The long QT syndrome affects heart rhythm by prolonging ventricular repolarisation; it is potentially life-threatening since it can evolve into torsades de pointes (a polymorphic ventricular tachycardia) and/or ventricular fibrillation. The case is presented of a 55-year-old liver transplant recipient with a genetically determined long QT syndrome not detected by the standard preoperative cardiological evaluation. It was mild in the immediate post-operative period but developed into torsades de pointes after discharge, probably as a result of therapy. This case was particularly challenging because the first arrhythmic episodes were short and electocardiographically silent, and thus the related faints were thought to have a neurological basis. When the true cause emerged during a monitored episode of torsades de pointes, electric defibrillation was used to restore sinus rhythm and isoproterenol administered to increase heart rate and thus shorten the prolonged QT interval Long-term control was obtained by means of an implantable intracardiac defibrillator. In orthotopic liver transplant recipients with long QT syndrome, particular attention should be given to post-operative therapy as some routinely used drugs can trigger life-threatening ventricular arrhythmias.

Arrhythmias, Cardiac↗

PubMedDate not supplied

Percutaneous cholecystostomy for acute cholecystitis in critically ill patients.

BACKGROUND/AIMS: The aim of this study was to ascertain the therapeutic efficacy of percutaneous cholecystostomy in a selected group of high-risk patients who were physiologically unable to tolerate an open procedure. METHODOLOGY: We reviewed the hospital records of 11 critically ill patients who underwent percutaneous cholecystostomy for acute cholecystitis during the intensive care unit course of major underlying diseases. RESULTS: Percutaneous cholecystostomy was easily performed in all cases (feasibility rate: 100%). No procedure-related death was recorded and minor complications occurred in 2 patients (18%). Percutaneous cholecystostomy led to resolution of the sepsis in all but 1 patient with gangrenous calcolous cholecystitis who required emergent cholecystectomy (success rate: 91%). Percutaneous cholecystostomy was the permanent treatment in all patients with acalcolous cholecystitis. Among patients with calcolous cholecystitis, 4 underwent delayed elective cholecystectomy, 1 required no further treatment, and 2 eventually died from the evolution of their underlying diseases. After a mean follow-up of 25 months (range: 12-32 months), none of the patients managed non-operatively required surgery or re-hospitalization. CONCLUSIONS: Ease of performance, low complication rate, and high success rate make percutaneous cholecystostomy the procedure of choice for critically ill patients with acute cholecystitis. Whenever possible, percutaneous cholecystostomy should be followed by elective cholecystectomy. However, especially in acalcolous cholecystitis, it may constitute the definitive treatment.

Acute Disease↗

PubMedDate not supplied

The dorsal sector of human liver: embryological, anatomical and clinical relevance.

The dorsal liver sector has been recognized as the parenchyma surrounding the vena cava and is quite independent of the remaining liver. It is that part of the organ in which the hepatic portion of the vena cava develops and its venous outflow remains strictly connected with the vena cava by means of multiple, not dissectable effluents as well as with the main hepatic veins. Therefore, this sector is a major shunt between the main hepatic veins and the inferior vena cava, which enlarges and ensures venous drainage for survival in cases of Budd-Chiari syndrome. The dorsal sector consists of two segments: a left one (segment I) corresponding roughly to the caudate lobe and a right one (segment IX) in front and on the right of the vena cava, including the so-called caudate process. The identification of a dorsal liver sector and its detailed anatomy is of primary importance for surgical practice, since cholangiocarcinoma of bile duct hilar confluence extends to the dorsal sector and makes resection of this sector necessary for efficient therapy and due consideration of the pedicles of segment I and IX is required to perform successful hemihepatectomy as well as liver partition for split liver grafting.

Hepatectomy↗

PubMedDate not supplied

Oxidative stress in fulminant hepatic failure: comparison of two pig models with and without liver necrosis.

