Direct evidence for the intact hepatocyte theory in patients with liver cirrhosis

An attempt was made to compare various morphometric parameters, including total hepatocyte number, with the in vivo clearances of aminopyrine and antipyrine in 26 cirrhotic and 14 noncirrhotic patients to evaluate the intact hepatocyte theory. Morphometric analysis was performed with a newly developed method using a computer-aided color image analyzer. Aminopyrine clearance was significantly correlated with liver volume (r = 0.434; P less than 0.05), parenchymal cell volume (r = 0.574; P less than 0.001), and most strongly with total hepatocyte number (r = 0.614; P less than 0.001) in all patients. Significant correlations were also observed between these three parameters and antipyrine clearance (r = 0.367, P less than 0.05; r = 0.663, P less than 0.001; and r = 0.807, P less than 0.001, respectively). The mean aminopyrine clearance per individual hepatocyte showed no significant difference between cirrhotic and noncirrhotic patients (3.52 +/- 1.60 x 10(-10) mL/min vs. 3.65 +/- 1.50 x 10(-10) mL/min, respectively; P greater than 0.10). Similar results were obtained for antipyrine clearance per hepatocyte (7.35 +/- 2.27 x 10(-11) mL/min for cirrhotics vs. 6.16 +/- 1.07 x 10(-11) mL/min for noncirrhotics; P greater than 0.10). Thus, the intrinsic clearances of drugs per individual hepatocyte, as originally proposed in the intact cell hypothesis, were directly evaluated for the first time, lending strong support to the intact hepatocyte theory.

Histopathological study of oesophageal mucosa in patients with varices: a comparison between bleeders and non-bleeders

Thirty-six patients with oesophageal varices underwent a non-shunting operation including oesophageal transection. Of these, 16 had an emergency or elective operation (bleeders) and the remaining 20 had prophylactic surgery (non-bleeders). A comparative study was performed between the bleeders and non-bleeders in terms of preoperative endoscopic findings and histopathology of the oesophagus. The severity of red colour sign showed no significant difference between the two groups. The venous dilatation in each of the three layers of the oesophageal mucosa was demonstrated histologically to be of the same degree in bleeders and non-bleeders. In addition, the hepatic venous pressure gradient in cirrhotic patients did not differ between the two groups; for bleeders this was a mean(s.d.) of 15.2(6.1) mmHg and for non-bleeders 14.4(2.9) mmHg. We were unable to find any factors differentiating bleeders from non-bleeders, although these results do not justify prophylactic surgery for oesophageal varices.

Quantitative evaluation of parenchymal liver cell volume and total hepatocyte number in cirrhotic patients

A simple morphometrical method was developed using a color image analyzing system, which allowed quantitative evaluation of parenchymal liver cell volume and total hepatocyte number in cirrhotic patients. With this method, we estimated these values in 29 cirrhotic patients who underwent hepatic resection (nine cases) or nonshunting operation (20 cases). Liver volume, calculated from computed tomographic images, was 976 +/- 196 cm3 (range = 602 to 1,376 cm3); the parenchymal cell volume ratio, obtained based on liver histological appearance with silver stain, was 0.665 +/- 0.092 (range = 0.510 to 0.881); and the parenchymal cell volume, calculated by multiplying the liver volume with the parenchymal cell volume ratio, was 645 +/- 140 cm3 (range = 403 to 936 cm3). The total hepatocyte number obtained in a similar manner using hematoxylin-stained specimens was 1.72 +/- 0.56 x 10(11) (range = 0.74 to 2.94 x 10(11)). The validity and applicability of the method is discussed, and the data are compared with those reported in other studies.

