BACKGROUND:Survival of the partial graft after living donor liver transplantation owes much to its tremendous regenerative ability.With excellent venous outflow capacity,a graft within a wide range of graft-to-standar...BACKGROUND:Survival of the partial graft after living donor liver transplantation owes much to its tremendous regenerative ability.With excellent venous outflow capacity,a graft within a wide range of graft-to-standard-liver-volume ratios can cope with portal hypertension that is common in liver transplant recipients.However,when the ratio range is exceeded,modulation of graft vascular inflow becomes necessary for graft survival.The interplay between graft-to-standard-liver-volume ratio and portal pressure,in the presence of portosystemic shunt or otherwise,requires individualized modulation of graft portal and arterial inflows.Boosting of portal inflow by shunt ligation can be guided by transonic flowmetry,whereas muting of portal inflow by splenic artery ligation can be monitored by portal electronic manometry.METHOD:We describe four cases to illustrate the above.RESULTS:One patient had hepatic artery thrombosis resulting from splenic artery steal syndrome which was the sequela of small-for-size syndrome.Emergency splenic artery ligation and re-anastomosis of the hepatic artery successfully muted the portal inflow and boosted the hepatic arterial inflow.Another patient with portal vein thrombosis underwent thrombendvenectomy.Portal inflow was boosted with ligation of portosystemic shunt,which is often present in these patients with portal hypertension.The coexistence of splenic aneurysm and splenorenal shunt required ligation of both in the third patient.The fourth patient,with portal pressure and flow monitoring,avoided ligation of a coronary vein which became a main portal inflow after portal thrombendvenectomy.CONCLUSION:Management of graft inflow modulation guided selectively by transonic flowmetry or portal manometry was described.展开更多
AIM: To evaluate the effects of varying ischemic durations on cirrhotic liver and to determine the safe upper limit of repeated intermittent hepatic inflow occlusion. METHODS: Hepatic ischemia in cirrhotic rats was in...AIM: To evaluate the effects of varying ischemic durations on cirrhotic liver and to determine the safe upper limit of repeated intermittent hepatic inflow occlusion. METHODS: Hepatic ischemia in cirrhotic rats was induced by clamping the common pedicle of left and median lobes after non-ischemic lobes resection. The cirrhotic rats were divided into six groups according to the duration and form of vascular clamping: sham occlusion (SO), intermittent occlusion for 10 (IO-10), 15(IO-15), 20(IO-20) and 30(IO-30) minutes with 5 minutes of reflow and continuous occlusion for 60 minutes (CO-60). All animals received a total duration of 60 minutes of hepatic inflow occlusion. Liver viability was investigated in relation of hepatic adenylate energy charge (EC). Triphenyltetrazollum chloride (TTC) reduction activities were assayed to qualitatively evaluate the degree of irreversible hepatocellular injury. The biochemical and morphological changes were also assessed and a 7-day mortality was observed. RESULTS: At 60 minutes after reperfusion following a total of 60 minutes of hepatic inflow occlusion, EC values in IO-10 (0.749 +/- 0.012) and IO-15 (0.699 +/- 0.002) groups were rapidly restored to that in SO group (0.748 +/- 0.016), TTC reduction activities remained in high levels (0.144 +/- 0.002 mg/mg protein, 0.139 +/- 0.003 mg/mg protein and 0.121 +/- 0.003 mg/mg protein in SO, IO-10 and IO-15 groups, respectively). But in IO-20 and IO-30 groups, EC levels were partly restored (0.457 +/- 0.023 and 0.534 +/- 0.027) accompanying with a significantly decreased TTC reduction activities (0.070 +/- 0.005 mg/mg protein and 0.061 +/- 0.003 mg/mg protein). No recovery in EC values (0.228 +/- 0.004) and a progressive decrease in TTC reduction activities (0.033 +/- 0.002 mg/mg protein) were shown in CO-60 group. Although not significantly different, the activities of the serum aspartate aminotransferase (AST) on the third postoperative day (POD(3)) and POD(7) and of the serum alanine aminotransferase (ALT) on POD(3) in CO-60 group remained higher than that in intermittent occlusion groups. Moreover, a 60% animal mortality rate and more severe morphological alterations were also shown in CO-60 group. CONCLUSION: Hepatic inflow occlusion during 60 minutes for liver resection in cirrhotic rats resulted in less hepatocellular injury when occlusion was intermittent rather than continuous. Each period of 15 minutes was the safe upper limit of repeated intermittent vascular occlusion that the cirrhotic liver could tolerate without undergoing irreversible hepatocellular injury.展开更多
