Evaluation of serum uric acid changes in different forms of hepatic vascular inflow occlusion in human liver surgeries

Uric acid values in serum have been analyzed as one of the markers to predict cellular damage due to ischemia reperfusion injury in the field of organ transplantation. The present study was conducted to confirm that uric acid values in serum could be an efficient marker of ischemic injury of liver parenchyma following hepatic vascular occlusion in human liver surgery. The changes in serum uric acid values were analyzed at fixed intervals during different liver surgeries. Significant increases in serum uric acid values were observed in patients who received the Pringle's maneuver in which hepatic vascular inflow was manipulated with a repetition of 15 min occlusion and 5 min perfusion, whereas almost no changes in uric acid values were found in both groups of patients who received the hemilobal occlusion of the Glisson's triad in which the right or left vessels were manipulated with a repetition of 30 min occlusion and 5 min perfusion and the "control method" in which the hepatic vessels of the lesion side were previously cut before liver resection. Uric acid values in serum increased in patients of Pringle's maneuver compared to those of the hemilobal occlusion of the Glisson's triad and the control method though these procedures were used in larger hepatectomies rather than Pringle's maneuver. The results indicated that serum uric acid values do not always reflect the severity of ischemia of the liver parenchyma but reflect intestinal congestion because marked intestinal congestion was observed in patients of Pringle's maneuver but not in patients of the hemilobal occlusion of the Glisson's triad and the control method. The evaluation of the severity of the ischemic injury of the liver should be done with caution when uric acid is used as a marker in human liver surgery.     

Effect of hemosorption on the ultrastructure of hepatocytes in toxic liver damage

Extracorporeal perfusion of toxic blood via carbonic sorbents is an effective method for correcting severe disturbances of hemostasis. Ultrastructural alterations in hepatic cells were studied in experimental toxic liver injury before and after hemosorption. It was established that after hemosorption the processes of intracellular regeneration were significantly activated in the liver parenchyma. The number of crysts in the mitochondria increased as did the electronic density of the matrix. At the same time the number of lysosomes rose as well. However, in persistent unresolved cholestasis, destructive alterations in the hepatic tissue progressed despite the performance of hemosorption.     

Effects of citrated whole blood transfusion in response to hemorrhage.

BACKGROUND AND PURPOSE: Standard treatment for massive hemorrhage in dogs is infusion of whole blood or of packed red blood cells with fresh frozen plasma if whole blood is not available. Although most whole blood is collected using a citrate-based anticoagulant, knowledge of citrate's relevant non-anticoagulant effects is not widespread. Citrate's anticoagulant activity is achieved through chelation of divalent metal cations (e.g., magnesium, calcium), which may exacerbate cardiovascular and metabolic insults attributable to hemorrhage. METHODS: Blood pressures, gas tensions, metabolites, and electrolytes; myocardial metabolites, pressures, and contractility; cardiac output; and left cranial descending and circumflex coronary artery flows were measured in 21 anesthetized dogs after hemorrhage was induced by collection of blood into a citrated reservoir to mean arterial pressure of 45 mm Hg for approximately 60 min (until arterial lactate concentration was 7.0 mmol/L), followed by a 1-h transfusion and 2 h of maintenance. RESULTS: Arterial ionized calcium concentration, total peripheral resistance, and myocardial function decreased significantly during hemorrhage. All aforementioned responses but myocardial function continued to decrease during the initial 20 min of transfusion, then began to recover. Total peripheral resistance and end-systolic elastance were the only factors significantly related to calcium concentration. CONCLUSION: Transfusion with citrated whole blood may significantly alter calcium concentration, negatively affecting myocardial and vascular function.     