Results of nonshunting operation and injection sclerotherapy for esophageal varices

The results of a total of 523 nonshunting operations performed at our institution from 1964 to 1990 were analyzed and compared to those of chronic sclerotherapy. Although the overall operative mortality rate of nonshunting operations was low (26/523:5.0%), it was relatively high in Child's C cirrhotic patients (22/129:17%) and in those who underwent surgery on an emergency basis (14/60:23%). Cumulative survival rates of Child's C cirrhotic patients at 5 and 10 years (37.4%, 13.0%) following nonshunting operations were much lower than those of Child's A (76.6%, 54.9%) or Child's B (71.6%, 35.5%). One- and three-year survival rates for patients treated with sclerotherapy were 90%, 72% in Child's A (22 patients), 82%, 49% in Child's B (47), and 56%, 30% in Child's C (50), while cumulative rebleeding rates at one and three years following sclerotherapy were 12%, 12% in Child's A, 18%, 27% in Child's B, and 35%, 55% in Child's C respectively. Our data indicated that nonshunting operations can be safely performed with a good long-term outcome in Child's A or B cases on an elective basis, and sclerotherapy may be the treatment of choice for emergency cases or for Child's C cases although the risk of rebleeding is high following sclerotherapy.

Development of a computer-aided surgery system: three-dimensional graphic reconstruction for treatment of liver cancer

Simulation of the needle puncture and volume estimation for the tumors in the liver were carried out with the three-dimensional image reconstruction system, which consists of a medical image acquisition system, a data processing system, and a graphic display. A set of sliced-image data from a computerized tomography and/or a magnetic resonance imaging was used to reconstruct the liver, the vessels, and the tumors of the patients with liver cancer. A good agreement of anatomic locations of both the intrahepatic vessels and the tumors between the reconstructed liver model and the echography done intraoperatively was observed. Surgical simulations with these graphic models clearly indicated safety areas for needle puncture in the laser coagulation therapy. In addition liver volumes were calculated within 3% of error in comparison to the measured values. These results indicate that the computer-aided surgery system is a highly promising method that avoids cumbersome stereoscopic recognition of the anatomical location of the diseased area and the vessels, before and after surgery.

Devascularization and transection procedures

Transection and devascularization procedures have been by far the most popular operations for the treatment of oesophagogastric varices in Japan during the last two decades and although since the new development of endoscopic sclerotherapy during the last ten years the number of patients treated by operation has decreased considerably, these procedures still remain the treatment of choice in many of the surgical institutions in Japan, especially in good-risk patients with oesophagogastric varices.

Aortobronchial fistula after an aortic operation

A 71-year-old man with a postoperative aortobronchial fistula was successfully treated. The fistula occurred between the left lower lobe and the descending thoracic aorta, to which a distal anastomosis of a temporary bypass graft had been placed during thoracic aortic aneurysmectomy 3 years before. For saving patients with this complication, early surgical treatment during episodes of intermittent hemoptysis is important. The use of an omentum pedicle flap for the isolation of the suture line is a important adjunct.

Bile acid profile and decrement rate of serum total bilirubin after biliary drainage

Non-esterified (non-sulfated and non-glucuronidated) bile acid profile in the serum and bile was assessed using mass fragmentation spectrometry in relation to the decrement rate of the serum total bilirubin after relief of the biliary obstruction by external biliary drainage in fourteen patients. Biliary excretion of the total bile acid was decreased and the serum ratio of cholic to cenodeoxycholic acid was low in the patients with refractory jaundice. An unusual bile acid, 3 beta,7 alpha-dihydroxy-5 beta-cholan-24-oic acid, was detected in the sera of all patients early after biliary drainage. Disappearance of this bile acid from the serum was delayed in refractory jaundice. These findings suggested that extremely prolonged jaundice after biliary drainage resulted from profound liver cell damage secondary to biliary obstruction.

Nonoperative removal of bilateral intrahepatic biliary stones by endoscopic electrohydraulic lithotripsy

We report the successful treatment of bilateral intrahepatic biliary stones by endoscopic electrohydraulic lithotripsy (EHL). EHL is a useful procedure by which large stones can be fragmented easily and complete removal of stones can be attained.

Experimental transcatheter hepatic subsegmentectomy using absolute ethanol in dogs

In this study, we evaluate the effect of an intraportal injection of absolute ethanol in the canine liver and discuss how to introduce it in clinical application. The intraportal injection of ten milliliters of ethanol using a balloon occlusion catheter created an evident and well-demarcated necrotic lesion in the right central lobe. Histological examination showed a typical coagulation necrosis with fibrous bands, which became thicker day by day. The weight of the necroses ranged from 5 to 55 grams with an average of 26.0 +/- 5.5 grams (mean +/- SE), which was approximately 20 to 40 per cent of the right central lobe. Complications resulting from the ethanol injection were minimal and although more studies need to be done to clearly establish its safety for cirrhotic patients with hepatoma, this technique may be an easier and less invasive substitute for operative hepatic subsegmentectomy.

