Twelve patients with multiple vavices were found adjacent to the common bile duct during cholecystectomy and exploration of the common blie duct in the presence of stones. Eleven of them were with cirrhosis. The authors recommend that retrograde cholecystecotomy, or partial cholecystestomy with electrical cauterization of the remaining gallbladder mucosa ,or even cholecystostomy be the optimal selection in the presence of a large venous channel in calot’s triangle. Multiple fine-needle puncture of the bile duct can be performed over the vascullar area until bile is aspirated; extracting the choledocholith from a transduodenal sphincterotomy is another selective maneuver; and if bleeding occurs, suturing for hemostasis can be placed on the connective tissue over both sides of the lacerated vessel instead of the wall of varices.
ObjectiveTo investigate impact of splenectomy plus pericardial devascularization on liver hemodynamics and liver function for liver cirrhosis patients with portal hypertension. MethodsThe internal diameter, maximum velocity, minimum velocity, mean velocity, and flow volume of portal vein and hepatic artery of 42 cases of liver cirrhosis with portal hypertension were measured by Doppler ultrasonic instrument on day 1 before operation and on day 7 after operation. The free portal pressures at different phases (after open abdomen, after splenic artery ligation, after splenectomy, and after devasculanrization) were read from the disposable pressure sensor. Twenty-four healthy people through physical examination were selected as control. Results① The free portal pressure of liver cirrhosis patients with portal hypertension was decreased from (29.12±1.40) mm Hg after open abdomen to (22.71±1.21) mm Hg after splenic artery ligation, and further decreased to (21.32±1.12) mm Hg after splenectomy, but increased to (22.42±1.15) mm Hg after devasculanrization, the difference was statisticly different (all P < 0.01). ② Compared with the healthy people, for the liver cirrhosis patients with portal hypertension, the internal diameter, maximum velocity, minimum velocity, and flow volume of portal vein were significantly enlarged (all P < 0.01), which of hepatic artery were significantly reduced (all P < 0.01) on day 1 before operation; On day 7 after operation, the internal diameter of portal vein was significantly reduced (P < 0.01), the maximum velocity, minimum velocity, and mean velocity of portal vein were significantly enlarged (all P < 0.01), but the internal diameter of hepatic artery was significantly reduced (P < 0.01), the maximum velocity, minimum velocity, mean velocity, and flow volume of hepatic artery were significantly enlarged (all P < 0.01). For the liver cirrhosis patients with portal hypertension, compared with the values on day 1 before operation, the internal diameter and the flow volume of portal vein were significantly reduced (all P < 0.01) on day 7 after operation; the internal diameter, maximum velocity, minimum velocity, mean velocity, and flow volume of hepatic artery were significantly enlarged (all P < 0.01) on day 7 after operation. ③ The Child-Pugh classification of liver function between before and after surgery had no significant difference (χ2=1.050, P > 0.05). ④ No death and no hepatic encephalopathy occurred, no thrombosis of splenic vein or portal vein was observed on day 7 after surgery. Conclusionsplenectomy plus pericardial devascularization could decrease portal vein pressure and reduce blood flow of portal vein, while increase blood flow of hepatic artery, it doesn't affect liver function.
Objective To introduce the clinical significance and pathophysiologic aspects of the circulatory and cardiac complications in terminal stage cirrhosis. Methods Recently relevant literatures were reviewed and summarized. Results Haemodynamic changes in cirrhosis arose on the basis of combined humoral and nervous dysregulation, with abnormalities in cardiovascular regulation, volume distribution and cardiac performance. Conclusion Comprehending the mechanisms of cardiovascular complications will contribute a lot for the treatment of terminal stage cirrhosis.
ObjectivesTo systematically review the efficacy of laparoscopic hepatectomy (LH) and open hepatectomy (OH) on the hepatocellular carcinoma patients with cirrhosis.MethodsPubMed, EMbase, Web of Science, The Cochrane Library, CBM, CNKI, WanFang Data and VIP databases were searched online to collect the cohort studies of LHvs.OH on hepatocellular carcinoma patients with cirrhosis from inception to November 31st, 2017. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies, then, meta-analysis was performed by using RevMan 5.3 software.ResultsA total of 15 cohort studies involving 1 720 patients were included. The results of meta-analysis showed that: compared with OH, LH had less blood loss (MD=–226.94, 95%CI –339.87 to –114.01, P<0.000 1), lower transfusion rate (OR=0.48, 95%CI 0.27 to 0.83,P=0.009), less occurrence of complications (OR=0.32, 95%CI 0.23 to 0.45, P<0.000 01), shorter postoperative hospital stay (MD=–3.66, 95%CI –5.19 to –2.14,P<0.000 01), lower mortality rate (OR=0.47, 95%CI 0.24 to 0.92,P=0.03), wider surgical margin (OR=0.78, 95%CI 0.20 to 1.36, P=0.009), higher 1, 3 and 5-year survival rate (OR=2.47, 95%CI 1.35 to 4.51, P=0.003; OR=1.62, 95%CI 1.11 to 2.36, P=0.01; OR=1.58, 95%CI 1.19 to 2.10, P=0.002, respectively) and 1-year disease free survival rate (OR=1.69, 95%CI=1.20 to 2.39, P=0.003). There were no significant differences in operation time (MD=28.64, 95%CI –7.53 to 64.82, P=0.12), tumor size (MD=–0.37, 95%CI –0.75 to 0.02, P=0.06), 3-year disease free survival rate (OR=1.14, 95%CI 0.86 to 1.51, P=0.36) and 5-year disease free survival rate (OR=0.99, 95%CI 0.77 to 1.28, P=0.97) between the two groups.ConclusionsThe perioperation and short-term postoperative outcomes of LH are significant in HCC patients with cirrhosis, and which have good long-term prognosis. Due to limited quality and quantity of the included studies, more high quality studies are required to verify above conclusions.
