BACKGROUND/AIMS:The use of drainage after liver resection remains controversial. Data of the usefulness of drains in cirrhotic patients undergoing surgical resection are scarce. The objective of our study is to assess the usefulness of intra-abdominal drainage after liver resection for hepatocellular carcinoma in cirrhotic patients.METHODOLOGY:We performed a randomized controlled trial to assess the benefits of abdominal drainage after resection of hepatocellular carcinoma in cirrhotic patients. The main end point was to compare postoperative complications and hospital stay in both groups.RESULTS:Abdominal drainage decreased ascites leakage and significantly reduced hospital stay in comparison to the non-drainage group. In addition, local complications were less frequent in the drainage group. Postoperative ascites leakage significantly complicated patients with clinically relevant portal hypertension.CONCLUSIONS:Intra-abdominal closed drainage is advisable in cirrhotic patients undergoing liver resection for hepatocellular carcinoma, mainly if presenting preoperative portal hypertension.

The aim of this study was to assess liver viability after different periods of cardiac arrest and the predictive value of two markers of ischemia-reperfusion injury. Methods: A pig liver transplantation model of non-heart-beating donors was studied. Four donor groups were designed; three groups were submitted to different periods of cardiac arrest (20, 30 and 40 min), and the fourth group served as the control group (without cardiac arrest). In the non-heart-beating donor groups, normothermic recirculation was established 30 min prior to total body cooling. Aminotransferase, α-glutathione-S-transferase, and hyaluronic acid determinations as well as liver biopsies, were serially performed. Results: Although hepatocellular function could be preserved after 40 min of cardiac arrest, histological lesions at 5 days were considered irreversible due to the presence of a necrotic biliary tract. An overall significant relationship was found between the time period of cardiac arrest (20, 30 or 40 min) and the levels of hyaluronic acid (p = 0.004) or α-glutathione-S-transferase (p = 0.01) obtained during liver procurement and transplantation. Conclusions: The period of cardiac arrest is the determinant factor of liver viability after liver transplantation from non-heart-beating donors. As early markers of endothelial or hepatocellular damage, hyaluronic acid or α-glutathione-S-transferase levels may help to evaluate the ischemic injury of a potential donor.

Arterio-portal shunt 324 Atherosclerosis 305 Autotransplantation 240 Balloon catheter 216 Bipolar cautery 173 Blood flow 19 -gas analysis 9 Bombesin 412 Bromodeoxyuridine 412 Bypass surgery, peripheral arterial 64 Calcium antagonist 259 -channel blocker 390 Cardiac output 19 Catecholamines, plasmatic 221 Cautery with irrigation forceps 173

BACKGROUND:Our aim was to evaluate the hepatic blood flows and oxygen metabolism of non-heart-beating donor (NHBD) pigs, with the use of cardiopulmonary bypass (CPB) and normothermic recirculation (NR) before total body cooling, and its relationship with recipient survival.METHODS:Thirty-five pigs were transplanted with an allograft from NHBDs. After warm ischemia (WI) time (20, 30, or 40 min), CPB and NR were run for 30 min. After this period, the animals were cooled to 15 degrees C. In the control group (20 min of WI), the period of NR was excluded. Liver procurement was then performed.RESULTS:Survival rate was 100% in the 20WI, 70% in the 30WI, and 50% in the 40WI. Control group survival rate was 0%. Hepatic artery blood flow and portal blood flow recovered during NR. Pump blood flow during CPB increased rapidly during NR and was significantly higher in the 20WI. When donors of the livers transplanted in "surviving pigs" (DSP) were compared with donors of the livers transplanted in "nonsurviving pigs" (DNSP), hepatic artery blood flow, portal blood flow, and pump blood flow were higher in the DSP. Hepatic oxygen extraction ratio increased in the three groups with respect to baseline values. Hepatic oxygen extraction ratio was lower in the 20WI than in the other groups and was lower in the DSP than in the DNSP.CONCLUSIONS:The use of a NR period before total body cooling improves survival of liver transplantation in NHBDs. Portal blood flow and pump blood flow measurements can predict the viability of the grafts.

