Does bilioenteric anastomosis impair results of liver resection in primary intrahepatic lithiasis?

AIM: To evaluate the long-term results of liver resection for the treatment of primary intrahepatic lithiasis. Prognostic factors, especially the impact of bilioenteric anastomosis on recurrence of symptoms were assessed. METHODS: Forty one patients with intrahepatic stones and parenchyma fibrosis/atrophy and/or biliary stenosis were submitted to liver resection. Resection was associated with a Roux-en-Y hepaticojejunostomy in all patients with bilateral stones and in those with unilateral disease and dilation of the extrahepatic biliary duct (> 2 cm). Late results and risk factors for recurrence of symptoms or stones were evaluated. RESULTS: There was no operative mortality. After a mean follow-up of 50.3 mo, good late results were observed in 82.9% of patients; all patients submitted to liver resection alone and 58.8% of those submitted to liver resection and hepaticojejunostomy were free of symptoms (P = 0.0006). Patients with unilateral and bilateral disease showed good late results in 94.1% and 28.6%, respectively (P < 0.001). CONCLUSION: Recurrence of symptoms in patients with hepaticojejunostomy showed that this may not be the ideal solution. Further studies are needed to establish the best treatment for patients with bilateral stones or unilateral disease and a dilated extrahepatic duct.

Evaluation of patients with schistosomal portal hypertension treated in a tertiary hospital / Perfil dos pacientes com Esquistossomose Mansoni tratados em hospital terciário

BACKGROUND: Schistosomiasis is an important public health issue in more than 70 countries around the world. About 600 million people are at risk to acquire the parasite and there are 200 million infected worldwide. AIM: To evaluate the characteristics of schistosomal portal hypertension individuals who underwent previous esophageal varices bleeding treated in a tertiary hospital. METHODS: The records of 155 patients were evaluated and clinical, laboratorial, endoscopic, epidemiological features and hemorrhagic event severity were analyzed to individualize this population. RESULTS: Mean age was 37.2 years and no clinical signs of hepatic failure were observed. Serum laboratory tests to evaluate liver function were normal or slightly alter. Anemia was present in 70 percent, leucopenia in 75 percent and thrombocytopenia in 86 percent of the patients. At endoscopic evaluation varices were classified as grade III and IV in 91.3 percent; red spots were observed in 40.3 percent and congestive gastropathy in 13.6 percent. Patients presented a mean of 2.8 previous episodes of variceal hemorrhage and, in 75 percent with hemodynamic instability. CONCLUSIONS: Patients with schistosomal portal hypertension and history of upper digestive bleeding from esophageal varices are young individuals, without either clinical or laboratorial evidence of liver dysfunction, that present high morbidity due to the severity of the acute event of bleeding.

RACIONAL: Esquistossomose é importante doença na saúde pública envolvendo mais de 70 países. Cerca de 600 milhões de pessoas estão em áreas de risco para adquirir a doença e em torno de 200 milhões estão por ela infectados. OBJETIVO: Avaliar as características da hipertensão porta esquistossomótica em indivíduos que se submeteram previamente a tratamento de varizes esofágicas hemorrágicas em hospital terciário. MÉTODOS: Os prontuários de 155 pacientes foram avaliados analisando-se aspectos clínicos, laboratoriais, endoscópicos, epidemiológicos e intensidade de eventos hemorrágicos. RESULTADOS: A idade média foi de 37.2 anos e não havia sinais clínicos de insuficiência hepática. Análises séricas para avaliação da função hepática foram normais ou levemente alteradas. Anemia estava presente em 70 por cento, leucopenia em 75 por cento e trombocitopenia em 86 por cento. Na endoscopia as varizes foram classificadas em graus III e V em 91.3 por cento; red spots foram vistos em 40.3 por cento e gastropatia congestiva em 13.6 por cento. Os pacientes apresentaram média de 2.8 prévios episódios de hemorragia por varizes e em 75 por cento havia instabilidade hemodinâmica. Conclusões - Pacientes com hipertensão porta esquistossomótica e histórico de sangramento digestivo alto por varizes esofágicas são jovens, sem evidências laboratoriais de alteração hepática importante e apresentam alta morbidade, devido à severidade do evento hemorrágico.