Objective: To evaluate the tolerance limit of rats tonormothermic hepatic inflow occlusion under portalblood bypass.Methods: A new rat model of normothermic hepaticinflow occlusion under portal blood bypass was estab-...Objective: To evaluate the tolerance limit of rats tonormothermic hepatic inflow occlusion under portalblood bypass.Methods: A new rat model of normothermic hepaticinflow occlusion under portal blood bypass was estab-lished by clamping temporarily the pedicles of all liverlobes while the caudal lobe was kept as a passage ofthe portal blood flow. After hepatic blood flow re-stored, the caudal lobe was cut off. On the 7th postop-erative day, survival rate, hepatic morphological changes,and the severity and reversibility of the injured energymetabolism of the liver were investigated.Results: All rats that had been subjected to 30, 60 and90 minutes of hepatic inflow occlusion under portalblood bypass survived on the 7th postoperativeday. Ischemia-reperfusion injury of the liver was re-versible and compensatory in rats with hepatic inflowocclusion within 90minutes. However, the survivalrates of rats with 100, 110 and 120 minutes of hepaticinflow occlusion were 50%, 30% and 20% respective-ly. Liver injury of rats with 120 minutes of hepatic in-flow occlusion was severe and irreversible.Conclusions: The tolerance limit of rats to normother-mic hepatic inflow occlusion is enhanced significantlyunder portal blood bypass and the upper limit is 90minutes.展开更多
Liver transplantation is performed in the recent decades with great improvements not only technically but also conceptually. However, there is still lack of consensus about the optimal hemodynamic characteristics duri...Liver transplantation is performed in the recent decades with great improvements not only technically but also conceptually. However, there is still lack of consensus about the optimal hemodynamic characteristics during liver transplantation. The representative hemodynamic parameters include portal vein pressure, portal vein flow, and hepatic venous pressure gradient; however, there are still others potential valuable parameters, such as total liver inflow and hepatic artery flow. All the parameters are correlated closely and some internal modulating mechanisms, like hepatic arterial buffer response, occur to maintain stable hepatic inflow. To distinguish the unique importance of each hepatic and systemic parameter in different states during liver transplantation, we reviewed the published data and also conducted two transplant cases with different surgical strategies applied to achieve ideal portal inflow and pressure.展开更多
The performance of hepatic surgery without a parenchyma-sparing strategy carries significant risks for patient survival because of the not negligible occurrence of postoperative liver failure.The key factor of modern ...The performance of hepatic surgery without a parenchyma-sparing strategy carries significant risks for patient survival because of the not negligible occurrence of postoperative liver failure.The key factor of modern hepatic surgery is the use of the intraoperative ultrasound(IOUS),not only to stage the disease,but more importantly to guide resection with the specific aim to maximize the sparing of the functional parenchyma.Whether in patients with hepatocellular carcinoma and underlying liver cirrhosis,or in patients with colorectal liver metastasis,IOUS allows the performance of the so-called "radical but conservative surgery",which is the pivotal factor to offer a chance of cure to an increasing proportion of patients,who until few years ago were considered only for palliative care.Using some new IOUS-guided surgical maneuvers,which are based on the liver inflow and outflow modulations,more precise anatomically subsegmental-and segmentaloriented resections can be effectively performed.The present work describes the rationale and the surgical technique for a precise tailoring of the area of hepatic resection using the most recent attainments in IOUS.Such important technical achievements should be a fundamental part of the surgical armamentarium of the modern liver surgeon.展开更多
