Use of a collagen-sealing device in hepatic resection: a comparative analysis to standard resection technique.

BACKGROUND: Blood transfusion has been reported as an independent risk factor for poor outcome after liver resection in spite of its well known benefits. Refinements in parenchymal dissection have been pursued to reduce blood loss and transfusion. A collagen-sealing device (CSD) has recently been touted as an alternative technique that aids in blood conservation. We report the results of our initial series of patients undergoing a CSD-assisted resection and present a historical comparison. PATIENTS AND METHODS: Consecutive patients who were undergoing liver resection at a single tertiary cancer centre were enrolled in this study. The Ligasure Atlas device (Valleylab Inc., Division of Tyco Healthcare) was used for parenchymal division in the CSD group. Known blood conservation techniques (i.e. low central venous pressure, ultrasonic dissection, Pringle clamp) were standardized in both groups. Clinical and outcome variables including operative time, estimated blood loss and transfusion requirements were collected. All statistical analyses were performed with SAS version 8.2e. RESULTS: In all, 28 consecutive patients underwent CSD-assisted hepatic resection between October 2003 and September 2004. The control group included 188 patients treated between January 1991 and September 2003. In the CSD group, we observed a reduction in mean estimated blood loss (930 vs 1450 ml, p=0.002) and mean transfusion requirements (0.46 vs 1.19 units, p=0.002). There was no increase in operative time with the new instrument (326 vs 363 min, p=0.167). DISCUSSION: Use of a CSD has the potential to further reduce blood loss and transfusion requirements without increasing operative time.

Surgical treatment of pancreatic cholera: a case report.

After surgical resection for rectosigmoid carcinoma a 63-year-old man had secretory diarrhea causing severe metabolic acidosis, hypokalemia, hypercalcemia and dehydration. Subsequent investigations revealed a mass measuring 4 x 5 cm in the uncinate process of the pancreas and an elevated vasoactive intestinal polypeptide concentration. The diarrhea responded to treatment with the somatostatin analogue. Sandostatin, and remained under control during a prolonged preoperative period. The patient underwent a Whipple procedure with immediate lessening of his diarrhea. This report illustrates a classic case of vipoma and demonstrates the need to consider this condition in the differential diagnosis of secretory diarrhea, even in the presence of other gastrointestinal lesions. The effectiveness of somatostatin analogues in stabilizing the diarrhea preoperatively is also well illustrated.

Post-traumatic small-bowel stricture: a case report.

The use of lap seat belts has recently been recognized as a mechanism of blunt injury to the small bowel. Patients usually present immediately after injury and require urgent laparotomy. An unusual case of delayed small-bowel stricture after conservative management of an injury resulting from blunt trauma is reported. A 37-year-old woman involved in a high-speed motor vehicle accident was managed in hospital by observation. She had abdominal distension and pain, which gradually decreased and allowed slow introduction of a liquid diet. She was discharged from hospital but returned 6 weeks after injury with pain, abdominal distension, vomiting and obstipation. Stricture of an 8-cm segment of distal jejunum was found. Resection of the involved segment with primary anastomosis was curative.

Classification of liver trauma.

The classification of liver injuries is important for clinical practice, clinical research and quality assurance activities. The Organ Injury Scaling (OIS) Committee of the American Association for the Surgery of Trauma proposed the OIS for liver trauma in 1989. The purpose of the present study was to apply this scale to a cohort of liver trauma patients managed at a single Canadian trauma centre from January 1987 to June 1992. 170 study patients were identified and reviewed. The mean age was 30, with 69% male and a mean ISS of 33. 90% had a blunt mechanism of injury. The 170 patients were categorized into the 6 OIS grades of liver injury. The number of units of blood transfused, the magnitude of the operative treatment required, the liver-related complications and the liver-related mortality correlated well with the OIS grade. The OIS grade was unable to predict the need for laparotomy or the length of stay in hospital. We conclude that the OIS is a useful, practical and important tool for the categorization of liver injuries, and it may prove to be the universally accepted classification scheme in liver trauma.

