Hepatolithiasis in East Asia. Retrospective study

Hepatolithiasis is a major disease in Asia but differences in operative incidence between countries have not been examined. A retrospective study was conducted in Taiwan, Hong Kong, and Singapore, and the results were compared with those in Japan with the aim of defining factors involved in the etiology of the condition. In order to ensure uniformity of the data collected, the same form was used throughout the study and was completed by the same personnel after reviewing the patient's record and radiographs in each case. The years 1976-1980 were chosen for the study, since the newer methods of diagnosis such as ultrasound, endoscopic retrograde cholangiography, and percutaneous transhepatic cholangiography became available during that period. The most significant finding was the difference in the relative prevalence of hepatolithiasis as a proportion of all gallstone cases in Taiwan, Hong Kong, and Singapore, where the majority of the population consisted of patients of Chinese descent. The highest prevalence, 53.5%, was found in Taiwan, while in Hong Kong it was 3.1% and in Singapore 1.7%. Environmental rather than ethnic factors are implicated in the cause of hepatolithiasis.

Centrosome abnormalities in human carcinomas of the gallbladder and intrahepatic and extrahepatic bile ducts

During mitosis, 2 centrosomes ensure accurate assembly of bipolar spindles and fidelity of the chromosomal segregation. The presence of more than 2 copies of centrosomes during mitosis can result in the formation of multipolar spindles, unbalanced chromosome segregation, and aneuploidy. Recent studies have provided evidence that centrosome hyperamplification plays a pivotal role in carcinogenesis. Using immunofluorescence analysis with gamma-tubulin and pericentrin antibodies, paraffin-embedded sections from 40 malignant biliary diseases including gallbladder cancers (GC; n = 13), intrahepatic cholangiocellular carcinoma (CCC; n = 19), and extrahepatic bile duct cancers (BDC; n = 8) were examined. Thirty-seven benign biliary diseases including chronic cholecystitis, gallbladder adenoma, hepatolithiasis, and choledochal cyst were included as benign controls. The frequencies of the centrosome abnormalities were 70% for GC, 58% for CCC, and 50% for BDC, respectively. The frequencies of centrosome abnormalities in malignant biliary diseases were significantly higher than in their benign counterparts (GC, CCC, BDC; P =.001,.002, and.001, respectively). The results of current study also indicated that biliary malignancy in the advanced stage (III-IV) displayed a higher frequency of centrosome abnormalities than in the early stage (I-II) (P <.001). We conclude that abnormalities in size, number, and shape of the centrosome are frequently observed in biliary tract malignancy. Centrosome abnormalities started to occur in the early stage of biliary malignancy and became very frequent in the advanced stage. This implies that centrosome abnormality might relate to the transition from early to advanced malignancy in biliary malignancy.

Liver Surgery for Hepatocellular Carcinoma: Laparoscopic versus Open Approach

In this study, we try to compare the benefit of laparoscopic versus open operative procedures. Patients and Methods. One hundred and sixteen patients underwent laparoscopic liver resection (LR) and another 208 patients went for open liver resection (OR) for hepatocellular carcinoma (HCC). Patients' selection for open or laparoscopic approach was not randomized. Results. The CLIP score for LR and OR was 0.59 ± 0.75 and 0.86 ± 1.04, respectively, (P = .016). The operation time was 156.3 ± 308.2 and 190.9 ± 79.2 min for LR and OR groups, respectively. The necessity for blood transfusion was found in 8 patients (6.9%) and 106 patients (50.9%) for LR and OR groups. Patients resumed full diet on the 2nd and 3rd postoperative day, and the average length of hospital stay was 6 days and 12 days for LR and OR groups. The complication rate and mortality rate were 0% and 6.0%, 2.9% and 30.2% for LR and OR groups, respectively. The 1-yr, 3-yr, and 5-yr survival rate was 87.0%, 70.4%, 62.2% and 83.2%, 76.0%, 71.8% for LR and OR group, respectively, of non-significant difference. From these results, HCC patients accepted laparoscopic or open approach were of no significant differences between their survival rates.

