A multicenter phase II study on the feasibility and efficacy of neoadjuvant chemotherapy for locally advanced rectal cancer

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Background: The aim of this prospective multi-center phase II study was to evaluate the feasibility and efficacy of neoadjuvant chemotherapy (NAC) for locally advanced rectal cancer (LARC). Methods: Patients with LARC (cStage II–III) were included; those with cT4b tumor were excluded. Six cycles of mFOLFOX6 plus either bevacizumab (bev) or cetuximab (cet), depending on KRAS status, were administered before surgery. Primary endpoint was R0 resection rate. Secondary endpoints included completion rate of NAC, response rate, postoperative complications, pathological complete response (CR) rate, overall and disease-free survival, and quality of life. Results: Sixty patients from 7 institutes were enrolled. mFOLFOX6 was administered with bev to 40 patients who had wild-type KRAS and with cet to 20 patients who had K-RAS mutations. Completion rate of NAC was 88.4% and overall response rate was 81.7%. Sphincter-preserving surgery and abdominoperineal resection were performed in 43 and 17 patients, respectively. Median operation time was 335 min and median blood loss was 40 g. R0 resection rate was 98.3% and pathological CR rate was 16.7%. Overall postoperative complication rate ( ≥ grade 2) was 21.7%, including anastomotic leakage (11.6%), surgical site infection (6.7%), and urinary dysfunction (3.3%). There were no significant differences between patients with wild-type KRAS and those with KRAS mutations in response rate, postoperative complication rate, and pathological CR rate. Conclusions: NAC was a feasible and promising treatment option for LARC. Clinical trial information: UMIN000005654.

Ischemic enteritis with intestinal stenosis

A 75-year-old man was admitted to our hospital with sudden onset of vomiting and abdominal distension. The patient was taking medication for arrhythmia. Computed tomography showed stenosis of the ileum and a small bowel dilatation on the oral side from the region of stenosis. A transnasal ileus tube was placed. Enteroclysis using contrast medium revealed an approximately 6-cm afferent tubular stenosis 10 cm from the terminal ileum and thumbprinting in the proximal bowel. Transanal double-balloon enteroscopy showed a circumferential shallow ulcer with a smooth margin and edema of the surrounding mucosa. The stenosis was so extensive that we could not perform endoscopic balloon dilation therapy. During hospitalization, the patient's nutritional status deteriorated. In response, we surgically resected the region of stenosis. Histologic examination revealed disappearance of the mucosal layer and transmural ulceration with marked fibrosis, especially in the submucosal layer. Hemosiderin staining revealed sideroferous cells in the submucosal layers. Based on the pathologic findings, the patient was diagnosed with ischemic enteritis. The patient's postoperative course was uneventful.

[CURRENT STATUS OF PERIOPERATIVE MANAGEMENT IN PATIENTS UNDERGOING ANTITHROMBOTIC (ANTIPLATELET OR ANTICOAGULATION) THERAPY: RESULTS OF A QUESTIONNAIRE SURVEY]

In non-cardiac surgery patients receiving antithrombotic therapy (antiplatelet therapy (APT) and anticoagulation therapy (ACT)) for prevention of cardiovascular and/or cerebrovascular complications, perioperative antithrombotic management is challenging due to increased risks of both bleeding and thromboembolic complications. The effect of APT and/or ACT on surgical outcomes in patients undergoing general or gastroenterologic surgery is still unknown because of the limited evidence. We conducted a survey of 38 major surgical facilities at Kyoto University Related Hospital Surgical Group of Cancer Research on perioperative management in patients undergoing antithrombotic therapy. In elective surgery, most facilities used heparin substitution during cessation of ACT or APT, while surgery was performed under continuation of APT in 22% of facilities. In emergent surgery, the effect of ACT was reversed before surgery, but surgery was performed without the reversal of APT effect. Laparoscopic surgery was performed in most facilities in spite of the use of ACT or APT. Severe bleeding complications requiring transfusion of fresh frozen plasma or platelet were experienced in over half of facilities. Conclusion : Variation of antithrombotic management has shown to be large between facilities. For safe surgical treatment, creation of the perioperative antithrombotic management guideline on the basis of the evidence from multicenter study is requisite.

