[Indications and results of pulmonary resections in a developing country]

INTRODUCTION

Indications for pulmonary excision are dominated by infectious pulmonary pathologies in developing countries. We conducted this study to describe the indications and results of pulmonary resections in the thoracic surgery department of the Mali hospital.

PATIENTS AND METHODS

This is a retrospective and descriptive study from January 2012 to December 2019, carried out in the thoracic surgery department of the Mali hospital. It involved 76 patients who had a pulmonary resection. The variables studied were the epidemiological data, the operating indications, the therapeutic data and the prognosis.

RESULTS

The mean age of the patients was 35.5 years. The sex ratio was 1.7. The average consultation time in thoracic surgery was 11.6 months with extremes of 7 days and 96 months. A history of pulmonary tuberculosis was noted in 46.1% of patients. The main indications for pulmonary resection were infectious parenchymal destruction in 64.5%, bullous dystrophy in 14.5%, bronchopulmonary cancer in 11.8% and thoracic trauma in 4% of the cases. The procedures performed were: a lobectomy (39.5%), atypical resection (36.8%), culminectomy (7.9%) and pneumonectomy (15.8%). Morbidity was dominated by thoracic empyema (9.2%) postoperative hemorrhage (5.2%), parietal suppuration (7.8%) and bronchopleural fistula (1.3%). The average length of hospital stay was 14.3 days. Mortality was 10.5%. There was a statistically significant correlation between pneumonectomy and deaths (P=0.01).

CONCLUSION

Infectious lung destruction is the main indication for pulmonary resection in Mali. The consultation period is quite long. Morbidity and mortality remains high.

[Diagnosis and therapeutic aspects of the amoebic liver abscesses in the surgery at point "G" Hospital]

AIM

Our aim was to evaluate the diagnosis and therapeutic aspects of the amoebic liver abscesses in the surgery «A» department of the University hospital Point "G".

PATIENTS AND METHODS

Were included in this study, patients admitted to the surgery «A» department for amoebic liver abscess confirmed by a positive amoebic serology and the chocolate appearance of bacteria-free pus. Bacterial liver abscesses were not included into this study.

RESULTS

Over a 10-year period, 52 cases of patients diagnosed with amoebic liver abscess were collected in the department. There were 41 men and 11 women, with a sex ratio of 3.7. The mean age was 37.8 years old with extremes of 15 and 66 years. The most represented professions were farmers (36.5%) followed by salesmen (26.7%) and students (11.5%). The average outpatient visit delay time was 18.5 days with the extremes of 5 and 34 days. The most frequent clinical signs were pain in the right hypochondrium (86.5%), fever (78.8%) and hepatomegaly (61.5%). Abdominal ultrasound showed a single located abscess in 44 patients (84.6%) and these abscesses were localized in the right hepatic lobe in 34 patients(65.4%). The average volume of the abscess was 366.5 cm³ with the extremes of 36 cm³ and 1580 cm³. Amoebic serology was positive in 38 patients (80.9%). Cytobacteriological analysis of pus in 37 patients (71%) was negative. Patients underwent an ultrasound assisted needle aspiration of pus in 65.4% he. Laparotomy and a laparoscopic approach were performed in 7.7% and in 5.8%, respectively. The clinical course was uneventfulin 94.2%. The mean hospital stay duration was 16.5 days with the extremes of 4 and 29 days. No death was recorded during hospitalization.

CONCLUSION

Amoebic liver abscess is an uncommon pathology in a surgical setting. Abdominal ultrasound andechography guided liver puncture allowed the diagnosis. Laparoscopic approach minimizes the burden of the laparotomy.

[Necrotizing cervico-facial cellulitis of dental origin in a developing country]

INTRODUCTION

Necrotizing cellulitis of dental origin is a serious disease and requires prompt and effective management to avoid adverse outcomes. The purpose of this work is to describe the diagnostic and therapeutic difficulties encountered in this condition.

METHODS

This was a prospective study in the thoracic surgery department of Mali Hospital from January 2011 to February 2015. We collected consecutively 19 cases of complicating cervico-facial cellulitis of dental origin. The anatomical and clinical aspects, therapeutic modalities and difficulties are described.

RESULTS

Dental pain and fever were the predominant symptoms followed by cervical edema. Chest CT-scan was the basis for the diagnosis in all cases. Cervicotomy with debridement was the most performed surgical procedure. Pleural drainage was performed in 6 cases. Three patients (15.8%) died.

CONCLUSION

Necrotizing cellulitis of dental origin is a serious disease with high morbidity and mortality. The key radiological examination is the thoracic CT-scan. Early medico-surgical management by emergency care, tailored antibiotic therapy, removal of necrotizing tissues and drainage of collections are required to deliver a good outcome.

[Management of goiters in the surgery «A» department of the Point G university hospital]

The aim of this study was to evaluate the surgical treatment of goiter in the «A» surgical department of the Point G University Hospital in Bamako.

PATIENTS AND METHODS

This was a retrospective and descriptive study in the «A» surgical department of the Point G University Hospital from January 2007 to August 2014. Included in the study were all the patients operated for goiter. The patients who underwent surgery for other thyroid diseases were not selected. Postoperatively patients were followed for one year. The sociodemographic, clinical, para-clinical, therapeutic aspects and the postoperative course were the study parameters. Data analysis was performed on SPSS 21. The Chi square test was used for statistical analysis. A p-value inferior to 0.05 was considered statistically significant.

RESULTS

A total of 378 patients' records were collected. Thyroidectomy represented 6.2% (378 cases) over 6027 operations. The mean age was 41.29 years with a standard deviation of 13.58. Extremes were 3 and 85 years. The sex ratio was 7.22 in favor of women. The frequent reason for consultation was due to antero-cervical tumor with 97.07% of cases (n = 367). We identified 118 cases (31.22%) of goiter in cooled hyperthyroidism patients, 211 cases (55.82%) of euthyroid goiter, 7 cases (1.85%) of the thyroid neoplasia and one case (0.3%) of hypothyroidism goiter. Pathological histology helped to highlight a micro-vesicular macro adenoma in 16.1% of cases (61 patients); adenocarcinoma in 0.7% of cases (3 patients) and papillary carcinoma in 1.1% of patients (4 patients). The patients classified as ASA I and ASA II represented the majority with respectively 248 cases (65.60%) and 120 cases (31.74%). The most performed surgical techniques were subtotal thyroidectomy (n=181; 49.7%), the isthmo-lobectomy (126; 33.3%), total thyroidectomy (n=11; 2.9%) and sternotomy in one case of endothoracic goiter. Intraoperative complications were marked by hemorrhage in 12.7% of cases (45 patients). The postoperative one month follow up was uneventful in 91.79% (n = 347) and transient recurrent nerve injury was found in 2% of cases (1 patient). In one year follow up the postoperative outcome was good in 94.17% (n = 356) of patients. The mean hospital stay was 4.18 days. Six deaths were recorded (1.7%).

