Transition of Spleen Volume Long After Pediatric Living Donor Liver Transplantation for Biliary Atresia

PURPOSE

After undergoing the Kasai procedure for biliary atresia (BA), most patients develop severe splenomegaly that tends to be improved by liver transplantation. However, fluctuations in splenic volume long after transplantation remain to be elucidated.

PATIENTS AND METHODS

Seventy-one consecutive patients who had undergone pediatric living donor liver transplantation (LDLT) for BA were followed up in our outpatient clinic for 5 years. They were classified into 3 groups according to their clinical outcomes: a good course group (GC, n = 41) who were maintained on only 1 or without an immunosuppressant, a liver dysfunction group (LD, n = 18) who were maintained on 2 or 3 types of immunosuppressants, and a vascular complication group (VC, n = 11). Splenic and hepatic volumes were calculated by computed tomography in 464 examinations and the values compared before and after the treatment, especially in the VC group.

RESULTS

Splenic volume decreased exponentially in the GC group, with splenic volume to standard spleen volume ratio (SD) being 1.59 (0.33) 5 years after liver transplantation. Splenic volume to standard spleen volume ratios were greater in the VC and LD groups than in the GC group. Patients in the VC group with portal vein stenosis developed liver atrophy and splenomegaly, whereas those with hepatic vein stenosis developed hepatomegaly and splenomegaly. Interventional radiation therapy tended to improve the associated symptoms.

CONCLUSIONS

Fluctuations in splenic volume long after pediatric LDLT for BA may reflect various clinical conditions. Evaluation of both splenic and hepatic volumes can facilitate understanding clinical conditions following pediatric LDLT.

Complementary Indicators for Diagnosis of Hepatic Vein Stenosis After Pediatric Living-donor Liver Transplantation

INTRODUCTION

Although hepatic vein stenosis after liver transplantation is a rare complication, the complication rate of 1% to 6% is higher in pediatric living-donor liver transplantation than that in other liver transplantation cases. Diagnosis is very important because this complication can cause hepatic congestion that develops to liver cirrhosis, graft loss, and patient loss. However, this is unlikely in cases where there are no ascites or hypoalbuminemia.

OBJECTIVES

Eleven of 167 patients who had undergone pediatric living-donor liver transplantation were identified in the outpatient clinic at Jichi Medical University as having suffered from hepatic vein stenosis, and were enrolled in the study.

METHODS

We conducted a retrospective study in which we reviewed historical patient records to investigate the parameters for diagnosis and examine treatment methods and outcomes.

RESULTS

The 11 patients were treated with 16 episodes of balloon dilatation. Three among these received retransplantation and another 2 cases required the placement of a metallic stent at the stenosis. Histological examination revealed severe fibrosis in four of nine patients who had a liver biopsy, with mild fibrosis revealed in the other five grafts. Furthermore, hepatomegaly and splenomegaly diagnosed by computed tomography, elevated levels of hyarulonic acid, and/or a decrease in calcineurin inhibitor clearance were found to be pathognomonic at diagnosis, and tended to improve after treatment.

CONCLUSIONS

Diagnosis of hepatic vein stenosis after liver transplantation can be difficult, so careful observation is crucial to avoid the risk of acute liver dysfunction. Comprehensive assessment using volumetry of the liver and spleen and monitoring of hyarulonic acid levels and/or calcineurin inhibitor clearance, in addition to some form of imaging examination, is important for diagnosis and evaluation of the effectiveness of therapy.

