ročník 4,1996 č.2-3

Editorial

  1. Resection of the liver: the state of the art

Abstrakta

  1. Aspergilóza u nemocné po transplantaci jater
  2. Naše zkušenosti s léčbou iatrogenních poranění a pooperačních změn žlučových cest

Editorial

Resection of the liver: the state of the art

Eldar M Gadžijev
Chirurgická klinika
Universitní nemocnice - Ljubljana, Slovinsko

Liver resection is today a reasonable, safe and effective surgical procedure used for treatment of benign lesions and malignant tumours of the liver and biliary tract. Advances in surgical techniques and an increase in indications for liver resection has resulted in a growing number of liver resections being performed, not only in specialist centres but also in smaller institutions. Half a century of detailed study of the anatomy of the liver has helped to build a more profound knowledge of liver anatomy (1), while the introduction of intraoperative ultrasound has enabled surgeons to view inside the liver, helping them to detect lesions that are undetectable by percutanous US or CT scan and to determine the extent of tumour invasion (2). Liver transplantation techniques have given surgeons new experiences concerning mobilisation, vascular occlusion and extreme liver surgery procedures. New technology with different kinds of dissectors have made liver transsection safer. The skill of surgeons and the support of anaesthetists and ICU specialists have contributed to the achievement of better results from surgical treatment and postoperative care. And a final but very important point is that a multidisciplinary approach to liver lesions enables a selection of patients to be made so that the decision as to whether to undertake operative treatment of a hepatic lesion is optimised and liver resection can be planned in detail. Surgical procedure is becoming a component in the complex treatment of hepatobiliary pathology.

Types of resection

Liver resection is a surgical procedure by which a pathological lesion or diseased part of the liver parenchyma is removed by dissection through the parenchyma.
Liver resections are usually divided into anatomical and nonanatomical.
Anatomical resections are segment-oriented resections and hepatectomies.
A segmentectomy is a resection of a single segment. Because the so-called upper and posterior segments I, II, IVa, VIII, VII and IX (the right paracaval region) are bordered by trunks of hepatic veins, resections of these segments are much more demanding than removal of the so-called lower or "overhanging" segments III, IVb, V, VI (Fig.1).

Fig.1 - Segment-oriented resection for a colorectal metastasis in segment V.

A bisegmentectomy is a resection of two neighbouring segments. In some cases this involves simply a sectoriectomy, for example when segments V and VIII, or VI and VII are resected. When two segments which do not constitute a sector are removed, for example segments V and VI, or IVb and V, or VII and VIII, the procedure is called a bisegmentectomy. Resection of segments II and III is often called a left lobectomy and it is in fact a resection of a small left lateral sector -- which consists of segment II -- and segment III. We can speak of plurisegmentectomy when three or more segments are resected which do not create a hemiliver, for example segments V, VI and VII, or III, IVb and V, or VI, VIII and II. Such a resection may be a combination of a bisegmentectomy and an additional segmentectomy from the other side of the liver such as a resection of segments VI, VII and III or segments II, III and V. We speak of perisegmentectomy when a resection of the segment is extended to the smaller parts of neighbouring segments in order to achieve radicality (3). Most segment-oriented resections are used to remove metastases from the liver. Anatomy related segmentectomies are safer than metastasectomies, and when properly performed under the guidance of intraoperative ultrasound such resections do not jeopardise the neighbouring liver tissue, whereas wedge resections can. Depending on the paths of growth of hepatocellular carcinoma with its portogenic spread, segmentectomies can be logical procedures, especially in cirrhotic patients. Subsegmentectomies are isolated resections of subsegments. They can be performed using intraoperative ultrasound and marking the subsegment branch of the portal vein with a stain or producing an ischemia with a balloon catheter. Subsegmentectomies are used to remove small hepatocellular carcinomas in a cirrhotic liver.
Hepatectomies are liver resections where the liver tissue of a hemiliver or even more is resected. A right hepatectomy is a resection of segments V, VI, VII and VIII, usually together with the right paracaval region (Fig.2).