CONCLUSION

Goiter surgery is relatively common in the surgery 'A' department of the Point G University hospital. Good patient preparation and a better postoperative monitoring could help to minimize postoperative complications.

[Heller myotomy by transthoracic procedure, a single center experience in Mali with 21 cases]

AIMS

To evaluate the midterm results of myotomy for achalasia by thoracotomy procedure with the introduction of anti-reflux system by diaphragmatic flap.

PATIENTS AND METHODS

This was a prospective study involved 21 patients (14 women and 7 men) operated for idiopathic megaesophagus during a period of 3 years. All the patients were operated by thoracotomy procedure. An anti-reflux system was performed using a diaphragmatic flap over the entire length of the myotomy.

RESULTS

The mean age was 32 years (range 16 and 68 years). After the surgery we have seen a complete disappearance of dysphagia in 21 patients (100 %) (p <0.001) and a significant weight regain. Short term outcomes were marked by the occurrence of clinical gastroesophageal reflux disease in 1 patient (4.76%) who has received the anti-reflux system (p> 0.05).

CONCLUSION

Oeso-cardio-myotomy of Heller by transthoracic procedure associated with the establishment of an anti reflux system by diaphragmatic flap has goods results.

Sphingosylphosphorylcholine induces α-smooth muscle actin expression in human lung fibroblasts and fibroblast-mediated gel contraction via S1P2 receptor and Rho/Rho-kinase pathway

Chronic airway diseases like COPD and asthma are usually accompanied with airway fibrosis. Myofibroblasts, which are characterized by expression of smooth muscle actin (α-SMA), play an important role in a variety of developmental and pathological processes, including fibrosis and wound healing. Sphingosylphosphorylcholine (SPC), a sphingolipid metabolite, has been implicated in many physiological and pathological conditions. The current study tested the hypothesis that SPC may modulate tissue remodeling by affecting the expression of α-SMA in human fetal lung fibroblast (HFL-1) and fibroblast mediated gel contraction. The results show that SPC stimulates α-SMA expression in HFL-1 and augments HFL-1 mediated collagen gel contraction in a time- and concentration-dependent manner. The α-SMA protein expression and fibroblast gel contraction induced by SPC was not blocked by TGF-β1 neutralizing antibody. However, it was significantly blocked by S1P2 receptor antagonist JTE-013, the Rho-specific inhibitor C3 exoenzyme, and a Rho-kinase inhibitor Y-27632. These findings suggest that SPC stimulates α-SMA protein expression and HFL-1 mediated collagen gel contraction via S1P2 receptor and Rho/Rho kinase pathway, and by which mechanism, SPC may be involved in lung tissue remodeling.

[Prise en charge chirurgicale des goitres hyperthyroïdiens a Bamako]

GOAL

To assess the surgical therapy in goiter with hyperthyroidism in a surgical unit of CHU du Point-G.

PATIENTS AND METHODS

A retrospective study was conducted, concerning 131 patients having undergone a thyroidectomy for goiter with hyperthyroidism from January 1st 1998 to December 31st 2007.

RESULTS

The files of 131 patients were analysed. The average age of patients was 39.74 years, with 114 women and 17 men. The goiter in Basedow disease was the first indication for surgery in hyperthyroidism (48 cases; 36.6%) followed by toxic adenoma (39; 29.8% of the cases) and toxic multinodular goiter (38; 29% of cases). Ninety patients had a subtotal thyroidectomy (68.7% of cases). One total thyroidectomy (0.8%), 39 isthmolobectomies (29.7%) and one isthmectomy (0.8%) were carried out. Anatomohistology showed 67.1% of colloid benign tumours, and 8 cases of cancers (6.2% of the cases). Early postoperative follow ups were due to hemorrhage (2 cases; 1.5%) and 3 cases of dysphonia (2.5%). One patient died (0.8%). After six months, 3 cases of wound cheloide (2.5%), one case of dysphonia, and one case of hypothyroidism were noted. For 86 patients (71.1%) the postoperative follow up was simple.

CONCLUSION

Surgery remains a treatment of choice for hyperthyroidism goiter. Other options are too expensive or not available.

[Digestive tract perforations at Point G Teaching Hospital in Bamako, Mali]

AIMS

To determine the most frequent causes of the digestive perforations and to evaluate the surgical procedures, the morbidity and mortality.

PATIENTS AND METHODS

It was about a retrospective descriptive study, over 5 year's period in a visceral service of CHU du Point G, Bamako. Were included in the study all the patients operated for digestive perforation and hospitalized in the service of surgery "A". Were not included in the study patient operated not presenting a digestive perforation. Per operational etiologies of the perforations and their frequency were determined, as well as the morbidity and morbidity and mortality.

RESULTS

Files of 202 patients were collected. The average age of the patients was 28.3 ± 15.5 years with extremes of 6 and 71 years. The frequency of digestive perforations was higher in the age from 11 to 20 years (29.7%). The average time of consultation was of 7± 6 days. Abdominal pains, nauseas and vomiting, matter and gas stop (48.5%) were the most current functional signs. A "wood belly" abdomen was found in 72,3% of the cases. The radiography of abdomen without preparation found a diffuse greyness (64.7%), a pneumoperitoine (30.7%). A double antibiotic therapy was made in all the cases. A median laparotomy was practiced in 98,5%, and laparoscopy in 3 cases (1.5%). A single perforation was found among 172 patients (85,1%). Morbidity, all confused causes, was made of 30 cases of parietal suppurations (14.8%). Total mortality was 74%. According to aetiologies it was 10.3% in the typhic perforations, 4.6% in the appendicular perforations and 4.9% in the perforations of gastroduodenal ulcers.

