Biliary complications in 106 consecutive duct-to-duct biliary reconstruction in right-lobe living donor liver transplantation performed in 1 year in a single center: a new surgical technique.

OBJECTIVE: Biliary complications remain a major source of morbidity after living donor liver transplantation (LDLT). Of 109 consecutive right lobe (RL)-LDLTs performed in 1 year in our institution, we present the biliary complications among 106 patients who underwent a new duct-to-duct anastomosis technique known as University of Inonu. METHODS: Of 153 liver transplantations performed in 1 year from January to December of 2008, 128 were LDLTs including 109 RL-LDLTs. The others were left or left lateral grafts. All RL-LDLT patients were adults, all of whom except three included a duct-to-duct anastomosis. RESULTS: All, but three, biliary reconstructions were completed with a surgical technique, so called UI, in which 6-0 prolene sutures were used. Nine bile leaks were seen in 106 recipients (8.49%) performed in a duct-to-duct fashion in a time period of 1 to 4 weeks. Seventeen patients (16.03%) posed bile duct stricture (BDS). Five patients had both. Although endoscopic stent placement and percutaneous balloon dilatation, 4 patients continued to suffer from BDS on whom a permanent access hepatico-jejunostomy (PAHJ) procedures were performed. CONCLUSION: We recommend a duct-to-duct biliary reconstruction because of its de facto advantages over other types of anastomosis provided the native duct is not diseased. After almost 2 years, the bile tract complication rate was 22.64%.

Surgical treatment of phytobezoars causes acute small intestinal obstruction.

PURPOSE: Our aim was to perform a clinical analysis of small intestinal obstructions caused by surgically treated phytobezoars. METHODS: Twenty-four patients, with small intestinal obstructions caused by phytobezoars, underwent surgery in our department between 1998 to 2008, were reviewed retrospectively. RESULTS: Twenty (83.3%) of 24 patients had previous gastric surgery. Preoperative computed tomography (CT) was performed in nine patients and seven (77.8%) patients, showed results consistent with a bezoar and subsequently, underwent surgery on the same day. The remaining patients had no preoperative diagnosis of a phytobezoar were typically followed-up for postoperative adhesion intestinal obstruction. Only those patients who showed no response to nonoperative treatment options underwent surgery. The phytobezoar was fragmented and milked into the cecum in 11 (45.8%) patients or extracted via longitudinal enterotomy in 12 (50%) patients; the remaining patient (4.2%) was treated via laparoscopy. Three patients had gastric phytobezoars, which were extracted via gastrotomy. There was no postoperative mortality. Two patients with previous enterotomy had either postoperative wound infection or wound infection and evisceration. CONCLUSIONS: Phytobezoars should be considered in the differential diagnosis of acute small intestinal obstruction in patients with prior gastric surgery, poor dentition, or consume fiber-rich foods. Abdominal CT is useful for both diagnosis and for the decision to perform emergency surgery. When possible, the phytobezoar should be fragmented and milked into the cecum. Laparoscopic fragmentation may be useful in such cases (Tab. 3, Ref. 28). Full Text (Free, PDF) www.bmj.sk.

Expression of matrix metalloproteinases 2 and 9 in donor liver, cirrhotic liver, and acute rejection after human liver transplantation.

Matrix proteinases are known to play an important role in the cell migration during cancer invasion, in organ development, and in tissue damage during inflammatory process. Among the matrix proteinases, matrix metalloproteinases (MMP) are the most powerful proteinases. Changes at the extracellular matrix components play an essential role in acute rejection after orthotopic liver transplantation (OLT). This prospective clinical study investigated the alterations in the expression of MMP-2 (72-kd gelatinase type IV collagenase [gelatinase A]) and MMP-9 (92-kd gelatinase type IV collagenase [gelatinase B]) in patients with acute cellular rejection (ACR) compared with the biopsies of cirrhotic livers (CL) of patients who underwent OLT, and with healthy livers (HL) of the donors. Although MMP-2 expression was not present in the hepatocytes of the HL, it was in the endothelium; it was moderate in CL and severe in the livers suffering from ACR. MMP-9 expression, on the other hand, is found to be present only in the inflammatory cells, with an increasing intensity in HL, CL, and in livers suffering from ACR. The results suggest that MMP-2 and MMP-9, beside their roles in liver injury with tissue remodeling and fibrosis as mentioned in the previous studies, can be a marker of acute rejection.

Effect of resveratrol and melatonin on oxidative stress enzymes, regeneration, and hepatocyte ultrastructure in rats subjected to 70% partial hepatectomy.

