1 TRANSPLANTATION OF HUMAN MONOCYTE-DERIVED ‘NEO-HEPATOCYTES’ INTORODENT ANIMAL MODELS—ANALYSIS OF INTEGRATION AND IN VIVO FUNCTION
Ruhnke M2, Hengstler J1, Dietl H2, Lange H2, Ungefroren H2, Nussler A3, Kremer B2, Faendrich F2, (1) Institute of Toxicology, University of Leipzig, Leipzig, Germany; (2) Department of General and Thoracic Surgery, University of Schleswig-Holstein, Campus Kiel, Kiel, Germany; (3) Fresenius Biotech AG, Bad Homburg, Germany
INTRODUCTION AND AIM: Liver transplantation is the only curative treatment of end-stage liver diseases. There is a great demand for alternatives such as biomedical bridging devices or hepatocyte transplantation. We have generated “neo-hepatocytes” from human monocytes which show specific in vitro functions and transplanted these “neo-hepatocytes” into livers of healthy mice and into the spleens of non-albuminergic Nagase rats. PATIENTS AND METHODS: Human monocytes were exposed to MCSF and IL-3 for 6 days, then to FGF4 for 10 days. After confirmation of albumin secretion 1×107 cells were injected intrahepatically into immunocompetent healthy mice or into the spleen of immunosupressed Nagase rats. Liver and spleen specimens were analyzed for human albumin expression at days 5,10 and 21 after transplantation. Fusion was analyzed by in situ hybridization. In Nagase rats levels of human albumin were measured in the serum at days 3, 7, 10 and 21. RESULTS: In mice “neo-hepatocytes” integrated into the liver parenchyma and could be visualized up to day 21. They specifically express human albumin, not mouse albumin and form small colonies. There were no signs of rejection. Fusion was excluded by FISH. In Nagase rats serum levels of human albumin increased rapidly after injection of “neo-hepatocytes” following a decrease after day 10. Cells integrated into the spleen and liver of Nagase rats. CONCLUSION: “Neo-hepatocytes” integrate into liver parenchyma of rodents and show reliable albumin synthesis in vivo. If produced from a human individual these cells could serve for autologous treatment of liver disease without the need for immunosuppressants.
2 TAURINE IMPROVES HEPATIC MICROCIRCULATION AFTER WARM ISCHEMIAIN THE RAT
Kincius M1, Ryschisch E1, Riu L1, Flechtenmacher C2, Mehrabi A1, Gebhard MM2, Kraus TW1, Büchler MW1, Schemmer P1, (1) Department of Surgery; (2) Department of Pathology; (3) Department of Experimental Surgery, Ruprecht-Karls-University, Heidelberg, Germany
INTRODUCTION AND AIM: Reperfusion injury is characterized by both activated Kupffer cells and disturbed hepatic microperfusion. As taurine, a conditionally essential amino acid, potentially prevents activation of Kupffer cells in vitro, this study was designed to investigate its effect on both liver injury and intrahepatic micro-circulation after warm ischemia. PATIENTS AND METHODS: Female Sprague Dawley rats (170–210 g) were divided into three groups. In sham controls only laparotomy was performed. Some animals were given taurine (10 mg/kg i.v.; 1.2 ml) 10 min prior to ischemia. Ringer's solution (1.2 ml) was given to controls. In both study groups the left liver lobe underwent 60 min of warm ischemia. Subsequently, both transaminases and histology were assessed to indicate liver injury. In vivo microscopy (IVM) was performed to evaluate interaction between leukocytes and endothelial lining cells. To determine whether taurine prevents activation of Kupffer cells, latex beads taken up by Kupffer cells were counted and the serum level of TNF-alpha was compared to controls. Further, ICAM-1 expression was shown with immunohistochemistry. For comparison between study groups ANOVA test was used as appropriate. Results are presented as mean±SEM. RESULTS: Taurine given before warm ischemia significantly decreased both ALT and AST from 278±74 U/l and 392±22 U/l in controls to 129±19 U/l and 268±26 U/l, respectively 8 h after reperfusion. Histological changes, i.e. neutrophil infiltration, necrotic cell death and ICAM-1 expression, were markedly reduced by 14% to 34% after taurine (p< 0.05) at 8 h after reperfusion. Further, taurine dramatically improved micro-circulation. The number of stickers was reduced to 76% of controls in sinusoids and to 53% of controls in venules (p < 0.05) while rolling was decreased to 37% in venules (p<0.05). Taurine significantly decreased both phagocytic activity of Kupffer cells and TNF-alpha release (p<0.05). CONCLUSION: This study demonstrates that taurine decreases liver injury after warm ischemia, most likely via Kupffer cell-dependent mechanisms including leukocyte-endo-thelial cell interaction upon reperfusion.
3 EXTENT OF HEPATIC RESECTION IN CAROLI DISEASE: AMULTI-INSTITUTIONAL RETROSPECTIVE STUDY OF 26 PATIENTS
Mabrut JY1, Baulieux J1, Boillot O2, Gigot JF4, Lerut J5, Otte JB6, De Ville de Goyet J6, Partensky C3, (1) Digestive Surgery and Liver Transplant Unit, Croix-Rousse Hospital, Lyon, France; (2) Liver Transplant Unit, Edouard Herriot Hospital, Lyon, France; (3) Hepato-Biliary and Liver Unit, Edouard Herriot Hospital, Lyon, France; (4) Hepato-Biliary and Liver Unit, Saint Luc Hospital, Bruxelles, Belgium; (5) Liver Transplant Unit, Saint Luc Hospital, Bruxelles, Belgium; (6) Pediatric and Liver Transplant Unit, Saint Luc Hospital, Bruxelles, Belgium
INTRODUCTION AND AIM: To report the results of a retrospective multi-institutional study of 26 patients suffering from Caroli disease. PATIENTS AND METHODS: The mean age was 51 years (range 11–76 years). Twenty-one patients were symptomatic at time of diagnosis; Intrahepatic bile duct stones, congenital hepatic fibrosis (CHF) and cholangiocarcinoma were associated in 13 patients, 4 patients and 1 patient, respectively. All patients, except one suffering from a unilobar disease with CHF, were operated on with liver resection tailored to the extent within the liver: for bilobar disease (2 liver transplantations for associated CHF, 2 left extended hepatectomy, 1 trisegmentectomy 4 to 6), for left unilobar disease (8 left lateral segmentectomies, 7 left hepatectomies) and right unilobar disease (3 right hepatectomies, 1 bisegmentectomy 5–6, 1 liver transplantation for associated CHF). RESULTS: Postoperative mortality and morbidity at 2 months occurred in 0 and 13 patients, respectively. Two patients presented with synchronous cholangiocarcinoma. During a mean follow-up of 94 months in 21 patients with a follow-up time exceeding 6 months, 4 patients developed recurrent complicated intrahepatic stones. Another elderly patient developed biliary cirrhosis. Patients are alive and disease-free in 11/13 of left unilobar forms, in 4/4 of right unilobar forms and in 1/3 of bilobar forms of the disease. CONCLUSION: Unilobar forms of Caroli's disease are successfully treated by radical hepatic resection. For bilobar forms, the therapeutic management is more difficult and liver transplantation could be mandatory, especially in case of CHF.
4 ADVANCED HEPATIC TISSUE DESTRUCTION IN ABLATIVE CRYOSURGERY: POTENTIALS OF INTERMITTENT FREEZING AND SELECTIVE VASCULAR INFLOW OCCLUSION
Richter S1, Kollmar O1, Menger MD2, Schilling MK1, Pistorius GA1, (1) Department of General, Visceral, Vascular and Pediatric Surgery; (2) Institute for Clinical & Experimental Surgery, University of Saarland, Homburg, Germany
INTRODUCTION AND AIM: Recent studies indicate that cryosurgery represents a promising approach to treat non-resectable liver tumours. To improve parenchymal tissue destruction, a variety of modifications of the freeze-thaw procedure have been suggested, including repetitive freezing and portal-triad cross-clamping. The aim of the present study was to analyse whether intermittent freezing by application of a double freeze-thaw procedure or selective vascular inflow occlusion are more effective than a single freeze-thaw cycle to achieve complete hepatic tissue destruction. PATIENTS AND METHODS: Using a porcine model, intrahepatic cryolesions were induced by freezing the hepatic tissue for a total of 15 min (n = 6, SF). Additional animals (n = 6) underwent a double freeze-thaw cycle of 7.5 min each (DF). Athird group of animals (n=6) was treated by a single 15-min freeze-thaw cycle during selective vascular inflow occlusion (VO-SF). RESULTS: 7 days after freezing, DF did not change the volume of the cryolesion (25.4±1.7 cm3) compared to SF (29.9±3.7 cm3), however, resulted in enhanced destruction of hepatocyte nuclear morphology (DF-score: 2.4±b0.2 vs SF-score: 1.1±0.3; p<0.05) and attenuated leukocyte infiltration within the margin of the cryolesion (DF-score: 1.5±0.2 vs SF-score: 2.8±0.1; p<0.05). VO-SF was also effective to significantly enhance destruction of hepatocyte nuclear morphology (2.8±0.1; p<0.05 vs SF), but, additionally, markedly increased the volume of the cryolesions (43.3±5.3 cm3; p<0.05 vs SF and DF). Interestingly, VO-SF further increased the number of apoptotic cells, while leukocyte infiltration (2.3±0.3) was not affected compared to that after SF treatment. CONCLUSION: Thus, our data indicate that both DF and VO-SF are effective to enhance parenchymal cell destruction within the margin of the cryolesion. VO-SF additionally increases the volume of the lesion, and may therefore be most attractive for successful clinical application.
5 EARLY AND LATE LOCAL RECURRENCE FOLLOWING RFA IN NON-RESECTABLE LIVER CANCER: DIAGNOSIS AND TREATMENT
Eisele RM1, Schumacher G1, Spinelli A2, Neuhaus P1, (1) General, Visceral & Transplantation Surgery, Charite Virchow Clinic, Berlin, Germany; (2) General Surgery, Istituto Clinico Humanitas, Italy
INTRODUCTION AND AIM: Radiofrequency ablation (RFA) provides excellent results in small liver tumors which are not resectable. So far, no standardized protocols are available for recurrent disease. This retrospective study describes strategies for follow-up and further treatment. PATIENTS AND METHODS: 91 RFA treatments in 61 patients were analyzed. RFA was only considered in non-resectable liver cancer. Postoperative screening included sonographic examinations at intervals of 3, 6 and 12 months postopera tively and further annual follow-up examinations. Mean follow-up period was 11.8 months. Whenever possible, further surgical or interventional treatment was offered incaseoflocal tumor recurrence (LTR). RESULTS: Overall local recurrence rate was 14% (13 patients); 9 of them (69%) were detected within the first 9 months after RFA, whereas 3 (23%) occurred later than 12 months after RFA. LTR could be observed up to 16 months following the procedure. In 9 patients (69%), further treatment was done: 6 patients (75%, 52% of all patients with LTR) underwent RFA again, one patient could be treated by LITT, and 2 patients (22%, 15% of all patients with LTR) recovered from hepatic dysfunction so that surgical resection was possible. CONCLUSION: Distribution of LTR in the post procedure time course suggests a rather strict examination schedule with time points every 3 months within the first year and an additional time point after 18 months following RFA. About half of all patients with LTR can be subjected to secondary RFA; however, liver resection is not excluded even in case of LTR.
