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.

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).

Growth control of human biliary epithelial cells by interleukin 6, hepatocyte growth factor, transforming growth factor beta1, and activin A: comparison of a cholangiocarcinoma cell line with primary cultures of non-neoplastic biliary epithelial cells

A well characterized human cholangiocarcinoma (CC) cell line, SG231, was compared with primary cultures of normal human biliary epithelial cells (BECs) for alterations in interleukin 6 (IL-6) and hepatocyte growth factor (HGF)-mediated stimulation and transforming growth factor beta1 (TGF-beta1) and activin A-mediated inhibition of growth. Results were compared with immunolabeling of the original tumor and after injection of SG231 into the liver of BALB/cByJ-scid mice. In vitro, both BECs and CCs expressed met, gp80, and gp130 messenger RNA (mRNA) and protein, but the levels of expression were higher in the CCs than in the BECs. In both the CCs and BECs, exogenous HGF or IL-6 induced phosphorylation of met or gp130, respectively, and a concentration-dependent increase in DNA synthesis. However, the CCs but not BECs, continued to grow in basal serum-free medium (SFM) and spontaneously produced both IL-6 and HGF under these conditions, which resulted in auto-phosphorylation of gp130 and met, respectively; and neutralizing anti-HGF or anti-IL-6 alone inhibited CC growth, indicative of autocrine growth control circuits. Conversely, activin A inhibits the growth of both BECs and CCs, but does not significantly increase apoptosis. Activin-A-induced growth inhibition of both CCs and BECs can be reversed by 100 ng/mL exogenous IL-6, but not by 10 to 100 ng/mL HGF. TGF-beta1 inhibited the growth of BECs but had no mitoinhibitory or proapoptotic effects on CCs. Immunolabeling of the original tumor and after inoculation into scid mice showed positive staining for met, gp130, gp80, and IL-6. This study contributes to a further understanding of BEC growth control and derangements that can occur during cholangiocarcinogenesis.

The effect of interleukin-6 (IL-6)/gp130 signalling on biliary epithelial cell growth, in vitro

The effect of IL-6 on the growth of mouse biliary epithelial cells (BEC), in vitro, was tested by comparing BEC obtained IL-6-deficient mice (IL-6(-/-)) to wild-type littermate controls (IL-6(+/+)), in two different media: simple serum-free media (S-SFM), and complete serum-free media (C-SFM) containing forskolin, which stimulates BEC IL-6 production. In S-SFM, neither IL-6(+/+)nor IL-6(-/-)BEC constitutively produced IL-6 mRNA or protein, and there was no difference between IL-6(+/+)and IL-6(-/-)BEC growth. In contrast, when the BEC were maintained in C-SFM, over 48 h, the growth of IL-6(+/+)BEC was 40% greater than IL-6(-/-)BEC (P<0.006). Enhanced IL-6(+/+)BEC growth in C-SFM was associated with induced expression of IL-6 mRNA and IL-6 protein secretion into the medium, upregulation of the IL-6Ralpha (gp80) and phosphorylation of the signal transducing molecule gp130. In C-SFM, anti-IL-6 neutralizing antibodies blocked enhanced IL-6(+/+)BEC growth, whereas exogenous rhIL-6 stimulated retarded growth of IL-6(-/-)BEC. Thus, under conditions that mimic an inflammatory or stressful microenvironment in vivo, BEC produce, secrete and respond to IL-6, via upregulation and activation of the IL-6Ralpha (gp80)/gp130 signaling system in an autocrine/paracrine manner.

Acute obstructive cholangiopathy in interleukin-6 deficient mice: compensation by leukemia inhibitory factor (LIF) suggests importance of gp-130 signaling in the ductular reaction

AIM

The hypothesis that interleukin-6-IL-6/gp130 signaling is involved in liver and biliary epithelial cell (BEC) biology and growth control was tested by subjecting homozygous IL-6 deficient mice (IL-6-/-) and wild type (IL-6+/+) littermate controls to bile duct ligation (BDL).

MATERIALS AND METHODS

During the first week after BDL, the two groups were compared with respect to routine liver injury tests, liver histology, BEC and hepatocyte DNA synthesis, together with the expression of mRNA and protein of IL-6 as well as related growth factors, and their receptors.

