Transient Liver Failure Research Articles

Application of a New Approach for Laparoscopic Resection of Bismuth IIIa Hilar Cholangiocarcinoma.

Background: Hilar cholangiocarcinoma (HCCA) has a high degree of malignancy and poor prognosis, and the best long-term prognosis can only be achieved by radical resection. However, the surgical steps are complicated, and the operating space is limited, making it hard to complete laparoscopically. So our team proposes a new surgical approach for laparoscopic left-liver-first anterior radical modular orthotopic right hemihepatectomy (Lap-Larmorh). In this way, we can simplify the operation steps and reduce the difficulty. Materials and Methods: We recorded and analyzed the clinical data of 26 patients with type IIIa HCCA, who underwent laparoscopic radical resection in our department from December 2018 to January 2023. According to the laparoscopic surgical approach, we divided the patients into the new approach (NA) group (n = 14) using the Lap-Lamorh and the traditional approach (TA) group (n = 12) not using the Lap-Lamorh. Results: All surgeries in this study were completed laparoscopically with no conversion to open surgery. The operation time in the NA group and TA group had statistically significant differences, which was 372.5 (332.8, 420.0) minutes versus 423.5 (385.8, 498.8) minutes (P = .019). The two groups showed no significant difference in other characteristics (P > .05). Only 1 patient suffered from transient liver failure due to portal vein thrombosis. Patients with pleural effusion or ascites were cured by catheter drainage and enhanced nutrition. Conclusion: Lap-Larmorh reduces the difficulty of serving the vessels at the second and third hepatic hilum by splitting the right and left livers early intraoperatively. The new approach is more suitable for the narrow space of laparoscopic surgery and reflects the no-touch principle of oncology.

TRMU deficiency: A broad clinical spectrum responsive to cysteine supplementation

TRMU is a nuclear gene crucial for mitochondrial DNA translation by encoding tRNA 5-methylaminomethyl-2-thiouridylate methyltransferase, which thiolates mitochondrial tRNA. Biallelic pathogenic variants in TRMU are associated with transient infantile liver failure. Other less common presentations such as Leigh syndrome, myopathy, and cardiomyopathy have been reported. Recent studies suggested that provision of exogenous L-cysteine or N-acetylcysteine may ameliorate the effects of disease-causing variants and improve the natural history of the disease. Here, we report six infants with biallelic TRMU variants, including four previously unpublished patients, all treated with exogenous cysteine. We highlight the first report of an affected patient undergoing orthotopic liver transplantation, the long-term effects of cysteine supplementation, and the ability of the initial presentation to mimic multiple inborn errors of metabolism. We propose that TRMU deficiency should be suspected in all children presenting with persistent lactic acidosis and hypoglycemia, and that combined N-acetylcysteine and L-cysteine supplementation should be considered prior to molecular diagnosis, as this is a low-risk approach that may increase survival and mitigate the severity of the disease course.

Portal vein embolization with n-butyl-cyanoacrylate before hepatectomy: a single-center retrospective analysis of 46 consecutive patients.

Preoperative portal vein embolization (PVE) is performed to induce hypertrophy of the future liver remnant enabling major liver resection in patients with various types of liver tumors. To evaluate safety and effectiveness of PVE with n-butyl-cyanoacrylate (NBCA). All consecutive patients referred to our hospital for PVE between July 2006 and July 2017 were retrospectively reviewed. Volumetry was performed on computed tomography images before and after PVE, segmenting the total liver volume and the future liver remnant (FLR), i.e. liver segments I-III. PVE was performed in 46 patients (18 women, 28 men; mean age = 61 years) using local anesthesia. The ipsilateral technique was used in 45 patients. Adverse events were rare. The mean FLR volume increase was 56%, the degree of hypertrophy was 9.7%, and the kinetic growth rate was 2.1%/week. The median ± SD period between PVE and liver surgery was 7 ± 3 weeks. Forty-two patients (91%) had surgery; liver resection was performed in 37 (80%) patients. Three patients (7%) developed transient liver failure after surgery. There was no 90-day post-PVE or postoperative mortality. PVE using NBCA through the ipsilateral approach in local anesthesia is safe and effective in inducing hypertrophy of the future liver remnant enabling surgery, and thereby increasing survival in patients with liver tumors.