Objective To explore the clinical value of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid （Gd-EOB-DTPA） enhanced magnetic resonance （MR） imaging for cirrhosis-related nodules. Methods Nineteen patients who were suspected cirrhosis with lesions of liver were prospectively included for Gd-EOB-DTPA enhanced MR imaging test between Nov. 2011 and Jan. 2013. The hepatobiliary phase （HBP） images were taken in 20 minutes after agents’ injection. The images were diagnosed independently in two groups： group A， including the plain phase and dynamic phase images； group B， including plain phase， dynamic phase， and HBP phase images. The signal intensity （SI） of lesions in HBP images， background liver SI， and background noise standard deviation were measured by using a circular region of interest， then the lesion signal to noise ratio （SNR） and contrast signal to noise ratio （CNR） were calculated. Results Nineteen patients had 25 tumors in all， including 18 hepatocelluar carcinoma （HCC） and 7 regenerative nodule （RN） or dysplastic nodule （DN）， with the diameter ranged from 0.6 cm to 3.2 cm （average 1.3 cm） . Sixteen HCC manifested hypo SI relative to the normal liver， while 2 HCC manifested hyper SI at HBP. Five HCC had cystic necrosis with the necrotic area， and there were no enhancement in artery phase， while performed flocculent enhancement at HBP. Six RN or DN showed hyper SI while another 1 showed iso SI to background liver at HBP. The diagnostic accuracy rates of group A and group B were 80.0% （20/25） and 92.0% （23/25）. SNR of RN or DN at HBP was 132.90±17.21， and of HCC was 114.35±19.27， while the CNR of RN or DN was 19.47±8.20， and of HCC was 112.15±33.52. Conclusion Gd-EOB-DTPA enhanced MR imaging can improve the diagnosis capacity of cirrhosis-related nodules， so as to develop more accurate and reasonable treatment options.
ObjectiveTo study the application value of multi-slice CT portography (MSCTP) in the diagnosis and evaluation of esophageal and gastric varices (EGV) caused by cirrhosis. MethodsPatients with cirrhosis diagnosed between September 2009 and December 2012 were screened in this study. And the consistency of MSCTP and digestive endoscopy in the diagnosis, classification and grading of EGV in cirrhosis were evaluated. ResultsA total of 78 patients were included in this study, and there were 55 patients with EGV diagnosed by endoscopy, including 35, 16 and 4 patients with GOV1, GOV2 and IGV1 respectively by Satin type standards; and the number of patients with mild, moderate and severe EGV by general grading standards was 2, 15, and 37, respectively. In this cohort, the findings of MSCTP examination also showed that 58 patients had EGV, including 36, 17, 4 and 1 patients with GOV1, GOV2, IGV1 and IGV2 by Satin type standards; and the number of patients with grade I,Ⅱ andⅢ EGV by Kim grading standards was 5, 16 and 37, respectively. Statistical analysis showed that there was a high consistency between endoscopy and MSCTP in the diagnosis (Kappa=0.712, P=0.000), typing (Kappa=0.732, P=0.000) or grading (Kappa=0.863, P=0.000) of EGV. ConclusionMSCTP has a high application value in the diagnosis and severity evaluation of EGV in patients with cirrhosis.
