Hepatic Veno-occlusive Disease

COVID-19 and Cardiovascular Manifestations

COVID-19 disease caused by Severe Acute Respiratory Syndrome CoronaVirus-2 (SARS-CoV-2) has rapidly established itself as a devastating pandemic of a larger magnitude. The most common symptoms of COVID-19 include fever, dry cough, myalgia, and fatigue. Severe symptoms and critical disease occur in 5 to 15% of patients, progressing to acute respiratory distress syndrome and multi-organ dysfunction syndrome. Risk factors for severe disease and death include old age, hypertension, diabetes, underlying cardiovascular and respiratory diseases, cancer, and obesity. The SARS-CoV-2 virus has broad tissue tropism, and a quarter of patients can have cardiac involvement. Cardiovascular (CV) manifestations include subclinical and overt myocarditis, acute coronary syndromes, arrhythmias, exacerbation of heart failure, thromboembolism, cardiogenic shock, and death. Patients with preexisting cardiovascular disease (CVD) or CV involvement during the course of illness may have poor clinical outcomes. Patients who have recovered from acute illness can have persistent long-term effects with clinical significance. The focus of this chapter is about the bidirectional interaction between COVID-19 disease and CVD, its various cardiovascular manifestations, their outcomes, and management.

Pediatric Hematological Malignancies – Clinical Manifestation, Treatment and Follow-Up

Hematological malignancies are the forms of cancer that begin in the cells of the blood- forming tissue, such as the bone marrow. Childhood blood cancers are relatively rare but are still found to be the major cause of death in children aged 1-14. Early detection increases the chances of successful treatment which paves the way to reduce the rate of mortality. Leukemias and lymphomas account for more than one half of new cancer cases in children. Despite major advances – from an overall survival rate of 10 percent to nearly 90 percent today, for many rare cancers, the survival rate is much lower. Enhancement of anti-leukemic efficacy and reduction of treatment related morbidity or mortality can be achieved by targeted therapy, but requires detailed understanding of pathways and genetic defects involved in leukemogenesis.

Interventional Therapy and Device Therapy

Despite therapeutic advances in the medical treatment of HF patients, the prognosis remains poor. Coronary revascularization in patients with ischaemic cardiomyopathy is associated with amelioration of symptoms and survival benefit. Percutaneous coronary intervention with stenting is associated with excellent outcome, high procedural success rate, low event rates, and can be safely performed in patients with ischaemic cardiomyopathy. Patients with complex coronary artery disease require surgical revascularization (Coronary Artery Bypass Grafting - CABG). Cardiac resynchronization therapy (CRT) aims to re-establishing synchronous contraction between the left ventricular free wall and the interventricular septum, resulting in an increase in stroke volume. In clinical terms, this is translated in functional class improvement. This generally involves biventricular pacing (pacing of the left and right ventricle through separate leads). Surgical strategy for the management of patients with end-stage ischaemic heart disease includes “conventional” techniques (surgical revascularization, the most common surgical procedure, surgical ventricular restoration in patient with a dyskinetic part in the left ventricle and mitral valve surgery for mitral regurgitation). Mechanical circulatory support aims to restore blood flow and pressure, and thus end-organ function, in patients with profound cardiogenic shock or in endstage patients (stage D) with advanced NYHA III-IV symptoms as a bridge to transplantation or as lifelong support (destination therapy). Heart transplantation is associated with excellent long-term results in terms of symptomatic relief and prognostic benefit under strict criteria involving the recipient and the donor. In the face of evolving technology, lifetime mechanical support provides a realistic alternative to heart transplantation.

Chemical Composition of Bee Pollen

Bee pollen, usually used as an important source of nutrients and micronutrients for the young bees in the hive, is also an important food for humans. This product is very rich in proteins, lipids, free sugars, carbohydrates, and it contains trace amounts of minerals, phenolic acids, flavonoids and a good range of vitamins. A brief look at bee pollen composition, it is easily recognised that it is a balanced food that can be used as a stand-alone food or as a nutritional supplement or even as a medicinal product. Several bioactivities, due to some of these compounds, were studied in bee pollen samples from different floral sources and the results conduce to important properties. The amount and diversity of micronutrients could induce vast benefits if used for health purposes following a complete risk assessment. Nevertheless, the results pointing towards the encouraged use of bee pollen, the risk assessment of some floral species containing toxic compounds has not been fully studied to insure the safety of consumption for all the gathered flowers, so this will also be discussed in this chapter. Admiration for its goodness and medicinal properties, bee pollen has been consumed for centuries, however, currently the efficacy and safety for all consumed products, foods, supplements or medicines is an important tool to guarantee correct quality control and essential to add value to the product.

