Problems of precision hepatic surgery in nowadays / 中华消化外科杂志

With the era of precision hepatic surgery coming,the hepatic surgery has been promoted to brand-new level,which would be more accurate and meticulous.However,all those advances,such as super-thin computed tomography scan,three-dimensional imaging and the technology of threedimensional printing,have not promoted the clinic results for patients overtly.The optimal curative effect could be attained,if there is a perfect combination of operators' experience and those advanced imaging.For two issues,the time of vascular inflow occlusion and residual hepatic volume,operators could flexiblely use of clinic existing researches with surgical team and instruments according to the medical condition of patients.Precision hepatic surgery could be promoted to a higher level through constantly clinical research and innovations.

Protective effect of portal vein occlusion without hepatic artery inflow control on cirrhotic rat liver / 中华肝胆外科杂志

Objective In order to improve cirrhotic liver management,each aspect of the liver's complex blood flow must be understood.This study investigates the protective effect of portal vein occlusion,with hepatic artery preservation,on cirrhotic liver after ischemia and reperfusion.Methods Carbon tetrachlorideand induced cirrhotic rats and normal rats were randomly assigned into 4 groups:normal sham operation (N-SO),cirrotic sham operation (C-SO),portal triad clamping (PTC),and portal vein clamping without hepatic artery inflow control (PVC).During the occlusion,the total 3-minute blood loss from the liver surface cut was weighed.At 1,6,and 24 hours post reperfusion,the serum alapine amino transferas (ALT),the adenosine triphosphate (ATP) of liver tissue,the malonolialdehgde (MDA) of liver tissue,and the morphological changes were evaluated.Result The amount of hemorrhage between the groups ranked as follows:PTC ＜ PVC ＜ N-SO ＜ C-SO (P＜0.05).At 1,6,and 24 hours post reperfusion.the ALT and MDA levels of the groups ranked as follows:PTC ＞ PVC ＞ C-SO ＞ N-SO (P＜0.05).Additionally,each group's ATP level ranked as follows:PTC ＜ PVC ＜ C-SO ＜ N-SO (P＜0.05).With histopathological examination,the hepatic injuries of the PTC and PVC group were more severe than those of the C-SO group,especially in the PTC group.Conclusion Therefore,the technique of portal vein clamping and hepatic artery inflow control can reduce the ischemic reperfusion injury of the cirrhotic rats' liver.

Laparoscopic right hemihepatectomy under selective hemihepatic inflow occlusion / 中华普通外科杂志

Objective To evaluate the feasibility and safety of laparoscopic right hemihepatectomy under selective hemihepatic inflow occlusion.Methods In performing this procedure,first dissect the right hepatic portal,and under selective hemihepatic inflow occlusion,laparoscopie Peng's multifunctional operative dissector (LPMOD) was used to transect the hepatic parenchyma by stepwise curettage and aspiration.Results Procedures were successful in all six patients of benign liver diseases,though a small subcostal auxiliary incision was needed in one case to control the middle hepatic vein branch hemorrhage.Operation time was 300-540 min[mean,( 399 ± 75 ) min].The time of hepatic portal dissect was 30-75 min[mean,(51 ± 16) min].The time of liver parenchyma transection was 60-160 min[mean,( 116 ± 32) min].Intraoperative blood loss was 600-3000 ml[mean,( 1486 ± 809 ) ml].The level of ALT increased to (302-557) U/L[mean,(386 ± 85 ) U/L]after the operation,and back to normal level in 5-11 d[mean,( 7.1 ± 2.0) d].The postoperative hospital stay was 10-18 d[mean,( 12.4 ± 2.6 ) d].No severe complication occurred after the operation.Conclusions Laparoscopic right hemihepatectomy under selective hemihepatic inflow occlusion is safe and feasible.