Focal fatty change of the segment IV of the liver has been attributed to local systemic venous inflow replacing the portal venous supply, which could develop or be accentuated after gastrectomy. However, focal fatty c...Focal fatty change of the segment IV of the liver has been attributed to local systemic venous inflow replacing the portal venous supply, which could develop or be accentuated after gastrectomy. However, focal fatty change due to aberrant pancreaticoduodenal vein that developed after cholecystectomy has never been reported. We report a 30-year-old man with such a rare lesion, which was initially misdiagnosed as a hepatocellular carcinoma, but was confirmed on computed tomography during selective gastroduodenal arteriography. The lesion disappeared 12 mo later without any intervention.展开更多
AIM To analyze the incidence, risk factors, prevention, treatment and outcome of small for size syndrome(SFSS) after living donor liver transplantation(LDLT). METHODS Through-out more than 10 years: During the period ...AIM To analyze the incidence, risk factors, prevention, treatment and outcome of small for size syndrome(SFSS) after living donor liver transplantation(LDLT). METHODS Through-out more than 10 years: During the period from April 2003 to the end of 2013, 174 adult-to-adults LDLT(A-ALDLT) had been performed at National Liver Institute, Menoufiya University, Shibin Elkoom, Egypt. We collected the data of those patients to do this cohort study that is a single-institution retrospective analysis of a prospectively collected database analyzing the incidence, risk factors, prevention, treatment and outcome of SFSS in a period started from the end of 2013 to the end of 2015. The median period of follow-up reached 40.50 m, range(0-144 m). RESULTS SFSS was diagnosed in 20(11.5%) of our recipients. While extra-small graft [small for size graft(SFSG)], portal hypertension, steatosis and left lobe graft were significant predictors of SFSS in univariate analysis(P = 0.00, 0.04, 0.03, and 0.00 respectively); graft size was the only independent predictor of SFSS on multivariate analysis(P = 0.03). On the other hand, there was lower incidence of SFSS in patients with SFSG who underwent splenectomy [4/10(40%) SFSS vs 3/7(42.9%) no SFSS] but without statistical significance, However, there was none significant lower incidence of the syndrome in patients with right lobe(RL) graft when drainage of the right anterior and/or posterior liver sectors by middle hepatic vein, V5, V8, and/or right inferior vein was done [4/10(28.6%) SFSS vs 52/152(34.2%) no SFSS]. The 6-mo, 1-, 3-, 5-, 7-and 10-year survival in patients with SFSS were 30%, 30%, 25%, 25%, 25% and 25% respectively, while, the 6-mo, 1-, 3-, 5-, 7-and 10-year survival in patients without SFSS were 70.1%, 65.6%, 61.7%, 61%, 59.7%, and 59.7% respectively, with statistical significant difference(P = 0.00). CONCLUSION SFSG is the independent and main factor for occurrence of SFSS after A-ALDLT leading to poor outcome. However, the management of this catastrophe depends upon its prevention(i.e., selecting graft with proper size, splenectomy to decrease portal venous inflow, and improving hepatic vein outflow by reconstructing large draining veins of the graft).展开更多
文摘BACKGROUND:Survival of the partial graft after living donor liver transplantation owes much to its tremendous regenerative ability.With excellent venous outflow capacity,a graft within a wide range of graft-to-standard-liver-volume ratios can cope with portal hypertension that is common in liver transplant recipients.However,when the ratio range is exceeded,modulation of graft vascular inflow becomes necessary for graft survival.The interplay between graft-to-standard-liver-volume ratio and portal pressure,in the presence of portosystemic shunt or otherwise,requires individualized modulation of graft portal and arterial inflows.Boosting of portal inflow by shunt ligation can be guided by transonic flowmetry,whereas muting of portal inflow by splenic artery ligation can be monitored by portal electronic manometry.METHOD:We describe four cases to illustrate the above.RESULTS:One patient had hepatic artery thrombosis resulting from splenic artery steal syndrome which was the sequela of small-for-size syndrome.Emergency splenic artery ligation and re-anastomosis of the hepatic artery successfully muted the portal inflow and boosted the hepatic arterial inflow.Another patient with portal vein thrombosis underwent thrombendvenectomy.Portal inflow was boosted with ligation of portosystemic shunt,which is often present in these patients with portal hypertension.The coexistence of splenic aneurysm and splenorenal shunt required ligation of both in the third patient.The fourth patient,with portal pressure and flow monitoring,avoided ligation of a coronary vein which became a main portal inflow after portal thrombendvenectomy.CONCLUSION:Management of graft inflow modulation guided selectively by transonic flowmetry or portal manometry was described.