Two genetic disorders (TRMU and SCYL1) explaining transient infantile liver failure in one patient

Two genetic disorders (TRMU and SCYL1) explaining transient infantile liver failure in one patient

Surgery for liver tumors that are close to major vascular structures of future liver remnant

Introduction: In patients with just enough future liver remnant (FLR) parenchymal transection preserving all the inflow or venous outflow of FLR is very important. Tumors close to the major hilar vessels or to the outflow of FLR pose unique challenges for assessment of resectability. In both benign and malignant conditions which are close to major vessels of FLR meticulous surgery is required to obtain good outcomes. Hence, we looked at the data of such tumors which are close to the inflow and outflow of FLR and studied the surgical feasibility and perioperative outcomes. Aim: The aim of the present study was to study the perioperative results of resection of tumors close to the inflow or outflow of future liver remnant. Material and methods: The study was a retrospective study conducted in the Department of Surgical Gastroenterology, Nizam’s Institute of Medical Sciences, Hyderabad between 2015 to 2018.All tumors of the liver which were close (9cm). One patient underwent 2 stage hepatectomy because of hemodynamic instability. The final histopathology was HCC in 4, Hepatoblastoma 1, Adenoma 1 and Tuberculosis in 1. Seven patients with hilar mass underwent surgery (3 had hilar cholangiocarcinoma, 1 intrahepatic cholangiocarcinoma and 3 benign). Segmentectomy was done in 3 (1 colorectal liver metastasis, 2 HCC with CLD) The final biopsy was malignancy in 12 patients. Two (2/12, 16.6%) of them had a positive resection margin). Five patients (5/ 17, 29%) with preoperative suspicion of malignancy had a benign etiology (1 adenoma, 2 tuberculosis, 2 granular cell tumor) on final histopathology. There was 1(1/23, 4.3%) mortality in our series due to bile leak and fungal sepsis. Two patients had transient liver failure (Grade II). Six (5 Grade II, 1 Grade V) patients had transient bile leak. Conclusion: Tumors close to inflow or outflow of FLR can be resected with acceptable morbidity and mortality.

Predictive Value of Intraoperative Indocyanine Green Clearance Measurement on Postoperative Liver Function After Anatomic Major Liver Resection

BackgroundThe aim of this study was to evaluate the predictive value of measuring indocyanine green (ICG) clearance during intraoperative partial occlusion of liver lobes to be resected on postoperative liver function following major anatomic liver resection. MethodsWe prospectively included 46 patients, and 35 patients ultimately underwent anatomic major liver resection. ICG clearance was measured preoperatively and intraoperatively. Intraoperative ICG clearance was measured immediately after selective occlusion of hepatic arterial, portal, and hepatic venous blood flow to the liver lobes to be resected. The albumin-bilirubin (ALBI) grade, albumin-indocyanine green evaluation (ALICE) grade, platelet count, remnant liver volume per kilogram of weight (RLV/kg), and future liver remnant plasma clearance rate of ICG (ICGK-FLR) were measured preoperatively. ResultsAn intraoperative ICG retention at 15 min (I-R15) greater than 13.8% indicates transient posthepatectomy liver failure (PHLF) and Clavien-Dindo > grade I complications. Receiver operating characteristic (ROC) curve analysis revealed that the area under the curve (AUC) for predicting PHLF and Clavien-Dindo > grade I complications was 0.797 and 0.734, respectively (p = 0.001 and 0.014). Furthermore, an I-R15 greater than 22.7% indicates mid-term PHLF, and the AUC was 0.911 (p < 0.0001). The I-R15 is a better predictor of PHLF than the ALBI grade, ALICE grade, platelet count, RLV/kg, and ICGK-FLR. ConclusionsIntraoperative ICG clearance measurements during partial occlusion of blood flow accurately predict postoperative liver function and could be new criteria for determining the feasibility and safety of anatomic major liver resection.

BubR1 Insufficiency Impairs Liver Regeneration in Aged Mice after Hepatectomy through Intercalated Disc Abnormality.

