title: Benefit of an implanted solid barrier for the feasibility of a sequence of three different hepato-biliary operations in a small animal model.
abstract: BACKGROUND
  Current liver surgery includes complex multi-stage procedures such as portal vein ligation (PVL) followed by extended liver resection, especially in patients with Klatskin tumours. The risk for severe adhesions increases with every procedure. Finally, this complex sequence could fail because of malignant adhesions. Therefore, we proved the hypothesis of reducing malignant adhesions and increasing feasibility of a sequence with three hepato-biliary operations by implantation of a solid barrier.
  
  
  METHODS
  We operated in male rats (n=40). Our sequence included as 1st operation bile duct ligation mimicking Klatskin III° or IV°, the 2nd operation was a selective portal vein ligation (sPVL) and 3rd procedure was a 70% liver resection. The mechanical barrier (part of a sterile glove) was implanted at the end of the first operation between the upper (median lobe+left lateral lobe [ML+LLL]) and lower (right lobe+caudate lobe [RL+CL]) rat liver lobes. We assessed the degree of adhesions and the feasibility of the 2nd and 3rd operation by using an established adhesion score (Zühlke) and a feasibility score. The severity of the adhesions and the pro-inflammatory cellular response were further evaluated by morphometry of thickness (HE) of the adhesion layer and quantification of infiltrating neutrophils (ASDCL) in the adhesion layer on the liver surface.
  
  
  RESULTS
  The planned liver resection as the third procedure was only feasible when a mechanical barrier was placed. Extent of cholestasis or time interval between the operations had no significant impact on adhesions score or feasibility of the whole sequence.
  
  
  CONCLUSIONS
  A sequence of three hepato-biliary operations in a small animal model (rat) is feasible. It should be considered to implant a mechanical barrier in a sequence of more than two surgical interventions in an experimental model in order to assure the feasibility of the final operation.
authors.affiliation: Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany. Electronic address: beate.richter@med.uni-jena.de.
authors.forename: B
authors.initials: B
authors.lastname: Richter
authors.affiliation: Experimental Surgery Unit, Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany. Electronic address: constanze.saenger@med.uni-jena.de.
authors.forename: C
authors.initials: C
authors.lastname: Sänger
authors.affiliation: Experimental Surgery Unit, Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany. Electronic address: franziska.mussbach@med.uni-jena.de.
authors.forename: F
authors.initials: F
authors.lastname: Mussbach
authors.affiliation: Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany. Electronic address: hubert.scheuerlein@med.uni-jena.de.
authors.forename: H
authors.initials: H
authors.lastname: Scheuerlein
authors.affiliation: Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany. Electronic address: utz.settmacher@med.uni-jena.de.
authors.forename: U
authors.initials: U
authors.lastname: Settmacher
authors.affiliation: Experimental Surgery Unit, Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany. Electronic address: uta.dahmen@med.uni-jena.de.
authors.forename: U
authors.initials: U
authors.lastname: Dahmen
mesh_terms: D000818:Animals; D001662:Biliary Tract Surgical Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D004195:Disease Models, Animal; D005240:Feasibility Studies; D006498:Hepatectomy / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D007430:Intraoperative Care / Q000379:methods; D008026:Ligation / Q000379:methods; D008099:Liver / Q000601:surgery; D008297:Male; D011169:Portal Vein / Q000601:surgery*; D019919:Prosthesis Implantation; D011897:Random Allocation; D051381:Rats; D011917:Rats, Inbred Lew; D012680:Sensitivity and Specificity; D000267:Tissue Adhesions / Q000517:prevention & control*; D016896:Treatment Outcome
keywords: Adhesions; Cholestasis; Experimental surgery; Feasibility; Multi-stage hepatectomy; Selective portal vein ligation