Retrospective observation of therapeutic effects of adult auxiliary partial living donor liver transplantation on postpartum acute liver failure: A case report

We present a female patient with preterm labor, severe viral hepatitis B of acute phase, hepatic encephalopathy stage Ⅲ and coma.After delivery, the illness was exacerbated and the patient presented with clinical signs of vital organ dysfunctions such as acute respiratory distress syndrome, cerebral edema and hypoxemia that needed mechanical ventilation.Emergency liver transplantation was recommended after multidisciplinary panel consultations.The donor, her mother, consented to donate her right liver.Auxiliary partial orthotopic living donor liver transplantion(APOLDLT) was performed.After operation, the patient was on triple medication of tacrolimus plus mofetil mycophenolate and prednisone for immunosuppression.The combination of antihepatitis B virus(HBV) immunoglobulin and entecavir was initiated for anti-HBV therapy.Both the patient and the donor recovered well without any complications.The patient was followed up regularly.Her liver function, clinical signs and symptoms improved significantly.Until now, the recipient has been living for more than 78 mo free of any complications.The APOLDLT is a life-saving modality for rescuing patients with high-risk acute liver failure following HBV infection without available donor and hence is recommended under standardized antiviral therapy coverage as stated above.

Abnormal splenic artery diameter/hepatic artery diameter ratio in cirrhosis-induced portal hypertension

AIM:To determine an optimal cutoff value for abnormal splenic artery diameter/proper hepatic artery diameter(S/P) ratio in cirrhosis-induced portal hypertension.METHODS:Patients with cirrhosis and portal hypertension(n = 770) and healthy volunteers(n = 31) underwent volumetric computed tomography threedimensional vascular reconstruction to measure the internal diameters of the splenic artery and proper hepatic artery to calculate the S/P ratio.The cutoff value for abnormal S/P ratio was determined using receiver operating characteristic curve analysis,and the prevalence of abnormal S/P ratio and associations between abnormal S/P ratio and major complications of portal hypertension were studied using logistic regression.RESULTS:The receiver operating characteristic analysis showed that the cutoff points for abnormal splenic artery internal diameter and S/P ratio were > 5.19 mm and > 1.40,respectively.The sensitivity,specificity,positive predictive value,and negative predictive value were 74.2%,45.2%,97.1%,and 6.6%,respectively.The prevalence of an abnormal S/P ratio in the patients with cirrhosis and portal hypertension was 83.4%.Patients with a higher S/P ratio had a lower risk of developing ascites [odds ratio(OR) = 0.708,95%CI:0.508-0.986,P = 0.041] and a higher risk of developing esophageal and gastric varices(OR = 1.483,95%CI:1.010-2.175,P = 0.044) and forming collateral circulation(OR = 1.518,95%CI:1.033-2.230,P = 0.034).After splenectomy,the portal venous pressure and maximum and mean portal venous flow velocities were reduced,while the flow rate and maximum and minimum flow velocities of the hepatic artery were increased(P < 0.05).CONCLUSION:The prevalence of an abnormal S/P ratio is high in patients with cirrhosis and portal hypertension,and it can be used as an important marker of splanchnic hemodynamic disturbances.

Anticoagulation therapy prevents portal-splenic vein thrombosis after splenectomy with gastroesophageal devascularization

AIM:To compare the incidence of early portal or splenic vein thrombosis(PSVT) in patients treated with irregular and regular anticoagulantion after splenectomy with gastroesophageal devascularization.METHODS:We retrospectively analyzed 301 patients who underwent splenectomy with gastroesophageal devascularization for portal hypertension due to cirrhosis between April 2004 and July 2010.Patients were categorized into group A with irregular anticoagulation and group B with regular anticoagulation,respectively.Group A(153 patients) received anticoagulant monotherapy for an undesignated time period or with aspirin or warfarin without low-molecular-weight heparin(LMWH) irregularly.Group B(148 patients) received subcutaneous injection of LMWH routinely within the first 5 d after surgery,followed by oral warfarin and aspirin for one month regularly.The target prothrombin time/international normalized ratio(PT/INR) was 1.25-1.50.Platelet and PT/INR were monitored.Color Doppler imaging was performed to monitor PSVT as well as the effectiveness of thrombolytic therapy.RESULTS:The patients' data were collected and analyzed retrospectively.Among the patients,94 developed early postoperative mural PSVT,including 63 patients in group A(63/153,41.17%) and 31 patients in group B(31/148,20.94%).There were 50(32.67%) patients in group A and 27(18.24%) in group B with mural PSVT in the main trunk of portal vein.After the administration of thrombolytic,anticoagulant and antiaggregation therapy,complete or partial thrombus dissolution achieved in 50(79.37%) in group A and 26(83.87%) in group B.CONCLUSION:Regular anticoagulation therapy can reduce the incidence of PSVT in patients who undergo splenectomy with gastroesophageal devascularization,and regular anticoagulant therapy is safer and more effective than irregular anticoagulant therapy.Early and timely thrombolytic therapy is imperative and feasible for the prevention of PSVT.