Assessment of serum and bile levels of CA19-9 and CA125 in cholangitis and bile duct carcinoma

In this study, CA19-9 and CA125 in serum and bile were measured to evaluate their diagnostic value in cholangitis and bile duct carcinoma. Patients were classified into three groups: group A, the control group, had cholelithiasis without infection (n = 23), group B had acute cholangitis (n = 25) and group C had bile duct carcinoma without bacterial infection (n = 18). All patients had undergone surgery, and bile and serum of the patients were measured for the two tumour markers by radio-immunoassay. The positivity rate for serum CA19-9 was 4.4% in the control group, 28.0% in group B and 61.1% in group C. The positivity rates for serum CA125 in groups control, B and C were 0%, 4% and 27.78% respectively. The diagnostic accuracy for bile duct carcinoma was 67.4% for both CA19-9 or CA125. The concentration of CA19-9 in bile was more than 1200 ng/mL in 72% of patients with acute cholangitis, in 61.1% of all patients with bile duct carcinoma and 0% in the control group. The frequency of concentrations of CA125 in bile greater than 200 ng/mL was 38.89% in bile duct carcinoma and none was observed in the control or acute cholangitis groups. In conclusion, the concentration of CA19-9 was increased not only by the tumour itself, but also by infection. In the diagnosis of bile duct carcinomas, the sensitivity of CA125 was low but its specificity was very high.

Pyogenic liver abscess: multivariate analysis of risk factors

Seventy-three patients with pyogenic liver abscess during the year 1978-1988 were studied in the Kaohsiung Medical College Hospital. The overall mortality rate was 19.2% in this study. By using univariate analysis, it was revealed that clinical jaundice, pleural effusion, bilobar abscess, profound hypoalbuminemia (less than 2.5 g/dl), hyperbilirubinemia (less than 2 mg/dl), elevated level of serum AST (greater than 100 IU/L), alkaline phosphatase (greater than 150 IU/L), and marked leukocytosis (greater than 20,000 mm3) were associated with a higher mortality rate. Multivariate stepwise logistic regression analysis detected only 3 factors of marked leukocytosis (greater than 20,000 mm3), profound hypoalbuminemia (less than 2.5 g/dl), and presence of pleural effusion with independent significance in predicting mortality. Meanwhile, it was also revealed that the laboratory data could not predict a risk factor to mortality unless they became markedly abnormal.

Ultrasonic guided percutaneous transhepatic bile drainage for cholangitis due to intrahepatic stones

Acute cholangitis due to intrahepatic stones is frequently associated with biliary sepsis. Emergency surgery for these high-risk patients is usually associated with a high mortality. Therefore, we recommend nonoperative methods for the management of this acute disease. Percutaneous transhepatic cholangiography and drainage (PTCD) combined with antibiotic and fluid treatment was used successfully in the management of 41 patients with acute pyogenic cholangitis due to intrahepatic stones. The general condition of these patients improved after treatment with PTCD. Repeated cholangiography should be performed so that the entire biliary tree and lesions can be viewed. Elective surgery (21 patients) or removal of the stone through the sinus tract via PTCD (14 patients) was performed when the patients' general condition improved following emergency PTCD. Therefore, we recommend PTCD over emergency surgery in the treatment of acute septic intrahepatic stones.

Ultrasound-guided percutaneous cholecystostomy as an initial treatment for acute cholecystitis in elderly patients

BACKGROUND/AIMS

Acute cholecystitis may atypically present itself in the elderly, thus causing diagnostic and therapeutic problems, and it is well recognized as a high-risk condition for morbidity. The outcome has been attributed to the presence of severe co-morbid disease. In an attempt to minimize the postoperative morbidity and mortality, we performed ultrasound-guided percutaneous transhepatic cholecystostomy (PC) on elderly patients with acute cholecystitis for both initial treatment and subsequent diagnosis of their biliary tract disorders.

METHODS

Those being more than 70 years old, had acute episode of cholecystitis for more than 48 h and still had positive Murphy's signs and distended gallbladders were candidates for ultrasound-guided PC.