AIM: We sought to compare the antioxidant effects of resveratrol (R) and melatonin (M) after 70% partial hepatectomy (PH) as evidenced by ultrastructural alterations and effects on hepatocyte proliferation and apoptosis. METHODS: Twenty-six male Wistar albino rats were randomized into four groups: group A (n = 8) resveratrol (R); group B (n = 8) melatonin (M); group C (n = 5) control PH; group D (n = 5) sham operated animals. The rats that received either R or M were sacrificed a week after PH. The malondialdehyde, glutathione, glutathione S-transferase, and nitric oxide levels were estimated in liver homogenates. The morphological changes were investigated using light and electron microscopy (EM). Cell proliferation was detected by immunohistochemical staining with monoclonal antibodies to Ki-67. Apoptosis was detected by the transferase-mediated dUTP nick end-labeling method. RESULTS: PH induced hepatic LP, decreased GSH and NO, and inhibited GST activity (P < .05). R and M completely prevented PH-induced lipid peroxidation, decreased hepatic GSH and NO levels (P < .05). The inhibition of GST activity was prevented by R (P < .05), but not with M (P > .05). In the PH group EM showed severe morphological changes: mitochondrial degeneration, vacuoles, lipid droplets, and myelin-like figures. In both the R and M groups, morphological alterations repaired protective effects more prominently in the R group. Ki-67 indices (KI) were increased in the PH group and decreased in both R and M groups (P < .001). In the M group, KI was the lowest, but the difference compared with R was not significant (P > .05). Apoptosis was slightly increased in PH, but in either the R or M groups, apoptosis was intensively increased (P < .001). Increased apoptosis was greatest in the M group and the difference compared with the R group was statistically significant (P < .05). CONCLUSION: R and M suppressed PH-induced oxidative damage, attenuated proliferation, and stimulated apoptosis. When we compared R and M, R showed more potent antioxidative effects and was morphologically more protective to hepatocytes. Antiproliferative effects of M were more potent. Because of their potent antioxidative effects, R and M can be effective for oxidative damage like ischemia-reperfusion injury; however, because of the adverse effects on proliferation and apoptosis more studies are needed in states in which regeneration is critical.

Protective effect of resveratrol, a red wine constituent polyphenol, on rats subjected to portal vein thrombosis.

This experimental study investigated the prophylactic effects of the antioxidant and antiaggregant compound resveratrol (R) on portal vein thrombosis (PVT) in rats. Thirty rats weighing 200- 250 g were distributed in 3 groups: Group A (n = 10) and underwent PVT+R, Group B (n = 10) PVT alone, and Group C (n = 10) were subjected to a sham operation. Group A rats received R (60 mg/d per naso-gastric tube) for 10 days before PVT. Concerning antioxidant status, statistically significant increases in both tissue and plasma levels of reduced glutathione (GSH) and decrease in malondialdehyde (MDA) levels were observed in the PVT+R group compared with the PVT group (P < .001 for all). Comparison of these parameters with those of the sham group revealed significantly higher tissue and plasma levels of GSH and low MDA levels among the sham-operated group when compared with to the PVT+R or PVT groups (P < .001 for all). Concerning the antiaggregant status, significant increases of c-AMP levels were detected in rats treated with R before experiencing PVT (P < .001). Cyclic AMP levels in the sham group were significantly higher than those of either the PVT or PVT+R groups (P < .001). One may advise patients undergoing liver transplantation and carrying certain cardiovascular disease risk factors to ingest foods containing R to minimize PVT.

Effect of resveratrol on oxidative stress enzymes in rats subjected to 70% partial hepatectomy.

This experimental study investigated the antioxidant status of rats after resveratrol (R) treatment following 70% partial hepatectomy. Thirty Wistar albino rats (200 to 250 g) were divided among: groups A and B (n = 10 each) underwent laparotomy and 70% partial hepatectomy (PH). Whereas rats in group A received resveratrol 60 mg/d per nasogastric tube for 7 days before and 3 days after PH (PH + R), those in group B underwent PH only. Rats in group C (n = 10) were subjected to a sham operation. Significant increases in tissue levels of reduced glutathione (GSH) and decreased malondialdehyde (MDA) levels were observed in the PH group receiving R compared with those of the PH group (P < .001 for all). Comparison of these parameters with those of the sham group revealed significantly higher tissue levels of GSH and lower MDA levels among sham-operated compared with PH + R and PH groups (P < .001 for all). Concerning the NO levels, a trend to a slightly decrease was observed in the PH + R group (P < .06). Interleukin-6 levels showed significant decreases in both PH + R and PH groups (P < .001 and P < .05, respectively). The tissue GSH levels were slightly decreased in PH + R (P < .05), and decreased in the PH group compared with the controls (P = .002). We have suggested that patients undergoing living donor liver transplantation would likely benefit from prophylactic treatment with foods having resveratrol.

