Dragon 1 Protocol Manuscript: Training, Accreditation, Implementation and Safety Evaluation of Portal and Hepatic Vein Embolization (PVE/HVE) to Accelerate Future Liver Remnant (FLR) Hypertrophy.

STUDY PURPOSE: The DRAGON 1 trial aims to assess training, implementation, safety and feasibility of combined portal- and hepatic-vein embolization (PVE/HVE) to accelerate future liver remnant (FLR) hypertrophy in patients with borderline resectable colorectal cancer liver metastases. METHODS: The DRAGON 1 trial is a worldwide multicenter prospective single arm trial. The primary endpoint is a composite of the safety of PVE/HVE, 90-day mortality, and one year accrual monitoring of each participating center. Secondary endpoints include: feasibility of resection, the used PVE and HVE techniques, FLR-hypertrophy, liver function (subset of centers), overall survival, and disease-free survival. All complications after the PVE/HVE procedure are documented. Liver volumes will be measured at week 1 and if applicable at week 3 and 6 after PVE/HVE and follow-up visits will be held at 1, 3, 6, and 12 months after the resection. RESULTS: Not applicable. CONCLUSION: DRAGON 1 is a prospective trial to assess the safety and feasibility of PVE/HVE. Participating study centers will be trained, and procedures standardized using Work Instructions (WI) to prepare for the DRAGON 2 randomized controlled trial. Outcomes should reveal the accrual potential of centers, safety profile of combined PVE/HVE and the effect of FLR-hypertrophy induction by PVE/HVE in patients with CRLM and a small FLR. TRIAL REGISTRATION: Clinicaltrials.gov: NCT04272931 (February 17, 2020). Toestingonline.nl: NL71535.068.19 (September 20, 2019).

Detection of pancreatic neuroendocrine tumors: 23 years of experience. / Detección de tumores neuroendocrinos pancreáticos: 23 años de experiencia.

INTRODUCTION AND AIMS: Neuroendocrine tumors are of great scientific interest, given that they are difficult to diagnose and treat. Despite being relatively rare (< 1/100,000 individuals, 1-2% of the gastrointestinal neoplasias) and indolent, their potential malignancy must not be forgotten. An increase in the number of diagnosed tumors has been observed in recent years. The aim of the present study was to update a published case series of 19 patients suspected of presenting with pancreatic neuroendocrine tumor with 51 current cases, to study and compare the new results with those of the previous case series, as well as with other recent publications from Spain, the United States, China, and India. MATERIALS AND METHODS: A retrospective, multicenter case series was conducted on 70 patients (19 cases published in 2011), whose data has been collected over a period of 23 years. The variables analyzed were: age, sex, symptomatology, tumor size, location, metastasis, final diagnosis, and surgery, among others. RESULTS: Mean patient age was 55 years and 60% of the patients were men. Disease location was the pancreatic head in 28.5% of the patients and the tail in 27.1%, mean tumor size was 3.9cm (0.2-10cm), 71.4% of the patients had non-functioning tumors, 32.8% had metastases (100% to the liver), 74.2% of the patients were operated on, and actuarial survival was 75%. CONCLUSIONS: Differences were observed between the previously published case series and the current results. There was an increase in incidentalomas and non-functioning tumors, but no variation in the overall survival rate. The differences with other case series (age, sex, and tumor location) were dependent on the country where the cases were compiled. The increase in tumors could be related to a higher number of diagnoses made through imaging studies and to the greater sensitivity of the devices employed.

Resultados iniciales del Registro Nacional de Cirugía Hepática por Laparoscopia / Initial results of the National Registry of Laparoscopic Liver Surgery