CONCLUSION

The most frequent aetiologies of digestive perforation in our context were the typhoid fever, acute appendicitis and the gastroduodenal ulcer. The résection - joining and peritoneal toilet were the most practised procedure. The main factor of bad outcome remains the diagnostic delay burdening morbidity and mortality.

New cannulation method for pancreatic duct cannulation-bile duct guidewire-indwelling method

The patient was a 58-year-old male with symptomatic alcoholic chronic pancreatitis. Since a 10 mm calculus was observed in the pancreatic body and abdominal pain occurred due to congestion of pancreatic juice, endoscopic retrograde cholangiopancreatography was conducted for assessment of the pancreatic duct and treatment of pancreatic calculus. Pancreatogram was slightly and insufficiently obtained by injecting the contrast media via the common channel of the duodenal main papilla. We tried to cannulate selectively into the pancreatic duct for a clear image. However, the selective cannulation of the pancreatic duct was difficult because of instability of the papilla. On the other hand, selective cannulation of the bile duct was relatively easily achieved. Therefore, after the imaging of the bile duct, a guidewire was retained in the bile duct to immobilize the duodenal papilla and cannulation of the pancreatic duct was attempted. As a result, selective pancreatic duct cannulation became possible. It is considered that the bile duct guidewire-indwelling method may serve as one of the useful techniques for cases whose selective pancreatic duct cannulation is difficult (“selective pancreatic duct difficult cannulation case”).

Clinical importance of serum hepatitis B surface antigen levels in chronic hepatitis B

Quantitative serology for hepatitis B surface antigen (HBsAg) is a new candidate marker for prediction of clinical outcome. The aim of this study was to investigate the clinical significance of quantifying HBsAg in patients with hepatitis B virus (HBV) infection. A total of 424 patients who tested positive for HBsAg and were referred to Chiba University Hospital between January 1985 and April 2008 were included in the study, and the following characteristics were analyzed: age, gender, status of hepatitis B e antigen (HBeAg), alanine aminotransferase level (ALT), HBV DNA level, number of platelets and development of hepatocellular carcinoma. Measurement of HBsAg was performed using the chemiluminescent enzyme immunoassay method. The study group consisted of 239 men and 185 women, and their average age was 40.6 ± 14.0 years. HBsAg showed a positive correlation with HBV DNA level (Pearson's product moment correlation, r = 0.586, P < 0.001) and a weak inverse correlation with age (r = 0.3325, P < 0.001). A control study, matched with age and sex, was performed between two groups with and without HBeAg seroconversion during follow-up period. Compared with the age and sex-matched controls, the change in HBsAg levels per year showed a significant decrease 2 years before seroconversion (paired t-test, P < 0.05). The serial measurement of quantitative HBsAg level has the possibility of predicting the occurrence of HBeAg seroconversion.

Pancreatic duct guidewire-indwelling method for patients resistant to selective biliary cannulation and usefulness of pre-cut papillotomy following unsuccessful biliary cannulation with pancreatic duct guidewire-indwelling method

BACKGROUND/AIMS

Pancreatic duct guidewire-indwelling method (P-GW) is effective when selective biliary cannulation (SBC) has failed, but neither its true success rate nor a salvage technique have been established. In this study, we examined the usefulness of pre-cut papillotomy employing a pancreatic duct guidewire as the salvage treatment after unsuccessful SBC under P-GW.

METHODOLOGY

P-GW was conducted in 55 patients. When cannulation under P-GW was unsuccessful, pre-cut papillotomy was performed. Then, if SBC after trial was still unsuccessful, ERCP was tried again at a later date. The incidence of pancreatitis following ERCP in patients with difficult SBC, with and without pancreatic duct stenting was determined.

RESULTS

P-GW resulted in successful SBC in 63.6% of patients. For the 20 patients in which SBC failed pre-cut papillotomy using the pancreatic duct guidewire was performed. Transpancreatic pre-cut papillotomy was performed in 17 patients; 3 patients underwent needle-knife pre-cut papillotomy. SBC was successful at first attempt in 89.1% and eventually in 96.4% of patients. Post-ERCP pancreatitis occurred in 7.3%, broken down into 0% for those with pancreatic duct stenting (p=0.03) and 16.7% for those without.

CONCLUSIONS

Pre-cut papillotomy using a pancreatic duct guidewire was useful for patients with unsuccessful SBC with P-GW alone, and the risk for pancreatitis was reduced by pancreatic stenting.

Utility of placement of pancreatic duct spontaneous dislodgement stent for prevention of post-ERCP pancreatitis in patients with difficulty in selective biliary cannulation

BACKGROUND/AIMS

To examine the utility of placement of pancreatic duct spontaneous dislodgement stents for prevention of post-ERCP pancreatitis in patients with difficulty in selective biliary cannulation.

METHODOLOGY

The incidence of pancreatitis was compared between the group with P(+) pancreatic duct spontaneous dislodgement stent placed for prevention of post-ERCP pancreatitis and the group without P(-) in patients with difficulty in selective biliary cannulation.

RESULTS

The final success rate of selective biliary cannulation was 94.45%. Post-ERCP pancreatitis was observed at 7.07%. The success rate of placement of pancreatic duct stent in the P(+) group was 99.0%. The incidence of pancreatitis in 99 patients in the P(+) group was 3.0%, that of abdominal pain was 3.0%, that of hyperamylasemia was 16.2%, and the mean post-ERCP amylase level was 353.031 +/- 520.792 IU/L. The incidence of pancreatitis in the P(-) group was 11.1%, that of abdominal pain was 20.2%, that of hyperamylasemia was 33.3%, and the mean post-ERCP amylase level was 541.204 +/- 771.843 IU/L. Comparing between the P(+) group and P(-) group, the incidence of pancreatitis, that of abdominal pain, that of hyperamylasemia and the mean post-ERCP amylase level were significantly decreased in the P(+) group (p<0.05).

CONCLUSION

Placement of pancreatic duct spontaneous dislodgement stent in patients with difficulty in selective biliary cannulation could be useful for prevention of post-ERCP pancreatitis.

