Insulin-induced gene 2 protects against hepatic ischemia-reperfusion injury via metabolic remodeling.

BACKGROUND: Hepatic ischemia-reperfusion (IR) injury is the primary reason for complications following hepatectomy and liver transplantation (LT). Insulin-induced gene 2 (Insig2) is one of several proteins that anchor the reticulum in the cytoplasm and is essential for metabolism and inflammatory responses. However, its function in IR injury remains ambiguous. METHODS: Insig2 global knock-out (KO) mice and mice with adeno-associated-virus8 (AAV8)-delivered Insig2 hepatocyte-specific overexpression were subjected to a 70% hepatic IR model. Liver injury was assessed by monitoring hepatic histology, inflammatory responses, and apoptosis. Hypoxia/reoxygenation stimulation (H/R) of primary hepatocytes and hypoxia model induced by cobalt chloride (CoCl2) were used for in vitro experiments. Multi-omics analysis of transcriptomics, proteomics, and metabolomics was used to investigate the molecular mechanisms underlying Insig2. RESULTS: Hepatic Insig2 expression was significantly reduced in clinical samples undergoing LT and the mouse IR model. Our findings showed that Insig2 depletion significantly aggravated IR-induced hepatic inflammation, cell death and injury, whereas Insig2 overexpression caused the opposite phenotypes. The results of in vitro H/R experiments were consistent with those in vivo. Mechanistically, multi-omics analysis revealed that Insig2 is associated with increased antioxidant pentose phosphate pathway (PPP) activity. The inhibition of glucose-6-phosphate-dehydrogenase (G6PD), a rate-limiting enzyme of PPP, rescued the protective effect of Insig2 overexpression, exacerbating liver injury. Finally, our findings indicated that mouse IR injury could be attenuated by developing a nanoparticle delivery system that enables liver-targeted delivery of substrate of PPP (glucose 6-phosphate). CONCLUSIONS: Insig2 has a protective function in liver IR by upregulating the PPP activity and remodeling glucose metabolism. The supplementary glucose 6-phosphate (G6P) salt may serve as a viable therapeutic target for alleviating hepatic IR.

A paradigm for fostering patient-centered research in liver disease: The liver transplant patient-engagement program.

BACKGROUND: Many federal funding and regulatory agencies require patient engagement to conduct patient-centered research and drug development. We developed a liver transplantation patient-engagement program, which can serve as a model for bringing the patient perspective to digestive diseases research. METHODS: Six liver transplantation patient-engagement program advisors completed training in patient engagement; participated in several virtual sessions; and completed postsession surveys. RESULTS: Qualitative and quantitative results elucidated patient-centered liver transplantation study outcomes and barriers/facilitators to conducting clinical research. Group satisfaction was very high. CONCLUSIONS: The liver transplantation patient-engagement program model provides a paradigm for how to engage patients in the formative steps of patient-centered clinical research.

Tissue Heavy Metals in Liver Diseases.

BACKGROUND: Our objective was to determine the levels of heavy metals, oxidants, and antioxidants in liver tissue of patients with chronic liver disease (CLD) compared with healthy living liver donors (LLDs). METHODS: We obtained liver specimens from patients undergoing liver transplant for CLD. Samples were also obtained from LLDs. Biochemical analyses were performed on all samples, and the levels of liver tissue, heavy metal, and oxidant-antioxidants biomarker levels in patients with CLD were compared with those measured in LLDs. RESULTS: One hundred and eighteen individuals were included for analyses. Fifty-nine were patients with CLD, and 59 were LLDs. The median levels of liver tissue of superoxide dismutase (P = .009), glutathione peroxidase (P = .042), total oxidant status (P = .006), oxidative stress index (P < .001), and copper (P = .035) were prominently more elevated in CLD than LLDs. On the other hand, the median levels of liver tissue of cadmium (P < .001), selenium (P = .042), and zinc (P < .001) levels were more elevated in the LLDs than patients with CLD. The 2 groups were similar in terms of total antioxidant status, manganese, arsenic, and lead levels. CONCLUSIONS: Superoxide accumulation in the liver was higher in patients with CLD. Concerning heavy metals, only the median tissue copper was elevated in patients with CLD with higher Cu/Zn ratio. Cadmium, selenium, and zinc were significantly higher in the healthy LLDs.