A delay in liver regeneration after partial hepatectomy (PHx) leads to acute liver injury, and such delays are frequently observed in aged patients. BubR1 (budding uninhibited by benzimidazole-related 1) controls chromosome mitotic segregation through the spindle assembly checkpoint, and BubR1 down-regulation promotes aging-associated phenotypes. In this study we investigated the effects of BubR1 insufficiency on liver regeneration in mice. Low-BubR1-expressing mutant (BubR1L/L) mice had a delayed recovery of the liver weight-to-body weight ratio and increased liver deviation enzyme levels after PHx. Microscopic observation of BubR1L/L mouse liver showed an increased number of necrotic hepatocytes and intercalated disc anomalies, resulting in widened inter-hepatocyte and perisinusoidal spaces, smaller hepatocytes and early-stage microvilli atrophy. Up-regulation of desmocollin-1 (DSC1) was observed in wild-type, but not BubR1L/L, mice after PHx. In addition, knockdown of BubR1 expression caused down-regulation of DSC1 in a human keratinocyte cell line. BubR1 insufficiency results in the impaired liver regeneration through weakened microstructural adaptation against PHx, enhanced transient liver failure and delayed hepatocyte proliferation. Thus, our data suggest that a reduction in BubR1 levels causes failure of liver regeneration through the DSC1 abnormality.

Postoperative Outcome after Major Liver Resection in Jaundiced Patients with Proximal Bile Duct Cancer without Preoperative Biliary Drainage

Background/Aims: The need for routine use of preoperative biliary drainage (PBD) before major liver resection in jaundiced patients has recently been questioned. Our aim was to present our experience of patients with proximal bile duct cancer who undergo major liver resection without PBD and compare these results with patients without biliary obstruction who underwent major liver resection. Methods: Eighty six consecutive jaundiced patients underwent major liver resection without PBD. The postoperative outcome was compared to the control group, which was the same size and matched. Design: A case-comparison study. Results: Fifty nine jaundiced patients (69%) and 22 non-jaundiced patients (25%) received blood transfusion (p = 0.04). Fifty-three patients (62%) in the jaundiced group and 17 (19%) in the non-jaundiced patients experienced postoperative complications (p = 0.003). A statistically significant difference could not be detected for mortality (6 vs. 2%) and transient liver failure (10 vs. 3%). Those patients who underwent extended right hemihepatectomy (with future liver remnant <50%) express high morbidity (55 vs. 24%; p = 0.04) and mortality (23 vs. 8%; p = 0.001) compared to the non-jaundiced patients. Conclusions: Major liver resection without PBD leaving a liver remnant of more than 50% is safe in jaundiced patients. However, transfusion requirement and morbidity are higher in jaundiced patients than in non-jaundiced patients.

Hepatic Copper Accumulation: A Novel Feature in Transient Infantile Liver Failure Due to TRMU Mutations?

Defects in the mitochondrial respiratory chain can induce a heterogeneous range of clinical and biochemical manifestations. Hepatic involvement includes acute fulminant hepatic failure, microvesicular steatosis, neonatal non-alloimmune haemochromatosis and cirrhosis. Recently pathogenic mutations in tRNA 5-methylaminomethyl-2-thiouridylate methyltransferase (TRMU) gene (OMIM 610230) have been demonstrated to cause transient infantile liver failure (OMIM 613070). The human TRMU gene encodes a mitochondrial protein, 5-methylaminomethyl-2-thiouridylate methyltransferase, whose molecular function is that of mitochondrial tRNA modification.We report an infant who presented with acute liver failure, in whom we observed hepatic copper intoxication and cirrhosis on liver biopsy. We postulate that the hepatic copper intoxication observed in our patient is most likely a secondary event associated with cholangiopathy. Periportal copper accumulation has been implicated in causing secondary mitochondrial dysfunction; the impact of copper accumulation in patients with TRMU mutations is unclear and warrants long-term clinical follow-up.

Lenalidomide and dexamethasone in overtreated multiple myeloma patients: A single center update.