6 INTER-ORGAN AMINOACID EXCHANGE ACROSS THE INTESTINES AND THE LIVER IN SURGICAL PATIENTS WITH ANORMAL LIVER
van de Poll MCG3, Siroen M1, Beets-Tan R2, Affourtit J2, Melis G1, van Leeuwen P1, Deutz N3, Soeters P3, Dejong C3, (1) Surgery, VU University Medical Center; (2) Radiology, Maastricht University; (3) Surgery, Maastricht University, Maastricht, The Netherlands
INTRODUCTION AND AIM: Due to difficult accessibility of the portal vein, human data on hepatic and intestinal amino acid metabolism are limited. Data concerning the healthy liver are completely lacking. We aimed at investigating inter-organ amino acid exchange across the normal human liver. PATIENTS AND METHODS: In 10 patients without parenchymal liver disease undergoing surgery, blood was sampled simultaneously from an indwelling arterial line, hepatic vein and the portal vein. Amino acid and ammonia concentrations were measured to calculate arteriovenous differences (V-A). Portal and hepatic arterial blood flow was measured using duplex to quantify metabolic flux ((V-A)×blood flow). RESULTS: Intestines: There was significant intestinal uptake of glutamine and glutamate: (mean (SEM) 41.5 (6.9) and 5.1 (1.6) µmol/kg/h respectively (p<0.05)) and release of alanine, citrulline and ammonia: 17.3 (3.6), 5.1 (1.0) and 38.7 (10.4) µmol/kg/h, respectively (p<0.005). There was no significant flux of essential amino acids and therefore no net protein breakdown in the gut. We found a stoichiometric correlation between intestinal glutamine uptake and ammonia release (r2=0.50, p = 0.023). Liver: Hepatic ammonia uptake (40.9 (12.3) µmol/kg/h) was directly related to intestinal ammonia production (r2=0.94, p<0.001) making total splanchnic ammonia release insignificant. Hepatic uptake of branched-chain amino acids (9.4 (2.8) µmol/kg/h, p = 0.01) reflects net hepatic protein synthesis in the postabsorptive state. CONCLUSION: This is the first report of amino acid and nitrogen exchange across the normal human liver. In these subjects the liver serves as an ammonia trap, metabolizing all intestinal-derived ammonia, making splanchnic ammonia release insignificant. The described methods will be implemented in forthcoming experiments.
7 COMPARISON OF HISTOLOGICAL AND MRI APPEARANCES OF LIVER ABLATION USING ELECTROLYSIS RADIOFREQUENCY THERAPY NEAR LARGE HEPATIC VEINS
Metcalfe MS1, Mullin E1, Maddern G2, Berry DP1, Dennison A1, (1) Hepatobiliary Surgery, Leicester General Hospital, Leicester, UK; (2) Hepatobiliary Surgery, Adelaide University, Adelaide, Australia
INTRODUCTION AND AIM: Hepatic ablation by radiofrequency (RF) or electrolysis may be less effective adjacent to large veins due to heat or current sink. The correlation of magnetic resonance imaging (MRI) appearances after ablation with tissue necrosis is not known. The aims of this study were to correlate MRI and histological findings after RF and electrolytic hepatic ablation adjacent to large hepatic veins. PATIENTS AND METHODS: Two central hepatic veins were identified in each of 10 large white pigs at laparotomy by ultrasound. Adjacent to one an electrolytic lesion was centred, and a radiofrequency lesion adjacent to the other. The livers were harvested 72 h later. MRI and histological examination were performed to determine volume of lesions produced and extent of necrosis. RESULTS: For technical reasons it was possible to perform RF in only 8 animals. On MRI, 9 of 10 electrolytic lesions and 5 of 8 RF lesions were seen to completely encase a hepatic vein with the remainder just touching the vessel. On histology all electrolytic lesions produced necrosis up to the vessel wall and only one radio-frequency lesion did not show necrosis up to the wall of the adjacent vein. The lesion volumes on histology and MRI correlated well. However, the necrosis was not complete adjacent to the vessel wall for any lesion. CONCLUSION: MRI accurately predicts the volume of necrosis produced by hepatic ablation. However, incomplete necrosis in lesions raises concerns for the efficacy of ablation of malignant lesions adjacent to large veins.
8 CCl4-INDUCED ACUTE LIVER FAILURE WITH PORTAL VEIN ARTERIALIZATION IN THE RAT
Nardo B1, Puviani L1, Bertelli R1, Beltempo P1, Cavallari G1, Montalti R1, Pacilé V1, Licursi M1, Caraceni P2, Pertosa AM2, Pariali M3, Cavallari A1, (1) Department of Surgery and Transplantations; (2) Department of Internal Medicine, Cardioangiology and Hepatology; (3) Biomedical Research Center, S. Orsola Hospital, Bologna, Italy
INTRODUCTION AND AIM: Liver transplantation remains the most effective therapy for acute liver failure (ALF). However, we aimed to determine whether the increase of oxygen supply to the liver by portal vein arterialization (PVA) is an effective treatment for ALF. PATIENTS AND METHODS: ALF was induced in rats by CCl4 solution i.p. Twenty-four hours later, the rats were divided: (1) Control-group: no treatment; (2) PVA-group: an arterial-portal shunt was performed by connecting left renal artery to splenic vein with a polyethylene stent following nephrectomy and splenectomy. The rats were sacrificed after 1, 2 and 10 days to collect serum and liver samples. Aseparate group was used to assess 10-day survival. RESULTS: CCl4-induced liver injury was greatly reduced in the PVA group compared with control rats as indicated by the significantly lower serum transaminases levels and degree of liver necrosis at histology. In contrast, rats treated with PVA showed a progressive and rapid improvement of liver tissue injury with a score of 2.7, 1.5 and 0.2 at 1, 2 and 10 days, respectively. Contrary to control rats, hepatocyte regeneration was observed already at 24 h in the peri-portal area and it diffused to the entire lobule at 48 h in the PVA group. Accordingly, PVAsignificantly improved survival after CCl4 administration compared to control group (100 vs 33%). CONCLUSION: The supply of oxygen to the portal system promotes hepatocyte regeneration leading to resolution of massive necrosis in a toxic model. Thus PVA may represent a novel approach for treatment of acute liver failure.
9 RADIOFREQUENCY ABLATION OF LIVER TUMOURS: ASAFE AND EFFECTIVE FORM OF THERAPY
Bhattacharya S, Fotheringham T, McGhie J, Krissat J, Hutchins R, Departments of Surgery and Radiology, Royal London Hospital, London, UK
INTRODUCTION AND AIM: To assess the efficacy and safety of radiofrequency ablation (RFA) of liver tumours as a therapeutic measure. PATIENTS AND METHODS: RFA was performed either percutaneously, under general anaesthesia or intravenous sedation, with ultrasound or CT to localize the lesions, or at open surgery as an adjunct to resection. The RFA kit used was manufactured by Boston Scientific, and standard technique was adopted. A follow-up CT scan was performed at 6–8 weeks. The decision to perform RFA as opposed to other therapies was made on the basis of age, performance status, tumour number/location, previous treatments, patient choice, tumour behaviour and prognosis, or irresectability found at laparotomy. All patients were treated by the same surgical team and the same radiologist. RESULTS: From 2001 to 2004 (40 months), 89 tumours in 32 patients were ablated at 40 sessions of RFA. Eight patients had primary hepatocellular carcinoma (HCC), 21 had metastatic colorectal cancer (CRC), 3 had other metastatic lesions. Of the 40 sessions, 26 involved percutaneous RFA, 8 involved RFA at laparotomy, and 6 involved RFA in conjunction with a liver resection. Five patients underwent more than 1 session of RFA, either to treat multiple lesions which could not all be treated at one session, or to treat metachronous recurrence. Tumour diameters ranged from 1 to 5 cm (mean 3.2 cm). Complications included significant pyrexia (n = 1), and a skin burn around the needle (n=1). One patient with HCC, cirrhosis and aortic stenosis died of bile leak, sepsis and respiratory failure 5 days after RFA of 4 lesions under general anaesthesia. In 31 of the 40 sessions, follow-up CT indicated a satisfactory burn. Of 8 patients with HCC, 3 received further chemoembolisation, and 1 received a transplant. Of 21 patients with CRC, 8 received further chemotherapy. Overall, 22 patients developed recurrent disease. Follow-up has ranged from 2 to 40 months, and 17 of 32 patients are alive. CONCLUSION: RFA is a safe and effective form of therapy for liver tumours, and needs to be used judiciously as part of a multi-disciplinary approach.
10 NOVEL PROCEDURE: PERCUTANEOUS, VIATIPS, PORTAL VEIN THROMBECTOMY IN PATIENTS WITH BUDD-CHIARI SYNDROME COMPLICATED BY ACUTE PORTAL VEIN THROMBOSIS
Ben-Haim M5, Samuels D1, Nakache R2, Oren R3, Kessler A4, Kori I1, (1) Invasive Radiology; (2) Transplantation; (3) Hepatology; (4) Sonography; (5) Liver Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
INTRODUCTION AND AIM: Acute portal vein thrombosis (PVT) is a devastating complication of Budd-Chiari syndrome and hypercoagulability. Conservative approach, anticoagulation, systemic or transarterial (SMA) thrombolysis and even urgent liver transplantation have been applied in this scenario, but with poor results. We describe a novel approach to treat acute PVT. PATIENTS AND METHODS: Clinical diagnosis was confirmed with US Doppler. Initial treatment was supportive. Right portal vein localization was achieved by transarterial portogram or by CT-guided microcoil placement. Trans-jugular intrahepatic porto-systemic shunt (TIPS) was performed and included three Wallstents© and a Jograft© in one case and a Viatorr© stentgraft that was extended later with a Hemobahn© stentgraft in another. Mechanical clot removal from the portal system was performed in the primary procedure and in a revision procedure in the following few days. Stents were placed precisely with no extension into the IVC or deeply into the main portal vein. Patients were fully anticoagulated and patency was assessed by US Doppler tests. RESULTS: Two young female patients were treated accordingly. Clinical presentation included acute liver failure, followed by rapidly progressive tense ascites, renal and respiratory failure. The procedures were performed on days 5 and 10 following admission. In both cases, successful thrombectomies were achieved and maintained. In one patient, partial occlusion of the TIPS and re-accumulation of ascites were conquered with repeated procedure. Both patients were discharged without ascites and with normal liver function. CONCLUSION: Urgent TIPS and TIPS via portal vein thrombectomy is a novel procedure which offers a safe and effective treatment for patients with acute portal vein thrombosis.
