Sinusoidal injury increases morbidity after major hepatectomy in patients with colorectal liver metastases receiving preoperative chemotherapy

OBJECTIVE

To investigate whether sinusoidal injury (SI) was associated with a worse outcome after hepatectomy in patients with colorectal liver metastases (CRLM).

BACKGROUND

Correlation between SI and oxaliplatin-based chemotherapy (OBC) was recently shown in patients with CRLM. However, it has yet to be fully clarified whether SI affects liver functional reserve and outcome after hepatectomy.

PATIENTS AND METHODS

Between 2003 and 2005, 90 patients with CRLM who underwent an elective hepatectomy after preoperative chemotherapies were included. Diagnosis of SI was established pathologically in the nontumoral liver parenchyma of the resected specimens, and perioperative data were assessed in these patients.

RESULTS

OBC was significantly associated with a higher incidence of SI. Preoperative indocyanine green retention rate at 15 minutes (ICG-R15) and postoperative value of total-bilirubin were significantly higher, and hospital stay was significantly longer in patients presenting with SI. Multivariate analysis showed that female gender, administration of 6 cycles or more of OBC, abnormal value of preoperative aspartate aminotransferase >36 IU/L, or abnormal value of preoperative ICG-R15 (>10%) were preoperative factors significantly associated with SI. Among patients undergoing a major hepatectomy, SI was significantly associated with higher morbidity and longer hospital stay.

CONCLUSION

The present study suggests that SI resulted in a poorer liver functional reserve and in a higher complication rate after major hepatectomy. Therefore, female patients who received 6 cycles or more of OBC, or presenting with abnormal preoperative aspartate aminotransferase and ICG-R15 values should be carefully selected before deciding to undertake a major hepatectomy.

Contrast-enhanced intraoperative ultrasonography equipped with late Kupffer-phase image obtained by sonazoid in patients with colorectal liver metastases

AIM

To find occult metastases during hepatectomy in patients with colorectal cancer liver metastases (CRCLM), contrast-enhanced intraoperative ultrasonography (CE-IOUS) was performed using a new microbubble agent, sonazoid, which provides a parenchyma-specific contrast image based on its accumulation in the Kupffer cells.

METHODS

Eight patients with CRCLM underwent CE-IOUS using sonazoid before hepatectomy. The liver was investigated during a late Kupffer-phase imaging, which is a valuable characteristic of sonazoid.

RESULTS

CE-IOUS using sonazoid provided the early vascular- and sinusoidal-phase images for 10 min followed by the late Kupffer-phase image up to 30 min after the injection of sonazoid. IOUS did not provide new findings of metastatic lesion in the 8 patients. However, during the late Kupffer-phase image of sonazoid, a metastatic lesion was newly found in two of the 8 patients. These newly detected lesions were removed by an additional hepatectomy and histopathologically diagnosed as a metastasis.

CONCLUSION

CE-IOUS using sonazoid can allow surgeons to investigate the whole liver with enough time and to find new metastases intraoperatively.

Efficacy of intraportal injection of anti-ICAM-1 monoclonal antibody against liver cell injury following warm ischemia in the rat

BACKGROUND

Increased expression of intercellular adhesion molecule-1 (ICAM-1) and lymphocyte-function-associated antigen-1 (LFA-1) has been reported to play a major role in reperfusion injury after ischemia. In the present study we tested the effects of anti-rat-ICAM-1 monoclonal antibody (1A29) on partial-liver warm ischemia in rats.

METHODS

Histological changes and expression of ICAM-1 and LFA-1 were investigated in rat partial-liver warm ischemia, performed by clamping hepatic hilar vessels distributing to the right lateral lobe for 30, 45, and 60 minutes. In a second study, the effects of intraportal 1A29 injection after 60 minutes of warm ischemia in the rat were examined histologically. In both studies, the liver tissue was removed for analysis 48 hours after clamping.

