No abstract

Over the past 4 decades, the surgical techniques of liver transplantation (LTx) have permanently evolved and been modified. Among these, the modified piggyback (MPB) technique by Belghiti offers specific advantages. The objective of this study was to present our single-center experience with the MPB technique in 500 cases. Recipients' perioperative data were prospectively collected and evaluated. Postoperative and specific complications, stay in the intensive and intermediate care unit, and the mortality rate with cause of death were analyzed. Most recipients were classified as Child C (49.1%). For the patients who underwent LTx for the first time, alcoholic (23.9%) and viral (22.2%) cirrhosis and hepatocellular carcinoma (15.1%) were the prevalent indications. The overall median warm ischemia time, anastomosis duration, and operative time were 45, 108, and 320 minutes, respectively. The median intraoperative blood loss was 1500 mL. A venovenous bypass was never needed to maintain hemodynamic stability. Only in a few cases was temporary inferior vena cava clamping necessary. Most prominent surgical complications were hemorrhage, hematoma, and wound dehiscence. Renal failure occurred in 6.2% of patients. The overall median stay in the intensive and intermediate care unit was 14 days. The mortality rates within 30 and 90 days were 6.3% and 13.3%, respectively. No technique-related death occurred. The MPB technique by Belghiti is a feasible and simple LTx technique. The caval flow is preserved during the anhepatic phase, and this minimizes the need for venovenous bypass or portocaval shunt. This technique requires only 1 caval anastomosis, which is easy to perform with a short anhepatic phase. To minimize the risk of outflow obstruction, attention should be paid by doing a wide cavocavostomy cranially to the donor inferior vena cava in a door-lock manner. This technique can be applied in almost all patients undergoing LTx for the first time and liver retransplantation as well. Liver Transpl 15: 466-474, 2009. © 2009 AASLD. Received December 9, 2007 accepted November 15, 2008. Liver transplantation (LTx) is a well-known and widely applied procedure for the treatment of end-stage liver diseases. Over the past 4 decades, the surgical techniques of LTx have permanently evolved and been modified.1 Conventional LTx with total hepatectomy and resection of the recipient retrohepatic inferior vena cava (IVC) and interposition of the donor IVC attached to the new graft was described by Starzl et al. 2 in 1963. In this procedure, during the anhepatic phase, there is a substantial decrease in venous backflow to the heart, causing hemodynamic instability, metabolic alterations, and reduction in renal flow.3 In contrast to the conventional technique, Calne and Williams 4 in 1968 reported a technique that was popularized in 1989 by Tzakis et al. 5 as the so-called piggyback (PB) technique. This technique includes hepatectomy with preservation of the recipient retrohepatic vena cava to maintain the venous return to the heart...

Partial cholecystectomy (PC) is an alternative choice to standard cholecystectomy in situations with increased risk of Calot's components injury. We reported our experience with the patients treated with PC and reviewed the literature. Fifty-four patients with complex acute cholecystitis underwent PC, including conventional partial cholecystectomy (CPC; n = 48) and laparoscopic partial cholecystectomy (LPC; n = 6). The clinical diagnosis was verified by ultrasonography. In addition, we reviewed 1190 published cases (1972–2005) who underwent a “nonconventional” surgery for severe cholecystitis, including cholecystostomy, CPC, or LPC. Review of the literature, including our cases, showed a male:female ratio of 1.3:1. The major operative indication was severe acute cholecystitis. Procedures included cholecystostomy (65.8%) and PC (34.2%). In the follow-up (n = 1190), biliary leak (4.8%), retained stones (4.6%), recurrent symptoms (2.3%), wound infections (1.9%), persistent biliary fistula (0.9%), and prolonged biliary drainage (0.2%) were found, with an overall mortality rate of 9.4 per cent. In 133 patients, because of postoperative complications ( e.g., recurrent symptoms, remaining common bile duct stones, or persistence of bile fistula), reoperation was necessary, including 121 cases (90.1%) of cholecystectomy, whereas the other 11 patients underwent other procedures such as common bile duct exploration or closure of the fistula. The surgical trend for complex acute cholecystitis treatment has been changed from only cholecystostomy to a spectrum of cholecystostomy, CPC, and LPC with the progressive increase of PC. The proportion of the LPC compared with CPC has also increased during recent years. It seems that PC is a safe procedure for treating complicated acute cholecystitis. Whether the indication and need for alternative techniques to standard cholecystectomy is changing should be evaluated in future studies.

Our data suggest that prior to operation, operative mortality can be best predicted by urgency of operation and left ventricle ejection fraction. After performing the operation, prognostic factors include preoperative LVEF < or = 35%, non-elective operation, and prolonged cardiopulmonary bypass time. Further study is required to assess the generalization of our findings to Iranian patients.

The mainstay of treatment for blunt or sharp liver trauma is conservative in 50%-80% of cases. When surgery is indicated, it is demanding and associated with substantial morbidity and mortality. Felt has been used extensively in cardiothoracic and vascular surgery to seal stitches and exposed surfaces. We describe how we used soft polyglycolic acid (PGA) felt to stop bleeding of a lacerated liver in two patients. To our knowledge, this is the first report of PGA felt being used to repair a lacerated liver. The main advantage of this felt lies in its combined effect of compressing the wound edges and applying a sealant that cannot be washed away. We compare soft PGA felt repair with the standard surgical approaches, including compression with packing or wrapping and local hemostasis with hemostatic felt or fibrin glue.