Management of Major Injuries to the Bile Duct at a Hepatobiliary Specialty Referral Center.

INTRODUCTION: Aim is to evaluate geographical and demographic factors influencing management of bile duct injuries occurring during cholecystectomy in a tertiary hepato-pancreato-biliary center in Southeast US. METHODS: All referrals for biliary injuries during cholecystectomy, between Jan 2017 and December 2020 were included. RESULTS: 19 patients were identified with a median age of 59 (47-65), average BMI of 30.3 (18-49), and the prevalence of diabetes mellitus, hypertension and cardiovascular disease of 11%, 47% and 16%, respectively. The average transfer distance was 76 miles (8-102) and median transfer time was 3 days (1-12). 16 (84%) had Strasberg E injury, with 4 (21%) having a concomitant vascular injury (3 - right hepatic artery, 1 - right portal vein). Two (10.5%) were managed non-operatively, immediate surgical repair was performed in 2 (10.5%) and 15 (78.9%) patients underwent a delayed repair with a median of 87 days (69-118) from injury to repair. Median operative time was 5 hours (4-7), blood loss was 150 mL (100-200) and hospital stay was 8 days (6-12). DISCUSSION: Factors including distance between hospitals, delays in patient transfer due to bed availability and transportation, play a role in the decision-making towards delayed repair. The delayed repair has the benefit of medical optimization of our high-risk patients' population.

Hydralazine-Induced Fulminant Liver Failure Requiring Urgent Liver Transplant: Common Drug With Rare Complication.

Drug-induced liver injury resulting in fulminant liver failure is a well-known condition, and many drugs have been documented in the literature as possible etiologies. However, hydralazine has seldom been reported as the offending agent. Our case report is about one such rare scenario of fulminant liver failure due to hydralazine use as an antihypertensive. A 65-year-old female patient presented with signs of fulminant liver failure 2 months after starting hydralazine for hypertension. She underwent extensive workup for the cause of acute liver failure. Other possible medications were ruled out, and workup for autoimmune and other etiologies were also negative. The patient underwent a deceased donor liver transplant and has been doing well since then. Her liver was found to be atrophic, with microscopically confirmed drug-induced liver injury. Hydralazine is used orally to treat essential hypertension and intravenously to emergently lower blood pressure. Hydralazineinduced acute liver failure is extremely rare. However, in this rare case where hydralazine-related drug-induced liver injury worsened to the extent of requiring liver transplant, we felt obliged to document and highlight this complication as a form of reminder to our colleagues of this serious outcome.

The role of extracorporeal membrane oxygenation in adult kidney transplant patients: A qualitative systematic review of literature.

BACKGROUND: A paucity of evidence exists regarding the risks and benefits of Extracorporeal Membrane Oxygenation (ECMO) in adult kidney transplantation. METHODS: This was a systematic review conducted from Jan 1, 2000 to April 24, 2020 of adult kidney transplant recipients (pre- or post- transplant) and donors who underwent veno-arterial or veno-venous ECMO cannulation. Death and graft function were the primary outcomes, with complications as secondary outcomes. RESULTS: Twenty-three articles were identified that fit inclusion criteria. 461 donors were placed on ECMO, with an overall recipient 12-month mortality rate of 1.3% and a complication rate of 61.5%, the majority of which was delayed graft function. Fourteen recipients were placed on ECMO intraoperatively or postoperatively, with infection as the most common indication for ECMO. The 90-day mortality rate for recipients on ECMO was 42.9%, with multisystem organ failure and infection as the ubiquitous causes of death. 35.7% of patients experienced rejection within 6 months of decannulation, yet all were successfully treated. CONCLUSIONS: ECMO use in adult kidney transplantation is a useful adjunct. Recipient morbidity and mortality from donors placed on ECMO mirrors that of recipients from standard criteria donors. The morbidity and mortality of recipients placed on ECMO are also similar to other patient populations requiring ECMO.

Radiologic Reporting of Simple Hepatic Cyst Versus Biliary Cystadenoma May Lead to Unnecessary Surgery.