Development of reformative surgery method using partial freezing for the liver

To minimize surgical stresses including blood loss and operation time to the patients during hepatic resection, we studied the feasibility of a combination of a partial liver freezing technique and shape-memory alloy, which also enables a free-designed resection curve. In this surgical procedure, the region surrounding a tumor in the liver is frozen to excise and prevent hemorrhage. The liver was frozen by a Peltier module. The effects of cooling rate and freezing temperature on the excision force that arise between a scalpel and the liver are carried out experimentally as a basic research for partial freezing surgical procedures. A porcine liver was used as a liver sample. The physical properties were estimated by using the finite element method based on the heat transfer characteristics of the liver. Isolation of the liver was conducted using a scalpel attached to the end-effector of a 3 degrees of freedom robot. In the experiments, the minimum excision force was obtained at a temperature between 272 K and 275 K; therefore, it is preferable that the liver be excised within this temperature range. Lowering of the cooling rate decreases the excision force even if the temperature of the liver remains unchanged. The lower the temperature of the liver is, the larger the increment rate of excision force is with regard to the cooling rate.     

Fibrin glue eliminates the need for packing after complex liver injuries.

Hemostasis after traumatic liver injury can be extremely difficult to obtain, particularly in coagulopathic patients who have suffered extensive liver damage. We determined the ability of a fibrin glue preparation (FG) to terminate ongoing bleeding using a new, clinically relevant porcine model of complex hepatic injury. Anesthetized swine (n = 6, 18 to 19 kg) received an external blast to the right upper abdomen and were immediately anticoagulated with intravenous heparin (200 u/kg). Uncontrolled hemorrhage from blast continued from time of injury (t = 0 minutes) to t = 15 minutes. Lactated Ringer's solution was infused to keep mean arterial pressure (MAP) > 80 mm Hg until the end of experiment (t = 90 minutes). Animals underwent routine surgical techniques to control bleeding, and FG was employed in the event these measures failed. Estimated blood loss and fluid resuscitation volume were measured. Serial MAP, arterial base excess, and temperature were recorded. Animals were severely injured with significant blood loss prior to laparotomy (26 +/- 6 cc/kg) and during routine surgical efforts to arrest hemorrhage (11 +/- 2 cc/kg). Bleeding could not be controlled with standard techniques in any animal. FG rapidly controlled hemorrhage and eliminated the need for packing. Re-bleeding was noted in only one animal (portal vein injury). FG can control severe hepatic hemorrhage when surgical techniques fail. Further work in the clinical arena is warranted to determine the potential benefits of FG in arresting hemorrhage in hemodynamically unstable coagulopathic patients with complex hepatic injuries.     

Selenium,oxygen-derived free radicals,and ischemia-reperfusion injury

Circulatory shock and its treatment have been compared to a whole-body ischemia and reperfusion with activation of oxygen-derived free radicals. A pilot study had suggested a selenium redistribution in this context. To verify this hypothesis, an experimental study was designed. Temporary occlusion of the superior mesenteric artery was performed in 18 male adult Wistar rats using clamping for 0, 10, and 20 min. Hemodynamic and biochemical data were assessed before clamping and 20 min after release of the mesenteric blood flow. After release, mean arterial pressure decreased, plasma lactate increased, and erythrocyte glutathione peroxidase decreased. Plasma and erythrocyte selenium did not change; however, a slight decrease in plasma selenium was observed when related to hematocrit (to take into account the fluid balance). Erythrocyte-reduced glutathione did not change. In contrast, liver and kidney selenium increased, whereas reduced glutathione decreased in kidney, but not in liver after 20 min of clamping as compared to the sham-operated group. These results suggest that, after temporary intestinal ischemia, the changes in selenium and reduced glutathione observed in blood and tissues, like liver or kidney, could be related to a redistribution pattern in selenium metabolism during shock injury.     