11 LOCAL PREDISPOSING FACTORS FOR FRANK INTRABILIARYRUPTURE OF HEPATIC HYDATID CYSTS
Ammori BJ1,l-Bahrani A1, Al-Maiyah M2, Finn P3, Al-Bahrani Z4, (1) Department of Surgery, Manchester Royal Infirmary, Manchester, UK; (2) Department of Surgery, Middlesbrough General Hospital, Middlesbrough, UK; (3) Medical Statistics Department, University of Teesside, Teesside, UK; (4) Department of Surgery, Medical City Teaching Hospital, Baghdad, Iraq
INTRODUCTION AND AIM: Frank intrabiliary rupture (FIBR) of hepatic hydatid cysts (HHC) is a common and serious complication, which occurs in 3–17% of cases. The aim of this study was to detect local factors that carry a significant association with FIBR of HHC and development ofbiliary cystic fistula (BCF). PATIENTS AND METHODS: This was a retrospective and prospective study of 741 patients with HHC operated upon during 1965–2000. The number, diameter, site, content and infection rate of the HHC were reviewed and correlated to FIBR, which was statistically analysed. RESULTS: Some 104 of 741 patients (14%) with a mean age of 42.9 years had FIBR with sizable BCF ranging between 3 and 8 mm (mean 4.2 mm). The incidence of FIBR occurred at significantly higher rates in patients with solitary rather than multiple cysts (18.5% vs 5.8%, p<0.001), cyst diameter > 10 cm compared with smaller cysts (45.8% vs 3.8%, p<0.001), left hepatic lobar compared with right lobarcysts (31.7% vs 12%,p<0.001),multivesicular compared with univesicular cysts (27.1% vs 2.8%, p<0.001), and infected compared with sterile cyst (34.3% vs 4.6%, p< 0.001). Multivariate analysis confirmed that all the above variables (with the exception of multiplicity of cysts) were independent predictors of FIBR. CONCLUSION: This study draws attention to the endogenous local risk factors for FIBR of HHC, which includes solitary, large, multi-vesicular, infected and left lobar cysts. Patients at high risk of FIBR should be offered early surgery.
12 MANAGEMENT OF HEPATOBILIARY CYSTS
Ali M, Department of Hepatobiliary Pancreatic Surgery, Birdem, Dhaka, Bangladesh
INTRODUCTION AND AIM: Hepatobiliary cysts consist of a heterogeneous group of diseases that differ in cause, prevalence and manifestations. Symptomatic cysts and those that endanger life need adequate treatment. The aim of the study was the evaluation and approaches to management of various types of heptobiliary cysts in a Hepato-Biliary-Pancreatic Surgery unit of a tertiary care hospital in Bangladesh. PATIENTS AND METHODS: We treated 145 patients with hepatobiliary cysts between October 1996 and July 2004. There were 5 children and 140 adults. The most common was simple cyst followed by hydatid and choledochal cysts. 54 (37.24%) cysts were asymptomatic and diagnosed incidentally. 75 (51.72%) had some form of symptoms. Complications like obstructive jaundice, portal hypertension, venacaval obstruction, bronchobiliary fistula and peritonitis were noted in the symptomatic patients. Extrahepatic cystic and intrahepatic non-cystic lesions might simulate the features of hepatobiliary cysts, producing a diagnostic dilemma. These cysts were treated by partial pericystectomy with omentoplasty (44.83%), excision of the cyst with Roux-en-Y hepaticojejunostomy (16.55%), partial pericystectomy with closure of the biliary leakage and omentoplasty (13.8%), closed total cystectomy (5.52%), right or left typical or atypical hepatectomy (14.49%), sequential deroofing and fenestration (4.8%). Histological confirmation was made for all the cysts. RESULTS: There were no perioperative mortality or major postoperative complications. Recurrence was documented in 7 (4.83%) patients in 93 months of follow-up. CONCLUSION: Hepatobiliary cysts demand a wide spectrum of surgical strategies. Adequate intervention can offer cure in most patients.
13 ADEQUATE SYMPTOM RELIEF JUSTIFIES HEPATIC RESECTION FOR BENIGN DISEASE
Fioole B, Kokke M, van Hillegersberg R, Borel Rinkes IHM, Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
INTRODUCTION AND AIM: The purpose of this study was to evaluate the long-term results of partial liver resection for benign liver lesions. PATIENTS AND METHODS: All patients operated on for benign liver lesions from 1991 to 2002 were included. Information was retrieved from medical records, the ZIS registration system and by a telephone questionnaire. RESULTS: Thirty-five patients with a median age of 41 years (17–71) were operated on (M/F ratio 6/29). The diagnosis was hemangioma in 8 patients, FNH in 6, HCAin 13, hydatid cyst in 3, and other diagnoses in 5. Ten patients were known to have relevant co-morbidity. Median operating time was 215 min (25–360). The morbidity and mortality rates were 31% and 2.9%, respectively. Twenty-nine patients (83%) had symptoms (mainly abdominal pain) prior to surgery. Twenty-eight patients were reached for a questionnaire. The median follow-up was 52 months (4–150). In 91% of patients preoperative symptoms had decreased or disappeared after surgery. Four patients developed late complications. CONCLUSION: Long-term follow-up after liver surgery for benign liver lesions shows considerable symptom relief and patient satisfaction. In addition to a correct indication these results justify major surgery with associated morbidity and mortality.
14 HEPATIC ATROPHY-HYPERTROPHY COMPLEX DUE TOECHINOCOCCUS GRANULOSUS
Karabulut K1, Ozden I1, Poyanli A2, Bilge O1, Tekant Y1, Acarli K1, Alper A1, Emre A1, Ariogul O1, (1) General Surgery; (2) Radiology, Istanbul University Istanbul Faculty of Medicine, Fatih—Istanbul, Turkey
INTRODUCTION AND AIM: Obstruction of a major hepatic vein or major portal vein or the biliary tree branch causes atrophy of the related hepatic region and, frequently, hypertrophy in the remaining liver—the atrophy-hypertrophy complex (AHC). Whether hydatid cysts can cause AHC is controversial. PATIENTS AND METHODS: The records of the 370 patients who underwent surgery for hepatic hydatid disease between August 1993 and July 2002 (inclusive) were evaluated retrospectively. RESULTS: Excluding 6 patients with previous interventions on the liver, AHC had been recorded in the operative notes of 16 patients (4.4%); a cyst located in the right lobe had caused atrophy of the right lobe and compensatory hypertrophy of the left lobe. The CT images of 7 patients were suitable for volumetric analysis. The median (range) right and left lobe volumes were 334 (0–686) ml and 1084 (663–1339) ml, respectively. The median (range) cyst volume was 392 (70–1363) ml. CONCLUSION: AHC due to E. granulosus was confirmed by objective volumetric analysis. The presence of AHC should alert the surgeon to two implications. First, pericystectomy may be hazardous due to association with major vasculobiliary structures. Second, in patients with AHC, the hepatoduodenal ligament rotates around its axis; this should be considered in order to avoid vascular injury if a common bile duct exploration is to be performed.
15 MINIMALLY INVASIVE THERAPY OF INOPERABLE HEPATOCELLULAR CARCINOMA(HCC) AND LIVER METASTASES: ACOMBINATION TREATMENT OF CHEMOEMBOLIZATION AND RADIOFREQUENCY THERMAL ABLATION (RFA)
Pomoni M1, Thanos L1, Mylona S1, Tsanis A1, Ellinas P1, Karaliotas K2, Batakis N1, (1) Radiology; (2) Surgical, Red Cross Hospital, Athens, Greece
INTRODUCTION AND AIM: To present an interventional therapeutic protocol of inoperable primary HCC or liver metastases, including RF and chemoembolization according to each lesion's characteristics. PATIENTS AND METHODS: In a period of 3 years, we treated 51 patients with HCC or liver metastases from a distal organ. The selection of method was according to the following criteria: unifocal HCC < 6 cm in diameter—RF; unifocal HCC > 6 cm in diameter—chemoembolization and, in selected cases, RF; multifocal HCC—chemoembolization of the large lesions and RF of the smaller lesions; liver metastases < 5 cm in diameter—RF; liver metastases > 5 cm (especially hypervascular)—chemoembolization. RESULTS: All lesions (100%) had good response in procedures, presenting total or segmental necrosis at the 6-month follow-up with dual-phase spiral CT. 85% of the treated lesions were stable or smaller in size. We had no major complications (except right upper quadrant pain after liver chemoembolization or mild pain at the region of puncture when RF was performed, which was treated by analgesics). CONCLUSION: Percutaneous treatment of inoperable primary and metastatic liver diseases by using chemoembolization and radiofrequency thermal ablation is a safe highly effective method which provides a better quality of life for patients.
16 EVALUATION OF ANOVEL REUSABLE BIPOLAR VESSEL SEALING DEVICE: EVIDENCE FOR ADIFFERENTIAL ARTERIAL AND VENOUS INFLAMMATORY RESPONSE
Richter S1, Kollmar O1, Schilling MK1, Menger MD2, Pistorius GA1, (1) Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital of Saarland; (2) Institute for Clinical & Experimental Surgery, Homburg, Germany
INTRODUCTION AND AIM: During the last few years a variety of energy-based techniques for arterial and venous vessel ligation have been introduced. With the use of a porcine model we herein compared the efficacy of the novel reusable BiClamp versus the standard disposable LigaSure bipolar vessel sealing device. We studied whether arteries respond differently to veins upon sealing. PATIENTS AND METHODS: Splenectomy and nephrectomy were performed in five Suabian Hall pigs with the use of the two different bipolar vessel sealing devices. Measurements of the sealed arteries and veins (diameters 2–7 mm) included rate of seal failure, burst strength and heat-associated vascular wall morphology appearance. An additional three animals underwent splenectomy, salpingo-oophorectomy and small bowel resection, and vessel seals were studied histologically after a 7-day survival period for vessel wall fusion, inflammation and fibrous organization. RESULTS: Seal failure was 5.9% after BiClamp and 0% after LigaSure sealing. Burst pressures of BiClamp-sealed arteries (842±117 mmHg) did not differ from those of arteries sealed with LigaSure (856±102 mmHg); however, they were significantly (p<0.05) higher compared than those of veins (155±26 and 216±71 mmHg). In addition, independent of the two sealing devices thermal spread was found to be increased in veins compared with arteries. Histological analysis after 7 days revealed appropriate healing of the vessel wall fusion, including thrombus fibrosis, fibroblast proliferation and collagen deposition. With both devices, however, the venous wall still presented with massive inflammatory cell infiltrate. CONCLUSION: Our study indicates that the BiClamp device is as appropriate as the LigaSure instrument to successfully ligate 2–7-mm arteries and veins, demonstrating supraphysiological bursting strengths and adequate luminal fusion healing. Of interest, veins are more prone to collateral tissue damage and inflammatory wall infiltration.
