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The purpose of this study is to report the variations in hepatic arterial supply of a mixed population of organ donors in which the anatomy was individually examined during the bench surgery, and patients who underwent a selective angiogram of the celiac axis and superior mesenteric artery. We reviewed the donor forms and/or angiograms of 701 patients. The donor forms were completed personally by one of the authors, while all the radiology images were obtained through studies performed by one single radiologist. The arterial anatomy was anomalous in 296 out of 701 cases with an overall incidence of hepatic artery anomalies of 42.22%. In this paper we describe previously unreported arterial anomalies of the hepatic artery, collecting the second largest series of hepatic artery anatomical variations of the English literature. This anatomical update can be useful for transplant and general surgeons, as well as vascular radiologists.

Malignant fibrous histiocytoma is a soft tissue sarcoma of mesenchymal origin. It can rarely present as a primary gallbladder tumor with only five cases having been reported to date in the English literature. Here we report the sixth documented case of malignant fibrous histiocytoma of the gallbladder, and we review all other cases reported. The outcome of the visceral sarcomas is poor when compared with tumors arising from the soft tissues. The treatment of primary malignant fibrous histiocytomas of the gallbladder is surgery. However, tumor recurrence is the norm even if wide clean margins are obtained. In contrast to tumors arising from the extremities the role of adjuvant radiotherapy and chemotherapy is less clear in the case of retroperitoneal and visceral sarcomas. Our patient is still alive and free of disease 46 weeks after surgery. The fact that this is the longest survival reported to date underscores the dismal prognosis of this disease.

The technique of a liver autograft in the pig has three advantages: (1) It provides an excellent training model of liver transplantation, (2) it provides an experimental model for cancer research, and (3) it is more economical than liver allotransplant. We describe a facilitated technique of liver autograft, which can be employed to develop experimental models without the use of a biopump. Mean blood arterial pressure, heart rate, pH, and lactates were tested during the liver grafting and at the end of the procedure in pigs that underwent autografting of the liver and compared with pigs that underwent an orthotopic liver allotransplantation. The cell damage was assessed in the same two groups of animals by monitoring aspartate aminotransferase (AST) and alanine aminotransferase (ALT) blood levels and with the MEGX test, 15 min after the beginning of reperfusion. The surgical procedure may be divided into three parts: hepatectomy, side-to-side portocaval shunt with passive caval-jugular shunt, and reimplantation. This procedure could have a clinical indication for otherwise unresectable liver tumors.

The aims of this investigation are: 1) to assess the function of the hepatocyte in transplanted porcine liver, immediately after reperfusion, by monitoring both LFTs and the MEGX levels; 2) to search for correlation between MEGX and LFTS, in an effort to evaluate the metabolic mechanisms occurring in the early liver transplantation revascularization phase. The MEGX test was found to be less than 50 micrograms/ml in all the recipients and all the LFTS tested have been reported to be out the normal range. Furthermore our data has shown a statistically significant correlationship between the MEGX values and those of alkaline phosphatase and prothrombin and a highly significant correlationship with cholinesterase.

Secondary tumors of the liver from primary tumors arising in organs of the head and neck are rarely diagnosed during the patient's lifetime, though they should be suspected. A case of parotid mucoepidermoid carcinoma with liver metastases, treated by liver resection, is described. The clinical features and biological behavior of this secondary tumor are similar to those of the rare primary mucoepidermoid carcinoma of the liver. This case is unique because it is such a very rare occurrence.