Perioperative omega-3 fatty acids for liver surgery: A meta-analysis of randomized controlled trials.

INTRODUCTION: The effect of perioperative omega-3 fatty acids for liver surgery remained controversial. We conducted a systematic review and meta-analysis to explore the influence of omega-3 fatty acids versus placebo in patients undergoing liver surgery. METHODS: We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through May 2020, and included randomized controlled trials (RCTs) assessing the effect of omega-3 fatty acids versus placebo for liver surgery. This meta-analysis was performed using the random-effect model. RESULTS: Five RCTs were included in the meta-analysis. Overall, compared with control group for liver surgery, omega-3 fatty acids were associated with substantially reduced incidence of infection (odd ratio [OR]=0.56; 95% confidence interval [CI] =0.34-0.91; P = .02), but revealed no remarkable influence on complications (OR = 0.60; 95% CI = 0.29-1.24; P = .17), mortality (OR = 0.76; 95% CI = 0.06-9.37; P = .83), liver failure (OR = 0.72; 95% CI = 0.10 to 5.00; P = 0.74), biliary leakage (OR=1.24; 95% CI = 0.41 to 3.76; P = .70), bleeding (OR = 1.76; 95% CI = 0.63-4.95; P = .28), or ileus (OR = 0.39; 95% CI = 0.07-2.05; P = .27). CONCLUSION: Perioperative omega-3 fatty acids may be beneficial to reduce the incidence of infection after liver surgery.

Electrolyte disorders are ERAS-associated in patients undergoing hepato-pancreato-biliary surgery.

PURPOSE: Emerging evidences have raised concerns about electrolyte disorders caused by restrictive fluid management in the enhanced recovery after surgery (ERAS) protocol. This study aims to investigate the morbidity and treatment of electrolyte disorders associated with ERAS in patients undergoing hepato-pancreato-biliary (HPB) surgery. METHODS: Clinical data from 157 patients under the ERAS program and 166 patients under the traditional (Non-ERAS) program after HPB surgery were retrospectively analyzed. Risk factors and predictive factors of postoperative electrolyte disorders were analyzed by logistic regression analysis and receiver operator characteristic (ROC) curve analysis, respectively. RESULTS: The average of intravenous fluid, sodium, chloride, and potassium supplementation after surgery were significantly lower in the ERAS group. Hypokalemia was the most common type of electrolyte disorders in the ERAS group, whose incidence was substantially increased compared to that in the Non-ERAS group [28.77% vs. 8.97%, p < 0.001, on postoperative (POD) 5]. Logistic regression analysis identified the ERAS program and age as independent risk factors of hypokalemia. ROC curve analysis identified serum potassium levels below 3.76 mmol/L on POD 3 (area under curve 0.731, sensitivity 58.54%, specificity 82.69%) as a predictive factor for postoperative hypokalemia in ERAS patients. Oral supplementation at an average of 35.41 mmol potassium per day was effective in restoring the ERAS-associated hypokalemia. CONCLUSIONS: ERAS procedures were particularly associated with a lower supplementation of potassium and a higher incidence of hypokalemia in patients after HPB surgery. Oral potassium supplementation could be an adopted ERAS program for the elderly undergoing HPB surgery.

Effects of Citrulline Supplementation on Body Weight in Patients With Hepatobiliary Pancreatic Surgery.

BACKGROUND: Many health benefits have been proposed for citrulline, but they lack evidence based on human research. This study was to evaluate whether an oral citrulline supplement affects body weight changes and laboratory values in patients with hepatobiliary and pancreatic surgery. METHODS: Patients who underwent hepatobiliary and pancreatic surgery during January to June 2015 were screened for analysis. Patients using citrulline during hospital stay and at discharge were classified as the citrulline group, whereas those without any records of citrulline were designated as the control group. The primary efficacy outcome was the change in body weight at discharge and at first outpatient visit. Other outcomes included change in laboratory values. RESULTS: A total of 138 patients were included in analysis. Citrulline group and control group did not differ with respect to baseline characteristics except for white blood cell count. Percent in change of body weight and body mass index from discharge to first outpatient visit was significantly different between the 2 groups, showing less weight loss in citrulline group than in controls (-0.8 ± 2.7% vs -2.5 ± 3.8%, P < 0.05). Especially in men, citrulline use significantly affected weight loss from the multivariate analysis (P < 0.05); percent change in weight in citrulline group was predicted to increase by 2.1 units. During hospital stay, significant differences between the 2 groups were found in changes of cholesterol and protein levels. CONCLUSION: Citrulline supplement reduced weight loss in surgical patients during recovery.