RESULTS

Reperfusion after 60 minutes of warm ischemia induced histological liver injury and strong expression of ICAM-1 and LFA-1, although 30 and 45 minutes of ischemia did not provoke either histological damages or the expression of ICAM-1 and LFA-1. Intraportal injection of 1A29 after 60 minutes of warm ischemia clearly suppressed liver cell injury histologically.

CONCLUSION

Intraportal injection of 1A29 prevented the histological inflammation of an ischemic liver and may be useful in liver surgery or liver transplantation, because high concentrations can reach the target organ and nonspecific immunosuppression in other tissues and organs can be decreased.

The effects of N-acetylcysteine and anti-intercellular adhesion molecule-1 monoclonal antibody against ischemia-reperfusion injury of the rat steatotic liver produced by a choline-methionine-deficient diet

Abundant fat in the liver has been implicated in poor outcome after liver transplantation or liver surgery, but the reasons for this association are still unclear. The aim of the present study was to examine mechanisms that may be involved in hepatic dysfunction after ischemia-reperfusion (I/R) of the steatotic rat liver. Steatosis was produced by a choline-methionine-deficient (CMDD) diet. In the first experiment, isolated perfused rat livers, subjected to 24-hour cold storage followed by 120-minute reperfusion, were used to investigate hypothermic I/R injury of the steatotic rat liver. In the second experiment, livers were subjected to 60-minute partial left lobar vascular clamping to allow study of normothermic I/R injury. In the first experiment, compared with normal nonsteatotic liver, steatotic livers showed significantly greater injury, as assessed by amounts of hepatic enzymes released into the perfusate, bile production, the concentrations of reduced glutathione (GSH) in the perfusate, as well as in the livers themselves, and electron microscopic findings of sinusoidal microcirculatory injury. The addition of N-acetylcysteine (NAC), a precursor of glutathione, to the liver before cold storage significantly improved these parameters in steatotic livers. The second experiment showed that, compared with nonsteatotic livers, steatotic livers had lower concentrations of GSH and impaired rates of bile production. There was also evidence of increased oxidative stress in polymorphonuclear leukocytes (PMNLs) in liver or peripheral blood of rats with fatty livers. An anti-rat intercellular adhesion molecule-1 (ICAM-1) monoclonal antibody inhibited neutrophil infiltration into pericentral sinusoids and improved these parameters in the steatotic rats. We conclude that sinusoidal microcirculatory injury is involved in hypothermic I/R injury, that oxidative stress produced by PMNLs is involved in normothermic I/R injury, and that NAC and anti-rat ICAM-1 monoclonal antibody restore liver integrity in I/R injury.

Liver scintigraphy is useful for selecting candidates for preoperative transarterial chemoembolization among patients with hepatocellular carcinoma and chronic liver disease

BACKGROUND

The indications for preoperative hepatic transarterial chemoembolization (TACE) have not been clarified by recent studies in patients with hepatocellular carcinoma (HCC) complicated by chronic liver diseases. The aim of the present study was to investigate which patients benefit most from preoperative TACE on the basis of hepatic functional reserve. Technetium-99m diethylenetriamine pentaacetic acid-galactosyl human serum albumin (Tc-GSA) liver scintigraphy was used to assess hepatic functional reserve before and after TACE.

PATIENTS AND METHODS

Liver scintigraphy was performed before and several weeks after TACE in 64 patients with HCC complicated by chronic hepatitis or cirrhosis. The ratio of liver to heart-plus-liver radioactivity of Tc-GSA 15 minutes after injection (LHL15) was calculated. Conventional hepatic functional tests were also performed. Whether to perform hepatectomy after TACE was decided mainly on the basis of the previously reported value of LHL15 > or =0.91.

RESULTS

LHL15, prothrombin time, and serum concentration of cholinesterase significantly decreased after TACE in patients with LHL15 > or =20.91 (P <0.01, P <0.05, and P <0.05, respectively). In patients with LHL15 <0.91, LHL15 and functional liver volume significantly increased after TACE (both P <0.05). Eight patients with LHL15 > or =0.91 did not undergo hepatectomy because LHL15 decreased to less than 0.91 after TACE, whereas 7 patients with LHL15 <0.91 underwent hepatectomy because LHL15 increased to more than 0.91 after TACE. Three major postoperative complications occurred in patients with LHL15 > or =0.91, and no major complications occurred in patients with LHL15 <0.91.