e19527 Background: Lenalidomide (Len - Revlimid) is a therapeutic option for relapsed and refractory multiple myeloma, especially in association with steroids. Methods: Oraldaily lenalidomide (10-25 mg) for 21 days every month (median courses 9.7) and weekly dexamethasone (Dex) were administered until progression in 41 pretreated patients (median age 66.2 yrs) observed between June 2008 and January 2013 at Hematology Department of Sant’Andrea Hospital in Rome. Past treatment included alkylants, anthracyclines, IFN-α, thalidomide, bortezomib and single or double autograft. Twenty five patients were evaluated after 6 courses of therapy, administered as second to fifth line, and prospectively followed-up; two patients weren’t considered because of early death. Treatment response was assessed according to IMWG uniform response criteria. Results: The overall response rate was 56% (14/25 pts) with a median duration of response of 13 months: 1 patient reached CR, 1 VGPR, 12 patients reached a partial response (PR), 10 showed a stable disease (SD) and 1 progressive disease (PD). The median progression free survival was 14.8 months. Among responder patients, 4 died due to progression disease after a median of 16.5 courses, while 9 are in continuous treatment (3 with over 33 courses each) and 1 in salvage therapy; among non responder ones, 7 died for PD, while 3 are in continuous treatment and 1 in salvage therapy. The reported side effects included pneumonia, neutropenia, diarrhea, peripheral sensitive polyneuropathy, transient liver failure, lower urinary tract infection, skin rash, transient aphasia, conjunctival hemorrhage and deep vein thrombosis, all resolved with brief discontinuance and specific support therapy without hospitalization. Conclusions: This study shows that Len-Dex combination is an effective oral salvage therapy with good response rate and manageable side effects for relapsed and refractory multiple myeloma patients.

Efficacy and safety of lenalidomide and dexamethasone in overtreated multiple myeloma patients.

e18566 Background: Lenalidomide is a therapeutic option for pretreated patients with multiple myeloma, especially in association with steroids. Methods: Oraldaily lenalidomide (10-25 mg) for 21 days every month (median courses 8.6) and weekly dexamethasone (Dex) were administered until progression in 33 pretreated patients (median age 68.1 yrs) observed between June 2008 and January 2012 at Hematology Department of Sant’Andrea Hospital in Rome. Previous treatment included alkylants, anthracyclines, IFN-α, thalidomide, bortezomib and single or double autograft. Fifteen patients were evaluated after 6 courses of therapy, administered as second to fifth line, and prospectively followed-up; two patients weren’t considered because of early death. Treatment response was assessed according to IMWG uniform response criteria. Results: The overall response rate was 53.3% (8/15 pts) with a median duration of response of 12 months: 8 patients reached a partial response (PR), 6 showed a stable disease (SD) and 1 progressive disease (PD). The median progression free survival was 14 months. Among patients in PR, 5 are alive in continous treatment, 2 died due to PD after 17 courses administered as fifth line therapy and 1 died for unrelated surgical complicancies. The whole responses were achieved indifferently if lenalidomide was administered as second, third or fifth line of therapy (2, 3 and 3 patients respectively). Out of patients in SD, all experienced progressive disease after a median of 12 courses: 3 are still alive in salvage therapy, 3 died during treatment. The only patient in PD died 9 months after the end of Len-Dex treatment during salvage chemotherapy. The reported side effects included pneumonia, neutropenia, diarrhea, peripheral sensitive polyneuropathy, transient liver failure, lower urinary tract infection, skin rash, transient aphasia, conjunctival hemorrhage and deep vein thrombosis, all resolved with brief discontinuance and specific support therapy without hospitalization. Conclusions: Len-Dex association is a completely oral effective salvage therapy with good response rate and manageable side effects also for overtreated relapsed and refractory multiple myeloma patients.

Sinusoidal obstruction syndrome compromises liver regeneration in patients undergoing two-stage hepatectomy with portal vein embolization

Several factors have been reported to affect liver regeneration after portal vein embolization (PVE); however, the effect of sinusoidal obstruction syndrome (SOS) has not been evaluated. Therefore, we assessed the effect of SOS on liver regeneration after PVE in patients with multiple bilobar colorectal liver metastases scheduled to undergo two-stage hepatectomy (TSH) combined with PVE. The subjects of this study were 78 patients prospectively scheduled to undergo TSH between December 1996 and August 2009. Archived formalin-fixed, paraffin-embedded nontumoral tissue samples were collected from the 1st- and 2nd-stage hepatectomies in 42 and 45 patients, respectively, and SOS and steatohepatitis were diagnosed pathologically. We analyzed the clinicopathological variables affecting liver regeneration after PVE. Sinusoidal obstruction syndrome was diagnosed in 11 (26.2%) and 20 patients (44.4%) at the time of the 1st- and 2nd-stage hepatectomy, respectively. Patients with SOS at the 1st-stage hepatectomy had a significantly lower hypertrophy ratio of the future remnant liver (FRL) after PVE than patients without SOS (16.8 ± 24.0 vs 55.6 ± 32.5; P < 0.001). Multivariate logistic regression analysis revealed that SOS was an independent factor predicting lower FRL hypertrophy after PVE (Δ% FRL <20: hazard ratio 31.7, 95% confidence interval 2.84-355.12; P = 0.005). The incidence of postoperative transient liver failure after the 2nd-stage hepatectomy in patients presenting with SOS was higher than that in those without SOS, but the difference did not reach significance (25.0% vs 4.0%; P = 0.052). Steatohepatitis was confirmed at the 1st- and 2nd-stage hepatectomy in 6 (14.3%) and 3 (6.7%) patients, respectively. Sinusoidal obstruction syndrome inhibits FRL hypertrophy after PVE and induces postoperative liver failure. Therefore, an alternative strategy is needed to perform TSH safely in the presence of SOS.