BACKGROUND/AIMS: No experimental study has clearly demonstrated how liver necrosis worsens the evolution of fulminant hepatic failure. Considering that several types of liver injury are associated with oxidative stress, we decided to measure plasma oxidative markers in two pig models of fulminant hepatic failure without and with liver necrosis. METHODOLOGY: Fulminant hepatic failure was produced in two groups of six pigs each by either total hepatectomy or complete hepatic devascularization. The following parameters were recorded before and during the course of hepatic failure: electrocerebral activity, plasma vitamin E, malondialdehyde and fluorescent protein-aldehyde adducts, total cholesterol, lactate-dehydrogenase, creatine phosphokinase, and ammonium. RESULTS: Despite comparable survival periods, hepatic necrosis was associated with earlier electrocerebral deterioration. Plasma concentration of malondialdehyde and fluorescent protein-aldehyde adducts rose and vitamin E content decreased in both groups. However, while in the group without liver necrosis the rates of cholesterol and vitamin E decay were identical, in the group with liver necrosis cholesterol concentration decreased less than vitamin E concentration, strongly indicating a true intravascular oxidation of vitamin E. Interestingly, in both models the rise of oxidative parameters preceded the development of cell injury. CONCLUSIONS: Oxidative stress, although present in both models, was significantly higher in the group with liver necrosis.

Animals↗

PubMedDate not supplied

[Orthotopic liver transplant in pigs: several variations of the surgical technic].

A technique of orthotopic liver transplantation in the pig is presented. The use of a veno-venous cava-portal-jugular shunt during the anhepatic phase helped by a roller pump with moderate systemic heparinization is described. Technical modifications of arterious and biliary anastomosis are described as well. This technique is not only similar to the procedure applied to man, but it also provides a safe and reproducible experimental model. It has produced good results according to a survival rate equal to 95% at 48 hour and 87.5% at one week in the orthotopic liver transplantation in the pig.

Animals↗

PubMedDate not supplied

Normothermic liver perfusion ex situ: a resuscitation tool for hepatic grafts damaged by warm ischemia.

Ex situ perfusion of the liver has been proposed as a preservation tool for organs to be grafted; in this study, we have investigated whether this procedure could help to reverse damage caused by prolonged ischaemia. The liver was explanted from 6 pigs under general anaesthesia. The organs were subject to warm ischaemia (37 degrees C) for 30 min., cooled in situ by portal infusion of Euro Collins, excised and maintained ischaemic at 4 degrees C for 30 min. more. Afterwards, normothermic perfusion was achieved through the portal vein and hepatic artery for 6 hrs. The parameters measured allowed to follow up the hemodynamic, metabolic and structural response of the liver to the experimental procedure. By electron microscopy, generalized hepatocyte damage was observed after ischaemia, but appeared to be reversed in most cells after ex situ perfusion. Wide areas of sinusoidal walls were devoid of endothelial lining; where this was present, however, it was normal in structure. Kupffer and Ito cells had normal structure whenever observed. Four livers were implanted orthotopically into recipient animals, which were monitored for hemodynamic and biochemical parameters during surgery and followed up to one week. Post mortem examination was performed on the animals which died before this end point. Two of them were alive after one week. Two animals died, one for a perforation of the right hepatic vein and the other for massive necrosis of the left lobe with sepsis and hemorrhage. These results indicate that normothermic ex situ perfusion of the liver has the potential to become a valuable tool to reverse ischaemic injury and monitor organ function before grafting.

Animals↗

PubMedDate not supplied

Exclusively aortic cold flushing for liver procurement from hemodynamically stable donors. An experimental study in the pig.

Liver cooling before grafting is usually achieved by aortic plus portal flushing; exclusively aortic flushing is reserved to hemodynamically unstable or non heart-beating donors. We have compared the effects of "aortic plus portal" (8 cases) and "aortic" (8 cases) cold flushing on the early function of pig liver grafts from hemodynamically stable donors. The time for liver removal (mean +/- standard deviation) was 30.4 +/- 7.1 min. in the "aortic plus portal" and 19.7 +/- 3.3 min. in the "aortic" group (p < 0.01). All the recipients survived for at least 72 hrs; only those of the "aortic plus portal" group showed some degree of primary liver dysfunction; recipient serum aspartate transaminase (AST) was significantly higher in the "aortic plus portal" than the "aortic" group. Since aortic flushing allowed for shorter operation times and was better tolerated than and at least as effective as aortic plus portal flushing, it can be proposed for routine liver procurement even from hemodynamically stable donors.

Animals↗