Surgical treatment of small hepatocellular carcinomas in cirrhosis

Over the last five years a policy of systematic screening for small hepatocellular carcinomas (HCC) in patients at risk has led to an increasing number of resections in patients with cirrhosis. Remarkable progress in the surgery of HCC in cirrhosis has been accomplished through: (a) a better understanding of the surgical anatomy of the liver, (b) the definition of new types of liver resection aimed at reducing the amount of parenchyma removed while still being oncologically satisfactory, (c) the reduction of intraoperative blood loss by various techniques of clamping afferent and efferent vessels, (d) the systematic use of intraoperative ultrasonography, and (e) the prevention of postoperative variceal bleeding and the formation of ascites. Results of resection of small HCC in cirrhosis have been quite impressive in Japanese series, with a low operative mortality and above 50% three-year survivals. Results in the West have been somewhat less good. Differences in the pathology of these tumours and particularly in the rate of encapsulation could account for these differences. Clearly, surgical resection has become an established treatment for small HCC in cirrhosis. More information is needed on the results of surgery in operated patients and this should be compared with the natural history of small HCC in cirrhosis in order to better define the patients who will most benefit from these operations and which tests performed at which intervals, are most reliable in screening patients at risk.

Management of colorectal cancer in patients with cirrhosis and a LeVeen shunt

Two cirrhotic patients with a LeVeen shunt presented with a large bowel cancer. In one patient, the shunt was removed and the venous catheter was ligated prior to the performance of a colon resection. The postoperative course was uneventful. A new valve was inserted and connected to the venous catheter two months later. The second patient had a carcinoma of the rectum. In order to prevent ascites and to ease the colorectal resection he had preliminary construction of a portacaval shunt. Six weeks later, he underwent an anterior resection of the rectum. The postoperative course was uneventful except for a self limiting episode of febrile subacute intestinal obstruction. These two cases demonstrate that it is possible to resect colorectal cancer in patients with cirrhosis, ascites and a peritoneovenous shunt provided measures are taken to avoid specific complications due to the presence of the shunt, ascites or portal hypertension.

Intractable ascites in systemic mastocytosis treated by portal diversion

A 50-year-old male presented with intractable ascites due to systemic mastocytosis. The diagnosis of systemic mastocytosis was established by histology of the bone marrow which showed mast cell infiltration and fibrosis. Ascites was related to portal hypertension which was documented by esophageal varices at endoscopy and by an increase of wedged-free hepatic venous pressure gradient. Liver biopsy disclosed dense fibrosis of hepatic arterial and portal venule walls, resulting in complete obstruction of some portal radicles. Peliosis hepatis and fibrous deposits in the walls of hepatic venules were also present. Because of intractable ascites and significant malnutrition, a portacaval shunt was performed which cleared ascites and dramatically improved the general condition of the patient.

[Sugiura's operation: a Japanese exclusive?]

Fifteen patients with liver cirrhosis (11) or intrahepatic non cirrhotic portal hypertension (4) and previous variceal bleeding were electively treated by Sugiura's operation. There were no operative death. One patient (6.6 p. 100) had recurrent variceal bleeding 58 months postoperatively. One other patient had a self-limited episode of encephalopathy The 5-year actuarial survival rate was 81 p. 100. Four of the cirrhotic patients operated more than 5 years ago were alive at 5 years. The operation resulted in portal vein thrombosis in 2 patients, one of whom died. Results of this small series are quite similar to those of the largest Japanese series. They suggest that Sugiura's procedure has a low operative risk, is very efficient in preventing variceal rebleeding and does not result in encephalopathy.

Recurrent ascites due to central venous thrombosis after peritoneojugular (LeVeen) shunt

Twenty-five patients with cirrhosis with a peritoneojugular (LeVeen) shunt had recurrence of ascites because of obstruction of the venous catheter. They were investigated by direct shuntography and angiography of the superior vena cava (SVC). Shuntograms were suggestive of venous obstruction in all patients and showed either complete blockage at the tip of the venous catheter (87%) or partial obstruction (13%). Cavography disclosed a complete obstruction of the SVC or one of its branches in 65% of the patients, a nonobstructive mural thrombus in 17.5%, and sheathing around the catheter in another 17.5%. Blood clots formed at the tip of the catheter and not at its entrance into the vein. Replacement of the venous tubing or a contralateral shunt was successful in only one of eight patients with incomplete obstruction of the SVC. Failure was always due to recurrent venous obstruction. In patients with complete occlusion of the SVC, portal systemic shunts (12 patients) or peritoneosaphenous shunts (two patients) were always successful. These results suggest: that obstruction of the venous tubing of a LeVeen shunt is chiefly caused by the formation of a clot at the outlet of the tubing and that local procedures are prone to failure. Improvement of the long-term results of peritoneojugular shunting in intractable ascites of cirrhosis is clearly dependent on improvement of the venous tubing to decrease its thrombogenicity.