[Portal vein thrombosis after esophagogastric devascularization and splenectomy in schistosomal portal hypertension patients: what's the real importance?]. / Trombose de veia porta após desconexão ázigo-portal e esplenectomia em pacientes esquistossomóticos: qual a real importância?

CONTEXT: Portal vein thrombosis is the most frequent complication after esophagogastric devascularization and splenectomy for hepatosplenic schistosomosis. OBJECTIVE: To evaluate portal vein thrombosis in 155 patients with schistosomal portal hypertension submitted to esophagogastric devascularization and splenectomy. METHODS: We retrospectively analyzed not only the incidence and predictive factors of this complication, but also clinical, laboratorial, endoscopic and Doppler sonography outcome of these patients. RESULTS: Postoperative portal thrombosis was observed in 52.3% of the patients (partial in 45.8% and total in 6.5%). Postoperative diarrhea was more frequent in patients with portal vein thrombosis. Fever was a frequent postoperative symptom (70%) but occurred in a higher percentage when total portal vein thrombosis was present (100%). Superior mesenteric vein thrombosis occurred in four patients (2.6%) and was associated with total thrombosis of the portal vein. There was no statistical difference between patients with and without portal vein thrombosis according to clinical and endoscopic parameters during late follow-up. It was not possible to identify any predictive factor for the occurrence of this complication. CONCLUSIONS: Portal vein thrombosis is an early and frequent event after esophagogastric devascularization and splenectomy, usually partial with benign outcome and low morbidity. Total portal vein thrombosis is more frequently associated with a high morbidity complication, the superior mesenteric vein thrombosis. Long-term survival was not influenced by either partial or total portal thrombosis.

Trombose de veia porta após desconexão ázigo-portal e esplenectomia em pacientes esquistossomóticos: qual a real importância? / Portal vein thrombosis after esophagogastric devascularization and splenectomy in schistosomal portal hypertension patients: what's the real importance?

CONTEXTO: A complicação mais frequente após a desconexão ázigo-portal e esplenectomia em doentes com esquistossomose mansônica hepatoesplênica é a trombose da veia porta. OBJETIVOS:Avaliar a incidência, os fatores preditivos dessa complicação, assim como, a evolução clínica, laboratorial, endoscópica e ultrassonográfica desses pacientes. MÉTODOS: Foram analisados retrospectivamente os prontuários de 155 doentes esquistossomóticos submetidos a desconexão ázigo-portal e esplenectomia. RESULTADOS: Trombose de veia porta foi observada em 52,3 por cento dos pacientes, sendo 6,5 por cento de trombose total e 45,8 por cento de trombose parcial. Os pacientes que evoluíram com trombose de veia porta apresentaram mais frequentemente diarreia no pós-operatório. Febre foi evento habitual que ocorreu em 70 por cento dos casos, mais frequente, entretanto, nos doentes com trombose total da veia porta (100 por cento). Trombose de veia mesentérica superior ocorreu em quatro doentes (2,6 por cento), sendo mais frequente entre os com trombose total da veia porta. Não se encontrou diferença estatística quanto aos parâmetros clínicos, laboratoriais, endoscópicos e recidiva hemorrágica no pós-operatório tardio, quando comparados os pacientes com e sem trombose portal. CONCLUSÕES: A trombose de veia porta no pós-operatório da desconexão ázigo-portal e esplenectomia é evento frequente, sem nenhum fator preditivo para sua ocorrência; na maioria dos casos a trombose é parcial e apresenta evolução benigna, com baixa morbidade; trombose total da veia porta está mais frequentemente associada à trombose da veia mesentérica superior, com elevada morbidade; a trombose da veia porta, parcial ou total, não acarretou complicações no período pós-operatório tardio.

