Short-and long-term outcomes of surgery for diffuse peritonitis in patients 80 years of age and older.

PURPOSE: We evaluated the impact of advanced age on the morbidity, mortality, and long-term outcome after emergency surgery for diffuse peritonitis. METHODS: We retrospectively evaluated the mortality and morbidity rates in 36 patients who were 80 years of age or older and who had undergone emergency surgery for diffuse peritonitis, and calculated 5-year survival by the Kaplan-Meier method. Factors compromising prognosis were identified by univariate and multivariate analyses. RESULTS: The median patient age was 84 years (range, 80-97 years); 16 patients were men and 20 were women. Preoperative concomitant disease was present in 81% of patients; cardiac disease was most common. Sites of visceral perforation were in the upper gastrointestinal tract in five patients, colon or rectum in 30, and gallbladder in 1. The postoperative morbidity rate was 72%, the surgical mortality rate was 11%, and the in-hospital mortality rate was 28%. The median hospital stay was 56 days. The median survival was 41 months, with a 5-year survival rate of 23%. A multivariate analysis identified number of failing organs as the only independent adverse prognostic factor (P < 0.001; relative risk 5.51, 95% confidence interval 1.97-15.4). CONCLUSIONS: Elderly patients with diffuse peritonitis had an unsatisfactory rate of short-term morbidity and mortality compared with those undergoing elective surgery. Postoperative organ failure was most likely to compromise survival.

Characteristics of biliary reconstruction, using a T-tube, as compared to those with other methods, in left-lobe adult living-donor liver transplantation.

BACKGROUND/PURPOSE: Postoperative biliary tract complications remain one of the most serious problems facing patients who undergo living-donor liver transplantation. The aim of this study was to analyze the clinical implications of three different methods of biliary reconstruction in left-lobe adult living-donor liver transplantation. METHODS: We retrospectively compared three groups of patients: those who had Roux-en-Y hepaticojejunostomy (HJ; n = 11) biliary reconstruction, those who had duct-to-duct hepaticohepaticostomy (HH) with external stent (n = 11), and those who had HH with a T-tube (n = 6). Median follow-up for each group was 31, 30, and 10 months, respectively. RESULTS: Bile leaks were observed in 45.5% of the patients in both the HJ group and the HH with external stent group. Biliary anastomotic strictures occurred in 9% of the Roux-en-Y HJ patients and in 27.2% of those who had HH with external stent. No biliary complications were observed in the HH with a T-tube group (P = 0.049). CONCLUSIONS: Biliary reconstruction using HH with a T-tube may decrease the incidence of biliary complications. Despite the relatively short follow-up period, these encouraging preliminary results may warrant further studies of this biliary reconstruction technique in left-lobe adult living-donor liver transplantation.

Augmentation of heme oxygenase-1 expression in the graft immediately after implantation in adult living-donor liver transplantation.

Heme oxygenase (HO)-1 is a cytoprotective protein and has recently been identified as a graft survival gene. However, there are little data currently available regarding the expression of HO-1 in human living-related liver transplantation. This is the first report that HO-1 expression is increased in small-for-size liver allografts. We performed biopsies of the graft liver and donor liver left in six patients at four time points during the procedure and studied HO-1 expression by reverse-transcriptase polymerase chain reaction and immunohistochemistry. HO-1 mRNA was expressed at a low level in steady-state liver tissue but was strongly expressed after perfusion of the graft liver. HO-1 expression increased in nonparenchymal cells in the human graft liver. The number of HO-1 positive cells increased threefold by the end of liver transplantation. This study suggests that ischemia-reperfusion injury and excessive shear stress secondary to portal hypertension might augment HO-1 expression in the graft liver.

The protective role of Kupffer cells in the ischemia-reperfused rat liver.

Kupffer cells constitute a major source of the heme-degrading enzyme, heme oxygenase (HO). This study examined the roles of Kupffer cells in the modulation of accelerated heme catabolism in ischemia-reperfused rat livers. Livers from rats treated with or without liposome-encapsulated dichloromethylene diphosphonate, a Kupffer cell-depleting reagent, underwent a 20-min ligation of the portal vein followed by reperfusion, The time course of the biliary output of bilirubin, the terminal heme-degrading product, and the expression of HO-1 mRNA and protein were monitored. HO-1 mRNA levels were elevated 3 to 12 h after ischemia/reperfusion in both control and Kupffer cell-depleted rats. Immunohistochemical analyses of control livers revealed that Kupffer cells expressed high levels of HO-1 while its expression in hepatocytes was low. In Kupffer cell-depleted livers, however, periportal hepatocytes displayed marked HO-1 expression. Under these conditions the two groups exhibited distinct profiles of biliary bilirubin excretion. In the controls, total bilirubin excretion increased 8-fold and peaked at 10 h after ischemia/reperfusion. In contrast, the Kupffer cell-depleting treatment resulted in a significant acceleration of the initial rise in bilirubin production, which peaked at 4 h. However, the total amount of bilirubin excreted within the initial 10 h after reperfusion was reduced by 50% as compared with that of the controls. In Kupffer cell-depleted rats, the levels of GOT and GPT as well as serum endotoxin concentrations were elevated after ischemia/reperfusion. These results suggest that Kupffer cells serve as an ischemia/reperfusion sensor that upregulates heme degradation and bilirubin excretion, and that Kupffer cells protect hepatocytes from gut-derived stressers--including endotoxin--following ischemia/reperfusion.