Fig.2 - After right hepatectomy for a large primary liver tumour.

When, for reasons of radicality, a resection is extended to a part of segment IV or to segment I, it is called an extended right hepatectomy. A right trisegmentectomy according to American surgeons is, in fact, a right hepatectomy which includes segment IV. A left hepatectomy is a resection of segments II, III and IV, sometimes together with segment I, while an extended left hepatectomy includes part of segments V and VIII or it can be extended only to segment V, or only to a part of segment VIII. The so-called left trisegmentectomy -- resection of the left liver and segments V and VIII -- is anatomically a left trisectoriectomy. For cases involving the presence of an inferior right hepatic vein, four new hepatectomy procedures with a resection of the superior right hepatic vein have been introduced (4). Extended left trisegmentectomy (trisectoriectomy) is a resection of the left liver plus segments V, VIII and VII, where only segment VI remains (Fig.3).

Fig.3 - Specimen of the liver with very large hepatocellular carcinoma resected with extended left hepatectomy - - trisectoriectomy.

Resection of segments IV, V and VIII (medial liver resection) together with segment VII demands a resection of the middle hepatic vein in addition to the resection of the superior right hepatic vein. We can perform a resection of segments V, VIII and VII where only segment VI of the right liver is spared, and the aforementioned bisegmentectomy of segments VII and VIII, both demanding resection of the superior right hepatic vein. Hemihepatectomies and extended resections are mostly used for primary and also secondary malignant tumours of the liver. They are also used in radical surgical treatment of carcinoma of the bile duct confluence and gallbladder cancer, as well as for some benign tumours and conditions such as hepaticolithiasis, or very large hemangiomas.
Nonanatomical resections are usually called wedge resections. They can be excisions at the very border of the lesion, as in pericystectomy of a hydatid cyst or excision of a hemangioma (Fig.4).

Fig.4 - Total pericystectomy for a Hydatid cyst in the right liver.

When proper metastasectomies are performed a safety resectional edge of noninvaded tissue is removed together with the metastasis. So-called "crater" wedge resections are also used, mostly for resection of the HCC, again trying to preserve a part of the noninvaded liver parenchyma around the tumour. This kind of resection is used mostly in cirrhotic livers in order to spare liver tissue.
When an anatomical resection, for example a left hepatectomy, is combined with a wedge resection then we call it a combined liver resection.

