Jonas Jurgaitis

Surgical strategies for liver transplantation in the case of portal vein thrombosis – current role of cavoportal hemitransposition and renoportal anastomosis

Abstract:  Portal vein thrombosis (PVT), a common complication of end stage liver disease, is no longer considered a definite contraindication for liver transplantation (LTx). The clinical decision to perform an LTx in the case of PVT depends on the degree of PVT and the experience of the surgeon. Eversion thromboendovenectomy was suggested by most authors as the surgical technique of choice for PVT grade 1, 2, and 3. If PVT obstructs more extended parts of the porto‐mesenteric venous circulation, surgical options would include different types of venous jump graft reconstructions or arterialization of the portal vein. Combined liver and small bowel transplantation is another possible alternative. Cavoportal hemitransposition (CPHT) and renoportal anastomosis (RPA) were recently particularly advocated as creative surgical strategies in case of diffuse PVT. In this work, we focus on CPHT and RPA surgical techniques during LTx, which attempts to secure the portal flow to the liver graft in case of pre‐existent diffuse PVT. We provide a review of all reported clinical experience at international clinical centers using these techniques. According to our meta‐analysis a total of 15 studies were published on this topic between 1996 and 2005. In summary, a total of 56 orthotopic LTx have been performed in 53 patients (28 men, 25 women) combined with either CPHT or RPA, for the purpose of providing the donor graft with adequate inflow. Mean age was 44 yr including two patients who were infants, with the youngest recipient being two yr old. Main indications for LTx were liver cirrhosis caused by viral hepatitis, alcoholic cirrhosis and cryptogenic cirrhosis. CPHT was performed in 46 cases, and RPA in 10 cases. Thirty‐five of 53 patients (66%) had surgery previous to LTx. Of these, 13 (37%) patients presented with a history of other previous surgical procedures for decompression of portal hypertension or treatment of associated complications (portocaval shunts, splenectomy, etc). Ascites, renal dysfunction, lower extremity and torso edema and variceal bleeding were dominant post‐operative complications after CPHT or RPA noted in 22 cases (41.5%), 18 cases (34%), 17 cases (32%) and 13 cases (24.5%) respectively. Patients’ follow‐up ranged from two to 48 months. Patients survived [39 (74%)] and patients died [14 (26%)] during the course of observation. Based on the literature, we conclude that the ideal technique to overcome PVT during LTx is still controversial. Short‐term follow‐up results of both methods are promising, however, long‐term results are unknown at present. Furthermore, clinical follow‐up and basic experimental work is required to evaluate the influence of systemic venous inflow to the liver graft with respect to long‐term liver function and liver regeneration.

Controlled‐surgical education in clinical liver transplantation is not associated with increased patient risks

Abstract:  Introduction:  A qualified surgical team is required to perform liver transplantation (LTX). Growing numbers of transplants at transplant centers and large variations of transplant frequencies make a continuous education to train young surgeons on this complex field of hepato‐biliary surgery mandatory, both from the organizational and motivational point of view (job enrichment and professional growth). On the contrary, perioperative patient risk management is of major importance in surgical practice and given growing organizational concern in hospitals. A retrospective clinical study was performed to describe and evaluate the process of surgical training for orthotopic LTX. Patient risks associated with or caused by the education process in clinical LTX were analyzed.