17 A 20-YEAR EXPERIENCE OF LIVER TRAUMA
Frena A, Martin F, La Guardia G, Catalano P, General Surgery 2, Regional Hospital, Bolzano, Italy
INTRODUCTION AND AIM: Liver trauma is a relatively frequent surgical emergency with significant mortality and morbidity rates. The management of liver injuries has dramatically changed in the past two decades, especially in the treatment of blunt trauma. PATIENTS AND METHODS: Adatabase of 112 hepatic injuries from 1984 to 2004 was analyzed. RESULTS: The majority of injuries occurred as a result of road traffic accidents (39.3%), the second cause was sport accidents (20.5%). Ninety-one patients (81.2%) were stable at presentation to the hospital. In 94 patients (83.9%) the liver injury was a component of multiple trauma. Ultrasonography and CT scan was used as a diagnostic tool in 95% and 57%, respectively. Operative management was undertaken in 68 patients (60.7%). The overall mortality rate was 12.5%. CONCLUSION: The treatment and outcome of liver injuries have really changed in 20 years. Most patients with liver trauma can be managed conservatively. Operative management is associated with high mortality and morbidity rates. CT of the abdomen should precede laparotomy, even in some haemodynamically unstable patients, to facilitate the best way of treatment.
18 ENDOMETRIAL CYST OF LIVER—A REVIEW
Yeluri S, Rao M, Ali A, Ching SS, Gledhill R, McMahon MJ, Academic Unit of Surgery, General Infirmary at Leeds, Leeds, UK
INTRODUCTION AND AIM: Although the pelvis is the most common site of occurrence of endometriosis, almost every site in the body, with the exception of spleen, has occasionally been implicated. Hepatic endometriosis is a rare occurrence and only a handful of cases have been reported in the literature. The aim of this paper is to report one such case and review literature behind this rare presentation. PATIENTS AND METHODS: This is a case report with a review of literature from a university hospital setting of a 50-year-old lady with an incidentally discovered cystic lesion of liver diagnosed as an endometrial cyst on cytology. After recurrence following minimally invasive surgery, the patient was successfully managed conservatively. RESULTS: Review of the literature suggests that most patients with hepatic endometriosis present with non-specific abdominal pain unrelated to menstruation, unlike the classical catamenial symptoms seen with pelvic and thoracic endometriosis. Half of these patients have a significant history of pelvic endometriosis and pelvic surgery. Malignant transformation has also been reported once. Theories behind pathogenesis include coelomic metaplasia, lymphovascular dissemination, iatrogenic injury and retrograde menstruation. Though radiological features are nonspecific, repeating the scan at a different stage of the menstrual cycle may be helpful. Gonadotrophin-releasing hormone analogues (GnRH-a) and surgery may be considered as the mainstay of treatment. CONCLUSION: Endometriosis should be considered in the differential diagnosis of a cystic liver mass, especially in patients with known pelvic endometriosis. Athorough history enquiring about endometriosis, pelvic surgery and uterine intervention (e.g. curettage) may help achieve the diagnosis in a patient presenting with an unexplained cystic liver lesion.
19 PREDICTIVE FACTORS FOR OPERATIVE OR NON-OPERATIVE MANAGEMENT OF BLUNT LIVER TRAUMA
Markogiannakis H2, Sanidas E1, Messaris E2, Tsiftsis D1, (1) Department of Surgical Oncology, Herakleion Medical School, University of Crete, Herakleion, Crete, Greece; (2) 1st Department of Propaedeutic Surgery, Hippocration Hospital, University of Athens, Athens, Greece
INTRODUCTION AND AIM: Non-operative management (NOM) is considered to be the treatment of choice for carefully selected patients with blunt liver trauma. The objective of this study was to evaluate the factors that can safely predict NOM of blunt liver trauma patients. PATIENTS AND METHODS: Our study is a retrospective analysis of Trauma Registry data of all 55 consecutive adult patients admitted with blunt liver injury to a Greek level I trauma center over a 4-year period. RESULTS: Nineteen (34%) of the 55 patients were immediately operated, whereas 36 (66%) were initially selected for NOM. Systolic arterial pressure (p=0.04), concomitant abdominal (p=0.04) and spinal cord injury (p=0.03) were independent predictive factors for operative or non-operative management of these patients. Patients with low systolic arterial pressure, concomitant abdominal injury and spinal cord injury were immediately operated. 33 of the 36 patients that were selected for NOM were successfully treated conservatively, while 3 were finally operated; thus, the rate of success of NOM was 92%. CONCLUSION: Non-operative management of carefully selected patients with blunt liver trauma is safe and efficient. Systolic arterial pressure along with concomitant abdominal and spinal cord injury are predictive factors for operative or non-operative management of these patients.
20 PREDICTIVE VALUE OF INJURY SCORING SYSTEMS AS CRITERION FOR NON-OPERATIVE MANAGEMENT OF BLUNT HEPATIC TRAUMA
Markogiannakis H2, Sanidas E1, Messaris E2, Tsiftsis D1, (1) Department of Surgical Oncology, Herakleion Medical School, University of Crete, Herakleion, Crete, Greece; (2) 1st Department of Propaedeutic Surgery, Hippocration Hospital, University of Athens, Athens, Greece
INTRODUCTION AND AIM: Non-operative management (NOM) is considered to be the treatment of choice for carefully selected patients with blunt hepatic trauma. The aim of this study was to evaluate the predictive value of injury scoring systems as criterion for NOM of blunt hepatic trauma. PATIENTS AND METHODS: Our study is a retrospective analysis of Trauma Registry data of all adult patients admitted with blunt liver injury to a Greek level I trauma center over a 4-year period. Trauma severity was estimated with Injury Severity Score (ISS), Revised Trauma Score (RTS), Trauma Score (TS), International Classification of Diseases-9th revision Injury Severity Score (ICISS) and Probability of survival (ps). RESULTS: Fifty-five consecutive patients were admitted to our hospital with blunt hepatic trauma. Immediate operation based on specific indications was decided for 19 patients (34%). These patients had lower ICISS (p = 0.03) than the 36 patients (66%) who were selected for NOM. On the contrary, there was no significant difference in ISS, RTS, TS and Ps between immediately operated and NOM patients. CONCLUSION: ICISS is useful for selecting patients with blunt hepatic trauma for NOM. Other injury scoring systems commonly used to estimate the total severity of injury of polytrauma patients such as ISS, RTS, TS and Ps cannot safely be used as criteria for the decision to treat these patients operatively or observationally.
21 THE CASE OF LIVER DUPLICATION
Beyayeva NV, Gubergrits N, Chair of Internal Diseases No 1, Donetsk State Medical University, Donetsk, Ukraine
INTRODUCTION AND AIM: Liver anomalies occur very rarely, and the development of an additional liver is not generally described. PATIENTS AND METHODS: We observed in our clinic a patient with liver duplication. RESULTS: Patient C, aged 32 complained of heaviness in the right part of the abdomen after having meals containing some fat and fried food and after some physical exertion. He also complained of general weakness. During the neonatal period he was operated on for pyelostenosis, liver anomaly having been revealed by laparotomy. Sonography: two parts of liver parenchyma—that is in the right hypochondrium and the right half of mesogastrium. These parts are connected by a thin intersection, which is 2.5 cm thick. Under the lower portion of the pelvic cavity we revealed the enlarged gallbladder with the diverticulum; under the upper one we found a formation which was like wrinkled gallbladder. Fibrogastroduodenoscopy showed two Vater's papilla. Cholecystography: the enlarged hypomotile gallbladder with the diverticulum on the level of the iliac bone wing is contrasted. CT and liver scintigraphy confirmed the presence of the two portions of liver parenchyma. Doppler US: anomalous structure of liver vascular system in both portions of liver parenchyma is like arch portocaval anastomosis. We performed puncture biopsy of the upper and lower portions of liver parenchyma (the results are like each other): there was chronic hepatitis with the minimal activity. CONCLUSION: Thus, this anomaly looks like Riedel's lobe, but it is differentiatedd by the presence of two Vater's papilla, and by two gallbladders.
22 THE EXPERIENCE OF TREATMENT OF CHRONIC VIRAL HEPATITIS C AMONG ELDERLY PATIENTS
Gubergrits NB, Lukashevich G, Chair of Internal Diseases No 1, Donetsk State Medical University, Donetsk, Ukraine
INTRODUCTION AND AIM: Under interferon therapy of chronic diffuse liver diseases connected to hepatitis C virus, accessory reactions often occur. These reactions are especially severe among elderly patients. The aim was to study the effectiveness of ursodeoxycholic acid (Ursofalk) in elderly patients with viral hepatitis C. PATIENTS AND METHODS: We observed 23 patients who were more than 65 years old. 18 of them suffered from chronic viral hepatitis C, 5 had viral C hepatic cirrhosis. RNA of virus C was revealed in blood of all patients. RESULTS: The activity of process among 15 patients was minimal, another 8 patients had moderate one. All patients were given Ursofalk 750 mg daily for a month and then 500 mg per 24 h for 3 months. 20 patients with the analogous pathology were studied under control. They were not administered interferon therapy because of side effects and Ursofalk was not given to them. At evaluation of results of treatment at 4 months those patients who were given Ursofalk had authentic reduction of ALT, alkaline phosphatase, the total and direct bilirubin of blood and the correction of dysproteinemia. The patients in the control group had authentic increase of ALT serum level and non-authentic tendency to increase of the rest of the biochemical findings and aggravation of dysproteinemia. Two patients treated by Ursofalk had negative results of polymerase chain reaction (PCR), while patients in the control group had the former results. CONCLUSION: Thus, Ursofalk therapy is effective among the elderly people suffering from chronic diffuse liver diseases caused by hepatitis C virus.