Introducción. La experiencia en cirugía hepática por laparoscopia es limitada; para realizar una valoración crítica son necesarias series amplias y multicéntricas. Objetivo. Analizar los resultados del registro nacional de cirugía hepática por vía laparoscópica. Valorar las indicaciones, los aspectos técnicos, el índice de conversión y la morbimortalidad. Pacientes y método. Se incluye a 74 pacientes de 10 centros de febrero de 2000 a abril de 2005. Cincuenta y ocho mujeres y 16 varones, con una edad media de 55 años. Dieciséis pacientes presentaban más de una lesión, por lo que se trató a 74 pacientes con 156 lesiones. Resultados. Cuarenta y seis pacientes presentaban lesiones quísticas (26 quistes simples, 13 enfermedad poliquística, 5 quistes hidatídicos y 2 cistoadenomas). Se practicaron 37 fenestraciones, 5 quistoperiquistectomías, 2 resecciones limitadas, 1 segmentectomía y 1 bisegmentectomía II-III. En 28 pacientes las lesiones eran sólidas (4 adenomas, 6 hiperplasias nodulares focales, 3 hemangiomas, 4 hepatocarcinomas, 5 metástasis colorrectales, 2 metástasis de pulmón, 1 metástasis de mama, 1 metástasis de melanoma maligno, 1 metástasis de vipoma pancreático y 1 linfoma). Se realizaron 10 bisegmentectomias II-III, 17 resecciones limitadas y 1 segmentectomía del segmento III. En 23 casos se asoció otra cirugía. El tiempo quirúrgico medio fue de 160,5 min y el índice de conversión, del 8%. La estancia media fue de 5,6 días, y el 78% de los pacientes estuvo menos de 5 días. En el 55% la analgesia se administró menos de 48 h. La morbilidad fue de 8 casos (11%). Tres casos fueron reintervenidos. No existió mortalidad en la serie. Conclusiones. La resección hepática laparoscópica es factible y segura en casos seleccionados. Se hace necesario disponer de series amplias y controladas para conocer los resultados a largo plazo. El registro nacional es una buena alternativa para valorar la cirugía hepática realizada por vía laparoscópica en España (AU)

Introduction. Experience in laparoscopic liver surgery is limited, and multicenter studies with large series are required for a critical evaluation of this type of surgery. Objective. To analyze the results of the National Registry of Laparoscopic Liver Surgery. Indications, technical features, conversion rates, morbidity, and mortality were analyzed. Patients and method. Seventy-four patients from 10 centers who underwent surgery between February 2000 and April 2005 were included. There were 58 women and 16 men, with a mean age of 55 years. More than one lesion was present in 16 patients. Consequently, 74 patients with 156 lesions were treated. Results. Forty-six patients had cystic lesions (26 simple cysts, 13 polycystic disease, five hydatid cysts and two cystic adenomas). Surgical treatment consisted of 37 fenestrations, five cystopericystectomies, two atypical resections, one segmentectomy and one bisegmentectomy of segments II-III. In 28 patients the lesions were solid (four adenomas, six focal nodular hyperplasias, three hemangiomas, four hepatocarcinomas, five colorectal metastases, two lung metastases, one breast metastasis, one malignant melanoma metastasis, one pancreatic vipoma metastasis, and one lymphoma). Ten bisegmentectomies of segments II-III, 17 atypical resections and one segmentectomy of segment III were performed. Other surgery was associated in 23 patients. The mean operating time was 160.5 minutes and the conversion rate was 8%. The mean length of hospital stay was 5.6 days and was less than 5 days in 78% of the patients. Analgesia was administered for less than 48 hours in 55%. Morbidity was observed in eight patients (10.8%). Reoperations were performed in three patients. There was no mortality in this series. Conclusions. Laparoscopic hepatic resection is safe and feasible in selected patients. Large, controlled series are required to determine long-term outcomes. The national registry provides a good basis for evaluating laparoscopic liver surgery in Spain (AU)

[Initial results of the National Registry of Laparoscopic Liver Surgery]. / Resultados iniciales del Registro Nacional de Cirugía Hepática por Laparoscopia.

