Orthotopic liver transplantation at King Chulalongkorn Memorial Hospital: a report.

Orthotopic liver transplantation (LT) is the treatment of choice for various liver diseases including early hepatocellular carcinoma (HCC). After the first successful LT in Thailand at King Chulalongkorn Memorial Hospital (KCMH) in 1987, the number of LT has gradually been increasing in parallel with the improvement in patient survival. The recent outcomes of LT are reported herein. From January 1, 2002 to June 30, 2013, 120 cases of adult LT and 24 cases of pediatric LT were performed. The most common indication for LT was HCC in the adult whereas biliary atresia was the most common indication for LT in pediatric patients. As for the severity of liver disease, the average model of end stage liver disease (MELD) and pediatric end stage liver disease (PELD) scores were 19 in adult LT and 21.5 in pediatric LT respectively. The most common perioperative complication in adult LT was acute renal failure (25%). One-, five-year patient survival in adult LT and pediatric LT were 85%, 69% and 96%, 91%, respectively. In conclusion, the outcomes of LT at KCMH have gradually been improving close to the world standard, especially the patient survival.

Partial segment-IV/V liver resection facilitates the repair of complicated bile duct injury.

The ability to perform a technically perfect anastomosis remains the key to success in bile duct repair. This report describes our technique in facilitating the performance of a good surgical anastomosis for difficult bile duct repair. In the present study are presented 3 cases of bile duct repair for a Strasberg type-E3 stricture, a Strasberg type-E4 fistula and an anastomotic stricture of a previously performed choledochojejunostomy for the correction of bile duct injury. The approach was to perform partial resection of the lower part of segments IV and V. The hepatoduodenal ligament was not dissected. The anterior surface of the bile duct was utilized to perform Roux-en-Y hepaticojejunostomy. Operative times ranged from 4 to 5 hours, and Pringle times 15 to 25 minutes. There was no vascular injury. We were able to perform wide anastomoses, facilitated by excellent exposure of the hilar plate. There was no any complication. Partial resection of the hepatic segments IV-V provides excellent exposure of the hilar plate. The risk of vascular injury was minimized by avoiding dissection of the hepatoduodenal ligament. It is believe this technique may offer a superior approach to difficult repair of complicated bile duct injury.

Acute mesenteric ischemia: still high mortality rate in the era of 24-hour availability of angiography.

BACKGROUND: Acute mesenteric ischemia (AMI) is a serious condition with high mortality rate due to difficult and late diagnosis. Early and aggressive evaluation in high risk patients by mesenteric angiography is the key to the reduction in mortality rate. However; many physicians hesitated to perform it because of its availability, the risk of complications and high negative results. This study reviewed outcome of AMI in term of mortality rate, factors associated with mortality and the rate of angiography in high risk patients. MATERIAL AND METHOD: The clinical data of the patients who were diagnosed as AMI were retrospectively reviewed. The clinical outcome was recorded and the factors associated with mortality were analysed. RESULTS: Thirty-five patients were enrolled into this study during 5 years. The mortality rate was 74.3%. There were 22 high risk patients for AMI. The rate of angiography performed in this group was 4.5% (1/22). The factors associated with mortality were age more than 60 years, patients with peritonitis, hypotension, arterial cause, time interval between admission and operation or treatment more than 24 hours, bowel gangrene >100 cms. However all these factors were not statistically significant. CONCLUSION: The mortality rate of AMI is still high even at the tertiary hospital where the angiography is available 24 hours. To decrease the mortality rate, the physicians must have the high index of suspicion in high risk patients and do not hesitate to perform early mesenteric angiography.

Risk factors associated with major intraoperative blood loss in hepatic resection for hepatobiliary tumor.

BACKGROUND AND PURPOSE: Hepatic resection is the mainstay treatment of hepatobiliary tumor Nowadays, mortality is less than 6%. However, morbidity is still high. Bleeding is one of the most common problems during hepatic resection which can sometimes lead to catastrophe. The purpose of the present study was to investigate the risk factors associated with major blood loss during hepatic resection for hepatobiliary tumor. MATERIAL AND METHOD: A total of 69 consecutive patients who underwent elective hepatic resection for hepatobiliary tumor from May 2002 to April 2004 were enrolled into this retrospective study. The Patients were divided into 2 groups(group I and II) according to the intraoperative blood loss. Patients who had a blood loss of more than 1000 ml were defined as the major blood loss group(group I). Thirteen variable factors were analyzed to determine the risk of major intraoperative blood loss. Operative outcomes between the two groups were also compared. RESULTS: Of the sixty-nine patients, 36 patients were in group I and 33 patients were in group II. 75% of the patients in group I and 36.4% of the patients in group II were transfused. Median blood transfusion in group I and II were 3 and 0 units of packed red cell. Univariate analysis showed tumor size, extent of hepatic resection, tumor pathology and operative time were factors affecting major intraoperative blood loss. However, multivariate analysis showed only operative time and tumor size to be independent risk factors. Patients in group I had higher surgical morbidity and prolonged hospital stay compared with patients in group II. CONCLUSION: Blood loss is still a major concern in performing hepatic resection. From the present study, tumor size and operative time are the independent factors affecting major intraoperative blood loss. Proper screening or a surveillance program may enhance the chance to find small tumors. Refined operative techniques such as anterior approach and liver hanging would facilitate resection for large right sided tumors.