Single vs. dual vessel porcine extracorporeal liver perfusion

BACKGROUND

The use of porcine extracorporeal liver perfusion (PECLP) to provide temporary hepatic support for patients in fulminant hepatic failure has been limited by the fact that individual perfusions can be sustained for only a few hours. Inadequate liver function and/or hemodynamic instability are the major contributing factors for early interruption of PECLP. Recent reports suggest that the choice of single (portal vein only) vs dual (portal vein and hepatic artery) vessel perfusion may influence the duration of perfusion. We hypothesize that PECLP with single vessel perfusion (SVP) is associated with worse liver function and greater hemodynamic instability than PECLP with dual vessel perfusion (DVP).

MATERIALS AND METHODS

To eliminate the potentially confounding influences of liver failure and xenograft rejection, liver isografts procured from White-Landrace pig donors were perfused by either SVP or DVP via an extracorporeal circuit established with normal White-Landrace pig recipients. The function of perfused livers was evaluated by measuring production of bile and Factors V and VIII, clearance of ammonia and lactate, and extraction of O(2) at baseline and at 0, 1, 3, 6, 12, and 24 h after initiation of PECLP. The impact of PECLP on recipient hemodynamic status was assessed by monitoring BP, heart rate, urine output, O(2) saturation, etc. Among other parameters evaluated were serum albumin and total protein and hepatic release of IL-1beta and nitric oxide to assess their possible contributions to hemodynamic instability.

RESULTS

DVP and SVP livers cleared ammonia and lactate similarly. Both approaches were associated with progressive hypoalbuminemia and hypoproteinemia. DVP livers produced more bile and Factor V and were associated with less recipient hypotension and IL-1beta and NO release than SVP livers.

CONCLUSIONS

Livers with DVP function better than livers with SVP. The duration of PECLP can be limited by recipient hypotension, although this complication is less severe with DVP than with SVP.

Congenital tracheoesophageal fistula without esophageal atresia

Congenital tracheoesophageal fistula (TEF) without esophageal atresia, commonly referred to as H-type fistula, comprises only 4.2% of all TEF's. Four infants with this entity were surgically treated at Santa Rosa Children's Hospital during the period of 1974 to 1977, and their diagnosis, surgical management, and hospital course are described in detail. H-type TEF is characterized by a clinical triad consisting of paroxysms of coughing precipitated by feeding, gaseous distention of the gastrointestinal tract, and pneumonitis. Demonstration of H-type TEF can be difficult and may be accomplished only by repeated examinations. The esophagogram using cinefluoroscopy and image intensification is the primary diagnostic technique utilized. If this is nondiagnostic, then tracheobronchoscopy should be performed in conjunction with ancillary techniques which improve endoscopic yield. Surgical correction can be accomplished through a cervical approach in 80% of cases. Preoperatival treatment of H-type TEF is dependent upon a high index of suspicion, an aggressive diagnostic approach, and prompt surgical correction. Our series of patients demonstrates that early diagnosis is feasible.

Appendicitis in acute leukemia

The cases of five children with acute leukemia complicated by appendicitis were reviewed. All but one child had typical signs and symptoms of acute appendicitis, though four children were receiving prednisone. All five children underwent appendectomy, and all survived the immediate postoperative period. One child had a spontaneous remission following appendectomy. Two of three children in relapse suffered serious postoperative complications. Our experience supports the surgical management of appendicitis in acute leukemia.