Effects of intraoperative blood loss during liver resection on patients' outcome: a single- center experience

Background/aim: Operative bleeding is one of the major determinants of outcome in liver surgery. This study aimed to describe the impact of intraoperative blood loss on the postoperative course of liver resection (LR). Materials and methods: The data of 257 patients who were treated with LR between January 2007 and October 2018 were retrospectively analyzed. LRs were performed via intermittent portal triad clamping (PTC) under low central venous pressure. Results: LRs were performed for 67.7% of patients with a malignant disease and 32.3% of patients with a benign disease. Major LR was performed in 89 patients (34.6%). The mean PTC period was 20.32 min (±13.7). The median intraoperative bleeding amount was 200 mL (5­3500 mL), the 30-day mortality rate was 4.3%, and the morbidity rate was 31.9%. The hospital stay (p = 0.002), morbidity (p = 0.009), and 30-day mortality (p = 0.041) of patients with a bleeding amount of more than 500 mL significantly increased. Conclusion: Surgeons should consider the adverse effects of intraoperative bleeding during liver resection on patients' outcome. Favorable outcomes would be obtained with diligent postoperative care.

Posthepatectomy liver failure

Liver surgery is one of the most complex surgical interventions with high risk and potential for complications. Posthepatectomy liver failure (PHLF) is a serious complication of liver surgery that occurs in about 10% of patients undergoing major liver surgery. It is the main source of morbidity and mortality. Appropriate surgical techniques and intensive care management are important in preventing PHLF. Early start of the liver support systems is very important for the PHLF patient to recover, survive, or be ready for a liver transplant. Nonbiological and biological liver support systems should be used in PHLF to prepare for treatment or organ transplantation. The definition of the state, underlying pathophysiology and treatment strategies will be reviewed here.

Chemoembolization for neuroendocrine liver metastasis.

The liver is the most common site for neuroendocrine tumor metastasis. The characteristic feature of these tumors is related to the secretion of biologically active compounds in large amounts. Systemic chemotherapy has limited success in treating patients with neuroendocrine liver metastasis. Surgical management remains the only potentially curative option for these patients. According to the high incidence of recurrence after surgery, the role of intra-arterial therapy (IATs) in neuroendocrine tumor metastasis has been evolved. This review evaluates the potential role of IATs in the light of current literature.

The role of liver resection in the management of severe blunt liver trauma.

BACKGROUND: The management of hepatic trauma has a historical progress from mandatory operation with selective non-operative treatment, to non-operative treatment with selective operation. Liver resection (LR) seems to have a minimal role in the management of liver injury. However, surgical treatment becomes the only life-saving treatment in cases with severe liver trauma. METHODS: It is a retrospective presentation of five cases with severe blunt liver injury whose were admitted at our center during the 8-year period. RESULTS: The median age of patients was 30.8 (23-43). The most frequent mechanism of injury was pedestrian struck (60%). Two of five cases were transferred to our hospital from rural state hospitals after initial attempt to achieving hemostasis. The majority of liver injury was grade V (80%). The right lobe of the liver was injured in different extensions. Major vascular injury was associated to liver injury in four of five cases. The right hepatectomy (n=1), resectional debridement of segments 5, 6, and 7 (n=1), posterior sectorectomy (n=2), and segment 7 resection (n=1) were performed for hemostasis. Vascular injuries in the junction of inferior vena cava and right hepatic vein (n=1), the anterior surface of the right hepatic vein (n=1), the junction of segment 7 hepatic vein and right hepatic vein (n=1), the main portal vein (n=1), and the right renal vein (n=1) were repaired. Median operation time was 162 min (120-180 min). Operative mortality was 20%. Reoperation was needed in three of four survived cases. In-hospital complications were observed in two of four survived cases. Median stay in intensive care unit and hospital was 12.4 days (1-48 days) and 28.2 days (1-65 days), respectively. CONCLUSION: When a severe liver injury is unresponsive to packing, the surgeon must always keep in mind that extensive maneuvers for vascular control and LR are required for bleeding control.

Liver transplantation as a treatment option for three siblings with homozygous familial hypercholesterolemia.

FH is a hereditary inherited disorder of cholesterol metabolism. Homozygous form of the disease associates severe form of atherosclerotic disease. Clinicians have been tried to inhibit the progression of the homozygous FH with medical and surgical treatment. We here present three siblings with homozygous FH who were successfully treated with liver transplantation.

Detailed dissection of hepato-caval junction and suprarenal inferior vena cava.