CONTEXT: Portal vein thrombosis is the most frequent complication after esophagogastric devascularization and splenectomy for hepatosplenic schistosomosis. OBJECTIVE: To evaluate portal vein thrombosis in 155 patients with schistosomal portal hypertension submitted to esophagogastric devascularization and splenectomy. METHODS: We retrospectively analyzed not only the incidence and predictive factors of this complication, but also clinical, laboratorial, endoscopic and Doppler sonography outcome of these patients. RESULTS: Postoperative portal thrombosis was observed in 52.3 percent of the patients (partial in 45.8 percent and total in 6.5 percent). Postoperative diarrhea was more frequent in patients with portal vein thrombosis. Fever was a frequent postoperative symptom (70 percent) but occurred in a higher percentage when total portal vein thrombosis was present (100 percent). Superior mesenteric vein thrombosis occurred in four patients (2.6 percent) and was associated with total thrombosis of the portal vein. There was no statistical difference between patients with and without portal vein thrombosis according to clinical and endoscopic parameters during late follow-up. It was not possible to identify any predictive factor for the occurrence of this complication. CONCLUSIONS: Portal vein thrombosis is an early and frequent event after esophagogastric devascularization and splenectomy, usually partial with benign outcome and low morbidity. Total portal vein thrombosis is more frequently associated with a high morbidity complication, the superior mesenteric vein thrombosis. Long-term survival was not influenced by either partial or total portal thrombosis.

Caudate lobectomy: tumor location, topographic classification, and technique using right- and left-sided approaches to the liver.

BACKGROUND: Resection of the caudate lobe (involving segments I [dorsal sector] and/or IX [right paracaval region]) often presents a technical challenge. It is difficult to perform because of its deep location and adjacency to the major hepatic vessels (ie, the left and middle hepatic veins). METHODS: A literature review was performed based on a Medline search to identify articles on caudate lobectomy published from 1990 to 2005. This article describes the right and left-sided approaches to the liver for caudate resection according to caudate lobe tumor location and topographic classification. RESULTS: The results of 377 lobectomies were analyzed in this review. The left-sided approach to the liver was used in 55 (14.58%), the right-sided approach in 24 (6.36%), and both approaches in 298 (79.04%) caudate lobectomies. Primary benign and malign liver tumors, as well as secondary liver tumors, were resected. CONCLUSIONS: Access to and resection of the caudate lobe should be determined on the basis of tumor location and hepatic function. The left or right approach to the caudate lobe can be recommended for local resection of tumor located at Spiegel's portion or process portion. Approaches to caudate lobectomy are therefore largely dependent on size and location of the lesion, type of associated resection, and presence of scarring from previous resection.

Hepatic adenoma. Timing for surgery.

BACKGROUND/AIMS: Hepatic adenoma (HA) is a rare benign tumor of the liver. Tumor resection has been recommended for symptomatic or enlarging HA because of the risk of intraperitoneal, intrahepatic hemorrhage or even the development of hepatocellular carcinoma. From 1989 to 2003 we reviewed the medical records and radiology files of 28 patients with a proved diagnosis of hepatic adenoma. This article summarizes a single-center experience with surgical treatment of hepatic adenoma. METHODOLOGY: 24 patients were female and 4 were male. Twenty-two patients had a history of oral contraceptive use. Abdominal pain was presented in 19 patients and 3 of them had had an acute episode. The mean age was 36.3 years. Preoperative assessment included liver test, ultrasonography and computed tomography in all patients plus technetium (99mTc)-sulfur colloid and 99mTc-labeled DISIDA (dimethyliminoacetic acid) liver scintigraphy (n=19) and magnetic resonance imaging (n=22). RESULTS: Operative procedures included enucleation in 3 patients, two of them associated with hepatic segmentectomy; resection of one or two segments in 14 patients; left and right hemihepatectomy respectively in 7 and 3 patients; right extended hepatectomy in one patient and nonanatomic resection in one patient. There was no postoperative death and the complications were: bile leakage (re-operation) one patient, intraperitoneal abscess (re-operation) one patient, pleural effusion two patients, venous thrombosis one patient and wound infection one patient. CONCLUSIONS: We recommend that since the diagnosis has been well-established both enucleation or anatomically based resections of hepatic adenoma should be performed in all cases mainly in female patients taking oral contraceptives with tumors greater than 3cm for the risk of hepatic hemorrhage or even when malignancy cannot be excluded.