RESULTS

During the first week after BDL, there was marked upregulation of IL-6 mRNA and protein in the IL-6+/+ mice only in the vicinity of the biliary tree; whereas, biliary/peri-biliary IL-6R, HGF and met mRNA and protein increased in both groups. IL-6, HGF mRNA and protein localized to periductal inflammatory cells and stellate cells, while met and IL-6R protein were upregulated in the BEC and, to a lesser extent, in hepatocytes. This occurred during maximal proliferation of the BEC. Despite the absence of IL-6 in the IL-6-/- mice, there were only mildly phenotypic differences between the two groups, and no differences in mortality. Compared to IL-6+/+ controls, IL-6-/- mice showed slightly less BEC proliferation, a trend toward more liver injury, and significantly higher total serum bilirubin (TB) levels, suggestive of impaired biliary tree integrity. These changes were associated with slightly less HGF mRNA and protein expression in the IL-6-/- mice, but the differences were not significant. Leukemia inhibitory factor (LIF), another gp-130 ligand, also showed marked peri-biliary upregulation after BDL in both groups, and also induced BEC DNA synthesis, in vitro.

CONCLUSIONS

The mild phenotypical differences between IL-6+/+ and IL-6-/- mice in the acute response to BDL is most likely attributable to the redundancy of the gp-130 signaling system. However, the long-term response to BDL results in a distinct phenotype in the IL-6-/- mice, marked by a relentless rise in serum total bilirubin and an inability to maintain compensatory increase in liver mass.

Mitosis and apoptosis in the liver of interleukin-6-deficient mice after partial hepatectomy

Recently, it was shown that hepatocyte DNA synthesis after partial hepatectomy (PH) is impaired in interleukin-6-deficient (IL-6(-/-)) mice, which results in significantly delayed, but eventual, recovery of normal liver weight, compared with the IL-6(+/+) controls. Four possible compensatory mechanisms might explain this phenomenon: 1) hepatocyte hypertrophy; 2) activation of the oval cell compartment and subsequent maturation to hepatocytes; 3) non-oval biliary epithelial cell (BEC) proliferation; and/or 4) differential rates of apoptotic cell death in the regenerating liver. These hypotheses were tested by subjecting IL-6(-/-) and IL-6(+/+) mice to PH and determining sequential liver weight, histology, hepatocyte and BEC 5'-bromo-2'-deoxyuridine (BrdU) labeling, liver DNA content, alpha-fetoprotein (AFP) mRNA production, and apoptosis at several time points after PH. Consistent with previous studies, we show that the absence of IL-6 significantly impairs hepatocyte DNA synthesis and delays liver weight recovery after PH, but the defect observed in this study is less severe than that previously reported, and no excess mortality, massive necrosis on histology, nor differences in liver injury test are seen. Interestingly, the IL-6(-/-) mice show more hepatocyte BrdU pulse labeling than the IL-6(+/+) controls at 24 hours, but less at 36, 48, and 60 hours. Continuous BrdU infusion up to 60 hours after PH showed a cumulative hepatocyte labeling index of 79.5% in IL-6(+/+) mice and 70.8% in IL-6(-/-) mice, respectively (P <.03). However, despite a lower labeling index and significantly delayed weight recovery, hepatic mass was equally restored in the two groups by 96 hours. There was no evidence of oval cell proliferation in the IL-6(-/-) mice, as determined by routine histology and AFP mRNA analysis, and non-oval BEC proliferation was also slightly impaired in the IL-6(-/-) mice compared with the IL-6(+/+) mice. In addition, liver DNA content per gram of liver showed an increase compared with normal at 60 hours in both groups, but by 96 hours, there was no difference between the two groups. Thus, neither oval cell nor BEC proliferation, nor hepatocyte hypertrophy, could account for the eventual equivalent weight recovery. There was, however, a difference between the two groups in the rate of apoptosis. In normal livers of both IL-6(-/-) and IL-6(+/+) mice, apoptotic cells were uncommon, and even fewer such cells were detected at 24, 36, and 48 hours after PH. Between 60 and 96 hours after PH, a wave of apoptosis spread through the livers of both groups. The number of apoptotic cells was directly proportional to the magnitude of hepatocyte BrdU labeling and liver DNA content after PH, and the difference between the nadir of apoptosis at 24 hours and the peak at 96 hours was greater for the IL-6(+/+) mice. In addition, a direct comparison between the two groups at 96 hours showed that hepatocyte apoptosis was significantly lower in the IL-6(-/-) versus the IL-6(+/+) mice (P <. 02). Treatment of the IL-6(-/-) mice with rIL-6 completely reversed the hepatocyte proliferation defect and increased the subsequent level of total apoptotic bodies. The fine control of liver weight recovery during regeneration after PH is a complex process that involves both mitosis and apoptosis. IL-6 affects this process by recruiting, and possibly synchronizing, the entry of hepatocytes into cell cycling, which quickly restores liver mass. However, this robust response generates superfluous hepatocytes, which are eliminated via apoptosis, similar to many other processes involving organ growth.