Opting for a liver resection and the factors to be considered for safety and prevention of major complications
Patients with different hepatic lesions should be properly selected, and in order to evaluate the probability of safe and successful liver resection the following factors should be considered:
- The general condition of the patient. This is the first factor to be evaluated. Impaired cardiovascular condition, metabolic disease (diabetes mellitus) and damaged renal function are important factors which have a significant influence on postoperative morbidity and mortality rates. Age and sex are not of significant importance. In order to evaluate the risk of operative mortality and postoperative morbidity, the preoperative APACHE II score may be used (5). The acute physiology and chronic health evaluation system is a severity-of-disease classification involving the summing of 12 physiological variables that are most predictive of death, with age points and chronic health points added to this score (APACHE II). An increase in score is closely correlated with a rise in operative mortality and postoperative morbidity rates.
- The state of the liver. There is a great difference between performing a liver resection in a normal liver and a resection in a chronically diseased liver. Several classifications have been made to provide an evaluation of the functional status of the liver, but considering the very complex functions of the organ a single universal test can hardly be expected. The Childs-Pugh classification based on simple laboratory tests - bilirubin, albumin and prothrombine activity - together with the presence of ascites, nutritional status and an evaluation of encephalopathy, is still useful. During the last ten years various clearance tests have been used because they are more related to the condition of the liver parenchyma. The Japanese are mostly using the indocyanine green (ICG) clearance test at different times (mostly after 15 minutes), while in Europe a lidocaine test called the MEGX test (monoethylglycinexilidide is a lidocaine metabolite) is used more and more often (6) and the values measured 15 minutes after bolus application of lidocaine (1 mg/Kg). Normal values obtained in this test are those over 50 mg/ml, while values below 25 mg/ml indicate serious impairment of the liver function. Measurements of the values of total cholesterol as well as serum cholinesterase are increasingly used as important predictive factors for an assessment of the functional reserve of the liver.
The volume of the expected remnant of the liver parenchyma is also a significant parameter, and various computer programs with CT, MR and even US investigations are used to help the surgeon determine the extent of the hepatic resection.
- Tumour or characteristics of a pathological condition. The location, number of lesions, extent of the pathological condition, the relationship of the lesion to the liver structures - vessels, bile ducts and inferior vena cava - are all factors that influence surgical strategy. The presence of extrahepatic liver disease and the involvement of neighbouring organs in malignant liver tumours should always be looked for and noted. When dealing with metastatic disease, control of the primary tumour and search for a possible recidivant tumour is essential to determine the kind of treatment to apply.
During liver resection special attention should be paid to blood loss, not only because it is a general tendency in surgery to perform operations without blood transfusion (primarily to reduce the possibility of transmission of infections through blood) but also because blood loss is related to postoperative morbidity, and blood transfusions may have an adverse effect on survival rate (7). Different kinds of dissectors, proper liver mobilisation, direct control of the inferior vena cava and hepatic veins with vascular occlusion techniques make almost bloodless liver resections feasible.
Normalisation of the coagulation status before operative treatment whenever it can be achieved is, of course, a sine qua non for minimisation of blood loss during liver resection. Reducing the operating time is important as some authors have demonstrated (8), although this seems to be mostly a Japanese problem. Preoperative treatment used especially for malignant tumours has a certain influence on the safety of liver resection and the rate of postoperative complications. Preoperative chemoembolisation with cytostatic agents, Lipiodol and macroembolisation with the aim of achieving a downstaging of a tumour affects the liver parenchyma, the surrounding tissue and also the hematopoietic system. Consequently, there may be some problems during the liver resection and a higher degree of morbidity after operation. On the other hand, preoperative portal embolisation of the diseased part of the liver can stimulate the growth of the part of the liver unaffected by the tumour, and in such a way enough liver parenchyma can be retained for it remain active after extensive liver resection (9). A new locoregional immunochemotherapy will apparently have an even greater effect on tumours than chemoembolisation. Both methods may promote extensive tumour necrosis. Attention should be paid to the renal function, which should sometimes be assisted with the use of plasmafiltration or plasmapheresis.

Effects of resection

The aim of resection is to eliminate a lesion or pathological condition from the liver tissue. Besides promoting hepatic regeneration, which has been extensively studied in normal and pathological conditions of the liver, resection has some local and general consequences. Extensive mobilisation of the liver, especially after extended right-sided liver resections, can cause a crimping of the common hepatic trunk or the left hepatic vein or even the inferior vena cava. It can cause such hemodynamic problems that the patient could expire if the situation were not quickly rectified.
An empty space after liver resection draws into it some abdominal organs, particularly the large intestine and the omentum, whose presence is generally beneficial. But if the space is not filled, fluid is prone to gather there. Irritation and transportation of fluid through the diaphragm is normal in such conditions, resulting in pleural effusions.
Of the general effects, temporary portal hypertension is a normal consequence of a hepatectomy. In cirrhotic patients, portal hypertension can deteriorate to the extent that there is a danger of variceal bleeding.

The effects of temporary liver ischemia produced by vascular clamping have been extensively studied. The effect on hemodynamic changes during and after portal triad clamping and hepatic vascular occlusion are well known. Variations in tolerance of the occlusion are possible because of the differences in the presence of porto-systemic and cavo-caval shunts, different cardiac function and peripheric vasoconstrictive capacity. As well as the influence on renal function, reperfusion problems are caused by a discharge of various substances from a temporarily blocked portal pool. Acidosis develops and ischemic products are released. Free oxygen radicals have general as well as local effects on the liver tissue. The use of cytoprotection, whether hormonal or with antioxidants, can reduce problems resulting from vascular occlusion and liver resection, but their effectiveness still needs to be studied.