23 METABOLIC CHANGES IN THE PIG LIVER DURING ISCHEMIAMEASURED BY MICRODIALYSIS
Thorsoe HJ, Mortensen FY, Funch Jensen P, Festersen M, Rokkjaer M, Gastrointestinal Surgery L, Aarhus University Hospital, Aarhus, Denmark
INTRODUCTION AND AIM: The aim of the present study was to evaluate microdialysis as a method to measure metabolic changes in the pig liver during ischemia. PATIENTS AND METHODS: Ten Landrace pigs, weighing 60 kg, were used for the experiments. Amidline laparotomy was performed under general anasthesia. Four catheters for microdialysis were placed in the liver, one in each lobe. Samples for determination of lactate, glucose, glycerol and pyruvate were collected every 30 min. After 3 h total ischemia by way of the Pringle maneuvre was performed. Hereafter measurements were continued for 3 h. RESULTS: After 30 min of total ischemia all pigs showed a significant increase in lactate and glycerol levels, and all pigs showed a significant fall in pyruvate levels. Glucose levels showed a tendency to decrease during ischemia. Different parts of the liver showed the same metabolic changes during ischemia. CONCLUSION: Microdialysis is a reliable method for continously measuring metabolic changes in the pig liver during ischemia.
24 DEVASCULARIZATION SURGICAL MODEL OF ACUTE LIVER FAILURE IN MINI-PIGS
Ryska M3, Kieslichova E1, Pantoflicek T2, Ryska O3, (1) Anestesiology, IKEM; (2) Surgery department, Central Military Hospital; (3) 3rd Faculty of Medicine, Charles University, Prague 6, Czech Republic
INTRODUCTION AND AIM: The study was designed to develop a readily reproducible model of acute liver failure (ALF) in the mini-pig, to gain an 8-h therapeutic window to mimic, as closely as possible, acute liver failure in man. PATIENTS AND METHODS: We used a reversible devascularization model of ALF in the mini-pig involving hepatic artery ligation and established an end-to-side portocaval anastomosis. Standard laboratory monitoring was complemented with intracranial pressure (ICP) measurement.Twenty mini-pigs (weight 25–30 kg) were used for the experiment. The animals were divided into 3 groups: I, 10 animals in an experimental group with ALF; II, 5 animals in an experimental group with ALF and ICP measurement; III, 5 animals in a control group without ALF. RESULTS: Laboratory testing has shown the significant changes in levels of AST (33.44±39.96 vs 1.56±0.50 mmol/l), lactate (2.97±1.16 vs 1.18±0.61 mmol/l), and ammonia (264.3±93.05 vs 42.5± 12.98 mmol/l) between ALF groups and controls (p < 001) 6 h after the operative procedure and significant changes in hypoglycemia and intracranial pressure were found 4 h after the operative procedure. The difference in Quick values (67.4±17.03 vs 75.2±2.68) was not significant. We assume that the therapeutic window starts 4 h after the beginning of the experiment. CONCLUSION: Our devascularization model of ALF is simple and readily reproducible. The therapeutic window occurring shortly after surgery and persisting for a mean 9 h is suitable to evaluate bioartificial liver devices.
25 ASSESSMENT OF TREATMENT EFFICACY OF HEPATITIS OR HEPATIC CIRRHOSIS WITH ESSENTIAL PHOSPHOLIPIDS BASED ON RESULTS OF BLOOD INTERFACIAL TENSIOMETRY
Gubergrits NB2, Lobas E1, (1) Department of Gastroenterology, Donetsk Regional Hospital; (2) Donetsk State Medical University, Department of Internal Diseases No. 1, Donetsk, Ukraine
INTRODUCTION AND AIM: The amount of surface-active substances is changed in chronic hepatitis (CH) or hepatic cirrhosis (HC). This contributes to changes in blood dynamic surface tension (DST). The aim was to assess the efficacy of essential phospholipids-based drug Essentialle N depending on DST indices. PATIENTS AND METHODS: We examined 44 patients with CH and 32 patients with HC of alcoholic etiology. 38 patients received Essentialle N; other patients received silimarine. Indices of interfacial tensiometry were registered with the help of a computerized tensio-meter MPT2 Lauda (Germany). We determined DST after t = 0.01 s (DST1), t = 1 s (DST2), t = 100 s (DST3) and assessed angle of tensiogram curve slope (ATCS). RESULTS: Increase of DST1 and reduction of DST3 is characteristic for CH and HC patients, and these data correlate with biochemical and morphological data. All CH patients who received Essentialle N reached normalization of interfacial tensiometry indices. In the group of HC patients ATCS became normal in 40.0%, DST3 alone in 60.0% and both DST1 and DST2 became normal in all HC patients who received Essentialle N. In those receiving silimarine normalization of blood DST indices were achieved rarely. CONCLUSION: Blood DST is an integral index, which allows us to assess efficacy of treatment of CH and HC.Essentialle N renders a positive therapeutic effect in treatment of chronic diffuse diseases of the liver.
26 DISORDERS OF SMALL INTESTINE ABSORPTIVE FUNCTION REVEALED BY MEANS OF D-XYLOSE TEST FROM PATIENTS WITH CHRONIC LIVER DISEASES
Linevsky YV, Gubergrits N, Zagorenko Y, Chair of Internal Diseases No 1, Donetsk State Medical University, Donetsk, Ukraine
INTRODUCTION AND AIM: Patients suffering from chronic diffuse liver diseases have an impaired process of digestion, although the absorptive function of the small intestine has not been studied yet. The aim was to assess the absorptive function of the small intestine in chronic diffuse liver diseases. PATIENTS AND METHODS: An absorptive function of small intestine was studied with the help of the D-xylose test in 86 patients who had chronic diseases of the liver such as chronic hepatitis (n=60) and hepatic cirrhosis (n=26) in the period of exacerbation. Biopsy of mucous membrane was taken simultaneously. RESULTS: The verified reduction of D-xylose excretion in urine in all observed groups with liver troubles was revealed. This was more evident in cases of hepatic cirrhosis and less evident in cases of chronic persistent hepatitis. The observed changes indicate differences of small intestine disorders. Histological findings of biopsies revealed the presence of small intestine changes in the majority of patients examined on chronic ileitis. CONCLUSION: Thus, the main reasons for small intestine absorptive function disorders in patients with liver troubles appear to be latent inflammatory dystrophical changes in the mucous membrane of small intestine. Accompanying changes of small intestine of patients having chronic liver troubles should be taken into account in treatment of this pathology.
27 APOPTOSIS AND HSP70 EXPRESSION IN TRANSITION ZONE FOLLOWING RADIOFREQUENCY ABLATION IN PORCINE LIVER
Rai RR4, Robertson C1, Flecknell PA1, Robertson H2, Burt AD2, Manas D3, (1) Comparative Biology Unit, University of Newcastle, UK; (2) Pathology, University of Newcastle, UK; (3) Department of HPB Surgery & Transplantation, Freeman Hospital, Newcastle, UK; (4) Dudley, UK
INTRODUCTION AND AIM: Following radiofrequency ablation in ex vivo human liver, we have identified a transition zone of tissue between the necrotic liver and viable normal liver parenchyma using a vital stain. The aim of this study was to investigate expression of HSP70 on hepatocytes in this zone as well as to identify any ongoing apoptosis in the zone of transition. PATIENTS AND METHODS: Five landrace pigs underwent RFA under general anaesthesia. In total 3 lesions were created in the liver using RFA generator. Four pigs were sacrificed 30 min after the end of the experiment. One pig was revived and sacrificed 5 days later. Lesions were excised and HSP70 expression was studied in tissues obtained from the centre of the lesion and from the margin of ablated tissue using TUNEL staining. HSP70 expression was also studied. RESULTS: There was no evidence of apoptosis or HSP70 expression in the tissues obtained from the pigs which were sacrificed 30 min following ablation but in tissues obtained from the pig that was revived and sacrificed 5 days later there was evidence of apoptosis of hepatocytes as well as increased HSP70 expression on the hepatocytes in the transition zone. CONCLUSION: Reperfusion following RFA induces increased HSP70 expression and apoptosis in the transition zone. This suggests sublethal cellular injury. Increased HSP70 expression will make these cells more susceptible to cytotoxic cellular killing thus improving the effects of RFA. The transition zone needs further study following ablation of liver tumour.
28 RADIOFREQUENCY ABLATION OF PRIMARY AND METASTATIC LIVER TUMORS—A4-YEAR EXPERIENCE
Ribeiro MAF Jr5, Gama-Rodrigues J1, Habr-Gama A1, Caib E, Fonseca A3, d'Ipollito G4, Saad W2, (1) Gastrointestinal Surgery, Hospital das Clinicas; (2) Liver Surgery, Hospital das Cinicas; (3) Liver Surgery, Hospital Sao Luiz; (4) Radiology, Hospital São Luiz; (5) Hospital das Clinicas e São Luiz Liver and Portal Hypertension Surgery, São Paulo, Brazil
INTRODUCTION AND AIM: Radiofrequency ablation of primary and metastatic liver tumors has been shown to be one of the promising new modalities to treat or to palliate liver tumors. It has been used as a bridge to liver transplantation as well as an approach to recurrent tumors after resection. PATIENTS AND METHODS: We present a series of 78 cases, 39 females and 39 males with a mean age of 61 years. RFA was used either by laparotomy or percutaneously to treat 117 lesions. There were 32 cases of hepatocellular carcinoma, 35 metastases of colorectal cancer and 11 cases of other tumors. RESULTS: The mean number of lesions treated were 1.5 per case with an average size of 3.6 cm per lesion. All liver segments were compromised, especially IV, VII, VIII. The morbidity was 28% and the mortality was 2.5%. In 20.5% of the cases we were able to find recurrence after the procedure, with a mean time of 10.5 months. CONCLUSION: The RFA procedure is safe, can be performed in different ways and in the group of patients who are candidates for liver transplantation, while waiting for the organ. For metastatic diseases it is not a substitute for surgery but can be used in patients who cannot be operated.
29 FUNCTIONAL PATHOLOGY OF SMALL INTESTINE OF PATIENTS SUFFERING FROM CHRONIC VIRAL HEPATITIS B
Gubergrits NB, Belyayeva N, Linevsky Y, Chair of Internal Diseases No. 1, Donetsk State Medical University, Donetsk, Ukraine
INTRODUCTION AND AIM: Not enough is known about the state of parietal digestion in chronic viral hepatitis. The aim was to study a functional state of jejunal mucosa in patients with chronic viral hepatitis B. PATIENTS AND METHODS: Biopsy of mucous membrane of the primary section of small intestines with the further examination of lactase, maltase, saccharase, glycine-L-leucine dipeptidase and monoglyceride lipase activity in its homogenate was carried out for 43 patients with chronic viral hepatitis B. A condition of membrane and cavitary digestion on resorption of amylase and lipase in bioptate was determined. Absorptive function of small intestine by way of D-xylose test, the contents of enterokinase and alkaline phosphatase were studied. RESULTS: An increased amylase and lipase activity of membrane and cavitary digestion of small intestine, a reduction of glycine-L-leucine dipeptidase and monoglyceride lipase production, an increased output of saccharase were revealed. Slight insufficiency of small intestine absorptive function was also observed. CONCLUSION: The above-mentioned disorders of small intestine should be taken into account in treatment of patients with chronic viral hepatitis B.
