Partial Portal Vein Arterialization to Treat Toxic Acute Liver Failure in Elderly Rats.

INTRODUCTION: Toxic acute liver failure can be fatal even after liver transplantation. Since there are data only in young rats, the aim of our study was to verify the effectiveness of the increase of oxygen to the liver by partial portal vein arterialization (PPVA) in elderly rats with acute liver failure induced by carbon tetrachloride (CCl4) intoxication. METHODS: Twenty elderly (30 months) Sprague-Dawley rats underwent a CCl4 intoxication (5 mL/kg). Animals were divided after 24 hours (n = 10 per group) to either undergo PPVA (G1, treated group) or be untreated (G2, control group). PPVA consisted of a shunt between the left renal artery and splenic vein after nephrectomy and spelnectomy. The G2 group animals underwent nephrectomy and splenectomy only. The 10-day survival was evaluated. Before euthanasia, blood samples from the portal vein were detected for blood gas analysis. Liver injury was evaluated by the serum alanine aminotransferase (ALT) and prothrombin time levels. Histology was done to evaluate the liver necrosis. Hepatocyte regeneration was assessed by the mitotic index at immunohistochemistry. RESULTS: The PPVA has resulted in a significant increase in the oxygen partial pressure and saturation in portal blood. A survival improvement at 10 days was registered in the PPVA-treated rats (90% vs 30%; P = .0065). After 24 hours from intoxication, ALT was high in both groups. A rapid decrease of ALT was observed in G1 as compared to G2. At the same time, livers showed a severe centrolobular necrosis. In the suviving G2 rats, a moderate necrosis was present, while only a mild necrosis was observed in the G1 rats. An higher mitotic index was detected in rats treated with PPVA. CONCLUSIONS: In our experimental study, the presence of oxygenated blood in the portal venous system following the PPVA procedure had positive effects on liver regeneration and rats' survival. The PPVA treatment had beneficial effects in elderly rats.

Portal blood arterialization with an extracorporeal device to treat toxic acute hepatic failure in a swine model.

PURPOSE: This study aimed to determine whether a controlled portal blood arterialization by a liver extracorporeal device (L.E.O2 NARDO) is effective in treating acute hepatic failure (AHF) induced through CCl4 administration in a swine model. METHODS: 20 swine with AHF induced by intraperitoneal injection of carbon tetrachloride (CCl4) in oil solution, were randomly divided into two groups: animals receiving L.E.O2 NARDO treatment 48 h after the intoxication (study group); animals sham operated 48 h after the intoxication (control group). Blood was withdrawn from the iliac artery and reversed in the portal venous system by an interposed extracorporeal device. Each treatment lasted 6 h. The survival was assessed at 5 days after L.E.O2 NARDO treatment or sham operation. In both groups blood samples were collected for biochemical analysis at different time points and liver biopsies were collected 48 h after intoxication and at sacrifice. RESULTS: We observed decreased transaminases levels and a more rapid INR recovery in the study group, as compared to the control group. Eight animals of the study group vs. two animals of the control group survived at five days after surgery with a statistically significant difference (p<0.05). Liver biopsies performed at sacrifice showed a reduction of the damaged hepatic areas in the study group as compared to the control group. CONCLUSIONS: Arterial blood supply in the portal system through the L.E.O2 NARDO device is easily applicable, efficacious, and safe in a swine model of AHF induced by CCl4 intoxication.

Reconstruction with fascia lata after extensive chest wall resection: results.

