Right Hemihepatectomy by Suprahilar Intrahepatic Transection of the Right Hemipedicle using a Vascular Stapler

Successful hepatic resection requires profound anatomical knowledge and delicate surgical technique. Hemihepatectomies are mostly performed after preparing the extrahepatic hilar structures within the hepatoduodenal ligament, even in benign tumours or liver metastasis.^1-5. Regional extrahepatic lymphadenectomy is an oncological standard in hilar cholangiocarcinoma, intrahepatic cholangio-cellular carcinoma and hepatocellular carcinoma, whereas lymph node metastases in the hepatic hilus in patients with liver metastasis are rarely occult. Major disadvantages of these procedures are the complex preparation of the hilus with the risk of injuring contralateral structures and the possibility of bleeding from portal vein side-branches or impaired perfusion of bile ducts. We developed a technique of right hemihepatectomy or resection of the left lateral segments with intrahepatic transection of the pedicle that leaves the hepatoduodenal ligament completely untouched. ⁶ However, if intraoperative visualization or palpation of the ligament is suspicious for tumor infiltration or lymph node metastasis, the hilus should be explored and a lymphadenectomy performed.Open in a separate windowClick here to view.^{(14M, flv)}     

巨大右半肝肿瘤切除术时的出血控制

巨大右半肝肿瘤切除过程中的出血量是决定手术能否成功的关键因素,控制手术过程中出血的技术也是右半肝切除术中的最重要的技术,有效控制术中出血的方法贯穿于整个手术过程中：良好的术前评估,术中于第一肝门处选择性阻断支配右半肝的入肝血流,于第二肝门处切断肝右静脉,于第三肝门处切断肝短静脉,在无血条件下用超声吸引刀切除预定的右半肝以及肝断面的处理等。此方法能有效控制手术过程中出血,保证左半肝血液供应,减轻肝脏缺血/再灌注损伤,减少术后肝功能不全的发生,保证了胃肠道血流的通畅,避免了黏膜屏障受损,全身血流动力学平稳,对其他脏器功能影响小,缩短了手术时间,极大地提高了手术的安全性。     

ALPPS Procedure for Extended Liver Resections: A Single Centre Experience and a Systematic Review

Aim

To report a single-centre experience with the novel Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) technique and systematically review the related literature.

Methods

Since January 2013, patients with extended primary or secondary liver tumors whose future liver remnant (FLR) was considered too small to allow hepatic resection were prospectively assessed for the ALPPS procedure. A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central.

Results

Until July 2014 ALPPS was completed in 9 patients whose mean age was 60±8 years. Indications for surgical resection were metastases from colorectal cancer in 3 cases, perihilar cholangiocarcinoma in 3 cases, intrahepatic cholangiocarcinoma in 2 cases and hepatocellular carcinoma without chronic liver disease in 1 case. The calculated FLR volume was 289±122 mL (21.1±5.5%) before ALPPS-1 and 528±121 mL (32.2±5.7%) before ALLPS-2 (p<0.001). The increase in FLR between the two procedures was 96±47% (range: 24–160%, p<0.001). Additional interventions were performed in 4 cases: 3 patients underwent Roux-en-Y hepaticojejunostomy, and one case underwent wedge resection of a residual tumor in the FLR. The average time between the first and second step of the procedure was 10.8±2.9 days. The average hospital stay was 24.1±13.3 days. There was 1 postoperative death due to hepatic failure in the oldest patient of this series who had a perihilar cholangiocarcinoma and concomitant liver fibrosis; 11 complications occurred in 6 patients, 4 of whom had grade III or above disease. After a mean follow-up of 17.1±8.5 months, the overall survival was 89% at 3–6 and 12 months. The recurrence-free survival was 100%, 87.5% and 75% at 3-6-12 months respectively. The literature search yielded 148 articles, of which 22 articles published between 2012 and 2015 were included in this systematic review.

Conclusion

The ALPPS technique effectively increased the resectability of otherwise inoperable liver tumors. The postoperative morbidity in our series was high in accordance with the data from the systematic review. Age, liver fibrosis and presence of biliary stenting were predisposing factors for postoperative morbidity and mortality.     