Liver resection by ultrasonic dissection and intraoperative ultrasonography.

Ultrasonic dissection (USD) and intraoperative ultrasonography (IOUS) have shown encouraging results in a retrospective analysis of 109 patients with benign or malignant liver disease. Of 109 patients assessed between 1980 and 1993, 84 were resected: 27 by finger fracture technique (FFT) and 57 by USD. Hospital mortality was 4.8% (4/84) and 30-day mortality was 6.0% (5/84). Overall morbidity was 48.8% (41/84) and liver related morbidity (hepatic bleeding, sepsis, and bile leak) was 34.5% (29/84); of the 29 patients, 5 required re-operation. Liver complications occurred in 12/27 (44.4%) in the FFT group as opposed to 17/57 (29.8%) in the USD group. The incidence of postoperative hepatic bleeding was significantly less by USD than by FFT (p = 0.03). As well, intraoperative blood loss (p = 0.01) number of intraoperative blood units used (p = 0.002), and postoperative length of stay (p = 0.009) have been significantly reduced by USD. IOUS was used on 64 patients. Not only has it improved the sensitivity (99%) and specificity (98%) for detection of hepatic neoplasms, it has also helped increase the precision and accuracy of anatomical tumour localization. As a result, 11/64 patients (17.2%) had their preoperative plans changed: 8 were abandoned and 3 were revised. In summary, USD has significantly reduced intraoperative blood loss and hence reduced the number of intraoperative transfusions, incidence of postoperative complications and postoperative length of stay. IOUS should be routinely employed in patients undergoing liver resection since it provides critical information that could obviate oncologically useless resections.

Peripancreatic retroperitoneal gas mimicking necrotizing pancreatitis after laparoscopic cholecystectomy.

The computed tomographic image of gas in the pancreas and peripancreatic retroperitoneum is strongly suggestive of necrotizing pancreatitis. The authors describe an 81-year-old woman who, 7 days after laparoscopic cholecystectomy, presented with retroperitoneal gas but did not have the clinical or biochemical features of necrotizing pancreatitis. Resolution of her low-grade fever and of the radiologic findings with conservative treatment and the absence of other causes for pneumoretroperitoneum suggest that the gas observed was related to the laparoscopic cholecystectomy.

The role of intraoperative ultrasonography in planning the resection of hepatic neoplasms.

OBJECTIVE: Both intraoperative ultrasonography (US) and computed tomography with arterial portography (CTAP) may be used in planning segment-oriented liver resection in patients with primary or secondary hepatic neoplasms. This study was conducted to determine if intraoperative US findings substantially alter surgical plans based on CTAP findings alone. PATIENTS AND METHODS: Patients with potentially resectable hepatic lesions were considered for the study; judgement as to whether a lesion was resectable was based on a clinical evaluation and CTAP. Over the period Apr. 4, 1991, to Oct. 1, 1993, 24 consecutive patients with hepatic lesions were examined; of these, 22 (13 men and 9 women with a mean age of 60.1 years) underwent US during resection, 1 did not undergo surgery and 1 was found at surgery to have carcinomatosis. The true nature of the lesions was verified pathologically or by follow-up imaging and assays for carcinoembryonic antigen. RESULTS: The surgical plan based on CTAP findings alone was altered by the intraoperative US findings in 9 (41%) of the 22 patients. A total of 60 intrahepatic abnormalities were evaluated: 49 malignant lesions and 11 artifacts. The specificity (100%) and negative predictive value (73.3%) for intraoperative US were significantly greater than for CTAP (specificity of 9.1% and negative predictive value of 14.1%). CONCLUSION: In a substantial proportion of patients undergoing hepatic resection, intraoperative US alters the surgical plan based on CTAP and provides additional specificity in the evaluation of liver lesions. This method of imaging is therefore justified for patients undergoing liver resection.

Radiographic features of hepatocellular carcinoma and their relation to prognosis in Canada.