Case report of FLT3-ITD-positive AML patient 11 years after living donor liver transplantation

With the increasing number of long-term survivors of living donor liver transplantation, the occurrence of secondary cancer is sometimes reported. Solid tumors such as lymphomas are mainly observed. However, only 8 cases of leukemia have been reported so far. For patients younger than 15 years old, leukemia developed in 4 within 3 years after the liver transplantation, whereas acute lymphoblastic leukemia developed in only 1 patient. This is the first case report of a patient in whom FLT3-ITD-positive acute myeloid leukemia (AML) developed more than 10 years after living donor liver transplantation for congenital biliary atresia. AML developed in a 14-year-old boy 11 years after living donor liver transplantation from his father. The patient received the transplant at the age of 3 years and was treated with tacrolimus and methylprednisolone for transplant rejection. Eleven years posttransplantation, he visited the hospital with general malaise and anemia. Blood tests revealed an elevated white blood cell count of 60,100/μL, and the patient was diagnosed with AML. Chromosome analysis revealed a t(6; 9) (p23 q34) translocation; moreover, genetic testing revealed a FLT3-ITD-positive mutation. We started treatment in accordance with the Tokyo Children's Cancer Study Group AML99 protocol. With chemotherapy treatment, the patient achieved complete remission. After chemotherapy, we performed stem cell transplantation from his father. Other patients were reported in relatively early stages after liver transplantation, but our case was more than 10 years posttransplantation. The association with the onset of congenital bile duct atresia and leukemia is still not clear, but we consider the possibility that long-term immunosuppressive drugs contribute to developing leukemia.

Splenic artery embolization before laparoscopic splenectomy in children

BACKGROUND

This study assessed the safety and utility of preoperative splenic artery embolization before laparoscopic splenectomy in children.

METHODS

Five young girls with a mean age of 13.2 years underwent laparoscopic splenectomies at the authors' institution from August 1998 to April 2003. Three of the patients had idiopathic thrombocytopenic purpura, and two had hereditary spherocytosis. Preoperative splenic artery embolization was performed the day before the surgery in all cases. The laparoscopic splenectomy was performed using traditional laparoscopic procedures and standard laparoscopic instruments with the patient in the right semilateral position.

RESULTS

The mean spleen weight was 252.6 g, and the mean length was 11.6 cm. All the patients reported postembolic pain, but not to a level unmanageable by intravascular narcotics. There were no severe complications in the splenic artery embolization. The laparoscopic splenectomies were completed in a mean of 211 min, with a mean estimated blood loss of 9 ml. None of the operations required conversion to traditional open laparotomy, and none of the patients died or experienced operative complications.

CONCLUSION

The authors concluded that splenic artery embolization is safe and useful as an adjuvant procedure performed before elective laparoscopic splenectomy in children.

Hand-assisted laparoscopic hepatectomy after partial splenic embolization

The case of a patient with hepatocellular carcinoma and thrombocytopenia secondary to liver cirrhosis who underwent successful hand-assisted laparoscopic hepatectomy after partial splenic embolization is described. A 67-year-old man with severe liver cirrhosis was admitted for treatment of hepatocellular carcinoma. His early phase of hepatic angiography showed two hypervascular tumors in segment 6. The patients liver function was poor, with the indocyanine green retention at 15 min of 49.5%, a total serum bilirubin concentration of 2.0 mg/dl, an albumin concentration of 2.8 g/dl, and an hyaluronic acid concentration of 649 ng/ml. The platelet count was 3.0 x 10(4)/microl secondary to hypersplenism. Partial splenic embolization decreased the splenic volume by 50% preoperatively. At 2 months later, the platelet count was 6.0 x 10(4)/microl, and hand-assisted laparoscopic partial hepatectomy was performed uneventfully. The patients postoperative course was unremarkable, and he was discharged on postoperative day 12.

Genetic polymorphisms of aldehyde dehydrogenase 2, cytochrome p450 2E1 for liver cancer risk in HCV antibody-positive japanese patients and the variations of CYP2E1 mRNA expression levels in the liver due to its polymorphism

BACKGROUND

Hepatocellular carcinoma (HCC) in persons with liver cirrhosis (LC) arises following hepatitis virus infection. Alcohol may accelerate the risk of development of LC and HCC. Cytochrome p450 2E1 (CYP2E1) oxidizes ethanol to form acetaldehyde and aldehyde dehydrogenase 2 (ALDH2) detoxifies acetaldehyde, which is carcinogenic in humans, and both alcohol-metabolizing enzymes show the genetic polymorphisms in a Japanese population.

