as an alternative to an emergency hysterectomy for postpartum hemorrhage

4. For obstetricians who perform cesarean sections who can easily perform selective ligation of the uterine and hypogastric arteries, we recommend performing selec-tive ligation.5. For obstetricians who cannot perform selective ligation easily, we recommend uterine compression sutures for obstetricians who can do so easily.6. If obstetricians cannot insert compression sutures, but UAe is available, then UAe should be considered.7. Finally, if the patient has unstable vital signs and dis-seminated intravascular coagulation (DIC), or UAe is not available, emergency postpartum hysterectomy should be considered.Based on our clinical data and experience, stable vital signs without DIC are key points to consider when decid-ing to perform UAe [5]. We found a significant difference in the outcome of UAe for Ph in referred patients. Dur-ing transfer, the patients are bleeding massively and often cannot endure UAe. the health care systems in other coun-tries might not be the same as the Korean system, but in countries with similar systems, it is helpful for evaluating patients transferred with Ph.Postpartum hemorrhage is an emergency and the stand-ard management is emergency postpartum hysterectomy. Nevertheless, uterine preservation is important when pos-sible. If a hospital is not equipped to perform UAe or if the obstetricians lack skill at performing uterine preservation procedures, such as ligation of the uterine artery or uterine compression sutures, then an emergency postpartum hys-terectomy should be performed immediately.We recommend following our algorithm for preserving the uterus and reducing the morbidity associated with Ph based on our clinical experience and the article by Sadik et al. Deliveries with Ph are very dynamic, stressful, Sir,We are responding to the article by Sadik et-al. and Furkan et al. on emergency postpartum hysterectomy, which is a very important obstetrics procedure [2]. We have 1, some comments regarding the control of postpartum hem-orrhage (Ph). Sadik etal. reported the incidence, risk fac -tors, indications, outcomes, and complications of emer-gency postpartum hysterectomy. the current management of Ph focuses on preserving the uterus, using uterine artery embolization (UAe), compression suture methods, and ligation of the hypogastric or uterine artery. We have reported methods such as a modified uterine compression suture for placenta previa; i.e., the hYUNhO method, and uterine compression sutures with intrauterine balloon tam-ponade, which is helpful for preserving the uterus [3, 4].Based on Sadik et al. and our articles, we take the fol-lowing steps in the management of Ph.1. Before a delivery or cesarean section, we check for placental abnormalities using ultrasonography and a history of risk factors.2. If we are suspicious after delivery or cesarean sec-tion, we immediately start conventional management, including fundal massage and the administration of oxytocin and prostaglandins.3. We monitor the vital signs closely, obtain a complete blood count and differential, and consider the use of blood products.

Sequential "click" - "photo-click" cross-linker for catalyst-free ligation of azide-tagged substrates.

Heterobifunctional linker allows for selective catalyst-free ligation of two different azide-tagged substrates via strained-promoted azide–alkyne cycloaddition (SPAAC). The linker contains an azadibenzocyclooctyne (ADIBO) moiety on one end and a cyclopropenone-masked dibenzocyclooctyne (photo-DIBO) group on the other. The first azide-derivatized substrate reacts only at the ADIBO end of the linker as the photo-DIBO moiety is azide-inert. After the completion of the first SPAAC step, photo-DIBO is activated by brief exposure to 350 nm light from a fluorescent UV lamp. The unmasked DIBO group then reacts with the second azide-tagged substrate. Both click reactions are fast (k = 0.4 and 0.07 M–1 s–1, respectively) and produce quantitative yield of ligation in organic solvents or aqueous solutions. The utility of the new cross-linker has been demonstrated by conjugation of azide functionalized bovine serum albumin (azido-BSA) with azido-fluorescein and by the immobilization of the latter protein on azide-derivatized silica beads. The BSA–bead linker was designed to incorporate hydrolytically labile fragment, which permits release of protein under the action of dilute acid. UV activation of the second click reaction permits spatiotemporal control of the ligation process.