Quantitative study on the inferior vena cava between the renal vein and diaphragm

50 dissections of the human inferior V. cava have been performed in order to measure its right renal vein - diaphragm, retrohepatic, and suprahepatic segments. We conclude that some individual parameters as skin type, age, height, weight did not influence the magnitude of the studied segments. The average measurements of the different parameters proposed for the inferior V. cava are: 1. The distances between the right renal vein and the diaphragm and between the right renal vein and the right atrium are 113.94 mm and 135.16 mm, respectively; 2. the length of the retrohepatic portion of the inferior V. cava and the suprahepatic one were 78.34 mm and 19.34 mm respectively; 3. the valve of the inferior V. cava is present in 46% of the observations; its length and width averages are 31 mm and 10.22 mm, respectively.     

Oral supplementation with carbohydrate- and branched-chain amino acid-enriched nutrients improves postoperative quality of life in patients undergoing hepatic resection

The long-term outcomes of branched-chain amino acid (BCAA) administration in patients undergoing hepatic resection remain unclear. The aim of this study is to assess the impact of oral supplementation with BCAA-enriched nutrients on postoperative quality of life (QOL) in patients undergoing liver resection. A prospective randomized clinical trial was conducted in 96 patients undergoing hepatic resection. Patients were randomly assigned to receive BCAA supplementation (AEN group, n = 48) or a conventional diet (control group, n = 48). Postoperative QOL and short-term outcomes were regularly and continuously evaluated in all patients using a short-form 36 (SF-36) health questionnaire and by measuring various clinical parameters. This study demonstrated a significant improvement in QOL after hepatectomy for liver neoplasm in the AEN group based on the same patients’ preoperative SF-36 scores (P < 0.05). Perioperative BCAA supplementation preserved liver function and general patient health in the short term for AEN group patients compared to those not receiving the nutritional supplement. BCAA supplementation improved postoperative QOL after hepatic resection over the long term by restoring and maintaining nutritional status and whole-body kinetics. This study was registered at (registration number: NCT00945568).     

Heterotopic Auxiliary Rat Liver Transplantation With Flow-regulated Portal Vein Arterialization in Acute Hepatic Failure

In acute hepatic failure auxiliary liver transplantation is an interesting alternative approach. The aim is to provide a temporary support until the failing native liver has regenerated.^1-3 The APOLT-method, the orthotopic implantation of auxiliary segments- averts most of the technical problems. However this method necessitates extensive resections of both the native liver and the graft.⁴ In 1998, Erhard developed the heterotopic auxiliary liver transplantation (HALT) utilizing portal vein arterialization (PVA) (Figure 1). This technique showed promising initial clinical results.^5-6 We developed a HALT-technique with flow-regulated PVA in the rat to examine the influence of flow-regulated PVA on graft morphology and function (Figure 2).A liver graft reduced to 30 % of its original size, was heterotopically implanted in the right renal region of the recipient after explantation of the right kidney.  The infra-hepatic caval vein of the graft was anastomosed with the infrahepatic caval vein of the recipient. The arterialization of the donor’s portal vein was carried out via the recipient’s right renal artery with the stent technique. The blood-flow regulation of the arterialized portal vein was achieved with the use of a stent with an internal diameter of 0.3 mm. The celiac trunk of the graft was end-to-side anastomosed with the recipient’s aorta and the bile duct was implanted into the duodenum. A subtotal resection of the native liver was performed to induce acute hepatic failure. ⁷In this manner 112 transplantations were performed. The perioperative survival rate was 90% and the 6-week survival rate was 80%. Six weeks after operation, the native liver regenerated, showing an increase in weight from 2.3±0.8 g to 9.8±1 g. At this time, the graft’s weight decreased from 3.3±0.8 g to 2.3±0.8 g.We were able to obtain promising long-term results in terms of graft morphology and function. HALT with flow-regulated PVA reliably bridges acute hepatic failure until the native liver regenerates.     

The metabolism of fructose in the bivascularly perfused rat liver.

