Challenging epidural analgesia as the preferred route for postoperative analgesia in liver surgery

Here is my highlight from the July issue of HPB.

Good post-operative pain control is a central part of recovery after surgery. ERAS programmes, in particular, have heavily promoted the use of epidural analgesia for abdominal surgery. This probably owes something to the roots of ERAS in colorectal surgery however many of the studies on which these recommendations were made are outdated and relate to very different operative procedures. Epidural analgesia is known to offer good dynamic and static pain control but does have drawbacks in terms of hypotension, immobility and rare but life threatening complications of epidural abscess or epidural haematoma. The liver surgery group in Basingstoke have been one of the major centres pioneering local anaesthetic wound catheter infiltration of upper abdominal wounds combined with patient controlled opiates as an alternative to epidural analgesia. In this edition of HPB, Wong-Lu-Hing and colleagues report the Basingstoke experience of wound catheter analgesia after liver resection in a retrospective comparative cohort analysis including a small group of contemporaneous patients receiving epidural analgesia (analgesic selection based on surgeon preference). Although not a randomized trial they clearly show some important benefits from wound catheter analgesia. These were equivalency of analgesia combined with reduced overall complication rates, reduced opiate requirement and a shorter length of stay compared with patients receiving epidural analgesia. Further refinements to local anaesthetic protocols such as additional transversus abdominis plane blocks may improve the effectiveness of this analgesic approach and it seems certain that this will remain an effective alternative if not a preferred alternative to epidural analgesia in liver surgery.

SINGLE-USE-EPIDURAL-NEEDLE

Postoperative pain control using continuous i.m. bupivacaine infusion plus patient-controlled analgesia compared with epidural analgesia after major hepatectomy (pages 601–609)
Edgar M. Wong-Lun-Hing, Ronald M. van Dam, Fenella K. S. Welsh, John K. G. Wells, Timothy G. John, Adrian B. Cresswell, Cornelis H. C. Dejong and Myrddin Rees
Article first published online: 23 OCT 2013 | DOI: 10.1111/hpb.12183

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What drives altruism in living liver donors – a risk-decision analysis?

Here is my editorial highlight from the June edition of HPB the official journal of the IHPBA, A-HPBA and EA-HPBA

Living organ donation is unusual in medical practice because for the donor there is a significant health risk incurred through donation which is only offset by a sense of well being from helping another human who is in clinical need. In his contemporary analysis of Darwinist theory ‘The Selfish Gene’, Richard Dawkins explains altruism in terms of protecting lines of inheritance and in this analysis he questions the illogicality of altruistic acts outside of this framework.

This issue of HPB contains an analysis by Molinari and colleagues of the drivers for living liver donors to donate. The paper acknowledges the balance between risk and benefit and there is a several log order increased risk of serious harm or death to otherwise healthy individuals compared with for example living kidney donation. Molinari et al. did find that altruism wasn’t given completely freely. Apart from the obvious need for a biological or close emotional relationship between donor and recipient, donors had an expectation of reasonable prospects of survival for the recipient at one and 3 years. Donors were likely to donate if there was an expectation that the recipient would have a protracted wait for a cadaveric graft.

Interestingly donors were prepared to accept a greater level of risk than clinicians. This study provides an important insight into the decision-making processes of potential liver donors. The authors conclude that living donors are ‘risk takers’, while this may be true, the risks are calculated and the donors in this study seemed well equipped to make the decisions underpinning the risk.

Based on the following original article in the June issue of HPB

Live liver donors’ risk thresholds: risking a life to save a life (pages 560–574) Michele Molinari, Jacob Matz, Sarah DeCoutere, Karim El-Tawil, Bassam Abu-Wasel and Valerie KeoughArticle first published online: 20 NOV 2013 | DOI: 10.1111/hpb.12192
transplant copy
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Segmental volumes analysis of the liver: neither segments nor patients are equal

Here is my editorial highlight from the May issue of HPB the official journal of the IHPBA, AHPBA, E-AHPBA.

The technology used to measure liver volume continues to improve and with it our understanding of liver anatomy in relation to surgery. In this month’s issue of HPB, Kokudo’s group from Tokyo present an analysis of single segment volumes of the livers of more than 100 patients. This detailed analysis was performed based on portal perfusion patterns to define segmental anatomy. The authors have produced a volume ‘road map’ of the liver demonstrating typical segmental volumes for each of the eight liver segments. On the face of it this information is extremely valuable for the surgeon, however, what this study also shows is the very major variation in segmental volumes that occur between different patients. An example of this is given by the data for segment VIII. This segment had the largest mean volume of functional liver accounting for on average 26% of total liver volume (TLV), however this ranged between individual patients from only 11% to as much as 38% of TLV. The message here is that individual patient assessment remains critical to pre-operative planning. Among the liver surgical community opinion is divided over how much anatomical planning is required in patients. There are clearly patients who may have precarious liver function or difficultly placed tumours where careful anatomical staging and volume analysis are imperative to successful outcome. Equally there are many others where standard anatomical resection is unlikely to compromise either resection margins or functional capacity of the liver. In those cases where planning is required, measurement of portal perfusion territories seems to offer the best basis for anatomical staging and volume assessment.