The impact of different hepatic vascular occlusion methods on hepatic parenchymal function in partial hepatectomy / 中华肝胆外科杂志

Objective To investigate the impact of different hepatic vascular inflow occlusion methods on hepatic parenchymal function in partial hepatectomy.Methods Between 2009 and 2010,62 hepatocellular carcinoma (HCC) patients underwent partial hepatectomy.In 13 patients,partial hepatectomy was carried out without using any inflow occlusion (group A).In 29 patients intermittent Pringle's maneuver (group B) while in 20 patients selective hepatic inflow occlusion (group C) were used.Intraoperative indocyanine green retention rate at 15 minutes (ICGR15) was measured using pulse spectrophotometry before and during hepatectomy. Results (1) Blood loss in group A was greater than group B and C (P=0.016,P=0.001).(2) There was no significant difference in the preoperative ICGR15 values among group A,B and C.The intraoperative ICGR15 for group B was significantly higher than group A and C (P=0.011,P=0.030).(3) A significant correlation was found between the level of ICGR15 and total inflow clamp time (r =0.484,P =0.001) and blood loss (r=0.349,P=0.005),respectively.(4) Compared with group A and B,postoperative liver function recovered significantly faster in group C.Conclusion Selective hepatic inflow occlusion was useful in controlling blood loss and it was beneficial to the hepatic functional reserve in the liver remnant.

Impact of hepatic vascular inflow exclusion on postoperative arterial lactate level in patients undergoing hepatectomy / 中华普通外科杂志

Objective To investigate the impact of vascular inflow occlusion of the liver on arterial lactate level and pH value. Methods In this study, 68 patients who underwent hepatectomy from January 2006 to December 2008 were retrospectively studied. The patients were assigned to one of the three study groups according the vascular inflow status: clamping of portal vein and hepatic artery in the hepatic pedicle (n = 20), hemihepatectomy under total hemihepatic vascular exclusion (THVE, n = 22), and non-vascular occlusion (n = 26). Postoperative arterial blood gas analysis including systemic arterial lactate concentration, and liver and renal function tests were performed. Results Systemic arterial blood lactate levels significantly elevated in the portal clamping and THVE groups (5.53 ±2. 31 mmol/L and 5.62 ±2.52mmol/L, respectively), compared to the non-occlusion group (3. 37 ± 1.56 mmol/L, P < 0. 05) ;significant increase in arterial HCO3- level was observed in the THVE group in comparison to the nonocclusion group (19. 68 ± 3. 82) mmol/L vs. (21.65 ± 2. 48) mmol/L, (P < 0. 05). There were no significant differences as to the changes of pH values, liver and renal function tests between the three groups. Conclusions Vascular inflow deprivation may result in significantly increased arterial lactate level. Thus, intense surveillance of blood lactate level with prompt treatment is necessary to prevent postoperative hyperlactatemia and metabolic acidosis.

Avaliação clínica de cães submetidos à parada circulatória total por diferentes períodos de tempo através da técnica de Inflow Occlusion / Clinical evaluation of dogs submitted to circulatory arrest for different periods of time by Inflow Occlusion

A técnica de "Inflow Occlusion" pode ser utilizada em cirurgias cardíacas quando se pretende manter o coração aberto apenas por alguns minutos, para realização de pequenos reparos. No entanto, a parada circulatória total (PCT), evento decorrente da técnica em questão, pode acarretar severas alterações metabólicas e neurológicas ao paciente. Neste estudo foram utilizados 12 cães sem raça definida, os quais foram divididos em dois grupos, A e B, sendo os mesmos submetidos a 7 e 8 minutos de PCT, respectivamente, utilizando-se da técnica de "Inflow Occlusion". Tentou-se estabelecer normotermia durante os procedimentos cirúrgicos. Avaliações clínica e comportamental foram realizadas nos dois grupos após os procedimentos cirúrgicos e dados bioquímicos foram coletados para comparação entre os períodos pré e pós-operatórios. Ocorreram dois óbitos transoperatórios no grupo B. Alterações clínicas transitórias foram observadas no grupo A até o momento M7 (48 horas após cirurgia), e no grupo B, as mesmas foram mais intensas e presentes mesmo após M7; e em um animal do grupo B foi observada cegueira permanente por todo o período de acompanhamento. Apesar das alterações observadas, há indícios que seja seguro realizar a técnica de "Inflow Occlusion" por até 7 minutos, sendo contra-indicada, no entanto, para períodos mais prolongados.