CONCLUSIONS

The results suggest that preoperative TACE should be performed in HCC patients only when LHL15 is less than 0.91, and that preoperative TACE is not an appropriate treatment for patients with LHL15 > or =0.91 when HCC is resectable.

Susceptibility to lipopolysaccharide of cholestatic rat liver produced with bile duct ligation: assessments of the mitochondrial glutathione pool and the effects of N-acetylcysteine

We investigated whether rats with obstructive jaundice produced with bile duct ligation for 2 weeks are more susceptible to the additional stress of lipopolysaccharide (LPS) administration than sham-operated rats and also examined the effects of N-acetylcysteine (NAC) on LPS stimulation in rats with bile duct ligation. The effects of LPS on the mitochondrial glutathione pool and on oxidative stress of polymorphonuclear leukocytes were investigated in cholestatic rats. Serum concentrations of alpha-glutathione S-transferase showed that lipopolysaccharide stimulation caused more severe hepatocellular injury in cholestatic rats than in sham-operated rats. In addition, concentrations of mitochondrial reduced and oxidized glutathione and hepatic adenosine triphosphate showed that LPS stimulation decreased mitochondrial function more in cholestatic rats than in sham-operated rats. Intraperitoneal administration of NAC for 2 weeks significantly improved mitochondrial function and decreased hepatocellular injury. However, the oxidative stress of polymorphonuclear leukocytes that had infiltrated hepatic tissue was increased by NAC. The present results indicate that the cholestatic liver is susceptible to the additional stress of LPS, that NAC suppresses the adverse effects of LPS in cholestatic livers, and that the oxidative stress of polymorphonuclear leukocytes is not significantly involved in mitochondrial dysfunction or hepatocellular injury in this model.

Amelioration of hepatocellular integrity and inhibition of sinusoidal oxidative stress by N-acetylcysteine pretreatment in cold ischemia-reperfusion injury of rat liver

Further improvements of donor liver preservation are still required in liver transplantation. In the present study, we investigated whether intraportal injection of N-acetylcysteine (NAC) 15 min before flush-out of UW solution (NAC pretreatment) improves liver dysfunction after cold preservation or has a protective effect on sinusoidal oxidative stress. The effect of NAC pretreatment was examined using an isolated perfused rat liver model. The NAC pretreatment significantly reduced sinusoidal oxidative stress relative to a control dextrose 5% injection. Under a glutathione-depleted condition produced by L-buthionine-[S-R]-sulfoximine, the NAC pretreatment also significantly reduced hepatocellular as well as sinusoidal oxidative stress, resulting in improvement of hepatocelllar integrity relative to a control dextrose 5% injection.

Histopathological response to preoperative chemotherapy including 5-fluorouracil additionally assessed by immunocytochemical and pharmacologic parameters in patients with advanced gastric cancer

To investigate quantitative methods for assessing the response to preoperative downstaging chemotherapy (PDC), the immunocytochemical expression of proliferating cell nuclear antigen (PCNA) and bromodeoxyuridine (BrdU) as well as a pharmacologic study of the rate of thymidylate synthetase inhibition (TSIR) were studied in resected specimens obtained from patients with advanced gastric cancer. Fifty-one patients with advanced gastric cancer who received PDC (30 with 5-fluorouracil peroral administration and the other 21 with intravenous administration of 5-fluorouracil and cisplatin) were studied. The labeling index of PCNA (PCNA-LI) and BrdU were measured. The PCNA suppression (PCNA-S), which was measured by both the values of prechemotherapeutic PCNA-LI in endoscopically biopsied specimens and postchemotherapeutic PCNA-LI in resected specimens, was also examined. TSIR was measured by a protein-bound radiochemical method. We compared the above-mentioned parameters with the histopathological response to PDC according to the General Rules for Gastric Cancer Study. In the patients with peroral 5-flurorouracil, a stepwise regression analysis showed that TSIR is a significantly effective for determining the histopathological response to PDC. In the patients with 5-fluorouracil and cisplatin, PCNA-S was the most effective indicator of the histopathological response to PDC, as shown by a stepwise regression analysis. The present study thus showed that both TSIR and PCNA-S were effective additional indicators of the histopathological response to PDC.