Selected patients with metastatic melanoma may benefit from liver resection.

BACKGROUND: In the last few years there has been expanding use of hepatic resection for non-colorectal metastases. The purpose of this study is to evaluate the experience of liver resection for patients with metastatic melanoma. METHODS: Eighteen patients with metastatic melanoma were explored for possible surgical resection. All patients fitted the following criteria: absence of extra-hepatic disease after evaluation with CT/MRI and FDG-PET scans; disease-free interval longer than 24 months after the resection of the primary melanoma; presumed completely resectable lesions; absence of clinical co-morbidities. RESULTS: Liver resection was performed in 10 patients; 8 out of 18 presented with irresectable tumors and/or peritoneal metastases and were not operated. One patient presented with postoperative biliary fistula and was conservatively managed. No other complications or postoperative mortality were observed. After a mean follow-up of 25.4 months, 5 patients are alive and without evidence of recurrence. Overall median survival was 22 months; overall survival and disease-free survival were 70% and 50% respectively. CONCLUSIONS: Resection of liver metastases from melanoma in a selected group of patients may increase survival. Exploratory laparoscopy should be included in the preoperative armamentarium of diagnostic tools.

Liver resection as the definitive treatment for unilateral non-oriental primary intrahepatic lithiasis.

BACKGROUND: The current study sought to evaluate the results of liver resection as the treatment for unilateral non-oriental primary intrahepatic lithiasis (PHIL). METHODS: Twenty-seven symptomatic patients (mean age 42 years) were submitted to liver resection; the indications were parenchymal fibrosis/atrophy in 22 and biliary stenosis in 5. Resection was associated with a Roux-en-Y hepaticojejunostomy in patients with a significant degree of dilation of the extrahepatic biliary duct. RESULTS: There was no operative mortality and the morbidity rate was 7.4% (2 patients with biliary fistula). After a median follow-up of 41.2 months, the overall rate of good results was 92.6%. All patients submitted to liver resection alone presented good late results, while 80% of those with associated hepaticojejunostomy did not have complications (P = .12). Late complications were observed in 2 patients (7.4%): 1 with a liver abscess and 1 with cholangitis and recurrent stones. There was no mortality during long-term follow-up. CONCLUSIONS: Liver resection showed low incidence of complications and good long-term results. None of the patients with unilateral disease without associated extrahepatic bile duct dilation presented complications and they were considered cured. We believe that resection indications should be expanded and the procedure should be indicated as routine in patients with unilateral PHIL even in the absence of parenchymal fibrosis/atrophy or biliary stenosis.

Functional evidence that the central renin-angiotensin system plays a role in the pressor response induced by central injection of cabachol

We investigated the effects of losartan, an AT1-receptor blocker, and ramipril, a converting enzyme inhibitor, on the pressor response induced by angiotensin II (ANG II) and carbachol (a cholinergic receptor agonist). Male Holtzman rats (250-300 g) with a stainless steel cannula implanted into the lateral ventricle (LV) were used. The injection of losartan (50 nmol/l mul) into the LV blocked the pressor response induced by ANG II (12 ng/1 mul) and carbachol (2 nmol/ 1 mul). After injection of ANG II and carbachol into the LV, mean arterial pressure (MAP) increased to 31 + 1 and 28 + 2 mmHg, respectively. Previous injection of losartan abolished the increase in MAP induced by ANG II and carbachol into the LV (2 + 1 and 5 + 2 mmHg, respectively). The injection of ramipril (12 ng/ 1 mul) prior to carbachol blocked the pressor effect of carbachol to 7 + 3 mmHg. These results suggests an interaction between central cholinergic pathways and the angiotensinergic system in the regulation of arterial blood pressure.

