Proximal Roux-en-y Gastrojejunal Anastomosis with Pyloric Ring Resection Improves Gastric Emptying After Pancreaticoduodenectomy.

BACKGROUND: Delayed gastric emptying (DGE) is a common complication of pancreaticoduodenectomy. We determined the efficiency of a new reconstruction technique, designed to preserve motilin-secreting cells and maximize the utility of their receptors, in reducing the incidence of DGE after pancreaticoduodenectomy. METHODS: From April 2005 to September 2014, 217 consecutive patients underwent pancreaticoduodenectomy at our institution. Nine patients who underwent total pancreatectomy were excluded. We compared outcomes between patients who underwent pancreaticoduodenectomy with resection of the pyloric ring followed by proximal Roux-en-y gastrojejunal anastomosis (group I, n = 90) and patients who underwent standard pancreaticoduodenectomy with the orthotopic reconstruction technique (group II, n = 118). RESULTS: Overall and clinically relevant rates of DGE were significantly lower in group I than in group II (10 and 2.2 % vs. 57 and 24 %, respectively; p < 0.05). Length of hospital stay as a result of DGE was shorter in group I than in group II. In univariate analysis, older age, comorbidities, ASA grade 4, operative time, preoperative diabetes, standard reconstruction technique, and postoperative complications were significant risk factors for DGE. In multivariate analysis, older age, standard technique, and postoperative complications were independent risk factors for DGE. CONCLUSION: Our new reconstruction technique reduces the occurrence of DGE after pancreaticoduodenectomy.

Topically applied 2-octyl cyanoacrylate (Dermabond) for prevention of postoperative pancreatic fistula after pancreaticoduodenectomy.

OBJECTIVE: We examined whether 2-octyl cyanoacrylate (Dermabond) topically applied to the pancreaticojejunostomy (PJ) anastomotic site after pancreaticoduodenectomy (PD) reduces the rate of postoperative pancreatic fistula (POPF). METHODS: Patients who underwent PD with duct-to-mucosa PJ were evaluated (n = 124). Outcome was compared between patients who received Dermabond (n = 75) after PD and historic patients who did not (n = 49). Risk factors for POPF were identified. RESULTS: Overall and clinically relevant rates of POPF were significantly lower in patients who received Dermabond than in patients who did not (2.6 % and 1.3 % vs. 22 % and 12 %, respectively; p = 0.001). In univariate analysis, pancreatic duct diameter ≤3 mm, low serum albumin level, and no Dermabond were independent risk factors for POPF; in multivariate analysis, no Dermabond was an independent risk factor for POPF. In patients with pancreatic duct diameter ≤3 mm, the rate of POPF was significantly lower in patients who received Dermabond than in patients who did not (3.5 % versus 36 %, respectively; p = 0.0001). Patients who received Dermabond had significantly shorter hospital stays and lower re-operation and re-admission rates. CONCLUSIONS: Topical application of Dermabond to the PJ anastomotic site after PD significantly reduced the rate of POPF, particularly in patients at risk.

Use of decellularized porcine liver for engineering humanized liver organ.

BACKGROUND: New bioartificial liver devices are needed to supplement the limited supply of organ donors available for patients with end-stage liver disease. Here, we report the results of a pilot study aimed at developing a humanized porcine liver by transplanting second trimester human fetal hepatocytes (Hfh) co-cultured with fetal stellate cells (Hfsc) into the decellularized matrix of a porcine liver. MATERIAL AND METHODS: Ischemic livers were removed from 19 Yorkshire swine. Liver decellularization was achieved by an anionic detergent (SDS). The decellularized matrix of three separate porcine liver matrices was seeded with 3.5 × 10(8) and 1 × 10(9) of Hfsc and Hfh, respectively, and perfused for 3, 7, and 13 d. The metabolic and synthetic activities of the engrafted cells were assessed during and after perfusion. RESULTS: Immunohistologic examination of the decellularized matrix showed removal of nuclear materials with intact architecture and preserved extracellular matrix (ECM) proteins. During perfusion of the recellularized matrices, measurement of metabolic parameters (i.e., oxygen concentration, glucose consumption, and lactate and urea production) indicated active metabolism. The average human albumin concentration was 29.48 ± 7.4 µg/mL. Immunohistochemical analysis revealed cell differentiation into mature hepatocytes. Moreover, 40% of the engrafted cells were actively proliferating, and less than 30% of cells were apoptotic. CONCLUSION: We showed that our decellularization protocol successfully removed the cellular components of porcine livers while preserving the native architecture and most ECM protein. We also demonstrated the ability of the decellularized matrix to support and induce phenotypic maturation of engrafted Hfh in a continuously perfused system.

Clinical value of plasma hepatocyte growth factor measurement for the diagnosis of periampullary cancer and prognosis after pancreaticoduodenectomy.