Preventive Effect of Antioxidative Nutrient-Rich Enteral Diet Against Liver Ischemia and Reperfusion Injury.

BACKGROUND: Liver ischemia and reperfusion injury (IRI) is a major problem associated with liver surgery. This study is aimed to compare the preventive effect of an antioxidative nutrient-rich enteral diet (Ao diet) with an ordinal enteral diet (control diet) against liver IRI. METHODS: The Ao diet was an ordinary diet comprising polyphenols (catechin and proanthocyanidin) and enhanced levels of vitamins C and E. Male C57BL/6 mice were fed the Ao or control diet for 7 days before ischemic insult for 60 minutes, followed by reperfusion for 6 hours. The levels of inflammatory cytokines, chemokines, and antioxidant enzymes and oxidative stress were evaluated. RESULTS: After 7 days of pretreatment with the Ao diet, the serum levels of vitamins C and E in mice were markedly elevated. The levels of serum aspartate aminotransferase and alanine aminotransferase, as well as the scores of liver necrosis caused by ischemia and reperfusion, were significantly lower in the Ao diet group than in the control diet group. The gene expression levels of inflammatory cytokines and chemokines, such as interleukin-6 and CXCL1, were significantly lower in the Ao diet group. In the liver, the levels of antioxidant enzymes superoxide dismutase 1 (SOD1) and SOD2 were significantly higher and the malondialdehyde levels were significantly lower in the Ao diet group. Cell adhesion molecule expression was significantly lower, and neutrophil and macrophage infiltration was less in the Ao diet group. CONCLUSIONS: Antioxidative nutrient supplementation to an ordinary enteral diet may mitigate liver IRI by causing an antioxidant effect and suppressing inflammation.

Patient blood management for liver resection: consensus statements using Delphi methodology.

BACKGROUND: Blood loss and transfusion remain a significant concern in liver resection (LR). Patient blood management (PBM) programs reduce use of transfusions and improve outcomes and costs, but are not standardized for LR. This study sought to create an expert consensus statement on PBM for LR using modified Delphi methodology. METHODS: An expert panel representing hepato-biliary surgery, anesthesiology, and transfusion medicine was invited to participate. 28 statements addressing the 3 pillars of PBM were created. Panelists were asked to rate statements on a 7-point Likert scale. Three-rounds of iterative rating and feedback were completed anonymously, followed by an in-person meeting. Consensus was reached with at least 70% agreement. RESULTS: The 35 experts panel recommended routine pre-operative transfusion risk assessment, and investigation and management of anemia with iron supplementation. Intra-operatively, restrictive fluid administration without routine central line insertion was recommended, along with intermittent hepatic pedicle occlusion and surgical techniques considerations. Specific criteria for restrictive intra-operative and post-operative transfusion strategy were recommended. CONCLUSIONS: PBM for LR included medical and technical interventions throughout the perioperative continuum, addressing specificities of LR. Diffusion and adoption of these recommendations can standardize PBM for LR to improve patient outcomes and resource utilization.

Ultrasound thermal monitoring with an external ultrasound source for customized bipolar RF ablation shapes.

PURPOSE: Thermotherapy is a clinical procedure which delivers thermal energy to a target, and it has been applied for various medical treatments. Temperature monitoring during thermotherapy is important to achieve precise and reproducible results. Medical ultrasound can be used for thermal monitoring and is an attractive medical imaging modality due to its advantages including non-ionizing radiation, cost-effectiveness and portability. We propose an ultrasound thermal monitoring method using a speed-of-sound tomographic approach coupled with a biophysical heat diffusion model. METHODS: We implement an ultrasound thermometry approach using an external ultrasound source. We reconstruct the speed-of-sound images using time-of-flight information from the external ultrasound source and convert the speed-of-sound information into temperature by using the a priori knowledge brought by a biophysical heat diffusion model. RESULTS: Customized treatment shapes can be created using switching channels of radio frequency bipolar needle electrodes. Simulations of various ablation lesion shapes in the temperature range of 21-59 [Formula: see text]C are performed to study the feasibility of the proposed method. We also evaluated our method with ex vivo porcine liver experiments, in which we generated temperature images between 22 and 45 [Formula: see text]C. CONCLUSION: In this paper, we present a proof of concept showing the feasibility of our ultrasound thermal monitoring method. The proposed method could be applied to various thermotherapy procedures by only adding an ultrasound source.