A survival case of ABO-incompatible liver transplantation complicated with severe preoperative infection and subsequent overwhelming postsplenectomy infection

A 47-year-old Japanese man was transferred to our hospital because of acute-on-chronic hepatitis B virus infection. On admission, he was suffering from sepsis due to a catheter infection and respiratory failure caused by pulmonary edema and pneumonia, but, as a result of preoperative intensive care, we avoided septic shock. ABO-incompatible liver transplantation (ABO-I-LT) was performed. In accordance with our ABO-I-LT protocol, we administered, rituximab and performed plasma exchange, splenectomy as well as hepatic artery infusion. The patient was discharged 80 days after living donor transplantation (LDLT). However, 136 days after LDLT, he experienced recurrent respiratory failure due to severe pneumonia. At that time, the CD19(+) B-cell count in the peripheral blood flow remained below 1%. We suspected a mixed infection involving Streptococcus pneumonia, Pneumocystis carinii, and fungus. The cause of the complication was overwhelming postsplenectomy infection (OPSI). We started administration of sulfamethoxazole and trimethoprim, ciprofloxacin hydrochloride, and micafungin sodium therapy as well as gamma-globulin. Oxygenation improved gradually; the patient was discharged at 41 days after re-admission. Although this patient survived the OPSI, it was clear that some aspects of the ABO-I-LT protocol should also be altered.

Cholangiopancreatography troubleshooting: the usefulness of endoscopic retrieval of migrated biliary and pancreatic stents

BACKGROUND

Stent migration in the hepatopancreatic duct might arise as one of the rare complications associated with biliary or pancreatic stenting. Although there are some procedures to retrieve the migrated stent, including surgical, percutaneous, and endoscopic approaches, endoscopy should be attempted first because it is least invasive. This study set out to evaluate the usefulness of endoscopic retrieval of migrated biliary and pancreatic stents.

METHODS

Plastic stents that migrated in the bile duct (35 patients) or pancreatic duct (2) were retrieved with endoscopic retrograde cholangiopancreatography. Devices used were snare forceps, a basket catheter, grasping forceps, biopsy forceps, a balloon catheter, and the Soehendra stent retriever.

RESULTS

Endoscopic retrieval of migrated stents was performed successfully in 36 (97.0%) of the 37 patients. The devices utilized for successful treatment were basket catheter (13 patients), grasping forceps (10), snare forceps (8), balloon catheter (3), biopsy forceps (1), and the Soehendra stent retriever (1). The unsuccessfully treated patient with chronic pancreatitis underwent surgery since the guide wire did not move forward due to bile duct stenosis, and there was also duodenal stenosis. One patient developed mild pancreatitis after withdrawal of the stent; the pancreatitis was relieved with conservative treatment.

CONCLUSIONS

Endoscopic retrieval of migrated biliary and pancreatic stents appears to be useful because of its safety and low invasiveness. However, various forceps should be prepared for the retrieval of a migrated stent.

Complete neurological recovery from fulminant hepatic failure with subarachnoid hemorrhage by living donor liver transplantation: a case report

A 29-year-old man was referred to our hospital with fulminant hepatic failure (FHF) and stage III hepatic coma (somnolence and confusion). Living donor liver transplantation (LDLT) was planned for 2 days after admission to our hospital. However, on the day after admission, he lapsed into stage IV hepatic coma: no right reflexes and no response to pain stimuli. Emergency cranial computed tomography revealed a subarachnoid hemorrhage (SAH), but no aneurysm was seen on magnetic resonance angiography. We speculated that the cause of the SAH may have been bleeding of intracranial veins secondary to coagulopathy and overextension of a vein due to brain edema. We considered that only LDLT could improve the coagulopathy and brain edema. The patient recovered consciousness on postoperative day (POD) 2 and was finally discharged from the hospital without neurological deficit on POD 85. This case suggested that SAH is not a prohibiting factor for LDLT in an FHF patient if the cause of the SAH is venous bleeding.

Statins inhibit matrix metalloproteinase release from human lung fibroblasts

Pleiotropic effects of statins have been reported to include inhibition of matrix metalloproteinase (MMP) release from macrophages and endothelial cells. We evaluated whether statins would inhibit MMP release from human lung fibroblasts, which play a major role in remodelling processes. Monolayer and three-dimensional (3D) collagen gel cultures of fibroblasts were used. Cytokines (tumour necrosis factor-alpha and interleukin-1alpha) were used to induce MMP release and mRNA expression. Collagen degradation induced by cytokines and neutrophil elastase (NE) was evaluated by quantifying hydroxyproline. Atorvastatin inhibited MMP-1 and -3 release and mRNA expression in both culture systems. Similar results were obtained with simvastatin and fluvastatin. In 3D cultures where cytokines also stimulated MMP-9 release, atorvastatin also inhibited MMP-9 release. In 3D cultures, cytokines together with NE induced collagen degradation, which was also inhibited by atorvastatin. The effect of atorvastatin was reversed by mevalonate and geranylgeranyl-pyrophosphate but not by farnesyl-pyrophosphate. The current data suggest that statins may modulate remodelling processes mediated by fibroblasts by inhibiting MMP release.

Correlating purity by microdissection with gene expression in gastric cancer tissue

Microdissection is a feasible tool for the purification of target cells from heterogeneous tissue components. However, the extent to which cells need to be purified by microdissection for use in gene expression analysis has not been determined. In the present study, we obtained diffuse-type gastric cancer tissues at varying purities, and evaluated the corresponding expression of a cancer-specific gene, KRT19, by quantitative real-time PCR. The relationship between the degree of purity and gene expression was confirmed by using 60-mer oligonucleotide microarray analysis. Cancer-specific gene expression was stable in tissues of 10-50% purity, but at 60% or greater purity the slope of the graph was much steeper, indicating a correlation between tissue purity and increased gene expression. Tissues of 70% purity for cancer cells, acquired by microdissection, were therefore deemed to be of sufficient quality to distinguish between gene expression profiles from microdissected and non-microdissected specimens.

