How we do it-the use of peritoneal patches for reconstruction of vena cava inferior and portal vein in hepatopancreatobiliary surgery

PURPOSE

Extended resections in hepatopancreatobiliary (HPB) surgery frequently require vascular resection to obtain tumor clearance. The use of alloplastic grafts may increase postoperative morbidity due to septic or thrombotic complications. The use of suitable autologous venous interponates (internal jugular vein, great saphenous vein) is frequently associated with additional incisions. The aim of this study was to report on our experience with venous reconstruction using the introperative easily available parietal peritoneum, focusing on key technical aspects.

METHODS

All patients who underwent HPB resections with venous reconstruction using peritoneal patches at our department between January 2017 and November 2021 were included in this retrospective analysis with median follow-up of 2 months (IQR: 1-8 months). We focused on technical aspects of the procedure and evaluated vascular patency and perioperative morbidity.

RESULTS

Parietal peritoneum patches (PPPs) were applied for reconstruction of the inferior vena cava (IVC) (13 patients) and portal vein (PV) (4 patients) during major hepatic (n = 14) or pancreatic (n = 2) resections. There were no cases of postoperative bleeding due to anastomotic leakage. Following PV reconstruction, two patients showed postoperative vascular stenosis after severe pancreatitis with postoperative pancreatic fistula and bile leakage, respectively. In patients with reconstruction of the IVC, no relevant perioperative vascular complications occurred.

CONCLUSIONS

The use of a peritoneal patch for reconstruction of the IVC in HPB surgery is a feasible, effective, and low-cost alternative to alloplastic, xenogenous, or venous grafts. The graft can be easily harvested and tailored to the required size. More evidence is still needed to confirm the safety of this procedure for the portal vein regarding long-term results.

Influence of an elevated nutrition risk score in patients suffering from esophageal cancer following tumor resection

Background: Patients who suffer from malignant tumors of the esophagus and esophagogastric junction have 5-year survival rates of up to 83%, something that is documented in the early stages of cancer. Too often, weight loss is an underestimated sign for patients suffering from cancer on the upper gastrointestinal tract. Weight loss is associated with different adverse outcomes. Even after tumor resection, malnutrition remains a severe problem that still affects long-term disease free survivors.Material and methods: This study included the clinical courses of 205 patients suffering from cancer of the esophagus or the esophagogastric junction who were operated on between July 2007 and December 2009. On admission, the nutrition risk score was evaluated. Follow-up data were collected routinely. The aim of the underlying study was to show the prevalence of an elevated nutrition risk score (NRS) and to demonstrate its influence on perioperative mortality and morbidity. Furthermore, the relevance of an elevated nutrition risk score on the postoperative survival was analyzed.Results: More than a third (35.8%) of the patients included in this study had a nutrition risk score of at least three. A preoperative elevated nutrition risk score did not have a significant influence on perioperative morbidity or on 30-days mortality rate. In patients with early tumor stage UICC stage I a/b, an elevated risk score of 3 or more had a significant influence on postoperative survival. In contrast, in advanced tumor stages an increased NRS did not have a significant negative influence on survival within both UICC II a/b and UICC IIII a/b. Conclusions: Further studies are required to demonstrate whether a nutritional intervention can improve the survival rates of patients suffering from malignant tumors within the esophagus and in whom an operation has to be performed.Keywords: Weight loss, esophageal cancer, NRS

Preoperative Serum Bilirubin and Lactate Levels Predict Postoperative Morbidity and Mortality in Liver Surgery: A Single-Center Evaluation

Background and Aims:

In spite of huge developments in liver surgery during the last decades, morbidity and mortality continue to pose problems in this field. The aim of this study was to identify preoperative predictors for postoperative mortality and morbidity in liver surgery.

Material and Methods:

In a single-center study, an extensive analysis of a prospective database, including clinical criteria and laboratory tests of patients undergoing liver surgery between July 2007 and July 2012 was performed. Cutoff values of selected laboratory tests were calculated.

Results:

In all, 337 patients were included in the study. Univariate analysis showed a statistically significant association of preoperative bilirubin, lactate, hemoglobin levels, platelet count, and prothrombin time with postoperative morbidity and mortality. Multivariate analysis revealed preoperatively elevated serum bilirubin and lactate levels as independent predictors for increased postoperative morbidity and mortality after liver surgery.

Conclusions:

The identified laboratory values showed a statistically significant association with postoperative morbidity and mortality in liver surgery and might be helpful in preoperative patient selection.

Cytomegalovirus infection of the major duodenal papilla in a renal allograft recipient with severe biliary obstruction and acalculous cholecystitis

Cytomegalovirus (CMV) can cause severe infections with serious consequences in renal transplant recipients. Disseminated CMV infections can affect almost every organ, but obstructive cholestasis and cholangitis, as a consequence of a CMV-induced papillitis, is extremely rare. We are reporting a rare case of obstructive cholestasis and cholecystitis due to CMV-related inflammation of the major duodenal papilla in a 60-year-old woman 3 months after renal transplantation. In addition, the patient suffered from a disseminated CMV infection with ulcerative esophagitis and gastritis. Because of the severe CMV infection, failure of the renal graft occurred. Obstructive cholestasis was resolved through internal stenting, and the progressive cholecystitis necessitated an emergency cholecystectomy. Following antiviral therapy with ganciclovir, the gastrointestinal ulcerations regressed and renal function was restored. Diagnosis of the CMV-related disease was established only in tissue samples, whereas standard serologic tests had failed.