Usefulness of three-dimensional visualization technology in minimally invasive treatment for infected necrotizing pancreatitis

AIM To explore the value of three-dimensional(3 D) visualization technology in the minimally invasive treatment for infected necrotizing pancreatitis(INP). METHODS Clinical data of 18 patients with INP, who were admitted to the PLA General Hospital in 2017, were retrospectively analyzed. Two-dimensional images of computed tomography were converted into 3 D images based on 3 D visualization technology. The size, number, shape and position of lesions and their relationship with major abdominal vasculature were well displayed. Also, percutaneous catheter drainage(PCD) number and puncture paths were designed through virtual surgery(percutaneous nephroscopic necrosectomy) based on the principle of maximum removal of infected necrosis conveniently.RESULTS Abdominal 3 D visualization images of all the patients were well reconstructed, and the optimal PCD puncture paths were well designed. Infected necrosis was conveniently removed in abundance using a nephroscope during the following surgery, and the median operation time was 102(102 ± 20.7) min. Only 1 patient underwent endoscopic necrosectomy because of residual necrosis. CONCLUSION The 3 D visualization technology could optimize the PCD puncture paths, improving the drainage effect in patients with INP. Moreover, it significantly increased the efficiency of necrosectomy through the rigid nephroscope. As a result, it decreased operation times and improved the prognosis.

Diagnosis and surgical treatment of esophageal gastrointestinal stromal tumors

AIM: To retrospectively evaluate our experience with the diagnosis and surgical resection of esophageal gastrointestinal stromal tumors(GISTs).METHODS: Between January 2003 and August 2014, five esophageal GIST cases were admitted to our hospital. In this study, the hospital records, surgery outcomes, tumor recurrence and survival of these patients were retrospectively reviewed.RESULTS: The median age of the patients was 45.6 years(range: 12-62 years). Three patients presented with dysphagia, and one patient presented with chest discomfort. The remaining patient was asymptomatic. Four patients were diagnosed with esophageal GISTs by a preoperative endoscopic biopsy. Three patients underwent esophagectomy, and two patients underwent video-assisted thoracoscopic surgery. The mean operating time was 116 min(range: 95-148 min), and the mean blood loss was 176 m L(range: 30-300 m L). All tumors were completely resected. The mean length of postoperative hospital stay was 8.4 d(range: 6-12 d). All patients recovered and were discharged successfully. The median postoperative follow-up duration was 48 mo(range: 29-72 mo). One patient was diagnosed with recurrence, one patient was lost to follow-up, and three patients were asymptomatic and are currently being managed with close radiologic and clinical follow-up.CONCLUSION:Surgery is the standard,effective and successful treatment for esophageal GISTs.Longterm follow-up is required to monitor recurrence and metastasis.

Postoperative inflammation as a possible cause of portal vein thrombosis after irreversible electroporation for locally advanced pancreatic cancer

Portal vein thrombosis(PVT) is a rare but serious postoperative complication associated with irreversible electroporation(IRE). We report a case of postoperative PVT in a 54-year-old woman who underwent IRE for locally advanced pancreatic cancer. Drain removal and discharge of the patient from the hospital were scheduled on postoperative day(POD) 7; however, a magnetic resonance imaging scan revealed the presence of PVT. We suspected postoperative inflammation in the pancreas as the main cause of PVT. However, the patient did not undergo any medical treatment because she did not have any clinical symptoms, and she was discharged on POD 8.