Hepatitis C virus directly associates with insulin resistance independent of the visceral fat area in nonobese and nondiabetic patients

Insulin resistance (IR) is known to be associated with the visceral adipose tissue area. Elucidation of the relationship between hepatitis C virus (HCV) and IR is of great clinical relevance, because IR promotes liver fibrosis. In this study, we tested the hypothesis that HCV infection by itself may promote IR. We prospectively evaluated 47 patients with chronic HCV infection who underwent liver biopsy. Patients with obesity, type 2 diabetes mellitus (DM), or a history of alcohol consumption were excluded. IR was estimated by calculation of the modified homeostasis model of insulin resistance (HOMA-IR) index. Abdominal fat distribution was determined by computed tomography. Fasting blood glucose levels were within normal range in all the patients. The results of univariate analysis revealed a significant correlation between the quantity of HCV-RNA and the HOMA-IR (r = 0.368, P = 0.0291). While a significant correlation between the visceral adipose tissue area and the HOMA-IR was also observed in the 97 control, nondiabetic, non-HCV-infected patients (r = 0.398, P < 0.0001), no such significant correlation between the visceral adipose tissue area and the HOMA-IR (r = 0.124, P = 0.496) was observed in the patients with HCV infection. Multiple regression analysis with adjustment for age, gender and visceral adipose tissue area revealed a significant correlation between the HCV-RNA and the HOMA-IR (P = 0.0446). HCV is directly associated with IR in a dose-dependent manner, independent of the visceral adipose tissue area. This is the first report to demonstrate the direct involvement of HCV and IR in patients with chronic HCV infection.

Remnant liver regeneration after two-stage hepatectomy for multiple bilobar colorectal metastases

AIMS

Two-stage hepatectomy for multiple, bilobar liver metastases from colorectal cancer aimed to minimize liver failure risk by performing the second resection after regeneration, but impact of this strategy on volume of the future liver remnant (FLR) remained to be demonstrated. We compared two-stage hepatectomy with one stage following portal vein embolization (PVE) for multiple, bilobar liver metastases from colorectal cancer as to effects on volume of the FLR.

METHODS

Forty-three patients undergoing major hepatectomy for multiple colorectal cancer metastases were divided retrospectively into patients undergoing hepatectomy following PVE (n=21) and those undergoing two-stage hepatectomy (n=22). Increases in FLR volume were compared.

RESULTS

While the increase in the volume FLR averaged approximately 70 mL (302.6 mL before PVE vs. 370.9 mL after PVE) and the increase in the ratio of FLR to total liver volume averaged approximately 7.5% (30.2% to 37.5%) following PVE, first-stage hepatectomy increased FLR volume by approximately 100mL (from 259.4 to 361.4), and the ratio, by 15% (26.9% to 41.6%). The FLR hypertrophy ratio relative to pre-procedure volume estimates in the two-stage group (50.2%) was twice that in the PVE group (25.3%).

CONCLUSIONS

Superiority of two-stage hepatectomy in hypertrophy of the FLR was confirmed.

Surgical outcome of solitary colorectal metastasis to the hepatic caudate lobe

Increased risk of early recurrence

Beneficial effect of hyperbaric oxygen therapy on liver regeneration after 90% hepatectomy in rats

BACKGROUND/AIMS

Hyperbaric oxygen therapy (HBOT) has been reported to augment oxygen delivery to ischemic tissues and improve the liver dysfunction in clinical cases. HBOT was performed after 90% hepatectomy in rats to determine its effect on the regeneration of remnant liver.

METHODS

After 90% hepatectomy was performed in 8-week-old male Wistar rats, the animals were subdivided into an HBOT (2 atm abs., 80% O2, 1 h/day, 3 days) group and a non-HBOT group. Members of both groups were sacrificed, usually every 4 h until a maximum of 50 h after hepatectomy, and the liver regeneration rate, the proportion of PCNA-positive cells and the ATP volume in the remnant tissues were examined.

RESULTS

In the HBOT group, the liver regeneration rate at 36 h and 50 h after operation and the proportion of PCNA positive cells at 8 h was significantly increased compared with the non-HBOT group. The ATP volume in the remnant livers in the HBOT group was also significantly increased at 12 h.

CONCLUSION

HBOT augmented liver regeneration after hepatectomy by stabilization of energy metabolism induced by oxygen delivery in rats.

Usefulness of artificial liver support for pretransplant patients with fulminant hepatic failure

This study assessed the usefulness of artificial liver support (ALS) for pretransplant patients with fulminant hepatic failure (FHF). Five patients (age 14 to 52 years, 3 men and 2 women) with FHF who were being prepared for living donor liver transplantation (LDLTx) were enrolled in this study. ALS included plasma exchange, using 40 to 50 units of fresh frozen plasma per session, and high-flow hemodiafiltration, using a high-performance polysulfone membrane. Variables such as circulatory and respiratory function, coma grade, and neurologic disorders were evaluated. Although systolic and diastolic blood pressures showed no statistical differences between pre-ALS and post-ALS, the difference in heart rates was statistically significant. After ALS initiation in the pre-LDLTx period, one of the three patients who needed mechanical ventilation was weaned from it. After LDLTx, all patients recovered neurologically; no neurologic disorder was observed. These results suggested that ALS could predict neurologic status after LDLTx. The difference in coma grades also achieved statistical significance. Our study indicates that short-term ALS is useful for improving circulatory and respiratory function prior to liver transplantation, as well as for predicting posttransplantation neurologic status. Although some patients recover by ALS alone, the survival rate of ALS-only patients is less than 50%. ALS prolongs intensive treatment, thus increasing both the risk of infection and the medical costs. Further investigation to determine a precise marker for liver regeneration will be needed to establish a consensus on the indications for long-term ALS. We conclude that ALS is useful to improve circulatory and respiratory functions among pretransplant patients, and to predict neurologic status after LDLTx.

Clinical significance of serum CEA protein and CEA mRNA after resection of colorectal liver metastases

BACKGROUND

It is difficult to predict the recurrence of colorectal liver metastasis after curative hepatectomy. We investigated the relationship between subsequent metastasis and both CEA protein and CEA mRNA (TaqMan PCR) diachronic levels.

PATIENTS AND METHODS

The subjects were 30 patients with colorectal liver metastases. Serum CEA protein and CEA mRNA assays were performed every month after hepatectomy.

RESULTS

Metastasis recurred in 21 of the 30 patients. The CEA mRNA assay showed 26 cases with high (H) levels and 4 with low (L). Among the 15 patients whose protein levels were not elevated (NE group), 6 had recurrence; all 6 belonged to the mRNA H group. None of the 4 patients in the mRNA L group had recurrence. In the protein-elevated (E) group (DFI > 6 months) (n = 7), mRNA was elevated in 5 cases (71.4%) 6 months before recurrence, whereas protein was elevated in 1 case. The sensitivity, specificity and accuracy of CEA protein/mRNA for identifying recurrence were 71.4/100, 100/44.4, and 80/83.3%, respectively.