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Three-dimensional volumetry in 107 normal livers reveals clinically relevant inter-segment variation in size (pages 439–447)

Yoshihiro Mise, Shouichi Satou, Junichi Shindoh, Claudius Conrad, Taku Aoki, Kiyoshi Hasegawa, Yasuhiko Sugawara and Norihiro Kokudo

 

Article first published online: 26 AUG 2013 | DOI: 10.1111/hpb.12157

 

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Reach for the endoscope or the wire but not the knife for biliary stricture after living donor liver transplantation

Here is my highlight from the April issue of HPB. This focuses on an excellent paper describing non-operative intervention for biliary stricture complicating living donor liver transplantation.

  1. Gun Hyung Na,
  2. Dong Goo Kim*,
  3. Ho Joong Choi,
  4. Jae Hyun Han,
  5. Tae Ho Hong and
  6. Young Kyoung You

 

Re-operating on patients after liver transplantation is never a rewarding experience and can be extremely dangerous. When a patient has undergone a living donor liver transplant (LDLT) the stakes are even higher as there may be no opportunity for deceased donor rescue in case of vascular complications. Biliary stricture is common after living donor liver transplant and can be difficult to manage. Many LDLT programmes are small and do not have the case experience to manage such complications with complete confidence. It is really important therefore to learn from centres like St Mary’s Hospital, Seoul, Korea who have a vast experience. In this edition of HPB this centre reports its approach to managing 160 biliary strictures occurring in almost 500 patients who received a right lobe LDLT with a duct to duct anastomosis. The greatest single risk for development of biliary stricture was a post transplant bile leak and urgent surgery was also associated with greater risk. The authors have shown that using a variety of techniques such as ERCP, PTBD or combinations of these procedures it is possible to manage almost all such strictures. The avoidance of major revisional surgery is undoubtedly to the advantage of these patients. The number of failures was remarkably small but sepsis combined with biliary stricture was associated with a small number of deaths. The value of these interventional approaches is shown by the observation that overall survival was not significantly different between patients with and without a biliary stricture and in both cases this exceeded 80% at 5 years.

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Subtotal hepatectomy and whole graft auxiliary transplantation for acetaminophen-associated acute liver failure

Here is my highlight from the February edition of the journal HPB the official journal of the IHPBA

The legend of Prometheus that first documented the extraordinary capacity of the liver to regenerate is familiar to liver surgeons. Major liver resection relies on this regenerative capacity of the liver to restore volume and function after surgery. Acetominophen toxicity (paracetomol) causes widespread hepatocyte necrosis but we know from animal models and human survivors that complete hepatic regeneration is possible. The time to allow liver regeneration is unfortunately too slow for many patients who will either die or require urgent liver transplantation to avoid the consequences of severe acute liver failure. In this edition of HPB, the Leeds group present a series of patients who have been managed in an extraordinary way. These patients who all had acute liver failure and who met criteria for urgent transplantation (which equates to a near 90% mortality without transplantation),underwent a right trisegmentectomy, preserving segments 1,2 & 3 and then underwent a reduced or split graft right lobe auxiliary liver transplant. After recovering from the procedure a HIDA scan was performed to test regeneration and function in the native remnant liver and then immunosuppression was gradually withdrawn over a 6–12 month period resulting in atrophy of the transplanted liver and compensatory hypertrophy of the native liver. This innovative approach to liver transplantation has allowed a resurrection of what by many would be considered an irretrievably damaged liver. The avoidance of the need for long term immunosuppression in what is usually a young population may contribute in part to the better 5 year survival in patients. This is however, a technical tour de force and it will be interesting to see if other centres are persuaded to give it a go.

Prometheus

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Bidloo’s liver: the story behind the story

We recently wrote an essay called Govert Bidloo’s liver; human symmetry reflected.” The story behind this essay is quite unusual and interesting. I thought I would just tell the story behind the story for interest without repeating the whole thing but there is a link to the article at the bottom of this blog.