Results of portal systemic shunts in Budd-Chiari syndrome

Nine patients with Budd-Chiari syndrome (BCS) were treated by a portal systemic shunt. One had thrombosis of the superior mesenteric vein (SMV) and another had complete obstruction of the retrohepatic inferior vena cava (IVC). All other patients had a marked stenosis of the retrohepatic IVC with caval pressure ranging from 12 to 24 mmHg (mean: 17 mmHg). Seven patients had an interposition mesocaval shunt using an autologous jugular vein. The patient with a thrombosed SMV had a portoatrial shunt. The patient with an obstructed IVC had a cavoatrial shunt after an erroneous portacaval shunt had failed to relieve ascites. There were no operative deaths and no major postoperative complications. One patient died 19 months after operation of acute leukemia complicating polycythemia rubra vera. All other patients were alive and well 8 months to 6 years after operation. None of them had encephalopathy. These results suggest several comments: Portal systemic shunts are a good treatment for BCS and have a low operative risk. The mesocaval shunt is an efficient procedure, even when there is stenosis of the IVC with high caval pressure; shunts to the right atrium should be performed only in the case of complete obstruction or inaccessibility of the IVC. The long-term prognosis is excellent, except in patients with potential malignancies. Therefore, portal systemic shunts should be indicated early in patients with symptomatic BCS.

Portoatrial shunt in Budd-Chiari syndrome

It is now well accepted that mesoatrial bypass is an efficient treatment of Budd-Chiari syndrome and that it is indicated when the inferior vena cava is obstructed. This report presents a patient in whom the superior mesenteric vein was thrombosed after a previous mesocaval shunt. A bypass was constructed between the left side of the portal vein and the right atrium with a 16 mm diameter reinforced polytetrafluoroethylene prosthesis. The prosthesis passed between the left lobe of the liver and the caudate lobe and had a direct trajection. The procedure was simple, the postoperative course was uneventful, and the patient was well 20 months later. This observation suggests that portoatrial shunt is a good alternative to mesoatrial shunts in patients with Budd-Chiari syndrome and unavailable inferior vena cava and superior mesenteric vein.

Surgical resection of segment VIII (anterosuperior subsegment of the right lobe) in patients with liver cirrhosis and hepatocellular carcinoma

A limited liver resection was performed in two patients with cirrhosis and a hepatocellular carcinoma situated in segment VIII (anterosuperior subsegment of the right lobe). One of the patient had previously bled from esophageal varices. Resection of segment VIII was performed following the anatomical planes of section after complete mobilization of the right lobe of the liver. Both patients were alive and free of recurrence 14 and 30 months after surgery. Hepatocellular carcinomas are thus treatable by limited anatomic liver resection even when they are situated in the vicinity of the major hepatic veins and the vena cava.

Primary myeloproliferative disorder and hepatic vein thrombosis. A prospective study of erythroid colony formation in vitro in 20 patients with Budd-Chiari syndrome

We assessed the prevalence of overt and latent primary myeloproliferative disorders in hepatic vein thrombosis. Cultures of bone marrow or peripheral blood mononuclear cells were done in 20 patients with Budd-Chiari syndrome. Erythroid colony formation in the absence of erythropoietin, which is a reliable indicator for a primary myeloproliferative disorder, was seen in 16 patients in whom Budd-Chiari syndrome was due to hepatic vein thrombosis, including 13 women aged 18 to 45 years. Among these 16 patients, the conventional criteria for the diagnosis of a primary myeloproliferative disorder were met in only 2. Primary myeloproliferative disorder, often without peripheral blood changes, is a major cause of hepatic vein thrombosis in young women.

The LeVeen shunt in the elective treatment of intractable ascites in cirrhosis. A prospective study on 140 patients

One hundred and forty patients with an intractable ascites complicating a chronic liver disease received a peritoneovenous shunt (PVS) using the LeVeen valve. Operative mortality was ten per cent but was 25% in patients with severe liver failure. Intraoperative drainage of ascites sharply decreased postoperative complications and mortality. One-year actuarial survival rate was 81.4%, respectively 77.7%, 61.3%, and 24.7% in patients with good liver function and moderate or severe liver failure. Variceal hemorrhage occurred in 11 patients and late infection in another 11 patients. Thirty-eight patients (30.5%) had recurrence of ascites. This was mostly due to an obstruction on the venous side of the shunt. An elective portacaval shunt had to be done in 23 patients for recurrence of ascites or variceal bleeding. Among the 57 patients still alive at time of writing, 51 were free of ascites. These results suggest that PVS is an efficient operation. This procedure may be largely indicated in the selected and small group of cirrhotic patients with true intractable ascites and moderate or no liver insufficiency.

[Encephalopathy following portal shunting in nodular regenerative hyperplasia of the liver]

Two patients with nodular hyperplasia of the liver developed a chronic disabling encephalopathy after an interposition mesocaval shunt. Both had a low total hepatic blood flow-rate postoperatively. Encephalopathy disappeared following surgical occlusion of the shunt. These observations emphasize the risk of postshunt encephalopathy in patients with non-cirrhotic intrahepatic portal hypertension.