Pathology treated with liver resections

Many different treatment modalities have been developed to treat liver lesions and diseases. In recent years we have witnessed enormous progress in medical science, with gene therapy promising radical changes. With new technologies, new techniques of treatment not only for tumours but also for benign conditions such as bile stone disease have been developed. Immunochemotherapy, chemoembolisation and percutane US, guided necrotising treatment with alcohol, or with cryoprobes introduced laparoscopically, are used for management of primary and secondary liver tumours. Nevertheless, liver resections remain the main and for now the most successful treatment for many liver lesions and certain pathological conditions.
Primary malignant liver tumours such as hepatocellular carcinoma and cholangiocellular carcinoma are still most successfully treated by liver resection. A different approach is used for HCC in a cirrhotic liver and for primary liver cell carcinoma in a noncirrhotic liver. Diseased liver is the main problem and dictates the extent of possible resection. So with HCC in a chronically diseased liver limited hepatic resections are used (subsegmentectomies, segmentectomies and crater resections), which should, whenever possible, still be anatomical. The main problem with HCC in a noncirrhotic liver is the size of the tumour. With the help of preoperative chemoembolisations such tumours, although very big but limited to the liver, could be reduced in size. After downstaging of such tumours in selected patients, extended hepatectomy can be a radical procedure.
Other malignant primary liver tumours (for example, hemangioendothelioma and some sarcomas) are rare and if diagnosed early enough could be removed by hepatectomy.
Of the benign tumours, only symptomatic and very large hemangiomas are resected and adenomas not related to contraceptives. Focal nodular hyperplasia is, in fact, a tumour-like lesion composed of a hyperplastic hepatic parenchyma with a central scar containing abnormal vessels and radiating septa, and does not require treatment.
The established treatment for tumours of the bile duct confluence is skeletonisation resection of the common hepatic and common bile duct combined with hepatic resection to a varying extent. Sometimes only resection of part of the liver tissue in segments V and IV is sufficient to achieve a radical margin of the uninvolved bile ducts. More often, at least a resection of the caudate lobe is necessary, and depending on the extent of the tumour, also a left or right hepatectomy. It is important to take samples of the resected edges of the bile ducts for a frozen section and "ex tempore" histopathological examination. This is because these tumours spread in the bile duct walls, sometimes beneath the endothelial layer and even in a skipping manner. Gallbladder carcinoma is another malignant tumour which, depending on its stage, calls for liver resection, usually of segments V and IVb, and because the gallbladder is drained through the portal vein branches the tumour spreads the same way into the liver tissue. In advanced cases limited to the liver, extended hepatectomy may be performed. In tumours of the gallbladder and biliary tree, lymphadenectomy is always part of a radical procedure.
Although percutanous ethanol injection seemed a promising treatment for small tumours in cirrhotic livers, and chemoembolisation often brings about a considerable reduction in the tumour, surgical removal with liver resections gives the best results. Combined treatment with a multidisciplinary approach can give better results than surgery alone.
Of the secondary liver tumours, only selected patients with liver metastases after radical removal of a colorectal carcinoma may expect some benefit from liver resections. Some metastases from endocrine pancreatic tumours can also be successfully treated with liver resection, although ischemic therapy has given some excellent results.
In resecting colorectal liver metastases there is still a question over how big the resection should be. There may be a microscopically small (occult) metastases present in addition to the macroscopically presented metastases. After liver resection, growth factors which promote the regeneration of liver cells are released, but they also stimulate the growth of the tumour cells (10). Extensive resection promotes greater regenerative response with greater release of growth factors and the possibility of a previously occult metastases bursting. On the other hand, a bigger resection potentially removes a greater number of microscopic metastases, which can sometimes be located mostly in one hemiliver.
Among cystic lesions, only hydatid cysts and cystadenomas should be treated with liver resection. Cystadenomas are rare cystic tumours which are prone to recur and with time develop into cystadenocarcinoma. Therefore total excision or resection is the best treatment.
Another pathological condition suitable for liver resection is a hydatid cyst of the liver, which should be removed by pericystectomy. If a radical operation for this parasitic disease is to be performed, the dissection should be made at the edge of pericyst when safe and possible.
Intrahepatic lithiasis, especially if associated with one-sided Caroli disease, can be successfully treated with a liver resection.
Classic anatomic liver resections for liver trauma have led to a very high mortality rate (50%) and are nowadays rarely performed. Resectional debridement is a justified and effective kind of resection that should be used when possible, although other methods of treating liver injuries are now popular, such as perihepatic packing and mash wrapping.