Initial safety report on the tolerability of modified FOLFOX6 as adjuvant therapy in patients with curatively resected stage II or III colon cancer (JFMC41-1001-C2: JOIN trial)

PURPOSE

Adjuvant FOLFOX is a widely accepted standard therapy for resected colon cancer. The incidence of grade 3-4 peripheral sensory neuropathy (PSN) was 12.4 and 5.7 % in the MOSAIC and Eastern MASCOT trials, while that of grade 3-4 allergic reactions (AR) was 2.9 and 3.1 %, respectively. The JFMC41-1001-C2 trial (JOIN trial) investigated the tolerability of modified FOLFOX6 (mFOLFOX6) in Japanese colon cancer patients.

METHODS

Twelve cycles of mFOLFOX6 were given to patients with the same eligibility criteria as in the MOSAIC study: stage II or III curatively resected colon cancer, performance status of 0-1, aged 20 years or older, starting mFOLFOX6 within 7 weeks of surgery, and adequate organ function. The primary endpoints were the incidence of PSN persisting for ≥8 days that interfered with daily activities and the incidence of grade 3-4 AR. The target sample size was 800.

RESULTS

From November 2010 to March 2012, 882 patients were enrolled at 198 institutions. Safety was analyzed in 828 patients with finalized data out of 848 patients receiving mFOLFOX6. The incidence of PSN persisting ≥8 days was 3.3 % [95 % confidence interval (CI) 2.2-4.7], while that of grade 3-4 AR was 1.7 % (95 % CI 0.9-2.8). The treatment completion rate was 67.0 %. The median total dosage of oxaliplatin was 811.1 mg/m(2). The overall incidence of grade 3-4 PSN was 5.8 %. Interstitial pneumonitis occurred in one patient. There were no treatment-related deaths.

CONCLUSIONS

Adjuvant mFOLFOX6 is tolerable for Japanese patients with colon cancer.

Conversion to complete resection with mFOLFOX6 with bevacizumab or cetuximab based on K-ras status for unresectable colorectal liver metastasis (BECK study)

BACKGROUND

Patients with colorectal liver metastasis (CRLM) might be down-staged by chemotherapy from an initially unresectable stage to a resectable stage. Because the tumor response to preoperative chemotherapy has been correlated with resection rate, the improved efficacy from the concept that only the patients without K-ras mutations receive an anti-EGFR antibody might be expected to increase the conversion rate. The purpose of this study is to evaluate the conversion rate from unresectable CRLM to complete resection.

METHODS

We conducted a multi-institutional phase II trial for unresectable CRLM. Patients received mFOLFOX6 with either bevacizumab (bev) or cetuximab (cet) based on K-ras status (UMIN000004310). Planned treatment was for six cycles during which tumors were assessed for resectability every three cycles. Patients whose disease was unresectable after six cycles switched their chemotherapy regimen from mFOLFOX6 to FOLFIRI. The primary endpoint was R0 resection rate.

RESULTS

Thirty-five patients with unresectable CRLM were enrolled. A total of 22/12 patients with K-ras wild-type/mutant (wt/mt) were treated with mFOLFOX6 plus cet/bev, respectively. The overall response rate was 64.7% (wt/mt; 77.3%/41.7%, P = 0.04). In 20 patients (58.8%), hepatectomy was performed according to protocol treatment, and the conversion rate was 72.7%/33.3% in wt/mt patients, respectively (P = 0.03). Finally, 23 patients (67.6%) underwent hepatectomy, and the conversion rate was 77.2%/50.0% in wt/mt patients (P = 0.09). The overall R0 resection rate was 47.1% (wt/mt; 50.0%/41.7%, P = 0.36).

CONCLUSIONS

This prospective study showed that combined chemotherapy based on K-ras status can facilitate conversion to resection in patients with unresectable CRLM.

Indication for neoadjuvant chemotherapy in patients with colorectal liver metastases based on a nomogram that predicts disease-free survival

BACKGROUND

The purpose of this study was to validate the Beppu nomogram, which predicts disease-free survival (DFS) after resection of colorectal liver metastases, and to investigate the efficacy of neoadjuvant chemotherapy based on the nomogram-predicted recurrence risk.

METHODS

We retrospectively analyzed 234 patients with colorectal liver metastases who underwent a hepatic resection at eight hospitals between 2005 and 2010.

