The role of hepatic venous congestion and endotoxaemia in the production of fulminant hepatic failure secondary to congestive heart failure

Laparoscopic anterior hepatic transection for resecting lesions originating in the paracaval portion of the caudate lobe (with videos)

BACKGROUND

The paracaval portion of the caudate lobe is located in the core of the liver. Lesions originating in the paracaval portion often cling to or even invade major hepatic vascular structures. The traditional open anterior hepatic transection approach has been adopted to treat paracaval-originating lesions. With the development of laparoscopic surgery, paracaval-originating lesions are no longer an absolute contraindication for laparoscopic liver resection. This study aimed to evaluate the safety and feasibility of laparoscopic anterior hepatic transection for resecting paracaval-originating lesions.

METHODS

This study included 15 patients who underwent laparoscopic anterior hepatic transection for paracaval-originating lesion resection between August 2017 and April 2020. The perioperative indicators, follow-up results, operative techniques and surgical indications were retrospectively evaluated.

RESULTS

All patients underwent laparoscopic anterior hepatic transection for paracaval-originating lesion resection. The median operation time was 305 min (220-740 min), the median intraoperative blood loss was 400 ml (250-3600 ml), and the median length of postoperative hospital stay was 9 days (5-20 days). No conversion to laparotomy or perioperative deaths occurred. Six patients had Clavien grade III-IV complications (III/IV, 5/1). Two patients developed tumor recurrence after 13 months and 8 months.

CONCLUSION

Although technically challenging, laparoscopic anterior hepatic transection is still a safe and feasible procedure for resecting paracaval-originating lesions in select patients.

RAP1 protects from obesity through its extratelomeric role regulating gene expression

RAP1 is part of shelterin, the protective complex at telomeres. RAP1 also binds along chromosome arms, where it is proposed to regulate gene expression. To investigate the nontelomeric roles of RAP1 in vivo, we generated a RAP1 whole-body knockout mouse. These mice show early onset of obesity, which is more severe in females than in males. Rap1-deficient mice show accumulation of abdominal fat, hepatic steatosis, and high-fasting plasma levels of insulin, glucose, cholesterol, and alanine aminotransferase. Gene expression analyses of liver and visceral white fat from Rap1-deficient mice before the onset of obesity show deregulation of metabolic programs, including fatty acid, glucose metabolism, and PPARα signaling. We identify Pparα and Pgc1α as key factors affected by Rap1 deletion in the liver. We show that RAP1 binds to Pparα and Pgc1α loci and modulates their transcription. These findings reveal a role for a telomere-binding protein in the regulation of metabolism.

Endotoxins-the invisible companion in biomaterials research

Metal implants and polymeric devices for the application in the clinical treatment of orthopedic tissue injuries are increasingly coated with bioactive biomaterials derived from natural substances to induce desirable biological effects. Many metals and polymers used in biomaterials research show high affinity for endotoxins, which are abundant in the environment. Endotoxin contamination is indicated in the pathology of periodontitis and aseptic implant loosening, but may also affect the evaluation of a biomaterial's bioactivity by inducing strong inflammatory reactions. In this review, we discuss the high affinity of three commonly used implant biomaterials for endotoxins and how the contamination can affect the outcome of the orthopedic fixation. The chemical nature of bacterial endotoxins and some of the clinical health implications are described, as this knowledge is critically important to tackle the issues associated with the measurement and removal of endotoxins from medical devices. Commonly used methods for endotoxin testing and removal from natural substances are examined and the lack of standard guidelines for the in vitro evaluation of biomaterials is discussed.

Hypoxic hepatitis: a challenging diagnosis

Hypoxic hepatitis (HH), one of the most common causes of acute liver injury, has a prevalence of up to 10% of admissions in intensive care units across the world. Inadequate oxygen uptake by the hepatocytes resulting in centrilobular necrosis associated with abnormally raised levels of the serum transaminases (ALT, AST) in patients with clinical history of cardiac, respiratory, or circulatory failures is the key feature of this condition. Abstracts, reviews, case reports, and research letters from various sources such as Pubmed, Proquest, Ovid, Google Scholar, and ISI Web of Knowledge dating from 1970 to 2011 were read and analyzed thoroughly. A study of 100 patients with HH, carried out from 2009 to 2010 at Tongji Hospital of Tongji University, Shanghai, People's Republic of China, is also documented. The contributing factors leading to HH are passive congestion, ischemia, and arterial hypoxemia of the liver. Ischemia/reperfusion injury also has a major role in HH. Some of its complications are spontaneous hypoglycemia, a high level of serum ammonia, and respiratory insufficiency due to hepatopulmonary syndrome. The therapy of HH lies mainly in the treatment of the main underlying causes, and this leads to the successful reversion of HH. The aim of this review is to present a simplified concept about the etiology, pathophysiology, mechanism, clinical manifestations, diagnosis, and treatment of HH.

