Sclerosing cholangitis secondary to hepatic artery ligation after abdominal trauma

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of abdominal vascular injuries

Abdominal vascular trauma accounts for a small percentage of military and a moderate percentage of civilian trauma, affecting all age ranges and impacting young adult men most frequently. Penetrating causes are more frequent than blunt in adults, while blunt mechanisms are more common among pediatric populations. High rates of associated injuries, bleeding, and hemorrhagic shock ensure that, despite advances in both diagnostic and therapeutic technologies, immediate open surgical repair remains the mainstay of treatment for traumatic abdominal vascular injuries. Because of their devastating nature, abdominal vascular injuries remain a significant source of morbidity and mortality among trauma patients. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seek to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of abdominal vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

Taurocholic acid prevents biliary damage induced by hepatic artery ligation in cholestatic rats

BACKGROUND

Ischemic injury by hepatic artery ligation (HAL) during obstructive cholestasis induced by bile duct ligation (BDL) results in bile duct damage, which can be prevented by administration of VEGF-A. The potential regulation of VEGF and VEGF receptor expression and secretion by bile acids in BDL with HAL is unknown.

AIMS

We evaluated whether taurocholic acid (TC) can prevent HAL-induced cholangiocyte damage via the alteration of VEGFR-2 and/or VEGF-A expression.

METHODS

Utilizing BDL, BDL+TC, BDL+HAL, BDL+HAL+TC, and BDL+HAL+wortmannin+TC treated rats, we evaluated cholangiocyte apoptosis, proliferation, and secretion as well VEGF-A and VEGFR-2 expression by immunohistochemistry. In vitro, we evaluated the effects of TC on cholangiocyte secretion of VEGF-A and the dependence of TC-induced proliferation on the activity of VEGFR-2.

RESULTS

In BDL rats with HAL, chronic feeding of TC prevented HAL-induced loss of bile ducts and HAL-induced decreased cholangiocyte secretion. TC also prevented HAL-inhibited VEGF-A and VEGFR-2 expression in liver sections and HAL-induced circulating VEGF-A levels, which were blocked by wortmannin administration. In vitro, TC stimulated increased VEGF-A secretion by cholangiocytes, which was blocked by wortmannin and stimulated cholangiocyte proliferation that was blocked by VEGFR-2 kinase inhibitor.

CONCLUSION

TC prevented HAL-induced biliary damage by upregulation of VEGF-A expression.

The implications of the presence of an aberrant right hepatic artery in patients undergoing a pancreaticoduodenectomy

PURPOSE

An aberrant right hepatic artery (ARHA) is a common anomaly and its implications for patients undergoing a pancreaticoduodenectomy (PD) have not yet been previously reported. We compared the outcomes following PD in patients with and without an ARHA. A novel classification of the anatomical course of ARHA, and surgical techniques for its identification and preservation are described herein.

METHODS

All patients undergoing PD between June 1, 2002, and May 31, 2007, were divided into two groups, one with ARHA and the other without. These groups were compared to identify differences in the intraoperative variables, the oncological clearance, the postoperative complications, and the survival.

RESULTS

A total of 135 patients underwent PD of which 28 (20.8%) patients were found to have either accessory or replaced right hepatic arteries (ARHA group). There were no significant differences in the intraoperative variables (blood loss and operative time) and the incidence of postoperative complications (pancreatic leak and delayed gastric emptying). Oncological clearance (nodal yield and resection margins) and survival were also similar in the two groups.

CONCLUSIONS

The surgical and oncological outcomes of PD remain unaffected by the presence of ARHA provided that the anatomy is recognized and appropriately managed. Aberrant right hepatic artery can be classified into three types according to their anatomical relationship with the head of the pancreas.