To summarise, in this chapter we will put the situation of gaps in bee pollen research into some kind of perspective, outlining some important points and discussing in more depth the implications of collecting samples, chemical composition and risk assessment.

Technical Aspects of Liver Transplantation

• The technical evolution and refinement of liver transplantation over the past 50 years has allowed liver replacement to alter the course of end-stage liver disease as a life-ending condition, thereby giving patients a second chance at a full and healthy life.

• The execution of donor hepatectomy, back-table preparation, recipient hepatectomy and graft implantation are all essential to the completion of a single liver transplant.

• Living donor liver transplantation needs to be carefully considered in select cases while preserving the well-being of the donor to the maximum extent possible.

• Early detection and management of vascular and biliary complications provides the best chance for a favorable outcome.

Liver Transplantation for Hepatic Failure

• Patient and graft survival after liver transplantation (LT) has improved over time. Despite the options available to increase the donor pool, the expansion on indications for LT has surpassed the availability of grafts, exacerbating the scarcity of grafts.

• Clinical evaluation of potential recipients is crucial to avoid excessively early LT (with no benefit for patients with a good predicted survival without LT) but also excessively late LT (resulting in poorer outcomes). Timing and methods for organ allocation remain challenging.

• Partial liver grafts (including living-donor and splitted grafts) and marginal grafts represent options to increase the graft pool.

• Postoperative complications after LT remain significant and are mainly related to graft quality, recipient clinical status, immunosuppression, recurrence of hepatic disease, and technical aspects.

• LT in the setting of acute liver failure is uncommon and is accompanied by specific factors related to organ allocation and technical aspects.

Anesthesia and Pain Control in Liver Surgery

• Anesthetic management plays a key role in the reduction of perioperative causes of mortality in liver surgery, such as bleeding and liver failure.

• Intraoperative reduction of the hepatic blood flow can result from changes in blood volume status and also from mechanical or pharmacological effects, and can lead to liver dysfunction.

• Central venous pressure lower than 5mmHg reduces blood loss during hepatic parenchymal transection.

• Inhalational anesthetics such as sevoflurane, desflurane, and isoflurane can maintainor even increase total hepatic blood flow; meanwhile, intravenous anesthetics have a modest impact on that.

• Intraoperative fluid management should not be guided exclusively by central venous pressure, and the use of colloids (such as 5% albumin) as a maintenance and replacement solution reduces extravascular translocation of fluids.

• Pharmacological preconditioning, mainly with the use of inhaled anesthetics, has been used to prevent ischemia-reperfusion syndrome, although its pathophysiology is not entirely understood.

Underlying Liver Disorders in Hepatic Surgery

• The function and the volume of the residual liver should be assessed prior to a hepatectomy. Combinations of imaging and blood samples are currently used to assessliver function but no optimal screening for liver injury exists. Thus, pre-resection biopsy may be indicated in selected cases. Volumetry based on imaging is used to estimate residual liver volume and can be used for treatment decision. Volumetry before and after portal vein embolization (PVE) also reveals the regenerative potential, a marker of underlying liver injury.

• Cirrhosis, a common finding in patients with primary liver malignancies, limits the extent of resection. Preoperative chemotherapy may cause different types of liver injury associated with adverse outcome events after liver resection.

• Non-alcoholic fatty liver disease (NAFLD) is associated with the use of irinotecan-based chemotherapy and features of metabolic syndrome. Sinusoidal liver injury occurs in 19-50% after preoperative treatment with oxaliplatin-based chemotherapy, and is associated with increased postoperative morbidity. Bevacizumab has oncological benefits in the treatment of colorectal liver metastases when administered together with oxaliplatin, and protects against oxaliplatin-induced sinusoidal injury.

• Regarding the volume of the future liver remnant (FLR), the following are suggested:>40% in patients with cirrhosis; >30% in patients who receive more than three months of preoperative chemotherapy; >20% in the normal liver.

Natural Compounds – Anti-Obesity Properties

Obesity is a global epidemic with increasing number of individuals becoming overweight. World Health Organization (WHO) has called obesity a preventable disease mainly because most obese patients benefit by changing food habits and lifestyle. It is very well established that obesity increases the risk of several life threatening diseases like insulin resistance, diabetes, atherosclerotic vascular disease (CVD), cancer, chronic inflammation, bone disorders etc. Several natural products like herbs, dairy products, and products from marine organisms have been reported to have anti-obesity properties. These products reduce obesity by influencing different pathways such as decreasing intestinal absorption, fatty acid synthesis, adipocyte differentiation as well as increasing intestinal transit, beta oxidation, and metabolic rate. In this chapter, we have compiled information about the use of different natural products as anti-obesity agents and how they affect body weight.