CONCLUSION

CEA mRNA is more sensitive than CEA protein in detecting recurrence. CEA mRNA may be useful for identifying high-risk groups or detecting recurrence at an early stage, when the CEA protein level is still low.

Usefulness of the prognostic score for donor safety in living donor liver transplantation

This study sought to determine whether a prognostic score is a useful indicator of donor safety using 13 consecutive donors enrolled for liver transplantation. The donor operations were right hepatic lobectomies (n = 10) and left hepatic lobectomies (n = 3). The postoperative maximal level of serum total bilirubin was used to assess the magnitude of surgical stress. Variables such as donor age, percentage of liver resection (PLR), indocyanine green 15-minute retention rate (ICGR15), operative blood loss, operation time, prognostic score and graft weight were evaluated as predictors of the magnitude of surgical stress. The PLR and prognostic score (PS) were calculated according to the following formulae: PLR (%) = 100*Graft weight (g)/standard liver volume of the donor (mL); PS = -84.6 + 0.933*PLR (%) +1.11*ICGR15 (%) +0.999*age (years); Standard liver volume (mL) = 706.2*body surface area (m2) + 2.39. No serious complications occurred after the donor operations. Maximal bilirubin ranged from 1.9 to 10.9 mg/dL. There were no mortalities, although there were two morbidities, bile leakage and prolonged liver dysfunction. Postoperative hyperbilirubinemia was observed in two donors and in one Gilbert's syndrome donor. Linear regression analysis of each variable indicated poor correlations between those variables and maximal bilirubin. However, close correlations were seen between maximal bilirubin and both donor age and PS except for the three patients who showed postoperative hyperbilirubinemia. In these uneventful donors, statistical formulae were obtained as follows: maximal bilirubin (PMB) = 0.271 + 0.056*donor age (correlation coefficient 0.612, P < .008), PMB = 1.541 + 0.059*PS (correlation coefficient 0.597, P < .009). In conclusion, PS is useful to predict maximal bilirubin and to ensure donor safety.

Surveillance of perioperative infections after adult living donor liver transplantation

AIM

This study was conducted to clarify the management of perioperative infectious complications after adult living donor liver transplantation (LDLT).

PATIENTS AND METHODS

Fourteen adult LDLT patients were enrolled in this study. We examined the occurrence of infectious complications in these cases and the relationships of infectious complications to UNOS status and MELD score. Surveillance culture and immunoserologic analyses were performed. From the results of these analyses, we made a diagram of infection surveillance using a matrix of time and sampling site. Using the diagram, we chose sensitive antibiotics as soon as possible.

RESULTS

The infection site and its pathogen were able to be detected in four (28.5%) patients, all of whom had MRSA infections, together with lung aspergillosis in one case, pseudomonas pneumonia in another, and both in another. Two patients died of lung aspergillosis. Bacteria detected in the airway tended to spread to other sites during the postoperative period. In all four patients in whom infectious diseases were detected, and in a fifth patient in whom the site of infection was not known, the UNOS status was 1. The MELD score was calculated in eight patients, six of whom had high MELD scores (>20).

CONCLUSION

Most cases were manageable by choosing and changing antibiotics and antifungal drugs according to the results of surveillance cultures twice a week. However, aspergillosis had an extremely poor prognosis. Patients with a high MELD score or low UNOS status, or both, showed poor prognosis; and in them, multiple drug resistance bacteria caused severe perioperative infectious complications.

Indications for hepatic vein reconstruction in living donor liver transplantation of right liver grafts

BACKGROUND

To overcome problems arising from a graft of insufficient size, right liver grafts have been used extensively for adult-to-adult living donor liver transplantation (LDLT). However, there are reports of severe congestion in the anterior segment of the graft after transplantation.

CASE REPORTS

Right liver transplantation without the middle hepatic vein was performed in six cases. In the second and third cases, the inferior right hepatic vein was reconstructed because it was thick (whereas the middle hepatic vein was not). Abdominal CT revealed congestive infarction of the anterior segment in the second case and of the posterior segment in the third. It was suspected that the former resulted from the lack of an middle hepatic vein, and the latter from obstruction of the reconstructed inferior right hepatic vein. Both patients died without improvement in liver function. Accordingly, in the fifth case, the middle hepatic vein was reconstructed. The postoperative course of this case was uneventful. Doppler ultrasonography showed profuse blood flow in the interposition graft. In the sixth case, the middle hepatic vein was not reconstructed because of technical difficulties. Although abdominal CT showed a congestive area in the anterior segment, the patient recovered uneventfully, probably because the volume of functional graft was sufficient even without the congestive area.

CONCLUSION

When the color becomes dark in more than half of the surface of the anterior segment following clamping of middle hepatic vein tributaries and the hepatic artery, the middle hepatic vein should be reconstructed. When the diameter of the inferior right hepatic vein is more than 5 mm, its reconstruction is also recommended.

Remaining caudate lobe in the right lobe graft in living donor liver transplantation: a blind spot?

The right margin of the caudate lobe is obscure. Therefore, a part of the caudate lobe (a part of the right side of the paracaval portion) seems almost always to remain with the right lobe graft during the standard harvesting procedure. We reviewed the intraoperative findings and the postoperative courses of donors and recipients of 11 consecutive living donor liver transplantations using right lobe grafts. Further, we used computed tomography during the postoperative course to investigate whether the remaining caudate lobe was present in the right lobe graft and whether it produced serious complications. Four recipients displayed an intraoperative bile leak from a remaining part of the caudate lobe after the completion of biliary reconstruction. With the exception of one case who developed repeated bile leakage from the same origin which eventually healed during a long-term postoperative course, Most recipients showed no postoperative biliary complications. Although a remaining caudate lobe was detected on postoperative computed tomography in all recipients, it produced no serious complications. In conclusion, a part of the right side of the paracaval portion of the caudate lobe almost always remains with a right lobe graft during the standard harvesting procedure. However, the implications of this phenomenon seem to be benign.

Gene expression profile analysis of regenerating liver after portal vein ligation in rats by a cDNA microarray system

AIMS

We assessed changes in gene expression of hypertrophied liver after portal vein ligation (PL) in a test group of rats compared to a control group, which had the same size liver but no PL.