METHODS

Using polymorphism analysis, we studied the frequency of ALDH2 functional deletion due to the G to A single-bp mutation in exon 12 and CYP2E1 polymorphism in the transcriptional region, both associated with higher levels of acetaldehyde, in 135 patients with LC and/or HCC, including 99 with HCC, and 135 non-cancer controls. The mRNA expression levels of CYP2E1 in the liver were also examined in 55 surgical specimens.

RESULTS

The allelic frequency of the homozygous ALDH2 2-2 genotype, coding for the enzyme deletion, was significantly higher compared to that of the homozygous or heterozygous ALDH2 1-1 genotypes in cases with HCC (OR = 5.4, 95% CI 2.1-14.0). There were no differences in the frequencies of specific genotypes of CYP2E1 in cases of HCC, but combined analysis of ALDH2 and CYP2E1 revealed that the odds ratio of occurrence of the C1/C1 homozygosity of CYP2E1 and the ALDH2 2-2 homozygosity was as high as 23.0 (2.9-182). The mRNA levels of CYP2E1 were higher in the liver of patients with the C1/C1 homozygosity of CYP2E1 than in those with other genotypes (P < 0.05).

CONCLUSIONS

ALDH2 and CYP2E1 polymorphisms may modify the risk of development of HCC against the background of LC in the Japanese. Polymorphism analysis of alcohol-metabolizing enzymes using molecular techniques may be useful in the risk assessment of liver cancer in patients with hepatitis C virus infection.

Combined endoscopic and radiologic intervention to treat esophageal varices

BACKGROUND/AIMS

In patients with esophageal varices, we investigated the impact on long-term outcome of combining interventional radiologic procedures with endoscopic therapy.

METHODOLOGY

Of 133 patients with esophageal varices, 86 were treated with endoscopic therapy alone and 47 underwent endoscopic therapy in addition to interventional radiologic procedures. End-points considered during 5-years of follow-up included recurrent bleeding and retreatment.

RESULTS

Bleeding rates were 24.4% in the endoscopy group and 25.4% in the combined therapy group. Retreatment rates at 1, 3, and 5 years for the endoscopy group versus the combined therapy group were 40.7% versus 30.3%, 72.0% versus 67.5%, and 88.2% versus 80.5%, respectively, representing no significant difference between two groups. However, cumulative retreatment rates in Child's class C cases were significantly lower in the combined therapy group than in the endoscopy group (P = 0.025). Patients who had combined therapy which included all embolizing techniques showed significantly lower retreatment rates than patients treated with endoscopy alone (P = 0.05).

CONCLUSIONS

In combination, interventional radiologic and endoscopic therapies are highly effective and can improve long-term outcome in patients with esophageal varices, especially those with poor liver function and those who undergo embolization by all techniques.

Liver cell adenoma in a 26-year-old man

This is a report of a case of liver cell adenoma (LCA) in a 26-year-old man with no prior history of liver disease or glycogen storage disease and no record of hormonal therapy. He was found to have an asymptomatic hepatic mass during a routine medical examination. The physical findings were unremarkable, and the results of routine laboratory studies were all within normal limits. Selective hepatic arteriography showed a hypervascular mass within the right lobe of the liver. Despite the radiological examination, the nature of the mass was unknown, and preoperative biopsy was unadvisable because of the risk of bleeding. Because of the difficulty of determining the malignancy of the hepatic tumor preoperatively, elective laparotomy for diagnosis and hepatectomy as treatment appeared to be the best available approach. Pathological examination of the surgical specimen resulted in a diagnosis of LCA. A review of the literature revealed that LCA unassociated with the use of oral contraceptives is rare.

