Plasma bilirubin correlations in non-obstructive cholestasis after partial hepatectomy

Post hepatectomy liver failure - A comprehensive review of current concepts and controversies

Post hepatectomy liver failure (PHLF) comprises of a conundrum of symptoms and signs following major hepatic resections. The pathophysiology essentially revolves around disruption of the normal hepatocyte regeneration and disturbed liver homeostasis. Prompt identification of the pre-operative predictors of PHLF in the form of biochemical parameters and imaging features are of paramount importance for any hepatic surgeon and forms the cornerstone of its management. Treatment revolves around a goal-directed resuscitation of the systemic organ failure. Auxiliary support systems such as liver dialysis devices and stem cell therapy are still under investigational trials for treatment of the same. Orthotopic liver transplantation (OLT) is the last resort in most cases not responding to other measures.

Post-hepatectomy liver failure

Hepatectomies are among some of the most complex operative interventions performed. Mortality rates after major hepatectomy are as high as 30%, with post-hepatic liver failure (PHLF) representing the major source of morbidity and mortality. We present a review of PHLF, including the current definition, predictive factors, pre-operative risk assessment, techniques to prevent PHLF, identification and management. Despite great improvements in morbidity and mortality, liver surgery continues to demand excellent clinical judgement in selecting patients for surgery. Appropriate choice of pre-operative techniques to improve the functional liver remnant (FLR), fastidious surgical technique, and excellent post-operative management are essential to optimize patient outcomes.

Systematic review of pathophysiological changes following hepatic resection

OBJECTIVES

Major hepatic resection is now performed frequently and with relative safety, but is accompanied by significant pathophysiological changes. The aim of this review is to describe these changes along with interventions that may help reduce the risk for adverse outcomes after major hepatic resection.

METHODS

The MEDLINE, EMBASE and CENTRAL databases were searched for relevant literature published from January 2000 to December 2011. Broad subject headings were 'hepatectomy/', 'liver function/', 'liver failure/' and 'physiology/'.

RESULTS

Predictable changes in blood biochemistry and coagulation occur following major hepatic resection and alterations from the expected path indicate a complicated course. Susceptibility to sepsis, functional renal impairment, and altered energy metabolism are important sequelae of post-resection liver failure.

CONCLUSIONS

The pathophysiology of post-resection liver failure is difficult to reverse and thus strategies aimed at prevention are key to reducing morbidity and mortality after liver surgery.

Systematic review and meta-analysis of the effect of perioperative steroids on ischaemia-reperfusion injury and surgical stress response in patients undergoing liver resection

BACKGROUND

Several therapeutic strategies, such as ischaemic preconditioning, intermittent or selective pedicle clamping and pharmacological interventions, have been explored to reduce morbidity caused by hepatic ischaemia-reperfusion injury and the surgical stress response. The role of steroids in this setting remains controversial.

METHODS

A comprehensive literature search in MEDLINE, Embase and the Cochrane Register of Clinical Trials (CENTRAL) was conducted (1966 onwards), identifying studies comparing perioperative administration of intravenous steroids with standard care or placebo, in the setting of liver surgery. Randomized Controlled trials (RCTs) and non-RCTs were included. Critical appraisal and meta-analysis were carried out according to the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement.

RESULTS

Six articles were included; five were RCTs. Pooling the results revealed that patients receiving intravenous glucocorticoids were 24 per cent less likely to suffer postoperative morbidity compared with controls (risk ratio 0.76, 95 per cent confidence interval 0.57 to 0.99; P = 0.047). The treated group experienced a significantly greater rise in early postoperative interleukin (IL) 10 levels compared with controls. In addition, steroids significantly reduced postoperative blood levels of bilirubin, and of inflammatory markers such as IL-6 and C-reactive protein. There was no evidence supporting a risk difference in infectious complications and wound healing between study groups.

CONCLUSION

Perioperative steroids have a favourable impact on postoperative outcomes after liver resection.

Urinary trypsin inhibitor attenuates liver enzyme elevation after liver resection

BACKGROUND

Urinary trypsin inhibitors (UTI) have been widely used for the treatment of diseases including disseminated intravascular coagulation, shock, and pancreatitis. Since UTI synthesis is likely to be reduced in patients who have undergone liver resection, the incidence of inflammatory reactions may be increasing accordingly. For such patients, the liver enzyme increases after the operation can reflect liver damage. The purpose of this study was to examine if ulinastatin can inhibit liver enzyme increases after liver resection.

