A modified radiofrequency-assisted approach to right hemihepatectomy

AIMS

To evaluate a modified radiofrequency-assisted approach to right hemihepatectomy.

METHODS

Following a bilateral subcostal incision and intraoperative ultrasonography, the liver was mobilized in the standard manner, and a cholecystectomy was performed. The portal vein was isolated, encircled, and ligated. After demarcating the liver parenchyma, coagulation necrosis was achieved using a radiofrequency-assisted device along the line demarcated for transecting the liver parenchyma. The actual transection of the liver parenchyma and the right portal vein was done using a surgical scalpel along the radiofrequency-coagulated line. The right hepatic vein was coagulated using the radiofrequency sealer or by stitching in the resection plane. The hepatic artery was not dissected and was sealed together with the bile ducts in the resection plane using the radiofrequency instrument. The hepatic vein was not divided.

RESULTS

Between July 2005 and July 2006, a total of 49 liver resections were performed in our unit. Of these, the radiofrequency-assisted technique was used in 33 cases with metastatic disease; 14 of these cases had right hemihepatectomies, including 2 repeat resections. The mean operation time was 180min (range, 120-240min), and the average blood transfusion was 0.14U (range, 0-2U). Postoperatively, there was no morbidity, such as bleeding, infection, or biliary fistula, related to the liver resection technique, and no patients died as a result of surgery. In 8 out of the 14 right hemihepatectomies, a right-sided pleural effusion was observed; 3 of them required evacuation.

CONCLUSION

This paper describes a modified radiofrequency-assisted hemihepatectomy, which allows one to obtain control of the portal blood flow going into the resected part of liver. The modified approach appears to be simple and safe.

[Radiofrequency assisted liver resection in non-cirhotic liver. Initial clinical experience]

AIM OF THE STUDY

To evaluate the radiofrequency assisted liver resection using Habib sealer (RITA Medical System, Inc., Mountain View, CA).

METHODS

The operation time, liver transection time, transfusion units used, and postoperative complications were recorded in a prospective way.

RESULTS

22 liver resections were performed between July 2005 and December 2005, 15 of them were done using radiofrequency technique. Twelve anatomical resections and three non-anatomical resections were performed in total. The mean operation time equalled 155 (120-240) minutes. An average of 0.6 (0-4) transfusion units was used. In 13 of the 15 operations, which represent 86% of the patients, no transfusions were used. Postoperatively, no major bleeding from the resection plane was noted and no biliary fistula was observed.

CONCLUSIONS

Radiofrequncy assisted liver resection is a safe technique with the major benefit of minimal perioperative blood lost.

A rare cause of mediastinal expansion with a massive pleural effusion

The authors present a case of a 53 year old woman, who was admitted to hospital because of an unusual cause of massive pleural effusion. During diagnostic examination the mediastinal propagation of the pancreatic pseudocyst was discovered as a complication of the chronic calcifying pancreatitis. The patient was operated on and the pseudocyst was resolved by Roux-en-Y cystjejunostomy. The diagnostics and treatment of this unusual pancreatic pseudocyst spreading is discussed.

[Amoebic liver abscess--case report]

The authors present a case of a young male, who suffered with extraintestinal form of amoebiasis-amoebic liver abscesses. The patient traveled to India two month before symptoms onset. The diagnosis based on ultrasonography and computed tomography was definetely confirmed by serological examination. Metronidazol treatment was given initially, followed by percutaneous drainage. Open surgical tretment was indicated due to failure of percutaneous treatment. Patient was discharged home in a good condition one month after surgery. At this time patient is doing well eight months after surgery.

[Diagnosis of spontaneous arteriovenous fistula complicating aortoiliac aneurysm using spiral CT. Report of 3 cases]

Acute spontaneous arterio-venous fistula complicating atherosclerotic abdominal aortic aneurysm (AAA) is rare. This life-threatening setting is observed in 1-2% of all AAAs and 2-4% of ruptured of AAAs. The triad of abdominal or lower back pain, pulsatile abdominal mass, and continual abdominal machinery-like bruit is seen only in half of cases. Currently, CT angiography is a noninvasive technique which enables a rapid and exact preoperative diagnosis. The authors describe three cases of aortoiliac aneurysm complicated by an acute arteriovenous fistula which were diagnosed using spiral CT.