Perioperative hepatic functional risk assessed with technetium-99m diethylenetriamine pentaacetic acid-galactosyl human serum albumin liver scintigraphy in patients undergoing pancreaticoduodenectomy complicated by obstructive jaundice

CONCLUSION

Liver scintigraphy with technetium-99m diethylenetriamine pentaacetic acid-galactosyl human serum albumin (Tc-GSA) can be used to predict outcome of biliary drainage and hepatic function after pancreaticoduodenectomy in patients with pancreatic, biliary, and ampullary carcinomas complicated by obstructive jaundice.

BACKGROUND

Preoperative obstructive jaundice has been reported as a crucial risk factor for serious postoperative complications in patients undergoing pancreaticoduodenectomy. The aim of the present study was to investigate whether Tc-GSA liver scintigraphy can assess hepatic functional risk in patients with pancreatic, biliary, and ampullary carcinomas complicated by obstructive jaundice.

METHODS

Liver scintigraphy was performed before biliary drainage in 18 patients with obstructive jaundice. The maximum removal rate of Tc-GSA (GSA-Rmax; standard normal value > or = 0.60) was calculated. These patients underwent pancreaticoduodenectomy with wide lymphadenectomy. The efficacy of preoperative biliary drainage was assessed with the decrease in serum bilirubin concentration in the first week after biliary drainage. Postoperative liver function was assessed with the increase in serum bilirubin concentration, which was the difference between the immediate preoperative and maximal postoperative bilirubin concentrations.

RESULTS

Serum bilirubin decreased more in the first week after biliary drainage in patients with GSA-Rmax > or = 0.60 (7.64 +/- 1.09 mg/Dl/wk) than in patients with GSA-Rmax < 0.60 (3.56 +/- 1.25 mg/DL/wk, p = 0.042). Postoperative bilirubin increased less in patients with GSA-Rmax > or = 0.60 (0.81 +/- 0.30 mg/dL) than in patients with GSA-Rmax < 0.60 (4.00 +/- 0.69 mg/DL, p = 0.0012). Multivariate analysis showed that GSA-Rmax significantly predicted the postoperative bilirubin increase (p = 0.020).

Protective effects of N-acetylcysteine on hypothermic ischemia-reperfusion injury of rat liver

We investigated whether intraportal injection of 150 mg/kg N-acetylcysteine (NAC) into rats reduced hepatic ischemia-reperfusion injury after 48 hours of cold storage and 2 hours of reperfusion. The organ was isolated and perfused to evaluate liver function. The control group received an intraportal injection of 5% dextrose. NAC increased L-cysteine concentrations 15 minutes after injection (1.29 +/- 0.11 mumol/g vs. 2.68 +/- 0.4 mumol/g, P < .05). However, neither treatment modified glutathione liver concentrations relative to preinjection values. After 48 hours of cold storage and 2 hours of reperfusion, livers from NAC-treated rats produced larger amounts of bile than those in the control group (5.04 +/- 1.92 vs. 0.72 +/- 0.37 microL/g liver; P < .05), and showed a significant reduction in liver injury, as indicated by reduced release of lactate dehydrogenase (679.4 +/- 174.4 vs. 1891.3 +/- 268.3 IU/L/g; P < .01), aspartate transaminase (AST) (13.94 +/- 3.5 vs. 38.75 IU/L/g; P < .01), alanine transaminase ALT) (14.92 +/- 4.09 vs. 45.91 +/- 10.58 IU/L/g; P < .05), and acid phosphatase, a marker of Kupffer cell injury (344.4 +/- 89.6 vs. 927.3 +/- 150.8 IU/L/g; P < .01) in the perfusate. Reduced glutathione concentrations in the perfusate were similar in the two groups (805 +/- 69 vs. 798 +/- 252 nmol/L/g), whereas oxidized glutathione (GSSG) concentrations were higher in the control group (967 +/- 137 vs. 525 +/- 126 nmol/L/g; P < .05). Reduced glutathione (GSH) concentrations in liver tissue collected at the end of perfusion were significantly higher in the NAC group (7.3 +/- 0.9 vs. 4.1 +/- 1.0 mumol/g; P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic evaluation of curatively resected locally advanced gastric cancer patients with preoperative downstaging chemotherapy assessed by histochemical and pharmacologic means