Liver echinococcosis is an endemic disease in some areas of the world like Middle East and is a serious problem both from social-economic and clinical-therapeutical stand-points in other areas like Mediterranean regions. We report our experience on hepatic echinococcosis diagnosis and treatment over a 20-year period. In this retrospective study we have reviewed 89 patients affected by hepatic hydatidosis who underwent surgery in our Unit (between November 1975 and October 1995). Patients were divided into two groups: group A including 65 patients (30 males and 35 females) operated on between 1975 and 1988 and group B including 24 patients (11 males and 13 females) operated on between 1989 and 1995. Main outcome measures reported were recurrence of echinococcosis, association with surgical procedure, complications, diagnostic trial. In group A we performed 41 marsupializations, 20 subtotal pericystectomies and 4 total pericystectomies; while 14 total pericystectomies and 10 liver resections were performed in group B. Postoperative hospital stay was of 30 days for group A patients and of 18 days for group B. A single death occurred in group A. Recurrences occurred in group A only (11 cases equal to 17%) and were treated with total pericystectomies (8 cases) and liver resections (3 cases). Our study shows the development of diagnostic procedures trial during the 20-year period and the different surgical approaches between the two groups. Nevertheless we believe that surgical procedures should be tailored to each patient avoid H high surgical risk due to the benign nature of the disease.

Portacaval shunt with interposition of 6 mm H-graft of PTFE is a real partial shunt. In this experimental study, the operation has been well tolerated and has been compared with 8 mm H-graft and direct "vein to vein" portacaval shunt. Intraoperative data show that 6 mm is the ideal diameter for a portacaval shunt to prompt an experimental model based on partial decompression of portal bed in animals in this size.

Oxygen free-radical reperfusion products play a critical role in postischemic tissues injury. In this study we used deferoxamine, an iron ligand that seems to inhibit hydroxyl radicals production, in renal normothermic acute ischemia in the rat. Our results demonstrated a significant protective effect of deferoxamine on kidneys subjected to normothermic acute ischemia.

In this experimental study the authors report an experience in the evaluation of hepatic blood flow with intraoperative echo-Doppler during orthotopic liver transplantation and side-to-side or end-to-side portacaval shunt. Doppler ultrasonography studied the flow of portal vein, hepatic artery and inferior vena cava before the recipient hepatectomy, and after reperfusion during liver grafting. Furthermore echo-Doppler of the portal system was performed to confirm portacaval shunt efficacy. Usually intraoperative Doppler ultrasonography may give informations about the patency of the shunt and regarding the development of early hepatic artery thrombosis during liver transplantation, but often unclear is the exact evaluation of the velocity of the blood flow through the liver. Further experimental studies and clinical evaluations need to find safe parameters and markers of vascular alteration using this superior diagnostic procedure.

It has been reported, in the recent literature, that fifteen minutes lidocaine-MEGX (monoethylglycinexylidide) test can also be used in case of acute hepatic failure because in these conditions the test allows a rapid evaluation of the hepatic damage, uneffected by te infusion of liquid or fresh plasma which can alter conventional laboratory parameters. The Authors have demonstrated, in a experimental model, the unreliability of the lidocaine-MEGX test as measure of functional hepatic damage in the early stages of an acute liver failure. The slight decrease of the rate of the MEGX test in these animals submitted to one-stage hepatic devascularization suggests that the hepatic failure is not so early detected by this specific liver function test. Accordingly, the 15' MEGX test should not be used as isolated discriminatory measure to detect an early hepatic failure following fulminant hepatitis or an early hepatic insufficiency as a result of extensive liver resection.

A facilitated technique of porcine donor hepatectomy is reported underlying the possibility to make an easy procedure without in situ portal perfusion, so other abdominal organs supplied by superior mesenteric system can be harvested at the same time. The viability of those grafts procured without in situ portal perfusion has been compared with an other group of livers harvested with in situ aortic and portal flushing. The evaluation of the histology and early graft function two hours after riperfusion has shown no differences between both groups.