[Puncture gastrostomy in oncologic patients]

Puncture gastrostomies--percutaneous endoscopic gastrostomy and radiologically assisted gastrostomy--are minimally invasive methods to ensure an approach for the administration of enteral nutrition. These methods replaced the insertion of tubes during surgery (surgical gastrostomy). Percutaneous endoscopic gastrostomy (PEG) is inserted by means of a gastroscope, usually by the pull method, radiologically assisted gastrostomy (RAG) is implemented after insufflation of the stomach by a thin tube directly across the abdominal wall by the push method. In oncological patients it is preferable to administer enteral nutrition via puncture gastrostomy in case of obstruction of the upper portion of the digestive tract (oral cavity, larynx, pharynx, oesophagus), in deglutition disorders caused by cerebral tumours or in order to improve the nutritional status of patients with tumour cachexia. In the authors group in 1995-2000 a total of 53 puncture gastrostomies were made in 53 patients, 37 men and 16 women, mean age 62 years (32-94 years, incl. 38 PEG and 15 RAG. In 30 patients the reason was obstruction of the upper digestive tract, in 11 patients impaired swallowing associated with a cerebral tumour and in 12 patients the cause was tumourous cachexia. Puncture gastrostomies are well tolerated by the attending staff and patients, in oncology they can be used for administration of enteral nutrition under hospital and domiciary conditions.

[Recurrent adhesive ileus after surgical treatment of ovarian teratoma, malposition of an intrauterine device and dolichosigmoid--case report] ]

A 30-year-old woman was operated for ovarian teratoma and repeatedly for adhesive ileus during 1995-1999. A partial left ovarectomy, extirpation of an intrauterine device (IUD) in malposition (greater omentum) and appendectomy were performed during the first operation. Early adhesive ileus developed on the fourth postoperative day. Adhesectomy was performed in the region of the terminal jejunum. A new adhesive ileus developed after twenty seven months when patient underwent laparoscopy for gynaecological problems with conversion to laparotomy because of greater adhesions intraperitoneally another adhesectomy was performed. During the next eleven months new adhesive obstructions of the bowel developed and a third operation had to be performed incl. resection of the dolichosigmoideum on account of chronic problems during defaecation. A special tube as a intraluminal splint was inserted as prophylaxis of mechanical ileus in the postoperative period. But during next thirteen months subileous conditions and mechanical ileus developed again (up to now). The picture of intraperitoneal conditions was disastrous: almost total fibrotic changes allowed only partial adhesectomy. The passage through bowel is limited and is restricted to dietetic and medicamentous preparations. This case-report demonstrates postoperative adhesions a very old and very serious problem at the beginning of the third millennium.

[Immunologic follow-up of HIV-positive patients. C3, C4 complement components during HIV infection]

Investigations of the authors' patients with HIV infection revealed marked changes in the C3 and C4 components of complement. Of 61 investigated patients with HIV infection only 23 patients (37.7%) had values of the C3 component at the level recorded in controls. Values of the C4 component comparable with the control group were recorded in 24 patients (39.3%). From figures 1 and 2 it apparent that in the investigated group there is a striking hypercomplementaemia of both components, as compared with hypocomplementaemia.

[Immunologic study in HIV-positive patients. Hypergammaglobulinemia in HIV infection]

In all groups of patients--HIV, ARC, AIDS carriers--elevated serum concentration of IgG, IgA, IgM were found. In the group of HIV carriers a significant increase of the serum concentration of IgG at the 5% level was observed and of IgM at the 1% level. In patients with ARC a significant increase of IgG and IgA was found at the 5% level and of IgM at the 1% level. In patients with AIDS significantly raised IgG values at the 5% level were recorded, and of IgA and IgM at the 1% level. In IgA a permanent increase of values occurs in AIDS carriers. In the AIDS stage 86% of the patients have values higher than mean +/- SD of controls. In all three stages of HIV infection a rise of concentrations of circulating immunocomplexes was observed (p < 0.01). The highest levels were recorded in patients with AIDS. In none of the patients the presence of antinuclear antibodies was detected. The authors discuss also possible causes of hypergammaglobulinaemia in HIV infection.

[Immunologic monitoring of HIV-positive patients. T-lymphocytes and their subpopulations in various clinical stages of HIV infection]

The authors evaluate T-lymphocytes and their sub-populations, the immunoregulating index and white cell haemogram in patients in different clinical stages of HIV infection. They discuss the importance of the investigated parameters, in particular the number of CD4+ T-lymphocytes in the peripheral blood stream as a laboratory criterium for the development of the disease. From the paper ensues that evaluation of the number of CD4+ T-lymphocytes in the peripheral blood stream can help to estimate the time of the primary infection and the selection of an optimal time for starting azidothymidine therapy, but alone it does not suffice for establishment of the prognosis of the development of the HIV infection.