OBJECTIVES: Following extensive chest wall resection, the reconstruction technique should fulfill two opposing functional requirements: adequate rigidity and flexibility of the chest wall during the breathing phases. Reconstruction with fascia lata enables a balance between these two parameters, thus favouring the patients' respiratory dynamics and producing low morbidity and good functional results. METHODS: Sixty patients underwent chest wall reconstruction using fascia lata alone or in combination with titanium plates between 2006 and 2011, due to primary tumours in 28 patients, metastases in 23 and local recurrences in 9. The mean area of resected tissue was 107.7 cm(2), distributed among the anterior, anterolateral, lateral and posterior zones. One-to-eight ribs were resected, and additional sternum resection was performed in 75% of patients. Forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were evaluated in 33 patients. RESULTS: 46.6% of patients underwent reconstruction with fascia lata alone, 1.6% with fascia lata, DualMesh® and titanium plates and 51.6% with fascia lata and titanium plates. There was no 30-day mortality. All patients were extubated after the operation with no need for reintubation. Five patients had postoperative complications: 2 wound dehiscences, 2 haematomas and 1 seroma. There were no significant differences between preoperative and postoperative FEV1 and FVC measurements in patients with or without lobectomy and wedge resections. CONCLUSIONS: Chest wall reconstruction with fascia lata, alone or in combination with titanium plates, allows the surgeon to perform a dynamic reconstruction without flail chest in extensive exeresis. Risks of infection associated with the use of prosthetic materials are also minimized. In addition, the characteristic flexibility of this tissue makes it a precious tool in paediatric chest wall reconstruction, since fascia lata naturally adapts to the physiological growth of younger bodies, thus reducing the risk of scoliosis and local deformities.

Tubercular bowel perforation: what to do?

BACKGROUND: The incidence of abdominal tuberculosis (TB) is increasing in western and developed countries. This pathology has several complications, including free intestinal perforation. The aim of this study was to analytically summarize all the pertinent literature discussing the various treatments for TB-related perforations. METHODS: We reviewed the patient database of the Emergency Surgery Department of the Bologna University Hospital, checking the last 13 years. A retrospective review was conducted of all reported cases of intestinal perforation due to intestinal TB published through 3 March 2009. RESULTS: 119 cases of abdominal TB presenting with intestinal perforation were published. There are no standardized guidelines regarding the surgical treatment. Of the 119 reported cases, 40 (33.6%) were treated with resection and anastomosis, 17 (14.2%) with direct sutures, 4 (3.3%) with a simple drain, and in 57, the treatment was not reported. CONCLUSION: No clinical evidence has been available for analysis to discern the optimal surgical strategy for treating intestinal perforations induced by TB. The direct closure of the perforation typically correlates with poor morbidity and mortality results. The better treatment seems to be the surgical resection of the perforated part with anastomosis. However, pharmacological therapy remains the essential pillar of treatment.

An in vivo autotransplant model of renal preservation: cold storage versus machine perfusion in the prevention of ischemia/reperfusion injury.

There is increasing proof that organ preservation by machine perfusion is able to limit ischemia/reperfusion injury in kidney transplantation. This study was designed to compare the efficiency in hypothermic organ preservation by machine perfusion or cold storage in an animal model of kidney autotransplantation. Twelve pigs underwent left nephrectomy after warm ischemic time; the organs were preserved in machine perfusion (n = 6) or cold storage (n = 6) and then autotransplanted with immediate contralateral nephrectomy. The following parameters were compared between the two groups of animals: hematological and urine indexes of renal function, blood/gas analysis values, histological features, tissue adenosine-5'-triphosphate (ATP) content, perforin gene expression in kidney biopsies, and organ weight changes were compared before and after preservation. The amount of cellular ATP was significantly higher in organs preserved by machine perfusion; moreover, the study of apoptosis induction revealed an enhanced perforin expression in the kidneys, which underwent simple hypothermic preservation compared to the machine-preserved ones. Organ weight was significantly decreased after cold storage, but it remained quite stable for machine-perfused kidneys. The present model seems to suggest that organ preservation by hypothermic machine perfusion is able to better control cellular impairment in comparison with cold storage.

Successful treatment of CCl4-induced acute liver failure with portal vein arterialization in the rat.