BACKGROUND AND AIMS: Simple liver cyst (SHC) is a benign condition with no malignant potential. They are typically discovered incidentally due to the increased use of abdominal imaging, but some patients may present with abdominal pain. A radiologist's differential diagnosis in cases of SHC will often include "rule out biliary cystadenoma." Under these circumstances, patients and surgeons are more likely to pursue surgical options even in asymptomatic cases. The aim of this study is to conduct a retrospective analysis of presentation, radiologic reporting, management plan, and histopathology of patients referred to a tertiary hospital in order to determine the correlation between radiology and histology. METHODS: We retrospectively analyzed the clinical, radiological, and histopathological data of 20 patients operated for a diagnosis of a cystic lesion in the liver. RESULT: The CT/MRI of 6 (30%) patients was reported as a biliary cystadenoma, 13 (65%) were reported as a simple hepatic cyst and 1 patient (5%) had hepatocellular carcinoma (HCC) with the additional diagnosis of multiple hepatic cysts. The lesion reported as HCC on the scan was separate from the cystic lesions. The modality of imaging for these cysts was evenly split, 50% of patients had a CT scan, and 50% had an MRI performed. All imaging studies were interpreted by an attending radiologist and most of them were discussed in multidisciplinary meetings. Nineteen patients (95%) had an intraoperative diagnosis of a simple liver cyst based on its visual appearance and clear fluid within the cyst. These patients underwent cyst wall fenestration and de-roofing with the cyst wall sent for histopathology. One patient (5%) with HCC underwent a non-anatomical liver resection. Histopathology was conclusive for a benign hepatic cystic lesion from the cyst wall biopsy. All 20 patients in this study underwent surgery, either due to symptoms or due to radiologic diagnosis of BCA. Four of the 20 cases (20%) were asymptomatic and out of these four cases, 3 (75%) were diagnosed as cystadenoma on the preoperative imaging studies. All 19 cases were diagnosed as a simple liver cyst on pathology. CONCLUSION: In summary, there is a growing trend of "ruling-out the diagnosis of biliary cystadenoma" in patients who present with liver cysts. Patients are appropriately more anxious after this preoperative diagnosis and the treating surgeons have medico-legal concerns regarding conservative management in asymptomatic patients diagnosed as BCA. This single center experience draws attention to the radiology criteria utilized for diagnosing a biliary cystadenoma and suggests that it is time to revisit the imaging interpretation and differential diagnosis.

Changing opportunities for liver transplant for patients with hepatocellular carcinoma.

INTRODUCTION: Aim was to study the early impact of acuity circle-based allocation implementation system on liver transplantation for hepatocellular carcinoma (HCC) patients. METHODS: We assessed characteristics of HCC and non-HCC deceased donor orthotopic liver transplants (OLT) in the year before (2/2019-2/2020) and after (3/2020-2/2021) introduction of the acuity circle policy using the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) database. RESULTS: Total OLTs reduced from 6699 in the preacuity circle era to 6660 in the postacuity circle era (-.6%); this decrease is mostly driven by a decrease in HCC transplants (1529 to 1351; -11.6%). Six out of 11 regions had a reduction in the absolute number and percentage of HCC transplants with significant reductions in regions 2 (-37.8%, p < .001) and 4 (-28.3%, p = .001). DISCUSSION: The introduction of median model for end-stage liver disease (MELD) at transplant minus 3 (MMaT-3) exception points, has created differential opportunities for HCC patients, in low-MELD as opposed to high-MELD areas, despite having the same disease. This effect has become more prominent following the implementation of acuity circle-based allocation system. Ongoing investigation of these trends is needed to ensure that HCC patients are not disparately disadvantaged due to their location.

The role of extracorporeal membrane oxygenation in adult liver transplant patients: A qualitative systematic review of literature.

BACKGROUND: A paucity of evidence exists regarding risks and benefits of extracorporeal membrane oxygenation (ECMO) in adult liver transplantation. METHODS: This was a systematic review conducted from January 1, 2000 to April 24, 2020 of adult liver transplant recipients (pre- or post-transplant) and donors who underwent Veno-arterial or Veno-venous ECMO cannulation. Death was the primary outcome, with graft function and complications as secondary outcomes. RESULTS: Forty-one articles were identified that fit criteria. A total of 183 donors were placed on ECMO, with recipient complication profiles and mortality that mirrored rates from standard criteria donors. Sixty-one recipients were placed on ECMO intraoperatively or postoperatively. Most patients experienced at least one complication with infections as the most common cause and minimal complications specifically related to ECMO use. Multisystem organ failure (MSOF) and infections were more common among liver recipients who died compared to those who survived. Overall mortality at 90 days was 45.9%. Causes of death were most commonly MSOF and infections. CONCLUSIONS: ECMO use in adult liver transplantation is a useful adjunct. Recipient morbidity and mortality from donors placed on ECMO parallel that of recipients from standard criteria donors, and morbidity and mortality of recipients placed on ECMO are similar to other ECMO populations.

Cholecystic Venous Anatomy: A Cadaveric Study with Implications for Portal Venous Interruption Procedure.