BACKGROUND/AIMS: There are few anatomical studies on hepatic vein compared to hepatic artery and portal vein. The aim of this study is to clarify the branching patterns of hepatic veins, supra and infra-diaphragmatic course of suprarenal inferior vena cava and its relation with the liver. METHODOLOGY: Between March and May 2008, 103 consecutive autopsy examinations were included in the study. Hepatic vein anatomy was classified according to the Broelsch classification. The anatomic relations of supra-diaphragmatic and infra-diaphragmatic (suprarenal) inferior vena cava were revealed. RESULTS: Majority of subjects have Type a (42.7%) variation. The inferior right hepatic vein was presented alone in 26 and together with middle right hepatic vein in 15 subjects. Most of the phrenic veins were drained to the right-anterior sidewall of inferior vena cava (n=21/25 above the diaphragm and, n=144/306 below the diaphragm). Drainage of the right adrenal vein directly into the right side of the inferior vena cava was found in 82 subjects (80%). Most of subjects had 2 lumbar branches in the posterior sidewall of infradiaphragmatic inferior vena cava (n=92/103). CONCLUSIONS: The proposed classification of hepatic veins and obtained anatomical details from this study provides useful assistance for hepatic surgeons in phases of operative planning and vascular control maneuvers required in liver surgery.

Awareness and wound assesment decrease surgical site infections.

Objectives: Various surveillance methods have been described for surveillance of surgical site infections (SSI). The aim of this study was to examine prac- ticality of SSI risk assessment methods (SENIC and NNIS) with a postoperative wound monitoring scale (ASEPSIS) as an outcome assessment measure and evaluation of the contribution of wound assesment to the reduction of wound infection. Material and Methods: Patients were followed with a prospective data chart through four year. Correlation of SENIC and NNIS together with ASEPSIS were performed. Results: During the study period, 275 SSI occurred. SSIs were determined within the 21 days-period after operations. Correlation between SENIC with ASEPSIS (rs= 0.41, p <0.001) was found better than that for NNIS with ASEPSIS (rs= 0.37, p <0.001). Type of operation (emergency vs. elective), body mass index, operation class and American Society of Anesthesiologists scores were found independently predictive factors for SSI. The forth year SSI rate was found to be significantly lower than the other years (p <0.001). Conclusion: This study indicates weak but significant correlation between preoperative risk assessment methods for SSI and ASEPSIS method. In addi- tion, surgical wound assesment and awarness of the wound infection rates, have decreased the SSI rates over the years.

Metastatic cutaneous melanoma presented with ileal invagination: report of a case.

We herein report a case of ileal invagination secondary to metastasis of a cutaneous melanoma. A 45-year-old female was admitted with intermittent abdominal pain and nausea. The patient's medical history was remarkable for cutaneous malignant melanoma. Imaging studies showed a solid mass in the right lower quadrant and the possibility of invagination. We made a preoperative diagnosis of partial intestinal obstruction, and laparotomy was performed. Intraoperative findings revealed ileal invagination. Segmental ileum resection with wide mesenteric lymph node dissection was performed. A polypoid metastasis of melanoma into the lumen of the ileum was confirmed with pathological examination. The diagnosis and management of intestinal metastasis of cutaneous malignant melanoma are discussed together with a literature review.

Is It Rational to Perform Liver Resection for Patients with Intermediate and Advanced Stages of Hepatocellular Carcinoma?

This study aimed to investigate clinical characteristics of hepatocellular carcinoma and the outcome of our aggressive treatment policy which follows the Barcelona Clinic Liver Cancer (BCLC) guidance. In this study, we retrospectively analyzed data of 102 patients who were treated for hepatocellular carcinoma between January 2007 and October 2016. Male predominance (81.4%) and a median age of 61 years were observed. Cirrhosis was evident in 88.2 per cent of patients. Viral hepatitis (77.5%) was the most common underlying etiology. The majority of our patients (71.6%) were in BCLC B and C stages. Liver resection was performed in 53.4 per cent of patients in those stages. Transarterial chemoembolization was the leading interventional treatment. Overall survival rates at three and five years were 75 per cent and 75 per cent in BCLC 0, 69 per cent and 58 per cent in BCLC A, 50 per cent and 41 per cent in BCLC B, and 11 per cent and 11 per cent in BCLC C, respectively. The BCLC treatment algorithm should consider the role of liver resection also for intermediate stages.

Umbilical trocar site closure with Berci's needle after laparoscopic cholecystectomy.

BACKGROUND/AIMS: The umbilical region is particularly susceptible for development of incisional hernia after laparoscopic cholecystectomy (LC). To evaluate the effects of port-closure techniques on the complications seen after umbilical port-site closure, we compared closure with Berci's needle and the standard technique of a hand-sutured closure. METHODOLOGY: A hundred patients underwent LC were randomly divided into two groups. We evaluated the required time for closure, the security of techniques and the factors affecting postoperative complications for both closure groups in a prospective manner. RESULTS: Closure of the umbilical port site was performed faster with the Berci's needle compared to standard hand-sutured technique. Postoperative hospital stay and complication rates were not altered significantly depend on the closure technique. Skin dimpling on the trocar site was observed predominantly after closure with Berci's needle. Spontaneous improvement on skin dimpling was observed within the 2 weeks after operation in all patients. During the follow-up period, there was no trocar site hernia observed in the study group. CONCLUSIONS: Closure of the umbilical port site with Berci's needle is found as an effective and safe method for laparoscopic cholecystectomy.