Technique Incision

Incision for liver resection depends mostly on the location and kind of pathological lesion within the liver. Sometimes a simple median incision is enough for a resection of the left liver; on other occasions an incision extended into the thoracothomy and phrenotomy is needed for segmental resection of the right liver.
A bilateral subcostal incision with an extension towards the sternum or even through it is practised mostly in liver transplants, but is also widely used for extended liver resections.
A "J" shaped incision and an "inverted T" incision introduced by Makuuchi has enabled excellent access to the posterior sector of the liver and to the inferior vena cava. Good retractors replacing assistants make most incisions suitable for liver resection provided they are long enough. Special care should be taken to achieve good hemostasis of the incision in order to avoid problems during liver resection.

Intraoperative ultrasound investigation

Peroperative use of ultrasound investigation is a prerequisite for safe liver surgery. Various useful ultrasound devices are available and better and better intraoperative probes are being manufactured. This method enables the surgeon to see inside the liver. Sometimes even lesions that are preoperatively undetectable by percutaneous US or CT can be detected. A great advantage is the possibility of evaluating the relationship of the liver lesion to the vascular and biliary structures and of planning the most convenient resection for each case. Surgeons can find some important variations, such as a portal trifurcation, a situation where the main right portal branch is absent, or they can determine the type of venous confluence, for example the absence or presence of a common hepatic trunk or the presence of two left hepatic veins, etc. Intrahepatic variations of the liver structures are becoming more and more important with the introduction of live donor transplantation as well as for precise planning of "simple" segmental resections. Usually 5 or 7.5 Mhz linear-array, T-shaped probes are used (Fig.5).

Fig.5: Intraoperative ultrasound investigation using "T" shaped operative probe.

The investigation is performed at the very beginning of the operation, usually before mobilisation of the liver or sometimes after dissecting the ligamentum teres and falciform ligament to obtain better access to the veins. Often it is useful to apply US investigation during transection through the liver tissue, especially in a cirrhotic liver, to see if the resection line is correct. Using intraoperative ultrasound guided biopsy, material for "ex tempore" pathohistological investigation can be obtained. In certain cases in cirrhotic patients, puncture and tatooing or balloon catheter occlusion of a portal branch for the segment or subsegment which is to be resected together with a tumour can be performed. Sometimes in liver trauma the extent of liver injury can be assessed properly only with intraoperative US investigation.
Dealing with a patient suffering from obstructive jaundice, an insight into the intrahepatic bile ducts in the liver is very important. We can plan the proper operative procedure or put a catheter into a suitable bile duct. Stones can be discovered and to certain degree tumour infiltration can be estimated.