基金This Work was supported by the grant from the Science and Technology Committee of Zhejiang Province,No.971103132
文摘AIM: To evaluate the effects of varying ischemic durations on cirrhotic liver and to determine the safe upper limit of repeated intermittent hepatic inflow occlusion. METHODS: Hepatic ischemia in cirrhotic rats was induced by clamping the common pedicle of left and median lobes after non-ischemic lobes resection. The cirrhotic rats were divided into six groups according to the duration and form of vascular clamping: sham occlusion (SO), intermittent occlusion for 10 (IO-10), 15(IO-15), 20(IO-20) and 30(IO-30) minutes with 5 minutes of reflow and continuous occlusion for 60 minutes (CO-60). All animals received a total duration of 60 minutes of hepatic inflow occlusion. Liver viability was investigated in relation of hepatic adenylate energy charge (EC). Triphenyltetrazollum chloride (TTC) reduction activities were assayed to qualitatively evaluate the degree of irreversible hepatocellular injury. The biochemical and morphological changes were also assessed and a 7-day mortality was observed. RESULTS: At 60 minutes after reperfusion following a total of 60 minutes of hepatic inflow occlusion, EC values in IO-10 (0.749 +/- 0.012) and IO-15 (0.699 +/- 0.002) groups were rapidly restored to that in SO group (0.748 +/- 0.016), TTC reduction activities remained in high levels (0.144 +/- 0.002 mg/mg protein, 0.139 +/- 0.003 mg/mg protein and 0.121 +/- 0.003 mg/mg protein in SO, IO-10 and IO-15 groups, respectively). But in IO-20 and IO-30 groups, EC levels were partly restored (0.457 +/- 0.023 and 0.534 +/- 0.027) accompanying with a significantly decreased TTC reduction activities (0.070 +/- 0.005 mg/mg protein and 0.061 +/- 0.003 mg/mg protein). No recovery in EC values (0.228 +/- 0.004) and a progressive decrease in TTC reduction activities (0.033 +/- 0.002 mg/mg protein) were shown in CO-60 group. Although not significantly different, the activities of the serum aspartate aminotransferase (AST) on the third postoperative day (POD(3)) and POD(7) and of the serum alanine aminotransferase (ALT) on POD(3) in CO-60 group remained higher than that in intermittent occlusion groups. Moreover, a 60% animal mortality rate and more severe morphological alterations were also shown in CO-60 group. CONCLUSION: Hepatic inflow occlusion during 60 minutes for liver resection in cirrhotic rats resulted in less hepatocellular injury when occlusion was intermittent rather than continuous. Each period of 15 minutes was the safe upper limit of repeated intermittent vascular occlusion that the cirrhotic liver could tolerate without undergoing irreversible hepatocellular injury.
文摘Objective: To evaluate the tolerance limit of rats tonormothermic hepatic inflow occlusion under portalblood bypass.Methods: A new rat model of normothermic hepaticinflow occlusion under portal blood bypass was estab-lished by clamping temporarily the pedicles of all liverlobes while the caudal lobe was kept as a passage ofthe portal blood flow. After hepatic blood flow re-stored, the caudal lobe was cut off. On the 7th postop-erative day, survival rate, hepatic morphological changes,and the severity and reversibility of the injured energymetabolism of the liver were investigated.Results: All rats that had been subjected to 30, 60 and90 minutes of hepatic inflow occlusion under portalblood bypass survived on the 7th postoperativeday. Ischemia-reperfusion injury of the liver was re-versible and compensatory in rats with hepatic inflowocclusion within 90minutes. However, the survivalrates of rats with 100, 110 and 120 minutes of hepaticinflow occlusion were 50%, 30% and 20% respective-ly. Liver injury of rats with 120 minutes of hepatic in-flow occlusion was severe and irreversible.Conclusions: The tolerance limit of rats to normother-mic hepatic inflow occlusion is enhanced significantlyunder portal blood bypass and the upper limit is 90minutes.
