[Treatment outcomes with vinorelbine for metastatic breast cancer patients previously treated with both doxorubicin and docetaxel]

The purpose of this study was to evaluate the efficacy and toxicity of weekly vinorelbine (VNB) in patients with metastatic breast cancer previously treated with both adriamycin (ADM) and docetaxel (TXT). VNB was administered weekly at the dose 20 mg/m2 by i.v. infusion over 20 minutes followed by flushing the vein with 100 ml of normal saline. From June 1999 to August 2000, ten patients were enrolled in this study. Patient characteristics were that the cumulative doses (median) of previous ADM and TXT were 300 mg (range, 120-880 mg), 560 mg (range, 120-960 mg) respectively. The median number of metastatic sites was four, with poor performance status (ECOG 1-2: 40%, 3-4: 60%). The median cycles of weekly VNB were seven (range: 2-12). Two of 10 assessable patients obtained partial response, with an overall response rate of 20%. The main toxicity (NCI grade 4) was leukopenia in 10% of 10 patients. Phlebitis (grade 2) was observed in 4 of 10 patients (40%). VNB is an active agent against metastatic breast cancer pretreated with both ADM and TXT, possessing no severe toxicities.

Adenosquamous carcinoma of the remnant stomach: report of a case

We report herein the case of a 59-year-old man found to have adenosquamous carcinoma of the remnant stomach which demonstrated rapid progression. The patient was admitted to our hospital to undergo surgery for a papillary tumor of the remnant stomach. Total resection of the remnant stomach with lymph node dissection was performed, and pathological examination confirmed a diagnosis of adenosquamous carcinoma with invasion into the muscularis propria and lymph node metastasis around the perigastric areas. Multiple liver metastases were found 6 months after the operation, for which a right hepatectomy was performed with curative intent; however, he died 2 months later due to lymphangitis carcinomatosa of the lung.

The mechanism of hepatic graft protection against reperfusion injury by prostaglandin E1

The purpose of this study was to evaluate the effect of prostaglandin E1 (PGE1) on protecting against hepatic endothelial cell damage and increasing graft viability after cold preservation and reperfusion, using an isolated perfused rat liver (IPRL) model. The grafts were divided into three groups, according to the cold preservation time and PGE1 administration, namely: 4h preservation (group 1, n = 9), 6h preservation (group 2, n = 9), and 6h preservation followed by PGE1 infusion (group 3, n = 9). After cold storage, the grafts were put on the recirculating IPRL system, then reperfused for 120 min at 37 degrees C with oxygenated Krebs-Henseleit buffer containing hyaluronic acid (HA). To examine the function of the sinusoidal endothelial cells and hepatocytes, serial measurements of HA, tumor necrosis factor-alpha (TNFalpha), thromboxane B2 (TXB2), acid phosphatase, and conventional parameters in the perfusate were made. After perfusion, the trypan blue exclusion test was performed to assess the presence of any microscopic sinusoidal lining cell damage. In group 3, the bile output and HA clearance were significantly greater, while glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, TNFalpha, TXB2, and acid phosphatase in the perfusate were significantly lower than in group 2. Histologically, less endothelial cell damage and hepatocyte damage than in group 2 was also confirmed. These results therefore suggest that the improvement of hepatic graft viability by PGE1 administration is mainly due to sinusoidal endothelial cell protection.

[Chronic liver disease prevents the development of atherosclerosis in spite the risk factor]

We investigated whether hypertension contributes to the development of atheloscrelosis in patients with chronic liver disease. There were no significant differences with respect to the ordinary biochemical data of serum concentrations of both protein and lipid metabolites between the hypertension group (n = 21) and the non-hypertension group (n = 31). In the hypertension group, serum creatinine level and serum concentration of lipoprotein (a) were significantly higher than those in non-hypertension group. However, there was no significant difference between the two groups with respect to the atherogenic index (apolipoproteins B versus A1 ratio). Serum glutamic oxaloacetic transaminase activity was positively correlated with serum apolipoprotein E concentration, and inversely correlated with serum lipoprotein (a) concentration, in 52 patients with chronic liver disease. Active hepatitis in patients with chronic liver disease might retard the development of atherosclerosis.

Peritoneal collagen type IV concentration in adenocarcinoma of the gastrointestinal tract and its relationship to histological differentiation, metastasis, and survival

To determine if peritoneal collagen type IV levels could serve as a parameter for predicting metastasis and the subsequent course of disease, the concentration of collagen IV in the peritoneal fluid of 85 patients with adenocarcinoma of the gastrointestinal tract, including 50 with gastric cancer and 35 with colorectal cancer, was measured radioimmunologically. The peritoneal collagen type IV levels were elevated in 13 (26%) of the patients with gastric cancer, in 8 (23%) of those with colorectal cancer, and in none of the control subjects. The mean concentration of collagen type IV in tumors characterized by peritoneal dissemination was significantly higher than that in those without metastasis; however, there were no significant differences in the collagen type IV levels between tumors with and those without liver metastasis, or between those with and those without lymph node metastasis. There was a significant correlation between the peritoneal collagen type IV level and survival time in patients with clinically evident peritoneal dissemination. A positive correlation was also found between collagen type IV and carcinoembryonic antigen levels. In conclusion, the levels of peritoneal collagen type IV provide evidence of peritoneal dissemination, and can aid in the prediction of life expectancy in patients with adenocarcinomas of the gastrointestinal tract.

[Spontaneous regression of hepatocellular carcinoma: a case report]

A 65-year-old woman with hepatocellular carcinoma underwent right hepatic lobectomy. Her alpha-fetoprotein levels significantly dropped from 285,000 ng/ml to 3,100 ng/ml for one month without any preoperative treatment. The tumor thrombus in the portal vein showed complete necrosis, and lymphocytes infiltration around the main tumor were present microscopically. However, there was no necrotic area in the main tumor. This patient is living with no evidence of recurrence for 3 years and 6 months following hepatic resection.

Right hepatic lobectomy in elderly patients with hepatocellular carcinoma

BACKGROUND/AIMS

The outcome of hepatectomy in elderly patients with hepatocellular carcinoma have been reported, however neither the morphological nor functional hepatic regeneration in elderly patients have been fully investigated.

MATERIALS AND METHODS

Fifty-six patients with hepatocellular carcinoma, who underwent a right hepatic lobectomy over an 8-year period, were classified into three groups according to their age; group 1 (n = 7), more than 70 years of age; group 2 (n = 40), patients from 50 to 69 years of age and group 3 (n = 9), under 50 years of age. There were no significant differences regarding backgrounds or intra-operative parameters among the three groups. The perioperative hepatic function, postoperative complications and the regeneration rate of the remnant left lobe at 1 month after operation were compared.

RESULTS

No differences were found in the regeneration rate, however, the levels of the hepaplastin test and lecithin:cholesterol acyltransferase at 7 days after hepatectomy in group 1 (31.3%, 8.8 U) were significantly lower than those in groups 2 and 3 (37.4%, 18.4 U; 47.9%, 29.4 U, respectively). The incidence of hospital death due to hepatic failure in group 1 (42.9%) was also significantly higher than that of group 2 (5.0%) or group 3 (0%).

