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Orthotopic transplantation of the human liver
388
INTERNATIONAL
Technically, for right hepatic lobectomy, a generous thoraco-abdominal incision is preferred. Particular emphasis is placed on careful ligation of the many hepatic veins running from the liver into the inferior vena cava, since injury to them may result in uncontrollable hemorrhage or massive air embolism. Transection of the liver parenchyma can be accomplished by incising the liver capsule, and division of the parenchyma with a blunt instrument. Blood vessels and bile ducts are clamped and individually ligated. Mattress sutures of chromic catgut through liver parenchyma may be employed if significant bleeding occurs. It is suggested that gastrostomy should be a routine addition to the operation, Left hepatic lobectomy is performed through either a vertical or transverse abdominal incision. Resection can be accomplished by through and through mattress sutures if the tumor is located far laterally in the left lobe, or by anatomic dissection of the hilum if the tumor is more centrally located. Blood loss should be monitored during the operation and hypothermia is of value if the circulation to the opposite Iobe of the liver is temporarily occluded. Postoperatively, careful monitoring of carbohydrate metabolism, albumin requireserum bilirubin levels and the ments, prothrombin time is essential. Since hepatomas are resistant to radiation therapy and chemotherapy, resection offers the only chance for cure. Seven of the 25 patients in the literature were living and apparently well at the time of reporting, which was one to 6 years following operation-A. M. Salzberg. ORTEIOTOPIC
HUMAN Surg.
TRANSPLANTATION OF THE LIVER. T. E. Starzl, et al. Ann.
168: 392415
( September),
1968.
The authors report their experiences with hepatic homotransplantation in 7 children ranging from 13 months to 16 years of age. Five children had extra hepatic biliary atresia and 2 had liver cell carcinoma. Donors were chosen on the basis of histocompatibility analysis, as well as compatibility of red blood cell types. Donor livers were cooled by extracorporeal hypothermic perfusion or infusion of cold balanced electrolyte solutions through
ABSTRACI’S
OF PEDIATRIC
SURGERY
the superior mesenteric vein. The authors emphasize the preservation of the donor superior mesenteric artery until it could be excluded as a source of hepatic arterial supply. After excision the organ was perfused in a hyperbaric chamber. The recipient operation included in order: the suprahepatic vena caval anastamosis, infrahepatic vena caval anastamosis, hepatic arterial and portal venous anastamosis. Biliary tract drainage is provided by cholecystoduodenostomy. Antibiotics included methicillin and an agent effective against gram-negative organisms. Immunosuppressives included azothroprine, prednisone, and heterolygous antilymphocyte globulin. Four patients died from 60 to 186 days postoperatively, and 3 are alive with excellent liver functions 33 to 269 days. The authors discuss in detail postoperative complications, hepatic function, and pathologic changes in those patients who expired.-K. M. Schneider.
ARFLHENOBLASTOMA OF THE OVARY IN AN ADOLESCENT.R. M. Ehrlich, M. J. Lynch, and B. Shandling. Canad. 99:1146-1142 (December),
Med. 1968.
Ass.
J.
A 13-year-old gir1 with recent onset of virilization is reported. No abdominal or pelvic masses were palpable. The fact that urinary 17-ketosteroids were only partially suppressed by dexamethazone suggested an ovarian rather than an adrenocortical source of the excess androgen: At laparotomy a 6 cm. mass involving the left ovary was discovered and removed. At 8 weeks postoperatively, the patient had an improved appearance and urinary 17-ketosteroid excretion was normal.-C. C. Ferguson. GENITOUIUNARY
TRACT
CADAVERIC RENAL TRANSPLANTATION. An ANALYSIS OF 65 CASES. P. Pletka, S. L. Cohen, B. Hulme, J. R. KenyMz, K. Owen, A. E. Thompson, M. Snell, J. F. Mowbray, K. A. Porter, D. A. Leigh, and W. S. Peart. Lancet 1: l-5 (January 4), 1969. The authors review 65 patients, including 2 in the pediatric age group, who received 76 cadaveric renal transplants. Thirty-two are still alive, including 22 at more than one year. Of the latter (plus 5 survivors from an earlier series) renal function is steady in 18 and deteriorating in 9.