The aim of the present study was to investigate whether the rate of thymidylate synthetase inhibition (TSIR) and the rate of proliferating cell nuclear antigen expression (PCNA-R) in gastric cancer tissues, which can be obtained within a short period after surgery, were predictive and quantitative prognostic factors for locally advanced gastric cancer patients with preoperative down-staging chemotherapy. Curatively resected 30 locally advanced gastric cancer patients with preoperative chemotherapies were studied. Three-year survival analysis showed that the higher TSIR and the lower PCNA-R significantly predicted better prognosis (p < 0.01 and p < 0.05, respectively). Multiple regression test showed that the TSIR was a significantly predictive variable for 1-year survival (p < 0.05). The TSIR and PCNA-R could be predictive and quantitative prognostic factors in advanced gastric cancer patients who received preoperative downstaging chemotherapy.

Prophylactic irrigation around a pancreaticojejunostomy for the treatment of a pancreatic fistula after a pancreaticoduodenectomy in patients with a risky pancreatic remnant

BACKGROUND/AIMS

Postoperative morbidity after a pancreaticoduodenectomy remains high mainly due to pancreatic fistula, but effective methods to prevent the development of pancreatic fistula have yet to be established. The present study prospectively investigated whether postoperative prophylactic irrigation around the pancreaticojejunostomy might be able to prevent eventual pancreatic fistula and infectious complications after a pancreaticoduodenectomy.

METHOD

Among 75 patients undergoing a pancreaticoduodenectomy between 2003 and 2005, 50 patients in whom the drain amylase level on postoperative day 1 were 1,500 IU/L or more were selected for the present study. Twenty-six of the 50 patients underwent postoperative prophylactic 72-hour continuous irrigation around the pancreaticojejunostomy starting from postoperative day 1 (Irrigation group). On the other hand, 24 of them did not undergo such irrigation (Non-irrigation group). The incidence of pancreatic fistula, infectious complications, delayed gastric emptying, and the length of hospital stay were then compared between the 2 groups.

RESULTS

The incidences of pancreatic fistula, wound infection, drain infection, sepsis, delayed gastric emptying, overall morbidity, and length of hospital stay were found to be significantly less in the irrigation group than in the non-irrigation group.

CONCLUSIONS

Prophylactic irrigation may possibly be able to prevent the occurrence of pancreatic fistula and infectious complications after a pancreaticoduodenectomy in patients with a risky pancreatic remnant.

Arterial and vena caval resections combined with pancreaticoduodenectomy in highly selected patients with periampullary malignancies

BACKGROUND/AIMS

To obtain a margin-negative resection and increase the indication for resection of periampullary malignancies, pancreaticoduodenectomy with a SM-PVR (superior mesenterico-portal vein resection) has been performed. However, an arterial resection, other vascular resections except SM-PVR (e.g., an inferior vena caval resection), or a metastatic tumor resection combined with pancreaticoduodenectomy has yet to be fully elucidated because of the high risk of postoperative complications and extremely poor long-term survival in patients undergoing these exceptional procedures. The present report focused on highly selected patients undergoing an arterial resection or a vena caval resection associated with pancreaticoduodenectomy.

METHODOLOGY

Besides 31 patients with periampullary tumors undergoing pancreaticoduodenectomy associated with SM-PVR in our department, a group of 4 patients underwent arterial resections and another patient underwent pancreaticoduodenectomy combined with a resection of liver metastasis together with an inferior vena caval resection. These five patients were reported in the present study.

