The neuroendocrine hormone changes and clinical significance in the syndrome of brain injury / 中华内分泌外科杂志

Objective To study the incidence and clinical significance of abnormal neuroendocrine hormone in patients with the syndrome of brain injury.Methods 67 cases with the syndrome of brain injury were included in the study group,and 95 cases without the post traumatic syndrome after brain injury were included in the control group.The level of FT3,FT4,TSH,growth hormone(GH),andrenocortico hormone(ACTH),cortisol (Cor),prolactin(PRL),testosterone (T),estradiol (E2),follicular stimulating hormone (FSH),luteotropic hormone (LH),and progesterone (P) in peripheral blood were measured by radioimmunoassay.The incidence of the abnormal neuroendocrine hormone after brain injury was statistically analyzed.Patients with abnormal hormone were given hormone replacement therapy and the curative effects were observed.Results The incidence of neuroendocrine hormone abnormalities was 38.8％ in patients with the syndrome of brain injury,while it was 10.5％ in the control group.There was significant difference between the 2 groups(P＜0.05).The symptom remission rate was 88.5％ after hormone treatment.Conclusions There was a high incidence of abnormal neuroendocrine hormone secretion in patients with the syndrome of brain injury.The hormone level may be used as an important index to guide clinical therapy.

Variation or newly identified glissonian pedicles between the lateral and medial sections of the liver, using cadaver dissection / 대한외과학회지

PURPOSE: Studies of liver anatomy have developed alongside clinical achievements, as these types of research complement each other. The aim of this study is to determine whether or not the portal vein branches (P4d) in 'Nagino's trisectionectomy' exist, and to examine their characteristics using cadaver dissection. METHODS: From April 2012 to July 2012, 31 adult cadavers were delicately dissected. We defined a 'NewGP' as an extra glissonian pedicle (GP) other than the traditional GPs that supply segments II, III, IVa, and IVb in the ordinary direction, and anatomically located superior to the umbilical fissure (UF). RESULTS: We identified 'NewGPs' based on the UF and UF vein. The incidence of 'NewGPs' was 30/31 (96.8%). The diameter of the 'NewGPs' ranged from 3.5 to 5.6 mm, which was not significantly different from that of traditional GPs (II-, III-, or IV-GP), which have diameters ranging from 3.7 to 9.7 mm. CONCLUSION: We think that the P4d in 'Nagino's trisectionectomy' correspond to the 'IVa NewGP' and the additional pedicle. We believe the clinical significance of the 'NewGP' is to complement the traditional II, III, IVa, and IVb pedicles in supplying the liver.

Usefulness of the Pinch-Burn-Cut (PBC) technique for recipient hepatectomy in liver transplantation

BACKGROUNDS/AIMS: Surgical bleeding during recipient hepatectomy is a major concern in liver transplantation (LT). Effective intraoperative control of bleeding is necessary. In the Pinch-Burn-Cut (PBC) technique, a small amount of tissue around the dissection plane is pinched with forceps, electocauterized and gently cut. The present study sought to estimate the usefulness of the PBC technique in LT. METHODS: Between June 2007 and December 2010, 123 adult cases underwent LT in our center. Of these, 72 involved a recipient hepatectomy using the PBC technique (PBC group). and 51 involved the conventional technique (non-PBC group). Clinical parameters were compared between two groups. RESULTS: The amount of blood loss and related transfusions were significantly reduced, and the operating time was shorter in the PBC group than in the non-PBC group (p=0.006, p<0.05 and p=0.002, respectively). There was also shorter duration of mechanical ventilation after LT in the PBC group (p=0.017). The incidence of postoperative hemorrhage was lower in the PBC group than in the non-PBC group, but had no statistical significance between two group (19.6% vs. 8.3%, p=0.101). CONCLUSIONS: Our data suggest that the PBC technique is effective for bleeding control during recipient hepatectomy in LT.