RESULTS

The nomogram c-index of all the patients was 0.59. The observed and the predicted 3-year DFS showed good agreement. When the patients were divided into two groups who received or did not receive pre-hepatectomy chemotherapy (PHC), the c-index of the patients who received PHC was inferior to that of the patients who did not (0.56 and 0.61, respectively). In patients who received PHC, DFS among the quintiles clustered by the nomogram score indicated no significant differences (P = 0.25), unlike in patients who did not receive PHC (P < 0.0001). Surprisingly, in patients with no risk factors for recurrence, neoadjuvant chemotherapy provided significantly lower DFS than no neoadjuvant chemotherapy (3-year DFS: 42.9% vs. 80.0%, P = 0.03).

CONCLUSIONS

The nomogram validation was shown to be moderately predictive. PHC decreased the performance of the nomogram and might produce no DFS benefit in patients with low recurrent risk.

Tolerability study of adjuvant modified FOLFOX6 treatment in curatively resected stage II/III colon cancer (JFMC41-1001-C2: JOIN trial)

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Background: Adjuvant FOLFOX is a widely accepted standard regimen for resected colon cancer. The incidence of grade ≥ 3 peripheral sensory neuropathy (PSN) was 12.4% and 5.7% in Western MOSAIC and Eastern MASCOT (outside Japan) trials, while that of grade ≥ 3 allergic reactions (AR) was 2.9% and 3.1%, respectively. JOIN Trial investigated the tolerability of modified FOLFOX6 (mFOLFOX6) in Japanese patients (UMIN ID: 000004443). Methods: Twelve cycles of mFOLFOX6 were given to patients fitting the following criteria, which were the same as those of MOSAIC: stage II/III resected colon cancer, PS of 0-1, 20 years or older, starting FOLFOX within 7 weeks of surgery, and adequate organ function. The primary endpoint was the incidence of PSN persisting for at least 8 days that interfered with daily activities and that of grade ≥ 3 AR. Target sample size was 800, assuming the expected incidence of grade ≥ 3 PSN and grade ≥ 3 AR would be 12.0% and 3.0%, and the two-sided 95% confidence interval (CI) would not include the corresponding threshold levels (16.5% for PSN and 6.5% for AR) with a 95% probability. Results: From Nov 2010 to Mar 2012, 882 patients were enrolled at 198 institutions. The safety data was analyzed in 828 patients whose data were finalized out of 848 patients received mFOLFOX6, and patient characteristics included: median age of 64 years (21-83); Male/ Female: 444/384; PS 0/1: 776/52; colon/rectosigmoid: 633/195; and stage IIA/IIB/IIC/IIIA/IIIB/IIIC: 96/33/23/61/437/178. The incidence of persistent PSN was 3.3% (95% CI: 2.2%-4.7%), while that of grade ≥ 3 AR was 1.7% (95% CI: 1.0%-2.8%), and the primary endpoint was met. Only grade ≥ 3 neutropenia showed a ≥ 10% incidence (28.7%). The incidence of grade ≥ 3 PSN was 5.8% and interstitial pneumonitis was observed in one case. There was no treatment-related death. The median number of cycles of chemotherapy was 12, and the completion treatment rate was 67.0%. The median total dosage of oxaliplatin (L-OHP) was 811.1 mg/m2. The median relative dose intensity of L-OHP, fluorouracil (FU) bolus and FU infusion were 90.0%, 76.9% and 81.7%, respectively. Conclusions: Adjuvant mFOLFOX6 is tolerable in Japanese patients with colon cancer. Clinical trial information: UMIN000004443.

[Long-term progression-free survival after reduction surgery and postoperative low-dose imatinib administration for multiple liver metastases of duodenal gastrointestinal stromal tumor]

A fifty-six year-old woman visited our institute, suffering from lower abdominal pain. A tumor was palpable in the pelvic cavity, having the diameter of 9.7 cm, as measured by transvaginal ultrasonography (US). Computed tomography and magnetic resonance imaging (MRI) revealed a high contrast-enhancement and the central necrosis of the tumor. Surgical resection was performed, and the tumor was found to have originated in the duodenum. Immunohistochemistry confirmed positive KIT, and the mitotic index was 4 per 50 high power field, so that the final diagnosis was a gastrointestinal stromal tumor of intermediate risk. After two years of observation, multiple liver metastases were found. Hepatectomy was performed as a volume reduction surgery, leaving three small lesions in the remnant liver. Imatinib administration was initiated at 400 mg a day two weeks after the surgery, but was interrupted two weeks later because of severe anorexia and a body weight gain of 7 kg due to the increased ascites and edema. Imatinib was resumed at 200 mg/day after a one-month interval. She has been enjoying relapse-free survival for 8 years since the recurrence was diagnosed. Although neither reduction surgery nor dose reduction of imatinib below 300 mg/day is recommended, there may be a possibility that a smaller tumor might be controlled by a lower dose of imatinib.