The metabolism of fructose was investigated in the bivascularly and hemoglobin-free perfused rat liver. Anterograde and retrograde perfusions were performed. In anterograde perfusion, fructose was infused at identical rates (19 mumols min-1 g-1) via the portal vein (all liver cells) or the hepatic artery (predominantly perivenous cells); in retrograde perfusion fructose was infused via the hepatic vein (all liver cells) or the hepatic artery (only periportal cells). The cellular water spaces accessible via the hepatic artery were measured by means of the multiple-indicator dilution technique. The following results were obtained. (i) Fructose was metabolized to glucose, lactate and pyruvate even when this substrate was infused via the hepatic artery in retrograde perfusion; oxygen consumption was also increased. (ii) When referred to the water spaces accessible to fructose via the hepatic artery in each perfusion mode, the rate of glycolysis was 0.99 +/- 0.14 mumols min-1 ml-1 in the retrograde mode; and, 2.05 +/- 0.19 mumols min-1 ml-1 in the anterograde mode (P = 0.002). (iii) The extra oxygen uptake due to fructose infusion via the hepatic artery was 1.09 +/- 0.16 mumols min-1 ml-1 in the retrograde mode; and, 0.51 +/- 0.08 mumols min-1 ml-1 in the anterograde mode (P = 0.005). (iv) Glucose production from fructose via the hepatic artery was 2.18 +/- 0.18 mumols min-1 ml-1 in the retrograde mode; and, 1.83 +/- 0.16 mumols min-1 ml-1 in the anterograde mode (P = 0.18). (v) Glucose production and extra oxygen uptake due to fructose infusion did not correlate by a single factor in all perfusion modes. It was concluded that: (a) rates of glycolysis are lower in the periportal area, confirming previous views; (b) extra oxygen uptake due to fructose infusion is higher in the periportal area; (c) a predominance of glucose production in the periportal area could not be demonstrated; and (d) extra oxygen uptake due to fructose infusion is not a precise indicator for glucose synthesis.     

Leadless pacemaker implantation for pediatric patients through internal jugular vein approach: A case series of under 30 kg

BackgroundWe demonstrate a case series of 8 pediatric patients, all under 30 kg, who had leadless pacemaker implants via the internal jugular vein.MethodsA retrospective review of pediatric leadless pacing placement via the internal jugular vein at the University of Minnesota Masonic Children's Hospital and UC Davis Medical Center from 2018 through 2021 was performed. Rationales for pacing, demographics of patients, pacing thresholds, and longevity of devices were recorded.ResultsEight internal jugular pacemaker insertions were performed successfully in patients weighing between 10.9 kg and 29 kg. Five patients had Micra implantation via the right internal jugular vein, whereas 3 patients had insertion via the left internal jugular vein. No surgical cut-downs were performed. No venous complications occurred. Up to 3 years of follow-up were noted.ConclusionLeadless pacemaker implantation, via left or right internal jugular veins, is feasible without surgical cutdown in patients <30 kg     

肝硬化患者肝脏门静脉血流与肝叶萎缩之间关系的研究

目的：探讨肝硬化患者肝脏右叶、左叶体积变化,检测肝硬化患者门静脉血流情况,分析二者之间的关系,以及门静脉血流与肝功能之间关系。方法：本研究纳入54例肝硬化患者和40例正常人,采用超声多普勒方法分析这些受试者的肝脏体积和门静脉主干及左右分支的内径、血流速、流量数据,并通过静脉血检测白蛋白、胆红素、胆碱酯酶水平等评估患者肝功能水平。结果：肝硬化组平均年龄46.3岁,男性32例,其中childA级患者16例,childB级患者27例,childC级患者11例;正常对照组平均年龄41．8岁,男性24例。肝硬化组患者右左肝叶之比明显低于正常对照组（p〈0．05）,门静脉内径和血流量明显高于正常对照组（p〈0．05）．随着child分级升高,门静脉血流量也明显升高。肝硬化组门静脉右支血流量明显低于左支血流量（p〈0．05）;此外肝硬化患者门静脉右支和左支血流量之比明显低于正常人群门静脉右左支之比（p〈0．05）;而且肝硬化患者门静脉右左支血流量之比与右左肝叶具有明显的相关性与右左肝叶之比具有明显的相关性（r=0．64,p〈0．05）。结论：评估肝硬化病人门静脉血流情况,对于判断肝脏病理变化程度,评价治疗效果,以及选择治疗方案方面都具有重要的临床价值     