Celiac artery aneurysm: a case evaluated preoperatively with three-dimensional computed tomographic angiography

In a 63-year-old woman computed tomography (CT) incidentally detected a celiac artery aneurysm approximately 3 cm in diameter. While conventional angiography suggested that the splenic artery and common hepatic artery arose from the celiac artery aneurysm, three-dimensional CT angiography indicated that the aneurysm involved only the mid portion of the celiac artery. Considering the risk of eventual aneurysm rupture, surgery was performed. Aneurysmectomy and devascularization of hepatic, splenic, and celiac arteries were carried out following complete cross-clamping of the celiac artery. The distal segment of the celiac artery was directly anastomosed to the proximal segment in an end-to-end fashion. Histologically, the aneurysm wall showed atheromatous changes. Contrast-enhanced abdominal CT confirmed complete removal of the celiac artery aneurysm, and postoperative angiography confirmed good arterial flow. The patient recovered uneventfully after surgery, with normalization of transiently abnormal hepatic function parameters. In this case of celiac artery aneurysm, three-dimensional CT angiography was found to be valuable in determining the relationships of the aneurysms to important arterial branches.

Hypersplenism induced by hepatectomy

BACKGROUND/AIMS

We encountered a case of posthepatectomy splenic enlargement and hypersplenism followed by disseminated intravascular coagulopathy with airway hemorrhage causing death.

METHODOLOGY

We, therefore, retrospectively investigated postoperative splenic enlargement, hypersplenism and disseminated intravascular coagulopathy by computed tomography and laboratory data in 57 hepatectomized patients with a malignant or benign disease in the postoperative period.

RESULTS

Of 32 patients with hepatocellular carcinoma or biliary tract carcinoma (group A), 12 with metastatic hepatic lesions (group B), and 13 with benign liver disease (group C); remarkable (20%) splenic enlargement was noted in 8 patients in group A, 2 in group B, and 2 in group C. Seven of the 12 patients were associated with liver cirrhosis, 5 with preoperative splenomegaly, and 8 had undergone major hepatectomy. Postoperative hypersplenism developed in 5 patients in group A, and one patient in group C. All of them were associated with liver cirrhosis or chronic hepatitis and preoperative splenomegaly, and five had undergone hepatic lobectomy or more extensive resections. All except for the disseminated intravascular coagulopathy case recovered. Statistically, splenic enlargement was significantly related to the extent of hepatectomy; lobectomy versus segmentectomy = 28.3 +/- 28.5% (n = 14) versus 12.4 +/- 13.8% (n = 20), (unpaired Student's t test, P = 0.037). Platelet counts of the patients with liver cirrhosis or chronic hepatitis is lower than those without the diseases, both pre- and postoperatively (14.0 +/- 6.0 x 10(4)/mm3 vs. 21.5 +/- 6.2 x 10(4)/mm3, P = 0.0001).

CONCLUSIONS

Postoperative hypersplenism was noted only in the patients with liver cirrhosis or chronic hepatitis and preoperative splenomegaly, and developed more frequently after larger hepatectomies than after smaller hepatectomies; 5 (45%) of 11 versus 1 (7%) of 14, chi 2 test, P = 0.026).

Acute cholecystitis caused by a cholesterol polyp

A 39-year-old man hospitalized with upper abdominal pain had been found to have a 3mm polyp in the body of the gallbladder 3 years previously. Laboratory tests on admission showed mild liver dysfunction. Ultrasonography depicted a dilated gallbladder with increased wall thickness; the polyp could no longer be seen. Computed tomography with drip infusion cholangiography again showed a dilated gallbladder, and also stenosis of the distal cystic duct. The resected specimen obtained by laparoscopic cholecystectomy showed disappearance of the polyp from the body of the gallbladder. A cholesterol stone was incarcerated in the cystic duct, representing an impacted detached cholesterol polyp causing acute cholecystitis. Spontaneous detachment of a cholesterol polyp from the gallbladder mucosa, then, can result in acute cholecystitis.

Spontaneous disappearance of a hepatic cyst

The spontaneous disappearance of a hepatic cyst is described. A 62-year-old woman presented with symptoms of general fatigue in August 1992. Her past medical history was significant for chronic hepatitis, which was diagnosed in 1990 but not treated. Initial laboratory tests revealed mild liver dysfunction with a positive serologic test for hepatitis C. In August 1992, ultrasonography and computed tomography disclosed a cystic lesion along the middle hepatic vein in the right anterior segment of the liver, which was 40 mm in diameter. Repeat radiologic studies in June 1994 demonstrated that the size of the cyst was unchanged. In May 1995, the cyst was only 25 mm in diameter, and it continued to decrease in size thereafter, to 10 mm in September 1995 and 7 mm in September 1996. No hepatic cyst was visualized in December 1996, though the region in which the cyst existed was hyperechoic. Laboratory data were essentially unchanged from August 1992 to December 1996. Clinically the patient remained asymptomatic.