Potrauminė blužnies pseudocista: klinikinis atvejis ir literatūros apžvalga

Ieva Martinaitytė 1 , Jonas Pivoriūnas 1 , Jonas Jurgaitis 2, 3 , Marius Paskonis 2, 3 Anatolij Ostapenka 2, 3 , Kestutis Strupas 2 1 Vilniaus universiteto Medicinos fakultetas, M. K. Ciurlionio g. 21, LT-03101 Vilnius 2 Gastroenterologijos, urologijos ir abdominalinės chirurgijos klinika, Vilniaus universiteto ligoninė Santariskių klinikos, Santariskių g. 2, LT-08661 Vilnius 3 Vilniaus universiteto Onkologijos institutas, Santariskių g. 1, LT-08660 Vilnius El pastas: jonas.jurgaitis@santa.lt Potrauminė blužnies pseudocista – tai labai reta dėl uždaros pilvo traumos issivystanti blužnies plysimo komplikacija, pasireiskianti tik 1 % pacientų, patyrusių uždarą pilvo traumą. Ligos simptomatika pasireiskia praėjus ilgam laikotarpiui po traumos, todėl yra sunku nustatyti blužnies pseudocistos etiologiją. Siame straipsnyje pristatomas klinikinis potrauminės blužnies pseudocistos atvejis ir aptariama chirurginio gydymo taktika. Reiksminiai žodžiai: potrauminis blužnies sužalojimas, blužnies pseudocista, blužnies pseudocistos gydymas. Post-traumatic splenic pseudocyst: case report and review of the literature Ieva Martinaitytė 1 , Jonas Pivoriūnas 1 , Jonas Jurgaitis 2, 3 , Marius Paskonis 2, 3 Anatolij Ostapenka 2, 3 , Kestutis Strupas 2 1 Faculty of Medicine, Vilnius University, M. K. Ciurlionio str. 21, LT-03101 Vilnius, Lithuania 2 Clinic of Gastroenterology, Urology and Abdominal Surgery, Vilnius University Hospital “Santariskių Klinikos”, Santariskių str. 2, LT-08661 Vilnius, Lithuania 3 Institute of Oncology, Vilnius University, Santariskių str. 1, LT-08660 Vilnius, Lithuania El pastas: jonas.jurgaitis@santa.lt The post-traumatic pseudocyst is a very rare complication of the spleen rupture after blunt abdominal trauma. It is known to occur only to 1% of patients who had undergone such blunt abdominal trauma. The symptoms of the disease are reported to develop after a long post-traumatic period, thus the etiology of the pseudocyst of the spleen is hard to reveal. The aim of this paper is to present a case of the post-traumatic pseudocyst of the spleen and to discuss the strategy of the surgical management. Keywords: post-traumatic spleen injury, splenic pseudocyst, management of splenic pseudocyst.

Hepatoceliulinės karcinomos prognostinės sistemos

Jonas Pivoriūnas 1 , Jonas Jurgaitis 2, 3 , Marius Paskonis 2, 3 , Agnius Juska 1 , Janina Didžiapetrienė 3 , Eugenijus Stratilovas 3 , Narimantas Evaldas Samalavicius 3 , Vitalijus Sokolovas 3 , Gintautas Brimas 2 , Kestutis Strupas 2 1 Vilniaus universiteto Medicinos fakultetas, M. K. Ciurlionio g. 21, LT-03101 Vilnius 2 Gastroenterologijos, urologijos ir abdominalinės chirurgijos klinika, Vilniaus universiteto ligoninės Santariskių klinikos, Santariskių g. 2, LT-08661 Vilnius 3 Vilniaus universiteto Onkologijos institutas Santariskių g. 1, LT-08660 Vilnius El pastas: jonas.jurgaitis@santa.lt Įvadas / tikslas Hepatoceliulinė karcinoma – tai penktas tarp dažniausių navikų pasaulyje ir trecias pagal mirstamumą. Per pastaruosius desimtmecius sergamumas siuo naviku didėja Jungtinėse Amerikos Valstijose ir Europoje. Lietuvoje hepatoceliulinės karcinomos atvejų taip pat daugėja. Manoma, kad kepenų navikų per kitus du desimtmecius dar padaugės. Hepatoceliulinė karcinoma yra sunkiai įvertinama, heterogoniska liga, dėl to pasaulyje kuriamos prognostinės sistemos, kurios turi padėti gydytojui parinkti tinkamą gydymą ir įvertinti ligos prognoze. Sio straipsnio tikslas – isrinkti ir apibūdinti labiausiai pasaulyje paplitusias hepatoceliulinės karcinomos prognostines sistemas, palyginti jų taikymo rezultatus, parinkti Lietuvai tinkamiausias sistemas. Metodai Pasinaudojus „PubMed“ duomenų baze ir įvedus reiksminius žodžius hepatocellular carcinoma, prognostic scores ir staging system buvo rasti 205 straipsniai, publikuoti nuo 1984 iki 2007 metų. Atrinkti 54 straipsniai, kuriuose minimos 24-ios hepatoceliulinės karcinomos prognostinės sistemos. Rezultatai Isanalizavus sistemas buvo nuspresta atmesti tas, kurių pritaikyti Lietuvoje nėra galimybių dėl to, kad salyje neatliekami tyrimai. Placiau aprasytos devynios sistemos. Isvados Isrinke placiausiai pasaulyje naudojamas hepatoceliulinės karcinomos prognostines sistemas ir palygine jų taikymo rezultatus, manome, kad būtų vertinga atlikti retrospektyvųjį lyginamąjį tyrimą, kad issiaiskintume, kokia prognostinė sistema geriausiai tinka hepatoceliuline karcinoma sergantiems Lietuvos populiacijos pacientams diferencijuoti pagal isgyvenamumą. Reiksminiai žodžiai: hepatoceliulinė karcinoma, prognostinė sistema, prognostiniai kriterijai, pacientų isgyvenamumas Prognostic scores of hepatocellular carcinoma Jonas Pivoriūnas 1 , Jonas Jurgaitis 2, 3 , Marius Paskonis 2, 3 , Agnius Juska 1 , Janina Didžiapetrienė 3 , Eugenijus Stratilovas 3 , Narimantas Evaldas Samalavicius 3 , Vitalijus Sokolovas 3 , Gintautas Brimas 2 , Kestutis Strupas 2 1 Vilnius University Faculty of Medicine, M. K. Ciurlionio str. 21, LT-03101 Vilnius, Lithuania 2 Clinic of Gastroenterology, Urology and Abdominal Surgery, Vilnius University Hospital Santariskių Clinic, Santariskių str. 2, LT-08661 Vilnius, Lithuania 3 Institute of Oncology, Vilnius University, Santariskių str. 1, LT-08660 Vilnius, Lithuania E-mail: jonas.jurgaitis@santa.lt Background / objective Hepatocellular carcinoma is the most common primary liver cancer. It is the fifth most common neoplasm and the third most common cause of cancer-related death in the world. Over the last decade the incidence of this cancer has been rising in the United States of America and in Europe as well as in Lithuania. The incidence of this cancer in the next two decades is expected to rise. Hepatocelullar carcinoma is a difficult and heterogenic disease. Therefore, prognostic scores are being created to help clinicians to choose the best treatment for the patient. The aim of this review is to select and describe the most widely used prognostic systems of hepatocellular carcinoma, to compare results of their usage, applicability and to choose the most suitable scoring systems for the further use in Lithuania. Methods The PubMed data base was used to search for the keywords: “hepatocellular carcinoma”, “prognostic scores” and “staging systems”. 205 published articles were found from the year 1984 though 2007; 54 articles with 24 prognostic systems were selected. Results Upon analysing the prognostic systems, it was decided to reject the scoring systems that are impossible to use in Lithuania because of the absence of related tests. In total, nine prognostic systems were overviewed. Conclusions A retrospective cohort study is advisable to ascertain which prognostic system of hepatocellular carcinoma is most suitable for Lithuanian population. Key words: hepatocellular carcinoma, prognostic score, prognostic factors, survival of the patient