Hepatitis B virus DNA in patients with chronic liver disease and negative tests for hepatitis B surface antigen

We assessed the presence of hepatitis B virus (HBV) DNA in liver or serum samples from 134 patients with hepatitis B surface antigen (HBsAg)-negative chronic liver disease, including 20 with hepatocellular carcinoma. HBV DNA sequences were detected in 52 of the 88 liver samples (59 per cent), including 17 of the 20 samples from patients with hepatocellular carcinoma. Presumably "replicative forms" of HBV DNA were detected in only 5 of the 88 liver samples, 3 of which were from patients with no serologic marker for HBV. In most of the liver samples the DNA patterns were consistent with the presence of HBV or a closely related virus. Of the 105 serum samples tested, HBV DNA sequences were identified in 10 (9.5 per cent), 6 of which had no HBV serologic marker. Moreover, HBsAg-associated determinants were detected in 5 of 17 patients who were positive for HBV DNA and in none of 14 patients who were negative. This study demonstrates the high frequency of HBsAg-negative HBV DNA-positive viral infection of the liver and suggests that multiplication of HBV may occur in the absence of any conventional serologic marker for HBV.

Deficient natural killer cell activity in alcoholic cirrhosis

Natural killer (NK) cell activity against two types of target cells was found to be low in patients with inactive alcoholic cirrhosis (AC). This defect was significantly more pronounced in AC patients with severe malnutrition than in those with mild or moderate malnutrition. This was not due to modifications of the kinetics of NK activity. The sera from AC patients had no inhibitory effect on the NK activity of normal subjects. Lymphocytes and macrophages from AC patients did not exert major suppressive effect on the NK activity of normal subjects. Interferon boosted the NK activity of cells from AC patients, but to a lesser degree than cells from normal controls. The findings show that a deficit of NK activity is clearly associated with inactive AC. This seems to be another consequence of AC on cellular immunity, and might be related to the protein calorie malnutrition often present in AC.

[Results of portasystemic shunts in the treatment of the Budd-Chiari syndrome]

Seven patients (6 women and 1 man) with a Budd-Chiari syndrome were treated by a portal systemic shunt (6 mesocaval and 1 portoatrial shunts). Budd-Chiari syndrome occurred after treatment by estrogen-progestational drugs in 3 cases and following delivery in one. It was due to a myeloproliferative syndrome in 2 cases and to narrowing of the ostium of the hepatic veins in one. All patients had ascites before operation and 5 had an increased serum activity of transaminases. One patient was operated in emergency for progressive massive liver cytolysis. There was no operative mortality. In all patients ascites cleared after operation and transaminases returned to normal values. There was no chronic encephalopathy. Six patients are alive and well with a follow-up of 5 to 66 months. One patient died of acute myeloblastic leukemia 19 months after mesocaval shunt. A liver biopsy was obtained in 2 patients 18 months and 2 years after operation. Hemorrhagic necrosis and sinusoidal dilatation had disappeared and there was annular fibrosis. These results suggest that portal-systemic shunting is a good treatment of the Budd-Chiari syndrome. Since the natural history of this syndrome is still poorly known, a surgical shunt should be rapidly decided upon.

Effect of the oral administration of branched chain amino acids on hepatic encephalopathy in the rat

The aim of this study was to investigate the effect of oral administration of branched-chain amino acid (BCAA)-enriched diets after portacaval shunt (PCS) in rats. Fifty-one Sprague-Dawley male rats (200 gm) underwent PCS and 55 a sham operation. Half of the animals received BCAA 142 mg per day through a gastric tube; the other half underwent a sham procedure. Sleep disturbances were evaluated at 7, 14, and 28 days postoperatively by measurement of the excitability of the reticular brain-stem formation during the slow-wave sleep and paradoxical sleep. Animals were killed at the same intervals and liver/body weight ratio, plasma, and brain amino acids, brain norepinephrine, brain serotonin, 5-hydroxyindolacetic acid and histamine were measured. Each group of animals was matched with a similar group of sham-operated rats, i.e., receiving or not receiving BCAA. After PCS (as compared to sham-operated animals) a significant hyperexcitability of the reticular brain-stem formation was found during the slow-wave sleep. The liver/body weight ratio was significantly lower. Tryptophan (free tryptophan in the plasma), phenylalanine, tyrosine, and histidine increased in the plasma and the brain. Leucine and isoleucine were decreased in the plasma. After PCS, an initial decrease at 7 days postoperatively of brain norepinephrine and blockade of the intracerebral metabolism of tryptophan were observed. These changes were transient and progressively disappeared at 14 and 28 days postoperatively. Brain histamine remained at a very high level through the experiment. A good correlation was demonstrated between modification of the sleep disturbance and tryptophan (or 5- hydroxyindolacetic acid) and histamine brain levels.(ABSTRACT TRUNCATED AT 250 WORDS)