Intraoperative cell salvage with autologous transfusion in elective right or repeat hepatectomy: a propensity-score-matched case-control analysis.

BACKGROUND: Liver resection may be associated with substantial blood loss, and cell saver use has been recommended for patients at high risk. We performed a study to compare the allogenic erythrocyte transfusion rate after liver resection between patients who had intraoperative cell salvage with a cell saver device versus patients who did not. Our hypothesis was that cell salvage with autologous transfusion would reduce the allogenic blood transfusion rate. METHODS: Cell salvage was used selectively in patients at high risk for intraoperative blood loss based on preoperatively known predictors: right and repeat hepatectomy. Patients who underwent elective right or repeat hepatectomy between Nov. 9, 2007, and Jan. 27, 2016 were considered for the study. Data were retrieved from a liver resection database and were analyzed retrospectively. Patients with cell saver use (since January 2013) constituted the experimental group, and those without cell salvage (2007-2012), the control group. To reduce selection bias, we matched propensity scores. The primary outcome was the allogenic blood transfusion rate within 90 days postoperatively. Secondary outcomes were the number of transfused erythrocyte units, and rates of overall and infectious complications. RESULTS: Ninety-six patients were included in the study, 41 in the cell saver group and 55 in the control group. Of the 96, 64 (67%) could be matched, 32 in either group. The 2 groups were balanced for demographic and clinical variables. The allogenic blood transfusion rate was 28% (95% confidence interval [CI] 12.5%-43.7%) in the cell saver group versus 72% (95% CI 56.3%-87.5%) in the control group (p < 0.001). The overall and infectious complication rates were not significantly different between the 2 groups. CONCLUSION: Intraoperative cell salvage with autologous transfusion in elective right or repeat hepatectomy reduced the allogenic blood transfusion rate.

CONTEXTE: La résection hépatique peut s'accompagner de pertes sanguines importantes et l'utilisation d'un système de récupération de sang autologue est recommandée chez les patients à risque élevé. Nous avons procédé à une étude pour comparer le taux de transfusion de sang allogénique après la résection hépatique selon que les patients avaient ou non été soumis à une intervention de récupération de sang autologue. Notre hypothèse est que la récupération de sang autologue peropératoire pourrait réduire le taux de transfusion de sang allogénique. MÉTHODES: La récupération de sang autologue a été utilisée sélectivement chez des patients exposés à un risque élevé à l'égard de pertes sanguines peropératoires, en fonction de facteurs prédictifs préopératoires connus : hépatectomie droite et reprise de l'hépatectomie. Les patients ayant subi une intervention chirurgicale non urgente pour hépatectomie droite ou reprise d'hépatectomie entre le 9 novembre 2007 et le 27 janvier 2016 ont été considérés comme admissibles à l'étude. Les données ont été récupérées à partir d'une base de données sur la résection hépatique et analysées de manière rétrospective. Les patients soumis à la récupération de sang autologue (à partir de janvier 2013) ont constitué le groupe expérimental, et les autres (2007-2012) ont constitué le groupe témoin. Pour réduire le risque de biais de sélection, nous avons apparié les scores de propension. Le paramètre principal était le taux de transfusion de sang allogénique dans les 90 jours suivant l'opération. Les paramètres secondaires étaient le nombre d'unités transfusées, le taux de complications infectieuses et le taux global de complications. RÉSULTATS: Quatre-vingt-seize patients ont pris part à l'étude, 41 dans le groupe soumis à la récupération de sang autologue et 55 dans le groupe témoin. Parmi les 96 patients de l'étude, 64 (67 %) ont pu être assortis, 32 dans chaque groupe. Les 2 groupes étaient équilibrés aux plans des variables démographiques et cliniques. Le taux d'allotransfusions a été de 28 % (intervalle de confiance [IC] de 95 % 12,5 %-43,7 %) dans le groupe soumis à la récupération de sang autologue, contre 72 % (IC de 95 % 56,3 %-87,5 %) dans le groupe témoin (p < 0,001). Le taux de complications infectieuses et le taux global de complications n'ont pas été significativement différents entre les 2 groupes. CONCLUSION: La récupération de sang autologue peropératoire dans les cas d'hépatectomie droite ou d'hépatectomie répétée a réduit le taux de transfusion de sang allogénique.