To determine the radiographic features of hepatocellular carcinoma (HCC) as seen in Canada and their relation to prognosis, multiple imaging studies for 40 patients with histologically proven HCC were reviewed. The patients, 34 men and 6 women ranging in age from 43 to 86 years, were selected from a larger database on the basis of the availability of ultrasound (US) images and at least one other imaging study. The patients had been examined between 1981 and 1991 at a tertiary-care hospital. In 35 of the 40 cases (88%) HCC had been detected by US assessment, the criterion for complete analysis, but in one of those cases the lesion was not observed in the initial scans. HCC was detected by computed tomography (CT) in the 27 cases in which that technique had been used. Cirrhosis was present in 27 of the 35 patients (77%) for which a complete analysis was performed. Median survival after diagnosis for all 40 patients was 14.1 weeks. Seven radiographic features were analysed for prognostic value by univariate and multivariate (Cox) regression analysis. However, the regression analysis indicated no relation between survival and tumour size, the nature of the tumour (diffuse and infiltrative or discrete), vascular involvement, encapsulation, extrahepatic spread, tumour location or echogenicity. No radiographic feature, including tumour size, correlated with the serum level of alpha-fetoprotein, which was elevated in 23 of the 32 cases (72%) in which it had been determined. These results confirm the variable radiographic appearance of HCC but differ in other respects from those reported previously, particularly those for studies performed outside North America.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of intraoperative ultrasonography in hepatic surgery: a preliminary report.

Twenty-four patients who underwent ultrasonography during hepatic surgery in the 22 months from October 1989 to July 1991 were studied prospectively to determine the value, if any, of intraoperative ultrasonography. For 6 (25%) of the 24 patients the operative plan was altered because of the ultrasonographic findings. In one of them resection was extended from a left lateral segmentectomy or sectorectomy to a left hemihepatectomy. In the other five patients the planned liver procedure was abandoned. Two of these five patients were cirrhotic--in one of them an additional metastasis was seen, and in the other there was tumour invasion of the portal vein. Of the three noncirrhotic patients, one had tumour invasion of the right hepatic vein, and the other two patients had additional metastases in the caudate lobe (Couinaud segment 1). Ultrasonography was found to be useful in 25% of patients who underwent this investigation during hepatic surgery--it avoided liver resections that would have failed because of advanced malignant disease.

Clinical presentations of gastrointestinal inflammatory fibroid polyps.

Two cases of inflammatory fibroid polyps are described. They involved the uncommon sites of the terminal ileum and ileocecal region respectively. Both lesions, although benign, presented as possible malignant tumours. One was associated with anemia and the other with obstructive symptoms. From a review of the literature and the two case reports the authors believe that the diagnosis of such inflammatory fibroid polyps, on clinical and gross appearance, can be difficult, and they emphasize the importance of awaiting histologic assessment before proceeding with extensive definitive surgery.

Clinical and radiologic study of the frequency and presentation of chest infection in children with severe protein energy malnutrition.

The association between P.E.M. and frequent and severe life threatening infections including lower respiratory tract infections have been always reported. Lack of the usual general and local signs of infection in P.E.M. makes the diagnosis difficult and sometimes only postmortem. This study evaluated the frequency of chest infections as well as the sensitivity, specificity and predictivity of different signs and symptoms of the disease in 100 children with severe P.E.M. (marasmus, kwashiorkor, and marasmic kwashiorkor). Sixty two percent of the studied children had chest infection (33% pneumonia, 29% bronchitis). Although most patients were symptomatic, yet, signs and symptoms were few and mostly non specific. Chest roentgenograms are thus mandatory in evaluating patients with P.E.M. whenever possible. The only valuable signs suggestive of chest infection in P.E.M. were tachypnea (> or = 40/min) and/or chest indrawing. Both were moderately sensitive, highly specific and predictive of the disease particularly pneumonia. Their presence thus, its indicative of the need for early institution of antibiotic therapy even before the results of chest roentgenograms. Total Leucocytic count was of little diagnostic value while contrary to the common belief that tuberculin test is usually negative in P.E.M., the use of double the usual dose of P.P.D. (i.e. 10 TU) yielded positive reaction in some of the studied patients and thus must not be omitted from the routine investigations of malnourished patients.