RESULTS

A 27 year-old-woman presented pancreatic ductal adenocarcinoma of the pancreatic head and a liver metastasis in which involvements of the superior mesenterico-portal vein and the inferior vena cava were shown. Pancreaticoduodenectomy was performed with SM-PVR associated with a left hemihepatectomy combined with a segment 1 resection and an inferior vena caval resection. The patient did not present severe postoperative complications and experienced a good quality of life during 16 months after surgery. Four other patients underwent arterial resections. These arterial resections were performed only when a margin-negative resection was feasible. The superior mesenteric artery was resected and reconstructed with a Goretex graft in one patient. The right hepatic artery was resected and reconstructed with a saphenous graft in two patients. The other patient underwent a resection of the common hepatic artery and reconstruction was performed with the splenic artery. Three of the four patients presented postoperative complications but were conservatively treated. Two patients are still alive 25 months and 8 months after surgery. One patient died of sepsis 5 months after surgery, and the other died of cancer progression 19 months after surgery.

CONCLUSIONS

The indication for retropancreatic arterial resection associated with pancreaticoduodenectomy should be carefully evaluated only when a margin-negative resection can be achieved. An appropriate bypass method of arterial reconstruction should be selected because a direct end-to-end anastomosis is not always feasible. Hepatectomy for metastases of pancreatic ductal carcinoma should be also regarded as an exceptional procedure.

Endocutter no-knife and extraparenchymal control of the main hepatic veins for major hepatectomy

BACKGROUND/AIMS

Extraparenchymal control of the main hepatic veins (ECHV) and use of vascular staplers are now considered as effective methods to prevent intraoperative hemorrhage and duration of hepatic transection. The aim of the present preliminary study was to investigate whether extraparenchymal control of the hepatic veins combined with inflow occlusion and a new articulating linear stapler without a knife (Endocutter no-knife) were effective for major hepatectomy.

METHODOLOGY

Twenty patients with hepatic malignant disease underwent major hepatectomies in which 4 or more Couinaud's segments were removed. Extraparenchymal control of the hepatic veins and Endocutter no-knife were used in 7 (Recent group) of the 20 patients after June 2003. Hemihepatic devascularization before hepatic transection, and intermittent hepatic inflow occlusion were also performed in these 7 patients. In the other 13 (Previous group) patients before June 2003, major hepatectomy was performed under only intermittent hepatic inflow occlusion. Intraoperative blood loss volume, transfusion of packed red blood cells, and duration of hepatic transection were compared between the Recent group and Previous group.

RESULTS

Estimated blood loss and number of intraoperative blood transfusion were significantly smaller in the Recent group than in the Previous group. Duration of hepatic transection was also significantly shorter in the Recent group than in the Previous group.

CONCLUSIONS

The present preliminary study showed that extraparenchymal control of the hepatic veins and Endocutter no-knife are useful for major hepatectomy.

Celiac axis occlusion of a patient undergoing pancreaticoduodenectomy after distal gastrectomy

In patients with celiac axis occlusion, performance of pancreaticoduodenectomy involves sacrifice of the gastroduodenal artery which results in a risk of hepato-pancreato-biliary and other organic ischemia. Celiac axis occlusion does not recently seem an uncommon finding in cases of pancreaticoduodenectomy but diagnosis of celiac axis occlusion may be difficult in patients with former abdominal surgery. The present case report shows a patient with pancreatic head adenocarcinoma, in whom a preoperative diagnosis of celiac axis occlusion was not proved because of displacement of the celiomesenteric arterial branches based on former distal gastrectomy with Kocher's maneuver. A 56-year-old man with malignant obstruction of the lower bile duct was referred to our hospital for undergoing pancreaticoduodenectomy. In his past history, the patient had undergone distal gastrectomy reconstructed with Billroth I method due to gastric ulcer. In preoperative abdominal angiography, the celiac axis was not detected at the normal position and was incorrectly recognized to be anomalously originated from the superior mesenteric artery. During surgery, hepatic arterial flow was markedly diminished by clamping of the gastroduodenal artery. Celiac axis occlusion was then proved and the thick and tight median arcuate ligament was detected. Hepatic arterial blood flow was recovered by a complete division of the median arcuate ligament. Postoperative course of the patient was uneventful. In cases of pancreaticoduodenectomy, careful preoperative angiographic diagnosis is needed for patients with celiac axis occlusion who have undergone former gastric surgery because the celio-mesenteric arterial branches have been displaced by Kocher's maneuver. The present report also demonstrates another patient with a typical celiac axis stenosis.