Positive pressure ventilation: what is the real cost?

Positive pressure ventilation is a radical departure from the physiology of breathing spontaneously. The immediate physiological consequences of positive pressure ventilation such as haemodynamic changes are recognized, studied, and understood. There are other significant physiological interactions which are less obvious, more insidious, and may only produce complications if ventilation is prolonged. The interaction of positive pressure with airway resistance and alveolar compliance affects distribution of gas flow within the lung. The result is a wide range of ventilation efficacy throughout different areas of the lung, but the pressure differentials between alveolus and interstitium also influence capillary perfusion. The hydrostatic forces across the capillaries associated with the effects of raised venous pressures compound these changes resulting in interstitial fluid sequestration. This is increased by impaired lymphatic drainage which is secondary to raised intrathoracic pressure but also influenced by raised central venous pressure. Ventilation and PEEP promulgate further physiological derangement. In theory, avoiding these physiological disturbances in a rested lung may be better for the lung and other organs. An alternative to positive pressure ventilation might be to investigate oxygen supplementation of a physiologically neutral and rested lung. Abandoning heroic ventilation would be a massive departure from current practice but might be a more rationale approach to future practice.

Hypoxic liver injury

Hypoxic liver injury is defined as a massive, but transient, increase in serum transaminase levels due to an imbalance between hepatic oxygen supply and demand in the absence of other acute causes of liver damage. It typically occurs in elderly individuals with right-sided congestive heart failure and low cardiac output. Precipitating factors include arrhythmias or pulmonary edema. Symptoms include weakness, shortness of breath, and right upper quadrant pain. Less commonly, hypoxic liver injury is seen in patients with severe hypoxemia or septic shock. Characteristically, the transaminase level is elevated 20-fold but normalizes rapidly over several days. Imaging studies reveal hypoechoic or hypodense lesions that resolve completely with reversal of the initiating event. Treatment and prognosis depend on the underlyIng disease.

In vivo studies of endotoxin removal by lysine–cellulose adsorbents

A new type adsorbent for removal of bacterial endotoxins was prepared by immobilizing lysine covalently onto cellulose beads. Endotoxins (Escherichia coli O55: B5) were injected into 13 healthy New Zealand white rabbits to induce infectious symptoms. Hemoperfusion using the adsorbent column removed endotoxins in the blood of eight rabbits during 2h while other five rabbits were used as control. The mean blood endotoxin concentration was reduced significantly from 5.56 +/- 0.54 EU/ml (1 EU = 100 pg) before treatment to 0.41 +/- 0.26 EU/ml after perfusion as measured by the limulus amebocyte lysate test (Chromogenix). Liver function and renal function tests showed significant improvement of septic symptoms in contrast to the control group. Other parameters such as superoxide dismutase and malondialdehyde were ameliorated markedly after the treatment. Moreover, the adsorbent showed good results in mechanical strength, blood compatibility and cytotoxicity, which suggested that lysine-cellulose adsorbent was of high ET-binding efficacy without significant side effect. It has a high potential of clinical application for treatment of patients with severe sepsis.

Inflammatory cytokine production enhancement in the presence of lipopolysaccharide after hepatic resection in cirrhotic patients

Postoperative infection is one of the main factors that affect mortality after hepatic resection, especially in patients with liver cirrhosis. In the pathogenesis of postoperative organ failures complicating endotoxemia or other surgical injuries, inflammatory cytokine has proved to play an important role. We herein report the changes in tumor necrosis factor-alpha, interleukin-1 beta, and granulocyte colony-stimulating factor in production from macrophages/monocytes stimulated with lipopolysaccharide (LPS) after hepatic resection of cirrhotic livers. Seven hepatocellular carcinoma patients with liver cirrhosis who were undergoing limited resection or segmental resection of the liver were examined. Peripheral blood monocytes were separated and incubated with 10 microg/ml LPS, and cytokine release was measured by ELISA before surgery as well as on Postoperative Days (PODs) 1, 3, 7, and 14. Preoperative cytokine production in cirrhotic patients was greater than cytokine production in noncirrhotic controls. Cytokine productivity increased after hepatic resection. TNF-alpha production was 1,846.6 +/- 882.6 pg/ml, 1,947.3 +/- 221.9 pg/ml, 2,486.9 +/- 519.7 pg/ml, and 1,640.2 +/- 416.0 pg/ml on PODs 1, 3, 7, and 14, respectively. The values on all PODs were significantly greater than the healthy control value, and the value on POD 7 was significantly greater than the preoperative value. Interleukin-1 beta and granulocyte colony-stimulating factor production values corroborated this result in general. In conclusion, macrophages/monocytes are primed in cirrhotic patients preoperatively, and they are supposed to carry greater cytokine producing abilities after hepatic resection. When endotoxin spills over in the blood or in the liver after hepatic resection, postoperative hepatic failure could develop as a result of hypercytokinemia.