RESULTS

Forty-two elderly patients underwent ultrasound-guided PC. Once the condition of each patient showed signs of improvement and stability, cholangiography was performed via PC tube. The results of the cholangiography showed 20 patients with gallbladder stones, 16 with common bile duct stones and 6 with acalculous cholecystitis. Once stable enough, 32 patients underwent definite surgery, 18 having cholecystectomies, 14 having cholecystectomies and choledocholithotomies. The 6 patients with acalculous cholecystitis had the PC tube removed 3 weeks later, without further surgery. Two patients had gallbladder stones removed by choledochofiberscope. Two patients had common bile duct stone removed by endoscopic sphincteroplasty. Although postoperative complications occurred in 5 patients (11.9%), no instance of operative mortality was found.

CONCLUSION

Our findings lead us to conclude that the use of PC in the early treatment of acute cholecystitis in elderly patients can decrease postoperative morbidity and mortality.

Electron microscopic assessment of bile regurgitation of humans in extrahepatic obstructive jaundice

Thirty-seven patients were studied on the anatomic routes of bile regurgitation into the blood stream by electron microscopy. The aim was to identify the relationship between the clinical results and pathway of bile regurgitation. These patients were classified into 3 groups; recovered, delayed, and fatal. Transcellular, paracellular, direct communication, necrotic hepatocyte and ruptured ductule pathway were found. In the recovered group, the transcellular pathway was most frequent with an incidence of 54.17%, and a direct communication pathway was found to be 54.55% in the fatal group with a significant difference between that of the recovered and delayed group. Long-duration bile duct obstruction creates bile regurgitation by way of direct communication between the canaliculi and Disse's space, and usually with a poor prognosis, since the serum bilirubin reached the high level of 22.65 mg%. Therefore, it is better to relieve the intrabiliary pressure as early as possible to prevent the jaundice from producing the irreversible change of hepatic canaliculi and Disse's space.

Changes of bile duct mucosa after choledochoduodenostomy in rats

This study investigated the changes of bile duct mucosa in rats after choledochoduodenostomy. Wistar rats were divided into three groups: group I (n = 6) was treated with sham operation as control; group II (n = 10) was treated with common bile duct ligation without choledochoduodenostomy, and group III (n = 12) had both common bile duct ligation and choledochoduodenostomy creation 4 days after common bile duct ligation. From our observations, retrograde induced cholangitis due to enteric reflux into the common bile duct is the possible cause of chronic inflammation after choledochuduodenostomy. At the end of the study, Choledocholithiasis developed in 5 of 12 rats. Severe dysplasia was present in the bile duct mucosa in 6 of 12 rats in group III, but not in group I or II. A technique for silver staining of nucleolar organizing regions (AgNOR) was applied. This technique demonstrated differences in AgNOR counts between normal mucosa and dysplasia. Under AgNOR stain, the number of AgNOR was significantly greater than in the normal or benign counterparts and gradually increased from the normal bile duct mucosa group to the severe dysplasia group (group I 2.1 +/- 0.8, group II 3.2 +/- 1.0, group III 5.3 +/- 1.1). All of these observations suggest that 'sump syndrome' and bile stasis could occur after choledochoduodenostomy in rats and can result in chronic inflammation of the bile duct. It has been well established that calcium bilirubinate is the major type of choledocholithiasis in Orientals. beta-Glucuronidase from bacteria, such as Escherichia coli present in the biliary tree, hydrolyzes bilirubin diglucuronide to bilirubin. Bilirubin combines with calcium in the bile flow to form calcium bilirubinate. Bacterial infection plays a key role in calcium bilirubinate stone formation. Since choledochoduodenostomy did increase reflux cholangitis, and bacterial infection would increase mucin overproduction, bile deconjugation and eventually new calcium bilirubinate stones would be formed. The dysplastic changes in the bile duct mucosa could possibly be related to the prolonged exposure to the biochemically altered infected bile. Thus choledochoduodenostomy might not be the perfect choice in treating calcium bilirubinate choledocholithiasis in Orientals.