Venovenous bypass ahead of mobilization of the liver in orthotopic liver transplantation

BACKGROUND: To evaluate feasibility and safety of venovenous bypass prior to mobilization of the liver during orthotopic liver transplantation (OLT). METHODS: Fifty-four patients were classified into two groups. Group A consisted of 23 patients receiving OLT with classical venovenous bypass. Group B consisted of 31 patients who received a modified-procedure: venovenous bypass ahead of the mobilization of the liver during ULT. The blood loss, duration of venovenous bypass, cold ischemia time, anhepatic phase, and transfusion during operation in the two groups were compared. Complications after the operation were also compared between the two groups. RESULTS: The duration of venovenous bypass and cold ischemia time in group A were longer than those in group B [(99.78±21.36 min) vs (96.32±22.25 min) and (484.78±134.01 min) vs (443.15± 85.27 min)]. The anhepatic phase lasted for about 100 min averagely in the two groups. The volumes of blood loss and transfusion during the operation were larger in group A than in group B [(5096±4243 ml) vs (1726±1125 ml) and (3676±2938.74 ml) vs (1217.69±829.72 ml)]. Postoperative complications occurred in 26 patients of group A and in 19 patients of group B. CONCLUSION: This modified-procedure or venovenous bypass ahead of mobilization of the liver in OLT can reduce the blood loss during OLT and the incidence of postoperative complications without prolongation of the anhepatic phase and duration of venovenous bypass.

Liver transplantation in patients with intrahepatic stones: report of two cases

To investigate the feasibility and rationality of liver transplantation as an indication for patients with intrahepatic stones. Methods: Liver transplantation was successfully per- formed for a 28-year-old man and a 42-year-old woman, both with intrahepatic stones. Results: Patient 1 had digestive tract bleeding on the postoperative day 6 and he was discharged from the hospital on the postoperative day 25. He is in good health 14 months after operation. Patient 2 also had hemorrhage from the digestive tract on the postope- rative day 44 and a leakage of end-to-side intestinal anastomosis on the postoperative day 47. She has re- sumed her work and is in good health from the post- operative month 12. Conclusion: Liver transplantation is safe and effec- tive for patients with intrahepatic stones.

Diagnosis and Treatment of Cholangiocarcinoma: A Consensus from Surgical Specialists of China

Cholangiocarcinoma refers to malignant tumors that develop in epithelial lining of biliary system, and it is divided into two categories according to tumor location, intrahepatic cholangiocarcinoma （ICC） and extrahepatic cholangiocarcinoma （ECC）. ICC occurs from the epithelial cells of the intrahepatic bile duct, its branches and interlobular biliary tree; and ECC is divided into hilar cholangiocarcinoma and distal cholangiocarcinoma by the circumscription at the confluence of cystic duct and the common hepatic duct.

A Single-institution Experience with Open Irreversible Electroporation for Locally Advanced Pancreatic Carcinoma

Background： Locally advanced pancreatic carcinoma （LAPC） is characterized by poor prognosis despite recommended concurrent chemoradiotherapy. Irreversible electroporation （IRE） has emerged as a potential option for the management of unresectable pancreatic cancer. This study was conducted to evaluate the safety and short-term efficacy of open IRE for the treatment of LAPC. Methods： Retrospective data of 25 consecutive patients receiving IRE for T3 lesions from July 2015 to June 2016 at a single center were analyzed. The perioperative and long-term IRE-related complications were reviewed to evaluate the safety of the procedure. The tumor reduction and biological response were analyzed through computed tomography/magnetic resonance imaging; the serum level of CA19-9 was measured as a secondary endpoint to evaluate the short-term efficacy of IRE. Results： All patients were successfully treated; the median tumor size was 4.2 cm and the median IRE time was 36 min. Four intraoperative procedure-related complications were observed （16%）： two transient hypertensive episodes, one hypotension case, and one transient supraventricular tachycardia case. Nine postoperative complications were described, including three Grade A pancreatic fistulas, three delayed gastric emptying, one acute pancreatitis, one upper gastrointestinal hemorrhage, and one portal vein thrombosis. The overall rate of stable disease was 28%, 36% achieved partial response, and lower serum CA19-9 levels were recorded in all patients at discharge. Conclusions： IRE is feasible for the treatment of LAPC and is a reasonable intervention strategy owing to its combined attributes of safety and efficacy.