CONCLUSION

The decline of postoperative protein synthesis regardless of the voluminal regeneration is a characteristic of the elderly. This phenomenon might thus be an important promoter of postoperative hepatic failure which remains unpredictable using any type of examination. Therefore, at this time, a major hepatectomy is not recommended as a viable treatment alternative in the elderly.

Circulating intercellular adhesion molecule-1 in patients with hepatocellular carcinoma before and after hepatic resection

BACKGROUND/AIMS

We recently demonstrated that an activated inflammation in a non-tumorous portion was a significant risk factor for recurrence in patients with small hepatocellular carcinoma. The purpose of this study is to provide further proof for this mechanism by explaining the relation ship between the post-operative hepatitis state and intrahepatic recurrence.

PATIENTS AND METHODS

We used an enzyme-linked immunosorbent assay to detect cICAM-1 in the serum of 18 patients with hepatocellular carcinoma before and after hepatic resection.

RESULTS

A complete surgical resection of the tumor masses did not result in a significant reduction of cICAM-1 levels. The levels of aminotransferase after hepatic resection in patients with an increased level of cICAM-1 in the post operative period (n = 7) were much higher than in patients with a decreased level of cICAM-1 (n = 11) (p < 0.05). The 1-, 2- and 3- year disease free survival rates in the former group were 42.9%, 14.3% and 0%, respectively, and those in the later group were 72.7%, 54.5% and 54.5%, respectively (p < 0.05).

CONCLUSIONS

The enhancement of inflammation in the remnant liver tissue is related to intrahepatic recurrence after hepatic resection through adhesion molecules, such as cICAM-1.

Indications for palliative reduction surgery in advanced hepatocellular carcinoma. The use of a remnant tumor index

OBJECTIVES

To clarify the indications for and the significance of palliative reduction surgery in the multidisciplinary treatment of advanced hepatocellular carcinoma (HCC) and to propose the use of a remnant tumor index (RTI) as a simplified criterion for palliative reduction surgery in cases of advanced HCC.

DESIGN

A comparison of survival based on the RTI.

SETTING

A large university hospital in Japan.

PATIENTS

Twenty-five patients with advanced HCC who underwent palliative reduction surgery were divided into 3 groups as follows: group 1 (n = 9), the remnant tumor after operation existed only in the liver and the RTI was less than 5.0; group 2 (n = 11), the remnant tumor after operation existed only in the liver and the RTI was greater than 5.0; and group 3 (n = 5), extrahepatic metastatic tumor existed after operation.

MAIN OUTCOME MEASURES

Pathological findings and survival rate after surgery.

RESULTS

There was no significant difference in the degree of macroscopic intrahepatic metastases among the 3 groups; however, both the portal vein invasion and the histological grade tended to be more severe in groups 2 and 3. The respective 1-year and 3-year survival rates for group 1 were 67% and 33%, and those for group 2 were 21% and 0%. There were no survivors in group 3 at 1 year after surgery. Significant differences were found in the survival rates between groups 1 and 2 (P < .05), and between groups 1 and 3 (P < .05).

CONCLUSION

Palliative reduction surgery for advanced HCC is only considered effective for patients with both an RTI of less than 5.0 and no extrahepatic metastasis.

Impaired systemic immunity and frequent infection in patients with Candida antigen after hepatectomy

BACKGROUND/AIMS

Infection after hepatic resection constitutes a major cause of morbidity and mortality. We examined the role of Candida antigen in systemic immunity and the infectious complications after hepatectomy.

MATERIAL AND METHODS

In 25 hepatectomized patients, the Candida antigen titers were measured by a latex agglutination test (CAND-TEC). In the patients with Candida antigen (n = 10; 40%) and those without (n = 15; 60%), multiple immunological parameters, including the total lymphocyte count, lymphocyte subpopulations, phytohemagglutinin (PHA) response, and natural killer (NK) activity, and the incidence of infectious complications were compared.

RESULTS

In the preoperative and operative parameters, there were no significant differences between the two groups. In the postoperative immune parameters, a significant attenuation in the total lymphocyte number (p < 0.01) and NK activity (p < 0.01) was observed in the patients with Candida antigen, compared with the findings in patients without Candida antigen. A bacterial infection was identified in 5 of 10 patients (50.0%) with Candida antigen, and in 1 of 15 patients (6.7%) without Candida antigen (p < 0.05). In contrast, the Candida culture was negative for all patients.

CONCLUSIONS

Both a profound attenuation of systemic immunity and frequent bacterial infections were observed in the hepatectomized patients with Candida antigen.

Relationship between hormone receptor levels and cell-kinetics in human colorectal cancer

BACKGROUND

This study was done to determine the potential role of sex steroid hormone receptors in the development of human colorectal cancer.

METHOD

Receptors for estrogen (ER) and progesterone(PgR) were investigated in surgical specimens from 22 patients with colorectal cancer, using enzyme immunoassay. These values were examined in relation to cell kinetics parameters determined by DNA flow cytometry.

RESULTS

ER and PgR were detected in 27% and 41%, respectively. There were no significant differences in the expression of ER or PgR according to the age, sex of the patients, tumor size, location, histological differentiation and lymph node metastasis. Although ER status appeared to be independent of DNA parameters, there were better correlations of PgR-negative tumors with increased hyperaneuploid levels. There were significantly higher values of heterogeneity index score in PgR-negative tumors compared with PgR-positive tumors. In the multiple regression analysis, PgR levels proved to be a major independent factor for changes in DNA index and heterogeneity index score.

CONCLUSION

The PgR status is a critical factor for determining the proliferative activity of colorectal cancer tissue and may play a biological role in regulating the growth of the tumor.

A comparison of open and laparoscopic cholecystectomy for patients with cirrhosis

To evaluate the benefits of performing laparoscopic cholecystectomy (LC) in patients with cirrhosis, data on 13 patients with liver cirrhosis who underwent cholecystectomy for gallstones between 1989 and 1995 were retrospectively collected from charts filed at Fukuoka City Hospital. These 13 patients were classified into two groups; one, comprised of 7 who underwent LC, and another, comprised of 6 who underwent open cholecystectomy (OC). No statistical differences were observed in the duration of surgery or the intraoperative blood loss between the two groups; however, the C-reactive protein (CRP) level in the serum was significantly higher in the OC group than in the LC group. LC was followed by a significantly earlier resumption of a normal diet (P < 0.05) and a shorter hospital stay (P < 0.05) in comparison to OC. All of the patients who underwent OC had an uneventful clinical course; however, one of the patients who underwent LC suffered from intractable ascites postoperatively. The difference in the cost of hospitalization between the two groups was not statistically significant. These findings suggest that the therapeutic significance of performing LC in patients with cirrhosis should be assessed after carefully evaluating all factors including mortality, morbidity, and cost-effectiveness. Thus, further controlled trials are necessary.