METHODS

The portal veins of the left and median lobes in the test group were ligated in an initial operation. Four days after the PL, the liver volume of the posterior caudate lobe (5%) increased two-fold and comprised 10% of the liver. A 90% hepatectomy was then performed, leaving only the hypertrophied posterior caudate lobe, and leaving the normal anterior and posterior caudate lobes (10%) in the control (sham) group. A comparison of the expression profiles between two groups was performed using cDNA microarrays and the hepatic ATP level was measured.

RESULTS

The survival rate for the PL group was significantly higher than for the sham group at 4 days after the hepatectomy (56.3% and 26.7%, P < 0.05). Gene expression of cyclin D1, proliferating cell nuclear antigen, cyclin A and B was upregulated, and the cyclin-dependent kinase inhibitor was downregulated. Increases were observed in: (i) pyruvate dehydrogenase, the tricarboxylic acid cycle cycle regulator, (ii) acyl-CoA dehydrogenase, the oxidation regulator, and (iii) cytochrome oxidases, the oxidative phosphorylation regulator. Hepatic ATP concentration after hepatectomy was better maintained in the PL group than in the sham group (0.48 +/- 0.01 micromol/ml vs. 0.33 +/- 0.01 micromol/ml, P < 0.05).

CONCLUSION

The regenerating liver increased tolerance for extended hepatectomy compared to normal liver. It is believed that this is because the induced rapid regeneration of the remaining liver after hepatectomy increases ATP metabolism.

Enhancement of the quantum-liquid phase by increased resistivity in thick a-MoxSi1-x films

Effects of normal-state resistivity rho(n) on the vortex phase diagram at low temperature T have been studied based on dc and ac complex resistivities for thick amorphous MoxSi(1-x) films. It is commonly observed irrespective of rho(n) that, in the limit T=0, the vortex-glass-transition line B(g)(T) is independent of T and extrapolates to a field below the T=0 upper critical field B(c2)(0), indicative of the quantum-vortex-liquid (QVL) phase in the regime B(g)(0)<B<B(c2)(0). The relative width of the QVL phase increases along the B and T axes approximately proportional to rho(n). This result is consistent with a view that the QVL phase is caused by strong quantum fluctuations, which are enhanced with increasing rho(n).

Sequential resection of lung metastasis following partial hepatectomy for colorectal cancer

BACKGROUND

Multiple organ metastases from colorectal carcinoma may be considered incurable, but long survival after both liver and lung resection for metastases has been reported.

METHODS

A retrospective analysis of 48 patients who underwent lung resection for metastatic colorectal cancer between 1992 and 1999 was undertaken. Twenty-seven patients had lung metastasis alone, 15 had previous partial hepatectomy, and six had previous resection of local or lymph node recurrence. The relationship of clinical variables to survival was assessed. Survival was calculated from the time of first pulmonary resection.

RESULTS

Five-year survival rates after resection of lung metastasis were 73 per cent in patients without preceding recurrence, 50 per cent following previous partial hepatectomy and zero after resection of previous local recurrence. Independent prognostic variables that significantly affected survival after thoracotomy were primary tumour histology and type of preceding recurrence. There was no significant difference in survival after lung resection between patients who had sequential liver and lung resection versus those who had lung resection alone.

CONCLUSION

Sequential lung resection after partial hepatectomy for metastatic colorectal cancer may lead to long-term survival.

Indications for curative resection of advanced gallbladder cancer with hepatoduodenal ligament invasion

PURPOSE

Hepatoduodenal ligament invasion (HLI) is an inhibiting factor for the curative resection of advanced gallbladder cancer. The aim of this study was to clarify the indications for surgical resection in patients with advanced gallbladder cancer with and without HLI by analyzing outcomes.

METHODS

The subjects were 58 patients with advanced gallbladder cancer who underwent aggressive resection, and 20 nonresected patients diagnosed as haring HLI. The presence of stromal cancerous infiltration at six sites in the hepatoduodenal ligament was investigated. The extent of cancer spread was classified into two grades by the number of sites where cancer cells detected: low grade, one or two invasion sites; high grade, three or more sites.

RESULTS

Pancreatoduodenectomy, vascular reconstruction, and extensive hepatectomy were frequently performed in the patients with HLI. The cumulative 5-year-survival rate of the HLI patients was 10.9%, significantly worse than that of the resected patients without HLI (46.6%; P < 0.01). Patients with paraaortic lymph node metastasis died within 1 year. The cumulative 5-year-survival rate after curative resection was 38.1%, significantly better than that after noncurative resection (0%; P < 0.05). The survival was significantly worse in patients with high-grade invasion than in these with low-grade invasion (P < 0.05), being equivalent to that in the nonresection patients. Of four factors, operative curability, hepatic lobectomy, HLI grade, and paraaortic lymph node metastasis, the HLI grade and hepatic lobectomy were considered to be significant prognostic factors by Cox's multivariate analysis (backward stepwise method).

CONCLUSIONS

Aggressive surgical resection for curative purposes should be limited to patients with low-grade HLI and metastasis-negative paraaortic lymph nodes.

[Indications for combined resection and reconstruction of the hepatic artery in biliary tract carcinoma]

More than 10 years have passed since hepatic artery resection was first performed for the treatment of biliary tract cancer. The safety of this procedure has been established with the introduction of the microsurgery technique. However, the benefits of and indications for this treatment have not yet been clarified. Twenty-three patients underwent vascular resection (portal vein in 7, portal vein + hepatic artery in 9, hepatic artery in 7) among 114 resected patients with biliary tract cancer in our institution. The right hepatic artery was reconstructed by end-to-end anastomosis in most cases. The curative resection rate was 88.9% in hilar bile duct cancer. However, it was less than 50% in other carcinomas. Cumulative 5-year survival rates of vascular resection patients with hilar bile duct cancer, lower bile duct cancer, gallbladder cancer, and cholangiocarcinoma were 14.8%, 25%, 0%, and 0%, respectively. On the other hand, the rates were 38.9%, 0%, 0%, and 0%, in the stage III + IV patients who did not undergo vascular resection. The longest survival period among patients with hilar bile duct cancer and lower bile duct cancer was 85 months and 65 months, respectively, whereas it was 15 months in gallbladder cancer and 20 months in cholangiocarcinoma patients. No hilar bile duct cancer patient who survived for more than 3 years had lymph node metastasis. The longest surviving cholangiocarcinoma patient has received adjuvant chemotherapy consisting of 5-fluorouracil and cisplatin. It is concluded that patients with hilar bile duct cancer are good candidates for vascular resection. Adjuvant chemotherapy should be administered to gallbladder cancer and cholangiocarcinoma patients, because vascular resection alone does not result in prolongation of life in these patients.

