Henricus BAC Stockmann, Coen A Hiemstra, et al (The Department of Surgery, University Hospital Dijkzigt and Erasmus University, Rotterdam, The Netherlands)
Extracorporeal Perfusion for the Treatment of Acute Liver Failure
Annals of Surgery 231(4), 460-470.
Because of the life-threatening complications of Acute Liver Failure, 75% die within a few days of onset. At present there is no satisfactory treatment for this condition except liver transplantation. Though this operation has a 70-80%, 5 year survival rate, there is a shortage of donor organs. Therefore several temporary liver assisting therapies have been developed. This article reviews the various forms of temporary liver support as well as the immunologic and metabolic developments toward a solution for this problem.
The authors conclude that renewed interest has developed in the various methods of temporary liver support from the early haemodialysis, haemofiltration, exchange transfusion, plasma exchange, resin haemoperfusion and charcoal perfusion to the bioartificial liver, extra corporeal liver assist device and extracorporeal whole liver perfusion. The immunologic implications and metabolic developments have also been discussed.
The clinical improvement though temporary, allows life to be prolonged. New developments in the field of genetic modification and tissue engineering await clinical application in the near future.
Bjorg Tilde Fevang, Jonas Fevang, Lodve Stangeland, et al (The Department of Surgery, Haukeland University Hospital, University of Bergen, Bergen, Norway)
Complications and Death After Surgical Treatment of Small Bowel Obstruction.
A 35-Year Institutional Experience
Annals of Surgery, April 2000, 231(4), 529-537.
This study was conducted to determine the factors influencing complications and mortality after surgery for small bowel obstruction using multifactorial statistical methods.
877 patients who underwent 1007 operations for small bowel obstruction (SBO) between 1961 and 1995 were studied retrospectively. Patients with paralytic ileus, intussusception and abdominal cancer were excluded.
43% were caused by adhesions and 41% were due to incarcerated hernias. Whereas the incidence of adhesions has increased with time but the incidence of hernias has dropped. The proportion of women has increased over the years. The overall incidence of viable strangulation was 26% and non-viable strangulation was 16%. 62% had a previous laparotomy like gynecological surgery, appendectomies and a small percentage had GI surgery done on them.
30% of patients had co-morbidity in the form of cardiovascular disease, lung disease, diabetes and central nervous system disease.
The results showed that old age co-morbidity, non-viable strangulation, and a delay in treatment for more than 24 hours were associated with an increased mortality. The rate of non-viable strangulation increased with age. The need for repeat surgery also increased morbidity and mortality. The overall death and complication rates decreased from 1961 to 1995.
Ronnie Tung-Ping Poon, Sheung-Tat Fan, et al (The Centre of Liver Diseases, Department of Surgery and Pathology, The University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China).
Significance of Resection Margin in Hepatectomy for Hepatocellular Carcinoma.
A Critical Reappraisal
Annals of Surgery, April 2000, 231(4), 544-551.
This study evaluates the influence of the width and the histologic involvement of the resection margin on postoperative recurrence after resection of hepatocellular carcinoma (HCC).
288 patients with macroscopically complete resection of HCC were divided into 2 groups with narrow (< 1cm) or wide (³ 1cm) resection margins, and compared.
The recurrence rates were similar between the two groups and they were similar in other clinicopathologic variables.
Most recurrences occurred away from the resection margin or at multiple sites. Those who had histologically involved resection margin or venous tumour emboli or multisatellites had higher recurrence rates then those without.
However, a positive histologic margin was not a significant risk factor for recurrence by multivariate analysis. The tumour stage and the perioperative transfusion were the only independent risk factor.
They conclude that the width of the resection margin did not influence the post-operative recurrence rate after hepatectomy for HCC. Most recurrences were considered to arise from venous dissemination.