Case report: primary splenic non-Hodgkin's B cell lymphoma in a patient with chronic hepatitis C

A case of primary splenic lymphoma in a patient with chronic hepatitis C is reported. A 69-year-old man with chronic hepatitis C was admitted to Fukuoka City Hospital for evaluation of an enlarging splenic tumour. In the spleen, ultrasonographic examination revealed a hypoechoic tumour and computed tomography demonstrated a non-enhancing low density area measuring 7 cm in diameter; coeliac angiography revealed a hypovascular tumour. Gallium scintigraphy showed uptake of the radioisotope in the splenic tumour. A splenectomy was performed and the morphological and immunohistochemical findings of this tumour were compatible with those of non-Hodgin's B cell lymphoma. Recently, cases of malignant B cell lymphoma associated with hepatitis C virus infection have been reported. Lymphotropism of hepatitis C virus may play a pathological role in the development of non-Hodgkin's lymphoma. We emphasize the importance of considering lymphoma in the differential diagnosis of extrahepatic disorders during the course of chronic hepatitis C virus infections.

Clinicopathologic features and prognosis of resected hepatocellular carcinomas of varied sizes with special reference to proliferating cell nuclear antigen

BACKGROUND

Proliferating cell nuclear antigen (PCNA) is an intranuclear protein that is linked closely to the cell cycle. An immunohistochemical study was performed on the expression of PCNA in various sized hepatocellular carcinomas (HCCs) to determine the relation between the proliferative activity of cancer cells and prognosis.

METHODS

One hundred forty-one neoplasms resected from 141 patients who underwent hepatic surgery for HCC at Kyushu University hospital from April, 1991, to July, 1993, were studied immunohistochemically using monoclonal antibody for PCNA (PC10), and analyzed for a possible correlation between PCNA labeling index (PCNA-LI) and the prognosis of patients with HCC.

RESULTS

Proliferating cell nuclear antigen reactive cancer cells were observed throughout the HCC. The PCNA-LI ranged from 1.2%-91.6%, with a mean of 37.7%. The high PCNA-LI (> 37.7) group showed a significantly higher incidence of tumor thrombus in the portal vein, higher Edmondson's Grade, and a higher recurrence rate than the low PCNA-LI (< 37.7) group. Hepatocellular Carcinomas were divided into three groups according to tumor size. Based on the clinicopathologic findings, in small (< 30 mm) HCCs, the high PCNA-LI (> 29.0) group showed a significant higher Edmondson's grade and a higher recurrence rate than the low PCNA-LI (< 29.0) group. In medium (30-60 mm) HCCs, the high PCNA-LI (> 36.1) group showed a significantly higher recurrence rate than the low PCNA-LI (< 36.1) group, although there was no difference in the pathologic findings between the high (> 59.4) and low (< 59.4) PCNA-LI groups.

CONCLUSIONS

Proliferating cell nuclear antigen labeling index is closely related to cell differentiation and the prognosis of HCC. Furthermore, PCNA-LI was found to be useful in predicting the intrahepatic spread and prognosis of small (< 30 mm) and medium (30-60 mm) but not large (> 60 mm) HCCs.

Thromboxane A2 in preservation-reperfusion injury: the effect of thromboxane A2 synthetase inhibitor

It has been suggested that thromboxane A2 (TXA) plays important roles in preservation/reperfusion organ injury. In this report, we investigated the prostanoid release from the liver and the effect of a selective TXA synthetase inhibitor (E)-3-[p-(1H-imidazol-yl-methyl)-phenyl]-2-propenoic acid, OKY046) during cold preservation and after reperfusion. Rat livers were preserved in lactated Ringer's solution at 4 degrees C for 2, 4, and 6 hr and perfused with oxygenated Krebs-Henseleit buffer using recirculating perfusion system, and prostanoids were measured during cold preservation and after reperfusion. OKY046 and a novel TXA receptor antagonist [(9,11), (11,12)-Dideoxa-9a, 11a-dimethyl-methano-11,12-methano-13,14-dihydro-13-aza-14-oxo-15-cyclo pentyl-16,17,18,19,20-pentanor-15-epi-TXA, ONO3708] were added into the preservation solution and perfusate. Along with the preservation time, both the production and release of TXA was observed to increase; however, almost all the produced TXA was stored in the liver tissue. Afterwards, the stored TXA was released into perfusate in 15 min after reperfusion. OKY046 significantly decreased both the production and release of TXA. In addition, OKY046 improved the histological damage and trypan blue uptake of liver cells. Our results demonstrate that TXA, stored in the liver during preservation, might therefore be a potential trigger of reperfusion injury, and as a result, OKY046 reduces reperfusion injury by decreasing the production of TXA during preservation.

The role of prostanoid in hepatic damage during hepatectomy

BACKGROUND/AIMS

The aim of this study in hepatectomy is to investigate whether or not hepatic ischemia elevates the serum prostanoid levels, and whether or not thromboxane A2 (TXA2) synthetase inhibitor (OKY 046) improves hepatic damage.

MATERIALS AND METHODS

The prostanoid levels were measured in 22 hepatectomy cases. The beneficial effects of thromboxane A2 synthetase inhibitor were examined in cases who underwent hepatectomy under hemihepatic vascular control. The total prostanoid levels (6-keto PG Fla+ PGE2 + TXB2) were measured in 22 cases before and after hepatectomy. The hepatic ischemic time (HIT) was defined as the time required to perform a hepatic mobilization plus the right hemihepatic vascular control technique.

RESULTS

The total prostanoid levels increased after hepatectomy (P < 0.01). The changes in the total prostanoid levels positively correlated with the HIT (P < 0.01). The 17 cases who underwent hepatectomy with the HIT were randomly divided into 2 groups; the OKY group (n = 9), OKY 046 (0.2 mg/kg/hr), the control group (n = 8); no drug was given. The OKY 046 administration reduced the TXB2 levels (P < 0.01), without any changes in the PGE2, or 6-keto PGF1a levels. The serum glutamic oxaloacetic transaminase levels after operation were lower, and the hepaplastin tests were higher in the OKY group than those of the control (P < 0.05).

CONCLUSION

These results demonstrated that hepatectomy under ischemia elevated the prostanoid levels. OKY 046 significantly reduced the TXB2 levels and the degree of hepatic damage in hepatectomy under ischemia.

Results of 280 liver resections for hepatocellular carcinoma

OBJECTIVE

To evaluate the recent results of liver resection in patients with hepatocellular carcinoma.

DESIGN

Retrospective study.

SETTING

A university hospital in Japan.

PATIENTS

Two hundred eighty patients who underwent liver resection with complete extirpation of hepatocellular carcinoma from 1985 to 1993.

MAIN OUTCOME MEASURES

Morbidity and survival after operation and the pathologic features of hepatocellular carcinoma according to the TNM classification of the International Union Against Cancer.

RESULTS

More than 40% of the patients with stages I and II disease underwent a partial resection of the liver, whereas 50% of those with stages III and IVA were operated on with more than a bisegmentectomy. Fifty percent of all patients had no postoperative complications. The morbidities included intra-abdominal abscess (7%), bile leakage (5%), and hepatic failure (4%, of whom half died; mortality rate, 2%). Histopathologically, 32% of the stage I tumors were well differentiated (grade 1), while, in stage III, 56% had portal invasion and 61% had daughter lesions in the liver. The cumulative survival rates of patients with stages I, II, and III disease and all patients at 5 years were 69%, 52%, 32%, and 50%, respectively, while the disease-free survival rates at 5 years were 38%, 34%, 17%, and 29%, respectively.