[Recurrent liver sigmoid cancer responding remarkably to neoadjuvant chemotherapy using bevacizumab/XELOX: report of a case]

A 65-year-old male experiencing the recurrence of a solitary sigmoid cancer liver tumor was treated with bevacizumab (Bev)/XELOX chemotherapy, because he had refused surgical resection. After 5 courses, CT findings showed a partial response( 80% size-reduction)of the recurrent liver tumor. There was no recurrence in any other organ. He then requested hepatectomy, so we performed it, and there were no complications. The histological diagnosis was metastatic liver tumor, the estimation of the histological change by chemotherapy was Grade 2, and no abnormalities were found in the background of the liver. Bev/XELOX was relatively safe and successful for pre-operative patients with liver tumor recurrence.

[Prognostic study of preoperative serum levels of CEA and CA 19-9 in colorectal cancer]

PURPOSE

Carcinoembrionic Antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9) are the most frequently used tumor markers in the clinical setting of colorectal cancer. The aim of this study is to evaluate the prognostic value of preoperative serum levels of CEA and CA 19-9 in colorectal cancer patients.

METHODS

Serum levels of CEA and CA 19-9 were examined in 586 patients with colorectal cancer. Cut-off levels were calculated at reference value:<2.5 ng/mL (group A) versus >2.5 ng/mL (group B) for CEA and, <37 U/mL (group A) versus >37 U/mL (group B) for CA 19-9.

RESULTS

According to tumor progression, each marker tended to show a higher level. Group A showed a significantly better prognosis than group B in both CEA and CA 19-9. In Dukes classification A, B and C, only CEA showed a better prognosis in group A than group B. At the time of recurrence compared to the pre-operative point, the CEA and CA 19-9 levels were significantly higher in both group A and B, however. In relation to the necessity of adjuvant chemotherapy (5-FU containing regimen) in Dukes A, the cases without adjuvant chemotherapy in group B of CEA showed a poor prognosis.

CONCLUSION

The measurement of preoperative serum CEA and CA 19-9 is useful for prognostic prediction in colorectal cancer. Cut-off levels calculated at the reference value reflect the prognosis in this study. Especially, preoperative CEA reveals a potential high risk group in Dukes A which should be carefully treated by adjuvant chemotherapy to avoid recurrence.

Triiodothyronine resuscitates the impaired liver function after Pringle's maneuver

OBJECTIVE

To evaluate the changes in thyroid hormone levels and the effectiveness of exogenous triiodothyronine (T3) in shock caused by prolonged use of Pringle's maneuver (cross-clamping of hepatic triads).

DESIGN

Pringle's maneuver was performed on dogs for 1 hour. In the T3 group (n = 7), 1 microgram/kg per hour of T3 was administered intravenously for 3 hours after declamping. In the control group (n = 7), the same volume of saline solution without T3 was administered.

MAIN OUTCOME MEASURES

Serum T3, reverse T3, thyroxine, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and the ketone body ratio (AKBR), which reflect the hepatic energy charge, were measured. Tissue blood flow, tissue blood velocity, and tissue blood mass of the liver were measured by means of a laser Doppler flowmeter. Oxygen saturation of the hemoglobin in the liver tissue was measured by tissue near-infrared spectroscopy. Dogs were observed until the seventh postoperative day.

RESULTS

In the control group, the low T3 syndrome was observed. None of the dogs recovered from the shock and none survived for more than 24 hours. In the T3 group, all dogs recovered from the shock and survived. In the control group, hepatic tissue blood flow and oxygen saturation of hemoglobin in liver tissue were decreased, and the AKBR was deteriorated. In the T3 group, however, these parameters were markedly improved.

CONCLUSION

It is suggested that T3 administration is beneficial in managing the critical resuscitation period of liver function after Pringle's maneuver is performed in dogs.