Interventional radiology and endoscopic therapy for recurrent esophageal varices

BACKGROUND/AIMS

We investigated the impact long-term prognosis of combined interventional radiology and endoscopic therapy in patients with esophageal varices.

METHODOLOGY

Patients with recurrent esophageal varices underwent treatment as follows: 54 were treated with endoscopic therapy alone and 32 underwent endoscopic therapy plus interventional radiologic procedures. Primary endpoints during 5-year follow-up included recurrent bleeding, second retreatment, and death.

RESULTS

The bleeding rates were 11.1% in the endoscopy group, and 9.4% in the combined therapy group. Second retreatment rates at 1 year, 3 years, and 5 years in the endoscopy group and combined therapy group were 25.4% and 17.2%, 70.2% and 39.3%, and 85.0% and 69.6%, respectively. The second retreatment rates in the combined therapy group were significantly reduced compared to the endoscopy alone group (P = 0.05). Cumulative retreatment rates in Child's class C cases were significantly lower in the combined therapy group than in the endoscopy group (P = 0.01). Survival at 3 years was 97.1% in the endoscopy group and 92.0% in the combined therapy group, and 5-year survival was 79.1% and 83.6%, respectively.

CONCLUSIONS

The combination of interventional radiologic and endoscopic therapy is highly effective and improves long-term prognosis in patients with recurrent esophageal varices.

Comparison of the long-term results of distal splenorenal shunt and esophageal transection for the treatment of esophageal varices

BACKGROUND/AIMS

This study was undertaken to evaluate the comparison of long-term results of distal splenorenal shunt and esophageal transection for the treatment of esophageal varices.

METHODOLOGY

Twenty-four cirrhotic patients underwent distal splenorenal shunt, and 19 cirrhotic patients underwent esophageal transection with complete variceal eradication and follow-up for at least 3 years.

RESULTS

No recurrent varix was observed in the distal splenorenal shunt group. The cumulative recurrence rates of varices in the esophageal transection group were 31.6%, and 52.5% at 5 and 10 years, respectively. The cumulative rates of hyperammonemia at 5 and 10 years were significantly higher in the distal splenorenal shunt group (30.4%, 30.4%) than in the esophageal transection group (0%, 5.6%) (P = 0.009). The cumulative survival rates in the distal splenorenal shunt group versus the esophageal transection group were 90.9% versus 94.7%, and 85.2% versus 81.7% at 5 and 10 years (NS).

CONCLUSIONS

These results suggest that distal splenorenal shunt is more effective than esophageal transection in preventing recurrence of esophageal varices, but is associated with a higher incidence of hyperammonemia.

Hepatocellular carcinoma responding to chemotherapy with 5-FU

A 69-year-old man with unresectable hepatocellular carcinoma and portal vein tumor thrombus was treated by chemotherapy with 5-fluorouracil. A dose of 500 mg/day of 5-fluorouracil was continuously administered via a central venous catheter. After 4 months, the alpha-fetoprotein level was decreased from 50,000 ng/mL to 4,760 ng/mL. Computed tomography revealed disappearance of the low-density area in the liver parenchyma, but the portal vein tumor thrombus was not changed. After 6 months, pancytopenia appeared and continuous infusion of 5-fluorouracil was stopped. After 8 months, the patient died of pneumonia, at which time the alpha-fetoprotein level was 12,000 ng/mL. Continuous intravenous infusion of 5-Fluorouracil was effective against unresectable primary hepatocellular carcinoma, but had little influence on portal vein tumor thrombus.

Long-term results of modified distal splenorenal shunts for the treatment of esophageal varices

BACKGROUND/AIMS

Long-term results were compared for 3 types of distal splenorenal shunt for the treatment of esophageal varices.