CONCLUSION

The recent results of liver resection for hepatocellular carcinoma are generally satisfactory; however, the recurrence rate is still high.

Laparoscopic hepatic resection for hepatocellular carcinoma

Despite recent progress in diagnostics for hepatocellular carcinoma, the rate of resectability remains low, mainly because of the advancement of the underlying liver disease. We report a case of a 54-year-old man with a hepatocellular carcinoma and poor liver function that was treated successfully with a laparoscopic hepatic resection. Laparoscopic hepatic resection is considered to be feasible with the aid of an ultrasonic dissector and a microwave coagulator; however, close attention should be paid to the development of air embolism and hepatic vein injury.

Significance of hyaluronic acid for evaluation of hepatic endothelial cell damage after cold preservation/reperfusion

Serum hyaluronic acid (HA) levels during or after liver transplantation can reflect graft viability in animal models. Decreased HA clearance in nonviable grafts seems to reflect hepatic endothelial cell damage induced by cold preservation/reperfusion. Therefore, we examined the relationship between HA clearance and endothelial cell damage, using an isolated perfused rat liver (IPRL) model. The grafts were separated into four groups, according to cold preservation time: minimal storage (

CONTROL

n = 9), 4-hr preservation (n = 9), 5-hr preservation (n = 8), 6-hr preservation (n = 9). After cold storage, grafts were put on the recirculating IPRL system and then reperfused for 120 min with 37 degrees C oxygenated Krebs-Henseleit buffer, containing HA and sodium taurocholate. To examine the function of sinusoidal endothelial cells and hepatocytes, serial measurements of HA, total bile acids, and conventional parameters in the perfusate were taken. After the perfusion, a trypan blue exclusion test was done to assess the microscopic sinusoidal lining cell (SLC) damage. HA clearance from the perfusate showed a preservation time-dependent decrease which clearly distinguished between 4- and 6-hr preserved grafts. Trypan blue uptake ratio of SLC increased in accordance with preservation time. HA clearance at 120 min after reperfusion showed a highly significant correlation with histologically assessed SLC damage. These results suggest that HA is useful to evaluate the extent of endothelial cell damage after cold storage and reperfusion. The significance of HA as a predictor of graft viability is also confirmed.

Partial hepatic grafting: porcine study on critical volume reduction

BACKGROUND

The safe limit of volume reduction in partial hepatic transplantation, including extracorporeal hepatic resection, remains to be clarified. This study evaluated such a limit and pathologic features associated with transplantation of a less than critical volume.

METHODS

Partial hepatic grafting was performed in a porcine orthotopic autotransplantation model. According to the remnant liver volume, animals were classified into three groups: group 1, 73.8% +/- 4.2% (SD); group 2, 52.6% +/- 6.7%; and group 3, 29.4% +/- 6.7% of the whole liver (n = 5 each).

RESULTS

Three-day survival was achieved in five (100%), four (80%), and zero animals, respectively. All animals in group 3 died of graft nonfunction; their intraoperative clearance of the total bile acids was significantly worse than the other groups (p < 0.01). After operation the clearance of the total bile acids and hyaluronic acid, which is selectively cleared by hepatic endothelial cells, was significantly better in group 1 than group 2 (p < 0.01 and < 0.05, respectively). On histologic examination postperfusion biopsy specimens of group 3 exhibited severe ischemic changes and portosinusoidal hyperemia, whereas that of groups 1 and 2 exhibited only mild ischemic damages.

CONCLUSIONS

Transplantation of less than 30% of expected full liver volume could lead to primary graft nonfunction after partial hepatic grafting.

A quick and simple technique for selective control of hepatic arterial bleeding

A quick and simple technique for the selective control of hepatic arterial inflow is described for hepatic resections or hepatic hilar lymph node dissection which allows arterial hemostasis without causing splanchnic congestion.

Influence of blood transfusion on postoperative long-term liver function in patients with hepatocellular carcinoma

BACKGROUND/AIMS

To research for possible adverse effects of blood transfusion on liver function at a relatively long term after hepatic resection, liver function tests at one and two years after the surgery were studied in patients with hepatocellular carcinoma.

MATERIALS AND METHODS

Seventy-one patients with no evidence of cancer recurrence during two years after the surgery were selected for this retrospective analysis. Patients were divided into two groups depending on perioperative blood transfusion: those who received blood transfusion (BT(+), n = 38), and those without blood transfusion (BT(-), n = 33).

RESULTS

There were no statistical difference in the preoperative clinical features including liver function tests except decreased prothrombin time index (P < 0.01) and larger amount of intraoperative blood loss (P < 0.01) in BT(+) group. Platelet counts at 2 year after the surgery were significantly higher in the BT(-) group (P < 0.05). Two-way ANOVA showed no significant difference in liver function tests between the two groups. In multiple regression analysis, blood transfusion significantly correlated with serum total bilirubin at 1 year, but did not at 2 years after the surgery.

CONCLUSIONS

The influence of blood transfusion in the patients with hepatocellular carcinoma was considered to be minimum within 2 years after hepatectomy.

Clinicopathologic features and prognosis of resected hepatocellular carcinomas of varied sizes with special reference to proliferating cell nuclear antigen

BACKGROUND

Proliferating cell nuclear antigen (PCNA) is an intranuclear protein that is linked closely to the cell cycle. An immunohistochemical study was performed on the expression of PCNA in various sized hepatocellular carcinomas (HCCs) to determine the relation between the proliferative activity of cancer cells and prognosis.

METHODS

One hundred forty-one neoplasms resected from 141 patients who underwent hepatic surgery for HCC at Kyushu University hospital from April, 1991, to July, 1993, were studied immunohistochemically using monoclonal antibody for PCNA (PC10), and analyzed for a possible correlation between PCNA labeling index (PCNA-LI) and the prognosis of patients with HCC.

RESULTS

Proliferating cell nuclear antigen reactive cancer cells were observed throughout the HCC. The PCNA-LI ranged from 1.2%-91.6%, with a mean of 37.7%. The high PCNA-LI (> 37.7) group showed a significantly higher incidence of tumor thrombus in the portal vein, higher Edmondson's Grade, and a higher recurrence rate than the low PCNA-LI (< 37.7) group. Hepatocellular Carcinomas were divided into three groups according to tumor size. Based on the clinicopathologic findings, in small (< 30 mm) HCCs, the high PCNA-LI (> 29.0) group showed a significant higher Edmondson's grade and a higher recurrence rate than the low PCNA-LI (< 29.0) group. In medium (30-60 mm) HCCs, the high PCNA-LI (> 36.1) group showed a significantly higher recurrence rate than the low PCNA-LI (< 36.1) group, although there was no difference in the pathologic findings between the high (> 59.4) and low (< 59.4) PCNA-LI groups.

CONCLUSIONS

Proliferating cell nuclear antigen labeling index is closely related to cell differentiation and the prognosis of HCC. Furthermore, PCNA-LI was found to be useful in predicting the intrahepatic spread and prognosis of small (< 30 mm) and medium (30-60 mm) but not large (> 60 mm) HCCs.