Mobilisation of the liver

A very important part of a liver operation is good mobilisation of the organ. The extent of mobilisation depends on the location and kind of liver lesion, but it must always bring the lesion close to the surgeon's hands. When dissecting the ligaments, hemostasis should be meticulously performed at the same time. The handling of a liver with a tumour must be very careful and tender in order to minimise the spread of tumour cells. When mobilising a liver with a hydatid cyst, any pressure over the cyst must be avoided because it can burst out or even into a vein and cause an anaphylaxis.
For hepatectomies, thorough mobilisation is necessary. In such cases the vena cava ligament should be transected, taking into account the possibility of a blood vessel or bile duct being in the ligament or even of liver tissue surrounding the inferior vena cava. When transecting the lesser omentum one should pay attention to the left hepatic artery emerging from the left gastric artery (in 10--20% of cases). This artery sometimes supplies the whole left liver, but mostly segments II and III, and sometimes only segment II. When planning hepatic vascular exclusion, the inferior vena cava should be clearly presented during mobilisation, and encircled in the subphrenic portion and above the renal veins. The right suprarenal vein should be presented and ligated if necessary and the possible presence of an inferior and/or middle right hepatic vein noted. Such precise mobilisation is also useful when hepatic vascular exclusion is not used, and in fact sometimes even avoids the necessity for it because the hepatic veins become easily accessible.

Vascular occlusion and vascular isolation

In order to diminish blood loss during an operation, most liver resections are performed using a kind of vascular occlusion (Fig.6).

Fig.6: Hepatic vascular exclusion - note the tourniquets around the subhepatic vena cava, the suprahepatic vena cava, and the superior right hepatic vein. There is also the inferior right hepatic vein present in this case.

Most often, portal triad clamping is used, which is generally very well tolerated, even causing an increase in arterial pressure because of the increased systemic vascular resistance. There is only a slight decrease in pulmonary arterial pressure and cardiac index (11). Once the hepatoduodenal ligament is freed from adhesions, the arterial and portal venous inflow to the liver is stopped with a clamp or a tourniquet. Portal triad clamping can be used continuously up to 60 minutes, and in very few cases up to 90 minutes. However, most surgeons practise intermittent clamping of 10 to 15 minutes and 5 minutes of unclamped portal triad for reperfusion. During that time the liver resection surface is packed or manually compressed.
For tumours and other lesions close to the inferior vena cava or at the trunk of a hepatic vein, this so-called Pringle manoeuvre is inadequate. In such cases hepatic vascular exclusion or total vascular occlusion should be used, meaning that portal triad clamping is combined with occlusion of the inferior vena cava below and above the liver. Appropriate anaesthetic management is required, and suitable surgical technique must be applied. In the planning of hepatic vascular exclusion, the anaesthetist should ensure adequate blood volume expansion. The portal triad is occluded and then the inferior vena cava is clamped below and finally above the liver. Before this, the right suprarenal vein must be located and ligated. In some cases, when anatomic conditions are suitable, a single clamp can be used for clamping the inferior vena cava (12), allowing blood to flow through the dorsal part of the vein, and sometimes even the suprarenal vein can remain untouched. The hemodynamic tolerance of the patient is checked over a period of five minutes. The cardiac index during that time should never fall below 50%. If the patient can tolerate the exclusion it can be used safely for up to 60 minutes. During this time most of the procedures can be performed. In my opinion there is also the possibility to use portal triad clamping for the major part of the procedure and to apply the hepatic vascular exclusion only for the critical period of liver dissection. This can sometimes take just 5--15 minutes and such a short time of total occlusion can easily be tolerated.
Other possibilities for vascular occlusion include selective clamping in the liver hilum, where the artery and portal branch to the hemiliver and even the sectorial pedicles could be located and clamped. This is best combined with isolation of the appropriate hepatic vein, which can also be clamped selectively after occlusion in the liver hilum.
Portal triad clamping can be used at the beginning and then replaced by selective occlusion after locating, for example, the sectorial portal pedicle. Sometimes the artery and portal branch at the operative side are isolated first, ligated and divided and then the appropriate vein clamped or simply oversewn and divided.
Vascular isolation in the liver hilum is part of the operative procedure in skeletonisation resection of the common hepatic and common bile duct when dealing with a cancer of the bile duct confluence. Arteries and portal branches to the liver are presented and then ligated and transected for the resected side. In some other pathological lesions or as a technical variation, the vascular structures on the operative side could be isolated and clamped, leaving the inflow on the other side undisturbed. This is useful for segmental resections, but while performing a hepatectomy through the demarcation line there will be bleeding from the nonoccluded side if the procedure is not combined with the Pringle manoeuvre. In some cases selective balloon occlusion of the portal branch could be performed using an ultrasonographically guided transhepatic insertion of a balloon catheter, or the portal system could be reached through the umbilical vein (13).