The aim of this study was to investigate the safe time limits of cold preservation in University of Wisconsin (UW) solution of liver grafts subjected to warm ischemia (WI) for 30 minutes from non–heart-beating donors (NHBDs).The safe time limits were studied in a simple porcine orthotopic liver transplantation (LTx) model. In donors, livers were subjected to 30 minutes of WI and subsequent 6-hour (Group 1, n = 5), 10-hour (Group 2, n = 5), and 14-hour (Group 3, n = 3) cold preservation in UW solution.All 5 animals in Group 1 survived up to 7 days, the survey endpoint. In Group 2, only 2 animals survived to the same survey endpoint. All animals in Group 3 died within 12 hours. The 1-week survival rate of Group 1 was significantly higher than those of the other 2 groups. Group 1 showed a lower level of alanine aminotransferase (ALT) or aspartate aminotransferase (AST) after LTx, less pathological damage, higher concentration of adenosine triphosphate (ATP), and higher microcirculation blood flux in the grafted liver tissue at 1 hour after reperfusion than the other 2 groups.It is concluded that about 6 hours is the safe time limit of cold preservation in UW solution for liver grafts from NHBDs subjected to WI for 30 minutes.

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease worldwide and the leading cause of liver-related morbidity and mortality. We aimed to predict the burden of NAFLD by examining and estimating the temporal trends of its worldwide prevalence and incidence.In this systematic review and meta-analysis, we searched MEDLINE, EMBASE, Scopus, and Web of Science without language restrictions for reports published between date of database inception and May 25, 2021. We included observational cross-sectional or longitudinal studies done in study populations representative of the general adult population, in whom NAFLD was diagnosed using an imaging method in the absence of excessive alcohol consumption and viral hepatitis. Studies were excluded if conducted in paediatric populations (aged <18 years) or subgroups of the general population. Summary estimates were extracted from included reports by KR and independently verified by HA using the population, intervention, comparison, and outcomes framework. Primary outcomes were the prevalence and incidence of NAFLD. A random-effects meta-analysis was used to calculate overall and sex-specific pooled effect estimates and 95% CIs.The search identified 28 557 records, of which 13 577 records were screened; 299 records were also identified via other methods. In total, 72 publications with a sample population of 1 030 160 individuals from 17 countries were included in the prevalence analysis, and 16 publications with a sample population of 381 765 individuals from five countries were included in the incidence analysis. The overall prevalence of NAFLD worldwide was estimated to be 32·4% (95% CI 29·9–34·9). Prevalence increased significantly over time, from 25·5% (20·1–31·0) in or before 2005 to 37·8% (32·4–43·3) in 2016 or later (p=0·013). Overall prevalence of NAFLD was significantly higher in men than in women (39·7% [36·6–42·8] vs 25·6% [22·3–28·8]; p<0·0001). The overall incidence of NAFLD was estimated to be 46·9 cases per 1000 person-years (36·4–57·5); 70·8 cases per 1000 person-years (48·7–92·8) in men and 29·6 cases per 1000 person-years (20·2–38·9) in women (p<0·0001). There was considerable heterogeneity between studies of both NAFLD prevalence (I2=99·9%) and NAFLD incidence (I2=99·9%).Worldwide prevalence of NAFLD is considerably higher than previously estimated and is continuing to increase at an alarming rate. Incidence and prevalence of NAFLD are significantly higher among men than among women. Greater awareness of NAFLD and the development of cost-effective risk stratification strategies are warranted to address the growing burden of NAFLD.Canadian Institutes of Health.

Background: This study was performed to prospectively assess the complications of 118 consecutive patients who underwent laparoscopic assisted colorectal resections.