30 PHYTOHEPATOPROTECTORS IN TREATMENT OF CHRONIC DIFFUSE LIVER DISEASES
Gubergrits NB, Zagorenko Y, Chair of Internal Diseases No. 1, Donetsk State Medical University, Donetsk, Ukraine
INTRODUCTION AND AIM: The advantages of the combined phytohepatoprotectors are as follows: good endurance, absence of toxic effects, rarity of allergic reactions, simultaneous effect on some pathogenic sections of the disease. The aim was to study the effectiveness of phytohepatoprotectors in chronic diffuse liver diseases. PATIENTS AND METHODS: Under our observation there were 62 patients with chronic hepatitis and hepatocirrhosis with a minimal activity of toxic and alcohol etiology. 34 of the examined patients took the combined phytohepatoprotectors Hepatofalk Planta or Hepabene (the first group). The rest of 28 patients took non-herbal phytohepatoprotectors, infusive therapy, polyvitamins (the second group). RESULTS: The treatment results in the first group were significantly better than those in the second group. The marked clinical manifestations were especially reduced among those patients who took phytohepatoprotectors: the heaviness in the right hypochondrium, asthenia, dyspepsia and so on. In three weeks after the treatment 28 patients (82%) of the first group achieved normalization of biochemical findings (aminotransferases, alkaline phosphatase, lactate dehydrogenase (LDG), gamma-glutamyltranspeptidase (GGT), serum protein, proteinogram). The most marked effect was achieved among the patients with chronic hepatitis in combination with the pathology of the bile ducts. The results of the treatment of the patients in the second group were significantly worse both in relation to clinical and biochemical manifestation of the disease. There was noted the increase of alanine-aminotransferase and GGT among four patients (14%) of the second group. CONCLUSION: Thus, the preparations of choice are the combined phytohepatoprotectors among the patients with non-viral diffuse liver diseases with minimal activity.
31 LIVER LESION IN PATIENTS WITH NON-SPECIFIC ULCERATIVE COLITIS
Gubergrits NB, Zagorenko Y, Chair of Internal Diseases No. 1, Donetsk State Medical University, Donetsk, Ukraine
INTRODUCTION AND AIM: Non-specific ulcerative colitis may be accompanied by liver pathology, which means extraintestinal manifestations of the main disease. The aim was to study peculiarities of liver lesions in non-specific ulcerative colitis. PATIENTS AND METHODS: We observed 38 patients with non-specific ulcerative colitis. RESULTS: Adipose hepatosis, which clinically presented with hepatomegalia, dyslipidaemia and an increase in the intensity of the sonographic picture of hepatic tissue, was diagnosed in 19 patients. In the blood chemistry there was a characteristic rise in the activity of gamma-glutamyltranspeptidase. The diagnosis was confirmed by punch biopsy of the liver. 8 patients had hepatitis with minimal or moderate activity. Among the signs of the clinical manifestations the following symptoms predominated: asthenia, dyspepsia, increased liver size and painful palpation. The results of biochemical analysis of the blood showed the presence of moderate cytolysis and dysproteinaemia. Different variants of dystrophy of the hepatocytes and portal field infiltration were revealed by studying the liver bioptate. Chronic hepatitis with significant activity was diagnosed in 4 patients with expressed biochemical signs of cytolysis, bilirubinaemia and a fall in the synthesizing function of the liver. The diagnosis was confirmed by the following morphological picture: ‘bridge-like’ necrosis, portal, periportal and also intralobular infiltration. Micronodular hepatic cirrhosis was diagnosed in one patient, macronodular disease in one, primary sclerosing cholangitis in two, and hepatic amyloidosis in one patient. Liver abscess as well as cholangiogenic liver cancer was revealed in a single case. CONCLUSION: The diversity of the variants of liver lesion in nonspecific ulcerative colitis needs a differential approach in diagnosis and treatment.
32 THE USE OF OCTREOTIDE FOR THE TREATMENT OF CHRONIC ABDOMINAL PAIN AFTER LIVER RESECTION
Severtsev AN, Tchudaev D, Mejgih T, HPB-Surgery, Central Clinical Hospital #1 OAO RZD, Moscow, Russia
INTRODUCTION AND AIM: One of the causes of chronic abdominal pain after abdominal surgery is the development of abdominal adhesions. There are some publications about the prevention and treatment role of octreotide in case of the development of abdominal adhesions. According to various data liver resection is the ideal clinical model which gives the maximal development of abdominal adhesions. The purpose of this clinical study is to assess the use of octreotide for abdominal adhesion prevention and the treatment of chronic abdominal pain. PATIENTS AND METHODS: From December 1994 until May 2001, 135 patients with liver tumors were surgically treated (resections) at the Surgical Department/Liver Unit of the MCRG (Moscow, Russia). The main (31) and control (44) groups were compared for the use of octreotide. The mean age of patients in the groups was 57±9 and 55±14 years and male/female ratio was 14/17 and 17/27, respectively. The mean octreodide (Sandostatin) dose was 0.1 mkg per day subcutaneously 3 days before surgery and 14 days after. The criteria of octreodide effectiveness were the absence of intestine obstruction and no need for postoperative laparotomy, the presence of chronical abdominal pain (1 month after surgery) which demands the use of analgetics. RESULTS: All general criteria were the same for both groups. Adhesive intestinal obstruction developed in 7 patients in the control group and in no patients in the main group. Laparotomy was used in 5 patients. Postoperative pain developed in 14 patients in the control group and 1 in the main group. CONCLUSION: Octreotide could be used for the treatment and prevention of abdominal adhesion formation after liver resections and the subsequent treatment of chronic abdominal pain after such surgery.
33 SPONTANEOUS RENAL RUPTURE INBUDD-CHIARI SYNDROME
Calheiros JPF, de Sa Ribeiro FA, Cordona Machado AL, Oliveira Gonçalves S, Fernandes Araujo GM, General Surgery, Bonsucesso General Hospital, Rio de Janeiro, Brazil
INTRODUCTION AND AIM: Budd-Chiari syndrome is characterized by hepatic venous outflow obstruction, causing a heterogeneous group of disorders which includes portal hypertension. The authors report a case of an uncommon clinical manifestation, spontaneous renal rupture, and its association with portal hypertension and Budd-Chiari syndrome is reviewed in the literature currently available. PATIENTS AND METHODS: The authors report the case of an 18-year-old male admitted to the Bonsucesso General Hospital's Emergency Department presenting spontaneous retro-peritoneal hemorrhage due to renal rupture and treated with surgical nephrectomy. Aliterature review, using MEDLINE, was performed for spontaneous renal rupture and its association with portal hypertension and Budd-Chiari syndrome. RESULTS: Spontaneous renal rupture is a rare clinical finding with varied causes. Only one single report was obtained for the causative association between portal hypertension and spontaneous renal rupture. CONCLUSION: Spontaneuos renal rupture, like other causes of retroperitoneal hemorrhage, is an extremely rare complication of portal hypertension. The association between spontaneous renal rupture and portal hypertension due to Budd-Chiari syndrome has not been reported in the literature before.
34 ALLOGENIC TRANSFUSION IN HPB PATIENTS: IMPLICATIONS
Serrablo A, Miguel Servet University Hospital, Zaragoza, Spain
INTRODUCTION AND AIM: There is currently a growing interest in the analysis of the harmful effects of allogenic blood transfusion (ABT) and of immunological type and the benefits of the blood-saving methods. The effects of the implementation of integrated blood saving programs are highlighted in them, and some of them include: a reduction in the nosocomial infection rate, morbidity/ mortality rates, ICU and hospital stay days, longer disease-free period in oncologic patients, reduced recurrence, improved liver parenchyma regeneration. Although in cancer surgery, the greatest concern is for immunomodulation induced by ABT (ATIS) and its possible repercussions, possibly, in hepatopancreatobiliary surgery, this effect should be thoroughly assessed even if they are not cancer patients. It is known that immunomodulation is currently not fully understood, but there are data and clinical observations that go beyond presumption; the changes in the balance between Th1 and Th2 responses possibly lead to susceptibility to the disease states. In hepatopancreato-biliary surgery, particularly liver surgery, a significant effort has been made to reduce allogenic blood exposure. Many authors show the need for reducing it to improve the outcome of this type of surgery. PATIENTS AND METHODS: To comment and analyze the implications on the basis of our data and to show current opinion about allogenic transfusion in HPB patients. RESULTS: Liver resections are a significant method of treatment for primary and secondary liver tumors. Major vascular structures, mainly suprahe-patic veins, accessory veins and inferior vena cava, are strong reasons for bleeding, sometimes abundantly, during resection. Atearing or any event can dramatically alter the blood loss, by increasing, as in the study by Bui, from 1000 ml to 4100 ml. As the loss of a large volume of blood is correlated to morbidity, it could be stated that in these cases the outcome of the patient has already been modified during the procedure. In colorectal oncology surgery, it has been published that, as in orthopedic or heart surgery, the allogenic transfusion-induced inmunosupression (ATIS) is dependent on the volume transfused, clearly related to intraoperative losses and preoperative hemoglobin, and the relative risk of suffering nosocomial infection or recurrent and distance metastasis changes. In liver surgery, the variability of this volume, the ranges published, are large, from 0 to 14 units, in most series. The mortality in the study by Figueras et al. is 14% when the volume transfused is 3 or more units and 1.6% when lower, evidencing the immunomodulating effect according to the volume transfused. In surgery of the pancreas, no data have been found assessing the harmful effects of ABT, maybe, particularly in patients with cancer of this organ, due to the particular circumstances of the time of diagnosis and the type of surgery, with a morbidity close to 50% and a mortality close to 10%, making difficult the application of techniques to minimize the transfusion of blood derivatives. These patients usually suffer multifactorial anemia and a marked nutritional deficit, if they do not suffer active or recent biliary infection, sometimes leading to the diagnosis. The possible impact of ABT in nosocomial infection (NI) could be determinant to try to modify the estimated reducible percentage of 32% of them. In this setting, we will report the results of two prospective studies performed in our unit. In the first, 468 patients during 1 year were included and in the multivariable analysis, the allogenic transfusion was the only amendable independent factor for reducing the nosocomial infection rate, with OR = 3.554. In the second, hepatic resections for colorectal metastasis were analyzed and we found that those patients that suffer allogenic transfusion had bigger NI and morbidity rate and longer length of UCI and hospital stay in comparison with those who underwent autotransfusion. We found the same results as Kooby et al. They concluded that perioperative blood transfusion is a risk factor for poor outcome after liver resection and that blood conservation methods should be used to avoid transfusion. CONCLUSION: If we reduce the allogenic transfusion rate we will improve our patients’ outcome and reduce the NI, morbidity and mortality rates. From a multidisciplinary oncologic point of view, we have several approaches to achieve the cure of our patients: radical surgery (R0), chemotherapy and radiotherapy in some cancer types. We believe that there is another complementary option that consists of avoiding or reducing the allogenic transfusion, allowing that the immune system concludes and support to the radical surgery.