Behavior od collagen extracellular liver matrix during regenerative growth after partial hepatectomy of after stimulation by exogenous hepatotrophic factors

During regeneration after partial hepatectomy, the hepatic parenchyma grows by reproducing its histological elements at different rates. The hepatic cells grow more rapidy and the collagen components of the extracellular matrix more slowly. This report studies the behavior of liver tissue collagen intact livers, increased in size by stimulation with exogenous hepatotrophic factors, comparing them to regenerated livers after hepatectomy. The series consists of a group of rats (n = 4), seven days after 70 percent hepatectomy, with an average growth of the residual liver mass of 71.55 percent and another group (n = 4), seven days after stimulation of the intract livers with an average growth of 121.05 percent. The exogenous hepatotrophic factors administered intraperitoneally (portal) included glucose, amino acids, insultin, glucagon and triiodothyronine. The hepatic collagen content was compared by studyng slides stained with Picrossirius and examined with an optical microscope attached to a computer with an image analyzing program. The hepatic collagen was reduced from 2.07 percent + 0.13 to 1.14 + 0.08 (a difference of 44.57 percent; P<0.001) after hepatectomy and from 1.98 percent + 0.19 to 1.24 percent + 0.07 (difference of 37.46 percent; P<0.01) after exogenous hepatotrophic factors stimulation. It was concluded that the production of collagen in hepatic growth initiating with intact livers stimulated by exogenous hepatotrophic factors, occurs with a time difference similarly to what is observed after 70 percent hepatectomy.

Inhibitory effect of DUP-753 on the drinking responses of rats to central administration of noradrenaline and angiotensin II and to dehydration

We investigated the effect of losartan (DUP-753) on the dipsogenic responses produced by intracerebroventricular (icv) injection of noradrenaline (40 nmol/mul) and angiotensin II (ANG II (2 ng/mul) in male Holtzman rats weighing 250-300g. The effect of DUP-753 was also studied in animals submitted to water deprivation for 30 h. After control injections of isotonic saline (0.15 M NaCl, 1 mul) into the lateral ventricle (LV) the water intake was 0.2 ñ 0.01 ml/h. DUP-753 (50 nmol/mul) when injected alone into the LV of satiated animals had no significant effect on drinking (0.4 ñ 0.02 ml/h) (N = 8). DUP-753 (50 nmol/mul) injected into the LV prior to noradrenaline reduced the water intake from 2.4 ñ 0.8 to 0.8 ñ 0.2 ml/h (N = 8). The water intake induced by injection of ANG II and water deprivation was also reduced from 9.2+ 1.4 and 12.7 ñ 1.4 ml/h to 0.8 ñ 0.2 and 1.7 ñ 0.3 ml/h (N = 6 and N=8), respectively. These data indicate a correlation between noradrenergic pathways and angiotensinergic receptors and lead us to conclude that noradrenaline-induced water intake may be due to the release of ANG II by the brain. The finding that water intake was reduced by DUP-753 in water-deprived animals suggests that dehydration releases ANG II and, that AT1 receptors of the brain play an important role in the regulation of water intake induced by deprivation.

