Eleazar Chaib

Spontaneous rupture of hepatic hemangiomas: A review of the literature

Hepatic hemangiomas are congenital vascular malformations, considered the most common benign mesenchymal hepatic tumors, composed of masses of blood vessels that are atypical or irregular in arrangement and size. Hepatic hemangiomas can be divided into two major groups: capillary hemangiomas and cavernous hemangiomas These tumors most frequently affect females (80%) and adults in their fourth and fifth decades of life. Most cases are asymptomatic although a few patients may present with a wide variety of clinical symptoms, with spontaneous or traumatic rupture being the most severe complication. In cases of spontaneous rupture, clinical manifestations consist of sudden abdominal pain, and anemia secondary to a haemoperitoneum. Disseminated intravascular coagulopathy can also occur. Haemodynamic instability and signs of hypovolemic shock appear in about one third of cases. As the size of the hemangioma increases, so does the chance of rupture. Imaging studies used in the diagnosis of hepatic hemangiomas include ultrasonography, dynamic contrast-enchanced computed tomography scanning, magnetic resonance imaging, hepatic arteriography, digital subtraction angiography, and nuclear medicine studies. In most cases hepatic hemangiomas are asymptomatic and should be followed up by means of periodic radiological examination. Surgery should be restricted to specific situations. Absolute indications for surgery are spontaneous or traumatic rupture with hemoperitoneum, intratumoral bleeding and consumptive coagulopathy (Kassabach-Merrit syndrome). In a patient presenting with acute abdominal pain due to unknown abdominal disease, spontaneous rupture of a hepatic tumor such as a hemangioma should be considered as a rare differential diagnosis.

Surgical management of spontaneous ruptured hepatocellular adenoma

AIMS Spontaneous ruptured hepatocellular adenoma (SRHA) is a rare life-threatening condition that may require surgical treatment to control hemorrhaging and also stabilize the patient. We report a series of emergency surgeries performed at our institution for this condition. METHODS We reviewed medical records and radiology files of 28 patients (from 1989 to 2006) with a proven diagnosis of hepatocellular adenoma (HA). Three (10.7%) of 28 patients had spontaneous ruptured hepatocellular adenoma, two of which were associated with intrahepatic hemorrhage while one had intraperitoneal bleeding. Two patients were female and one was male. Both female patients had a background history of oral contraceptive use. Sudden abdominal pain associated with hemodynamic instability occurred in all patients who suffered from spontaneous ruptured hepatocellular adenoma. The mean age was 41.6 years old. The preoperative assessment included liver function tests, ultrasonography and computed tomography. RESULTS The surgical approaches were as follows: right hemihepatectomy for controlling intraperitoneal bleeding, and right extended hepatectomy and non-anatomic resection of the liver for intrahepatic hemorrhage. There were no deaths, and the postoperative complications were bile leakage and wound infection (re-operation), as well as intraperitoneal abscess (re-operation) and pleural effusion. CONCLUSION Spontaneous ruptured hepatocellular adenoma may be treated by surgery for controlling hemorrhages and stabilizing the patient, and the decision to operate depends upon both the patient’s condition and the expertise of the surgical team.

Cost-effectiveness analysis of a hypothetical hepatitis C vaccine compared to antiviral therapy.

We propose a mathematical model to simulate the dynamics of hepatitis C virus (HCV) infection in the state of São Paulo, Brazil. We assumed that a hypothetical vaccine, which cost was taken to be the initial cost of the vaccine against hepatitis B exists and it is introduced in the model. We computed its cost-effectiveness compared with the anti-HCV therapy. The calculated basic reproduction number was 1.20. The model predicts that without intervention a steady state exists with an HCV prevalence of 3%, in agreement with the current epidemiological data. Starting from this steady state three interventions were simulated: indiscriminate vaccination, selective vaccination and anti-HCV therapy. Selective vaccination proved to be the strategy with the best cost-effectiveness ratio, followed by indiscriminate vaccination and anti-HCV therapy.