Blunt liver trauma at sunnybrook Medical Centre: a 13 year experience.

Between June 1, 1976 and June 30, 1989 The Regional Trauma Unit at Sunnybrook Medical Centre in Toronto, Ontario, Canada received 3730 patients. Of these 335 (9%) sustained a liver injury, 95% being due to blunt trauma. Open peritoneal lavage was performed on 80% of liver trauma patients (267/335), 99% being true positive. A laparotomy was performed on 97% of patients (324/335). Major surgical treatment was required in 132 patients (41%) and minor treatment in 192 patients (59%). The remaining 11 patients were treated conservatively (n = 3) or died during resuscitation (n = 8). Morbidity directly related to the liver injury was seen in 29 of 249 surviving patients (11%) although overall morbidity was 27% (67/249). Reoperation was required in 6% (14/249) with abscess or hematoma accounting for 11 of 14 operations. The overall mortality rate was 26% (86/335). Eighty two percent of patients (n = 276) had a grade I, II or III liver trauma according to Moore's classification with a mortality of 12% (n = 32). The remaining 18% of patients (n = 59) had a grade IV or V liver trauma with a mortality of 44% (n = 26). Of the 86 deaths, head injury accounted for 48 (56% of deaths); liver hemorrhage for 17 (20%), liver sepsis for 1 (1%) and other causes for 20 deaths (23%). Thus death due to the liver injury itself (hemorrhage and sepsis) occurred in 18 out of 335 patients (5% overall). Head injury accounted for the death of 48 out of 335 patients (14% overall). Over the past 13 years a trend has occurred at our institution whereby we are seeing less liver trauma in our population of multiply injured patients from 12% (1976-1983) down to 7% (1985-1989); with a gradual decline in overall mortality from 32% (1976-1983) to 19% (1985-1989), whereas the percentage of deaths due to head injuries and liver injury have increased.

Liver blood flow after major hepatic resection.

The factors involved in liver regeneration are poorly understood, but it has been suggested that blood flow plays a role. This paper documents the changes in liver blood flow (LBF) that occur after major hepatic resection. Eight patients, ranging in age from 37 to 76 years, underwent liver resection. Liver blood flow was measured preoperatively and on days 1, 4 and 7 postoperatively by low-dose galactose clearance. There was a significant (p less than 0.01) fall in LBF on day 1 compared with the baseline value, followed by a significant (p less than 0.01) rise from the baseline value by day 4. By day 7, LBF had returned to baseline levels and was significantly (p less than 0.01) lower than on day 4. These changes in LBF may be related to the stimulus for liver regeneration and increased functional demands during the early regenerative phase.

Drug extravasation along the route of a peritoneal catheter during intraperitoneal chemotherapy.

A patient receiving intraperitoneal chemotherapy with cisplatin and cytosine arabinoside developed an abdominal skin rash similar in appearance to Cullen's sign. She subsequently received intraperitoneal mitoxantrone, which became visible in the skin close to the peritoneal catheter tract in the region of the skin rash within 24 hours of drug administration. There was no evidence for drug extravasation from the entry portal of the peritoneal catheter or visible fluid leakage. Although the clinical picture was dramatic there was no significant clinical sequela to the extravasation of these drugs. The potential significance of this event is discussed.

Blunt liver trauma at Sunnybrook Medical Centre.