Bouveret sindromas: klinikinis atvejis ir literatūros apžvalga

Lina Praleikienė, Marius Paskonis, Jonas Jurgaitis, Eligijus Poskus, Kestutis Strupas Vilniaus universiteto ligoninės Santariskių klinikų Pilvo chirurgijos centras, Santariskių g. 2, LT-08661 Vilnius El pastas: lenana2000@yahoo.com Bouveret sindromas – skrandžio turinio slinkimo sutrikimas, kurio priežastis – didelis akmuo, patekes į dvylikapirste žarną per biliogastrine ar bilioduodenine fistule. Straipsnyje aprasomas Vilniaus universiteto ligoninės Santariskių klinikose gydytas ligonis, kuriam diagnozuotas Bouveret sindromas – tulžies pūslės akmenys pragulėjo dvylikapirstės žarnos serozinį dangalą, raumeninį sluoksnį ir gleivine, taciau į dvylikapirstės žarnos spindį dar nebuvo pateke. Bouveret sindromas įtartas sonoskopijos ir kompiuterinės tomografijos tyrimais, patvirtintas atliekant cholecistektomiją ir piloroplastiką. Pateikiama literatūros apžvalga: diagnostikos problemos, instrumentinių tyrimų nauda ir gydymo būdai. Reiksminiai žodžiai: Bouveret sindromas, tulžies pūslės akmenligė, žarnų nepraeinamumas Bouveret’s syndrome: clinical case and review of the literature Lina Praleikienė, Marius Paskonis, Jonas Jurgaitis, Eligijus Poskus, Kestutis Strupas. Vilnius University Hospital Santariskių Klinikos, Centre of Abdominal Surgery, Santariskių 2, LT-08661 Vilnius, Lithuania E-mail: lenana2000@yahoo.com Bouveret’s syndrome is described as gastric outlet obstruction caused by a large gallstone passing into duodenal bulb through a biliogastric or bilioduodenal fistula. We describe a clinical case of the forming Bouveret syndrome – the gallstones had separated serous, muscular and mucose layers of the duodenum, but did not enter the lumen of it. Bouveret’s syndrome was diagnosed by ultrasound and computed tomography and treated by cholecystectomy and pyloroplasty. Various symptoms, diagnostic and treatment approaches are discussed. Key words: Bouveret’s syndrome, cholecystitis, gallstone ileus