Islet transplantation in rodents. Do encapsulated islets really work

CONTEXT Diabetes mellitus type I affects around 240 million people in the world and only in the USA 7.8% of the population. It has been estimated that the costs of its complications account for 5% to 10% of the total healthcare spending around the world. According to World Health Organization, 300 million people are expected to develop diabetes mellitus by the year 2025. The pancreatic islet transplantation is expected to be less invasive than a pancreas transplant, which is currently the most commonly used approach. OBJECTIVES To compare the encapsulated and free islet transplantation in rodents looking at sites of islet implantation, number of injected islets, viability and immunosuppression. METHODS A literature search was conducted using MEDLINE/PUBMED and SCIELO with terms about islet transplantation in the rodent from 2000 to 2010. We found 2,636 articles but only 56 articles from 2000 to 2010 were selected. RESULTS In these 56 articles used, 34% were encapsulated and 66% were nonencapsulated islets. Analyzing both types of islets transplantation, the majority of the encapsulated islets were implanted into the peritoneal cavity and the nonencapsulated islets into the liver, through the portal vein. In addition, the great advantage of the peritoneal cavity as the site of islet transplantation is its blood supply. Both vascular endothelial cells and vascular endothelial growth factor were used to stimulate angiogenesis of the islet grafts, increasing the vascularization rapidly after implantation. It also has been proven that there is influence of the capsules, since the larger the capsule more chances there are of central necrosis. In some articles, the use of immunosuppression demonstrated to increase the life expectancy of the graft. CONCLUSION While significant progress has been made in the islets transplantation field, many obstacles remain to be overcome. Microencapsulation provides a means to transplant islets without immunosuppressive agents and may enable the performance of xenotransplantation. The use of alternative donor sources, fewer islets per capsule and the appropriate deployment location, such as the peritoneal cavity, may give a future perspective to the application of immunoprotective capsules and viability in clinical practice. A variety of strategies, such as genetic engineering, co-encapsulation, improvement in oxygen supply or the establishment of hypoxia resistance will also improve the islet transplantation performance. It remains to be determined which combination of strategies with encapsulation can fulfill the promise of establishing a simple and safe transplantation as a cure for diabetes.

Variações do sistema arterial hepático e sua aplicabilidade na bipartição do fígado: estudo anatômico em cadáveres

Background - The liver donor shortage and the higher demand on liver transplantation led to advanced liver surgery techniques in order to better utilization of the cadaveric liver donors. That is why the split-liver technique had been applicated in liver transplantation where the liver after been divided into two lobes would be implanted in two recipients. Aims - This paper has the goal of study both the extra-hepatic arterial distribuition and anatomie of the liver with application on the split-liver transplantation separating the liver in right and left hepatic lobe. Patients and Methods - The authors studied 60 livers from fresh cadaver looking at hepatic artery and its main anatomic variations correlating with split-liver surgery. The liver was split into two portions, right and left lobe. Results - The total liver weight was 1536 ± 361,8 g, right hepatic lobe 890,3 ± 230,9 g and left hepatic lobe 649,3 ± 172,6 g. Common hepatic trunk was found in one (1,6%) case and came from superior mesenteric artery and in another one (1,6%), both left hepatic artery and left gastric artery came from the abdominal aorta. The right hepatic artery raised from celiac trunk in 44 (73,3%) cases, and in 15 (25%) from superior mesenteric artery it was acessory in 11 (18,3%) cases and dominant in 4 (6,6%). The left hepatic artery was acessory of left gastric artery in 2 (3,3%) cases. Hepatic artery trifurcation was found in 9 (15%) cases out of this 6 (10%) to segment IV, 2 (3,3%) to segment III and 1 (1,6%) to segment II. Also we found 2 (3,3%) medium hepatic artery to segment IV. Conclusion - Hepatic artery variations allowed liver section into right and left hepatic lobe.

Intestinal transplantation including anorectal segment in the rat

Transplantation of small bowel and colon has been recently advocated, aiming to prevent dehydration, reduce stoma output, and promote earlier post-transplant weaning from parental nutrition. Some patients needing intestinal transplantation may also have anorectal dysfunction or a permanent colostomy, which impairs quality of life. The inclusion of the anorectal segment in the intestinal graft may be an attractive improvement for such patients. In this letter, we describe a model of en bloc intestinal transplantation in the rat, including jejunum, ileum, cecum, entire colon, rectum, and the anus. In donor operation, we performed a combined perianal and midline abdominal incision (Fig. 1A). The completely dissected anorectal segment was mobilized to inside the abdomen through the perineum, sectioning rectal vessels and pudendal nerves and preserving the inferior mesenteric artery and vein. The superior mesenteric and portal veins were separated from the pancreas by division of duodenal, splenic, and left gastric veins. The abdominal aorta was dissected from the iliac bifurcation up to the diaphragm by dividing lumbar and renal arteries and the celiac trunk (Fig. 1B). After heparinization, we tied the aorta distally to the inferior mesenteric artery and cut it near the diaphragm and after the tie to perform a long aortomesenteric conduit including the superior and inferior mesenteric arteries. The portal vein was dissected and cut near the hepatic hilum, the proximal jejunum was sectioned, and the graft was removed and placed in cold preservation solution. During back table procedures, we placed a cuff in portal vein, as previously described (Fig. 1C). In the recipient, we performed the same combined incision and anorectal mobilization. The infrarenal abdominal aorta was cross-clamped, and a continuous end-to-side hand-sewn microanastomosis was performed between recipient’s aorta and donor’s aortomesenteric conduit. Below the second jejunal branch, we dissected approximately 1 cm of the recipient superior mesenteric vein, which was clamped and sectioned. The donor portal cuff was introduced in the recipient’s superior mesenteric vein, and an encircling ligature was performed to fix the cuff and complete the anastomosis. Subsequently, we tied and divided the superior and inferior mesenteric arteries and removed en bloc the native mesentery, jejunum, ileum, cecum, entire colon, rectum, and anus. After clamps removal, immediate pulsation of the aortomesenteric conduit and flow throughout the portal vein were observed (Fig. 1D). To restore the intestinal tract, recipient’s and donor’s jejunum were anastomosed, and the anorectal segment was replaced in its ortothopic position and fixed by stitches between donor’s skin surrounding the anus and recipient’s perineal skin. Total operating time was about 3 hours and total ischemia time was about 60 minutes. This intestinal transplantation modification of our previously described models preserves bowel intrinsic innervation, ileocecal valve, and anal sphincter, which may improve graft physiology. It also allows studies evaluating the regeneration of intestinal and anorectal innervation by anorectal electromyography and manometry. Furthermore, it maintains physiological portal drainage and may be useful for metabolic and Presented at the 10th Congress of the International Society for Experimental Microsurgery (ISEM), São Paulo, Brazil, October 29th–November 1st, 2010. *Correspondence to: Flávio Henrique Ferreira Galvão, Av. Dr. Arnaldo, 455Cerqueira Cesar, Room 3206, São Paulo, SP, Brazil. E-mail: fgalvao@usp.br Received 30 April 2011; Accepted 9 August 2011 Published online 17 October 2011 in Wiley Online Library (wileyonlinelibrary. com). DOI 10.1002/micr.20958

