Kęstutis Strupas

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.

Alveolar echinococcosis, Lithuania.

Alveolar Echniococcosis, Lithuania

Echinococcus infections in the Baltic region

In the Baltic countries, the two zoonotic diseases, alveolar echinococcosis (AE) caused by Echinococcus multilocularis, and cystic echinococcosis (CE) caused by Echinococcus granulosus, are of increasing public health concern. Observations from Estonia, Latvia and Lithuania indicate that the distribution of both parasites is wider in the Baltics than previously expected. In this paper, we review and discuss the available data, regarding both parasitoses in animals and humans, from the Baltic countries and selected adjacent regions. The data are not easily comparable but reveal a worrisome situation as the number of human AE and CE cases is increasing. Despite improvements in diagnostics and treatment, AE has a high morbidity and mortality in the Baltic region. For the control of both zoonoses, monitoring transmission patterns and timely diagnosis in humans as well as the development of local control programs present major challenges.

Value of adipokines in predicting the severity of acute pancreatitis: Comprehensive review

AIM To analyze the prognostic value of adipokines in predicting the course, complications and fatal outcome of acute pancreatitis (AP). METHODS We performed the search of PubMed database and the systemic analysis of the literature for both experimental and human studies on prognostic value of adipokines in AP for period 2002-2012. Only the papers that described the use of adipokines for prediction of severity and/or complications of AP were selected for further analysis. Each article had to contain information about the levels of measured adipokines, diagnosis and verification of AP, to specify presence of pancreatic necrosis, organ dysfunction and/or mortality rates. From the very beginning, study was carried out adhering to the PRISMA checklist and flowchart for systemic reviews. To assess quality of all included human studies, the Quality Assessment of Diagnostic Accuracy Studies tool was used. Because of the high heterogeneity between the studies, it was decided to refrain from the statistical processing or meta-analysis of the available data. RESULTS Nine human and three experimental studies were included into review. In experimental studies significant differences between leptin concentrations at 24 and 48 h in control, acute edematous and acute necrotizing pancreatitis groups were found (P = 0.027 and P < 0.001). In human studies significant differences between leptin and resitin concentrations in control and acute pancreatitis groups were found. 1-3 d serum adiponectin threshold of 4.5 μg/mL correctly classified the severity of 81% of patients with AP. This threshold yielded a sensitivity of 70%, specificity 85%, positive predictive value 64%, negative predictive value88% (area under curve 0.75). Resistin and visfatin concentrations differ significantly between mild and severe acute pancreatitis groups, they correlate with severity of disease, need for interventions and outcome. Both adipokines are good markers for parapancreatic necrosis and the cut-off values of 11.9 ng/mL and 1.8 ng/mL respectively predict the high ranges of radiological scores. However, the review revealed that all nine human studies with adipokines are very different in terms of methodology and objectives, so it is difficult to generalize their results. It seems that concentrations of the leptin and resistin increases significantly in patients with acute pancreatitis compared with controls. Serum levels of adiponectin, visfatin and especially resitin (positive correlation with Acute Physiology and Chronic Health Evaluation II, Ranson and C-reactive protein) are significantly different in mild acute pancreatitis and severe acute pancreatitis patients, so, they can serve as a markers for the disease severity prediction. Resistin and visfatin can also be used for pancreatic and parapancreatic necrosis prediction, interventions needs and possible, outcome. CONCLUSION High levels of adipokines could allow for prediction of a severe disease course and outcome even in small pancreatic lesions on computed tomography scans.

Hypertriglyceridemia-Induced Acute Pancreatitis in Pregnancy

CONTEXT Hypertriglyceridemia is a well known phenomenon of pregnancy occurring due to physiologic changes in sex hormone levels. Occasionally, it could lead to development of acute pancreatitis. Gestational hypertriglyceridemia-induced acute pancreatitis occurs in pregnant women usually with preexisting abnormalities of the lipid metabolism and is associated with additional diagnostic and therapeutic challenges related to hypertriglyceridemia and pregnancy. CASE REPORT We present a case of the hypertriglyceridemia-induced acute pancreatitis in pregnant woman with no previous history of lipid abnormality and pregnancy as the only known triggering factor for hypertriglyceridemia. CONCLUSIONS Hypertriglyceridemia-induced acute pancreatitis is a rare complication of pregnancy; however, it should be suspected in all pregnant patients admitted for nonobsteric abdominal pain.