BACKGROUND: Optimization of the conditions for regeneration is a major goal in the management of patients with acute liver failure (ALF). Previous observations suggested that hyperoxygenation of the liver may improve its regenerative capacity. Thus, this study aimed to determine whether an additional supply of oxygenated blood achieved by portal vein arterialization (PVA) is protective in rat ALF caused by toxin administration or hepatectomy. METHODS: Sprague-Dawley rats were subjected or not to PVA after CCl(4) intoxication or extended hepatectomy. PVA was performed by interposing a stent between the left renal artery and splenic vein after left nephrectomy and splenectomy. Liver injury was evaluated by the serum ALT level and necrotic cell count. Hepatocyte regeneration was assessed by calculating the mitotic index and bromodeoxyuridine (BrdU) staining. The 10-day survival was assessed in separate experimental groups. RESULTS: The pO(2) in portal blood increased significantly following PVA. In the CCl(4)-induced ALF, serum ALT levels and necrosis were significantly reduced in arterialized than non-arterialized rats. PVA greatly promotes liver regeneration in both models. Finally, PVA significantly improved survival compared to controls (CCl(4): 100 versus 40%; 90% hepatectomy: 90 versus 30%). Interestingly, in the CCl(4)-induced ALF, survival was 100% even when the shunt was closed after 48 h. CONCLUSION: These data indicate that the additional supply of arterial oxygenated blood through PVA promotes a rapid regeneration leading to the resolution of toxic-induced massive liver necrosis and a faster restoration of liver mass after partial hepatectomy in rats. Thus, PVA may represent a novel tool for optimizing hepatocyte regeneration.

Hepatic resection for primary or secondary malignancies with involvement of the inferior vena cava: is this operation safe or hazardous?

BACKGROUND: This study evaluated surgical techniques and results of patients with tumors who had undergone liver resection with partial resection and reconstruction of the IVC. STUDY DESIGN: We performed a retrospective analysis of all patients who underwent combined liver and IVC resection and reconstruction at a single institution. We identified 19 patients and two categories of tumors, primary (n = 8) and metastatic (n = 11). In 12 patients, a direct suture of the IVC was performed; in 3 patients a pericardium bovine patch was applied; in another 4 patients the IVC was replaced by PTFEt prosthesis. In nine patients, total hepatic vascular occlusion was required. RESULTS: Perioperative mortality was 5.9%, related to technical complications and hepatic insufficiency. Postoperative morbidity was 57.9%. Median survival time was 32 months (range 3 to 125 months). The 1-, 2-, and 5-year cumulative survival rates were 78.9%, 68%, and 49.1%, respectively. Tumor recurrence appeared in 13 patients and was the main cause of death (55.5%). Among the seven patients suffering from hepatocellular carcinoma, three are still alive at 31, 60, and 125 months after resection. In this group, 1-, 2-, and 5-year survival rates were 71.4%, 57.1%, and 38.1%. Among the 11 patients resected for colorectal liver metastases, the 1-, 2-, and 5-year survival rates were 81.8%, 62.3%, and 51.9%, respectively. CONCLUSIONS: Liver resection combined with IVC resection and reconstruction is a feasible procedure that can be performed with an acceptable operative risk leading to longterm outcome in selected patients.

Radical surgical treatment of recurrent hepatic hydatidosis.

BACKGROUND/AIMS: The treatment of relapsing hydatidosis must aim at the reduction of both morbidity and mortality rates and the risk of new recurrences. METHODOLOGY: Thirty-three patients with recurrence of hepatic ecchinococcosis were observed between January 1975 and May 2001. All selected patients received a first conservative surgical treatment, and recurrences developed in a period ranging from 1 to 46 years from the therapy. All patients with secondary hydatidosis were then submitted to radical surgical treatment. Ultrasound examinations, the first after 3 months from surgery, were performed to evaluate disease recurrence. Intraoperative morbidity and mortality were also evaluated. RESULTS: No intraoperative mortality was encountered. Intraoperative and postoperative morbidity were 6% and 12% respectively. During follow-up, (mean duration 53 months) no recurrences were recorded. CONCLUSIONS: Radical surgical approach is the best treatment of recurrent hydatid cysts as it represents a valid compromise between the need of a surgical radicality and a low intraoperative and postoperative morbidity.