Hemodiafiltration treatment for high bilirubinemia state after hepatectomy.

Hyperbilirubinemia which developed after right hepatectomy is reported in a 66-year-old male. The application of hemodiafiltration treatment in the postoperative course of the patient and the effect of treatment in his healing process are summarized and discussed.

Role of percutaneous transhepatic biliary drainage in the management of blunt liver trauma: A case report.

The liver is the most commonly injured intra-abdominal organ after blunt trauma. The management of massive liver injury is complex. Percutaneous transhepatic biliary drainage is the first approach considered, particularly for proximal bile duct strictures after liver surgery. A 27-year-old female patient was transferred to our emergency department with grade V blunt injury. Regarding the patient's unresponsive hemodynamic instability, right hepatectomy was performed. The patient presented with benign biliary duct stricture after surgery that were treated via the percutaneous approach.

Enhancing Hepatic Microcirculation in Postoperative Hepatic Failure With Intra-arterial Recombinant Tissue Plasminogen Activator Treatment.

Postoperative hepatic failure is one of the most severe complications after liver resection. Treatment protocols have varied from medical support to liver transplant. Here, we describe the clinical course of an 18-year-old female patient with postoperative hepatic failure. The combined use of intra-arterial tissue plasminogen activator infusion and concurrent liver support facilities resulted in successful treatment of postoperative hepatic failure. The role of thrombolytic treatment for postoperative hepatic failure may include future placement in routine treatment protocols, as seen in liver transplant.

Synchronous and metachronous occurrence of gastric adenocarcinoma and gastric lymphoma: A review of the literature.

The occurrence of both primary gastric lymphoma and gastric adenocarcinoma in the same patient is a rare entity. The possible causative factors of synchronous or metachronous occurrence of both malignancies and varieties in the treatment modalities are reviewed according to published cases in English language medical literature.

Comparison of bariatric and non-bariatric elective operations in morbidly obese patients on the basis of wound infection.

BACKGROUND: Wound infection rates after various types of bariatric operations have been well described. The question of whether bariatric surgery increases wound infection rate compared with similar elective surgical procedures in obese patients has not been clearly answered. The purpose of this study was to investigate wound status of morbidly obese patients after elective general surgery. METHODS: A prospective evaluation was conducted of 141 morbidly obese patients undergoing bariatric (n=60) and non-bariatric elective general surgery operation of similar invasiveness (n=81) with the ASEPSIS wound surveillance method. RESULTS: Median age of patients undergoing non-bariatric elective surgery (51, 32-68) was significantly higher than patients exposed to bariatric surgery (39, 24-57). Patients undergoing bariatric surgery had higher BMIs (44.0, 35-52.5) compared to the others (38.4, 35-43). All patients enrolled in the study were followed for a 21-day period. At the 7th postoperative day, 9 patients in the bariatric surgery group developed infection (15%), whereas 13 patients (16%) in the non-bariatric surgery group suffered wound infection. Wound infection was still present in 2 patients (3.4%) in the bariatric surgery group and 3 patients (3.7%) in the non-bariatric surgery group at the 21st day. Risk factors for wound infection included history of coronary artery diseases, diabetes, chronic respiratory illness and malignant disease. CONCLUSION: Bariatric surgery does not cause an additional risk of postoperative wound infection in morbidly obese patients, compared to elective general surgical operations of the same invasiveness.

Strangulated congenital mesenteric hernia: a case report.

Congenital mesenteric defects are rare and often recognized only in surgery or autopsy. Preoperative diagnosis of an internal hernia is quite rare. A common symptom of trans-mesenteric intestinal herniation is intermittent postprandial pain. If there is strangulation of the mesenteric internal herniation, there is often vomiting and constipation. Signs and symptoms of a bowel obstruction in a patient without previous abdominal surgery or inguinal hernia as well as without history of intra-abdominal operation and infection suggest the possibility of a congenital mesenteric defect with internal herniation. Early diagnosis and surgical treatment are important to reduce morbidity and mortality. This study aimed to present the case of a 20-year-old female patient on whom preoperative diagnosis of internal trans-mesenteric internal hernia was made.

Preoperative arterial embolization of large liver hemangiomas.

