Application of Right Hemihepatic Vascular Exclusion in Liver Resection

PURPOSE: Control of bleeding and preservation of liver function are still major keys for successful liver resection. We applied right hemihepatic vascular exclusion (RHVE) in patients with a right lobe liver tumor to verify the usefulness and safety of RHVE. METHODS: Between March 1998 and August 2002, 12 patients (Control group) underwent right liver surgeries without inflow occlusion, and 22 patients (RHVE group) underwent right liver surgeries under RHVE. Hemodynamic changes during the operation, amount of transfusion, and post- operative liver function were compared between the two groups. RESULTS: The mean duration of RHVE was 32.3+/-13.9 (15~60) minutes. The mean arterial pressure of the control group and the RHVE group after liver resection were reduced, but these changes were not statistically significant. The amount of transfusion in the RHVE group (2.66+/-1.4 unit) was significantly lower (P<0.05) than that of the control group (4.56+/-3.3 unit). AST/ALT level of the RHVE group were significantly higher on POD#1, but there were no statistically significant differences on POD#3, 5 and 7. Also, the differences in the changes of total bilirubin and IL-6 after liver resection were not significant. Cirrhotic patients in both groups were compared with the same analysis. Only the amounts of transfusion in the RHVE group were significantly lower (P<0.05) than that of the control group. CONCLUSION: RHVE is a safe and useful procedure for right liver surgery with minimal blood loss, but without significant hemodynamic alteration and functional deterioration. These characteristics are shown especially in cirrhotic liver and non-anatomical resection of metastatic cancer.

Analysis of the Clinical Factors Affecting Graft Patency Rate after Infrainguinal Arterial Reconstruction

PURPOSE: This study was designed to determine the clinical factors affecting the long-term graft patency of leg arterial bypass for the patients with chronic lower limb arterial occlusion. METHOD: The clinical data of 81 femoro-distal bypasses performed at Yeungnam University Hospital from January 1996 to December 2002 were included for this retrospective study. A Log-Rank test of Kaplan-Meier method and Cox proportional hazard analysis were performed to identify those main effects that were predictive of graft patency. The patients, 79 males and 2 females, ranged from 37 to 81 years of age, with a mean age of 64. The highest incidence occurred among those in their 60s and 70s. Associated diseases were hypertension in 42 cases (51.8%), diabetes mellitus in 15 (18.8%), cardiac disease in 26 (32.1%) and cerebrovascular disease in 6 (7.4%). A history of smoking was noted in 76.5% of the cases. As for the clinical grades of chronic limb ischemia according to SVS/ISCVS classification, 21 limbs (25.9%) were classified as grade I (category 3), 40 (49.4%) as grade II, and 20 (24.7%) as grade III. The site of distal anastomosis was above the knee popliteal artery in 53 limbs (65.4%), below the knee popliteal artery in 8 (9.9%) and tibial artery in 20 (24.7%). As bypass conduit, autologous vein graft was used in 67 limbs (82.7%) and polytetrafluoroethylene (PTFE) graft in 14 (17.3%). There were no hospital mortalities or major perioperative complications. RESULT: From the univariate analysis of 21 clinical variables (age, sex, smoking, hypertension, diabetes mellitus, coronary arterial disease, congestive heart failure, chronic pulmonary disease, cerebrovascular disease, malignancy, hypercholesterolemia, clinical grade of chronic limb ischemia by SVS/ISCVS, level of occlusion, preoperative ankle-brachial index, type of graft, site of distal anastomosis, operation time, status of inflow artery, postoperative ankle-brachial index, clinical outcome criteria by SVS/ISCVS, postoperative anticoagulation therapy), 5 factors were identified as being associated with long-term graft patency: preoperative clinical grade (P=0.03), preoperative ankle-brachial index (P=0.00), level of occlusion (P=0.03), type of graft (P=0.00) and clinical outcome criteria (P=0.00). In multivariate analysis, type of graft, PTFE graft (vs. autologous vein graft, P=0.002), and clinical outcome criteria, minimally improved (vs. moderately, and markedly improved, P=0.029), showed a lower graft patency rate. CONCLUSION: These results suggest that autogenous vein is more acceptable for leg arterial bypass and poor early clinical outcome predicts poor long term graft patency rate.