Anatomical Variation of the Glissonean Pedicle of the Right Liver

PURPOSE: Many studies have been conducted to date regarding whether the right hepatic vein is the accurate border that divides the anterior and posterior section of the right liver. It has been reported that the Glisson pedicle of the right liver may be an anatomical variation that does not have a consistent morphology. We analyzed the relationship between the true borders of the anterior and posterior sections, and the right hepatic vein, based on cadaver dissection and MD-CT image analysis of the anatomical variation of the Glisson pedicle of the right liver. METHODS: Sixteen cadaver livers were available for dissection from the Department of Anatomy, and pre-operative MD-CTs of 20 donor livers who underwent living donor liver transplantation prior to December 2009, were obtained. We analyzed the 3D-relationship between the branches of the Glisson pedicles and the right hepatic vein of the right liver. They were divided into 3 groups according to the sliding pattern of the branches of the Glisson pedicle origin. When all segmental branches of the anterior pedicle arise from the main trunk of the anterior pedicle and all branches of posterior pedicle arise from the main trunk of posterior pedicle, it was designated as Group A (Normal Group). When a portion of the segmental branches of the anterior pedicle arises from the main trunk of the posterior pedicle, it was designated as Group B (Posterior dominant group). When a portion of the branches of the posterior pedicle arises from the main trunk of the anterior pedicle, it was designated as Group C (Anterior dominant group). RESULTS: Among the 16 cadaver liver dissections, 6 cases were in Group A, 5 in Group B, and 3 in Group C. Two cases were excluded from the study because the inferior right hepatic vein was the main draining vein of the right liver. The analysis of preoperative MD-CT of the 20 donor livers showed that there were 13, 4, and 3 patients in Groups A, B, and C, respectively. CONCLUSION: According to Couinaud's theory of anatomy, the right hepatic vein serves as the border between the anterior and posterior sections of the right liver. But, due to the frequent anatomical variations, an adequate understanding of the anatomical variations of the right Glisson pedicle should be necessary for liver surgery.

Serial Monitoring of Portal Venous Pressure/Flow during Living Donor Liver Transplantation

PURPOSE: Although living donor liver transplantations (LDLTs) are widely performed, a shortage of living donors exists continuously, which makes it difficult to find the optimal graft. A high portal venous pressure (PVP) is mainly related to small for size syndrome (SFSS), and low portal venous flow (PVF), to ischemic liver damage, leading to potential liver failure after surgery. We reviewed the literature in search of optimal PVP and PVF values during LDLTs, and tried to determine the clinical meaning of measurements of PVP and PVF for liver transplantation. METHODS: Between June, 2008 and June, 2009, we did 38 LDLTs. PVP and PVF were measured in 13 patients after laparotomy, after implantation of graft and after splenectomy. In addition, compliance (PVF/PVP) and compliance (mL/min/mmHg/g) per unit graft weight were calculated. Splenectomy was done when continuously maintained portal hypertension (>20 mmHg) occurred even after implantation. Splenectomy was also done for patients who presented preoperatively with splenomegaly and pancytopenia. RESULTS: After graft implantation, portal venous pressure decreased (16.8+/-4.1 mmHg vs. 14.7+/-3.1 mmHg)(p=.003), whereas portal venous flow increased (1236.4+/-725.3 mL/min vs. 1916.9+/-603 mL/min)(p=.019). Also, after splenectomy, portal venous pressure/flow decreased (16.4+/-3.7 mmHg vs. 13.8+/-3.3 mmHg)(p=.009)/(2136.4 mL/min vs. 1619.1+/-336.3 mL/min) (p=.001). Finally, after implantation, compliance increased (60+/-40 mL/min/mmHg vs. 126+/-18 mL/min/mmHg)(p=.007). CONCLUSION: After splenectomy, compliance remained constant (126+/-18 mL/min/mmHg vs. 122+/-34 mL/min/mmHg)(p=.364). After implantation of the graft, portal pressure decreased and portal venous flow increased. The compliance of the graft was not influenced by splenectomy. This shows that splenectomy is a good method to control high portal pressure without influencing the compliance of the graft.