Hepatic heterogeneity in the response to ATP studied in the bivascularly perfused rat liver

The zonation of the purinergic action of ATP in the hepatic parenchyma was investigated in the bivascularly perfused rat liver by means of anterograde and retrograde perfusion. Livers from fed rats were used, and ATP was infused according to four different experimental protocols: (A) anterograde perfusion and ATP infusion via the portal vein; (B) anterograde perfusion and ATP via the hepatic artery; (C) retrograde perfusion and ATP via the hepatic vein; (D) retrograde perfusion and ATP via the hepatic artery. The following metabolic parameters were measured: glucose release, lactate production and oxygen consumption. The hemodynamic effects were evaluated by measuring the sinusoidal mean transit times by means of the indicator-dilution technique. ATP was infused during 20 min at four different rates (between 0.06-0.77 µmol min_-1 g liver_-1; 20-200 µM) in each of the four experimental protocols.The results that were obtained allow several conclusions with respect to the localization of the effects of ATP along the hepatic acini: (1) In retrograde perfusion the sinusoidal mean transit times were approximately twice those observed in anterograde perfusion. ATP increased the sinusoidal mean transit times only in retrograde perfusion (protocols C and D). The effect was more pronounced with protocol D. These results allow the conclusion that the responsive vasoconstrictive elements are localized in a pre-sinusoidal region; (2) All hepatic cells, periportal as well as perivenous, were able to metabolize ATP, so that concentration gradients were generated with all experimental protocols. Extraction of ATP was more pronounced in retrograde perfusion, an observation that can be attributed, partly at least, to the longer sinusoidal transit times. In anterograde perfusion, the extraction of ATP was time-dependent, a phenomenon that cannot be satisfactorily explained with the available data; (3) ATP produced a transient initial inhibition of oxygen uptake when protocols A and B were employed. These protocols are the only ones in which the cells situated shortly after the intrasinusoidal confluence of the portal vein and the hepatic artery were effectively supplied with ATP. The decrease in oxygen consumption was more pronounced at low ATP infusions when protocol B was employed. These observations allow the conclusion that the former phenomenon is localized mainly in cells situated shortly after the intrasinusoidal confluence of the portal vein and hepatic artery. Oxygen consumption in all other cells, especially the proximal periportal ones, is increased by ATP; (4) In agreement with previous data found in the literature, glycogenolysis stimulation by ATP was more pronounced in the periportal region. The cells that respond more intensively are not the proximal periportal ones, but those situated in the region of the intrasinusoidal confluence of the portal vein and the hepatic artery.     

Mitral re-repair and right coronary fistula closure: advantage of minimally invasive approach

A 51-year-old man developed severe mitral regurgitation 10 years after previous mitral valve repair; the echocardiographic images showed a remarkable eccentric jet toward posterior wall of left atrium associated with a high degree of pulmonary vein retrograde flow. The coronary arteriography pointed out no pathologic lesions but a coronary fistula from the proximal right coronary to the right atrium. The standard approach was avoided, and a right anterolateral minithoracotomy was chosen, providing an excellent view. Under cardiopulmonary bypass and mild hypothermia, the mitral valve was re-repaired, and a new ring was implanted. After aortic cross-clamp release, the right coronary fistula was closed through the right atrium. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. In such a high-risk reintervention and concomitant procedure, we think that this different approach may represent a feasible and reliable alternative.     