The clinical boundaries of transplantation have been set in an era of simple cold storage. Research in organ preservation has led to the development of flush solutions that buffer the harsh molecular conditions which develop during ischaemia, and provide stored organs that are fit to sustain life after transplantation. Although simple and efficient, this method might be reaching its limit with respect to the duration, preservation, and the quality of organs that can be preserved. In addition, flush preservation does not allow for adequate viability assessment. There is good evidence that preservation times will be extended by the provision of continuous cellular substrate. Stimulation of in-vivo conditions by ex-vivo perfusion could also mean that marginal organs will be salvaged for transplantation. Perfusion will also allow for assessing the viability of organs before transplantation in a continuous fashion. The cumulative effect of these benefits would include expansion of the donor pool, less risk of primary non-function, and extension of the safe preservation period. Use of non-heart-beating donors, international organ sharing, and precise calculation of the risk of primary organ failure could become standard.

Based on similar anatomy, physiology, and size to humans, pigs provide an excellent means for studying new therapies related to orthotopic liver transplant (OLT). Techniques that have been described to date, however, are unnecessarily complex and increase the likelihood of morbidity and adverse outcome.Male outbred weanling pigs underwent OLT according to our procedure, with a short anhepatic time (<20 min) and without veno–venous bypass or vasoactive substances during the anhepatic phase. Vascular anastomoses were performed identical to the clinical setting, and a simple stented choledochocholedochostomy was created.The authors have performed this procedure 130 times using four transplant models: standard, whole-liver (n = 10), small-for-size (n = 48), donor after cardiac death (n = 44), and donor adenoviral gene transfection (n = 28). The average cold ischemic and anhepatic times were 302 ± 43 and 17 ± 3 min, respectively. Hypotension was successfully treated with intravenous fluids. In all cases, the recipient survived the operation and was extubated. Survival to the end follow-up varied according to the model and was 56% (73/130) for all cases. At autopsy or euthanasia, no vascular thrombosis or outflow obstruction was found. Survival was 100% for pigs transplanted with standard, whole-liver grafts (n = 10). In this group, AST and bilirubin rose during the first 24 h after graft reperfusion, while the Quick prothrombin time (QPT) fell. By the fifth postoperative day, these parameters had returned to baseline.This model is straightforward and reproducible and offers surgeons and researchers the opportunity to perform OLT studies under clinically relevant conditions.

OBJECTIVE The authors analyze the outcomes of patients with hepatocellular carcinoma (HCC) and cirrhosis who underwent liver resections. BACKGROUND Liver resection is the best option for HCC arising from hepatic cirrhosis. The experience of Western centers with these patients is shorter than the Asian series. METHODS Forty-eight consecutive patients with cirrhosis and HCC who underwent liver resections were studied after a similar diagnostic and therapeutic process. Survival and cumulative recurrence were calculated according to pathologic findings. RESULTS Factors influencing survival at 3 years were as follows: type of resection, absence of vascular invasion, size of the tumor, absence of satellite nodules, and the number of nodules. Factors influencing the rate of recurrence at 3 years were the presence of vascular invasion and the presence of satellite nodules. Patients with favorable prognostic factors have a good survival rate with an acceptable recurrence rate. CONCLUSIONS Identification of prognostic factors may help in the selection of the appropriate treatment for these patients with HCC and cirrhosis.