INTRODUCTION: Experience in laparoscopic liver surgery is limited, and multicenter studies with large series are required for a critical evaluation of this type of surgery. OBJECTIVE: To analyze the results of the National Registry of Laparoscopic Liver Surgery. Indications, technical features, conversion rates, morbidity, and mortality were analyzed. PATIENTS AND METHOD: Seventy-four patients from 10 centers who underwent surgery between February 2000 and April 2005 were included. There were 58 women and 16 men, with a mean age of 55 years. More than one lesion was present in 16 patients. Consequently, 74 patients with 156 lesions were treated. RESULTS: Forty-six patients had cystic lesions (26 simple cysts, 13 polycystic disease, five hydatid cysts and two cystic adenomas). Surgical treatment consisted of 37 fenestrations, five cystopericystectomies, two atypical resections, one segmentectomy and one bisegmentectomy of segments II-III. In 28 patients the lesions were solid (four adenomas, six focal nodular hyperplasias, three hemangiomas, four hepatocarcinomas, five colorectal metastases, two lung metastases, one breast metastasis, one malignant melanoma metastasis, one pancreatic vipoma metastasis, and one lymphoma). Ten bisegmentectomies of segments II-III, 17 atypical resections and one segmentectomy of segment III were performed. Other surgery was associated in 23 patients. The mean operating time was 160.5 minutes and the conversion rate was 8%. The mean length of hospital stay was 5.6 days and was less than 5 days in 78% of the patients. Analgesia was administered for less than 48 hours in 55%. Morbidity was observed in eight patients (10.8%). Reoperations were performed in three patients. There was no mortality in this series. CONCLUSIONS: Laparoscopic hepatic resection is safe and feasible in selected patients. Large, controlled series are required to determine long-term outcomes. The national registry provides a good basis for evaluating laparoscopic liver surgery in Spain.

Mujer de 18 años que acude a urgencias por presentar traumatismo abdominal / An 18-year-old woman who presented to the emergency room with closed abdominal trauma after a road traffic

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[Laparoscopic resection of hepatic hydatid cyst under general anesthesia with remifentanil infusion]. / Resección de quiste hidatídico hepático por laparoscopia bajo anestesia general con perfusión de remifentanilo.

We report the case of a 52-year-old woman who underwent scheduled laparoscopic resection of a hydatid liver cyst under general anesthesia by infusion of remifentanil and sevoflurane. Surgery was uneventful, although invasive monitoring was required, just as it would have been in major open abdominal surgery, given the risk of bleeding secondary to organ manipulation, the risk of anaphylactic shock related to the etiology of the cyst and the possibility of gas embolism related to laparoscopy. The concept of "minimally invasive" surgery has developed thanks to continued progress in laparoscopy. The considerable advantages of such procedures in comparison with "open" or "conventional" surgery has led to their use with organs such as the liver, which in principle require caution. In such cases, the anesthesiologist must take an approach that is not as simple or minimalist as the term "minimally invasive" might lead us to expect.

Resección de quiste hidatídico hepático por laparoscopia bajoanestesia general con perfusión de remifentanilo / Laparoscopic resection of a hydatid liver cyst under general anesthesia with infused remifentanil

Una mujer de 52 años diagnosticada de un quiste hidatídico hepático, que fue sometida de forma programada a su resección por laparoscopia bajo anestesia general con perfusión de remifentanilo y sevoflurano. La cirugía trascurrió sin incidencias, destacando la necesidad de una monitorización invasiva como si se tratara de una cirugía abdominal mayor abierta, dado el riesgo de sangrado secundario a la manipulación del órgano, el riesgo de shock anafiláctico por la etiología del quiste y la posibilidad de un embolismo gaseoso en relación con la laparoscopia. El concepto de "cirugía mínimamente invasiva" desarrollado gracias a la continua evolución de la cirugía laparoscópica, y sus importantes ventajas frente a la "cirugía abierta o convencional", ha favorecido el abordaje de órganos que como el hígado planteaban a priori, una serie de grandes reservas. Este tipo de cirugía obliga al anestesiólogo a realizar un abordaje anestésico, no tan simple o minimalista como podría engañosamente hacernos creer la denominación inicial de "mínimamente invasiva" (AU)

Tratamiento combinado endoscópico-laparoscópico de la coledocolitiasis / Treatment of choledocolithiasis combined endoscopic and laparoscopic