Losartan (DUP-753) blocks the natriuretic, kaliuretic and antidiuretic effect of intracerebroventricular injection of carbachol in water-loaded rats

We determined the effect of intracerebroventricular (icv) administration of losartan, an angiotensin II NG II), subtype I receptor (AT1) antagonist, on icv carbachol-induced natriuresis, kaliuresis and antidiuresis in water-loaded male Holtzman rats (250-300 g) with a cannula implanted into the lateral ventricle (LV). The rats were water loaded with 5 per cent of their body weight by gavage twice, with the second gavage one hour after the first. Carbachol (2 nmol in mul) was injected icv immediately after the second load. When losartan (DUP753, 50 nmol in 1 mul) was administered icv, it was given 3 min before carbachol. Previous icv treatment with losartan significantly reduced the icv carbachol-induced natriuresis (324 ñ 17 muEq/120 min), kaliuresis (103ñ15muEq /120min) and antidiuresis(13.5ñ2.1 ml/120 min) compared to the effects of previous icv injection of saline (Na+ excretion = 498 ñ 22 muEq/120 min; K+ excretion = 167 ñ 20 muEq/120 min; urine volume = 5.2 ñ 1.2 ml/l20 min). These results, reported as means ñ SEM for 12 rats in each group, are consistent with the hypothesis that AT1 subtype receptors participate in the regulation of body electrolyte balance.

Trombose mesentérica após a desconexão ázigo-portal com esplenectomia para o tratamento das varizes esofageanas sangrantes na esquistossomose mansônica, relato de três casos / Mesenteric venous thrombosis after azygos-portal disconnection with splenectomy for the treatment of bleeding esophageal varices in mansonian schistosomiasis. Three cases reports

The consequence of an acute mesenteric venous thrombosis following porta-azygos disconnection for the treatment of bleeding esophageal varices due to mansonian schistosomiasis has not been well defined in the literature. The clinical manifestations reported were fever, spasmodic abdominal pain associated with food intake. We treated three patients with thrombosis of the portal-mesenteric trunk following porta-azygos disconnection and adopted a conservative clinical approach in two patients while one had to have a surgical small bowel ressection.

Tratamento cirúrgico do cisto solitário de fígado / Surgical treatment of solitary liver cysts

Os cistos hepáticos simples, incomuns no passado, sao atualmente achados incidentais freqüentes em exames como ultra-sonografia e tomografia computadorizada. Os cistos muitas vezes atingem grandes proporçoes, levando à sintomatologia dolorosa ou complicaçoes, necessitando tratamento cirúrgico. A ressecçao cirúrgica ampla da cúpula do cisto, conhecida como "unroofing" ou marsupializaçao é uma técnica simples, advogada para o tratamento dos cistos sintomáticos. Dez pacientes com cistos simples, foram tratados através desta técnica, com bons resultados imediatos e tardios.

Aneurisma da artéria hepática: tratamento pela hepatectomia esquerda; relato de caso / Hepatic artery aneurysm: treatment by left hepatectomy; report of a case

É descrito um caso de aneurisma roto da artéria-hepática esquerda de 71 anos, do sexo feminino, com dor abdominal, emagrecimento e febre. O diagnóstico foi feito com uso de ultra-som com "doppler", tomografia computadorizada com contraste e angiografia do tronco celíaco e da artéria mesentérica superior. A rapidez no diagnóstico e a hepatectomia esquerda regrada levaram a um resultado satisfatório.

Estudo do sistema venoso hepático e sua aplicaçäo na técnica de transplante de fígado chamada Split-liver / Hepatic venous system and its application in liver transplantation technique named Split-liver

Estudou-se 60 fígados de cadáveres frescos adultos com o tronco celíaco, cabeça do pâncreas e artéria mesentérica. A veia porta direita, esquerda e seus ramos foram dissecados bem como as veias hepáticas. Encontrou-se ramo único da veia hepática direita em 59(98,3 por cento) casos, média em 53(88,3 por cento) e a esquerda em apenas 46(76,3 por cento). Em 59(98,3 por cento) casos havia os ramos portais direitos e esquerdos porém em um (1,6 por cento) näo havia bifurcaçäo da veia prota. A veia porta média foi encontrada em novel(15,2 por cento) casos. Em conclusäo, a técnica do "split-liver" seria contra-indicada no caso de näo bifurcaçäo portal