Alternative Cell Sources to Adult Hepatocytes for Hepatic Cell Therapy.

Adult hepatocyte transplantation is limited by scarce availability of suitable donor liver tissue for hepatocyte isolation. New cell-based therapies are being developed to supplement whole-organ liver transplantation, to reduce the waiting-list mortality rate, and to obtain more sustained and significant metabolic correction. Fetal livers and unsuitable neonatal livers for organ transplantation have been proposed as potential useful sources of hepatic cells for cell therapy. However, the major challenge is to use alternative cell sources for transplantation that can be derived from reproducible methods. Different types of stem cells with hepatic differentiation potential are eligible for generating large numbers of functional hepatocytes for liver cell therapy to treat degenerative disorders, inborn hepatic metabolic diseases, and organ failure. Clinical trials are designed to fully establish the safety profile of such therapies and to define target patient groups and standardized protocols.

[Comparison of Effects of Exhalation and Inhalation Breathing Exercises on Pulmonary Function and Complications in Elderly Patients with Upper-abdominal Surgery].

PURPOSE: The purpose of this study was to identify the effects of exhalation breathing exercises using expirometer and that of inhalation breathing exercises using incentive spirometry on pulmonary function and complications in elderly patients with upper-abdominal surgery. METHODS: The research design was a nonequivalent control group non-synchronized design. Participants were 63 patients who underwent upper-abdominal surgery under general anesthesia (32 in experiment group, 31 in control group). They were recruited at P university hospital from August 1 to November 30, 2015. Effects were evaluated by measuring pulmonary functions (Forced Vital Capacity [FVC], Forced Expiratory Volume in 1 second [FEV1]) and pulmonary complications. Data were analyzed using SPSS/WIN 18.0 program. RESULTS: There was no difference in FVC between the experimental group and the control group, but FEV1 in the experimental group increased significantly compared to the control group by time change (p=.001). Also, there were no pulmonary complications in the experimental group but there were 5 cases (16.1%)(p=.018) in the control group. CONCLUSION: Findings indicate that exhalation breathing exercises by elderly patients following upper-abdominal surgery is an effective nursing intervention in enhancing pulmonary function and preventing pulmonary complications.

Liver transplantation and adolescence: The role of mental health.

Young people (YP) with chronic illness have higher rates of mental health problems than the general population, with psychosocial complexity associated with nonadherence and poorer health outcomes. This study aimed to describe the prevalence of anxiety and depression in YP after liver transplantation, with autoimmune liver disease and other chronic liver diseases, identify the factors YP attribute their distress to and the relationship between anxiety/depression, and describe YP's beliefs about their illness and treatment. An electronically administered questionnaire battery was given routinely to YP attending an outpatient liver transition clinic; 187 YP participated, of which 17.7% screened positive for anxiety or depression. There were no significant differences between disease groups. This is significantly higher than the prevalence of common mental health problems in the general adolescent population. Patients most frequently attributed their distress to fatigue, sleep difficulties, financial concerns, problems at work/school, worry, and low self-esteem. Higher levels of depression and anxiety were significantly associated with specific illness and treatment beliefs but not with perceived understanding of illness or treatment control. In conclusion, the increased prevalence of mental health problems in YP and the intertwined nature of these with their physical health outcomes provide evidence that holistic care should be delivered as standard for this age group. Liver Transplantation 22 1544-1553 2016 AASLD.

Impact of Perioperative Phosphorus and Glucose Levels on Liver Regeneration and Long-term Outcomes after Major Liver Resection.