Kupffer cell activation after no-flow ischemia versus hemorrhagic shock

Kupffer cell-derived oxidant stress is critical for reperfusion injury after no-flow ischemia. However, the importance of Kupffer cells as source of reactive oxygen formation is unclear in a hemorrhagic shock model. Therefore, we evaluated Kupffer cell activation after 60 or 120 min of hemorrhage and 90 min of resuscitation (HS/RS) in pentobarbital-anesthetized male Fischer rats. Plasma glutathione disulfide (GSSG) as indicator for a vascular oxidant stress showed no significant changes after HS/RS. Plasma ALT activities were only moderately increased (100-200 U/L). Kupffer cells isolated from postischemic livers did not generate more superoxide than cells from sham controls. In contrast, the 10-fold increase of plasma GSSG and the 9-fold higher spontaneous superoxide formation of Kupffer cells after 60 min of hepatic no-flow ischemia followed by 90 min of reperfusion demonstrated the activation of Kupffer cells in this experimental model. Plasma ALT activities (1930 +/- 240 U/L) indicated severe liver injury. These results demonstrate a fundamental difference in the degree of Kupffer cell activation between the two models of warm hepatic ischemia. Our findings suggest that different therapeutic strategies are necessary to ameliorate the initial injury after low flow ischemia (hemorrhage) compared to cold (transplantation) or warm (Pringle maneuver) no-flow ischemia.     

Successful use of recombinant factor Viia in traumatic liver injury--a case report

The paper describe the use of rFVIIa in the management of massive bleeding in a patient with polytrauma involving liver injury. An 18-year-old girl with severe polytrauma sustained during a bus-car collision. She had multiple musculoskeletal injuries, severe concussion of the liver with amputation of the left liver lobe, disruption of the left hepatic vein from the inferior vena cava, and impaired hemostasis. Acute bleeding (> 5 L) was not improved by conservative methods and a single dose of rFVlla 90 pg/kg was administered. Infusion of rFVlla resulted in an immediate clinical effect with rapid improvements in blood laboratory measurements and coagulation parameters. rFVIIa should be considered as an adjunctive treatment for the control of hemorrhage in severely injured patients with uncontrolled bleeding and impaired hemostasis.     

Hypoxia enhances unilateral lung injury by increasing blood flow to the injured lung

We hypothesized that in unilateral lung injury, bilateral hypoxic ventilation would induce vasoconstriction in the normal lung, redirect blood flow to the injured lung, and cause enhanced edema formation. Unilateral left lung injury was induced by intrabronchial instillation of 1.5 ml/kg of 0.1 N HCl. After HCl injury, blood flow to the injured left lung decreased progressively from 0.70 +/- 0.04 to 0.37 +/- 0.05 l/min and percent of flow to the injured left lung (QL/QT) decreased from 37.7 +/- 2.2 to 23.6 +/- 2.2% at 240 min. Exposure to hypoxia (12% O2) for three 10-min episodes did not affect QL/QT in normal animals, but after unilateral HCl injury, it caused blood flow to the injured left lung to increase significantly. A concomitant decrease in blood flow occurred to the noninjured right lung, resulting in a significant increase in QL/QT. The enhanced blood flow to the injured lung was associated with a significant increase in the wet-to-dry lung weight ratio in the dependent regions of the injured lung. These findings demonstrate that in unilateral HCl-induced lung injury, transient hypoxia can enhance blood flow to the areas of injury and increase lung edema formation.     

Neutrophils are not necessary for induction of ischemia-reperfusion lung injury

Ischemia-reperfusion lung injury limits lung transplantation. Neutrophil activation and/or xanthine oxidase-mediated purine degradation may cause toxic oxygen metabolite production and lung injury. We investigated whether circulating blood elements are involved in the pathogenesis of ischemia-reperfusion lung injury. Isolated rat lungs were perfused with physiological salt solution (PSS) stabilized with Ficoll until circulating blood elements were not detected in the lung effluent. Lungs were then rendered ischemic by stopping ventilation and perfusion for 45 min at room temperature. Lung injury occurred and was quantitated by the accumulation of 125I-bovine serum albumin into lung parenchyma and alveolar lavage fluid during reperfusion. Lung injury occurred, in the absence of circulating blood elements, when ischemic lungs were reperfused with PSS-Ficoll solution alone. Reperfusion with whole blood or PSS-Ficoll supplemented with human or rat neutrophils did not increase lung injury. Furthermore, during lung ischemia, the presence of neutrophils did not enhance injury. Experiments using PSS-albumin perfusate and quantitating lung injury by permeability-surface area product yielded similar results. Microvascular pressures were not different and could not account for the results. Toxic O2 metabolites were involved in the injury because addition of erythrocytes or catalase to the perfusate attenuated the injury. Thus reperfusion after lung ischemia causes injury that is dependent on a nonneutrophil source of toxic O2 metabolites.     

