Complex hepatectomy under total vascular exclusion of the liver: impact of ischemic preconditioning on clinical outcomes.

BACKGROUND: Hepatic inflow clamping during hepatectomy introduces ischemia-reperfusion (I/R) injury, and many authors regard the addition of caval occlusion as adding increased risk. Ischemic preconditioning (IPC) is one of the protective strategies employed to reduce I/R injury in animal experiments and limited clinical series. The aim of the present study was to determine the impact of systematic adoption of IPC in patients undergoing complex hepatectomy under total hepatic vascular exclusion (TVE) based on outcomes review. METHODS: The records of 93 patients who underwent major hepatectomy involving TVE at our center from February 1998 to December 2008 were reviewed. These patients were divided into two groups: group 1 (n = 55, TVE alone) and group 2 (n = 38, TVE with IPC). IPC was performed by portal triad clamping for 10 min followed by 3-5 min of reperfusion prior to TVE and resection. RESULTS: The two groups were comparable regarding demographics, underlying liver diseases, indications for hepatectomy, duration of TVE, and preoperative liver and kidney function tests. Overall postoperative laboratory results of liver function tests were not significantly different between the two groups. Creatinine levels and prothrombin times were not significantly different between the groups. The use of IPC had no impact on the duration of the operation, blood loss, or hospital stay. The morbidity rates were 37.5 and 34.2 %, respectively. CONCLUSIONS: Our adoption of IPC as a protective strategy against I/R injury under TVE did not affect operative or laboratory parameters and clinical outcomes when compared to continuous clamping for comparable ischemic periods.

Distal appendiceal dilatation in equivocal appendicitis may be a useful sign for prediction of normal appendix.

Despite many efforts to reduce unnecessary appendectomy for appendicitis, the negative appendectomy rate remains relatively high. Here, we investigated predisposing factors for normal appendix by analyzing the surgical outcomes for patients with equivocal appendicitis. Over a 3-year period, 1516 patients underwent treatment for appendicitis and 148 (10%) were prospectively diagnosed with equivocal appendicitis. We defined equivocal appendicitis as a right lower quadrant pain with tenderness and an apppendiceal diameter of 6 to 9 mm without appendicolith or severe adjacent inflammation as radiological findings. We investigated normal appendix rates in relation to clinical and radiological features. Of the 148 patients, 48 (32%) had a normal appendix and 100 had appendicitis. A higher normal appendix rate was found for low white blood cell count than for leukocytosis (41% vs 23%, odds ratio (OR) = 2.48), and laparoscopic treatment was then open (42% vs 21%, OR = 2.58). Distal appendiceal dilatation, as determined by radiological imaging, was associated with a higher normal appendix rate than whole dilatation (60% vs 27%, OR = 3.96). Low white blood cell count, laparoscopic treatment, and distal appendiceal dilatation were significant predisposing factors for normal appendix after surgery. Radiologically determined distal dilatation of the appendix may be a useful sign for predicting normal appendix.

Totally laparoscopic left hemihepatectomy using ventral hilum exposure (VHE) for intrahepatic bile duct stone.

The unique technique of ventral hilum exposure (VHE) was reported that it had excellent surgical outcomes in patients with intrahepatic bile duct stone. The basis of this surgical technique is that all the openings of the 2nd-order bile duct branches are exposed fully. In this article, we describe laparoscopic hemihepatectomy from using the VHE method in a patient with intrahepatic bile duct stone. Our patient was a 70-year-old female who had been diagnosed with an intrahepatic duct stone 30 years prior. Multiple intrahepatic bile duct stones in the left lateral section of the liver were revealed by abdominal computed tomography and magnetic resonance cholangiopancreatography. The patient resumed her oral intake on postoperative day 6. The patient had hyperbilirubinemia (10.3 mg/100 mL) on postoperative day 10. However, her serum bilirubin level decreased to 2.7 mg/100 mL on postoperative day 28. She was discharged without any serious complications on postoperative day 31. Totally laparoscopic left hemihepatectomy, using the VHE method, can be one option of surgical procedure in the near future, although a larger series of cases should be necessary to prove the feasibility of laparoscopic VHE.