Percutaneous post-operative choledochofiberscopic lithotripsy for residual biliary stones

A total of 5,116 post-operative percutaneous choledochofiberscopy (POC) sessions were performed on 739 patients with residual bile duct stones between 1980 and 1988. These residual stones were detected and removed by choledochoscopy. The success rate of non-surgical stone removal using POC was 100% for residual common duct stones and required 414 treatment sessions in this group of 168 patients. The success rate was 92.2% (525/569) for patients with residual intrahepatic stones; in this group a total of 4,694 treatment sessions were needed. Two patients with residual cystic duct stones were also successfully treated with POC. The distribution of residual intrahepatic stones was as follows: 166 (29.2%) in the right hepatic duct, 255 (44.8%) in the left hepatic duct and 148 (26.0%) in both hepatic ducts. Complications after POC were minimal and subsided after conservative treatment except in 2 patients. One patient had hemobilia and another a large subphrenic abscess, which required surgical drainage. Choledochofiberscopic electrohydraulic shock-wave lithotripsy was effective treatment for large stones and was well tolerated. Residual stones in Oriental gallstone disease are not preventable, and we believe that POC should be the first choice for these patients. Many of the problems associated with residual stones can be overcome by this method and good results achieved.

Instrumental neutron activation analysis of gallstones

Four kinds of gallstones from 40 patients have been analyzed for the presence of a total of 18 elements by instrumental neutron activation analysis. Of these elements, Ca, Mg, Fe, Co, Zn, Na, and Cl are found in the core of all types of stones. The differences in elemental composition of the various types of stones as well as the differences in the cross-sectional layers of stones are statistically evaluated.

Elevation of carcinoembryonic antigen related to biliary malignancy in hepatolithiasis

Bile duct neoplasms occur relatively often in patients with hepatolithiasis in Taiwan. In this study, 49 patients with a positive immunoperoxidase stain for carcinoembryonic antigen (CEA) in the bile duct glands were examined in relation to the concentration of CEA in serum and bile. The bile concentrations of CEA in 15 control patients, 16 patients with hepatolithiasis only, 7 with hepatolithiasis and bile duct carcinoma, and 11 with bile duct carcinoma only were 4.09 +/- 4.12, 70.49 +/- 81.62, 137.73 +/- 66.15, and 144.3 +/- 117.31 ng/ml (mean +/- SD), respectively. A positive CEA stain from the bile duct was seen in 13.33%, 81.23%, 85.71%, and 90.91% of each group, respectively. No strongly positive staining, (2+ or 3+) was found in the control group, but it was found frequently in the hepatolithiasis and bile duct carcinoma groups. The findings of this study therefore suggest the probability of a combined neoplasm in patients with hepatolithiasis if the CEA value is unusually elevated in the serum or bile.

Ultrasound survey of hepatobiliary lesions in Kaohsiung, Taiwan

An ultrasound survey of the liver and biliary system was made in the city of Kaohsiung and a neighbouring village in the southwest of Taiwan. 1,166 persons (538 males and 628 females between 5 and 83 years) from 388 families were examined. Abnormalities were found in 104 cases (8.9%). Hepatolithiasis was suspected in 22 cases (1.9%). This gives an incidence of hepatolithiasis of 42.3% in a total of 52 cases of cholelithiasis. Hepatoma was suspected in 4 (0.3%) of cases.

The role of insulin and glucagon in experimental obstructive jaundice

BACKGROUND/AIMS

The oxidative phosphorylation of liver mitochondria is regulated by the amount of portal insulin available to the hepatocytes. Thus, hepatic energy is mediated by the values of blood sugar and insulin. Insulin and glucagon are the main fuel homeostats in the liver. This study was performed to investigate the concept of energy mediated by glucose, during the process of obstructive jaundice and its recovery.

METHODOLOGY

Experimental Wistar rats were studied, with bile duct tied for 4, 7 and 14 days respectively. The serum concentration and relative tissue concentration of insulin and glucagon were measured. And the common bile duct was tied for 4, 7 and 14 days, then relieved by time sequences for 4, 7 and 14 days. Serum concentration and relative tissue concentration of insulin and glucagon were also measured.