A comparison of the surgical results in patients with hepatitis B versus hepatitis C-related hepatocellular carcinoma

To assess the differences in the surgical results between patients with hepatitis B- and hepatitis C-related hepatocellular carcinoma (HCC), the operative outcomes of 30 patients with hepatitis B surface antigen (HBsAg)-positive (the B-HCC group) and 96 patients with hepatitis C antibody (HCVAb)-positive (the C-HCC group), who had undergone hepatic resection from 1989 to 1993, were compared. The mean age of the patients in the C-HCC group was higher than that in the B-HCC group (61.7 years vs. 57.0 years, P < .05). The C-HCC group demonstrated both a greater decrease in liver function and a larger enhancement of inflammatory changes in the liver under a pathological examination (the current rate of active hepatitis: 69% vs. 27%, P < .001). There was also a higher incidence of total postoperative complications in the C-HCC group (60% vs. 37%, P < .05); however, regarding each individual complication, the rate was similar between the two groups. Two of the six patients with postoperative hepatic failure in the C-HCC group died. The mortality rate in the C-HCC group was 2%, but no operative death was encountered in the B-HCC group. The crude survival and the disease-free survival rates at 5 years were similar, 61.8% and 46.2% in the B-HCC group and 52.8% and 23.2% in the C-HCC group, respectively. The patterns of recurrence were also similar in both groups. The pathological features of HCC were similar between the two groups. In conclusion, the surgical results between the two groups were almost identical.(ABSTRACT TRUNCATED AT 250 WORDS)

Des-gamma-carboxy prothrombin and proliferative activity of hepatocellular carcinoma

BACKGROUND

Des-gamma-carboxy prothrombin (DCP) is a useful marker for the prognosis of hepatocellular carcinoma (HCC). In this report we investigated the relationship between the positivity of DCP and proliferative activity of HCC and discuss the cause of poor prognosis of DCP-positive HCC.

METHODS

Immunohistochemical and clinicopathologic study was done in 114 patients with resected HCC measuring less than 6 cm in diameter by using monoclonal antibody for proliferating cell nuclear antigen (PCNA).

RESULTS

PCNA labeling index (PCNA-LI) was significantly higher in the patients with DCP-positive HCC than in those with DCP-negative HCC; also a positive correlation was noted between the PCNA-LI and the DCP level. We divided patients into two groups according to the PCNA-LI. In the high PCNA-LI group the patients with DCP-positive HCC exhibited a higher PCNA-LI than did the patients with DCP-negative HCC. As for pathologic prognostic factors, the DCP-positive high PCNA-LI group showed the highest incidence of tumor thrombus of the portal vein and intrahepatic metastasis while also exhibiting the lowest recurrence-freedom rate. From multivariate analysis we find that DCP, as well as PCNA-LI, is one of the risk factors for recurrence of HCC after hepatectomy.

CONCLUSIONS

Our results thus suggest that DCP-positive HCC showed high PCNA-LI, and this might be the main cause for early intrahepatic spread and poor prognosis of DCP-positive HCC.

A new approach for liver surgery. Transdiaphragmatic hepatectomy for cirrhotic patients with hepatocellular carcinoma

OBJECTIVE

To clarify the efficacy of transdiaphragmatic hepatectomy.

DESIGN

Transdiaphragmatic hepatectomy and transabdominal hepatectomy were retrospectively compared.

SETTING

This technique is used in cirrhotic patients with hepatocellular carcinoma located near the diaphragm.

PATIENTS

Thirty-six cirrhotic patients with hepatocellular carcinoma who underwent transdiaphragmatic (group 1 [n = 8]) or transabdominal (group 2 [n = 28]) hepatectomies between April 1985 and March 1993 were investigated. All patients underwent a partial hepatectomy for hepatocellular carcinoma less than 3 cm in diameter located in segment VII or VIII or near the confluence of the hepatic veins.

MAIN OUTCOME MEASURE

Intraoperative and postoperative clinical parameters, including operative time, blood loss, and length of hospital stay.

RESULTS

The mean +/- SD operative time was significantly shorter in group 1 (184 +/- 25 minutes) than in group 2 (270 +/- 79 minutes). The intraoperative blood loss was significantly smaller in group 1 (857 +/- 622 mL) than in group 2 (1318 +/- 926 mL). The rate of postoperative complications was lower in group 1 (13% [n = 1]) than in group 2 (43% [n = 12]). The postoperative hospital stay was significantly shorter in group 1 (16 +/- 5 days) than in group 2 (23 +/- 16 days).

CONCLUSIONS

Transdiaphragmatic hepatectomy is a useful technique for cirrhotic patients with hepatocellular carcinoma located near the diaphragm.

Outpatient follow-up system using a personal computer for patients with hepatocellular carcinoma after surgery

A simple outpatient follow-up system was developed with a laptop personal computer to assist management of patients with hepatocellular carcinoma after hepatic resections. Since it is based on a non-relational database program and the graphical user interface of Macintosh operating system, those who are not a specialist of the computer operation can use it. It is helpful to promptly recognize current status and problems of the patients, to diagnose recurrences of the disease and to prevent lost from follow-up cases. A portability of the computer also facilitates utilization of these data everywhere, such as in clinical conferences and laboratories.

Beneficial effect of thromboxane A2 synthetase inhibitor on cold-stored rat liver

Prostanoids such as prostacyclin and thromboxane A2 have recently been suggested to play important roles in cold ischemia/reperfusion injury. The purpose of this study was to investigate the effect of thromboxane A2 synthetase inhibitor (OKY-046) on cold-stored livers of the rat using an ex vivo perfusion system. Addition of OKY-046 to preservation solution and the perfusate of livers stored cold (4 degrees C) in lactated Ringer's solution resulted in significantly lower glutamic pyruvic transaminase release (3.01 +/- 0.86 IU/g liver vs. 1.79 +/- 1.08 IU/g liver at 120 min after perfusion; P < 0.05), reduced perfusate ammonia levels (8.51 +/- 2.51 micrograms/dl/g liver vs. 3.62 +/- 1.71 micrograms/dl/g liver at 60 min; P < 0.05 and thereafter), lower perfusate taurocholate levels (0.63 +/- 0.10 vs. 0.18 +/- 0.05 at 15 min; P < 0.01 and thereafter), perfusate hyaluronic acid clearance (0.934 +/- 0.132 vs. 0.76 +/- 0.127 at 30 min; P < 0.05 and thereafter), and a reduced number of trypan blue-positive sinusoidal lining cells (50.1 +/- 9.9%; vs. 17.4 +/- 7.0%; P < 0.01). Histologically, the liver preserved for 6 hr in simple cold lactated Ringer's solution exhibited interstitial edema, various degrees of hepatocyte swelling, and sinusoidal stenosis, as well as dilatation, while the livers treated with OKY-046 demonstrated much less hepatocyte swelling, and change in sinusoidal width was nearly absent. We conclude that OKY-046 reduces post-preservation reoxygenation injury by protecting sinusoidal endothelial cells and hepatocytes.