Objetivo. Evaluar los resultados de la colangiopancreatografía retrógrada endoscópica (CPRE), esfinterotomía endoscópica y colecistectomía por laparoscopia en el diagnóstico y tratamiento de la coledocolitiasis. Pacientes y métodos. Entre junio de 1991 y diciembre de 1998, se han estudiado de forma prospectiva 1.667 pacientes sometidos a cirugía laparoscópica. Se observaron criterios clínicos, analíticos o ecográficos de sospecha de coledocolitiasis asociada en 394 pacientes (23 por ciento) y fueron estudiados mediante CPRE preoperatoria. En caso de diagnóstico de coledocolitiasis se practicó esfinterotomía y se intentó su extracción endoscópica. Posteriormente, fueron sometidos a colecistectomía laparoscópica, excepto 25 pacientes, que fueron excluidos. Resultados. El rendimiento diagnóstico fue, para la coledocolitiasis de un 57,7 por ciento (213 pacientes), para la vía biliar dilatada sin litiasis de un 10,5 por ciento (39 pacientes) y para la exploración normal de un 28,7 por ciento (106 pacientes). Se produjo fracaso por imposibilidad de evaluación de la vía biliar principal en el 2,9 por ciento (11 pacientes). Mediante la CPRE se consiguió un tratamiento satisfactorio en el 93,4 por ciento (199/213 pacientes) y fracasó en 14 pacientes (6,6 por ciento). La tasa de complicaciones relacionadas con la CPRE fue de 7,8 por ciento y con la colecistectomía laparoscópica del 10 por ciento. La mortalidad de la serie para la totalidad del procedimiento diagnóstico-terapéutico fue del 0,5 por ciento (2 pacientes). Once pacientes (5 por ciento) presentaron coledocolitiasis residual tras CPRE-colecistectomía laparoscópica tratada con éxito en todos ellos mediante una nueva CPRE. Conclusiones. El abordaje combinado en dos tiempos de la coledocolitiasis utilizando CPRE selectiva, seguida de colecistectomía laparoscópica, es una buena alternativa terapéutica. No obstante, los criterios de sospecha de coledocolitiasis empleados clásicamente implican un considerable número de exploraciones con probabilidad innecesarias, y por tanto, parece necesario modificar la estrategia diagnóstica actual (AU)

Estadificación laparoscópica del cáncer digestivo / Laparoscopic staging of gastrointestinal cancer

Introducción. Establecer el estadio de los tumores digestivos es de gran importancia a la hora de plantear su tratamiento. La estadificación laparoscópica y la ecografía por laparoscopia, como método para explorar la cavidad abdominal, se han introducido de forma progresiva en los algoritmos diagnóstico-terapéuticos de estos pacientes. Resultados. En la experiencia de los autores, la estadificación laparoscópica en el cáncer gástrico evita la laparotomía innecesaria en el 40 por ciento de los casos, con una exactitud en la resecabilidad tumoral del 98 por ciento. En el cáncer de cardias y esófago, así como en el cáncer colorrectal, ofrece importante información en cuanto a la existencia de diseminación a distancia o metástasis hepáticas, especialmente con la ayuda de la ecografía por laparoscopia. En cirugía hepatobiliopancreática es donde se manifiesta especialmente la utilidad de la ecografía por laparoscopia, permitiendo modificar el estadio tumoral establecido preoperatoriamente y evitar un 25 por ciento de laparotomías en tumores hepáticos. En el cáncer de páncreas, la estadificación y ecografía por laparoscopia modifica la actitud inicial en el 35 por ciento de los casos y evita una laparotomía innecesaria en el 20 por ciento. Conclusión. La estadificación laparoscópica es de gran utilidad para establecer el estadio intraoperatorio de los tumores digestivos y puede ayudar a la hora de tomar decisiones intraoperatorias. En el caso de los tumores hepatobiliopancreáticos, la información adicional ofrecida por la ecografía laparoscópica permite disminuir la incidencia de laparotomías innecesarias y debe plantearse como paso previo a la cirugía (AU)

Opciones actuales para el diagnóstico y tratamiento de la coledocolitiasis / Existing options for the diagnosis and treatment of choledocholitiasis