METHODS

After receiving Institutional Review Board approval, a retrospective chart review was performed on 201 patients who underwent hepatic resection from 2006 to 2010. We divided the records into the control (n = 69) and ulinastatin (n = 132) groups according to the use of intraoperative ulinastatin and compared the preoperative and postoperative laboratory test results. The number of patients who had > 400 U/L elevation of aspartate transaminase (AST) level after surgery was compared between the 2 groups.

RESULTS

The mean AST, alanine transaminase (ALT), and total bilirubin levels after liver resection were significantly lower in the ulinastatin group than in the control group. The number of patients who showed an AST > 400 U/L after liver resection was significantly higher in the control group (odds ratio = 3.02).

CONCLUSIONS

Ulinastatin attenuates the elevation of hepatic enzymes and bilirubin after liver resection.

Characterization of alpha-amino-n-butyric acid correlations in sepsis

Little information is available on the patterns of changes and significance of plasma alpha-amino-n-butyric acid (ABA, μmol/L) in various conditions, particularly in sepsis. This study has been performed to assess the patterns of correlation among ABA, other amino acids, and other variables in a group of septic patients with various degrees of illness. More than 400 determinations of ABA, other amino acids, and simultaneously collected blood variables were obtained in 17 patients with sepsis. The distribution of ABA was characterized by the clustering of most measurements within the normal range (<41 μmol/L), with the spreading of abnormally increased values up to 151 μmol/L. Abnormal increases in ABA were related directly to alanine, serine, tyrosine, histidine, proline, threonine, glycine, glutamine, cysteine, lysine, cystathionine, leucine, valine, phenylalanine, arginine, and citrulline (r(2) from 0.86 to 0.32) and related inversely to aspartate, taurine, and phosphoethanolamine (r(2) from 0.62 to 0.50) (P < 0.001 for all). Furthermore, increased ABA was correlated with increasing total aminoacidemia, lactate, neutrophil concentration, creatinine, ammonia, osmolarity, glucose, and bilirubin and with decreasing AA Fischer ratio and peripheral O(2) extraction (r(2) from 0.87 to 0.16) (P < 0.001 for all). High ABA was also associated with low cholesterol, taurine, and platelet count, and with high 3-methylhistidine (partly anticipating the increase), high blood urea nitrogen, and pulmonary shunt (P < 0.001 for all). Finally, high ABA was related to the worsening of sepsis-related organ failure assessment score (SOFA score) and of most plasma AA clearances (P < 0.001 for all). Abnormally increased ABA may signal and partly anticipate the transition to an extreme derangement of septic metabolic patterns, characterized by the worsening of protein hypercatabolism with hyperaminoacidemia and by signs of impaired hepatic amino acid metabolism and oxidative metabolism. Increased ABA may represent an additional landmark of transition to extreme illness, compelling the need for the aggressive resolution of sepsis.

Validation of perioperative steroids administration in liver resection: a randomized controlled trial

OBJECTIVE

We performed a randomized controlled trial to investigate the clinical benefits of perioperative treatment with steroids in patients undergoing liver resection.

BACKGROUND

Perioperative steroids are considered to reduce surgical stress, but evidence supporting proposed clinical benefits is largely anecdotal.

PATIENTS AND METHODS

The 210 patients scheduled to undergo liver resection were randomly assigned to a steroids group (n = 105) or a control group (n = 105). The steroids group received 500 mg hydrocortisone immediately before hepatic-pedicle clamping, followed by 300 mg hydrocortisone on postoperative day (POD) 1, 200 mg on POD 2, and 100 mg on POD 3. Serum levels of total bilirubin, aminotransferases coagulation factors, and inflammatory-related cytokines, and the clinical course were compared between the 2 groups. The primary end point was the postoperative bilirubin level.

RESULTS

All 210 patients underwent radical liver resection with no operative mortality. The median bilirubin level on POD 2 was significantly lower in the steroids group [0.71 mg/dL (0.33-2.17)] than in the control group [1.03 mg/dl (0.39-3.57); P = 0.01]. The postoperative time courses of the bilirubin level (P = 0.01), the interleukin-6 level (P = 0.01) and the C-reactive protein level (P = 0.01) were significantly lower whereas the the prothrombin level (P = 0.01) and interleukin-10 level (P = 0.01) were significantly higher in the steroids group. There was no difference between the groups in the proportion of patients with complications (40% vs 43%; P = 0.66) or the length of the hospital stay (14 days vs 13 days; P = 0.68).

CONCLUSIONS

Perioperative treatment with steroids has a positive impact on the liver function of patients who undergo liver resection, without increasing the risk of complications.