INTERNATIONAL
Technically, for right hepatic lobectomy, a generous thoraco-abdominal incision is preferred. Particular emphasis is placed on careful ligation of the many hepatic veins running from the liver into the inferior vena cava, since injury to them may result in uncontrollable hemorrhage or massive air embolism. Transection of the liver parenchyma can be accomplished by incising the liver capsule, and division of the parenchyma with a blunt instrument. Blood vessels and bile ducts are clamped and individually ligated. Mattress sutures of chromic catgut through liver parenchyma may be employed if significant bleeding occurs. It is suggested that gastrostomy should be a routine addition to the operation, Left hepatic lobectomy is performed through either a vertical or transverse abdominal incision. Resection can be accomplished by through and through mattress sutures if the tumor is located far laterally in the left lobe, or by anatomic dissection of the hilum if the tumor is more centrally located. Blood loss should be monitored during the operation and hypothermia is of value if the circulation to the opposite Iobe of the liver is temporarily occluded. Postoperatively, careful monitoring of carbohydrate metabolism, albumin requireserum bilirubin levels and the ments, prothrombin time is essential. Since hepatomas are resistant to radiation therapy and chemotherapy, resection offers the only chance for cure. Seven of the 25 patients in the literature were living and apparently well at the time of reporting, which was one to 6 years following operation-A. M. Salzberg. ORTEIOTOPIC
HUMAN Surg.
TRANSPLANTATION OF THE LIVER. T. E. Starzl, et al. Ann.
168: 392415
( September),
1968.
The authors report their experiences with hepatic homotransplantation in 7 children ranging from 13 months to 16 years of age. Five children had extra hepatic biliary atresia and 2 had liver cell carcinoma. Donors were chosen on the basis of histocompatibility analysis, as well as compatibility of red blood cell types. Donor livers were cooled by extracorporeal hypothermic perfusion or infusion of cold balanced electrolyte solutions through
ABSTRACI’S
OF PEDIATRIC
SURGERY
the superior mesenteric vein. The authors emphasize the preservation of the donor superior mesenteric artery until it could be excluded as a source of hepatic arterial supply. After excision the organ was perfused in a hyperbaric chamber. The recipient operation included in order: the suprahepatic vena caval anastamosis, infrahepatic vena caval anastamosis, hepatic arterial and portal venous anastamosis. Biliary tract drainage is provided by cholecystoduodenostomy. Antibiotics included methicillin and an agent effective against gram-negative organisms. Immunosuppressives included azothroprine, prednisone, and heterolygous antilymphocyte globulin. Four patients died from 60 to 186 days postoperatively, and 3 are alive with excellent liver functions 33 to 269 days. The authors discuss in detail postoperative complications, hepatic function, and pathologic changes in those patients who expired.-K. M. Schneider.
ARFLHENOBLASTOMA OF THE OVARY IN AN ADOLESCENT.R. M. Ehrlich, M. J. Lynch, and B. Shandling. Canad. 99:1146-1142 (December),
Med. 1968.
Ass.
J.
A 13-year-old gir1 with recent onset of virilization is reported. No abdominal or pelvic masses were palpable. The fact that urinary 17-ketosteroids were only partially suppressed by dexamethazone suggested an ovarian rather than an adrenocortical source of the excess androgen: At laparotomy a 6 cm. mass involving the left ovary was discovered and removed. At 8 weeks postoperatively, the patient had an improved appearance and urinary 17-ketosteroid excretion was normal.-C. C. Ferguson. GENITOUIUNARY
TRACT
CADAVERIC RENAL TRANSPLANTATION. An ANALYSIS OF 65 CASES. P. Pletka, S. L. Cohen, B. Hulme, J. R. KenyMz, K. Owen, A. E. Thompson, M. Snell, J. F. Mowbray, K. A. Porter, D. A. Leigh, and W. S. Peart. Lancet 1: l-5 (January 4), 1969. The authors review 65 patients, including 2 in the pediatric age group, who received 76 cadaveric renal transplants. Thirty-two are still alive, including 22 at more than one year. Of the latter (plus 5 survivors from an earlier series) renal function is steady in 18 and deteriorating in 9.