prospective study of the predictors of the clinical outcome after Kasai portoenterostomy done for cases with biliary atresia

Objectives: The purpose of this study was to determine the predictors of the clinical outcome after Kasai portoenterostomy done for cases with biliary atresia [BA]

Study design: a prospective clinical study involving twenty patients with billay atresia that underwent Kasai operation. All patients underwent a detailed history taking, clinical examination and were investigated for liver function tests. US abdomen was also done in addition to preoperative liver biopsy and intra-operative cholangiogram. Patients were followed up for a period of 6 months post operatively and complications such as cholangitis, progress to liver failure and cirrhosis was noted. The schedule and indications for liver transplantation were also followed

Results: There were no mortalities within the 6 months of follow up, 11 patients showed gradual reduction of serum bilirubin [<2mg/dI] as well as liver enzymes [Non-icteric] and 9 patients' maintained high levels of serum bilirubin [>2mg/d1] and liver enzymes [Icteric].There was statistically significant difference between the two groups regarding age at operation, presence of preoperative ascites, hepatomegaly and patients' child-Pugh score. Preoperative total serum bilirubin and its direct fraction, preoperative liver enzymes [AST-ALT-GGT-alkaline phosphatase], preoperative serum albumin and total proteins, advanced pathological changes in preoperative liver biopsy showed statistically significant difference between the two groups. However; sex, splenomegaly, associated anomalies, bleeding profile, presence of preoperative TC sign and operative duration didn't show statistically significant difference between the two groups

Conclusion: Kasai portoenterostomy showed better results with short term follow up if done at an early age. Presence of ascites, hepatomegaly and advanced Child-Pugh score adversely affect the clinical outcome, Better outcome is predicted also by lower preoperative serum bilirubin with its direct fraction, lower levels of liver function tests and higher levels of plasma proteins and serum albumin. Advanced liver fibrosis and pathological changes in preoperative liver biopsy are predictors of bad outcome after Kasai portoenterostomy

Role of radiofrequency ablation in the treatment of colorectal liver metastases

Surgical resection is the standard of care for colorectal metastases isolated to the liver. However, only 10-25% are eligible for resection because of extent and location of the disease in the liver or concurrent medical conditions. Severe series have shown that radiofrequency ablation [RFA] can result in tumor eradication in properly selected candidates. The purpose of this study was to determine the efficacy of RFA for treatment of such lesions. Thirty patients with documented colorectal liver metastases who met the following criteria were considered for RFA: metastases confined to the liver; judged irresectable due to technical considerations or co-morbidity, number of metastatic deposits no greater than 5; and size less than 10 cm. Median follow-up was 26 [range 9-63] months. Overall 1-and 2-year survival rates were 76 and 61% respectively. Median survival was 32 months. Disease-free survival at 1 year was 35% at 2 years 7%. Six patients developed recurrence at the site of RFA; given that the total number of RFA-treated lesions was 69 the local recurrence rate was 9%. RFA can achieve effective local treatment for patients with colorectal liver metastases who were considered unsuitable for surgical treatment

Role of spiral CT scan and endoscopic ultrasonography in assessing operability of peri-ampullary tumors

Pancreatic cancer is associated with an extremely poor prognosis with less than 5% of patients surviving 5 years after the diagnosis. Current preoperative staging modalities include various cross sectional imaging techniques. including spiral CT and endoscopic ultrasound [EUS]. This prospective study aimed at demonstrating the role of spiral CT and endoscopic ultrasonography in early diagnosis staging and assessment of operability of periampullary tumors. Sixty-two patients with periampullary tumors were included in this study. All cases were subjected to abdominal ultrasound. Spiral CT. ERCP. EUS and operative interference. Surgical findings were considered the gold standard for assessing the sensitivity of spiral CT and EUS in diagnosing, staging arid estimating resectability of periampullary tumors. Endoscopic Ultrasonography was very sensitive in detecting periampullary masses [93.5%] especially masses smaller than 20mm while the sensitivity of spiral CT was 71%. EUS was also very sensitive in detecting ampullary masses [100%] in contrast to spiral CT chat missed the diagnosis of the 14 ampullary masses found in our work. EUS was more sensitive than Spiral CT in detecting malignant vascular invasion [95% versus 75%] while it was slightly less specific than spiral CT in that context [74 versus 80%]. The predictive value of spiral CT was 60% for tumor resectability while it was 100% for tumor unresectability. The predictive value of EUS was 735% for tumor resectability while it was 96.4% for tumor unresectability. When combining both techniques the predictive value for tumor resectability was 65% while it was 100% for tumor unresectability. No complications were encountered in both techniques. We concluded that EUS is more sensitive than spiral CT in detection and staging of periampullary masses. Also. the non-invasive spiral CT and the minimally invasive EUS are very valuable tools in predicting uresectability of periampullary masses while EUS is slightly more valuable in detecting tumor resectability