METHODOLOGY

Between July 1983 and December 1997, 45 patients with esophageal varices underwent distal splenorenal shunt. Group 1 underwent standard distal splenorenal shunt (n = 11). Group 2 underwent distal splenorenal shunt with splenopancreatic disconnection (n = 11). Group 3 underwent distal splenorenal shunt with splenopancreatic disconnection and gastric transection (n = 23).

RESULTS

Additional treatment for recurrent varices was required in group 1, (n = 1, 9.1%), group 2 (n = 2, 18.2%), and group 3 (n = 1, 4.3%). All of the patients with recurrent varices developed a shunt stenosis within the 1st year after distal splenorenal shunt. The prevalence of hyperammonemia in group 1 was 40.0% at 1, 5, and 10 years. In group 2, the prevalence was 14.3% at 1 year, 31.4% at 5 years, and 54.3% at 10 years. In group 3, the prevalence was 0% at 1 year, and 9.1% at 5 and 10 years. The differences between group 3 and groups 1 and 2 were significant (P < 0.01). The cumulative survival rates at 1 year were 90.9%, 63.6%, and 95.7% for groups 1, 2, and 3, respectively. At 10 years, the cumulative survivals rates were 70.7%, 63.6%, and 69.4% for groups 1, 2, and 3, respectively. There were no significant differences in survival between the 3 groups.

CONCLUSIONS

Distal splenorenal shunt with splenopancreatic disconnection and gastric transection may reduce the incidence of postoperative hyperammonemia.

Colonic varices ruptured via drainage catheter after extended right hepatectomy

Extended right hepatectomy was performed on a 69-year-old woman with bile duct carcinoma of the hepatic hilum. Three weeks after the operation, an abscess was detected at the resected surface and a drainage catheter was inserted. The patient was discharged with the drainage catheter in place and followed-up at a local hospital. Three months later, the drainage catheter was removed. Bleeding immediately occurred through the fistula, and fistulography revealed varices. Angiography demonstrated right colonic varices, and the fistula was embolized with coils. There was no further bleeding. In conclusion, colonic varices that ruptured via a fistula of a drainage catheter were embolized through the fistula. Embolization of the fistula was useful in stopping the bleeding.

Reconstruction of the vena cava with the peritoneum

BACKGROUND

Reconstruction of the vena cava with an autologous vein requires extra incisions. Prosthetic material is associated with an increased risk of infection. We therefore created an animal model of vena cava reconstruction using the peritoneum.

METHODS

A 2.5 x 2.5 cm piece of peritoneum was resected from 7 pigs weighing 30 to 40 kg. An oval window (long axis: 1.5 cm) was made in the infrarenal vena cava. This was repaired with the peritoneal patch fixed in alcohol.

RESULTS

In 2 animals sacrificed at 5 hours, there was no evidence of thrombosis, but there was fibrin clot on the patches. Two animals sacrificed on day 8 exhibited excellent patency of the vena cava. Complete endothelialization of the patch was noted at day 15. At 6 weeks, the vena cava was healed. No infections or other problems were noted.

CONCLUSIONS

The peritoneum is an accessible and safe substitute for reconstruction of the vena cava.

Rupture of a hepatic metastasis from renal cell carcinoma

We describe a rare case of spontaneous rupture of a hepatic metastasis from renal cell carcinoma that was treated successfully by hepatic arterial embolization. A 65-year-old woman, who had been undergoing immunotherapy for inoperably disseminated renal carcinoma and lung metastases, presented with severe abdominal pain in a state of hypovolemic shock. Computed tomography revealed a highly attenuated mass lesion in the right lobe of the liver and massive intraperitoneal hemorrhage. Subsequent hepatic angiography showed extravasation from the feeding right hepatic artery. Transcatheter embolization of the right hepatic artery was subsequently performed, and the patient made an uneventful recovery. Although hepatic rupture due to metastatic cancer is extremely rare, transcatheter arterial embolization (TAE) is an appropriate and useful treatment for massive hemorrhage caused by spontaneous rupture of liver metastasis.