Pathological mechanisms of hepatic tumour formation in rats exposed chronically to dietary hexachlorobenzene

The chronic dietary administration of hexachlorobenzene (HCB) to rats for a year or more results in the formation of liver tumours described as hepatocellular carcinomas, hepatomas or haemangiomas. The hepatotoxicity of HCB, which is greatest in hamsters and rats, gives rise to peliosis and necrosis with haemosiderosis. This pattern of hepatotoxicity indicates vascular damage, which through haemosiderosis could increase not only the toxic effect of HCB to hepatocytes but also its tumourogenic potential. The present study confirmed vascular damage by the identification of widespread fibrin deposits in the livers of rats chronically exposed to HCB, using an antibody to rat fibrin. Based on our study we suggest that the formation of hepatomas and haemangiomas with elements of peliosis (cystic blood-filled cavities) could be explained by the compensatory hyperplastic responses to hepatocellular necrosis and by the simultaneous loss of hepatocellular cords. The accumulation of iron in the liver would strongly potentiate the development of hepatic tumours, as has been found in HCB and polychlorinated biphenyl-treated mice with iron overload. The implications of this non-genotoxic mechanism of hepatoma formation for the assessment of human health risk are discussed.

Pathogenesis of centrilobular necrosis following congestion of the liver

The exact pathogenesis of centrilobular necrosis following congestion of the liver is still unknown. We reviewed the clinical data related to systemic circulatory disturbance and histopathology of the liver and the gut in 320 autopsy subjects. Congestion of the liver alone was associated only with atrophy and loss of hepatocytes in centrilobular areas, but not with hepatocellular coagulative necrosis. In many patients with coagulative necrosis of centrilobular hepatocytes and congestion of the liver, fibrin thrombi and neutrophil infiltration in the sinusoids, which are the characteristic histopathological features of the liver in endotoxaemia, were found in and around the necrotic area. Congestion, erosion or haemorrhage of the intestinal mucosa, which may allow entrance of endotoxin into the liver through the portal vein, was seen in such patients. Prolonged hypotension or shock, which may lead to portal endotoxaemia, was present in half the patients with centrilobular necrosis and congestion of the liver. These results suggest that not only congestion of the liver but also portal endotoxaemia may be involved in the pathogenesis of centrilobular necrosis in patients with congestion of the liver.

Extracorporeal endotoxin removal by immobilized polyethylenimine

The neutralization of bacterial endotoxins (ET) is still an unsolved problem in therapeutic medicine. The efficacy of anti-endotoxin antibodies or receptor antagonists and other substances interfering with the endotoxin-induced pathomechanisms is dependent on an intact cellular degradation system of the host. However, the phagocytosis function of that system seems to be impaired regularly in patients with intense or long-lasting endotoxemia or septic shock and in patients undergoing hemodialysis. Extracorporeal adsorption of ET might well be an effective support in the anti-ET therapy by lowering the amount of circulating ET and thus relieving the defense system of the body. In this work a new ET-adsorbent based on macroporous cellulosic beads with immobilized polyethylenimine (PEI) was tested for its ET-removal capacity in vitro. A test solution with 100 ng/ml ET from Escherichia coli 055:B5 was recirculated in a system containing the adsorbent beads. Polymyxin B immobilized to the same carrier was used for comparison. PEI as well as polymyxin B showed complete removal of ET from plasma and water as was measured by the Limulus Amebocyte Lysate (LAL) test (Chromogenix). The biocompatibility of the PEI absorber was superior to that of polymyxin B. The results indicate that the PEI absorber is of high efficacy and possibly of interest for the treatment of endotoxemia.