Transient fulminant liver failure as an initial presentation in citrullinemia type I

Citrullinemia type I (CTLN1) is a urea cycle disorder which typically presents in the neonatal period or infancy with hyperammonemia and concurrent neurologic deterioration. We report a 15-month-old female with CTLN1 who presented with encephalopathy and seizures with hyperammonemia requiring emergency treatment. Although there was a rapid resolution of her hyperammonemia, she developed fulminant liver failure. The severe increase of transaminases (aspartate aminotransferase and alanine aminotransferase levels peaking at 19,794 UI/L and 19,938 UI/L, respectively) and concurrent disturbances in her hepatic synthetic functions led to the consideration of a liver transplantation. However, there was a normalization of her liver function tests over the course of weeks with supportive therapy alone. Molecular analysis of the ASS1 gene confirmed the diagnosis of CTLN1 by revealing the known mutation c.1087 C > T (p.R363W) on the paternal allele and an intronic nucleotide exchange leading to an insertion of 69 bp on the transcript resulting in a frameshift and premature stop of translation on the maternal allele. We also briefly report another case of CTLN1 where liver failure was a prominent feature of the presentation. Fulminant liver failure has been described with a variety of other urea cycle disorders, but has been described in infantile onset presentation of CTLN1 in only two other cases recently. Our observation suggests that in some cases of CTLN1 with acute liver failure, emergency intervention such as transplantation is not warranted despite evidence of severe hepatotoxicity.

Transient acute liver failure complicating transurethral resection syndrome

Transurethral resection (TUR) syndrome, resulting from dilutional hyponatraemia for excessive absorption of irrigating fluid, represents the most relevant complication of transurethral resection of prostate (TURP). Ethanol is used as a tracer in the irrigant solution to monitor fluid absorption with a breathalyser. An unusual case of transient acute liver failure complicating TUR syndrome is reported. A 54-year-old male patient, without risk factors for the development of toxic hepatitis, was subjected to TURP for treatment of benign prostatic hyperplasia. Fluid absorption (2275 ml), estimated by breathalyser, exceeded maximum allowed absorption (2000 ml) only at the end of the surgical intervention. No signs of possible toxicity were evident in the few hours following the intervention. About 10 h after the end of TURP, the patient developed sweating, vomiting and diarrhoea. Laboratory analysis revealed severe hyponatraemia (116 meq/l) with signs of severe liver impairment (total bilirubin 5.8 mg/dl, alanine aminotransferase 56,500 U/l, aspartate aminotransferase 32,700 U/l), kidney failure (serum creatinine 1.93 mg/dl) and serum ethanol levels of 219 mg/dl (0.2%). The patient was treated with acetylcysteine 150 mg/kg i.v. and furosemide 50 mg i.v. Liver and renal functions improved in few days and recovered completely within 30 days. The TUR syndrome observed in this case was probably extravascular in nature, and could have been identified and prevented by measuring ethanol levels 10 min after ending the surgical procedure. The performance of such a test should be strongly recommended to all surgeons. The clinicians attributed the development of liver impairment in this case to ethanol toxicity. However, further studies are warranted to confirm whether hepatic injury can represent a possible complication of TUR syndrome when ethanol solution is used as irrigant fluid.