Monocyte CD14 changes and endotoxemia after major hepatectomy

BACKGROUND/AIMS

This study was designed to ascertain whether decreases in membrane CD14 (mCD14), the endotoxin receptor on the surface of the monocyte cell membrane, reflect the presence of endotoxemia, and whether endogenous endotoxemia is present after hepatectomy.

METHODOLOGY

First, in cases with a definitive clinical diagnosis of endotoxemia, we determined the serum endotoxin level by the ES (Endospesy) method, from the percentage of cells positive for membrane CD14, from the CD14 fluorescence intensity (MFI-CD14), and from the quantification of soluble CD14 (sCD14); and calculated the diagnostic accuracy obtained with each. Next, in 13 cases of extended hepatectomy (in excess of lobectomy) the mCD14-positive rates were determined around the time of the operation, and compared with the clinical courses of infection foci, if any, and other findings.

RESULTS

The diagnostic accuracy of endotoxemia obtained by ES, mCD14, MFI-CD14 and sCD14 were 77.3%, 95.5%, 86.7% and 66.7%, respectively, so that the highest was given by the positive mCD14 cell rate. Although no infectious complication was detected in any of the 9 patients in whom the mCD14-positive rates changed within the normal range, of the 4 patients in whom the mCD14-positive rates fell, 2 had cholangitis due to gram-negative bacilli, one who was infected by central vein catheterization, was thought to have exogenous endotoxemia; and the fourth, in whom no clear focus of infection was detected, ran a temperature of 38 degrees C (over 100 degrees F) of unknown origin for 16 days. In this last patient, gram-negative bacilli were detected in both the saliva and the gastric juice, and so endogenous endotoxemia was suspected.

CONCLUSIONS

These results show that decrease in the mCD14-positive rate is more accurately diagnostic of endotoxemia than the endotoxin value obtained by the ES method, and was considered to be a definitive diagnosis of endotoxemia. In addition, from the reduction of the mCD14-positive rate after extended hepatectomy, it was considered that endogenous endotoxemia occurred in one case out of 13 (8%).

Successful left trisegmentectomy for polycystic liver disease accompanied by jaundice

BACKGROUND

We report a case of severe polycystic liver disease (PLD) with jaundice in a 57-year-old woman who underwent successful left trisegmentectomy.

METHOD

She was admitted for the first time in February 1992 to our hospital with a 7-year history of PLD, and became jaundiced in June 1995. Because normal liver parenchyma was confirmed mainly to the posterior segment, left trisegmentectomy was performed.

RESULTS

No postoperative complication occurred. The serum bilirubin level decreased promptly after the operation, but postoperative endoscopic retrograde cholangiography showed that the root of the posterior hepatic duct remained thin. Thus, the elimination of jaundice was presumed to have been caused by a decrease of intra-abdominal and peripheral biliary pressure, since a large volume of tissue had been removed from the peritoneal cavity. She has since remained well without any symptoms.

CONCLUSION

This procedure is useful for severe PLD, because it can be performed safely and the symptoms disappear dramatically. However, further follow-up is needed to determine the long-term effects of this procedure, because the remaining liver has shown some increase in size.

Adjuvant therapies using biliary stenting for malignant biliary obstruction

The aim of this study was to analyze the patency of expandable metallic stents in malignant biliary obstruction and to evaluate the efficacy of adjuvant therapy accompanied by biliary stenting. We analyzed 29 patients in whom bile duct stenting was performed for malignant biliary obstruction. Their types of disease were: hilar ductal carcinoma (n = 8), gallbladder carcinoma (n = 11), and pancreatic carcinoma (n = 10). Initially, 46 expandable metallic stents were placed in 29 patients. In 23 of the 29 patients, adjuvant therapy was administered. Seventeen patients underwent radiotherapy, and 16 patients received various systemic chemotherapies. In principle, hyperthermia was performed twice a week, simultaneously with radiotherapy. Patient survival and the probability of stent patency were calculated using actuarial life table analysis. There was no significant difference in stent patency among the patients according to type of disease. Hyperthermia did not influence the stent patency rate. The median stent patency time was significantly greater in the chemo-radiation group than in the no-adjuvant therapy group: 182 days versus 68 days, respectively (P = 0.017). Moreover, a significant increase was seen in the median survival time in the chemo-radiation group: 261 days versus 109 days (P = 0.0337). Complications occurred in 9 patients (31.0%). Stent occlusion occurred in 6 patients (20.7%), with all of these patients managed successfully using a transhepatically placed new expandable metallic stent, employing the stent-in-stent method. Stent migration occurred in 2 patients after radiotherapy. Adjuvant therapies such as radiotherapy and systemic chemotherapy, in combination with stent insertion, resulted in an increase in the patency period of expandable metallic stents and in increased patient survival time.

Expression of Bcl-2 family reduces apoptotic hepatocytes after excessive hepatectomy

Excessive hepatectomy often causes fatal hepatic failure, but the mechanism is unknown. We used a novel protocol of partial 90 and 95% hepatectomy (PHx) to investigate this mechanism in 2 groups of rats. The 90% PHx rats survived, but the 95% PHx animals died of hepatic failure. In the latter, cytokine (interleukin-6, tumor necrosis factor-alpha) levels and the apoptotic hepatocyte count increased, and there were few mitotic cells. By contrast, in the 90% PHx rats, the mitotic cell count increased, and more anti-apoptotic Bcl-xL protein was expressed. These results demonstrate that expression of Bcl-xL protein as an anti-apoptotic factor or regeneration factor contributes to survival after 90% PHx. Using an adenovirus vector, the human bcl-2 gene (hbcl-2) was therefore transfected to DA rat livers where it was efficiently expressed, and then 95% PHx was performed. Liver damage was decreased and the apoptotic cell count decreased too, but the rats died. We concluded that transfection of the hbcl-2 gene partly prevents cytotoxicity (apoptosis), but cannot ensure survival. Thus, some other factor is required (e.g., a regeneration stimulator) to maintain life in these models.