How to successfully resect 70 % of the liver in pigs to model an extended hepatectomy with an insufficient remnant or liver transplantation with a small-for-size graft

An insufficient remnant in extended hepatectomy and small-for-size graft in liver transplantation are critical matters in the field of liver surgery, and reliable and reproducible animal models that can provide clinically relevant and reliable data are needed. We herein describe our detailed surgical procedures for performing 70 % hepatectomy in pigs, and discuss the critical anatomical features, key techniques and pitfalls based on our experience. The porcine liver is divided into four lobes. The right lateral lobe (RLL) accounts for 30 % of the liver volume. Important points, such as selective temporal clamping of the arterial branch, confirmation of a related demarcation line, a two-step process to skeletonize Glisson's capsules during liver resection and selective ligation of the portal venous branch to the right medial lobe without inducing any subtle injuries to Glisson's capsules from the RLL to common bile duct, are discussed.

Use of Resuscitative Endovascular Balloon Occlusion of the Aorta in a Highly Lethal Model of Noncompressible Torso Hemorrhage

Noncompressible torso hemorrhage is a leading cause of death in trauma, with many patients dying before definitive hemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct than can be used to expand the window of salvage in patients with end-stage hemorrhagic shock. The aim of this study was to evaluate the effect of continuous and intermittent REBOA (iREBOA) on mortality using a highly lethal porcine model of noncompressible torso hemorrhage. Male splenectomized pigs (70-90 kg) underwent a laparoscopic liver injury (80% resection of left lobe) followed by a 10-min free-bleed period. Animals were then divided into three groups (n = 8) for a 60-min intervention phase (n = 8): continuous occlusion (cREBOA), iREBOA, or no occlusion (nREBOA). Groups then underwent whole blood resuscitation, damage control surgery, and further critical care. Endpoints were mortality and hemodynamic and circulating measures of shock and resuscitation. Systolic blood pressure (in mmHg) at the end of the free-bleed period for cREBOA, iREBOA, and nREBOA was 31 ± 14, 48 ± 28, and 28 ± 17, respectively (P = 0.125). Following the start of the intervention phase, systolic blood pressure was higher in the iREBOA and cREBOA groups compared with the nREBOA (85 ± 37 and 96 ± 20 vs. 42 ± 4; P < 0.001). Overall mortality for the cREBOA, iREBOA, and nREBOA groups was 25.0%, 37.5%, and 100.0% (P = 0.001). Resuscitative endovascular balloon occlusion of the aorta can temporize exsanguinating hemorrhage and restore life-sustaining perfusion, bridging critical physiology to definitive hemorrhage control. Prospective observational studies of REBOA as a hemorrhage control adjunct should be undertaken in appropriate groups of human trauma patients.

Venous ligation: a novel strategy for glans enhancement in penile prosthesis implantation.

Although penile implantation remains a final solution for patients with refractory impotence, undesirable postoperative effects, including penile size reduction and cold sensation of the glans penis, remain problematic. We report results of a surgical method designed to avoid these problems. From 2003 to 2013, 35 consecutive patients received a malleable penile implant. Of these, 15 men (the enhancing group) were also treated with venous ligation of the retrocoronal venous plexus, deep dorsal vein, and cavernosal veins. The remaining 20 men formed the control group, treated with only a penile implant. Follow-up ranged from 1.1 to 10.0 years, with an average of 6.7 ± 1.5 years. Although preoperative glanular dimension did not differ significantly between the two groups, significant respective difference at one day and one year postoperatively was found in the glanular circumference (128.8 ± 6.8 mm versus 115.3 ± 7.2 mm and 130.6 ± 7.2 mm versus 100.5 ± 7.3 mm; both P<0.05), radius (38.8 ± 2.7 mm versus 37.1 ± 2.8 mm and 41.5 ± 2.6 mm versus 33.8 ± 2.9 mm; latter P<0.01), and satisfaction rate (91.7% versus 53.3%, P<0.01) as well. Based on our results, selective venous ligation appears to enhance the glans penis dimension in implant patients.