The aim of this study is to investigate the role of prostaglandins (PGI2 and TXA2) in relation with the hemodynamic alterations occuring after graft reperfusion in patients undergoing OLT. A total of 40 patients with liver cirrhosis were studied. Systemic 6-keto-PGF1 alpha and TXB2, stable metabolites of PGI2 and TXA2 respectively, were determined at the radial artery, at four different surgical stages: basal, hepatectomy, anhepatic, and 10 minutes after graft reperfusion. Overall results showed that 6-keto-PGF1 alpha levels were significantly elevated during hepatectomy (1143 +/- 204) when compared to values in the basal stage (p = 0.007). During hepatectomy, 6-keto-PGF1 alpha levels did not correlate to systemic vascular resistance index (SVRI), neither with the cardiac index (IC) nor with the medial arterial pressure (MAP) in the same stage. During the anhepatic stage, only IRVS was inversely correlated with 6-keto-PGF1 alpha levels (p = 0.004): there was no relation with MAP and CI. During reperfusion no correlations were observed between 6-keto-PGF1 alpha levels and MAP, CI or SVRI. We conclude that systemic PGI2 levels are very high in cirrhotic patients undergoing OLT. The absence of correlation between the magnitude of changes in hemodynamic parameters and 6-keto-PGF1 alpha levels during reperfusion of the new liver suggests that other factors must play a role in these hemodynamic changes.

Paraesophageal hernias are uncommon conditions which appear mainly in elderly people, frequently associated with sliding hernias or gastric volvulus, Considered a high risk pathology, surgical management is preferred to avoid serious complications. Due to advanced age and operative risks, a laparoscopic approach was performed in the three patients with paraesophageal hernia. In mixed hernias, a Nissen or Toupet fundoplication and closure of the hiatal defect was carried out. In a case with gastric rotation, reduction of the herniated stomach and posterior partial fundoplication with gastropexy was performed. No postoperative complications occurred and recovery was satisfactory. Laparoscopic management seems to be a good choice for elective treatment of paraesophageal hernias in elderly patients.

Paraesophageal hernias are uncommon conditions which appear mainly in elderly people, frequently associated with sliding hernias or gastric volvulus. Considered a high risk pathology, surgical management is preferred to avoid serious complications. Due to advanced age and operative risks, a laparoscopic approach was performed in the three patients with paraesophageal hernia. In mixed hernias, a Nissen or Toupet fundoplication and closure of the hiatal defect was carried out. In a case with gastric rotation, reduction of the herniated stomach and posterior partial fundoplication with gastropexy was performed. No postoperative complications occurred and recovery was satisfactory. Laparoscopic management seems to be a good choice for elective treatment of paraesophageal hernias in elderly patients.

The aim of this study is to investigate the role of prostaglandins (PGI(2) and TXA(2)) in relation with the hemodynamic alterations occuring after graft reperfusion in patients undergoing OLT. A total of 40 patients with liver cirrhosis were studied. Systemic 6-keto-PGF(1 alpha) and TXB(2), stable metabolites of PGI(2) and TXA(2) respectively, were determined at the radial artery, at four different surgical stages: basal, hepatectomy, anhepatic, and 10 minutes after graft reperfusion, Overall results showed that 6-keto-PGF(1 alpha) levels were significantly elevated during hepatectomy (1143 +/- 204) when compared to values in the basal stage (p = 0.007). During hepatectomy, 6-keto-PGF(1 alpha) levels did not correlate to systemic vascular resistance index (SVRI), neither with the cardiac index (IC) nor with the medial arterial pressure (MAP) in the same stage. During the anhepatic stage, only IRVS was inversely correlated with 6-keto-PGF(1 alpha) levels (p = 0.004): there was no relation with MAP and CI. During reperfusion no correlations were observed between 6-keto-PGF(1 alpha) levels and MAP, CI or SVRI. We conclude that systemic PGI(2) levels are very high in cirrhotic patients undergoing OLT. The absence of correlation between the magnitude of changes in hemodynamic parameters and 6-keto-PGF(1 alpha) levels during reperfusion of the new liver suggests that other factors must play a role in these hemodynamic changes.

Laparoscopic excision of a gastric lipoma is reported here. The diagnosis was done preoperatively be computed tomography, which gave evidence of fat tissue due to its low attenuation. The patient undergoes a complete submucosal excision enjoying the benefit of the laparoscopic approach with rapid postoperative recovery. This procedure offers a good alternative to open laparotomy in the treatment of benign gastric tumours.