Hepatic failure after partial hepatectomy due to synergism between endotoxaemia and congestion of the liver

To determine whether hepatic failure after partial hepatectomy is due to synergism between endotoxaemia and congestion of the liver, we examined endotoxin hepatotoxicity in partially hepatectomized rats with and without congestion of the liver. In partially hepatectomized rats without congestion of the liver, endotoxin administration induced slight elevation of the serum transaminase activity and mild or moderate hepatocellular necrosis in a few rats: these findings were not significantly different from those in sham operated rats treated with endotoxin. On the other hand, in partially hepatectomized rats with congestion of the liver, endotoxin administration induced marked elevation of serum transaminase activity and moderate or severe hepatocellular necrosis in almost all rats: these findings were significantly different from those in endotoxin-treated partially hepatectomized rats without congestion of the liver. These experimental data suggest that synergism between endotoxaemia and congestion of the liver may be a cause of hepatic failure after partial hepatectomy.

Haemodynamic alterations and their morphological basis in biliary obstruction

The relationship between the haemodynamic alterations and morphological changes in the liver caused by biliary obstruction was investigated in rats after ligation of the common bile duct. In these rats, the portal vein pressure was markedly elevated, and the differences in blood pressure between the portal vein and the terminal portal venule and between the terminal portal venule and the terminal hepatic venule were greater than in the sham-operated rat. The livers showed narrowing of the most peripheral branches of the portal vein due to compression by proliferated bile ductules and sinusoidal stenosis due to enlarged liver cells, but there was no perceptible change in the hepatic vein branches. These data suggest that hepatic circulatory disturbance in biliary obstruction is caused by deformation of the peripheral portal vein branches and sinusoidal stenosis.

A study of endotoxin-associated hepatotoxicity on proliferating hepatocytes

It is thought that regeneration of the liver provides a state of preparedness for the Shwartzman reaction and contributes to the development of endotoxin-associated massive hepatic necrosis following partial hepatectomy. Therefore we examined endotoxin hepatotoxicity in rats with hepatic regeneration after 35% hepatectomy and in rats with liver cell proliferation induced by lead nitrate. Biochemical and histopathological studies showed no enhanced endotoxin hepatotoxicity in either partially hepatectomized rats or in rats with lead nitrate-induced liver cell proliferation. These results indicate that the development of endotoxin-associated hepatic damage after partial hepatectomy may not relate to regeneration and proliferation of the liver.

Endotoxaemia and hepatic injury in obstructive jaundice

To examine whether endotoxaemia contributes to the development of bile infarction and whether obstructive jaundice enhances endotoxin hepatotoxicity, the present study was undertaken in rats. The development of bile infarction and the elevation of serum transaminase activities in rats following ligation of the common bile duct were not prevented by administration of polymyxin B, neomycin, or lactulose, which have anti-endotoxin properties. Moreover, the morphological and functional changes in obstructive jaundice were not enhanced by administration of endotoxin. These data indicate that endotoxaemia does not contribute to the development of bile infarction. On the other hand, the administration of a small dose of endotoxin to rats with biliary obstruction--a dose which does not induce abnormalities of liver function tests or any morphological changes in the liver in non-jaundiced rats--led to focal hepatocellular coagulative necrosis and elevation of serum transaminase levels. These data indicate that endotoxin-induced hepatic injury is potentiated in obstructive jaundice.

On the pathogenesis of hepatic dysfunction and necrosis following acute circulatory failure

To clarify whether diminished hepatic blood flow and portal endotoxaemia interact in the pathogenesis of hepatic dysfunction secondary to acute circulatory failure, such as shock, prolonged hypotension, or left-sided heart failure, the present study was undertaken in rats. Reduced hepatic perfusion, which was produced by partial obstruction of the portal vein, caused elevation of serum transaminase activities and electron microscopic abnormalities of hepatocytic structure, namely, disruption of plasma membrane, swelling of mitochondria, vesiculation and disruption of endoplasmic reticulum, etc. Portal endotoxaemia, which was induced by infusion of endotoxin into the portal vein, led to a rise of serum transaminase activities and random, focal coagulative hepatocellular necrosis. In contrast, massive hepatic necrosis and excessive elevation of serum transaminase activities, which are similar to those seen in patients with shock, etc., were produced when portal endotoxaemia was superimposed upon poor hepatic perfusion. These experimental results suggest that acute hepatic failure and massive hepatic necrosis secondary to acute circulatory failure may be induced by the coexistence of reduced hepatic blood flow and portal endotoxaemia.