Urinary metabolic network analysis in trauma, hemorrhagic shock, and resuscitation

Hemorrhagic shock, often a result of traumatic injury, is a condition of reduced perfusion that results in diminished delivery of oxygen to tissues. The disruption in oxygen delivery induced by both ischemia (diminished oxygen delivery) and reperfusion (restoration of oxygen delivery) has profound consequences for cellular metabolism and the maintenance of homeostasis. The pathophysiologic state associated with traumatic injury and hemorrhagic shock was studied with a scale-invariant metabolic network. Urinary metabolic profiles were constructed from NMR spectra of urine samples collected at set timepoints in a porcine model of hemorrhagic shock that included a pulmonary contusion, a liver crush injury, and a 35 % controlled bleed. The network was constructed from these metabolic profiles. A partial least squares discriminant analysis (PLS-DA) model that discriminates by experimental timepoint was also constructed. Comparisons of the network (functional relationships among metabolites) and PLS-DA model (observable relationships to experimental time course) revealed complementary information. First, ischemia/reperfusion injury and evidence of cell death due to hemorrhage was associated with early resuscitation timepoints. Second, evidence of increased protein catabolism and traumatic injury was associated with late resuscitation timepoints. These results are concordant with generally accepted views of the metabolic progression of shock.     

Detection of antileukoprotease in connective tissue of the lung

An indirect immunofluorescence technique was applied to frozen sections of central and peripheral human lung tissue to search for extracellular localizations of antileukoprotease (ALP). Two monoclonal anti-ALP antibodies recognizing different epitopes and polyclonal anti-ALP antibodies were used. ALP was found to be localized along elastic fibers in alveolar septa, and also along elastic fibers in the walls of bronchi, bronchioles and blood vessels. Serous cells of bronchial submucosal glands showed labelling as well. In frozen sections of liver and spleen no label was found. Cells and elastic fibers were not labelled when lung tissue sections were processed with polyclonal or monoclonal anti-ALP antibodies, that were blocked with purified ALP before the immunostaining. The association of ALP with elastic fibers of human pulmonary connective tissue is of importance in understanding the role of the inhibitor in the defense of the lung parenchyma against the action of proteolytic enzymes, which is thought to result in emphysema.     

Detection of antileukoprotease in connective tissue of the lung

Summary An indirect immunofluorescence technique was applied to frozen sections of central and peripheral human lung tissue to search for extracellular localizations of antileukoprotease (ALP). Two monoclonal anti-ALP antibodies recognizing different epitopes and polyclonal anti-ALP antibodies were used. ALP was found to be localized along elastic fibers in alveolar septa, and also along elastic fibers in the walls of bronchi, bronchioles and blood vessels. Serous cells of bronchial submucosal glands showed labelling as well. In frozen sections of liver and spleen no label was found. Cells and elastic fibers were not labelled when lung tissue sections were processed with polyclonal or monoclonal anti-ALP antibodies, that were blocked with purified ALP before the immunostaining. The association of ALP with elastic fibers of human pulmonary connective tissue is of importance in understanding the role of the inhibitor in the defense of the lung parenchyma against the action of proteolytic enzymes, which is thought to result in emphysema.     