Living-related liver transplantation for biliary atresia

We reviewed our initial experience of 29 living-related liver transplantations (LRLT) for children with biliary atresia in terms of postoperative complications and management to analyze the factors that may influence the outcome. All patients underwent an initial portoenterostomy at 17-134 days of age. The age distribution at the time of LRLT ranged from 6 months to 12 years, following revised portoenterostomy 0 to 3 times, and with (n=5) or without enteric stoma (n=24). Living-related donors provided the partial liver grafts weighing 170 to 630 g according to recipient size. Twenty-six of the 29 recipients are alive and well with follow-up between 1 and 27 (mean=14) months. Three patients died of extrahepatic complications including aspiration asphyxia, Candida infection and lymphoproliferative disorder. Four of 5 children with enteric stoma had 9 incidences of postoperative complication, while only 4 incidences occurred in 4 out of 24 children without stoma (p=0.007). Children hospitalized at the time of transplantation seemed to have early postoperative complications more frequently than home-bound children (p=0.06). The present results indicated that LRLT could offer satisfactory outcome for children in whom repeated Kasai's operation could not attain adequate biliary diversion and for those who developed cirrhosis despite good initial bile drainage.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of triiodothyronine on canine hepatic ischemia caused by Pringle's maneuver

BACKGROUND

A significant reduction in the serum concentration of triiodothyronine is frequently observed in surgical stress and may influence the severity and prognosis of the underlying disease.

METHODS

Alterations of thyroid hormone levels and effects of triiodothyronine were evaluated in the shock state after Pringle's maneuver for 60 minutes in dogs. Triiodothyronine (1 micrograms/kg/hr) was infused intravenously for 3 hours after declamping in the triiodothyronine-treated group. The effect of triiodothyronine on hepatic mitochondrial function was investigated by measuring the arterial ketone body ratio (AKBR).

RESULTS

In the control group (n = 6) the low triiodothyronine syndrome was observed and progressive deterioration of AKBR and standard liver functions represented by aspartate aminotransferase, glutamic-pyruvic transaminase, and lactic dehydrogenase were noted after declamping. All dogs went into shock and died within 24 hours. By contrast, in the triiodothyronine-treated group (n = 6), hemodynamics were stabilized and standard liver functions were maintained favorably (p < 0.01). AKBR was fully restored to the preischemic liver within 30 minutes after declamping, with a decrease in serum lactate levels (p < 0.05). All dogs survived at least 7 days after operation (p < 0.01).

CONCLUSIONS

These results indicate that triiodothyronine has beneficial effects on cytoprotection, hemodynamics, and hepatic energy metabolism in the ischemic liver injury. Furthermore, it improves survival in the shock state after Pringle's maneuver.

Arterial ketone body ratio as a predictor of donor liver viability in human liver transplantation

The viability of the donor liver was assessed with regard to early postoperative survival in human liver transplantations from 40 brain-dead donors at Hannover Medical College and 13 living donors at Kyoto University by measuring the arterial ketone body ratio (AKBR). Of 40 grafts harvested from brain-dead patients in Hannover, 35 survived the first week after operation, but 5 developed initial nonfunction of the transplanted graft within the first week. The mean AKBR values were 1.11 +/- 0.11 for grafts that survived and 0.44 +/- 0.10 for grafts that failed (P < 0.01). The AKBR values of the 5 initially nonfunctioning cases were all below 0.7. Of 13 grafts harvested from the living donors in Kyoto, all survived the first week. The AKBR values of the donors were all above 1.0, with a mean value of 1.87 +/- 0.23. Among all 53 cases, the survival rate of the grafts with AKBR above 0.7 was significantly higher than that of the grafts with AKBR below 0.7 (100% vs. 62%, P < 0.01). No other donor parameters, including age, dose of dopamine administered, and clinical laboratory findings, were significantly related to differences in graft survival rates. AKBR is a useful index for the evaluation of donor liver viability. Grafts used from donors with AKBR of less than 0.7 have a significantly increased risk of early nonfunction. Grafts from donors with AKBR of greater than 1.0 have, in our experience, always been viable after transplantation.