Some surgeons practice and advocate aortic occlusion and vascular isolation (14). This procedure involves clamping of the supraceliac abdominal aorta, approached through the crura of the diaphragm, clamping of the infrahepatic and suprahepatic inferior vena cava after isolation as well as clamping of the hepatoduodenal ligament. Such a complex occlusion causes significant hypertension and can only be used for a short time (5-30 minutes). During this time only quick resection using a scalpel is possible. Although gradual release of aortic clamping is used after completing the resection and hemostasis of the rough surface, hypotension may cause problems. Some surgeons could find indications for this kind of occlusion, but it involves a high degree of skill on the part of the anaesthetist.

Liver tissue transection, hemostasis and biliostasis

For transecting liver tissue during resection, the once popular finger fracture technique has been replaced by crushing the tissue with clamps, dissecting with coagulators, adjusted suction tips and a number of more sophisticated devices such as water jets, and ultrasonic and laser dissectors (Fig.7).

Fig.7: Ultrasonic dissector in use during resection through the liver parenchyma.

All this armamentarium is widely used, but whatever tool is chosen for transecting liver tissue, it can be effective only when good vascular control and thorough mobilisation are achieved and with the effective participation of a skilled anaesthetist. Dissection through the liver parenchyma must be straight and precise and should sometimes be controlled using intraoperative ultrasound investigation. It is important to recognise the internal liver structures and to be aware of their course and direction before ligating and transecting them. Proper control of the central venous pressure is important in cases where only portal triad clamping is used to diminish bleeding from the branches of the hepatic veins and also to prevent air embolism. Fig.7: Ultrasonic dissector in use during resection through the liver parenchyma.
When transecting liver tissue, small structures may be cut using a coagulator while others should be ligated or oversewn. Clips can be used, but never on bile ducts because they can fall off. Meticulous hemostasis and biliostasis should be practised, thus preventing postoperative collections of blood and bile. When liver resection is combined with cholecystectomy, as in all hepatectomies and some segmental resections, the effectiveness of biliostasis can be checked using a tiny catheter inserted through the cystic duct. Saline is instilled into the biliary tree and the resectional surface controlled. Fig.7: Ultrasonic dissector in use during resection through the liver parenchyma.
Additional hemostasis after the liver resection and the release of the vascular occlusion is often necessary. Wet and "hot" laparotomy pads are usually the first thing applied to the resection surface of the liver. To prevent them adhering, a rubber glove may be inserted between the pads and the liver. Hot air, Argon beam coagulation or light coagulation are useful for superficial oozing of blood, while meticulously placed fine sutures are most effective to stop bleeding from haemorrhage points - usually veins. Topic agents like fibrin glue are useful to cover the practically dry rough surface of the liver. When there is a diffuse oozing from the resection surface it is mostly due to coagulation disorders induced by hypothermia, acidosis and blood transfusions. In such cases only perihepatic packing can help the surgeon and save the patient's life. Omentum or a sterile plastic sheet should be placed over the rough surface before the dry laparotomy pads are put on it. Fig.7: Ultrasonic dissector in use during resection through the liver parenchyma.
Although some surgeons reject the use of drainage, most surgeons are using closed suction drainage after liver resections. This seems acceptable because it has not been proven that such drainage increases morbidity. It can be omitted in patients with a cirrhotic liver, but if placed it can easily be removed at the point when nothing but ascitic fluid flows out. Nevertheless, postoperative drainage will probably be abandoned in the future. Fig.7: Ultrasonic dissector in use during resection through the liver parenchyma.