A novel swine model for evaluation of potential intravascular hemostatic agents

Because uncontrolled hemorrhage is a leading cause of battlefield mortality, finding an intravenous treatment that could assist endogenous clotting mechanisms is a major mission for military researchers. Evaluation of potential intravenous hemostatic agents requires both in vitro and in vivo tests. For in vivo evaluation, we have developed a novel swine model in which 1) bleeding times (BT) and coagulation function could be ascertained after multiple doses of hemostatic drug administration and 2) a subsequent exsanguinating injury could be performed in the same animal, yielding screening information regarding the effects of drug pretreatment on blood loss and survival. Transection of small mesenteric arteries and veins allowed for multiple and reproducible BT measures that correlated with coagulation function. Subsequent excision of defined areas of the liver produced bleeding predominantly from small vessels (diameter, less than 2 mm) and parenchyma while resulting in 62% mortality without the use of either heparinization or aggressive fluid infusion. This swine model allows for multiple, repeatable BT measures in the same animal in experiments already involving laparotomy. Such a model is well suited for terminal studies to test effects of multiple doses of the same drug or multiple drugs on BT and allows for multiple, easily visualized measures that permit enhanced repeatability. The liver injury provides for numerous small vessel lesions that could be amenable to closure by coagulation. Therefore, drugs or mechanisms that enhance coagulation and concomitantly decrease blood loss and increase survival time may be accurately evaluated in this new model.     

Experimental hepatic cryosurgery

In 28 dogs, a major portion of a lobe of the liver was frozen, either by contact with a cryoprobe or by spraying liquid nitrogen (?196 °C) over the exposed liver or by pouring liquid nitrogen into a plastic barrel placed on the lobe of the liver, which was wrapped in a Dacron velour cloth. With the probe technique, the amount of tissue that could he frozen was not as great as with direct application of liquid nitrogen to the liver. The spray technique allowed freezing of a larger area but with cracking of the liver substance with considerable mortality from bleeding. With the pour technique, even a larger area of liver could be frozen and bleeding was much less because of the protection afforded by the Dacron cloth. There were no toxic effects from the devitalized liver which was left to be resorbed. These techniques are applicable for treating localized lesions in the liver in humans, but the experiments demonstrate the difficulty of achieving great depth of freezing with any currently available technique of freezing tissue in situ. Clearly, advances in cryosurgical equipment are needed.     

缺血预处理通过激活自噬保护肾缺血-再灌注损伤

目的:探讨缺血预处理对缺血-再灌注所致急性肾损伤的保护作用与可能机制。方法:将健康雄性SD大鼠18只随机分为三组:假手术组(Sham组)、肾缺血组(I/R组)、实验组,Sham组大鼠开腹后游离左侧肾蒂血管,不夹闭,观察60 min关闭腹部。I/R组大鼠开腹后切除右肾,左肾蒂血管分离,观察15 min后用无损伤动脉夹持续夹闭左肾蒂血管45 min后,关闭腹部,恢复左肾血流。实验组开腹后切除切除右肾,左肾蒂血管分离,行4个循环夹闭左肾蒂血管1 min/再灌注4 min预处理后,无损伤动脉持续夹闭45 min,关闭腹部,恢复左肾血流。比较各组大鼠术后尿素氮值(Burea nitrogen,BUN)与肌酐值(Serum creatinine,SCR)水平,肾组织病理学评分及微管相关蛋白轻链3(Microtubule-associated protein l light chain 3,LC3)和自噬基因Beclin-1的表达。结果:所有大鼠在实验过程无死亡。I/R组、实验组再灌注后4 h、24 h的BUN与SCr值显著高于Sham组(P0.05),肾脏组织病理学评分显著高于Sham组(P0.05),实验组以上指标均显著低于I/R组(P0.05);I/R组LC3-Ⅱ/LC3-Ⅰ比值、Beclin-1相对表达量显著高于Sham组(P0.05),实验组以上指标均显著低于I/R组(P0.05)。实验组大鼠再灌注后24h LC3-Ⅱ/LC3-Ⅰ比值、Beclin-1相对表达量与肾组织病理学评分、BUN、SCr值呈显著相关性(P0.05)。结论:缺血预处理可能通过激活自噬,减轻缺血-再灌注所致急性肾损伤,并改善肾功能。     