半肝及肝三叶切除25 例临床分析

目的:探讨半肝及肝三叶切除术在临床应用的安全性和可行性。方法:2005年6月至2008年6月,我们实施半肝切除19例,肝三叶切除6例。其中左半肝切除8例,右半肝切除11例,巨大肝癌20例,巨大肝血管瘤4例,肝包虫病1例。结果:全组术中无死亡,术后发生明显并发症6例,其中腹水3例,胸腔积液2例,胆瘘1例。肝癌患者中术后生存超过12个月19例(95%),24个月13例(65%),36个月7例(35%)。结论:掌握手术指征和手术技巧,并作好围手术期处理,半肝及肝三叶切除术是安全、有效的。     

Klatskin tumor--results of surgical therapy

Between January 1st 1990 and December 31st 1999, 24 patients affected by Klatskin tumor underwent operation in our department of surgery. According to Bismuth's classification, there were 0 (0%) type I, 5 (21%) type II, 6 (25%) type IIIa, 4 (17%) type IIIb and 9 (37%) type IV tumors. Five patients (21%) were treated by curative resection (group I) while in 14 patients (58%) palliative surgical procedure was performed (group II). In 5 cases (21%) the extension of malignancy did not allowed any procedure (group III). Curative resection for malignant tumors of the hepatic duct bifurcation included wide tumor excision and bile duct resection at the liver hilum (with wedge hepatic resection in one patient) and creation of biliary-enteric anastomosis. Palliative surgical procedure included stent insertion. Jaundice was completely relieved in all patients undergoing resection, since 3 patients (21%) after stenting hadn't satisfactory biliary drainage. There was 1 (20%) perioperative death in the group 1, while in group 2, 5 patients (36%) died postoperatively. In this series, the mean postoperative survival of all patients was 16 months. The mean postoperative survival of patients undergoing localized tumor resection with curative intent was 38 months, in contrast to 10 months for those undergoing operative stent insertion. in addition, only 1 patient from group III, in whom only exploratory surgery were performed survived 7 months, while other 4 patients died in the hospital. This retrospective review suggests that aggressive surgical treatment could improve survival and quality of life in patients suffering from Klatskin tumor.     

Contribution of erythrocytes and plasma in threonine and lysine transfer across the portal drained viscera and the liver in pigs. Effect of threonine and lysine dietary supply

Contributions of erythrocytes and plasma to threonine and lysine transport across the PDV and the liver were determined in growing pigs successively fed a threonine deficient diet and a control well-balanced diet (experiment 1) or a lysine deficient or a well-balanced diet (experiment 2). The animals were surgically prepared for insertion of chronic catheters in the mesenteric vein (MV), the portal vein (PV), a hepatic vein (HV) and the carotid artery (CA). Plasma and whole blood AA concentrations in PV, HV and CA and PV and HV blood flows were determined during 6 hours of para-aminohippuric acid constant infusion. During this period the pigs were continuously fed (1 meal per hour). The contribution of plasma to lysine and threonine transport was higher in pigs fed the well balanced diets. More than 50% of threonine and lysine appearing in the PV and in the HV are transported by the plasma. Our results suggest that erythrocytes are probably little involved in lysine and threonine transfer across the liver and digestive tract of pig continuously fed.     

Hepatoportography via the Umbilical Vein: A Superior Approach to Diagnosis in Liver Disease

The umbilical vein in adults is patent but collapsed. There is a membranous valve at its entrance into the left portal vein. Cannulation of the portal vein via the umbilical vein permits direct access to the portal system for portography and hepatography. This procedure was performed under local or general anesthesia in 30 patients and was successful in 22. It is useful in the investigation of patients with portal hypertension, and suspected intrahepatic tumours or abscesses. It gives excellent contrast visualization of the liver and definition of lesions as small as 1.0 cm. This technique is superior to both hepatic scanning and splenoportography.     

Hemodynamic evaluation of the right portal vein in healthy dogs of different body weights

Background  

Doppler ultrasonography is an important tool for evaluating hepatic portal hemodynamics. However, no study in dogs of different body weights, in the range encountered in routine clinical veterinary practice, has been reported. It can be difficult to obtain an ideal insonation angle when evaluating the main portal vein, so evaluation of the right portal vein branch has been described in humans as an alternative. The aim of this study was to analyze, through Doppler ultrasonography, the hemodynamics in the right portal vein branch in dogs of different body weights.     