35 HEPATOCYTE INJURY ASSOCIATED WITH EXCESSIVE GENERATION OF PORTAL CYTOKINE IN ISCHEMIA/REPERFUSION (I/R) OF HUMAN LIVER
Kim YI, Kyungpook National University, Biomolecular Engineering Center, Department of Surgery, Taegu, South Korea
INTRODUCTION AND AIM: Clinical implications of acute reactant cytokine responses need to be clarified in the setting of I/R of human liver during liver resection. PATIENTS AND METHODS: Serial samples of portal and systemic venous blood were obtained and were analyzed for the cytokine activities at the time points, before (I), at the end of hepatic pedicle clamping (II) and 1 h (III) after continuous hepatic inflow occlusion (HIO) in 25 patients with normal backgroud liver who underwent elective hepatectomy (15 major and 10 minor resections). The interleukin-6 (IL-6) responses (ELISA) were compared with HIO, portal pressure on clamping (PVP) and postoperative liver function tests. RESULTS: Portal IL-6 levels rose significantly during HIOas compared with the systemic levels (562 + /–431 vs346 + /–262 pg/ml, p<0.02). The portal IL-6 concentrations during liver resection (time points II and III) were significantly correlated positively with postoperative serum levels of ALT (day 1705 + /–1023U/L), AST (892 + /–1255), and maximum bilirubin (2.5 + /–2.5 mg/dl) (p<0.002). The PVP (500 + /–127 mmH2O) and HIO(48 + /–9 min) had also shown a substantial correlation with the IL-6 levels at time point II (p<0.05). CONCLUSION: These results suggest that overproduction of acute reactant cytokine from the portal circulation in hepatic I/R is positively related to the postoperative hepatocyte injury in humans.
36 CHANGES IN BIOIMPEDANCE OF RABBITS’ LIVER DURING ISCHEMIA- EPERFUSION INJURY AND CELL VIABILITY
Yun SS1, Kim HJ1, Lee DS1, Shin HJ2, AhnHS2, Kim JY3, Kim JH4, (1) Surgery; (2) Institute of Biomedical Engineering; (3) Physiology; (4) Biochemistry, Yeungnam University Hospital, Taegu, South Korea
INTRODUCTION AND AIM: During liver resection and liver transplant, the liver is damaged by ischemia-reperfusion injury. Until now, there has been no approved method to measure or predict the extent of liver injury during the operation. This is the preliminary study to make the real-time monitoring system by quantification of bioimpedance and ischemia-reperfusion injury in liver. PATIENTS AND METHODS: Ten New Zealand White rabbits (male 3.5–4.0 kg) were divided into two groups. In group 1 (n=5), we induced 30 min ischemia and 20 min reperfusion. In group 2 (n=5), we induced 120 min ischemia. We measured liver tissue bioimpedance (120 Hz–1000 KHz) at 5-min intervals with two mono-polar needles coated with white gold using an LCR meter (GS-4311B, Ando, Japan). Cell viability was assessed by metabolic capacity of fatty acid (palmitic acid metabolic rate) and histologic examination (H/E stain) at 30-min intervals during ischemia. RESULTS: Bioimpedance was changed significantly (p<0.05) during ischemia at lower frequency compared with those of higher frequency. In group 1, the levels of bioimpedance (120 Hz) at pre-ischemia, 5, 10, 15, 20, 25 and 30 min after ischemia were 7.3 + /–1.5, 9.6 + /–0.8, 10.5 + /–1.2, 12.0 + /–1.4, 13.6 + /–3.0, 14.8 + /–3.7 and 16.3 + /–4.9 (mean + /–SD), respectively. The level of bioimpedance returned to baseline level after reperfusion. In group 2, the level of bioimpedance (120 Hz) increased gradually after ischemia for 1 h. After 1 h, the level of bioimpedance had a tendency to maintain plateau. Palmitic acid oxidation rates were not changed significantly during 120 min of ischemia and there were no differences in histologic examinations. CONCLUSION: We found a possible role of bioimpedance to measure and predict the extent of ischemia-reperfusion injury. However, we need further study to clarify the relationship between bioimpedance and ischemia-reperfusion injury and we also need further study to prove the cause of bioimpedance change during ischemia-reperfusion injury.
37 ISCHEMIC PRECONDITIONING IMPROVES BILE FLOW AFTER ISCHEMIAAND REPERFUSION INJURY TOTHE LIVER IN RATS
Nieuwenhuijs VB1, Padbury R1, Hughes R2, Stahl J3, Barritt G2, (1) Surgery, Flinders Medical Centre; (2) Medical Biochemistry, Flinders University School of Medicine; (3) Pathology, Flinders Medical Centre, Bedford Park, Australia
INTRODUCTION AND AIM: Ischemia and reperfusion (IR) injury to the liver is a well known phenomenon in liver transplant and major liver resections and trauma. Ischemic preconditioning (IPC) potentially attenuates IR injury. While there are many proposed mechanisms to explain damage caused by IR and how this may be alleviated by IPC, these are generally not well understood. The reduction of bile flow following IR injury may lead to intrahepatic cholestasis and secondary liver failure. There have been few studies of the effects of an IPC regime on bile flow in liver models reflecting the clinical situation. The aim was to elucidate the effect of IPC on bile flow after IR injury in an intact rat liver model and to investigate the intracellular mechanisms involved. PATIENTS AND METHODS: Three groups of Hooded Wistar rats were studied. Group 1 (n=5) were controls (selective bile duct cannulation (BDC) of the left lateral and median lobes, 2-h measurement of bile flow). Group 2 (n=7) received IR injury (BDC; 45-min clamping of portal vein (PV) and hepatic artery (HA) to the left lateral and the median lobes followed by 60 min of reperfusion). Group 3 (n=7) were pre- treated with IPC (BDC; 10 min of PV and HA clamping followed by 10 min of reperfusion prior to 45 min ischemia and 60 min reperfusion). Bile flow was measured at 5-min intervals. Serum AST, ALT and LDH levels were measured at the beginning and at the end of the experiment. Liver histology was examined by H&E staining. F-actin distribution was measured using confocal fluorescence microscopy after staining with Texas Red-X phalloidin. RESULTS: Ischemia reduced bile flow to nil and bile flow did not recover after reperfusion (p<0.001 group 2 vs controls). IPC significantly improved bile flow during reperfusion (p<0.05 group 3 vs group 2). IPC did not significantly reduce ALT, AST and LDH levels. Light microscopy showed mild portal inflammation and hepatocyte damage in group 2; this was less obvious in group 3. Cellular F-actin distribution did not differ between groups. F-actin was located around the peripheral cell membrane and the bile canaliculus. CONCLUSION: IPC significantly improves bile flow after warm ischemia to the liver in rats. F-actin distribution was not significantly altered by IR or IPC. Future experiments are directed at elucidation of the mechanisms, including the roles of F-actin, cytoplasmatic Ca2 + and Ca2 + regulatory enzymes.
38 SPLENORENAL SIDE-TO-SIDE SHUNT FOR EXTRAHEPATIC PORTAL VEIN THROMBOSIS
Wolff M, Schaefer N, Hirner A, Surgery, University of Bonn, Bonn, Germany
INTRODUCTION AND AIM: In contrast to cirrhotic portal hypertension, extrahepatic portal hypertension (EPH) due to chronic thrombosis of the portal vein and its tributaries is rare and may occur in young patients with well preserved liver function. Herein, our long-term results with spleno-renal side-to-side shunt (SRSS), which was first described by Cooley in 1963 for cirrhotic portal hypertension, are reported. PATIENTS AND METHODS: From 1989 to 2004 a group of 131 patients with EPH were treated by devascularization and shunt procedures. In 32 patients a SRSS was applied. The indications for SRSS (mean age 21, range 2–69) were recurrent variceal bleeding (n=28) or primary prophylaxis in patients on warfarin (n=4). Follow-up included SF-36 and Reitan-test for quality of life and subclinical encephalopathy (HE) after 6 and 12 months. Shunt patency was assessed by Doppler sonography, by helical CT scan or MR angiography when necessary. RESULTS: All patients were alive after a mean follow-up of 51 (range 6–92) months without evidence of recurrent bleeding and with excellent quality of life. There was no clinical or subclinical HE with hemodynamically total shunts (portosystemic pressure gradient after shunt (4±3 mmHg) in patients with normal liver histology. In one 13-year-old child with congenital liver fibrosis episodic HE developed and the SRSS was successfully changed to a selective DSRS. CONCLUSION: In patients with portal vein thrombosis, normal liver function, and a patent splenic vein an SRSS can be applied with a low procedural and follow-up complication rate. Quality of life becomes better with time by decreasing fear of recurrent bleeding and repeated endoscopy. In thrombophilic disorders oral anticoagulation becomes possible, thus providing a better chance to avoid further thrombosis of the portal system.
39 DUAL LIGATION OF PORTAL VEIN AND HEPATIC ARTERY IS NOT MORE EFFECTIVE THAN PORTAL VEIN LIGATION ALONE IN INDUCING CONTRALATERAL LIVER HYPERTROPHY IN ARAT MODEL
Veteläinen R, Dinant S, van Vliet A, van Gulik T, Surgery, Surgical Laboratory, Academic Medical Center, Amsterdam, The Netherlands
INTRODUCTION AND AIM: Dual embolization of hepatic artery and portal vein has been proposed to enhance liver regeneration and to gain tumor destruction prior to resection. However, the proin-flammatory effect of dual embolization is unclear. This study evaluated the effect of portal vein ligation (PVL) compared to a dual ligation of the hepatic artery and portal vein on liver regeneration and on inflammatory response in a rat model of portal vein embolization. PATIENTS AND METHODS: 5 groups were studied: laparotomy only, a single hepatic artery ligation, a single portal vein ligation, dual ligation of both artery and vein simultaneously (DUAL0) or with 48-h interval (DUAL48). Rats were sacrificed 1, 2 or 14 days after surgery (n = 6/group). We assessed liver regeneration (regenerating liver mass, proliferation index: MIB-5), inflammatory response (IL-1beta and TNF-alpha in plasma and liver), synthesis function (prothrombin time: PT-TT), hepatocellular damage (ALT, necrosis) and apoptosis (caspase-3). RESULTS: After 24 h the MIB-5 index was increased in the DUAL and DUAL48 groups compared with PVL (p<0.05); however, there was no difference in regenerating liver volume after 14 days (p = 0.06). After DUAL0 and DUAL48, TNF-alpha and IL-1beta were significantly increased in plasma and regenerating liver compared with PVL (p<0.05). Also, caspase-3 positive cells were increased at 24 h and 48 h in both dual ligated groups compared with PVL (p<0.05). PT-TT stayed prolonged until 14 days after DUAL0 and DUAL48 (p<0.05). CONCLUSION: Dual ligation is as effective as portal vein ligation in inducing liver regeneration. An additional hepatic artery ligation leads to both local and systemic inflammatory response impairing synthesis function.