Partial hepatectomy is curative for the localized type of Caroli's disease: a case report and review of the literature.

The case of a 58-year-old woman who was diagnosed with the localized type of Caroli's disease is presented. This disease involves the whole of the left half of the liver. A left hepatectomy was followed by complete resolution of symptoms. The current article suggests that hepatic resection may be aggressively performed in selected patients with the localized form of Caroli's disease.

Protective effects of resveratrol on spleen and ileum in rats subjected to ischemia-reperfusion.

Resveratrol is as an antioxidant with free radical-scavenging activity and finds its clinical application in the prevention of postischemic tissue injury following solid organ transplantation. This study investigates the effect of Resveratrol on spleen and ileum tissues subjected to hepatic ischemia-reperfusion (I/R) in rats. Twenty-four rats were recruited in the study as follows: group A: I/R (n = 8), group B: I/R + Resveratrol (n = 8), and group C: sham operation (n = 8). After intraperitonealy pretreatment of eight rats with resveratrol (15 mg/kg/d) for 5 days, 16 rats were subjected to 45 minutes of hepatic ischemia followed by 30 minutes reperfusion period. Resveratrol was given 15 minutes prior to ischemia and just before the reperfusion in rats. After reperfusion period all rats were sacrificed. Spleen and ileum tissues were examined spectrophotometrically to measure malondialdehyde (MDA), glutathione (GSH), and total nitrite, nitrate as an end product of nitric oxide (NO) levels. Concerning the spleen, statistically significant decrease of GSH and increase of MDA and NO levels were found group A when compared to groups B and C (P = .040, P = .004, and P = .001 group A vs group B; P = .05, P = .003, and P = .001 group A vs group C, respectively). Parallel results were obtained in ileum. A statistically significant decrease in GSH and an increase in MDA and NO levels in group A in respect to group B and group C was obtained (P = .048, P = .034, and P = .001 group A vs group B; P = .004, P = .001, and P = .003 group A vs group C, respectively). The result of this study shows that resveratrol has a protective effect on spleen and ileal mitochondrial oxidative stress in rats subjected to I/R.

Effect of steroid on mitochondrial oxidative stress enzymes, intestinal microflora, and bacterial translocation in rats subjected to temporary liver inflow occlusion.

Protective effects of steroids against ischemia-reperfusion (I/R) injury are well known, but there is little information about the influence of temporary inflow occlusion on intestinal barrier function or bacterial translocation. The aim of this experimental study was to investigate the effects on liver, kidney, spleen, ileal mitochondrial stress enzymes, and bacterial translocation of methylprednisolone (MP) in rats undergoing temporary liver inflow occlusion. Twenty-seven pathogen-free Wistar albino rats were randomized into three groups: group A: I/R (n = 10); group B: I/R + MP (n = 10); and group C: sham (n = 7). Rats in groups A and B were subjected to 20 minutes of portal vein and hepatic artery occlusion with 3 mg/kg MP injected into group B animals intraperitoneally during the occlusion. Twenty-two hours later, all rats were sacrificed to measure mitochondrial oxidative stress enzymes in liver, kidney, spleen, and ileum. We evaluated intestinal bacterial counts, intestinal mucosal histopathology, bacterial translocation to mesenteric lymph nodes (MLN), liver, spleen, and kidney. Decreased levels of malondialdehyde and increased levels of glutathione were observed in all examined tissues of group B compared to those of group A rats. Statistically significant increases in the intestinal counts of Klebsiella spp and Proteus spp and of bacterial translocation to liver, kidney, spleen, and MLN were measured in group B with respect to group A.

Effect of fish oil, olive oil, and vitamin E on liver pathology, cell proliferation, and antioxidant defense system in rats subjected to partial hepatectomy.