Objective To approach whether the postoperative recovery processes of the living donors and hepaticpatients after right hepatectomy is similar. Methods The clinical data of consecutive cases from 2009 to 2010 in our liver transplantation center was retrospectively analyzed， including 40 cases who donated the right lobe without the middlehepatic vein （living donor liver transpalntation-donor group， abbreviated as LDLT-D group） and 80 hepatic patients forright hepatectomy， in which 40 cases were hepatic patients without cirrhosis （liver disease-noncirrhosis group， abbreviatedas LD-NC group） and 40 cases were hepatic patients with cirrhosis （liver disease-with cirrhosis group， abbreviated asLD-WC group）. Preoperative liver function and general clinical data， intraoperative blood loss and transfusion， postoper-ative liver function， and complications were statistically analyzed in this study. Results The preoperative parameters of three groups were comparable. LDLT-D group experienced more intraoperative bleeding than LD-NC group 〔（765±411） mL vs. （584±242） mL， P=0.008〕， and was similar to LD-WC group 〔（666±224） mL， P=0.136〕. However， the average amount of blood transfusion products was similar among the 3 groups （P=0.108）. The levels of total bilirubin and INR of LDLT-D group were higher than LD-NC group and LD-WC group on the first and third day after operation （P＜0.05）. The levels of ALT and AST of LD-WC group were higher than LDLT-D group and LD-NC group （P＜0.05）. The overall postoperative surgical morbidity incidence of LDLT-D group， LD-NC group， and LD-WC group were 30.0%（12/40）， 27.5% （11/40）， and 37.5% （15/40） respectively， and were not statistically significant （P=0.606）. However， the ClavienⅢcomplication rate of LD-WC group was higher than LDLT-D group and LD-NC group 〔27.5% （11/40） vs. 7.5%（3/40） and 10.0% （4/40）， P=0.024〕. Conclusions Liver function of living donors is injured more seriously during the early postoperative period. The total complication rates after right hepatectomy are similar among the living liver donation and hepatic patients with or without cirrhosis. However， the serious complication rate of cirrhotic liver recipients is higher than living donors and patients without cirrhosis.
Objective To evaluate hepatic functional reserve and investigate the clinical value through measuring hepatic functional blood flow by D-sorbitol clearance rate and liver volume changes with CT. Methods Ninety-two patients with portal hypertension due to posthepatic cirrhosis were investigated (cirrhosis group). Twenty healthy volunteers were used as control group. D-sorbitol was infused intravenously at a steady rate. Blood and urine were collected and recorded once before infusion and at 120, 150 and 180 min after infusion, and their concentrations of D-sorbitol were examined by enzyme spectrophotometry. From pharmacokinetic equations, hepatic clearance rate of D-sorbitol (CLH) was calculated. Total hepatic blood flow (QTOTAL) was measured by Doppler sonography, intrahepatic shunt rate (RINS) was obtained. The liver volume change rate was obtained in patients with cirrhosis through the abdominal CT scan. The relations among the indicators, Child classification and postoperative complications were studied. Results After D-sorbitol was infused intravenously for 120 min, the plasma concentration was at the steady state. The plasma concentration was (0.189±0.05) mmol/L in control group and (0.358±0.06) mmol/L in cirrhosis group (Plt;0.01). CLH was (1 248.3±210.5) ml/min in control group and (812.7±112.4) ml/min in cirrhosis group (Plt;0.01). Although QTOTAL in cirrhosis group was declined, compared with the control group 〔(1 280.6±131.4) ml/min vs. (1 362.4±126.9) ml/min〕, Pgt;0.05, while RINS increased markedly 〔(36.54±10.65)% vs. (8.37±3.32)%, Plt;0.01〕. In cirrhosis group, the mean liver volume of Child A, B and C patients were (1 057±249) cm3, (851±148) cm3 and (663±77) cm3 respectively. There were significant differences among the mean liver volume (Plt;0.05). The liver volume was significantly smaller in Child B and C patients than that in Child A (Plt;0.05, Plt;0.01). When CLH was less than 600 ml/min, and liver volume decreased by more than 40%, postoperative complications increased significantly. CLH and the liver volume change rate were not in absolutely good accordance with Child classification. Conclusion The hepatic clearance of D-sorbitol and the quantitative determination of the liver volume with CT can be an objective evaluation of the liver metabolism of the inherent capacity and the hepatic functional blood flow changes. It contributes to the correct understanding of the hepatic functional reserve and lay the foundation for determining a reasonable treatment plan, surgical methods and time.
ObjectiveTo observe the efficacy of dense ligation and non-dense ligation in treating severe esophageal varices. MethodsSixty cirrhotic patients with severe esophageal varices treated in our hospital between January 2009 and October 2011 were divided into two groups based on their operative ways.Group A was the dense ligation group including 32 patients,and group B was non-dense ligation group in which there were 28 patients.Six-shooter multi-band ligators were used for endoscopy.If the number of loop ligature collar was larger than six,it was regarded as dense ligation and the rest was regarded as non-dense ligation. ResultsIn group A,one month after first ligature,six patients were basically cured,24 were greatly improved,and two did not respond to the treatment,with a total effective rate of 93.8% and an average ligation of 1.94 times.In group B,one month after first ligature,one patient was basically cured,24 were greatly improved,and three did not respond to the treatment,with a total effective rate of 89.3% and an average ligation of 2.75 times. ConclusionDense ligation is a safe,reliable and effective approach for esophageal varices,which brings about a high disappearance rate of esophageal varices and reduced ligation frequency.
Cirrhosis is an end stage of condition of various liver diseases with specific clinic and pathologic process. The incidence is high and it seriously affects the quality of life for patients. In order to obtain the best prevention and treatment for end-stage cirrhosis, we searched The Cochrane Library (Issue 3, 2004), SUMsearch (1981~2004) and MEDLINE (1981~2004), and identified 15 systematic reviews and 65 randomized controlled trials. We critically assessed the quality of studies. The results showed the principal treatment of cirrhosis was to deal with complications, such as the prevention and treatment of variceal bleeding, the treatment of ascites etc.