A phase II experience with neoadjuvant irinotecan (CPT-11), 5-fluorouracil (5-FU) and leucovorin (LV) for colorectal liver metastases

BackgroundChemotherapy may improve survival in patients undergoing resection of colorectal liver metastases (CLM). Neoadjuvant chemotherapy may help identify patients with occult extrahepatic disease (averting unnecessary metastasectomy), and it provides in vivo chemosensitivity data.MethodsA phase II trial was initiated in which patients with resectable CLM received CPT-11, 5-FU and LV for 12 weeks. Metastasectomy was performed unless extrahepatic disease appeared. Postoperatively, patients with stable or responsive disease received the same regimen for 12 weeks. Patients with progressive disease received either second-line chemotherapy or best supportive care. The primary endpoint was disease-free survival (DFS); secondary endpoints included overall survival (OS) and safety.Results35 patients were accrued. During preoperative chemotherapy, 16 patients (46%) had grade 3/4 toxicities. Resection was not possible in 5 patients. One patient died of arrhythmia following surgery, and 1 patient had transient liver failure. During the postoperative treatment phase, 12 patients (55%) had grade 3/4 toxicities. Deep venous thrombosis (DVT) occurred in 11 patients (34%) at various times during treatment. Of those who underwent resection, median DFS was 23.0 mo. and median OS has not been reached. The overall survival from time of diagnosis of liver metastases was 51.6 mo for the entire cohort.ConclusionA short course of chemotherapy prior to hepatic metastasectomy may serve to select candidates best suited for resection and it may also direct postoperative systemic treatment. Given the significant incidence of DVT, alternative systemic neoadjuvant regimens should be investigated, particularly those that avoid the use of a central venous line.Trial RegistrationClinicalTrials.gov NCT00168155.

Preoperative Portal Vein Embolization for Major Liver Resection

Preoperative portal vein embolization (PVE) is used clinically to prevent postoperative liver insufficiency. The current study examined the impact of portal vein embolization on liver resection. A comprehensive Medline search to identify all registered literature in the English language on portal vein embolization. Meta-analysis was performed to assess the result of PVE and its impact on major liver resection. A total of 75 publications met the search criteria but only 37 provided data sufficiently enough for analysis involving 1088 patients. The overall morbidity rate for PVE was 2.2% without mortality. Four weeks following PVE, 85% patients underwent the planned hepatectomy (n = 930). Twenty-three patients had transient liver failure following resection after PVE (2.5%) but 7 patients developed acute liver failure and died (0.8%). The reason for nonresection following PVE (n = 158, 15%) included inadequate hypertrophy of remnant liver (n = 18), severe progression of liver metastasis (n = 43), extrahepatic spread (n = 35), refusal to surgery (n = 1), poor general condition (n = 1), altered treatment to transcatheter artery embolization or chemotherapy (n = 24), complete remission after treatment with 3 cycles of fluoracil and interferon alpha in a patient with hepatocellular carcinoma (n = 1), incomplete pre- or postembolization scanning (n = 8). Of those who underwent laparotomy without resection, (n = 27) reasons included intraoperative finding of peritoneal dissemination (n = 15), portal node metastasis (n = 2), severe invasion of the tumor to the hepatic artery and portal vein (n = 1), and gross tumoral extension precluding curative resection (n = 9). Two techniques were used for portal vein embolization: percutaneous transhepatic portal embolization, (PTPE) and transileocolic portal embolization, (TIPE). The increase in remnant liver volume was much greater in PTPE than TIPE group (11.9% vs. 9.7%; P = 0.00001). However, the proportion of patients who underwent resection following PVE was 97% in TIPE and 88% PTPE, respectively (P = <0.00001). Although there was no significant difference in patients who had major complications post-PVE, the rate for minor complications was significantly higher among patients who had PTPE (53.6% vs. 0%, P = <0.0001). PVE is a safe and effective procedure in inducing liver hypertrophy to prevent postresection liver failure due to insufficient liver remnant.

Laparoscopic liver resection for hepatocellular carcinoma

Single, small hepatocarcinomas (HCC) are still an indication for partial liver resection in patients ineligible for transplantation. Anatomical resections are recommended for oncological reasons. The mini-invasive approach of laparoscopy should minimize hepatic and parietal injury, thereby decreasing the risk of liver failure and ascites. However, the oncological results of this approach and its presumed benefits remain undemonstrated. We evaluated the short- and midterm results of laparoscopic liver resections for HCC. Between 1999 and 2006, we performed 32 laparoscopic liver resections for HCC. Mean tumor size was 3.8 +/- 2 cm and the mean age of the patients was 65 +/- 11 years. Twenty-two patients had cirrhosis (21 Child A and one Child C). Operative and postoperative results were analyzed, together with recurrence and survival rates. We carried out 13 unisegmentectomies, nine bisegmentectomies, one trisegmentectomy, two right hepatectomies, one left hepatectomy, and six atypical resections. The duration of the operation was 231 +/- 101 minutes. Conversion to laparotomy was required in three patients (9%), none in emergency situations. Mean blood loss was 461 ml, with five patients (15.6%) requiring blood transfusion. The mean surgical margin was 10.4 mm. One cirrhotic patient (Child C) underwent surgery for a partially ruptured tumor and died of liver failure. Two patients had ascites and no transient liver failure occurred in the other 19 cirrhotic patients. Mean hospital stay was 7.1 days. During a mean follow-up of 26 months, 10 patients (31%) presented recurrence within the liver. None of the patients had peritoneal carcinomatosis or trocar site recurrence. Three-year overall and disease-free survival rates were 71.9% and 54.5%, respectively. Laparoscopic liver resection for HCC is feasible and well tolerated. Midterm survival and recurrence rates are similar to those after laparotomy.