The techniques of portal vein embolization (PVE) or ligation (PVL) have the goals of combining an induced atrophy of metastatic segments with the rapid relative compensatory hypertrophy of the postresection future liver remnant (FLR). Our study examines the anatomy of right-left hepatic lobar venous connections in the adult cadaver using corrosion cast analysis in an effort to define some of the inherent anatomical reasons why both PVL and PVE may be technically unsuccessful. Corrosion cast models of 215 cadaveric liver specimens were evaluated for hepatopetal venous blood flow, with a particular emphasis on cholecystic venous drainage patterns, including 57 cases prepared after lobar portal venous ligation. In 88.8 per cent of corrosion casts, there was a segmental venous communication between the gallbladder and all segments of the liver, except segment II. There was cystic vein drainage directly into a main lobar branch or directly into the portal vein itself in 11.2 per cent of cases. In all 57 cases, after portal lobar venous division, in situ cystic veins allowed persistent venous communication between lobes. Our cadaveric corrosion cast study has suggested that there is extensive intrahepatic cholecystic venous drainage to many segments of the liver. Perfusion from the gallbladder may potentially contribute to a limited response to procedures which interrupt the portal venous flow and could affect their capacity to induce an adequate FLR which would permit a wider hepatectomy.

The Impact of Bariatric Surgery on Thyroid Function and Medication Use in Patients with Hypothyroidism.

BACKGROUND: Bariatric surgery (BS) is effective in treating obesity and its associated comorbidities. However, there is a paucity of data on the effect of BS on thyroid function in hypothyroid patients, specifically in those treated with thyroid hormone replacement therapy (THR). The aim of this study was to assess the effect of BS on thyroid function and on THR dosage in patients with hypothyroidism. METHODS: A retrospective analysis of prospectively collected data of all hypothyroid patients who underwent BS between 2010 and 2014 was performed. Data collected included demographic and anthropometric measurements, as well as changes in thyroid hormone levels and THR dosage up to a year from surgery. RESULTS: During the study period, 93 hypothyroid patients (85 females, 91%), 83 of which treated with replacement thyroid hormone, underwent BS. Laparoscopic sleeve gastrectomy was performed in 77 (82.8%) and Roux-en-Y gastric bypass in 16 patients. Average age and body mass index (BMI) were 46.6 ± 11.2 years and 43.7 ± 6.4 kg/m2, respectively. Mean BMI and thyroid-stimulating hormone (TSH) significantly deceased after 6 and 12 months following surgery whereas mean free T4 levels remained stable. TSH decrease was directly correlated to baseline TSH but not to BMI reduction. One year after surgery, 11 patients (13.2%) did not require THR, while the rest required a significantly lower average dose (P < 0.02). CONCLUSIONS: There is a favorable effect of BS on the hypothyroid bariatric population. This includes improvement of thyroid function and reduction of thyroid medication dosages. Further studies are required to evaluate an influence of THR absorption and compare different types of bariatric surgeries.

Bariatric Surgery Improves Sexual Function in Obese Patients.

BACKGROUND: Obesity causes specific sexual problems, including diminished sexual desire, poor performance and avoidance of sexual encounters. OBJECTIVES: To systematically evaluate the effect of bariatric surgery on patients' sexual function as compared to their preoperative status. METHODS: Bariatric surgery candidates were given a validated sexual function questionnaire the day before surgery and again 6 months after surgery. Females were polled with the Female Sexual Function Index (FSFI) and males with the Brief Sexual Function Inventory (BSFI). Statistical analysis was performed to elucidate differences in response to the questionnaires. RESULTS: The study population included 34 females and 14 males. Mean age and body mass index (BMI) were 40.2 ± 10.2 years and 43.4 ± 5.3 kg/m2, respectively. Postoperative BMI was 31.4 ± 4.9 kg/m2 (P < 0.001). Laparoscopic sleeve gastrectomy was performed in 36 patients and laparoscopic Roux-Y gastric bypass in 12. In females, the FSFI index rose significantly from 24 to 30 (P = 0.006), indicating increased sexual performance and satisfaction. In males the BSFI increased from 40.2 to 43.9 but did not reach statistical significance (P = 0.08). However, general satisfaction, desire and erection were each significantly improved within the BSFI. CONCLUSIONS: In addition to the well-documented medical and quality-of-life benefits of bariatric surgery, there is also clear improvement in patients' sexual function, both physical and psychosexual.

"Vanishing liver metastases"-A real challenge for liver surgeons.

Expanded surgical intervention in colorectal liver metastasis (LM) and improved chemotherapy led to increasing problem of disappearing liver metastases (DLM). Treatment of those continues to evolve and poses a real challenge for HPB surgeons. This review discusses a clinical approach to DLM, emphasizing crucial steps in clinical algorithm. Particular issues such as imaging, intraoperative detection and surgical techniques are addressed. A step-by-step algorithm is suggested.