Effect of Microsurgery Training Program for Hepatic Artery Reconstruction in Liver Transplantation

PURPOSE: During liver transplantation (LT), complications of the hepatic artery have been decreased because of microsurgery in reconstruction of hepatic artery has been widely adopted. However, in an early step of the LT program, hepatic artery reconstruction generally tends to be done with the help of a micro-surgeon from the the plastic surgery in most of Korean medical centers. In our center, we also have done reconstruction of the hepatic artery using a microscope and the skills of a plastic surgeon. We did this between Feb, 2005 and Jun, 2008 for liver transplantations. The increased the need for micro-surgeons in liver surgery as increased the cases of liver transplantation steadily. After training general surgeons of the surgical department who had no experience with microsurgery, we invested in the micro-surgery of hepatic artery reconstruction. Here we report the result of that investment. METHODS: Liver transplant patients (n=176) were enrolled between Feb, 2005 and Jul, 2009. Between Jul, 2008 and Jul, 2009, 28 cases of reconstruction of the hepatic artery were done by a general surgeon who had micro-surgery training. Before training in hepatic artery reconstruction, the general surgeon spent 3 months being introduced to micro-surgery in the micro animal laboratory. Because the training was repeated, the surgeon became skilled in doing artery anastomosis using rat's abdominal aorta. At the same time, we trained a plastic surgeon to do hepatic artery reconstruction during liver transplantation as the first assistant. From Jul, 2008 to the present time, the general surgeon was exclusively in charge of hepatic artery reconstruction during liver transplantation. Hepatic artery reconstruction was done using a microscope. Stitching was done using 8-0 or 9-0 nylon, and an interrupted end-to-end anastomosis was done. After hepatic artery reconstruction, artery flow was confirmed by ultrasonic doppler. For group A patients, left lobe grafts were used in 33, right lobe grafts in 73, dual grafts in 6, and whole liver grafts in 36. RESULTS: For group B patients, left lobe grafts were used in 1 and right lobe grafts in 21, while whole liver grafts were used in 6. In Group A, hepatic artery complications occurred in 5 cases (3.3%), and in Group B such complications did not occur (0%). There was no statistical difference (p=0.312). CONCLUSION: For hepatic artery reconstruction, during micro-surgery under a surgical microscope, it is thought that it is best to invest in a general surgeon who has been trained in micro-surgery. We suggest that a general surgeon is suitable for hepatic artery reconstruction after only a short time of micro surgery training.

Living donor liver transplantation for Patients with beyond Milan hepatocellular carcinoma

BACKGROUND: To find the patients who have a significant chance of cure with living donor liver transplantation (LDLT) among the patients suffering with beyond-Milan hepatocellular carcinoma (HCC), we retrospectively analyzed the tumor factors that could affect a good prognosis after LDLT for patients who suffer with beyond Milan HCC. METHODS: Between March 2005 and May 2007, 18 cases of LDLT for beyond Milan HCC were performed. None of the patients had preoperative radiological evidence of vascular invasion. Excluding the 3 cases of in-hospital mortality, we analyzed the survival, the disease-free survival and the prognostic factors for recurrence in 15 beyond Milan HCC patients. The mean follow-up period was 18.8degrees +/- 8.8 months (range: 4-34 months). RESULTS: The two-year survival and disease-free survival rates after LDLT were 61.7% and 31.1%, respectively, in 15 beyond-Milan patients. Among them, 9 patients had recurrence of HCC during follow-up. The one-year survival rate after tumor recurrence was 55.5%. An alphafetoprotein (AFP) level < 400 ng/mL, Edmonson-Steiner histology grade I and II and the presence of graft rejection were analyzed as the good prognostic factors of disease-free survival after LDLT for beyond-Milan HCC (p < .05). The patients with negative preoperative positron emission tomography (PET) findings (n = 5) showed a better prognosis than the PET-positive patients (n = 10) with statistical significance (p = .05). CONCLUSION: Allowing that HCC patients exceed the Milan criteria, we can find the potentially curable candidates for LDLT with using tumor biologic markers such as a serum AFP level < 400 ng/mL, negative PET uptake or low grade histology, as assessed by preoperative needle biopsy. Further investigation is needed to evaluate the relation between graft rejection and tumor recurrence after liver transplantation.