Between 1 June 1976 and 30 June 1985 Sunnybrook Medical Centre Regional Trauma Unit admitted 2,016 patients of whom 220 (11%) sustained liver injury. Of these 220 patients, 211 (96%) sustained blunt liver trauma; 175 of 176 patients who underwent open peritoneal lavage had a true positive lavage. Resuscitation was successful in 212 patients, of whom 209 underwent laparotomy and three were treated nonoperatively: 129 of 209 patients (62%) required only minor surgical treatment; the remaining 80 patients (38%) required major surgical procedures. The overall mortality was 29% (64/220). Eight patients died during resuscitation, one of them of liver hemorrhage. Of the 56 patients who died after admission, the cause of death was head injury in 31, liver hemorrhage in 11 (five intraoperatively) and 14 died of other causes. Overall, liver hemorrhage was the cause of death in 12 of 64 deaths (19%). In other words, 12 of the total of 220 patients (6%) died from liver-related mortality.

Determinants of Legionella pneumophila contamination of water distribution systems: 15-hospital prospective study.

We conducted a prospective environmental study for Legionella pneumophila in 15 hospitals in Pennsylvania. Hot water tanks, cold water sites, faucets, and showerheads were surveyed four times over a one-year period. Sixty percent (9/15) of hospitals surveyed were contaminated with L pneumophila. Although contamination could not be linked to a specific municipal water supplier, most of the contaminated supplies came from rivers. Parameters found to be significantly associated with contamination included elevated hot water temperature, vertical configuration of the hot water tank, older tanks, and elevated calcium and magnesium concentrations of the water (P less than 0.05). This study suggests that L pneumophila contamination could be predicted based on design of the distribution system, as well as physicochemical characteristics of the water.

Abdominopelvic computerized tomography and open peritoneal lavage in patients with blunt abdominal trauma: a prospective study.

This prospective trial compares abdominopelvic computerized tomography and open peritoneal lavage in the diagnosis of blunt abdominal trauma. Fifteen patients (group 1) were evaluated by both methods. Another 15 patients (group 2) had only computerized tomography. Criteria for a "positive" scan were hemoperitoneum and evidence of solid organ injury. Criteria for "positive" lavage were a grossly bloody return, erythrocyte count greater than 20.0 X 10(9)/L and leukocyte count greater than 0.5 X 10(9)/L. At laparotomy, only injuries requiring repair or excision were considered "true positive". Patients who did not have laparotomy and had an uncomplicated clinical course were considered "true negative". With tomographic criteria alone for diagnosis there would have been one false-positive and three false-negative results, compared with three false positive and no false negatives for open peritoneal lavage alone. None of the three patients who had negative findings on laparotomy suffered any morbidity or died. Results of computerized tomography and open peritoneal lavage agreed in 8 of 15 patients (kappa value = 0.52), indicating a low level of agreement between the two. The authors believe that open peritoneal lavage remains the diagnostic procedure of choice in blunt abdominal trauma.

Effect of portal vein occlusion on liver blood flow in normal and cirrhotic dogs.

The purpose of this study was to demonstrate that galactose clearance (GC) can measure acute changes in liver blood flow (LBF) in normal and cirrhotic dogs. Ten dogs were studied. GC was measured preop. At laparotomy, GC, hepatic artery (HA) flow, portal vein (PV) flow, and cardiac output (CO) were measured at baseline, 50% portal vein occlusion (PVO), and portal vein release. HA and PV flows were measured using a flow probe (FP). Common bile duct ligation was then performed to cause cirrhosis and all measurements were repeated in 7 weeks. Statistical analyses showed that on PVO in both normal dogs (n = 10) and cirrhotic dogs (n = 5) the GC, HA flow, and CO were significantly different from their baseline values. In both groups PVO caused HA flow to increase, thus keeping FP-LBF unchanged while GC-LBF was significantly reduced compared to baseline. The possible explanations for this are discussed in the text. PVO also caused a significant reduction in CO due to splanchnic pooling in both normal and cirrhotic dogs. In both groups PVO results in an increased percentage of CO going to FP-LBF, while the percentage of CO going to GC-LBF remains unchanged. We conclude that GC can measure acute changes in LBF caused by a 50% PVO in both normal and cirrhotic dogs.