Beneficial effect of combined 3,5,3'-triiodothyronine and vasopressin administration of hepatic energy status and systemic hemodynamics after brain death

The influence of combined replenishment of L-3,5,3'-triiodothyronine (T3) and vasopressin (antidiuretic hormone [ADH]) on both hepatic metabolism and systemic hemodynamics was assessed in brain-dead dogs. Arterial ketone body ratio (AKBR) was measured as a parameter of hepatic metabolism, which reflects the redox state (free nicotinamide adenine dinucleotide/reduced nicotinamide adenine dinucleotide) of liver mitochondria. Mean arterial blood pressure (MAP) was significantly decreased from 110.4 +/- 3.8 to 44.4 +/- 1.7 mmHg, at 1 hr after completion of brain death (P less than 0.01). In the control group AKBR was maintained thereafter at near control value of 1.0 with a significant decrease in serum lactate concentration in spite of marked hypotension. T3 infusion at a rate of 1 microgram/kg/hr elevated the AKBR but did not elevate MAP. Vasopressin infusion at a rate of 0.1 U/kg/hr sustained AKBR and elevated MAP significantly at 1 hr after administration but tended to decrease thereafter. Combined administration of T3 and ADH elevated the AKBR to about 2.0, and MAP was restored to near-normal level. Other parameters such as glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, and lactic dehydrogenase, reflecting liver cell injury and serum creatinine, and blood urea nitrogen as renal function, were maintained within normal range. These results indicate that combined T3 and vasopressin administration has a beneficial synergistic effect on both hepatic energy metabolism and systemic hemodynamics without any detrimental influence to other conventional parameters. Therefore, it is suggested that this combined administration may contribute to the management of potential multiorgan donors.

Decrease in arterial ketone body ratio indicating graft dysfunction after liver transplantation

In 3 cases of living related liver transplantation, arterial ketone body ratio (AKBR) showed secondary decrease in the early postoperative period, indicating the graft dysfunction more rapidly and sensitively than other liver function tests. Significance of AKBR for monitoring the graft function in postoperative management after liver transplantation is discussed.

Maintenance of liver graft viability in the state of brain death. Synergistic effects of vasopressin and epinephrine on hepatic energy metabolism in brain-dead dogs

The influence of vasopressin and epinephrine on hepatic energy metabolism in the state of brain death was assessed by measuring arterial ketone body ratio (AKBR) and hepatic energy charge (EC) in brain-dead dogs. Mean arterial blood pressure (MABP) was significantly decreased from 125.5 +/- 5.5 to 53.4 +/- 1.7 mmHg after complete brain death (P less than 0.01). In the control group AKBR and EC were maintained at near the normal values thereafter, despite marked hypotension. Combined administration of vasopressin and epinephrine sustained AKBR normally and improved MABP above 90 mmHg (P less than 0.01). EC was also maintained within the normal range at 5 hr after initiation of administration of the drugs. By contrast, vasopressin or epinephrine alone maintained AKBR and EC at near the normal values, but improved MABP just slightly to around 60 mmHg (P less than 0.01). As for the volume control, the urinary output was significantly smaller in the vasopressin and epinephrine-treated group than in the control group (P less than 0.05). It is suggested that combined administration of vasopressin and epinephrine has a synergistic effect in improving the hemodynamics and maintenance of the energy status of the liver. This regimen is recommended as a good one for maintaining potential liver donors in the state of brain death.

Hepatic energy status in hypotension of different aetiologies in dogs

1. The alterations in hepatic energy metabolism in hypotension induced by the administration of trimetaphan camsylate (Arfonad) were investigated in comparison with those produced by hypotension resulting from massive haemorrhage by measuring the arterial ketone body ratio, which reflects the hepatic mitochondrial redox state, and other indices of hepatic energy metabolism together with simultaneous measurement of hepatic blood flow in dogs. 2. Mean arterial blood pressure was decreased from 130 mmHg to 60 mmHg by the continuous intravenous infusion of trimetaphan camsylate or by the use of Wiggers' shock model. In hypotension induced by trimetaphan camsylate, the arterial ketone body ratio, ATP and total adenine nucleotide concentrations and energy charge were maintained at near-control values throughout the experimental period. By contrast, the arterial ketone body ratio decreased from 1.04 +/- 0.09 to 0.29 +/- 0.06 at 3 h after haemorrhage in Wiggers' shock model (P less than 0.01). The ATP and total adenine nucleotide concentrations and energy charge also decreased significantly in this model (P less than 0.05). The difference in hepatic energy status was also shown by data from 31P nuclear magnetic resonance spectroscopy. 3. During hypotension, portal venous and total hepatic blood flows diminished significantly compared with the control values in each group (P less than 0.01). Although there was no significant difference in total hepatic flow between the two groups, the portal venous blood flow in hypotension induced by trimetaphan camsylate was significantly higher than that in Wiggers' shock model (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)