Graft-versus-host disease after liver transplantation

Graft-versus-host disease (GVHD) following liver trans-plantation (LT) is an uncommon complication but has highmortality and represents a major diagnostic challenge.GVHD occurs when immunocompetent donor lymphocytesoriginating from the transplanted liver undergo activationand clonal expansion, allowing them to mount a destructivecellular immune response against recipient tissues.Humoral GVHD is usually seen after an ABO-mismatchedliver transplant, but cellular GVHD is directed against themajor histocompatibility complex and often results in severemultisystem disease with high mortality.

Expected number of deaths in the liver transplantation waiting list in the state of São Paulo, Brazil

São Paulo is the pioneer Brazilian state in transplantation surgery. The biggest challenge facing the field of transplantation is the critical shortage of donor organs, which has led to a dramatic increase in the number of patients on the waiting-list as well as in their waiting time for transplantation. In a previous work [1], we projected the size of the waiting-list of Sao Paulo State in comparison with the number of transplantations carried out in the same period. We demonstrated [1] that the list size grows at a rate much higher than the number of transplantations actually performed. We wish to report the expected number of deaths in the waiting-list of liver transplantation in the State of São Paulo for a projected period of 10 years starting from the year 2005.

Effects of hyperbaric oxygen therapy as hepatic preconditioning in rats submitted to hepatic ischemia/reperfusion injury

PURPOSE To analyze the role of hyperbaric oxygen therapy as hepatic preconditioning in rats submitted to hepatic ischemia and reperfusion. METHODS Wistar rats were randomly divided into three groups: SHAM, rats submitted to surgical stress without hepatic ischemia and reperfusion, I/R, rats submitted to total hepatic pedicle ischemia for 30 min, followed by 5 min of reperfusion; HBOI/R, rats submitted to 60 minutes of hyperbaric oxygen therapy at 2 atm and immediately submitted to the experimental protocol of ischemia and reperfusion. Liver function was assessed by measuring serum alanine aminotransferase and aspartate aminotransferase, as well as mitochondrial function by determining states 3 and 4 of mitochondrial respiration, respiratory control rate and mitochondrial permeability transition (mitochondrial swelling). The results were analyzed by the Mann-Whitney test and all P-values <0.05 were considered significant. RESULTS There were significant differences in serum aspartate aminotransferase values in groups SHAM vs. HBOI/R, I/R vs HBOI/R, alanine aminotransferase in groups SHAM and I/R; State 3 in SHAM groups vs. I/R, SHAM vs. HBOI/R, State 4 in I/R vs HBOI/R groups, respiratory control rate in SHAM vs I/R groups; mitochondrial swelling in SHAM vs. I/R groups, and SHAM vs HBOI/R. CONCLUSION Hyperbaric preconditioning improved hepatic mitochondrial function and decreased serum markers of liver injury in the ischemia and reperfusion process.

Myeloperoxidase activity is increased in hepatopulmonary syndrome in rats

BACKGROUND Hepatopulmonary syndrome is formed by a triad of liver disease, intrapulmonary vascular dilatation and changes in blood gases. Its pathogenesis is not well defined, but it is speculated that a combination of factors, such as the imbalance of endothelin receptor responses, pulmonary microvascular remodeling, and genetic predisposition, leads to bacterial translocation and intrapulmonary vascular dilatation. AIM To evaluate the myeloperoxidase activity in hepatopulmonary syndrome in rat model. METHOD Twenty-nine rats were divided into control, sham and experimental hepatopulmonary syndrome groups. Was evaluated the myeloperoxidase activity and the experimental model used to induce hepatopulmonary syndrome was common bile duct ligation. RESULTS The myeloperoxidase activity levels were significantly increased in the common bile duct ligation group as compared with the other groups. Myeloperoxidase activity was higher in the common bile duct ligation group than control group (p<0.05) and than sham group (p<0.05). CONCLUSION The myeloperoxidase activity is increased in experimental hepatopulmonary syndrome in rats.