Synchronous carcinoma of the gallbladder in a patient with intrahepatic bile duct carcinoma

An 83-year-old woman, diagnosed as having cholelithiasis, was admitted to the Department of Surgery, Nippon Medical School, with right hypochondrial pain. Ultrasonography and computed tomography revealed a mass in the gallbladder fundus and a hypovascular tumor in the anterior segment of the liver. Magnetic resonance imaging showed stenosis of the intrahepatic bile duct and dilatation of its proximal portion. She was diagnosed as having intrahepatic bile duct carcinoma combined with gallbladder carcinoma. At laparotomy, there was evidence of multiple peritoneal metastases and intraoperative histological examination of the gallbladder tumor revealed adenocarcinoma. Accordingly, only cholecystectomy and needle biopsy of the liver tumor was performed. Histological examination of the gallbladder revealed papillary adenocarcinoma invading the muscularis propria with medullary growth or intermediate stroma. There was no microvessel invasion, no perineural invasion and no lymph node involvement. On the other hand, the liver tumor was a cholangiocarcinoma with a well-differentiated tubular pattern. Therefore, this was a rare case of synchronous carcinoma of the gallbladder associated with intrahepatic bile duct carcinoma.

Endoscopic variceal ligation (EVL) combined with partial splenic embolization (PSE)

BACKGROUND/AIMS

The effectiveness of reducing the recurrence rate of esophageal varices by combining partial splenic embolization (PSE) with endoscopic variceal ligation (EVL) was investigated.

METHODOLOGY

Patients with complete eradication of esophageal varices were collected as study cases with the following results: 31 cases with PSE and EVL (PSE+EVL group), 25 cases with EVL alone (EVL group), and 33 cases with EIS alone (EIS group). The cumulative recurrence rates were obtained by observing new varices.

RESULTS

The cumulative recurrence rates at 6 months were 21.1% in the PSE+EVL group, 58.1% in the EVL group and 32.5% in the EIS group. Those at 1 year were 37.0%, 70.7% and 50.2%, respectively, and those at 2 years were 58.1%, 80.4% and 73.0%, respectively. For all 3 time periods, recurrence rates of the PSE+EVL group were significantly lower than those of the EVL group (p=0.042). Cumulative rates in the PSE+EVL group tended to be lower than those in the EIS group. Further analysis was made on the comparative recurrence rates of the 3 groups, according to Child's classification. The cumulative recurrence rates in Child A cases did not significantly differ between the 3 groups. Cumulative rates in Child B cases were significantly lower in the PSE+EVL group than in the EVL group (p=0.032), and those in the PSE+EVL group tended to be lower than those in the EIS group. These trends were observed between the PSE+EVL group and the EVL group in Child C cases, while cumulative rates did not show differences between the PSE+EVL group and the EIS group.

CONCLUSIONS

It was inferred that PSE-combined EVL therapy is a very effective therapy for achieving long-term complete eradication of esophageal varices.

Adrenal metastasis from hepatocellular carcinoma (HCC): report of 3 cases

Although autopsy reports show that the adrenal gland is the second most common organ of hematogeneous metastasis from hepatocellular carcinoma (HCC), paradoxically there is found to be a very scarce number of the adrenal metastasis in clinical practice. We have recently experienced rare patients with right adrenal metastasis from HCC. Case 1: A 51 year-old man with a 5-year history of chronic hepatitis was admitted with hematemesis to Nippon Medical School Hospital. CT revealed a main tumor associated with a few daughter tumors in the hepatic posterior segment and in addition another tumor located between the right hepatic lobe and right kidney. The diagnosis of HCC with a right adrenal gland metastasis was made, and hepatectomy and right adrenalectomy was performed. Twenty months after operation he was alive and free of disease. Case 2: A 78 year-old man underwent resection of the lateral segment of the left hepatic lobe for HCC. Twelve months later, recurrent foci in the residual liver were found and those were treated with transarterial embolization (TAE). Right adrenal metastasis was found on CT 26 months after hepatectomy. TAE was done for the hepatic recurrent tumors and adrenal metastasis. Twelve months after, he survived in good condition. Case 3: A 47 year-old man presented with liver cirrhosis with a long history. He was diagnosed as having HCC with multiple intrahepatic metastases and was treated with TAE 4 times. Follow-up CT revealed right adrenal metastasis. TAE was done for hepatic recurrent tumor and right adrenal metastasis. Three months later the patient died of liver failure.