Minimally invasive management of pancreatic pseudocysts

Introduction The laparoscopic and endoscopic approaches to internal drainage of pancreatic pseudocysts (PP) are the current minimally invasive management options. Indications, and early and late results of endoscopic and laparoscopic approaches are being discussed. Aim To present experience in treatment of PP by laparoscopic pseudocystogastrostomy (LPGS) and endoscopic pseudocystogastrostomy (EPGS) and to compare results, feasibility and safety. Material and methods Thirty patients underwent surgical intervention: 18 patients – LPGS (group I), 12 – EPGS (group II). Groups were compared by age, gender, pancreatic pseudocysts’s age, diameter and localization, as well as intraoperative, early and late postoperative complications. Results Gender distribution, group I: 14 (77.8%) men and 4 (22.2%) women, group II: 4 (33.3%) men and 8 (66.7%) women, p = 0.02. Average cyst diameter: group I – 149.9 ±52.1 mm, group II – 119 ±37.9 mm, p = 0.07. Average time between diagnosis and operation performance: group I – 12 (3-60) months, group II – 8 (2-36) months, p = 0.19. Neither in group I nor in group II did intraoperative complications occur. Early postoperative complications were divided into minor and major. Early minor complications: group I – 2 (11.1%), group II – 0, p = 0.5. Early major complications: group I – 0, group II – 2 (16.7%), p = 0.15. Late postoperative complications: group I – 0, group II – 1 (8.3%), p = 0.4. In group I there was no case, whereas in II group there was 1 (8.3%) case of recidivation, p = 0.4. Conclusions For selected patients both minimally invasive methods are equally safe an effective. For comprehensive evaluation of methods prospective trials are needed.

Minimally invasive retroperitoneal necrosectomy in management of acute necrotizing pancreatitis

Introduction One of the most important requirements in treatment of acute necrotizing pancreatitis is minimized invasion. Aim We are presenting experience in treatment of acute necrotizing pancreatitis by an original minimally invasive retroperitoneal necrosectomy technique, comparing our results to other studies, evaluating feasibility and safety, discussing advantages and disadvantages of this method. Material and methods We performed a retrospective analysis of 13 patients who had acute necrotizing pancreatitis with large fluid collections in retroperitoneal space and underwent retroperitoneal necrosectomy. Results There were eight males and three females aged between 24 and 60 years, average age was 42.8 ±9.2 years. The most common cause of pancreatitis was alcohol, 10 patients (76.9%). Average time between diagnosis and performance of operation was 25.7 ±11.3 days. One patient underwent eight repeated interventions: two retroperitoneal necrosectomies; five laparotomies; ultrasound-guided drainage. One patient underwent four reinterventions: lumbotomy; revision; two lavages. Three patients had two reinterventions: one had laparotomy and tamponation; one had two repeated retroperitoneal necrosectomies; third had one repeated retroperitoneal necrosectomy and one had ultrasound-guided drainage. Three patients needed one additional retroperitoneal necrosectomy. Five patients did not required additional interventions. 61.5% of our patients did not require more than one reintervention. Postoperative stay varied from 9 to 94 days, average 50.8 ±32.6 days. Conclusions Minimally invasive techniques should be considered as first-choice surgical option in treating patients with acute necrotizing pancreatitis. Pancreatic necrosis occupying less than 30% and with massive fluid collections in the left retroperitoneal space can be safely managed by minimally invasive retroperitoneal necrosectomy.