PURPOSE: We aimed to investigate the efficacy and safety of preoperative selective intra-arterial embolization (PSIAE) in the surgical treatment of large liver hemangiomas. METHODS: Data of 22 patients who underwent resection of large liver hemangiomas were retrospectively analyzed. PSIAE was performed in cases having a high risk of severe blood loss during surgery (n=11), while it was not applied in cases with a low risk of blood loss (n=11). RESULTS: A total of 19 enucleations and six anatomic resections were performed. Operative time, intraoperative bleeding amount, Pringle period, and blood transfusion were comparable between the two groups (P > 0.05, for all). The perioperative serum aspartate transaminase level was not different between groups (P = 1.000). Perioperative total bilirubin levels were significantly increased in the PSIAE group (P = 0.041). Postoperative hospital stay was longer in the PSIAE group. Surgical complications were comparable between groups (P = 0.476). CONCLUSION: Patients who underwent PSIAE due to a high risk of severe blood loss during resection of large liver hemangiomas had comparable operative success as patients with a low risk of blood loss who were operated without PSIAE. Hence, PSIAE can be used for the control of intraoperative blood loss, especially in surgically difficult cases.

Improvement of vertical banded gastroplasty by strict dietary management.

BACKGROUND: Vertical banded gastroplasty (VBG) has been found to reduce BMI significantly during the first postoperative year. However, the same trend in weight loss has not been established thereafter. The purpose of this study was to evaluate the effects of our dietary program on morbidly obese patients treated with VBG. METHODS: A prospective evaluation of 40 obese patients (25 female, 15 male) undergoing VBG over a 3-year period was undertaken. RESULTS: The age range was 24-57 (median 38) years, mean weight 133+/-2 SD kg, and mean BMI 45+/-6.4 SD kg/m2. After VBG, a special follow-up program was applied to patients. All patients (100%) were available for follow-up. Operative mortality was zero. 4 patients developed an early postoperative complication, and 1 patient was re-operated because of staple-line disruption 8 months after VBG. BMI decreased to 34+/-3.2 after 12 months, 27+/-1.3 after 24 months, and 28+/-1.4 after 36 months. All patients showed weight loss after VBG, and the weight loss continued with the strict follow-up program during a 3-year period, except in 1 patient who regained the weight lost despite an intact staple-line and stoma. CONCLUSION: Our policy for patients after VBG appears to be effective.

Diphenhydramine and hyaluronic acid derivatives reduce adnexal adhesions and prevent tubal obstructions in rats.

OBJECTIVE: The purpose of this study is to investigate the effects of diphenhydramine-HCl and Na-hyaluronate derivatives on the development of postoperative peritoneal adhesion and tubal obstruction. STUDY DESIGN: Forty female rats of Sprague-Dawley type were used in the study. The rats were divided into four groups, each comprising 10 subjects. After all the rats were anaesthetized with 50mg/kg ketamine HCl, their abdomens were opened with a lower midline incision. Injury was induced on the right pelvic peritoneum and on the peritoneal surface of left uterine tube. No additional procedure was applied to the first group. 10 mg/kg diphenhydramine-HCl was given to the second group intravenously. In the third group, 0.25 mg/kg Orthovisc, a Na-hyaluronate derivative was diluted with 2 ml physiological saline and poured into the abdomen. For the fourth group, Seprafilm, a Na-hyaluronate derivative was covered in a layer of 0.7 cm x 3 cm over the left uterine tube. After 14 days, the rats were anaesthetized with ketamine HCl again, and 5 cm(3) blood sample was taken with cardiac puncture. The abdomen was opened with an incision transverse to the upper end of the midline incision, and the presence of adhesions was investigated. Detected adhesions were staged according to the Mazuji classification. Tubal patencies were inspected by injecting methylene blue from the uterine corpus into the lumen using an injector. A piece of abdominal wall of 4 cm x 4 cm was removed by extending the incision in the reverse U shape. The tensile strength and bursting pressure of the suture line were determined using the Peacock method. One gram of tissue was taken from the incision line, and hydroxyproline levels were determined by the Bergman-Loxley method. Aspartate aminotransferase (AST) levels were measured. RESULTS: All of the rats completed the study. AST levels, tissue hydroxyproline levels and tensile strength and bursting pressure test results were found to be similar in all groups. While adhesion rates in the groups were 100, 40, 40 and 30%, respectively, adhesion stages were found to be, respectively as 2.1+/-1.7, 0.6+/-0.67, 0.6+/-0.67 and 0.5+/-0.85. Adhesion stages in the study groups were significantly lower (P<0.05). Tubal obstruction rates were found to be 70, 30, 30 and 20%, respectively. CONCLUSION: Diphenhydramine, Orthovisc and Seprafilm significantly reduce postoperative peritoneal adhesion development, and they allow the uterine tubes to remain open.