Strategies for a successful hepatic artery anastomosis in liver transplantation: A review of 51 cases

INTRODUCTION@#Hepatic artery reconstruction is a critical aspect of liver transplantation. The microsurgeon faces several challenges when reconstructing the hepatic artery-the donor hepatic artery stalk is short and often a poor match for the usually hypertrophic recipient vessels. Previous inflammation impedes vessel dissection, and recipient vessels have a tendency to delaminate with manipulation. We review 51 consecutive liver transplantations to highlight these problems and propose strategies for a successful reconstruction of the hepatic artery.@*METHODS@#A prospective study involving all adult patients undergoing liver transplantation at the Singapore General Hospital from January 2015 to December 2018 was undertaken. All hepatic artery anastomoses were performed by 2 microsurgeons at 10x magnification. Patients were started on a standard immunosuppressive regimen. Postoperative ultrasound scans on days 1, 3, 5, 7, 9 and 14 were used to confirm arterial patency.@*RESULTS@#There were 51 patients who underwent liver transplantation during the study period. Of this number, 31 patients received deceased donor grafts and 20 received living donor grafts. A total of 61 anastomoses were performed (5 dual anastomosis, 4 radial artery interposition grafts) with 1 case of hepatic artery thrombosis that was successfully salvaged. The mean (range) postoperative resistive index and hepatic artery peak systolic velocity were 0.69 (0.68-0.69) and 1.0m/s (0.88-1.10m/s), respectively.@*CONCLUSION@#Hepatic artery thrombosis after liver transplantation is poorly tolerated. The challenges of hepatic artery reconstruction in liver transplantation are related to vessel quality and length. The use of microsurgical technique, appropriate recipient vessel selection, minimisation of vessel manipulation with modified instruments, variation in anastomosis techniques, and use of radial artery interpositional grafts are useful strategies to maximise the chances of success.

Colorectal cancer liver metastases - understanding the differences in the management of synchronous and metachronous disease

<p><b>INTRODUCTION</b>Metastatic disease to the liver in colorectal cancer is a common entity that may present synchronously or metachronously. While increasing surgical experience has improved survival outcomes, some evidence suggest that synchronous lesions should be managed differently. This review aims to update current literature on differences between the outcomes and management of synchronous and metachronous disease.</p><p><b>MATERIALS AND METHODS</b>Systematic review of MEDLINE database up till November 2008.</p><p><b>RESULTS</b>Discrete differences in tumour biology have been identified in separate studies. Twenty-one articles comparing outcomes were reviewed. Definitions of metachronicity varied from anytime after primary tumour evaluation to 1 year after surgery for primary tumour. Most studies reported that synchronous lesions were associated with poorer survival rates (8% to 16% reduction over 5 years). Sixteen articles comparing combined vs staged resections for synchronous tumour showed comparable morbidity and mortality. Benefits over staged resections included shorter hospital stays and earlier initiation of chemotherapy. Suitability for combined resection depended on patient age and constitution, primary tumour characteristics, size and the number of liver metastases, and the extent of liver involvement.</p><p><b>CONCLUSIONS</b>Surgery remains the only treatment option that offers a chance of long-term survival for patients amenable to curative resection. Synchronicity suggests more aggressive disease although a unifying theory for biological differences explaining the disparity in tumour behaviour has not been found. Combined resection of primary tumour and synchronous metastases is a viable option pending careful patient selection and institutional experience. Given the current evidence, management of synchronous and metachronous colorectal liver metastases needs to be individualised to the needs of each patient.</p>

Characteristics, and disease control and complications of hypertensive patients in primary-care - a community-based study in Singapore

<p><b>INTRODUCTION</b>Hypertension is a common chronic condition usually managed by primary-care practitioners in Singapore. This study assessed the characteristics, control and complications of non-diabetic hypertensive patients managed at government primary healthcare clinics.</p><p><b>MATERIALS AND METHODS</b>A cross-sectional study involving 9 clinics was conducted over 1-week in 2006. Five hundred and six non-diabetic hypertensive patients were systematically sampled from all clinic attendees. Data relating to socio-demographic, lifestyle factors, treatment and complications were collected by interviewer-administered questionnaires and review of clinic medical records. Blood pressure (BP) measurements were taken with validated automated sets following a standard protocol.</p><p><b>RESULTS</b>The prevalence of good BP control (<140/90 mmHg) was 37.7% (95% CI: 33.6% to 41.8%). Ninety seven percent were on medication with about half on monotherapy. Seventy percent of patients had a body mass index (BMI) of 23.0 kg/m(2) or higher, 64% did not exercise regularly and 8% were current smokers. After adjusting for age and lifestyle factors, male hypertensive patients had poorer BP control compared to females. Nineteen percent of patients reported at least 1 complication of hypertension, especially cardiac disease. After multivariate analysis and duration of disease, age and the male gender were associated with the presence of hypertensive complications.</p><p><b>CONCLUSIONS</b>More than half of the patients were not controlled to target levels. Male patients were more likely to have poorer control of hypertension and significantly higher risks of complications. Control of BP could be further improved by lifestyle modifications - weight reduction, promotion of physical activity, healthier eating habits and smoking cessation.</p>