文摘Liver transplantation is performed in the recent decades with great improvements not only technically but also conceptually. However, there is still lack of consensus about the optimal hemodynamic characteristics during liver transplantation. The representative hemodynamic parameters include portal vein pressure, portal vein flow, and hepatic venous pressure gradient; however, there are still others potential valuable parameters, such as total liver inflow and hepatic artery flow. All the parameters are correlated closely and some internal modulating mechanisms, like hepatic arterial buffer response, occur to maintain stable hepatic inflow. To distinguish the unique importance of each hepatic and systemic parameter in different states during liver transplantation, we reviewed the published data and also conducted two transplant cases with different surgical strategies applied to achieve ideal portal inflow and pressure.
文摘The performance of hepatic surgery without a parenchyma-sparing strategy carries significant risks for patient survival because of the not negligible occurrence of postoperative liver failure.The key factor of modern hepatic surgery is the use of the intraoperative ultrasound(IOUS),not only to stage the disease,but more importantly to guide resection with the specific aim to maximize the sparing of the functional parenchyma.Whether in patients with hepatocellular carcinoma and underlying liver cirrhosis,or in patients with colorectal liver metastasis,IOUS allows the performance of the so-called "radical but conservative surgery",which is the pivotal factor to offer a chance of cure to an increasing proportion of patients,who until few years ago were considered only for palliative care.Using some new IOUS-guided surgical maneuvers,which are based on the liver inflow and outflow modulations,more precise anatomically subsegmental-and segmentaloriented resections can be effectively performed.The present work describes the rationale and the surgical technique for a precise tailoring of the area of hepatic resection using the most recent attainments in IOUS.Such important technical achievements should be a fundamental part of the surgical armamentarium of the modern liver surgeon.
文摘Focal fatty change of the segment IV of the liver has been attributed to local systemic venous inflow replacing the portal venous supply, which could develop or be accentuated after gastrectomy. However, focal fatty change due to aberrant pancreaticoduodenal vein that developed after cholecystectomy has never been reported. We report a 30-year-old man with such a rare lesion, which was initially misdiagnosed as a hepatocellular carcinoma, but was confirmed on computed tomography during selective gastroduodenal arteriography. The lesion disappeared 12 mo later without any intervention.
文摘AIM To analyze the incidence, risk factors, prevention, treatment and outcome of small for size syndrome(SFSS) after living donor liver transplantation(LDLT). METHODS Through-out more than 10 years: During the period from April 2003 to the end of 2013, 174 adult-to-adults LDLT(A-ALDLT) had been performed at National Liver Institute, Menoufiya University, Shibin Elkoom, Egypt. We collected the data of those patients to do this cohort study that is a single-institution retrospective analysis of a prospectively collected database analyzing the incidence, risk factors, prevention, treatment and outcome of SFSS in a period started from the end of 2013 to the end of 2015. The median period of follow-up reached 40.50 m, range(0-144 m). RESULTS SFSS was diagnosed in 20(11.5%) of our recipients. While extra-small graft [small for size graft(SFSG)], portal hypertension, steatosis and left lobe graft were significant predictors of SFSS in univariate analysis(P = 0.00, 0.04, 0.03, and 0.00 respectively); graft size was the only independent predictor of SFSS on multivariate analysis(P = 0.03). On the other hand, there was lower incidence of SFSS in patients with SFSG who underwent splenectomy [4/10(40%) SFSS vs 3/7(42.9%) no SFSS] but without statistical significance, However, there was none significant lower incidence of the syndrome in patients with right lobe(RL) graft when drainage of the right anterior and/or posterior liver sectors by middle hepatic vein, V5, V8, and/or right inferior vein was done [4/10(28.6%) SFSS vs 52/152(34.2%) no SFSS]. The 6-mo, 1-, 3-, 5-, 7-and 10-year survival in patients with SFSS were 30%, 30%, 25%, 25%, 25% and 25% respectively, while, the 6-mo, 1-, 3-, 5-, 7-and 10-year survival in patients without SFSS were 70.1%, 65.6%, 61.7%, 61%, 59.7%, and 59.7% respectively, with statistical significant difference(P = 0.00). CONCLUSION SFSG is the independent and main factor for occurrence of SFSS after A-ALDLT leading to poor outcome. However, the management of this catastrophe depends upon its prevention(i.e., selecting graft with proper size, splenectomy to decrease portal venous inflow, and improving hepatic vein outflow by reconstructing large draining veins of the graft).
