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Steatosis as a Risk Factor in Liver Surgery

Reeta Vetelinen, MD, Arlne van Vliet, PhD, Dirk J. Gouma, MD, and Thomas M. van Gulik, MD Author information Copyright and License information This article has been cited by other articles in PMC. Go to:

Abstract
Objective:
To review present knowledge of the influence of hepatic steatosis in liver surgery as derived from experimental and clinical studies.

Summary Background Data:


Hepatic steatosis is the most common chronic liver disease in the Western world, and it is associated with obesity, diabetes, and metabolic syndrome. Fatty accumulation affects hepatocyte homeostasis and potentially impairs recovery of steatotic livers after resection. This is reflected clinically in increased mortality and morbidity after liver resection in patients with any grade of steatosis. Because of the epidemic increase of obesity, hepatic steatosis will play an even more significant role in liver surgery.

Methods:
A literature review was performed using MEDLINE and key words related to experimental and clinical studies concerning steatosis.

Results:
Experimental studies show the increased vulnerability of steatotic livers to various insults, attributed to underlying metabolic and pathologic derangements induced by fatty accumulation. In clinical studies, the severity of steatosis has an important impact on patient outcome and mortality. Even the mildest form of steatosis increases the risk of postoperative complications.

Conclusions:
Hepatic steatosis is a major factor determining patient outcome after surgery. Further research is needed to clarify the clinical relevance of all forms and severity grades of steatosis for patient outcome. Standardized grading and diagnostic methods need to be used in future clinical trials to be able to compare outcomes of different studies.

Gastroduodenal artery aneurysm, diagnosis, clinical presentation and management: a concise review
Nicholas Habib, Samer Hassan, Rafik Abdou, Estelle Torbey, Homam Alkaied, Theodore Maniatis, Basem Azab, Michel Chalhoub and Kassem Harris* .

Abstract
Gastroduodenal artery (GDA) aneurysms are rare but a potentially fatal condition if rupture occurs. They represent about 1.5% of all visceral artery (VAA) aneurysms and are divided into true and pseudoaneurysms depending on the etiologic factors underlying their development. Atherosclerosis and pancreatitis are the two most common risk factors. Making the diagnosis can be complex and often requires the use of Computed Tomography and angiography. The later adds the advantage of being a therapeutic option to prevent or stop bleeding. If this fails, surgery is still regarded as the standard for accomplishing a definite treatment.

Vascular clamping in liver surgery: physiology, indications and techniques


Elie K Chouillard1*, Andrew A Gumbs2 and Daniel Cherqui3

* Corresponding author: Elie K Chouillard chouillard@yahoo.com

Abstract
This article reviews the historical evolution of hepatic vascular clamping and their indications. The anatomic basis for partial and complete vascular clamping will be discussed, as will the rationales of continuous and intermittent vascular clamping. Specific techniques discussed and described include inflow clamping (Pringle maneuver, extrahepatic selective clamping and intraglissonian clamping) and outflow clamping (total vascular exclusion, hepatic vascular exclusion with preservation of caval flow). The fundamental role of a low Central Venous Pressure during open and laparoscopic hepatectomy is described, as is the difference in their intra-operative measurements. The biological basis for ischemic preconditioning will be elucidated. Although the potential dangers of vascular clamping and the development of modern coagulation devices question the need for systemic clamping; the preoperative factors and unforseen intra-operative events that mandate the use of hepatic vascular clamping will be highlighted.

The etiology and prevention of feeding intolerance paralytic ileus revisiting an old concept
Gerald Moss

Correspondence: Gerald Moss gerald_moss@mossmed.com

Abstract
Gastro-intestinal (G-I) motility is impaired ("paralytic ileus") after abdominal surgery. Premature feeding attempts delay recovery by inducing "feeding intolerance," especially abdominal distention that compromises respiration. Controlled studies (e.g., from Sloan-Kettering Memorial Hospital) have lead to recommendations that patients not be fed soon after major abdominal surgery to avoid this complication. We postulate that when total fluid inflow of feedings, digestive secretions, and swallowed air outstrip peristaltic outflow from the feeding site, fluid accumulates. This localized stagnation triggers G-I vagal reflexes that further slow the already sluggish gut, leading to generalized abdominal distention. Similarly, vagal cardiovascular reflexes in susceptible subjects could account for the 1:1,000 incidence of unexplained bowel necrosis reported with enteral feeding. We re-evaluated our data, which supports this postulated mechanism for the induction of "feeding intolerance." We had focused our efforts on postoperative enteral nutrition, with the largest reported series of immediate feeding of at least 100 kcal/hour after major surgery. We found that this complication can be avoided consistently by monitoring inflow versus peristaltic outflow, immediately removing any potential excess from the feeding site. We fed intraduodenally immediately following "open" surgery for 31 colectomy and 160 consecutive cholecystectomy patients. The duodenum was aspirated simultaneously just proximal to the feeding site, efficiently removing all swallowed air and excess feedings. To

salvage digestive secretions, the degassed aspirate was re-introduced manually (and later automatically) via a separate feeding channel. Hourly assays were performed for nitrogen balance, serum amino acids, and for the presence of removed feedings in the aspirate. The colectomy patients had X-ray motility studies initiated 5 17 hours after surgery. Clinically normal motility and absorption resumed within two hours. Fed BaSO4 traversed secure anastomoses, to exit in bowel movements within 2448 hours of colectomy. All patients were in positive protein balance within 2 24 hours, with elevated serum amino acids levels and without adverse G-I effects. Limiting inflow to match peristaltic outflow from the feeding site consistently prevented "feeding intolerance." These patients received immediate full enteral nutrition, with the most rapid resolution of postoperative paralytic ileus, to date.

Intra aortic balloon pump: literature review of risk factors related to complications of the intraaortic balloon pump
Haralabos Parissis*, Alan Soo and Bassel Al-Alao

* Corresponding author: Haralabos Parissis hparissis@yahoo.co.uk

Abstract
The increasing use of the intra aortic balloon pump is attributed to the relatively easy percutaneous insertion and the low threshold of use over the past few years, especially in elderly patients with multi-vessel diseases and an affected ejection fraction. Unfortunately, the clinical assessment of the complications associated to the use of this supporting device, underestimates the frequency of such complications. This report has looked at the current literature and attempt to identify incremental risk factors related to the development of adverse effects during support with an intaaortic balloon pump. The paper concludes that in contrary to early reports, newer studies have shown that complications following intraaortic balloon pump treatment, is decreasing. Moreover the literature suggests that the thrombosis and infective complications are relevant to the duration of the pump treatment, while the ischemic problems of the limbs are mostly linked to the atherosclerotic status of the common femoral artery.
Keywords: intra aortic balloon pump; IABP; complications by the use of intra aortic balloon pump

A review of bronchiolitis obliterans syndrome and therapeutic strategies


Don Hayes .

Abstract
Lung transplantation is an important treatment option for patients with advanced lung disease. Survival rates for lung transplant recipients have improved; however, the major obstacle limiting better survival is bronchiolitis obliterans syndrome (BOS). In the last decade, survival after lung retransplantation has improved for transplant recipients with BOS. This manuscript reviews BOS along with the current therapeutic strategies, including recent outcomes for lung retransplantation.

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