ObjectivesIn the early recognition of portal vein ligation (PVL) induced tumor progression, positron emission tomography and magnetic resonance imaging (PET/MRI) could improve diagnostic accuracy of conventionally used methods. It is unknown how PVL affects metabolic patterns of tumor free hepatic tissues. The aim of this preliminary study is to evaluate the effect of PVL on glucose metabolism, using PET/MRI imaging in healthy rat liver.Materials and MethodsMale Wistar rats (n = 30) underwent PVL. 2-deoxy-2-(18F)fluoro-D-glucose (FDG) PET/MRI imaging (nanoScan PET/MRI) and morphological/histological examination were performed before (Day 0) and 1, 2, 3, and 7 days after PVL. Dynamic PET data were collected and the standardized uptake values (SUV) for ligated and non-ligated liver lobes were calculated in relation to cardiac left ventricle (SUVVOI/SUVCLV) and mean liver SUV (SUVVOI/SUVLiver).ResultsPVL induced atrophy of ligated lobes, while non-ligated liver tissue showed compensatory hypertrophy. Dynamic PET scan revealed altered FDG kinetics in both ligated and non-ligated liver lobes. SUVVOI/SUVCLV significantly increased in both groups of lobes, with a maximal value at the 2nd postoperative day and returned near to the baseline 7 days after the ligation. After PVL, ligated liver lobes showed significantly higher tracer uptake compared to the non-ligated lobes (significantly higher SUVVOI/SUVLiver values were observed at postoperative day 1, 2 and 3). The homogenous tracer biodistribution observed before PVL reappeared by 7th postoperative day.ConclusionThe observed alterations in FDG uptake dynamics should be taken into account during the assessment of PET data until the PVL induced atrophic and regenerative processes are completed.
Introduction: Resecability of liver tumors is exclusively depending on the future liver remnant (FLR). The remnant can be hypertrophised using portal vein occlusion techniques. The latest hypertrophising method is Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS), which provides the most significant induced hypertrophy in the shortest time. Morbidity and mortality of this procedure were initially unacceptably high. Aim: Reducing complications by better patient selection and modified surgical technique. Method: The First Department of Surgery, Semmelweis University, Budapest, prefers the ‘no touch’ technique, instead of ‘complete mobilization’. For optimizing patient selection, an international registry (including our patients’ data) was established. In addition to the surgical, we collected demographic, disease, liver function, histology, morbidity (Clavien–Dindo) and mortality parameters. Volume and function measurements were performed by using CT-volumetry and 99mtechnecium-mebrofenin SPECT/CT. Data were analyzed by multivariate analysis (significance: p<0.05). Results: We performed 20 ALPPS procedures from 2012 to 2018. The relative volume increment and resectability in our department and among the 320 registry patients were 96% vs. 86% and 95% vs. 98%. Using ‘no touch’ technique, the Clavien–Dindo III–IV morbidity and mortality rates were significantly lower (22%–0%) than with ‘complete mobilization’ (63%–36%) (p<0.05). Based on the multivariate analysis of the registry patients, age over 60 years, liver macrosteatosis, non-colorectal liver tumor, >300 minutes operation time, >2 units of red blood cell transfusion, or insufficient FLR function before stage 2 were identified as independent factors influencing mortality (p<0.05). Conclusion: Mortality and morbidity of ALPPS can be reduced by proper patient selection and ‘no touch’ surgical technique. Orv Hetil. 2019; 160(32): 1260–1269.
Background/Purpose: Intraductal papillary neoplasm of the bile duct (IPNB) is a rare disease in Western countries. The main aim of this study was to characterize current surgical strategies and outcomes in the mainly European participating centers. Methods: A multi-institutional retrospective series of patients with a diagnosis of IPNB undergoing surgery between 1 January 2010 and 31 December 2020 was gathered under the auspices of the European-African Hepato-Pancreato-Biliary Association. The textbook outcome (TO) was defined as a non-prolonged length of hospital stay plus the absence of any Clavien–Dindo grade at least III complications, readmission, or mortality within 90 postoperative days. Results: A total of 28 centers contributed 85 patients who underwent surgery for IPNB. The median age was 66 years (55–72), 49.4% were women, and 87.1% were Caucasian. Open surgery was performed in 72 patients (84.7%) and laparoscopic in 13 (15.3%). TO was achieved in 54.1% of patients, reaching 63.8% after liver resection and 32.0% after pancreas resection. Median overall survival was 5.72 years, with 5-year overall survival of 63% (95% CI: 50–82). Overall survival was better in patients with Charlson comorbidity score 4 or less versus more than 4 (P=0.016), intrahepatic versus extrahepatic tumor (P=0.027), single versus multiple tumors (P=0.007), those who underwent hepatic versus pancreatic resection (P=0.017), or achieved versus failed TO (P=0.029). Multivariable Cox regression analysis showed that not achieving TO (HR: 4.20; 95% CI: 1.11–15.94; P=0.03) was an independent prognostic factor of poor overall survival. Conclusions: Patients undergoing liver resection for IPNB were more likely to achieve a TO outcome than those requiring a pancreatic resection. Comorbidity, tumor location, and tumor multiplicity influenced overall survival. TO was an independent prognostic factor of overall survival.