RESULTS

When the common bile duct was tied for 4, 7, and 14 days respectively, the serum concentration and relative tissue concentration of insulin declined (p < 0.05) and glucagon concentration was elevated (p < 0.05). When the common bile duct was tied for 4, 7 and 14 days, then relieved by time sequences for 4, 7 and 14 days, the concentrations of insulin in both groups appeared to decline at first (p < 0.05) and then progressively increase (p < 0.05). The concentrations of glucagon exhibit the reverse behavior. Both serum and tissue concentration are elevated at first (p < 0.05), then progressively decline (p < 0.05).

CONCLUSIONS

These studies indicated that, during obstructive jaundice, more fuel is demanded to make up for the energy deficiency. In spite of surgical or non-surgical relief of obstructive jaundice, the energy reserve is still not sufficiently recovered. The recovery of the hepatic energy reserve takes longer than we expected.

Laparoscopic subsegmentectomy for hepatocellular carcinoma with cirrhosis: a case report

Laparoscopic liver resection is feasible for both benign and malignant disease with present laparoscopic techniques and technology. Laparoscopic liver tumor resection is indicated instead of the conventional hepatectomy if the tumor is located in the peripheral part of the liver. Here, we reported a case of a 73-year-old woman who accepted laparoscopic subsegmentectomy for hepatocellular carcinoma of segment 6. After traditional laparoscopic trocar was settled down under the low pneumoperitoneal pressure of 8 mm Hg, laparoscopic ultrasound allowed exact localization of lesions first and then transection line was marked. Then, dissection the liver parenchyma was carried out with laparoscopic microwave coagulator and ultrasonic aspirator gradually. After operation, she resumed full diet on the second day and was discharged on the 5th post-operative day with no complications and high patient satisfaction. She had follow-up study regularly in our clinic and was disease free at nine months. With the improvement of laparoscopic techniques and the development of new and dedicated technologies, laparoscopic hepatectomy has become feasible.

Clinical significance of cell differentiation in hepatocellular carcinoma

BACKGROUND/AIMS

Hepatocellular carcinoma is commonly found in Asian countries and prognosis still remains unsatisfactory due to recurrence after surgical tumor resection.

METHODOLOGY

We try to demonstrate the recurrence and survival time in 99 surgical patients grading by tumor cellular differentiation from surgical specimen.

RESULTS

The rates of well, moderate, and poor differentiation were encountered in 21 cases (21.2%), 61 cases (61.6%) and 17 cases (17.7%), respectively. Small tumor (< 3 cm) was found in only one (5.9%) in the poor differentiation group and 38.1% and 37.7% in the well and moderate differentiation groups. Capsular invasion was found in 13 (61.9%), 39 (63.9%) and 7 (41.1%) in the well, moderate and poor differentiation group, respectively. We found 41.9% (18/43) and 22.4% (13/58) to be tumor free in capsule invasion (-) and (+) after a period of 18.1 and 29.9 months, respectively. However, the recurrent time was 10.6 and 11.3 months, respectively with no significant difference (p > 0.05). Vascular invasion was more frequent in the poor differentiation group (76.5%) than the well (23.8%) and moderate (60.7%) differentiation groups (P < 0.05). We found 23.5% (4/17) and 35% (21/60) to be tumor free but the recurrence time was 6.5 and 14.1 months for the vascular invasion (-) and (+), respectively. The residual median survival times were 6.5 and 14 months after recurrence, respectively. The tumor recurrence rates were 52.7% (11/21), 52.4% (32/61), and 35.5% (6/17) and recurrence times were 11.7, 11.9, and 4.5 months for the well, moderate and poor differentiation group respectively totally. The recurrence time of young age group (< 39 years old) was shorter than the others and there was no patient of well differentiation less than 40 years old. The recurrence time was shorter in the poor differentiation group but there was no significant difference according to age group. The median survival times were 22.2, 22.9, and 9.5 months for each group, respectively.

CONCLUSIONS

Differentiation of hepatocellular carcinoma cell had a clinical significance and was found to be positively correlated with the invasive proclivity. The median survival time was longer in both the well and moderate differentiation group, but not in the poor differentiation group. The clinical data revealed that the extended operations performed upon the patients with poor differentiation effected the recurrence time but not the survival time.