Marino Murazio

Pedicle clamping with ischemic preconditioning in liver resection

Hepatic pedicle clamping (HPC) is widely used to control intraoperative bleeding during hepatectomy; intermittent HPC is better tolerated but is associated with blood loss during each period of reperfusion. Recently, it has been shown that ischemic preconditioning (IP) reduces the ischemia‐reperfusion damage for up to 30 minutes of continuous clamping in healthy liver. We evaluated the safety of IP for more prolonged periods of continuous clamping in 42 consecutive patients with healthy liver submitted to hepatectomy. IP was used in 21 patients (group A); mean ± SD of liver ischemia was 54 ± 19 minutes (range, 27‐110; in 7 cases >60 minutes). In the other 21 patients, continuous clamping alone was used (Group B); liver ischemia lasted 36 ± 14minutes (range, 13‐70; in 2 cases >60 minutes). Two patients in Group A (9.5%) and 3 in Group B (14.2%) received blood transfusions. In spite of the longer duration of ischemia (P = .001), patients with IP had lower aspartate aminotransferase (AST; P = .03) and alanine aminotransferase (ALT; P = not significant) at postoperative day 1, with a similar trend at postoperative day 3. This was reconfirmed by multiple regression analysis, which showed that although postoperative transaminases increased with increasing duration of ischemia and of the operation in both groups, the increases were significantly smaller (P < .001) with the use of preconditioning. In conclusion, the present study confirms that IP is safe and effective for liver resection in healthy liver and is also better tolerated than continuous clamping alone for prolonged periods of ischemia. This technique should be preferred to continuous clamping alone in healthy liver. Additional studies are needed to assess the role of IP in cirrhotic liver and to compare IP with intermittent clamping. (Liver Transpl 2004;10:S53–S57.)

Advantages of multidisciplinary management of bile duct injuries occurring during cholecystectomy

BACKGROUND The aim of the present study was to highlight the advantages of treatment of bile duct injury (BDI) occurring during cholecystectomy on the basis of a multidisciplinary cooperation of expert surgeons, radiologists, and endoscopists. METHODS Sixty-six patients had major BDIs or short- or long-term failures of repair. BDI was diagnosed intraoperatively in 27 patients (40.9%) and postoperatively in 39 (59.1%) patients. Among referred patients, 30 had complications from bile leak, 15 from obstructive jaundice, and 20 from recurrent cholangitis. Two patients died from sepsis after delayed referral before repair was attempted. Eleven additional patients had minor BDIs with bile leak both with and without choleperitoneum. RESULTS Of patients with major BDI, surgical repair was performed in 41 (64.1%). Postsurgical morbidity rate was 15.8%, and there was no mortality. The rate of excellent or good results after surgical repair was 78.0% (32 of 41 patients), and this increased to 87.8% (36 of 41 patients) by continuing treatment with stenting in postsurgical strictures. Biliary stenting alone was performed in 23 patients (35.9%), with excellent or good results in 17 (73.9%). More than 200 endoscopic and percutaneous procedures were performed for initial assessment, treatment of sepsis, nonsurgical repair, contribution to repair, and follow-up. Patients with minor BDIs underwent various combinations of surgical and endoscopic or percutaneous treatments, always with good results. CONCLUSIONS A multidisciplinary approach was of paramount importance in many phases of treatment of BDI: initial assessment, treatment of secondary complications, resolution of sepsis, percutaneous stenting before surgical repair, dilatation of strictures after repair, final treatment in patients not repaired surgically, and follow-up.

Severe hypocholesterolemia in surgical patients, sepsis, and critical illness

After surgery, in sepsis and various critical illnesses, factors such as severity of the acute phase response, liver dysfunction, and hemodilution from blood loss have cumulative impacts in decreasing cholesterol; therefore, degree of hypocholesterolemia often reflects severity of illness. The direct correlation between cholesterol and several plasma proteins is mediated by the parallel impact of commonly shared determinants. Cholestasis is associated with a moderation of the degree of hypocholesterolemia. In human sepsis, the poor implications of hypocholesterolemia seem to be aggravated by the simultaneous development of hypertriglyceridemia. Cholesterol and triglyceride levels reflect altered lipoprotein patterns, and the issue is too complex and too poorly understood to be reduced to simple concepts; nevertheless, these simple measurements often represent helpful adjunctive clinical tools.

An Extreme Case of Heyde Syndrome

Background: The Heyde syndrome consists of the association of gastrointestinal bleeding from angiodysplasia with aortic valve stenosis. Its existence has been repeatedly questioned or reconfirmed, and the proposed underlying mechanism is the degradation of a coagulation factor caused by the stenotic valve, which facilitates bleeding from angiodysplastic lesions. Patient Case: We report the case of a patient with severe recurrent small-intestinal bleeding from angiodysplasia, diagnosed by a videocapsule, and aortic valve stenosis. He underwent aortic valve replacement with a bioprosthesis as an extreme life-saving procedure. The operation was followed by the cessation of bleeding for 10 months, then bleeding recurred, emergency bowel resection was needed, and was followed by a chain of events which led to the patient’s death. Conclusion: This case offers an extreme example of the challenging issues still involved in the management of patients with Heyde syndrome.