Low central venous pressure anaesethesia in major hepatic resection

Blood loss and transfusion requirements are major determinants of morbidity and mortality following liver resection. This study evaluates the association of low central venous pressure [LCVP] with blood loss and blood transfusion during liver resection. Thirty consecutive hepatic resections were studied prospectively concerning CVP, volume of blood loss and volume of blood transfusion and renal outcome. Data were analyzed for those with a CVP 5 mmHg. A muitivariate analysis assessed potential confounding factors in the comparison. The mean blood loss in patients with a CVP of 5 mmHg or less was < 500 ml and that in those with a CVP > 5 mmHg was > 2000 ml. [p <0.0001]. Only two patients with a CVP of 5 mmHg required transfusion. No incidences of air embolism or permanent renal shutdown have been reported. In conclusion: The volume of blood loss and blood transfusion during liver resection correlates with the CVP during parenchyma! transection. Lowering the CVP to less than 5 mmHg is a simple and effective technique to reduce blood loss during liver resection and delete the need for blood transfusion with its hazards

Effect of albumin administration prior to graft reperfusion on the severity of reperfusion syndrome during living related liver transplantation

A prospective randomized study to evaluate the effect of intra-operative use of Albumin [20%] infusion prior to graft reperfusion on the severity of reperfusion syndrome during living donor liver transplantation Twenty patients were included with Child-Pughs C classification [ESLD]. Samples and measurements were taken pnor to reperfusion, during and after reperfusion of the donor liver graft. I. V fluids, blood and blood products were used to adjust a Hb level at [8-10 gm/dl] and Hct between 24-28% for better graft function and survival The reperfusion syndrome was severe as regard the decrease in MABP in No Albumin group [MABP = 48.2 +/- 7.23 mmHg] compared to Albumin group [MABP = 63.45 +/- 6.96 mmHg]. [P=00002] CVP was highly significant increased in Albumin group during reperfusion compared to No Albumin group [p = 0.0002]. Also. CVP correlated positively with S albumin level [r = 0.81. p = 0.002] dunng reperfusion syndrome. Patients of No Albumin group needed more motropic support than patients of Albumin group. In conclusion Albumin 20% in a dose of 1.5 ml/kg causes volume retention and expansion of intravascuiar volume which was a beneficial effect in liver transplant surgery to elevate the CVP prior to graft reperfusion and hence decreasing the severity of reperfusion syndrome and also elevating the already low serum albumin level and oncotic pressure

Aprotinin versus tranexamic acid in cirrhotic patients undergoing hepatic surgery

Patients with liver cirrhosis have complex hemostatic dysfunction characterized by impaired clotting factor synthesis, thrombocytopenia and accelerated fibrinolysis. Pharmacological management has been advocated to decrease bleeding and transfusions during major hepatic surgery, with the use of either aprotinin or tranexamic acid. In the present study, aprotinin was given in moderate doses to 10 patients and tranexmaic acid was given to another 10 patients compared with control group. Hemostasis was significantly better preserved after aprotinin treatment [blood loss of 373 ml in the aprotinin group, 524 ml in tranexamic acid group versus 956 ml in the control group]. Platelets were better preserved in aprotinin and tranexamic acid groups. Fibrinolysis was significantly reduced in aprotinin and tranexamic acid groups, where fibrinogen level was significantly reduced in the control group [206.8 mg/dl, 184 mg/dl at 4 and 6 hours intraoperatively] and FDPs were significantly increased in the control group [FDPs changed from 4.8 micro g/dl to 26 micro g/dl during surgery]. We conclude that prophylactic use of either aprotinin [in moderate doses] or tranexamic acid is equivocal and is mandatory in the operative management of hepatic resection