To Pringle or not to pringle: is Pedicle clamping a necessity in liver resection?

A single center prospective study was done to evaluate the role of hepatic portal pedicle clamping (PC) during right hepatectomy (RH) in patients with primary and secondary liver tumors. Cirrhotics were excluded. Two groups were compared for preoperative demographics including diagnosis, tumor size, portal vein embolization and liver enzymes, pre and postoperative hemoglobin levels, percentage of residual liver mass, morbidity and mortality, pedicle clamp time, intensive care unit stay, length of hospital stay and blood loss. We observed no significant difference in the analysis of the post-operative hemoglobin, liver enzymes, residual liver size, size of tumor resected, need for postoperative monitoring in ICU stay, length of hospital stay and blood loss. Mortality and morbidity were the same. None of the patients were transfused during surgery. Our findings show that pedicle clamping was beneficial 15% of the time when uncontrolled intra-operative bleeding was encountered or in a subset of patients with peliosis, steatohepatitis, Jehovah Witness patient, and post-chemotherapy patients. However, its advantage has to be weighed against the disadvantages.

Colon carcinoma in patients undergoing liver transplantation.

BACKGROUND: Organ recipients are at risk for certain neoplasms. Ulcerative colitis (UC) is itself a strong risk factor for the development of colon carcinoma (CCa). Transplant patients with UC might be at higher risk for CCa. We analyzed these patients to compare the incidence and pattern of CCa development in these and non-UC patients following liver transplantation (OLTX). PATIENTS AND METHODS: Retrospective study of 1,085 OLTX patients. RESULTS: In 1,022 patients without UC, 1 patient (< 0.1%) developed adenocarcinoma in a colonic polyp 46 months after OLTX. Sixty-three of 108 (60%) patients undergoing OLTX simultaneously had UC. Five OLTX patients (8%) with UC developed colon adenocarcinoma 22 to 66 (mean 48) months after OLTX. Two have died. CONCLUSIONS: Coexistent UC in patients requiring OLTX constitutes a potentially high risk for the development of colonic cancer, a late-appearing event. These patients require close observation and frequent colonoscopic/histologic screening of the colon.

Does intraoperative hepatic artery flow predict arterial complications after liver transplantation?

BACKGROUND: Little is known about the value of intraoperative hepatic artery (HA) flow measurement on the development of HA complications in orthotopic liver transplantation (OLT). We undertook this study to see whether assessing HA flow at the OLT helps predict posttransplant HA complications (HA thrombosis or stenosis). METHODS: Four hundred and eleven consecutive OLT in 367 adult patients who received grafts between November 1992 and August 1995 were reviewed. Of these, 259 grafts in 255 patients with at least 1 year of follow-up and with complete data were studied. HA flow, portal vein flow, percentage of cardiac index going to HA (HA/CI), HA flow per 100 g of liver tissue, mean arterial pressure, central venous pressure, and CI were analyzed. Preservation injury was assessed by posttransplant alanine aminotransferase and aspartate aminotransferase levels. RESULTS: Thirty-four patients with 35 grafts developed HA thrombosis or stenosis during a median follow-up time of 29 months. HA complications occurring within the first 100 days of OLT were classified as early complications. HA flow at the time of surgery and percentage of CI going to the liver were found to be significant variables in early HA complications. Hepatic hemodynamics were not different in the late HA complication group compared to the control. Systemic hemodynamics and posttransplant alanine amino-transferase and aspartate aminotransferase levels were similar in all three groups. Logistic regression analysis showed that patients with HA flows less than 400 ml/min were more than 5 times as likely to develop HA complications (risk ratio 5.1). CONCLUSIONS: HA flow measurement should be obtained at the time of OLT and may help to predict early but not late posttransplant HA complications. Patients with HA flows less than 400 ml/min or HA/CI values of less than 7% may carry a higher risk for HA stenosis or thrombosis and may need close surveillance to detect such problems.