Role of tracheal and bronchial circulation in respiratory heat exchange

Due to their anatomic configuration, the vessels supplying the central airways may be ideally suited for regulation of respiratory heat loss. We have measured blood flow to the trachea, bronchi, and lung parenchyma in 10 anesthetized supine open-chest dogs. They were hyperventilated (frequency, 40; tidal volume 30-35 ml/kg) for 30 min or 1) warm humidified air, 2) cold (-20 degrees C dry air, and 3) warm humidified air. End-tidal CO2 was kept constant by adding CO2 to the inspired ventilator line. Five minutes before the end of each period of hyperventilation, measurements of vascular pressures (pulmonary arterial, left atrial, and systemic), cardiac output (CO), arterial blood gases, and inspired, expired, and tracheal gas temperatures were made. Then, using a modification of the reference flow technique, 113Sn-, 153Gd-, and 103Ru-labeled microspheres were injected into the left atrium to make separate measurements of airway blood flow at each intervention. After the last measurements had been made, the dogs were killed and the lungs, including the trachea, were excised. Blood flow to the trachea, bronchi, and lung parenchyma was calculated. Results showed that there was no change in parenchymal blood flow, but there was an increase in tracheal and bronchial blood flow in all dogs (P less than 0.01) from 4.48 +/- 0.69 ml/min (0.22 +/- 0.01% CO) during warm air hyperventilation to 7.06 +/- 0.97 ml/min (0.37 +/- 0.05% CO) during cold air hyperventilation.     

Effect of maternal exercise on fetal liver glycogen late in gestation in the rat

To determine the effect of maternal exercise on fetal liver glycogen content, fed and fasted rats that were pregnant for 20.5 or 21.5 days were run on a rodent treadmill for 60 min at 12 m/min with a 0% grade or 16 m/min up a 10% grade. The rats were anesthetized by intravenous injection of pentobarbital sodium, and fetal and maternal liver and plasma samples were collected and frozen. Fetal liver glycogenolysis did not occur as a result of maternal exercise. Fetal blood levels of lactate increased 22-60%, but glucose, plasma glucagon, and insulin were unchanged during maternal exercise. Maternal liver glycogen decreased as a result of exercise in all groups of rats except the fasted 20.5-day-pregnant group. Plasma free fatty acids increased in all groups and blood lactate increased in fed (20.5 days) and fasted (21.5 days) pregnant rats. Maternal glucose, glucagon, and insulin values remained constant during exercise. The fetus appears to be well-protected from metabolic stress during moderate-intensity maternal exercise.     

The hemodynamic consequences of hemorrhage and hypernatremia in two amphibians

1. Graded hypovolemia was induced by hemorrhagic blood loss and graded hypernatremia by salt load in the toad, Bufo marinus, and the bullfrog, Rana catesbeiana. Maximal blood flow rates in the systemic arches and arterial and venous pressures were measured during activity after each stress. 2. Maximal blood flow rates in the B. marinus did not decline until blood loss exceeded 5% of initial body mass. In R. catesbeiana, losses of 2% initial body mass caused a decline (Fig. 1). 3. Maximal heart rates did not change with hemorrhage (Fig. 2). The decline in blood flow rates with hemorrhage was due to declining pulse volumes in both species (Fig. 3). 4. Arteriovenous pressure difference declined with hemorrhage in both species (Fig. 4). Peripheral resistance increased with hemorrhage in parallel with compromised blood flow rates (Fig. 5). 5. Plasma sodium concentration slightly increased with hemorrhage, while plasma protein concentration and hematocrit declined. Lymphatic compensation for hemorrhagic loss is indicated in both species (Fig. 6). 6. Induced hypernatremia compromised blood flow rates in both species at plasma sodium concentrations above 175 mM. The decline in flow rates was principally a result of a decrease in pulse volume, though maximal heart rates also declined (Figs. 2, 3, 7). 7. Induced hypernatremia had no effect on the arteriovenous pressure difference in B. marinus but caused it to decline in R. catesbeiana. Peripheral resistance increased in only B. marinus but not R. catesbeiana (Figs. 4, 5). Hematocrit did not change with salt load, indicative of a constant vascular volume.