A case of abscess caused by a penetrating duodenal ulcer

A case of abscess caused by a penetrating duodenal ulcer in a 34 year-old female patient is presented. She had a past history of duodenal ulcer and presented with a low grade fever which had persisted for 1 month. Abdominal ultrasound confirmed a hypoechoic mass and computed tomography revealed a low density area in the posterior side of the hepatoduodenal ligament. The common bile duct and portal vein were compressed. Mild peripheral enhancement was detected. Laparotomy was performed and an abscess in the posterior side of the hepatoduodenal ligament was confirmed. The abscess was firmly adhered to the lesser curvature side of the bulbus and a penetrating duodenal ulcer scar was noted. In conclusion, this report describes a rare event where penetrating duodenal ulcer formed an abscess with only mild complaints.

New techniques: splenic artery embolization followed by intraarterial infusion chemotherapy for the treatment of pancreatic cancer

We present a new intraarterial infusion chemotherapy technique for the treatment of inoperable cancer in the body and tail of the pancreas. The spleen was embolized at its hilum with coils to infuse an anti-tumor agent selectively into the pancreatic parenchyma and a catheter was placed into the splenic artery and connected to the reservoir. 99mTc-macroaggregated albumin+diethylenetriaminepenta-acetic acid (MAA+DTPA) was injected into the reservoir and the body and tail of the pancreas were visualized on the image. For inoperable cancer in the body and tail of the pancreas, splenic artery embolization followed by the placement of a catheter into the splenic artery can deliver a highly concentrated anti-tumor agent to the tumor.

[Changes in distribution of reticuloendothelial function in transcatheter arterial embolization (TAE) for hepatocellular carcinoma (HCC), estimated by single photon emission computed tomography (SPECT)]

In order to study the changes in distribution of reticuloendothelial function in transcatheter arterial embolization (TAE) for hepatocellular carcinoma (HCC), the radioactivity of 99mTc-phytate was calculated by the accumulation rate in the organs by means of the single emission computed tomography (SPECT). It was regarded as the reticuloendothelial function in the liver and spleen, and was evaluated independently. Before TAE, significant increases were noted in both splenic activity and splenic volume in the cirrhotic patients, as compared with non-cirrhotic patients. After TAE, the activity in the liver was reduced at the first day after TAE, which returned to the normal level by 5 days. While that in the spleen increased immediately after TAE. After one day of TAE, reticuloendothelial functions of the spleen was significantly higher in the cirrhotic cases then in the non-cirrhotic cases. Furthermore, in the cirrhotic patients, it was significantly higher in the cases embolizated in more than two segments than in those embolizated in one segment only. In conclusion, the reticuloendothelial function of the liver was significantly reduced by the TAE in the cirrhotic patients as compared with non-cirrhotic patients. However the reduced reticuloendothelial function of the liver in the cirrhotic patients was compensated by the increased reticuloendothelial function of the spleen.

[Two cases of improved quality of life with intra-arterial infusion of CDDP or unresectable gallbladder and pancreatic cancer]

The prognosis of patients with advanced gallbladder and pancreatic cancers is poor. Intra-arterial infusion chemotherapy with CDDP was imported in patients with unresectable gallbladder cancer (First case) and pancreatic cancer (Second case). The values of CEA and CA 19-9 were reduced after chemotherapy in the first case, but the CA 19-9 level was not reduced in the second case. Their hospital free survival (HFS) has been more than one year and they could return to their respective occupations. QOL was thought to be improved when considering their HFS. Intra-arterial infusion of CDDP might be one of the multimodal therapies to improve QOL for patients with unresectable gallbladder and pancreatic cancers.