Special techniques

In certain circumstances special or additional procedures must be used to deal with a complicated or unusual condition. Fig.7: Ultrasonic dissector in use during resection through the liver parenchyma.
In order to avoid hemodynamic problems as well as general reperfusion troubles, extensive liver resections may be performed using veno-venous by-pass and a biopump as in liver transplants. Extracorporeal circulation is used with cannulas introduced into the femoral vein, portal vein or inferior mesenteric vein carrying blood through the biopump into the axillary vein. This procedure is combined with hepatic vascular exclusion and hypothermic perfusion of the liver through the portal vein or umbilical vein, and an incision made in the subhepatic vena cava to allow the perfusion liquid - University of Wisconsin solution (UW) - to flow out (15). The procedure performed using such a technique is also called "ex situ" liver resection. 2. část číslo 96-4

Abstrakta

Aspergilóza u nemocné po transplantaci jater

Kasuistika
*Trunečka P, **Kolník P, ***Ryska M, ***Bělina F,
Mazárová V, Dutka J, *Šperl J
*Klinika diabetologie a hepatogastroenterologie IKEM
přednosta: Doc MUDr J Špičák CSc
**Patologicko-anatomické pracoviště IKEM
přednosta: MUDr P Kolník
***Klinika kardiochirurgie a transplantační chirurgie IKEM přednosta: MUDr J Pirk DrSc
Klinika radiologie IKEM
přednosta: MUDr J Peregrin CSc

Souhrn

U šestnáctileté nemocné s neléčenou Wilsonovou chorobou ve fázi fulminantního jaterního selhání byla provedena urgentní transplantace jater. Pacientka zemřela 30.pooperační den na krvácení z mykotického aneuryzmatu a. basilaris při mozkové aspergilóze. Mykotické infekce jsou častou komplikací po transplantaci jater. Diagnostika, léčba i prevence invazívních mykóz po transplantaci orgánů vyžadují zlepšení.
Klíčová slova: Wilsonova choroba - fulminantní jaterní selhání - transplantace jater - aspergilóza

Summary

Aspergilosis after liver transplantation
Trunečka P, Kolník P, Ryska M, Bělina F, Mazárová V, Dutka J, Šperl J
Sixteen-years old female was transplanted for fulminate hepatic failure in course of untreated Wilson's disease. Patient died on postoperative day 30, of cerebral hemorrhage from aneurysm of basillaris artery caused by Aspergilus. Mycotic infections are very frequent complication after liver transplantation. Efficacy of diagnostic and therapeutic measures in patients with invasive mycotic infection after organ replacement are questioned.
Key words: Morbus Wilson - fulminant hepatic failure - liver transplantation - aspergilosis

Naše zkušenosti s léčbou iatrogenních poranění a pooperačních změn žlučových cest

Černoch J
Chirurgická klinika FNsP Ostrava Poruba
přednosta: MUDr Tomáš Posolda

Souhrn

Uvádíme zkušenosti s léčbou iatrogenních lézí žlučových cest za posledních 15 let. Z 55 nemocných bylo konzervativně léčeno 40. 22 je zcela bez obtíží. 15 bylo operováno a 8 je zcela bez obtíží. Dáváme přednost neoperačnímu postupu.
Klíčová slova: iatrogenní léze žlučovodů - neoperační léčba

Summary

Our experience with treatment biliary duct injuries
Černoch J
We are demonstrated our experience with treatment of biliary tract injuries in period last 15 years. 4O patients of 55 were managed by nonsurgical procedures. 22 patients are without complaints. 15 patients were operated, 8 are without complaints. We prefere nonsurgical treatment.
Key words: Biliary tract injuries - nonsurgical treatment.