BACKGROUND: Previous studies suggest that serum hepatocyte growth factor (HGF) level may be a useful diagnostic and prognostic biomarker for various tumors. We investigated the utility of plasma HGF level measurements in diagnosing periampullary cancer (PAC). METHODS: Of the patients enrolled in this pilot study (n = 118), 57 had PAC, 21 had benign pancreatic tumor (BPT), 20 had chronic pancreatitis (CP), and 20 were healthy controls. Plasma HGF was measured with ELISA kits. It was measured again at 10 days and 1, 2, 3, 6, and 12 months after pancreaticoduodenectomy (PD). RESULTS: Plasma HGF levels were significantly higher in PAC patients than in BPT patients, CP patients, or healthy controls. When a cutoff value of 1,120 pg/ml was used, 48/57 (84%) patients with PAC were positive for elevated HGF, but only 6/20 (30%) of patients with CP and none of the controls or patients with BPT were positive for elevated HGF. After PD, HGF levels were significantly elevated at day 10. CONCLUSIONS: Plasma HGF level discriminates well between PAC and other, benign diseases. Therefore, HGF measurement could be a useful addition to the existing array of diagnostic tools for PAC pancreatic cancer. The higher postoperative value may reflect the stress of surgery.

Morphological features of advanced hepatocellular carcinoma as a predictor of downstaging and liver transplantation: an intention-to-treat analysis.

In selected patients, locoregional therapy (LRT) has been successful in downstaging advanced hepatocellular carcinoma (HCC) so that the conventional criteria for liver transplantation (LT) can be met. However, the factors that predict successful treatment are largely unidentified. To determine these factors, we analyzed our experience with multimodal LRT in downstaging advanced HCC before LT in a retrospective cohort study. Thirty-two patients with advanced HCC exceeding conventional and expanded criteria for LT underwent therapy, but only those patients whose tumors were successfully downstaged were considered for LT. Eighteen patients (56%) had their tumors successfully downstaged; 14 patients (44%) did not. No intergroup differences existed with respect to patient characteristics or the types and number of treatments. However, mean alpha-fetoprotein levels were significantly higher in the non-downstaged group than in the downstaged group (P < 0.048), and significantly more patients in the non-downstaged group had infiltrative tumors (P = 0.0001). The median survival time was 42 and 7 months for the downstaged and non-downstaged groups, respectively (P = 0.0006). Fourteen patients (43.3%) underwent LT. After a median follow-up period of 35 months (range, 1.5-50 months) after LT, 2 patients (14.2%) developed tumor recurrence. The Kaplan-Meier survival rates after LT were 92% at 1 year and 75% at 2 years. The noninfiltrative expanding tumor type was the sole predictor of successful downstaging and improved outcome on univariate and multivariate analyses. Our study suggests that, in patients with advanced HCC, morphological characteristics of the tumor may predict a good response to downstaging and an improved outcome after LT.

Major liver resection for hepatocellular carcinoma in the morbidly obese: a proposed strategy to improve outcome.

BACKGROUND: Morbid obesity strongly predicts morbidity and mortality in surgical patients. However, obesity's impact on outcome after major liver resection is unknown. CASE PRESENTATION: We describe the management of a large hepatocellular carcinoma in a morbidly obese patient (body mass index >50 kg/m2). Additionally, we propose a strategy for reducing postoperative complications and improving outcome after major liver resection. CONCLUSION: To our knowledge, this is the first report of major liver resection in a morbidly obese patient with hepatocellular carcinoma. The approach we used could make this operation nearly as safe in obese patients as it is in their normal-weight counterparts.

Complex liver resection for a large intrahepatic cholangiocarcinoma in a Jehovah's witness: a strategy to avoid transfusion.

Although morbidity and mortality after liver resection have improved over the last two decades, complex liver resections still require perioperative blood transfusions. In this report, we describe the use of a combined left trisegmentectomy and caudate lobectomy, along with resection of the inferior vena cava, to treat a large intrahepatic cholangiocarcinoma in a Jehovah's Witness. To our knowledge, this is the first report of major liver resection for a large malignant tumor in this patient population. We also discuss the perioperative strategy and surgical technique we used to minimize blood loss and avoid transfusion. This approach could be a safe alternative for use in all patients with complex liver tumor, regardless of their religious beliefs, to reduce the risks and cost associated with blood transfusion.

Extended right trisegmentectomy using in situ hypothermic perfusion with modified HTK solution for a large intrahepatic cholangiocarcinoma.

The technique of right hepatic trisegmentectomy has been standardized for large tumors that involve the right lobe and extend into the medial segment of the left lobe. However, these tumors are deemed unresectable if they encroach across the falciform ligament into the left lateral segment. We report the technique of extended right trisegmentectomy in a patient with a large intrahepatic cholangiocarcinoma that involved the right lobe of the liver and extended into the medial and lateral segments of the left lobe. The resection was performed by using total hepatic vascular isolation and in situ hypothermic perfusion with modified histidine-tryptophan-ketoglutarate (HTK) solution into the left lateral segment. The biliary enteric anastomosis was constructed using a double hepaticojejunostomy to Segments II and III bile ducts. The procedure allowed safe parenchymal dissection with preservation of the blood supply to Segments II and III. Furthermore, in situ hypothermic perfusion protected the remnant liver from the deleterious effects of warm ischemia during parenchymal dissection and facilitated postoperative recovery. To the best of our knowledge, this is the first report of extended right trisegmentectomy for the treatment of intrahepatic cholangiocarcinoma in the Western literature.