Emerging alveolar echinococcosis (AE) in humans and high prevalence of Echinococcus multilocularis in foxes and raccoon dogs in Lithuania

Summary The presence of the most important definitive and intermediate hosts suggests that conditions for the live cycle of E. multilocularis are favorable in Lithuania. While the main rodent hosts have not been investigated systematically in Lithuania, E. multilocularis has already been identified in one of 5 muskrats (Ondatra zibethicus) captured in the Silutė district. The high prevalence of E. multilocularis in red foxes and raccoon dogs as well as a notable increase of AE in humans document that E. multilocularis is of emerging concern in Lithuania. The human AE cases were recorded from many parts of the country suggesting that the whole territory of Lithuania should be considered as an endemic area for E. multilocularis. Considering the long prepatent period of AE in humans we suggest that this zoonosis is present in the area investigated for at least a few decades.

Sulforaphane decreases kidney injury after transplantation in rats: role of mitochondrial damage

BACKGROUND Sulforaphane is a naturally occuring antioxidative and anti-inflammatory isothiocyanat. In this study, its impact on experimental kidney transplantation was evaluated. MATERIAL AND METHODS Male Brown Norway rats (n=112) were used as experimental animals. Donor kidneys were harvested and stored for 12 hours in HTK-solution at 4°C. D,L-Sulforaphane (4.4 mg/kg BW; 0.2ml) or normal saline (0.2 ml) was given i.v. to the recipients 24 and 1 hour before, and 6 hours after transplantation. Recipients were nephrectomized bilaterally and subsequently transplantation was performed. After 6 and 48 hours, biopsies were taken and processed for light and electron microscopy. Graft function was monitored using serum values of creatinine and BUN after 6 and 24 hours. Quantitative real-time PCR was used to detect differences in SOD2-gene expression after 6 hours and apoptotic activity was detected after 6 hours using propidium iodide flow cytometry. RESULTS Recipient preconditioning improved reperfusion damage index from 12.8±1.6 in controls to 8.8±1.8 (p<0.001). Serum levels of creatinine and BUN decreased from 4.29±0.25 mg/dl and 119±23 mg/dl in controls to 3.65±0.7 mg/dl and 81±19 mg/dl (p<0.05). The number of severely injured tubules decreased (p<0.05). Apoptotic activity was increased in SFN-treated rats. Mitochondrial microstructure was better preserved after SFN, while SOD 2 gene expression increased (p<0.05). CONCLUSIONS SFN ameliorates ischemia/reperfusion injury after KTx, most likely through anti-oxidative effects.

Video-assisted loboisthmectomy by the subclavicular approach. A case report

The main advantage of minimally invasive thyroidectomy is a good cosmetic effect. Minimally invasive video-assisted thyroidectomy (MIVAT) is performed without gas insufflation in contrast to endoscopic thyroidectomy. In general, MIVAT is carried out through an incision in the middle part of the neck, not covered with clothes. The MIVAT thyroid lobectomy can also be done through the subclavicular approach. We describe a case of a 19-year-old female patient with a tumour of the left side of the neck. Thyroid ultrasound scan (UST) with thyroid fine-needle aspiration and cytological examination (FNAC) were performed. Thyroid-stimulating hormone (TSH), free triiodothyronine (FT3) and anti-tyreoperoxidase (ATPO) were checked. Video-assisted hemithyroidectomy was performed through an incision below the left clavicle. Intraoperative pathology examination of the specimen was carried out. The UST showed a solitary 13 mm × 23 mm nodule in the left lobe of the thyroid, the FNAC showed benign pathology. Thyroid function tests were normal (TSH 0.90 mIU/l; FT3 4.70 pmol/l). Video-assisted hemithyroidectomy was done through the incision below the left clavicle. Histopathological examination proved thyroid hyperplasia nodosum. There were no intra- or postoperative complications. The patient was discharged on the second day. Clinical and cosmetic outcomes 2 months after surgery were good. Minimally invasive video-assisted thyroid lobectomy performed via the subclavicular area is feasible and provides good cosmetic outcomes.