Squamous cell carcinoma after endoscopic injection sclerotherapy for esophageal varices

We report two cases of squamous cell carcinoma of the esophagus following endoscopic injection sclerotherapy for esophageal varices. The interval between sclerotherapy and the development of carcinoma was 24 months in case 1 and 21 months in case 2. The sclerosant was 5% sodium morrhuate in case 1 (total dose, 10 ml) and 5% ethanolamine oleate in case 2 (45.5 ml). Although no recurrent variceal bleeding occurred after sclerotherapy, we could not perform any curative surgical treatment for esophageal cancer because of the advanced stage of the cancer and the severity of the accompanying liver dysfunction. It is difficult to determine the relationship between sclerotherapy and carcinoma; however, long-term surveillance is essential to avoid overlooking a neoplasm in the esophagus after endoscopic injection sclerotherapy.

Basic studies on a new material for inducing antitumor immune cells

Recently, adoptive immunotherapy for cancer with lymphokine activated killer (LAK) cells has been widely used experimentally. The therapy has several problems, including difficulty in handling, sterilization, and time consumption. To solve these problems, new materials able to induce antitumor immune cells were investigated. Pokeweed mitogen (PWM) and PWM-conjugated materials (CMC-1) could induce strong killer cells by short-term stimulation of human peripheral blood lymphocytes (PBL). The induced killer cells showed a wide killing spectrum in vitro against human tumor cell lines (MKK-1, PRMI4788, NBT-2, ZR-7530, H-1, Hela, KB, HMV-1, PC-10, C-1). Human PBL stimulated for a short time by CMC-1 also showed a tumoricidal effect on tumor bearing (MKN-1, MKN-45) nude mice. These results suggest that CMC-1 may solve the problems with currently used LAK therapy and may provide easily applicable extracorporeal immunotherapy for cancer.

Current strategy for esophageal varices in Japan

Management of bleeding esophageal varices in Japan includes tamponade, sclerotherapy, devascularization, and shunt procedures. Sclerotherapy is the most widely used treatment in both acute and chronic management. The Japanese Research Society for Sclerotherapy of Esophageal Varices monitors and surveys this treatment method at 152 institutions. Extensive devascularization operations now include a thoracotomy less frequently than previously, and they have a 6.6% rebleeding rate in elective patients. Shunt operations are applied in 20% of cases of bleeding esophageal varices in Japan. Effective medical and surgical treatments have led to changes in management strategy and to diversity in treatment during the last decade. The timing of treatment, the nature of the disease, the patient's liver function, and the distribution of collaterals should all be considered in selecting treatment.

[A successfully treated case of aortouretric fistula associated with pelvic exenteration]

A 64-year-old man was hospitalized for massive bleeding from the cutaneous ureterostomy. He had undergone pelvic exenteration with the ureterostomy for rectal cancer invading the bladder five months previously and retrograde ureteric catheters were inserted bilaterally into the ureters. An aortography revealed a pseudoaneurysm of the abdominal aorta in the region transversed by the left ureter. He was successfully treated by en bloc resection of the aortoureteric fistula and the left ureter and repair of the aorta by Dacron patchplasty. Left nephrectomy was also performed because of pyelonephritis. He has had no signs of cancer recurrence or graft infection five years after this operation.

Congenital arteriovenous fistula in the gluteal region--a report of five cases

Five cases of congenital arteriovenous fistula in the gluteal region have been encountered in our department in the past 20 years. In all cases, the fistulous masses were in the connective tissue between the gluteal muscles and well-localized. Preoperative angiography showed the feeding arteries to be the superior gluteal, the inferior gluteal, and/or the lateral femoral circumflex arteries, and all the arteriovenous fistulae were excised almost completely with success. In this report, we emphasize the importance of precise estimation of the feeding arteries on preoperative angiography and ligating them before excising the fistulous masses, to ensure safe surgical treatment.