40 MUCINOUS CYSTADENOMAS IN LIVER AND PANCREAS FEATURE ACOMMON ORIGIN FROM GONADAL EPITHELIUM DURING FETAL DEVELOPMENT
Erdogan D3, Lamers WH1, Offerhaus GJA2, Busch OR3, Gouma DJ3, van Gulik TM3, (1) Department of Anatomy and Embryology; (2) Department of Pathology; (3) Department of Surgery, Academic Medical Center-University of Amsterdam, Amsterdam, The Netherlands
INTRODUCTION AND AIM: Mucinous cystadenomas of liver and pancreas are rare cystic neoplasms which contain ovarian stroma (OS) and tend to occur more often in middle-aged women. The aim of this study was to show that these tumors have a common origin from gonadal epithelium in early fetal development, explaining the presence of OS. PATIENTS AND METHODS: From 1997 to 2004, 21 female patients presented with mucinous cystadenomas with OS (11 in liver of which one cystadenocarcinoma and 10 in pancreas of which one cystadenocarcinoma). The regional differences in morphology of the peritoneal cavity epithelium and the position of the gonads in relation to the embryonic liver, pancreas and spleen were examined in embryos at 5–8 weeks development. RESULTS: In all patients, OS could be identified, also in the 2 patients with mucinous cystadenocarcinomas as is compatible with the pre-malignant nature of mucinous cystadenoma. In the fetal period before the gonads descend, these are situated directly dorsal to the liver, tail of the pancreas and the spleen, but are separated from these organs by the peritoneal cavity. The cells covering the gonads in the urogenital folds may become detached on physical contact with a neighbouring organ. They then lodge into that organ givingrise to acystadenoma with OS. CONCLUSION: Our findings suggest that mucinous cystadenomas of pancreas and liver have a common origin in the epithelial cells that cover the embryonic gonads in early fetal life. These covering cells are easily mobilized and lodge in adjacent liver or pancreas where they give rise to mucinous cystadenomas with OS.
41 IMPROVEMENT OF NONALCOHOLIC STEATOHEPATITIS IN SEVEREL Y OBESE PATIENTS AFTER MASSIVE WEIGHT LOSS INDUCED BY GASTROPLASTY
Papakonstantinou A1, Stratopoulos C1, Terzis I1, Spiliadi C2, Dimitriades G3, Komesidou V4, Kitsanta P2, Argyrakos T2, Argyrakos T2, Hadjiyannakis EJ1, (1) First Department of Surgery & Transplant Centre; (2) Department of Cellular Pathology; Second Academic Department of Internal Medicine; Department of Dietetics, Evagelismos Hospital of Athens, Athens, Greece
INTRODUCTION AND AIM: Nonalcoholic steatohepatitis (NASH) is common in the morbidly obese. The purpose of this study was to evaluate the alterations in liver histology and biochemistry with massive weight loss in severely obese patients following Mason's vertical banded gastroplasty. PATIENTS AND METHODS: This prospective study included 51 non-diabetic, non-alcoholic, severely obese patients with a mean age of 33.92 years, a mean body weight of 150.92 kg and a mean body mass index (BMI) of 52.8 kg/m2. RESULTS: At entry, liver histology was abnormal in 50 patients. Steatosis and steatohepatitis were present in 98.03% of the subjects, with the majority having grade 3. Fibrosis was found in 94.1% of the patients, with the majority having stage F2. Lipogranulomas and regenerative activity were found in 56.9% and 41.2% of patients. During the weight-losing period, excess weight loss of 66% had been achieved (p< 0.001). A significant improvement was noted regarding steatosis, steatohepatitis, lipogranulomas (p<0.001) and fibrosis (p = 0.002). Regenerative activity was markedly increased, but did not reach statistical significance (p = 0.053). A significant correlation between the reduction of BMI and the decrease of steatohepatitis was noted (r=0.354, p=0.011). Fasting serum glucose, lipids, lipopro-teins, transaminases, gamma-glutamyl transpeptidase, alkaline phosphatase and fibrinogen were significantly improved at the time of the second biopsy. CONCLUSION: Bariatric surgery is the best and recommended treatment for NASH in the non-diabetic, non-alcoholic, severely obese patient.
42 THE SEGMENTS OF THE HEPATIC VEINS—IS THERE ASPATIAL CORRELATION TOTHE COUINAUD LIVER SEGMENTS?
Fischer L2, Thorn M1, Neumann JO2, Heimann T1, Grenacher L3, Meinzer HP1, Friess H2, Büchler MW2, (1) Department MBI, DKFZ Heidelberg; (2) Department of Surgery, University of Heidelberg; (3) Department of Radiology, University of Heidelberg, Heidelberg, Germany
INTRODUCTION AND AIM: The exact definition of venous segments/subsegments and their spatial correlation to Couinaud liver segments has an increasing clinical importance especially against the background of living-related liver transplantation. PATIENTS AND METHODS: In 3-D liver models of 19 patients volume, position and shape of 3 venous segments, 6 venous subsegments, 8 Couinaud segments and 8 portal vein segments were defined and compared with each other. RESULTS: The right hepatic vein covers with 539.8 ml + /–119.5 ml (47.1%) the largest part of total liver volume followed by the middle hepatic vein 372.7 ml + /–151.1ml (32.5%), and the left hepatic vein 248 ml + /–75.9 ml (20,4%). Within these 3 venous segments the Couinaud/portal vein segments 2, 3, 5, 7, and 8 have an identical positional assignment, whereas the Couinaud/portal vein segments 4a, 4b, and 6 showed significant positional differences (p<0.03). The size of venous subsegments reached from 79.3 ml to 337 ml. There is no positional correlation between venous subsegments and Couinaud segments (kappa 50.75). In contrast, venous segments/subsegments which reflect either liver half/liver lobe have an identical volume, shape and position compared to the corresponding Couinaud segments (kappa 40.75). CONCLUSION: The venous segments distinguish liver areas divided by the left and middle hepatic vein in exactly the same pattern as Couinaud segments do. However, the comparison of shape and position of venous subsegments showed no correlation with the Couinaud segments.
43 EX SITU RESECTION TECHNIQUES AND LIVER AUTO-TRANSPLANTATION: LAST RESOURCE FOR OTHERWISE UNRESECTABLE MALIGNANCY
Gruttadauria S2, Marsh W1, Gridelli B2, Marcos A1, Transplantation, University of Pittsburgh Medical Center; Abdominal Transplant Surgery, IsMeTT-UPMC ITALY, Palermo, Italy
INTRODUCTION AND AIM: Ex vivo liver resection and hepatic auto-transplantation allow treatment of otherwise unresectable hepatobiliary malignancy. Recently improvement in outcomes in selected cases has been reported. The aim of this study is to describe our experience with two cases where we applied the combination of the ex situ resection with hepatic auto-transplantation for intended cure of two otherwise untreatable malignancies. PATIENTS AND METHODS: A41-year-old Caucasian male with diagnosis of cholangiocarcinoma type IV according to Bismuth classification after two previous exploratory laparotomies, underwent total hepatectomy and ex vivo extended left lobectomy with reconstruction of the portal vein with autologous iliac vein graft, auto-transplantation, aortosaphenous to right hepatic artery bypass, and Roux-en-Y hepaticojejunostomy. A second patient, a 58-year-old Caucasian male with a diagnosis of recurrent leiomyosarcoma of the suprahepatic inferior vena cava after two previous operations, underwent total hepatectomy and ex vivo resection of a segment of supra hepatic inferior vena cava and auto-transplantation with intra-pericardial access to the vena cava. RESULTS: In the first case cold ischemia time to the liver was 5 h; the total operating time was 19 h, and patient is still alive at 23 months after surgery. In the second case cold ischemia time to the liver was 2 h; the total operating time was 9 h, and patient is alive at 2 months after surgery. CONCLUSION: These two cases are the paradigm of the possibility of performing extreme salvage procedures after the failure of more conventional treatments allowing improvement in survival and quality of life in a controversial clinical scenario.
44 THE USE OF THE PROMETHEUS SYSTEM IN THE TREATMENT OF ACUTE LIVER FAILURE IN THE COURSE OF AMANITAPHALLOIDES INTOXICATION
Krawczyk M1, Skwarek A1, Grodzicki M1, Nyckowski P1, Zieniewicz K1, Najnigier B1, Patkowski W1, Smoter P1, Paczek L2, Department of General, Transplant and Liver Surgery; Departmet of Immunology, Transplantation Medicine and Internal Disease, Medical University, Warsaw, Poland
INTRODUCTION AND AIM: The authors present outcomes in patients with acute liver failure in the course of Amanita phalloides intoxication treated with the Prometheus system. PATIENTS AND METHODS: Between September 2003 and November 2004 fractionated plasma separation and adsorption (FPSA) procedures were performed in 4 patients. The patients qualified for the procedure according to King's College Hospital criteria. The procedures were performed with a Prometheus 4008H Fresenius Medical Care unit. The patient's general condition was assessed on the basis of UNOS, Child, GCS and 4-grade encephalopathy classifications. The following the liver function tests (LFTs) were determined before and after the procedure. RESULTS: 11 procedures were performed. Mean duration of procedure was 6.5 h. Mean values of LFTs before and after procedure were as follows: bilirubin (10.2 mg/dl vs 5.1 mg/ dl;p<0.01), ammonia (246.4 µg/mlvs 138.2 mg/ml; p<0.01), AST (2149.5 U/L vs 878.9 U/L; p<0.01), ALT (3678.6 U/L vs 1453.7 U/L; p<0.01), urea (56.7 mg/dl vs 23.7 mg/dl), creatinine (2.7 mg/dl vs 1.2 mg/dl), pH (7.28 vs 7.38). One patient did not require OLTx. In 3 patients OLTX was performed. In one case OLTx outcome was positive. 2 patients died after OLTx due to sep-ticemia. CONCLUSION: The results suggest that the Prometheus system allows for detoxication treatment of these patients, already to qualified for urgent OLTx.