The high capacity of liver regeneration after partial hepatectomy (PH) is well known. This study investigated the role of the antioxidant defense system in regeneration among Wistar-albino male rats subjected to 70% partial hepatectomy after a pretreatment period of 2 weeks with eicosapentanoic acid (EPA) rich fish oil (FO), first pressed virgin olive oil (OO), or vitamin E. The control group of 10 rats underwent PH only. On postoperative day 3, all rats were humanely killed. Liver sections of animals treated with FO or vitamin E showed significant increases in regeneration within both liver parenchyma and cut surface compared with the control group (P < .05). Liver sections of OO displayed an insignificant increase in liver regeneration (P > .05), with less increase in parenchyma than of the cut surface. The enhancement of the liver parenchymal regeneration in the FO group was significantly greater than that of the vitamin E group. Concerning liver function tests (LFT), there was no significant difference among the groups. When the treatment groups were compared to the control group glutathione (GSH) levels were increased and content of malondialdehyde (MDA), nitric oxide (NO), and superoxide dismutase (SOD) were decreased. Based on these results, we concluded that after 70% PH in rats, the liver parenchyma and cut surface regeneration were greatest with FO and least with OO treatment. Both FO and vitamin E served to improve the antioxidant defense system more than OO treatment.

Effects of nucleoside analogues on liver regeneration 70% partially hepatectomized rats.

The alternatives for prophlaxis and treatment of recurrent hepatitis B virus infection have increased since new oral nucleoside analogues have become available. We conducted this experimental study to investigate the effect in the liver of these agents on the expression of transforming growth factor alpha (TGF-alpha) and on proliferation index, estimated by Ki-67. Thirty male Wistar albino rats were randomized into three groups: group A (n = 10) received adefovir dipivoxil (40 mg/kg/d per gavage); group B (n = 10), lamivudine (L; 30 mg/kg/d per gavage); and group C (n = 10) did not receive any treatment and were the control group. Groups A and B were treated for 3 days. Animal treatment began on day -1. After performing 70% partial hepatectomy on day 0, all rats were sacrificed on postoperative day 2 to harvest liver tissues for histopathological examination. We stained and indexed Ki-67 and TGF-alpha immunohistochemically on the hepatectomy surface and in the parenchyma, Ki-67 and TGF-alpha indices were significantly higher in group A compared with group B (P = .001 and P = .004, respectively, and P = .003 and P = .001, respectively). When the L group was compared with the control group for results on the hepatectomy surface and the parenchyma, Ki-67 and TGF-alpha indexes were insignificantly different (P = .6 and P = .3, respectively, and P = .1 and P = .6, respectively). Based on the results of this experimental study, we concluded that Adefovir dipivoxil has greater proliferative effect on liver parenchyma and in the cut surface than does lamivudine.

Liver pathology and cell proliferation after calcineurin inhibitors and antiproliferative drugs following partial hepatectomy in rats.

Immunosuppressants are the cornerstones of treatment after solid organ transplantation. This study investigated the pathology and cell proliferation following partial hepatectomy (PH) in rats undergoing immunosuppressive treatment. After 1 day, all rats were subjected to 70% PH. Groups A and B (n = 10) received calcineurin inhibitors subcutaneously: either FK506 or cyclosporine (CyA). Groups C and D (n = 10) received antiproliferative drugs: either mycophenolate mofetil (MMF) or sirolimus (SRL) by gavage. A control group (n = 5) received 1 mL of tap water daily. On postoperative day 2, all rats were sacrificed to obtain liver tissue for pathologic examination. Using immunohistochemistry we separately examined the hepatectomy surface and the liver parenchyma. In the parenchyma, the Ki-67 indices were higher in the CyA and FK506 groups and lower in the SRL and MMF groups compared with controls (P < .01). CyA had the highest and MMF the lowest values. On the hepatectomy surface, Ki-67 indices and TGF-alpha expressions were higher in the CyA group and lower in the SRL and MMF groups compared with the control group (P < .01). Slightly higher values in the FK506 group were not significantly different compared with the control group (P > .05). All groups other than FK506 showed prominent cholangiolar epithelial phenotypes compared with the control group. In the CyA and SRL groups, the number of cholangiolar cells was higher (P < .01), and in the MMF group lower than in the control group (P < .01). Among all groups, SRL had the highest values.

Maxillary brown tumor and uremic leontiasis ossea in a patient with chronic renal insufficiency.

Findings of renal osteodystrophy in cranial bones are not uncommon and include osteomalacia, osteosclerosis, erosion of the cortical bone, brown tumors and resorption of the lamina dura. However, massive thickening of the cranial vault and facial bones, called uremic leontiasis ossea, have been reported very rare. In the present article, we describe the case of an uncooperative female patient with a brown tumor, involving the left maxillary sinus and massive thickening of the cranial vault and facial bones, secondary to severe secondary hyperparathyroidism during 8 years of regular hemodialysis treatment.

Hypertonic saline in hydatid disease.