Initiation of a fibrinolytic system in hepatic resection: the roles of tissue-type plasminogen activator and plasminogen activator inhibitor-1

The factors related to the initiation of fibrinolysis, especially with regard to the tissue-type plasminogen activator (tPA) and the plasminogen activator inhibitor-1 (PAI-1), were investigated in 15 patients who underwent hepatic resection, and the findings were compared between those with normal livers and those with diseased livers. It was found that tPA increased before hepatic division, whereas PAI-1 increased after hepatic division and reached a peak immediately following the operation. Plasminogen decreased during hepatectomy, reaching its lowest point on postoperative day 1, and increasing later. Decreased levels of both plasminogen and the alpha 2-plasmin inhibitor were considered to be partly due to plasmin formation in the blood. Patients with a diseased liver tended to have higher intraoperative values of euglobulin lysis activity and higher postoperative values of plasminogen activator, but significantly lower postoperative values of alpha 2-plasmin inhibitor than those with a normal liver. The results of this study suggest that activation of the fibrinolytic system occurs both during hepatectomy and in the early postoperative period, and that patients with a diseased liver are prone to develop hyperfibrinolysis during hepatectomy. Moreover, the increased levels of both tPA and PAI-1 can serve as one of the most sensitive markers for the vital reaction against surgical stress.

Serum hyaluronic acid for the assessment of graft viability in porcine liver transplantation

For the assessment of graft viability, serum hyaluronic acid (HA) levels during porcine orthotopic liver transplantation were measured in two groups: group 1 (viable: n = 5) in which allografts were transplanted following a minimal cold (4 degrees C) preservation, and group 2 (nonviable: n = 4) in which allografts were transplanted after cold static storage (4 degrees C) for 24 h in University of Wisconsin solution. The changes in the HA levels reached a significant difference between the two groups at 30 min after reperfusion (P < 0.02). In group 1, all animals survived for over 4 days, while all animals in group 2 died within 24 h. The serum HA also demonstrated a significant correlation with prothrombin time, beta-glucuronidase, and aspartate aminotransferase at 120 min after reperfusion. These results suggest that the measurement of serum HA is a potentially effective index for evaluating hepatic allograft viability.

The significance of tissue-type plasminogen activator for pretransplant assessment of liver graft viability: analysis of effluent from the graft in rats

We studied the significance of tissue-type plasminogen activator (tPA) on the pretransplant assessment of liver graft viability in rats. The liver grafts were excised from the rats and then divided into two groups. Group 1 consisted of grafts preserved for 4 h in chilled, lactated Ringer's solution (4 degrees C) and group 2 consisted of grafts preserved for 6 h in the same solution. After preservation, the liver grafts were flushed out through the portal vein using 5 ml of chilled, lactated Ringer's solution (4 degrees C). The entire effluent from the hepatic veins was then collected and analyzed for tPA, ammonia, lactate, pyruvate, glutamic oxaloacetic transaminase, and lactate dehydrogenase. The tPA concentration of effluent in group 2 was significantly higher than that in group 1 (0.80 +/- 0.23 ng/ml vs 0.42 +/- 0.08 ng/ml, P < 0.05). The lactate, pyruvate, and ammonia levels in group 2 were also higher than those in group 1 (134 +/- 13 mg/dl vs 120 +/- 2 mg/dl, 0.34 +/- 0.40 mg/dl vs 0.09 +/- 0.01 mg/dl, and 183 +/- 79 micrograms/dl vs 102 +/- 40 micrograms/dl, respectively). However, the discriminative power of tPA was stronger than that of the other parameters. Histological findings revealed a higher number of trypan blue-stained sinusoidal lining cells that were detached and swollen in group 2. We conclude that the amount of tPA in the effluent flushed from the graft can serve as a sensitive and reliable indicator of cold-preserved liver grafts in rats.

Protein induced by vitamin K absence or antagonist II as a prognostic marker in hepatocellular carcinoma. Comparison with alpha-fetoprotein

BACKGROUND

Protein induced by vitamin K absence or antagonist II (PIVKA-II) was widely used as a diagnostic marker for hepatocellular carcinoma (HCC), however, its prognostic value is unclear. The authors evaluated PIVKA-II clinicopathologically as a prognostic marker for HCC.

METHODS

The relationship between pathologic prognostic factors and plasma PIVKA-II and alpha-fetoprotein (AFP) was investigated in 72 patients with resectable HCC measuring less than 6 cm in greatest dimension.

RESULTS

PIVKA-II shows significantly lower sensitivity, but higher specificity than AFP, and the use of these two complementary markers appears to be useful in the diagnosis of HCC. The frequencies of intrahepatic metastasis, portal vein tumor thrombus, hepatic vein tumor thrombus, and capsular infiltration were significantly higher in patients with positive PIVKA-II than in those with negative-PIVKA-II, and the recurrence-free rate was significantly lower in patients with positive rather than with negative PIVKA-II. However, there were no significant differences between the patients who were AFP positive and those who were AFP negative in pathologic prognostic factors and the recurrence-free rate. From univariate and multivariate analyses, the authors find that PIVKA-II is one of the risk factors for recurrence of HCC after hepatectomy.

CONCLUSIONS

PIVKA-II may be a useful marker for the prediction of intrahepatic spread and for the prognosis of HCC. In addition, PIVKA-II-positive patients, thus, need aggressive postoperative adjuvant therapy for undetectable residual tumors and careful postoperative monitoring to enable the early recognition of recurrence.

Repeat hepatectomy for recurrent hepatocellular carcinoma

BACKGROUND

The significance of repeat hepatectomy for recurrent hepatocellular carcinoma remains controversial. Therefore the aim of this study was to reevaluate both the survival and the surgical risks of repeat hepatectomy.

METHODS

The significance of repeat hepatectomy including the survival and the surgical risks for recurrent hepatocellular carcinoma were investigated with 21 patients who underwent a curative repeat hepatectomy during the period between May 1975 and July 1993. For a comparison of survival, 253 patients who underwent a curative primary hepatectomy during the period between April 1985 and July 1993 were used. Moreover, the preoperative liver function tests were also compared between the first and second hepatectomies.

RESULTS

Regarding the preoperative liver function tests, the indocyanine green dye excretion rate at 15 minutes in the second hepatectomy (18.7% +/- 8.7%) was significantly higher than that in the first hepatectomy (14.7% +/- 5.9%). With regard to the surgical risks, there was no difference in the clinical parameters for blood loss, operation time, and the incidence of postoperative complications between the first and second hepatectomies. The postoperative hospital stay for the second hepatectomies was relatively shorter than that for the first hepatectomies. In addition, the patient's survival and disease-free survival after a curative repeat hepatectomy were almost identical to that after a curative primary hepatectomy.

CONCLUSIONS

A curative repeat hepatectomy is thus considered to be the most effective therapeutic modality for recurrent hepatocellular carcinoma.