La colangiografía retrógrada endoscópica y la cirugía mínimamente invasiva han modificado el protocolo clásico de tratamiento de la litiasis de la vía biliar principal. En la actualidad, existen diferentes estrategias diagnósticas y terapéuticas para abordar la coledocolitiasis, en un intento de que los pacientes con esta afección se beneficien también de un abordaje mínimamente invasivo. Sin embargo, no existe consenso respecto a cuál es el algoritmo de diagnóstico y tratamiento de la litiasis de la vía biliar principal que pueda considerarse el patrón oro o gold standard, y el manejo de esta enfermedad depende hoy día de la experiencia y las posibilidades de disponibilidad tecnológica de cada grupo de trabajo. El objetivo de este artículo es revisar las diferentes opciones técnicas de las que se dispone en la actualidad para el diagnóstico y tratamiento de la coledocolitiasis, describiendo sus resultados, ventajas e inconvenientes (AU)

Treatment options for villous adenoma of the ampulla of Vater.

INTRODUCTION: Duodenal villous adenoma arising from the ampulla of Vater has a high risk of malignant development. Excluding associated malignant disease prior to resection of an adenoma of the ampulla is not always possible. Therefore, the surgical procedure of choice to treat this rare tumour is still controversial. OBJECTIVE: To evaluate retrospectively results of treatment of villous adenoma arising from ampulla of Vater with dysplasia or associated carcinoma limited to the ampulla. PATIENTS AND METHODS: From 1985 to 1996, eight patients have been diagnosed with ampullary villous adenoma suitable for resection. We have reviewed treatment, morbidity, mortality, follow-up and final outcome. RESULTS: Pancreatoduodenectomy (PD) was performed in 4 patients. Transduodenal ampullectomy and endoscopic resection was performed in 2 patients each. There was no perioperative mortality. None of the patients had biliary, pancreatic or intestinal leakage but two patients who underwent PD had minor postoperative complications. The mean follow-up was 44 (range: 6-132) months. Villous adenoma was associated with adenocarcinoma in 50% of the cases (4/8 patients). During the follow-up both patients who underwent transduodenal ampullectomy developed recurrent disease. All patients initially treated by PD are alive without evidence of recurrent disease. CONCLUSIONS: Treatment of villous adenoma of the ampulla must be individualized within certain limits. In our series, PD achieve good results and it appears to be the procedure of choice in order to treat villous adenomas with proved presence of carcinoma, carcinoma in situ or severe dysplasia. Endoscopic or local resection may be appropriate for small benign tumours in high risk patients.

Must ERCP Be routinely performed if choledocholithiasis is suspected?

OBJECTIVE: To evaluate the results of preoperative endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of those patients suspected of harboring bile duct stones before laparoscopic cholecystectomy (LC). PATIENTS AND METHODS: A total of 1,235 consecutive LCs performed between 1991 and 1997 were studied prospectively. ERCP was performed to explore the common bile duct (CBD) preoperatively when choledocholithiasis was suspected on the basis of clinical, analytical or echographical data. RESULTS: ERCPs were performed in 268 patients: unsuccessful CBD evaluation in 3%; dilated CBD without lithiasis in 13%, and normal exploration in 37% (99 patients). CBD stones were found in 46% (124 patients), and endoscopic sphincterotomy was then performed and stone extraction attempted. Endoscopic therapy achieved 92.8% successful removal of CBD stones (115 patients). There was no ERCP-related mortality and the morbidity rate was 6%. Retained CBD stones have been observed in 7 cases after ERCP-LC; all of them have been successfully treated by ERCP. CONCLUSIONS: A combined approach to bile duct stones with selective use of ERCP followed by LC is a good therapeutical alternative. Nevertheless, the usual selection criteria for ERCP may lead to unnecessary exploration. It appears to be necessary to modify the current diagnostic and therapeutic strategy.

[Survival after resection of lung metastasis from colorectal cancer]. / Supervivencia tras resección de metástasis pulmonares de cáncer colorrectal.