Endoscopy and radiological investigations, using contrast medium, have been the only available methods in the study of urethral pathology. In this article we have suggested using the technique of urethral ultrasound to visual the urethra before using ultrasound. Our study included 16 patients ranging in age from 23 to 82 years with urethral stenosis already diagnosed or suspected on the basis of symptomatology at referral. When the urethra is distended by the gel it appears to be a black tube with a smooth surface which does not produce echoes. The gel determines the compression of the corpus spongiosa which is normally a rigid, inelastic tissue because of the prevalence of collagen fibres. The possibility of adding further gel inside the urethra to confirm the echo results even after the introduction of a standard quantity at the start of the procedure we feel is the second definitive advantage with this method. In fact it was possible in our survey by increasing the quantity of gel to currently differentiate between complete and partial stenosis. No patient suffered from a temperature or using retention after this test. No-one complained of discomfort during the procedure. The anterior and posterior urethra are separated by the external sphincter. Radiological images are better obtained from the anterior urethra than the posterior urethra. We have found that ultrasound is a reliable and possibly superior method. With this method it is possible to obtain more information about the peri-urethral scar tissue, the length of the stenosis, the degree of spongy fibrosis therefore allowing more precise urethrotomies to be performed. The test is comfortable for the patient, simple and reduces the risk of radiation. The disadvantages of this method are that the posterior urethra is poorly visualized. Examination of the posterior urethra using a trans-scrotal approach have given poor results. It is necessary to avoid excessive pressure on the probe which could give false positive results. To eliminate this problem it is necessary to scan longitudinally and transversally within the lumen at various stages of filling. It is important to note that air present within the gel could simulate urethral calculi, if the image has been frozen. During the test the presence of air helps to evaluate the degree of flow through the stenosis.

An experience is reported with solitary necrotic nodules of the liver, rare benign lesions described for the first time in 1983. Two patients were referred to our department because of the presence of hepatic lesions that radiology showed to be suspected secondary liver tumors. At laparotomy, both patients underwent liver resections because the lesions appeared to be malignant. Subsequent histological examination of the surgical specimens revealed that both were solitary necrotic nodules of the liver. These were the only solitary necrotic nodules found in a total of 840 operations carried out in our department since October 1981. Although they are completely benign, solitary necrotic nodules have a similar ultrasound pattern and radiological features to metastases and have been described in the literature during the follow-up of patients with other tumors. Uncertainty remains as to the etiology of these lesions, which still represent an occasional finding in liver surgery.

A group of 36 patients, observed between 1985 and 1995, with primary carcinoma localized in the medium and distal third of biliary tract is presented. Sixteen patients (44.4%) have undergone radical surgical treatment and the other twenty (55.5%) received a palliative procedure with an average survival of 33.7 months and 8.8 months for the first and second group respectively. The actual location of the tumor was obtained by ERCP and its final stadiation occurred during operation mainly trough intraoperative ultrasonography. The preoperative biliary drainage led to a better postoperative outcome and to a better prognosis. In the case where the tumor was localized only in the third medium of the biliary tract, a limited resection of the biliary tract with Roux's reconstruction was carried out. Otherwise in the cases where the lesion was localized in the border between the medium and distal third and in the distal tract, a duodenocephalopancreasectomy was performed. Even if this is a group of lesions with a poor prognosis, when it is possible to have an early diagnosis it is necessary to carry out an aggressive surgical treatment considering the higher percentage of survival compared to any other palliative procedure.

We have studied the levels of the MEGX test in a heterogeneous group of 50 patients with chronic liver disease and with hepatic tumours and we have compared it with the routine LFTS commonly used to assess liver function and with the Child-Pugh Classification system. Our results demonstrate a statistically significant relationship between MEGX levels and prothrombin levels, and between MEGX and alkaline phosphatase and a highly significant relationship between MEGX and cholinesterase. In the group of patients with cirrhosis we found a statistically significant difference amongst the MEGX levels in the 3 classes of the Child Classification system. The MEGX test is a good index in evaluating hepatic function and it is also quick and easy to perform and capable of determining residual liver function. The test can also be used for preoperative assessment in patients with focal hepatic lesions, especially in those with a previous history of cirrhosis, and in patients with functional hepatic disease.