Small for size liver remnant following resection: prevention and management.

In the latest decades an important change was registered in liver surgery, however the management of liver cirrhosis or small size hepatic remnant still remains a challenge. Currently post-hepatectomy liver failure (PLF) is the major cause of death after liver resection often associated with sepsis and ischemia-reperfusion injury (IRI). ''Small-for-size'' syndrome (SFSS) and PFL have similar mechanism presenting reduction of liver mass and portal hyper flow beyond a certain threshold. Few methods are described to prevent both syndromes, in the preoperative, perioperative and postoperative stages. Additionally to portal vein embolization (PVE), radiological examinations (mainly CT and/or MRI), and more recently 3D computed tomography are fundamental to quantify the liver volume (LV) at a preoperative stage. During surgery, in order to limit parenchymal damage and optimize regenerative capacity, some hepatoprotective measures may be employed, among them: intermittent portal clamping and hypothermic liver preservation. Regarding the treatment, since PLF is a quite complex disease, it is required a multi-disciplinary approach, where it management must be undertaken in conjunction with critical care, hepatology, microbiology and radiology services. The size of the liver cannot be considered the main variable in the development of liver dysfunction after extended hepatectomies. Additional characteristics should be taken into account, such as: the future liver remnant; the portal blood flow and pressure and the exploration of the potential effects of regeneration preconditioning are all promising strategies that could help to expand the indications and increase the safety of liver surgery.

Complications after percutaneous ablation of liver tumors: a systematic review.

BACKGROUND: Although ablation therapy has been accepted as a promising and safe technique for treatment of unrespectable hepatic tumors, investigation of its complications has been limited. A physician who performs ablation treatment of hepatic malignancies should be aware of the broad spectrum of complications. Proper management is possible only if the physician Performing ablation understands the broad spectrum of complications encountered after ablation. OBJECTIVES: TO SYSTEMATICALLY REVIEW THE COMPLICATIONS AFTER DIFFERENT ABLATION MODALITIES: Radiofrequency ablation (RFA), microwave ablation (MWA) and Nano knife for the treatment of liver tumors and analyze possible risk factors that precipitate these complications. SEARCH METHODS: WE PERFORMED ELECTRONIC SEARCHES IN THE FOLLOWING DATABASES: MEDLINE, EMBASE and COCHARNE. Current trials were identified through the Internet (from January 1, 2000 to January 1, 2014). We included only studies who specific mentioned complications after liver ablation therapy (RFA/MWA/Nano knife). MAIN RESULTS: A total of 2,588 publications were identified, after detailed examination only 32 publications were included in the review. The included studies involved 15,744 participants. According to the type of technique, 13,044 and 2,700 patients were included for RFA and MWA. Analysis showed a pooled mortality of 0.15% for RFA, and 0.23% for MWA. CONCLUSIONS: This systematic review gathers information from controlled clinical trials and observational studies which are vulnerable to different types of bias, never the less RFA and MWA can be considered safe techniques for the treatment of liver tumors.

Postoperative swallow study as a predictor of intermediate weight loss after sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an accepted bariatric procedure. Swallow studies (SS) after LSG are not uniform and display different patterns with regard to contrast passage through the gastric sleeve. The impact of immediate postoperative contrast transit time on weight loss has not been studied. The influence of immediate fluid tolerance on weight loss after LSG is herein reported. METHODS: Ninety-nine patients after LSG were included. There were 67 females, mean age 41 (range 17-67), mean BMI 44.4 (range 37-75). A routine SS was performed on postoperative day (POD) 1. Pattern of contrast transit was noted. Patients were followed-up in our bariatric clinic. RESULTS: Percent excess weight loss was significantly lower in the patients with rapid contrast passage (Group 1, n = 50) than those with delayed passage (Group 2, n = 49). Group 1 achieved 62, 58, and 53 % at 1, 2, and 3 years, respectively, while Group 2 attained 69, 74, and 75 % at the same time points (p = 0.05, 0.001, and 0.04, respectively). Group 1 patients displayed a negative weight loss trend after 1 year whereas Group 2 patients plateaued after 2 years. CONCLUSIONS: Tolerance of fluid intake after LSG is crucial for patient recovery and discharge. Distinct radiologic appearance on POD 1 helps predict this behavior. Mid-term weight loss after LSG appears to be dependent on immediate postoperative contrast transit time, whereas patients with slow contrast passage tend to lose more weight. Long-term follow-up will reveal whether this finding will hold true.