The objective of this study was to determine the scolicidal effects of saline in different concentrations using different exposure times and to examine whether hypertonic saline can be used to irrigate the abdomen when there is a free intraperitoneal perforation of hydatid disease. Various concentrations of saline solutions (0.09%, 3.0%, 6.5%, 10%, 15%, 20%, 25%, 30%) were added to concentrated echinococcus granulosus sediments for the following times: 1, 2, 3, 4, 5, 10, 15, 30, 45, and 60 minutes. Normal (0.09%), 3.0%, and 6.5% saline resulted in high viability ratios after 60 minutes' exposure. Complete lethality for 10%, 15%, 20%, 25%, and 30% saline occurred at the end of 75, 10, 6, 3, and 3 minutes, respectively. During the second part of the study, 20 Sprague-Dawley rats were used for abdominal saline irrigation in four groups: 30% NaCl for 3 minutes; 20% NaCl for 6 minutes; intravenous isotonic dextrose water and furosemide plus 30% NaCl irrigation for 3 minutes; the same prophylactic therapy plus 20% NaCl irrigation for 6 minutes. Sodium and chloride values rose significantly (20-30%) shortly after hypertonic saline irrigation in each group (p < 0.01). Support with isotonic dextrose and furosemide before irrigation did not have any beneficial effect on biochemical values or mortality. The 24- and 48-hour mortality rates were 70% and 90%, respectively. These studies illustrate that the scolicidal effect of hypertonic saline is limited in low concentrations, but an increase in the concentration can augment its adverse effects. Peritoneal irrigation with hypertonic saline should be avoided for intraabdominal perforated hydatid disease. Therefore, we concluded that hypertonic saline is not a good scolicidal agent to prevent recurrence of hydatid disease.

Randomised clinical trial of two bypass operations for unresectable cancer of the pancreatic head.

OBJECTIVE: To compare two different types of prophylactic gastric bypass in patients with cancer of the pancreatic head who were not suitable for curative resection. DESIGN: Prospective study. SETTING: University hospital, Turkey. SUBJECTS: 44 patients with unresectable cancer of the pancreatic head without duodenal obstruction who presented between May 1995 and June 2000 who were randomised into 2 groups. INTERVENTIONS: 22 patients had an antecolic, isoperistaltic gastrojejunostomy, jejunojejunostomy, and hepaticojejunostomy after cholecystectomy. The remaining 22 had a hepaticojejunostomy and antecolic, antiperistaltic gastrojejunostomy procedure after cholecystectomy. MAIN OUTCOME MEASURES: Mortality, morbidity, postoperative course, and survival. RESULTS: There were no significant differences between the groups in the incidence of postoperative complications, time until restoration of oral diet, relaparotomy rate, late upper gastrointestinal bleeding, mortality, duration of hospital stay, and survival. The isoperistaltic operation took significantly longer than the antiperistaltic operation (p < 0.001) and there was less delayed gastric emptying in the antiperistaltic group but not significantly so. Both operations caused a significant lengthening in the postoperative gastric emptying time (p = 0.04 and p = 0.01, respectively). CONCLUSION: Both procedures are suitable for patients with unresectable carcinoma of the pancreatic head without impending duodenal obstruction. There was a trend towards better clinical results with the isoperistaltic procedure.

Palliative decompression of obstructive hilar malignancies utilizing an extrahilar biliary approach.

Hilar cancers carry a dismal prognosis. Palliation of obstructive jaundice in patients with hilar cancer can be achieved by either surgical or nonsurgical means. Selection of the appropriate palliative measures is a challenging problem. Segmental bilioenteric anastomosis procedures were performed on 19 patients with hilar cancer. Seventeen of the bypasses were done to the segment III duct, known as the ligamentum teres approach, and two bypasses were to the segment V duct. Five patients, who had already been stented percutaneously or endoscopically, were operated on after the stents were clogged and a duodenal obstruction ensued. There were two postoperative deaths (10.5%) and four postoperative complications (21%). All of the 17 surviving patients experienced improvement in the level of jaundice postoperatively and the levels of serum total and direct bilirubin decreased by 78.9% and 84.2%, respectively. Two patients developed late cholangitis before death and were treated by external biliary drainage; one developed duodenal obstruction and was treated by gastrointestinal anastomosis. The mean length of hospital stay was 15.2 days. Mean survival was 8.2 months and the mean period of well-being was 7.8 months. Median survival was 7 months and median period of well being was 7 months. Three patients are still alive at 8, 8, and 24 months. These data suggest that the ligamentum teres approach offers effective palliation for patients with unresectable hilar cancer.