Dependence of the topography of the hepatic veins on the external shape of the liver, its size and on age

Hepatic preparations obtained from 186 newborns, children and mature persons have been studied. In newborns and babies the size of the right and left hepatic lobes are nearly the same. Beginning from an early age, the right hepatic lobe begins to grow, and the oblongatal or oval form of the liver changes into a triangle one. With changes in its size and form, the topography of the hepatic veins changes, too. In children younger than 1 year of age having the oblongatal or oval form of their liver, the diameters of the right, middle and left hepatic veins are nearly equal. In mature persons having the triangle form of the liver, the right hepatic vein is the largest and its diameter is twice as large as that of the left hepatic vein. Additional hepatic veins flowing into the inferior vena cava, are mainly formed by the branches participating in drainage of the right hepatic lobe. In 25 cases there are additional large hepatic veins; they are observed in cases when the right hepatic vein is poorly developed.     

Rhythmic contractility in the hepatic portal “corkscrew” vein of the rat snake

Terrestrial, but not aquatic, species of snakes have hepatic portal veins with a corkscrew morphology immediately posterior of the liver. Relatively large volumes of venous blood are associated with this region, and the corkscrew vein has been proposed to function as a bidirectional valve that impedes gravitational shifts of intravascular volume. To better understand the functional significance of the corkscrew anatomy, we investigated the histology and contractile mechanisms in isolated corkscrew segments of the hepatic portal vein of a yellow rat snake (Pantherophis obsoletus). Morphologically, the corkscrew portal vein is here shown to have two distinct layers of smooth muscle – an inner circular layer, and an outer longitudinal layer, separated by a layer of collagen, – whereas only a single circular layer of smooth muscle is present in the adjacent posterior caval vein. Low frequency (~ 0.3 cycles*min^? 1) spontaneous and catecholamine-induced rhythms were observed in 11% and 89% of portal vein segments, respectively, but neither spontaneous nor agonist-induced cycling was observed in adjacent posterior (non-corkscrew) caval veins. Catecholamines, angiotensin II, or stretch increased the amplitude and/or frequency of contractile cycles. Ouabain, verapamil or indomethacin, but not tetrodotoxin, α-, or ß-adrenergic receptor antagonists, inhibited cyclical contractions indicating a dependence of these cycles on Na⁺/K⁺ ATPase, extracellular Ca²⁺ and prostanoid(s). These data suggest that the rhythmic contractility of the corkscrew segment of the ophidian portal vein may act in conjunction with its morphological features to improve venous return and to prevent retrograde shifts of blood that might otherwise pool in posterior veins.     

A causal analysis of intra-abdominal hemorrhage after reduced-size liver transplantation in rat

In this study, we analyzed causes of abdominal hemorrhage after reduced-size liver transplantation in rat. Healthy SD rats (weight range of 260–280 g) underwent liver transplantation, the donors were female and the recipients were male rats. The recipients were, on average, by <10 g heavier than the donors. All operations on donor rats were performed by the same person using unaided eyesight. Operations on recipient rats were performed by two persons using unaided eyesight. About 270 rats received reduced-size liver transplantation of which 44 died because of intra-abdominal hemorrhages. The distribution of abdominal hemorrhage sites was as follows: 28 cases with anastomotic hemorrhages of the inferior vena cava of the superior liver, 9 cases with subcapsular hemorrhage, 9 cases with tied hemorrhages from the left lateral lobe, 7 cases with hemorrhages from the papillary lobe, 7 hemorrhages from the triangular lobe, 5 hemorrhages of the right suprarenal vein and lumbar veins, 4 hemorrhages caused by mechanical injury, 4 cuff hemorrhages of the portal vein and the inferior vein cava of the inferior liver, 8 anastomotic hemorrhages of the inferior vena cava of the superior liver and the tied hemorrhage of the left outboard lobe, and 5 hemorrhages of the two tied points of the reduced-size liver. Ten hemorrhages were stopped by suture or/and ligature, and 6 were stopped by washing with or soaking in hot water. Results of this study will be helpful to raise success rates of reduced-size liver transplantation.