A patient undergoing pancreaticoduodenectomy in whom involved common hepatic artery anomalously arising from the superior mesenteric artery was removed and reconstructed

Identifying anatomical variations of the celio-mesenteric arterial branches is important when performing pancreaticoduodenectomy. A relatively rare variation is the common hepatic artery entirely originated as a branch of the superior mesenteric artery. This type of variation is termed hepatomesenteric trunk type common hepatic artery, in which an accessory left hepatic artery arising from the celiac trunk is absent. Preservation of hepatomesenteric trunk type common hepatic artery is indispensable during pancreaticoduodenectomy because fatal hepatic injury or leak of hepaticojejunostomy can occur. The present case report shows a patient with pancreatic head tumor in whom hepatomesenteric trunk type common hepatic artery was involved by the tumor. The patient underwent pancreaticoduodenectomy during which the involved hepatomesenteric type common hepatic artery was removed and reconstructed using saphenous venous grafts. Histopathological examination showed double cancers which were composed of an advanced ductal adenocarcinoma of the pancreas and early bile duct adenocarcinoma. The patient is alive 18 months after the surgery without recurrence.

Preservation of segment 4 inferior by distal middle hepatic vein reconstruction combined with extended right hepatectomy after portal vein embolization in a patient with a huge initially unresectable HCC

An extended hepatectomy combined with preoperative portal venous embolization can offer curative resection in patients with initially unresectable hepatocellular carcinoma. However, hypertrophy of the future remnant liver is occasionally unsatisfactory after portal venous embolization in some patients to remove the initially unresectable tumor. In these patients, hepatic venous reconstruction to preserve hepatic parenchyma may contribute to the possibility of resection. The present case report shows a patient with an initially unresectable huge hepatocellular carcinoma in whom transarterial chemoembolization, portal vein embolization, and an extended right hepatectomy combined with distal middle hepatic venous reconstruction were performed to preserve Segment 4 inferior. The patient was a 66-year-old male. He presented with a huge hepatocellular carcinoma located at Segment 8, 7 and 4 superior, but the volume of the left lateral segment was only 267 mL. Transarterial chemoembolization was performed twice and right portal vein embolization was performed once, but the volume of the left lateral segment was only 318 mL compared to 487 mL which was a limit of future remnant liver volume. We therefore performed an extended right hepatectomy combined with distal middle hepatic venous reconstruction to preserve Segment 4 inferior. The left saphenous venous graft was used for this hepatic venous reconstruction. His postoperative course was almost uneventful. Postoperative abdominal computed tomography showed the satisfactorily preserved Segment 4 inferior. Distal hepatic venous reconstruction combined with an extended hepatectomy may further offer a chance of a curative resection for patients in whom enough hypertrophy of the future remnant liver is not obtained after portal venous embolization.

Second surgery after a pancreaticoduodenectomy in patients with periampullary malignancies

BACKGROUND/AIMS

Few case reports have previously documented a second surgery after pancreaticoduodenectomy due to recurrence or other reasons in patients with periampullary malignancies. The present report summarized the experience of this clinic with secondary surgery after Pancreaticoduodenectomy (PD).

METHODOLOGY

During the past 7 years, 7 out of 95 patients with periampullary malignancies underwent a second surgery after pancreaticoduodenectomy at this institution. The clinical courses of these patients are presented and 2 interesting cases are shown in the present study.