Carotid artery pseudoaneurysm following internal jugular vein cannulation

A case of right common carotid artery pseudoaneurysm following internal jugular vein cannulation is reported. The aneurysm appeared three days after removal of the catheter, which had been in the right internal jugular vein for three weeks. There was a pin-hole communication between the common carotid artery and the pseudoaneurysm, which was successfully obliterated by surgery. Carotid pseudoaneurysm formation is a rare complication of internal jugular vein cannulation, and there has been no report of its formation after apparently successful jugular vein cannulation. This complication is difficult to predict, and careful observation after removal of the catheter is mandatory.

A case of inflammatory pseudotumor of the gallbladder and bile duct

A rare cause of obstructive jaundice is presented. A 43-yr-old man developed jaundice with fever and weight loss, and showed lymphadenopathy, reticular shadows on chest roentgenogram, deranged liver function tests, eosinophilia, low values of complement proteins, and hypergammaglobulinemia. There was a stricture throughout the bilateral hepatic ducts and common hepatic and bile ducts with dilated intrahepatic bile ducts on imagings. The walls of the gallbladder and common bile duct were thickened due to diffuse granulomatous lesions of unknown etiology, composed mainly of plasma cells, lymphocytes, and fibroblasts identical with inflammatory pseudotumor. The same histological findings also were observed in the lung and lymph nodes. Jaundice disappeared, with reduced thickening of the common bile duct wall. All clinical and laboratory abnormalities subsided after high-dose prednisolone therapy, starting when dyspnea developed. There is no similar case in the literature.

A clinicopathologic study of aneurysm formation of glutaraldehyde-tanned human umbilical vein grafts

To clarify the process of graft degeneration and aneurysm formation we reviewed the angiographic and pathologic findings of three cases where aneurysms developed in glutaraldehyde-tanned human umbilical vein grafts. Seven aneurysms were detected in these three grafts 4 years after implantation. Six aneurysms originated from the bodies of the grafts and one originated from the factory-created anastomosis required for fabrication. Wrinkling and segmentation of the dilated graft documented by arteriography corresponded to mural dissection of the graft wall. Large protrusions near the aneurysms were revealed to be the transmurally dissected graft walls. At the site of dissection, blood escaped through the surrounding mesh of the graft to form a preaneurysmal change. Two aneurysms developed without breakdown of the outer mesh. The aneurysm of factory-created sutures was caused by tearing of the graft wall. Degeneration of human umbilical vein grafts, which appears to ensue inevitably with the passage of time after implantation, leads to the tear of the graft wall and transmural dissection to form aneurysm. In our department, candidates for human umbilical vein graft implantation have recently been restricted to the patients whose life expectancy is limited to only a few years because of the risk of aneurysm formation.

Twenty-five-year experiences with esophageal transection for esophageal varices

Results of 287 transthoracoabdominal esophageal transections (Sugiura procedure), 125 transthoracic esophageal transections, 48 transabdominal esophageal transections, and 58 other nonshunting operations performed during the past 25 years were analyzed. Overall operative mortality rate was 5.0% (26/518); however, it was observed only in patients with liver cirrhosis (7.0%) and was higher in emergency cases (23.3%) and patients classified Child C (17.1%). Two hundred two patients died during the follow-up period, which lasted 24 years; 33 patients died of rebleeding, 89 of hepatic failure, 65 of hepatoma, and 35 of other causes. Cumulative survival rates of patients after non-shunting operations differed significantly according to the nature of the original diseases and the severity of liver damage. The cumulative survival rate at 10 years in patients with extrahepatic portal obstruction was 90.7%, 77.6% in idiopathic portal hypertension, and 33.0% in liver cirrhosis and at 20 years, 85.6%, 37.9%, and 8.1% respectively. The cumulative survival rate at 5 years in patients classified Child A was 88.7%, 77.7% in Child B, and 39.5% in Child C, and at 10 years, 73.4%, 45.3%, and 14.1%, respectively. Esophageal transection can be performed safely and is recommended in patients classified Child A or B. Patients in Child C should be treated by endoscopic sclerotherapy and other conservative measures.