Herpes simplex virus sepsis and acute liver failure

Acute liver failure is a life threatening disease mostly triggered by drug-induced or toxic liver damage or viral hepatitis. Herpes Simplex virus (HSV) hepatitis is rare and accounts for only 1% of all acute liver failures. The importance of HSV-induced acute liver failure is based on its extremely severe clinical course with lethality rates of almost 75%. HSV hepatitis is just one of several clinical manifestations of HSV sepsis leading more frequently to encephalitis, pneumonia and esophagitis. Local herpes infection or recurrence of dermal lesions (herpes labialis, herpes genitalis), however, is common and account for the high prevalence of HSV-1 or HSV-2 infection in adults. Another rare entity is visual dissemination, which mostly affects immunocompromised patients. Compromised cellular immunity is a major risk factor for HSV sepsis because of either primary infection or reactivation of occult chronic HSV infection. Delayed diagnosis without antiviral therapy significantly contributes to the unfavorable outcome. Typically, anicteric hepatitis is seen in patients with HSV hepatitis. Because of its low incidence, however, and the lack of dermal manifestations, HSV hepatitis is rarely considered in the context of acute liver failure. In addition, diagnostic tests might not always be available. Therefore, it is a generally accepted consensus to begin antiviral therapy pre-emptively with acyclovir in cases of acute liver failure of unknown origin, in which high urgency (HU) liver transplantation remains the only therapeutical option. Even in the case of early specific therapy, sepsis may prevail and the indication for HU transplantation must be evaluated carefully. The outcome after liver transplantation for HSV-induced liver failure with reported survival rates of more than 40% is good. Because of the risk of recurrence, lifelong prophylaxis with acyclovir is recommended.

Thymoglobulin and ischemia reperfusion injury in kidney and liver transplantation

Since the beginning of organ transplantation, graft preservation has been one of the most important concerns. Ischemia reperfusion injury (IRI), which plays an important role in the quality and function of the graft, is a major cause for increased length of hospitalization and decreased long term graft survival. Among numerous attempts which have been made to minimize graft damage associated with IRI, the use of Thymoglobulin (TG) seems to offer potential benefits. TG is a polyclonal antibody which blocks multiple antigens related to IRI, in addition to its better known T cell depleting effects. This review will focus on the use of TG in preventing IRI in kidney transplantation (KTx) and liver transplantation (LTx). Different studies in experimental and clinical transplantation have shown that TG protects renal and liver grafts from IRI. Improvement in early graft function and decreased delayed graft function (DGF) rates are some of the clinical benefits of TG. Additionally, it is used in patients with hepatorenal syndrome to support the recovery of kidney function after LTx, by allowing reduced exposure to nephrotoxic calcineurin inhibitors as well as improving liver graft function by minimizing IRI. TG can reduce acute rejection rates in kidney and liver transplant recipients, decrease the length of hospital stay, and hence reduce transplantation costs. TG can play an important role in expanding the donor pool in both KTx and LTx by improving long-term graft and patient survival rates which increases the possibility of using marginal donors. Although controversial, the development of post-transplant lymphoproliferative disorder is a potential side effect of TG. No single optimal immunosuppressive regimen has given consistent results in decreasing the graft damage following IRI; however, TG usage in KTx and LTx appears to have some benefits in reducing IRI.

Combined activity of azithromycin and lansoprazole against Helicobacter pylori

BACKGROUND

Due to its unique pharmacokinetic properties, azithromycin may be an attractive combination partner for H. pylori eradication regimens. However, up to 15% of clinical isolates are primarily resistant to azithromycin as well as to other macrolide antibiotics. Combination therapy with lansoprazole, a proton pump inhibitor known to have intrinsic antibacterial activity against H. pylori, may be useful to counteract such resistance. We therefore evaluated the combined effects of azithromycin and lansoprazole in vitro.

MATERIALS AND METHODS

Minimal inhibitory concentrations (MICs) of azithromycin and lansoprazole alone and in combination were determined for 106 clinical H. pylori isolates by means of an agar dilution technique. Killing kinetics of seven isolates were also studied in fluid medium.

RESULTS

MIC values for 50 and 90% of the isolates (MIC50, MIC90) were 0.19 and 0.5 mg/l for azithromycin, and 44.5 and 104 mg/l for lansoprazole. Nine strains (8.5%) had an MIC of azithromycin > or = 16 mg/l and were regarded as resistant. An additive interaction between the two drugs was found in 72 (68%), and indifferent effects in 24 strains (23%). Three of 9 azithromycin-resistant strains regained sensitivity in the presence of lansoprazole. In fluid culture, synergism between the two drugs occurred in 6 out of 7 strains tested.

CONCLUSION

In the majority of strains, lansoprazole and azithromycin interacted in an additive or synergistic manner depending on the test method employed. Addition of lansoprazole restored in vitro sensitivity to azithromycin in 3 out of 9 azithromycin-resistant strains. Such effects may enhance the elimination of H. pylori during clinical eradication therapy.