It's well known that patients was acquired immunodeficiency syndrome (AIDS) can develop various kinds of hepatobiliopancreatic diseases, for causes related to AIDS and for causes not related to HIV infection. The authors describe a case to their attention due to a suspected acute pancreatitis. The patient presented with abdominal pain, increased serum alkaline phosphatase and amylase levels. Serological test and stool concentration didn't show any opportunistic infection (Cytomegalovirus, Cryptosporidium). Abdominal ultrasonography showed enlargement of the head of the pancreas, gallbladder with biliary sludge, and a little dilatation of the biliary tree. The patient didn't feel better despite the medical treatment, so considering the probability of the migration of calculus, the patient underwent cholecystectomy. After the operation the patient felt better quickly. This case confirms the presence in HIV patients of pancreatitis for causes unrelated to AIDS like cholelithiasis as we showed, alcoholism, hypercalcemia, and the importance of an opportune surgical treatment that was resolutive.

The authors report on their experience with a case of liver hemangioma; after exploring the trade-off between the risk and expected benefit from resection of giant liver hemangioma, because of this searched literature for studies of with rupture. Controversy persists regarding management of these lesions with the development of non invasive modalities treatment, such as use of embolizing agents; Elective surgery can be performed, such as treatment resective, according to the size of the hemangioma.

The chronic alitiasic cholecystopathy represents an unusual trmorphological disease not well defined in literature; it is characterized by a chronic alteration of gallbladder without gallstones. The authors present a retrospective study on a group of 21 patients having undergone cholecistectomy from January 1992 to January 1995. The choice for the surgical treatment was made on the basis of blind gallbladder after i.v. cholangiography, and cholecystography and/or tickning of the gallbladder wall performed through ultrasonography, in patients with hystory of biliary pains not responding to the pharmacological therapy. The removed gallbladder has been histologically examined, observing the absence of gallstone and the presence of chronic inflammation of the gallbladder wall. The c.a.c. is a pathology whose etiopatogenesis is yet discussed, some authors assert in fact that on its basis there are functional symptoms. Although in the past these kinds of disease were considered functional disorders this study revealed that in some cases there are organic problems and that the surgical treatment is necessary.

A retrospective study was carried out of 522 elective liver resections to determine the impact of blood transfusion on the immediate postoperative outcome and on long-term survival. The number of liver resections without transfusion has increased in recent years, as a result of improvement in surgical technique with less blood loss during operation and more careful choice of the timing of transfusion. In resections carried out in the past 5 years, the indication for intraoperative transfusion was restricted and the decision was made jointly by the surgeon and anaesthetist, and in any case only if the haematocrit was below 25 per cent. Of resections carried out in the past 2 years, 59 per cent did not require intraoperative transfusion. Postoperative deaths and complications were related to blood transfusion, particularly in patients with cirrhosis, in whom stepwise logistic regression analysis showed that transfusion was the only factor that correlated significantly with complications. Transfusion also affected the long-term survival of patients operated on for hepatocellular carcinoma and colorectal carcinoma metastases in univariate analysis and was the only factor shown by multivariate analysis to correlate with survival for hepatocellular carcinoma in patients with cirrhosis.

The Authors present a case of congenital dilatation of the common bile duct in adult life, selecting this lesion from the cystic dilatations of biliary tract group. The type I of biliary tract cystic dilatations is, in fact, considered a clinical-pathological situation apart, that, because of his frequence and his peculiar characteristics especially present in the adult, puts particular problems regarding his arrangement an treatment. The most recent aspects of etiophatogenetic and therapeutic problems of this lesion are treated. The increased risk of neoplastic degeneration in the adult, the recognition of an anomalous pancreaticobiliary duct junction as etiophatogenetic fondamental cause and the necessity of a radical exeretic treatment in in opposition to the old therapheutic orientations are especi-5ally considered.

The Authors report their experience, referred to the last 10 years (1980-1989), concerning 169 cases of anterior resection of the rectum. Manual and mechanical anastomoses were performed in 83 and 86 cases, respectively. Immediate and long-term complications are evaluated considering the type of anastomosis used, while results are correlated to the stage of the tumor.