Interleukin-6, hepatocyte growth factor, and their receptors in biliary epithelial cells during a type I ductular reaction in mice: interactions between the periductal inflammatory and stromal cells and the biliary epithelium

The interleukin-6 (IL-6)/gp-80 and hepatocyte growth factor (HGF)/met ligand/receptor systems have been shown to stimulate biliary epithelial cell (BEC) DNA synthesis in vitro. The mRNA and protein production of these two in vitro mitogens were mapped in vivo during the first week after bile duct ligation (BDL) when peak BEC DNA synthesis is seen. Changes around the biliary tree were compared with those seen in the peripheral liver using a combination of Northern blotting and a unique biliary tree isolation technique, in which the bile ducts and the surrounding portal stroma and inflammatory cells are separated from the hepatocytes by perfusion digestion. Further localization was performed with in situ hybridization and immunohistochemistry. In the normal liver, there is low-level expression of HGF mRNA by periportal stellate cells, and HGF protein localizes to these cells and to neutrophils; extracellular HGF protein is present in the bile. There is no detectable IL-6 mRNA by Northern analysis or IL-6 protein expression in the normal liver, but both met and IL-6 receptor (IL-6R) mRNA are detectable; met mRNA is expressed strongly in the biliary tree, and met protein is expressed weakly on hepatocytes and strongly on BEC. IL-6R mRNA is weakly expressed in the biliary tree, and IL-6R protein is detectable on hepatocytes, with a periportal-to-perivenular gradient, but not on BEC. During the first 3 days after BDL, HGF mRNA expression is increased in both the biliary tree and in the peripheral liver, and production is localized to stellate cells, periductal neutrophils, and stromal cells, which typically accompany the proliferating ductules. IL-6 mRNA and protein were detected only near the biliary tree after BDL, and not in the peripheral liver, and the production was localized to periductal hematolymphoid cells, which had the morphological appearance of macrophages and/or dendritic cells. There is also a distinct up-regulation of met and gp-80 mRNA and protein in the biliary tree, which is stronger than that seen in the peripheral liver. Met protein expression is increased, and IL-6R(gp-80) protein is induced on the proliferating BEC, consistent with the participation of both the HGF/met and IL-6/gp-80 systems in the early phases of type I ductular reactions. These observations show that periductal hematolymphoid and stromal cells are the source of BEC growth factors, and receptors for these factors are up-regulated on BEC during active ductular proliferation. Complex interactions between the inflammatory, stromal, and BEC results in a dysmorphogenic repair response that eventually leads to cirrhosis.

Effect of mixing ratio in lecithin/bile acid mixed micelles on Na(+)-K+ ATPase

Lecithin and bile acid form mixed micelles in the bile. We found that the mixing ratio in lecithin/bile acid mixed micelles directly changes the activity of Na(+)-K+ ATPase. Na(+)-K+ ATPase activity was suppressed to 13.3% of that in the buffer alone at a lecithin/bile acid mixing ratio of 0.1 in the presence of 10(-2) M bile acid (that is, a concentration level close to that of the hepatic bile). With increase in the mixing ratio in the presence of 10(-2) M bile acid, the activity of the enzyme was found to be augmented accordingly. Thus addition of lecithin to an extent such that the mixing ratio reached 0.6 led to an enhancement of enzymatic activity to 193.8%. If lecithin addition is made in the presence of bile acid at the near gallbladder concentration of 10(-1) M, however, the Na(+)-K+ ATPase activity can be observed to increase with the increase in the lecithin/bile acid ratio. Yet, at the same mixing ratio of 0.6, the enzyme activity was arrested at only 25.7%. However, this change in mixing ratio had no effect on ouabain-insensitive ATPase. The state of mixed micelles may exert the same effect on Na(+)-K+ ATPase activity in vivo.

Immunohistochemical localization of Na+, K+-ATPase in human normal and malignant pancreatic tissues

Localization of Na+, K+-ATPase in the human pancreas was investigated immunohistochemically using rabbit antisera against Na+, K+-ATPase of the human kidney. The reaction product existed only on the luminal surfaces of both centroacinar and ductal cells in normal pancreatic tissue, whereas in chronic pancreatitis the localization of Na+, K+-ATPase was found frequently on the luminal surfaces of both centroacinar and ductal cells, and on the basolateral surfaces of some ductal cells. However, in acinar cells, the distribution of Na+,K+-ATPase was not detected in either the normal pancreas or chronic pancreatitis. In pancreatic carcinoma tissues, Na+,K+-ATPase existed very rarely in malignant cells. These results indicate that Na+,K+-ATPase is immunohistochemically localized on the membranes of centroacinar and ductal cells of the human pancreas, and that the antigenicity of Na+,K+-ATPase in pancreatic carcinoma cells differs from that in normal cells.