"Inflow Occlusion" technique can be used in heart surgeries when heart is required to be opened just for few minutes, to allow quick repairs. However, circulatory arrest, event occasioned by this technique, may produce serious metabolic and neurological consequences to the patient. In this study, 12 mongrel dogs were used, divided into two groups, A and B, which were submitted to 7 and 8 minutes of total circulatory arrest, respectively, using "Inflow Occlusion" technique. Normothermia was tried during surgical procedures. Clinical and behavior evaluation were performed after surgery to both groups, and biochemical data were collected to compare pre and post-operatory moments. There were two transoperatory deaths in Group B. Transitory clinical problems were observed in group A until moment M7 (48 hours after surgery), and in Group B these problems were more intense and seen even after M7; and permanent blindness in one animal of Group B was present during all follow up period. Despite all alterations found during the study, it might be safe to use "Inflow Occlusion" technique for periods up to 7 minutes, however, it is contra-indicated for longer periods.

A comparative study on continuous hemihepatic with intermittent total hepatic inflow occlusion in hepatectomy for liver tumors / 中华普通外科杂志

Objective To evaluate if continuous hemihepatic inflow occlusion(HH)during hepatectomy can be as safe and effective as intermittent total hepatic inflow occlusion(TH)in reducing blood loss during hepatectomy.Methods From November 2001 to March 2006.eighty patients undergoing liver resections were included in a prospective randomized study comparning the intra-and postoperative course underTH(n=40)or HH(n=40).TH was performed with periods of 20 minutes of occlusion and 5 minutes of releasing,while HH with continuous occlusion.The surface area of liver transection was measured and blood loss was calculated.The amount of blood loss,levels of alanine aminotransferuse (ALT)and aspartate aminotransferase(AST),and postoperative course were recorded. Results The total ischemic time of the HH groups was longer than in the TH group[(42±13)min,(31±13)min,P=0.37],and the operative time in the HH group was longer than in the TH group[(236 ±49)min,(204±38)min,P=0.02 ].No signincant difierenee was found between HH and TH group in blood loss during liver parenchyma transection[(500 ±269)ml,(416 ±235)ml,P=0.14]and in the changes of ALT and AST on the first postoperative day[ALT:(677±572)IU/L,(577 ±327)IU/L,P=0.12;AST:(591 ±468)IU/L,(512±301)IU/L,P=0.66].There were no difierences on postoperative morbidity between the two groups(22.5%versus 20.0%,P=0.35).Conclusion The technique of continuous hemihepatic inflow occlusion is as safe and effective as intermittent total hepatic inflow occlusion.

Randomized controlled study on selective hepatic vascular versus complete clamping in hepatectomy / 国际外科学杂志

Objective To valuate different effects in hepatectomy of three inflow occlusion methods including pringle maneuver, hemihepatic occlusion and portal venous occlusion. Methods 180 patients undergoing hepatectomy were randomly assigned to pringle group (group A), hemehepatic occlusion group (group B)or PV occlusion group (group C). The amount of blood lost, measurements of liver enzymes alanine aminotransferase (ALT), aspirate aminotransferase (AST), total bilirubin (TB), Serum albumin (ALB) and postoperative complication were also recorded. Results There was no operative mortality. One patient in group B changed into pringle maneuver due to the difficulties in dissecting the hemi-hepatic portal and was excluded. The amount of hemorrhage of three groups had no statistical difference. The ALT, AST, ALB and TB level of 1,3,7 days after operation had significant differences in three groups. The pringle group had a higher level ALT,AST,TB and lower ALB level than the other two groups. Conclusions All techniques of occlusion are effective and feasible for patients undergoing hepatectomies. However, compared with pringle maneuver, PV clamping and hemihepatic occlusion can relieve the liver function damage after hepatectomy.