OBJECTIVE: To analyze the results of resection of lung metastases from colorectal adenocarcinoma in selected patients, evaluating type of resection, morbidity and mortality associated with the procedure, and overall actuarial survival rates after surgery. PATIENTS AND METHODS: Between 1988 and 1996, 811 patients were treated surgically for colorectal adenocarcinoma. Recurrent chronic lung metastases were resected, presumably with the intention to cure, in 15 patients in the series. One patient underwent surgery for pelvic recurrence and another seven for liver metastases, before resection of the lung metastases. RESULTS: Twenty-seven wedge resections were performed, two being non-malignant and one patient requiring re-resection of new lung metastases. Unsuspected locations of lung metastasis were found in three patients during surgery. Perioperative mortality was zero. Mean follow-up was 50 months (range 28 to 99). Seven patients presented new occurrences of metastasis or tumor recurrence and died as a result. The actuarial survival rate was 48% at 5 years. CONCLUSIONS: In selected patients, surgical resection of lung metastasis from colorectal cancer, with the assumed intention of cure, has yielded a good survival rate and zero perioperative mortality. It appears advisable to use an approach that permits exhaustive palpation of the pulmonary parenchyma, due to the risk of finding unsuspected metastases.

Laparoscopic ultrasound guidance for laparoscopic resection of benign gastric tumors.

Laparoscopic excision of gastric leiomyoma is technically feasible and safe, but it may fail to localize the exact placement of the lesion because of the lack of tactile sensitivity. The authors present two cases of small gastric leiomyomas that were resected by a totally laparoscopic approach, assisted with intraoperative laparoscopic ultrasonography because the lesions could not be palpated. A gastric wedge resection with tumor-free margins was performed with an endostapler device. Use of a harmonic scalpel to divide the gastroepiploic vessels facilitated the laparoscopic procedure.

How, when, and why bile duct injury occurs. A comparison between open and laparoscopic cholecystectomy.

BACKGROUND: Bile duct injury (BDI) is a severe complication of laparoscopic cholecystectomy (LC). There is general agreement about the increase of this complication after LC vs open cholecystectomy (OC), but comparative studies are scarce. The aim of this paper has been to compare the incidence and clinical features of BDI after LC vs open procedures. MATERIALS AND METHODS: 3,051 OC, performed from June 1977 to December 1988 were retrospectively analyzed and compared with 1,630 LCs performed from June 91 to August 96, for which data were prospectively recorded. Age, sex, type of BDI, performance of intraoperative cholangiography (IOC), underlying biliary pathology, morbidity, mortality, and late morbidity were all analyzed. RESULTS: BDI incidence was higher in group II (LC) (N: 16, 0.95%) than in group I, (OC, N: 19. 0.6%). BDI incidence was also higher in the group of patients in which it was necessary to convert to an open procedure (3/109, 2.7%, p < 0.05). BDIs were more frequently diagnosed intraoperatively in group I (OC, 18/19) than in group II (LC, 12/16). In both groups, BDI was more prevalent in cases operated by staff surgeons than residents, mainly in complicated gallbladder patients, with a bile duct of less than 7-mm diameter. Morbidity, postoperative stay, mortality, and late morbidity were similar after a BDI in both types of approach. CONCLUSIONS: (1) BDI increases with LC. (2) BDI after LC carries a similar postoperative morbidity and mortality to those after OC. (3) Incidence of BDI in converted cases increases significantly and this constitutes a high-risk group.

Vena cava vascular reconstruction during orthotopic liver transplantation: a comparative study.

The aim of this study was to evaluate the influence of preserving the recipient's inferior vena cava during orthotopic liver transplantation (OLT) on hemodynamic alterations, blood component requirements, postoperative liver and renal function, as well as vascular-related complications. A total of 122 OLTs was studied. In 35 OLTs, venovenous bypass (BP) was used; in 35 OLTs, bypass was not used (NBP); and in 52 OLTs, the recipient's inferior vena cava was preserved (PC). Preservation of the inferior vena cava means that venous return is not compromised at any time during transplantation. The time of hepatectomy was not different among the three groups (208 +/- 11, 188 +/- 13, and 194 +/- 6 minutes for BP, NBP, and PC, respectively); however, the total operating time was significantly lower in PC patients (492 +/- 24, 459 +/- 18, and 419 +/- 10 minutes for BP, NBP, and PC, respectively; P = .004, ANOVA). Blood component requirements were significantly lower in patients with PC. For red blood cells, these were 15.2 +/- 2.6, 16 +/- 3.4, and 7.1 +/- 1.5 units for BP, NBP, and PC, respectively (P = .009, ANOVA), and for fresh-frozen plasma, these were 5.4 +/- .7, 5.8 +/- .9, and 3 +/- .4 L for BP, NBP, and PC, respectively (P = .005, ANOVA). Postoperative liver and renal function did not differ among the three groups. The incidence of surgical complications (bleeding and vascular) was similar. Preservation of the inferior vena cava of the recipient significantly reduces the magnitude of OLT.