RESULTS

One patient with lower bile duct adenocarcinoma underwent a remnant splenopancreatectomy due to pancreatic recurrence 36 months after pancreaticoduodenectomy. The other patient with lower bile duct adenocarcinoma underwent a hepatectomy due to a solitary liver metastasis 47 months after a pancreaticoduodenectomy. These 2 patients have survived 4 and 13 months after the second surgery. In the 7 patients requiring secondary surgery, 5 underwent the procedure due to recurrent disease, and 4 of the 5 received the second surgery to remove the lesion. The mean interval between pancreaticoduodenectomy and the second operation was 32 months in the 5 patients with recurrent disease and 27 months in the all 7 patients. One of the 5 patients died of recurrent disease only 5 months after the second procedure because the surgery was a palliative bypass. However, the other 3 survived more than 1 year after the resection of the lesion at the recurrent site.

CONCLUSIONS

The present study reports 2 rare cases with lower bile duct adenocarcinoma in which a recurrent tumor was removed after pancreaticoduodenectomy. In this study, 4 patients undergoing a curative re-operation survived more than 1 year after the surgery. The present study was small, but the findings are significant because of the scarcity of reports of patients undergoing secondary surgery after PD.

A multi-institutional prospective study of lentinan in advanced gastric cancer patients with unresectable and recurrent diseases: effect on prolongation of survival and improvement of quality of life. Kanagawa Lentinan Research Group

BACKGROUND/AIMS

Lentinan is one of the host-mediated anti-cancer drugs which has been shown to affect host defense immune systems. Although the mechanisms involved in the antitumor effects of lentinan have been reported experimentally, the clinical outcome on prolongation of survival and improvement of quality of life in gastric cancer patients with unresectable or recurrent diseases has yet to be clarified. The aim of the present study was to investigate whether administration of lentinan prolonged survival or improved quality of life in these patients.

METHODOLOGY

A multi-institutional randomized prospective protocol, consisting of patients administered tegafur and cisplatin (control group), and patients administered lentinan, tegafur and cisplatin (lentinan group), was performed. Quality of life was investigated using a questionnaire survey.

RESULTS

Median survival was significantly longer in the lentinan group than in the control group (297 days vs. 199 days, p = 0.028). One-year survival rate was greater in the lentinan group than in the control group (49.1% vs. 0%). Total QOL score, especially appetite and sleep quality, was significantly improved with the administration of lentinan.

CONCLUSIONS

Lentinan is considered to prolong survival and improved quality of life when gastric cancer patients with unresectable or recurrent diseases are treated in combination with other chemotherapeutic agents.

[The evaluation of cellular proliferating activity in gastric carcinoma with the proliferating cell nuclear antigen (PCNA) expressive rate: its fundamental examination of the immunohistochemical procedures and its clinical applications]

PCNA is known as a cell cycle-related nuclear antigen. We stained PCNA immunohistochemically, and examined whether or not PCNA expressive rate could be applied clinically for a biological parameter of the histopathological effects in preoperative chemotherapy. PCNA was stained in proliferating cell by measuring nuclear DNA simultaneously. The most suitable fixation time in PCNA expression was 24 hours. On the examination of fixation fluid, ethanol was considered to be more suitable than buffer formaldehyde because PCNA expressive rate in ethanol correlated to BrdU labeling index with statistical significance. We examined PCNA expressive rate in gastric carcinomas. In the group whose histopathological effects of preoperative chemotherapy was recognized to be positive, PCNA expressive rate was significantly lower than in the group of negative effect. We measured thymidylate synthetase inhibition rate (TSIR) in the cases of preoperative oral administration of 5-FU, and the significantly negative correlation was seen between TSIR and PCNA expressive rate in the cases of differentiated adenocarcinoma (p < 0.05). The proliferating activity was recognized to be lower in the cases of higher inhibitional effect for DNA synthesis. PCNA expressive rate was considered to be a more effective and objective biological parameter on the evaluation of malignant potential in gastric carcinoma.