Left Ventricular Inflow Obstruction Caused by a Persistent Left Superior Vena Cava and a Dilated Coronary Sinus: A case report / 대한흉부외과학회지

Left ventricular inflow obstruction can be caused by a persistent left superior vena cava (SVC) and a dilated coronary sinus. A 31-day-old male infant with secondum atrial septal defect (ASD) and bilateral SVC underwent an operation for treating his uncontrollable congestive heart failure. The preoperative 2-dimensional echocardiography showed a normally sized mitral valve shrouded by a dilated coronary sinus. The operation consisted of pericardial patch closure of the ASD, coronary sinus unroofing and left SVC transfer to the right atrial auricle. The postoperative course was complicated by persistent chylothorax, which was controlled by thoracic duct ligation. He was discharged to home at the postoperative day 39. He has been followed up for 9 months and has displayed normal development.

Ressecções hepáticas com oclusão vascular aferente: análise de fatores de risco / Hepatic resection with afferent vascular occlusion: analysis of risk factors

OBJETIVO: O controle da perda sangüínea nas cirurgias de ressecção hepática está associado à diminuição dos índices de morbimortalidade. As técnicas para minimizar a hemorragia transoperatória são aquelas associadas à redução do fluxo sangüíneo ao fígado, através da oclusão vascular aferente (manobra de Pringle) ou exclusão vascular total do órgão. O objetivo deste estudo foi o de avaliar uma série de hepatectomias parciais com oclusão do fluxo sangüíneo aferente, em pacientes portadores de doenças benignas e malignas. MÉTODOS: Foram analisadas 60 hepatectomias em 59 pacientes com clampeamento do pedículo hepático quanto a possíveis fatores de risco para morbidade e mortalidade, a relação entre o tempo de isquemia hepática e a variação das transaminases, tempo de protrombina e bilirrubinas, e destes, com a evolução pós-operatória. RESULTADOS: A prevalência de complicações pós-operatórias foi de 43,3 por cento e a mortalidade de 6,7 por cento. O fator de risco significativo para mortalidade foi tempo cirúrgico mais prolongado. Para a morbidade pós-operatória, os fatores de risco foram idade acima de 60 anos, cirurgia por neoplasia maligna, parênquima hepático anormal, perda sangüínea necessitando reposição de mais de uma unidade de sangue e outra cirurgia abdominal concomitante. Na análise multivariada por regressão logística, estes fatores de risco foram reduzidos para parênquima hepático anormal. CONCLUSÕES: O tempo de isquemia não apresentou relação com a morbimortalidade pós-operatória. A variação das transaminases foi mais acentuada nos casos com maior tempo de isquemia, porém essas retornaram aos níveis pré-operatórios em aproximadamente uma semana. A variação das transaminases não foi diferente entre os pacientes com e sem morbidade pós-operatória.

BACKGROUND: The control of blood loss during liver resection has been related to lower rates of perioperative mortality and morbidity. Techniques to minimize intraoperative bleeding are associated with blood flow interruption to the liver, either through an afferent vascular occlusion (Pringle maneuver) or by total vascular isolation of the organ. The aim of this study was to evaluate a series of partial hepatectomies with afferent blood flow occlusion, in patients with benign or malignant diseases. METHOD: Sixty hepatic resections with inflow occlusion, in 59 patients, were analyzed in order to search possible risk factors for morbidity and mortality, the connection between the hepatic ischemic time and the transaminases variation, the prothrombin time and bilirrubins and the postoperative evolution. RESULTS: The prevalence of postoperative complications was 43 percent and the mortality rate was 6.7 percent. The significant risk factor for mortality was the long lasting operative time when compared to patients who did not die. For the postoperative morbidity, the identified risk factors were age over sixty years old, surgery for malign neoplasm, abnormal liver parenchyma, blood loss demanding replacement of more than one unity of blood transfusion and another concomitant abdominal surgery. In a multiple regression analysis, those risk factors were reduced only to abnormal hepatic parenchyma. CONCLUSIONS: The ischemia time did not have any connection with the postoperative morbidity or mortality. The transaminases levels were higher in cases of longer ischemic time, however they returned to the preoperative levels in about a week. The transaminases variations were not different amongst patients who had postoperative morbidity or not.

Application of Selective Hepatic Vascular Occlusion to Laparoscopic Hepatectomy / 中国微创外科杂志

0.05).Conclusion Selective hepatic vascular occlusion is superior to complete hepatic vascular occlusion,and is worth being widely used.