Major hepatic resection in patients with a prosthetic heart valve receiving anticoagulation treatment

We experienced two patients with a prosthetic heart valve, who underwent hepatic resection for hepatoma while on anticoagulation therapy. Patients with a prosthetic heart valve have the following characteristics; an increased risk of thromboembolism due to diminished anticoagulation in the perioperative period, a greater risk of endocarditis due to the artificial material in the heart, and impaired cardiopulmonary function including possible arrhythmia and heart failure. Furthermore, when such patients also have liver cirrhosis with a hepatoma, there is an increased risk of perioperative bleeding while on anticoagulation due to coagulopathy and also a risk of infection due to decreased cellular immunity. Patients with a prosthetic heart valve therefore require special care and attention whenever they have to undergo hepatic resection. With respect to anticoagulation, a minimal level is required to prevent bleeding and thromboembolism. Warfarin being administered preoperatively may be switched to heparin while closely monitoring the activated clotting time (biomaterial valve: 130-150 sec, non-biomaterial valve: 150-180 sec); the heparin should then be changed back to warfarin immediately after starting oral intake following operation. For the prevention of infection, a broad spectrum antibiotic should be used prophylactically both intra-operatively and postoperatively. The cardiopulmonary function must also be carefully monitored. For the assessment of postoperative liver function, lecithin: cholesterol acyltransferase, serum bilirubin and albumin are useful because there is no relevance of coagulation parameters such as prothrombin time under anticoagulation.

Protein induced by vitamin K absence or antagonist II as a prognostic marker in hepatocellular carcinoma. Comparison with alpha-fetoprotein

BACKGROUND

Protein induced by vitamin K absence or antagonist II (PIVKA-II) was widely used as a diagnostic marker for hepatocellular carcinoma (HCC), however, its prognostic value is unclear. The authors evaluated PIVKA-II clinicopathologically as a prognostic marker for HCC.

METHODS

The relationship between pathologic prognostic factors and plasma PIVKA-II and alpha-fetoprotein (AFP) was investigated in 72 patients with resectable HCC measuring less than 6 cm in greatest dimension.

RESULTS

PIVKA-II shows significantly lower sensitivity, but higher specificity than AFP, and the use of these two complementary markers appears to be useful in the diagnosis of HCC. The frequencies of intrahepatic metastasis, portal vein tumor thrombus, hepatic vein tumor thrombus, and capsular infiltration were significantly higher in patients with positive PIVKA-II than in those with negative-PIVKA-II, and the recurrence-free rate was significantly lower in patients with positive rather than with negative PIVKA-II. However, there were no significant differences between the patients who were AFP positive and those who were AFP negative in pathologic prognostic factors and the recurrence-free rate. From univariate and multivariate analyses, the authors find that PIVKA-II is one of the risk factors for recurrence of HCC after hepatectomy.

CONCLUSIONS

PIVKA-II may be a useful marker for the prediction of intrahepatic spread and for the prognosis of HCC. In addition, PIVKA-II-positive patients, thus, need aggressive postoperative adjuvant therapy for undetectable residual tumors and careful postoperative monitoring to enable the early recognition of recurrence.

The prediction of portal pressure: a multivariate analysis of clinical data and intraoperative portal pressure

Portal pressures were estimated non-invasively in 100 patients who underwent hepatic resection and completely fulfilled the 21 variables evaluated. Ten variables were selected from among all those in the univariate analysis, and a stepwise discriminant analysis revealed four independent significant variables, namely: The indocyanine green dye retention test at 15 min (ICGR15); the prothrombin time index; the platelet count; and the globulin fraction. An equation to estimate the portal pressure was made using the coefficients in the analysis, the reliability of which was confirmed (r = 0.70484, P = 0.0001). The univariate analysis revealed ten significant variables to discriminate portal hypertension, defined as a portal pressure of over 200 mmH2O. A multiple logistic regression analysis of these variables revealed two independent variables, being ICGR15 and the platelet count. Thus, we consider that our equation for estimating portal pressure is potentially useful, and that the platelet count and ICGR15 are the most significant parameters in discriminating between the presence or absence of portal hypertension. Moreover, a platelet count of less than 120 x 10(3)/mm3 and an ICGR15 value of more than 15% correlated well with portal hypertension.

Estimation of risk of major complications after hepatic resection

To identify the risk factors predicting major postoperative complications from among preoperative and intraoperative variables, an extensive retrospective analysis of 209 patients who underwent hepatic resections was performed using multivariate logistic regression. The major complications were defined as liver failure, intractable ascites and pleural effusion, intraperitoneal infection, intra-abdominal hemorrhage requiring reoperation, major bile leakage, and gastrointestinal tract bleeding. First, detailed pre- and intraoperative data including medical history, laboratory data, portion and extent of hepatectomy, operative time, and amount of blood loss were univariately analyzed. Next, any significant variables were multivariately analyzed using the logistic regression method. Diabetes, increased intraoperative blood loss, resection of segment 8, and an increased serum blood urea nitrogen level were independent and significant variables predicting major postoperative complications. A higher level of serum cholesterol and a procedure involving a portion of left lateral segment were found to decrease the risk. Both more careful operative procedures and intensive management of DM and renal dysfunction in the perioperative period could result in a better quality of life after hepatic resection.

Estimation of degree of liver cirrhosis using a fibrosis score; a multivariate analysis of clinical parameters and resected specimens

We designed this study to estimate the degree of liver cirrhosis using clinical parameters and surgically resected specimens. One hundred and twenty-nine cases who underwent hepatic resection in the Department of Surgery II, Kyushu University Hospital during the period between April 1985 and July 1991 for whom data for all 29 variables evaluated were available, were admitted to this study. On the basis of the histological findings of fibrosis of the liver, the non-neoplastic part of the resected specimens were classified into 3 groups; Z0, no cirrhosis (n = 63), Z1, mild cirrhosis (n = 38), and Z2, severe cirrhosis (n = 28). A univariate analysis revealed 14 significant variables. After multiple logistic regression analysis of these, five independent variables (low platelet count, female, low value of hepaplastin test, a high Pugh's score and a high value of ICG) were identified. We obtained a fibrosis score using the coefficient of each above-mentioned variable. This score increased the discriminative power. The fibrosis score is therefore considered useful for estimating the severity of liver cirrhosis.

Modification of rejection by polyethylene glycol in small bowel transplantation

The use of polyethylene glycol (PEG) in preservation solutions has been associated with a decreased incidence of rejection in clinical and experimental organ transplantation. In this study, we examined the effect of PEG with different molecular configurations on rejection of small bowel allografts in the rat. Male ACI and LEW rats were used as donors and recipients, respectively. Orthotopic small bowel transplantation was performed using the following preservation solutions: lactated Ringer's solution (n = 7), University of Wisconsin solution (n = 7), University of Wisconsin solution without hydroxyethyl starch (sUW; n = 7), sUW with PEG20M (n = 9), sUW with PEG8000 (n = 6), and sUW with PEG20L (n = 7). No immunosuppression was given. In orthotopic small bowel transplantation, only groups with a high molecular weight PEG, PEG20M and PEG20L, demonstrated longer survival (P < 0.01 and P < 0.001, respectively) and delayed onset of unkempt appearance (P < 0.05 and P < 0.001, respectively). In heterotopic small bowel transplantation, sUW was compared with sUW with PEG20L. Rejection occurred later and its progression was slower in the sUW with PEG20L than in the sUW alone. Our observations suggest that the onset and progression of rejection after small bowel transplantation were influenced by the molecular weight and configuration of the PEG molecule. The mechanism is unclear, but high molecular weight PEG appears to reduce or change the immunogenicity of the small bowel allograft.