INTRODUCTION: The impact of phosphorus as well as glycemic alterations on liver regeneration has not been directly examined. We sought to determine the impact of phosphorus and glucose on liver regeneration after major hepatectomy. METHODS: Early and late liver regeneration index was defined as the relative increase of liver volume (RLV) within 2[(RLV2m-RLVp)/RLVp] and 7 months[(RLV7m-RLVp)/RLVp] following surgery. The association of perioperative metabolic factors, liver regeneration, and outcomes was assessed. RESULTS: On postoperative day 2, 50 (52.6 %) patients had a low phosphorus level (≤2.4 mg/dl), while 45 (47.4 %) had a normal/high phosphorus level (>2.4 mg/dl). Despite comparable clinicopathologic characteristics (all P > 0.05) and RLV/TLV at surgery (P = 0.84), regeneration index within 2 months was lower in the normal/high phosphorus group (P = 0.01) with these patients having increased risk for postoperative liver failure (P = 0.01). The inhibition of liver regeneration persisted at 7 months (P = 0.007) and was associated with a worse survival (P = 0.02). Preoperative hypoglycemia was associated only with a lower early regeneration index (P = 0.02). CONCLUSIONS: Normal/high phosphorus was associated with inhibition of early and late liver regeneration, as well as with an increased risk of liver failure and worse long-term outcomes. Immediate preoperative hypoglycemia was associated with a lower early volumetric gain. Metabolic factors may represent early indicators of liver failure that could identify patients at increased risk for worse outcomes.

Emergence of linezolid resistance in hepatobiliary infections caused by Enterococcus faecium.

Enterococcal infections are common in liver transplantation and hepatopancreaticobiliary (HPB) surgery. Linezolid is frequently used to treat not only vancomycin-resistant Enterococcus (VRE), but also vancomycin-sensitive Enterococcus (VSE) infections, and resistance can develop. This study evaluated all the Liver Unit patients who developed infections with linezolid-resistant Enterococcus (LRE) in order to elicit the association with prior linezolid usage, to explore possible risk factors for infection, and to better understand the epidemiology of these isolates in this patient group. Between 2010 and 2015, infections with LRE developed in 10 patients (8 following liver transplantation and 2 following HPB surgery) after 22-108 days of treatment. Selected pulsed-field gel electrophoresis demonstrated that 2 out of 10 patients were cocolonized with different strains and indicated that cross-transmission may have occurred. In conclusion, in this group of patients with complex hepatobiliary infections, the optimal antibiotic strategies for the treatment of Enterococcus faecium infections are not clearly defined, and there is a significant risk of emergence of resistance to linezolid in E. faecium after exposure to this agent in patients, especially in the presence of a deep source of infection on a background of hepatic artery insufficiency. Caution is needed when using prolonged courses of linezolid in this setting, and further studies are necessary to determine the optimum treatment.

Implantación de un programa ERAS en cirugía hepática / Implementation of an ERAS program in liver surgery

El manejo perioperatorio de los pacientes sometidos a cirugía abdominal se ha basado en conceptos tradicionales y frecuentemente no avalados por la evidencia científica. Recientemente han aparecido varios estudios científicos que demuestran que algunos procedimientos tradicionales para el manejo perioperatororio de los pacientes como, el ayuno preoperatorio, la preparación intestinal, el uso de sondas naso-gástricas, la colocación de drenajes intraabdominales, el ayuno en el postoperatorio etc., son innecesarios e incluso a veces contraproducentes. Los protocolos de manejo perioperatorio de ERAS o Fast-Track (Enhanced Recovery After Surgery) se basan en la utilización de medidas en el periodo perioperatorio que están avaladas por la evidencia científica actual. A partir del año 2000 empiezan a aparecer en la bibliografía científica varios trabajos que recogen la aplicación de protocolos ERAS o Fast- Track en la cirugía del aparato digestivo en los que se nuestra de manera uniforme, no solo la seguridad de su aplicación sino también, la disminución de las complicaciones y de la estancia postoperatoria. Aunque inicialmente estos protocolos fueron descritos en la cirugía colo-rectal, debido a los buenos resultados obtenidos, la aplicación de estos protocolos se ha expandido rápidamente a otras especialidades quirúrgicas como la cirugía torácica, la Urología, la Ginecología, etc. En todos estas especialidades se ha mostrando de forma unánime la mejoría de la recuperación postoperatoria con la aplicación de protocolos ERAS. El motivo de este artículo es doble. Por un lado examinar la evidencia científica que existe en la actualidad sobre los elementos mas importantes de un programa ERAS y presentar los resultados preliminares de la implantación (AU)