Effect of venovenous bypass on perioperative renal function in liver transplantation: results of a randomized, controlled trial.

Although venovenous bypass (VVBP) has been suggested to protect the kidneys during liver transplantation and its systematic use has therefore been recommended, this beneficial effect of VVBP has not been clearly demonstrated. In a prospective, randomized, controlled trial, 77 patients receiving liver transplants for chronic liver disease were allocated to be supported with VVBP (group 1, 38 patients) or not (group 2, 39 patients). Both groups were similar in relation to preoperative clinical and laboratory data and operative transfusion requirements. Inulin clearance and urinary beta(2)-microglobulin and N-acetyl-beta-D-glucosaminidase (NAG) excretion (to determine glomerular filtration rate and tubular damage, respectively) were measured at different perioperative periods (anesthesia induction, hepatectomy, anhepatic phase, biliary anastomosis, and 24 hours after surgery). A significant decrease in inulin clearance and increase in tubular damage markers were observed in the anhepatic phase, which only partly improved in the subsequent phases. No significant differences were observed between groups 1 and 2 at any perioperative phase, except during the anhepatic phase, in which a more marked renal function impairment occurred in group 2 patients. However, renal function on the 7th postoperative day and the need for hemodialysis/ hemofiltration during the 1st week were similar in both groups. Among 40 variables analyzed, only low mean arterial pressure at anesthesia induction was identified as an independent predictor for early postoperative severe renal failure (inulin clearance < 10 mL/min/1.73 m(2) at the 24th postoperative hour), with no significant relationship between this complication and the use of venovenous bypass. Renal function markedly deteriorates during liver transplantation, and renal impairment persists during the early postoperative period. Because VVBP support is not associated with any clear benefit in renal function, its systematic use does not seem to be justified.

Prostacyclin, thromboxane, and oxygen free radicals and postoperative liver function in human liver transplantation.

The aim of this prospective study is to evaluate prostanoid (prostacyclin and thromboxane) and lipid peroxide levels at the portal and hepatic veins, and their relation to immediate postoperative liver function. Nineteen patients with liver cirrhosis undergoing orthotopic liver transplantation were prospectively studied. Blood samples were obtained within 5 min and 1 and 2 hr after reperfusion of the new liver, through a catheter placed at the portal vein in the recipient and another at the left hepatic vein in the donor liver. Plasma prostacyclin and thromboxane were analyzed by HPLC and RIA. The formation of lipid peroxides was determined and expressed in terms of thiobarbituric acid-reacting substances. Immediate postoperative liver function was evaluated using the transaminase levels within the first 48 hr and the early postoperative graft function score, as described previously. After reperfusion, only determinations at 5 min were related with liver function. Either prostacyclin (R = -0.61, P = 0.004) levels at the hepatic vein or prostacyclin production (subtraction between hepatic and portal vein levels) (R = -0.47, P = 0.04) correlated significantly with the early postoperative graft function score. Besides, there was a significant relationship between lipid peroxide production as measured by thiobarbituric acid-reacting substances and a worse early postoperative graft function score (R = 0.61, P = .005). These results suggest that prostacyclin released after liver grafting attenuates preservation and reperfusion damage of the liver, supporting the hypothesis that there is an imbalance of prostanoids within the microvasculature in patients with a compromised postoperative liver function. Our results agree with the involvement of some degree of lipid peroxidation products in the damage of hepatocytes during anoxia and reperfusion.