Hepatic regeneration following right lobectomy: estimation of regenerative capacity

The regenerative capacity of the liver was assessed using a volumetric method on computed tomography in 21 adults: 16 underwent a standard right hepatic lobectomy for hepatocellular carcinoma, there were hepatic metastases in 3 others, and 2 suffered from other diseases. The patients' ages ranged from 33 to 68 years with a mean age of 57.0 years. The regeneration rate was expressed as the rate of the volume increase of the remnant left lobe compared with the preoperative volume of the left lobe. A univariate regression analysis showed that the portal pressure had a highly inverse correlation with the regeneration rate of the liver (r = -0.4753, P = 0.0397), while a multiple regression analysis demonstrated the correlation between the portal pressure, age, and the regeneration rate (multiple r = 0.5640). The regeneration rate of the normal liver (97.6 +/- 53.5%) was significantly higher than that of the chronic hepatitic (43.0 +/- 40.7%), and also tended to be higher than that of the cirrhotic liver (51.5 +/- 13.2%). However, there were no differences between chronic hepatitic and cirrhotic livers. The portal pressure before hepatectomy of the normal liver (149 +/- 19 mmH2O) was significantly lower than those of chronic hepatitic (188 +/- 38 mmH2O) and cirrhotic (245 +/- 78 mmH2O) livers. We thus conclude that the regenerative capacity of the liver following a right hepatic lobectomy could be estimated on the basis of both portal pressure and age. The regenerative capacity was also influenced by underlying liver diseases.

Changes in regulating blood coagulation in hepatic resection with special references to soluble thrombomodulin and protein C

The protein C anticoagulant pathway in hepatic resection was studied. The patients were divided into two groups--group 1 consisted of patients with a normal liver and group 2 consisted of patients with either hepatitic or a cirrhotic liver. Plasma protein C activity and soluble thrombomodulin were then sequentially measured during hepatectomy and in the early postoperative period. The protein C activity in group 1 decreased during hepatectomy and reached a low immediately after operation, and thereafter, recovered to near preoperative levels. However, the preoperative value in group 2 was lower than that in group 1 and the postoperative values were significantly lower than those in group 1 (p < 0.05). The level of soluble thrombomodulin in group 1 decreased during hepatectomy but later returned to preoperative levels. However, in group 2, the preoperative value was higher than that in group 1 and the postoperative values were greater than that of the preoperative values, while the values were significantly higher than those in group 1 (p < 0.05). During hepatectomy, hypercoagulability may contribute to the low levels of protein C and soluble thrombomodulin. The postoperative significant increase of soluble thrombomodulin may, thus, indicate the occurrence of endothelial injury in the remnant liver. The sequential measurements of both parameters can, therefore, be useful in detecting coagulopathy and endothelial injury in hepatic resection.

Strategies for reducing blood transfusions in hepatic resection

A comparison of 60 blood transfused and 71 nonblood transfused hepatic resection patients was done to evaluate strategies for reducing blood transfusions during hepatic surgery. There were no significant differences between the two groups with regard to preoperative laboratory data, except for prothrombin time and hematocrit value. The mean operative blood loss was 1990 ml and 760 ml in the blood transfused and nonblood transfused groups, respectively. A multivariate analysis suggested that the patient's body weight, preoperative prothrombin time, and operative blood loss independently predicted the need for intraoperative blood transfusion. Major postoperative complications developed more frequently in the blood transfused group than in the nonblood transfused group (31.7 vs. 11.3%, p < 0.005). These results suggest that the difference in operative blood loss between the two groups was related to the prolonged prothrombin time and a susceptibility for blood transfusion was found to exist particularly in patients with a lower hematocrit value as well as a lower body weight. Thus, the improvement of these preoperative laboratory data combined with avoiding the use of the hematocrit value as a determining factor for intraoperative transfusion could correspond to a reduction in operative blood loss, while curtailing the demands on blood bank facilities, and lowering the risk of postoperative complications.

Characterization of cholecystokinin receptors on the human sphincter of Oddi

BACKGROUND

The present in vitro study investigated the interaction between cholecystokinin (CCK) and receptors on human sphincter of Oddi tissue obtained from donated human livers that were being transplanted.

METHODS

Radiolabeled ligands with cholecystokinin receptor specificity, autoradiography, and crystal scintillation counting were used to directly characterize cholecystokinin receptors on tissue sections.

RESULTS

The binding of 125I-BH-CCK-8 to the tissue was saturable, specific, and dependent on time, pH, and temperature. Saturable binding of 125I-BH-CCK-8 was localized on the smooth muscle layer, and binding was inhibited only by cholecystokinin-related peptides. Computer analysis of 125I-BH-CCK-8 binding indicated the presence of two classes of binding sites, one with a high affinity and the other with a low affinity for CCK-8. CCK-8 caused relaxation (half-maximal concentration, 6 nmol/L) and carbachol caused contraction (half-maximal concentration, 10 nmol/L) of circular, cross-sectional strips of the tissue. Longitudinal strips were less responsive. The relative 125I-BH-CCK-8 binding inhibition potency of CCK-8 agreed closely with its relative ability to cause sphincter relaxation. Tetrodotoxin (1 mumol/L) and atropine (1 mumol/L) caused a rightward shift of the dose-response curve for CCK-8-stimulated sphincter relaxation.

CONCLUSIONS

The present results indicate that cholecystokinin receptors on the human sphincter of Oddi are sulfate dependent and mediate sphincter relaxation.

The significance of methicillin-resistant Staphylococcus aureus infection in general surgery: a multivariate analysis of risk factors and preventive approaches

To investigate the characteristics, risk factors, and prevention of methicillin-resistant Staphylococcus aureus (MRSA), a total of 3,627 patients were studied. Among these, 1,336 patients with various infections were used in a risk factor analysis of MRSA to determine the relationship between the use of antibiotics and the incidence of MRSA. Only 3.0% of infections were attributed to MRSA, the esophagus and colorectal region being highly involved, as anastomotic or pelvic abscesses, while the lung had a lower incidence. Almost half the patients with MRSA infections (47.6%) had concomitant infection. A univariate analysis revealed the following significant factors: The coexistence of gastrointestinal or metastatic malignancy, sepsis, tracheostomy, and the prior use of antibiotics such as the beta-lactam compounds or aminoglycosides. A multivariate analysis showed that gastrointestinal malignancy, sepsis, and the prior use of aminoglycosides, tetracycline, macrolides, and carbapenems were independently significant factors. To promote the education of doctors and nurses, regular in-service meetings on MRSA were held in the ward. Moreover, preventive approaches such as patient isolation, strategically placed hand washing equipment, and the use of disposable gloves and contaminated waste bags, have been initiated, and the incidence of MRSA has decreased significantly since then. Thus, to control MRSA, the following steps should be taken: (1) constant and careful surveillance, (2) regular risk factor analyses, (3) the optimal administration of antibiotics, and (4) the education of all hospital staff.

The research trend of life sciences in Japanese universities based on literature database search

We searched literature databases regarding the four Japanese universities that published the highest number of life science papers. The databases used in this study were MEDLINE and EMBASE. As a result, there was a 30% difference in the number of papers among the four universities.