The perioperative management of patients undergoing abdominal surgery has been based on traditional concepts and often not supported by scientific evidence. Recently there have been several scientific studies showing that some traditional procedures for the perioperative management of patients as preoperative fasting, bowel preparation, use of naso-gastric tubes, placement of intra-abdominal drainage, postoperative fasting etc. They are unnecessary and sometimes counterproductive. Perioperative management protocols ERAS or FastTrack (Enhanced Recovery After Surgery) are based on the use in the perioperative period of measures that are supported by current scientific evidence. Since 2000 appear in the scientific literature several works that reflect the application of protocols ERAS or Fast- Track in surgery of the digestive system where it´s shown uniformly, not only the security of your application but also, decreased complications and hospital stay. Although initially these protocols were described in colorectal surgery, due to the good results obtained, the application of these protocols has rapidly expanded to other surgical specialties such as thoracic surgery, Urology, Gynaecology, etc. In all these specialties has unanimously showing improved postoperative recovery with ERAS application protocols. The purpose of this paper is twofold. On the one hand examine the scientific evidence that exists today on the most important elements of an ERAS program and present preliminary results of the implementation of a program ERAS in our hospital (AU)

Role of coronary artery calcium score in identifying occult coronary artery disease in patients evaluated for deceased-donor liver transplant - a preliminary report.

Coronary artery disease may affect cirrhotic patients regardless of age and etiology of the underlying liver disease. Early identification of coronary artery disease is important to be able to achieve the best posttransplant outcomes and survival. The coronary artery calcium score can be used as a screening tool to supplement the results of cardiac stress tests to identify a subgroup of patients who may benefit from further investigation with coronary arteriogram. Arteriogram is an invasive test and may cause renal compromise and risk of bleeding associated with coagulopathy. The present retrospective study showed that coronary artery calcium score > 250 Agatston units may help select the subgroup of patients who will benefit from further investigation with cardiac catheterization, and determining this score may limit the risks of catheterization.

Cell therapy for liver diseases: current medicine and future promises.

Liver diseases are a major health problem worldwide since they usually represent the main causes of death in most countries, causing excessive costs to public health systems. Nowadays, there are no efficient current therapies for most hepatic diseases and liver transplant is infrequent due to the availability of organs, cost and risk of transplant rejection. Therefore, alternative therapies for liver diseases have been developed, including cell-based therapies. Stem cells (SCs) are characterized by their self-renewing capacity, unlimited proliferation and differentiation under certain conditions into tissue- or organ-specific cells with special functions. Cell-based therapies for liver diseases have been successful in experimental models, showing anti-inflammatory, antifibrogenic and regenerative effects. Nowadays, clinical trials using SCs for liver pathologies are increasing in number, and those that have reached publication have achieved favorable effects, encouraging us to think that SCs will have a potential clinical use in a short time.

Does inchinkoto, a herbal medicine, have hepatoprotective effects in major hepatectomy? A prospective randomized study.

OBJECTIVES: This randomized clinical trial was designed to investigate whether inchinkoto has a hepatoprotective effect on postoperative outcome after major hepatectomy. METHODS: Sixty-one patients scheduled for major hepatectomy were randomly assigned to one of two groups in which preoperative inchinkoto was (inchinkoto group, n = 30) or was not (non-inchinkoto group, n = 31) administered. Inchinkoto was administered for at least 7 days before surgery. The primary endpoint was the incidence of post-hepatectomy liver damage. The expression of nuclear factor E2-related factor 2 (Nrf2) and other oxygen stress-related markers in the liver were also determined. RESULTS: There was no significant difference in clinical characteristics between the inchinkoto and non-inchinkoto groups. Serum levels in liver function tests and incidences of post-hepatectomy liver failure did not differ significantly between the two groups. However, there was a significantly higher induction of antioxidant factors in the liver, such as Nrf2 protein and heme oxygenase-1 mRNA, after hepatectomy in the inchinkoto group than in the non-inchinkoto group. CONCLUSIONS: The preoperative administration of inchinkoto did not have a significant impact on the overall outcome of major hepatectomy. However, inchinkoto induced the expression of Nrf2 during hepatectomy and may have exerted an antioxidative effect on the liver.