Bidloo first came into my consciousness  when one of our research fellows in Edinburgh, Rachel Guest, sent around an email encouraging a few of our research group to have a look at an item made public by the Vassar College library in New York. The Vassar library has a great reputation and to mark the one millionth acquisition  to their collection they decided to purchase a very special book. The book that they chose was one of a few existing copies of an anatomical atlas created by the Dutch anatomist Govert Bidloo. The atlas, which is titled Anatomia humana corporis, was published in 1685 and is particularly famous because of the quality of the imagery indeed it was the first anatomical atlas to use the novel (for the time) high resolution copperplate printing technique. Due to the significance of this book in their collection, Vassar made the book available on the internet, the first time it was accessible to the general public in this way. As I flicked through the pages and being a liver specialist, I was looking for a plate that showed a representation of the liver. When I found it  (plate 37) I can remember looking at the image with absolute horror. The cause of my alarm was that the liver was the wrong way around! If you had only ever seen a right hand drive car it was the equivalent to seeing a car with the steering wheel on the opposite side, such an obvious anomaly. I immediately assumed that it had been noted previously but some preliminary researches showed that this did not appear to be the case other than a small footnote by William Cowper of whom more later. I made the rest of the group aware and we considered the explanation? Could the liver have been drawn the wrong way around? Could it have been that the cadaver on whom the illustration was based had situs inversus where there is a complete transposition of organs from left to right in the abdominal cavity? This is an extraordinarily rare condition and was therefore extremely unlikely. It then occurred to us that the most likely explanation was a printing error. In copperplate printing an illustration in the correct orientation has to be copied in reverse or mirror image on to a plate so that when it is printed the image is in the correct orientation.

Rachel went to work investigating and discovered that the BIU Sante’ institute in Paris actually had images of all of the original drawings made by the artist Gerard de Lairesse from which the copperplates had been made. We were then able to compare the original drawings with the plates to check for orientation. We looked through the atlas and actually found other plates, apart from the liver, where the image was reversed but in most of these reversal of the image did not change it’s meaning, since much of human anatomy is symmetrical. The liver of course is an exception. We then realised that the atlas had been famously plagiarised with an English version written by William Cowper which added drama and intrigue to the story.

To verify our assumptions and investigations we really needed an expert to comment on the historical accuracy of our observations. We particularly needed someone with expertise in the Dutch Golden Age, anatomical illustrations and printing techniques of the time. This seemed a very tall order, however, we found one such expert, Daniel Margocsy, who lectures in history in Hunter College New York. After an email approach, Daniel expressed his interest, corrected us on some points and embellished others and added colour and richness to our understanding of the period. Rachel crafted a beautiful manuscript which we tweaked and adjusted until we were all happy and then, more in hope than expectation, we submitted it to the Lancet for publication. After a long delay we all assumed that the manuscript had been consigned to recycling however a probing email revealed quite the opposite and the journal were prepared to publish the article. You can read it here http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60248-8/fulltext

bidloo copy

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Liver transplantation for cholangiocarcinoma- a hammer to crack a very tough nut?

I am woefully behind in posting new material on my blog for which I apologise. Everyone else’s deadlines seem to have taken over mine. Nevertheless it is a new year and I will resolve to spend more time and effort posting here.

Here is my highlight from the january edition of the journal HPB on quite a controversial area.

This month’s HPB sees the much awaited publication of the Dublin experience of liver transplantation for cholangiocarcinoma. The group followed the previously published Mayo protocol of treating patients with cholangiocarcinoma with brachytherapy, external beam radiotherapy and 5-fluorouracil. Patients who had no radiological evidence of disease progression underwent laparotomy or laparoscopy and negative lymph node biopsy and ifthere was no evidence of peritoneal dissemination were listed for transplantation. 27 patients entered the protocol and 20 progressed to transplantation, 6 of whom required a simultaneous pancreaticoduodenectomy. Hospital mortality was 4/20 or 20% but thereafter survival was reasonable giving overall survival estimates of approximately 75% at 1 year and 60% at 3 years. Liver transplantation for cholangiocarcinoma is a major undertaking but in oncological terms the results are very good. The present series found best outcomes in patients with a complete pathological response to neoadjuvant therapy although it could be argued that such patients may have experienced prolonged survival without transplantation. The authors highlight the difficulty in determining the presence or absence of viable tumour in the liver after chemoradiotherapy. The Dublin series did not replicate the excellent results previously published in similarly selected patients from the Mayo Clinic, however, there is increasing interest in the use of liver transplantation for primary and metastatic disease including cholangiocarcinoma, neuroendocrine and colorectal metastases. The availability of organs for transplantation remains a limiting factor but carefully designed studies such as this, strengthen the case for extending indications for liver transplantation at least within the context of a clinical trial.

Neoadjuvant chemoradiotherapy followed by liver transplantation for unresectable cholangiocarcinoma: a single-centre national experience (pages 91–98)

Sophie Duignan, Donal Maguire, Chamarajanagar S. Ravichand, Justin Geoghegan, Emir Hoti, David Fennelly, John Armstrong, Kathy Rock, Helen Mohan and Oscar Traynor

Article first published online: 18 APR 2013 | DOI: 10.1111/hpb.12082

 

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