Összefoglaló. A focalis nodularis hyperplasia (FNH) a máj második leggyakrabban előforduló benignus góca. Nem malignizálódik, így a jelenlegi ajánlások szerint eltávolítása relatív indikációt képez. Kezelését illetően több különböző módszer is ismert. A közlemény célja, hogy összefoglalót adjon az FNH ellátásáról és két esetben bemutassa az alternatív kezelési lehetőségeket. Egy 40 éves nőbetegnél hasi panaszok miatt indult kivizsgálás során a májban CT-morfológiailag FNH igazolódott. A laesio lokalizációját figyelembe véve, a sebészeti reszekció magas rizikója miatt, transarterialis embolisatio (TAE) mellett döntöttünk. Többszörös kezelést követően a kontroll képalkotó vizsgálatok alapján jelentős regressziót értünk el, mindemellett a beteg panaszmentessé vált. Egy 25 éves nőbetegnél hasi panaszok miatt történt MR-vizsgálat igazolt FNH-t. Az elhelyezkedésre tekintettel TAE-t végeztünk, a beteg azonban ezúttal nem vált teljesen panaszmentessé. Definitív megoldásként májreszekció történt, melyet követően panaszai megszűntek. Tünetmentes FNH felfedezésekor elegendő lehet a betegek hosszú távú követése. Tünetek, illetve nagy műtéti kockázat esetében a malignus májtumoroknál rutinszerűen alkalmazott TAE az FNH-ban akár önmagában vagy sebészi kezeléssel kombinálva is eredményesen alkalmazható. Kisebb rizikó esetén a legmegfelelőbb választás a primer laparoszkópos reszekció. Orv Hetil. 2022; 163(15): 606–612. Summary. Focal nodular hyperplasia (FNH) is the second most common benign mass of the liver. According to the current recommendations, removal makes relative indication. Several different treatment methods are known. The purpose of the paper is to provide a summary of FNH care and to present alternative treatment options in two cases. A 40-year-old woman was investigated for abdominal complaints; CT scan confirmed FNH of the liver. Given the localization of the lesion, we chose transarterial embolization (TAE) due to the high risk of surgical resection. After multiple treatments, regression was achieved, and the patient became asymptomatic. Painful FNH in a 25-year-old female was confirmed by MRI. The lesion was dominantly seen in segment 1, causing vena cava compression and collaptiform episodes. As a definitive solution, liver resection was performed, after which her complaints ceased. Long-term follow-up of patients may be sufficient when asymptomatic FNH is detected. In the case of symptoms or high risk of surgery, TAE can be used effectively by FNH either alone or in combination with surgical treatment. For lower-risk patients, primary laparoscopic resection is the most appropriate choice. Orv Hetil. 2022; 163(15): 606–612.
A máj rendhagyó keringéséért két afferens (arteria hepatica, vena portae) és egy efferens rendszer (venae hepaticae) felelős. Speciális vérellátásának köszönhetően az akut, izolált -szelektíven egy-egy érképletet érintő -vascularis okklúziók eltérő, életet veszélyeztető klinikopatológiai tünetegyütteshez vezethetnek, ezért azonnali felismerésük elengedhetetlen a máj állapota, illetve a beteg túlélésének szempontjából egyaránt. Akut keringészavarok kialakulásával elsősorban májműtétek kapcsán kell számolnunk. Az adekvát terápia mielőbbi megkezdése szempontjából kiemelten fontos a kóros keringési állapotok sajátosságainak pontos ismerete. Jelen tanulmány célja a szelektív posztoperatív keringési anomáliák etiológiájának, illetve tünettanának bemutatása, továbbá javaslat megfogalmazása a diagnosztikai lépések és a lehetséges terápia terén klinikai esetek ismertetése alapján. A szerzők bemutatják a májsebészetben használatos vascularis kirekesztés (Pringle-manőver) okozta ischaemiás-reperfúziós májkárosodást is. Orv. Hetil., 2015, 156(48), 1938-1948 Kulcsszavak: arteria hepatica, májkeringés, májreszekció, vena hepatica, vena portae The importance of postoperative circulatory alterations in hepatic surgeryThere are two afferent (hepatic artery, portal vein) and one efferent (hepatic veins) systems responsible for the unique circulation of the liver. Given this special form of vasculature, acute, isolated (i.e. involving selectively one particular vessel) vascular occlusions may lead to different, however still life threatening conditions. Hence, it is essential to recognize these anomalies in order to preserve the healthy state of both the liver and the patient's lives. Acute circulatory failures are dominantly associated with liver surgery. Adequate therapy can only be provided promptly, if the clinician is well aware of the peculiarities of these conditions. The aim of this study is to overview the etiology and symptoms of these clinical conditions; furthermore to offer technical proposals for the required diagnostic and therapeutical steps via case reports. Furthermore, hepatic injury, caused by ischemia-reperfusion secondary to total vascular occlusion (Pringle maneuver) used in hepatic surgery is outlined.Keywords: hepatic artery, hepatic vein, liver circulation, liver resection, portal vein Koós, O., Kovács, T., Fülöp, A., Pekli, D., Ónody, P., Lukovich, P., Harsányi, L., Kupcsulik, P., Hahn, O., Szijártó, A. [The importance of postoperative circulatory alterations in hepatic surgery]. Orv. Hetil., 2015, 156(48), 1938-1948. (Beérkezett: 2015 elfogadva: 2015. szeptember 26.) ÖSSZEFOGLALÓ KÖZLEMÉNY Rövidítések ALT = alanin-aminotranszferáz; AST = aszpartát-aminotranszferáz; BCS = Budd-Chiari-szindróma; BE = (base excess) bázis felesleg; CT = komputeres tomográfi a; eGFR = becsült glomerulusfi ltrációs ráta; ERCP = endoszkópos retrográd cholangiopancreatographia; FLR = (future liver remnant) posztreszekciós májtömeg; GGT = gamma-glutamiltranszferáz; HGF = (hepatocyte growth factor) hepatocytanövekedési fa...
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