[The significance of endoscopic retrograde cholangiopancreatography in the diagnosis of pancreatic injuries in children]

The condition of the main pancreatic duct determines very probably in a decisive way the fate of posttraumatic pancreatic pseudocysts and acute pancreatic injuries. Endoscopic retrograde cholangiopancreatography is the only diagnostic method which makes possible to evaluate the condition of this duct. The authors performed ERCP in three children, in two of them an internal drainage of the pseudocyst was carried out on account of verified ductal rupture. In the third girl, after evidence of an intact main pancreatic duct, conservative therapy was successfully applied. In the discussion the authors summarize data from the literature regarding the use of ERCP in the preoperative diagnosis of posttraumatic pancreatic pseudocysts and acute pancreatic injuries. The authors consider ERCP a method which renders the diagnosis of posttraumatic pancreatic pseudocysts and acute pancreatic injuries more accurate.

[Submicroscopic structure of amniotic fluid cells]

Submicroscopic examination of amniotic fluid cells in the second trimester of pregnancy revealed that the cells are from the morphological aspect a very heterogeneous population, comprising vital and degenerated cells the ultrastructure of which rules out the possibility of cultivation of cells of foetal as well as of maternal origin. As to degenerated cells, the authors identified circular cells with a granular cytoplasm and nucleus originating from the urogenital or digestive tract of the foetus. Furthermore cells with a process and segmented or fragmented pycnotic nucleus derived from granulocytes and macrophages of maternal origin. Also circular cells of the periderm with short microvilli and advanced regressive changes of the nucleus and cytoplasm are degenerated. Among non-vital elements also anuclear completely keratinized cells of the stratum corneum originating from the skin of the maternal abdomen can be included. As to vital elements, the amniotic fluid contains cells of the amniotic ectoderm which are large, have numerous microvilli, a dense margin and a network of filaments in the cytoplasm. They are the most numerous cells. Other vital elements in amniotic fluid include granulocytes and macrophages with a typical ratio of lyzosomes. Both are considered elements of maternal origin. Maternal origin is assumed also in fibroblasts which along with collagen particles may penetrate into the aspirating needle. From the results ensues that the cells in amniotic fluid are not a homogeneous population of unequivocally foetal origin and that a better technique of collection of samples and cultivation must be developed.

[Morphologic changes in the heart atrium in frogs after extinction of current due to suction electrode induced damage]

In biological model experiments in frog heart morphological substrate was observed in current extinction due to damage under suction electrode. After short-term suction discharge monophase recording disappeared without demonstrable myocyte ultrastructure changes by means of reparation ad integrum. Monophase recording spontaneously disappeared in distinct changes of monocyte structure with enlarged spaces in between myofibrils, with breakdown of cristae in mitochondria and with dilatation of tubules and cisternae of the endoplasmic reticulum. This tissue disintegration leads to demarcation and forming of new cellular surfaces on the border with the healthy tissue so that the damaged area turns into a mere electric conductor.

Some immunological characteristics of subjects suffering from frequent herpes simplex virus recrudescences

Some parameters of specific and non-specific immunity were tested in a group of 44 subjects suffering from frequent herpes simplex type 1 (HSV-1) or herpes simplex type 2 (HSV-2) recrudescences. The tests performed included determinations of (i) HSV complement-independent and complement-dependent neutralizing antibodies, (ii) antibodies to glycoprotein C of HSV-1 and glycoprotein G of HSV-2, (iii) antibodies to viral capsid and early antigens of Epstein-Barr virus, (iv) antibodies to tetanus toxoid, (v) serum levels of IgM, IgG, IgA, transferrin, prealbumin and C'3 and C'4 components of complement, (vi) active and total T lymphocytes, (vii) phagocyting activity of polymorphonuclear neutrophils, eosinophils and mononuclear cells, (viii) skin reactivity to tuberculin, toxoplasmin, candidin, tetanus and diphtheria toxoids. In the patients the following deviations from the control groups were noted: (i) Antibody levels to homotypic but not to heterotypic HSV were enhanced, (ii) serum IgM levels were elevated, (iii) percentages and numbers of active and total T lymphocytes were decreased, (iv) phagocyting activity of neutrophils was depressed but that of eosinophils was increased.

[Treatment of pyogenic liver abscesses using percutaneous transparietal drainage]

Authors present their own experience with the method of external transparietal drainage of pyogenic hepatic abscesses. It is both effective and available method with minimum complications if performed in time. Mortality rate is much lower than in surgical drainage. Percutaneous drainage of hepatic abscesses depends on the possibility of their diagnostics by means of ultrasonography or computer tomography and access to special instruments.