Factors predicting early postoperative liver cirrhosis-related complications after lung cancer surgery in patients with liver cirrhosis

We aimed to determine the factors predicting liver cirrhosis-related complications in the early postoperative period after lung cancer surgery in patients with liver cirrhosis. We retrospectively reviewed the medical records of patients who underwent curative surgery for primary lung cancer in our institute from January 1990 to March 2007, finding 37 cases with comorbid liver cirrhosis. These patients were divided into two groups, according to whether liver failure, bleeding, and critical infection had occurred postoperatively. Various clinical parameters were analyzed statistically between the bigeminal groups. Liver cirrhosis-related complications occurred in seven of the 37 patients (18.9%). Transient liver failure occurred in two patients (5.4%) after pulmonary resection. Acute intrathoracic bleeding occurred in four cases (10.8%). Two patients died (5.4%) in both cases due to sepsis. Preoperative total bilirubin (P<0.05), and indocyanine green retention rate at 15 min (P<0.05) were significantly higher in patients with liver failure. Only serum value of total bilirubin was an independent risk factor (P<0.05) by multivariate analysis. In predicting death from infection, only preoperative nutritional status was a significant risk factor (P<0.05). To avoid postoperative cirrhosis-related complications, preoperative preparation to improve their liver function and nutrition status is essential.

Laparoscopic liver resection assisted with radiofrequency

Background Radiofrequency-assisted laparoscopic liver resection is reported. Methods Patients suitable for liver resection were carefully assessed for laparoscopic resection. Patient and intraoperative and postoperative data were prospectively collected and analyzed. Results Eighteen patients underwent laparoscopic liver resection. All operations were performed without vascular clamping and consisting of tumorectomy (n = 9), multiple tumoretcomies (n = 2), segmentectomy (n = 2), and bisegmentectomies (n = 2). Mean blood loss was 121 ± 68 mL, and mean resection was time 167 ± 45 minutes. There was no need for perioperative or postoperative transfusion of blood or blood products. One patient developed pneumothorax during surgery as a result of direct puncture of pleura with the radiofrequency probe, and 1 patient had transient liver failure and required supportive care after surgery. The mean length of hospital stay was 6.0 ±1.5 days. At follow-up, those with liver cancer had no recurrence. Conclusions Radiofrequency-assist laparoscopic liver resection can decrease the risk of intraoperative bleeding and blood transfusion.

Liver resection with normothermic ischaemia exceeding 1 h.

A retrospective study was made of 34 patients who underwent major liver resection with a single period of vascular occlusion exceeding 60 min. The liver remnant was normal in all cases. Vascular occlusion was achieved by continuous portal triad clamping (15 patients), hepatic vascular exclusion (15) or a sequential combination of both procedures (four). Liver cooling was not used. The mean (s.e.m.) duration of continuous normothermic liver ischaemia was 73.6 (2.5) (range 60-127) min. The mean (s.e.m.) amount of blood transfused during operation was 5.3(0.8) units packed red cells. There were no deaths after surgery and the postoperative course was uneventful, or limited to asymptomatic pleural effusion, in 18 patients. Three patients suffered postoperative bleeding necessitating further surgery and one of these required reintervention for a prolonged bile leak. Four patients had transient liver failure that resolved spontaneously within 15 days. There was a 13-fold increase in serum transaminase activities and the proaccelerin level was 45 per cent that of normal on day 1 after operation. These changes were returning to normal levels within 15 days. Continuous vascular occlusion during major liver resection is a useful manoeuvre that may be performed safely on normal hepatic parenchyma for up to 90 min.